Healthy babies start with healthy pregnancies. The United States has a robust healthcare infrastructure, spending more per capita on healthcare than any other nation, but U.S. maternal health in this country has lagged behind that of other countries in the developed world. Why? There’s no single reason, said Dr. Tiffany Inglis, medical director of clinical programming and population health for Elevance Health. Instead, a variety of issues and barriers to access have converged to create a challenging landscape for those who are expecting babies as well as maternity care providers in this country.
The U.S. maternal mortality rate in 2020 rose from 17.4 to 23.8 deaths per 100,000 live births, with 861 known deaths during pregnancy or within 42 days of the end of pregnancy. That’s three times higher than France, the developed country with the next highest rate. The maternal mortality rates are higher for people of color. There are multiple reasons for those disparities, but many maternal health inequities can be traced back to issues of access, including access to medical care, nutritious food, and community support.
The current statistics — and, more importantly, the people and babies behind the data — are why the Elevance Health Foundation has committed $30 million over the next three years toward programs that support maternal and infant health. They’re why Elevance Health is advancing strategies that can produce healthier outcomes: The use of doula care, for example, has demonstrated positive results. And they are why the entire healthcare system is taking a careful look at the health inequities and barriers to access that create disparities in outcomes.
Research shows that our overall health is determined more by factors such as our ZIP code than our doctor. Social drivers of health, such as where we live, economic stability, education, ethnic background, and more, all have a greater impact on our health than we realize. This is especially true before, during and following pregnancy, so taking social drivers into account— along with physical and behavioral drivers — is a key component of our whole-health approach to improving maternal health outcomes.
Taking a closer look, there are specific social drivers that contribute to poor maternal and infant health outcomes.
Access to Medical Care
Where we live is one of the biggest social drivers of health. According to an internal review of Elevance Health data, pregnant women who live more than 50 miles from a delivery facility are twice as likely to experience preterm birth, before 37 weeks of gestation. A 2022 report from the March of Dimes found that 2.2 million people of childbearing age lived in maternity care deserts (1,119 counties) and had no access to a hospital offering obstetric care, a birth center, or an obstetric provider. That same report found that an additional 4.7 million people of childbearing age live in counties with limited access to maternity care.
When we take a closer look at these maternity care deserts, they not only have a higher poverty rate but a lower median household income than counties with access to maternity care. As a direct result of this social driver, it is more challenging to receive prenatal care in these communities — and that has real consequences. A pregnancy without prenatal care is five times more likely to end in a pregnancy-related death than one that is supported by prenatal care. A 2022 study from the U.S. Centers for Disease Control and Prevention found that 80% of 2017–2019 pregnancy-related deaths — which can happen during pregnancy, during labor, and for a year after childbirth — were preventable.
Access to primary and mental health care is also crucial in supporting maternal health. Research shows that medical coverage before, during, and after pregnancy facilitates access to care that supports healthy pregnancies, as well as positive maternal and infant outcomes after childbirth. The CDC report found that mental health conditions (suicide and overdose) were the largest cause of pregnancy-related death (23%) when a cause was identified, followed by excessive bleeding or hemorrhage (14%), cardiac and coronary conditions (13%), infection (9%), and other medical conditions.
Inequities in Access to Care
Every year about 700 people die during pregnancy or in the year thereafter, with another 50,000 people experiencing severe complications during pregnancy. But pregnancy-related deaths do not impact everyone equally: Black people are three times more likely to die from a pregnancy-related cause than White people. And more than 90% of pregnancy-related deaths among Indigenous people were preventable, according to the CDC report.
Racial disparities in maternal health, in part, reflect barriers to equitable care for people of color. Overall, people of color are more likely to be uninsured and experience other barriers such as lack of access to care providers, hospitals, and culturally and linguistically appropriate care. But even for those who do have access, inequities cross socioeconomic lines: Among women with a college degree, Black women have a pregnancy-related mortality rate that is five times that of White women. Some of the factors that contribute to these disparities include underlying health conditions, implicit bias, structural racism, and inconsistent quality of healthcare.
Community groups, government officials, and the healthcare system are working to develop and test effective ways to close gaps for people who have been historically marginalized.
Access to Nutritious Food
The food we eat directly correlates to our health, and this is especially true during pregnancy: Pregnant people need sustainable nutrition for themselves as well as their growing babies.
Food security is the most reported unmet social need in the U.S., affecting 13.5 million households in 2021. Food insecurity may increase the release of stress hormones, which has been linked to preterm birth as well as unhealthy changes in a mother’s pregnancy weight. It’s also been linked to an increased risk for post-partum depression. Unfortunately, food insecurity in the Black community has increased during the pandemic, which only heightens existing racial disparities.
Where Do We Go From Here?
To improve maternal health, the system needs to reduce inequities in care and outcomes. This means investing in greater behavioral health support during and after pregnancy and for new parents, as well as enabling access to support services for those who need them most.
More and more organizations are making an investment in maternal health, prioritizing equity, and creating tools to support pregnancy, birth, and beyond. Creating Healthier Communities (CHC) is using racially and culturally specific measures of stress for Black parents to screen thousands of Black mothers in Indiana, Georgia, and Ohio. The project will identify stressors and other health-related social needs affecting preterm births, and it will work with community-based organizations to provide appropriate interventions.
Elevance Health is driving specific strategies across the organization to support improved maternal health. That includes using a data-driven and “health equity by design” approach to review the latest data on maternal health and uncover opportunities for new programs and initiatives that address inequity and improve outcomes. Our efforts to promote whole health focus not just on the healthcare industry but also on social drivers that impact health. Examples include the Housing Flex Fund, which is used to support housing solutions for plan members experiencing housing insecurity; efforts to support the use of doula care for those who are expecting; and advocating for an expansion of Medicaid to provide a full 12 months of health insurance coverage for women and babies.
“We’re really focusing our whole health work on identifying the inequities that exist for each population, and then driving to create programs locally that complement our system-wide initiatives,” said Dr. Inglis. “The work that we’re doing to improve whole health uses the data to drive what we do next.”