The Lactation Gap: Disparities in Maternal Health
As members of our health care system struggle to correct systemic inequities, the fight against disparities in maternal care outcomes should be ground zero. A recent Commonwealth Fund report found that among developed countries, the United States has the highest maternal mortality rate. Maternal care issues are worse for black women who are three times more likely than their white counterparts to die from pregnancy-related causes. These disparities in maternal care have an impact throughout the life of the mother and child.
The American Rescue Plan, signed into law in March 2021, targets this disparity by increasing access to maternal coverage for all populations by giving states the choice to extend postpartum Medicaid coverage from 60 days to a full year. through the Children’s Health Insurance Plan (CHIP) for those living up to 138% of the poverty line. But there is still a lot more to do. Efforts to support and increase accessibility to breastfeeding can build on these other initiatives to address disparities in maternal care.
Breastfeeding may have long-term health benefits for both mother (reduction in postpartum blood loss, type II diabetes, breast cancer, and ovarian cancer) and child (protection against diabetes, high blood pressure and obesity). In the short term, it supports the immune system and protects against ear infections and gastrointestinal disorders. Yet there are significant disparities in who breastfeeds. For example, a study of breastfeeding initiation and duration for infants born in 2015 found that black mothers were less likely to initiate breastfeeding and if they did, they were less likely to continue it. , based on 3- and 6-month follow-up data.
Policy solutions that increase the supply of International Board Certified Lactation Consultants (IBCLC) who have specialized training in breastfeeding care and support can help close this disparity. To work toward this end, we offer Medicaid reimbursement for IBCLC providers who are not physicians, NPs, PAs, or RNs; parity in coverage of lactation services outside of hospital settings; and creating value-based care models for breastfeeding.
IBCLC Non-Clinical Staff Reimbursement
Currently, lactation support services are reimbursed by Medicaid in only 26 states, and of those states, only 10 states and Washington, DC reimburse lactation services outside of a hospital setting. Additionally, only four states have laws that allow for reimbursement of an IBCLC who is not a physician, NP, or PA. Due to these political constraints, the supply of lactation consultants is significantly lower than the demand. This supply gap highlights the need to allow non-physicians with the required training to practice and be remunerated. Increasing the supply of lactation consultants would also reduce the cost of lactation services, making the service more accessible to pregnant women and new mothers. In turn, this could reduce the cost of covering the service for cash-strapped Medicaid programs, making it easier for states to provide. In addition, using the Medicaid payment system to fill this supply gap would help alleviate disparities in access to lactation services.
Increasing the supply of providers would also help improve the diversity and cultural competence of IBCLC providers. This is essential for spotting how breastfeeding problems, such as mastitis, present in women of different racial backgrounds. For example, providers often learn that mastitis presents with red streaks. However, it presents differently in mothers who have darker skin pigmentation. A larger, more culturally competent population of IBCLC providers would be better positioned to detect mastitis in diverse populations and reduce the incidence of breast abscesses in new mothers. This has the potential to save, on average, $2,340 to $4,012 per mother.
State Medicaid Coverage
Medicaid coverage of lactation services via telehealth at parity with in-person care can help fill this gap in provider supply and alleviate geographic disparities in access to lactation support in rural areas. First, telehealth can help mothers who do not have access to adequate transportation. Additionally, financial support for lactation services via telehealth would reduce costs and increase the convenience associated with lactation. It should be noted that low breastfeeding rates increase health costs attributable to mother and child by $3 billion each year. Mothers, who do not have access to adequate maternity leave, often return to work after giving birth. Therefore, the ability to access an IBCLC virtually would help mothers juggle lactation needs with professional and personal obligations. More importantly, from a health perspective, new mothers and infants often have weaker immune systems, making it more optimal to receive care outside of the hospital when possible. Overall, financial reimbursement for virtual lactation support would increase lactation access and convenience.
The Case for Value-Based Breastfeeding Reimbursement
Payers are increasingly adopting value-based models to financially reward providers for outcomes of care rather than volume. Since lactation support and breastfeeding require follow-up with the patient, this would be an area of care that would benefit from a values-based model. Here’s a solution to test how it might work: The Center for Medicare and Medicaid Innovation could include lactation support as part of responsible care organization models to show how increasing the initiation and duration of breastfeeding improves health outcomes and lowers costs. The duration factor is just as important as initiation, as increased duration of breastfeeding is associated with improved cardiovascular health and cognitive development in children. To this end, payers and providers would benefit from creating a benchmark closely tied to the American Academy of Pediatrics recommendations that new mothers breastfeed for the first 6 months of their child’s life. These value-based models would also provide another opportunity to test how telehealth should be integrated and financially supported post-pandemic.
Currently, the lack of available lactation consultants contributes to existing disparities in breastfeeding and maternal outcomes. This leaves a ripe opportunity for policymakers to take the lead and for private payers, providers, innovators, investors and advocates to come together to drive innovation and improve access to lactation care.
Victor Agbafe is dean and researcher in medical innovation at the University of Michigan Medical School, and MD/JD candidate at the University of Michigan and Yale Law School. Andrea Ippolito, MS, is the CEO of SimpliFed and former director of the Department of Veterans Affairs Innovators Network. His graduate research focused on improving access to telehealth assistance for underserved populations.
Agbafe is a member of Third Culture Capital.