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Addressing stark rural and black maternal health disparities is going to require strong intervention addressing patient access to care, provider bias, and the social determinants of health, according to the American Academy of Family Physicians (AAFP).

In a letter responding to a February CMS request for information, AAFP outlined how both pervasive provider bias and implicit racism, coupled with limited patient access to care, have resulted in woeful outcomes disparities between pregnant patients of color and their white peers.

“Currently, the United States’ maternal mortality rate (MMR) is alarmingly high and reveals existing faults within the health care system,” read the letter, signed by AAFP Board Chair John S. Cullen, MD, FAAFP. “During a time when maternal outcomes were improving for women in most developed countries, the U.S. MMR is worsening.”

Seven hundred patients die from pregnancy each year in the US, with three in five of those deaths being preventable, according to figures from the Centers for Disease Control & Prevention. Those outcomes are even more stark for people of color.

A September 2019 report from CDC revealed that MMRs are four to five times higher for non-Hispanic black and American Indian or Alaska Native patients. This is the outcome of decades of systemic racism, AAFP contended.

“The AAFP recognizes that these unequal outcomes are the consequence of decades of structural and systemwide inequities designed to deliver unequal and disparate care for women of color based on institutionalized racism and the unconscious biases of health care providers toward women of color,” the letter said.

To that end, the first step to addressing black maternal mortality disparities is to drive strong provider education and cultural reform. AAFP called for better provider training to acknowledge and then correct provider bias. These efforts should focus on delivering culturally competent, patient-centered care.

Second, the organization called for stronger provider education about healthcare disparities and the health equity issues surrounding maternal healthcare. This should outline a path toward what the AAFP termed birth equity, meaning every pregnant patient has an equal opportunity to have a healthy birth.

“Additionally, all health care systems, hospitals, clinics, and institutions should adopt anti-racist policies that advocate for individual conduct, practices, and policies that promote inclusiveness, interdependence, acknowledgment, and respect for racial and ethnic differences,” the AAFP letter added.

“These organizations should also take an active approach to dismantling racism by conducting a comprehensive critical examination of policies and procedures, empowering the development of diverse formal and informal leadership and developing a plan that increases accountability, demonstrates transparency, and reorganizes power.”

Efforts to address health equity and black maternal health disparities must also look at patient access to care and the social determinants of health. Data shows that MMRs are worse for pregnant patients living in rural or low-income regions largely because access to care is left wanting in those areas.

Specifically, pregnant patients living in rural areas face three key obstacles to care:

• Hospital closures
• Workforce shortages
• Rural health disparities

CMS may work to address those equity gaps by driving a stronger, more diverse healthcare workforce in rural regions.

“Family physicians have historically provided maternity care, especially with rural and underserved populations,” AAFP said in the letter. “More than one-half of rural hospitals with obstetrics units depend on family physicians to attend births and family physicians continue to attend the majority of births in small hospitals. Twenty-eight percent of rural family physicians continue to provide obstetrical services.”

Supporting a stronger rural workforce should begin with incentivizing more providers to work in rural areas. CMS may consider increasing Medicaid primary care reimbursement rates to match Medicare reimbursement rates, which are traditionally higher.

Additionally, CMS should support the Helping Medicaid Offer Maternity Services Act, which calls for state Medicaid programs to cover pregnant patients one year post-partum. The Act also calls for a five percent bump in federal funding to incentivize states for that coverage access expansion.

Finally, CMS may consider funding home visits, which AAFP said are critical for addressing the social determinants of health. Historically, federal programs to enhance payments for home visits have improved both parent and child health, but these programs are currently not widely available. Medicaid funding may help remedy that, AAFP noted.

Further work to address social determinants of health, including neighborhood screening and intervention and support of outside social services will as be integral to closing maternal health disparities.

As noted above, these disparities are growing, not shrinking. As the rest of the developed world observes improvements in maternal mortality rates, the US is slipping, especially among pregnant patients of color and those living in rural or low-income areas.

“The United States currently has worsening maternal health outcomes,” AAFP concluded its letter. “The reasons are multifactorial, but family physicians are essential for improving these statistics. The AAFP looks forward to working with CMS to address these issues.”