Title: Maternal Deaths Are Increasing--Here's Why Description: Each year, hundreds of women die in the U.S. from complications during pregnancy and childbirth. While the number of deaths has increased steadily, in 2021, during COVID, it reached more than a thousand. What factors have contributed to this growing number of maternal deaths? We'll find out from GAO health policy experts Carolyn Yocom and Alissa Hundrup, who each have new reports out this month on maternal health. Thanks for joining us. Related GAO Work: GAO-23-105871, Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic. GAO-23-105515, Maternal Health: Availability of Hospital-Based Obstetric Care in Rural Areas. Released: October 2022 [Alyssa Hundrup:] In terms of hospital based access to maternal care, availability continues to decrease, particularly for the most vulnerable. [Holly Hobbs:] Hi, and welcome to GAO's Watchdog Report, your source for news and information from the U.S. Government Accountability Office. I'm your host, Holly Hobbs. Each year, hundreds of women die in the U.S. from complications during pregnancy and childbirth. While the number of deaths has increased steadily, in 2021, during COVID, it reached more than a thousand. What factors have contributed to this growing number of maternal deaths? We'll find out from GAO health policy experts Carolyn Yocom and Alissa Hundrup, who each have new reports out this month on maternal health. Thanks for joining us. [Carolyn Yocom:] Thank you. [Alyssa Hundrup:] Thank you. [Holly Hobbs:] So, Carolyn, Why do maternal deaths keep going up? [Carolyn Yocom:] Well, the pandemic certainly had an effect on maternal deaths. The virus definitely had an impact, particularly for 2021. As one example, the Delta-variant of COVID was around in the end of June, all the way through December. And during that time, the risk of death for pregnant women was three times higher compared with earlier months. But there is another piece, and that's that COVID exacerbated factors that have long contributed to disparities in maternal health outcomes, especially for black women. For example, access to maternal health care is problematic in many communities, and that got worse during the pandemic. As another example, many pregnant individuals were able to use telehealth instead of going to a doctor's office. But this wasn't consistent across the board. Where you lived and what resources you had affected your ability to use telehealth as a service during the pandemic. [Holly Hobbs:] Can you tell us a little bit more about the women affected? Did they have anything else in common or were some women more likely to have complications? [Carolyn Yocom:] There were. Black women were close to three times higher to have maternal deaths compared with White women. And then Hispanic women, the outcomes overall worsened. The likelihood of death were two times higher for White women. There's really two broad things that affected these outcomes. One is racism itself. It increases chronic stress, which causes health issues. And it can affect how patients are treated and also create communication challenges between doctors and patients. And this is across the board. This isn't about people's wealth, education, or even access to care. A second broad factor is really social determinants of health. So the extent to which a person has access to care, what their living environment is like, and what employment looks like for them. And some of the research looking at the Hispanic outcomes that increases in death basically focused on the fact that the living conditions may have affected their ability to socially distance. Many Hispanic individuals had jobs that were public facing so they couldn't work from home and they were therefore facing increased exposure to COVID. [Holly Hobbs:] Alyssa, in your report, you look specifically at maternal health for another underserved population, rural America. What did you find? [Alyssa Hundrup:] So in our report we looked at the availability of hospital based obstetric care or OB care in rural areas. We found that hospitals offering OB services had decreased from 2004 to 2018. By 2018, more than half of rural counties did not offer such services. This is problematic because the loss of this care is associated with increased distances that moms must travel, increases and out of hospital births, and that in turn gives to a higher rate of preterm births, as well as poor health outcomes for both moms and then their infants as well. We found that OB closures are really more likely in rural counties that are first sparsely populated, so there's a low volume of patients having babies. Second, a higher proportion of lower income residents. And then lastly, a majority of populations that are Black or African-American. [Holly Hobbs:] It sounds like we have a pretty good idea of where this is happening. -But do we know why this is happening? [Alyssa Hundrup:] Yeah, there's a number of factors really causing the decline. I think most commonly, what we heard is, perhaps not surprisingly, financially related. So it's very costly to operate the OB services in hospitals, and the reason for that is there's a need for a continuous 24/7 access to the care. And so you have doctors and nurses and different specialty providers that really have to be on call all the time, even when there's a low volume of patients. And we found that OB services often are the biggest reason for financial losses at hospitals. So then, in turn, they're the first to close when hospitals are struggling financially. I would also point out that there's lower Medicaid reimbursement rates. And so we found that oftentimes reimbursement rates for Medicaid don't cover the full cost of childbirth at a hospital. And we found that there's a higher proportion of patients reliant on Medicaid in rural areas. And then lastly, I would just mention another factor is recruiting and retaining the various different providers. And we found that more so of a challenge in rural hospitals specifically than in those urban areas. [Holly Hobbs:] And for your report, your team interviewed stakeholders, people like patient advocacy groups and health care provider associations. What did they say might help improve access to OB care? [Alyssa Hundrup:] Well, given the low Medicaid rates I just mentioned, stakeholders certainly cited increasing those rates; although, I will acknowledge that it is mostly up to states to set those rates. Other things that were commonly mentioned were increasing remote consultations. So that's using video conferences or phone calls to connect rural providers with more specialists that might be farther away in those urban areas. One program, for example, we saw was where one state had a specific health institute and they had a 24/7 hotline where both patients and doctors could call in to ask questions and get advice. Another one that was commonly mentioned were regional partnerships, and that's where we learned about a hub and spoke model, and that's where the hub would be those larger hospitals in those urban areas, whereas the spokes would be those smaller rural areas. And there there'd be a lot of coordination across the hub and spokes for coordination and training and sharing resources, and really applying kind of a risk based approach to providing that maternal care. {MUSIC} [Holly Hobbs:] So we just heard that maternal health outcomes worsened during the pandemic, particularly among Black and Hispanic women. And that women in rural areas might also face additional challenges accessing care because of limits in services. This topic is going to be in the news and continue to be an issue. Do we have any future work planned? [Carolyn Yocom:] Yes we do. We're starting a second study on maternal health outcomes, and it's going to do a couple of things. First, we're going to continue to add to the data we've already reported, adding on additional years and additional detail as it becomes available. And then secondly, we're going to look at in more detail severe pregnancy complications, and try to better understand the extent to which these were also occurring during the COVID time period. And finally, we're going to look at both federal and state efforts that are underway to improve maternal health outcomes. [Alyssa Hundrup:] And I would just add that we also have work getting underway now looking at maternal health issues in the veteran population, and specifically looking at the prevalence of health outcomes such as maternal mortality and severe maternal complications. [Holly Hobbs:] And last question, what's the bottom line of these reports? Carolyn, maybe we can start with yours. [Carolyn Yocom:] The bottom line is that COVID did increase the number of maternal health deaths. And these deaths has a long history of disparate treatment and disparate outcomes for people who are not White. So to reduce maternal mortality, we need to address these disparities in health outcomes. [Holly Hobbs:] And Alyssa. [Alyssa Hundrup:] In terms of hospital-based access to maternal care, availability continues to decrease, particularly for the most vulnerable, rural populations. It's really a multifaceted problem, and there really is no easy solution. But there are many things the federal government, the states, and others can do to help address the widening gap. [Holly Hobbs:] That was Carolyn Yocom and Alyssa Hundrup talking about GAO's recent review of maternal health. Thanks for your time, ladies. [Carolyn Yocom:] Thank you, Holly. [Alyssa Hundrup:] Thank you. [Holly Hobbs:] And thank you for listening to the Watchdog Report. To hear more podcasts, subscribe to us on Apple Podcasts, Spotify, or wherever you listen and make sure to leave a rating and review to let others know about the work we're doing. For more from the congressional watchdog, the U.S. Government Accountability Office, visit us at GAO.gov.