One way to increase access to midwives and ensure high-quality maternity care is through the integration of midwifery care with primary health care. A study, conducted by the Birth Place Lab in the Division of Midwifery at the University of British Columbia, found that for states with integrated midwifery care throughout health care systems, families were more likely to have full access to high-quality maternity care.143 The study conceptualized integration as the ability of midwives to work fully in the scope of their practice autonomously and without unnecessary restrictions, within both traditional (hospitals) and nontraditional health settings (birthing centers and home births).144 This work was done collaboratively with other health care professionals. Washington state, New Mexico, and Oregon were ranked highest for integration.145 The states that were cited as being hostile to midwives were concentrated in the South and also had large African American populations.146 In addition to coverage expansions and easing restrictive laws and regulations on the practice of midwifery, policymakers should do more to fully integrate both midwifery care and doula services in health systems, which could be particularly impactful in states with large African American populations or within states with high rates of maternal and infant mortality. Better integration could be achieved by ensuring the availability of skilled doulas and midwives in hospitals and birthing centers, with a focus on doulas and midwives of color, and ensuring close coordination and collaborative working partnerships with nurses and OB-GYNs.
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Policymakers need to take a multipronged approach to address barriers to accessing care, which in many cases are interconnected. In the short term, policymakers should focus on encouraging existing mental health providers to participate in greater numbers in Medicaid as well as in other public and private insurances sources so that patients can access a greater breadth and quality of care and associated benefits. Higher Medicaid payment rates will encourage more behavioral health providers to participate in the program. Second, to help offset these costs for states, federal policymakers should increase the federal share of Medicaid payments for mental health care services. Higher payment rates are a critical first step in ensuring that all women enrolled in Medicaid can access vital benefits such as screenings for depression for pregnant and postpartum women.240 Additionally, public and private health insurers should consider covering nontraditional, alternative behavioral health therapies such as meditation or art therapy, which promote good mental health and patient choice in treatment options.
These changes are certainly important short-term interventions, but federal policymakers must also make longer-term investments to build a more robust, well-trained behavioral health care workforce that can provide culturally appropriate care. Proposals to accomplish this include expanding federal and state loan repayment programs for mental health professionals to practice in underserved areas and expanding the numbers of midlevel and paraprofessional providers added to the workforce. For example, federal policymakers should increase funding for the Substance Abuse and Mental Health Services Administration (SAMHSA) Minority Fellowship Program.254 SAMHSA, an agency within the HHS, aims to reduce the impact of substance abuse and mental health in America, and its Minority Fellowship Program is a grant initiative that provides funding to organizations to build out a pool of mental health practitioners that can serve communities of color. In addition, programs run by nonprofit, community-based organizations such as Mamatoto Village are also vital to addressing mental health conditions amongst pregnant and postpartum women, particularly women of color, because they are rooted in the community and are committed to crafting solutions that meet a woman where she is.255 By increasing funding for these programs, not only can mental health professionals attain proper training, but more mental health professionals of color can also enter the workforce, which is key to ensuring the development and implementation of culturally sensitive mental health treatment.
Despite the importance of this legislation, more work is needed. Review committees rely on accurate vital statistics data in order to identify cases to review and recommend improvements, but states too often inconsistently report this information. Moreover, not all states have review committees, and even among states with established committees, underfunding compromises the efficacy of their work. Given the recent legislative advances on collecting data on maternal mortality, it will be especially important that policymakers at all levels ensure that data collection efforts around fetal and infant mortality keep pace. Given the racial disparity in both maternal and infant mortality, states need to better incorporate equity in their review processes.
Finally, as states and localities establish or expand their MMRCs and FIMR committees, local policymakers must ensure that they include people affected by maternal and infant mortality at all levels. Community engagement has been an integral part of the FIMR process since its inception, and MMRCs are beginning to more thoughtfully integrate representation in the review process. For example, both Washington, D.C., and Maryland have recently introduced legislation that would better integrate community voices by requiring that review boards include individuals directly affected by maternal mortality or severe maternal morbidity.401
The Center for American Progress has recommended a set of policy strategies that includes improving access to critical services; improving the quality of care provided to pregnant women; addressing maternal and infant mental health; ensuring supports for families before and after birth; and improving data collection and oversight. If implemented fully, these policy strategies will allow African American women to navigate a more compassionate and woman-centered health care system and do so freely with the bodily autonomy they deserve. The policy strategies also promote the overall health and well-being of families of color, helping to instigate better health outcomes for African American infants and ensure that they thrive throughout childhood.
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