Maternity care and care during the perinatal time period (defined as prenatal to two years postpartum) is arguably the most influential part of our health-care system on the health of our population. Quality maternity care — care during the prenatal period, labor and birth, and in the postpartum time — is vital to achieving better health outcomes over the lifespan of both the birthing parent and their newborn. Delivery of better maternity care is still undervalued as a way to positively impact a baby’s health for the remainder of their life. The quality of prenatal care, labor and birth also affects the shorter- and longer-term health of pregnant parents who give birth one or more times. This is why a policy that supports birthing people and addresses inequities in birth and maternity care is so important for the well-being of communities, particularly communities that experience the additional health impact of systemic racism.
The U.S. is known for its high maternal mortality rate, but we are especially known for the widening gap of racial inequities that families of color face. In a comparison of ten developed countries, the U.S. rated highest in maternal mortality in 2018, with a death rate that was over double rates of all other countries — and was triple in contrast to Netherlands, Norway and New Zealand. We can arguably say that the U.S. is far from figuring out how to stop preventable deaths of its birthing parents and infants.
As we look to other countries that have eradicated maternal mortality or have achieved the best birth outcomes for families, there are a couple of commonalities: They all have integrated the model of midwifery care, including universal postpartum home visiting; they have universal paid leave; and Medicaid or public insurance covers birthing families up to one year postpartum. The U.S. lacks a system for postpartum supports and has not undone systemic racism fast enough to make sure that Black women and their children have the same chance of survival during the perinatal period when compared to white families. Luckily for Coloradans, we have a Birth Equity Bill package at the state legislature right now that will provide these exact solutions for Colorado birthing families.
Among developed countries, the U.S has the highest maternal mortality rate and an over-representation of obstetrician-gynecologists. In countries that fare much better than the U.S. in preventing maternal death, midwives outnumber OBGYNs severalfold. The U.S. has a relative undersupply of maternity care providers, especially midwives, and lacks comprehensive postpartum supports like postpartum home visits or federal paid parental leave.
In 2019 in Colorado, just shy of 40 percent of births were covered by Medicaid. Pregnancy is considered an eligible condition to receive Medicaid, and the income limit for pregnant individuals is much higher than income eligibility limits for non-pregnant individuals. As in many other states, this means that after childbirth, there is often a transfer of insurance providers from receiving Medicaid to then disqualifying from Medicaid, and going to another insurer. Why does this matter in the care that you receive? A change in provider can often mean a gap in care or impede achieving optimal postpartum care. We also know that Coloradans who died in the perinatal period from 2014-2016 died predominantly within six weeks postpartum, and the second highest-group was from six weeks to one year postpartum. This means we have a unique opportunity to prevent death in the time period between six weeks and one year postpartum.
As Colorado sees the opportunity to expand postpartum coverage for up to one year through the Birth Equity Bill Package, we have the opportunity to provide higher-quality care by not interrupting care or transferring care in that first year postpartum. Expanding care up to one year postpartum is one recognized solution in the medical community to achieving adequate access for all birthing families accessing maternity care, just like the integration of midwifery into the wider maternity care system.
The American Medical Association voted to adopt a policy that encourages Medicaid coverage up to one year postpartum, and many states have already set up more inclusive Medicaid eligibility requirements for pregnant women. To achieve better health outcomes in maternity and perinatal care, we also have to strive for high-quality, prevention-focused care that is often low-interventive, and subsequently low-cost. Addressing the shortage of diverse perinatal care providers, and addressing the sustainability issues that freestanding birth centers face under current reimbursement policies and/or license requirements are also a recommendation to policymakers and malpractice insurance providers by the Health Care Transformation Task Force — a committee of national providers, and insurers that embrace value-based payment models.
Colorado has geographical diversity, which means we also face geographical inequities in care. In June 2019, the Centers for Medicare and Medicaid Services hosted a forum on maternal health, in which speakers shared challenges for women and birthing parents from rural communities and encouraged expanding the availability of freestanding birth centers to fill in maternity care gaps for women and birthing parents in rural communities as one solution (not to substitute for hospital obstetrics care for high-risk pregnancies).
The Birth Equity Bill Package, comprising bills SB21-101, SB21-193 and SB21-194, is Colorado’s chance at achieving better birth outcomes for communities of color, and bolsters the maternity care system in Colorado by following universal standards that have proven success in achieving optimal birth outcomes. Coloradans need the Birth Equity Bill Package to pass; it is an obvious solution that builds on decades of proven successful policies, and was built by listening to communities, midwives and birth workers of color who know the solutions their communities need.
Kayla Frawley is a single mom in Denver who's a former midwife and a former midwifery educator; she's currently a master's in public health candidate with New Mexico State University, focusing on social welfare policy.
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