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8 ways U.S. employers can improve access to maternal healthcare

By Jeff Levin-Scherz, MD, MBA | April 20, 2022

Despite the challenges of racial disparity and high overall maternal mortality, there are steps employers can take to improve maternal health for all pregnant women.
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About the series

“Dr. Jeff Levin-Scherz provides regular updates on the latest COVID-19 developments with a focus on the implications for employers and guidance on how they can tackle pandemic-related challenges to keep their workplaces safe. Explore the series.

Historically, employee health plans have concentrated efforts on educating pregnant women and less on driving change in the healthcare system. But there are steps employers can take to reduce the racial disparity and improve access and maternal healthcare.

The U.S. has a higher maternal mortality rate than most other developed economies. For example, maternal mortality in the U.S. is more than three times higher than in France and Canada and over seven times higher than in Germany, which has the second lowest rate in Western Europe after Norway, which reported no maternal deaths in 2020. The disparities are even starker when you look at different races.

In 2020, the total maternal mortality in the U.S. was 23.8 deaths per 100,000 live births and 55.3 deaths per 100,000 births for U.S. Black women. - description below

Germany had 3.2, Canada had 7.5 deaths per 100,000 live births.

2020 maternal mortality rate

Source: U.S. National Center for Health Statistics and OECD.Stat. Note: This data is pre-pandemic.

The figure below contains data from the Centers for Disease Control and Prevention (CDC) illustrating the increased risk Black women face in pregnancy. This graphic also shows that the problem is getting worse.

In 2020, the maternal mortality rate for non-Hispanic Black women was 2.9 times the rate for non-Hispanic White women.
Maternal mortality rates in U.S. by race

Source: CDC

In addition to maternity-related deaths, 60,000 women annually in the U.S. suffer from severe maternal mortality such as having a heart attack or stroke, or being admitted to the intensive care unit or requiring four or more transfusions.

Maternity care is costly. The Commonwealth Fund found that half (49%) of women of reproductive age in the U.S. report that they skipped medical care because they were worried about cost. Postpartum depression is common. Yet many women and their families have difficulty obtaining necessary mental health care during and after pregnancy.

The good news is that we know how to improve maternal outcomes. For instance:

  • Hospitals should not allow early elective deliveries, which lead to more newborns needing intensive care.
  • Midwives have lower rates of surgical intervention on low-risk pregnancy than obstetricians.
  • Doulas (birth coaches) can effectively advocate for pregnant women, especially Black women, who often feel they have difficulty getting attention and respect from healthcare providers.

We’ve made large strides in improving maternity care in some parts of the country. Hospitals in California that participated in the California Maternal Quality Care Collaborative (CMQCC) reduced maternal mortality by over half in just five years. Participating hospitals commit to implementing evidence-based care bundles to decrease unnecessary interventions and standardize treatment for the most common serious medical hazards of pregnancy, including infection, bleeding and high blood pressure. They share their data to identify opportunities for improvement. This type of rigorous intervention saves lives and reduces disparities. The Alliance for Innovation in Maternal Health (AIM), founded by the American College of Obstetrics and Gynecology, also offers evidence-based guidelines for better pregnancy care.

8 examples of actions employers can take to promote improvement in maternity care

  1. Insist on more meaningful member information in directories, including nurse midwife listing, birth-center listing and quality reporting on providers including:
    • Low-risk cesarean section rate
    • Rate of severe maternal morbidity and other complications
    • Early elective delivery rate
  2. Provide a robust mental health benefit with excellent access to care for postpartum depression of either parent.
  3. Offer at least one plan benefit design that does not have a large amount of cost sharing for maternity care.
  4. Consider a reimbursement account (e.g., health saving account, health reimbursement account or flexible spending account) to allow members to hire a doula, which can be reimbursable if considered medically necessary.
  5. Offer generous maternity and paternity leave and provide a location and time for nursing women to express milk at the workplace. Some employers offer a dedicated lactation room with commercial breast pumps for increased efficiency of pumping.
  6. Require medical carriers to report regularly on low-risk cesarean section rate, early elective deliveries and cases of severe maternal morbidity, and include questions in renewal request for proposals (RFPs) to signal the importance of this issue.
  7. Be sure maternity programs offer comprehensive, culturally appropriate resources to pregnant and postpartum women.
  8. Include questions in renewal RFPs to signal to carriers that this issue is important and give additional credit to those willing to do more to improve maternal quality, such as:
    • Encouraging vaginal deliveries by paying a single facility rate for deliveries. (Carriers are not likely to prioritize this in provider contracting unless they feel pressure from their employer customers.)
    • Incorporating performance guarantees in their provider contracts to encourage participation in collaboratives like CMQCC or AIM to improve maternal health quality and safety.
    • Encouraging providers to participate in the Leapfrog Group’s maternal quality transparency initiative and incorporate results of this reporting in their member educational materials.
    • Utilizing a Catalyst Payment Reform toolkit or something similar to build a high-value maternity network.

Health plans have historically concentrated their efforts on educating pregnant women and have focused less on driving change in the healthcare system. Employers can provide better information to their members and pressure carriers to require or promote these necessary changes.

COVID-19 cases up as Omicron BA.2 represents vast majority of cases

Case rates have risen in the U.S. to about 30,500 as the Omicron BA.2 variant now accounts for nearly all cases. Hospitalizations across the country have fallen 15% in the past 14 days, and deaths have fallen 26% to 533 per day.

Cases continue to rise the most in the Northeast, where BA.2 became dominant earlier. The CDC reports that 95% of the country has a “low” rate of community risk (which incorporates hospital capacity). At the same time, 12% of counties have a high current transmission rate (over 200 new cases per 100,000 per week).

Our undercounting of case rates has likely gotten worse in recent weeks, as more are testing at home, rather than in facilities, and the federal government stopped paying for confirmatory PCR tests for the uninsured.

Philadelphia is the first large city to reinstitute a mask mandate due to rising rates of infection, and the CDC announced an extension of mask mandates on public transportation until May.

Employers can use this period of relatively low COVID-19 infections to develop proactive plans for how to address future localized or general outbreaks of COVID-19 in the coming months. Employers can also monitor wastewater surveillance and hospitalizations and capacity when assessing community risk.

Boosters for young, low-risk people decrease cases and deaths across the population

Israel was one of the first countries to recommend COVID-19 booster shots. These were recommended for those over 60 in July 2021 amid the Delta wave, and boosters were recommended for all those over age 16 by the end of August 2021.

Researchers published a report in Science Translational Medicine this week on mathematical modeling of what would have happened had the Israelis made different policy decisions. This model showed that deaths would have been over 10 times higher without boosters, 2.7 times higher if boosters were restricted to those over age 60, and 1.9 times higher if Israel had delayed booster recommendations for two weeks. It also showed deaths would have been halved had boosters been recommended two weeks earlier.

Deaths would have been over 10 times higher without boosters, 2.7 times higher if boosters were restricted to those over age - description below

60 and 1.9 times higher if Israel had delayed booster recommendations for two weeks.

Modeled impact of different booster strategies – Israel

Source: Science Translational Medicine, April 12, 2022

Researchers just published separate data from a study of over 360,000 people in the New England Journal of Medicine showing that those who got fourth doses had 68% fewer hospitalizations and 74% fewer deaths in the first 30 days after the second booster dose, compared to a matched group that had only three doses.

COVID-19 vaccinations estimated to have prevented over 2 million deaths in the U.S.

The Commonwealth Fund published research showing that vaccination prevented over 2.2 million deaths and 17 million hospitalizations in the U.S. through last month. Researchers estimate that we had about 90% fewer hospitalizations from Omicron than we would have if we did not have the COVID-19 vaccines. They also estimated that vaccinations led to almost $900 billion less in medical costs.

We suffered only localized intensive care shortages this winter during the Omicron wave, thanks to vaccinations. Employers can feel proud of their efforts to promote vaccination of the population.

Implications for employers
  • First boosters were very effective at decreasing cases, severe cases and deaths. Everyone should receive at least a first booster if they are eligible. Additionally, emerging data provides more evidence supporting a second booster.
  • We still don’t know how long boosters will provide protection against infections, and all vaccines are more effective at preventing hospitalization and death than preventing infections. Adults who are more than four months out from their first booster are eligible for a second booster.
  • Employers should continue to strongly encourage booster shots for all employees, not just those who are older or have known risk, as this lowers risk for the entire population.

Population Health Leader, Health and Benefits, North America

Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.

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