The U.S. continues to have the highest rate of maternal mortality among developed nations. Stark disparities exist among pregnant people. American Indian, Alaskan Native, and Black women are two to three times more likely to die of pregnancy-related causes than White women. Over 800 women die each year in the U.S. from maternal-related causes, with more than 80 percent of these deaths being preventable. Factors that can lead to a pregnancy-related death include access to care and timeliness of diagnoses.

Through the Supporting State Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the federal Maternal and Child Health Bureau, Health Resources and Services Administration, NASHP worked with seven states (Idaho, Illinois, Iowa, Louisiana, Pennsylvania, South Dakota, and Virginia) to support and advance innovative policy initiatives that build state capacity to address maternal mortality for Medicaid-eligible pregnant and parenting people and ultimately improve access to quality care.

Over the past two years, the seven state teams that participated in the MCH PIP Policy Academy, comprised of officials from state Medicaid, public health, and other relevant agencies/groups (e.g., Medicaid managed care plans, behavioral health agencies) identified and advanced policies and plans to address maternal mortality and improve maternal health outcomes, with a specific focus on reducing disparities. NASHP provided targeted technical assistance to states and shared promising practices to help states achieve their goals.

Highlights of the participating states’ achievements include the following:

Idaho

The state Medicaid agency gained a formal seat on Idaho’s Maternal Mortality Review Committee (MMRC) during the MCH PIP Policy Academy, enabling greater engagement of key agencies pushing forward policy initiatives to improve maternal health outcomes. Unfortunately, the Idaho MMRC has since sunsetted. However, collaboration across state agencies to advance maternal health outcomes has improved due to participation in the MCH PIP Policy Academy and Medicaid participation in the MMRC. Idaho Medicaid also conducted meetings with behavioral health clinicians, prenatal care clinicians, and persons in recovery to inform the development of a potential case management program for pregnant and postpartum people with substance use disorder (SUD). The state Medicaid agency is in the process of standing up this case management program based on input received during these sessions.

Illinois

In 2021, Illinois became the first state to extend Medicaid postpartum coverage to 12 months. A new Moms & Babies data mart is in development to allow Illinois Department of Public Health (IDPH) to access Medicaid enrollment and claims data. This will allow IDPH to link specified Medicaid data with other public health data systems and to independently analyze data related to maternal and infant health. After discussion with IDPH, Illinois Department of Healthcare and Family Services (HFS) also established a prenatal and postpartum care HEDIS (Healthcare Effectiveness Data and Information Set) measure performance improvement project for Medicaid managed care organizations (MCOs) to identify and close a health disparity gap. HFS has named maternal and child health as one of its five quality strategy pillars and requires its Medicaid MCOs to report results by race, ethnicity, and geography.

Iowa

The state has recently aligned its Medicaid and public health agencies to create one Department of Health and Human Services, which will further advance the interdisciplinary work and collaboration between the two agencies. Iowa’s Medicaid agency and Bureau of Family Health synthesized their strategic planning goals for improving maternal health outcomes and proposed policies to leadership and partners. Iowa is also developing a conceptual model for how alternative payment models can be used to improve maternal health outcomes using quality measures, accountable care organizations, and other methods.

Louisiana

The state Medicaid agency allowed MCOs to create an “in lieu of” services program for doula coverage and hospital-based care coordination for pregnant women with SUD. The state Medicaid agency is also developing an “in lieu of” services program for outpatient lactation consultations. Louisiana became the first state to extend the Medicaid and CHIP (Children’s Health Insurance Program) postpartum coverage period to 12 months under the American Rescue Plan Act state plan option. Louisiana Medicaid also extended coverage of blood pressure monitors to pregnant people with chronic hypertension. The state hopes this initiative will increase uptake of this treatment among pregnant people engaged in remote patient monitoring and increase access to care in rural areas. The Louisiana Department of Health and the Bureau of Family Health awarded new “Gift” designations to 16 birthing facilities through the statewide breastfeeding quality improvement initiative (42 of 48 birthing facilities now have this designation). This will enable the state to increase breastfeeding rates and improve the quality of maternity services delivered in these birthing facilities. Louisiana Medicaid has also begun providing provider outreach and education to increase reimbursement of caregiver depression screening performed during well-child visits.

Pennsylvania

The state Medicaid agency is working with the University of Pittsburgh to establish a process to track the success of the extended Medicaid and CHIP postpartum coverage to 12 months. Pennsylvania has also expanded its Moving on Maternal Depression program, a maternal depression screening program, to over 30 birthing hospitals. The Medicaid agency is working to connect members who screen positive for maternal depression with mental and behavioral health services. The Department of Health, using Title V funds, supports two community-based doula grants: one that serves individuals affected by opioid use disorder, through the Philadelphia Department of Public Health, and one that provides doula care to individuals within the Healthy Start Pittsburgh service area.

South Dakota

The state expanded its Bright Start home visiting program, which provides prenatal and parenting support during pregnancy through age two of the child. The program was initially limited to high-need counties and has now expanded statewide through Medicaid and the federal economic assistance program funding, general state funds, and Maternal, Infant, and Early Childhood Home Visiting federal funding. South Dakota is also developing an upcoming Pregnancy Health Home program that seeks to improve pregnancy and postpartum care through enhanced case management and care coordination. In addition to connecting Medicaid-enrolled members with resources that address social needs, medical providers will be required to work on a quality improvement project. As part of the program, Department of Health community health nurses will collaborate with enrolled medical providers in collecting pregnancy risk assessments and addressing social determinants of health. The state aims to begin implementation of the Pregnancy Health Home program in 2024.

Virginia

The state was the third in the country to implement a 12-month Medicaid and CHIP postpartum coverage extension and the fourth to implement a statewide Medicaid doula benefit. Virginia Medicaid has developed a doula registry, and 120 doulas have achieved state certification. Of the 120 state-certified doulas, 89 have been approved by Medicaid and enrolled as Medicaid doula providers as of July 2023. The state Medicaid agency is currently developing a maternal and child health strategic plan, and maternal and child health-focused performance improvement projects for Medicaid MCOs to improve overall outcomes for Virginia children and families.

The participating states of the MCH PIP Policy Academy identified several lessons learned as they worked on policy initiatives to improve maternal health and reduce maternal mortality.

Strategies include the following:

• Cross-agency collaboration is critical in creating lasting changes among state behavioral health, public health, and Medicaid agencies in improving maternal health.
• Engaging community providers in policy initiatives can bridge gaps in access to care.
• Data sharing across multiple state agencies (e.g., public health and Medicaid) can facilitate tracking health outcomes.