Introduction and summary
The COVID-19 pandemic and economic crisis have shone a light on some of the most underinvested and unstable sectors of American life. For children born during the past two years, the stress their new parents have faced is different from that seen for decades; and the financial, professional, and health inequities among marginalized and underserved communities have become even greater. Supporting the next generation begins with supporting the current one. Healthy babies start with healthy parents, families, and communities.1
While the tendency is often to focus on the physical and medical aspects of pregnancy, it is the interplay and overlap of a suite of social determinants that ultimately shape the health of the pregnancy, delivery, and subsequent well-being of the child, mother, and overall family. Therefore, it is vital to account not only for medical care but also for employment stability, nutrition, education, disability services, public health screenings, and healthy environments in order to shape interventions that support children and families. Moreover, protecting against trauma and the impacts of climate change while also ensuring financial security and access to education is critical for health and well-being during pregnancy.
Supporting the next generation begins with supporting the current one. Healthy babies start with healthy parents, families, and communities.
This report takes a holistic view of perinatal health and, as people progress through different stages of development, puts it in context as a developmental precursor to later indicators of wellness, including birth outcomes, postpartum wellness, and subsequent child development.
The five domains of social determinants of health and well-being serve as the framework for this report:
- Health care: access to quality health care, maternal health coverage, and reproductive health
- Neighborhood and physical environment: neighborhood health and safety, housing insecurity, environmental pollution and climate change, and barriers to services during the pandemic
- Education: social support services that provide information and resources
- Economic stability: employment status, poverty status, food insecurity, and supportive policies such as paid family and medical leave
- Social and community context: considerations of discrimination related to race, disability status, gender identity, incarceration status, and community violence
The Center for American Progress’ work prioritizes social and economic policies that are critical across the social determinants of health to achieve health equity.
The COVID-19 pandemic has revealed fissures in many of the core support systems in the United States, and though it has had broad impacts on health and well-being during pregnancy, it has wielded its influence inequitably across communities. Pregnant women of color, in particular, face increased risk of getting sick because of many different health inequities, including their increased likelihood of living in areas of high case concentration or with low levels of vaccination and of living or working in environments that make it difficult to social distance.2
The pandemic also prompted changes to perinatal care policies, as hospitals were overwhelmed with patients infected with COVID-19 and faced increased barriers to providing obstetric services. In particular, the ability of physicians to provide patient-centered care was heavily affected, and physicians surveyed about changes to perinatal care experiences noted that reactive health care policies, such as not allowing support people to accompany their loved ones during delivery and immediately postpartum, may have long-term unintended negative consequences for patients and infants.3 Many new parents, before and after the birth of their child, relied on prenatal telemedicine to receive care without undue exposure to COVID-19. However, this route also presented challenges, including issues with broadband access or connectivity, accessibility barriers for disabled people, child care responsibilities for older children, and lack of privacy during telemedicine calls.4
For many places in this country, access to health care coverage is a significant barrier. Medicaid, for example, provides health care coverage to almost 80 million people, nearly 30 million of whom are children,5 and is the single-largest financial provider of perinatal care, accounting for 43 percent of births in the United States—and almost 60 percent in rural areas.6 All states are required under federal law to cover pregnancy-related services for individuals making up to 133 percent of the federal poverty level (FPL), which amounts to an average of less than $40,000 per year for a family of four,7 throughout pregnancy and for up to around 60 days postpartum.
However, beyond that, states can determine additional eligibility pathways and the scope of maternity care benefits; and while most states have either expanded the scope of pregnancy-related services to meet the Centers for Medicare and Medicaid Services’ minimum essential coverage standards or made pregnant women eligible for full-scope Medicaid coverage, a small number of states have elected not to do so. What is more, women who gain Medicaid coverage due to being pregnant can lose that coverage about 60 days after they give birth, resulting in inadequate or altogether absent postpartum care and, as a result, an increased risk of both mortality and morbidity during the postpartum period.
Additionally, a large swath of people continues to struggle to find affordable coverage during pregnancy and the critical postpartum period because they do not have access to employer-sponsored health care but their earnings are too high to qualify for Medicaid or other marketplace insurance subsidies. Births are incredibly expensive in the United States: The average vaginal birth costs more than $15,000, and a surgical cesarean section (C-section) can cost more than $20,000.8
The perinatal insurance churn
Continuity of insurance coverage to offset these costs is often a challenge for low-income women, who may move between different insurance plans or fluctuate between having and losing insurance coverage because of changes to employment, income level, or marital status—known as the “perinatal insurance churn.”9
Medicaid expansion is a critical tool for ensuring access to and continuity of coverage by protecting the ability for low-income families to afford health services. Additionally, the American Rescue Plan (ARP) Act of 202110 includes a provision that gives states the option to extend Medicaid coverage to 12 months postpartum rather than the usual 60 days.11 This option became available in April 2022 and expires in five years. In states that have not expanded Medicaid or have not elected to extend postpartum coverage, many families continue to face coverage losses and perinatal insurance churn.
In many other areas, including rural America, access to physical health infrastructure is a primary barrier. More than 100 rural hospitals have closed, predominantly in the South and in non-expansion states, largely because of financial instability: too few insured patients, large tabs of unpaid care, and broader community poverty.12 These closures further weaken the quality of care that people receive during and after pregnancy by reducing capacity, which compounds issues of access to routine prenatal checkups and later labor and delivery services that can negatively affect infant and maternal health outcomes.13 Moreover, these issues are exacerbated by sparsity in the availability of maternal-fetal medicine, leading to areas with too few accessible care providers to meet demand, known as “maternity care deserts,”14 which are common in rural areas.15 Among pregnant disabled women, these issues of access are all the greater. A lack of accessible physical infrastructure, particularly in rural areas, makes it difficult to access accommodating care facilities or travel to find a facility that can provide maternal-fetal care.16
While many states have at least 10 clinicians who can provide obstetric care, some deserts necessitate a three- to six-hour commute to see a provider, and for some, the closest may be in a neighboring state, which presents challenges for pregnant women who have state-funded insurance coverage.17
Reproductive health care
Access to reproductive health services, such as contraceptives, is key to family planning decisions. Contraceptive access varies by social and geographic factors but is universally recognized as a critical component of family planning linked to improved birth outcomes, reductions in pregnancy-related morbidity and mortality, and reductions in the risk of developing some types of reproductive cancers.18 It is sometimes even used for noncontraceptive reasons, such as to treat menstrual-related symptoms or disorders. Family planning clinics, where people can obtain contraceptive care, often also offer screenings and treatment for communicable diseases and cancers, as well as resources for victims of domestic partner violence.19
The proportion of births in the United States covered by Medicaid
For women who do become pregnant, the ability to exercise bodily autonomy and make choices about their own physical and financial futures is fundamental. Access to abortion care is foundational to reproductive rights,20 yet much of the public rhetoric around the issue obfuscates the extent to which it is related to broader health outcomes and overall well-being. States with stricter access to abortion tend to have relatively poorer maternal health outcomes—in part because people with chronic health conditions or illnesses that are exacerbated by pregnancy may be unable to obtain needed abortion care and are instead forced to continue a pregnancy that puts their health and life at risk.21
Neighborhood and physical environment
The pandemic resulted in enormous upheaval on top of the challenges of pregnancy itself.22 In particular, disruptions to hospital services and policies around the provision of health services, in addition to the stress of avoiding infection and balancing economic, social, and occupational demands, have created significant challenges for pregnant women and their families in the past three years. Moreover, these risk factors disproportionately affect parents from marginalized communities and individuals who experienced disruptions in their housing stability. Housing insecurity is associated with poor birth outcomes, including low birth weight and preterm birth, and pregnant people living in shelters are almost twice as likely as those in secure, private housing to face pregnancy and delivery complications.23
Environmental impacts are strongly linked with reproductive health and infant well-being. Communities of color are significantly more likely to live near areas of greater environmental pollution and to experience the ill effects of climate change, which contribute to increases in rates of cancer, asthma, neurological conditions, cardiac conditions, and other serious health issues that negatively affect well-being.24 Areas that face the greatest risk of near-term climate risks will also exert a negative influence on prenatal and maternal health through increased risk of preterm birth, low birth weight, pregnancy complications, and maternal mental health conditions.25
There is a significant need for sustained funding for initiatives that support key social determinants of health and well-being that can mitigate the negative consequences of this kind of upheaval and that support pregnant women and their families through vulnerable times. These initiatives, in addition to the critical services they provide to children and families, also create educational opportunities that shape long-term family well-being.
For families, education has compounding benefits over time. Access to critical educational resources helps promote healthy fetal and child development, supports families’ economic security through access to jobs with higher pay and more comprehensive benefits or additional education and training, and sustains better health over time.26
Parents’ levels of education—particularly maternal education—are known to have intergenerational returns, shaping economic security and adult earnings as well as the financial investments that parents make in their children.27 The association between maternal education and children’s early educational experiences is significant in the United States, affecting children’s enrollment in early education programs and even the likelihood of them participating in literacy-based activities with family at home. Notably, the role of maternal education in children’s educational experiences in the United States is much larger than it is in peer nations such as the United Kingdom, Ireland, and Australia, mainly because America invests comparatively less in its families.28
Programmatic educational resources
An additional dimension of education is health education and health literacy. This is one aspect of the significant role that social support programs play in families’ lives—particularly families with low incomes. Many social support programs, including the Maternal, Infant, Early Childhood Home Visiting (MIECHV) Program and the Special Supplemental Nutrition Assistance Program for Women Infants and Children (WIC), provide services to expand education and access to resources for expecting families.
Federally funded programs such as these are built around the goal of promoting maternal, infant, and early childhood health and development and often connect families to needed community support.29 WIC, for example, offers informational resources about nutrition and breastfeeding and even connects families with the Affordable Connectivity Program, which offers financial discounts toward internet services for low-income households.30 Other critical services—such as access to birth centers, midwives, doulas, and lactation experts who provide resources and guidance—are likewise associated with healthy pregnancies and deliveries.31 When pregnant women can access these sources and specialists, they benefit from a reduction in the risk of preterm birth, low birth weight, birth complications, neonatal loss, surgical intervention, and maternal physical and mental health complications.32
Using social support programs as an avenue for disseminating key health information and resources to families who otherwise lack access is critical for supporting parents and their children. It is also important to note the critical role that social support programs play in promoting parents’ access to more stable work, higher education, and training or certification programs that help to promote their long-term earnings and economic security.
Nearly 1 in 10 Americans live in poverty, with women—especially women of color and disabled women —as well as LGBTQI+ people being more likely to live in poverty, which itself is associated with health status.33 Recent research finds that when families with low incomes are given income supplements, through programs such as Temporary Assistance for Needy Families (TANF), the child tax credit (CTC), and the earned income tax credit (EITC), their young infants see measurable neurological benefits within the first years of early development.34
Food insecurity, experienced by more than 10 percent of families across the country and particularly by those living in poverty,35 is known to lead to a host of health risks outside of pregnancy, including obesity, diabetes, and mental health conditions.36 Food security is not typically included as part of prenatal wellness checks in routine obstetrical care, and so, the risks during pregnancy are less well-documented.37
This is particularly concerning given that the cumulative impact of good nutrition begins during the earliest stages of embryonic development, and poor nutrition is a significant risk factor for poor maternal health that can adversely affect the well-being of the pregnancy. Notably, marginalized communities, including people with disabilities, experience food insecurity at high rates: In 2020, disabled people faced food insecurity at more than double the rate of nondisabled people.38 In a recent study in North Carolina, researchers found that the percentage of a county reporting food insecurity, the percentage of a county reporting other kinds of adverse health risks such as obesity, and county population were all predictive of county-level infant mortality rates.39
Families’ lack of economic security is also felt most deeply along race and gender lines: Black women, who have higher labor force participation rates than the overall population but typically work in lower-paying jobs or with limited benefits, still make up a disproportionate share of family breadwinners in the United States.40 Disruptions in employment are negatively associated with perinatal health and well-being—for example, by making it harder to attend doctors’ visits and manage caretaking responsibilities—and therefore have a disproportionate effect on women of color.41 In fact, Black women have reported higher rates of employment disruption due to the pandemic.42 Because women of color are perpetually underpaid for their work, they are less able to build savings, achieve sustained financial stability, and withstand economic downturns such as that caused by the pandemic.43
Without these critical supports for women—through their jobs or other economic or social safety nets—the negative impacts on the health and well-being of their pregnancies can be significant.
In addition, and related to concerns about health, housing, and food security, perinatal health is affected by employment status and access to other necessary benefits. For instance, only 20 percent of private sector workers had access to paid family leave during the first year of the pandemic.44 Federal and state paid family and medical leave (PFML) is critical for new parents caring for their infants. While the Family and Medical Leave Act (FMLA) of 1993 guarantees workers 12 weeks of leave from work,45 just 15 percent of workers take any PFML each year, and the time they do take can be unpaid depending on the stipulations made by the employer. Moreover, 4 in 5 private sector workers are still not afforded any kind of paid leave, and disparities in access often fall along racial and ethnic lines, leaving slightly more than 40 percent of Black workers and just one-quarter of Latino workers with any kind of paid parental leave.46 At a time when families are experiencing significant economic upheaval, paid support is critical to reducing and preventing poverty and ensuring stability for a new family.47
Many working parents—particularly low-income women, single parents, and women of color—simply cannot afford to go without earnings, despite having some of the highest labor force participation rates.48 For instance, more than 60 percent of leaves needed by Black women are either forgone or are taken without pay.49 This disproportionately burdens women—especially women of color—with economic insecurity that can last for generations. And the persistent wage gap only compounds their economic hardship, leaving women at a significant disadvantage despite the fact that their families are often relying on their incomes to make ends meet.50 Moreover, only slightly more than half (58 percent) of working women are included in the calculations made to determine the gravity of the gender wage gap: Women who may work part time or part year are often excluded, which inflates the value on the dollar that women appear to make relative to their white male counterparts.51 On average, full-time, year-round working women lose a combined $1.6 trillion in annual earnings.52
The gender wage gap can be attributed to many multifaceted factors. This includes occupational segregation, which leaves women of color and other marginalized individuals disproportionately in jobs with low pay and poor benefits—a stark reality for many working families.53 This segregation, as well as the tendency for people of color to have worked on the front lines during the pandemic,54 has exacerbated the risk that pregnant women from marginalized communities face and coincides with higher rates of infant mortality in this population.
PFML secures parents the time they need to bond with their new infants, increases their flexibility to attend all necessary postpartum checkups, and reduces the risk of hospital admissions or poor health outcomes for themselves and their babies.55 Going without leave or experiencing increases in economic instability because of the need to take leave without pay escalates the risk of these adverse outcomes.
Abortion and economic security
On June 24, 2022, the Supreme Court released its decision in Dobbs v. Jackson Women’s Health Organization, overturning Roe v. Wade, which protected the constitutional right to abortion for nearly 50 years.56 States now have the authority to decide the extent to which abortion care is accessible, and many states have already banned abortion altogether or are imposing significant restrictions on access.
Not only do abortion bans affect health and well-being, but as discussed throughout this report, they also have a pronounced effect on economic security. As women across the country face increasingly restrictive state laws that limit their access to this fundamental health care, congressional leaders, policymakers, and advocates continue to fight for bodily autonomy and to secure protections for other constitutional rights rooted in privacy, including the right to contraception (Griswold v. Connecticut), same-sex relationships (Lawrence v. Texas), and same-sex marriage (Obergefell v. Hodges).57
The cost of an abortion or other critical reproductive health services can be significant and can have long-term impacts on other elements of a person’s well-being, including their ability to afford safe and reliable housing, food, and other necessities. Almost 1 in 6 pregnant workers are employed in low-wage jobs, which often are more physically demanding, introduce risk of exposure to disease or injury, and have less flexible schedules and limited benefits.58 Moreover, it is marginalized communities who feel these burdens most deeply. This includes pregnant women who live in poverty, pregnant women of color, and people who live in poverty and/or are disabled, live in rural areas, have been incarcerated, or identify as LGBTQI+.
The consequences of overturning Roe will reach everyone. But they will render its effect unequally, mirroring the systemic inequities in U.S. society, and the economic and societal impacts of this decision will be cascading and intergenerational.
Enabling families to make choices about their own family planning and supporting those choices through progressive reproductive policy and responsive employer coverage helps families to retain economic power. These investments in parents’ careers can boost their earning potential and reduce the financial burden of having and raising multiple children.59
Enabling families to make choices about their own family planning and supporting those choices through progressive reproductive policy and responsive employer coverage helps families to retain economic power.
Social and community context
Social and community-level conditions—such as poverty status, race and ethnicity, incarceration status, disability status, gender identity, and the physical environment in which women live, work, and give birth—shape parents’ health and well-being during and after pregnancy.
Broader community factors concerning the physical environment—in particular, safety—continue to affect the health and well-being of pregnant women and infants. For example, living in neighborhoods with higher rates of gun violence or intimate partner violence (IPV) negatively affects the mental and physical well-being of inhabitants, particularly during pregnancy, for whom social and economic stability is particularly critical.60 Women, who are already disproportionately victims of IPV,61 face even greater risk of IPV during pregnancy; indeed, research has found that rates can climb as high as 20 percent during pregnancy.62 Moreover, gun prevalence in a community has shown some association with rates of IPV—though there are some confounds in the variability at state and regional levels, as states with higher prevalence of firearms also have higher rates of firearm-related IPV.63
At the start of the coronavirus pandemic, as sweeping stay-at-home policies were adopted and women were forced to socially isolate with potentially abusive partners, these rates only worsened throughout the United States.64 Creating environments that help ensure not only the psychological well-being but also the physical safety of individuals before, during, and after pregnancy can set the stage for a successful pregnancy, safe delivery, and healthy infant.
Women of color, in particular, suffer from less economic security due to a larger gender wage gap and relatively less access to benefits such as paid family and medical leave, all while they grapple with the trauma of systemic racism, which is known to undermine their health65 and the health of their infants.66 The criminal justice system serves as perhaps the clearest example of the impact that systemic racism has on historically marginalized communities: Black adults are almost five times as likely to be incarcerated as their white counterparts, and they are twice as likely to have a family member imprisoned.67 The effects of incarceration range from potential loss of income and increased housing and food insecurity to greater risk of sexual violence and significant emotional distress to, though not studied directly, increases in infant mortality.
Research has made clear that racism and discrimination—which show up in everything from interpersonal interactions to overarching institutions and structures and which manifest across various social, economic, and physical domains—can create pervasive, chronic stress for Black and Latino people. This affects not only individual health but also the health of a pregnancy.68 “Weathering”—a term that describes the cumulative effects of racism and discrimination on a person’s physical health, often leading to early health deterioration—can explain some of the higher rates of illness and chronic disease among Black Americans.69 Researchers often adopt this “weathering framework” to describe the intersectional nature of racism, stigma, and the various other social determinants of health that influence the development of disease and increase the risk of mortality among marginalized communities.70
Likewise, disabled people, who are twice as likely as their nondisabled counterparts to face food insecurity71 and who already face enormous discrimination regarding reproductive health access and overall bodily autonomy,72 are another vulnerable community deeply affected by inequitable social determinants of health. For example, access to reproductive rights continues to be riddled with barriers for disabled women. A long history of eugenics, forced sterilization, guardianship, and sexual violence reinforces feelings of distrust among members of the disability community toward the medical community, which further impedes comprehensive research and data collection on the cross-section of race, gender, and disability status in reproductive policy.73 Transgender and nonbinary individuals face similar issues: A long history of discrimination, lack of understanding, and continued misgendering by health professionals, coupled with a tendency to “de-sexualize” the community, contributes to persistent barriers to reproductive health services.74
Perinatal SDOH and wellness in context: Policy and legislative priorities
A vast network of social support programs cross the five social determinant areas and intersect with one another in critical ways. Bringing together a range of policies that help address the trauma of racism, secure housing and nutritious food, enhance insurance coverage and access to key health services, expand family planning options, and promote economic and community stability is key to ensuring a healthy populace to raise the next generation.
Several of the policies and programs listed above are coming up for legislative reauthorization. For example, the Supplemental Nutrition Assistance Program (SNAP), which was last reauthorized in the 2018 Farm Bill, is reauthorized every five years and will expire at the end of September 2023.75 Meanwhile, MIECHV, which extends home-visiting services to low-income families, connecting them with needed resources, is due for reauthorization in September 2022.76
Providing the necessary congressional reauthorization and funding for the operation of these programs and the others illustrated in Table 1 has wide-ranging benefits across multiple facets of the social determinants. The funds are ultimately an investment in the overarching health and well-being of entire communities, starting as early as the perinatal period.
Regardless of income, background, or ZIP code, the interplay between the different social determinants of health exerts significant influence over the health and well-being of pregnancies and families. There is no shortage of empirical and policy research supporting the connection between prenatal health and well-being as well as a host of social, fiscal, and developmental outcomes for children and families. State and federal economic policies that fund programs to address social determinants reduce adverse perinatal and infant health outcomes,77 and Congress has taken steps to enhance maternal and infant health, including the Black Maternal Health Momnibus Act of 2021 (H.R. 959),78 expansions to Medicaid through the full postpartum period, and enhancements to network coverage and adequacy to ensure that pregnant women can find and obtain high-quality services.
It will take all of these efforts and more to break down the silos between different care initiatives and to ensure that people and their families can receive the care and support research has shown will be most meaningful for their health, the health of their pregnancy, and the developmental well-being of their children.
The authors would like to thank Rasheed Malik, Jill Rosenthal, Emily DiMatteo, Mia Ives-Rublee, Mara Rudman, and Jesse O’Connell for their invaluable guidance and feedback on this report.