Maternal Health Care & Health Equity in the U.S.

What is Maternal Health?

Maternal health refers to the physical, emotional, and social well-being of women during pregnancy, childbirth, and the postpartum period. Research shows that improving maternal health outcomes requires not only provision of excellent obstetric services but also attention to complex health and social needs before, during, and after pregnancy. Evidence shows that entering pregnancy with uncontrolled diabetes, hypertension, depression, malnutrition, and substance use disorders greatly increases the likelihood of adverse outcomes during the pregnancy, delivery, and postpartum periods. Economic and social stability—as measured by income, educational attainment, and safe housing—also positively influence maternal health outcomes. Efforts to address these health and social conditions are essential to improving maternal health and reducing maternal morbidity and mortality in the United States.

The State of Maternal Health in the United States

Despite advances in innovative medicine and health care, the United States remains one of the most dangerous developed countries in the world for pregnant people and infants. Maternal mortality in the United States was more than double that of other high-income countries in 2018, with 80% of deaths considered preventable. Stark racial disparities in maternal mortality exist, with Black and American Indian/Alaska Native women being more than twice as likely to die during pregnancy as White women, and these disparities are worsening despite increasing access to care.

In June 2022, the Biden-Harris administration released the White House Blueprint for Addressing the Maternal Health Crisis. The Blueprint calls for widespread action to increase access to and coverage of respectful care; ensure that pregnant people are active decision-makers throughout their pregnancy experience; advance data collection and research; expand and diversify the perinatal workforce; and strengthen economic and social supports before, during, and after pregnancy.

RTI International’s portfolio of maternal health research provides stakeholders, including policymakers, with critical information about health system costs, integrated approaches to care delivery, expanding equitable access to care, and data on key maternal health and family planning indicators. Our areas of expertise include the following:

Evaluating the impacts of alternative payment models in Medicaid and commercial insurers
Researching innovations in behavioral health integration
Generating knowledge through systematic reviews
Expanding equitable access to contraceptives
Providing training and technical assistance to expand reproductive health education
Collecting nationally representative survey data

Our clients include governmental entities—such as the Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention, Health Resources and Services Administration, Office of Population Affairs, Office of the Assistant Secretary for Planning and Evaluation, and the Patient-Centered Outcomes Research Institute—and public and private organizations.

Evaluating the Impacts of Alternative Payment Models

Evaluating State Investments in Maternal Episodes of Care

RTI is a leader in evaluating the health and economic impacts of maternity alternative payment models. As the evaluators of the Centers for Medicare & Medicaid Services’ State Innovation Models Rounds 1 and 2, comprehensive mixed-methods evaluations of maternity episodes-of-care models were conducted in Arkansas, Ohio, and Tennessee. The evaluation found that states can leverage their purchasing power and foster alignment among payers to bolster provider participation in value-based care, ultimately advancing patient-centered care, care coordination, and population health outcomes.

Examining Uptake of Value-Based Payment Models in Medicaid

RTI led the Medicaid and CHIP Payment and Access Commission’s Value-Based Payments for Maternity Care, a research project assessing the three most common value-based payment models used by Medicaid agencies: episodes-of-care, pregnancy medical homes, and pay-for-performance. The mixed-methods research project generated comprehensive case studies for five states (Arkansas, Colorado, Connecticut, North Carolina, and Tennessee) through document review and key informant interviews with providers, policymakers, and patient advocates.

Researching Innovations in Behavioral Health Integration

Identifying Best Practices for Incorporating Substance Use Treatment into Obstetrical Services

Maternal substance use disorders (SUD) can have damaging and far-reaching impacts on birth outcomes, quality of life, and health care costs. Rising rates of maternal SUD have particularly affected state Medicaid programs, which pay for 45% of all births nationwide. RTI conducted research for the Office of the Assistant Secretary for Planning and Evaluation on policies that support or hinder integration of SUD treatment into gynecological and obstetrics services. This project used policy analysis and input from a technical expert panel to synthesize how factors such as stigma, postpartum Medicaid coverage, and fragmented funding mechanisms impact effective integration of treatment of SUD during and after pregnancy.

Supporting Clinical Trials as a National Data Coordinating Center

For nearly 50 years, the severity of neonatal opioid withdrawal syndrome has largely been assessed using subjective, observer-related scales despite concerns that assessment tools overestimate the need for pharmacologic treatment. RTI recently supported a new clinical trial combining experts from the National Institute of Child Health and Human Development Neonatal Research Network and the National Institutes of Health Helping to End Addiction Long-term (HEAL) Initiative. RTI experts contributed to findings that may improve outcomes for newborns exposed to opioids during pregnancy.

Generating Knowledge Through Systematic Reviews

RTI is conducting a systematic review, supported by the Patient-Centered Outcomes Research Institute, on the impact of doula support during pregnancy, childbirth, and in the postpartum period on health and patient-reported outcomes for pregnant, birthing, or postpartum individuals; their partners; and infants. The systematic review employs a health equity perspective in the design, engages doulas as part of the review team, and explores implementation strategies and barriers to doula support.

Three graduates in caps and gowns hugging and smiling while holding their diplomas.

Expanding Equitable Access to Contraceptives

Developing Evidence to Support Equitable Access to Contraceptive Services

Research shows that when pregnancies are planned, maternal and infant health and social outcomes are better. Access to safe and effective contraceptives is essential to preventing unintended pregnancies. RTI is working with several government agencies and community-based organizations to expand equitable access to contraceptives throughout the United States. For more than 25 years, RTI has supported the Office of Population Affairs in analyzing data related to equitable access to a broad range of family planning methods and preventive health services that are funded by the Title X National Family Planning Program. RTI’s current analyses incorporate risk adjustment for local social determinants of health believed to influence access to and initiation of contraceptive services.

Working with Community-Based Organizations to Meet the Needs of Rural Appalachia

Throughout the country, community-based organizations are working to close the gaps in contraceptive access. RTI has collaborated with A Step Ahead Chattanooga as it works to remove barriers to contraception use through education, outreach, and provision of no-cost birth control. RTI has conducted two independent evaluations of A Step Ahead Chattanooga’s programming, which included focus groups with program participants and local community members, key informant interviews, and data analysis.

Providing Training and Technical Assistance to Expand Reproductive Health Education

RTI provides training and technical assistance to the Family and Youth Services Bureau’s Adolescent Pregnancy Prevention Program, providing grantees with individual, small group, and peer-to-peer learning to ensure fidelity to evidence-based programming. RTI also hosts an annual national conference for grantees and the government and maintains The Exchange, an interactive platform for Adolescent Pregnancy Prevention Program grantees, partners, and stakeholders.

In 2022, RTI developed the award-winning We Think Twice campaign, a multimedia campaign designed to build teen knowledge and skills to form healthy relationships with peers and adults; set and achieve their goals; and make healthy decisions about sex, substance use, and other topics relevant to teens.

Collecting Nationally Representative Survey Data

The National Survey of Family Growth is a principal source of national estimates of factors affecting pregnancy and birth rates, including sexual activity, cohabitation, marriage and divorce, frequency of intercourse, contraceptive use for birth control and disease prevention, miscarriage and stillbirth, infertility, wanted and unwanted births, and use of medical services for family planning and infertility. RTI supports the National Center for Health Statistics and the Centers for Disease Control and Prevention by overseeing the execution of this survey, including sampling, data collection, and data processing.