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April 3, 2025
Quarterly Opinion
Ezekiel J. Emanuel
Patricia Hong
Jul 6, 2023
Mar 22, 2023
Oct 6, 2020
Back to The Milbank Quarterly Opinion
Everyone is familiar by now with the United States’s appalling maternal and infant mortality statistics. Despite leading the world in health care spending, the United States has, for decades, experienced higher maternal mortality rates than other high-income nations, with stark racial, geographic, and insurance-based disparities. The US maternal mortality rate in 2022 was 22 per 100,000 births—double, triple, and even ten times higher than the rate of other high-income countries.1 Medicaid, which covers nearly 40% of US births, is linked to poorer outcomes, including reduced prenatal care, higher preterm births, and increased infant mortality.2 These tragic statistics reflect the limited attention the United States dedicates to maternal and child health.
Earlier this year, the Centers for Medicare and Medicaid Services (CMS) announced 15 states selected for the Transforming Maternal Health (TMaH) Model, an initiative aimed at improving “outcomes and experiences for mothers and their newborns” enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).3 The TMaH Model focuses on improving access to care, driving quality improvements, and emphasizing a whole-person approach. It includes efforts to develop data systems, reduce unnecessary cesarean sections, and expand access to midwifery services and doula care.4 While these elements are important, the model’s current scope and funding are woefully inadequate to achieve its objectives, reducing it to little more than a modest step in the right direction.
Unfortunately, instead of scaling up, the program has seen setbacks. The quality and safety lead for the TMaH Model was recently dismissed as a part of the Trump Administration’s mass firings across health agencies. This is poor strategy for improving efficiency and cutting costs for the country. America’s short- and long-term well-being depends on how it invests in maternal and child health, and the TMaH model offers the greatest return on any government investment. Rather than cutting support, the TMaH Model must be strengthened.
The Administration is correct that the TMaH Model needs reform. The model needs greater funding, improvements in its data collection strategy, and the adoption of strategies and practices from successful state programs. More expansive investments that broaden the scope of the model to include mother-child pairs, and a focus on evidence-based solutions are necessary to truly realize the model’s potential and improve its efficacy.
The $17 million allocated over a decade for each of the 15 participating states, which have some of the highest maternal mortality rates in the country, is miserably insufficient to achieve its goals in any serious manner. With more than 457,000 annual births financed by Medicaid in these states in 2023, the investment translates to less than $40 per Medicaid-covered birth over 10 years if implemented statewide—far too meager to achieve sustainable improvements.5 This lack of financial investment fails to match the ambitious goals of the model, particularly when considering that training a doula, just one element of the model, costs between $300 and $1,000. While the model may cover doula services, scaling this workforce, especially in underserved areas, is a resource-intensive task, and the current funding levels are grossly inadequate. Underinvestment directly undermines the goals of the model and risks further entrenching poor outcomes.
A unified data infrastructure is essential for tracking outcomes and quality improvement. The model aims to expand data systems and integrate Medicaid and social service data, but it risks perpetuating today’s fragmented and disconnected reporting mechanisms. Without uniform adoption and coordination, varying regulations and inconsistent implementation may result in siloed systems. CMS should prioritize the creation of a standardized system that mandates consistent reporting of all births from all states, and integrates data from Medicaid, health systems, and community organizations. This would allow for the tracking of critical metrics such as those relating to prenatal care, behavioral health screenings, preeclampsia, C-section rates, and NICU admissions, enabling timely and targeted interventions. Data collection should extend into the postpartum period, lasting two years following birth, as over half of pregnancy-related deaths occur during this time. This will also help ensure well-baby visit interventions.6
As states move forward with implementation, it is crucial to learn from the successes of states like California that have made remarkable strides in reducing maternal mortality. California is proof that the United States can do better. While maternal mortality rates in the United States increased during the 2010s, California cut its rate almost by half, from 13.1 per 100,000 in 2005-2009 to 7.0 per 100,000 in just two years, making it comparable to some Western European countries.7 California’s Maternal Quality Care Collaborative (MQCC) reduced maternal deaths by over 20% in participating hospitals, compared to just 1% in non-participating ones.8 This success didn’t happen by chance—it resulted from focused investment in training, rigorous quality and safety standards, and collaboration across stakeholders. Key components of the safety tools included mandatory maternal and neonatal “crash carts” in hospitals analogous to “code carts,” and routine emergency preparedness drills. These measures could be implemented across all hospitals to improve emergency response. However, rural and less-resourced urban hospitals often lack the funding to meet these standards. Expanding support for these hospitals and ensuring the adoption of successful practices through the model would help standardize emergency and safety preparedness across states, thereby reducing maternal and infant mortality rates.
To make a lasting difference, the TMaH model must evolve to support not just maternal health, but also child health, particularly in the critical first two years of life. A mother’s health is deeply intertwined with her child’s well-being and addressing one without the other misses a critical opportunity for impact. Expanding the model to include coordinated support for mother-child pairs would align the program with the science of brain development. During this sensitive period, the brain undergoes rapid growth, forming more than a million new neural connections per second, setting a foundation for a child’s future physical, social, cognitive, and emotional development.9 This approach also would bridge the gap to later programs like universal pre-Kindergarten, which have long been advocated to foster early child development.
Preventing factors such as malnutrition, environmental toxins, and child maltreatment during the earliest years is crucial for improving long-term outcomes. Intervening in the lives of children during these years to give them the best chance for success is not just the right thing to do—it benefits society. One in eight children will have a confirmed case of maltreatment, which contributes to 20 – 25% of the risk for psychiatric conditions.10-11 Maltreatment often begins in the first few years of life, a time when caregivers are under significant stress. However, maltreatment is preventable, and we can predict with over 70% certainty whether a child will experience it based on various factors at birth. The return on investment is undeniable: a stronger economy, fewer crimes, and a brighter future for all. Child maltreatment alone carries an estimated lifetime economic burden of $124 billion to $428 billion annually.12 Early intervention in children’s lives sets the stage for a generation of healthier, more successful individuals.
Evidence-based interventions, such as SYNCHRONY and the Incredible Years , focus on strengthening parenting strategies and fostering childrens’ social and emotional development.13-14 Families participating in these programs saw a three- to five-fold reduction in the likelihood of children re-entering protective custody, highlighting the effectiveness of targeted interventions for high-risk families.15
Programs like SYNCHRONY, which provided comprehensive care at just $1,500 above Medicaid reimbursement per child, not only improve outcomes but also reduce long-term costs by preventing expensive treatments and lost productivity down the road.
The TMaH Model presents a bold opportunity to tackle the inequities in maternal and child health in the United States and drive real, meaningful change in addressing longstanding disparities. We possess the knowledge and capabilities needed to make a substantial improvement in outcomes. We can make the right choices to broaden the Model’s scope to at least the first two years following birth, and to center program design around the data, past successful initiatives, and science. In doing so, we can prove through scalable policy action that we are serious about the health of mothers and children.
Ezekiel J. Emanuel is vice provost for global initiatives and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. From January 2009 to January 2011, he served as special advisor for health policy to the director of the White House Office of Management and Budget. Since 1997 he was chair of the Department of Bioethics at The Clinical Center of the National Institutes of Health and a breast oncologist. Emanuel received his MD from Harvard Medical School and his PhD in political philosophy from Harvard University. After completing his internship and residency in internal medicine at Boston’s Beth Israel Hospital and his oncology fellowship at the Dana-Farber Cancer Institute, he joined the faculty at the Dana-Farber Cancer Institute. He has since been a visiting professor at the University of Pittsburgh School of Medicine, UCLA, and New York University Law School, the Brin Professor at Johns Hopkins Medical School, and the Kovitz Professor at Stanford Medical School. Emanuel has written and edited 9 books and over 200 scientific articles. He is currently a columnist for the New York Times.
Patricia Hong holds an ScM from Brown University and a BA from Wake Forest University.
