A strategy map for improving equity and outcomes
A woman in the United States today is more likely to die from a pregnancy-related cause than a woman was in the 1990s. And racial disparities in maternal health are stark, with Black, American Indian, and Alaska Native women two to three times more likely than White women to die from pregnancy-related causes. With medical advancements taking place all the time, it begs the question, why is this happening?
Chronic conditions, maternal age, and rising rates of Cesarean births could be part of the reason for declining maternal health. But the reproductive justice movement, and the Black women who started it, have for decades called out the many ways reproductive policies and politics are rooted in “gendered, sexualized, and racialized acts of dominance that occur on a daily basis.” The uncomfortable truth is that maternal health, or lack thereof, in part reflects the deeper ways women generally, and women of color specifically, are pushed to the margins and treated as disposable by our society.
For example, the leading cause of death during pregnancy is not related to the physical strain of carrying a child; it is murder at the hands of an intimate partner. At the same time, when common pregnancy complications like cardiovascular conditions and infections do arise, implicit bias often makes clinicians actively ignore Black women’s pain and symptoms. It leads clinicians to misdiagnose and improperly treat pregnancy complications. These are just two of the ways that the misogyny and racism embedded in our society and its systems affect maternal health.
It is critical that we support programs and policies that will ensure women—and birthing people of all genders—survive pregnancy. Yet mere survival is an extremely low bar for what should constitute maternal health. The reproductive justice movement calls for systems and policies that not only support a birthing person’s right to choose if and when they have a child, but that also support their right to raise the children they choose to have in a safe, sustainable community. That means safety from gun violence, access to affordable housing, and the security of being paid a living wage. In other words, true maternal health is about thriving, not just surviving. (For more information on reproductive justice, follow the work of SisterSong Women of Color Reproductive Justice Collective and the Guttmacher Institute.)
To help women and families thrive, we must go upstream—to care for a woman throughout her whole life, not just during the narrow pregnancy and postpartum windows. And this can only happen if we look at the full environment she lives in, not just the clinic where she goes for care. Because while a 17-year-old with a substance use disorder who is inadequately employed may not be pregnant today, she may choose to be in the future. And how we care for her now will affect her future wellbeing and the wellbeing of her future child.
To do this upstream work, health systems and insurers must invest in strategies that promote maternal health equity across levels of prevention (health promotion, primary and secondary prevention, and treatment) and levels of intervention (care delivery, system, ecosystem, and societal). HealthBegins developed a tool called the Upstream Strategy MapTM to help health systems and insurers assess and plan strategies across these different levels and decide where they can most effectively lead and partner. (Read this post to see how the tool works, and click through the interactive graphic below to see a sample Upstream Strategy MapTM for maternal health.)
Here are examples of what a multi-level approach to maternal health could look like.
Invest in Programs and Care Delivery That Treat the Whole Birthing Person
There are many promising evidence-based treatments that healthcare organizations are implementing at the program and care delivery level to improve maternal care and reduce racial disparities. For example, women who receive care from doulas and midwives are less likely to have a preterm birth, C-section, or pregnancy complications. Women need broader and more consistent access to these programs.
But it is critical that maternal health care delivery also addresses women’s mental and social health. According to The Commonwealth Fund’s 2024 State Scorecard on Women’s Health and Reproductive Care and the CDC’s 2020 Maternal Mortality Review Committee, mental health conditions are the most frequently reported cause of preventable pregnancy-related death postpartum, including deaths by suicide and overdoses related to substance use disorders. And analysis from the AAMC’s Center for Health Justice found that Black women were more likely than White or Hispanic women to report suffering from postpartum depression, but that Hispanic people were screened at lower rates for depression and anxiety.
Health systems and insurers can support mental and social health by strengthening screening for mental health disorders and social needs during pregnancy, embedding mental health services more deeply in maternal health care, deepening partnerships with community-based organizations that provide social services and resources, and investing directly in these programs. In a letter to the Biden Administration this May, the American Medical Association (AMA) called for an expansion of evidence-based programs to treat substance use disorder during pregnancy and postpartum periods. The AMA also asked for a deeper focus on addressing social needs among patients who are pregnant or postpartum by enhancing medical-legal partnerships and access to civil legal services.
Promote Policies Inside and Outside the Clinic That Support Birthing People
Birthing people need healthy food, safe housing, personal safety, and physical rest before, during, and after pregnancy to promote maternal health. However, there are systemic and societal barriers to accessing these things. Look at the issue of workplace safety. Many birthing people are forced to work in unsafe conditions during pregnancy and/or go back to work immediately after giving birth because their jobs offer no paid parental leave, further putting their health at risk. According to the AAMC Center for Health Justice, women who took paid leave have lower rates of depression than women who took unpaid or no leave. Racial inequities show up here too. Black and Latina women are less likely to have access to paid parental leave than White women.
The healthcare sector—which employs 23% of all Black women in the labor force—can support workplace safety at a systems level by ensuring that its own institutions follow robust safety standards and provide pregnant employees with reasonable accommodations when needed to continue working safely (accommodations that are now required by law under the Pregnant Workers Fairness Act). Organizations should also offer healthcare coverage and paid parental leave to all employees.
Health systems can go further by advocating at a societal level for policies that would guarantee paid parental leave for all birthing people. The Family and Medical Insurance Leave Act—which has been introduced in both the House and Senate—would guarantee a person up to 12 weeks of paid leave per year to care for a newborn or newly adopted child, address their own serious health condition, or care for a parent, child, spouse, or domestic partner with a serious health condition.
Build Societal Supports that Help Birthing People Thrive Throughout Their Lifespan
Extensive research has highlighted many ways poverty perpetuates poor health throughout a person’s lifespan. Lack of nutrition and toxic stress cause chronic health conditions, increase pregnancy complications, and harm child development. Just last month, the Surgeon General issued an advisory about parental stress and its harmful effects on the health of both parents and children. The advisory named financial strain as one of the major stressors parents face, and data analysis from economist Emily Oster shows how deeply poverty correlates with parent stress.
Healthcare and other systems throw all sorts of band-aids at the health problems created by poverty, but the only real solution and means of health promotion is to create lasting economic security for individuals and families. That is a much larger goal than the healthcare sector can or should tackle alone. However, it has a critical role to play in using its voice and resources to advocate for policies at a societal level that promote economic security, and with it, better health at all ages. When it comes to maternal health, this includes policies that allow birthing people to choose when and if to have children, such as increasing access to family planning services, ensuring family planning services are covered by Medicaid, and increasing access to abortion services.
The healthcare sector can also leverage its power and expertise to move the dial on policies that ensure parents have resources to care for the children they choose to have. The recent advisory from the Surgeon General specifically called out the need for paid family leave and affordable child care to support economic security and reduce stress. Other critical economic policies for families include increasing the child tax credit, raising the minimum wage, and closing the gender wage gap, which increased last year for the first time in two decades. In every community, there are local community organizers and community-based organizations leading on issues of reproductive and economic justice. Health systems can research the work happening locally, learn from organizers, provide resources where needed, follow the lead of those closest to this work, and work in tandem to move toward big societal changes.
Just as isolation from resources and support can undermine the health of a new mother and her child, so can isolating prenatal and birthing services from all other elements of a woman’s lifelong health care. The path to lasting improvement is to address health needs across the lifespan and the arenas of daily living, and to do so through a deliberate, multi-level strategy.
Because equity—from the smallest interaction in the clinic to the largest policy efforts of a health system—is not only the outcome of excellent health care. It is the means to get there.
This article was conceived by Eva Batalla-Mann, Kathryn Jantz, Vince Pancucci, and Taleen Yepremian, and written by Kate Marple.