Maternal deaths are public health and health equity problems. They’re also preventable.


The maternal mortality rate in the U.S. is rising, and Black women have the highest risk. Extending access to postpartum health care would prevent deaths.

The maternal mortality rate in the U.S. is rising, and Black women have the highest risk. Extending access to postpartum health care would prevent deaths.

Each year, around 700 women die from pregnancy-related complications in the United States. Approximately two-thirds of those deaths could have been prevented. According to a report from the Texas Health and Human Services Commission, the overwhelming majority of pregnancy-related deaths in the state are preventable as well. The commission’s Texas Maternal Mortality and Morbidity Review Committee found there was at least some chance of avoiding death in 89% of cases.

Maternal mortality and morbidity is also a pressing issue in Harris County, where the percentage of women with severe maternal morbidities increased by 53% between 2008 and 2015. During the same time, the percentage of women with severe maternal morbidities statewide increased as well, but only by 15%.

The COVID-19 pandemic has renewed awareness about public health issues in the United States and the Houston area. Concerns about public health are the biggest problem facing people in the Houston area today, according to participants in the 2021 Kinder Houston Area Survey released earlier this month. While efforts to reduce deaths from maternal mortality and morbidity predate the coronavirus, currently, there’s a chance Texas Legislatures could take a big step toward extending preventive care to many mothers in the state.

Contributing factors to maternal mortality

There’s a long list of factors that contribute to a woman dying because of pregnancy, including chronic disease, lack of knowledge related to treatment or follow-up, delays in seeking or providing care, and disruptions in care, among others. There are also disproportionately high rates of maternal mortality and morbidity among Black women.

And pregnancy-related deaths don’t just occur during delivery. The CDC defines maternal mortality as deaths during pregnancy, at delivery, or up to one year after pregnancy. Nationwide, one-third of these deaths are postpartum, and increasingly, these deaths occur more than 43 days after giving birth. In Texas, according to the Texas Maternal Mortality and Morbidity Task Force, 56% of all maternal deaths between 2012 and 2015 occurred more than 60 days after the end of pregnancy.

These statistics illustrate the importance of care for new mothers beyond childbirth. Postpartum care—and by extension, coverage—is essential to preventing, detecting and mitigating pregnancy-related complications, such as cardiovascular disease, diabetes and hypertension. This is especially true for Black, Hispanic and American Indian and Alaska Native women who disproportionately are affected by disruptions in perinatal care (immediately before and after birth), which likely contribute to the higher rates of pregnancy-related deaths among these groups.

Postpartum care includes recovery from childbirth and any complications from pregnancy, management of chronic health conditions, such as hypertension or diabetes, access to family planning, and follow-ups on a mother’s mental health. In the U.S., one in seven women experiences postpartum depression, underscoring the critical need to care for mothers’ mental health both during and after pregnancy. In light of these factors, there has been a greater emphasis on postpartum care that extends to multiple visits up to a year or longer after delivery, the so-called “4th trimester.”

The need to extend pregnancy-related Medicaid coverage

Medicaid “finances” four in 10 births in the U.S. and provides postpartum care for 60 days after childbirth. In Texas, to qualify for pregnancy-related Medicaid coverage, a woman must be a U.S. citizen or qualified noncitizen and meet a certain income level—up to 198% of the federal poverty-income level (FPIL): $25,502 for an individual or $43,480 for a family of three. Though the benefits vary by state, most include basic prenatal services, counseling and support services and two months of postpartum care, including breastfeeding services.

Increasingly, doctors, public health experts, advocates and policymakers recognize postpartum care’s critical role in maternal health. There has been a paradigm shift to emphasize that postpartum care is an ongoing process that typically requires multiple visits and follow-up care that may last a year or even longer, according to the Kaiser Family Foundation. Maternal Mortality and Morbidity Review Committee reports from Arizona, Georgia, Maryland, Texas, Utah, and Washington all recommend extending postpartum Medicaid coverage. And many states, both those that have expanded Medicaid and those that do not, are looking to extend pregnancy-related Medicaid benefits from 60 days postpartum to at least 12 months.

In the 2021 legislative session, Texas lawmakers have filed a number of bills that would extend pregnancy-related Medicaid coverage, including HB 98, HB 107, HB 143, HB 146, HB 414, SB 121 and SB 141, all of which were referred to the Health and Human Services Committee. The Texas House passed HB 133 in April, which extended Medicaid coverage for mothers to a year. Last week, Texas Senators reduced the extension to six months, and now it’s waiting for Senate approval before going back to the House. The session ends May 31.

The benefits of expanding postpartum care

The primary reasons for extending coverage beyond 60 days postpartum are to reduce churn, improve the efficiency of health care coverage and prevent pregnancy-related complications.

Many women experience disruptions in perinatal insurance coverage, and among women who rely on Medicaid for pregnancy-related care, most of these disruptions occur during the postpartum period. In Texas, a pregnant woman earning up to 198% of the FPIL can be covered by Medicaid through 60 days after pregnancy, but on day 61, she must earn less than 17% of the FPIL to maintain her coverage ($3,733 for a family of three), leading to loss of coverage for many. These disruptions in coverage are a phenomenon called “churn” and affect half of women in states such as Texas that have not expanded Medicaid, and a third of women in states that have expanded Medicaid.

In addition, coverage for mothers does not currently align with coverage of their newborns. Babies born on Medicaid maintain coverage up to one year after birth. If the time for benefits is expanded such that the mother also maintains coverage for this time, the redetermination of eligibility for the infant and for the mother can occur simultaneously, improving both administrative and cost efficiency.

Lastly, if coverage for postpartum care is extended, new mothers will be able to receive preventative care that is likely to reduce spending in other programs such as Emergency Medicaid. For example, bipartisan federal bill HR 4996 (Helping Medicaid Offer Maternity Services) was introduced in 2019 and would provide a temporary increase in funds if a state chose to extend Medicaid postpartum coverage to 12 months. A Congressional Budget Office analysis predicts that the bill will generate a net gain of $894 million of revenue for the total period of 2020-2030.

Efforts to extend coverage at the federal level

During the pandemic, a provision in the Families First Coronavirus Response Act stated that new mothers enrolled in Medicaid wouldn’t lose coverage at 60 days postpartum, effectively extending pregnancy-related Medicaid coverage. This will be in effect until the end of the month in which the public emergency period ends. Currently, the public emergency period is set to end in July.

Additionally, at the federal level, the American Rescue Plan, which was signed into law March 11, provides a new option for states to extend postpartum Medicaid and Children’s Health Insurance Program (CHIP) coverage for one year after the end of pregnancy. States can receive matching federal funds for this coverage, but they must opt in sometime before five years from when the new policy begins in April 2022. This new option bypasses a lengthy waiver application process and, instead, only requires states to notify the federal government before moving forward. This is crucial because five states that submitted the waiver previously were waiting for approval and unable to provide benefits. The projected cost is $1,500 per person, but this estimate does not consider the cost saved through increased use of preventative care.

In July 2020, the Center for Children and Families of the Georgetown University Health Policy Institute and a coalition of 279 national, state and local Medicaid advocates, patient groups and provider organizations wrote a letter to Health and Human Services Secretary Alex Azar calling for the extension of Medicaid postpartum coverage to 12 months to reduce racial disparities in health care. Members of the coalition included the NAACP, American Heart Association, Every Texan, and others.

Other options for maternity health care

For those who do not meet the eligibility requirements for Medicaid because of income level or immigration status, Texas authorized the CHIP Perinatal program in 2005 to provide prenatal visits and limited postpartum care. For example, CHIP Perinatal provides coverage if a pregnant woman has a household income below 202% of the FPIL but does not qualify for Medicaid because of immigration status. Pregnancy-related Medicaid benefits in Texas are not extended to lawfully present immigrant women who came to the U.S. on or after Aug. 22, 1996, or to undocumented immigrants; these populations must seek care under CHIP Perinatal.

However, CHIP Perinatal only really covers prenatal care. The program covers two postpartum visits for the mother, though the child will receive the traditional CHIP or Medicaid benefits, depending on income level. Furthermore, many services are excluded from the prenatal benefits in CHIP Perinatal. Inpatient hospital care for the pregnant woman that is not related to labor or delivery, such as a serious injury or illness, false or premature labor (without delivery of the baby), and most outpatient specialty services (such as mental health and substance abuse treatment, asthma management and cardiac care) are not covered. In these situations, one may apply for Emergency Medicaid, but Emergency Medicaid will only cover services related to labor and delivery, such as outpatient specialty services.

Expanding coverage to immigrants

Texas is one of six states to exclude legal immigrants from Medicaid eligibility. However, pregnant immigrant women should receive similar coverage to pregnant U.S. citizens, especially considering that lawfully present immigrant children receive similar coverage to U.S. citizens under the 2009 Congressional CHIP Reauthorization Act (CHIPRA).

Given the limitations in coverage of both CHIP Perinatal and Emergency Medicaid, there is momentum to extend traditional Medicaid coverage to immigrants. In Texas, HB 734 and SB 521 extend Medicaid coverage to lawfully present immigrants who came to the U.S. on or after August 22, 1996. Though these bills have been referred to committee, they are not likely to pass in the current legislative session.

Additional steps to extend coverage

In addition to extending postpartum Medicaid coverage to 12 months and to immigrant populations, other approaches to extending coverage and reducing maternal mortality are:

► Expanding full-scope Medicaid

► Raising parental income eligibility levels under Medicaid

► Expanding coverage for specific postpartum services or specific populations such as individuals diagnosed with a maternal mental health condition

► Providing postpartum coverage for family-planning services

Rithika Proddutoor is a bioengineering and civic leadership graduate from Rice University.

The views, information or opinions expressed in this post are those of the author and do not necessarily represent those of the Kinder Institute for Urban Research

Rithika Proddutoor
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