In October 2017, the Los Angeles Times reported the story of Cassaundra Lynn Perkins, a 21-year-old Texas mother who had recently given birth to premature twins. She had been ill throughout her pregnancy, culminating in liver failure and the birth of her twins at just 6 months. Perkins was readmitted to the hospital after giving birth and died 3 days later, leaving behind three children to be raised by her mother.
Note: It is important to acknowledge that transgender men and nonbinary individuals are also part of the pregnant and birthing populations. However, given the limitations of existing data, this article will focus on outcomes among self-identified cisgender women.
Cassaundra’s life and death are emblematic of wide racial gaps in maternal health in the United States. Non-Hispanic (NH) Black pregnant women are disproportionately more likely than non-Black pregnant women to be disabled, have chronic illnesses, or both.
Compared to NH white females, they are also more than twice as likely to experience life threatening pregnancy complications and approximately 2.5 times more likely to die from pregnancy-related causes.
Like Cassaundra’s twins, Black infants are more likely to be born preterm and with low birth weight relative to white infants. Black infants also experience the highest infant mortality rates of any racial or ethnic group.
The consequences of these health inequities — poorer health and well-being among surviving mothers and long-term adverse impacts on health and labor market outcomes of their children — have important implications for both population health and the U.S. economy at large.
The upcoming U.S. elections are some of the most consequential in recent memory, and healthcare policies that will impact the health of Black females and infants are on the ballot.
Understanding how policy agendas advanced by the Trump-Pence and Biden-Harris administrations might widen or narrow Black-white gaps in maternal and child health is imperative.
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These include policies relating to the Patient Protection and Affordable Care Act (ACA), hospital-level reforms, racial bias in healthcare, and family planning.
While I focus exclusively on healthcare policies here, ensuring equal access to quality care is only a starting point for addressing these longstanding health inequities.
The ACA was landmark legislation designed to expand insurance coverage in the U.S. among low-income populations dramatically.
Several key components of the ACA, including Medicaid expansions — 38 states and the District of Columbia as of October 2020, insurance subsidies and dependent coverage provisions have dramatically decreased rates of uninsurance and financial barriers to care among low-income women of reproductive age.
This is particularly true of women without children, women of color, or both, including Black women. The ACA also mandates that insurance companies cover essential reproductive health services such as maternity care.
Since the beginning, the Trump administration has worked to scale back Medicaid and overturn the ACA, primarily through executive orders. The Supreme Court is set to hear oral arguments in California v. Texas on November 10, a case that challenges the constitutionality of the law.
If the ACA is declared unconstitutional, many Americans will lose their health insurance. Despite the promises that the Trump administration’s yet-to-be-revealed new healthcare plan will cover all pre-existing conditions and lower healthcare insurance premiums, there is little information on how they will implement this new plan.
While it is not fully clear what this would mean for birth outcomes, evidence from Tennessee suggests that sudden Medicaid disenrollment increases financial distress, cost barriers to care, and avoidable hospital visits.
In contrast, the Biden-Harris campaign promises to protect and strengthen the ACA. The campaign platform pledges to provide Americans with a public health insurance option — such as a form of Medicare, expand coverage and lower insurance premiums via tax credits, and extend premium-free public option coverage to eligible low-income Americans in states that have chosen not to expand Medicaid.
The question is: would strengthening the ACA improve racial disparities in maternal and child health?
On the one hand, the ACA has improved rates of preconception counseling, preconception folic acid use, and preconception or postpartum insurance coverage.
However, there is little evidence that dependent coverage provisions and Medicaid expansions improve birth outcomes such as low birth weight, preterm births, or neonatal intensive care unit admissions. These findings are consistent with those from prior studies examining the initial impacts of the prenatal Medicaid expansions of the 1980s and early 90s on birth outcomes.
Yet, studies examining these outcomes separately by race or ethnicity find that the positive benefits of the ACA Medicaid are almost exclusively concentrated among black mothers, including declines in preterm birth, infant mortality, and maternal mortality. For an exception, see here.
Another important issue is that the in utero effects of public health insurance expansions may not emerge until decades after implementation. Given this, it is plausible that further expanding Medicaid could reduce Black-white disparities in maternal and child health, particularly in Southern states that have chosen not to expand the program.
Finally, should the Biden-Harris administration prevail, it is crucial to monitor the financing and delivery of healthcare to avoid exacerbating maternal and child health disparities.
Both the ACA insurance exchanges and most Medicaid expansions rely on capitated private insurance plans, such as managed care, underscoring the general shift from providing insurance through fee for service options in the U.S. While the intention of managed care is to control healthcare costs, it can have unintended consequences, such as worsened prenatal care use and birth outcomes.
Findings from Texas show that the implementation of managed care improves preterm birth and infant mortality among Hispanic infants but worsens these outcomes among Black infants.
There is suggestive, though not definitive, evidence in the Texas case that insurance companies may have targeted women with less complicated and costly births, such as Hispanic mothers, to control costs. Because of this, states must consider whether managed care organizations have incentives to engage in risk selection when negotiating contracts.
Much of the policy conversation around maternal mortality prevention focuses on hospital-level reforms that enable healthcare providers and systems to be more responsive to delivery-related emergencies.
The Trump-Pence 2020 campaign platform does not specifically address maternal mortality or morbidity in hospital settings. However, a bipartisan Congress passed legislation in 2018 to fund state maternal mortality review committees and improve maternal health outcomes, including disparities.
In contrast, the Biden-Harris campaign has made it a goal to address maternal mortality, which they note “disproportionately impacts women of color.” If elected, the Biden administration plans to replicate the approaches taken by California’s Department of Public Health and Maternal Quality Care Collaborative, a public-private partnership.
California undertook several quality improvement initiatives that successfully reduced maternal morbidity and mortality from obstetric hemorrhage. These initiatives halved maternal mortality overall and reduced maternal mortality rates among all racial and ethnic groups.
However, while adopting California’s approach would likely improve maternal morbidity and mortality overall, it would not necessarily move the needle on Black-white health disparities.
Although maternal mortality declined by about 40–50% among Black and white women in California, relative racial gaps remained very similar. This is partly because while obstetric hemorrhage is a very defined event, a significant proportion of maternal deaths occur outside of the hospital and are attributable in part to cardiovascular conditions.
It will be imperative for states to carefully tailor California’s approach to their maternal populations and create systems to help alert women and families to warning signs for life threatening conditions.
The Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act, sponsored by Senator Cory Booker (D-NJ), Congresswoman Ayanna Presley (D-MA), and other Democratic colleagues, would extend Medicaid coverage from 60 days to one full year postpartum.
Given the evidence that Medicaid expansions may mitigate Black-white disparities in maternal mortality, the MOMMIES Act could further improve Black-white inequalities in maternal morbidity and late maternal deaths.
Legislators and advocates have also increasingly focused on racial bias in reproductive healthcare, including stories like those of Kira Dixon Johnson and Amber Rose Isaac, who reportedly complained that clinical staff did not listen to their concerns before they died from pregnancy-related causes.
In its executive order banning discussions of white privilege and similar concepts in federally funded diversity training as un-American, the Trump administration clearly signals that it does not consider racial bias, such as anti-Black sentiment, to be a problem in American life.
Therefore, it is improbable that the Trump administration will consider legislation addressing racial bias in healthcare.
Further, given that studies find that support for the Trump administration, and its rhetoric, is linked to racist attitudes and violence, it is plausible that another term could further exacerbate maternal and child health disparities.
In contrast, Congresswoman Alma Adams (D-NC) and Senator Kamala Harris (D-CA) champion the Maternal Care Access and Reducing Emergencies Act (CARES).
CARES would establish a grant program to provide implicit bias training for health professionals, commission a National Academy of Medicine study on bias recognition in clinical skills testing, and provide grants to states to establish or operate medical homes for low-income women.
Arguably, however, CARES does not go far enough if the goal is to improve Black maternal health. There is little evidence that existing implicit bias training can improve disparities in medical treatment or healthcare outcomes.
A more effective approach might focus on explicit stereotyping in clinical algorithms, including those related to obstetrical care.
Further, while bias recognition in clinical skills testing is also important, reforming medical school training to focus on the social determinants of health, including racism, is also a critical priority. Finally, strengthening and enforcing civil rights laws can also help address individual- and structural-level racial discrimination in healthcare, including obstetrics.
Family planning care, which includes contraception and abortion, plays a critical role in maternal health and well-being. Yet, access to contraception and abortion has become increasingly challenging.
While the ACA’s original contraception mandate required most private insurance plans to provide no-cost contraception, Supreme Court rulings in favor of religious exemptions have weakened this requirement.
For more than four decades, the Hyde Amendment has prevented federal funds from being used for abortion, except when the mother’s life is in danger, or for rape or incest, which affects access for low-income women.
The ACA further entrenched these existing bans: at least 26 states have enacted policies that severely restrict abortion coverage for plans purchased through market exchanges.
Finally, there has been a significant increase over the past decade in state-level abortion restrictions, such as those laws requiring mandatory waiting periods and counseling.
The Trump administration has successfully worked to severely restrict access to contraception and abortion during the last 4 years.
The Republican-controlled Congress has approved the lifetime appointments of at least 200 anti-choice federal judges and filled two — soon to be three — Supreme Court seats, fundamentally reshaping the federal judiciary in a more conservative direction.
The Department of Health and Human Services (HHS) has implemented increasingly substantial financial and procedural hurdles for purchasing abortion care coverage via the marketplace insurance exchanges.
Finally, the domestic gag ruling issued by HHS in 2019 prohibits organizations that receive federal Title X family planning funds from performing abortions or referring patients for abortions. Planned Parenthood and other providers have exited the Title X program in protest, which could restrict access to care for millions of low-income women.
This increasingly restrictive reproductive rights climate is very likely to exacerbate racial disparities in maternal and child health. Women living in states with more stringent reproductive rights climates are more likely to experience higher rates of poor birth outcomes and maternal morbidity and mortality.
These environments may be even more consequential for Black women: Medicaid and other state restrictions on abortion have widened Black-white disparities in low birth weight, preterm birth, and infant deaths from congenital anomalies.
In contrast, Joe Biden, after first declaring his support for the Hyde Amendment earlier in his campaign, now promises to support its repeal and would include access to abortion and contraception in a public health insurance option.
The Biden campaign also plans to restore the ACA contraception mandate, reverse the domestic gag rule to restore funding to Planned Parenthood, and push back on state laws that seek to circumvent Roe v. Wade.
Given the existing evidence, it is likely that the long-term impacts of these proposed changes would improve maternal health overall and improve Black-white health disparities.
As physician Tim Wise notes, “The tragedy of poor birth outcomes in the U.S. is largely a legacy of the poor general health status of women in the U.S. Accordingly, programs and policies that are concerned for the health of the mother only to the extent that it affects that of the newborn are technically unsound and morally illegitimate.”
Ultimately, improving Black-white disparities in maternal and child health requires a societal commitment to supporting Black women’s health and well-being throughout the life course — not just during pregnancy.
Healthcare policies related to the ACA, hospital-level reforms, discrimination in healthcare, and family planning are just the tip of the iceberg as we work to eradicate structural racism and related inequalities.
Holding elected officials accountable to evidence-based healthcare policies that improve outcomes must begin, but not end, at the ballot box. Cassaundra, Kira, Amber Rose, and their families deserve no less.
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