Disparities in cardiovascular maternal health

While global maternal mortality has decreased in the last three decades, pregnancyrelated deaths remain prevalent in the USA, even after accounting for possible overreporting based on changes in death certificates. In 2017, approximately 17 US mothers per 100 000 live births died due to complications related to pregnancy or childbirth; in contrast, only 7 UK mothers per 100 000 live births died that year. Up to twothirds of US maternal deaths may have been preventable. Cardiovascular disease has emerged as the driving cause of current maternal mortality rates, causing or related to over onethird of US maternal deaths, with most deaths occurring during or after delivery. Recent studies worldwide have also begun to elucidate the longterm consequences of pregnancyrelated cardiovascular conditions such as gestational hypertension or preeclampsia 6 ; for instance, a largescale population study in the UK found hypertensive disorders of pregnancy increased risk across a multitude of cardiovascular disorders with the impact starting soon after pregnancy. In the USA, preeclampsiarelated deaths have decreased in the last two decades, while deaths associated with or due to chronic hypertension have been increasing. However, one striking difference between the USA and similarly wealthy countries, which may contribute to rising maternal mortality, is its fragmented insurance coverage. Marschner et al give readers a revealing snapshot of the intersection between cardiovascular maternal health and insurance coverage in an important and unique US demographic, pregnant women covered under Medicaid. As the US public insurance programme aimed to improve access to basic healthcare for those otherwise cannot afford it, Medicaid plays a pivotal role in supporting pregnant women living in poverty and currently provides coverage for half of all US births. Marschner et al take a deeper dive into the Medicaid population by exploring pregnancyrelated cardiovascular conditions and early postnatal adverse outcomes among Medicaidinsured pregnant women in three states in the USA between 2015 and 2019. They found that a striking onefourth of these women were diagnosed with a pregnancyrelated cardiometabolic condition, including hypertensive disorders of pregnancy and gestational or preexisting diabetes. Furthermore, between pregnancy and 60 days after delivery, over onetenth of these women were found to have a severe cardiovascular outcome, including heart failure, pulmonary embolism, stroke, cardiac arrest and myocardial infarction. Their study concluded that any type of pregnancyrelated cardiometabolic condition is associated with a threefold higher risk of a severe cardiovascular outcome. Marschner et al point out that current literature suggests the Medicaid population is at much higher risk of pregnancyrelated cardiometabolic conditions compared with those who have private insurance. Their analysis is based on claims data submitted to one Medicaid management company (the major company in Ohio, and a minority of Medicaid patients in Georgia and Indiana). As such, there may be a tendency for overcoding, and there are no clinical data to confirm the accuracy of the billed diagnoses—to differentiate between preeclampsia and heart failure, for instance. While Marschner et al add compelling data that further elucidate the rise in adverse US maternal health outcomes, it is important to note that it only provides a small glimpse into the stark disparities that underlie its findings. First, over onefourth of Medicaidinsured pregnant women were uninsured before their pregnancy, making the distinction between preexisting cardiometabolic conditions and pregnancyrelated cardiometabolic conditions more difficult. This then leads to difficulty in distinguishing cardiovascular complications arising specifically from pregnancy, such as preeclampsia, with cardiovascular disease noted during pregnancy such as hypertension or heart failure. Furthermore, the study only examined adverse cardiovascular outcomes up to 60 days post partum, whereas most maternal deaths have been found to occur in the 42–365 days after birth, suggesting the already high cardiovascular burden risk in the postpartum period for Medicaidinsured pregnant women with cardiometabolic conditions may even be an underestimate. This limitation in data likely comes from a federal mandate only requiring health insurance coverage for pregnant women through 60 days post partum; while the majority of states have expanded this coverage up to a year, a number of states still have yet to do so, and over onefifth of Medicaidinsured pregnant women lose insurance 2–6 months after giving birth. Perhaps one of the most understated aspects in this study is its allusion to the striking racial disparities underpinning adverse cardiovascular maternal health outcomes. Black maternal mortality accounts for a skewed proportion of total US maternal deaths, with Black women up to three times more likely to die compared with their White counterparts. 2 The reasons for this are likely multifactorial, including unconscious provider bias, and the study acknowledged limitations in ethnicity data collection and therefore direct examination of racial disparities within the Medicaid population. However, a disproportionate lack of access to care as a driving factor may be extrapolated when taking the study’s mention that the Medicaid population ‘skews nonWhite, with 65% of Black women being covered by Medicaid.’ The issues Marschner et al highlight by focusing on a Medicaidinsured population demonstrate policy solutions will be a key aspect of providing equitable care and reducing disparities in cardiovascular maternal health. Indeed, extending Medicaid coverage for postpartum women past 60 days for up to 6–12 months has been shown to reduce cardiovascular maternal mortality through improved access to care for women who would otherwise lose insurance. In March 2021, the American Rescue Plan Act of 2021 was passed by Congress which included a provision allowing states the option to extend Medicaid for up to 1 year post partum; states that opt in could receive their regular federal matching rate for the additional 10 months of coverage they provided. Additionally, the Black Maternal Health Momnibus Act of 2021 has been introduced in the US Congress as a package of 12 comprehensive evidencebased bills to improve Black maternal health, including improvement in data collection and quality measures as well as ensuring Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA