Disparities: Problems and System Goals

Problems

Disparities in maternal and newborn outcomes

In the United States, women from racial and ethnic minority communities and low-income women and their newborns are more likely to report worse overall health and poorer performance on standard indicators of maternal and newborn health. For example, the midcourse Healthy People 2010 review found that disparities for black non-Hispanic women were increasing for numerous indicators, including neonatal deaths, very low birthweight infants, mental retardation, and cerebral palsy.

Disparities in health system access and provider-level barriers

Non-Hispanic black, Hispanic, and American Indian-Alaskan Natives were more than twice as likely as non-Hispanic white women to receive late or no prenatal care in 2006; as of 2008, nearly 40% of low-income women ages 18 to 44 were uninsured. Access to high-quality maternity care is impacted by insurance transitions in pregnancy, daunting documentation processes, language and cultural barriers, limited health literacy, out-of-pocket costs, and financial disincentives for providers to accept underserved women and provide high-quality, comprehensive services. Women in remote rural areas face particular challenges, and immigrants and refugees also face disparities. Even in urban areas, provider maldistribution and transportation barriers may impact access to timely maternity care. Care available to underserved women is often more fragmented.

Unequal treatment, including provider prejudice and stereotyping, and a limited ability to understand perspectives of patients with diverse backgrounds, contributes to health disparities. Communication that fails to convey respect, collaboration, and transparency reinforces mistrust.

Limitations of current ‘‘safety net’’ government care programs Caregivers who participate in Medicaid and other public insurance programs may not be fairly compensated for care of vulnerable populations with complex health challenges and may not have access to participating specialists for needed referral. Women with public insurance may have difficulty finding participating providers. For many women, Medicaid eligibility begins only when the pregnancy is medically determined and ends 60 days postpartum, resulting in problems accessing family planning, preconception care, and long-term postpartum services. Although Medicaid is the primary payor for about 42% of births in the country, a large proportion of which are to women of color, at the federal level CMS has not provided national leadership in developing strategies to address maternity disparities through the program.

Poor understanding of disparities and inadequate ability to measure and address them

Although this is a growing field of study, more research is needed to clarify the complex factors leading to disparities in the outcomes of care for childbearing women and newborns. While the NQF identified disparities-sensitive criteria and recommended that they be used when submitting and reviewing all candidate measures, this has been done for just 5 of the NQF-endorsed maternity care measures (all relating to prenatal care). No NQF-endorsed maternity care measures have been stratified by priority considerations of race/ethnicity, socioeconomic status, primary language, and health insurance status. Without measuring disparities, safety net providers may be penalized, and little attention may be paid to closing gaps. (See the Blueprint section on Performance Measurement and Leveraging of Results.)

The maternity care system is ill-equipped to address many perinatal disparities that arise from social factors (e.g., intergenerational poverty, social isolation, low education, and racism); these contribute through nutritional, inflammatory, infectious, and vascular pathways to preterm birth, fetal growth restriction, and other pregnancy-related morbidity, and take a toll on women, newborns, and society.

Reimbursement and funding misalignment contributes to disparities in maternity care outcomes

Payment is misaligned with goals of care. Payors often fail to reimburse for preventive services that might especially benefit low-income and minority women and ameliorate disparities, but pay readily for various overused maternity services. There is no financial reward for good outcomes, and separate, lucrative NICU payment further lessens incentives for optimal outcomes.

Pay for performance (P4P) without case-mix adjustment to account for disparities in baseline population risks has the potential for unintended consequences, including diverting resources from safety net providers if the lack of adjustment makes it appear that their performance is poor compared to care of lower-risk populations. Furthermore, these settings may be less prepared for P4P because, for example, they have fewer resources to invest in health IT.

Health IT infrastructure, including electronic medical records, is inadequate, particularly among safety net providers

Inadequate health IT is a major obstacle to data collection for measuring and understanding disparities in care processes and outcomes in the settings where vulnerable populations receive care. Safety net providers may also have fewer available resources for transitioning to health IT for solutions to care coordination and decision support that can improve quality and reduce disparities. This poses a particular problem for small practices and community clinics, especially those located in medically underserved areas, and those who serve a disproportionate share of the uninsured. (See the Blueprint section on Development and Use of Health Information Technology.)

System Goals

  • All women and newborns have access to and receive comprehensive high-quality, high-value reproductive health and maternity care.
  • Comprehensive health care reform strategies address maternity care disparities.
  • As a recognized national priority, fundamental responsibility for eliminating maternity care disparities is shared by federal agencies with broad engagement from multiple stakeholders.

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