The United States has the highest maternal mortality rate among high-income countries and this rate has been steadily increasing. More than 80% of recorded pregnancy-related deaths are preventable. Causes range from obstetric hemorrhage to heart conditions (including heart failure and high blood pressure) as well as mental health-related conditions that surface during pregnancy and worsen during the postpartum period.
Black women, Native women, and women and birthing people in rural communities experience maternal mortality and morbidity at significantly higher rates than their White and urban counterparts. For Black women, the maternal mortality rate is three times the rate for non-Hispanic White women. Contributing to this disparity in outcomes are chronic conditions, which are exacerbated in pregnancy by unequal access to high-value care and limited availability of culturally sensitive and patient-centered maternal health care.
The employer role in supporting favorable birth outcomes in their populations
Addressing maternal mortality also means addressing healthcare inequity. Employers are in a unique position to hold health insurers and vendors accountable for the work they do and how equitable access to quality care is achieved. Without pressure from employers, insurers and vendors are unlikely to change the current practices that are not adequately supporting birthing people of color. As with many areas of health, employers can look to public health initiatives and follow Medicaid’s focus on trying to address the complex factors that contribute to maternal mortality and morbidity in the United States.
Primary efforts should focus on ensuring access to quality providers of choice and reducing barriers to true and informed choice during pregnancy, birth, and early postpartum. It is widely documented that provider characteristics impact birth outcomes. Implicit biases can cause providers to knowingly or unknowingly provide differential support, for example dismissing a Black woman expressing discomfort or pain, providing reduced support for breastfeeding in populations where breastfeeding initiation rates are historically lower than other groups, or initiating medical intervention (such as an epidural, Pitocin induction, or Cesarean section) without receiving true informed consent from the patient.
Access to certified nurse midwives and certified professional midwives, whose model of care focuses on holistic, patient-centered care with the assumption that birth is a unique life event rather than a strictly medical event, is associated with significantly lower rates of intervention compared to obstetric care, and should be prioritized as an option, particularly for low-risk individuals. Midwives often provide a higher level of care in the postpartum period – some offering up to 3-5 visits in the first 6 weeks postpartum, compared to one visit at 6 weeks, the standard of care with OB/GYN – which allows them to identify physical and mental health concerns sooner and avert a number of possible negative physical and mental health outcomes.
Lastly, continuous labor support from doulas is associated with lower rates of medical intervention and better birth outcomes – particularly for women of color. As doulas typically provide in-person support, they are often community-based and selected by members based on “fit.” While the relatively low cost of doula support can still be a barrier for members, for an employer it would represent a minimal investment with probable far-reaching positive impacts for a member’s physical and emotional health.
Specific actions for employers include:
Provide expectant families with financial reimbursement to cover doula support. Ensure that members have access to a network of community-based providers who can support them in-person if desired, and that members can select doulas based on racial, ethnic, religious, gender, or sexual identity, as well as lived experience.
Review plan language and limitations surrounding out-of-hospital birth (at-home birth and birth centers). Consider an out-of-network benefit to provide some level of assistance where health plan networks may be insufficient.
Review network access and discuss network inclusion requirements with the health plan administrator for freestanding birth centers and midwives using state regulations and evidence-based recommendations from leading regulatory bodies such as the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and American College of Nurse-Midwives as a guide.
Hold your carrier partners and vendors accountable for provider matching capabilities, ensuring that members can search for and select providers who self-identify with a particular race or ethnicity, sexual and/or gender orientation, lived experience, or training/expertise.
Collect race and ethnicity data from your members, send it on eligibility files to your vendors, and hold your vendors accountable for health outcomes stratified by race and ethnicity.
Review your health plan’s maternity coverage. Ensure that members have virtual and in-person access to both traditional and alternative providers, such as midwives and pelvic floor physical therapists.
In addition to increasing access to providers, employers should ensure that their culture and policies support pregnant, birthing, and newly postpartum individuals through generous paid parental leave and phased return to work programs. Manager training on how to support expectant and new parents of all genders and family makeups to reduce stigma associated with talking about pregnancy and birth, as well as lactation. Finally, consider whether you need to reset the standards for benefits communications within your organization to ensure that images and language are inclusive.
For more information check out Maternal mortality in America see our report, Sobering reality and the employer’s role.
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