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Position Statement: Reducing Maternal Mortality and Morbidity and Advancing Maternal Health Equity
 
American Academy of Nursing Position Statement | June 20, 2024
American Academy of Nursing Statement on Reducing Maternal Mortality and Morbidity and Advancing Maternal Health Equity
Supporting Evidence-Based Policies to Ensure Care Access for Pregnant People 

Position

High rates of maternal mortality and morbidity as well as poor perinatal health outcomes and inequities are crises for women in the United States (U.S.).The American Academy of Nursing (Academy) has long championed policies to address these critical public health issues.1 The Academy supports evidence-based policies that ensure all pregnant people have access to critical resources, high-quality health care, and social supports throughout the perinatal period.2 While recent state and federal legislative efforts have attempted to address the maternal mortality and morbidity health crises, health inequities exacerbated by systemic and structural racism, bias, and a shortage of perinatal care providers are still evident. Increasing access to services supporting mothers and families throughout the perinatal period and promoting the growth and diversity of the perinatal workforce are essential to addressing these crises. 

The terms “maternal,” “women,” and “mothers” are used throughout this statement. However, the Academy recognizes and affirms that some individuals who are pregnant and give birth may be transgender men or nonbinary people. Perinatal is defined as the period of pregnancy through 12 months post-birth.3,4

 

Background

Rates of maternal mortality and morbidity in the U.S. are higher than in other high-income countries, a longstanding trend despite the U.S. spending more per person on health care.5 The maternal mortality rate was 32.9 deaths per 100,000 live births in 2021 and 22.3 deaths per 100,000 live births in 2022, significant increases over 2018’s rate of 17.4 deaths per 100,000 live births.6,7 The Centers for Disease Control and Prevention (CDC) found that 80% of pregnancy-related deaths (2017-2019) were preventable, highlighting the pressing need for increased action to reduce these mortalities.8 Additionally, while perinatal health concerns impact women in all demographics, there are significant disparities among women from different racial and ethnic groups. In 2022, the maternal mortality rate for Black women in the U.S. was 49.5 deaths per 100,000 live births, significantly higher than rates for white (19.0), Hispanic (16.9), and Asian (13.2) women.7 The high rate of maternal mortality and the striking inequities in maternal health in the U.S. require increased action at the state and federal levels directed toward improving access to services and care, addressing the social determinants of health, and strengthening the perinatal workforce.

Expanding Access to Insurance Throughout the Perinatal Period

Mental health conditions, hemorrhage, and cardiac/coronary conditions are the leading causes of pregnancy-related mortalities.8 Increasing access to care lowers the risk of complications for mothers throughout the perinatal period.9 In the U.S., Medicaid is a primary source of payment for births, financing 41.3% of births overall.10 Promoting equitable insurance provision is critical as historically marginalized racial and ethnic groups have Medicaid coverage rates disproportionate to other groups. Of women ages 18-49, 37% of American Indian/Alaska Native women, 33% of Black women, 32% of Native Hawaiian and Other Pacific Islanders, and 27% of Hispanic women are covered by Medicaid compared with 18% of white women.11  Starting in 2014, Medicaid expansion through the Affordable Care Act (Public Law No. 111 – 148)12  enabled states to extend Medicaid coverage to most individuals with incomes up to 138% of the Federal Poverty Level.13 Forty states and the District of Columbia have since adopted the expansion, while ten states have not.13 Studies have consistently found that Medicaid expansion has led to increased coverage rates before, during, and after pregnancy; increased access to prenatal and postpartum care; and better birth and postpartum outcomes.14  Furthermore, while states are required to provide pregnancy-related Medicaid coverage for 60 days after birth, expanded Medicaid coverage became available through funding in the American Rescue Plan Act of 2021 (Public Law No. 117-2)15 and the Consolidated Appropriations Act of 2023 (Public Law No. 17-328),16 giving states the option to extend postpartum Medicaid coverage to 12 months.17 Forty-seven states and the District of Columbia have extended Medicaid postpartum coverage to 12 months.17 Medicaid expansions are an important step to address disparities and ensure that mothers have continuous insurance coverage throughout the perinatal period. Maintaining coverage and promoting further expansion where possible should remain a priority.

Social Determinants of Health and Access to Support Services

Health inequities in the U.S. are associated with the social determinants of health (SDOH)— the non-medical factors that influence health outcomes. The SDOH include the conditions in which individuals are born, grow, work, live, and age, as well as the wider set of forces and systems shaping the conditions of daily life.18 Addressing the SDOH is crucial to achieving health equity and promoting maternal health.19 Social support services, including but not limited to adequate housing, nutrition, transportation, and social and economic mobility, are critical to reducing preventable negative health outcomes.19 Environmental and planetary health factors are key considerations during the perinatal period as well, given that the spread of certain diseases as a result of climate change, extreme weather events, and environmental toxins impact the long-term health of pregnant people and infants.20

Furthermore, it is essential that families have adequate time available to care for themselves and their infants during the perinatal period. Unpaid leave is not affordable for many workers and the adoption of a national paid family and medical leave program would provide parents with paid time off to care for their infant or recently adopted children, leading to improved long-term economic and health outcomes.21 Mothers who take paid family leave are less likely to experience symptoms of postpartum depression or parenting stress.21

Proposed legislation such as the Black Maternal Health Momnibus Act,22 which includes 13 individual bills, addresses the improvement of perinatal health through multi-agency efforts directed toward the root causes of maternal mortality, morbidity, and disparities. For example, the Social Determinants for Moms Act would fund community-based organizations and public health departments to address SDOH throughout the perinatal period and the Protecting Moms and Babies Against Climate Change Act would direct investments to reduce environmental threats to mothers and infants.22

Strengthening the Perinatal Workforce

Study findings have repeatedly demonstrated that implicit bias and racism in the health care system contribute significantly to adverse maternity care outcomes for Black mothers.23 In addition to implicit bias training for providers, it is critical to diversify the perinatal workforce and increase the number of providers from historically marginalized racial and ethnic groups. Exploring opportunities for partnerships with postsecondary institutions, especially Historically Black Colleges and Universities (HBCUs) and other minority-serving institutions, would increase the number of providers from historically marginalized racial and ethnic groups.

Furthermore, hospitals designated as “Birthing Friendly,” with a diverse and growing workforce that includes registered nurses, advanced practice registered nurses (APRNs),25 and other providers, could also contribute to advancing health care quality, safety, and equity for perinatal patients by decreasing the rates of low-risk cesarean birth rates and severe obstetric complications. Incentives for private health insurers and expansion of Medicaid are needed to provide sustainable reimbursement for care provided by APRNs and others that has been demonstrated to reduce perinatal morbidity and mortality, even among the most at-risk populations.

As noted above, the Black Maternal Health Momnibus Act22 encompasses multiple strategies to address root causes of maternal mortality, as well as growing the workforce and addressing bias. For example, the Kira Johnson Act would allocate funding to implement and study bias, racism, and discrimination trainings for all employees in maternity care settings.22 The Perinatal Workforce Act would increase the number of maternity care providers and promote culturally safe and supportive care.22 Further, legislation such as the Midwives for Maximizing Optimal Maternity Services (MOMS) Act26 would strengthen the perinatal workforce and improve outcomes by establishing grants to expand accredited midwifery and nurse-midwifery programs, focusing on increasing the number of midwives from historically marginalized racial and ethnic groups.

Perinatal Mental Health

With 23% of pregnancy-related mortalities caused by mental health conditions (2017-2019),8 perinatal mental health is of the upmost importance for protecting the lives of infants and mothers. An estimated 500,000 pregnant women in the United States will experience a mental health disorder either prior or during pregnancy each year, and suicide accounts for 5-20% of mortalities in the perinatal period.27 Nearly 40% of Black women experience mental health symptoms, which is nearly twice the rate of all women.28 Among American Indian/Alaskan Native mothers, mental health conditions accounted for 31% of mortalities (2017-2019).29 Ensuring access to mental health care during this period is critical. The Department of Health and Human Services’ (HHS) National Strategy to Improve Maternal Mental Health Care30  outlines recommendations on improving perinatal mental health and substance use disorders, now a priority for implementation. Additionally, the Moms Matter Act, part of the Black Maternal Health Momnibus Act,22 would address maternal mental health through grant funding for mental health initiatives as well as growing the maternal mental and behavioral health care workforce.

Rural Communities and Telehealth

Approximately 20% of individuals in the U.S. live in a rural community, including approximately 18 million women of reproductive age.31 While there are shortages of perinatal providers in both rural and urban areas, concerningly, less than 50% of rural-residing women have access to perinatal services within a 30-mile drive from their home and more than 10% of rural-residing women drive 100 miles or more to access these services.31 These barriers contribute to gaps in care throughout the perinatal period, impacting maternal and infant health outcomes. Increasing access to care is a priority in rural areas. Along with growing the perinatal provider workforce, telehealth plays a key role in connecting rural-residing mothers to care. Expanding telehealth services should be highlighted as a key strategy in these areas.

The Data Mapping to Save Moms’ Lives Act (Public Law No. 117-247),32 which guides efforts on advancing perinatal telehealth services by directing the Federal Communications Commission (FCC) and CDC to incorporate data on maternal mortality and morbidity into the Mapping Broadband Health in America platform, outlines the intersection of broadband connectivity and maternal health outcomes. This recently enacted legislation is an important step in identifying areas where increased connectivity is needed for perinatal services.

Perinatal Health Research and Innovative Care/Payment Models

Research is crucial in the development of interdisciplinary models addressing adverse perinatal health outcomes. Increased funding levels are essential to support research into evidence-based solutions to address the contributors to negative perinatal health outcomes and to assess innovative models of care that bridge mental health and perinatal health care gaps.

Considering the political, cultural, and racist factors that influence women’s health care services, women often face additional barriers compared to men in accessing care. Barriers include women traveling longer distances to access needed care; perinatal system barriers to health innovation; failure to maximize pregnancy-timed health promotion care that benefits the maternal/child dyad; and a lack of foundational science defining normal vs. pathological childbearing processes. Research examining the impact of these factors on women’s lifespan health outcomes is also needed as many perinatal events (e.g., hypertension; diabetes) may be a precursor to future health concerns for the mother and infant. There is a sizeable need to build the foundational population-level evidence on these topics.

Additionally, there is an opportunity to devise innovative payment models that would further strengthen care delivery and maternal outcomes. For example, in December 2023, the Centers for Medicare & Medicaid Services (CMS) announced the Transforming Maternal Health (TMaH) Model which seeks to develop a value-based alternative payment and care delivery model for maternity care services.33 The TMaH model, projected to run for ten years, will support state Medicaid agencies in the development of improved perinatal care through three pillars: access to care, infrastructure, and workforce capacity; quality improvement and safety; and whole-person care delivery.33 Furthermore, proposed legislation such as the IMPACT to Save Moms Act34 would launch a demonstration project to test new payment models for maternity care provided to pregnant and postpartum people.

Policy Recommendations

The Academy supports evidence-based policies that ensure all pregnant people have access to critical resources, high-quality health care, and social supports throughout the perinatal period. There is a need for increased action at the state and federal levels directed toward improving access to services, coverage, and care, addressing the social determinants of health, and strengthening the perinatal workforce to promote maternal health equity.

  1. Extend Medicaid eligibility expansion and coverage of pregnancy-related care to 12 months postpartum in all states.
  2. Enact the Black Maternal Health Momnibus Act, which would address the root causes of maternal mortality, morbidity, and disparities through multi-agency efforts.
  3. Advance legislation at the state and federal level that would provide paid family leave.
  4. Enact the Midwives for MOMs Act and explore opportunities to partner with postsecondary institutions, including HBCUs and other minority-serving institutions, to grow the number of nurses and APRNs, in particular, nurse-midwives from accredited nurse-midwifery programs, who are from historically marginalized populations.
  5. Implement the recommendations from HHS’s National Strategy to Improve Maternal Mental Health Care to improve perinatal mental health and substance use disorders.
  6. Utilize data made available through the Data Mapping to Save Moms’ Lives Act to identify areas for needed maternal telehealth service expansion, particularly in medically underserved rural areas.
  7. Invest in perinatal research with a multifactorial approach that prioritizes mitigating disparities.
  8. Incentivize the development of interdisciplinary models of care to improve maternal and perinatal health outcomes.
  9. Incentivize reimbursement for APRN care through Medicaid and other insurance and enact the IMPACT to Save Moms Act to test innovative payment models for maternity care.

The Academy’s Board of Directors approved this statement on June 5, 2024.

Citations

  1. American Academy of Nursing. (2021, February). Momnibus Support Letter. https://cdn.ymaws.com/aannet.org/resource/resmgr/policydocuments/pastpolicywork/momnibus_support_letter.pdf
  2. American Academy of Nursing. (2021, September). Build Back Better Maternal Health Stakeholders Letter. https://cdn.ymaws.com/aannet.org/resource/resmgr/policydocuments/pastpolicywork/build_back_better_maternal_h.pdf
  3. The American College of Obstetricians and Gynecologists. Perinatal Mental Health Toolkit. (2019). https://www.acog.org/programs/perinatal-mental-health.
  4. Garcia, E.R., Yim, I.S. A systematic review of concepts related to women’s empowerment in the perinatal period and their associations with perinatal depressive symptoms and premature birth. BMC Pregnancy Childbirth 17 (Suppl 2), 347 (2017). https://doi.org/10.1186/s12884-017-1495-1
  5. Fleszar, L.G., Bryant, A.S., Johnson, C.O., et al. Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States. JAMA. 2023;330(1):52–61. DOI: https://doi:10.1001/jama.2023.9043
  6. Hoyert DL. Maternal mortality rates in the United States, 2021. NCHS Health E-Stats. 2023.
    DOI: https://dx.doi.org/10.15620/cdc:124678.
  7. Hoyert DL. Maternal mortality rates in the United States, 2022. NCHS Health E-Stats. 2024.
    DOI: https://dx.doi.org/10.15620/cdc/152992.
  8. Centers for Disease Control and Prevention. Four in 5 pregnancy-related deaths in the U.S. are preventable. (2022). https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html.
  9. Pregnancy complications. (2023, February 8). Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-complications.html
  10. Osterman, MJK, Hamilton, BE, Martin, JA, Driscoll, AK, & Valenzuela, CP. Births: Final data for 2022. National Vital Statistics Reports; vol 73, no 2. Hyattsville, MD: National Center for Health Statistics. 2024. DOI: https://dx.doi.org/10.15620/cdc:145588.
  11. Hill, L., Artiga, S., Ranji, U., Gomez, I., & Ndugga, N. (2024, April 24). What are the implications of the Dobbs ruling for racial disparities? KFF. https://www.kff.org/womens-health-policy/issue-brief/what-are-the-implications-of-the-dobbs-ruling-for-racial-disparities/
  12. The Patient Protection and Affordable Care Act, Pub. L. No. 111-148 (2010).
  13. Status of state Medicaid expansion decisions: Interactive map. (2024, May 8). KFF. https://www.kff.org/affordable-care-act/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
  14. Guth, M., & Diep, K. (2023, June 29). What does the recent literature say about Medicaid expansion? : Impacts on sexual and reproductive health. KFF. https://www.kff.org/medicaid/issue-brief/what-does-the-recent-literature-say-about-medicaid-expansion-impacts-on-sexual-and-reproductive-health/
  15. American Rescue Plan Act of 2021, Pub. L. No. 117-2 (2021).
  16. Consolidated Appropriations Act, 2023, Pub. L. No. 117-328 (2022).
  17. Medicaid postpartum coverage extension tracker. (2024, May 7). KFF. https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/
  18. World Health Organization: WHO. (2019, May 30). Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
  19. Whitman, A., De Lew, N., Chappel, A., Aysola, V., Zuckerman, R., & Sommers, B. (2022, April). Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts. ASPE. https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-Review.pdf
  20. Wright, M. L., Drake, D., Link, D. G., & Berg, J. A. (2023). Climate change and the adverse impact on the health and well-being of women and girls from the Women’s Health Expert Panel of the American Academy of Nursing. Nursing Outlook, 71(2), 101919. https://doi.org/10.1016/j.outlook.2023.101919
  21. Romig, K., & Bryant, K. (2021). A national paid leave program would help workers, families. Center on Budget and Policy Priorities. https://www.cbpp.org/research/economy/a-national-paid-leave-program-would-help-workers-families
  22. Black Maternal Health Momnibus Act. H.R.3305, 118th Congress (2023-2024). https://www.congress.gov/bill/118th-congress/house-bill/3305
  23. Teleki, S. (2021, July 6). Challenging providers to look within themselves: A new tool to reduce bias in Maternity Care: Health Affairs Forefront. Health Affairs. https://www.healthaffairs.org/do/10.1377/forefront.20210630.980773/
  24. Press release CMS proposes policies to advance health equity and maternal health, Support Hospitals. CMS. (2022, April 18). https://www.cms.gov/newsroom/press-releases/cms-proposes-policies-advance-health-equity-and-maternal-health-support-hospitals
  25. APRNs include certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), clinical nurse specialists (CNSs) and nurse practitioners (NPs).
  26. Midwives for Maximizing Optimal Maternity Services Act of 2023 or the Midwives for MOMS Act of 2023. H.R.3768, 118th Congress (2023-2024). https://www.congress.gov/bill/118th-congress/house-bill/3768
  27. American Psychiatric Association. (2023). Perinatal Mental and Substance Use Disorders. https://www.psychiatry.org/getmedia/344c26e2-cdf5-47df-a5d7-a2d444fc1923/APA-CDC-Perinatal-Mental-and-Substance-Use-Disorders-Whitepaper.pdf
  28. March of Dimes. Black Maternal Health Week. https://www.marchofdimes.org/black-maternal-mental-health-week.
  29. Pregnancy-Related Deaths Among American Indian or Alaska Native Persons: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019. Centers for Disease Control and Prevention. (n.d.). https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc-aian.html
  30. Biden-Harris administration announces Maternal Mental Health Task Force’s national strategy to improve maternal mental health care amid urgent public health crisis. (2024, May 14). https://www.samhsa.gov/newsroom/press-announcements/20240514/maternal-mental-health-task-force-national-strategy-improve-maternal-mental-health-care
  31. Improving Access to Maternal Health Care in Rural Communities: Issue Brief. (2019, September 3). Centers for Medicare and Medicaid Services. https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/rural-health/09032019-Maternal-Health-Care-in-Rural-Communities.pdf
  32. Data Mapping to Save Moms’ Lives Act, Pub. L. No. 117-247 (2022).
  33. Transforming maternal health (TMaH) model. (2023, December 15). Centers for Medicare & Medicaid Services (CMS). https://www.cms.gov/priorities/innovation/innovation-models/transforming-maternal-health-tmah-model
  34. IMPACT to Save Moms Act. S.1797, 118th Congress (2023-2024). https://www.congress.gov/bill/118th-congress/senate-bill/1797/text
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This position statement originated from the Academy’s Expert Panels on Maternal & Infant Health; Health Equity; Women’s Health; Breastfeeding; and Environmental & Public Health. The Academy’s Expert Panels are the organization’s thought leadership bodies. Through the Expert Panels, Academy Fellows, with subject matter expertise, review the current trends, research, and issues within their field to make informed and evidenced-based recommendations.

The American Academy of Nursing serves the public by advancing health policy and practice through the generation, synthesis, and dissemination of nursing knowledge. Academy Fellows are inducted into the organization for their extraordinary contributions to improve health locally and globally. With more than 3,000 Fellows, the Academy represents nursing’s most accomplished leaders in policy, research, administration, practice, and academia. 

American Academy of Nursing. (2024). American Academy of Nursing Statement: Reducing Maternal Mortality and Morbidity and Advancing Maternal Health Equity. Retrieved: https://aannet.org/page/maternal-health-position-statement-2024.