By Rachel Bluth November 13,
2019
When
Madavia Johnson gave birth to Donald Ray Dowless III last year, she was hit by
a case of severe postpartum anxiety.
She was
scared to carry her son downstairs or drive him in a car. She couldn’t manage
to continue law school ― and could hardly leave the house ― because she didn’t
trust anyone to watch him. Her weight dropped from 140 to 115 pounds.
“It was
very stressful for me mentally,” said Johnson, now 29, who lives in Clayton,
N.C. And she found it hard to secure medical assistance because her Medicaid
coverage ran out just two months after her son’s birth. Public health advocates
are pushing to change that.
The difficulties
Johnson faced contribute to the United States’ dismal record on maternal and
child health. The U.S. is one of only three countries where maternal deaths are
on the rise, joining Sudan and Afghanistan, according to the Alliance for Innovation on Maternal
Health, a program of the Council on Patient Safety in
Women’s Health. And data from the Centers for Disease Control and
Prevention indicates that about 700 women die in the U.S. every year from
pregnancy complications. Sixty percent of those deaths are deemed preventable.
Democratic
presidential candidates such as Sen. Cory Booker of New Jersey and Sen. Kamala Harris of California have
talked about those problems on the campaign trail, offering sweeping proposals
to address disparities that lead to poor health for many new mothers.
Though
maternal and child health experts appreciate the attention to the issue, they
also point to what they say is a fairly minor policy option that could make a
major difference: increasing access to Medicaid for postpartum women.
“Given
that we know that this crisis disproportionately falls on low-income people …
Medicaid is a very smart starting place to make sure these people are getting
access to needed care,” said Valarie Blake, an
associate professor of law at West Virginia University who focuses on health
care law.
Take
Johnson, for instance. At the time of her pregnancy, she was eligible for
Medicaid based on a rule that provides women who otherwise might not qualify
under strict income restrictions with coverage during pregnancy and for 60 days
after. She gave birth Aug. 14, 2018.
But
North Carolina has tight eligibility requirements. It is also one of the 14
states that have not chosen to expand Medicaid under the Affordable Care Act.
So, by mid-October, Johnson was no longer “Medicaid eligible.” Because her
physician was backed up on appointments, she lost her coverage before she had a
“six-week” checkup.
Eventually,
she reapplied for Medicaid and was able to qualify because her status had
changed since she had a child. But Donald was 8 months old before she saw a
doctor.
Experts
point to the 60-day timeline as a sort of clock ticking on some severe
postpartum medical issues: bleeding, infections, breastfeeding issues and
mental health screening, among others.
“If
you’re on postpartum Medicaid, you need to get those issues solved right away,”
Blake said.
And
that 60-day countdown? It is arbitrary, said Dr. Alison Stuebe, a professor of obstetrics and
gynecology at the University of North Carolina School of Medicine. It has roots
in a general idea across cultures that women need special care after giving
birth, but the 60-day mark isn’t based on medicine.
“It
comes from the same place as the six-week postpartum visit,” Stuebe said. “We
don’t know where it comes from either.”
Stuebe
chaired a task force for the American College of Obstetricians and
Gynecologists that recommended a different approach. Providers should check
women two weeks after giving birth, and then continue holistic care for 12
weeks, eventually transitioning the patient to primary care.
That
prolonged contact is essential, she said. “Postpartum depression, if untreated,
can begin to spiral,” Stuebe said. “Even if you’re in treatment, after 60 days,
you’re not better.”
Johnson,
though, was left to wrestle with severe postpartum anxiety on her own.
She
sought support from other new moms on Facebook who were coping with anxiety.
Since her son had Medicaid for the first year of his life, his pediatrician was
a source of help. She also got care through her local health department’s free
clinics.
At the
federal level, the idea of extending postpartum Medicaid is getting more
attention. At a September House hearing, representatives
from the American Medical Association, the Icahn School of Medicine and the
Kaiser Family Foundation called for expanding postpartum Medicaid
as a possible solution to the maternal mortality crisis. The American College
of Obstetricians and Gynecologists has also recommended it. (Kaiser
Health News is an editorially independent program of the foundation.)
Beyond
protecting women during the medically vulnerable time after they deliver,
experts think increasing Medicaid could go a long way toward addressing the
racial disparities that exist in maternal mortality rates. Black women are two
to three times more likely to die from pregnancy-related causes than white
women.
“It’s
not a silver bullet,” said Jamila Taylor, the
director of health care reform at The Century Foundation,
a nonpartisan think tank. “There’s racism in the health care system. Coverage
is a piece of that, but we need to transform the system.”
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