Maternal morbidity and mortality are ongoing crises in the US. Every year, 50,000 women experience serious complications following birth. These complications can be a result of health conditions experienced before and during pregnancy, and women of color have disproportionately high maternal morbidity rates.

Policymakers have begun to take action to address this problem. As we shared in a recent blog, many states are enthusiastically taking up the new Medicaid state plan option to extend postpartum Medicaid coverage from 60 days to 12 months after the end of pregnancy. These extensions have been high-profile, but states have many opportunities throughout their Medicaid programs to make improvements that will support better maternal health outcomes.

A recent 50-state inventory of state Medicaid programs, policies, and initiatives released by Mathematica details hundreds of state-level initiatives intended to improve maternal care and outcomes. The inventory contains a range of state efforts, spanning managed care contracting, performance measurement, eligibility and enrollment, education and outreach, benefits, and payment and care delivery models. Benefits and outreach improvements were among the most popular areas for state changes. Detailed below are a few noteworthy strategies states are using to improve benefits and conduct outreach.

Benefits

To address high maternal mortality and morbidity rates, many states have elected to offer more and better benefits to eligible pregnant women. These enhanced benefits include:

• Labor and delivery support from doulas or other community-based providers (six states). In Minnesota, for instance, education and support from certified doulas has been covered by Medicaid since 2013. Research on Minnesota’s program has shown that doula presence has helped address health disparities due to racial and economic determinants during pregnancy and birth.
• Home visits for pregnant and postpartum women by doctors, nurses, or community health workers (26 states). In some cases, the home visits can be part of an evidence-based home visiting model. For example, New Mexico is currently running an MCO pilot program where each MCO is required to offer evidence-based home visiting models through Medicaid in at least two high-risk counties with high maternal mortality rates. Home visits are a crucial benefit especially for women who are high risk, on bed rest or are recently postpartum.
• Substance use disorder (SUD) treatment, or information about where SUD services are available–specifically tailored to pregnant women (21 states). Ohio is among the states that have specific strategies to support pregnant women with an SUD. The state’s MOMS+ program is designed to support pregnant people with SUD (especially those with Opioid Use Disorder, or OUD) as early as possible in their pregnancy and connect them to existing community resources.
• Group prenatal care (9 states) and maternal medical homes (4 states). Group-based prenatal care models like CenteringPregnancy provide consistent and motivating prenatal care and support throughout pregnancy through facilitated discussions with peer groups and support from nurse educators. Maternal medical homes also serve to connect primary care providers, specialists, patients, and their families to facilitate better communication and coordinate accurate and high-quality perinatal care. A recent report from Planned Parenthood recommends clinical-community partnerships to facilitate these connections and address social determinants of health that affect women of childbearing age.

Outreach

Even though Medicaid finances nearly half of all births in the U.S., there are thousands of eligible but unenrolled pregnant women across the country who miss out on the essential benefits each year. Between 2016 and 2018, 27% of uninsured mothers (118,800 women) were eligible but unenrolled in Medicaid. Deliberate and targeted outreach to pregnant women can help get them enrolled and utilize all the benefits available.

Among the strategies states have employed:

• Preemptively contact Medicaid-enrolled pregnant women about case management and other benefits available to them (34 states). This early contact is designed to promote better prenatal care, prenatal vitamin usage, and postpartum outcomes.  Idaho requires contractors to specifically reach out to pregnant beneficiaries about their dental care options during pregnancy.
• Screening tools to identify beneficiaries whose pregnancies are at high risk for poor maternal or newborn outcomes (32 states). For example, West Virginia requires MCOs to perform Prenatal Behavioral Risk Assessments and provide information to beneficiaries about prenatal services available to them.

Taken together, the recent activity on extending postpartum Medicaid coverage for 12 months after the end of pregnancy, combined with Mathematica’s inventory and MACPAC’s report on smaller-scale initiatives in state Medicaid agencies demonstrate that many states are taking action to address the maternal morbidity and mortality crisis in the US. We look forward to more research on the efficacy of these initiatives.