Healthy and Equitable Births

WHY IS HEALTHY AND EQUITABLE BIRTHS AN IMPORTANT PRENATAL-TO-3 GOAL?

Setbacks and trauma that children and families experience due to often preventable pregnancy and birth complications can have lifelong consequences for children’s health and wellbeing. Many babies in the US are born thriving, but each child who is not may need substantial resources and care not just to survive infancy but to meet the challenges beyond.¹ A child born prematurely arrives before the 37th week of pregnancy, a time during which the rapidly developing brain and other organs still benefit dramatically from the unique advantages of the intrauterine environment.² Premature birth increases the likelihood of low birthweight (less than 2,500 grams), which predisposes children to breathing and feeding difficulties, vision and hearing problems, developmental delays, and learning disabilities, among other short- and long-term complications.³

Adverse birth outcomes disproportionately affect Black families. Compared to White and Hispanic infants and mothers, Black infants are more likely to be born low birthweight,⁴ and Black mothers are more than twice as likely to die in childbirth⁵ or experience severe maternal morbidity⁶—regardless of education level or socioeconomic status.⁷ A woman needs adequate health care over her life course to ensure a healthy pregnancy, and disparities can be a reflection of exposure to adversity across the lifespan.⁸ Supporting women throughout the life course increases the likelihood that they will have healthy pregnancies, fewer birth complications, and healthier newborns.⁹

MATERNAL MORTALITY RATE
The number per 100,000 women who were pregnant who died while pregnant or within 42 days of pregnancy, “from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”

Hispanic: 11.8 deaths per 100,000
White, non-Hispanic: 14.9 deaths per 100,000
US Average: 17.4 deaths per 100,000
Black, non-Hispanic: 37.3 deaths per 100,000

CDC National Vital Statistics Report: Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, 2018. For additional information, please refer to Methods and Sources.

Our comprehensive reviews of rigorous research show that solutions currently pursued by some states, including Medicaid expansion and support of group prenatal care programs, can be effective in promoting healthy and equitable pregnancy and birth experiences.

HOW ARE STATES CURRENTLY MEETING THIS PRENATAL-TO-3 GOAL?

Three outcome measures illustrate the health of babies at birth, which is often also an indicator of maternal health during the perinatal period: (1) preterm births, (2) low birthweight, and (3) infant mortality. Birth outcomes vary considerably across states, as well as by race and ethnicity. Maternal mortality and morbidity are also important indicators of healthy and equitable births, but the sample sizes of the data are too small to measure these outcomes at the state level. Racial and ethnic disparities in these outcomes reveal long-standing patterns of racism and policy choices within states that discriminate against families of color. Eliminating these disparities must be a goal for all states.

Out of 51 states, the worst state ranks 51^st, and the best state ranks first. The median state indicates that half of states have outcomes that measure better than that state, whereas half of states have outcomes that are worse.

OUTCOME MEASURE: PRETERM BIRTHS
% of babies born prior to 37 weeks of gestation

Median state value: 9.8%

Preterm delivery is associated with subsequent negative health and developmental outcomes for children, and it is often an indication of poor maternal health during the pregnancy. Approximately 1 out of every 10 babies is born before the 37th week of gestation in the US, but that number varies considerably across states; for example, more than 14% of babies are born preterm in Mississippi, compared to less than 8% of babies in Oregon. The percentage of Black infants who are born preterm is more than 50% higher than White or Hispanic infants.

See the Prenatal-to-3 State Policy Roadmap Appendix for a table of state variation in Healthy and Equitable Births outcomes and corresponding ranks for each state.
Source: Vital Statistics from CDC WONDER 2018 Natality Expanded; for additional information, please refer to Methods and Sources.

OUTCOME MEASURE: LOW BIRTHWEIGHT
% of babies born weighing less than 5.5 pounds (2,500 grams)

Median state value: 8.3%

Being born low birthweight is associated with a host of health risks in the immediate and longer term; in the US, 8.3% of all infants are born low birthweight, but babies born in the five worst states are nearly twice as likely to be born low birthweight as those who are born in the five best states, and Black babies are more than twice as likely to be born low birthweight as compared to White or Hispanic babies.

Source: Vital Statistics from CDC WONDER 2018 Natality Expanded; for additional information, please refer to Methods and Sources.

OUTCOME MEASURE: INFANT MORTALITY RATE
Number of infant deaths within the first year per 1,000 live births

Median state value: 5.9

In the six worst states, twice as many children die in their first year of life as in the six best states. Black families are disproportionately likely to experience this traumatic loss: The number of Black infants who die is double the number of White or Hispanic infants.

Sources: State Estimates: CDC National Center for Health Statistics (NCHS); States of the States: Infant Mortality Rates by State; National Estimates: National Vital Statistics Reports, Infant mortality in the United States, 2018: Data from the period linked birth/infant death file. For additional information, please refer to Methods and Sources.

WHAT ARE THE MOST EFFECTIVE POLICIES AND STRATEGIES TO IMPACT HEALTHY AND EQUITABLE BIRTHS?

Effective policies have a demonstrated positive impact on at least one prenatal-to-3 goal, and the research provides clear guidance on legislative or regulatory action that states can take to adopt and implement the policy. By contrast, effective strategies have demonstrated positive impacts on prenatal-to-3 outcomes in rigorous studies, but the research does not provide clear guidance to states on how to effectively implement the program or strategy statewide.

EXAMPLES OF IMPACT

Effective state policies and strategies to impact Healthy and Equitable Births

Effective Policies	Examples of Impact on Healthy and Equitable Births
Expanded Income Eligibility for Health Insurance	Medicaid expansion led to 52.6 fewer infant deaths per 1,000 live births among Hispanic infants (V) Medicaid expansion led to 16.3 fewer maternal deaths per 100,000 live births among Black mothers (6.7 per 100,000 fewer overall) (J)
State Minimum Wage	A 10% increase in the minimum wage reduced infant mortality by 3.2% (H) A $1 increase in the minimum wage reduced births to adolescents by 2% (B) A $1 minimum wage increase led to a 1% decrease in low birthweight (Q)
State Earned Income Tax Credit	State EITC led to increases in birthweight of between 16 to 104 grams, depending on the generosity level (B, CC) In states with generous, refundable credits, Black mothers saw the greatest reductions in low birthweight (up to 3,760 fewer babies born low birthweight annually) (II) Increasing the maximum state and federal EITC by $1,000 during childhood decreased the likelihood of giving birth before age 20 by 2% (BB)

Effective Strategy	Examples of Impact on Healthy and Equitable Births
Group Prenatal Care	Group prenatal care had both positive and null impacts on the rate of preterm (G, F) and low birthweight births (A, O)

Note: The letters in parentheses in the tables above correspond to the findings from strong causal studies included in the comprehensive evidence reviews of the policies and strategies. Each strong causal study reviewed has been assigned a letter. A complete list of causal studies can be found in the Prenatal-to-3 State Policy Roadmap Appendix. Comprehensive evidence reviews of each policy and strategy, as well as more details about our standards of evidence and review method, can be found at in the Prenatal-to-3 Policy Clearinghouse.

POLICY VARIATION ACROSS STATES

Have states adopted and fully implemented the effective policies to impact Healthy and Equitable Births?

Expanded Income Eligibility for Health Insurance

37 states have adopted and fully implemented the Medicaid expansion under the Affordable Care Act (ACA) that includes coverage for most adults with incomes up to 138% of the federal poverty level (FPL).

Sources: As of October 1, 2020. Medicaid state plan amendments (SPAs) and Section 1115 waivers.

State Minimum Wage

19 states have adopted and fully implemented a minimum wage of $10 or greater.

Sources: As of October 1, 2020. State labor statutes and State Departments of Labor.

State Earned Income Tax Credit

18 states have adopted and fully implemented a refundable EITC of at least 10% of the federal EITC for all eligible families with any children under age 3.

Sources: As of October 1, 2020. State income tax statutes.

STRATEGY VARIATION ACROSS STATES

Have states made substantial progress toward implementing the effective strategy to impact Healthy and Equitable Births?

Group Prenatal Care

10 states have supported the implementation of group prenatal care financially through enhanced reimbursements for group prenatal care providers.

Sources: As of June 8, 2020. State health department websites and proposed and passed state legislation.

Note: Some states in the “no” category for Policy Variation Across States have adopted a policy, but they have not fully implemented it, or they do not provide the level of benefit, indicated by the evidence reviews, necessary to impact the PN-3 goal. Many states in the “no” category for Strategy Variation Across States have implemented aspects of the effective strategies, but states are assessed relative to one another on making substantial progress. For additional information, go to the State Data Interactives.

WHAT OTHER SOLUTIONS ARE STATES PURSUING THAT CAN HELP BUILD THE EVIDENCE BASE?

Approximately 700 women die in childbirth each year in the US.¹² Most of these new mothers’ deaths—an estimated 60%—are considered preventable. Black families experience this tragedy in disproportionate numbers.¹³ Although maternal mortality has fallen globally, the maternal mortality rate in the US increased between 50% and 70% over the past 20 years, and the rate of severe maternal morbidity has doubled.¹⁴ Among developed countries, the US stands alone in these troubling upward trajectories.¹⁵

Despite the urgency of this issue, lack of adequate state-level data on maternal mortality and morbidity has frustrated efforts to meaningfully parse the varied causes of the problem and to evaluate states’ strategies to combat it. Observational studies point to some success among states’ varied strategies, which include support of perinatal quality collaboratives, toolkits and bundles to guide medical practice, funding of doulas, and implicit-bias training. However, conclusions about their effectiveness or how best to implement them, either individually or in combination, are difficult to draw, given the lack of rigorous research.

To date, California is the only state that has successfully reversed trends in maternal mortality. Between 2006 and 2013, during a period of collaboration between the California Department of Public Health, the California Maternal Quality Care Collaborative, and the California Hospital Association, the state’s rate of maternal mortality dropped by 50%, even as the national rate continued to rise.¹⁶However, research shows that this drop did not include an overall reduction in racial disparities in maternal mortality and morbidity.¹⁷Since that time, the California Maternal Quality Care Collaborative has launched the California Birth Equity Collaborative, and an evaluation of this collaborative is ongoing.¹⁸

Due to the urgency of this issue, as well as states’ considerable interest in identifying effective solutions, it is imperative that states continue to improve data collection related to maternal mortality and morbidity, and that research continue to move forward on promising solutions and on policies to support them. In the absence of rigorous research, California’s collaborative approach and use of rapidly updated and accessible data systems might serve as a model to other states.

Perinatal Quality Collaboratives and Maternal Mortality Review Committees (PQCs and MMRCs): These statewide, multidisciplinary networks promote evidence-based clinical practices by bringing key stakeholders together, producing issue briefs and strategic plans, and holding symposia and other events. PQCs often serve as the “action arm” of MMRCs, which operate at the state level to identify and analyze maternal deaths, disseminate findings, and develop recommendations. PQCs often translate MMRC findings into clinical reforms. Together, PQCs and MMRCs are thought to improve birth outcomes through systemwide changes across a state. State governments’ involvement in these efforts include key leaders’ participation in PQCs, and states can also use legislation to mandate and fund MMRCs.¹⁹ Federal grants also provide funding to establish and support existing MMRCs in states.²⁰ Currently, most states have active PQCs and MMRCs; the table below lists those states that do not.

Participation in the Alliance for Innovation on Maternal Health: States that wish to support efforts to reduce maternal mortality and morbidity can enroll and participate in the national Alliance for Innovation on Maternal Health (AIM), which works to bring maternal health improvement efforts at the national, state, and hospital level into alignment.²¹ For example, AIM provides hospitals with toolkits and bundles of medical information—generally articles, guidelines, and educational documents—about evidence-based practices for improving specific patient outcomes. A bundle might address a specific medical cause (such as preeclampsia or obstetric hemorrhage) of maternal mortality and morbidity, for example. In contrast to a PQC, a toolkit or bundle is thought to improve birth outcomes not through systemwide changes but through adjustments to practices in particular hospital settings. To date, research on this approach is limited to observational studies; although research suggests that toolkits and bundles can help reduce maternal morbidity, more rigorous studies would help in drawing firm conclusions about causality.^22,23 The majority of states participate in AIM, but 22 still do not.

State Does NOT Participate in Initiative to Reduce Maternal Mortality and Morbidity

Does NOT Have an Active Perinatal Quality Collaborative	Maternal Mortality Review Committee is NOT Reviewing Cases	Does NOT Participate in the AIM Program
Arkansas	Maine	Alabama
District of Columbia	Nevada	Arkansas
Idaho	North Dakota	Connecticut
Iowa	Rhode Island	District of Columbia
Kentucky	South Dakota	Hawaii
Montana	Vermont	Idaho
Nevada	Wyoming	Iowa
North Dakota		Kansas
Rhode Island		Kentucky
South Dakota		Maine
Wyoming		Minnesota
		Montana
		Nevada
		New Hampshire
		North Dakota
		Ohio
		Pennsylvania
		Rhode Island
		South Dakota
		Vermont
		Wisconsin
		Wyoming
11 states	7 states	22 states

Sources:
PQC: As of January 2020. Centers for Disease Control and Prevention.
MMRC: As of May 2020. Centers for Disease Control and Prevention.
AIM: As of May 2020. Council on Patient Safety in Women’s Health Care.
For additional information, please refer to Methods and Sources.

Doula funding: Doulas are trained, typically nonmedical, professionals who provide physical, emotional, and educational support to parents before, during, and immediately following childbirth. Doulas can work alongside medical professionals to help advocate for patients’ needs.²⁴ They work not toward system- or hospital-level change, but rather toward improving birth outcomes for individual patients. Their support and advice are thought not only to improve patients’ physical and emotional wellbeing, thereby increasing the likelihood of a healthy pregnancy and birth, but also to minimize, through direct patient advocacy, the likelihood of miscommunication, cultural differences, or biases affecting the quality of medical care a patient receives. Observational studies to date have found positive impacts of doulas on birth outcomes; however, to better understand these impacts and how best to implement doula support, more rigorous research is needed.^25,26 States can act now to expand patients’ access to doula services through Medicaid funding, but currently only four states allow Medicaid to reimburse for doula care: Indiana, Minnesota, New Jersey, and Oregon.

Implicit-bias training: In an effort to combat disparities in adverse birth outcomes, implicit-bias training teaches medical professionals how to recognize and understand racial and cultural differences and biases, as well as how to interact with patients in a way that is sensitive to these differences and accommodates patients’ diverse needs.²⁸ Thought to improve patient outcomes by improving quality of care, this intervention can be folded into toolkits and bundles, an approach taken by AIM and the California Maternal Quality Care Collaborative (CMQCC).^29,30 States also can provide financial support for these efforts, as well as legislatively mandate that professionals participate in training; for example, California has enacted legislation mandating implicit-bias training for perinatal health care professionals,³¹ but more rigorous evaluations are needed to determine the causal impact these trainings can have on improving birth outcomes.

Policy Goals

Effective policies and strategies to impact this goal include: