Maternal Health by Design: Reimagining Systems to Better Support Families
Intro / Context: The Family Benefits Lab + Center for Children and Families
The Family Benefits Lab (FBL) is an initiative of the Beeck Center for Social Impact + Innovation at Georgetown University, which partners with state and local governments to improve how families access critical benefits and support services, with a focus on maternal health and early childhood.
The Center for Children and Families (CCF), part of Georgetown University’s McCourt School of Public Policy, is a nonpartisan policy and research center founded in 2005 with a mission to support access to high-quality, comprehensive and affordable health coverage for all of America’s children and families. CCF conducts research, analyzes data, develops strategies, and offers solutions to improve the health of America’s children and families, particularly those with low and moderate incomes. In particular, CCF examines policy development and implementation efforts related to Medicaid, the Children’s Health Insurance Program (CHIP), and the Affordable Care Act. CCF works in close partnership with state and national policy leaders in health, early childhood, and maternal health policy.
The Family Benefits Lab has multiple state partnerships focused on supporting young mothers and families.
- In California, our team is working to streamline referrals and enrollment across Medi-Cal, CalFresh, and the Women, Infants, and Children (WIC) program by interviewing staff and young mothers to identify pain points in eligibility and enrollment processes, data-sharing challenges across agencies, and opportunities to reduce administrative burden.
- In Maryland, we partnered with the Maryland Higher Education Commission and the Governor’s Office for Children to address barriers student parents—most of whom are mothers—face in completing degrees, including child care access, financial challenges, and academic support.
- In Arkansas, we are working to understand and improve the experience of mothers who use the Proactive Postpartum Call Center service that launched last year, through which nurses call new mothers five to ten days after discharge to identify risk factors and improve maternal health.
These partnerships reflect our broader hypothesis:
When public benefits and services are accessible, effective, and designed with the people they serve in mind, mothers and their children can access these critical supports sooner, with long-term improvement on the health and economic well-being of families.
Workshop Purpose and Goals
The U.S. maternal mortality rate is among the highest of any high-income nation, and our racial disparities remain unacceptable. More than one in three counties (36 percent) are classified as maternity care deserts, and 4.7 million women live in counties with limited maternity care access.
As Heartland Forward’s research documents, poor maternal health outcomes cost the U.S. $165 billion annually in avoidable medical expenses and lost economic productivity, making this both a moral imperative and a major economic opportunity.
Most of these deaths are preventable. The biggest barriers aren’t a lack of knowledge about what works, but instead a result of insufficient investment, fragmented systems, limited data visibility, and services that are hard for families to navigate.
However, progress can be made at the state and local levels:
- California has the lowest maternal mortality rate in the country. The state has cut maternal mortality in half since 2006 by creating the California Maternal Quality Care Collaborative (CMQCC). The CMQCC identified common causes of maternal mortality and created toolkits to help hospitals address them. The toolkits include checklists, response carts, and drills for hospitals. They also established a mentor model for providers and nurses. CMQCC also created a statewide data center to monitor maternal mortality and provide technical assistance to hospitals.
- Baltimore City reduced its infant mortality rate from 13.75 to 7.5 deaths per 1,000 live births and reduced Black-White disparity by 40 percent in 2021 through B’more for Healthy Babies. The program brought together stakeholders across the city and identified common causes of infant mortality. Through community outreach and support programs in high-risk neighborhoods, including training for clinicians and service providers and deploying toolkits, they were able to address these causes directly within the community.
- New Jersey lowered their C-section rate from 27.8 percent to 24.9 percent from 2018 to 2024, and hospitals with higher-than-average hemorrhage rates decreased from 19 to 16 through the Nurture NJ Initiative. The program expanded NJ FamilyCare (Medicaid) to cover a year postpartum, expanded doula services, increased reimbursement rates, and expanded supportive services like home visits.
Maternal Health by Design brought together over 30 practitioners, state and local government leaders, service delivery implementers, and funders to validate and prioritize evidence-driven interventions and ideas that are implementable at the state or local level within the next two to three years.
The central question we explored was: What would it take to meaningfully improve maternal health outcomes through human-centered policy design, better data use, and improved service delivery?
Context of this Moment – Ensuring Continuous Coverage and Stable Benefits Amid New State Challenges
As the group came together to consider actionable solutions, it’s difficult to ignore policymaking that could add new challenges to these efforts in states. H.R.1, the reconciliation bill passed last year, made the largest cuts in the history of Medicaid: nearly $1 trillion over the next decade. States are already beginning to grapple with state budget impacts that could mean cuts to optional maternal health services or benefits.
In addition to budget constraints, states must implement new requirements for Medicaid, the Supplemental Nutrition Assistance Program (SNAP), and other programs that risk some enrollees becoming uninsured. New work reporting requirements for adults in the Medicaid expansion will add red tape and new hurdles to getting and staying enrolled. Pregnant, postpartum women, and parents of children under age 14 are among the list of groups exempted from this requirement, but implementing exemptions effectively will be a challenge for states. More than one-third of pregnant or postpartum women are enrolled in the Medicaid expansion category (more than 130,000 nationwide). These rates vary by state, as high as 43 percent of pregnant women enrolled in Medicaid in the expansion category in Montana, and 40 percent in Louisiana. In pure numbers, pregnant women in the expansion category range from just over 100 in Rhode Island and Utah to more than 20,000 pregnant enrollees in California.
It will take dedicated attention in every state to ensure pregnant or postpartum women don’t fall through the cracks and become uninsured during this crucial period of change due to unnecessary red tape.
Cross-Cutting Themes
Payment must be intentionally designed to reward quality, not merely quantity
Payment is the driver that influences all other interventions. Attendees generally supported the idea of value-based maternity care (paying for value, not simply volume) but raised important considerations about pay-for-performance incentives tied to health equity metrics; reimbursement for perinatal mental health screening and follow-up; quality measures that are adjusted for social risk; and specific incentives for improved outcomes among Black, Indigenous, People of Color (BIPOC) patients.
A 2021 Medicaid and CHIP Payment and Access Commission review of five state value-based payment (VBP) models (Arkansas, Connecticut, Colorado, North Carolina, Tennessee) found mixed results. Models that worked tended to reward specific quality metrics rather than simply constraining cost. Concerns were also raised about VBP as a signal for some payers as code for cost-savings, over the primary goal of quality. Some services may require additional investments.
The Policy Center for Maternal Mental Health’s analysis of bundled payment rates reinforces this: The global maternity bundled rate does not allow for the monitoring of the types of maternity care that is being provided, nor does it incentivize/reimburse additional care being provided to high-risk patients. Further, the bundle does not include care coordination, or social support services, making these interventions financially unfeasible for OBs to provide, even when clinically essential. Payment policy implementation is also occurring at this time, with the American College of Obstetricians & Gynecologists (ACOG) moving toward the unbundling of maternity billing codes.
Investing in the Maternal and Child Health Care (MCH) workforce
Investing in obstetricians and gynecologists (OB/GYNs), midwives, doulas, and community health workers is a structural necessity. Our lack of sufficient provider coverage in many maternity care deserts is becoming a crisis in several parts of the United States. Attendees noted that many OBs feel pressure to see patients in 15 or 20 minute increments, which is not nearly enough time to fully understand and address the experience of patients with complex needs. Community health workers, social workers, and case managers can help address patients’ social risk factors, but the education, certification, and billing barriers to entry for these jobs can be high.
Reducing the administrative burden associated with training, licensing, certifying, improving reimbursement, and creating cultural concordance in the workforce could directly reduce workforce attrition, improve patient experiences and trust, and expand access in care deserts.
Integrate quality data more rapidly into a continuous, learning maternal health system
Attendees emphasized that we already collect a lot of data on maternal health, but raised issues and concerns about whether and to what extent it is actually being used to drive behavior change in clinical settings.
State maternal mortality review committees (MMRCs) offer strong data on mortality but have significant lag in data availability, making it harder to take immediate action on what we’ve learned. This data lag could be the result of several factors: Manual review of data files, staffing and investment limitations, data access issues, and liability. Regardless, the delay makes it difficult for stakeholders to respond to these committees’ output. State Perinatal Quality Collaboratives are important among these stakeholders. These organizations exist in most states, and offer a way to bring experts together at the state level to improve quality in clinical settings informed by MMRC and other data sources.
Screening data (e.g., to identify risk factors for depression or anxiety, or social determinants of health) is collected throughout the perinatal journey, but providers struggle to complete closed-loop referrals to address patients’ needs and barriers to accessing care. Attendees called for better integration of screening data with Medicaid claims, pediatric visit data, and hospital discharge records.
With Medicaid paying for more than 40 percent of births nationally (and more in many states), knowing the performance of individual managed care organizations (MCOs) responsible for the care of pregnant women is an important step. CCF’s 2023 report scanning 12 state Medicaid managed care organizations’ (MCO) data reporting suggested that MMRCs and Medicaid agencies could do more to align and inform MCO-level data reporting and transparency. A webinar recording of the findings is available here.
Trust and trusted messengers are non-negotiable
No intervention, however well-designed, achieves impact without trust. Attendees noted how critically important trust-building is for BIPOC communities where historical trauma and systemic racism shapes how women of color engage with the health care system (not just through the perinatal journey, but often throughout their lives).
Group care models like Centering Pregnancy, peer support networks, and community health worker programs are valuable not just as clinical interventions but also as trust-building infrastructure.