To: U.S. Congresswoman Jaime Herrera Beutler
From: Angelika Dabu
Date: January 20, 2020
Re: Policy Revisions to Further the Preventing Maternal Deaths Act

Statement of Issue: Though the Preventing Maternal Deaths Act was mandated in December 2018 to address the unacceptable high incidence of maternal deaths in our country and analyze each state’s data on maternal mortality, further revisions to the act must be made to increase efforts to minimize the evident disparities between black women and white women, who suffer significantly fewer maternal deaths. The CDC has revealed that 43 in 100,000 live births have resulted in maternal deaths among black women while 13 in 100,000 maternal deaths resulted among white women (Krisberg, 2019). Without increased focus on the contributing factors that lead to maternal mortality inequities, these racial disparities will persist and continue to be largely and unjustly felt among the black population.

• Maternal mortality is a clinical, public health, and social issue. Social determinants, such as access to care, socioeconomic status, and structural racism, are factors not adequately accounted for by Maternal Mortality Review Boards (Kozhimannil et al., 2019).
• Medicaid finances a significant amount of births and thus holds power in being able to offer additional benefits that will help reduce maternal death disparities and ultimately decrease maternal mortality in the process.
• Reducing the rate of maternal mortality by 10 percent is one of the objectives for Healthy People 2020 and had been for Healthy People 2010 though it was not achieved. Thus, more aggressive policy change is required to actualize this goal (Healthy People 2020).
• Maternal deaths are largely preventable.

Policy Options:
• A federal mandate for Medicaid expansion to include coverage for doula care, which in various settings has proven to improve health outcomes for black women and women of color.
◦ Advantages
‣ Doulas are professionally trained to provide non-clinical care that includes physical, emotional, and educational support before, during, and after delivery. Such care has been found to be associated with lower cesarean rates, fewer obstetric interventions, fewer complications, less pain medication, shorter labor hours, and higher APGAR scores (Kozhimannil and Hardeman, 2016, 1).
‣ Timely patient education will result from communication with doulas rather than patients having to wait to speak to doctors at longer-standing scheduled appointments to have their concerns addressed.
‣ Birthing experiences and labor and delivery outcomes will improve overall.
◦ Disadvantages
‣ Doula care is costly with private doulas typically charging between $700-$1,500, and would thus require increased funding (Kozhimannil and Hardeman, 2015).
‣ Doulas are not widely available geographically and are limited in diversity. Thus, measures to increase access to doula care and support would need to be implemented. Additionally, training, certification and registration to become a doula is expensive, especially for those of lower income thus presenting a financial barrier (Kozhimannil and Hardeman, 2016, 2).
• A federal mandate for every state to follow a national data collection standard and have active CDC-recognized maternal mortality review committees (MMRCs) that includes informed members, such as those who have lost women to maternal mortality, to focus on those at disproportionate risk and develop strategies to prevent death and thus decrease the maternal mortality rate.
◦ Advantages
‣ Currently, only 38 states have active MMRCs recognized by the CDC (Kozhimannil et al., 2019). Therefore, the requirement of more and better informed MMRCs in every state would lead to an increase in comprehensive equal opportunities to address maternal mortality and identify effective measures for prevention.
‣ More formal, standardized collection of data and review would result as only 46 states and the District of Columbia currently hold some level of maternal death review (Kozhimannil et al., 2019). This will necessitate action and decrease high percentages of variability and inaccuracy in documentation.
◦ Disadvantages
‣ Increased funding would be necessary to sustain the functional capabilities of each MMRC.
‣ State-based grant opportunities are only currently available to states with MMRCs that have been active for at least one year and are currently reviewing deaths (Kozhimannil et al., 2019).
• A federal mandate to implement protocol that addresses and eliminates structural racism among health care providers in all health care settings. In a study that analyzed preeclampsia, eclampsia, abruption, placenta previa, and postpartum hemorrhage, no racial differences were found in the prevalence of any of the complications between black women and white women yet black women with each condition died at two to three times the rate as white women with the same conditions (Kramer et al., 2019, 610).
◦ Advantages
‣ Proactive measures will increase awareness and influence systematic change to combat implicit bias that negatively affects quality of care and health outcomes for black women.
‣ An increase in education about the historical trauma and racism faced by black people will help to change the preconceived attitudes and thoughts associated with black women.
‣ A systematic cultural shift may encourage an increased number of providers who are black and of color.
◦ Disadvantages
‣ Requires sustained efforts that drive introspection and self-acceptance of internal bias, which may involve shame, embarrassment, and denial.
‣ Largely systemic therefore it will take the collective effort and active participation and accountability of many to produce meaningful change. Re-structuring takes time, and it may be long before a noticeable shift can be observed.

Policy Recommendation: As disparities in maternal mortality rates are perversely noted in the United States, implementation of reform on a federal level is necessary to minimize the overwhelmingly apparent gap between black women and white women who give birth and die in consequence. The Preventing Maternal Deaths Act has initiated the process of seeking to prevent such deaths. However, it does not consider the many complex causes of maternal deaths, some of which are deeply-rooted and largely systemic. Though financing and funding may initially present as significant challenges, a federal mandate aimed to improve the quality of care for black mothers and eliminate health disparities is a cause in which the benefits may ultimately prove to be cost-effective. Black women should not be over three times more likely to die maternal deaths that are preventable. Reform would thus both reduce death by childbirth for black women as well as reduce the number of black children growing up without their mothers, overall optimizing family and health outcomes and positively promoting health equity.

Sources:

Kozhimannil, Katy B., Hernandez, Elaine, Mendez, Dara D., and Chapple-McGruder, Theresa (2019).
Beyond The Preventing Maternal Deaths Act: Implementation And Further Policy Change. Health
Affairs. doi: 10.1377/hblog20190130.914004.
Retrieved from: https://www.healthaffairs.org/do/10.1377/hblog20190130.914004/full/

Kozhimannil, Katy B. and Hardeman, Rachel R. (2016). Coverage for Doula Services: How State
Medicaid Programs Can Address Concerns about Maternity Care Costs and Quality. Birth
(Berkeley, Calif.), 43(2), 97–99. doi:10.1111/birt.12213.
Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5530734/

Kozhimannil, Katy B. and Hardeman, Rachel (2015). How Medicaid Coverage For Doula Care Could
Improve Birth Outcomes, Reduce Costs, And Improve Equity. Health Affairs. doi: 10.1377
hblog20150701.049026.
Retrieved from: https://www.healthaffairs.org/do/10.1377/hblog20150701.049026/full/

Kramer, Michael R., Strahan, Andrea E., Preslar, Jessica, Zahartos, Julie, St Pierre, Amy, Grant,
Jacqueline E., Davis, Nicole L., Goodman, David A., and Callaghan, William M. Changing the
conversation: applying a health equity framework to maternal mortality reviews. American Journal
of Obstetrics and Gynecology (2019). Volume 221, Issue 6. Pages 609-616, ISSN 0002-9378.
https://doi.org/10.1016/j.ajog.2019.08.057.
Retrieved from: http://www.sciencedirect.com/science/article/pii/S0002937819311044

Krisberg, Kim. Programs work from within to prevent black maternal deaths: Workers targeting root
cause — Racism. The Nation’s Health. August 2019, 49 (6) 1-17.
Retrieved from: http://thenationshealth.aphapublications.org/content/49/6/1.3-0

Maternal, Infant, and Child Health Objectives. Healthy People 2020.
Retrieved from: https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant- and-
child-health/objectives