Katy B. Kozhimannil, PHD, MPA, is an associate professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health and Director of Research at the University of Minnesota Rural Health Research Center. Her research applies health policy and health services research to the field of women's health, with a focus on maternal and child health. Dr Kozhimannil conducts research to inform the development, implementation, and evaluation of health policy that impacts reproductive-age women and their families. Twitter @katybkoz. E-mail firstname.lastname@example.org
Truly improving equity in childbirth care requires a bold new path forward.
We are failing our mothers, babies, and families in the United States. We are failing them on every level, with inadequate access to care, variable quality of care, and persistent disparities in maternal and infant outcomes of childbirth.
Too few women have access to needed care before, during, and after pregnancy, and access barriers include money, distance, and pervasive structural factors like racism and classism. First is money. Healthcare is expensive, and most people need health insurance to afford access to care. Recent health policy discussions have included:
1) Cuts to Medicaid, which funds half of all US births, with variability across states
3) Reducing regulations that require health plans to include “essential benefits” such as maternity and newborn care and mental health services
Altogether, these changes could increase the chances of becoming pregnant while decreasing access to necessary care. Reductions in health insurance access during pregnancy affect access to, quality of, and outcomes of care.
Secondly, access is hindered by distance, with women in the most remote rural communities losing access to hospital-based obstetric services with each passing year. Additionally, not all rural communities are affected equally. Rural communities with more black residents and lower median incomes are more likely to lack maternity services. Also, hospitals are more likely to close down their maternity units in rural counties in states with more restrictive Medicaid policies, highlighting the intersection of vulnerability of geography, race, income, and policy.
Among those who do have access to care, the quality of care during pregnancy and childbirth varies widely across hospitals, communities, and even racial and socioeconomic groups within hospitals. This variability in quality occurs in the context of broad structural factors that shape the allocation of opportunity and resources (environment, education, housing, etc) to produce disparate birth outcomes. Indeed, disparities in infant and maternal outcomes by race are widely documented. We have long been aware of these racial disparities in birth outcomes, and—in spite of this awareness—the needle has barely budged. Truly improving equity in childbirth care requires a bold new path forward.
We recently published a paper (freely available as full text until Dec 5, 2017) in Seminars on Perinatology, which describes these challenges and addresses the road ahead, with suggestions for systems-level reforms across 4 categories:
1) Risk-based triage of care
2) Maternity care quality measurement
3) Recognizing both medical and nonmedical aspects of childbirth
4) Addressing social determinants of health and birth outcomes
Transforming maternity care toward greater equity will also require actions in research, clinical care, and policy. We highlight specific strategies that researchers, clinicians, hospital administrators, and policymakers can take toward systems transformation across all 4 categories. Together, it is possible to take steps toward change to address longstanding problems with maternity care access, quality, and outcomes that have persisted for decades and worsened in recent years. Through innovation and collaboration across sectors, motherhood and infancy can become safer and more equitable for families across the United States. Betterment of birth is good for all of us.