AMA Vows Action on Maternal Mortality, Debates Funding Sources

Recommendations in a joint report on systemic causes as to why the maternal mortality rate (MMR) is rising in the United States were adopted November 16 by the American Medical Association's (AMA's) House of Delegates.

The report, by the Council on Medical Service and the Council on Science and Public Health, notes that there are myriad reasons the United States is the only industrialized country in the world in which the MMR is rising. The current report, which is intended to be the first in a series, focuses on insurance gaps and healthcare inequities.

Patrice Burgess, MD, delegate from Idaho and an author of the report, who was speaking on behalf of the Council on Medical Service, noted that about two thirds of these deaths are preventable.

"Causes of maternal death vary considerably, and approximately one third of pregnancy-related deaths occur in the postpartum period, including almost 12% that occur between 45 and 365 days post partum," she said at the November meeting of the House of Delegates.

Racial inequities persist as well. Black, American Indian, and Alaska Native women are two to three times more likely to die from pregnancy-related causes than White women, the Centers for Disease Control and Prevention notes.

Among the recommendations is for federal and state policymakers to expand Medicaid and Children's Health Insurance Program (CHIP) coverage from 60 days to at least 1 year after the end of pregnancy.

"If Medicaid and CHIP coverage were extended for the entire year of the postpartum period, an estimated 70 percent of uninsured new mothers would be eligible for some kind of publicly subsidized coverage," the joint report states.

"Notably," the authors write, "[N]onexpansion states are home to 83 percent of the uninsured new mothers who would become newly eligible for Medicaid/CHIP under a postpartum extension."

The authors of the report call for the AMA to do the following:

Support the development of a standard definition of maternal mortality and support allocating resources to states and Tribes to collect and analyze maternal mortality data to better understand causes of maternal deaths and improve outcomes;
Promote research to examine barriers that contribute to inequities in maternal health outcomes, as well as research into the effectiveness of interventions to address barriers;
Support adequate payment for evidence-based healthcare across the spectrum of prepregnancy, prenatal, peripartum, and postpartum care;
Encourage hospitals, health systems, and states to participate in maternal safety and quality improvement initiatives, such as the Alliance for Innovation on Maternal Health program and state perinatal quality collaboratives;
Ask the Commission to End Health Care Disparities to evaluate health disparities in maternal mortality and offer recommendations to address existing disparities in the rates of maternal mortality in the United States.

In a press release, AMA immediate Past-President Susan R. Bailey, MD, said, "The AMA is committed to being a leader on maternal mortality prevention, and the nation's physicians have charged the AMA to prioritize the elimination of racial and ethnic inequalities in maternal health care while increasing access to affordable health insurance for new mothers. As a first step, the AMA acknowledges the roles that structural racism and bias play in negatively impacting health care, including maternity care."

A Matter of Care vs Cost

A proposed resolution on expanding Medicaid eligibility for pregnant and postpartum noncitizen immigrants drew lengthy discussion at the meeting.

The overwhelming majority supported the need for providing the full spectrum of care, from prepregnancy through the postpartum period, for all women.

Kasandra Scales, MD, MPH, delegate for the American College of Obstetricians and Gynecologists, speaking on behalf of the delegation, said, "Our AMA has adopted multiple policies to address maternal mortality and morbidity. Our immigrant patients deserve no less.

"We, as the obstetricians who provide the bulk of care to pregnant individuals, know that routine prenatal care means that we can manage conditions such as hypertension, gestational diabetes, and cardiac conditions. If we don't see patients until they are in active labor, these conditions could put their lives and their babies' at risk, and we may never see them again after they deliver. This is not the way we were trained to care for patients. We must commit to improving maternal health for all of our patients."

But some questioned how to pay for the care.

Don Cinotti, MD, an alternate delegate from the American Academy of Ophthalmology, said, "No one is against paying or giving care to people that are in this country. The problem that we're discussing is, how are we going to pay for it?

"Medicaid is not the right place," he said. "Medicaid is a combined state and federal program. The people that are here ― the states don't choose them ― they're here. The state then has to pick up the price. States don't necessarily have the budget to do this. So we would look to the AMA to discuss other ways of paying for this rather than putting everybody on Medicaid, which may bankrupt the Medicaid system."

Christopher Garafolo, MD, a family physician and alternate delegate from Massachusetts, speaking on behalf of the New England delegation, disagreed.

"Medicaid makes the most sense," he said. "As soon as the baby is born, these babies will transition over to Medicaid most likely, so having them on that insurance makes the most sense."

The delegates adopted an amended resolution that directed the AMA to work with relevant entities to extend Medicaid and CHIP coverage to at least 12 months after the end of pregnancy and to work to expand Medicaid and CHIP eligibility for pregnant and postpartum noncitizen immigrants.

Marcia Frellick is a freelance journalist based in Chicago. Follow her on Twitter at @mfrellick.

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