Supporting Success: ASTHO's Strategies for Reducing Maternal Mortality and Morbidity

The United States spends more on health care than any other country, yet persistently has some of the worst rates of maternal mortality and morbidity (MMM) among high-income nations.^1,2 There are significant disparities, with Black and American Indian/Alaska Native women dying at a rate nearly 3 to 4 times higher than White women. Nearly two-thirds of these maternal deaths are known to be preventable.³ The national health and well-being of pregnant and postpartum people are priorities, and legislative proposals to address this issue, including the MOMNIBUS Act, are taking center stage in policy and funding discussions at the federal level.

State and territorial health agencies (S/THAs) and their associated state and territorial health officials (S/THOs) have been entrusted with supporting the health and well-being of mothers and children since the early 20th century. These agencies and leaders have the authority to make structural changes through regulatory means. They also have substantial influence on leaders from across their jurisdictions including commissioners of Medicaid, Social Services, and their own governors and legislators.

Development of the MMM Technical Package

The Association of State and Territorial Health Officials (ASTHO) began the process of developing a technical package of priority approaches to assist health officials in their efforts to address MMM. The technical package builds on ASTHO's strategic priority areas: health and racial equity, workforce development, building sustainable infrastructure, modernizing data systems, and incorporating evidence-based and promising public health practices into action. ASTHO's technical package focuses on the role that S/THOs and their agencies play in creating change under these strategies. The package further identifies areas in which ASTHO already has existing resources to share with leaders and areas where the organization can provide support through its Capacity Building and Technical Assistance (CBTA) framework.

In 2021, ASTHO's Board of Directors approved an MMM Policy Statement, providing recommendations for how to reduce rates of illness and death among pregnant and postpartum people.⁴ These recommendations from the policy statement served as the starting point for the technical package and were weighed against a functional model developed in 2021 depicting both the broad health agency leadership responsibility areas for promoting change and the means for achieving and sustaining those responsibilities (Figure). After ASTHO cross-checked each policy statement recommendation against the functional model, the recommendations were then sorted into ASTHO's strategic priority areas thereby establishing how the organization may best support leaders in implementing this work. ASTHO also aligned the format of this technical package with other packages across the organization, including those related to chronic disease prevention and health equity. The resulting list of ASTHO MMM priority interventions is outlined in the Table.

FIGURE: Functional Model of Health Agency Leadership ResponsibilitiesThis figure is available in color online (www.JPHMP.com).

TABLE - Technical Package of Approaches to Address Maternal Mortality and Morbidity

Approaches for Addressing Maternal Mortality and Morbidity	S/THO Authority	S/THO Influence	Functional Model Fit
ASTHO strategic priority: Health and racial equity and workforce development
Identify opportunities to promote maternal health in all policies on intersectional issues including climate change, emergency management, technology access, transportation, food insecurity, and homelessness (eg, establish protocols that support the prioritization of pregnant people in emergency response).	X	X	Policy Equity Collaboration and engagement
Adopt risk-appropriate and coordinated plans of care models to ensure equitable access to obstetric services for all pregnant and postpartum people.		X	Policy Equity Collaboration and engagement
Ensure the public health workforce receives training on structural racism and the role it plays in negative maternal health outcomes.	X	X	Workforce development Equity Collaboration and engagement
Promote and collaborate with state, community, and nonprofit partners to develop and sustain perinatal quality collaboratives that directly integrate data, findings, and recommendations from Maternal Mortality and Fetal Infant Mortality Review Committees.	X	X	Workforce development Collaboration and engagement Equity Evaluation and quality improvement
ASTHO strategic priority: Sustainable infrastructure improvements
Develop flexible policies and mechanisms to leverage federal, state, and local funding to address maternal mortality and morbidity risk factors (eg, Title V Maternal and Child Health Services Block Grant; Title X Family Planning Program).	X	X	Policy Equity Sustainable funding
Support the expansion of telehealth/telemedicine services, specifically for prenatal and specialty care services.		X	Policy Workforce development Sustainable funding
ASTHO strategic priority: Data modernization and interoperability
Invest in a robust, integrated data infrastructure, focused on data linkage, sharing, and interoperability across the health agency to better identify and quickly address factors leading to maternal mortality and morbidity, focused on maintaining the maternal-infant dyad.	X		Data collection and analysis Workforce development Evaluation and quality improvement
ASTHO strategic priority: Evidence-based and promising health practices
Assess and address barriers to practice to build an adequate perinatal workforce to provide woman and community-centered obstetric care.	X	X	Workforce development Equity Policy Collaboration and engagement
Support or establish mechanisms for doula and community health worker reimbursement.	X	X	Workforce development Equity Policy Collaboration and engagement
Enhance and expand home-visiting services.	X	X	Workforce development Equity Policy Collaboration and engagement
Increase access to regular well-woman care, including preconception and interconception care and access to family planning services.	X		Equity Engagement
Promote the use of and reimbursement for evidence-based screening tools to detect substance misuse and addiction, intimate partner violence, and perinatal mood and anxiety disorders early in pregnancy through 1 y postpartum.		X	Equity Policy Data collection and analysis

Abbreviations: ASTHO, Association of State and Territorial Health Officials; S/THO, state and territorial health official.

Authority Versus Influence in the ASTHO MMM Technical Package

Within the technical package under each recommendation, there is an indication of whether S/THOs have broad authority or influence (or both) over implementation, recognizing that there are jurisdictional variations in officials' power and the agency structure. For example, S/THOs have the authority to develop flexible policies and mechanisms to leverage federal, state, and local funding to address MMM risk factors (eg, Title V Maternal and Child Health Services Block Grant; Title X Family Planning Program). S/THOs have the authority to coordinate these funding streams and create new policies and programs that promote the health and well-being of all mothers in an equitable way.

Recommendations such as extending Medicaid to 1 year postpartum are also included in the MMM Policy Statement. While S/THOs may be able to influence and advocate for this recommendation, they do not have the authority or means to achieve and sustain it, as it exists in another agency. Therefor, the recommendation is not included in this technical package.

ASTHO's Maternal Mortality Reduction Technical Package provides focused recommendations of how ASTHO can best assist S/THOs to promote the health and well-being of mothers in their jurisdictions. The package provides a framework for how ASTHO can support S/THOs as they strengthen partnerships, evaluate policies, improve data systems, and adopt transformative approaches to reduce MMM. These activities and their solutions also consider the roles that racial and economic disparities play in the MMM crisis. ASTHO will use this technical package to develop clear measures around how its programs and strategies will be evaluated for their ability to address structural racism and reduce the disparities in death rates for marginalized populations. While the interventions in this technical package are not comprehensive, they provide an opportunity for ASTHO to help promote the adoption of innovative solutions, as well as provide the tools, guidance, and technical assistance to sustain these solutions in the long term.