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Advancing Health Equity

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Policies for Reducing Maternal Morbidity and Mortality and Enhancing Equity in Maternal Health

A Review of the Evidence

Mother wipes toddler daughters face while baby sleeps next to table in bassinet

Geri Andre-Major speaks with her daughter Marley, 4, as her 2-1/2-week-old son Maverick sleeps on March 26, 2020, in Mount Vernon, N.Y. Andre-Major was furloughed as a preschool teacher on March 13, four days after giving birth, and her maternity leave pay abruptly cut off as schools closed because of the coronavirus pandemic. The health of women is undermined by conditions of financial insecurity, with the related stress often resulting in compromised physical and mental health. Photo by John Moore via Getty Images

Geri Andre-Major speaks with her daughter Marley, 4, as her 2-1/2-week-old son Maverick sleeps on March 26, 2020, in Mount Vernon, N.Y. Andre-Major was furloughed as a preschool teacher on March 13, four days after giving birth, and her maternity leave pay abruptly cut off as schools closed because of the coronavirus pandemic. The health of women is undermined by conditions of financial insecurity, with the related stress often resulting in compromised physical and mental health. Photo by John Moore via Getty Images

Introduction

There is a maternal health crisis in the United States. The number of pregnant and birthing people dying more than doubled between 1987 and 2018, rising from 7.2 deaths per 100,000 live births to 17.4 deaths per 100,000 live births.1 Moreover, racial disparities are stark: Black pregnant and birthing people are three times more likely to die from pregnancy-related causes than their white counterparts; Indigenous Americans are approximately twice as likely.2 Geographic disparities are also evident, with rural Americans experiencing rates of maternal mortality twice as high as those for urban residents.3

But maternal mortality is only the tip of the iceberg. Rates of severe maternal morbidity (SMM), which includes unexpected, life-threatening outcomes (often called “near deaths”), are also rising. The latest estimates indicate that more than 60,000 birthing people per year experience severe maternal morbidity, with similarly wide racial and geographic disparities as those found with maternal mortality.4

As bipartisan legislation in the U.S. House of Representatives and the Senate seeks to address the maternal health crisis and narrow racial disparities in outcomes, this report is intended to inform policy aimed at lowering rates of maternal morbidity and mortality and eliminating inequities. We highlight both the evidence underpinning various approaches and the importance of employing an equity framework in designing and implementing these policies.

Given the rapid evolution of the field of maternal health and the large body of research available, we have sought to describe the most recent and relevant findings. Nevertheless, our report is not intended as a comprehensive systematic review of the literature. We compiled evidence based on searches of the peer-reviewed and gray literature, review of references, and consultation with clinical and research expertise in pregnancy and maternal health.

Much of our research was undertaken prior to the start of the COVID-19 pandemic. New evidence is emerging about how COVID-19 has exacerbated many of the adverse outcomes and inequities we describe, thus heightening the urgency of action on maternal mortality and morbidity.

What the Available Evidence Shows

Making Critical Investments to Address Social Determinants of Health

Social determinants of health (SDOH) are defined as “conditions in environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (Exhibit 1).5 Examples include housing security, convenient access to nutritious food, employment opportunities, and the safety of the home or neighborhood environment. SDOH have long been recognized as important factors in maternal morbidity and mortality.6

Katon_policies_reducing_maternal_morbidity_mortality_exhibit_01

In the U.S., SDOH disproportionately affect people of color, owing to systemic racism and policies dating back to the country’s founding that have been directly or indirectly discriminatory in their design and/or implementation. In turn, these policies have led to pronounced racial inequities in access to quality health care and education, food security, safe housing, employment, and more, ultimately producing racial disparities in health outcomes.7

Many SDOH are interrelated, and they can affect pregnancy outcomes through complex interactions.8 For example, prepregnancy health and health behaviors that increase risk for maternal morbidity and mortality, such as hypertension and lack of physical activity, are influenced by the availability of safe to places to exercise and access to affordable, nutritious food. The health of women is further undermined when SDOH result in financial insecurity, with the related stress often resulting in compromised physical and mental health.9 Additional studies of maternal health point to the impact of racism on stress, health, and well-being.10

Economic security. The systemic and structural factors that underpin SDOH have led to lower incomes and disparate educational and employment opportunities for people of color. Economic insecurity, in turn, has contributed to a higher burden of preventable health conditions in communities of color.11 Understanding racial disparities in maternal morbidity and mortality requires connecting these outcomes with their economic foundations.

For instance, the median white family in the U.S. holds nearly 10 times the wealth of the median Black family.12 A major cause of the wealth gap is historical redlining, the discriminatory practice of restricting access to financing and economic opportunities that helped to shape highly segregated communities across the country. Broadly, lower levels of wealth and income and higher levels of poverty are associated with greater risks of morbidity and mortality.13 Racial disparities in maternal morbidity and mortality, however, are apparent across all income and educational levels.14 For example, one study in New York City found that even among those living in the highest-income communities, Black pregnant and birthing people had a maternal mortality ratio nearly four times that for non-Black pregnant and birthing people.15 This suggests the need for equitable policy solutions that address not only SDOH but also structural racism overall and bias in health care settings.16

Neighborhood and built environment. In the U.S., where a person lives and the quality of their physical environment reflect historical and current discriminatory housing and loan practices. Such practices have led to continued segregation, with lower housing quality, environmental hazards, and other risks to health and safety concentrated in neighborhoods primarily populated by people of color. Housing instability and poor housing quality are associated with poorer maternal mental health, which in turn is a risk factor for maternal morbidity and mortality.17 There is growing evidence of the potential impact of environmental contaminants and pollution on risk of pregnancy complications such as preeclampsia and placental abruption, which in turn can raise the risk of maternal morbidity and mortality.18

Social and community context. Living in an unsafe community or social context can have physical and mental health consequences. Because of the legacy of redlining and continued housing segregation, pregnant and birthing people of color are more likely than white pregnant or birthing people to reside in communities with higher rates of crime, interpersonal violence, instability, and overpolicing.19

Living in a community with high rates of violence, including police violence and mass incarceration, is associated with both direct and indirect increased risk of maternal morbidity and mortality and preterm birth.20 Evidence highlights the profound negative impacts of interpersonal violence on maternal morbidity and mortality, including increased risk of pregnancy-associated homicide and suicide as well as other maternal mental health issues.21 Extensive research has clarified the role of neighborhood deprivation, crime rates, racial segregation, and other characteristics on birth outcomes, specifically preterm birth and low birth weight.22 However, there is significantly less research into how these factors affect maternal outcomes such as chronic health conditions and severe maternal morbidity.

Health care access. Access to health care is interwoven with both economic stability and neighborhood environment. Black people tend to give birth in hospitals marked by lower quality-of-care indicators than the hospitals where white people give birth.23 One study suggests that patient- and hospital-level factors — for example, the proportion of patients who are Medicaid beneficiaries — may be more immediate determinants of maternal morbidity than neighborhood factors like median household income.24 Compared to urban dwellers, rural residents have a 9 percent higher risk of maternal morbidity and mortality, with lack of access to obstetric care likely a key contributor to this disparity.25

The Affordable Care Act (ACA) has been particularly important in ensuring greater access to and use of health services before and after pregnancy.26 The law’s expansion of Medicaid eligibility appears to have been particularly effective in slowing the rise of maternal mortality among Black pregnant and birthing people in states that have taken up the expansion.27 The ACA also mandated coverage of preventive care, including contraception, and prohibited discrimination based on preexisting conditions, including pregnancy.

Growing and Diversifying the Perinatal Workforce

Nearly all U.S. births (98%) occur in hospital settings.28 Approximately 91 percent of hospital births are attended by a physician, while 8.7 percent are attended by midwives. This is unique to the United States; the majority of other high-income countries rely much more heavily on midwifery care and have fewer hospital births.29 Access to midwifery care is currently limited by state “scope of practice” laws, which in many states require nurse midwives to be supervised by a physician.30 Lack of coverage via Medicaid or many commercial insurers and high out-of-pocket costs also prevent access to doula services and nonhospital births.

Barriers to access particularly affect low-income and birthing people of color, who may get greater benefit from access to these services.31 Midwifery and doula care can raise patient satisfaction, reduce medical interventions during childbirth, and improve maternal and neonatal morbidity and mortality, particularly among women at higher risk of these outcomes.32

Not only is the birth workforce lacking in diversity in terms of training and discipline, but it does not reflect the racial and ethnic identities of the birthing population in the U.S. For example, while 14 percent of birthing individuals in the U.S. identify as Black, only 6.3 percent of certified nurse midwives and 11 percent of ob-gyns identify as Black (Exhibit 2).33 The high cost for enrolling and completing doula and midwifery training, low payment once in the field, and racism within training programs serve as barriers for people of color entering the perinatal workforce.34

Katon_policies_reducing_maternal_morbidity_mortality_exhibit_02

Lack of racial and ethnic diversity in the perinatal workforce contributes to the mistreatment and abuse that Black pregnant and birthing people frequently experience within our medical system.35 Black patients who have Black physicians have greater trust in their provider, are more likely to obtain needed care, adhere to medical advice more frequently, and ultimately have lower infant mortality.36 Diversifying the birth workforce, both in terms of training and race and ethnicity, is necessary for ensuring that all birthing people can receive pregnancy-related care from a culturally competent provider in a setting of their choice. Potential policy pathways for meeting this goal include 1) increasing the number of states that allow midwives to operate autonomously and 2) investing in programs and policies to diversify the racial and ethnic makeup of the birth workforce across all types of training, including grants and fellowships.37

Funding Organizations That Are Working to Improve Maternal Health Outcomes in Black Communities

Community-based organizations (CBOs) can be critical partners for improving maternal health outcomes for Black women. Because of their engagement and continuing relationships with the people they serve, CBOs are well positioned to support birthing people during and beyond pregnancy.38

Evidence demonstrates the effectiveness of CBO-led programs for improving birth outcomes, particularly among local Black residents.39 CBO-led programs also can provide a buffer against SDOH through advocacy and access to food, housing, and other resources.40 Community-based doula and midwifery care and autonomous, stand-alone birth centers, for example, have demonstrated notable reductions in preterm birth, low birth weight, and cesarean section.

But many CBOs are locked out of traditional funding sources, such as philanthropic or government grants — a problem disproportionately affecting Black-led CBOs.41 A report from the National Partnership for Women and Families found that a recurrent theme across CBOs providing care to pregnant and birthing people of color was the difficulty they had accessing sustainable funding streams both for provision of services and training providers.42 Even when legislation allows for reimbursement of services, the rates may be too low to be sustainable, and administrative barriers to payment may be difficult to overcome.43 Throughout the COVID-19 pandemic, many of these CBOs struggled to stay afloat while meeting increased demand and keeping their staff, providers, and clients safe.

Understanding the Unique Maternal Health Risks Facing Women Veterans

Approximately 2 million veterans in the U.S. identify as women. Of these, 37 percent are of childbearing age, a share that has increased in recent years.44 Of the nearly 500,000 women veterans who use Veterans Affairs (VA) health care, two of five (42%) are of childbearing age.45 Women veterans have early life and military exposures that may increase their risk for maternal morbidity and mortality: adverse childhood experiences, such as physical and sexual abuse, environmental and occupational hazards related to military service, sexual assault, and combat-associated injuries.46

Women veterans also have a higher prevalence of posttraumatic stress disorder (PTSD) than their nonveteran peers, which is a risk factor for pregnancy complications and SMM.47 Recent findings suggest that those using VA maternity benefits constitute a group at high risk for adverse maternal and neonatal outcomes such as preterm birth, gestational diabetes, and preeclampsia, potentially linked to trauma and PTSD (Exhibit 3).48

Katon_policies_reducing_maternal_morbidity_mortality_exhibit_03

Notably, Black women are disproportionately represented in the military, comprising 19 percent of active service members and 30 percent of veterans who use VA health care.49 Reducing racial disparities in maternal morbidity and mortality therefore also requires understanding the unique maternal health risks facing women veterans.

Finally, while maternity care coordination helps ensure pregnant and birthing veterans receive the care they need, implementation across the VA and within VA health care systems remains variable in terms of dedicated resources and time.50 Care coordination is particularly helpful in light of the ever-changing policies regarding pregnancy care and hospital visitation during the COVID-19 pandemic.

Improving Data Collection and Quality Measures to Understand Causes of the Maternal Health Crisis

Since 1987, the U.S. Centers for Disease Control and Prevention (CDC) Division of Reproductive Health has overseen the Pregnancy Mortality Surveillance System.51 Copies of all death certificates for women dying within one year of pregnancy (with identifying information removed) are reviewed by experts to identify which deaths are pregnancy-related. Death caused by a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy during or within one year of pregnancy is considered pregnancy-related. However, data included in death certificates are insufficient to determine whether injury-related deaths — such as drug overdoses, suicides, homicides, or cancer-related deaths during pregnancy or within one year postpartum — are pregnancy-related.52 This is important, as overdoses, suicide, and homicide are some of the leading causes of mortality in the year after pregnancy.53

Maternal mortality review committees (MMRCs) can provide critical information regarding preventable fatalities. For example, recent reviews by an MMRC of fatalities from 13 states revealed that more than half of all maternal mortality was preventable.54 Ideally, MMRCs should include a broad range of stakeholders, including patient–family representatives, and consider how state and federal policies and social determinants of health shape risk of maternal mortality.55 Further, adequate geographic representation, including stakeholders from rural areas, is essential for optimal outcomes.56

CDC-funded perinatal quality collaboratives are a means of addressing some of these shortfalls with respect to maternal morbidity, and they have other advantages as well.57 Such collaboratives may provide a means for developing, validating, and implementing patient-reported experience measures as an additional tool for quality improvement. Effective development and implementation of patient-reported experience measures necessitates approaches that engage patients and communities most affected by the maternal health crisis to prioritize and capture the experience of these groups.58

Investing in Maternal Mental Health Care and Treatment for Substance Use Disorders

Perinatal mood and anxiety disorders are associated with a range of adverse outcomes for pregnant and birthing people and their families.59 Evidence suggests that 11 percent to 21 percent of birthing people, depending on the study population and the screening tool used, have perinatal mood and anxiety disorders.60 Substance use in pregnancy varies in prevalence, depending on the type of substance. In 2012, estimates indicated that 15.9 percent of pregnant people in the United States smoked cigarettes, 8.5 percent consumed alcohol, and 5.9 percent used illicit drugs.61 In the context of the opioid epidemic, there is also concern about use of opiates during pregnancy. The COVID-19 pandemic may be further exacerbating mental health and substance use disorders before and during pregnancy and postpartum. Data regarding the prevalence and frequency of vaping are limited.

Access to and engagement in treatment for perinatal mood and anxiety disorders and substance use in pregnancy remains challenging, with notable racial disparities.62 Universal screening for perinatal depression and substance use are currently recommended, but there are significant barriers to implementation:63

  • an inability to conduct screening in languages other than English and Spanish, as well as issues with the cultural relevance of screening tools
  • provider payment structures
  • referral requirements, particularly in areas where services are unavailable
  • the stigma of depression
  • a lack of privacy at many screening locations, which can deter people from seeking mental health screening.64

Perinatal mood and anxiety disorders and, especially, substance use in pregnancy have been used legally to criminalize pregnant and birthing people and can result in removal of children from birth parents.65 Birthing people of color are especially likely to be criminalized for mental illness.66 The removal of children and the arrest of parents does irreparable harm to many families; moreover, these actions can pose a barrier to getting evidence-based treatment and can lead individuals to avoid seeking prenatal care.67 Notably, criminalization does not increase access to treatment: people referred into substance use treatment through criminal justice agencies are in fact less likely to receive treatment.68

Recent research findings suggest that patients are receptive to routine verbal screening for substance use.69 And investment in consultation hotlines, distance coaching for providers under collaborative care models, and telehealth may help to improve access to treatment for perinatal mental health and substance use.70

Improving Maternal Health Care and Support for Incarcerated Women

While the majority of Americans experiencing incarceration are men, those identifying as women represent the fastest-growing demographic in U.S. jails and prisons.71 Up to three-quarters of incarcerated women are of childbearing age.72 Black women are imprisoned at twice the rate of white women, a reflection of the racism embedded in the U.S. criminal legal system. While no nationwide data collection system regarding pregnancy in all federal and state prisons is available, the best recent estimates, from 2016–2017, indicate that 3 percent to 4 percent of incarcerated women in U.S. prisons are pregnant at intake, though this is likely an underestimate.73 Shackling in labor, compulsory induction of labor at a date predetermined by health care providers or prison administrators, and the separation of parents and infants postpartum are routine practices in the context of birthing within the carceral system.

Care and accommodations for pregnant inmates vary widely, with many prisons not providing adequate nutrition, physical supports (such as lower bunks and extra mattresses), or adjustments to workload.74 And while some studies suggest incarceration may reduce rates of preterm birth and low birth weight when compared with rates for nonincarcerated people, this effect is not evident among Black women.75 Notably, those who are incarcerated have a higher prevalence of risk factors for these outcomes, such as poverty, substance use, interpersonal violence, and mental health conditions. Finding an appropriate comparison group is therefore challenging.76

There is a growing body of evidence pointing to the critical importance of improving pregnancy care and support for incarcerated women.77 While more prisons are starting to offer promising supports such as parenting programs, prison nurseries, and midwifery care during birth, many of these efforts do not or cannot adequately address the structural factors contributing to incarceration that also undermine health.78 Programs and policies for incarcerated pregnant women that address health needs are needed along with policies targeting structural factors that lead to higher incarceration risk, such as inadequate access to employment, education, and housing, as well as exposure to violence.

Investing in Telehealth to Improve Maternal Health Outcomes in Underserved Areas

Telehealth and other digital health tools can play a role in reducing barriers to health care access, provided that services are delivered in a way that does not detract from quality of care or the patient experience. Careful consideration of equity issues related to access to high-speed internet and privacy concerns is also necessary. Before the COVID-19 pandemic, just 0.1 percent of all maternity visits were virtual,79 but payment and policy changes have allowed an increasing amount of health care to be offered digitally.80 This includes some prenatal care offered via telehealth and digital tools for home monitoring.

Among the research exploring the effectiveness and feasibility of these approaches to maternity care were two U.S.-based studies, conducted prior to the pandemic, that looked at a combination of telehealth visits and reduced in-person visits for prenatal care.81 Together, these studies demonstrated higher satisfaction and lower prenatal stress for patients in the telehealth group compared to those receiving usual care.

With regard to maternal morbidity and mortality, the evidence on telehealth’s impact is limited. Telehealth may be effective for managing conditions such as gestational diabetes and gestational hypertension, and for reinforcing maintenance of health behaviors like smoking cessation.82 It is clear, however, that to ensure equitable access to the potential benefits of telehealth, policymakers will need to close the gap in access to technology, including high-speed broadband internet, and address language and cultural barriers.83 Thus, investing in telehealth availability means investing in digital tools and necessary infrastructure, as well as ensuring that programs are culturally relevant and responsive.

Promoting Payment Models That Incentivize High-Value Maternity Care and Continuous Health Coverage from Pregnancy Through One Year Postpartum

Paying for value in health care means promoting the delivery of care that yields better outcomes and better health.84 High-value care is care that reliably enables all pregnant and birthing individuals and newborns to experience healthy maternity care that addresses their health needs and preferences.85 Proven models of high-value care that reduce medical intervention and costs while improving outcomes include team-based models that incorporate doulas, midwives, and community health care workers; pregnancy medical homes; and culturally competent group prenatal care.86 However, current provider payment mechanisms do not support access to these high-value models of care.

An additional consideration is the expansion of Medicaid benefits for up to one year postpartum. Currently Medicaid coverage ends 60 days after birth, leaving many new parents with no access to health care, although recent legislation may extend coverage in some states for up to a year. Ensuring availability of care for up to a year following delivery is critically important to addressing the current maternal health crisis, given that more than half of pregnancy-related deaths occur during this period. Evidence indicates that the failure of all states to expand Medicaid eligibility as provided for under the Affordable Care Act has limited access to postpartum health coverage. However, it should be noted that, for certain populations, such as those with opioid use disorder, Medicaid expansion alone was insufficient for ensuring access to preventive care.87

Conclusion

Addressing the U.S. maternal health crisis and racial inequities in maternal health and health care outcomes will require a multifaceted policy approach to address critical gaps in access to care, adopt and incentivize high-value models for care, diversify the perinatal workforce, and invest in community-based organizations. But the success of these approaches also relies on putting in place policies that take on structural racism and its impact on health and health care. Policy change is even more urgent given the ways COVID-19 has changed the delivery of health care — through increased telehealth use and reduced in-person clinic visits — and disproportionately affected the same communities experiencing high rates of maternal morbidity and mortality.

Evidence for the effectiveness of many of these policy reforms is strong. To achieve their potential, they will require collaboration and coordinated efforts by policymakers, community members, and providers across the nation.

NOTES

  1. Pregnancy Mortality Surveillance System,” Centers for Disease Control and Prevention (CDC).
  2. Emily E. Petersen et al. “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” MMWR Morbidity and Mortality Weekly Report 68, no. 35 (2019): 762–65.
  3. Katy Backes Kozhimannil et al., “Rural-Urban Differences in Severe Maternal Morbidity and Mortality in the U.S., 2007–15,” Health Affairs 38, no. 12 (Dec. 2019): 2077–85; Peter T. Merkt et al., “Urban-Rural Differences in Pregnancy-Related Deaths, United States, 2011–2016,” American Journal of Obstetrics and Gynecology 225, no. 2 (Feb. 25, 2021): 183.e1–16; and Lindsay K. Admon et al., “Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012–2015,” Obstetrics and Gynecology 132, no. 5 (2018): 1158–66.
  4. Admon et al., “Racial and Ethnic Disparities,” 2018.
  5. Office of Disease Prevention and Health Promotion, “Social Determinants of Health,” HealthyPeople.gov.
  6. Eileen Wang et al., “Social Determinants of Pregnancy-Related Mortality and Morbidity in the United States: A Systematic Review,” Obstetrics and Gynecology 135, no. 4 (2020): 896–915.
  7. Richard Hofrichter and Rajiv Bhatia, Tackling Health Inequities Through Public Health Practice: Theory to Action (Oxford University Press, 2010); and Brittany D. Chambers et al., “Testing the Association Between Traditional and Novel Indicators of County-Level Structural Racism and Birth Outcomes Among Black and White Women,” Journal of Racial and Ethnic Health Disparities 5, no. 5 (2018): 966–77.
  8. Lochan M. Shah et al., “Reducing Disparities in Adverse Pregnancy Outcomes in the United States,” American Heart Journal 242 (Sept. 2021): 92–102.
  9. Ann E.B. Borders et al. “Racial/Ethnic Differences in Self-Reported and Biologic Measures of Chronic Stress in Pregnancy,” Journal of Perinatology 35 (2015): 580–84.
  10. Joia Crear-Perry et al., “Social and Structural Determinants of Health Inequities in Maternal Health,” Journal of Women’s Health 30, no. 2 (2021): 230–35.
  11. Merlin Chowkwanyun and Adolph L. Reed Jr., “Racial Health Disparities and COVID-19 — Caution and Context,” New England Journal of Medicine 383, no. 3 (2020): 201–3; and William F. Owen Jr., Richard Carmona, and Claire Pomeroy, “Failing Another National Stress Test on Health Disparities,” JAMA 323, no. 19 (2020): 1905–6.
  12. Kriston McIntosh et al., “Examining the Black-White Wealth Gap,” Up Front (blog), Brookings Institution, Feb. 27, 2020.
  13. Wang et al., “Social Determinants of Pregnancy-Related,” 2020.
  14. Renata E. Howland et al., “Determinants of Severe Maternal Morbidity and Its Racial/Ethnic Disparities in New York City, 2008–2012,” Maternal and Child Health Journal 23, no. 3 (2019): 346–55.
  15. Jing Fang, Shantha Madhavan, and Michael H. Alderman, “Maternal Mortality in New York City: Excess Mortality of Black Women,” Journal of Urban Health 77, no. 4 (Dec. 2000): 735–44.
  16. Howland et al., “Determinants of Severe Maternal Morbidity,” 2019.
  17. Shakira Franco Suglia, Cristiane S. Duarte, and Megan T. Sandel, “Housing Quality, Housing Instability, and Maternal Mental Health,” Journal of Urban Health 88, no. 6 (2011): 1105–16.
  18. Boubakari Ibrahimou et al., “Ambient PM2.5 Aluminum and Elemental Carbon and Placental Abruption Morbidity,” Journal of Occupational and Environmental Medicine 59, no. 2 (2017): 148–53; Pauline Mendola et al., “Air Pollution Exposure and Preeclampsia Among U.S. Women With and Without Asthma,” Environmental Research 148 (2016): 248–55; Amelia K. Wesselink et al., “Residential Proximity to Roadways and Ischemic Placental Disease in a Cape Cod Family Health Study,” International Journal of Environmental Research and Public Health 14, no. 7 (2017): 682; Cande V. Ananth et al., “Exposures to Air Pollution and Risk of Acute-Onset Placental Abruption: A Case-Crossover Study,” Epidemiology 29, no. 5 (2018): 631–38; Carrie J. Nobles et al., “Differential Effect of Ambient Air Pollution Exposure on Risk of Gestational Hypertension and Preeclampsia,” Hypertension 74, no. 2 (2019): 384–90; and Megan E. Romano et al., “Maternal Urinary Cadmium, Glucose Intolerance and Gestational Diabetes in the New Hampshire Birth Cohort Study,” Environmental Research 179, Part A (2019): 108733.
  19. Crear-Perry et al., “Social and Structural Determinants,” 2021.
  20. Maeve E. Wallace et al., “Violence as a Direct Cause of and Indirect Contributor to Maternal Death,” Journal of Women’s Health 29, no. 8 (2020): 1032–38; and Lauren Dyer et al., “Mass Incarceration and Public Health: the Association Between Black Jail Incarceration and Adverse Birth Outcomes Among Black Women in Louisiana,” BMC Pregnancy and Childbirth 19, no. 1 (2019): 525.
  21. Wallace et al., “Violence as a Direct Cause,” 2020; Jeanne L. Alhusen et al., “Intimate Partner Violence During Pregnancy: Maternal and Neonatal Outcomes,” Journal of Women’s Health 24, no. 1 (2015): 100–106; Christie Lancaster Palladino et al., “Homicide and Suicide During the Perinatal Period: Findings from the National Violent Death Reporting System,” Obstetrics and Gynecology 118, no. 5 (2011): 1056–63; and Jay G. Silverman et al., “Intimate Partner Violence Victimization Prior To and During Pregnancy Among Women Residing in 26 U.S. States: Associations with Maternal and Neonatal Health,” American Journal of Obstetrics and Gynecology. 195, no. 1 (2006): 140–48.
  22. Collete N. Ncube et al., “Association of Neighborhood Context with Offspring Risk of Preterm Birth and Low Birthweight: A Systematic Review and Meta-Analysis of Population-Based Studies,” Social Science & Medicine 153 (2016): 156–64.
  23. Elizabeth A. Howell et al., “Black-White Differences in Severe Maternal Morbidity and Site of Care,” American Journal of Obstetrics and Gynecology 214, no. 1 (2016): 122.e1–122.e7.
  24. Jean Guglielminotti et al., “Patient-, Hospital-, and Neighborhood-Level Factors Associated with Severe Maternal Morbidity During Childbirth: A Cross-Sectional Study in New York State 2013–2014,” Maternal and Child Health Journal 23, no. 1 (2019): 82–91.
  25. Kozhimannil et al., “Rural-Urban Differences,” 2019; Merkt et al., “Urban-Rural Differences,” 2021; and Nowhere to Go: Maternity Care Deserts Across the U.S., 2020 Report (March of Dimes, 2020).
  26. Esther Kathleen Adams et al., “Prepregnancy Insurance and Timely Prenatal Care for Medicaid Births: Before and After the Affordable Care Act in Ohio,” Journal of Women’s Health 28, no. 5 (2019): 654–64; and Erica L. Eliason, “Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality,” Women’s Health Issues 30, no. 3 (2020): 147–52.
  27. Eliason, “Adoption of Medicaid Expansion,” 2020.
  28. National Academies of Sciences, Engineering, and Medicine, Birth Settings in America: Improving Outcomes, Quality, Access, and Choice (National Academies Press, 2020).
  29. Aaron B. Caughey and Melissa Cheyney, “Home and Birth Center Birth in the United States: Time for Greater Collaboration Across Models of Care,” Obstetrics and Gynecology 133, no. 5 (2019): 1033–50.
  30. Y. Tony Yang, Laura B. Attanasio, and Katy Backes Kozhimannil, “State Scope of Practice Laws, Nurse-Midwifery Workforce, and Childbirth Procedures and Outcomes,” Women’s Health Issues 26, no. 3 (2016): 262–67.
  31. Kenneth J. Gruber, Susan H. Cupito, and Christina F. Dobson, “Impact of Doulas on Healthy Birth Outcomes,” Journal of Perinatal Education 22, no. 1 (2013): 49–58; Katy Backes Kozhimannil and Rachel R. Hardeman, “Coverage for Doula Services: How State Medicaid Programs Can Address Concerns About Maternity Care Costs and Quality,” Birth 43, no. 2 (2016): 97–99; and Katy Backes Kozhimannil et al., “Disrupting the Pathways of Social Determinants of Health: Doula Support During Pregnancy and Childbirth,” Journal of the American Board of Family Medicine 29, no. 3 (2016): 308–17.
  32. Meghan A. Bohren et al., “Continuous Support for Women During Childbirth,” Cochrane Database of Systematic Reviews 7, no. 7 (2017); Gruber, Cupito, and Dobson, “Impact of Doulas,” 2013; and Mary-Powel Thomas et al., “Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population,” Maternal and Child Health 21, no. S1 (Dec. 2017): 59–64.
  33. William F. Rayburn et al., “Racial and Ethnic Differences Between Obstetrician-Gynecologists and Other Adult Medical Specialists,” Obstetrics and Gynecology 127, no. 1 (Jan. 2016): 148–52; and American Midwifery Certification Board, 2019 Demographic Report (AMCB, Aug. 2019).
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Jodie G. Katon, Research Assistant Professor, Health Services, University of Washington School of Public Health

Citation

Jodie G. Katon et al., Policies for Reducing Maternal Morbidity and Mortality and Enhancing Equity in Maternal Health: A Review of the Evidence (Commonwealth Fund, Nov. 2021). https://doi.org/10.26099/ecxf-a664