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Strategies to Reduce Maternal Mortality; Meeting Summary

By Phyllis C. Leppert, CNM, MD, PhD

Strategies that work in reducing maternal mortality in the United States were the focus of the September 19th virtual meeting sponsored by Frontier Nursing University and the Campion Fund. Susan Stone, DNP CNM and Phyllis Leppert, CNM. MD, PhD were the Co-chairs of the organizing committee. The Conference Leader was Yvonne Maddox, PhD, former Deputy Director of NICHD, former acting Director of  the National Institute of Minority Health and Health Disparities and Acting Director of NIH during the second Bush administration. The conference underscored the reality of well documented high USA maternal mortality. This public health crisis has multifactorial causes and thus must have multiple solutions. The United States maternal mortality rate is the highest of any developed nation.  Furthermore, the rate of deaths among blacks is three times higher than that of whites. Even so, the death rates of all races are exceedingly high. Multidisciplinary Maternal Mortality Review Committees (MMRC) in each of the states review all deaths during pregnancy, birth and one year from the end of pregnancy. At the end of the review a determination of whether or not the death was related to the pregnancy is determined and if the death was preventable. The 2024 CDC report of the findings of the MMRCs demonstrated that 83.5% of the deaths were preventable (1). The committees also recommend needed changes in maternal health care. The Alliance for Innovation on Maternal Health (AIM) has instituted Safety  Bundles or evidence-based guidelines for specific clinical conditions during pregnancy, birth and the postpartum period. When implemented by providers these Safety Bundles reduce maternal mortality (2). These are supported by specific quality measures through the AIM Data Center (3). However, it is harder to find solutions to deaths due to community environments and bias.  

Sixteen health professionals with experience working on impactful solutions to this unprecedented public health crisis presented methods and programs that aim to further reduce maternal mortality and provide good health care. The speakers provided research data that leads to approaches to good maternal outcomes. In summarizing the day-long conference, I have chosen to emphasize the strategies presented rather than reiterate data that is well known, and usually published although I will mention critical factual information.

Defining a problem by gathering the necessary population statistics is always the first step in creating awareness and understanding and thus is a critical strategy in working to overcome a crisis. Eugene DeClercq, PhD,  Professor at Boston University School of Public Heath is a leader in defining US maternal mortality rates and its causes. The United States has three systems for collecting maternal mortality statistics: The US Vital Statistics of  the ; The Centers for Disease Control Maternal Mortality Review; and individual State data. All these databases demonstrate the high rates of maternal mortality in the United States. While the death rates were increased greatly during the Covid pandemic, they are leveling off but are still very high. He prefers the CDC database which contains pregnancy related deaths during pregnancy and birth through the first postpartum year. His carefully collected and analyzed data has dissected the issues well and is essential in the appreciating the full extent of the problem the US faces. I will summarize some of his data here that point to ways in which the delivery of care In the US must change if we are to address the challenge of reducing maternal mortality.  I will cite some statistics, but suggest that the reader should go to his website (4), an extensive site curated by his students, to completely study and understand the extent of this major public health problem. Deaths during birth itself are 11% of maternal deaths as the majority occur during pregnancy and in the postpartum year following birth. An astounding 25% of postpartum deaths are due to suicide.  A complete, full collection of statistics provides a basis for action and in itself is a strategy that works. In fact, it is essential. It will lead to action. One clear example of this is that when his team’s reported data clearly demonstrated that a large percentage of maternal deaths occurred in the postpartum year was noted by policy makers and the public Medicaid payment was extended for continued maternity care for the entire postpartum year. Previously maternal care payment had stopped at the six- week postpartum visit. This one important change in payment has had a tremendous impact on the ability of health care providers to improve the health of childbearing women and potentially prevent maternal death. During his talk he highlighted data describing racial disparities – disparities not only in rates but in terms of the conditions that lead to death in various races. The most common cause of death for black mothers is due to cardiovascular events, while deaths of white women were commonly seen postpartum and involved mental health issues such as depression. Dr. DeClercq stated that therefore, maternal mortality is a public health and community problem and not just a medical one. He also spent time discussing the three data system in the United States that collect maternal mortality information. They are the US Vital Statistics System, the CDC system and the system of data collected by the States and State MMRCs. Each system has its own definition of maternal mortality. He prefers the CDC system for analysis. The fact that there are three systems in the United States is confusing, especially to the public. This strongly indicates that one of the most important strategies that needs to be implemented is to develop one system that reflects the total spectrum of maternal mortality. Another important point that was raised was that maternal mortality is associated with the lack of integration of midwives into the maternal care system. The highest maternal mortality occurs in states in which midwives are not able to practice to the extent of their training and education. Their scope of practice in these areas is limited. In states in which midwives are able to practice and are integrated into the maternity care system, maternal mortality is lower.  Clearly, an essential strategy to reduce maternal mortality is to utilize and educate midwives as full members of the maternal health care team throughout the whole childbearing cycle.

A critical strategy to reduce maternal morality in the United States is to determine the full economic cost of this morality to society including costs to families.  The implication of such information in changing policy cannot be minimized as the public and elected officials respond to economic facts. For some individuals, the economic cost is perhaps the only thing that will change their response to a crisis. Preventive care is expensive. However, when put in the context of the economic burden to society as a whole, it is cost-effective. Robert S. White, an anesthesiologist at Cornell Weill College of Medicine has conducted one of the first studies to elucidate these costs. He conducted a study of maternal deaths during the period of 2018 to 2020 to access the economic cost or burden. During each study year the costs increased. The total costs were 27.4 billion dollars during this time period. He calculated this figure using  two parameters, the value of statistical life (VSL) and years of potential life lost (YPLL) which are accepted measures used by health economists in studies reporting on the economic cost of deaths caused by disease and other conditions. The data bases used for calculations were obtained from the CDC wide ranging online data for epidemiology research database; life expectancy was obtained from Social Security actuarial tables. Data was stratified by age and race/ethnicity. Deaths increased over age 40 years compared to those less than 40. The black-white health disparities were striking indicating that the economic burden among blacks is significantly higher. He pointed out that his study does not include the costs to the families of the individuals who died, costs such as child care, as well as other coasts to the family in raising children by a single parent, loss of job mobility or advancement for the surviving parent as this data is simply not available currently. However, when the field of health economics develops the appropriate tools to access this aspect of the economic burden of maternal death, the total costs will be much higher. The study is published and is available to interested persons (5). Economic  analysis will be helpful to all health professionals in advocating for programs to reduce maternal mortality with local, state and national elected officials. I cannot emphasize enough how vital it is for every physician, midwife, maternity nurse, social worker, doula and all others concerned about the high maternal mortality rate in the US make a pledge to speak to those who are our elected representatives and agencies and organizations interested in the health of the public to emphasize the crisis of maternal deaths and their staggering financial costs.

Analysis of severe maternal morbidity, the “near miss” strategy of looking at clinical studies of woman who almost died during gestation and birth is an approach to preventing maternal mortality. Wendy Post, DNP, MSN, RN of Georgetown University School of Nursing conducted a qualitative study of black women from the five US zip codes with the highest maternal mortality rates who experienced severe maternal morbidity. These were 20060 (Washington, DC) 30303 (Atlanta, GA) 70112 (New Orleans, LA,) 46290 (Carmel, IND) and 10467 (Bronx, New York). The subjects were treated in hospitals that treated blacks primarily. Subjects were recruited in 2022. Twelve individuals who volunteered met inclusion criteria. In addition, the mothers of two black women who died volunteered to tell their daughters’ experiences. The interviews were recorded and analyzed using accepted qualitative research techniques. The participants had graduate level education and came from households with an average income of $123,750.  A point was made that race is not a proxy for poverty nor poverty a proxy for race. During her presentation, with informed consent of the participant,  Dr. Post included several recordings which were extremely informative and poignant. Her results demonstrated a number of factors which contributed to the severe morbidities and to the two deaths: communication failure, stereotyping by the providers, differential treatment, medical error. Often the medical error was not acknowledged. Subjects reported that they were not listened to when they presented their concerns and symptoms and were often treated as if they were not educated. This study as been published in Birth (6). I recommend reading it.

Nikia Grayson, DNP, MPH, MSN, CNM, FNP-C, Chief Clinical Officer of CHOICES Center for Reproductive Health In Memphis, Tenn, the first non-profit comprehensive Center for Reproductive Health  that includes a Birth Center, presented a very informative and detailed look at the state of black midwifery in the United States. Her talk was entitled “ Empowering Change: Advancing Black Midwifery and Maternal Health Equity”.  Her strategy to reduce maternal mortality is to foster and empower black midwives. The American Midwifery Certification Board reports that in 2024 there are 14,198 certified midwives in the United States. Despite the three times greater maternal mortality among individuals of color, of this number only 8.3% of certified midwives are Black, while 1.9% are of heritage, 0.6% are Native American/Alaskan Native and 0.2 % are Native Hawaiian. For clarity I add that the history of midwifery in the United States reveals past incredible discrimination toward midwives overall but particularly toward black midwives, primarily in the South beginning in the seventeenth and eighteen centuries and continuing to the present. When the nurse-midwifery profession was initiated in the US during the 20th century, the schools accepted and educated white nurses, many who were public health nurses to fill this role (7).Some but not many black nurses received education as nurse-midwives until recently. There are 45 accredited midwifery programs of which 39 reside in Schools of Nursing. In absolute numbers only 1,179 CNMs are Black, Astoundingly, there are no midwifery programs in Historically Black Colleges and Universities (HBCUs). In the past there was a program at Tuskegee, that kept its doors open for six years and one at Meharry which also closed. Thus, there are fewer black midwives in proportion to the percentage of the black population creating a situation in which racial concordant care is lacking. Despite a considerable body of research demonstrating that maternity care providers who are of the same race as those they serve improves birth outcomes, empowers community centered care and emphasizes prevention and holistic care including mental health support, there is a lack of representation of black midwives in the workforce. The American College of Nurse-Midwives has published two reports on this issue (8,9). The challenges for recruiting and educating black midwives are multiple including lack of black faculty who are role models, shortage of clinical training sites, and difficulty of black students and graduates to advance to leadership positions, lack of scholarships, as well as issues related to structural racism. CHOICES Center for Reproductive Health under Dr. Grayson’s leadership has a completely black midwifery staff and is situated in a black neighborhood in Memphis. She has worked to expand black nurse-midwifery by developing CHOICES Fellowships which promote leadership within the profession and provide the ability to promote educational avenues to enhance professional skills. Her goal is to expand the  number of black midwives, especially in the South. Dr. Grayson has a faculty appointment at The University of California San Francisco and has developed a Mentoring and Belonging Group for black midwives.  The University of Illinois Chicago has established a Melanated Group Care Group centered on prenatal care.  Another program promoting black midwives is the New York University-Howard University Partnership. During a brief discussion following Dr. Grayson’s  talk, Dr Maddox mentioned the need to develop opportunities for the education of black midwives through HBCUs and to also work on developing a pipeline of potential midwives by working with high school students and encouraging them to start a career path to nurse-midwifery education. To summarize, it is essential to increase the black and persons of color midwifery workforce to enable the provision of racially concordant care to  to reduce maternal mortality.

Comparing the US maternal mortality rates with those in other similar developed countries is a strategy that provides an understanding of the differences in the US health care system with these countries to determine where a change in our system would be beneficial. Dr. Holly Kennedy, Professor Emerita of Nurse-midwifery at Yale was the next speaker. She as the lead author on a multi-author team that analysis the maternal care systems of the United Kingdom, Australia, Canada and the Netherlands and compared them to the United States (10). A memorable quote from her talk is that the United States dose not have a health care system, we have a health care industry. Our health care system costs more than the other countries and yet our outcomes are much worse, not only in terms of maternal mortality but in overall health. Dr Kennedy presented the findings from the study that was requested by the National Academies of Science, Engineering and Medicine to  compare the US maternal care system with four high resource countries. The team examined the resources in each of the four countries to ascertain the health care organization, financing of the system, types of maternity care providers and clinical guide lines and health policies, surveillance data collection and the education of the public to determine the differences between the four countries and the US system. While the systems in each country were not completely identical all had lower rates of maternal mortality, low birth weight births, newborn and infant deaths than the Unite States. The commonalities in all countries were that they all had affordable and accessible health care for all, a maternity care workforce that included and emphasized midwifery care and interprofessional collaboration. Most importantly they all had systems that mandated respectful care and maternal autonomy. Evidence based guidelines agreed to by all professional providers were included in their systems and all had maternal data collection systems. The data surveillance systems were not perfect; however, they were more adequate than the US system which often does not provide complete data. For instance, it is often impossible in some state statistical databases to determine what providers actually managed the birth, especially if it was a midwife managed birth. Dr Kennedy stated that the UK was considered the best in terms of surveillance data collection. The majority of births were managed by midwives in three of the four countries. Midwifery is relatively new to Canada. Midwives are well integrated into the maternal health care systems however in Ontario, British Columbia, Alberta and Quebec. The most important features of the maternal care system in the comparison countries are that the largest proportion of births are managed by midwives in three of the four countries; the expressed policy of maternal autonomy and respectful care; and universal access to maternal health care throughout the childbearing period. The comparisons point to the need for the United Sates to increase the utilization of midwives, assure access to maternal health care for all and provide autonomy for the childbearing individual. It is not necessary to have an expensive system to ensure good outcomes. The US health care system is the most expensive in the world but fails to provide excellent outcomes to justify the expense. Dr. Kennedy presented information regarding a birth center in northern Uganda, a resource poor country. In over 20,000 births, they have had no maternal deaths. A report in the journal Birth authored researchers from Yale as well at Makerere University describes the care which is based on community understanding as well as respectful maternal care given at the Birth Center in northern Uganda (11). The northern Uganda Birth Center website provides more information (12). By presenting this Birth Center’s experience, Dr. Kennedy reminds us that care that costs a great deal of money is not superior to maternity care given by midwives who respect the community, its culture and its childbearing traditions and desires of individuals. We must learn from this experience.

Four members of the University of Utah’s intergrated maternal care team, Bob Silver, MD, Karlie Masaga DNP, CNM WHNP, Jeelan Fall, DNP, CNM, WHNP and Michelle Debbink, MD, PhD  discussed their experiences as well as presented principles of how effective teams operate. During the panel discussion, Bob Silver stated that Utah has had a team approach to care for 35 years. He stressed that it is a “work in progress” meaning that the team is always striving to improve. To clarify their integrated program, the University is a tertiary care center that serves a multiple state area in the intermountain west providing health care to urban and rural areas, some being quite isolated. The physicians on the panel are maternal-fetal medicine specialists who are clinicians and researchers, the nurse-midwives practice full scope midwifery as University of Utah BirthCare HealthCare Midwives with their own practice in the Salt Lake City area. They also work as “hospitalists” on the labor floor to serve individuals and their families who have received prenatal care in the community but who are admitted to the university hospital for delivery, either as high-risk transfers and transfers from community midwife practices. And community prenatal clinics. In this role they are successful in developing a collaborative practice with resident obstetricians including a role in their education. The midwife in this role has been able to manage births for women with high-risk pregnancies who desired a midwifery birth experience. Dr. Fall mentioned that she provided such an experience for a mother with Type 1 Diabetes who had received prenatal care from Dr. Silver. Providing midwifery care at birth to individuals with high- risk pregnancies is a way to decrease unnecessary interventions  to ensure good maternity outcomes,  20 % of births in the Utah experience are managed by midwives. The team treats doulas as members of the team.  The Utah team has encouraged community midwives to remain with their laboring person after transfer. Dr. Masaga discussed her experience in caring for a population  of Pacific islanders who live in Salt Lake City.  Dr Debbink presented key aspects of what makes an effective integrated team. She stressed that the team includes maternity nurses, other physician specialists, community workers and the pregnant individual. There is a large body of research that demonstrates that midwifery integration goes along with better maternal outcomes (13-14). By definition the pregnant individual is a member of the team and must be given autonomy. Midwifery integration is ongoing work and does not happen just because of a regulation. The integrated team is a nonhierarchical team where every member is important. Those working on an integration team must use excellent communication skills. There must me trust and respect for each profession and for the education and abilities of each team member. This trust must be complete. It is not enough to express trust in front of a pregnant person if the team member makes negative comments about fellow team members approach to care to others on the team (14). Clear guidelines must be established and followed, with professional respect among all team members. Each team member needs to have autonomy to work within their respective profession. She said the key is for members to have the idea that all members of the team are smart and work to do their very best. The Utah team works hard on communication and trust and has adopted ways to formally evaluate these important team aspects. She also presented a tool designed by Birthplace Lab which is a map of the United States showing the practice integration of each state and their outcome measures.  This map is interactive (15). I highly recommend accessing it. As I  listened to this panel, I was reminded that team work is hard and that it must be  continually cultivated. Team members change as new members join the team; students in the professions should learn together. It is imperative to accomplish a truly integrated approach to maternity care in our country. This is one very necessary strategy for reducing the high maternal mortality in the United States. We must accomplish this. By respecting each other and their professional background we will find the ability to respect the childbearing individual and give that person true autonomy.

Postpartum depression is diagnosed in 1 of 5 pregnancies. In 50% of pregnancies and the postpartum period, the individual does not receive treatment. Dr Kathleen Scott a CNM from the University of Nebraska presented a quality improvement project implementing a perinatal depression screening and treatment referral plan. In a previous chart review at the University of Nebraska Hospital, she noted that many mental health symptoms were described as “discomfort of pregnancy”. She instituted a pilot protocol that was utilized from 14 to 38 weeks in the Prenatal Clinics by selected providers. Using the Edinburgh Depression Screening tool, patient engagement, and referral for care she developed an effective program for the detection of depression and treatment referrals.  Over an eight- week period, roughly 20% of the prenatal population were involved in the project. During this time frame, 97% were screened using the Edinburgh survey tool. The screening was given at the onset of visits by the clinic clerks. During the pilot project, providers became more experienced in making referrals to appropriate care. In total 85% of patients were referred. Counseling was the most common intervention. Suicidal ideation was taken seriously and treatment instituted quickly. The success of this pilot was recognized by administration with the screening program extended to include all those enrolled in the clinic.

In Kentucky, the highest cause of maternal mortality is due to substance abuse. Angie Chisholm, a Frontier Nursing University educated CNM presented a program that extended a substance abuse program for pregnant individuals to the postpartum year. Many barriers to treatment exist in including stigma of being on drugs. Prior to the initiation of the program, only 15% of those with substance abuse during pregnancy received treatment in the postpartum year. Co-morbidities were common and there was a lack of access to family planning and the risk of sexually trans mitted disease is high. 70% of women entering addiction treatment have children. Often family responsibilities interfere with addiction treatment. Importantly, many women do not enter treatment as they fear that their children may be taken away from them. The extended substance abuse program discussed by Dr. Chisholm was possible because Medicaid was expanded for mothers to include the twelve months after birth in Kentucky. The program included weekly visits of one hour and included group work and medication when appropriate. Screening for depression was conducted. These visits were individualized and often the visits were spaced out as the year progressed. The care team included a midwife, registered nurse, licensed social worker and peer support person. Secondary support was provided by other disciplines. Pediatric care for infants was provided in the same location. And community support was available. The outcomes of this program show that there is an increased use of long- acting reversible contraception (LARC). 100% of those enrolled in the program obtained an obstetrical postpartum visit and many returned to school. The most heartening outcome was that the majority of the women retained custody of their infant. This program is possible because of the success of the strategy of collecting data and compiling statistics that compelled the expansion of Medicaid to cover the postpartum year as described by Dr. DeClercq.

Rebecca Bhansali, CNM and PhD candidate at Johns Hopkins University presented her work aimed at developing an equity-driven prediction model for cardiovascular problems and long- term cardiovascular disease. Research shows that gene-environmental factors underlie hypertensive disorders of pregnancy and preeclampsia. For this work she is using a number of large data sets for developing an integrated model that includes environmental and genetic factors as well as biological data to find an algorithm to predict long  cardiovascular disease during the maternity cycle using current statistical methods. She evaluated a number of large birth data sets to be used but discovered that most were did not include diverse populations. The Boston Birth Cohort of births from 1998 to 2013 following in vitro fertilization is a data set that includes a diverse population as opposed to the many birth sets that lack diversity. Therefore, she chose to use the Boston Birth Cohort for the data analysis. She is using other data bases on Social determinants of disease, polygenic scores of genetic risks for hypertensive disease of pregnancy and preeclampsia as well as clinical factors in her algorithm as well. This is an important work in progress and when completed and tested in clinical situations will be an vital tool to predict and thus prevent the development of serious cardiovascular disease in pregnancy and the postpartum period.  Cardiovascular disease is one of the leading causes of maternal mortality especially among blacks.

Virginia Glifort, CNM was educated at Frontier Nursing University and is employed as one of six nurse-midwives in a collaborative practice with six obstetrician-gynecologists in American Fork, Utah.  She began her presentation stating the in Utah 92% of maternal deaths are deemed preventable. Many of the preventable deaths occur in the postpartum period of one year following birth. On chart review conducted in her collaborative practice she found that 100% of the charts indicated that current practice guidelines were not being followed. She has established ways to educate pregnant people during the antepartum visit about to expect postpartum to empower patients to advocate for themselves as well as to prevent complications. Her model is similar to teaching surgical patients at presurgical sessions of what to expect after surgery and to acquaint them of ways to avoid complications. She presented her outline of what topics she teaches during the antenatal visits. Visits close to delivery include lessons regarding specific untoward events. She also sees her postpartum patients frequently for care starting with a visit in 24-72 hours following current American College of Obstetricians and Gynecologists guidelines for postpartum care. She schedules postpartum visits at 2 weeks postpartum, and at 4-6 weeks and at 12 weeks.  During the discussion questions were raised as to how insurance paying a global fee would pay for such enhanced care.  Her response was that issues such as breastfeeding and lactation issues, mood changes including depression and infection are able to be billed since they are not directly related to the birth experience and a are thus not a part of the global fee. One very innovative teaching method she has started is to use QR codes for quick access to information modules regarding the postpartum year. As a retired clinician I find Jenny Gilfort’ s approach to be refreshing, innovative and easily doable and I would encourage every practitioner to incorporate her teaching methods in their own practice. This excellent prevention teaching is proactive and can be done well by every provider.

Carrie Belin, FNP DNP and  Marianne Mariano, FNP, MSN  presented a poster describing a innovative program to increase maternal health  and protect black mothers through community support. Called M-NEST which stands for maternal essential support team it is a supportive approach that includes weekly home visits by a supportive community doula and other visits by a team that also includes a public health nurse and mental health counselors. Financial support is also included in the intervention. This community centered program allows the team to tailors the support for each individual mother.  Team members meet on a regular basis. During home visits needs are assessed, referrals to physicians community workers made and support is given.

Kathleen Hewitt-Masson, CNM from New Mexico presented a poster describing the implementation of effective perinatal preventive care. 42 % of mortality in their region is related to mental health issues. In their program  in a metropolitan community practice, they established a screening program using the Edinburgh Postnatal Depression Scale which was given electronically to the patients enrolled in a 1,700-birth shared practice. The screening was done on the 2nd prenatal visit between 12-16 weeks as it was observed that the 1st visit comprised so much evaluation and examination and compliance was decreased with depression screening.  32% of the screens were positive for perinatal depression. Following the screen the pregnant person was received options on how to proceed in a shared decision- making process using case management and team engagement.  Thus, the management plan was developed by the individual themselves. Patients choose the therapy, exercise or watchful waiting most frequently.  They screened multiple times during the pregnancy and at all postpartum visits. The watchful waiting approach helped in gaining trust with pregnant individuals.  As the screening was repeated many then were comfortable with therapy.  Evaluation  of the program showed that care of mental health issues increased by 82% in eight weeks.

Diane Ortega- Smith, CNM of Willow Midwifery Care presented a new psychiatric in  hospital mother-baby unit planned for Arizona: Willow-Reborn. This unit well be for the sickest mothers who need mental health care to prevent serious outcomes, including suicide. Mothers who are depressed lose confidence in their ability to mother the baby. Infants mental health and well- being is negatively affected when they are separated from their mothers. Therefore, keeping the mothers and babies together is paramount for the treatment plan. Fathers are able to visit freely and are supported. These types of psychiatric in- patient units have been available in  the UK for some time (17). 20 % of postpartum deaths are due to suicide. Unfortunately, depression is recognized among pregnant persons less than in the general population. The unit will be staffed by CNMs and Mental Health Nurse-Practitioners. It is anticipated that the average stay will be 4-8 weeks. At the present time the project is in the fund-raising stage. The CNMs who are planning this psychiatric unit are optimistic regarding its start. To clarify the situation in the US, currently there are Mother-Baby Units in the US staffed by psychiatrists: The Women's Inpatient Unit at the UAMS Psychiatric Research Institute in Little Rock, Arkansas; The UNC Perinatal Psych Inpatient Unit in Chapel Hill, North Carolina; Northwell Health Perinatal Psychiatry Service in New York; The El Camino Inpatient Psychiatric Care Women's Specialty Unit in California. They are not completely similar to those in the United Kingdon, however. (18). The concept of this in hospital mother-baby unit for the sickest individuals with postpartum depression is a strategy that could be very helpful in reducing maternal death due to postpartum depression and psychosis. Insurance coverage is not yet available.

In summary I think that it is imperative that the US needs to ensure that all persons have access to perinatal care that includes wellness care preconception, maternal care from early pregnancy through birth and one year postpartum that is covered by financial insurance. The midwife/physician ratio should change in the USA. Midwives should be the primary maternal health care provider for the majority of childbearing people with highly educated physicians providing care for those in complex and high-risk situations.The total Momnibus package should be passed by congress. Midwifery education must be expanded in order to right size the maternal care workforce with a goal toward midwifery care within accepted full scope of practice. Black and other persons of color should be recruited to allow for culturally congruent care. Postpartum heath must be emphasized by all providers. The maternal health surveillance system should be streamlined to insure accurate maternal health care statistics. Fundamental research on the biological, social and genetic factors for maternal health must be expanded and supported.  A hallmark of an advanced society is to ensure the safety and health of all childbearing persons and their children. The USA must do better than are doing at the present.

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The Campion Fund provides awards to junior investigators presenting the best research talks at the Annual Consortium for Reproductive Biology Meeting.