Black Maternal Mortality Rates in Chicago: Why the Recently Passed IL 1115 Waiver Is Not Enough

Sara Bovat ‘21 graduated with a MA in Social Work, Social Policy, and Social Administration at the University of Chicago Crown Family School of Social Work, Policy, and Practice and the Graduate Program in Health Administration and Policy . She can be reached via LinkedIn.

Severe maternal morbidity is not distributed equally throughout the city of Chicago. The CDPH report includes a city map of severe maternal morbidity organized by zip code and high economic hardship. It shows that zip codes on the South Side experienced both increased maternal morbidity rates per 10,000 deliveries as well as increased economic hardship, while more North Side zip codes experienced neither.

Certainly, neighborhood-level determinants impact Black women’s health conditions, as well as their increased risk of maternal morbidity and mortality rates. New literature demands that structural racism no longer be overlooked as a key social determinant of health. Dr. Jamila K. Taylor, PhD, MPA, argues that other, more commonly named social determinants do not serve as protective factors for Black women, as providers and the healthcare system have historically trafficked in racism, discrimination, and bias. Structural racism needs to be explicitly treated as a social determinant, which will allow for effective implementation of policies that address it.

The Centers for Medicare and Medicaid Services (CMS) approved the Illinois Department of Healthcare and Family Services’ proposed solution to address the well-evidenced disparity in maternal mortality. On April 12, 2021, Illinois became the first state to expand Medicaid coverage from 60 days postpartum to 12 months postpartum via its approved IL Continuity of Care & Administrative Simplification 1115 Waiver. In addition to extending Medicaid coverage to a longer postpartum period, the demonstration waiver proposal also aimed to reinstate managed care within 90 days and waive Hospital Presumptive Eligibility. These additional two goals would not only remove administrative burden for the State, but would also help to ensure that new, low-income mothers have uninterrupted access to full Medicaid benefits throughout their critical first year postpartum.

This 1115 waiver marks a significant step toward decreasing the Black maternal mortality rate in Chicago and blazes a path for states to follow in its trend. Its greatest strength is the expansion of eligibility to cover the entire 12-month postpartum period. In the two-year period from 2016 to 2017 captured by the 2019 CDPH report, out of the 78% pregnancy-associated deaths that occurred after delivery, only 28% took place within in the immediate postpartum period of 42 days. Expanding Medicaid is imperative to improving outcomes.

However, while expanding Medicaid coverage to 12 months postpartum reflects a momentous stride forward, this alone is not enough to avert Black pregnancy-associated deaths altogether. Medicaid coverage is not as comprehensive as other forms of insurance, and those relying on Medicaid often experience less care coordination and more fragmentation of health care access. This is reflected in the rates of maternal mortality: the 2019 CDPH report found that women covered by Medicaid were nearly three times more likely to experience a pregnancy-associated death than women with private insurance, and 71% of women who experienced a pregnancy-associated death were on Medicaid. We must continue to work towards larger payment and delivery system–reform at the state and national level to eliminate such inequities.

The racially neutral discourse in the U.S. capitalist health care system and political economy hides the fact that Black women are disproportionately dying due to maternity-related “care” in Chicago and the entire country. The neutralized rhetoric of calling maternal mortality rates “health disparities” implicitly suggests that the concern is a matter of differences in outcomes and not structural racism. Efforts to create a more antiracist health care system need to prioritize trauma-informed care training, antiracism training, training on cultural competency, and training related to unconscious racial bias. Some experts, including Dr. Taylor, have stated that the onus should be on health care providers to work with partnership and collaboration with patients and families. While I agree with the importance of clinician engagement, I feel that larger health systems must also equip providers with the tools to combat structural racism in their practice and set a precedent to ensure these issues are being prioritized. To that end, the CMS should create more specific guidelines for healthcare providers to attend reoccurring trainings on trauma-informed care, antiracism, cultural competency, and unconscious racial bias.

Now that the IL demonstration waiver to expand Medicaid coverage for the entire postpartum period has been approved, CMS also has the urgent responsibility to create further specified guidelines to address structural racism in the U.S. health care system that particularly target implicit bias. Chicago would be an apt model for how the rest of the nation can more comprehensively address and decrease its disturbingly disproportionate Black maternal mortality rates.

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Chicago Department of Public Health (CDPH). (2019). CDPH Data Report: Maternal Morbidity & Mortality In Chicago. Chicago: City of Chicago. Retrieved from: https://www.chicago.gov/dam/city/depts/cdph/statistics_and_reports/CDPH-pdf

Illinois Department of Healthcare and Family Services (HFS). (2020). Illinois Continuity of Care & Administrative Simplification 1115 Waiver. Springfield. Retrieved from: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/il/il-continuity-care-admin-simplification-pa.pdf

Taylor, J. K. (2020). Structural Racism and Maternal Health Among Black Women. Journal of Law, Medicine & Ethics, 506-517.