The views expressed are those of the authors and should not be attributed to the Robert Wood Johnson Foundation or the Urban Institute, its trustees, or its funders. November 2020 The Pandemic Has Increased Demand for Data and Accountability to Decrease Maternal Health Inequity Kimá Joy Taylor and Sarah Benatar The United States is facing a maternal mortality crisis1 that has been particularly acute for women2 of color. Black and indigenous women are two to three times more likely to experience worse maternal health outcomes than white women.3 Increasingly, structural racism is recognized as a key driver of maternal health inequities.4 This extends to systems and organizations that provide perinatal care5 and wraparound health and social services for pregnant and postpartum women with low incomes,6 many of whom are at highest risk of poor maternal health outcomes. These services and supports are funded through a patchwork of public and private sources that are often stretched thin, leaving critical gaps that perpetuate maternal health inequities. And the COVID-19 pandemic has put even more strain on these resources and exacerbated those inequities. In this brief, part of a larger series on COVID-19 and maternal health equity, we draw on interviews with maternal care stakeholders and available literature and reports (Box 1) to assess if and how our current data systems provide the information needed to track inequities in maternal health outcomes, as well as what data collection efforts must be prioritized to establish accountability and reduce inequities. Our key findings are as follows: ›Mothers and infants are facing changes in their health care delivery during the pandemic, such as greater reliance on telehealth, greater discontinuities in care during the prenatal period, and shifting birthing and infant separation practices. For Black, Hispanic/Latinx, and American Indian mothers, these changes are compounded by the economic fallout’s disproportionate effects on their communities. ›Existing data systems cannot support maternal health equity. Payers, providers, health departments, and communities lack data on maternal health outcomes and patient satisfaction disaggregated by race and ethnicity. Therefore, they cannot assess whether changes in practices are improving or worsening maternal and infant health outcomes and/or mitigating the spread of the virus, and whether these answers differ by race, ethnicity, and other characteristics. This information is critical for communities and providers identifying policies that can reduce and ultimately eliminate racial and ethnic inequities while mitigating virus spread. ›Data collection efforts that support improved maternal health equity will require that payers and providers track multiple dimensions of health care practice and policy, including staffing and reimbursement policies and mothers’ access to high-quality, culturally effective, respectful, and affordable prenatal and birthing care. 1|QUALITY. DATA. ACCOUNTABILITY. ›For data-sharing platforms to improve care quality and ›Achieving sustained improvements in care quality and outcomes and reduce inequities, they must ensure privacy reducing inequities in outcomes will require that providers (e.g., include only deidentified data) and provide information and payers invest in collecting high-quality, reliable data on accessible to patients and other community members. Such maternal health care and health outcomes disaggregated platforms will also need to be created in partnership with a by race, ethnicity, and other characteristics. It also requires range of stakeholders. funding to support (1) needed practice changes and trainings that reduce bias and inequities and (2) community-driven testing and evaluation of changes in service delivery models. BOX 1. RESEARCH METHODS In spring and summer 2020, we conducted individual and small-group interviews with 40 maternal health experts, perinatal care providers, consumer advocates, philanthropic funders, and frontline health workers serving pregnant women to identify and examine key concerns about maternal health equity and challenges raised by the pandemic. We also conducted, and periodically updated, a comprehensive scan of publicly available information on maternal health equity during the pandemic from national policy and research organizations, professional and provider trade organizations, and leading maternal and infant health advocacy groups. Our findings primarily reflect insights into and responses to the pandemic that emerged between March and September 2020. Because of social distancing requirements and the urgency of this topic during the pandemic, this analysis has some limitations. We could not interview mothers directly, and though we interviewed provider and advocate stakeholders, we recognize they do not represent mothers’ viewpoints. In addition, our interviewees were predominantly on the East Coast, but we acknowledge community needs and realities differ by location and understand the importance of authentic community voice, partnership, and engagement as solutions are developed, implemented, and evaluated. We center this work, part of the Urban Institute’s larger Transforming Health and Health Care Systems project, around the Center for Social Inclusion’s definition of racial equity:* when “people, including people of color, are owners, planners, and decisionmakers in the systems that govern their lives” and society “[acknowledges and accounts for] past and current inequities and provides all people, particularly those most impacted by racial inequities, the infrastructure needed to thrive.” * What is racial equity? Center for Social Inclusion website. https://www.centerforsocialinclusion.org/our-work/what-is-racial-equity/. Accessed October 19, 2020. Before the pandemic, U.S. maternal health outcomes were changes:8 some states used pay-for-performance packages worse than those of other wealthy countries, and declining.7 to incentivize health and social service partnerships that could The maternal mortality rate doubled to almost 24 deaths in improve outcomes, and some used maternal care practice 100,000 live births from 1991 to 2014.1 This tragic outcome has bundles, which identified quality care tools for improving affected women of color most acutely; data show that Black outcomes (e.g., the American College of Obstetricians and women’s and American Indian women’s maternal mortality rates Gynecologists’ Alliance for the Improvement of Maternal Health are four to five times that of white women.3 program). 9 These efforts raised awareness that improving maternal outcomes does not decrease long-standing racial As data began highlighting the United States’ poor maternal and ethnic inequities. health outcomes in the 2000s, states focused on improving maternal mortality and morbidity for all populations. These In response to the data, California was among the first states efforts included establishing quality committees of experts that to create a targeted equity effort, developing its Birth Equity analyzed data and identified ways to address services and Collaborative to promote implicit bias training and other equity- quality; almost every state created fetal and infant mortality focused measures.10 Other states passed legislation or created review boards, maternal quality review committees, perinatal guidelines requiring implicit bias training for perinatal teams. quality review committees, and/or other oversight committees. Key advocacy organizations, like Black Mamas Matter,11 the The data also moved states to make practice and policy Center for Law and Social Policy, and Movement for Family 2|QUALITY. DATA. ACCOUNTABILITY. Power, consistently reminded state and federal policymakers Though more data are needed to fully understand how the of the importance of authentically including those affected by pandemic and U.S. responses to it have affected maternal inequities not only in developing solutions but in defining success care and outcomes, our interviews and scans of the evidence measures. And data groups, like Race for Equity,12 have called suggest they may be worsening maternal inequities. Society for the “use of data-driven decisionmaking to achieve outcomes lacks a full picture of maternal and infant outcomes associated that center upon the lived experiences of community members.” with COVID-19, in part because of the rapidity of the response. But to date, few states have systematically monitored relevant This incomplete picture also owes to inadequacies in our data outcomes by race and ethnicity or embedded accountability collection efforts and a lack of health system accountability for for equitable outcomes in their programs (i.e., used financial or inequities in maternal outcomes by race, ethnicity, and other other tools to require programming and practices that decrease characteristics. Dartmouth College’s COVID and Reproductive inequities). However, the pandemic has focused attention on Effects (CARE) study, 13 which seeks to understand how maternal health inequities and is leading to budgetary, clinical, COVID-19 is affecting pregnant women’s well-being and and system changes that could spur programmatic innovation, health care experiences, is a beginning, but more is needed. payment reform, and community partnerships that will help Ideally, future efforts would include more community-based eliminate inequities. participatory research to expose the breadth of the pandemic’s effects on maternal morbidity and mortality. In the following section, we describe how maternal health care has been changing during the pandemic, whether maternal The pandemic has led to changes in clinical practice, health inequities have been exacerbated, and how well our data hospital policies, social service access, and patient realities. systems allow us to track those measures. We then identify Understanding these changes allows stakeholders, including key health care practices and policies and maternal health community members, to assess the links between current measures to be tracked and assessed by race and ethnicity. practices and outcomes for different women and identify Finally, we describe what it will take to build a data system that successes, solutions, and concerns. Both qualitative and supports achieving maternal health equity through incentives or quantitative data are needed to understand how to create a other quality measures. culturally and linguistically effective and equitable maternal and child health care system. Such work would be incomplete Maternal Care During the Pandemic without community members, including Black and indigenous mothers, providing input on the questions asked, context for COVID-19, the disease caused by the novel coronavirus, has led results, and ideas for outcome measures and solutions. to rapid changes in the way health systems and providers1 care for pregnant and postpartum women2. These changes have Clinical Practice been necessary to protect both staff and patients. However, We interviewed providers who feared that existing inequities the evidence is limited regarding the quality of care provided, have worsened during the pandemic, because of systemic and how maternal health outcomes and racial inequities in such individual biases and barriers predating the crisis. Concerns outcomes are changing, or whether new rules, regulations, and about changes in clinical practice loomed large. Interviewees practices are protecting providers and patients or exacerbating acknowledged that, even before the pandemic, many women long-standing inequities. saw a different provider each time they sought care, especially those who are uninsured or enrolled in Medicaid. Though new When the pandemic began, interviewees noted that attention providers have access to a new patient’s chart, those charts and funding shifted away from maternal health efforts. Health, can lack important health and social indicators. And if women public health, social service, and other systems were unprepared assume their chart captures their full history, they may not bring and could not rely on experiences from prior epidemics. up past concerns. During the pandemic, staffing shortages14 Attention and resources shifted to virus treatment, control, have increased the likelihood that patients will see different and, eventually, prevention. Because of a constantly changing providers each visit. The usage of telehealth, though important, knowledge base and lack of adequate testing supplies, hospital also worried many key informants; they reported difficulty reading leadership made rapid decisions that were often implemented nonverbal cues, struggling to fully bond with new patients, and, chaotically (e.g., isolation and visitor protocols implemented along with lack of continuity, feeling or knowing they may not for people in labor with suspected COVID-19). Even before fully understand women’s overall health, which could lead to news reports exposing racial and ethnic inequities in COVID-19 worse outcomes for mothers and infants. Some providers outcomes, stakeholders worried the pandemic’s rapid onset noted the pandemic has disrupted access to on-site translators, was exacerbating long-standing maternal health disparities. and video coordination can be challenging because of timing Over time, federal, state, and local policymakers and provider and technology issues. Finally, providers and patients lacked organizations began to more coherently address maternal and equitable access to telehealth or telemonitoring technology child health concerns related to COVID-19. because of cost, limited data plans, and lack of internet access. 3|QUALITY. DATA. ACCOUNTABILITY. Often, these bonding and continuity gaps have disproportionately policies will likely continue changing as the epidemic and their affected Medicaid-enrolled or uninsured patients, those in rural understanding of the virus evolve. Collecting disaggregated areas, and those in other marginalized populations. However, outcome data and patient satisfaction surveys will help them the pace of the pandemic meant few providers were collecting understand which efforts may worsen inequities and need to outcome data, disaggregated or not, when we spoke with be altered. These data, in conjunction with patient surveys and them in the summer. On a more positive side, providers felt interviews, can help identify policies that can ultimately eliminate teleservices increased care access for some mothers, especially racial and ethnic inequities while mitigating virus spread. with postpartum visits, because mothers no longer had to find transportation or babysitters for a short appointment. Social and Economic Concerns Finally, broader social and economic concerns could increase Hospital Practice Changes inequities during the pandemic. Interviewees feared, and The pandemic has also caused myriad hospital policy and studies are beginning to show, that required postpartum practice changes. Initially, hospitals prohibited advocates, isolation during the pandemic is leading to increased anxiety doulas, or family members from being present during prenatal and depression.19 Mothers and their infants may not be able to visits and birth. Without this support, many women feel access family or community support because of quarantining vulnerable and isolated. Before the pandemic, doulas were and physical distancing. Few patient surveys, claims data, or shown to improve maternal health outcomes and decrease provider data are catching the number of patients who need, maternal health inequities.15 We spoke with service providers can access, and are receiving care—much less disaggregated who noted that their Black participants, other participants by race. Unmet behavioral health needs already contributed of color, and participants with behavioral health concerns to maternal and infant morbidity before the pandemic,20 and appreciated the doula support, even though hospitals may stakeholders felt pandemic-induced isolation is likely worsening not fully embrace their efforts. Though barring such supports this. Stakeholders also noted patients are struggling to access from visits and delivery can help control infection, it is also likely basic needs, like diapers, food, and clothing, because of supply associated with worse outcomes. Further, we heard often that issues and shopping restrictions related to the pandemic. these restrictions contributed to patient stress. As states and Though these restrictions have eased in some localities, they hospitals balanced maternal health and disease spread, many may be restored in anticipation of a second wave of infections began to ease restrictions. Only hospitals in some states, like this fall. Because the pandemic has required some providers’ New York, now allow one support person in the birthing room; offices to close, uncertainty regarding the availability and elsewhere, some mothers must still choose between having a accessibility of supports has grown. Key informants described doula or family member present. confusion over whether WIC offices are open and whether, and if so which, behavioral and physical health providers are Unfortunately, stark examples of implicit bias have come to light operating. In addition, people are facing increased stress during the crisis. A New Mexico hospital used American Indian/ because of the virus, such as unemployment or employment in indigenous race as a proxy for COVID-19 risk among mothers,16 risky environments, financial stressors, and lack of child care. leading to American Indian/indigenous mothers and infants Before the crisis, public and private health and social systems being separated at a higher rate than other mothers and infants. were beginning to talk about and work with communities Concerned whistleblowers exposed this policy, but, as one to address societal and social determinants of health; with informant noted, separating a mother from her infant based on the pandemic, new and heightened needs—from losses of race or ethnicity has been a long-standing practice in the U.S. child employment, health insurance, and child care to other social welfare system.17 Though data have not been collected to assess distancing realities—are being revealed. the extent of separations based on race and ethnicity, the New Mexico example is chilling and highlights the work hospitals must Inadequacies in Available Perinatal Care and do to develop trusting relationships with Black and indigenous Maternal Outcome Data mothers. A continued lack of bias education makes it unlikely that the pandemic will change these discriminatory practices. And Before the crisis, many data collection systems failed to policies leading to separation have deleterious effects on mothers monitor maternal outcomes across race and ethnicity.21 Given and their children, such as decreased maternal-infant bonding the inadequacies in data collection and existing information and decreased initiation of breastfeeding.18 on the pandemic and related recession’s disproportionate effects on Black, Hispanic/Latinx, and indigenous populations, Finally, ever-changing hospital and provider polices and a lack inequities in maternal health and morbidity and mortality are of standardization or rules have reportedly led some mothers likely growing. Key informants shared that data collection has and their families to mistrust both the health care system taken a back seat to keeping systems running as efficiently as and their providers, further affecting a relationship already possible. Now that systems are stabilizing and policies and changed by limited in-person visits. Hospitals’ and providers’ practices have adapted, collecting disaggregated outcome 4|QUALITY. DATA. ACCOUNTABILITY. and patient satisfaction data at all service levels is critical. the right domains are targeted, and contextualize results as Doing so helps researchers, policymakers, practitioners, and solutions are developed. This approach is endorsed by the community members understand how the pandemic may be Maternal Child Equity Collaborative,22 which promotes Black disproportionately affecting some communities and, in turn, maternal and child health equity and seeks to ultimately provide care and engagement that supports equitable maternal eliminate the Black infant mortality disparity. and child health outcomes. This should extend to provider practices of all types, hospitals, public and private payers, With appropriate high-quality data collection, health systems can health departments’ maternal child health programs, and social analyze how changes in policies, programs, and practices during service providers. In turn, stakeholders can assess whether the pandemic have affected selected outcomes. Providers and COVID-19 practices and policies, in conjunction with previous payers will need to pair data collection with critical assessments practices, are improving or worsening patient care. of (1) policies, practices, and supports that may improve or worsen inequities and (2) access to culturally and linguistically Despite key informants’ consistent concerns that maternal health effective care. It will be critical to understand and track the inequities are worsening during the pandemic, our existing data following health care practices, policies, and measures, as well systems do not provide the information necessary to assess as their effects by race, ethnicity, and other characteristics: how health care practices and policies and maternal outcomes are changing according to race, ethnicity, or other relevant ›Prenatal care staffing: What is the provider team’s maternal characteristics. Payers, providers, health departments, composition? Who are the new reimbursable staff and and communities lack outcome data that could show how providers (e.g., doulas)? Is the number of currently changes have affected maternal and infant health outcomes reimbursable providers (e.g., midwives) adequate? Are they and/or mitigated spread of the virus. Moreover, they cannot offering culturally and linguistically appropriate care? distinguish whether these answers differ by race, ethnicity, and other intersections, so they can begin addressing inequities. With ›Access to prenatal and postpartum services: What disaggregated outcome data and patient satisfaction surveys, access and barriers to obstetric/gynecological services do payers, providers, and communities will better understand which mothers face? To what extent are women experiencing efforts may be worsening inequities and need to be altered and continuity of care during their pregnancies? To what extent which are working and should be expanded. are women screened for other health needs and referred to and engaged with appropriate supports? Did patients have Designing Data Collection Systems to Improve consistent access to telehealth and telemonitoring services Maternal Care Outcomes and Equity and, if not, what barriers prevented use of those services? If so, were the services effective? Were providers able to High-quality, stratified data including race and ethnicity identifiers, assess and respond to emerging health needs? at a minimum, can help reveal how pregnant and parenting women of color are faring during the pandemic and track efforts ›Adequate financing: To what extent have financing of and to advance equity in their care. Care and outcomes can be reimbursement rates for services changed? Can available optimized, for example, if providers, hospitals, health departments, reimbursements support provision of culturally effective care and private and public payers systematically collect data on and equitable outcomes? depression, anxiety, social needs, postpartum attachment, prenatal and postpartum visit attendance, patient perceptions ›Birthing facilities: What birthing facilities are available? and trust, and other measures that capture access to and use of Where are they located, and are they accessible to everyone? culturally and linguistically effective services. Effectively stratified Are they providing culturally and linguistically appropriate health care data on other outcomes, such as blood pressure services? It not, why not? Do they conduct risk assessments trends and diabetes control, would also contribute to improved to determine clientele? understanding of health and health care inequities. ›Health care coverage: What does health insurance coverage Additionally, patient perspectives can identify areas of success for pregnant women look like overall and for different and failure, which can then inform care models that improve populations? What health care services are health insurance care and outcomes. Each time a patient interacts with the plans actually covering for pregnant women (e.g., COVID-19 health care system is an opportunity to collect data to improve testing, antibody testing, telehealth, behavioral telehealth, equitable outcomes; collecting data during different health care medication, and medication delivery)? Do providers and engagements can not only lead to more equitable outcomes patients know about and understand coverage changes? but spur innovation and increase knowledge about effective solutions. Further, equitable partnerships with community ›Access to respectful care: What share of women report members can identify additional outcome measures, ensure having positive birth experiences? How much does the care 5|QUALITY. DATA. ACCOUNTABILITY. received differ from what is recommended? Does this answer created a California Birth Equity Collaborative 10 and could vary across populations? What level of trust do women have serve as a template for other states. Successful models exist in their providers and the staff they interact with in the health in other health areas, too: the Ryan White CARE Act developed care system? What are patients’ and providers’ perceptions planning councils24 that brought together diverse community of care, bias, mistreatment,23 access to needed care, and stakeholders, proactively including those with lived experience system challenges/improvements? to use the data effectively and distribute resources to improve outcomes. Such efforts require leadership, innovation, funding, ›Access to social services: Did providers complete and commitment to eliminate inequities, and relying on past screenings for social determinants of health? Did they make practices will not suffice. To succeed, data collecting and referrals in response to screening results? What health care sharing efforts must account for several issues: engagement resulted from such referrals? Did access to needed services differ? If so, why? ›Privacy: These platforms must contain deidentified data, so they do not invade consumer privacy and/or lead to punitive ›Birthing policies: At what rates have mothers and babies actions in systems with racially disparate outcomes (e.g., been separated at birth and subsequently reunited? Why, child welfare and criminal justice). when, and for how long were birthing persons separated from their infants? ›Transparency: Information provided via these platforms should be accessible, allowing consumers to easily choose In addition to assessing whether and how these prenatal providers, alternative birthing locations, hospitals, and payers and delivery practices and policies have changed during the that have demonstrated high-quality, equitable outcomes. pandemic and whether they have disproportionately affected certain women, it will be important to examine these practices’ ›Community partnership: To identify affected subgroups effects on outcomes. Future analyses should assess whether and add context to data analyses, states could immediately and how racial and ethnic inequities in maternal and birth develop an advisory board of diverse stakeholders outcomes have been affected or, as feared, increased as the representing their unique community make-up and needs, pandemic has unfolded. including currently or recently pregnant women. This group could monitor data in their community and provide guidance Longer-Term Investments in Data Collection on how to improve metrics and hold systems accountable. and Practice Change to Support Maternal Health Equity ›Cross-sector collaboration: States can ensure maternal and child health and social service providers systematically collect, Creating appropriate training, infrastructure support, and share, and stratify robust deidentified data on outcomes incentivizing payment policies and enhancing community related to health, social services, patient satisfaction, and members’ abilities to use and understand data, and act based more. Shared data can identify areas where policies could be on that information, could promote high-quality maternity and developed and enacted to improve outcomes for all people. child health outcomes for Black, Hispanic/Latinx, and indigenous women, as well as women at higher risk of poor outcomes. Improved data collection must be paired with—and will in turn be improved by—greater investments by providers and payers One such change is providing care to Black and indigenous in the development and sustainability of culturally effective care, women using the existing, culturally responsive and effective including the following: care approaches in their respective communities, which predate the pandemic and have been historically underfunded or ignored. ›Funding, training, and infrastructure support for data Of course, any past and new programming must be continually collection: Such support can ensure providers, payers, and evaluated using stratified data to see if it should be altered to administrators collect high-quality, reliable data that include ensure equitable outcomes. patients’ races, ethnicities, and other intersectional data. States are well positioned to work with public and private ›Funding practice changes for providers with limited payers, hospitals, providers, and communities to (1) ensure resources: Many providers need time and funding to they are collecting necessary maternal health care data and change how they provide care. This may require changing (2) create a data-sharing platform that allows stakeholders to engagement practice, clinical workflow, staffing, and follow- identify, understand, and remedy deficiencies and inequities up approaches. This type of introspection and restructuring, in the health care system. Data systems will be imperfect at especially among clinics serving the underinsured, is rarely first but can be improved and effective with leadership and funded and impossible with limited profit margins. support. Such a process has already occurred within the California Maternal Quality Care Collaborative, which ultimately 6|QUALITY. DATA. ACCOUNTABILITY. ›Funding for trainings to reduce bias and inequities: equitable maternal health outcomes on both health systems Providers, alternative birthing locations, hospitals, and and communities. Finally, tying programming and data to state health departments must engage in bias training, payment establishes the importance of equity within a system educate themselves on culturally and linguistically effective and ultimately ensures more accountability. States have already care practices, and learn about, implement, and evaluate begun using maternal and child value-based purchasing25 for promising practices to decrease inequities (e.g., virtual or maternal and child health outcomes and adding indicators aimed in-person doulas). at eliminating inequities is a crucial next step. Other incentives that might also be considered include ›Supporting community-based interventions and evaluations: The evidence base regarding culturally and ›Medicaid managed-care organization contracts that assign linguistically effective maternal health practices across more patients to payers achieving high-quality, equitable communities is sorely lacking. Many communities have outcomes or incentivize payers in other ways; developed effective, culturally relevant services that have not been evaluated. In other areas, supposedly evidence- ›private-insurer adjustments that create narrow networks with based solutions have not been evaluated to see if they lower costs, based on high-quality, culturally effective services are effective within Black, indigenous, or other diverse and equitable outcomes across diverse intersections; and populations, and they often exclude cultural context. Supporting evidence-informed interventions will depend on ›adjustments to private insurers’ network panels to reward supporting community-based evaluations by researchers providers demonstrating more equitable outcomes. working together with communities. These efforts can build on existing maternal and child health With strong leadership, commitment, community partnership, improvement practices and benefit from lessons learned during and changes in priorities and financing, equitable maternal the pandemic. Understanding what has worked well during the child health outcomes can become a reality. The pandemic crisis, especially for Black, Hispanic/Latinx, indigenous, and other has laid bare existing structural deficits but also showed marginalized populations, can help the health system combat our systems can quickly adapt. To reduce maternal health the currently overlapping maternal health and COVID-19 crises inequities, we must use the current moment to create a new in ways that will also be effective after the crisis. future. During and after the pandemic, providers, public and private payers, and governmental entities will first need to The pandemic has shown that the U.S. health system can collect and analyze information on maternal health care and change and innovate on short notice and tackle important outcomes disaggregated by race and ethnicity to identify areas problems. To eliminate inequities in maternal health care, federal, of inequitable mortality and morbidity. Next, federal, state, and state, and local health authorities, public and private payers, local governments must work with communities to identify hospitals, and providers can collect and analyze maternal health, social, and economic practices, programming, and and child outcomes data stratified by race and ethnicity (at a policies that improve equity. This will require conducting needs minimum). Such authorities must also examine the effects of assessments and gathering in-depth information from women sexual orientation, class, gender identity, and other factors–as in groups who experience inequities, addressing implicit and well as these factors’ intersections—to eliminate inequities. explicit biases in delivery of health care and social services, Payers, providers, and community stakeholders must agree and developing innovative and/or scaling up existing culturally on shared outcome metrics and work together to develop effective services. Though some of this work started before the new or scale existing effective responses, using disaggregated crisis, continuing stark racial inequities in maternal outcomes data to identify areas of success or for improvement. Finally, in 20193 showed more work can be done and commitments payment reform or other incentives will be needed to hold made at the federal, state, and local levels. systems accountable to community stakeholders for ultimately eliminating racial, ethnic, and other inequities in maternal care. Leadership will be needed to try new policy, practice, and programming ideas—whether they already exist in the community, exist in other health or social fields, or must be developed. Such practices must be evaluated to assess the effects of improving 7|QUALITY. DATA. ACCOUNTABILITY. References 1 Delbanco S, Lehan M, Montalvo T, Levin-Scherz J. The rising U.S. maternal mortality rate demands action from employers. Harvard Business Review. 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Accessed October 26, 2020. 20 Rahman A, Surkan PJ, Cayetano CE, Rwagatare P, Dickson KE. Grand challenges: Integrating maternal mental health into maternal and child health programmes. PLoS Medicine 2013;10(5):e1001442. https://dx.doi.org/10.1371%2Fjournal.pmed.1001442. Published May 7, 2013. Accessed October 26, 2020. 21 Castellucci M. Better data needed to tackle maternal mortality. Modern Healthcare. September 1, 2018. https://www.modernhealthcare.com/ article/20180901/NEWS/180829900/better-data-needed-to-tackle-maternal-mortality. Accessed October 26, 2020. 22 Vision and mission. Maternal Child Health Equity Collaborative website. http://www.mchecollaborative.com. Accessed October 26, 2020. 23 About. University of British Columbia, Birth Place Lab website. https://www.birthplacelab.org/about. Accessed October 26, 2020. 24 Centers for Disease Control and Prevention. HIV Planning Guidance. Atlanta: Centers for Disease Control and Prevention; 2012. https://www.cdc.gov/hiv/ pdf/p/cdc-hiv-planning-guidance.pdf. Accessed October 26, 2020. 25 Medicaid and CHIP Payment and Access Commission. Medicaid payment initiatives to improve maternal and birth outcomes. 2019. https://www.macpac.gov/ wp-content/uploads/2019/04/Medicaid-Payment-Initiatives-to-Improve-Maternal-and-Birth-Outcomes.pdf. Published April 4, 2019. Accessed October 26, 2020. 8|QUALITY. DATA. ACCOUNTABILITY. The views expressed are those of the authors and should not be attributed to the Robert Wood Johnson Foundation or the Urban Institute, its trustees, or its funders. About the Authors Kimá Joy Taylor is the founder of Anka Consulting, a health care consulting firm, and a nonresident fellow at the Urban Institute. Taylor collaborates with Urban Institute researchers on a number of topics, including analyses of racial disparities in screening and treatment practices for parents with substance use disorder, management of neonatal abstinence syndrome at hospitals in California, and prevention and early detection of mental and behavioral health problems among adolescents and young adults. She most recently served as the director of the Open Society Foundations’ National Drug Addiction Treatment and Harm Reduction Program. She oversaw grantmaking that supported the expansion of access to a nonpunitive continuum of integrated, evidence-informed, and culturally effective substance use disorder services. Before joining the Open Society Foundations, Taylor served as deputy commissioner for the Baltimore City Health Department, a health and social policy legislative assistant for Senator Sarbanes, and a pediatrician at a federally qualified health center in Washington, DC. Taylor is a graduate of Brown University, Brown University School of Medicine, and the Georgetown University residency program in pediatrics. In 2002, Taylor was awarded a Commonwealth Foundation fellowship in minority health policy at Harvard University. Sarah Benatar is a principal research associate in the Health Policy Center. Her research investigates how public policies affect vulnerable populations’ health outcomes, access to care, use of services, and enrollment in coverage programs, with a particular focus on maternal and child health. Benatar has led and participated in several projects focused on maternal and child health, the Children’s Health Insurance Program, and Medicaid, combining qualitative and quantitative methods to achieve the richest findings. She is working on a national evaluation of the Centers for Medicare and Medicaid Services’ Strong Start for Mothers and Newborns enhanced prenatal care program; she leads the evaluation’s process measurement and monitoring task and is a senior member of the case study team. Benatar is also deputy project director for a multiyear evaluation of a home visitation and community-based program intervention in Los Angeles, aimed at improving health and developmental outcomes for low-income mothers and children. She is coleading a study to examine the impact of the Affordable Care Act on women’s preventive health care service use. Additional recent work includes an evaluation of ongoing efforts to redesign the county clinic system in San Mateo County, California, an evaluation of a physician incentive program in Los Angeles, a review of recent family planning research, and a feasibility assessment of a universal vaccine-purchasing program for children in New York State. Benatar holds a PhD in public policy from George Washington University. Acknowledgments This brief was funded by the Robert Wood Johnson Foundation. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission. We are also grateful to the stakeholders we interviewed for their insights and to Genevieve M. Kenney for helpful comments. About the Robert Wood Johnson Foundation For more than 45 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and well-being. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook. About the Urban Institute The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people’s lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance fairness and enhance the well-being of people and places. 9|QUALITY. DATA. ACCOUNTABILITY.