States, health systems look to curb pregnancy-related deaths

Hundreds in the US die annually from pregnancy-related conditions, but that could soon change under bipartisan efforts to revamp state Medicaid programs.

More than half of all states (and DC!) implemented a postpartum coverage extension to ensure more residents receive care up to one year postpartum. The policy change—made easier through recent federal legislation—seeks to curb deaths deemed largely preventable (up to 80%, according to one CDC analysis). And other states, including New York, are set to follow once they also receive federal approval to modify their Medicaid programs.

A February 2021 report from the Congressional Budget Office estimated that the “combined federal and state cost to provide 10 additional months of Medicaid coverage would be about $1,500 per person, on average, in 2022,” and increase at an average annual rate of 6% through 2030.

The American College of Obstetricians and Gynecologists (ACOG) and other supporters of the extension argue that providing Medicaid coverage up to one year after a person gives birth will not only improve patient outcomes and prevent deaths—of which there are about 700 annually in the US—but also reduce costly emergency room visits and uncompensated care.

And since Black and Hispanic people are nearly three times more likely to die from pregnancy-related conditions, advocates say it will address critical racial disparities in healthcare.

“We are in a maternal health crisis right now, especially for Black and Indigenous birthing people,” said Taylor Platt, health policy manager for ACOG. “The first thing we can do [is give these people] an additional 10 months of insurance coverage to make sure that they are able to have the first step in accessing the care they need.”

How we got here

Medicaid, a joint federal-state health insurance program for low-income people, is required to cover qualified individuals during their pregnancies and at least 60 days after delivery. It covers about 42% of all births in the US, according to the Department of Health and Human Services.

With more than half of all pregnancy-related deaths occurring seven days to one year post birth, federal lawmakers included a provision in the American Rescue Plan Act to make it easier for states to extend their postpartum Medicaid coverage from 60 days to one year. The Biden administration estimated that the policy, which took effect last April, would benefit as many as 720,000 pregnant and postpartum people across the US.

It’s still too early to say how the policy has affected pregnancy-related deaths, said Jamie Daw, an assistant professor of health policy and management at Columbia University’s Mailman School of Public Health. But the last few years of pandemic-era rules prevented states from kicking people off of Medicaid, offering a preview of sorts.

“It’s kind of like we had this national experiment over the last […] two years where states couldn’t disenroll anybody from Medicaid, so that’s beyond a year postpartum,” she said. “I think we should be looking at the impact of that on postpartum people and just low-income people in general.”

Daw, the senior author of a January 2022 study examining how the Affordable Care Act’s Medicaid expansion improved insurance coverage for pregnant people, said there’s not much data on postpartum individuals. New research, however, ties Medicaid expansion to a 17% reduction in hospitalizations in the 60 days following birth and a smaller decrease in hospitalizations 61 days to six months postpartum, she noted.

But having extended coverage alone is not enough to prevent pregnancy-related deaths: People must also be able to access care—something which can be challenging in communities with few providers who accept Medicaid, limited transportation options, or even cultural barriers.

“It’s going to take more than just a coverage expansion to address racial disparities and maternal health outcomes,” Daw said. “It’s simply not that simple.”

Health systems take action

In New York, Northwell Health created a Center for Maternal Health in 2022 to help reduce the country’s maternal mortality rate, particularly among Black women. The center has launched programs that screen patients for conditions like preeclampsia and behavioral health risks, among other efforts, and connects patients with postpartum follow-up care.

Adriann Combs, clinical director for Northwell’s ob-gyn service line, said the initiatives seek to ensure patients receive proper care and don’t die from pregnancy-related conditions. But it also has another benefit: reducing the overall costs of care.

The system anticipates the interventions will reduce the likelihood of a patient needing an ICU visit, she said.

“It will, if a patient has the appropriate resources, prevent a lot of people showing up in the ER—when much of what shows up in the emergency department could probably have been managed if it was identified earlier in the outpatient setting,” she said.

Extending coverage, Combs added, could help patients dealing with behavioral health and substance use disorder, who account for about a quarter of pregnancy-related deaths at Northwell.

“Those are things that are not cured in the first six weeks postpartum. Those are things that require ongoing care,” she said.