Despite being one of the wealthiest countries in the world — and one which famously spends a large chunk of its GDP on healthcare — the United States has a dismal record on maternal health outcomes. In 2018, the U.S. maternal death rate was 17.4 per 100,000 pregnancies — placing the U.S. last overall among industrialized countries.
The issue is complex, with various factors contributing to poor performance in this arena, including the chasm between how racial minorities, especially Black women, and white women experience pregnancy and delivery.
Players across the healthcare delivery system — from providers and payers to startups — are working to turn the tide in various ways. Startups are focused on reducing care gaps through expanding access to prenatal services and connecting them to women of color, so they have a community to support them through their pregnancy. Digital health startups for women are gaining steam, receiving $388 million in funding in 2018. Within this landscape, fertility and pregnancy/motherhood represent two key segments.
Mainstream providers, on the other hand, are employing clinical tools to predict potential delivery complications and partnering with community-based organizations to provide wraparound care.
But it’s going to take more than just innovative care strategies to truly make a difference. Policymakers must also get involved and implement regulations that can have a huge impact, like extending Medicaid coverage from 60 days to one year post-partum and setting up a data collection mechanism to gather race-related information on maternal outcomes.
Maternal care startups are trying to fill in the gaps
A number of startups have sprung up in the U.S. with a dedicated focus on maternal health.
Among them is Maven Clinic, a company that offers digital programs to facilitate care across the motherhood journey — from pre-conception to delivery and beyond. The New York City company’s chief commercial officer Sonia Millsom believes that maternal care in the U.S. is fragmented, leaving women unsupported at several key moments in their journey.
The healthcare system does not engage women early enough, so many do not get the prenatal care they need, she said. Further, reimbursements are focused on services, like tests, instead of on the entire care continuum, which disincentivizes physicians from providing comprehensive services.
“Our system is really outdated, and our families are paying the price,” Millsom said in a phone interview.
Maven Clinic was founded in 2014 with the critical inception point in mind — when women are thinking of becoming mothers. It provides a variety of programs via its mobile application, from fertility and prenatal care to pediatrics services up to the age of 10.
In addition, it offers access to telehealth services. Maven’s provider network is diverse and includes lactation consultants and mental health providers, Millsom said. The app, which is available through employers or payers, can be customized to each woman’s specific pregnancy and motherhood experience.
“[With Maven] you don’t have to look through a book or call just one provider, you have an entire platform that…facilities all of the information and access to [all the] different types of providers that you could possibly need, and helps break the barriers around access,” Millsom said.
Fragmentation and a lack of access are not the only issues facing women who want to have children in the U.S.
Here, pregnancy is approached as a disease state versus a new life stage, which is one of the reasons it is so costly, said Layo George, founder and executive director of Wolomi — a startup based in Washington, D.C. targeting women of color. The company was founded in 2019.
When treated as a disease state, certain aspects of the maternal care continuum, such as delivery, become the most important, and then factors like convenience take precedence. For example, the popularity of Cesarean sections, which constitute one-third of all U.S. deliveries, is largely driven by the convenience they offer to both providers and patients. They are generally safe, but it is important to remember that they are still major surgeries that can result in complications, driving up costs, George said in a phone interview.
And then, there is the race factor. Part of the issue is the fact that women of color tend to face higher barriers to care, like being uninsured or experiencing income insecurity. But there is also the more intractable problem of Black women not being seen as fully human.
“[Equity] is treat[ing] me as you would an average white woman when I walk in your door,” George said. “There is research that shows that Black women are less likely to be listened to, less likely to be believed — and if you are less likely to listen to someone or believe them, then you are less likely to intervene on time [as a provider].”
This makes any sort of major surgery for Black women a huge risk. And statistics bear this out — Black women are more than twice as likely to die in childbirth as white women.
George founded Wolomi to help Black women own their maternal health. The company’s offerings, which like Maven are app-based, enable women to have informal conversations with a wide range of providers, from dermatologists to midwives.
“We serve as a [bridge] between the health system and the community,” George said. “Women of color, a lot of Black women, don’t trust the healthcare system. But what we don’t want them to do is to completely turn off from the healthcare system…We want to make sure they have clinically sound information, but at the same time we want it to be relaxed and [in a space] where they don’t feel judged.”
Among Wolomi’s offerings is a pregnancy circle, where women can talk about their experiences with others who may be going through the same thing and share tips.
When it comes to pregnancy and child delivery, poor outcomes are not just relegated to low-income women of color. World-famous tennis champion Serena Williams almost died in 2017 after giving birth to her daughter.
Two years later, Williams invested in Los Angeles-based Mahmee, a data-driven maternal and infant health tech company.
Data is one of the root causes of the abysmal maternal outcomes and racial disparities in America, said Melissa Hanna, co-founder and CEO of Mahmee, in an email.
“… patient data is siloed, making collaboration across divisions very difficult,” she said. “There is [also] very little technology that connects providers in order for them to share EHRs, limiting information sharing and limiting how much comprehensive support moms and babies can be given. This means critical red flags can be missed.”
Mahmee has set out to connect data and resources, creating a network of support for Black mothers. The company links the mother and baby’s health history and data, and then engages, checks on and monitors patients. Through a HIPAA-secure, online dashboard, mothers are connected to a care team, which includes registered nurses, lactation consultants, mental health counselors, nutritionists and other specialists that provide help well beyond the hospital period, Hanna said.
“This type of collaborative care is essential to…change the outcomes to stop moms from dying,” she said.
Mainstream healthcare also honing in on the issue
The U.S.’s poor record on maternal health has not only spurred the rise of startups but has also pushed major providers and payers to tackle the issue head-on.
Renton, Washington-based Providence Health & Services is focused on moving from a reactive to a proactive approach when it comes to maternal care, said Jacquelyn Bombard, executive director of federal relations at Providence, in a phone interview. The health system is expanding access to preventive care services before pregnancy, as well as conducting clinical analyses on pregnant women before delivery to try and predict potential complications, like hemorrhages.
Further, Providence has standardized its labor and delivery care protocols and is providing simulation training.
“That way, our whole care delivery team is part of the process and are on the same page and they know what to do in case of emergency,” Bombard said. “So, if we have nurses that are shifting from one hospital to another, they know what to do in each situation. It’s a seamless and consistent process.”
While these strategies can help improve care, tackling the racial disparities portion of the issue requires a more hands-on approach.
For Black women, engaging with healthcare often means engaging with predominantly white spaces on their own. This is why Providence’s affiliate Seattle-based Swedish Health Services is trying to reduce care gaps by adding a patient advocate to the delivery room. It implemented a doula program last June for its low-income Black mothers-to-be. The program, called the Black Birth Empowerment Initiative, provides women with Black doulas free of charge, said Sauleiha Akangbe, certified birth doula and community engagement lead for Swedish’s doula services, in a phone interview.
The program matches women to doulas who are culturally similar — for example, linking a Somali woman to a Somali-speaking doula — if they request it. The doulas care and advocate for the women during delivery in rooms that are usually filled with white doctors and nurses, said Akangbe. They are also available to women post-partum.
But enhancing care won’t make much of a dent if the care itself isn’t easily available. More than 2.2 million U.S. women of childbearing age live in areas that have no hospital offering obstetric care, no birth center and no obstetric provider, that is, maternity care deserts, according to a 2020 report from March of Dimes.
Eden Prairie, Minnesota-based Optum, a part of UnitedHealth Group, is attempting to solve this problem by using data. The company identifies areas where outcomes are poorest and partners with local community-based organizations to enhance them from the ground up, said Dr. Janice Huckaby, CMO of maternal-child health at Optum Population Health Services, in a phone interview.
For example, in New York, the company collaborated with the Ladies of Hope Ministries, which trains currently or recently incarcerated women as doulas so they can assist pregnant women still in prison or those who were recently released.
Optum is also focused on reducing maternal death rates.
Along with hemorrhage, heart disease and hypertension, homicide is one of the leading causes of death among women in the first year post-partum, and this is another area where Optum is trying to make a difference, Huckaby said.
Optum has partnered with Winston-Salem, North Carolina-based Wake Forest Baptist Health to run a pilot program around intimate partner violence. The program includes connecting pregnant women in need with a navigator who can provide community and medical resources to ensure they have a successful pregnancy and delivery, she said.
Tackling an issue as complex and multifaceted as maternal care will require sustained, long-term effort, however. This is why Blue Cross Blue Shield Association, through its new national health equity strategy, has set a goal reduce racial disparities in maternal health by 50% in five years.
“To reach this goal, we’re leveraging existing programs and partnerships that BCBS companies have across the country,” said Justine Handelman, senior vice president of the association’s office of policy and representation, in an email.
One example of this is BlueCross BlueShield of South Carolina, which along with its foundation, launched Diabetes Free SC. The statewide initiative is dedicated to improving pregnancy outcomes in women with diabetes, one of the key racial disparities in maternal care today.
To track its progress toward the goal, the association will use several national measurement metrics, including the Centers for Disease Control and Prevention’s Severe Maternal Morbidity measures, which include indicators like heart attacks and aneurysms.
The healthcare policies that can help move the needle
Improving maternal health outcomes and equity is certainly on the Biden administration’s radar. The White House has requested millions in funding to support and extend various maternal programs, including ones focused on rural obstetrics care.
In addition, the administration recently approved Illinois’ Medicaid waiver, allowing the state to extend post-partum coverage up to 12 months from 60 days.
More states need to do the same — 60 days of post-partum coverage is not enough, Maven Clinic’s Millsom said. Many concurrent health issues, like mental health problems or cardiovascular issues, go untreated after that coverage falls off.
“The current disparate nature of Medicaid has really made it hard to drive wholesale change,” Millsom said. “We really need more standard models for states to implement in order to allow for that continuity of care.”
Extending Medicaid post-partum coverage could have a big impact on maternal outcomes as a large number of U.S. births are covered by the state-based insurance — in 2018, nearly half (43%) were, according to a 2020 MACPAC report.
In general, health plans offer different levels of coverage and different types of provider networks to new and expecting mothers, Mahmee’s Hanna said. So state and federal policies that standardize what comprehensive maternal and infant healthcare looks like can spur improvements in this area.
“The reality is that the amount, and type, of maternity care you receive can be heavily dependent on the part of the country in which you live,” she said. “These discrepancies between policies are putting whole communities of birthing persons at unnecessary risk.”
Further, maternity and paternity leave policies need a boost, which can be provided by employers, Hanna said.
“The pandemic has revealed just how far we still have to go in supporting parents’ needs in the workplace and in society at large,” she added.
Change is needed on the payment side of things too.
For example, there are global professional fees for OB-GYNs, but these often don’t cover the cost of labor and delivery or neonatal intensive care units, Maven Clinic’s Millsom said. So, payers and providers should consider opportunities in bundled payments that approach maternal care more comprehensively.
Aligning payment and maternal health equity goals can accelerate progress toward those goals, and there is at least one major effort in Congress that seeks to make that alignment happen. The Black Maternal Health Momnibus Act of 2021, which was introduced in the House in February, has some serious support and funding behind it, said Wolomi’s George. Among other goals, the act aims to promote payment models that incentivize high-quality maternity care and non-clinical perinatal support. Further, the act states that critical investments need to be made in social determinants of health that influence maternal outcomes.
“We support the Momnibus package,” BCBSA’s Handelman said. “Once passed, this set of bills will take a huge step to save the lives of women of color and help address key barriers to appropriate care and access issues.”
Aside from legislation, the government can help support efforts in the maternal care arena by creating a central mechanism for data collection, Optum’s Huckaby said. Clean, reliable data is needed, so stakeholders can drill down into race and ethnicity information to really understand the root causes of poor outcomes and customize interventions.
It would be best if the Centers for Medicare & Medicaid Services or the Department of Health and Human Services took the lead, as they are responsible for about half of the claims in the country, she said. If each state was to do its own data collection, there would be a hodge-podge of tools and measures, making analytics more complicated.
“This is an issue that’s going to take all of us working together to solve,” Huckaby said. “It’s going to take policymakers, it’s going to take healthcare providers, healthcare payers and social and probably religious leaders in communities to address. If we all pull together, we can accomplish great things. Doing it in a vacuum…probably won’t get us the results we so desperately need.”
Photo: Vladimir Kononok, Getty Images