Federal and State Policymakers Must Address Alarmingly High Maternal Mortality Rates and Racial Disparities

The United States has an unacceptably high maternal mortality rate and it is getting worse. The latest data from the CDC shows that maternal mortality increased significantly between 2018 and 2019, topping out at the highest recorded rate since the agency began tracking the rate more than 30 years ago.

A country’s maternal mortality rate is a key measure of how we’re doing as a society on health. And the alarming U.S. rate—higher than any other industrialized nation—shows us that we are not doing well. The U.S. maternal mortality rate in 2018 was twice as high as the rate in Canada, and nearly 10 times as high as the maternal mortality rate in Norway.  Black women in the U.S. have the highest maternal mortality rates of any group in the country, more than twice as high as the U.S. average for all women. Mortality rates in the U.S. have been rising for all women in recent years.

Change in Maternal Mortality Rate, 2018-2019

Maternal death is devastating to families and communities. And as state maternal mortality review committees in dozens of states have shown, these deaths are often preventable. The committees, along with advocates, clinical experts and researchers, have overwhelmingly recommended Medicaid expansion as an essential first step for supporting maternal health. Despite major new fiscal incentives on the table, there are 12 states where people below the poverty line still have no affordable option for comprehensive coverage. As a consequence, Congressional lawmakers are currently considering the “Build Back Better Act” to create a comprehensive and permanent fix to close the coverage gap for those left behind.

A great deal of research findings support the many benefits of Medicaid expansion. Among them, Medicaid expansion is significantly associated with seven fewer maternal deaths per 100,000 live births relative to non-expansion states, with the greatest decreases in mortality rates among Black, non-Hispanic women and Hispanic women. Medicaid expansion has also been linked to declines in infant mortality, with the steepest declines for Black babies. Expansion has also been associated with reductions in reported child neglect rates, and greater financial security for families.

State uninsured rate data shows why Medicaid expansion is important to maternal health. Our report released today shows that women of childbearing age who lived in non-expansion states were more than twice as likely to be uninsured than women living in states that had expanded Medicaid in 2019, and the trend extended to all racial and ethnic groups.

Uninsured Rate for Women of Childbearing Age (18-44) by Expansion Status, 2019

For instance, a Black woman in Texas, a non-expansion state, had an uninsured rate (21.4 percent) more than double the average rate for Black women living in expansion states (9.0 percent).

Women who identify as Hispanic/Latina and who live in non-expansion states have the highest uninsured rates of any racial or ethnic group, with more than one-third, or 35.5 percent, of women reporting being uninsured in 2019.

You can explore data by race and ethnicity from all states in our interactive online chartbook.

Disparities in Uninsured Rates for Women of Childbearing Age (18-44) by Expansion Status and Demographics, 2019

The data make clear that expanding coverage must be the first step to address maternal health inequities, and state and federal policymakers have a responsibility to act. But more must be done to address the persistent racial disparities in health coverage and outcomes for women of childbearing age and their families. Even after states expand Medicaid, there are still wide gaps in coverage rates by race and ethnicity within states. The widest disparities are between women who identify as Hispanic/Latina and those who do not.

Disparity in Uninsured Rate for Latina Women of Childbearing Age (18-44), 2019

Coverage is an essential first step, but it is not enough. When comparing racial groups, Black and white women’s average uninsured rates are within one point of each other in expansion states, yet Black women are still much more likely to die of a pregnancy-related cause than white women in those states. For instance, in New Jersey, Black women have an 11 percent uninsured rate compared to 10 percent for white women, yet Black women in New Jersey are seven times more likely than white women to die of a pregnancy-related cause.

This reality underscores the role of social determinants of health, including racism and discrimination, that studies show can lead patients to avoid or delay seeking care, be misdiagnosed, or receive inappropriate treatment. Multiple studies have shown that women who experienced racism and discrimination were more likely to have an infant born at low or very low birth weight.

To address the harms of racism in health care and better serve women of color before, during, and after pregnancy, state and federal policymakers are leveraging Medicaid for change. Some states are pursuing additional benefits, such as group prenatal care, evidence-based home visiting programs and substance-use disorder services tailored specifically to those who are pregnant or postpartum.

The “Build Back Better Act” being marked up in the House today takes a two-track approach. Coverage changes in the bill include a permanent, comprehensive solution to closing the coverage gap in non-expansion states and a requirement that all states extend postpartum Medicaid coverage for one year after the end of pregnancy.  In addition, the legislative language makes significant investments to improve the quality of care women receive by growing and diversifying the perinatal workforce, promoting education and anti-bias training for health care providers, and supporting a more robust data infrastructure to better track and improve maternal health outcomes for women of color.

Policymakers in the U.S. must act to address the crisis the nation is facing. Women of all races, regardless of where they live or what they earn, deserve the support they need to take care of themselves and their families before, during, and after pregnancy. The data shows us that closing the coverage gap will help support maternal health, reduce racial health disparities and support the healthy development of parents and children together.

Editor’s note: To maintain accuracy, CCF uses the term “women” when referencing statute, regulations, research, or other data sources that use the term “women” to define or count people who are pregnant or give birth. This includes self-reported data collected by the U.S. Census Bureau. Where possible, we use more inclusive terms in recognition that not all individuals who become pregnant and give birth identify as women. Available data included in this report does not capture information about pregnant people and people who give birth who do not identify as women.

Medicaid Expansion Narrows Maternal Health Coverage Gaps, But Racial Disparities Persist

Maggie Clark is a Program Director at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.