ACE

Author: Juliana Carreiro-Oliver

  • Maternal Mortality Review Committees and the PMDR Reauthorization of 2023: Key Perspectives

    Maternal Mortality Review Committees and the PMDR Reauthorization of 2023: Key Perspectives

    Introduction

    The United States faces a maternal mortality crisis, with maternal death rates significantly higher than other high-income nations. According to the CDC, maternal mortality disproportionately affects Black, Indigenous, and rural communities, with Black women experiencing maternal deaths at 2.6 times the rate of White women. The factors contributing to these disparities are complex and include unequal access to quality healthcare, socioeconomic barriers, and more. Despite advancements in healthcare, 80% of maternal deaths are preventable through timely medical intervention and comprehensive data collection. 

    What are MMRCs?

    State-based Maternal Mortality Review Committees (MMRCs) have been shown to play a pivotal role in analyzing maternal deaths to recommend evidence-based interventions. MMRCs are multidisciplinary teams that examine maternal deaths occurring during pregnancy or within one year postpartum. They utilize comprehensive data sources, including medical records, autopsy reports, and social service information. MMRCs assess preventability and contributing factors, allowing them to identify patterns and propose targeted policy solutions. Their review process centers on critical questions related to medical factors, social determinants, delays in care, and provider bias. By systematically addressing these factors, MMRCs generate insights that inform strategies to reduce preventable maternal deaths, which comprise 20% to 50% of all maternal deaths in the U.S.

    However, MMRCs face inconsistent funding and regulatory barriers, limiting their ability to track and analyze maternal deaths across states. Disparities in data collection methods and access to comprehensive patient records further hinder efforts to address maternal health inequities. Some states lack the authority to access certain medical records, while others experience delays in data sharing, reducing the timeliness and effectiveness of recommendations. Without consistent federal funding, many MMRCs struggle to maintain operations, particularly in rural and underserved areas, where maternal health disparities are often most pronounced. 

    Introduction to the Preventing Maternal Deaths Reauthorization Act

    The Preventing Maternal Deaths Reauthorization Act of 2023 (PMDR) was introduced to the House Committee on Energy and Commerce by Congresswoman Robin Kelly (D-IL) on May 18, 2023. The bill passed out of the Senate Health, Education, Labor, and Pensions (HELP) Committee in Fall 2023 and passed the House with bipartisan support in March 2024. However, the bill failed to pass the Senate before the end of the legislative calendar, rendering the bill “dead”. The reauthorization built upon the original Preventing Maternal Deaths Act of 2018, which helped establish and fund state-based Maternal Mortality Review Committees (MMRCs) to investigate maternal deaths and identify preventable causes. It sought to extend funding for MMRCs, enhance data collection, and address racial disparities in maternal health outcomes through the following provisions:

    1. Extending funding for state-level MMRCs to continue investigating maternal deaths
    2. Authorizing $58 million annually for the CDC to support state-level efforts
    3. Enhancing data collection on factors related to maternal health outcomes, particularly for minority populations
    4. Strengthening community-based interventions to reduce racial and ethnic disparities 
    5. Enhancing coordination among agencies to implement evidence-based solutions
    6. Expanding research on social determinants of maternal health 

    Arguments in Support

    Proponents of the PMDR Act of 2023 argue that the bill provides critical support for tried and true interventions to prevent maternal deaths. They emphasize that scientific literature identifies state-based MMRCs as the “gold standard” for preventing maternal deaths due to their multidisciplinary analysis. However, inconsistent funding threatens the effectiveness of MMRCs, particularly in states with high maternal mortality rates. In a letter to Congress, 125 public health and social services associations urged legislators to treat the PMDR as a top-priority bill, stressing the nation’s consistently high maternal mortality rate. Several national associations, including the American Medical Association, argue that continued federal funding is crucial to preventing maternal deaths. They highlight that past funding gaps resulted in reduced MMRC operations, hospital closures, and increased barriers to care. Supporters contend that the only way to ensure MMRCs can continue their vital work without funding disruptions is to pass the PMDR.

    Proponents of the PMDR Act also highlight its potential to promote health equity. Beyond identifying risk factors, MMRCs are critical in addressing racial, socioeconomic, and geographic disparities in maternal health by filling critical knowledge gaps on the drivers of maternal mortality in underserved populations. The PMDR Act directly supports these efforts by requiring MMRCs to report on disparities in maternal care and propose solutions. Federal support through this bill enables MMRCs to strengthen provider training, expand access to prenatal care, and address structural barriers contributing to maternal deaths. Without reauthorization, proponents argue, efforts to close maternal health gaps would be fragmented, leaving vulnerable populations without necessary protections.

    Arguments in Opposition

    The most prominent critique of the PMDR Act is that it focuses too heavily on MMRCs. Critics voiced concerns about MMRCs’ inconsistency, lack of accountability, and failure to acknowledge all social determinants of health. 

    Opponents highlight that legal and logistical challenges, such as data collection issues and lack of legal protections for participants, can create disparities in MMRC operations. Rural populations, who face higher maternal mortality rates and limited access to care, are often overlooked in MMRCs, further exacerbating disparities. Additionally, bureaucratic barriers and state laws limiting community involvement in MMRCs reduce their effectiveness in addressing maternal health challenges. 

    Others argue that MMRCs lack accountability, particularly regarding inclusivity and equitable decision-making. Advocates contend that MMRCs often exclude community representatives or organizations that challenge the status quo, prioritizing clinical expertise over individuals with lived experience. This exclusion can foster distrust, as community members may feel their knowledge and perspective are undervalued. The lack of compensation for community members to attend all-day MMRC meetings – unlike salaried clinicians – adds another barrier, further entrenching inequalities. Laws that impose burdensome requirements on MMRCs further complicate the process and reduce diversity in ideas. Opponents of the PMDR contend that these factors contribute to a lack of accountability from MMRCs, preventing them from fully creating lasting and inclusive solutions. 

    Finally, critics assert that MMRCs often fail to adequately address the underlying social determinants of health that contribute to maternal mortality. While MMRCs focus on clinical factors, such as healthcare quality and implicit bias, they can lack the frameworks to assess other social determinants like housing instability, food insecurity, or socioeconomic status. Often, these factors are deeply rooted in the broader healthcare system and community environments. Critics argue that the absence of these social factors in MMRC reviews limits the committees’ ability to develop holistic prevention solutions. Reports suggest MMRCs could benefit from incorporating a health equity framework and utilizing socio-spatial measures to address the full spectrum of challenges mothers face. Without this consideration, critics argue that MMRCs fall short of offering effective solutions to reduce maternal deaths and disparities. 

    Due to these critiques of MMRCs, critics of the PMDR argue that the bill should allocate more funding toward alternate interventions 

    Conclusion 

    The Preventing Maternal Deaths Reauthorization Act of 2023 represented an effort to extend investment in evidence-based maternal health interventions. While it received strong bipartisan support in the House, it died before a vote in the Senate, leaving MMRC funding uncertain in the years to come. While the bill was applauded for its potential to expand access to maternal care and fill critical knowledge gaps on maternal mortality factors, critics argued it placed too much emphasis on an intervention that lacked consistency and accountability to marginalized communities. 

    Future Outlook

    The Trump administration has implemented significant changes to the National Institutes of Health (NIH), including halting medical research funding and restructuring the agency, which has led to delays and uncertainties in grant approvals. These actions have raised concerns about the future of critical medical research, including studies on maternal health. Given these developments, the future of the PMDR may depend on an evolving public health funding environment. Advocacy groups and policymakers will need to collaborate to ensure that maternal health research and interventions receive the necessary support, despite the current challenges in the federal funding landscape.

  • Understanding Midwife and Doula Healthcare Integration

    Understanding Midwife and Doula Healthcare Integration

    Background

    In the U.S. today, Black women are nearly three times more likely to die during childbirth as White women. One potential remedy to address this and other disparities in maternal health outcomes, which has gained recent attention, is the integration of midwives and doulas into the U.S. healthcare system. Doulas are trained professionals who provide physical, emotional, and educational support before, during, and after childbirth. While their role is non-medical, doulas often enhance maternal outcomes by reducing stress, increasing patient satisfaction, and lowering the need for interventions like Cesarean sections. Midwives are licensed healthcare providers who manage pregnancy, childbirth, and postpartum care. Unlike doulas, midwives perform clinical duties, including monitoring fetal development, conducting births, and providing postpartum care.

    Community-based midwives and doulas, particularly those who serve Black, Indigenous, Latinx, and LGBTQ+ communities, play an essential role in supporting populations disproportionately affected by adverse maternal health outcomes. These birth practitioners provide critical culturally relevant care that reflects the cultural values, communication styles, and traditions of their patients, filling gaps in treatment that general hospitals do not address. Despite this, their integration into mainstream healthcare has faced obstacles. 

    The current regulatory landscape for midwives and doulas is complex and varies widely by state. Some states require licensing, training, and specific scope-of-practice guidelines for midwives, given that they provide medical care. Regulations on doulas are less stringent, but still differ state-to-state. Regulatory variation affects insurance coverage and reimbursement, creating inconsistent support for integrating doulas and midwives into mainstream care nationwide.

    Pros of Integration

    Proponents argue that integrating midwives into the U.S. healthcare system could significantly improve maternal and infant health outcomes, particularly in underserved communities. Establishing a nationwide credentialing system would standardize qualifications and scope of practice, ensuring consistent, high-quality care across states. This approach would address disparities caused by restrictive state-specific regulations, which currently limit midwives’ ability to practice. Under current guidelines, midwives oversee only about 8% of U.S. births. Research shows that healthcare systems with greater midwife involvement report better maternal and infant health metrics, including higher rates of vaginal deliveries, fewer C-sections, and reductions in preterm births and low-birthweight infants. Nationwide credentialing policies could enhance collaboration between midwives and traditional medical providers, creating a more cohesive maternity care model. These measures would expand access to midwife and doula care and optimize care delivery nationwide.

    Rather than establishing a national credentialing system for doulas, proponents of doula integration point to solutions like reimbursement policies, standardized training programs, and partnership programs with healthcare centers. Reimbursement policies would increase insurance coverage of doula care, which could significantly increase low-income families’ access to doula services. Nationwide training programs could ensure consistent qualifications and high-quality care, ensuring that families who opt to receive doula services can expect a certain standard of care. Proponents also hold that national training programs are uniquely poised to recruit trainees from underserved populations, which would expand the pool of trained professionals serving diverse communities. Additionally, much like credentialing programs for midwives, collaboration programs between doulas and hospitals could embed doulas within care teams and strengthen the continuity of care for birthing families. 

    State regulations for doulas and midwives vary widely, creating disparities in access and care quality. Proponents advocate for nationwide standards for Medicaid and private insurance reimbursement to establish a uniform baseline for coverage of doula and midwife services. Proponents of nationwide coverage point to the example of Rhode Island, where demand for doulas among high-risk pregnant clients increased significantly after the state expanded its coverage guidelines for doula services. However, given that few doulas currently accept insurance, consistent certification and reimbursement processes are necessary to ensure that expanded coverage effectively connects patients to providers. Collaborating with doulas to design reimbursement structures that reflect their unique services– such as extended client access and billing for long labor–would ensure proper recognition and compensation for their work. Standardized insurance policies, supporters argue, would promote equity, reduce administrative burdens, and enable consistent, high-quality care across states. 

    Cons of Integration

    Opponents argue that regulating and standardizing midwives and doulas may undermine their autonomy and ability to advocate for birthing people, particularly those in underserved communities. While formalizing doula services with official billing codes could expand insurance coverage, critics warn it could also introduce conflicts of interest and compromise patient-centered advocacy. Regulation under hospital systems or boards could stifle advocacy due to fears of repercussions such as losing credentials or hospital partnerships. Michelle Drew, a maternal health historian, highlights that nationwide regulation of midwives and doulas risks repeating the historical erasure of Black birthing practitioners. Critics also warn that credentialing programs could reduce the already limited pool of doulas, counteracting efforts to expand care access amid rising maternal mortality. They worry that standardizing care through rigid oversight may ultimately compromise the culturally tailored, client-focused support that doulas and midwives provide. 

    Critics also argue that integrating midwives and doulas into mainstream healthcare systems raises challenges related to medical oversight, liability, and professional dynamics. One significant concern involves the potential for malpractice or birth injuries, especially in high-risk scenarios where midwives or doulas prioritize natural birth over necessary medical intervention. Some say this tension can lead to critical disagreements with medical professionals, persuading patients to refuse essential care and endangering maternal and infant health. 

    Resistance from medical professionals complicates the integration of doulas and midwives into traditional healthcare settings. Studies indicate that the role of doulas and midwives is often unclear to providers, leading to tension in healthcare practices. Many obstetricians assume that doulas and midwives “work against the hospital” because they advocate for their clients’ birthing preferences. Only 48% of obstetricians agree that doulas improve maternal and newborn outcomes. Moreover, doulas often report feeling unsupported by physicians, labor and delivery nurses, and other clinicians, which hinders collaboration and limits their effectiveness. Critics warn that integrating doulas and midwives into healthcare settings could exacerbate provider conflict and add unnecessary stress to patient experiences. 

    Conclusion and Future Outlook

    Integrating midwives and doulas into the U.S. healthcare system requires consideration of the complex benefits and drawbacks to standardized care  While proponents argue that nationwide standards for training, certification, and reimbursement will expand access to crucial midwife and doula services, critics warn that these solutions risk limiting practitioner autonomy and adding tension to healthcare workspaces. Moving forward, efforts to integrate doulas and midwives into mainstream services through insurance coverage expansion, hospital partnerships, and investments in community-based programs must balance the need for integrated birthing care with the need for an autonomous and diverse workforce of doulas and midwives. 

  • The Pros and Cons of the Black Maternal Momnibus Act

    The Pros and Cons of the Black Maternal Momnibus Act

    Background on Black Maternal Health 

    The Centers for Disease Control and Prevention (CDC) estimates that Black women are over three times more likely to die during or after childbirth than white women, often facing life-threatening complications from early pregnancy to postpartum. Unfair treatment and lower quality of care contribute to these disparities, with more than 80% of pregnancy-related deaths among Black women being preventable. For every maternal death, 100 Black women experience near maternal death, highlighting the broader maternal health crisis for Black women in the U.S.

    Structural racism and various social determinants of health (SDOH), such as access to quality healthcare, safe housing, nutrition, and socioeconomic conditions, shape maternal health outcomes. Both implicit and explicit provider biases worsen these disparities. Research suggests the accumulated experiences of interpersonal racial discrimination across life can negatively impact Black women’s pregnancy outcomes, increasing the risk of complications. Further, surveys that sampled more than 2,500 women in the U.S. showed that Black women were more likely than white women respondents to report experiencing discrimination during childbirth, communication barriers with providers, and a lack of emotional support. Additionally, many Black mothers report feeling unheard or pressured into medical decisions, which can sometimes be attributed to providers’ implicit racial biases around pain tolerance and treatment. 

    The Momnibus

    The Black Maternal Health Momnibus Act of 2021, introduced by Congresswoman Lauren Underwood [D-IL], is still in the early stages of the legislative process and has been stuck in committee since April 2021. The bill targets multiple agencies’ efforts to improve maternal healthcare, particularly among ethnic and racial minority groups, veterans, and other vulnerable populations. The bill is a comprehensive package of several individual bills that support investments in: 

    1. Social determinants of health that influence maternal health outcomes 
    2. Expanding WIC eligibility for postpartum and breastfeeding parents
    3. Funding for community-based organizations
    4. Maternal healthcare for veterans and incarcerated moms
    5. Growing and diversifying the perinatal workforce
    6. Improving data collection processes and quality control measures 
    7. Maternal mental health
    8. Digital tools like telehealth and innovative payment methods
    9. Access to maternal vaccinations

    Arguments in Support of the Momnibus

    Proponents of the Black Maternal Health Momnibus Act argue that systemic racism and healthcare inequities drive the higher maternal mortality rates among Black women, and that the Act is a necessary intervention. While racial health disparities were once wrongly attributed to biological differences, research now shows that systemic racism affects social determinants of health (SDOH) – specifically access to nutrition, clean water, and safe housing. These inequalities, along with fewer healthcare facilities, food deserts, and environmental hazards in Black neighborhoods, restrict access to essential prenatal care, proper nutrition, and timely medical interventions. Compounding these issues, Black women often experience gaps in Medicaid coverage and limited access to quality birthing hospitals. Proponents assert that the Momnibus Act’s investments will improve these conditions, thereby supporting better outcomes for Black mothers. 

    Supporters of the Momnibus Act also argue that expanding access to comprehensive prenatal and postpartum care is crucial for addressing disparities that disproportionately affect Black mothers. They contend that programs like extended Women, Infant, and Children (WIC) eligibility for up to two years postpartum ensure consistent access to essential nutritious foods during critical recovery and developmental periods. Advocates highlight that limited prenatal care and late entry into antepartum care often correlate with lower attendance at postpartum visits, which leaves vulnerable Black women without vital health monitoring. They hold that expanding the availability of these services throughout the care spectrum – from preconception to postpartum – is therefore essential to ensure mothers receive the monitoring and support needed for positive health outcomes. 

    Proponents also praise the Momnibus for its provisions to address gaps in the healthcare workforce, arguing that diversifying the perinatal workforce is crucial in addressing the maternal health crisis among Black mothers. Although Black Americans make up 13% of the U.S. population, they represent only 5.7% of physicians, with Black women making up just  2%. Studies show that Black patients experience better health outcomes, including lower infant mortality when treated by Black doctors or culturally competent providers. This may be due to the shared experience of facing racism, which fosters trust and understanding between patients and providers. Supporters of the Momnibus Act praise its investments in measures such as implicit bias and anti-racism training to ensure culturally responsive care, viewing these steps as essential for improving health outcomes for Black mothers.  

    Arguments Against the Momnibus

    Critics argue that while the Momnibus Act brings essential attention to maternal health disparities, it may fall short of fully addressing the root causes of Black maternal health crisis. They argue that the Momnibus will necessitate large-scale government expenditures, increase taxes, and add to the national debt without delivering sustainable solutions. Critics contend that many provisions of the Momnibus do not account for the broader socio-economic factors contributing to Black maternal mortality, such as healthcare deserts, insurance coverage, and institutionalized racism that cannot be eliminated with bias trainings. Research suggests that policies focused on race and maternal health fail to yield positive outcomes without provisions to address institutional racism in areas like housing, employment, and education as well, so critics hold that addressing maternal health alone is insufficient. They argue that broader reforms across these areas are essential and emphasize the need for a robust, structural approach to truly address health disparities. 

    Many opponents specifically question the effectiveness of implicit bias training included in the Momnibus Act, suggesting that implicit bias is deeply ingrained in the healthcare system and cannot be eliminated via occasional trainings. Without robust, systemic reforms – such as building quality healthcare facilities in low-resource communities and providing long-term maternal health support – they believe the Act’s provisions will yield only temporary improvements leaving underlying inequalities largely unchallenged. 

    Conclusion

    The Black Maternal Health Momnibus Act seeks to address racial disparities in maternal health by investing in prenatal and postpartum care, diversifying the perinatal workforce, and investing in social determinants of health. Supporters argue these measures are essential for reducing maternal mortality among Black women, while critics question whether the Act alone can tackle deep-rooted systemic issues. The future success of the bill’s central goal may depend on securing federal support and enacting comprehensive, structural changes beyond healthcare.

  • Juliana Carreiro-Oliver, University of Chicago

    Juliana Carreiro-Oliver, University of Chicago

    Juliana is a third-year student at the University of Chicago studying Public Policy and History, Philosophy, and Social Studies of Science and Medicine (HIPS). Through conversations with her mother, a registered nurse, she found her passion in health policy focused on improving healthcare systems to be more equitable and accessible, especially in minority-populated areas. With this passion, she is focused on improving maternal health, creating more community-based interventions, and improving equity and accessibility in hospital care and treatment for minorities. Juliana has previously worked in city government, aiming to develop more progressive legislation for the greater Chicago area, and worked on Capitol Hill, helping many Democratic members of Congress with their campaign efforts. She is super excited to be a Student Fellow with ACE to help voters learn about Public Health policy that affects the day-to-day lives of people everywhere. Outside of work and academics, Juliana loves the NYT crossword, listening to music, and trying new restaurants around Chicago. 

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