Center for Mississippi Health Policy

Addressing gaps in coverage to improve maternal health

For the print-friendly version, click here.

Receiving medical care at all stages of childbearing from preconception and pregnancy to delivery and postpartum has implications for women’s health, infant health, and later episodes of pregnancy. This brief explores the postpartum period when some women are at risk of illness or death due to pregnancy-related complications. Medical care after pregnancy has the potential to address pregnancy-related injury or illness as well as control lingering conditions that could impact a subsequent pregnancy.

THREE IN FIVE MATERNAL DEATHS IN THE UNITED STATES ARE PREVENTABLE¹

^{Centers for Disease Control and Prevention (CDC). (May 2019).}

Medicaid is a critical source of coverage for maternal care in Mississippi and covers the greatest portion of births each year as well as the most women at risk of negative outcomes. Medicaid expansion in other states is an indicator of the benefits of extended coverage for postpartum women. Early results show higher usage of recommended services before, during, and after a pregnancy. Uninterrupted access to services through continued health coverage allows women who are at the greatest risk to access timely care which saves lives. States, too, could benefit through reduced costs for complicated care.

EIGHTY-SIX PERCENT OF MATERNAL DEATHS IN MISSISSIPPI OCCUR POSTPARTUM²

^{Mississippi State Department of Health. (2019).}

From 2013 to 2016, 136 Mississippi women died due to pregnancy-related causes. Most of these deaths occurred after pregnancy and many after Medicaid coverage ended at 60 days following a delivery. Health experts recommend extending Medicaid coverage for pregnant women to 12 months after delivery as a crucial step in supporting good maternal health and preventing pregnancy-related death. More than 22,000 Mississippi mothers are covered by Medicaid every year (61% of all deliveries in 2019)^2,3.

---

Postpartum

Refers to the period After Pregnancy.

Maternal Morbidity

Illness Related to Pregnancy or Childbirth

Maternal Mortality

Refers to Deaths of Women Who Are Pregnant, Pregnant within 42 Days of Death, Or Pregnant Up to One Year Prior to Death.

---

Health Coverage Can Impact Pregnancy Care and Risks

Lack of health insurance often translates to delayed care for health conditions. For women with health concerns but no insurance prior to pregnancy, risks of complications during or after pregnancy are higher. Twenty-five percent of recently pregnant women in 2018 did not have insurance just before becoming pregnant⁴. More than one in three (35%) Mississippi Medicaid covered deliveries occur to women with at least one known pregnancy risk factor3. Mississippi Medicaid covers care for the greatest portion of pregnant women with identified risk factors at time of delivery.

Forty-six Percent of Medicaid-Covered Deliveries Reported No Postpartum Visit.⁷

^{Maternal Mortality in the United States: Changes in coding, publication, and data release, 2018.}

Mississippi Medicaid reports nearly half (46%) of covered women who delivered babies in 2019 did not have a postpartum visit at all, while the average number of visits is just over one (1.1) visit per woman⁵. The American College of Obstetricians and Gynecologists (ACOG) recommends that all women who have recently delivered have an initial postpartum assessment within three weeks and a comprehensive check-up no later than 12 weeks⁶. Despite changes in medical guidelines, many initial visits occur around six weeks postpartum.

Postpartum visits are opportunities for identifying unresolved health concerns, counseling on family planning and contraception, screening for postpartum depression and domestic abuse, and promoting healthy behaviors like smoking cessation and healthy diet and exercise. Any necessary referrals and treatment plans can be initiated at these visits, but care sought after 60 days postpartum is currently not covered by Medicaid, making it unlikely low-income women will continue to get necessary care.

---

Risk Factors for Maternal Morbidity & Preterm Birth

• Short time period between pregnancies (<18 months)
• Prior preterm birth
• No insurance prior to pregnancy
• Health conditions like high blood pressure, diabetes, and obesity

---

Pregnancy-Related Illness and Death in Mississippi

Maternal mortality rates in the United States appear to have increased in the last 30 years. Mississippi’s rate of maternal mortality of 22.1 per 100,000 live births is well above the national average of 17.4⁷. However, Black women in the state are affected more than other racial groups (51.9 deaths per 100,000 compared to 18 for White women)². Health issues that endanger women’s lives after delivery include blood clots, high blood pressure, infections, heart conditions, depression, and substance use. These are treatable with standard medical care–if care is properly sought and delivered.

BLACK WOMEN IN MISSISSIPPI ARE THREE TIMES MORE LIKELY TO DIE FROM PREGNANCY COMPLICATIONS THAN WHITE WOMEN.²

^{Mississippi State Department of Health. (2019).}

As the following chart shows, women in Mississippi have died six months or more after a pregnancy from associated, treatable conditions. Some women experience serious pregnancy-related injury or illness that impacts their health long after delivery. Nearly 500 Medicaid-covered women were identified as having experienced Severe Maternal Morbidity (SMM) at or immediately after delivery in 2017⁸. Conditions of SMM indicate higher risk of death. Mississippi reported the highest levels of SMM out of 26 states reporting such data.

Postpartum Coverage Offers Preconception Care for a Later Pregnancy

Preterm birth is a leading cause of infant deaths and is impacted by many of the same risk factors that contribute to preventable maternal morbidity and mortality. Extending postpartum coverage can treat these issues and may also benefit future pregnancies and offset higher costs to the state. Preterm birth is one of the top costs for Medicaid and impacts infant and child health for years. The average medical costs in the first year of life for a preterm baby was more than $110,000 in 2017 compared to $5,400 for a full-term baby⁹.

Postpartum women covered by Medicaid maintain their insurance coverage after pregnancy in Medicaid expansion states (and are more likely to have coverage before becoming pregnant). Studies have shown that women in these states are significantly more likely to get health counseling before pregnancy, take folic acid during pregnancy, and use effective methods of contraception postpartum10. Maternal death rates have dropped by almost 2 deaths per 100,000 live births (1.6) in expansion states, which researchers attribute to improved access to care via insurance coverage prior to becoming pregnant and after delivery¹¹.

Most Postpartum Care Occurs After Medicaid Coverage Ends

A recent study of over 160,000 women with employer-sponsored insurance illustrated that pregnancy-related healthcare spending continues for the full year following a birth¹³. In the study, most (81%) postpartum healthcare expenses occurred between 60 days and twelve months following delivery. A full year of postpartum care was estimated to cost $3,100 per person. Surgery, ambulance services, and emergency room visits accounted for the greatest portion of costs but reflected low-frequency events.

Low-frequency events (e.g. heart failure or hemorrhage) did not occur for most insured births studied, but when they did occur, these events often happened after 60 days postpartum and had high associated costs. Under the current Medicaid policy of ending coverage at 60 days postpartum, uninsured, low-income women needing care would either delay getting services, or seek care that left them with medical debt or hospitals burdened by uncompensated care.

The Mississippi Maternal Mortality Review Committee has laid out additional steps for government, insurance companies, and medical providers to take to support the health of pregnant and post-partum women.

^{Updated Link: https://msdh.ms.gov/page/resources/20200.pdf}

Discussion

Extending postpartum coverage has the potential to protect maternal health and promote infant health by removing a primary barrier to care that is closely associated with poor maternal and child health. While continued coverage means increased access to care, utilization of care is necessary for improved women’s health. Experience in states that expanded Medicaid suggest that continued coverage postpartum improves utilization of beneficial care. It is critical that managed care organizations administering Medicaid benefits continue to support postpartum women with robust care coordination to make use of improved access. Extending Medicaid coverage to one year after delivery would provide an opportunity to receive this care.

Sources

1. Centers for Disease Control and Prevention (CDC). (May 2019). Pregnancy-Related Deaths. Retrieved from https://www.cdc.gov/vitalsigns/maternal-deaths/index.html
2. Mississippi State Department of Health. (2019). Mississippi Maternal Mortality Report, 2013-2016. National Academy for State Health Policy.
3. Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics, Natality Public-Use data 2016-2019, on CDC WONDER Online Database, October 2020.
4. Mississippi State Department of Health. (2018). PRAMS Surveillance Report Brief https://msdh.ms.gov/msdhsite/_static/resources/10774.pdf
5. Mississippi Division of Medicaid. (August 2020). Pre-and Post-Natal Medicaid Utilization Info Request.
6. American College of Obstetricians and Gynecologists. (2018). Committee Opinion No. 736.
7. Hoyert, D. & Minino, A. Maternal Mortality in the United States: Changes in coding, publication, and data release, 2018. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020.
8. Mississippi State Department of Health. (2017). Hospital Discharge Data. Severe Maternal Morbidity Conditions, 2017.
9. Mississippi Division of Medicaid. (2017). Presentation to Mississippi Medical Care Advisory Committee.
10. Myerson, R., Crawford, S., and Wherry, L. (November 2020). Medicaid Expansion Increased Preconception Health Counseling, Folic Acid Intake, and Postpartum Contraception. Health Affairs, 39(11), 1883-1890.
11. Zephyrin, L., Coleman, A., Nuzum, R., & Getachew, Y. (November 2019). Increasing Postpartum Medicaid Coverage Could Reduce Maternal Deaths and Improve Outcomes. Retrieved from https://www.commonwealthfund.org/blog/2019/increasing-postpartum-medicaid-coverage
12. Mississippi State Department of Health. (2017). Hospital Discharge Data. Preterm Births, 2017.
13. Bloschichak, A. & Martin, K. (2020). Most Postpartum Spending Occurs Beyond 60 Days After Delivery. Retrieved from https://healthcostinstitute.org/hcci-research/most-postpartum-spendingoccurs-beyond-60-days-after-delivery