This past week at the She the People Forum, Elizabeth Warren outlined a plan to address the United States’s maternal health crisis. It is clear that she has made an effort to understand this issue. Among the things her proposal gets right: the United States has the highest rate of maternal mortality of any wealthy country in the world (Kassenbaum 2016). US Black women are particularly, differentially vulnerable to dying as a result of pregnancy, labor, and delivery; the rate of maternal mortality for Black women in the US is consistently estimated to be 3–4 times higher than that of white women (CDC 2018). More than half of all maternal deaths in the US — around 60% — are preventable (Building US Capacity to Review and Prevent Maternal Deaths, 2018). She is also right that much of the disparity can be ascribed to prejudice and racism even across levels of income and education (what we might broadly refer to as “socioeconomic status”).
Warren’s proposed solution to bring down maternal mortality rates and specifically to close the Black-white disparity in maternal mortality is to manipulate hospitals’ “bottom lines” to incentivize better maternal care. The proposal is something analogous to value-based purchasing payment structures developed by the Centers for Medicare and Medicaid Services as part of the implementation of the Affordable Care Act. Warren’s plan has the prototypical outline of a standard value-based purchasing scheme: to use the payment and reimbursement structure to reward hospitals that perform well on specific quality metrics and punish hospitals that perform poorly. A large literature on value-based purchasing exists, some of which is reviewed in Chee et al. (2016).
Rates of Black maternal death are a crisis and a national disgrace, and I am glad to see one of the 2020 presidential hopefuls proposing a solution and making this emergency a feature of their campaign. We agree that urgent attention to this issue is needed. However, there are several aspects of the proposal that deserve more careful attention.
First and most obviously, hospitals with higher maternal mortality rates tend to serve more poor and Black women. Hospitals themselves, and patterns of hospital access, are segregated in the United States; Black women who deliver at primarily “Black-serving” hospitals have the highest rates of severe maternal morbidity and mortality (Howell et al., 2016). Thus, any plan that attempts to financially penalize hospitals with high morbidity and mortality rates could have the paradoxical effect of exacerbating the problem it intends to solve. Penalizing “Black-serving” hospitals, which are likely to be under-resourced compared to “white-serving” hospitals, is unlikely to improve maternity care and may actually make implementation of any obstetric quality-improvement program more difficult. Gilman et al. (2015) report that so-called “safety-net” hospitals are most likely to be penalized under a value-based purchasing plan similar to the one Warren proposes. There is also some evidence that hospital-level indicators of obstetric care quality are variably (i.e., not strongly) associated with actual levels of maternal morbidity (Howell et al., 2014). This suggests another unintended consequence of a proposal similar to Warren’s: that, similar to the experience of the No Child Left Behind program, resources become devoted to achieving progress on metrics that are only tangentially related to the phenomenon they ostensibly measure. Some evidence indicates that health care quality improvement initiatives can even exacerbate disparities if they are differentially and more frequently uptaken in better-resourced settings (Sehgal et al., 2003).
Withholding resources from hospitals with high rates of maternal mortality, or wide disparities, will also not solve the racism that is baked into the practice of American medicine and particularly American obstetric and maternity care (Henderson et al., 2013). To address what Warren refers to as “prejudice” at the point of care will require better and more extensive training for doctors, nurses, administrators, and medical students at the least (Howell at al., 2018). Things like implicit bias training can be helpful and have shown some promise, but it is critical to make real anti-racist praxis a core element of medical, nursing, and public health curricula (Ford et al., 2010). However, It is not just exposure to racism within the medical system that conditions Black women’s vulnerability to premature maternal death but the total experience of racism in American society. In epidemiology, ecosocial theory posits that lifetime exposure to interpersonal, structural, and systemic racism is “embodied” as a variety of adverse outcomes and conditions (Krieger 2005). Black women are more likely than white women to have the comorbidities that increase risk of maternal morbidity or death (Leonard et al., 2019; Metcalfe et al., 2018), to have more fragmented health insurance coverage, to live in under-resourced environments, and to experience violence (Bailey et al., 2017; Black et al.; 2015; Williams et al., 2016). It seems inevitable that a value-based purchasing scheme for maternal mortality implemented in this setting would worsen health disparities and make little impact on overall rates of maternal death.
Finally, the Black-white disparity in maternal mortality is not an aberration in an otherwise well-functioning health care system that delivers quality outcomes for all people. Maternal mortality generally and the Black-white disparity in maternal mortality specifically are not simple functions of hospitals’ “bottom lines,” or the misalignment of profit motive in the health care system with social imperative. Rather, like many of the United States’s poor health indicators and marked health disparities, these reflect deep structural forces in American society that determine receipt and quality of care. To decouple receipt and quality of care from social position, we need universal, socialized medical care as a starting point. While I believe that only radical changes to the social fabric itself can guarantee a healthier and more equitable future for everyone, I don’t believe that the necessity of radical change preempts the need for more piecemeal interim improvements. Warren’s proposal, while itself limited, will helpfully open a conversation about the kinds of steps we can take both in the short and long term to address the emergency of maternal death in the US.
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