Maternal Mortality In America: The American Rescue Plan Act of 2021 Is Here To Help

The maternal mortality rate in the US is the highest in the developed world.

The World Health Organization and the OECD define maternal mortality as “the annual number of female deaths from any cause related to, or aggravated by, pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy.” The rate of maternal mortality is the number of these deaths per 100,000 live births.

The U.S. defines it differently. In the U.S., the maternal mortality ratio (MMR) covers a full year following birth, not the 42 days of the WHO and OECD. This is why the CDC reports the latest MMR figures  in the U.S. as 17.3, while the OECD has it at 5.8 (for 2020). To confuse things even more, a highly regarded study in The Lancet in 2016 noted, ” The overall decrease from 1990 to 2015 in global maternal deaths was roughly 29% and the decrease in MMR was 30%.” However, the same study pointed out the U.S. rate for 2015 had risen to 26.4.

But regardless of how you count it, our rate still outpaces all the other developed nations. Moreover, according to the CDC, the U.S. rate has been rising since 1987, while our OECD global competitors have seen theirs decline since 1990.

In America, the maternal mortality rate is much higher among Black, Hispanic, and Native American communities. An October 2022 study by  the GAO (Government Accountability Office) put it this way:

• The maternal death rate for Black or African-American (not Hispanic or Latina) women was 44.0 per 100,000 live births in 2019, then increased to 55.3 in 2020, and 68.9 in 2021. In contrast, White (not Hispanic or Latina) women had death rates of 17.9, 19.1, and 26.1, respectively.
• The maternal death rate for Hispanic or Latina women was lower (12.6) compared with White (not Hispanic or Latina) women (17.9) in 2019, but increased significantly during the pandemic in 2020 (18.2) and 2021 (27.5).

Disparities in other adverse outcomes, such as preterm and low birthweight births, persisted for Black or African-American (not Hispanic or Latina) women, according to GAO analysis of CDC data.

The GAO study lays this squarely at the wide open door of racism:

Additionally, racism negatively affects the health of millions of people, according to CDC. We previously reported, and research has shown, that racial and ethnic disparities in maternal health outcomes persist, even after controlling for other factors like socioeconomic status, education, and access to care.¹ Some studies described specifically how racial discrimination can contribute to worsened maternal health outcomes. For example, chronic stress associated with racism can cause physiological changes and adverse health conditions. Moreover, bias or discrimination within the health care system can create communication challenges between providers and their patients, which may increase the risk of adverse outcomes. For example, pregnant women may be reluctant to ask questions about their condition if they faced discrimination from their provider.² In addition, the COVID-19 pandemic has highlighted racial and ethnic health disparities.³

From the GAO study

MMR is highest in Louisiana, at 58.1, and lowest in California, at 4.0, which is the average for the OECD.

Federal law requires Medicaid to cover postpartum care for only 60 days following birth, which is one of the prime reasons for our lagging global performance. In the OECD, mothers not only receive postpartum care for a year, they also average 51 weeks of paid maternity leave. (The U.S. is the only OECD country with no requirement for paid maternity leave.)

Enter the  American Rescue Plan Act of 2021 (ARPA), the Act Republicans derided and didn’t vote for, but love to take credit for back in their home districts. The Act offers significant resources for states to extend postpartum care for Medicaid beneficiaries.

Here’s how it’s working. ARPA created an option for states to extend postpartum coverage for Medicaid beneficiaries from 60 days to a full year. Under the Act, the option was scheduled to expire in 2027. Under the Consolidated Appropriations Act of 2023, the 12-month extended Medicaid postpartum coverage option was made permanent. Now once states take up the option to extend the postpartum period from 60 days to 12 months, federal matching funds will continue to flow. Thus far, 35 states have already taken advantage of the option and the federal cash that goes with it.

And today, the Washington Post’s McKenzie Beard, author of The Health 202 newsletter, reported Republican legislatures in nine red states have pending legislation to extend postpartum health coverage for their Medicaid beneficiaries, thereby joining the other 35 states in taking up the option created by the ARPA.

For these nine states, and their red state peers, this is all in response to the repeal of Roe v. Wade, a highly unpopular decision all around the country, which could create a significant uptick in pregnancies. There is a quite justified fear among Republican Governors and legislators that as they severely tighten restrictions on abortion our already horrible maternal mortality rate will worsen even more and they will be the ones held responsible. By extending postpartum care for 12 months they may avoid that unhappy and unfortunate political outcome while actually doing something good for the poorest of their citizens.

This is the one positive thing I have seen come out of the Roe v. Wade decision.

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¹See two studies of severe maternal morbidity in New York City: E. Howell et al., “Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal Morbidity Disparities,” Obstetrics & Gynecology, vol. 135, no. 2 (Feb. 2020): 285-293; and
M. Angley et al., “Severe Maternal Morbidity in New York City, 2008–2012,” New York Bureau of Maternal, Infant and Reproductive Health (New York, N.Y.: 2016).

²See R. Hardeman et al., “Developing Tools to Report Racism in Maternal Health for the CDC Maternal Mortality Review Information Application (MMRIA): Findings From the MMRIA Racism & Discrimination Working Group,” Maternal and Child Health Journal, vol. 26 (2022): 661–669.

³See Centers for Disease Control and Prevention, “COVID-19 Weekly Cases and Deaths per 100,000 Population by Age, Race/Ethnicity, and Sex,” accessed 9 February 2023.