Primary Care Can Play Key Role in Closing Care Gaps After Women Give Birth & that Affect them for a Lifetime

WASHINGTON, March 8, 2021—The Primary Collaborative (PCC), along with a number of its members and members of the Bridging the Chasm Collaborative, is releasing a women-first agenda today, International Women’s Day. This agenda closes the healthcare gaps that contribute to preventable maternal deaths and chronic illness later in life among all women, especially Black, Indigenous, and other women of color. PCC believes that primary care can play a key role in closing care gaps often evident in the year after women give birth but that can affect them for a lifetime.

The agenda is presented in two articles published today in the journal Women’s Health Issues: “Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action,” and an accompanying commentary, “It’s Time to Eliminate Racism and Fragmentation in Women’s Health Care.” The agenda comes as Congress considers legislation to tackle huge racial inequities in maternal health with the 2021 Black Maternal Health Momnibus Act.

The broad coalition of clinicians, researchers and advocates that formulated the agenda includes PCC members - Black Women’s Health Imperative, Mathematica, Johns Hopkins Community Physicians -  and is led by the Boston University Schools of Public Health and Medicine.

“Many women, especially women of color, fall into a healthcare chasm after they give birth. That gap is a major factor in preventable deaths and chronic illness for these women,” said Ann Greiner, PCC’s president and CEO and a contributing author to the journal articles. “Primary care can step into that gap and provide the care that these mothers need after giving birth and stave off pregnancy-related conditions that can affect them for a lifetime. Providing such care can address fragmentation and improve healthcare equity.”

The journal articles present remedies to the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, healthcare leaders, educators, and the media (see more below).

“The United States has an abysmal record when it comes to Black maternal health. We know that change comes through both practice and policy. The Bridging the Chasm agenda sets the strategy for addressing structural racism in systems of care and identifies the policy changes required to eliminate needless inequities in Black maternal outcomes,” says Linda Goler Blount, MPH, president and CEO of the Black Women’s Health Imperative and another contributor to the journal articles.

The agenda is the product of two years of collective work, launched at an innovative national conference hosted at Boston University in 2018. The conference brought together women with lived experiences of complicated pregnancies, clinicians, researchers, health system innovators, policymakers, and private sector advocates to identify the gaps in care after pregnancy and other systemic issues, and to outline an agenda for transformation. A group of dedicated stakeholders—the Bridge the Chasm Collaborative—co-created the resulting agenda. 

The Gaps

• The healthcare system is divided into reproductive functions and “all the rest.” Pregnancy and birth have long-term effects on health, but, even after clear warning signals, follow up care after pregnancy is exceedingly poor, as low as 50% for gestational diabetes among insured women (and lower for women on Medicaid), and 26% for gestational hypertension.
• Healthcare and insurance policies support birthing people when they are pregnant and for about 8 weeks postpartum—then new mothers fall into a chasm of disconnected health care at best, and no health care at worst. Medicaid coverage for mothers ends after 60 days, while children remain covered by public insurance (CHIP). Well childcare for the first three years of life is routine, but no such system exists for mothers. 
• Inequities between Black and White women extend from maternal mortality to chronic illnesses that place women at risk during reproductive years and beyond. Black women across the income spectrum and from all walks of life die from preventable pregnancy-related complications at 3 to 4 times the rate of non-Hispanic White women, and experience severe maternal morbidity (life-threatening complications) at twice the rate. Among pregnant and postpartum women, Black women had a 50% greater risk than Whites of dying from heart disease.
• Women’s needs and voices are often ignored or simply not central to their healthcare experience, and disrespect and racism (interpersonal and structural) are common in reproductive health care for Black women. In the 2019 Giving Voice to Mothers survey, 27.2% of women of color with low socioeconomic status reported verbal or physical abuse during maternity care, compared with 18.7% of White women.

The Agenda

• Hold healthcare institutions and clinicians responsible for ending the epidemic of disrespect for women of color, linking progress to accreditation.
• Provide infrastructure support to community-based organizations run by and for Black, Indigenous, and other women of color.
• Extend holistic, team-based care to the postpartum year and beyond, with integration of doulas and community health workers on teams.
• Expand Medicaid coverage across the full postpartum year and support the development of Medicaid pay-for-performance policies that require linkage to primary care. 
• Preserve maternal narratives and data across providers and specialties.
• Align research with women’s lived experiences and center their voices in the design, conduct, and dissemination of findings.

In their commentary, the authors note that the Momnibus Act offers an ideal platform on which to build key planks of the Bridge the Chasm Agenda, investing in mothers not only during but long after pregnancy.