The State of Maternal and Infant Health: An Unrelenting Crisis

On November 16, 2023, the March of Dimes released its 16th annual Report Card on the “state of maternal and infant health for American families.” ¹ Among its most notable observations, the Report Card makes note of the reality that maternal and infant health in the U.S. is characterized by an “alarmingly high preterm birth rate.” ¹ The Report Card goes on to state that among the infants born in 2022, over 380,000 (10.4%) were born prematurely, that is, prior to 37 weeks of gestation. ¹ The Report Card makes further note of the finding that “maternal mortality rates have nearly doubled since 2018” to reach an annual rate of 32.9 deaths per 100,000 live births in 2021. In addition, the Report Card observes that infant mortality (5.4 deaths per 1,000 live births) claimed nearly 20,000 infants in 2021 alone. ¹ An equally important note is made of the persistent racial and ethnic disparities in the aforementioned adverse outcomes the impact of which proved most notable in non-Hispanic Black, Native Hawaiian or other Pacific Islander, and American Indian or Alaska Native. ¹ It is the objective of this Commentary to explore the policy levers that could be brought to bear with an eye towards effectuating meaningful improvements in the safety of pregnancy and the outcome thereof.

In one of its key recommendations, the Report Card makes note of its conviction that any state policy initiative must include the enhancement of access to “affordable quality public health insurance programs to women before pregnancy.” ¹ To reach this goal, states would have to consent to the expansion of Medicaid in keeping with expectations first laid out by the Patient Protection and Affordable Care Act [ACA; Public Law No: 111–148]. It was the goal of the ACA to extend coverage to nearly all low-income adults (≤ 65 years of age) who are U.S. citizens or legal residents whose total earnings did not exceed 138% of the Federal Poverty Level. In return, the ACA was to guarantee all of the participating states enhanced Federal Medical Assistance Percentages in all Federal matching funds. Thus far, a total of 40 states and the District of Columbia (DC) have seen to the implementation of this statutory proposition. ²

In yet another Medicaid-focused recommendation, the Report Card makes note of the reality that 53% of all pregnancy-associated deaths transpire within one year of childbirth. ¹ In recognition of this reality, the Report Card calls for the “extension of Medicaid healthcare benefits to 1 year after the birth of a child.” ¹ Absent such, postpartum Medicaid benefits are destined to remain limited to 60 days, the duration heretofore required by Federal law. The statutory realities that make it possible for states to extend postpartum coverage by Medicaid to a total of 12 months, comprise the American Rescue Plan Act of 2021 [Public Law No: 117–2] and the Consolidated Appropriations Act, 2023 [Public Law No: 117–328]. At the time of this writing, a total of 38 states and DC have taken advantage of this novel legislative option. ³ If and when all states resolve to extend their Medicaid postpartum coverage to 12 months, the total complement of women beneficiaries could reach 720,000 as per the Office of Health Policy of the Assistant Secretary for Planning and Advancement (ASPE). ⁴

Weighing in on yet another key recommendation, the Report Card calls for “paid family leave systems” that would “support families during parental leave.” ¹ Adoption of such policy will require employers to provide family members who are out on parental leave with 12 weeks of paid leave. At the time of this writing, only 10 states and DC have enacted laws in support of this family-sustaining measure. ¹ Congressional efforts to enact bills intent on rendering paid family leave a reality have thus far fallen short. One such bill, Caring for All Families Act, was introduced by Sen. Richard J. Durbin [D-IL] on February 2, 2023 only to be referred to the Committee on Health, Education, Labor, and Pensions. An identical House bill introduced by Rep. Jahana Hayes [D-CT-5] was referred to the Committee on Education and the Workforce as well as to the Committee on Oversight and Accountability. Multiple other bills intent on expanding the reach of the Family and Medical Leave Act of 1993 (FMLA; Public Law No: 103–3) were similarly sidelined. The above notwithstanding, the notion of paid family leave was favorably reviewed at a meeting of the Senate Committee on Finance as recently as October 25, 2023. Strong support was recently articulated as well by Senators Ronald L. Wyden (D-Ore) and William M. Cassidy (R-LA).

Finally, the Report Card makes note of a series of additional measures in support of maternal and infant health that have yet to be implemented nationwide. ¹ One such measure, the reimbursement of Doula services by Medicaid, is presently limited to 11 states and DC. ¹ Federally funded Maternal Mortality Review Committees, a critical quality control mechanism, are presently active in 44 states. ¹ Fetal and Infant Mortality Review Committees and Perinatal Quality Collaboratives, for their part, are currently in effect in 28 and 36 states, respectively. ¹ Moreover, significant efforts must be directed at the elimination of Maternity Care deserts, primarily in rural segments of the nation. ⁵ It is the hope and vision of the Report Card that the nationwide representation of the aforementioned functionalities will, in time, see to a meaningful improvement in the “state of maternal and infant health for American families.” ¹

The annual Report Card of the March of Dimes constitutes an all-important reminder of the dismal “state of maternal and infant health for American families.” ¹ The policy levers enumerated by the Report Card deserve the utmost attention if progress is to be made. Only in so doing will the “state of maternal and infant health for American families” approximate that of most other high-income countries. It remains the view of the American College of Obstetricians and Gynecologists that “the maternal access crisis in the United States is nothing short of catastrophic. We agree with the view of the American College to reverse course and improve outcomes.” ⁶