April 11th marks the start of Black Maternal Health Week, which draws attention to worsening health disparities caused by systemic racism. This week offers an opportunity to consider state policies that reduce racial and ethnic disparities for moms and all birthing people. Given that one single policy can’t reverse the trends in Black maternal health outcomes, we need to take a broader look.
The statistics on health inequities paint a bleak picture about systemic issues. Black birthing people face:
Research links these disparities to inequitable systems. Fortunately, we know what can help.
Our Prenatal-to-3 State Policy Roadmap features multiple evidence-based policies and strategies. Research shows that these solutions improve outcomes such as maternal mortality and morbidity, maternal mental health, and access to care. When implemented alone, some of these policies and strategies can decrease disparities—but when combined, they can create a comprehensive system of care for Black birthing people.
In this post, we consider some of the most effective policies—including Medicaid expansion, group prenatal care, and paid family leave—and emerging research on community-based doulas. Additionally, we list economic policies that can contribute to a comprehensive system of care.
States have a variety of strategies to increase health insurance coverage, but the most widely studied is expanding Medicaid income eligibility as part of the Affordable Care Act. States that opt in to Medicaid expansion must meet the minimum eligibility level of up to 138% of the federal poverty level.
Evidence shows that Medicaid expansion improves attendance and receipt of perinatal care. Medicaid expansion has also resulted in maternal mortality reductions.
For the most part, research also shows that Medicaid expansion reduces maternal mental health conditions, such as symptoms of depression and mental distress, but subgroup studies are needed to determine the effectiveness at decreasing disparities. Medicaid expansion is the only health insurance policy on our Roadmap that has been explicitly studied for its ability to reduce disparities in maternal health outcomes, but other health insurance coverage policies—such as continuous coverage postpartum—are theorized to decrease disparities in these areas as well.
Group prenatal care
Prenatal care delivered in a group setting has also been found to improve the physical and mental health of birthing people. Under this model, a trained healthcare provider integrates health assessments, education and skills building, and peer social support.
Studies show participation in group prenatal care increases rates of adequate prenatal care and decreases the frequency of depressive symptoms and stress. In particular, group prenatal care strongly improves access to prenatal care for Black birthing people, which may reduce disparities in access to adequate care. Results on the impact of group prenatal care on reducing maternal health disparities are inconclusive and require further research.
Paid family leave
State paid family leave programs require employers to allow eligible parents time off from work to bond with a new child while receiving a portion of their wages. Paid family leave decreases disparities in leave-taking among new parents and improves maternal mental health outcomes in general.
Improvements are seen for all birthing people in self-reported health, maternal mental health, and psychological distress. Research has not been conducted on subgroups to determine the ability to reduce disparities in maternal health outcomes, but the reduction in disparities in leave-taking has been proven and is a hopeful indicator.
Medicaid postpartum extension (and supplemental solutions)
Implementing each policy individually can reduce disparities in some areas, but simultaneous implementation of multiple policies may be required to address related issues undermining the new policy’s effectiveness. Take the example of a postpartum Medicaid extension.
Typically, Medicaid pregnancy coverage only lasts for 60 days after birth. At that point, the birthing person must switch to traditional Medicaid or use a subsidy to purchase health coverage on the Marketplace.
Emerging research on the effect of postpartum Medicaid extension shows the need for a multi-pronged approach that addresses disparities’ underlying causes, such as inequitable systems and social determinants of health. Although White birthing people benefited in postpartum appointment attendance and maternal mental health, researchers did not observe the same improvements for Black birthing people.
This study also determined that insurance expansion alone may not decrease disparities in postpartum health. Expanding income eligibility for health insurance may increase access to adequate prenatal care for Black birthing people, but underlying systemic issues—such as lower household income and unstable living conditions—will continue to indirectly affect health outcomes. Evidence-based policies and strategies that address these outcomes include state earned income tax credits, reduced administrative burden for SNAP, and a higher state minimum wage.
Addressing the social determinants of health and the inequitable systems in which policies and strategies operate can help dismantle barriers that create disparities. Without barriers, policies and strategies like Medicaid expansion, group prenatal care, and paid family leave can work effectively for all families—including those who are negatively impacted by inequitable systems.
One strategy with the potential to greatly affect Black maternal health is community-based doulas. Doulas are nonmedical, unlicensed, trained professionals who provide emotional, physical, and informational support—as well as health care system navigation assistance, advocacy support, and empowerment. Doulas work in tandem with doctors, nurses, and midwives to provide care for birthing people throughout the perinatal period.
Community-based doula care grew as a response to systemic racism and discrimination experienced by people of color in healthcare systems and disparities in birth outcomes. Doulas rely heavily on shared lived experiences with patients.
Research shows that community-based doula interventions increase postpartum care use for birthing people and improve child birth outcomes such as preterm birth, low birthweight, and NICU admissions. Maternal and parental health outcomes such as mental and physical health have not been studied as frequently and require further research. Because of their focus on populations who historically experience discrimination in the healthcare system, community-based doulas are predicted to decrease disparities in health outcomes—especially on Black maternal health.
For more information on community-based doulas, check out our new evidence review.