ACE

Tag: Challenges

  • 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.

  • Failures and Successes of NATO

    Failures and Successes of NATO

    Introduction

    NATO, or the North Atlantic Treaty Organization, is a military and political alliance founded in 1949 and dedicated to ensuring the security and freedom of its members. As the Cold War took shape and the Soviet Union threatened European governments, the founding countries of NATO determined that a transatlantic alliance was necessary to both deter Soviet aggression and promote political integration rather than militarism. In the decades since, NATO has grown in structure and members into the organization it is today. The primary political council of NATO is the North Atlantic Council (NAC), and it is chaired by NATO’s Secretary General. Each member has a seat on this council and all decisions are made by consensus, so that any decision made by NATO reflects the will of all members. If a decision reached under the NAC or a political subcommittee has military implications, the Military Committee is responsible for giving expert advice to the NAC and for organizing and carrying out NATO’s military operations. 

    The United States is the largest financial contributor to NATO and a key member of the alliance. The alliance promotes democratic ideas and peaceful conflict resolution around the world. Countries looking to join must have a functioning democratic government and a commitment to peacefully resolve conflict. With a large network of members and resources, NATO aims to hold its members to a standard of democracy and intervenes to defuse conflicts before they happen. However, there is continuous debate over how to handle NATO member states experiencing democratic backsliding. In addition, conflict is deterred by the collective defense aspect of NATO, where an attack on one member is an attack on all members. Despite its shortcomings and the challenges it faces, it is often considered to be one of the most successful international alliances in history.

    There are currently thirty members of NATO and several countries are aspiring to join. Other countries are engaged in working partnerships with the alliance, while not being members.

    Source: Statista

    A Brief History

    • 1949: As communism spread across Europe, and the Soviet’s influence increased, the United States’ desire for a security treaty with Western Europe outside of the UN’s Security Council (where the USSR held veto power) led to the creation of NATO.
    • 1955: In response to West Germany joining NATO, the Soviet Union and seven other Eastern European countries formed the Warsaw Pact.
    • 1991: The Soviet Union collapsed, leading to the dissolution of the Warsaw Pact. The North Atlantic Cooperation Council was created as a platform for cooperation between old Warsaw Pact members and NATO.
    • 1995: NATO became involved in its first ever crisis response operation, leading the Implementation Force, a peace enforcement force during the Bosnian War.
    • 2001: 9/11 resulted in NATO invoking Article 5 of the Washington Treaty for the first, and only, time. Article 5 states that “an attack against one… shall be considered an attack against them all.” NATO launched several counter-terrorism initiatives and deployed military forces to Afghanistan.
    • 2003: NATO takes control of the International Security Force (ISAF) in Afghanistan, a UN-mandated security force responsible for ensuring the Afghan government’s authority.
    • 2014: NATO suspends most relations with Russia over their illegal annexation of Crimea.

    Successes

    1. The Cold War: During the Cold War, NATO’s efforts were centered around three goals: controlling the Soviet Union, dissuading militant nationalism and communism across Europe, and establishing greater European political unity. The alliance played a major role in maintaining the tense peace of the Cold War and ensuring the war remained ‘cold’. With the end of the war, NATO worked to further maintain peace. They established the North Atlantic Cooperation Council and, in 1997, NATO encouraged bilateral discussion between the United States and Russia through the Founding Act.
    2. Modern Day Protection: Today, NATO continues to provide a level of protection for its members. Since its founding, a NATO member has only been attacked and evoked Article 5 once (the United States after 9/11). Member countries are afforded collective security, just as NATO originally sought to do. Additionally, NATO has created a global network of more than 40 countries and other partners around the globe—ranging from the African Union to the Organization for Security and Cooperation in Europe (OSCE). This network provides NATO support in its crisis management operations, ranging from aid operations such as its delivery of relief supplies after the 2005 Kashmir Earthquake to counter-terrorism operations in the Mediterranean and the coast of Somalia.
    3. The Ukraine War: NATO has publicly denounced the Russian invasion of Ukraine and NATO member countries and allies have provided substantial aid to Ukraine. The United States has contributed roughly $54 billion to Ukraine. Other countries have provided humanitarian aid and support for the more than 5 million refugees of the war. The Ukraine war has reaffirmed the importance of NATO, and even spurred Finland and Sweden to increase their efforts to join the alliance. These countries’ membership would strengthen the alliance militarily through increased air and submarine capabilities, allowing for NATO to further dissuade Russian aggression.

    Failures

    1. Funding Issues: In 2006, NATO Defense Ministers agreed to a commitment that 2% of their countries’ GDP would be allocated towards defense spending. However, the majority of NATO members do not meet this goal. Currently, the United States accounts for over two-thirds of the alliance’s defense spending.
    2. Afghanistan: After 9/11, NATO was a considerable presence in Afghanistan, and their forces were crucial in their support of the Afghan government. When President Donald Trump signed an agreement with the Taliban in 2020, both NATO and American troops were withdrawn from Afghanistan. What followed was an immediate fall in the Afghan government at the hands of the Taliban. Despite the two decades NATO spent in Afghanistan, no long term solution was reached, and without their presence, the nation’s former government could not survive.
    3. Right-Wing Nationalism: With the spread of right-wing nationalism across Europe, discontent with international institutions like NATO and the EU grows. If right-wing nationalist movements continue to increase in popularity across Europe, there could be increased calls for countries to leave institutions like NATO. The challenge NATO faces now is how to combat and address their criticism, and how to unify a divided Europe.
    4. Russian Aggression: Despite supposed verbal promises to Russia that it would not expand to the east, NATO has admitted several former Warsaw Pact members since the fall of the Soviet Union. Now, with NATO members bordering Russia and the promise of further expansion, Russia feels increasingly threatened. The possibility of Ukraine joining NATO has been cited as a significant reason for Vladmir Putin’s invasion of the country.

    The Future of NATO

    As the war in Ukraine continues, NATO is more relevant now than it has been in decades. NATO plays a role in distributing military and humanitarian aid to Ukraine, and the alliance will be influential in the outcome of the war. NATO serves as a means of collective defense and security against Russia and the increasing threat to international order that they represent. With debates over how NATO can best assist Ukraine, and how to best avoid conflicts such as this in the future, NATO will have to revisit its current deterrence strategy in the upcoming years. Also at play is the growing role of China on the world stage. NATO must consider that the world does not revolve solely around the Euro-Atlantic region, and address questions about its role outside this region and across the globe. NATO continues to be essential towards not only the security of its members including the United States, but to the world.