Postpartum Medical Coverage

Women are at increased risk of pregnancy-related death for a year after birth.

Maternal mortality refers to the pregnancy-related death of a woman while pregnant or within one year of birth.

• Missouri’s maternal mortality rate is 1.4x higher than the national rate.
• More than half of maternal mortalities in MO occur between 45 days and 12 months of delivery, roughly 4x the national rate (MO DHHS 2022; CDC 2019).

Physical and Behavioral Mortality Risks: In 2019, 75% of pregnancy-related deaths in MO were determined to be preventable. The leading causes of maternal mortality in MO are embolism and hemorrhage during pregnancy, infection and amniotic fluid embolism within 42 days, and gastrointestinal and cardiovascular issues within one year of birth (MO DHHS 2022).

Chronic health conditions (e.g., diabetes, heart disease, mental illness) increase the risk of death during pregnancy/postpartum, especially among ethnic minorities in MO who have higher rates of chronic disease (MO DHHS 2022; Moe 2020; Yun 2013).

• Cesarean deliveries (C-sections) are associated with increased mortality (Collier 2019). In MO, a third of live births in 2022 were by C-section (CDC 2022)
• Other risk factors include limited access to care, age, carrying multiples, or having five or more births (Collier 2019).

Social Mortality Risks: Black Missourians are at 3x higher risk for maternal mortality than White Missourians; women in poverty in MO have 2x greater risk for maternal mortality (MO DHHS 2022). Minoritized women are more likely to live in underserved communities, lack health literacy, insurance, or have delayed access to prenatal/postpartum care (Walker 2019).

• Lack of prenatal care in the 1st trimester is associated with increased maternal mortality; a third of first-time mothers in MO do not have access to prenatal care, 57% of which were Black women (MO DHHS 2022).
• Social factors that increase maternal mortality risk include: income, education, housing/food access, employment status (including partner), migration status, and the environment (Jones 2022; Crear-Perry 2021; Wang 2020). The relative impact of these social factors on maternal mortality in MO remains understudied.

Postpartum coverage for some low-income women in Missouri covers 60-days after birth.

A 2021 MO law extended Medicaid to all adults within 1.4x the poverty level, but does not extend postpartum coverage to women above this threshold.

MO HealthNet for Pregnant Women (MPW) provides medical coverage during pregnancy and 60-day postpartum for women who apply while pregnant with a household income within 2x the federal poverty level ($39,440 for a family of two). In November 2022, 34,660 women were enrolled in MPW (MO DSS 2022).

The Show-Me Healthy Babies (SMHB) program covers labor, delivery, and 60 days postpartum if mothers have no access to insurance and their household income is within 2-3x the federal poverty level (up to $59,160 for a family of two). In February 2020, 3,606 women were enrolled in the SMHB program (MFFH 2022).

Medicaid coverage for pregnant & postpartum women can reduce maternal mortality.

One in five women become uninsured in the first six months of pregnancy, increasing maternal mortality risk (Shah 2022).

Twenty-six states and DC have extended postpartum Medicaid coverage to 12-months through general Medicaid expansion (Figure 1).

• Overall Medicaid expansion is associated with a 25-40% reduction in maternal deaths, compared to non-Medicaid-expansion states (Luther 2021; Eliason 2020).
• States that expanded Medicaid have increased maternal healthcare use, management of chronic or pregnancy-related diseases, and prenatal nutrient use (Shah 2022; Clark 2022).

Nine non-expansion states have extended some form of postpartum coverage through legislation, approved Medicaid waivers that differ from federal standards, or parts of their state budgets (Figure 1) (NCSL 2022; KFF 2022)

• 61% of postpartum mothers (2x that of expansion states) in the nine states without full Medicaid expansion are disenrolled from Medicaid within one year (KFF 2022).
• Postpartum women in CO (12-month coverage) have nearly 2x as many clinical visits within six months compared to UT (2-month coverage) (Gordon 2020).

The federal American Rescue Plan Act funds states extending Medicaid coverage up to one year postpartum, and is available through March 2027.

Figure 1. States that have expanded 12-month postpartum coverage through Medicaid. Twenty-seven states (blue) have extended postpartum coverage through Medicaid. Seven (green) are in the planning phase. Two (light blue) have limited additional coverage (TX, 6 months; WI, 90 days). Data from the Kaiser Family Foundation.

References

Cesarean Delivery Rate by State. (2020). Centers for Disease Control and Prevention Retrieved from https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm

Clark, M., Burak, EW. (2022, July 15 2022). Opportunities to Support Maternal and Child Health Through Medicaid’s New Postpartum Coverage Extension. Retrieved from https://ccf.georgetown.edu/2022/07/15/opportunities-to-support-maternal-and-child-health-through-medicaids-new-postpartum-coverage-extension/

Collier, A. Y., & Molina, R. L. (2019). Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions. Neoreviews, 20(10), e561-e574. doi:10.1542/neo.20-10-e561

Corallo, B., Tolbert, J, Saunders, H, Frederiksen, B. (2022). Medicaid Enrollment Patterns During the Postpartum Year. Retrieved from https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-patterns-during-the-postpartum-year/

Crear-Perry, J., Correa-de-Araujo, R., Lewis Johnson, T., McLemore, M. R., Neilson, E., & Wallace, M. (2021). Social and Structural Determinants of Health Inequities in Maternal Health. J Womens Health (Larchmt), 30(2), 230-235. doi:10.1089/jwh.2020.8882

DSS Caseload Counter. (2022).  Retrieved from https://dss.mo.gov/mis/clcounter/history.htm

Eliason, E. L. (2020). Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality. Women's Health Issues, 30(3), 147-152. doi:10.1016/j.whi.2020.01.005

Examining the 12-Month Postpartum Medicaid Coverage Option for Missouri. (2022). Retrieved from https://mffh.org/wp-content/uploads/2021/05/Postpartum-coverage.pdf

Gordon, S., Sommers, BD, Wilson, IB, Trivedi, AN. (2020). Effects Of Medicaid Expansion On Postpartum Coverage And Outpatient Utilization. Health Affairs, 39(1), 77-84. doi:10.1377/hlthaff.2019.00547

Luther, J. P., Johnson, D. Y., Joynt Maddox, K. E., & Lindley, K. J. (2021). Reducing Cardiovascular Maternal Mortality by Extending Medicaid for Postpartum Women. J Am Heart Assoc, 10(15), e022040. doi:10.1161/jaha.121.022040

Medicaid Postpartum Coverage Extension Tracker. (2023). Retrieved from https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/

Moe, K., Sugulle, M., Dechend, R., & Staff, A. C. (2020). Risk prediction of maternal cardiovascular disease one year after hypertensive pregnancy complications or gestational diabetes mellitus. Eur J Prev Cardiol, 27(12), 1273-1283. doi:10.1177/2047487319879791

A Multi Year Look At Maternal Mortality In Missouri, 2017-2019 Pregnancy-Associated Mortality Review. (2022).  Retrieved from https://health.mo.gov/data/pamr/pdf/2019-annual-report.pdf

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Mayes, N., Johnston, E., . . . Barfield, W. (2019). Vital Signs: Pregnancy-Related Deaths, United States, 2011-2015, and Strategies for Prevention, 13 States, 2013-2017. MMWR: Morbidity and Mortality Weekly Report, 68(18), 423-429. doi:10.15585/mmwr.mm6818e1

Shah, S., & Friedman, H. (2022). Medicaid and moms: the potential impact of extending medicaid coverage to mothers for 1 year after delivery. Journal of Perinatology, 42(6), 819-824. doi:10.1038/s41372-021-01299-w

Walker, K. C., Arbour, M. W., & Wika, J. C. (2019). Consolidation of Guidelines of Postpartum Care Recommendations to Address Maternal Morbidity and Mortality. Nursing for Women's Health, 23(6), 508-517. doi:10.1016/j.nwh.2019.09.004

Wang, E., Glazer, K. B., Howell, E. A., & Janevic, T. M. (2020). Social Determinants of Pregnancy-Related Mortality and Morbidity in the United States: A Systematic Review. Obstetrics and Gynecology, 135(4), 896-915. doi:10.1097/aog.0000000000003762

Yun, S., Kayani, N., Homan, S., Li, J., Pashi, A., McBride, D., & Wilson, J. (2013). The burden of chronic diseases in Missouri: progress and challenges. Missouri Medicine, 110(6), 505-511.

**This Note has been updated since its original publication. Previous versions are not up-to-date, but can be accessed here: Version 1 (April 2022).