Optimizing Health And Well-Being For Women And Children
The high rate of maternal mortality in the US, which is twice as high as in the United Kingdom or Canada, is a national disgrace.1 From 2000 to 2014 maternal mortality in the US more than doubled, while most other countries reported significant declines.2 Each year, more than 700 women in the US die during pregnancy and childbirth, and more than 50,000 pregnant women experience a life-threatening complication. Maternal mortality is associated with racial, ethnic, socioeconomic, and geographic disparities. For example, African American women are more than three times as likely to die during pregnancy and childbirth as White women—a gap that has not narrowed in decades.3
Because of socioeconomic disparities, disadvantaged women enter pregnancy with fewer resources. For instance, disadvantaged women may have lower educational attainment and lower income and lack the emotional and financial support of a partner. They also have higher rates of preexisting morbidity such as cardiovascular conditions, obesity, and diabetes. The impact of such maternal factors varies by race and ethnicity; cardiovascular conditions account for the majority of deaths among non-Hispanic Black women.4
Preconception morbidity leads to higher rates of pregnancy complications including hemorrhage, infection, hypertensive disease, and premature delivery.5 One in ten newborns in the US are born preterm—the highest proportion of any developed nation—with major differences by race and ethnicity.6 Prematurity is the leading cause of infant mortality and a contributor to lifelong morbidity. Thus, maternal health and well-being, reflecting experiences throughout the life course, may determine the health of the next generation and, ultimately, the health of the nation.
Another challenge to maternal health is the fact that nearly 70 percent of pregnant women take prescription medications for acute or chronic conditions during pregnancy, yet very few medications have Food and Drug Administration approval for use during pregnancy.7 The lack of robust human safety data regarding the use of medications during pregnancy complicates the management of preexisting conditions as well as illnesses diagnosed during pregnancy, which may harm pregnant women and fetuses alike.
Children and youth in the US experience higher rates of poor health and developmental outcomes, including developmental disorders, mental health conditions, severe asthma, and obesity, as well as other correlates of poor health, including poverty, hunger, poor educational outcomes, and adolescent incarceration, than their counterparts in other countries.8 Low-income children in the US have higher rates of developmental, mental, and behavioral health conditions—and greater severity of these conditions—than non-low-income children.9 The impact of adverse health extends into adulthood, as young adults (ages 15–24) in the US have higher mortality rates than their counterparts in other Organization for Economic Cooperation and Development countries.10 The pattern of increased mortality continues throughout adulthood; this underscores the importance of addressing the health needs of infants, children, adolescents, and young adults to improve long-term health outcomes.
Stresses in early life, including adverse childhood experiences (ACEs) such as child maltreatment, poverty, and parental loss, affect health outcomes and are associated with morbidity and mortality during adulthood.11 The prevalence of adverse experiences varies by ethnicity and socioeconomic status; Black, Hispanic, and low-income children have much higher rates of ACEs.12 This finding has particular importance in the context of a country with an increasingly ethnically diverse population. In 2018 the US population of young children (younger than age five) was already “majority minority,” with a distribution of 50 percent non-Hispanic White, 26 percent Latinx, 14 percent non-Hispanic Black, 5 percent non-Hispanic Asian, 0.8 percent non-Hispanic American Indian and Alaska Native, 0.2 percent non-Hispanic Hawaiian and other Pacific Islander, and 4 percent two or more races.13
The coronavirus disease 2019 (COVID-19) pandemic puts further stress on children’s health. Recent studies have reported major increases in children’s mental health issues,14 and the pandemic has highlighted racial and ethnic disparities in disease burden and mortality. Health care has transformed rapidly, with widespread implementation of telehealth, but an unintended consequence is lower rates of critical childhood immunizations, which require in-person visits.15 The educational disruption experienced by children and youth also will likely have long-term consequences. Furthermore, young families, especially among communities of color, are particularly vulnerable to economic losses from the pandemic and the associated effects on housing, nutrition, and parental well-being.
The importance of accumulated life-course experiences on long-term health and well-being is supported by a large, growing body of literature. The life-course framework uses a longitudinal perspective to assess the role of hereditary, physiologic, psychologic, and environmental influences on health. As individuals grow and mature, they experience positive and negative impacts on health, development, and social-emotional functioning. Furthermore, children experience critical periods during which positive and negative experiences have particularly strong and lasting effects. Poorer outcomes occur in the context of exposure to negative events with insufficient resources to buffer their effects. Familial support is critical during early childhood, but other factors can ameliorate adverse events, such as neighborhood characteristics (schools, recreation, and well-stocked stores) and specific policies and programs (access to health care through public insurance, educational policies, financial support, and adequate housing).
In this fashion, social determinants affect health over the course of a person’s life. Childhood trauma has been linked to chronic health problems into adulthood, with time-specific effects of toxic social or interpersonal experiences.16 Many women enter childbearing age with lengthy histories of ill health and adversity, often beginning during childhood. During pregnancy, the accumulation of poor health and adverse experiences affects intrauterine growth, emotional health, and nutrition status.17 For women of color, the experience of racism contributes to accelerated aging or “weathering,”18 which in turn contributes to the development of chronic health conditions. Weathering may help explain the elevated risk for maternal and infant mortality among African American women, even college-educated women—a risk that socioeconomic status does not explain.19
In this article, part of the National Academy of Medicine’s Vital Directions for Health and Health Care: Priorities for 2021 initiative, which aims to provide expert guidance on several focus areas for US health policy, we use a life-course perspective to highlight promising interventions and recommend key improvements in programs and policies to optimize health and well-being among women and children in the US.20 We provide targeted recommendations that are eminently achievable, as well as “moonshot” recommendations that are more sweeping and transformative. All of our recommendations are intended to optimize the health of women and children so that the US sets a global standard.
Initiatives To Improve Maternal Health
Data from the Centers for Disease Control and Prevention (CDC) indicate that nearly two-thirds of maternal mortality is preventable.21,22 In general, the underlying factors contributing to preventable maternal mortality relate to errors at the level of the clinician, health care facility, and health system, such as inadequate training, missed or delayed diagnoses, delayed or ineffective responses to complications, poor communication, and ineffective coordination of care.22
Quality improvement strategies can improve maternity care and outcomes. In 2006 the California Maternal Quality Care Collaborative, in collaboration with the state’s Department of Public Health and others, launched an initiative to improve the quality and safety of maternity care. The statewide effort focused on the implementation of “maternal safety bundles,” a curated set of best practices, protocols, checklists, and other resources focused on improving the 4Rs: readiness, recognition, response, and reporting. The Postpartum Hemorrhage Bundle required the creation of well-stocked hemorrhage carts (readiness), tools to measure blood loss (recognition), early use of uterotonic medications (response), and mandatory reporting to a centralized data center (reporting). In a controlled trial involving 147 hospitals, implementation of the Postpartum Hemorrhage Bundle resulted in a 20.8 percent reduction in severe maternal morbidities compared with a 1.2 percent reduction among control hospitals.23 From 2006 to 2013 maternal mortality in California decreased by 57 percent, and maternal mortality among Black women decreased by nearly 50 percent.24
In 2015 the federal Maternal and Child Health Bureau established the Alliance for Innovation on Maternal Health to disseminate and scale California’s success to other states. Championed by the American College of Obstetricians and Gynecologists and implemented in collaboration with twenty-five national organizations, the alliance has engaged 33 states and more than 1,400 hospitals in implementing maternal safety bundles, with the goal of engaging every birthing hospital in the US and achieving a 50 percent reduction in maternal mortality by 2025.25
Reducing and eradicating maternal deaths in the US will require improving the quality and safety of maternity care as well as women’s health across the life course. A first step is providing women with access to comprehensive health services, including primary and preventive care, preconception and interconception care, and family planning. Healthy Start is a promising federal program that takes a comprehensive, community-based approach to improving perinatal outcomes in 100 at-risk communities by promoting women’s health before, during, and beyond pregnancies; strengthening families and communities; and addressing social determinants of health.25 Recognizing that many maternal health disparities are rooted in institutionalized racism, advocates have recently called for a redesign of intervention programs from a reproductive justice framework, which maintains that “reproductive safety and dignity [depend] on having the resources to get good medical care and decent housing, to have a job that [pays] a living wage, to live without police harassment, to live free of racism in a physically healthy environment.”26
Interventions To Improve Child Health
Improving child health, development, and well-being involves providing services across sectors, including the health, education, child welfare, and justice sectors. A succession of National Academies reports, beginning with From Neurons to Neighborhoods27 to, most recently, Vibrant and Healthy Kids,28 have summarized the substantial literature that documents the positive effects of early childhood education and family support on cognitive abilities and educational success, which translates into long-term economic well-being, including reduction in justice system involvement and incarceration.29,30 Home visiting services for families contribute to improved cognitive development and, in some cases, improved trajectories for parents.31 Paid family leave also improves birth outcomes.32
The Vibrant and Healthy Kids report reviewed an array of programs, including economic, family support, health care, and early education programs, to assess their effectiveness.28 Multiple programs, including nutrition support through the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); income support such as the Child and Dependent Care Credit and the Earned Income Tax Credit; and adequate health insurance, have demonstrated improvements in the health of parents and health and developmental outcomes for children. Despite this success, most programs other than health insurance have reached only half of eligible households.33 Bringing these programs to scale will have substantial impact on the health and well-being of children and youth.
Issues In Access To Care
For women and children, access to medical care is one buffer against poor health. However, disadvantaged women experience limited access to care and are more likely to have an unplanned pregnancy, partly reflecting inadequate preconception care and family planning. They are also more likely to start prenatal care later than more advantaged peers and to deliver in hospitals with lower quality-of-care indicators.34
Despite the gains in coverage provided by the Affordable Care Act (ACA), in 2018 there were 10.8 million women ages 19–64 who lacked insurance, including more than a million poor women who lived in states that did not expand Medicaid.35 Furthermore, many childbearing women who reside in nonexpansion states lose Medicaid coverage at sixty days postpartum. In addition, recent changes in Medicaid eligibility, such as work requirements, have reduced women’s enrollment in the program.36
Changes affecting the ACA include the expansion of short-term health plans that are not required to comply with coverage and benefit requirements and the exemption of employers from providing contraceptive coverage on the basis of a company’s religious or moral objections. Efforts to defund Planned Parenthood could further restrict women’s access to preventive services, preconception and interconception care, and family planning.
Medicaid and its partner program, the Children’s Health Insurance Program (CHIP), are essential for children. Approximately one-third of US children and youth have public insurance.37 Medicaid differs substantially from Medicare because states are required to provide some funding and because states control many program elements, including eligibility and benefits. Medicaid pays providers at rates typically one-third lower than Medicare payments, making many providers unwilling to accept Medicaid-insured patients.38
In addition, access to oral health services is important for children because dental caries is the most common chronic disease of childhood.39 Despite Medicaid coverage of oral health services under the Early and Periodic Screening, Diagnostic, and Treatment benefit, fewer than half of all children on Medicaid receive dental services in a given year.40
Policy Recommendations
We believe that the health and well-being of women and children in the US should set the world’s standard.
We believe that the health and well-being of women and children in the US should set the world’s standard. Specifically, no woman in the US should die from a preventable complication of pregnancy or childbirth, and children should live in a society that allows them to thrive and maximize their full potential.
To achieve these goals, we recommend applying a life-course perspective from preconception to pregnancy and at all life stages including fetal development, childhood, adolescence, and adulthood. This perspective promotes family-centered design and equity by acknowledging and addressing adversity and disparities across the life course. We recommend improving access to care, transforming health care delivery and financing, and addressing social and environmental drivers of health. Achieving these goals requires fundamental components such as the collection of robust data to inform research and policy, attention to safety and accountability, and sustained research into effective programs and implementation. Building broad programs to achieve equity and diminish disparities, integrate health care with other sectors, and transform health care to population health models will require corresponding changes in the workforce.
We categorize our recommendations as targeted and moonshot. The targeted recommendations focus on existing programs and policies and are eminently achievable. The moonshot recommendations are transformative and broadly impactful, and they and require support and resources from multiple sectors.
Targeted Recommendations
Data:
The CDC should expand support of maternal mortality review committees to all fifty states and the District of Columbia. The Enhancing Reviews and Surveillance to Eliminate Maternal Mortality program should be expanded throughout the country.
Federal data sets should harmonize the definitions used to delineate subpopulations of children, resulting in more consistent groupings based on race and ethnicity, age, and clinical characteristics. Data sets should be integrated across data sources, and longitudinal studies are needed to assess the determinants of child and adult health outcomes.
Safety:
The Maternal and Child Health Bureau should expand its support of the Alliance for Innovation on Maternal Health program to achieve the goals of applying maternal safety bundles to every birthing hospital and a 50 percent reduction in maternal mortality by 2025.
For children, the Department of Health and Human Services and the Agency for Healthcare Research and Quality should ensure the nationwide adoption of safety interventions in all sectors of the health care system and conduct research to address gaps related to quality and safety.
Research:
Congress should support the Task Force on Research Specific to Pregnant and Lactating Women, which was established through the 21st Century Cures Act of 2016. The task force’s goal is to remove regulatory barriers that prohibit pregnant women from participating in research and to require the drug development industry to include pregnant women in clinical trials.
The National Institutes of Health and other funders should enhance support for studies to identify the mechanisms that link adverse events during early childhood to health outcomes across the life course and assess the relative effectiveness of prevention versus intervention strategies.
Moonshot Recommendations
Ensure Access:
Society must ensure that women, their partners, and children have access to high-quality comprehensive health services across the life course. Care should be patient and family centered and emphasize preventive services, with culturally and linguistically appropriate outreach and services. Access strategies should address racial and ethnic disparities. Specific strategies include Medicaid expansion; providing a public option in the ACA Marketplace; enforcing the ACA’s coverage and benefits requirements, which require insurance plans to provide maternity care, mental health, and women’s preventive services; limiting restrictions on employers’ exemptions for contraceptive coverage; and repealing the Hyde Amendment, which prohibits the use of federal funds to pay for abortion except in certain instances.
All children should have access to health care services that emphasize the prevention of adversity and ill health.
All children should have access to health care services that emphasize the prevention of adversity and ill health. Coverage should ensure access to behavioral and mental health and oral health services. Children with special health care needs require integrated, coordinated care and habilitative services.
We recommend strengthening public insurance (Medicaid/CHIP) for children through structural change. First, Medicaid should ensure universal coverage for all children from birth through age twenty-one years. Second, Medicaid for children and youth should transform to a fully federally financed program to reduce the burden on states and facilitate the development of national standards with physician payment rates comparable to those of Medicare. States often struggle to balance their budgets, which is related, in part, to the fact that Medicaid consumes a sizable proportion of the budget (15 percent, on average) and because demand for services increases when revenues plummet, such as during the COVID-19 pandemic.41 Federalizing the Medicaid program for children and youth would generate some additional costs. However, at this time, only about 10 percent of the total federal spending on health care is allocated to children and youth, and a new program could be gradually implemented. Under this construct, families could maintain employer-based insurance with the understanding that the federalized program could support them if needed. Third, Medicaid should expand its focus on population health, including focusing on upstream prevention of poor health, incentivizing transformation of health care, and promoting cross-sector collaboration.
Transform Health Care Delivery And Financing:
The health care sector has witnessed much experimentation with value-based payment arrangements and population health. Defining value in child and adolescent health care requires different metrics from those applied to adults. For example, cost savings will accrue over the long term and may return to nonhealth sectors such as education and juvenile justice.42 Innovative multidisciplinary models of team care, often supported by Medicaid programs, may include staff members who connect enrollees with community resources, expand the use of technology—including telemedicine—and proactively monitor health and disease. Teams could expand capacity in behavioral and mental health, improve coordination and management of chronic conditions, and focus attention on the social drivers of health. The Department of Health and Human Services, including the Centers for Medicare and Medicaid Services, should support new programs to improve and transform the content, delivery, organization, and financing of health services for women and children, including preconception, prenatal, postpartum, and pediatric care.
Address Social And Environmental Factors:
Improving women’s and children’s health requires systematic, coordinated efforts across several sectors, including health, education, justice, and social services. For example, efforts to reduce poverty should strengthen household income through expansion of the Earned Income Tax Credit and the Child and Dependent Care Tax Credit and conversion of the Child Tax Credit, which lowers the tax that families pay, into a child allowance, which would apply to all families whether or not they pay taxes.43 Efforts to enhance family resiliency require new paid family leave policies, expanded programs for child care, and enhanced access to early childhood education. Programs to enhance family stability should explicitly address the need for stable housing. Successful nutrition programs such as SNAP, WIC, and school-based meals, which currently reach only a fraction of eligible households, should be brought to scale.28 Recent events, including the COVID-19 pandemic, have highlighted inequities in most of the programs noted here, and we call for acknowledging and addressing disparities to achieve equity.
Conclusion
Women and children in the US face challenges to optimal health and well-being. In this article we have outlined a set of policies and programs focused on access to health care, health care transformation, and attention to social drivers of health for women and children. Our recommendations are highly relevant for an administration and Congress that are prepared to address inequities and make meaningful, lasting improvements for women, children, families, and the entire country.
ACKNOWLEDGMENTS
This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits others to distribute this work provided the original work is properly cited, not altered, and not used for commercial purposes. See https://creativecommons.org/licenses/by-nc-nd/4.0/. [Published online January 21, 2021.]
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