Scope of Covered Services for Maternity Care: Problems and System Goals

Problems

Women face barriers to accessing maternity care benefits in both group and individual private health insurance markets and in Medicaid programs

Widespread discriminatory practices create barriers for women of childbearing age to obtain coverage for maternity care services in private insurance markets. Exclusion of maternity benefits, considering past obstetric history a preexisting condition, and gender-rating similar plans at a higher price for women than for men are among the most pervasive problems. Many low-income, pregnant women are currently eligible for Medicaid coverage only during their pregnancy, leading to delays in care and lack of coverage for critical early primary and secondary prevention and for adequate follow-up in the postpartum period.

Lack of a standardized set of covered evidence-based maternity services

The lack of consensus on a comprehensive package of essential maternity services that have been shown to improve health outcomes, and should be covered by public and private insurance, leads to unwarranted variation in maternity care. This involves both the missed opportunity to deliver effective, high-value services and the wastefulness of delivering services that are ineffective, compare unfavorably with other options, or are provided outside of supported indications.

Typical maternity coverage leaves major gaps in critical aspects of care

The current system for reimbursement of maternity services favors volume of acute interventions and diagnostic procedures concentrated around the time of birth, and leaves important gaps in preventive care and wellness services. These include counseling and behavioral services, preconception and interconception care, postpartum care that includes mental health and family support services, and care that is tailored to meet the needs of women and families related to such factors as language, access, and socioeconomic status.

Gaps in knowledge about the effectiveness of many maternity services

Despite extensive research to clarify the effectiveness of interventions for childbearing women and newborns and to compare alternative approaches, significant gaps in knowledge remain. However, maternity care research and development are systematically underfunded (Fisk & Atun, 2008, 2009), leading to uncertainty about optimal coverage and provision of services. Comparative effectiveness research is needed to answer many such questions.

System Goals

  • Maternity care is a part of a continuum of women’s health care through the life span.
  • All childbearing women and newborns have access to evidence-based maternity services that foster healthy development and address special needs.
  • Benefits coverage and service delivery are outcome driven.

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References

Fisk, N.M., & Atun, R. (2008). Market failure and the poverty of new drugs in maternal health. PLoS Med., 22, e22.

Fisk, N.M., & Atun R. (2009) Systematic analysis of research underfunding in maternal and perinatal health. British Journal of Obstetrics and Gynecology, 116, 347–356.