The maternal mortality rate in the United States is higher than any comparable high-income nation. One third of pregnancy-related deaths occur from one week to one year postpartum (the “fourth trimester”) and more than half are preventable. Beyond mortality, many more women also experience morbidities from physical and mental health conditions in the year after childbirth.
Medicaid, the public health insurance program for low-income Americans that covers nearly half of all U.S. births, has been an underused tool in the effort to reduce postpartum maternal mortality and morbidity. This is partly the result of the lack of systematic data available to help direct and prioritize policymakers’ efforts to improve the health of new mothers.
This project aims to drive the development and evaluation of evidence-based Medicaid policies to improve the health of women in the year after childbirth. Starting in 2020, new mothers are being contacted to participate in a first-of-its-kind multi-state survey on health outcomes, overall well-being, experience of care, as well as health care access, quality, costs, and barriers for women one-year postpartum. This data will be used to help advocacy organizations, governments and medical professional organizations develop recommendations for improvements to health and social policy – and the Medicaid program in particular – that have the potential to meaningfully affect maternal health.
A second proposed part of this project would partner with interested state Medicaid programs to implement Medicaid policy changes that respond directly to the gaps and barriers identified; and to conduct a study of the effects of implemented reforms. The project team is currently working to identify interested jurisdictions for this collaboration. Building on lessons learned from this pilot, the project team would engage with other states and federal actors to encourage broader Medicaid policy change. By pursuing changes at the policy-level, this project has the potential to significantly reduce population-level maternal mortality and morbidity in the United States.
Heidi L. Allen, MSW, PhDRead Full Bio arrow_right_alt
Heidi L. Allen, MSW, PhD is an Associate Professor at Columbia University’s School of Social Work, and is a nationally recognized expert on Medicaid policy.
Jamie Daw, PhDRead Full Bio arrow_right_alt
Jamie Daw, PhD is an Assistant Professor of Health Policy and Management at Columbia University’s Mailman School of Public Health. She is a quantitative health services researcher whose...
Kristen Underhill, JD, DPhilRead Full Bio arrow_right_alt
Kristen Underhill, JD, DPhil is an Associate Professor of Law at Columbia Law School. Her expertise is in both law and public health, including legal research, survey methods, and qualitative data collection.
The maternal mortality rate in the United States is higher than that of any comparable high-income nation. While reducing maternal deaths that occur during pregnancy and childbirth has been a major focus of current public health efforts and investments, much less attention has been paid to morbidities that occur after delivery.
While there is no systematic, ongoing surveillance for maternal morbidity in the United States, individual studies have found that severe maternal morbidity has been rising in the past decade. More moderate but prevalent physical and mental health problems also affect women’s quality of life and require follow-up and treatment in the postpartum period. Further, the wide racial disparities in physical and mental health morbidities after childbirth can lead to long-term racial health disparities for both women and children.
Medicaid covers nearly half of all U.S. births but low-income women who obtain Medicaid during pregnancy are only insured from conception to 60 days after pregnancy, even though one in three pregnancy-related deaths occurs in the first year after delivery and over half of these deaths are estimated to be preventable. Major factors driving preventable maternal deaths include missed early warning signs and inadequate access to timely, respectful and high-quality care. Uninsurance and/or lack of access to services that fit women’s needs (even among the insured) exacerbate these factors.
Many state and federal lawmakers are interested in strategies to reform Medicaid to address the maternal health crisis. The policy options are wide-ranging, from extending postpartum coverage to expanding coverage for non-medical services that address the social determinants of health. States have wide discretion in how to administer Medicaid, but policymakers often do not have sufficient information on how to most effectively extend and reform Medicaid to cover the major drivers of maternal mortality and morbidity in their states. This lack of information presents an ideal opportunity for academic research to inform policymaking that would improve public health. Tackling the problem of maternal mortality and morbidity at the policy level has the potential to positively impact the health of millions of women for years to come.
This project emerged from the Columbia World Projects Forum on maternal health.
- 1 in 3Pregnancy-related deaths occurs in the year after delivery
- 87-94Percentage of women who report at least one health problem in the first three months postpartum
- 1 in 2Pregnancy-related deaths is estimated to be preventable
This Columbia World Project has multiple components, which together will engage with advocacy organizations, policymakers and other stakeholders at the city, state and federal level. Columbia World Projects has committed initial funding for the PAWS survey, and is seeking funding partners to help expand the project.
Postpartum Assessment of Women Survey (PAWS): This project will implement and analyze a comprehensive multi-state survey of women at one-year postpartum. Where possible, the survey data will be linked to other relevant state data sources where possible such as PRAMS and birth certificate data. This will be the first large-scale data collection effort on the health of American women and their families in the year after birth. This survey has launched and will be distributed to a representative sample of thousands of women who give birth in 2020 in New York City and seven partner states.
Development of policy interventions: Using data from the PAWS and other sources on the unmet needs of postpartum women, the interdisciplinary research team will develop evidence-based recommendations for changes to state Medicaid or other social policies that can improve maternal health. These recommendations will be developed in collaboration with state governments, patient advocacy organizations, and the clinical community.
Evaluate policy interventions: If funding is available to support further project activities, the project team will work to develop a relationship with one or more states to develop and implement policy interventions to improve postpartum health. Further, the project team will design and implement a comprehensive evaluation strategy to measure the impact of any implemented reforms on maternal health care access, health outcomes, and state Medicaid expenditures. Where interventions are not implemented, understanding of the state-level barriers to their uptake will be sought.
Translate knowledge: The project team will also implement a comprehensive knowledge translation (KT) strategy to promote interjurisdictional learning across multiple stakeholders. The general strategy will be to accelerate the inter-state learning that is already a part of the culture of Medicaid, focusing specifically on maternal health issues. Potential knowledge translation tools may include the creation of state policy toolkits and a multi-stakeholder convening.
In Partnership With:
- Kansas Department of Health & Environment
- Michigan Department of Health and Human Services
- Montana Department of Health and Human Services
- New Jersey Department of Health
- New York City Department of Health and Mental Hygiene
- Pennsylvania Department of Health
- Utah Department of Health
- Virginia Department of Health