The County Maternal Health Landscape: Inequities, Barriers and Recommendations
Overview:
Counties play a critical role in improving the health of pregnant and postpartum people. As owners and administrators of the local health and human services social net, county leaders recognize that rising instances of maternal health complications and deaths underscore the necessity for enhanced provision and accessibility of maternal health services. Further, disparities in maternal health experiences pose a serious equity issue that can be addressed through policies and programs that lead to strong birth outcomes.
To better understand the challenges and opportunities for county government in supporting pregnant and postpartum people, the National Association of Counties Research Foundation (NACoRF) surveyed county officials on their role and authority in maternal health, gaps and barriers in maternal care systems and county-level solutions and priorities. This report highlights survey findings alongside focus group and interview responses to share the critical role of counties in serving pregnant and birthing residents. County leaders can use this information to guide development of comprehensive, accessible and equitable local maternal health care systems.
The Problem
The United States is facing a growing national crisis in maternal health as pregnant and postpartum people face worsening health outcomes and disparities continue to widen. We continue to have one of the highest maternal mortality ratios – the number of maternal deaths for every 100,000 live births – among other high-income nations.¹ In the U.S., 700 mothers die each year from complications during or after pregnancy and 4.7 million women live in counties with limited maternity care access.² The national maternal mortality rate increased from 23.8 to 32.9 deaths per 100,000 live births between 2020 to 2021.³
Maternal health is vital for both the well-being of pregnant individuals and the health of their infants. For infants and children, maternal morbidity can increase risk of developing chronic health conditions, behavioral or developmental disorders or mental health challenges, all of which have future impacts on children. Providing safe and quality care can prevent adverse long-term outcomes.
The connection across maternal health and the health of infants, families and communities is visualized in the Birth Equity Ecosystem Map, created by The Association of Maternal and Child Health Programs’ (AMCHP). The innermost layer of the map displays the interrelated health stages that impact individuals across the ecosystem. These stages exist in the intersections of social and economic supports, policies, clinical care and the physical environment. Centering a whole family ecosystem approach that recognizes and reflects the various systems that impact maternal, infant and child health will help counties improve equity and improve maternal health outcomes.
Adverse birth outcomes and experiences have a direct impact on pregnant people. Maternal death or mortality is the loss of a pregnant person’s life during the perinatal period – the period that includes the duration of pregnancy, childbirth and up to 42 days postpartum. ⁸ It includes deaths caused by pregnancy related complications or any aggravation of pre-existing conditions due to the physiological effects of pregnancy. Greater experiences of morbidity are associated with higher mortality rates, greater risk of unemployment, absenteeism, reduced productivity and greater costs.9
A maternal mortality rate is the measure of the frequency of occurrence of death, specifically the number of maternal deaths per 100,000 live births.6 Maternal morbidity is defined as any short- or long-term health problems that result from being pregnant and giving birth, or in other terms, the physical and psychological conditions resultant or aggravated by pregnancy.7
Maternal health is a particularly pressing issue for people of color and other historically marginalized populations, including pregnant people living in rural communities and those living with behavioral health conditions and other barriers. In 2021, the maternal mortality rate for non-Hispanic Black women was 69.9 deaths per 100,000 live births, 2.6 times the rate for nonHispanic White women.10 For American Indian/ Alaskan Native women, the maternal mortality rate is 118.7 deaths per 100,000 live births, 4.5 times the rate for non-Hispanic White women.11