The Transforming Maternal Health (TMaH) model’s original requirements include developing and implementing a health equity plan as one of the mandatory elements of the Whole-Person Health pillar. However, the current administration is actively excising health equity from federal programs as part of their attack on diversity, equity and inclusion (DEI). Nevertheless, just as TMaH provides a useful framework for action for any state Medicaid agency and partners that seek to improve maternal health, integrating a health equity plan in maternal health transformation efforts can be a powerful strategy for closing access, quality and outcome gaps in any state where specific communities are falling behind – whether because of race, ethnicity, rurality, or other factors.

To support Medicaid programs and partners working to transform maternal health in their state, we developed the following Maternal Health Infrastructure Policy Checklist in parallel with the playbook support for all other model elements.

Develop health equity plan

Rationale and Evidence

• Maternal health in the United States is rife with extreme inequities by race and ethnicity and – though less studied – by such other factors as geography, disability status, income, sexual orientation, and gender identity. Hill, L., Rao, A., Artiga, S., & Ranji, U. (2024, October 25). Racial disparities in maternal and infant health: Current status and efforts to address them. KFF. Retrieved 14 January 2025 from https://www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-in-maternal-and-infant-health-current-status-and-efforts-to-address-them/; Sakala, C., Mackay, E., Hernández-Cancio, S., Gray, V., Coombs, S., & Arora, A. (2023, March). Raising the bar for maternal health equity and excellence: Actionable strategies for Healthcare Systems. Retrieved 14 January 2025 from https://nationalpartnership.org/health-justice/raising-the-bar/report/
• Structural, institutional, and interpersonal racism are known drivers of adverse maternal and infant outcomes.Hailu, E. M., Maddali, S. R., Snowden, J. M., Carmichael, S. L., & Mujahid, M. S. (2022, November). Structural racism and adverse maternal health outcomes: A systematic review. Health and Place, 78. https://doi.org/10.1016/j.healthplace.2022.102923
• Structurally marginalized women have commonly experienced intergenerational trauma, accelerated aging or “weathering,” disrespectful care, and historical and contemporary obstetric harm.Foster, V.-A., Harrison, J. M., Williams, C. R., Asiodu, I. V., Ayala, S., Getrouw-Moore, J., … Jackson, F. M. (2021, October). Reimagining perinatal mental health: An expansive vision for structural change. Health Affairs, 40(10) https://doi.org/10.1377/hlthaff.2021.00805; Riggan, K. A., Gilbert, A. & Allyse, M. A. (2021). Acknowledging and addressing allostatic load in pregnancy care. Journal of Racial and Ethnic Health Disparities, 8 https://doi.org/10.1007/s40615-020-00757-z; Fraser, L. K., Cano-Ibáñez, N., Amezcua-Prieto, C., Khan, K. S., Lamont, R. F., & Jørgensen, J. S. (2024, September 15). Prevalence of obstetric violence in high-income countries: A systematic review of mixed studies and meta-analysis of quantitative studies. Acta Obstetricia et Gynecologica Scandinavica, 104(1) 13–28. https://doi.org/10.1111/aogs.14962

Current State

• Despite increased attention to maternal health inequities in recent years, there has been little to no improvement, and even worsening according to some indicators.
• Concrete, tailored strategies and interventions are needed to achieve progress.
• Comprehensive approaches that impact purchasers, payers, providers, and patients, and hold stakeholders accountable are needed.National Partnership for Women & Families. Comprehensively integrating equity into maternity care alternative payment models. Retrieved 14 January 2025 from https://nationalpartnership.org/wp-content/uploads/maternityAPM-framework-integrating-equity.pdf

Original CMS-Provided Guidance for Pre-Implementation (first three model years, 2025-2027)

Health Equity Plans, at a minimum, should answer the following questions:

• What are the features, obstacles, and demographics of the test region population?
• What is the state of health equity in this region?
• Which health disparities will be addressed?
• What are the health equity goals to be attained in five years?
• What are the health equity goals to be attained in ten years?
• What strategies will you use to overcome obstacles to equitable care?
• How are leaders in the Medicaid program and other relevant organizations held accountable for equitable outcomes?
• Develop and submit a plan to CMS to comply with Non-Emergency Medical Transportation, if needed.
• Develop and submit a plan to CMS to comply with translation requirements, if needed.
• Establish a process for measuring and tracking stratified outcomes in state or sub-state region of interest for conditions with identified disparities.

Policy Checklist

• Review disaggregated maternal-infant data with birth justice leaders and childbearing people from the most adversely affected communities in your area to identify priority action areas and approaches to reduce inequities.Haley, J. M., Dubay, L., & Garrett, B. (2024, August 29). Implementing revised federal race/ethnicity data standards won’t sufficiently address health inequities. Health Affairs. Retrieved 14 January 2025 from https://www.healthaffairs.org/do/10.1377/forefront.20240828.438120/full/
• Include plans for promoting the reliable provision of care that is respectful and unbiased, which may include community-based perinatal health workers.
• With input from representatives and leaders of the most affected communities, identify concrete improvement strategies and performance indicators and set targets.
• Work with your state legislature to enact state-level “Momnibus” packages (see, e.g., legislation in CA, CO, and MA).Prenatal-to-3 Policy Impact Center. (2024, May). State policies to promote equity in healthy perinatal outcomes: A summary of the evidence. Retrieved 14 January 2025 from https://pn3policy.org/wp-content/uploads/2024/05/PN3PIC_EquityinHealthyPerinatalOutcomes.pdf; National Partnership for Women & Families. (2023, May). Raising the bar for moms & babies: Advocate for and invest in maternal health equity. Retrieved 14 January 2025 from https://nationalpartnership.org/wp-content/uploads/rtb-op-guidance-health-plans-advocate-invest.pdf; Rhode Island Department of Health. Health equity zones: A toolkit for building healthy and resilient communities. Retrieved 14 January 2025 from https://health.ri.gov/publications/toolkits/health-equity-zones.pdf; National Academy for State Health Policy. (2021, March 31). Resources for states to address health equity and disparities. Retrieved 15 January 2025 from https://nashp.org/resources-for-states-to-address-health-equity-and-disparities/; Medicaid. (2024, May 14). Maternal & infant health care quality: Promoting maternal health improvement and equity through collaboration. Retrieved 15 January 2025 from https://www.medicaid.gov/medicaid/quality-of-care/quality-improvement-initiatives/maternal-infant-health-care-quality/index.html#2024WebSeries:~:text=Webinar%20%231%3A%20Promoting,to%20address%20outcomes
• Work with stakeholders to diversify the perinatal workforce by demographics and disciplines. National Partnership for Women & Families. (2023, May). Raising the bar for moms & babies: Advocate for and invest in maternal health equity. Retrieved 14 January 2025 from https://nationalpartnership.org/wp-content/uploads/rtb-op-guidance-health-plans-advocate-invest.pdf
• Work with stakeholders to develop executive-level or legislative statewide strategies to coordinate across multiple agencies to address health inequities.
• Ensure that data systems collect and track data disaggregated by race and ethnicity and other dimensions of inequity (see Improve Data Infrastructure in the TMaH Playbook).
• Ensure that payment models integrate equity goals and hold providers accountable for making progress on closing gaps (see Develop Payment Model in the TMaH Playbook).
• Support and engage with community-based organizations and others in the community as a pathway for advancing equity (see Cover Perinatal Health Workers in the TMaH Playbook).

Key Resources

• NGA’s Leading State Approaches and Communications Strategies to Support Health EquityNational Governors Association. Leading state approaches and communication strategies to support health equity. Retrieved 15 January 2025 from https://www.nga.org/publications/leading-state-approaches-and-communication-strategies-to-support-health-equity/
• NASHP’s Resources for States to Address Health Equity and DisparitiesNational Academy for State Health Policy. (2021, March 31). Resources for states to address health equity and disparities. Retrieved 15 January 2025 from https://nashp.org/resources-for-states-to-address-health-equity-and-disparities/
• CMS’s Promoting Maternal Health Improvement and Equity Through CollaborationMedicaid. (2024, May 14). Maternal & infant health care quality: Promoting maternal health improvement and equity through collaboration. Retrieved 15 January 2025 from https://www.medicaid.gov/medicaid/quality-of-care/quality-improvement-initiatives/maternal-infant-health-care-quality/index.html#2024WebSeries:~:text=Webinar%20%231%3A%20Promoting,to%20address%20outcomes
• Prenatal-to-3 Policy Impact Center’s State Policies to Promote Equity in Healthy Perinatal Outcomes: A Summary of the EvidencePrenatal-to-3 Policy Impact Center. (2024, May). State policies to promote equity in healthy perinatal outcomes: A summary of the evidence. Retrieved 14 January 2025 from https://pn3policy.org/wp-content/uploads/2024/05/PN3PIC_EquityinHealthyPerinatalOutcomes.pdf
• NPWF’s Advocate for and Invest in Maternal Health Equity: Operational Guidance for Health PlansNational Partnership for Women & Families. (2023, May). Raising the bar for moms & babies: Advocate for and invest in maternal health equity. Retrieved 14 January 2025 from https://nationalpartnership.org/wp-content/uploads/rtb-op-guidance-health-plans-advocate-invest.pdf
• California Department of Public Health’s State Health Equity Plan: OverviewCalifornia Department of Public Health. State health equity plan. Retrieved 15 January 2025 from https://www.cdph.ca.gov/Programs/CCLHO/CDPH%20Document%20Library/State_Health_Equity%20_Plan.pdf
• Rhode Island Department of Health’s Health Equity Zones: A Toolkit for Building Healthy and Resilient CommunitiesRhode Island Department of Health. Health equity zones: A toolkit for building healthy and resilient communities. Retrieved 14 January 2025 from https://health.ri.gov/publications/toolkits/health-equity-zones.pdf

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