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October 18, 2024
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Sofia Espinosa
Mary Louise Gilburg
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The Commonwealth Fund’s first State Scorecard on Women’s Health and Reproductive Care uses 32 measure to explore how health care access, quality, and health outcomes differ across the United States. The report finds stark disparities by state and highlighted the links between access to reproductive services and the availability of maternity care providers and insurance coverage. Overall, deaths from preventable causes are rising, underscoring that many states are facing challenges in providing comprehensive health care for women. In this briefing, Scorecard authors provided key findings and state policymakers from Arkansas, Mississippi and New Jersey offered discussed state strategies to increase reproductive health care access and improve maternal health outcomes.
The Commonwealth Fund researchers reported significant regional differences in death rates among women of reproductive age, with the highest all-cause mortality rates in the southeastern states; the top causes of death included pregnancy complications, substance use, Covid-19, and breast and cervical cancer. The highest maternal mortality rates occurred in the Mississippi Delta region, which includes Arkansas, Louisiana, Mississippi, and Tennessee.
To assess quality, the researchers measured births by cesarean section for low-risk pregnancies, preventive care use, prenatal and postpartum care, and mental health screening. Low-risk cesarian births, which are an indicator of lower quality in maternal health care, were most common on the East Coast and in southern states. Across states, higher rates of postpartum depression were correlated with lower rates of screening. All states had room for improvement on rates of breast and cervical cancer screenings.
States that performed well across indicators for health care access and outcomes had several commonalities. These states invested in health insurance coverage for nearly all residents, had legal and accessible reproductive health care, and achieved lower maternal mortality rates with more maternal health workers and higher rates of prenatal and postpartum check-ups and postpartum depression screening.
After the Commonwealth Fund presentation, state officials from Arkansas, Mississippi, and New Jersey shared how their states are working to improve maternal health outcomes. The table below provides an overview of relevant policies in these three states.
State Policy Landscape
Elizabeth Pitman reported that Arkansas Medicaid covers 50% of births in her state. Despite scoring well on access to coverage, Arkansas scored poorly on quality metrics impacting maternal health outcomes. In response to high maternal and infant mortality rates, Pittman said, Governor Sanders established the Arkansas Strategic Committee for Maternal Health in March 2024.The committee identified key priorities for the state, including coordinating care across siloed health and social service providers and improving the data infrastructure to establish presumptive eligibility for pregnancy and increase care coordination and access to services. The Arkansas Department of Health, Department of Human Services, and Surgeon General, as well as University of Arkansas for Medical Sciences, community-based organizations, and large employers, have since created a statewide plan to coordinate resources to improve the quality of maternal health care.
“What we’re really trying to do is explore how we improve quality in addition to access because just improving access, as I think our data shows with our coverage versus our quality, isn’t the only thing you can do.” – Elizabeth Pitman, Director of Division of Medical Services, Arkansas Department of Human Services
Dr. Daniel Edney highlighted the role of poverty in perpetuating poor health outcomes in Mississippi, including poor maternal and child health outcomes. Although 65% of births are covered by Medicaid, Mississippi has large health care and obstetrical care deserts and significant workforce shortages. In the Mississippi Delta, an area the size of Delaware, there are only seven obstetricians and no neonatal intensive care units. To address this challenge, the Department of Health is using its public health authority to explore perinatal regionalization and a system of care that ensures pregnant people can safely deliver at hospitals with the correct maternal level of care designation. Dr. Edney also discussed efforts to address rising rates of congenital syphilis.
“We have to help our mom to survive pregnancy. I’m not talking about improving outcomes, I’m talking about surviving during pregnancy and then giving that baby a chance to live to be a year old. I don’t think that’s asking too much, and the people in Mississippi want it, and we’re doing what we have to do to try to make it happen.” – Daniel Edney, State Health Officer, Mississippi State Department of Health
The New Jersey’s Department of Human Services is working to improve maternal and infant health, with an emphasis on reducing racial and ethnic health disparities, through the Nurture New Jersey Initiative. Dr. Shin-Yi Lin explained that this initiative focuses on whole person health, which includes caring for the health of a mother before and after pregnancy and using new state funds to support prenatal and contraceptive care.
In addition, in 2021, the state required perinatal providers to conduct a standardized risk assessment at the beginning of every Medicaid pregnancy to identify clinical and behavioral health risks, substance use disorder screening, and health-related social needs (e.g., food, housing, job insecurity) to inform care and connections with community-based organizations. Dr. Lin also pointed out that New Jersey Medicaid is interested in disaggregating its health data to understand how different subsets of the population access care based on their age, race and ethnicity, and geography.
“Only caring for people when they’re pregnant just is not really moving the needle and so we are not only improving the whole person care of that pregnancy event, but also for the lifespan of the individual.” – Shin-Yi Lin, Deputy Director of Policy, New Jersey Department of Human Services
Participants discussed the role of insurance coverage to improve maternal health outcomes. In Arkansas, the Department of Human Services is focused on helping families transition from Medicaid to private insurance when they lose eligibility by coordinating with other agencies and providing education and outreach. And a newly enacted law in Mississippi allows local health departments, as well as hospitals and other providers, to serve as access points for presumptive eligibility determinations to increase access to Medicaid for pregnant people. Another theme was provider engagement and capacity: New Jersey is supporting innovative clinical models like group pregnancy care, group pediatric care, and birth centers to improve access. And its Medicaid program is supporting midwifery care by moving toward equal reimbursement for midwives.
