The recession caused by the COVID-19 pandemic has brought renewed attention to the ties between public health and the economy. There has been no shortage of news accounts of workers facing health crises and lacking paid sick leave (an unacceptably high portion of the U.S. workforce), uninsured and underinsured Americans struggling to pay medical expenses, and rhetoric that falsely frames restrictions meant to protect workers’ health as an obstacle to economic prosperity. In short, the pandemic has demonstrated the disastrous economic effects when a society lacks universal health care and adequate social supports for families.
At the same time, COVID-19 has brought unique challenges to pregnant and birthing individuals in particular. Partners, doulas, and other support persons have been excluded from birthing rooms—leaving mothers unsupported—and women have had to risk potential exposure to COVID-19 in order to access perinatal care. Evidence suggests pregnant women may be at higher risk for hospitalization due to COVID than non-pregnant women, yet pregnant and breastfeeding women have been excluded from clinical vaccine trials. Now, at the second Mother’s Day of the pandemic, it is worth examining the unique ways in which pregnant women and new mothers experience the intersection of maternity, maternal health, and economics.
Maternal Health Is an Economic Issue
It has long been evident that the ability to control whether and when to have children is central to women’s economic wellbeing. Access to contraception and abortion have been linked directly to gains in women’s workforce participation, education, and earnings. But maternal health is an important macroeconomic issue as well. Globally, investments in women’s health are associated with long-term economic productivity, while maternal morbidity places substantial financial burdens on health systems and societies. Yet, despite maternal health’s importance as an economic issue, in the United States, commitments to improve maternal health are generally considered only as a health care issue.
The impact of maternal death goes beyond families’ experiences of loss and grief, causing economic devastation that ripples across generations, as over 40 percent of mothers are sole or primary breadwinners for their families. For women who survive severe maternal morbidity, also known as “near misses” for maternal mortality, physical recovery may be accompanied by financial strain. Severe maternal morbidity—which is rising at a faster rate than maternal mortality, despite nearly always being preventable—increases the cost of a delivery to three times that of an uncomplicated delivery. And although mothers’ need for care does not stop at birth, too often their health coverage ends shortly after—particularly for women with lower incomes. Medicaid, which finances 43 percent of births in the United States, is only mandated to provide postpartum coverage for sixty days after the end of a pregnancy. Over half of pregnancy-related deaths, however, occur up to a year after birth.
Where maternal mortality has the greatest impact, however, is among communities of color. America is currently gripped by a maternal mortality crisis driven by racial disparities in health care coverage and provision, causing Black and Indigenous women to die from pregnancy-related causes at three to four times the rate of white women. The racial disparities seen in maternal health outcomes are complex and go deeper than economic resources alone: having a higher income or more education does not protect Black mothers from increased rates of maternal mortality and morbidity. Still, Black individuals are more likely to be uninsured than their white counterparts, and have less wealth and income—a critical factor in America, where access to financial resources impacts the ability to access quality health care services. These factors are compounded by maternity care deserts—areas of the United States where over two million women live in counties without obstetric care. Among rural areas that lost obstetric services, Black women were more likely to lose access to care. Crucially, access to obstetric care is not enough: the hospitals that serve Black women provide lower-quality care. Unsurprisingly, maternity care deserts have higher poverty rates and lower median incomes than counties with sufficient access to maternity care. This trend of reduced access among lower-income communities is reflected in access to other acute care, and threatens to exacerbate existing disparities in health and economic outcomes, as the U.S. health care system actually increases income inequality.
The Importance of Paid Leave for Mothers Who Work
While poor maternal health can have disastrous economic effects on families and communities, even healthy mothers find that having a child can present tremendous challenges when it comes to staying employed. Although some of these effects could be mitigated by access to paid family and medical leave and paid sick days, women are more likely to be in low-wage jobs, which do not typically provide either. Women of color, particularly Black and Latina women, endure the worst of this crisis, as they are both more likely to work low-wage jobs and more likely to be sole breadwinners for their families. They are also less likely to have access to leave from their employers.
The only federally guaranteed family leave is unpaid, offered under the Family and Medical Leave Act (FMLA), which allows parents to take up to twelve weeks of job protected time away from work to care for a newborn, as well as for other family and serious medical care needs. FMLA also does not cover all workers (largely because it only covers employers with fifty or more employees): just 56 percent of all employees are covered under FMLA, and only 38 percent of low-wage workers are eligible.
For mothers in the U.S. workforce, this means there is no guarantee of paid maternity leave, forcing many women to return to work during the immediate postpartum period. Data from a 2012 survey found that one in four women returned to work within two weeks of giving birth. This is especially troubling for women who required time off during their pregnancy and those recovering from complicated pregnancies and deliveries. It comes as no surprise that access to paid maternity leave improves outcomes for both mother and infant, reducing risk of subsequent hospitalization and preterm birth. Paid leave is also associated with improved mental health outcomes and increased breastfeeding duration—and may even increase mothers’ employment and job continuity. And paid parental leave is critical so that in two-parent families both can take paid time to care, which can not only significantly increase the personal and economic wellbeing of their families, but also provide important support for mothers and children.
The financial precarity faced by birthing and pregnant people has been exacerbated by the pandemic, as mothers have had to leave the workforce at appallingly high rates because of a lack of affordable child care. Nearly 1.5 million fewer mothers are working now than in February 2020. Women of color, and Black women in particular, have borne the brunt of the job loss in the pandemic; in December 2020: all jobs lost among women were lost by Black, Asian, and Hispanic women and 154,000 Black women alone left the labor force. As women of reproductive age, and especially women of color, experienced greater financial insecurity during the pandemic, their desire for pregnancy also decreased—at the same time that barriers to accessing contraception increased.
Opportunities for Progress in Maternal Health Policy
The economic and health challenges that the COVID-19 pandemic has brought to the surface are incredibly salient for pregnant women and mothers, and addressing these challenges through maternal health and employment policy is crucial to undoing these harms. And so, it is heartening that, in the first few months of the Biden–Harris administration, progress has been made to improve maternal health and reduce racial disparities in pregnancy-related outcomes. In April, the administration released a proclamation recognizing Black Maternal Health Week and calling on Americans to recognize the country’s maternal health crisis. We must both celebrate these wins and continue working towards equity. Here are notable additional actions by the Biden–Harris administration and Congress in recent months:
- The president’s discretionary budget calls for funding for a number of initiatives that would reduce disparities in maternal health, as well as increased funding for the Department of Health and Human Services’ Office of Civil Rights and Title X program. The budget calls for a renewed focus on rural health and increased investment in the Women, Infants, and Children (WIC) program, to ensure better nutrition for low-income families. It is critical that Congress follows this leadership to invest in maternal health.
- The American Rescue Plan Act of 2021 included an option for states to adopt a twelve-month postpartum extension to Medicaid, for the temporary period of five years. This is a step in the right direction, but even better would be mandated twelve-month coverage postpartum so that women with middle and low incomes can receive the health care they need for a full year after pregnancy.
- One bill that would make this coverage mandatory has recently been brought to Congress. Representative Ayanna Pressley introduced the COVID-19 Safe Birthing Act, which would also address maternal health issues both specific to this pandemic and beyond by allowing support persons to accompany pregnant and birthing individuals in hospitals, expanding access to maternal telehealth services, and ensuring access to COVID testing, treatment, and vaccination to pregnant individuals.
- The MOMMIES Act, just reintroduced this week by Senator Booker and Representative Pressley, would also take this step of extending postpartum Medicaid. The act would expand access to oral health services and doula care for pregnant individuals, as well as other steps to improve maternal health.
- The Black Maternal Health Momnibus has been reintroduced in Congress, and the twelve pieces of legislation it encompasses offer crucial opportunities to achieve equity for birthing individuals, including expanding and diversifying the perinatal workforce, investing in improving the social determinants of health (such as housing, transportation, and nutrition) that affect maternal health outcomes, and improved data collection and quality measures to better understand and address the maternal health crisis.
- President Biden’s American Families Plan proposes a national comprehensive paid family and medical leave program which would support new parents, boost women’s workforce participation, and help reduce economic inequalities. Congress should act on this proposal to make paid parental leave a reality for more Americans.
Mother’s Day finds us over a year into a devastating pandemic that has exposed pre-existing disparities in health care access and outcomes, economic opportunity, and social support. Access to maternal health care, particularly for Black women and other women of color, is controlled by many factors—including structural racism—but a significant determinant is women’s access to financial resources. And because poor maternal health outcomes serve to perpetuate economic inequities, improvements at either end of the relationship between maternal health and women’s economic prospects could induce a virtuous cycle, not only leveling the employment playing field but also ensuring that all individuals are able to have safe and healthy pregnancies. Congress and the Biden–Harris administration must continue to elevate solutions and pass legislation addressing the maternal health crisis, while also pushing for paid leave solutions, such as those presented in the American Families Plan. Not only will doing so improve mothers’ health, but it could enhance the economic security of mothers and families—a priority throughout this pandemic and beyond.