Midwifery, fair funding can ease racial, rural inequities

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The crisis in U.S. maternal health outcomes, persistent racial inequities and rural and urban maternity deserts are the equivalent of a five alarm fire.

Since 2017, there has been increasing public outcry as even the United Nations has highlighted this tragedy in the nation that spends more on health care per capita than any other.

About 40% of all births in this country utilize the public funds of Medicaid as their insurance payer.

Yet, while the fire of crisis burns, state Medicaid agencies and their contracted managed care organizations have failed to take action to put out the blaze. This is especially true in Minnesota.

We are two obstetricians from very different backgrounds and political perspectives who both have tired of the institutional inertia that lets this inferno rage. One of us started life as a Black girl from rural Louisiana and the other as a white boy born in rural Minnesota. We are both committed to better care for mothers, babies and families. We are also convinced that a better maternity and newborn care system in our country is well within reach — without spending much more than the current $145 billion expended per year. The dollars just need to be allocated for care that works.

Bearing children comes with some risk, but it is 100 times safer than a century ago. However, continuing to treat pregnancy as a disease is a prescription for episodes that are too often traumatic and expensive. The evidence is clear that cultural humility and primary midwifery care in birth centers within a strong medical safety net is a high-value option for the majority of low-risk pregnancies.

This is the experience of mothers in Europe and was confirmed by the Strong Start study funded by President Barack Obama’s health care legislation a decade ago. Follow up studies have shown lower rates of cesarean section, preterm birth and NICU admission rates while racial disparities fall. Yet the system refuses to change. Why? Follow the money.

Combined federal and state funds account for more than $50 billion in national Medicaid spending for mothers and babies. More than $600 million per year is spent in Minnesota. That means that $25,000 of public money is spent per pregnancy episode that extends through the first year of care for the new mother and baby. Most of this $600 million is managed via contracts through managed Medicaid companies.

Some of these organizations are big names that you may recognize like Blue Cross and United. Others are smaller and less well known by the general public.

A quietly buried 2013 outside review of the Minnesota Medicaid managed care program reported: “There did not seem to be any critical or diligent review of the administrative components going into the base rates.”

In Louisiana we add Aetna and United to the list with others who are Fortune 100 Companies.

A recent Georgetown University 12-state maternity care scan noted there is little or no transparency or accountability for how the money is spent or for the outcomes of care.

At the same time, proven high-value care is woefully underpaid. This lack of support is the reason that midwife birth center practices in Minnesota have begun to close. Minnesota DHS officials and managed care leaders have known of the problem for years and have done nothing about it.

What should be done?

Last year’s legislative session laudably brought increased funding for doula services — a personal nonmedical support model proven to improve outcomes and address racial disparities. Yet underpayment for midwife and birth center care continues. Minnesota and Louisiana should follow Oregon’s lead in tripling payment for beneficial care while paying retroactively for care already provided. That would incentivize large health care systems to collaborate with the grassroots in the design of a pregnancy care system that serves everyone well, especially the most vulnerable.

Racial and rural outcome inequities are real. They have complex causes. The CDC Maternal Mortality Review System defines structural racism as the systems of power based on historical injustices and contemporary social factors that systematically disadvantage people of color and advantage white people. We contend that the failure to provide and pay for identified high-value care is a major factor. Conversations within hospital systems always mention “payer mix” — a euphemism meaning “how many mothers on Medicaid do we have to serve?” For most, the message is the fewer the better.

This segregation is a form of pregnancy apartheid.

Our country is deeply divided over elective abortion — over rights and responsibilities in pregnancy for moms, families and communities. But there should be no division regarding the priority of providing the highest quality pregnancy care to everyone. This is a requirement of gestational and reproductive justice. There is expansive common ground. Blue and red states should all guarantee support for compassionate, culturally humble pregnancy care that makes it possible for more women to have the social, familial, spiritual and communal support to be able to carry pregnancies to term.

Joia Crear Perry is founder and president, National Birth Equity Collaborative. Steve Calvin is owner and medical director of the Minnesota Birth Center.