Senator and presidential candidate Kamala Harris (D-Calif.) reintroduced her 2018 bill that seeks to address rising maternal mortality rates, particularly among black women. Harris’s Maternal CARE Act, and the accompanying House version, would authorize $150 million toward programs that seek to help medical professionals identify high-risk pregnancies and establish implicit-bias training curriculum for medical schools.
Her bill seeks to address a deeply troubling development: Severe maternal complications have more than doubled in the past 20 years and the U.S. maternal mortality rate has become the highest among high-income countries. Estimates of the maternal mortality rate span from 17.2 maternal deaths per 100,000 live births from the Centers for Disease Control (CDC) to 30.1 women per 100,000 births from the Institute for Health Metrics and Evaluation.
The United States and Great Britain used to have similar maternal mortality rates. But in the 1940s, the UK changed how it looked at the issue — treating each maternal death as a public health failure. It set up a commission to assess each maternal fatality, learn how it might be avoided, and then standardize the care women receive. This approach has improved outcomes. Now, the United States maternal mortality rate is three times higher than Britain’s.
So, what can we learn from the UK?
Collect more data
As the adage goes, “you can’t fix what you don’t know.” The UK started their maternal health improvement efforts back in the 1940s when they began collecting data on maternal mortality. Data collection on maternal mortalities in the United States is spotty at best. Each state has its own process and the collection is inconsistent and incomplete. Washington has the ability to collect robust data on many other conditions including teen pregnancy, infant mortality, and cardiovascular conditions. It’s not a lack of ability but a lack of prioritization from both state and federal policymakers.
Use midwives
Midwives deliver 53 percent of babies in England. In the United States, however, midwives deliver less than 10 percent of babies despite a widespread shortages of OB/GYNs in rural areas. States that better integrate midwives into their health care delivery systems, including Washington, New Mexico and Oregon, have better outcomes for moms and babies on average. Integration of midwives and care coordination across the delivery system could help improve outcomes.
Address underlying health issues
On average, pregnant women are older and heavier than they used to be. This means that more pregnant women have chronic conditions such as hypertension, asthma and diabetes that, when combined with pregnancy, increase the risk of complications. In the UK, these high-risk women see an OB/GYN, midwife and a specialist during their pregnancy. Most of these conditions can be managed if treated promptly. Many women in the United States, however, find that their symptoms are not taken seriously. Pain, discomfort, swelling and bleeding can all be normal during pregnancy or postpartum, but they can also be symptoms of larger problems. Treatment protocols for symptoms with comorbidities should be standardized.
Standardize care
The UK has emphasized using standardized, evidence-based care. In the US, each hospital has its own protocols, and variation is common. Minor changes such as weighing hygiene products during birth to calculate how much blood the mother has lost and administering blood pressure medication quickly as a mother’s blood pressure rises could help reduce the risk of hemorrhage and stroke. To improve outcomes for seniors, the Centers for Medicare and Medicaid Services (CMS) required that hospitals report on readmissions and complications with hip and knee surgery in order to receive Medicare reimbursement. The agency could easily adopt similar metrics for expectant mothers.
Close insurance gaps
The UK has public insurance for everyone — regardless of their pregnancy status. While low-income women in all states can enroll in Medicaid once they are pregnant, in Medicaid expansion states, low-income women can enroll prior to being pregnant. This allows for greater access to care and can help address lingering or chronic health conditions prior to pregnancy. A recent study found that states that expanded Medicaid under the Affordable Care Act (ACA) had 1.6 fewer maternal deaths per 100,000 women compared with states that haven’t expand the program. Additionally, the postpartum period is often neglected in new mothers: Medicaid is only required to cover new mothers for 60 days postpartum. Approximately 13 percent of maternal deaths occur six or more weeks after a woman gives birth, tied to chronic conditions and mental health disorders. Expanding coverage beyond the 60-day threshold could help new mothers access needed health care.
It’s important to note that these deaths are not the inevitable result of the United States health-care system. In fact, experts estimate that over 60 percent of pregnancy-related deaths are preventable. A few years ago, California started collecting data on maternal deaths and reviewing the clinical failures that led to fatalities. As a result, the state was able to produce evidence-based checklists and training programs to help clinicians address two lethal conditions: high blood pressure and hemorrhage. Now, its maternal death rate is a quarter of the United States as a whole.
Sen. Harris is on the right track. Another presidential hopeful, Sen. Amy Klobuchar (D-Minn.), advocated for changing practices after she was forced to leave the hospital early after giving birth. Now all women can stay in the hospital for 48 hours after delivery to help monitor their health — and their baby’s .
The United States should not be the laggard in maternal health. But it shouldn’t only be women candidates talking about these issues. Though Congress passed legislation to update how data on maternal deaths is collected, it is not enough. Our lack of focus on maternal mortality reflects the an all- too-common hurdle of most women’s issues, they get punted to the back burner. It’s time for our policymakers to understand that maternal health isn’t a “women’s issue” but a national emergency that demands their urgent attention.
Arielle Kane is the director of Health Policy at the Progressive Policy Institute. Her research focuses on what comes next for health policy in order to expand access, reduce costs and improve quality.