Maternal Care in During A Global Pandemic
Sara Moreno, Princeton University
Maternal Mortality in the United States
Early in February, the Biden administration released their plan for the Covid-19 relief bill, which included a provision to extend maternal care coverage for up to a year for new moms who are insured under Medicaid.[1] Currently, Medicaid covers more than 4 in ten births in the country[2]. Thus, this is not only a step towards mitigating the effects of the pandemic on pregnancy outcomes, but also a way to address the United States’ issue of maternal mortality.
Although most maternal deaths and complications are preventable, rates have been increasing in the United States[3]. In fact, the United States has one of the highest rates of maternal mortality rates amongst developed nations. However, the burden of pregnancy-related complications is not shared equally, as it disproportionately affects Black and Indigenous women, with a mortality rate almost three times as high as those of non-Hispanic white women[4].
This disparity has been largely attributed to systemic racism and inequalities that exist within the system. For instance, one of the social determinants influencing this healthcare disparity is inequities in terms of access to insurance that covers perinatal medical expenses[5]. Although a lack of insurance coverage does not explain the whole story, it is an important factor that contributes to the national maternal mortality crisis.
As of 2017, around half a million new mothers remained uninsured in the United States[6], with rates of 24.4%, 12.1 % and 7.0% amongst Hispanic new mothers, Black new mothers and white new mothers, respectively.[7] Although Medicaid covers pregnancy care for women who are not under private insurance, women who are part of the insurance gap can lose this government sponsored coverage two months after delivery. This forces new moms to switch plans, but around 45% are unable to do so and thus remain uninsured[8]. This lack of healthcare coverage is especially concerning, given that up to a third of pregnancy related deaths occur between six weeks to a year after delivery and that one in eight women experience postpartum depression.[9] (CDC). Therefore, increased access to postpartum coverage is a potential avenue to aid in the national crisis.
The coronavirus pandemic has further increased the need to address the maternal mortality crisis. Pregnant people are at a higher risk of developing Covid-19 related complications, and unfortunately, pregnancy related complications seem to have increased this past year[10]. Evidence shows that Hispanic and Black pregnant women are at a higher risk of being affected by Covid-19, highlighting the racial disparities at play[11]. Now, more than ever, it is necessary to take steps to address this national crisis.
The Effect of Covid-19 Pandemic on Access to Perinatal Coverage
The ongoing pandemic has created changes in the healthcare system that have both provided avenues to extend access and coverage for perinatal health, but that have a risk of exacerbating the previously highlighted disparities.
For instance, in-person consults have been restricted due to lockdowns, clinic closures as well as the fear of Covid-19 infections, which has prompted a shift to online platforms for healthcare delivery. The use of telehealth has helped breach certain barriers to access, such as the lack of transportation or childcare. In fact, evidence suggests an increase in attendance to healthcare visits as a result of online consults. This is especially important, as telehealth could serve as a platform to not only help monitor women’s physical health after birth, but also to receive mental health counseling and mitigate the risks of postpartum depression.
However, while the expansion of telehealth has allowed many people to continue receiving care during the pandemic, it has also restricted access to those without the financial and technological capabilities. While some studies have pointed out that pre and post-natal care attendance has increased during the pandemic through the use of telehealth, this seems to be restricted to those who, in a pre-pandemic world, already had better access to care.
In a study published in the American Journal of Perinatology (2020) on the transition to obstetric care via telehealth, healthcare providers cited the main issue of virtual healthcare delivery to be access to internet, where women under private insurance were more easily integrated into the world of online health delivery than women under Medicaid[12]. This highlights how the implementation of telehealth, with no structural or additional reforms, can lead to unwanted increased disparities.
Implications for the Future of Maternal Health
While the pandemic has underscored many of the issues in the healthcare system, it has also allowed for new avenues of healthcare delivery that might help solve these issues if these policies and implementations are maintained long term.
For example, while the use of telehealth has shed a light on the effects that the technological gap has on marginalized populations, the increase in attendance to healthcare visits seems promising and hints towards possible ways to improve childbirth outcomes even in a “post-Covid” world. Therefore, it is important that steps be taken to ensure that these changes help the most vulnerable populations as well.
Medicaid coverage for online consults was updated as a result of the pandemic; with the growing use of telehealth, it is necessary that this service is covered even after the pandemic to promote equity in terms of access. Additionally, even if telehealth continues to be covered through Medicaid, this would not be as useful to mothers who lose their insurance. As previously mentioned, the Covid Relief Bill has expanded Medicaid coverage for up to a year for new mothers, which is especially important due to the complications that can arise after childbirth. However, this change is only in place for the next five years.
Policymakers should strongly consider making this a permanent change in Medicaid, as it would ensure that mothers have access to both in person and online care during this high risk period of their lives. Furthermore, steps could be taken to close the digital gap by broadening access to technological services and increasing internet access and connectivity, which would allow more new mothers to take advantage of the benefits provided by telehealth.
Finally, there should be campaigns to provide education and awareness of these new services and policies. Altogether, these things could widen access to perinatal health coverage by addressing issues that affect vulnerable populations.
Conclusion
While the government has responded to the pandemic by adjusting things such as Medicaid coverage for telehealth and expansion of coverage for new mothers, these provisions are temporary. However, while these changes were driven by the ongoing world crisis, they have also been steps to addressing the national crisis regarding maternal mortality.
Sustained expansion of coverage and continued access to more resources could be a way to improve maternal health outcomes. Thus, the aim should be to make these changes to the system permanent, rather than temporary band-aids. At the end of the day, the pandemic is not the cause of the United States’ high maternal mortality and racial disparities in access to perinatal health, but rather, it is a lens that has highlighted the inequalities and fractures of the health system that allows for this to happen.
Works Cited
[1] (https://www.washingtonpost.com/politics/2021/02/11/health-202-congress-is-moving-lengthen-medicaid-coverage-new-moms/)
[2] https://www.kff.org/womens-health-policy/issue-brief/expanding-postpartum-medicaid-coverage/
[3]https://www.booker.senate.gov/news/press/maternal-health-bills-inspired-by-bookers-mommies-act-passes-house-subcommittee
[4]https://www.urban.org/sites/default/files/publication/103126/maternal-telehealth-has-expanded-dramatically-during-the-covid-19-pandemic_3.pdf
[5]https://www.urban.org/sites/default/files/publication/103126/maternal-telehealth-has-expanded-dramatically-during-the-covid-19-pandemic_3.pdf
[6]https://www.urban.org/sites/default/files/publication/100693/racial_disparities_in_uninsurance_among_new_mothers_following_the_affordable_care_act_0.pdf
[7]https://www.kff.org/medicaid/state-indicator/nonelderly-medicaid-rate-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
[8]https://www.urban.org/sites/default/files/publication/100693/racial_disparities_in_uninsurance_among_new_mothers_following_the_affordable_care_act_0.pdf
[9] https://www.webmd.com/baby/news/20190507/cdc-many-maternal-deaths-months-after-delivery#1
[10] https://www.usnews.com/news/health-news/articles/2021-04-01/stillbirths-other-pregnancy-complications-up-during-pandemic
[11] (Haley and Benatar)
[12] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416212/
https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/executive-order-on-strengthening-medicaid-and-the-affordable-care-act/-- information on covid impact on Latino/Black/Indigenous communities