Addressing the U.S. maternal mortality crisis
October 31, 2024—Throughout the fall, Harvard Chan faculty will share evidence-based recommendations on urgent public health issues facing the next U.S. administration. Alecia McGregor, assistant professor of health policy and politics, offered her thoughts on what’s driving the country’s rising rates of maternal morbidity and mortality, and what policies could help begin mitigating the crisis.
Q: Why is maternal health a pressing public health issue?
A: The U.S. spends more on health care than any other country in the world, yet we have the highest maternal mortality rate of all wealthy nations. According to the Centers for Disease Control and Prevention, 80% of pregnancy-related deaths are preventable. What’s more, rates of severe maternal morbidity—unexpected complications near or during childbirth that result in short- or long-term health consequences—are high and getting worse. For example, over the last decade in Massachusetts, severe maternal morbidity has nearly doubled.
What’s deeply disturbing is that women of color bear the brunt of these adverse outcomes. My research team recently published a study on maternity care in New Jersey that found that for deliveries without recorded clinical indications for a cesarean delivery, Black women were more likely to have a cesarean delivery than white women. For deliveries with recorded possible clinical indications for a cesarean delivery, Black women were less likely to have a cesarean delivery than white women. This discrepancy was found even when making adjustments for other factors associated with the likelihood of having a cesarean delivery. Relatedly, nationwide, Native American and Alaska Native women and Black women are two and three times likelier to die from pregnancy-related causes than white women, respectively. Disparities in morbidity follow a similar racialized pattern.
Our country’s most vulnerable groups are also being put in danger by a rapidly dwindling supply of maternal health care. Each year, hospital obstetric units continue to close across the country. Unsurprisingly, because these closures are happening against the backdrop of racial residential segregation, they’re more often happening in communities of color. Washington, D.C., for instance, has lost more than a quarter of its hospital obstetric units in the last decade—including the only two located in the eastern quadrants of the city, where Black residents are concentrated. Rural communities are also hugely impacted by these closures. A recent report showed that nearly 60% of rural counties have no hospital obstetric services.
Q: What challenges does the next administration face around maternal health?
A: Obstetric units rely heavily on Medicaid reimbursements and are otherwise paid by insurers that reimburse according to set rates that devalue maternal health care. As such, they are money losers for hospitals and will continue to close as long as hospital systems’ business decisions remain inadequately checked by regulation. So that’s one of the fundamental issues facing out next administration: the commodification of health care and our deeply flawed payment system.
Policymakers must also contend with a shrinking maternity care workforce; the role of private equity and for-profit providers in women’s health and reproductive technology; prohibitive abortion policies, which have already begun to have deadly consequences; and ongoing issues of racism and inequity that disproportionately leave communities of color and rural communities without quality maternal health care, or any care at all.
Q: What are your top policy recommendations to improve maternal health care and outcomes?
A: We need a large-scale federal funding initiative to infuse necessary capital into hospital obstetric units, with special attention paid to bolstering safety-net maternity hospitals and supporting freestanding birth centers. Policies that financially protect obstetric units are also critical. In the absence of government action—and dollars—unfortunately our health system may increasingly rely on private equity firms and other for-profit entities that may be more interested in extracting returns for investors than providing quality care.
Q: What’s the evidence supporting those recommendations?
A: Studies have shown that Black-serving hospitals have lower revenues and fewer capital assets and, relatedly, that delivering at a Black-serving hospital is associated with a greater likelihood of severe maternal morbidity. There’s also evidence that expanding Medicaid, as most states have done following passage of the Affordable Care Act, is not enough to prevent the closure of hospital obstetric units. It’s clear, then, that multiple forms of financial investment in and protection of obstetric units, particularly those in low-wealth communities, are needed.
Q: What do you hope could be accomplished to address our maternal health crisis in the next four years?
A: Putting an end to the upward trajectories of maternal mortality and morbidity and starting to decrease those numbers should be simple. So should taking steps to eliminate racial inequities within maternal health. We know how to improve quality of care and where improvements are most needed—not just in financially-strained hospitals, but also in the doula collectives and midwife-led birth centers seeking to open. We need to take these challenges seriously and devote the necessary funds. I also hope to see the Medicaid reimbursement rate for obstetric services increased. As a health system, we are overdue for this change, and at this point it should be considered low-hanging fruit.
Top photo: iStock/LumiNola; Alecia McGregor: Oby Ojimba
