Higher Medicaid reimbursements, midwives could improve Louisiana maternal death rate, expert says

Louisiana may be able to improve its dire outcomes for pregnant people if the state raised its Medicaid reimbursement rate for live births and boosts its number of nurse midwives, a leading expert on maternal mortality said Wednesday. 

Dr. Veronica Gillispie-Bell is a New Orleans gynecologist and co-director of the Louisiana Perinatal Quality Collaborative with the state health department. She is also an author of the state’s 2022 Louisiana Pregnancy-Associated Mortality Review report. 

Louisiana had the fifth-highest maternal mortality rate of any state in the country from 2018 to 2021, with 39 pregnant parent deaths per 100,000 live births, according to KFF, a health policy research organization. The only states with higher rates were Arkansas, Mississippi, Tennessee and Alabama. 

Gillispie-Bell said the state’s pregnancy outcomes might be improved if Louisiana paid hospitals and medical providers more money to deliver babies. The state’s current Medicaid reimbursement rates for births are too low to provide an incentive for medical providers to continue offering those services, she said.

Medicaid, a public insurance provider, pays for approximately 60% of the births that take place in Louisiana, but the reimbursement rates are half of what a private insurer offers. Louisiana’s Medicaid program gives a health care provider $5,131 for overseeing a birth, whereas private insurance pays out an average of $11,990 for the same service, Gillispie-Bell said.

“It is really hard for them to keep their doors open when they are not being paid to do so,” Gillispie-Bell said of medical providers during Wednesday’s state Nursing Maternal Mortality and Preterm Birth Task Force meeting.

Many hospitals lose money on their obstetrics services, she said. They mostly offer baby delivery as a way of potentially luring a parent and their family back for other medical care. It can be harder for smaller facilities in rural areas to offset those costs, she added. 

“When they are not able to break even [on live births], I think [rural medical providers] are making hard decisions,” Gillispie-Bell said.

Finding pregnancy health care in rural parishes is already difficult. GIllispie-Bell said 27% of Louisiana parishes have no medical care for pregnant people and 12% of women had no hospital that handles live births within 30 minutes of where they live.

The Louisiana Legislature and Gov.-elect Jeff Landry will have the authority to increase Medicaid reimbursement rates next year, though a rise in payments would result in the state health care budget growing as well.

Both state and federal tax dollars cover the costs of the Medicaid program, and conservative legislators are sometimes reluctant to increase spending on public health care services.

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Gillispie-Bell also believes Louisiana should expand the use of nurse midwives for live births, especially as a national shortage of obstetricians looms in 2030. Louisiana has one of the lowest rates of midwife use in the country and should look at models in other rural states — such as Alaska — where midwives routinely handle baby delivery. 

Some of the challenges Louisiana faces in tackling its high maternal mortality rate also have to do with its other chronic social and health challenges. Of the people who give birth in Louisiana, 35% live in a home with an income of $16,000 or less; 64% are overweight or obese; and 53% did not intend to become pregnant, Gillispie-Bell said during her presentation.

From 2017 to 2019, there were 182 confirmed deaths of people during pregnancy or within a year after their pregnancy ended.

The leading cause of those deaths were accidental overdose (31), homicide (24), motor vehicle crash (23) and cardiovascular conditions (20), according to the state’s most recent maternal mortality report. Nine of the deaths could also be attributed to suicide.

Almost half of the people who gave birth in Louisiana during that time had only a general equivalency diploma (GED) or less. Yet 68% of the people who died during pregnancy or in the year that followed fit into that demographic group. 

Racial discrimination also plays a role in the state’s maternal mortality rate, Gillispie-Bell said. Over those two years, 33% of people who gave birth identified as Black, but people who were Black made up 57% of the individuals who died during pregnancy or in the year after their pregnancy ended.

“We have to address the minimum wage, violence, access to care … and access to education” to help improve outcomes for pregnant people, she said.