The day she introduced the "Momnibus" in March 2020, Rep. Lauren Underwood, D-Ill., warned of a public health crisis that would not abate unless lawmakers took action: Black birthing parents were dying at unacceptable rates, she said.
"While maternal mortality rates continue to drop around the world, they are rising in the U.S., leaving behind devastated families and children who will never grow up knowing their moms," Underwood said in a statement introducing the Black Maternal Health Momnibus, a legislative package with an unprecedented focus on Black moms.
"This crisis demands urgent attention and serious action to save the lives of Black mothers and all women across the country," Underwood added.
When Underwood made those remarks on Monday, March 9, 2020, she was unaware that in two days, the entire landscape of public health in America would change. By Wednesday night, the World Health Organization had declared covid-19 a pandemic, prompting cities to ban large gatherings, close schools and send many office workers home.
Still, Underwood and other members of the Black Maternal Health Caucus, which was established in 2019 and assembled the wide-ranging Momnibus, kept their eye on maternal care. They continued trying to lobby the 12 bills and weave in maternal health resources within other covid relief packages, Underwood said.
Now, they're celebrating a big first step.
Last Tuesday, nearly 17 months after the Momnibus was unveiled, the first bill from the package was signed into law by President Biden: the Protecting Moms Who Served Act, which puts $15 million into boosting maternity care for military veterans. The bill's co-sponsors included 41 Democrats and two Republicans. (Biden signed three other bills supporting the country's veterans that day.)
Even bigger strides could be on the horizon. The Build Back Better Act, the president's social spending and climate bill, includes many provisions from the Momnibus, including setting up grant programs, establishing research and training programs, as well as expanding and diversifying the perinatal health workforce.
"We were able to get every eligible provision of the Momnibus into Build Back Better," Underwood said. "It just is such great progress."
The Build Back Better Act is in the hands of the Senate, which hopes to bring the legislation to a vote before Christmas - but the path to passage looks to be an uphill battle.
In the United States, maternal and infant mortality rates are far higher than those in other large and wealthy countries. And unlike many other countries, which have lowered these death rates, the U.S. maternal mortality has gotten substantially worse in the past 30 years, according to a September report published by the U.S. Commission on Civil Rights. According to the Centers for Disease Control and Prevention, for every maternal death in the United States, there are almost 100 women who experience "severe maternal morbidity," which can carry significant short- and long-term consequences to their health.
Those rates are even worse for Black and Native American birthing parents: Black women are more than three times more likely to die during pregnancy or postpartum than their White counterparts. They also experience poorer health outcomes during pregnancy and delivery. According to the Population Reference Bureau, Black Americans are also more than 50 percent more likely to deliver a premature baby than White Americans.
Only in the past several years have media outlets and lawmakers paid substantial attention to the issue. In April 2019, Reps. Underwood and Alma Adams, D-N.C., founded the Black Maternal Health Caucus to help tackle the problem at the federal level. (Vice President Kamala Harris also champions the issue: As a U.S. senator representing California, Harris introduced the Momnibus to the Senate in March 2020.)
This legislative focus on maternal health "hasn't been done before," said Judith Solomon, a senior fellow at the Center on Budget and Policy Priorities, a left-leaning think tank that analyzes federal and state government budget policies.
The approach spearheaded by the Momnibus and its leaders is also noteworthy, Solomon said: "The members that are leading this really focus on whole people, and all the factors that contribute to health, not just health coverage. This is so important."
Still, the potentially most impactful change for Black birthing parents within Biden's landmark spending bill wasn't part of the Momnibus, Solomon said: It is the Build Back Better Act's Medicaid expansion.
Medicaid - federal and state-subsidized health care for low-income Americans - covers a large share of births in the United States: more than 40% in 2017, according to the CDC. This rate is even higher for Black birthing parents, at 68%. The program plays an even more pronounced role in poorer states, such as Mississippi and New Mexico, where Medicaid funded 67 and 71 percent of births in recent years, according to the Kaiser Family Foundation.
Build Back Better would "close the coverage gap" in states that have refused to adopt the Affordable Care Act's Medicaid expansion, opening up a greater array of health-care options to Black women, Solomon wrote in a CPBB blog post earlier this year.
While people are eligible for Medicaid once they become pregnant, they are shut out of vital preconception coverage, Solomon said. Being uninsured before pregnancy has been linked to worse health outcomes, such as pre-term births and low birth weights among infants, she explained, and uninsured people may delay prenatal care until after they apply for and enroll in Medicaid. For some, this could mean not getting prenatal care until early in the second trimester.
Build Back Better would also expand coverage up to a year postpartum. While 17 percent of maternal deaths occur the day of delivery, 12 percent happen between six weeks and one year after birth (basic Medicaid cuts off 60 days after birth).
Underwood agrees: "Medicaid is critically important," she said. "The postpartum Medicaid expansion, in my view, is the single most important thing that we can do to save mom's lives in this country."
But, she added, it isn't enough to address the Black maternal health crisis.
This is because disparities in maternal death cuts across factors like income, education and health-care coverage, Underwood said. She believes that saving Black birthing parents requires a multifaceted, "comprehensive" approach.
This has been especially true during the pandemic, she added, citing a CDC report that found pregnant Black and Hispanic people who caught the coronavirus were more likely to get severe covid infections during their pregnancy. (Some health experts say covid-19 may be here to stay, even with vaccinations.)
The Momnibus provisions, as well as Medicaid expansion, have to be approved by the Senate, which has been divided along partisan lines about the $2 trillion cost of the package, amid larger concerns about aligning with the Democratic president (no House Republicans voted for the bill). Although Underwood has emphasized the bipartisan support for the Momnibus bills, Solomon is more cautious.
"I don't see very much happening on the bipartisan level," she said. The success of the Momnibus will depend on the bigger packages it is included in - such as last week's veterans bills and Biden's spending plans.
Still, Underwood said, she could feel the momentum finally shifting for Black maternal health care in Congress: "This is a really special moment."