On April 3, 2020, TCF director of health care reform and senior fellow Jamila Taylor responded to a request for information from the U.S. Senate Committee on Finance regarding America’s ongoing maternal health crisis. Dr. Taylor’s letter is provided below.
Dear Chairman Grassley and Ranking Member Wyden:
Thank you for the opportunity to respond to your request for evidence-based solutions to improve America’s maternal health crisis. I serve as the Director of Health Care Reform and Senior Fellow for the Century Foundation—a 100-year-old progressive, nonpartisan think tank that seeks to foster opportunity, reduce inequality, and promote security at home and abroad. As you may know, the United States ranks tenth out of ten similarly wealthy countries in maternal deaths. For a wealthy country that spends more on health care than any other country, this may seem surprising. In 2017, the United States spent approximately $3.5 trillion, or 18 percent of GDP, on health expenditures. This is more than twice the average among developed countries.
What lies at the heart of America’s maternal health crisis is a woefully unequal health care system that perpetuates vast racial disparities in maternal mortality and morbidity. While the overall rate of 17.2 maternal deaths per 100,000 live births among all American women is cause for alarm, Black women are dying more often than any other racial or ethnic group. The widest disparity is seen when compared with white women, where Black women are two to three times more likely to die of pregnancy-related causes. During 2011–2015, the pregnancy-related mortality ratio was 42.8 deaths per 100,000 live births for Black non-Hispanic women and 13.0 per 100,000 for white non-Hispanic women. They are also more likely than white women to experience severe maternal morbidity—nearly dying of a complication, also known as a “near miss.” Based on qualitative research designed to highlight the personal stories of women and their experiences during the birthing process and up to a year after giving birth, poor maternal health outcomes among Black women cannot solely be attributed to social determinants such as poverty, educational attainment, or access to health care.
Racial disparities in maternal mortality and morbidity are not associated with the socioeconomic status of Black women. A Black woman with an advanced degree is more likely to die of preventable, pregnancy-related causes than a white woman who never finished high school. Indeed, it can be gleaned from the examination of these racial disparities that the issue of maternal mortality in the United States is multifactorial with the underpinning of structural racism.
In order to adequately address this crisis, and close the racial gap in maternal health outcomes, policy solutions must have an intentional focus on Black women and families. The COVID-19 pandemic requires us to not only address people’s health care needs, but also the social and economic needs that intersect with the ability to be healthy and thrive. Black women and families deserve to be healthy and thrive. Below is a presentation of rich information and policy proposals geared toward addressing racial disparities in maternal health and ensuring better health care access and outcomes for pregnant women and new mothers.
Incentivize Medicaid expansion for states; require states to extend Medicaid coverage for new mothers to at least one year postpartum.
African Americans are disproportionately poorer than other groups on average, and so Medicaid and other public insurance programs play an important role in ensuring the health of millions—especially expecting and new mothers. Research from Georgetown University’s Center for Children and Families found that Medicaid expansion has been vital in improving the health of women of childbearing age. Women in expansion states have seen greater access to preventative services, which has reduced adverse health outcomes before, during, and after pregnancy, and reduced maternal mortality rates in those states. To this date, however, fourteen states have not expanded Medicaid; most of these states are in the South, where there are larger shares of Black residents. Resistance to Medicaid expansion has led to disparities in coverage: uninsured Black adults are more than twice as likely to fall into this coverage gap than white and Hispanic uninsured adults, and the uninsured rate for women in non-expansion states (16 percent) is nearly double the rate for women in expansion states (9 percent). There are also higher rates of postpartum uninsurance in non-expansion states. Overall, new Black mothers face higher uninsurance rates than new white mothers (12 percent compared to 7.0 percent). At this critical time in the U.S. response to the spread of COVID-19, expanding health coverage for pregnant and postpartum women through Medicaid is more critical than ever.
The role that Medicaid plays in improving Black maternal health cannot be overstated. Black women face greater barriers than other demographic groups in accessing adequate health care, including reproductive health services and culturally congruent care. Having continuous and affordable health coverage through Medicaid is a decisive factor in care-seeking behaviors and health outcomes. The cost and breadth of health coverage determines whether people have a regular source of care, get preventative care and screenings, and receive treatment for chronic conditions in the recommended time frame. People who are uninsured and underinsured are more likely to delay care due to cost, resulting in worsening health status and more costly care later.
Access to care through Medicaid can greatly improve Black maternal health outcomes. Better and early initiation of preconception and prenatal care; responsive care during pregnancy; treatment of chronic conditions; and continuous care postpartum (the “fourth trimester,” when approximately a third of pregnancy-related deaths occur) to treat complications from delivery and mental health conditions are necessary for lowering rates of maternal mortality and morbidity among new mothers. For Black mothers, medical care is an important tool to ensure their health when institutionalized racism and social determinants of health have disadvantaged Black women for centuries. Due to inequities in care, Black women are at increased risk of chronic and pregnancy-related hypertension, increased risk of late-stage diagnoses of HIV and cancer, and are less likely to receive quality prenatal care, preconception counseling, and care for pre-existing conditions. Compared to white women, Black women are more likely to live in areas that lack access to maternity care and comprehensive reproductive services. These findings help explain racial disparities in maternal mortality, as the CDC reports that 60 percent of pregnancy-related deaths are preventable.
The poor outcomes that Black mothers face are partly explained by a lack of access to health care. Black Americans are more unlikely to be uninsured. In 2018, 9.7 percent of non-elderly adult (18–64 year old) Blacks lacked health insurance, significantly higher than their white counterparts (5.4 percent). Although the passing of the ACA has expanded coverage to millions of Americans, especially for Black Americans, 45 percent of non-elderly adults—approximately 87 million people—are inadequately insured. And while Blacks only make up 12 percent of the non-elderly adult population, 18 percent were underinsured and 16 percent experienced a coverage gap in 2018. One reason for this is that Black families face higher out-of-pocket health care costs; while the average American family spends 11 percent of their household income on premiums and out-of-pocket costs, Black families spend almost 20 percent of their household income.
Health coverage is one factor, among many, that impacts the health of Black mothers and their infants. Timely care can help identify, manage, and treat health conditions that complicate pregnancy, reduce the risk of poor birth outcomes, and reduce rates of maternal mortality and morbidity. Redress of racial disparities in maternal health outcomes must tackle the lack of continuous, quality, and affordable care for many Black women.
Address bias and racism in the health care system by supporting the Maternal CARE Act.
For centuries, racism has permeated our social systems, including our health system. Racism impacts how women interact with health personnel and how they are treated by providers, and adversely impacts whether women get the appropriate and timely care they need. In 2018, the National Partnership for Women and Families published the “Listening to Mothers” study, which asked California women about their maternity care and birthing experiences. Respondents reported facing discrimination during childbirth; Black women and women enrolled in Medicaid were more likely to report unfair treatment than women with private insurance or women in other racial groups. Such treatment includes having their concerns ignored or diminished, being spoken disrespectfully to by hospital personnel, and “rough handling” by hospital staff. The survey also examined racial disparities in treatment practices. Black women (over 40 percent) were more likely than white women (29 percent) to be given a caesarean section. Black women also reported higher rates of depression and lack of emotional support from their providers.
These experiences are not uncommon for women of color, especially Black women. In 2003, the Institute of Medicine published a seminal report on health care disparities, showing that disparities remain even when controlling for socioeconomic factors. The report brings attention to the role of explicit and implicit bias in the health care setting, which shape the patient-provider relationship and decisions of preventative care and treatment. There is significant literature that shows that Black patients receive suboptimal care for cancer, HIV, cardiovascular procedures, and are more likely to die from these diseases, even when adjusting for age, insurance, education, and severity of disease. Studies have found that despite higher rates of reported pain, Black patients are significantly undertreated; providers who subscribe to false beliefs of biological differences between Black and white people (for example, “black people’s skin is thicker than white people’s skin”) were more likely to under-assess the severity of Black patient’s pain.
One study found that Black patients are less likely to be treated for myocardial infarction—a life-threatening condition during pregnancy that requires early detection and treatment. National statistics also show a higher rate of caesarean sections performed on Black women, compared to women of other racial groups, even for low-risk pregnancies. In a systematic review of studies on implicit bias in the clinical setting, researchers found that there was an implicit preference for white patients, especially among white physicians. These preferences have a wide impact, since only 9 percent of medical doctors are Black, Latinx, and Native women—even though these groups make up 30 percent of the general population. Implicit bias has negative consequences on Black women’s health and exacerbate existing health and health care disparities. The overuse of cesarean sections has been a concern in the United States for decades due to the danger they can pose to mothers: the rates for maternal mortality and morbidity are about three times higher for women who have cesarean sections than vaginal deliveries. Disparities in pain assessment and treatment is one example of how Black women are invisible to health care providers, leading to unresponsive, poor quality, and delayed care.
While the research that attempts to measure implicit bias and its effect on clinical decision-making is inconclusive, we know from Black women’s personal accounts that they are not receiving the care they need and deserve. Shalon Irving and Kira Johnson, two highly educated Black women with strong support systems from friends and family, died of preventable pregnancy-related causes (Shalon died of complications associated with high blood pressure and Kira died of postpartum hemorrhage). When they voiced concerns about their wellbeing during their treatment, their concerns landed on deaf ears.
Long-standing racism and negative cultural representations of people of color in American life in general, and in our health care system in particular, translates into bias and unequal treatment at the interpersonal and institutional levels. Given the United States’ history of experimentation on Black women’s bodies and continued devaluation of their pain and concerns, minority patients have a higher distrust for physicians and the health care system. Trust is a fundamental component of patient-provider relationships; it impacts care-seeking behaviors, adherence to treatment, and overall health status. In addition to stereotypes, some physicians have a harder time making accurate diagnoses of their patients across lines of race and class, possibly due to cultural and language barriers. More work needs to be done to strengthen the patient-physician relationship and ensure patient-centered care, rooted in cultural competency.
The Maternal Care Access and Reducing Emergencies (CARE) Act (S. 1600), introduced by Senator Kamala Harris (CA) and Representative Alma Adams (NC-12), seeks to address the persistent biases in our health system and provide greater access to culturally competent, holistic care to reduce preventable maternal deaths. The bill makes investments to tackle racial disparities in maternal health, creating a new $25 million program to fight bias in maternal health care through health professional training programs, such as implicit bias training; allocating $125 million to identify high-risk pregnancies and provide those women with the culturally competent care they need, making available a new demonstration project for pregnancy medical home (PMH) programs; and working with the National Academy of Medicine to study bias, make recommendations, and help medical schools incorporate bias recognition training.
Support the Black Maternal Health Momnibus, helping to ensure a comprehensive U.S. response to the maternal health crisis.
The Black Maternal Health Momnibus (S. 3424) is a package of nine bills that work to address gaps in existing legislation to comprehensively address every dimension of the Black maternal health crisis in the United States. Led by Senator Kamala Harris (CA), Representative Lauren Underwood (IL-14), Representative Alma Adams (NC-12), and other congressional members of the Black Maternal Health Caucus (BMHC), the Momnibus advances critically important policies to address the maternal health crisis among Black women.
The legislation will make investments to improve treatment and services for maternal mental health, substance use disorders, and pregnant and postpartum women who are incarcerated; fund community-based organizations working to improve maternal health outcomes; expand telehealth and other digital tools in underserved areas; and improve social determinants of health that impact maternal health outcomes, such as nutrition, housing, and transportation.
In addition to investments in services, the legislation also works to improve data collection processes and continue study of the maternal health crisis—especially in areas lacking data, such as veteran women, Native women, and minority-serving institutions—in order to inform solutions and better coordinate care. It will also transform the health care system by growing and diversifying the perinatal workforce; promote payment models that incentivize high-quality care; develop strategies to ensure continuous postpartum insurance coverage; establish avenues of recourse and accountability for women who experience discrimination; and expand evidence-based implicit and explicit bias training.
Address the social factors that compound the likelihood of poor maternal health outcomes among Black women by supporting the Social Determinants for Moms Act.
In addition to health status, access to health care, and racism in the health system, social factors—such as socioeconomic status, education, and income—impact a women’s ability to have a healthy pregnancy and positive birth outcomes. While these factors have not been as protective for Black women compared to other mothers—Black women, regardless of social or economic status, are more likely to die of pregnancy-related causes—improving them will lead to better outcomes in Black maternal health. Policies that correct for the social determinants of health associated with institutionalized, systemic, and interpersonal racism—such as poverty, residential segregation, and income inequality—will make Black women less likely to suffer disparate reproductive health outcomes.
Residential segregation is one of the greatest contributing social factors to poor Black maternal health. Decades of residential segregation and disinvestment in Black communities have shaped neighborhood conditions and the Black–white wealth gap. It has resulted in lower quality housing, concentrated poverty, lower rates of homeownership, and shortages of healthcare providers and hospitals in Black communities. Approximately 2.6 million (7.5 percent) non-Hispanic Black people live in substandard housing, compared to 5.9 million (2.3 percent) whites. This poor quality housing has led to higher risk of lead toxicity in Black communities, putting pregnant Black women at risk of their own health as well as their children’s health. Segregated and poor housing quality is correlated with a significant increase in cardiovascular disease and asthma.
Economic disparities compound disparities in housing quality, homeownership, and health. Black people are nearly two times more likely to be unemployed than white people (6.0 percent versus 3.1 percent as of January 2020). Black women are more likely to work low-wage jobs, which translates to less access to benefits such as paid sick leave, paid family leave, or employee-sponsored health care. In 2014, the Pew Research Center reported that white households’ median wealth was thirteen times greater than that of Black households. The median household income for Black Americans in 2018 was $41,361, while white households earned $70,642. This wealth gap is partly mediated by income inequality—where Black Americans tend to earn less for the same jobs as whites—and inequities in opportunities for quality education.
The disparities exacerbated by residential segregation greatly impact Black families’ access to health services; they determine whether women are able to take time off to go to doctors appointments, care for their child, or afford the necessary treatment and resources to improve their health. In light of the COVID-19 pandemic, it is even more abundantly clear that low-income workers are compelled to make the difficult and life-threatening decision of continuing to work, trading off their health for financial stability.
Another social factor directly impacting Black maternal health is access to food and nutrition. Black households face the highest rates of food insecurity, compared to other demographic groups. Low-income and racial/ethnic minority populations face substantial challenges in accessing healthy and nutritious foods, including poverty, poor access to transportation, lack of healthy food retail, and greater access to unhealthy food sources, such as convenience stores, fast-food restaurants, and alcohol outlets. Neighborhood socioeconomic disadvantage, compounded by healthy food access challenges, have been associated with increased risk of gestational diabetes, pregnancy-related hypertension, and outcomes related to pregnancy-related weight.
Racism, systems of racial exclusion, and racial disparities—that is, the very existence of racism itself— can have a cumulative negative effect on people that directly impacts Black maternal health. Women of color experience higher rates of depression; depression during pregnancy is associated with poor maternal outcomes. Years of enduring racist experiences and social conditions of poverty and inequality lead to “weathering,” or cumulative stress that adversely impacts one’s mental and physical health. Thus, Black women experience disparities in health status even before pregnancy—and, when becoming mothers, their health status and pregnancy stand to be worsened by unequal access to quality and preventative care.
The Black Maternal Health Momnibus (S. 3424) seeks to make critical investments in addressing and alleviating the impact of these social factors that impact maternal health outcomes. Title I of the legislative package, the Social Determinants for Moms Act, works specifically to establish a task force to coordinate federal efforts across agencies and departments to address social determinants for pregnant and postpartum women. Such efforts include studies of transportation barriers, work to improve access to safe and affordable housing, and creation of a federal guidance on employing Medicaid funding to address these social factors.
In conclusion, it is my hope that you find these policy proposals and rich information valuable as you consider how the Senate Finance Committee can play a role in helping to address America’s maternal health crisis. The spread of COVID-19 has presented unforeseen challenges in adequately addressing the health care needs of those most vulnerable among us. It also presents an opportunity to rethink the nation’s approach to providing equitable, universal health care that is affordable and of high quality for all Americans. I stand ready to work with you in developing new solutions that will effectively address the burgeoning health and social needs of pregnant women and new mothers.
Jamila K. Taylor, PhD
Jamila Taylor would like to thank Olivia Chan, health care policy intern, for her support on this letter.