Maternal mortality rates in the United States continue to grow, with widening disparities in outcomes for Black, Indigenous, People of Color (BIPOC). According to the Centers for Disease Control and Prevention (CDC), Black, American Indian, and Alaska Native (AI/AN) women are two to three times more likely to die from pregnancy-related causes than white women, with certain conditions, such as cardiomyopathy and hemorrhage more likely to contribute to pregnancy-related deaths among Black women and AI/AN women, respectively, than among white women.
A relatively large share of pregnancy-related deaths occurs in the postpartum period, often referred to as the “fourth trimester.” Approximately 19% of all pregnancy-related deaths occur between 7 and 42 days postpartum, and 24% occur in the later postpartum period (43-365 days), with significant racial and ethnic disparities in occurrence. Research has also shown that nearly half of severe maternal morbidity and maternal deaths are preventable, signifying great opportunity in this space to address racial and ethnic disparities.
During the postpartum period, women can experience stress, breastfeeding difficulties, lack of sleep, fatigue, pain, and urinary incontinence, let alone the potential for worse maternal complications and even death. It is also increasingly common for women to experience new onset or the exacerbation of mental health disorders, including postpartum depression. One in 10 new mothers experience perinatal depression, and over the past decade, suicide attempts during pregnancy and the postpartum period tripled. While these health complications may occur for periods extending up to and beyond a year after birth, for many individuals insured through Medicaid—the largest payer for maternal care in the United States—insurance coverage ends 60 days after childbirth.
In 2014, the Affordable Care Act (ACA) expanded Medicaid access to low-income adults, and many states increased coverage options for women in the postpartum period. States that opted to expand Medicaid improved access to care for millions of women. A recent study comparing Colorado (an expansion state) to Utah (a non-expansion state) found that among new mothers with severe pregnancy-related health conditions, postpartum visits were 50% higher in Colorado than in Utah. Additional analyses have found that in states that did not expand Medicaid, postpartum people were three times more likely to be uninsured three to six months after childbirth.
There are important implications for the Medicaid program in the maternal health of Black and Hispanic women, whose births are more likely to be financed by Medicaid (68 and 63 percent, respectively). Several studies examining ACA Medicaid expansion have concluded that Medicaid expansion reduced disparities for Black and Hispanic people across several measures of maternal and infant health, including health coverage, maternal mortality, infant mortality, low birthweight, and preterm birth.
Under the recently passed American Rescue Plan, states are given the option to extend Medicaid postpartum coverage from 60 days to 12 months. Postpartum coverage duration can also be extended under the Children’s Health Insurance Program (CHIP) in the six states that cover low-income pregnant women through this program. States that elect to extend coverage must provide full Medicaid benefits through pregnancy and the extended postpartum period. This new option, which can take effect on April 1, 2022, could provide some relief to new mothers and their families by providing continued health coverage during this postpartum time. Several states—both ACA Medicaid expansion and non-expansion states—have shown interest in extending postpartum coverage beyond 60 days.
Throughout the year, SWHR advocates for policies and research to address the maternal mortality crisis in this country. Earlier this year, SWHR joined several organizations in support of the Black Maternal Health Momnibus, a package of bills aimed at comprehensively addressing this crisis, and was pleased to see its provisions included in the House’s Build Back Better Act. SWHR also sees an important research opportunity surrounding pregnant and lactating populations that could help address disparities in health outcomes. As an example, the inclusion of pregnant people in COVID-19 clinical trials could have led to earlier and stronger recommendations on vaccine uptake, thus reducing the number of deaths.
SWHR is committed to ensuring that women have access to continuous affordable and quality care and that researchers have the tools they need to produce evidence-informed guidelines and research that will contribute to addressing the maternal mortality crisis in this country.
SWHR’s blog series on maternal and infant health disparities is supported by a grant from Covis Pharma. SWHR maintains editorial control and independence over blog content.