More than one out of every four Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries are females in their reproductive years (ages 15–49), and Medicaid finances about 41% of all births in the United States.1 Given this reach, state Medicaid and CHIP programs are uniquely positioned to improve the quality of maternity care, strengthen birth outcomes, and advance the measurement of how care is delivered during pregnancy and postpartum.
The Maternal Health Infographic provides a snapshot of demographics, access to care, health status, health outcomes, risk factors, and health care utilization among beneficiaries seeking pregnancy-related care and those with a recent live birth. These data underscore opportunities for the Centers for Medicare & Medicaid Services (CMS) (CMS) and state Medicaid and CHIP programs to strengthen perinatal outcomes through targeted quality improvement (QI) initiatives.
Maternal and Infant Health Quality Improvement: What’s New
Beginning in May 2024, the CMS Maternal and Infant Health Initiative (MIHI) launched QI technical assistance (TA) opportunities focused on two of the main drivers of poor maternal health outcomes, “Addressing Maternal Mental Health and Substance Use” and “Improving Control of Hypertensive Disorders of Pregnancy.” Maternal mental illness is the leading cause of pregnancy-related deaths in the U.S.2 Substance use during pregnancy- including alcohol, tobacco, opioids, and marijuana- can lead to severe health consequences, such as maternal mortality, preterm birth or stillbirth, and neonatal abstinence syndrome (NAS).3 Uncontrolled high blood pressure (hypertension), which is both common and preventable, contributes to complications and mortality before, during, and after pregnancy, with effects that can extend decades later.4
For each topic area, CMS provides QI TA to help states improve maternal health care access, quality, and outcomes. Supports include:
- QI TA Resources, to help state Medicaid and CHIP staff and their QI partners get started on projects aimed at improving access to and quality of maternal health care.
- A Webinar Series featuring presentations from CMS, state Medicaid and CHIP programs, and subject matter experts who share strategies, promising practices, and actionable insights to help states strengthen maternal health care.
- An action-oriented Affinity Group, convening Medicaid- and CHIP-led state teams to implement QI projects addressing maternal mental health and substance use, as well as maternal hypertension and cardiovascular health. Participating states collaborate with CMS, peer states, and subject matter experts to explore key strategies and promising models of care, and receive tailored support on their QI projects.
QI TA Resources
A driver diagram is a visual display of what “drives” or contributes to improvements within a system. The maternal health-related driver diagrams below show the relationship between the primary drivers (the high-level elements, processes, structures, or norms in the system that must change to improve maternal health care access and quality) and the secondary drivers (the places, steps in a process, time-bound moments, or norms where targeted changes can support improvement). Each diagram also includes a change ideas table with examples of evidence-informed QI interventions tailored for Medicaid and CHIP.
These resources can help states get started in developing their own maternal health QI initiatives:
- Addressing Maternal Mental Health and Substance Use Driver Diagram
- Improving Control of Hypertensive Disorders of Pregnancy Driver Diagram
Webinar Series
Webinar #1: Promoting Maternal Health Improvement and Equity Through Collaboration, May 14, 2024 (slides, video, transcript)
As the single largest payer of pregnancy-related services, state Medicaid and CHIP programs play an important role in enhancing access to high-quality care and improving maternal health outcomes. This webinar introduces a multilevel framework for leveraging Medicaid, systems of care, technology, and community-based partners to drive improvements. Experts describe strategies to promote collaboration across the maternal health ecosystem, and state presenters share the experiences building successful partnerships to improve outcomes.
Webinar #2: Maternal Mental Health Screening, Treatment and Improvement Strategies, June 4, 2024 (slides, video, transcript)
Undiagnosed and undertreated mental health challenges are among the leading contributors of maternal mortality. This webinar reviews clinical guidelines for perinatal mental health screening that improve early detection, diagnosis, and treatment, as well as management of pre-existing mental health conditions during pregnancy. Experts and Medicaid and CHIP programs, along with their QI partners, present strategies to promote behavioral health integration, leverage technology, and enhance provider capacity and access to address maternal mental health.
Webinar #3: Decreasing Fragmentation in Maternal Substance Use Disorder Screening and Treatment, June 25, 2024 (slides, video, transcript).
Substance use is a leading cause of pregnancy-related death and adverse birth outcomes, yet provider and health systems capacity for treatment is often fragmented or insufficient for pregnant women covered by Medicaid and CHIP. This webinar outlines strategies to reduce fragmentation across SUD screening, referral, tracking, and treatment by improving clinical care coordination and integrating behavioral health services and supports. State presentations highlight approaches to engaging communities, expanding the workforce, and promoting collaboration collaborating across systems.
Webinar #4: Addressing Hypertension Before, During and After Pregnancy, July 16, 2024 (slides, video, transcript)
High blood pressure, or hypertension, is common, preventable, and treatable- but when left untreated, it can lead to serious and lifelong health consequences. Current clinical recommendations call for screening and treatment during the preconception, pregnancy and postpartum periods. In this webinar, experts and state presenters share strategies for Medicaid and CHIP programs to improve hypertension screening, treatment, and care coordination.
Webinar #5: Medicaid and CHIP Program Collaboration with Hospitals on AIM Bundles, August 20, 2024 (slides, video, transcript)
The Alliance for Innovation on Maternal Health (AIM) is a national, cross-sector initiative that identifies, develops, implements, and disseminates maternal health patient safety bundles. AIM safety bundles are evidence-based hospital and community practices that improve the quality of care provided during delivery and in the postpartum period. This webinar highlights how Medicaid and CHIP programs can collaborate with hospitals and AIM partners to support the implementation of these practices, strengthen management of high-risk care, and address regional differences in maternal health outcomes.
Affinity Group
Beginning in December 2024, CMS convened an affinity group that will run through September 2026. The affinity group supports states in implementing QI projects to address maternal mental health and substance use and improve maternal hypertension and cardiovascular health. Eleven state teams, led by Medicaid or CHIP program staff, are participating in this action-oriented affinity group, which includes group learning through workshops and learning sessions, tailored one-on-one coaching, and opportunities to collaborate with peer states pursuing similar projects.
History of CMS’s Maternal and Infant Health Initiative
To improve access to and quality of care during the pregnancy, the postpartum period, and infancy, CMS launched the Maternal and Infant Health Initiative (MIHI) in July 2014. MIHI was informed by recommendations from CMS’s Improving Maternal and Infant Health Outcomes in Medicaid and CHIP Expert Panel Guided by these recommendations, MIHI focused on improving the rate and quality of postpartum visits and increasing the use of effective methods of contraception among beneficiaries enrolled in Medicaid and CHIP.
Five years into MIHI- and in light of rising maternal and infant mortality and morbidity rates- CMS identified a need to assess progress of the MIHI and chart a course for the next phase of the work. To support this effort, CMS convened a new expert workgroup comprised of new and returning members of the first Expert Panel, representing providers, health plans, quality collaboratives, state Medicaid and CHIP programs, and federal partners. The workgroup helped identify and prioritize three areas of focus where Medicaid and CHIP have a significant opportunity to influence change through TA:
- Increase the use and quality of postpartum care visits;
- Increase the use and quality of well-child visits; and
- Decrease the rates of cesarean section births in low-risk pregnancies, defined as nulliparous (first-time pregnancies), term (37 or more weeks gestation), singleton (one fetus), vertex (head facing down in the birth canal) or “NTSV births.”
The workgroup emphasized the need for a comprehensive life-course approach to maternal and infant health- one that recognizes the mother-infant dyad and how their inter-connectedness affects both maternal and infant health outcomes throughout the childbearing years, infancy, and early childhood. Read the full report of the Expert Workgroup recommendations.
[1] National Center for Health Statistics. Key Birth Statistics (2022 data, released 2024)
[2] JAMA Psychiatry. Published online February 21, 2024.
[3] NIDA. "Substance Use While Pregnant and Breastfeeding." National Institute on Drug Abuse, 18 Jan. 2024.
[4] Ford ND, Cox S, Ko JY, et al. Hypertensive Disorders in Pregnancy and Mortality at Delivery Hospitalization — United States, 2017–2019. MMWR Morb Mortal Wkly Rep 2022;71:585–591.
[5] Valenzuela CP, Osterman MJK. Characteristics of mothers by source of payment for the delivery: United States, 2021. NCHS Data Brief, no 468. Hyattsville, MD: National Center for Health Statistics.