Rates of maternal mortality and morbidity are climbing in the United States,1 and states across the country have begun to implement policies aimed at improving birth outcomes for mothers to prevent maternal mortality and morbidity. Maternal mortalityi is defined as the death of a woman while pregnant, at delivery, or up to one year postpartum, with rates of mortality split approximately equally across these three time periods.2 The leading medical causes of maternal mortality vary by time period, though heart disease and stroke are the leading causes of maternal deaths overall.2 Cause of death also varies by race, with more Black women than White women dying from hypertension and embolisms.6 An estimated 60 percent of maternal deaths in the United States are considered preventable.7 Maternal morbidity is defined as health complications occurring during labor and delivery that result in significant negative consequences to a mother’s health.3 Over the past 20 years, the national rate of maternal mortality in the United States has increased between 50 and 70 percent, and the rate of severe maternal morbidityii has more than doubled.1 Although rates of maternal mortality and morbidity have increased in the United States, they have declined in other developing countries.2
To reduce rates of maternal mortality and morbidity, strategies at the federal and state levels have focused on addressing the complex causes of the problem. These strategies can be categorized as systems-, hospital-, and individual-level approaches. Systems-level approaches bring together state leaders, clinicians, hospital leaders, public health leaders, community members, insurers, and others for collective implementation of initiatives. These approaches act as an “umbrella” to strategies at the hospital and individual levels. One example of a systems-level approach is maternal mortality review committees (MMRCs), which operate at the state level to identify and analyze maternal deaths, disseminate findings, and develop recommendations.7 By collecting and analyzing a combination of vital statistics records and sources such as medical and social services records,8 MMRCs provide unique insights to inform quality improvement initiatives. Perinatal quality collaboratives (PQCs), another systems-level approach, are state networks of multidisciplinary teams that promote evidence-based clinical practices to improve maternal and infant health.9 PQCs are considered by some to be the “action arm” of MMRCs because they can translate MMRC findings into clinical reforms.10 Additionally, states can enroll in the Alliance for Innovation on Maternal Health (AIM), which aligns national-, state-, and hospital-level efforts to improve maternal health and safety using evidence-based patient safety bundles of medical practices.11
Approaches at the hospital level focus on strategies that overhaul practices and procedures in hospitals. Toolkits and bundles aim to reduce rates of maternal mortality and morbidity by standardizing hospital care and practices and include articles, guidelines, and educational documents aimed at addressing specific medical causes of maternal mortality and morbidity, such as preeclampsia and obstetric hemorrhage.9 Because they are organized in a systematic manner, these tools should be easier for hospitals to implement successfully.9 With more protocolized responses to maternal health complications, some of the racial disparities in maternal mortality and morbidity may be addressed, as there should be less space for disparate medical treatment.12 Another hospital-level approach to reducing maternal mortality and morbidity is anti-bias training, which aims to combat racism and unequal treatment in the health care system.7 Trainings teach current and aspiring medical professionals to be affirming of and sensitive to cultural differences.7 In theory, this training should make clinicians treat patients of color more equitably, thereby narrowing racial gaps in maternal health outcomes. AIM and the California Maternal Quality Care Collaborative (CMQCC) have begun to wrap anti-bias training into new toolkits, bundles, and quality improvement initiatives that are aimed at addressing racial and ethnic disparities in maternal and infant health outcomes.13,14
Approaches at the individual level focus on addressing the unique needs of individual patients. One example is funding for doula services, such as through Medicaid, which can expand access to doula services for those who might not otherwise be able to afford such services. Doulas are trained, nonmedical professionals who provide physical, emotional, and educational support to mothers before, during, and immediately following childbirth.15 They can work alongside medical professionals to help advocate for patients’ needs. Doula services aim to be affirming and supportive of cultural differences, increasing attention to the needs of women of color, which may narrow racial disparities in adverse maternal health outcomes.
Who Is Affected by Strategies to Reduce Maternal Mortality and Morbidity?
Each year, approximately 700 US women die from pregnancy-related complications, and thousands more experience severe maternal morbidity.2 Racial disparities are stark: Black women die from pregnancy-related causes at three to four times the rate of White women3 and are twice as likely as their White counterparts to experience severe maternal morbidity.4 These racial disparities persist across educational level and socioeconomic status.5
What Are the Funding Options for Strategies to Reduce Maternal Mortality and Morbidity?
Funding for strategies to reduce maternal mortality and morbidity can come from a range of providers, and can support systems-, hospital- and individual-level strategies. At the systems level, for example, states currently fund MMRCs, and federal grants also provide funding to establish and support existing MMRCs in states.16 Additional examples of funding for systems-level strategies include federal funding from the Maternal and Child Health Bureau (MCHB) to support AIM,11 private funding to support public-private partnerships in California, and philanthropic funding from Merck for Mothers to support a range of systems-level initiatives in states across the country.17 At the hospital level, state, local, federal, and private funding can be used to fund efforts such as toolkits and bundles and anti-bias training. At the individual level, state Medicaid dollars can fund doula support in those states that allow Medicaid to reimburse for doula services. Philanthropic dollars can fund other individual-level initiatives, such as Merck for Mothers’ funding for community-based organizations through its Safer Childbirth Cities initiative.18 Other individual-level approaches can be funded by state, local, federal, and corporate sources. Though funding sources can vary significantly by strategy, state, federal, and philanthropic funding play particularly substantial roles in supporting efforts to reduce maternal mortality and morbidity.
- Maternal mortality is defined by the Centers for Disease Control and Prevention (CDC) as “the death of a woman while pregnant or within 1 year of end of pregnancy—regardless of the outcome, duration, or site of pregnancy—from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”
- Severe maternal morbidity, according to the CDC, includes “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health.” Examples of severe maternal morbidity include the following pregnancy-related health issues: obstetric hemorrhage with 4 or more units of red blood cells transfused, eclampsia and pre-eclampsia, any emergency/unplanned peripartum hysterectomy, deep vein thrombosis or pulmonary embolism, septic shock, peripartum cardiomyopathy, and epidural hematoma.