Adverse pregnancy outcomes can have significant and long-term effects on maternal, infant, and child health beyond pregnancy, delivery, and the postpartum period. In the U.S. there are disparities in maternal mortality, with Black women 2.6 times more likely to die from pregnancy-related causes compared to non-Hispanic White women. Factors that contribute to disparate maternal health outcomes, such as limited access to health care, income and economic insecurity, food insecurity, housing insecurity, and personal safety. Additional factors, including maternal age, cesarean delivery, and preexisting comorbidities (e.g., diabetes, hypertension), are also associated with poor maternal health outcomes.
States are prioritizing a range of policy and programmatic strategies to increase health insurance coverage during the perinatal period, improve access to timely and high-quality maternity care, and strengthen the perinatal health care delivery system, with the ultimate goal of improving maternal health outcomes. States are also advancing strategic cross-sector work to strengthen collaboration across state Medicaid and public health agencies, including Title V Maternal and Child Health Services Block Grant Programs, and other key agencies (e.g., behavioral health) to support aligned work across the state perinatal health care system.
Many states are building and strengthening perinatal health care systems with emerging key trends, based upon a recent NASHP analysis of states’ perinatal health strategic plans. These priorities include ensuring access to timely and high-quality care, developing and sustaining the perinatal health workforce, and supporting care coordination for pregnant and postpartum women.
Access to Timely and High-Quality Care
Timely access to high-quality perinatal health care is critical for providing preventive services and early identification and treatment of health needs and complications that can arise during pregnancy and postpartum. However, many women of reproductive age live in maternity care deserts and experience barriers to accessing timely and high-quality care. State approaches to improve access to timely and high-quality care include training non-obstetric providers to support obstetrics and maternal mental health interventions, supporting collaboration across health care facilities and providers to serve areas with limited or no maternity care providers, and leveraging different delivery modalities, such as telehealth and mobile clinics.
Iowa provides training for emergency room providers and emergency medical technicians (EMTs) on caring for pregnant and postpartum patients. The Obstetrics Mobile Simulation Training Program employs public health clinicians who travel to hospitals located in maternity care deserts and/or with low birth volumes. These clinicians facilitate simulation drills and promote the use of Alliance for Innovation on Maternal Health (AIM) bundles (e.g. obstetric hemorrhage, perinatal mental health conditions). The program plans to provide training for emergency providers on identifying perinatal mood disorders and supporting pregnant or postpartum women experiencing a mental health crisis. Clinicians at participating hospitals have access to monthly calls and on-demand access to virtual training sessions. The state’s Department of Health and Human Services and Maternal Quality Care Collaborative developed the training program with grant funding from the Health Resources and Services Administration (HRSA) State Maternal Health Innovation Program.
North Carolina’s Region IV Provider Support Network connects obstetric, family medicine, and pediatric providers to ensure access to continuous care for women from preconception, pregnancy, and postpartum. The network disseminates maternity care guidelines, provides trainings on basic obstetrics care for family medicine and pediatric clinicians, and develops provider toolkits to support further education on obstetrician services (e.g. outpatient bundle for severe hypertension). The network manages the North Carolina Birth Capacity Connector, which allows labor and delivery (L&D) and neonatal intensive care units (NICUs) to share up-to-date bed capacity across the region. The state’s Department of Health and Human Services collaborates with the University of North Carolina School of Medicine’s Collaborative for Maternal and Infant Health and leverages HRSA funding to operate the Region IV Provider Support Network.
Develop and Sustain the Perinatal Workforce
Many parts of the country are experiencing shortages of health care providers, including shortages of obstetrician-gynecologists. In addition, supporting and expanding the perinatal workforce is a priority for many states, including providing Medicaid coverage for services provided by doulas, midwives, and community health workers. States are advancing strategies to support both the clinical and community-based perinatal workforce, including through trainings for providers on culturally competent care, loan repayment programs for maternity care providers in underserved communities, and resources for providers to address perinatal mental health.
Illinois DocAssist is a free statewide psychiatric access program providing pediatric and perinatal mental and behavioral health telephone consultation services to primary care providers (PCPs) and allied clinicians. Consultations may be general questions or patient specific (e.g., substance use disorders, trauma-informed care, medication prescribing), may involve provision of resources such as screening tools or medication algorithm charts or referrals for psychiatric care, and include caller education and ongoing support to enhance PCPs’ ability to screen, diagnosis, and treat mental health disorders within a primary care practice setting. Consultations can be real time or scheduled at the provider’s convenience. Consultants are board-certified adult and child psychiatrists and psychiatric social workers who have specialized training to support the mental health needs of perinatal women. Illinois DocAssist can be used by PCPs for any patient regardless of their health insurance status or insurance type (i.e., public or private). The initiative was implemented by Illinois’ Department of Healthcare and Family Services in partnership with the University of Chicago-Illinois and is funded through state and federal grants.
New Jersey’s Maternal and Infant Health Innovation Center is an academic research and workforce development center designed to support the perinatal workforce. The Innovation Center will provide culturally centered and equity-driven training to support the development and retention of culturally competent perinatal health providers (i.e., clinicians, community health workers, doulas). Supporting and retaining a culturally competent clinical workforce is one of many strategies under the Nurture New Jersey Strategic Plan, New Jersey’s statewide initiative to address disparities in maternal and child health. In 2023, the state established the New Jersey Maternal and Infant Health Innovation Authority, which is responsible for establishing and overseeing the Innovation Center, and appropriated $2.2 million in state general funds to support the operations of the authority.
High-Quality Care Coordination for Pregnant and Postpartum Women
Care coordination, defined as organizing a patient’s care across multiple providers, can support pregnant and postpartum women in managing chronic health conditions, facilitating referrals to specialty care services (e.g., maternal-fetal medicine specialists, behavioral health providers), and navigating postpartum support services (e.g., lactation services). States are advancing strategies to support high-quality care coordination during the perinatal period, including public insurance financing for enhanced care management, using health information exchange to facilitate data-sharing and collaboration among providers, and leveraging community health workers to provide peer support and connections for pregnant and postpartum women.
California’s Enhanced Care Management (ECM) Birth Equity Population of Focus under the California Advancing and Innovating Medi-Cal (CalAIM) transformation project provides person-centered care coordination for high-risk Medi-Cal beneficiaries during the perinatal period. CalAIM is a framework that encompasses the broad delivery system, program, and payment reforms across the Medi-Cal program under California’s 1115 demonstration waiver. Enhanced Care Management is a statewide Medi-Cal benefit available to select beneficiaries with high needs to address both clinical and non-clinical needs, such as nutrition and housing supports. Under the ECM Birth Equity Population of Focus, launched in January 2024, eligible Medi-Cal beneficiaries receive comprehensive care management that includes physical, mental, and dental care, as well as connections to social services (e.g., Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and housing support).
Texas’s pilot project, the High-Risk Maternal Care Coordination Services Program, works to improve pregnancy. This pilot project supports women at higher risk for poor pregnancy, birth, and postpartum outcomes in Smith County. Trained community health workers (CHWs) provide care coordination services to eligible participants that includes peer support, coaching, and referrals to services. The Department of State Health Services collaborated with a nursing school to develop a CHW training course. The county’s public health district partners with local providers and community organizations. Together, they improve service referral systems and care coordination. This work is funded through the Health Resources and Services Administration (HRSA).
Acknowledgments
The author would like to thank Anoosha Hasan and Robin Buskey for their research that contributed to the content of this blog post and Anna Lipton Galbraith and Karen VanLandeghem for their guidance and review of this post.
This blog post is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. government.
