Achieving Maternal Health Equity in the Debate for Health Reform

Major parts of healthcare legislation have been under debate by the U.S. Senate to replace the Affordable Care Act (ACA) and restructure Medicaid. The plan to repeal the ACA raises concerns as it will most likely affect low-income and middle-income Americans. Among those that will take a major hit by these changes are women who may lose access to comprehensive services and experience a rise in premiums, gaps in coverage for basic preventative services, and other essential benefits. At a time when the United States is experiencing increased rates in maternal mortality and poor child birth outcomes, this causes a state of alarm for patients, health professionals, and public health advocates.A recent study from the Centers for Disease Control and Prevention’s National Center for Health Statistics estimates that the maternal mortality rate in 48 U.S. states increased by 26.6% between 2000 and 2014(1). A recent analysis by The Lancet indicates that the Unites States has the highest Maternal Mortality Ratio (MMR) among all developed countries with an increase from 16.9 in 1990 to 26.4 in 2015 (per 100,000 live births)(2). Higher rates of maternal deaths have been reported in the District of Columbia, New Jersey, Georgia and Arkansas, especially among black women(3). Though the overall cause for this disturbing trend has yet to be identified, studies indicate that poor health prior to pregnancy could be a contributing factor(4).It is crucial that all women have access to quality and affordable prenatal, perinatal and postnatal services to improve the health outcomes of women and infants before and long after birth. The Affordable Care Act (ACA) made advances to improve women’s health by expanding access to contraceptives, requiring small-group insurers to cover maternity care, and expanding Medicaid access. However, the new Senate Better Care Reconciliation Act (BCRA) proposes to roll back Medicaid expansion and remove the Essential Health Benefits requirement by 2020. Both of these provisions promote health at every stage of life including periods before and between pregnancies, and removing them can lead to a more drastic increase in maternal mortality trends.Women’s access to affordable preventative care, such as contraceptives, is essential to improving the well-being of women of childbearing age and their future children. Given that fair access to these services enables women to make deliberate choices related to family planning, women are more likely to have healthy pregnancies and consequently deliver healthier babies. Medicaid ensures that low-income people have coverage for contraceptives, pregnancy related care, STI testing and treatment, among other reproductive health services(5). The use of contraceptives has well-documented health benefits for women, babies, and families. They can help delay pregnancies, space out births, and achieve a desired family size(6). Pregnancies that occur too early or too late in a woman’s life, or that are spaced too closely can also negatively affect the health of the mother and increase the risk of prematurity and low birth weight(6). STI testing is also a critical component of routine health visits and prenatal care because untreated infections can complicate pregnancies and be transmitted to the baby if left untreated(7).In 2010, nearly half of all U.S. births, and 42% Georgia births, were covered by Medicaid(8). Phasing out Medicaid expansion threatens Medicaid’s ability to provide critical healthcare services to many vulnerable communities impacted by a range of social, economic, and environmental factors. These limitations can place some women at higher risk for complications during their pregnancy which can lead to severe birth outcomes such as infant death, long-term health issues, and lifelong disabilities(9).Repealing mandatory coverage of essential health benefits will remove coverage for maternity care, prescription drugs, and mental health services for people. According to a recent analysis by the Congressional Budget Office, by 2026 these changes could result in approximately 23 million fewer people without health insurance(10).Maternity care includes the prenatal, maternity, and postnatal health services related to pregnancy and childbirth, which is critical to the health of women and healthy development of children. Waiving the requirement limits the amount of affordable options available to women in individual or small group insurance plans, leaving them with high-cost premiums or with extensive out-of-pocket costs and ultimately, facing more barriers to achieve health equity(5).Guaranteeing that every woman, irrespective of insurance status, is able to afford maternity care while she is pregnant is an important step forward that addresses the growing rates of maternal mortality and poor infant health outcomes in the United States. As congress continues to debate healthcare reform, policymakers need to assure that any bill proposed includes provisions that promote the well-being of women in all stages of life. These include:

Continued coverage of preconception, prenatal, and interconception healthcare in all insurance plans

Required coverage of the 10 “Essential health Benefits” which allows affordable access to mental health, substance abuse treatment, prescription drugs, and maternity and newborn care through cost-sharing;

Funding for Medicaid; and

Continued coverage of preventative healthcare services.

For now, the Senate Better Care Reconciliation Act does not appear to have enough support to move forward. However, this bill or other healthcare reform bills can be introduced at any time. Contact your Senators from Georgia to let them know that coverage for maternal and infant care is of vital importance to address the fact that we are 47th in infant mortality, 49th in maternal mortality, 47th in low birth weight babies and 43rd in prematurity in the nation.Senator David PerdueDC: (202) 224-3521Georgia: (404) 865-0087https://www.perdue.senate.gov/connect/emailSenator Johnny IsaksonDC: (202) 224-3643Georgia: (770) 661-0999isakson.senate.gov/public/index.cfm/email-me

SOURCES:

1. MacDorman MF, Declercq E, Cabral H, Morton C. Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues Short title: U.S. Maternal Mortality Trends. Obstetrics and gynecology. 2016;128(3):447-455. doi:10.1097/AOG.0000000000001556.
2. "Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015," The Lancet. Only data for 1990, 2000 and 2015 was made available in the journal
3. Tavernise S. “Maternal Mortality Rate in U.S. Rises, Defying Global Trend, Study Finds,” The New York Times https://www.nytimes.com/2016/09/22/health/maternal-mortality.html
4. Centers for Diseases Control and Prevention. Pregnancy Mortality Surveillance System: Trends in Pregnancy-Related Deaths. Accessed July 3, 2017 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
5. Sonfield A. Why Protecting Meddicaid Means Protecting Sexual and Reproductive Health. Guttmacher Policy review. 2017. Vol 20. Accessed July 5, 2017. https://www.guttmacher.org/sites/default/files/article_files/gpr2003917.pdf
6. Guttmacher Institute, Testimony of Guttmacher Institute: submitted to the Committee on Preventive Services for Women, Institute of Medicine, 2011, http://www.guttmacher.org/pubs/CPSW-testimony.pdf.
7. Centers for Disease Control and Prevention. STDs During Pregnancy- CDC Fact Sheet. 2016. https://www.cdc.gov/std/pregnancy/std-pregnancy-april-2016.pdf
8. Markus AR, Andres E, West KD, Garro N, & Pellegrini C. (2013). Medicaid Covered Births, 2008 Through 2010, in Context of the Implementation of Health Reform. Women’s Health Issues; 23-5, pp. e273-e280.
9. Institute of Medicine (US) Committee to Study Outreach for Prenatal Care; Brown SS, editor. Prenatal Care: Reaching Mothers, Reaching Infants. Washington (DC): National Academies Press (US); 1988. Chapter 2, Barriers to the Use of Prenatal Care. Available from: https://www.ncbi.nlm.nih.gov/books/NBK217704/
10. Congressional Budget Office, Cost Estimate: H.R. 1628, American Health Care Act of 2017, May 24, 2017, https://www.cbo.gov/publication/52752.