It’s an unfortunate truth that the U.S. health care system does not serve all pregnant and postpartum people as well as it should. Rates of maternal death and severe maternity-related complications in the United States are much higher than in other developed and technologically advanced countries. These poor health outcomes are especially prevalent for people who are Black, American Indian, Alaska Native, or residents of rural communities. A host of factors are linked to poor maternal outcomes, but many are preventable, and the health system can do more. As a country, we have both the imperative and the enormous opportunity to support the health of all birthing people.
The White House Blueprint for Addressing the Maternal Health Crisis, released in 2022, issues a call to action and galvanizes resources across the U.S. Department of Health and Human Services (HHS), bringing states, the health care delivery sector, and communities together to address this pressing national issue. Real change requires contributions from every part of the health care ecosystem to improve maternal health. As the HHS agency providing coverage for more than 42 percent of all births, the Centers for Medicare & Medicaid Services (CMS) and state Medicaid agencies have incredible leverage to help birthing people enrolled in Medicaid.
The CMS Maternal and Infant Health Initiative has worked with state Medicaid agencies on quality and system improvement since its launch in 2014. Most recently, the initiative focused on improving postpartum care. Research shows that 65 percent of maternal deaths occur within the first year after delivery and, of that percentage, only half occur during the six weeks after delivery , underscoring the importance of early care and well beyond the first few weeks.
Severe maternal morbidities occur more often than maternal death. These unexpected health problems can happen at any point during pregnancy and delivery or after pregnancy. And rates are rising. Severe morbidities might be linked to chronic conditions before pregnancy, cesarean delivery, conditions arising during pregnancy, and other factors that can affect birthing people even decades after pregnancy.
Potential ways to improve postpartum care
Several strategies are key to meeting the maternal health needs of postpartum people. CMS introduced new ways to extend coverage for people who would otherwise lose Medicaid 60 days after delivery. Almost all states have now expanded Medicaid coverage to 12 months postpartum.
But coverage is just the first step. The CMS Postpartum Care Toolkit provides more strategies to help Medicaid programs increase access, quality, and equity during the critical postpartum window. A checklist in the toolkit offers a starting point for state assessment and planning. These strategies are important to enhance the overall health of postpartum people and to enable healthier later pregnancies.
State Medicaid agencies can develop person-centered care in partnership with managed care plans, other state agencies , and community-based providers through an array of strategies, including:
- Enhancing screening for depression, anxiety, and other mental health disorders—one of the leading causes of maternal death and severe illness. Including payment for screening of the birthing person during pediatric appointments, completing maternity risk surveys, and requiring or encouraging multiple screenings have all shown to be effective.
- Supporting postpartum people in transitions to primary and specialty care, other insurance coverage, state programs, community-based resources, and other clinical and social supports
- Requiring data stratification to highlight disparities and develop customized improvement projects
Changes to the system are needed, too
Improving health through the postpartum period (and the perinatal period more broadly) also requires considering health system design issues that cut across insurers and health plans, including:
- Workforce—Given provider shortages, strategies are needed to develop, recruit, and enroll a range of staff as eligible providers in maternal health care systems. In recent years, doulas, community health workers, and midwives have emerged as key players helping to foster better connections between people accessing maternity care and clinical care delivery providers. States and other partners should review and resolve persisting program, payment, and operational barriers that reduce the impact of these personnel. Integrated approaches are also important, as a single role cannot bear the full weight of transforming the maternal health system.
- Infrastructure and data sharing—One barrier to reducing fragmentation of care is ensuring that data are available across various points of connection, including community-based organizations. Linking data across systems, enhancing data quality, and integrating referral and coordination processes are challenging but necessary to improve care delivery. Some states have started to address this challenge by creating platforms through which a diverse array of partners can enter information, enabling clinical providers and key partners to coordinate on clinical and social issues that affect health.
- Technology—The number of apps available to support aspects of prenatal and postpartum care has grown exponentially, including those that support remote monitoring of conditions such as hypertension and diabetes. States can continue to consider new resources that support and promote the use of technology to lower barriers, support connection, and reduce fragmentation of care.
The CMS Postpartum Care Toolkit is not the only new initiative from CMS. A grant opportunity known as the Transforming Maternal Health Model seeks to jump-start state innovation in tackling these broader systems issues. Announced in December 2023, the model will support states in a 10-year initiative to test system improvements that address the needs of underserved and rural communities. Notably, these tests will include new payment approaches to promote financial sustainability for these systems improvements.
Mathematica looks forward to supporting CMS’s efforts toward seamless, person-centered, and optimal maternity care—something all pregnant and postpartum people in the United States need and deserve .
