Snigdha Banda (‘20)

Eshaan Patel (‘20)

David Yang (‘20)

Rice University

Policy Initiatives Targeting Maternal Morbidity & Death:

The Women’s Health Community Collaborative and National Paid Family Leave

Policy Initiatives Targeting Maternal Morbidity & Death:

The Women’s Health Community Collaborative and National Paid Family Leave

Maternal mortality has reached unprecedented levels in the United States. The trend is

concerning especially because nearly half of all maternal deaths are preventable. Factors

contributing to maternal death include high rates of heart disease, diabetes, obesity, hypertension,

and depression. Existing data shows that improving the overall health of women and reducing the

childbearing burden on women and their families would contribute to a reduction in maternal

death. Consequently, our team proposes the adoption of two new evidence-based federal

policies: the Women’s Health Community Collaborative (WHCC) and National Paid Family

Leave. The WHCC will serve as a federally funded community initiative that extends access to

pregnancy-related services, aids with management of chronic disease, and improves behavioral

health of Medicaid-eligible women of all reproductive ages. The framework for the WHCC

includes teams of healthcare professionals from an implementing agency leading weekly

community meetings focused on education and peer support groups. WHCC will be funded

federally through the Affordable Care Act’s existing State and Community Grants and by the

implementing agency during its pilot phase. Unlike existing federal initiatives, WHCC

emphasizes longitudinal care, provides care between pregnancies instead of only in the prenatal

and postpartum periods, and is a cost-effective model that reduces reliance on emergency

hospital services and public assistance. Secondly, in order to allow women to recover from the

taxing act of childbearing, a national paid family leave program following the framework of the

current campaign for the Family and Medical Insurance Leave Act is proposed. This proposal

will be funded by a marginal increase in employee-side payroll tax and will dispense benefits for

12 weeks to all workers, regardless of gender. National paid family leave has shown to improve

maternal health in the postpartum period, primarily by mitigating chronic disease, reducing

psychological and emotional stress, and increasing financial independence. By shifting focus from

pregnancy-centered care to longitudinal care and reducing the burden of simultaneous

childbearing and income-earning, the WHCC and national paid family confer positive effects on

women’s health and, in the long term, lead to a reduction in maternal death.

I. Introduction to Maternal Morbidity and Death in the United States

Maternal mortality is on the rise in the United States. From 1990 to 2013, the maternal

mortality rate has more than doubled , placing the US 47th globally for maternal death . Most 1 2

importantly, nearly half of all maternal deaths in the US have been ruled preventable. Texas in 3

particular has been ranked as having the highest maternal mortality rate in the developed world.

The doubled increase in maternal death in Texas from 2010 to 2013 has been ruled as extremely

unusual “in the absence of war, natural disaster, or severe economic upheaval.”1

The high maternal mortality rate nationwide has been attributed to a host of factors.

While data collection has improved over the years, researchers state that better recordkeeping

could not be the sole cause for the increase. The official leading cause of maternal death in US

hospitals is cardiovascular disease . In fact, thirty percent of all maternal deaths are attributed to 4

chronic disease, including cardiovascular disease, diabetes, obesity, and depression. Such 5

medical conditions increase risk of complications during pregnancy and subsequent morbidity

and mortality.5

Access to healthcare is another issue. Nearly half of all counties in the US lack an

obstetrician-gynecologist, and hospitals in low-income areas are overcrowded and understaffed. 6

Seventeen percent of mothers surveyed in thirty states reported being unable to access prenatal

care as early as desired. Delayed prenatal care has shown to increase the risk of maternal death 7

by three to four times.7 Additionally, in the postpartum period, only one visit to a health provider

is covered by health plans unless in the case of a complication, ultimately increasing the chances

of hemorrhage and infection. 8

Thus, main factors contributing to the high mortality rates nationwide include poor

chronic disease prevention and management, lack of access to services, and provision of poor

quality care in low-income areas. The Women’s Health Community Collaborative and the

Family and Medical Insurance Leave Act aim to reduce the childbearing burden and target

women’s health issues that are at the forefront of increased pregnancy-related mortality risk, in

an effort to eventually curb the incidence of maternal death.

II. Policy #1: The Women’s Health Community Collaborative

A. Introduction: Existing Policy and Inadequacies

In 2010, the Patient Protection and Affordable Care Act brought into effect the Federal

Home Visiting Program, creating the nationally acclaimed Nurse Family Partnership (NFP)

among other home visiting models. The NFP provides weekly home visits by professional nurses

for Medicaid-eligible mothers before the 28th week of pregnancy until the child is of two years. 9

The program increases direct, individualized care for at risk-women, and is one of the main

federal initiatives that directly expands women’s access to health services. Thus, in order to

propose more comprehensive and effective policy, the benefits and inadequacies of the NFP will

be addressed.

First, while the NFP provides prenatal, perinatal, and postpartum services,

interconception care, or the services provided between pregnancies, is absent. The CDC has

recommended interconception care as crucial to mitigating chronic disease, considering thirty

percent of all maternal deaths in the US are attributed to chronic disease.5 Diabetes,

hypertension, and depression, the most common chronic diseases for women of reproductive age,

increase the risk for a host of pregnancy-related complications and subsequent morbidity and

mortality.5 This data indicates the need for care that targets chronic disease and improves the

overall health of women rather than solely pregnancy-centered care, as is the focus of the NFP.

Additionally, several maternal health outcomes have been unaddressed by the NFP. While

NFP trials have proven effective in reducing women’s subsequent births and prenatal smoking

and positively impacting child development, the program has shown to have no effects on

maternal weight gain, blood pressure, substance abuse, depression, and anxiety. These 10

conditions are high impact measures for predicting pregnancy outcomes, and the need to manage

them is urgent and significant. In 2013, nearly half of all pregnant women were overweight or

obese, and while 1 in 9 pregnant women experienced depression, only half received treatment. 11

Currently, there is an absence of policy that shifts the focus from singular interventions during

the time of pregnancy to longitudinal care that improves the overall health of all women of

reproductive age.

In the last decade, healthcare professionals have begun spearheading maternal health

coalitions in their communities to improve health-related behaviors of low-income women of

reproductive age and consequently reduce the risk of complications during pregnancy. The

success of these initiatives in increasing access to pregnancy-centered services for entire

communities while improving the overall health of low-income women calls for legislation that

funds and integrates such programs into the maternal healthcare system on a national level.

B. Evidence in support of a Women’s Health Community Collaborative

A literature review of previous maternal health programs shows community-based

initiatives to be particularly effective in improving pregnancy outcomes and the overall health of

women. The Northern Manhattan Perinatal Partnership (NMPP), a non-profit in New York, has

convened medical facilities and health centers to provide “comprehensive health and social

services and programs to women during pregnancy, childbirth, adolescence, and to women over

35.” NMPP, by educating women on chronic disease management, has been instrumental in 12

improving perinatal health outcomes and reducing disparities in women’s overall health. 13

Another program run by the Parkland Memorial Hospital in Dallas, Texas, by providing

neighborhood-based services for inner city pregnant women, has reduced preterm births for

Hispanic and African-American women, a high impact perinatal measure. Additionally, a 14

randomized controlled trial has shown group prenatal care, integrating family, peer support, and

education, to be successful in reducing preterm births. 15

The findings from these programs point to three important conclusions. First,

community-based initiatives connect women to the larger healthcare system and increase

awareness and use of pregnancy-related services. Second, education-based interventions in

group settings, such as NMPP and group prenatal care can improve high impact pregnancy

measures and overall pregnancy outcomes. Most importantly, a life-course model that aims to

improve the overall health of all women from adolescence to over 35, such as the NMPP, has

shown to reduce the levels of chronic disease, improve health-related behaviors, and

decrease reliance on emergency-based services. The success of these ongoing initiatives as well

as 16 previous community-based interventions that used “outreach, family-community, and

facility-based clinical care” point to the potential effectiveness of a Women’s Health Community

Collaborative. 16

C. Design: The Women’s Health Community Collaborative

In order to address the increasing rates of maternal mortality and chronic disease

nationwide, an ongoing education-based community initiative that provides pregnancy-related

services and preventative care measures for Medicaid-eligible women in group settings is

proposed and titled the Women’s Health Community Collaborative (WHCC). The WHCC will

be funded through the Affordable Care Act (ACA) and implemented at the state level by

participating agencies; the program will operate in conjunction with other existing federal

initiatives such as the NFP. Unlike the NFP and other federal initiatives, however, WHCC will

place a greater emphasis on improving maternal health and reducing mortality through high

impact pregnancy measures and include the added outcome of improving the overall health of

women from adolescence past the age of 35. The specific targets include extending access to

prenatal and postpartum care services, aiding with management and prevention of chronic

disease, and improving behavioral health.

In the basic design, the WHCC head organization created through federal funds will

develop an evidence-based curriculum and designate regions of high maternal mortality

nationwide, in an effort to encourage hospitals in the area to become participating agencies and

implement the program. Teams of healthcare professionals, including nurses, dieticians,

behavioral health counselors, and medical assistants, from the participating agency will then

conduct weekly visits to central locations (ie. community center) in the low-income

neighborhood and meet with a group of 20-30 Medicaid-eligible women who have enrolled in

the program. The teams will lead one-to-two hour meetings focused on education and peer

support discussions. The focus of these meetings will be to provide information on chronic

disease prevention and management, improve health-related behaviors, provide prenatal and

postpartum-related information, increase awareness of surrounding services, especially in the

area of mental health, and facilitate peer-to-peer discussion and support.

The WHCC model of weekly community meetings has shown to be effective in the past

in managing chronic disease and improving pregnancy outcomes. In 2000, Project Dulce,

implemented by the San Diego County, aimed to manage chronic disease in a low-income

Hispanic neighborhood through teams of nurses, diabetes educators, medical assistants,

dieticians, and peer educators. Through an eight-week curriculum of classes, the teams were able

to improve HbA1C, blood pressure, total cholesterol, and LDL-C, and reduce patients’ visits to

emergency departments. Another population-based studying in Quebec confirmed the potential 17

of community education in improving pregnancy outcomes, and showed discussion and

counseling to be associated with fewer pregnancy-related deaths. The mechanisms of education 18

and peer support in WHCC community meetings have also shown successful in improving high

impact pregnancy outcomes, in ongoing community coalitions and sixteen community-based

initiatives discussed previously.

Participants for the WHCC will be recruited through their visits to a hospital or

community center; participants and graduates of the NFP, which caters to only first-time

pregnancies and provides no care after the child is of two years, will also be encouraged to

enroll. The key feature of the program that encourages women to enroll is the peer-support

discussion groups, which allow women to share their experiences and forge relationships.

Previous studies have shown that the establishment of a relationship between a woman and a

healthcare provider results in enrollment rates of 90% or higher in programs such as the NFP,

and peer support often bolsters this rate10. Women’s participation in the WHCC is required for at

least one year, and can be extended beyond that period as well.

The teams of WHCC healthcare professionals will be led by a nurse designated by the

participating agency and receive three to four training sessions from the central WHCC

organization. The professionals on these teams will then rotate weekly through the same

community based on the focus topic of the week. For example, during weeks centered on mental

health and counseling, behavioral health counselors will visit the community and work with the

participating women. Once every month, medical and administrative assistants will visit the

group of women and assist in tracking the incidence and progression of chronic conditions such

as hypertension, obesity, diabetes, and heart disease, provide surveys to track smoking, drinking,

depression, and anxiety, and record the number of women accessing prenatal and postpartum

care and emergency services. While the aim is to implement Women’s Health Community

Collaborative nationally, each community possesses unique characteristics, and thus, the

variations in social, mental, and environmental determinants of health will be left to the

discretion of the WHCC teams from the participating agency.

Initial funding to create the WHCC head organization and provide program materials,

training, salaries for the teams of professionals, and transportation costs can be provided through

ACA’s State Grants to Promote Community Health Teams and the competitive Community

Transformation Grants. These grants promote the assembling of healthcare professionals to

strengthen preventative care, health education, and chronic disease management, all of which are

characteristic of the WHCC. After a period of two years of being piloted in a state such as Texas

(an area of concentrated maternal mortality), the WHCC can be implemented in other states

through a source of stable and permanent funding, such as the ACA’s Prevention and Public

Health Fund and Pregnancy Assistance Fund. Currently, the NFP, which provides individualized

home visits instead of community meetings, is estimated at $102,000 in the first year and

$14,900 in subsequent years for the participating agency.9 The WHCC utilizes resources similar

to the NFP and thus has a similar estimated cost. While the WHCC will provide 75% of initial

funding for participating agencies in initial years (agreed upon by both the WHCC head

organization and the agency), in subsequent years, a greater percentage of cost will be subsidized

by the agency itself.

D. Analysis of the Women’s Health Community Collaborative

There are few drawbacks to the WHCC, if any. The program will be implemented

through competitive grants and existing funding in the ACA, and thus requires no external

sources of funding. The WHCC is also an evidence-based program, created by showing the

effectiveness of sixteen other previous programs and current community coalitions in improving

high impact pregnancy measures. The WHCC addresses high impact measures that predict the

outcomes of pregnancies, such as chronic disease, mental health, and timely access to prenatal

and postpartum care. The outcomes of the WHCC will also be tracked monthly for enrolled

participants through monitoring of medical conditions such as diabetes, hypertension, and

obesity and behavioral health conditions, and thus the effectiveness of the WHCC model during

its pilot phase will be evident. Low enrollment rates or dropout may be cited as a disadvantage of

the WHCC. However, the mechanisms of establishing relationships with a healthcare provider

and with other similar women have shown to boost completion of programs such as the NFP.

Additionally, since participants will also be participating in or will have recently graduated from

the NFP or other home visiting models, their respective nurses will be present to encourage their

attendance at WHCC meetings. The NFP, which provides individual home visits instead of

community meetings, has maintained consistent enrollment and high graduation rates. Thus, a

similar level of participation and enrollment is expected for the WHCC.

III. Policy #2: National Paid Family Leave

A. Introduction to National Paid Family Leave

Childbirth is an important issue that affects nearly all families and is especially important

in the context of maternal wellbeing. Thus, there have been multiple initiatives in the United

States at a federal and state level to improve the process of childbirth. The Pregnancy

Discrimination Act of 1978 was a federal law that prohibited any firm from discriminating

against pregnant women in its hiring practices and its employee benefits. This allowed women 19

to join the workforce without fearing employer retaliation in the event of pregnancy. The next

major federal legislation was the Family and Medical Leave Act of 1993, which allowed eligible

employees to receive up to 12 weeks of unpaid leave with continued employer health insurance

and the guarantee of a job when they return from the leave.19 In addition to federal laws, eighteen

states have some sort of laws aimed at aiding pregnant women by creating new legislation or

expanding federal initiatives. One of these state initiatives is the Temporary Disability Insurance

laws (under the Federal Unemployment Tax Act of 1946), which allow for surpluses from

unemployment insurance programs to be directed towards new disability insurance programs.

This provides a certain percentage (usually between 50-60%) of monthly pay to disabled

individuals, which include pregnant women.19 Recently, five states have enacted a paid family

leave program that provides a statewide insurance fund and grants pregnant women paid leave to

bond with the child.19 Although popular and successful, paid leave is not a federally funded

initiative in the United States, despite high public approval of the measure.

B. Existing Policy and Inadequacies

The most recent and comprehensive federal legislation was the Family and Medical Leave

Act of 1993, signed under Bill Clinton. This act strengthened previous anti-discrimination laws

concerning pregnancy and additionally mandated 12 weeks of unpaid leave to bond with the

newborn child for both men and women.19 However, this law only applied to firms of 50 or more

employees and excluded more than 40% of the workforce.19 This was particularly harmful for

low-income workers and other marginally attached workers. Additionally, this law did not ensure

paid leave for women, which further excluded many low-income and middle class women.

While these women are covered for unpaid leave, many simply cannot afford to take the unpaid

leave. When faced with the choice of improving and nurturing the health of themselves and their

child or earning enough to put food on the table, women are not able to prioritize their health.

This limitation causes mothers to rush back to work in order to make sure they are able to pay

the bills, often sacrificing their own health.

Although previous policy measures strengthened pregnant women’s rights in the

workforce, they did not address the need for paid leave. Even with paid family leave offered in

a few states and a few private companies, only

12% of workers have some sort of paid family leave option; this lack of paid leave puts mothers

and their children at risk for many pregnancy related disabilities, impacts long-term life

expectancy, and causes a myriad of other emotional and psychological stress in the family.19 Paid

family leave provides a portion of monthly wages to women after childbirth so that they can

recuperate in a timely manner, reducing the economic burden that many middle class and lower

class women face during and after pregnancy.

C. Design: National Paid Family Leave

In order to address current inadequacies in paid family leave legislation, the second

policy proposed is to adopt the current campaign for federal insurance for paid family leave

(called the Family and Medical Insurance Leave Act). This proposal creates a national insurance

program to provide partial pay to every eligible employee for up to 60 workdays to bond with a

newly born child, among other things.19 All workers, regardless of gender, would be eligible as

long as they qualify for disability insurance benefits under the Social Security Act and have

earned some income in the last 12 months, which includes a vast majority of the workforce,

many more than was included in the Family and Medical Leave Act of 1993.19 This federal

insurance program would result in significant cost savings, since only 13% of the workforce

would utilize it in any given year. 20

The proposal would be funded for by a 0.2% increase in payroll tax on employees and

employers, approximately 2 cents for every $10 in wages. This marginal increase in tax would 21

amount to a mere $1.50 per week for a typical worker ($65-88 per year) and contributions would

be capped at $243 per year.19,21 This tax would cover all the administrative costs as well as the

costs of dispensing benefits. During the paid leave, workers would receive 66% of highest

monthly wage in the last 3 years with a minimum of $580 and a maximum of $4000 per month.21

This would cover low-income and middle class families, only capping benefits for high earning

workers. Additionally, states that have implemented such policies have seen the largest usage of

paid family leave from the lowest quintile of the workforce. This could potentially reduce the 22

gap between white maternal mortality and maternal mortality in communities of color, which can

be 3-4 times higher.9

!

D. Analysis: National Paid Family Leave

Paid family leave has numerous health benefits for the mother and the child.

Since 66% of maternal deaths happen 1-365 days after pregnancy, paid family leave

allows mothers to take care of themselves without worrying about economic costs.9 Paid

family leave can also reduce infant mortality by up to 10%, increase rate of infant

vaccinations by up to 25%, and can double length of breastfeeding.19 While

breastfeeding has numerous health benefits for the infant, it also has many health

benefits for the mother, such as helping the mother return to pre-pregnancy weight and

reducing risk of breast cancer, ovarian cancer, type 2 diabetes, and rheumatoid arthritis.

19, Additionally, it saves money and promotes emotional bonding, which can 23

significantly reduce postpartum depression. Postpartum depression is very prevalent,

affecting about 12% of all mothers. Paid family leave has been shown to reduce 24

depression by 15% and can even reduce depression 30 years after pregnancy by

18%. , Thus, paid family leave can significantly improve maternal health by 25 26

promoting emotional bonding, reducing stress, and ensuring financial stability. In

conjunction with the first proposed piece of legislation, the Women’s Health Community

Collaborative, which is focused on longitudinal health benefits for women of all

reproductive ages, the Family and Medical Insurance Leave Act would result in stable

benefits right after the pregnancy. Together, these two policies together would contribute

to the reduction of maternal morbidity and mortality in the long term.

In addition to a multitude of health benefits, paid family leave can have other substantial

benefits. The policy also improves income for women four quarters after they make the claim.22

By promoting workforce attachment, paid family leave has positive economic impacts for

women, which could aid in reducing the gap in wages between genders. Paid family leave

improves employee retention because it usually costs up to 10 weeks of full time work to replace

a worker; many companies are better off just shifting work around until the employee returns.19

A vast majority of firms neither replace workers during their leave nor use overtime for other

employees.19 By reducing turnover and increasing wages, this policy can also reduce government

burden on public assistance. A study by Houser and Vartanian reveals that employees who

receive paid family leave are 39% less likely to receive public assistance than those who

continued working; this difference amounted to an average of $413 less in public assistance for

those with paid family leave.19 Critics state that paid family leave causes women to exit the labor

market; while this is true to an extent, it is unclear whether this is because of paid family leave or

because of childbirth in general. Additionally, there is a significant number of women that

remain attached to the workforce and that return to the same firm.22 Moreover, this claim ignores

the positive societal benefits of women caring for newborn children during their vitally important

first few months without facing inordinate financial stress. This benefit is magnified since young,

low-income, women drop out of the workforce to care for their newborns at a larger rate than

older, high-income women. In the end, firms are the best indicator of whether the program hurts

or helps the labor market, and a survey of businesses in California revealed that close to 90% of

firms reported positive or neutral effect on productivity and almost 100% reported increase in

employee morale.19 Additionally, since family leave is not restricted to mothers, fathers can take

family leave and spend time to bond with the child and relieve stress for the mother. Studies

show that fathers who take paid leave to bond with babies are more engaged in the child’s life as

they get older.19 This can also reduce the wage gap between genders and reduce mental and

physical stress for the mother. All of these various benefits combined, including higher fertility

rates and a larger labor force, would increase the overall, long-term Gross Domestic Product of

the United States.

There are few, if any, drawbacks for the Family and Medical Insurance Leave Act. The

slight increase in payroll taxes may have a minor effect on employment rates, but since the

increase in payroll tax is so small, the effect is likely negligible. A strong criticism of federally

mandated paid family leave policies is the burden that it places on businesses. However, unlike

national mandates, such as the Family and Medical Leave Act of 1993, the proposed policy sets

up a federal insurance funded through marginal increases in the employee side payroll tax. Thus,

there are no extra costs to businesses. Moreover, a paid family leave program has been enacted in

a few states around the country, such as California. These states have seen high public approval

of such measures and low retaliation from businesses. A study that assessed the policy

implications in California cited that “there is no evidence that firms with higher rates of [paid

family leave] take-up are burdened with higher wage costs or significantly increased employee

turnover rates”.22 Many businesses have given neutral or positive ratings, and this state-wide

insurance program may even result in cost-savings for businesses, due to the fact that some

companies that currently offer paid family leave can now dissolve their program.22

Another criticism from opponents is that paid family leave stigmatizes female workers

causing possible discrimination. While a fair criticism of today’s employment practices, paid

family leave does nothing to change this gender dynamic -- women are going to have children

with or without paid family leave. Moreover, other federal and state laws aim to prevent such

discrimination. Lastly, and most importantly, critics argue that the initiative does not extend

worker protections to all employees covered by it like the Family and Medical Leave Act of

1993. This is the most valid criticism of the current proposal because it could possibly discourage

low-income workers that are not covered by the latter act from taking the leave because of

possible retaliation by their employers.20 While this would likely only affect a small percentage of

workers, a suggested remedy for this problem would be to add a clause that grants worker

protections, similar to the 1993 Act, for all eligible employees under the new paid family leave

program, thus granting protections to workers not covered by the 1993 Act. Although seeming to

impose a burden, this would likely not cause adverse economic costs because firms do not

experience higher wage costs, lower productivity, and higher turnover rate when employees take

leave.19 Ultimately, this last clause could be managed at the state level, to accommodate local

sentiments, without negating from the overall positive effects of the paid family leave proposal at

the national level.

IV. Conclusion

In conclusion, a federally funded Women’s Health Community Collaborative and

national paid family leave proposal following the lines of the current campaign for the Family

and Medical Insurance Leave Act would greatly boost maternal health.

The Women’s Health Community Collaborative is an education-based community

initiative aimed at chronic disease prevention and management, improvement of health-related

behaviors, provision of prenatal and postpartum-related information, increased awareness of

surrounding services, and facilitation of peer-to-peer discussion and support. The WHCC will be

funded through the Affordable Care Act and carried out by teams of healthcare professionals

from an implementing agency through weekly community meetings for all Medicaid-eligible

women of reproductive age. By helping manage chronic disease, currently responsible for 30%

of maternal deaths nationwide, providing access to timely prenatal and postpartum care, crucial

for reduced risk of complication during pregnancy, and serving as a source of support and

information, often lacking for women in low-income neighborhoods, the WHCC aims to curb the

incidence of maternal morbidity and death in the long term. The WHCC is an evidence-based

program and a cost-effective model of care, and its outcomes will be tracked during the two-year

pilot phase.

The Family and Medical Insurance Leave Act has a minute cost, while greatly improving

maternal health overall. It would boost the number of people covered by paid family leave

policies, usually from private companies or state insurance funds, from 12% to the eligible

workforce to 100% of the eligible workforce. Aside from numerous benefits for children,

society, and the economy, paid family leave has a multitude of positive effects on the long-term

well-being of women by reducing rates of chronic disease, reducing psychological and emotional

stress, and increasing financial independence. One change to the current campaign for paid

family leave is to extend worker rights to prevent hiring and firing discrimination by those who

take advantage of the policy. By allowing women to spend time recovering from pregnancy and

bond with their new child, paid family leave works well in conjunction with the Women’s Health

Community Collaborative to achieve outcomes to improve the health of women. Implemented

together, the Women’s Health Community Collaborative and National Paid Family Leave could

alter the concerning trend of increasing rates of maternal morbidity and death in the United

States and confer additional benefits on the lives of women and their families.

V. Endnotes

"State of the World's Mothers." (2015): Save the Children. 1

MacDorman, Marian F., et al. "Is the United States Maternal Mortality Rate Increasing? 2

Disentangling trends from measurement issues Short title: US Maternal Mortality

Trends." Obstetrics and gynecology 128.3 (2016): 447.

Bacak S, Berg CJ, Desmarais J, Hutchins E, Locke E editor. State maternal mortality 3

review: accomplishments of nine states. Atlanta: Centers for Disease Control and

Prevention. (2006).

Creanga AA, Berg CJ, Syverson C, Seed K, Bruce C, Callaghan WM. “Pregnancy-Related 4

Mortality in the United States, 2006–2010”. Obstetrics & Gynecology. 2015;125(1):5–12.

Kuklina EV, Callaghan WM. “Chronic heart disease and severe obstetric morbidity among 5

hospitalizations for pregnancy in the USA: 1995–2006”. Br J Obstetrics &

Gynacology.

2011;118(3): 345–352.

Regenstein M, Huang J. Stresses to the safety net: the public hospital perspective, Kaiser 6

Commission on Medicaid and the Uninsured, report no.7329, June 2005.

Chang, Jeani, Laurie Elam-Evans, Cynthia Berg, Joy Herndon, Lisa Flowers, Kristi Seed, and 7

Carla Syverson. "Pregnancy-Related Mortality Surveillance --- United States,

1991--1999." Centers for Disease Control and Prevention. Centers for Disease Control

and Prevention, 4 Feb. 2003.

Coeytaux, Francine, Debra Bingham, and Nan Strauss. "Maternal Mortality in the United 8

States: A Human Rights Failure." Contraception Journal. Association of Reproductive

Health Professionals.

"Implementing Nurse Family Partnership (NFP)®." HomVEE - Nurse Family Partnership 9

(NFP). US Department of Health and Human Services, June 2011.

"Nurse Family Partnership." Social Programs That Work. Coalition for Evidence Based 10

Policy.

"Advancing the Health of Mothers in the 21st Century At A Glance 2016." Maternal Health. 11

Centers for Disease Control and Prevention, 17 Aug. 2016.

Ashton, Diane. “Quality Improvement Opportunities to Promote Equity in Perinatal Health 12

Outcomes.”

New York Nonprofit Press. Northern Manhattan Perinatal Partnership: Maternal Health from 13

Womb to Tomb. In: New York Nonprofit Press, Agency of The Month section. February

2007:12-4.

Leveno KJ, McIntire DD, Bloom SL, Sibley MR, Anderson RJ. Decreased preterm births in 14

an inner-city public hospital. Obstet Gynecol 2009;113:578-84.

Ickovics JR, Kershaw TS, Westdahl C, et al. Group prenatal care and perinatal outcomes: A 15

randomized controlled trial. Obstet Gynecol 2007;110:330-9.

Darmstadt, Gary L., et al. "Evidence-based, cost-effective interventions: how many newborn 16

babies can we save?." The Lancet 365.9463 (2005): 977-988.

Gilmer TP, Philis-Tsimikas A, Walker C. Outcomes of Project Dulce: A culturally specific 17

diabetes management program. Ann Pharmacother 2005;39:817-22.

Luo, Zhong-Cheng, et al. "Effect of neighbourhood income and maternal education on birth 18

outcomes: a population-based study." Canadian Medical Association Journal 174.10 (2006):

1415-1420.

Gault, Barbara, Heidi Hartmann, Ariane Hegewisch, Jessica Milli, and Lindsey Reichlin. 19

"Paid Parental Leave in the United States: What the Data Tell Us about Access, Usage,

and Economic and Health Benefits." Institute for Women's Policy Research (2014).

Staley, Oliver. "The US Has Never Been Closer to Passing a Paid Parental Leave Bill than It 20

Is Now." Quartz. Quartz, 06 Nov. 2016.

"Family And Medical Insurance Leave (FAMILY) Act." National Partnership for Women & 21

Families. Mar. 2015.

Bedard, Kelly, and Maya Rossin-Slater. "The Economic and Social Impacts of Paid Family 22

Leave in California: Report for the California Employment Development Department." (2016).

"Why Breastfeeding Is Important." Office on Women's Health. US Department of Health and 23

Human Services, 21 July 2014.

"Depression Among Women." Centers for Disease Control and Prevention. Centers for 24

Disease Control and Prevention, 18 Aug. 2016.

Chatterji, Pinka, and Sara Markowitz. "Family Leave after Childbirth and the Health of New 25

Mothers." Journal of Mental Health Policy and Economics 15 (2008): 61-76.

Avendano, Mauricio, Lisa Berkman, Agar Brugiavini, and Giacomo Pasini. "The Long-Run 26

Effect of Maternity Leave Benefits on Mental Health: Evidence from European Countries."

Network for Studies on Pension, Aging, and Retirement (2014).