Opinion | The Lactation Gap: Disparities in Maternal Health – MedPage Today

As members of our healthcare system wrestle with correcting systemic inequities, addressing disparities in maternal care outcomes should be ground zero. A recent report from the Commonwealth Fund found that among developed countries, the U.S. has the highest maternal mortality rate. The issues with maternal care are worse for Black women who are three times as likely as their white counterparts to die of pregnancy-related causes. These disparities in maternal care have a lifelong impact for mother and child.

The American Rescue Plan, signed into law in March 2021, takes aim at this disparity by increasing access to maternal coverage for all populations by giving states the choice to expand Medicaid postpartum coverage from 60 days to a full year via the Children’s Health Insurance Plan (CHIP) for those who live up to 138% of the poverty line. But much more needs to be done. Efforts to support and increase accessibility of breastfeeding can build on these other initiatives to address maternal care disparities.

Breastfeeding can provide 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 provides support for the immune system and protects against ear infections and GI distress. Yet, there are significant disparities in who is breastfeeding. For example, a study on 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 towards this end, we propose Medicaid reimbursement of IBCLC providers who are not MDs, NPs, PAs, or RNs; parity in coverage of lactation services outside of hospital settings; and the creation of value-based care models for lactation.

Reimbursement of Non-Clinical Staff IBCLC

At the moment, lactation support services are only reimbursed by Medicaid in 26 states, and of these states, only 10 states and Washington, D.C. reimburse lactation services outside of a hospital setting. In addition, only four states have laws that enable reimbursement of an IBCLC that is not a physician, NP, or PA. Due to these policy constraints, the supply of lactation consultants sorely undershoots demand. This supply gap underscores the need to allow non-physicians with the requisite training to practice and get paid. Increasing the supply of lactation consultants would also lower the cost of lactation services, which would make the service more accessible for expectant and new mothers. In turn, this could lower the cost of covering the service for cash-strapped Medicaid programs, making it more feasible 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 competency of IBCLC providers. This is critical for spotting how breastfeeding issues, 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 a darker skin pigmentation. A larger and more culturally competent population of IBCLC providers would be better positioned to spot mastitis in diverse populations and lower the incidence of breast abscess 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 void in provider supply and alleviate geographic disparities in access to lactation support in rural areas. First, telehealth can help mothers who lack access to adequate transportation. In addition, financial support for lactation services via telehealth would lower cost and increase convenience associated with lactation. It is worth noting that low rates of breastfeeding increases healthcare costs attributable to mother and child by $3 billion each year. Mothers, without access to adequate maternity leave, often return to work after delivering. As a result, the ability to virtually access an IBCLC would help mothers juggle lactation needs with career and other 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 of virtual lactation support would increase lactation access and convenience.

The Case for Value-Based Reimbursement of Breastfeeding

Payers are increasingly embracing value-based models to financially reward providers for care outcomes rather than volume. Given that lactation support and breastfeeding require follow-up with the patient, this would be an area of care that would benefit from a value-based model. Here’s one solution to test how this might work: the Center for Medicare and Medicaid Innovation could include lactation support as part of accountable care organization models to show how increasing breastfeeding initiation and duration improves health outcomes and decreases costs. The duration factor is just as important as initiation because increased length of breastfeeding is associated with improved cardiovascular health and cognitive development in the child. To this end, it would be beneficial for payers and providers alike to create 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.

At the moment, 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 spur innovation and improved access to lactation care.

Victor Agbafe is a Deans and Medical Innovation Scholar at the University of Michigan Medical School, and an 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. Her graduate research focused on increasing access utilizing telehealth for underserved populations.

Disclosures

Agbafe is a fellow for Third Culture Capital.