Data-Driven Efforts to Support Maternal and Infant Health
Legislators play a vital role in strengthening data systems as well as supporting cost-effective and research-based investments in their states. Evidence-based home visiting programs support pregnant moms and new parents. Programs are voluntary and are commonly led by nurses, social workers, early childhood educators or other trained professionals. Home visiting improves maternal and child health and has been shown to reduce infant mortality, preterm births and emergency room utilization (NCSL; NCSL; HRSA).
Federal investment in home visiting—that is, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program—funds states and territories to develop evidence-based home visiting programs to support pregnant women and parents with young children up to kindergarten entry. MIECHV home visitors educate parents about safe sleep practices and the importance of postpartum care. They also screen for intimate partner violence and maternal depression. Depression during pregnancy affects between 14% and 23% of women, according to the American Congress of Obstetricians and Gynecologists. Left untreated, depression may increase the likelihood of preterm delivery and affect an infant’s development (Wiley).
In 2012, Maryland passed legislation to establish standardized home visiting measures, many of which align with MIECHV benchmarks. Such measures focus on screening for intimate partner violence and mental health conditions as well as adherence to regular well-child visits. Five years later, approximately 94% of children enrolled in a home visiting program were up to date on their child well visits (MD State-funded Home Visiting Outcomes Report). Likewise, in 2012, Michigan passed legislation to support home visitation programs to improve maternal and child health, and reduce preterm births. Five years later, 87% of mothers who had enrolled in a home visiting program delivered their baby at full term (Michigan Home Visiting Report). More recently, New Jersey passed legislation establishing a three-year Medicaid home visitation demonstration project to provide information, support and essential referrals to health and social services to families and young children.
Access to High-Quality Prenatal Care
Generally, prenatal care includes physical exams, laboratory screening tests, nutrition counseling and mental health services for pregnant women. Yet, approximately one quarter of U.S. women are unable to access the recommended number of prenatal visits, in part because of disparities in insurance and a shortage of maternity care providers (March of Dimes). Counties with limited or no obstetric care or obstetric providers, called “maternity care deserts” by the March of Dimes, may be at an increased risk of adverse outcomes since women who do not receive prenatal care die at three to four times the rate of those who do. States, hospitals and non-profits improve access to prenatal care in a variety of ways and through various payment or program models. For example, some states allow for “presumptive eligibility,” which automatically enrolls low-income pregnant women in Medicaid so they are eligible for prenatal services.
Medical practices in at least 46 states have adopted the Centering Pregnancy model. This model, thus far implemented as hospital-based pilot programs, brings together expectant mothers for a series of enhanced prenatal visits. In addition to medical care, participating women receive guidance about nutrition, breastfeeding, labor and delivery. The program also builds community and peer support. Where implemented, Centering Pregnancy can decrease the rate of preterm and low-weight births, reducing costly neonatal intensive care unit (NICU) admissions. One study estimated more than 4-to-1 return on investment for every dollar spent on Centering Pregnancy (District of Colombia Primary Care Association).
Between 2012 to 2014, the March of Dimes expanded Centering Pregnancy in 13 states— Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin. More than 8,000 women received group prenatal care and the preterm birth rate among these women was 7.4%, significantly lower than the 12% average for those 13 states over the same two-year period (March of Dimes).
Colorado’s Prenatal Plus Program targets Medicaid-enrolled, expectant mothers with early and comprehensive services, such as nutrition counseling, mental health services and coordinated care. A 2002 study by the Colorado Health Sciences Center found that each dollar spent on the program saved Medicaid approximately $2.48 in an infant’s first year of life. Additionally, the rate of low birthweight infants born to Prenatal Plus Program participants was 22.5% lower than the expected rate for women without Prenatal Plus services (AMCHP).
National Data Collection
In 1986, the CDC partnered with the American College of Obstetricians and Gynecologists (ACOG) to develop a national surveillance system to track pregnancy-related deaths. Since this time, several states have gone on to establish their own data tracking systems to fill knowledge gaps needed to determine causes of maternal and infant death, as well as to ensure that programs are evidence-based and achieving desired results. The Association of Maternal & Child Health Programs (AMCHP) published a policy brief about such data systems, including information about the Pregnancy Risk Assessment Monitoring System (PRAMS) and how states are using PRAMS data to support moms and babies. Forty-seven states participate in PRAMS, along with New York City, Puerto Rico, the District of Columbia and the Great Plains Tribal Chairmen’s Health Board. PRAMS participants represent about 83% of all U.S. births (CDC).
Relatedly, in 2012, the U.S. Department of Health and Human Services (HHS) announced the first national strategy to address infant mortality. This announcement led to the establishment of the Infant Mortality Collaborative Improvement and Innovation Network (CoIIN), which seeks to advance state and local infant mortality reduction efforts and encourage state health officials to identify and scale demonstrated strategies to reduce infant mortality. To learn more about how the Infant Mortality CoIIN supports states making changes to decrease infant mortality rates and reduce disparities, please visit the Infant Mortality CoIIN Prevention Toolkit.
Fatality Review Committees
In 1990, the American College of Obstetricians and Gynecologists (ACOG) and the Maternal and Child Health Bureau (MCHB) established the Fetal and Infant Mortality Review (FIMR) program. The program was designed to examine fetal and infant deaths, determine preventability, and engage community leaders to take action. FIMR programs provided specific recommendations, such as service system improvement, community education and improved clinical practices.ACOG provides free access to evaluations and resources related to FIMR programs.
Such efforts to measure, understand and classify infant death provided the foundation for contemporary infant mortality review committees. Now, many states have established multidisciplinary fatality review committees, commonly composed of members from each legislative chamber and representatives from child protective services, law enforcement, public health, behavioral health and the medical community (CDC et al). These committee teams investigate and evaluate fatality data to accurately identify the conditions, policies, and behaviors that contribute to preventable deaths (Christian et al).
State maternal mortality review committees (MMRCs) are the primary data source detailing pregnancy-associated and pregnancy-related death. In addition to monitoring the maternal mortality rate, states can expand their review of maternal deaths by considering pregnancy-related and pregnancy-associated deaths. Pregnancy-related deaths cover maternal death occurring within one year after the end of pregnancy from a pregnancy complication or events initiated by pregnancy. Pregnancy-associated death covers all maternal death within a year of the end of pregnancy, regardless of the cause.
State legislatures authorize maternal mortality review committees and establish their composition and purpose. State MMRC legislation may also determine how the state will maintain patient privacy for the records they review. Generally, MMRCs investigate at a more detailed level than the death certificate. There are 38 states and two cities with MMRCs operating through partnerships with the state vital statistics office and epidemiologists to examine deaths of women of reproductive age to determine if they occurred during pregnancy or within one year of delivery. Generally, representatives from each chamber of the state legislature are members of the MMRC, in addition to state and local maternal health experts.
Analyzing data and common themes from MMRCs can help to identify groups of people, illnesses and settings where outcomes are worst. In recent years, states sought to refine their approach, but improving data can uncover more challenges. For example, data from a report from nine MMRCs pointed to the disparate outcomes across race and other demographics: “Recent trends address efforts to measure maternal mortality and understand the drivers of maternal mortality in terms of death in relation to pregnancy, cause of death and other demographic data. This data uncovered racial, income-related and geographic disparities in maternal mortality rates.” Such data inform the policy recommendations put forth by MMRCs. Recommendations largely focus on clinical protocols, documentation, systems-level care coordination and provider training. Review committees can be an effective vehicle for state leaders working to reduce infant and maternal mortality.
In 2018, Louisiana enacted a bill that created the Healthy Moms, Healthy Babies Advisory Council within the Louisiana Department of Health. The legislation provided that the council, made up of experts and stakeholders committed to addressing racial and ethnic disparities in maternal health outcomes, will support the state Perinatal Quality Collaborative by incorporating a community-engaged approach to preventing maternal mortality and morbidity. Additionally, the legislation expanded public coverage options to provide access to provider services and other delivery-focused reforms that address maternal health outside the hospital setting.
Maine includes infant, fetal and maternal mortality in its review panel. In 2017, Maine House Bill 366 expanded tracking and investigative activities for fetal death and extended the timeline for investigating maternal death from 42 days to one year after pregnancy. Through a confidential process, Maine’s state health officer connects with surviving family members to ask for voluntary participation in creating a case summary to be shared with the review panel.
In 2010, Ohio established the Ohio Pregnancy Associated Mortality Review (PAMR). Ohio’s statistical reporting and policy recommendations are extensive. The Health Policy Institute of Ohio and the Ohio Legislative Service Commission collaborated to produce a 233-page report recommending state policy reforms for the legislature and other state agencies. The recommendations focused on housing, transportation, education, employment and other cross-cutting policies that support mothers, families and children.
Quality Improvements in Maternity Care
With support from the Maternal and Child Health Bureau in the Health Resources and Services Administration, at least 21 states and more than 650 hospitals work with the Alliance for Innovation in Maternal Health (AIM). AIM promotes safe and consistent maternity care through clinical quality improvements and works directly with practitioners in health care facilities who perform approximately 45% of all U.S. births.
Among the program’s tools are “maternal safety bundles”—one- to two-page briefs divided into bulleted sections with reminders for clinical staff on best practices to prevent, recognize, respond to and report on pregnancy-related conditions. When performed collectively and reliably, the strategies work. Safety bundles cover such topics as:
- Early warning signs of complications
- Vaginal births
- Racial disparities
- Postpartum care
- Care for opioid-dependent women
The American College of Obstetricians and Gynecologists reports that Illinois has reduced severe maternal morbidity by about 22% and morbidity due to hypertension by nearly 20% through the AIM initiative. Oklahoma reduced severe maternal morbidity by roughly 20% in its participating hospitals.
Additionally, perinatal quality collaboratives (PQCs) are state or multi-state networks of teams working to improve infant and maternal health by advancing evidence-informed clinical best practices. State PQCs can be considered the action arm of maternal mortality review committees (MMRCs) as they frequently translate the data collected and analyzed by review committees into action through clinical reforms. For example, the California Maternal Quality Care Collaborative (CMQCC), which began at Stanford University in 2006, is an active AIM member and works closely with the state’s maternal mortality review committee. In 2016, the CMQCC, in partnership with the Hospital Quality Institute, developed a toolkit of clinical best practices to help hospitals reduce preventable mortality and morbidity and racial disparities in California. The toolkit provides users with resources to: improve the culture of care, awareness, and education for cesarean reduction; support intended vaginal birth; manage labor abnormalities and safely reduce cesarean births; and use data to drive reduction in cesarean births.
California is currently the only state showing consistent reductions in maternal mortality. California reduced the state maternal mortality rate from 16.9 per 100,000 live births in 2006 to 7.3 in 2013. The state attributes the improvement to a variety of efforts, including public-private partnerships and quality improvement efforts through the Alliance for Innovation in Maternal Health.
Additionally, some states have begun applying the principles of patient-centered medical homes to perinatal care in the form of maternity medical homes. Maternity medical homes emphasize early entry into prenatal care, care coordination and standardized risk assessments for moms. In 2011, North Carolina launched the Pregnancy Medical Home model, which focuses on reducing the rate of preterm birth and establishing care pathways for conditions such as hypertension and substance use disorder, along with several other improvement goals. Missouri, Oregon and Wisconsin have similar initiatives. Early findings suggest that maternity medical home models may benefit the health of moms and babies.An evaluation of North Carolina’s Pregnancy Medical Home model found that the state saw a nearly 7% decrease in the rate of low birthweight babies within the Medicaid population. Such outcomes may signal the benefit of a shift toward a holistic, patient-centered approach to pregnancy care.
Additional State Policy Innovations
In addition to the efforts mentioned in earlier sections of this brief, states continue to explore innovative approaches to support maternal and child health. Providing services through telehealth is an innovative approach states employ to address access to care, particularly in rural areas. Arkansas and Virginia operate telehealth programs for high-risk pregnant women. These programs consist of video conferencing with maternal and fetal medicine specialists, and each have demonstrated significant outcome improvements, such as fewer deliveries of very low birthweight infants and shorter stays in neonatal intensive care units.
Expanding the Health Care Workforce
Some states, such as Washington and Oregon, are expanding their health care workforce by allowing Medicaid reimbursement for midwives. Expectant women who interact with midwives or doulas report more hands-on care and personal support and may be at decreased risk of delivering early or losing their infant (Horton et al; Sandall et al; Saraswathi Vedam et al). However, while the integration of midwives and doulas into health care systems may facilitate greater patient-centered care and contribute to positive birth outcomes, women at high risk of pregnancy complications are encouraged to deliver under the guidance of a specialized physician.
Addressing Maternal Mental Health
In addition to improving clinical services that address physical maternal health, addressing maternal mental health is an important strategy to reduce maternal mortality rates. As rates of suicide increase across the United States, maternal and child health professionals are increasingly concerned about suicide as a cause of death among pregnant and post-partum women. Likewise, the correlation between mental health conditions and substance use disorders suggests that efforts to coordinate mental health services with substance use disorder treatment may keep more moms alive as they work through recovery. The Missouri legislature enacted a bill to extend substance use and mental health treatments for Medicaid-eligible mothers for to up to one year after giving birth. Other state legislative examples can be found in NCSL’s brief “From Pregnancy to Postpartum: The Effects of Maternal Depression on Mothers, Infants and Toddlers.”
For additional examples of enacted maternal and child health (MCH) legislation, please visit NCSL’s Maternal and Child Health Database. This resource tracks several MCH priorities, including maternal mortality and morbidity, infant mortality, newborn screening and maternal mental health.