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Excerpted From: Andrea M. Ferrari, Developments in the Quest to Advance Equity in Maternal and Child Health in the Age of Covid-19: the Bad, the Good, and the Promising, 16 Journal of Health & Life Sciences Law 145 (2022) (63 Footnotes) (Full Document)
Each year, an estimated 50,000 women in the United States suffer severe pregnancy-related morbidity, and approximately 700 women consequently die. In 2018, before the COVID-19 public health emergency (the COVID PHE), more than 21,000 infants born in the U.S. died from causes such as birth defects, preterm birth, low birth weight, injuries during or after delivery, sudden infant death syndrome, and maternal pregnancy complications.
Alarmingly, while rates of maternal mortality are declining elsewhere in the world, they have been increasing in the U.S. since 1987. Infant mortality rates, which are widely regarded as a significant measure of population health, have been declining in the U.S. in recent years, but they are declining at a slower rate in the U.S. than in other developed nations, and overall, they remain higher in the U.S. than in other developed nations.
Equally concerning as the overall rates of maternal and infant mortality are the disparities in the rates based on race, ethnicity, and geography. Data from the Centers for Disease Control and Prevention's (CDC) Pregnancy Mortality Surveillance System indicate that Black and American Indian/Alaska Native women have significantly more pregnancy-related deaths per 100,000 births than other women giving birth in the U.S., and that these disparities exist across age groups and education levels. As an example, pregnancy-related mortality data for the period 2007 to 2017 indicate that pregnancy-related deaths are significantly higher for Black women who have completed college than for White women with a high school diploma. Similarly, infants born to Black women are more than twice as likely to die in the first year of life than those born to White, Hispanic, or Asian women. Stillbirths (defined as death after 20 weeks of gestation) are significantly higher for Black women as well.
Causes of pregnancy-related maternal mortality vary, include causes related to underlying health, and may be affected by population health disparities and social determinants of health. Only about 20% of pregnancy-related maternal deaths occur during labor and delivery, while approximately one-third occur during pregnancy and an estimated 52% occur postpartum. These statistics suggest that efforts to improve hospital perinatal care, such as through the Joint Commission's updated perinatal standards introduced in 2021, cannot alone solve the problems. For each pregnancy-related death (defined as a death from a pregnancy-related cause occurring during or within one year following pregnancy), an average of three to four contributing factors were identified by Emily E. Petersen et al. in analyzing CDC data. These factors include:
1. Community factors, such as securing transportation for medical visits and safe housing.
2. Health facility factors, such as preparedness to provide the required level of specialty care.
3. Patient/family factors, such as exposure to economic, psychosocial, and environmental stressors, including the absence of adequate support systems to cope with them.
4. Provider factors, such as lack of cultural competency and/or the existence of biases that affect patient-provider interactions, treatment decisions, and patient trust and adherence to recommendations.
5. Health care delivery system factors, such as gaps in health care coverage and preventive or follow-up care.
A November 2020 report by the Kaiser Family Foundation (the KFF Report) echoes many expert opinions that several of the disparities in maternal and infant morbidity and mortality reflect higher barriers to care for people of color. As articulated in the KFF Report, health plan coverage and access to care before, during, and after pregnancy supports healthy pregnancies and positive maternal and infant outcomes after childbirth, but people of color are more likely to be uninsured and face other barriers to care. The KFF Report notes that Medicaid helps fill coverage gaps during pregnancy and for children, but women of color are still at increased risk of being uninsured prior to their pregnancy and of losing coverage at the end of the 60-day Medicaid postpartum coverage period. Finally, the KFF Report notes that people of color may lack access to culturally appropriate care, particularly in rural and medically underserved areas where closures of hospitals and obstetric units have exacerbated provider shortages and left gaps in locally accessible and culturally competent care. Other studies and reports have made similar observations.
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There is significant overlap in the factors that have exacerbated health disparities during the COVID PHE and the factors that are likely contributors to relatively poor and disparate rates of morbidity and mortality for pregnant women, new mothers, and babies. Current focus on measures to address these factors may help address historical and continuing challenges with maternal and child health and outcomes. The COVID PHE has shone a spotlight on social determinants of health and areas of critical need in health care delivery, such as addressing gaps in access to care and ensuring an adequate and culturally competent workforce that is supported by appropriate payment and quality infrastructure. It seems unlikely that all of the regulatory changes made during the COVID PHE will be fully reversed, or that expanded services such as telemedicine and telehealth will be completely abandoned when the COVID PHE ends. In this sense, the COVID PHE may ultimately have a silver lining in the form of new and enduring attention to and options for addressing the social, community, health facility, and infrastructure factors that have historically contributed to this country's higher than expected rates of maternal and infant morbidity and mortality.
ANDREA M. FERRARI is a regulatory health care attorney and legal consultant focusing on solutions for public and population health and provider staffing.
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