Proposed first-ever federal standards for maternal care met with mixed response from hospitals

The Centers for Disease Control and Prevention estimated the U.S. maternal mortality rate for 2022 to be 22.3 deaths per 100,000 live births, one of the highest ratios among developed countries. (Thanasis Zovoilis/Getty Images)

As part of President Joe Biden’s initiative to reduce maternal mortality rates and improve health outcomes in underserved communities, the Centers for Medicare and Medicaid Services announced new policy proposals that would require hospitals to adhere to more rigorous maternal care standards or risk losing their ability to participate in Medicare.

According to the proposed rule, the changes would cost close to $4.5 billion over 10 years, with an average annual cost of $70,671 to individual hospitals. The policies would represent the first attempts at federally prescribed maternal health standards for hospitals, and include baseline requirements for organization, staffing, and delivery of care within obstetrical units, as well as transfer protocols, emergency services readiness and annual staff training on evidence-based maternal health practices and cultural considerations. The requirements would apply to critical access hospitals, which is a federal designation for a clinic in a rural area, and hospitals that don’t have an obstetrics unit would still be required to have basic emergency equipment and protocols for emergency deliveries.

Particularly in the two years since the U.S. Supreme Court’s Dobbs decision allowing states to regulate abortion, there has been more attention paid to rising maternal mortality rates around the country, which have long been higher in states that now have near-total abortion bans, including Mississippi, Louisiana and Arkansas. Those states also have high numbers of Black women, who die at much higher rates during and in the year after pregnancy than white women. The Centers for Disease Control and Prevention estimated the U.S. maternal mortality rate for 2022 to be 22.3 deaths per 100,000 live births, one of the highest ratios among developed countries.

“For too long, too many women in the United States have been dying during pregnancy or in the postpartum period, and this crisis has disproportionately affected women of color,” Health and Human Services Secretary Xavier Becerra said in the release. “(We are) taking additional steps to improve maternal health by strengthening the care new moms and their babies receive at our nation’s hospitals.”

The department requested feedback from hospitals who would be affected by the changes, and so far the response has been mixed. March of Dimes, an organization that has been raising alarm for years about maternity care deserts and rising maternal mortality rates, praised the proposal on social media, saying it was pleased to see the development.

But provider-centric organizations were less enthused in their responses. The American Hospital Association sent a letter to the federal agency outlining its concerns, which were largely about the costs of implementing the changes, given Medicaid reimbursement rates. The problems contributing to poor maternal outcomes largely occur outside of hospitals, the organization argued, and the agency’s requirements as proposed are “ill-suited” to address them.

“Over 40% of births are paid for by Medicaid, and Medicaid has historically reimbursed less than the cost of providing care,” wrote Ashley Thompson, the AHA’s senior vice president of public policy analysis and development, in a letter. “Payment rates from public payers have not kept pace with inflation, and the cost of providing care has increased dramatically over the last four years. On average, hospitals experienced negative margins (-18% across all payers) for labor and delivery services in 2023.”

Those financial burdens have been cited in the announcement of clinic closures in several states since the Dobbs decision, including three clinics in Idaho, which has a near-total abortion ban. One clinic in a North Idaho town said the financial concerns on top of the political environment made their situation untenable, while another in a rural area of the state capital said a staffing crisis on top of financial difficulties were what led to its decision to close.

In the letter, Thompson said part of the challenge in improving maternal health is that many factors contributing to adverse outcomes are attributable to high rates of chronic illness, economic issues, including the lack of affordable housing, domestic violence, substance abuse and food insecurity, with often higher rates among those living in rural and underserved communities.

“Although well intentioned, (requirements) for hospital-based obstetrical services will not address the main drivers of maternal morbidity and mortality. Instead, this approach may further compound the problem for many women by negatively affecting the quality of care and accelerating hospital closures in the areas that need hospitals the most,” Thompson wrote.

In a statement to Axios, a representative from the American College of Obstetricians and Gynecologists was also concerned about the effects of the proposed standards on providers.

“[W]e need smart and innovative policy solutions that do not further stress an overstretched health care system,” Lisa Satterfield, ACOG’s senior director of health and payment policy, told the outlet.

The changes, if approved, would take effect on Jan. 1, 2025.

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