The $1.9 trillion American Rescue Plan Act (ARPA) signed into law by President Biden on March 11 provides direct relief to those impacted by COVID-19. Additionally, it could benefit low-income pregnant and postpartum individuals. The ARPA includes provisions that offer new incentives for states that have not expanded Medicaid through the Affordable Care Act (ACA). It also provides the option to extend the postpartum coverage period under Medicaid from 60 days to one year after the date of delivery through a State Plan Amendment (rather than submitting a waiver to Centers for Medicare and Medicaid Services and awaiting approval). Articles are starting to surface with proposed budgets from state legislatures and governors to use ARPA funds, and we will soon see which states do the right thing for their pregnant and postpartum people.
Maternal mortality is staggering in the United States. We have the highest maternal mortality rate among developed countries — 20.1 maternal deaths per 100,000 pregnancies in 2019. This alarming statistic is consistent with my experience as a physician providing maternity care for over 12 years.
Unfortunately, I know it is our country’s reality.
Because Medicaid finances approximately 40 to 45 percent of all U.S. births annually, the ARPA provisions offer hope that more pregnant women will obtain access to the maternity care they need. Per the 2020 March of Dimes report card, 14.9 percent of pregnant women have inadequate prenatal care, and among women aged 15 to 44 years, 11.9 percent are uninsured and 14.7 percent live in poverty.
Expansion of Medicaid under the ACA and extension of postpartum coverage to one year, regardless of the state’s Medicaid expansion status, can yield considerable gains for coverage and access to care for low-income reproductive-age women.
When looking at maternal mortality in the U.S., we must acknowledge the disproportionate effect on Non-Hispanic Black women.* A pregnancy-related death (occurs while pregnant or within one year postpartum) is four to five times more likely to occur for Black than white women.l A large proportion are preventable. Providing access to maternity care could significantly benefit Black pregnant women since they are more likely to be uninsured than white women. But, is increased access enough?
The answer: No, it is not.
The risk of pregnancy-related death for Black women spans income and education levels. Implicit bias, structural racism, low-quality care and inaccurate research are contributors. The question then becomes what will we, as health professionals, do differently today to improve maternal mortality for Black women and move towards health equity? We have opportunities to act now.
First, we can understand our implicit bias and learn how to address it. Implicit bias involves “associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender.” Many health professionals have implicit biases that lead to negative attitudes toward people of color.
Health professionals can often recognize that health disparities impact people of color, but they underestimate the magnitude. Implicit biases can be activated during stress, often present on labor and delivery and postpartum units in the hospital. We need to understand the implicit biases all of us have through an implicit association test and realize their consequences for patients. We can then learn how to apply bias-reduction strategies, such as replacing stereotyped with non-stereotyped responses, focusing on individual rather than group-based characteristics, and consciously considering situations from other racial viewpoints.
Second, we can address structural racism in our health systems. Structural racism describes “the totality of ways in which societies foster racial discrimination through mutually reinforcing inequitable systems,” such as in housing, education, employment, health care, and criminal justice. As health professionals, we serve in positions with associated power, and we can influence system change. We need to look for discrimination our patients face and say something when we witness it. We need to push for reliable and respectful collection of patient identity data to improve maternity care safety. and facilitate quality research. We need to name racism as the cause of racial health disparities and recognize that structural racism leads to poor health over time. We need to advocate for policy change and intersectoral efforts that lead to equitable infrastructure, services, and quality of care at all health care facilities.
Third, we can focus on providing high-quality care to all pregnant people. We can learn cultural humility, so our care is based on our patients’ needs and not assumptions we subconsciously make. If our state expands coverage for prenatal and postpartum care through the ARPA provisions, let’s take advantage of that opportunity. We can carefully monitor and address blood pressure and blood sugar control, mental health, and reproductive health care needs for our patients during extended postpartum coverage. For those who work in states that expanded Medicaid through the ACA, we can identify opportunities to enhance preconception and preventive health care.
You may be reading this opinion piece and wonder, “Does this apply to me?” I implore you to consider how it does. Many health professionals have not considered it, which is precisely why maternal mortality in the United States is so horrifying for Black women. Let’s believe that we can all do better to address these preventable pregnancy-related deaths.
The ARPA provisions can significantly increase access to maternity care for low-income pregnant and postpartum individuals if states appropriate funds. But for Black pregnant people, access is not enough. We need to do something different today to address racial health disparities. Only then can we improve the care of Black pregnant people tomorrow and decrease maternal mortality.
* In this article, the term “women” describes people who are pregnant or recently gave birth and aligns with the language used for Medicaid eligibility for pregnant and postpartum women as well as March of Dimes and CDC statistics. It is recognized that not all people who become pregnant or give birth identify as women.
Christina Kelly is a family physician.
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