Adequate pre- and postnatal care ensures a healthy baby and a healthy mother who can care for that baby. Regardless, maternal healthcare challenges persist in the U.S.
According to the National Center for Health Statistics, U.S. maternal mortality in 2018 was 17.4 deaths per 100,000 live births. The woman’s age influences how well she can cope with pregnancy and childbirth. Among women over 40 years of age the mortality rate is about 8-times higher than those under 25. Racial differences also play a strong role—maternal mortality is higher among African American women:
- 37.1 deaths per 100,000 live births among non-Hispanic black women
- 14.7 deaths per 100,000 live births among non-Hispanic white women
- 11.8 deaths per 100,000 live births among Hispanic women
The Racial Divide in Maternal Healthcare
In the African American population, it is sexism and racism that have been blamed for high maternal and infant mortality rates. Some corrective actions for this population might include:
- Access to health insurance. For example, infant mortality in states that expanded Medicaid fell at twice the rate compared to non-expansion states
- The option of staying on their parents’ insurance till 26 years. This could improve access to early prenatal care, adequate prenatal care, and lower preterm births
- Better quality of healthcare services
- Increased access to health care services, before and after pregnancy
- Access to contraception
- Healthcare providers that practice patient-centered and culturally sensitive care, such as access to doulas and midwives
The Rural Divide in Maternal Healthcare
Pregnant women living in rural areas face their own set of challenges. They lose access to local maternal healthcare providers due to hospital closures or the closure of obstetrics units. This increases the risk of preterm births and has also led to women giving birth outside of a hospital or without expert care, which can prove dangerous for the mother and the baby in case complications arise. This also raises challenges for adequate prenatal or postnatal care.
Instersection between Rural and Indigenous People
Approximately 40% of all Indigenous people (Native American or Alaskan Natives) are rural residents. This is a substantially higher percentage than other racial/ethnic groups. Rural residents, as mentioned, face heightened risks of severe maternal morbidity and mortality. Among Indigenous mothers, factors such as financial and partner stress are particularly predictive of infant risk.
The COVID-19 Pandemic Has Presented Some Viable Solutions
In the midst of the COVID-19 pandemic, telehealth services have helped provide a bridge to connect care providers with patients. Perinatal and support services for maternal health have evolved to deliver maternal healthcare via telehealth. Reimbursement changes for the providers has supported this.
To improve health equity—meaning to ensure continued access to maternal care for all—providers should:
- Continue providing care via telehealth even after the pandemic
- Include additional services, such as
- doula support
- prenatal risk assessment
- postpartum depression screening
- home visits and childbirth education
- substance use treatment
- recovery services
- Increase infrastructure investment in low-income and rural communities, specifically to improve access to the internet, data plans, and communication devices.
Financial Impact of Maternal Care
Pre- and postnatal care, in addition to the baby’s birth, can be financially taxing on a family. A recent study from the University of Michigan found that the Affordable Care Act (ACA) has not reduced the cost burden of maternal care for most families. Requirements for large employer-based health plans to cover maternity care have not helped; the way deductibles, copays, and coinsurance are structured fails to help patients. Over the 7-year period from 2008 to 2015, women on employer-sponsored plans saw an increase in out-of-pocket (OOP) spending for maternal care from $3,069 to $4,569. The Table lists the cost increases that the authors identified.
| Procedure | 2008 | 2015 |
| C-section | $3,364 | $5,161 |
| Vaginal birth | $2,910 | $4,314 |
The cost of the actual procedures did not increase as much during that time. However, there was an increase in high deductibles. This shifted the OOP cost for enrollees, including pregnant women who were responsible for shouldering about 7% more of their pregnancy-related expenses.
And this expense varies based on the state. 2016-2017 data for commercially insured individuals across 35 states found that OOP cost just for childbirth ranged from $1,077 (Washington, D.C.) to 2,473 (South Carolina). The main reason for the differences in OOP costs was variation in the cost of vaginal birth, along with the different health plan structures (a.k.a. ‘benefit design’).
With such high OOP costs, it is important to find out:
- Does your health plan cap the OOP cost for an individual?
- Do OOP costs count towards the entire family’s deductible?
Adding a baby to your health plan may also increase your monthly premium.
Medicaid
Medicaid pays for about 40% of births in the U.S.. While federal law mandates health coverage for pregnant women with income up to 138% of the federal poverty level (FPL), 48 states and Washington, D.C. have expanded this coverage threshold from 138% to 380%, which vastly expands eligibility. All pregnant women are eligible for prenatal care, childbirth, and delivery services. Pregnancy-related coverage lasts for 2 months after birth and the infant can be covered till his or her first birthday. However, states have the right to decide the specific maternity services that are offered for Medicaid enrollees.
For insurance coverage after the 60-day post-partum period, there are the following options:
- States that have expanded Medicaid coverage under the ACA provide a path for insurance coverage for mothers whose income is up to 138% of FPL. You can visit this website for eligibility and coverage information.
- Those whose income is above 138% FPL can buy coverage on their state’s ACA Marketplace through the HealthCare.gov website
Surabhi Dangi-Garimella, Ph.D. is a biologist with academic research experience, who brought her skills and knowledge to the health care communications world. She provides writing and strategic support to non-profit groups via her consultancy, SDG AdvoHealth, LLC.
from the editor:
Read more about telehealth:
Telemedicine as the New Face of Healthcare in the US?
Read more about maternal healthcare:
At Last! Reproductive Guidelines for Rheumatologists
Or, if you’d prefer to listen…
In Season 2: Episode 6 of the Patients Rising Podcast, among other topics they discuss the Momnibus Legislation