Employers’ Role in Reducing Maternal Deaths
Bono and Leu discuss a report they wrote for Mercer at the end of 2022, “Maternal mortality in America: sobering reality and the employer’s role.”
The report notes that the United States has one of the highest rates of maternal mortality of high-income countries, that much of this is preventable, and that employers can support better birth outcomes for their employees. In 2020, the latest data, 861 women died of maternal causes in the United States, according to the CDC.
Bono: We wrote this now because of Roe v. Wade and the Dobbs decision. That has created an opportunity for us to talk more about reproductive health and women’s health in general. It’s been bubbling up for a while; this whole issue has been becoming more and more discussed. We’ve seen a lot more information lately about how the U.S. is just not quite doing enough in reproductive health and pregnancy support—and in all areas of women’s health—so that made us want to put together this report to offer suggestions of how employers can help. It’s a huge issue, but there are lots of innovative solutions. In terms of budget or implementation, there are small things that can make a really big impact.
Leu: We play an important role in helping employers with a variety of strategies, and when you look at the landscape of the U.S. and how Americans receive benefits, more than half are through their employers. Because the number of workers ages 20 to 60 who get care through their employers is so high, those employers play an important role in supporting people when there is a public health emergency. What we saw in our research is that, when it comes to maternal mortality and morbidity, we have a state of emergency that is happening. We’re working on helping employers come to the table with actionable steps to help solve the problem.
Bono: By collecting demographic information that hasn’t historically been collected, the employer can send that to insurance companies. Employers are already sending information to insurers in their eligibility reports, so some of that demographic information is already going over. If they add a few fields, like race and ethnicity, insurers can use that to connect people to more appropriate providers. And if employers are requesting this information about providers in their listing, it’s more likely that insurers will include that on their websites.
One of biggest points we tried to communicate in the report is creating provider concordance; there is really something to be said of the relationship between a patient and provider, how comfortable and encouraged a patient feels, and how that can support better medical care. We think plan members should have a choice—as much as possible—of their providers and location for birth. This would allow someone to determine if they want an epidural or slower induction or if they prefer a birth out of a hospital; we want them to choose the options that are best for them.
Employers can be an example by collecting and using this data and putting pressure on insurers to make sure appropriate care is available for all employees. We have seen it in other areas of health where this pressure has been successful. Like in behavioral health, it has expanded over the last few years as the number of employees presenting with mental health concerns has grown and demand for services has increased. We are seeing it in the employer space, some improvements in matching employees with providers who come from similar backgrounds to provide better care. If they can do it in behavioral health, they can do it for OB-GYNs and midwives as well.
Bono: As for midwives, what we most commonly see is that certified nurse midwives are covered. Some insurance covers birthing centers, and we see some plans that cover home births. But there is still a lot of confusion about what is covered, if something is freestanding or a birthing center, what kind of providers can you have, etc. It is complicated, and sometimes you have to do some digging into your plan design to find out what is available.
Increasing the options available for pregnant people could have a positive impact on health outcomes and labor and delivery costs. If better care helps avoid unnecessary interventions or deaths related to pregnancy or birth, it is beneficial to all of those involved. We have seen compelling data about members’ outcomes when they have access to midwives and alternative birthing options and locations. Oftentimes at a birthing center, patients go home much sooner, don’t have an extended medical facility stay, and there is often no medical intervention at all—no IVs or anesthesia—so employers are avoiding a lot of delivery costs.
1. Provide financial reimbursement for doulas through a pretax benefit like health savings or flexible spending accounts.
2. Review plan limitations on out-of-hospital births and offer coverage for women who prefer this kind of delivery.
3. Review access and inclusion for licensed freestanding birth centers and certified nurse midwives.
4. Ensure your insurance carrier and vendors offer search capabilities based on race, ethnicity, sexual orientation, gender and training. Request carriers and vendors perform a diversity audit.
5. Collect race and ethnicity data from plan members and hold vendors accountable for good outcomes among at-risk populations.
6. Review maternity coverage, paying attention to virtual care and alternative providers.
7. Support new parents for a year postpartum with paid leave, lactation consultants, virtual health and phased return to work.
8. Provide training for managers to support pregnant women and new parents from diverse family types.
9. Create inclusive benefits communication and package benefits to help parents navigate all available resources.
Leu: Training for managers is crucial here because that training can support employees and families who are expecting and new parents. Managers can help reduce stigma and make sure employees know what benefits are provided and how to get access to them.
Bono: Manager support and training is critical, and so is getting creative about employee communications. Businesses need to make sure communications are designed in a way that reaches people at the right time and are neatly packaged together. For instance, when someone becomes pregnant, employers can send information out to that employee about leave, doula reimbursement and postpartum care.
Bono: The goal here, as with pregnancy and labor and delivery, is to increase access to midwives or freestanding birth centers. Lots of midwives do home visits after delivery, and there are more postpartum visits with nurse midwives than there are with OB-GYNs [instead of one visit at six weeks, many midwives have three to five visits in the first six weeks postpartum]. There are even some postpartum-focused doulas. If benefits cover explicitly postpartum, they can come to someone’s home and take an evening shift so parents can get sleep or teach a new mom how to get into a routine with feeding.
Telehealth access from vendors can be key here, too. With some of the biggest issues people have, like lactation or blood clots, having someone you can go to to ask a question in the middle of the night is crucial.