What was announced
On September 10, 2026, Olivia and Tom Walton committed an initial $100 million over five years to Healthy Moms Healthy Babies America (HMHBA), a program housed within Heartland Forward’s Maternal and Child Health Center for Policy and Practice, with Neel Shah as president and Robin Reck as executive director.
The stated goal is to cut the US maternal mortality rate in half within five years.
The money is described as catalytic capital for state matching grants, “high-impact partnerships,” and infrastructure, with four pillars:
prenatal care (virtual care, community health workers, doulas, midwives),
“protecting maternity units as more units close,”
a first year of family support (postpartum home visits, mental health screening, paid leave), and
better data (2,3).
On closures the language is careful.
The press release says hospitals “are closing obstetric units at an accelerating pace,” and the Call to Action says “hundreds of U.S. hospitals, disproportionately in rural communities, have closed maternity wards,” attributing this to liability cost and workforce shortage and stating that families “must travel farther,” disrupting continuity of care. Neither document states that closures caused the rise in maternal deaths; the causal inference is left to the reader, and the press coverage has supplied it (2,3). On midwives, the Call to Action cites the Lancet Global Health modelling estimate that midwifery could avert 41% of maternal deaths, and on doulas it cites a 52.9% reduction in cesarean odds and 57.5% reduction in postpartum depression or anxiety (3). Each of these claims is examined below against the primary literature.
The baseline matters for a “halve it” target. NCHS reports 649 maternal deaths in 2024, a rate of 17.9 per 100,000 live births, not significantly different from 18.6 in 2023; the non-Hispanic Black rate was 44.8, the non-Hispanic White rate 14.2, the Hispanic rate 12.1, and the rate at age 40 and over 62.3 (1). HMHBA’s own website uses a pooled 2019–2023 figure of 23.5, which includes the pandemic years. Halving 17.9 means roughly 9 per 100,000 by 2031; halving 23.5 means roughly 12, a number the country is arguably within measurement error of already. Which baseline is chosen will determine whether the program is later judged a success.
Claim 1: obstetric unit closures drive maternal mortality
The closures are real and well counted. Among 4,964 short-term acute-care hospitals, the share without obstetric services rose from 35.2% in 2010 to 42.4% in 2022; 537 hospitals lost obstetric care (238 rural, 299 urban) and 138 added it (5). Kozhimannil’s original rural analysis found that 179 rural counties lost hospital obstetric services between 2004 and 2014 (4). March of Dimes counts 96 labor and delivery closures across 35 states from January 2024 to May 2026, 58% of them the county’s sole birthing facility, and estimates 1,113 counties (34.6%) as maternity care deserts (6). None of this is in dispute.
What is in dispute is the outcome. No quasi-experimental study of closures in the United States has demonstrated an effect on maternal death. The closure literature measures place of birth, travel time, prenatal visit counts, preterm birth and, less often, maternal morbidity, and the results are summarized in the table below.
The only positive severe morbidity signal comes from New Jersey, a largely urban and suburban setting (10). The most rigorous rural analysis, covering 605 closures over three decades, found maternal morbidity slightly better after closure, which the authors attribute to women delivering at higher-volume, higher-quality hospitals (7). That interpretation is consistent with the volume literature: among low-risk women, delivery at rural hospitals with 10 to 110 births a year carried an adjusted SMM risk ratio of 1.65 compared with rural hospitals above 460 births (14). Keeping the smallest units open is therefore not self-evidently protective; it may trade one risk for another.
The mortality signal that advocacy documents cite comes from cross-sectional comparisons of places, not from closures. Atwani and colleagues, using county-level data on 14.8 million births from 2018 to 2021, found a maternal mortality rate of 32.25 per 100,000 in desert counties versus 23.62 in full-access counties (adjusted incidence rate ratio 1.36, 95% CI 1.21–1.54), with no difference for low- or moderate-access counties (12). In Louisiana, desert residence carried an adjusted relative risk of 3.37 for pregnancy-related mortality on 112 deaths (13). Driving distance to the delivery hospital in Pennsylvania was associated with a composite of transfusion, ICU admission and hysterectomy (aRR 1.53 at 80 km), but the authors themselves ask whether distance is a cause or “simply a marker of social deprivation” (11). Desert counties are poorer, sicker, more rural and more often in the South; the same counties had high maternal mortality before their units closed.
The honest summary is this: closures worsen access, lengthen travel by about 14 to 25 minutes on average, push a small fraction of births out of hospital, and in rural counties may modestly increase preterm birth (4,6). There is no evidence that they have contributed measurably to the national maternal mortality rate, and the best-designed study could not detect an effect because maternal death in closure counties is too rare to study. Any statement that closures are “responsible for” US maternal mortality outruns the data. The more defensible claim is that they are a threat to timely care in specific communities, which is a legitimate reason to fund rural obstetric readiness and transfer systems, but not a mechanism that will halve the national rate.
Claim 2: more midwives and doulas will reduce maternal deaths
This claim rests on three literatures, none of which measures maternal mortality in a high-income country.
The 2024 Cochrane review of midwife continuity models pooled 17 randomized trials with 18,533 women in Australia, Canada, China, Ireland and the United Kingdom (no US trial). It found moderate-certainty increases in spontaneous vaginal birth (RR 1.05) and reductions in cesarean (RR 0.91) and regional analgesia; the 2016 review’s apparent reductions in preterm birth and fetal loss did not persist in the update (preterm RR 0.95, 95% CI 0.78–1.16; neonatal death RR 0.85, 0.43–1.71, low certainty). Maternal death was a prespecified outcome: no deaths occurred in the three trials reporting it, so the effect is unestimable rather than null (15). The 2017 Cochrane review of continuous labor support (27 trials, 15,858 women) found a cesarean RR of 0.75 and better birth experience; maternal mortality does not appear among its outcomes (16).
The US doula evidence is observational Medicaid claims work. The Minnesota comparison behind the original cost argument found cesarean 22.3% versus 31.5% (17). The eClinicalMedicine study cited by HMHBA compared 298 propensity-matched pairs across three states and reported cesarean OR 0.47 and postpartum depression or anxiety OR 0.43; it did not report maternal death or severe morbidity (18). The 2024 follow-up on 722 matched pairs found lower cesarean and preterm rates and more postpartum visits, but no difference in emergency visits, admissions, depression or severe maternal morbidity within 30 days, and the authors state they “did not evaluate maternal mortality, because we lacked statistical power” (19). A 2026 systematic review of midwifery and doula care specifically for Black women located 16 studies and concluded the literature “remains severely limited”; none reported mortality or SMM (58). Both the Elevance studies were authored by the insurer that funds the benefit, and propensity matching cannot remove the selection of motivated, engaged women into doula programs.
The “41% of maternal deaths” figure is a Lives Saved Tool model of 88 low- and middle-income countries that together account for 98% of the world’s maternal deaths. It estimates what would happen if midwife-deliverable interventions (uterotonics, antibiotics, antihypertensives, skilled attendance) were scaled from current low coverage; the authors describe the results as “indicative and directional rather than exact.” No high-income country is modelled, and the interventions being credited are already nearly universal in US hospitals (20). Citing this number for the United States is a category error.
Ecological comparisons are the remaining support. The Commonwealth Fund notes the United States has about 4 midwives and 12 obstetrician-gynecologists per 1,000 live births against 61 and 13 in the United Kingdom and 81 and 5 in Sweden (23). Vedam’s state integration index correlated with vaginal birth, breastfeeding and neonatal outcomes, not maternal mortality (21). But the country with the most midwife-led system in Europe, the United Kingdom, reports a maternal mortality rate of 12.80 per 100,000 maternities for 2022–2024, described by MBRRACE as roughly 20% higher than in 2009–2011 and rising (25). The Netherlands, the archetype of community midwifery, had a confidential-enquiry rate of 12.1 in 1993–2005 that fell to 6.2 in 2006–2018 while home birth declined and hospital care was reorganized (26). Nothing in either series attributes change in mortality to midwifery workforce size.
Midwives and doulas have a solid evidence base for what they do: fewer cesareans, fewer instrumental births, less regional analgesia, better experience, and, for doulas in Medicaid populations, plausibly fewer preterm births. These are worthwhile ends and they may reduce the morbidity that follows surgery.
But a program that promises to halve maternal deaths and then invests in workforce categories whose trials have never recorded a maternal death is promising an outcome the intervention has not been shown to deliver.
The one caveat on the other side is that a US planned home birth attended by a midwife carries a roughly threefold higher neonatal mortality than hospital birth (22); “more midwives” is only safe as “more midwives in integrated hospital and birth-center systems.”
The European comparison: how much of the gap is real
The claim that US mortality is “more than double” or “three times” the European rate rests on comparing the US vital-statistics number with OECD civil-registration counts for Europe. Both sides of that comparison are biased, in opposite directions.
On the European side, Euro-Peristat declines to publish routine maternal mortality at all because certificate data are “unreliable.” The eight-country enhanced-surveillance study in the BMJ found that vital statistics “underestimated maternal mortality by 36% or more in all countries except Denmark,” and produced rates per 100,000 live births of 2.7 in Norway, 3.4 in Denmark, 4.3 in Finland, 5.3 in the Netherlands, 6.3 in Italy, 8.0 in France, 9.6 in the United Kingdom and 10.9 in Slovakia (24). Germany, which has no confidential enquiry, reports 3.5 through Destatis, but a certificate-by-certificate review in Berlin found 7.8 to 9.1, “over double the official estimate” (27). The Dutch audit figure of 6.2 is more than double the OECD figure of 2.8 used in the Commonwealth Fund exhibit (23,26).
On the US side, the pregnancy checkbox inflates the count. NCHS’s own linkage found that in 2014 and 2016 more than half of certificates with a positive checkbox had no pregnancy-related hospitalization, and that if the checkbox were ignored entirely the 2018 rate would have been 8.7 rather than 17.4 (28). Rossen and colleagues attributed 9.6 deaths per 100,000 to the checkbox and found no significant trend once it was removed (29). Joseph and colleagues showed that when pregnancy must appear among the recorded causes of death rather than only on the checkbox, the rate is 10.2 in 1999–2002 and 10.4 in 2018–2021, with no increase; their bias-corrected sensitivity estimate is about 16 to 17 in both periods (30). Declercq and Thoma found that for the same 42-day window, NCHS runs 44% to 63% above the CDC Pregnancy Mortality Surveillance System (31). The rebuttal from Janevic, Declercq and Howell is that the checkbox also has false negatives: 62% of decedents with a pregnancy hospitalization in the prior year were not flagged, and New York’s review committee identified 386 potential deaths of which only 129 were identifiable from certificates alone (32). Both positions have merit; the debate is about the size of the correction, not whether one is needed.
A like-for-like comparison therefore places the United States at roughly 16 to 18 per 100,000 against 13 in the United Kingdom, 8 to 9 in France and Germany, 6 in the Netherlands and 3 to 4 in Scandinavia. The gap is real, but it is a factor of 1.3 to 3, not 5 to 10, and the “two-thirds lower” figure that HMHBA and others use is an artefact of comparing a checkbox-inflated numerator with under-ascertained European ones. One consequence for the Waltons’ target deserves saying plainly: if NCHS ever adopts Joseph’s multiple-cause criterion, the national rate will “halve” on paper without a single death prevented, and if states finish building enhanced surveillance, the rate will rise. A program that promises a 50% fall measured by a statistic this unstable has set itself a target that measurement changes can meet or defeat.
What is not an artefact is the Black rate. At 44.8 per 100,000 in 2024, it exceeds every European figure under any method, and the composition of US deaths differs from Europe’s. In the 36-state review committee data for 2017–2019, mental health conditions accounted for 22.7% of pregnancy-related deaths, hemorrhage 13.7%, cardiac conditions 12.8%, infection 9.2%, thrombotic embolism 8.7% and cardiomyopathy 8.5%, with 84% judged preventable and 30% occurring between 43 and 365 days (33). France and the United Kingdom are dominated by cardiac disease, thrombosis and suicide; hemorrhage and infection deaths of the kind that safety bundles address have largely been driven out. Outside the WHO definition altogether, US pregnancy-associated homicide (3.62 per 100,000 live births, exceeding every leading obstetric cause) and overdose (11.85 per 100,000 in 2020, rising to 13.0 by 2023) have no European counterpart at that scale (34,35,36). The US excess is real, but a substantial part of it is not obstetric.
What reduces maternal mortality among Black women
The disparity is not explained by education or income. In the 2007–2016 pregnancy mortality data, Black women with a college degree or higher had a ratio of 40.2 per 100,000 against 7.8 for White women with the same education, a 5.2-fold difference, and higher than White women who had not finished high school (25.0) (37). The ratio widens with age, from 1.5 under 20 to 4.3 at 30–34, consistent with cumulative physiological burden. The leading causes among Black women are cardiac and coronary conditions (15.9%), cardiomyopathy (13.9%), thrombotic embolism (11.9%) and hypertensive disorders (9.9%); more than half of cardiomyopathy deaths in the 32-state review were among non-Hispanic Black women, and more than three quarters were judged preventable (33,41).
A large part of the disparity is located in which hospital a woman delivers in. In New York City, 65% of White deliveries but 23% of Black deliveries occurred in hospitals in the lowest SMM tertile, and Howell estimated that site of delivery accounted for up to 47.7% of the Black-White SMM gap (38). Within the same hospital, the adjusted odds of SMM for Black women remained 1.52, independent of insurance (39). Nationally, among 73.9 million delivery hospitalizations, the failure-to-rescue rate after SMM was 1.79 times higher for Black women (40). The disparity is therefore three things at once: worse hospitals, worse care within hospitals, and worse rescue when things go wrong. Each is a hospital-quality problem, which is the one domain in which we have interventions with measured effects.
The following table ranks interventions by the strength of evidence for reducing mortality or severe morbidity specifically among Black women.
Two cautions belong beside this table. First, California’s overall rate halved to about 7.0 per 100,000 by 2013, on par with Western Europe (44), but its Black pregnancy-related mortality was 56.2 per 100,000 in 2014–2016 and 49.7 in 2019–2021 against 14.0 for White women, and the state’s own reviewers reported that the disparity widened between 2008 and 2016 (45). Hemorrhage bundles narrowed the SMM gap; they did not close the mortality gap, because the deaths of Black women in California are increasingly cardiovascular, and the bundle does not treat cardiomyopathy. Second, a 2026 scoping review found only 16 peer-reviewed intervention studies aimed at maternal disparities in the entire US literature and described them as “limited” in rigor (57). No intervention has yet demonstrated a reduction in Black maternal mortality in a controlled analysis. What has been demonstrated, repeatedly, is that when hospitals measure SMM by race and run standardized hemorrhage and hypertension protocols, Black women benefit disproportionately, because they were disproportionately harmed by the absence of those protocols.
The implication for priorities follows from the cause distribution. Cardiac disease, cardiomyopathy, hypertension and embolism together account for roughly half of pregnancy-related deaths among Black women, and 30% of all deaths occur after six weeks, when the woman has left obstetric care (33). The interventions with the best mechanistic fit are the ones that treat those conditions: universal postpartum blood pressure surveillance with remote monitoring, treatment of chronic hypertension from the first trimester (50), cardio-obstetric pathways for women with cardiomyopathy risk factors, structured postpartum follow-up in the first year with insurance to pay for it, and objective blood-loss measurement with escalation protocols. Review committees also judge more than 90% of preeclampsia and mental-health deaths preventable (60), which argues for the same postpartum year of contact HMHBA proposes, but delivered by clinicians who can prescribe an antihypertensive, not only by a visitor who can recognize a warning sign.
Does the plan address access to physicians and specialists?
No.
The press release does not mention obstetricians, maternal-fetal medicine, cardiologists, anesthesiologists, hospital quality, safety bundles or perinatal quality collaboratives; its workforce language is “growing the maternal health workforce with an emphasis on training midwives” and scaling “integrated care teams, including midwives and doulas” (2).
The Call to Action goes further in the opposite direction. It describes prenatal care as having “traditionally centered on obstetricians as the primary, and often sole, providers of care” and proposes “shifting from siloed OB-GYN care to a broader suite of maternal health providers” so that services “become more accessible.”
It acknowledges that “cardiovascular disease is the leading cause of maternal death, yet prenatal care often focuses narrowly on pregnancy-specific conditions,” but proposes no mechanism for getting a woman with cardiomyopathy risk to a cardiologist.
Physician supply, subspecialist consultation, levels of maternal care, transfer protocols and hospital quality measurement do not appear (3). The plan is, in effect, a substitution plan: fewer encounters with physicians, more with midwives, doulas, community health workers and telehealth.
That is a defensible strategy for low-risk women and a poorly matched one for the women who die.
The evidence on specialist access is thinner than one would like, but what exists points one way. Sullivan and colleagues showed in 2005 that an increase of five maternal-fetal medicine specialists per 10,000 live births was associated with a 27% reduction in state maternal mortality (RR 0.73, 95% CI 0.58–0.93) after adjustment for poverty, education, race and age (61). Kawakita and colleagues replicated this with 2018–2021 data: states in the highest tertile of MFM density had an adjusted incidence rate ratio of 0.70 (0.58–0.85) for maternal mortality and 0.83 (0.71–0.98) for pregnancy-related mortality compared with the lowest, although the middle tertile showed no effect, so the relationship is not a clean gradient (62). An HRSA analysis found the South had the lowest availability of nearly every relevant occupation, obstetrician-gynecologists included, and the highest mortality, while explicitly disclaiming causation (63). These are state-level ecological studies with the usual limits, and none adjusts for hospital quality, but they are the only mortality data we have on any workforce category, and they concern subspecialists, not midwives.
Regionalization is the operational form of specialist access, and here the evidence is mixed in an instructive way. In Massachusetts, women with high-risk conditions who delivered at a hospital without the resources their condition required had an adjusted odds ratio of 3.34 (2.24–4.96) for severe maternal morbidity (64), and in a national sample the excess SMM risk of high-comorbidity women was 9.55-fold at low-acuity hospitals versus 6.50-fold at high-acuity ones (65). But hospital level as such is not protective: in four states, SMM rose with level of care and level I hospitals had marginally lower adjusted risk than level IV (66), and Georgia found no difference in maternal outcomes by service level among high-risk women (67). Risk-appropriate matching helps; a level designation on the door does not. Rural access to the right level is poor: only 27.5% of higher-risk rural women who needed level IV care delivered at such a hospital (68). Twenty-four-hour in-house obstetric coverage has no mortality data, and its SMM signal is one unadjusted survey (69,70). Cardio-obstetric teams reduce 30-day readmission (RR 0.29) but the pooled maternal mortality estimate is null on six small studies with approximated controls (71). MFM telehealth in Arkansas raised consultation rates without outcome data (72).
The most direct evidence that specialist involvement matters for death comes from the confidential enquiries HMHBA says it admires. MBRRACE-UK judged that improvements in care may have made a difference to the outcome in 45% of deaths in 2020–2022 and 2021–2023 and 61% in 2022–2024; in the cardiovascular chapter the figure was 38%, with named failures such as “she was not seen by a cardiologist until 32 weeks’ gestation” and a woman with severe postpartum hypertension who “was not reviewed by a senior doctor prior to her discharge” (73,74). In France, care was suboptimal in 66% of maternal deaths in 2016–2018 and 59.7% were preventable; for cardiovascular deaths the enquiry’s recommendations are multidisciplinary follow-up, repeated risk assessment and “early referral to an expert centre (expert cardiologists, obstetricians, anaesthetists and intensive care)” (75,76). These are expert judgments, not effect estimates, but they come from midwife-led systems, and what they keep finding is not too few midwives. It is delayed senior and specialist review.
For Black women the point is sharper. Their leading causes are cardiac disease, cardiomyopathy, embolism and hypertension (33,41); a substitution model that reduces physician contact in pregnancy and the postpartum year moves in the wrong direction for exactly those conditions.
Nothing in the HMHBA documents proposes to get more Black women to hospitals in the lowest SMM tertile, which is where roughly half of the SMM disparity lives (38), or to a cardiologist before 32 weeks. A plan that names cardiovascular disease as the leading cause and then omits cardiologists has a gap at its center.
Would universal coverage make a big difference?
Coverage is the strongest single policy lever in the evidence base, and it is also the one whose limits are best documented. The two facts need to be held together.
On the first, the only causal-design estimate of a mortality effect is Eliason’s difference-in-differences across 612 state-years, which associated Medicaid expansion with 7.01 fewer maternal deaths per 100,000 live births overall and 16.27 fewer among Black women (53). That is a large effect, about a third of a non-expansion-state rate, and it has not been replicated; it uses death-certificate data across the checkbox transition and the Black subgroup estimate has visible outliers. Delivery-hospitalization SMM studies with stronger designs are null or small: a synthetic-control analysis of 12 million deliveries in 26 states found a 0.02 percentage point change in SMM after expansion (77), a Health Economics event study found “little evidence” of morbidity change (78), and New York’s 2014 expansion produced a 0.42 percentage point relative improvement in the SMM trend for low-income women (79). The coverage-to-utilization chain is robust: expansion reduced early postpartum hospitalizations by 17% (80), the pandemic continuous-enrollment rule raised 12-month postpartum coverage from 59% to 91% (81), and Colorado’s postpartum extension increased treatment of perinatal mood disorders by 20.5 percentage points (82). No study has yet linked the 12-month extension to mortality; the review-committee lag makes that impossible before about 2027 (54).
The reason coverage would help is timing. Thirty percent of pregnancy-related deaths occur 43 to 365 days after delivery, after the historical 60-day Medicaid cutoff, and another 23% between 7 and 42 days (33). In 2015–2018, 26.8% of women with prenatal Medicaid were uninsured before pregnancy and 21.9% were uninsured two to six months after it (83); continuous perinatal coverage was 75.3% among White women and 55.4% among Black women (84). Medicaid pays for roughly two thirds of Black births. Those are the women, and the months, in which cardiomyopathy, postpartum hypertension, overdose and suicide kill. Much of that counterfactual, however, is already spent: 40 states and the District of Columbia have expanded Medicaid and nearly every state now covers twelve months postpartum. The marginal step to universal coverage mainly reaches the roughly eight million uninsured women of reproductive age concentrated in the Southern non-expansion states, which are also the states with the highest Black pregnancy-related mortality.
On the second fact, every universally insured system that has been examined still carries a large Black or African-origin excess, and the table below is the cleanest natural experiment available on what coverage alone does.
Two US findings deserve emphasis. In the TRICARE system, where every woman has the same coverage and most deliver in the same military hospitals, the Black excess in non-transfusion SMM is 68%; the one outcome where the military system appears to have equalized risk is preeclampsia-related SMM, plausibly because military hospitals apply hypertension protocols uniformly (85,89). And in the ACA dependent-coverage study, the reduction in SMM accrued to non-Hispanic White women (aOR 0.89) and not to others, a caution that coverage gains do not flow automatically to the women who need them most (90).
A defensible estimate is that universal coverage would remove on the order of 10% to 25% of the US rate, perhaps two to four deaths per 100,000, concentrated in late-postpartum, cardiovascular, mental-health and chronic-disease deaths in the South, and would narrow the absolute Black-White gap by more than that because Black women are disproportionately uninsured and in non-expansion states. It would not bring the United States to European rates, and the relative Black-White ratio would most likely remain in the 1.5 to 3 range seen in every universal system, because the remainder of the gap lives in which hospital a woman delivers in, what happens to her inside it, her chronic disease burden, and factors that operate identically under the NHS and under TRICARE. Universal coverage is necessary; the countries that have it and still run 12 to 13 per 100,000 show that it is not sufficient. HMHBA’s plan, to its credit, does address coverage: it treats Medicaid as the financing vehicle for 40% of births and supports the postpartum extension (3). It does not address what the coverage buys, which is the specialist and hospital-quality problem above.
Assessment
HMHBA has chosen a target, halving maternal mortality in five years, that is measured by a statistic whose level is disputed by a factor of two and whose year-to-year changes since 2022 have not been statistically significant. It has chosen mechanisms, protecting rural units and expanding midwives and doulas, that improve access and the experience of birth but have never been shown to reduce maternal death in a high-income country, and it has justified them with numbers that do not transfer (a low-income-country model for midwifery, cross-sectional desert associations for closures, an insurer’s propensity-matched claims study for doulas). The comparison with Europe that motivates the program overstates the gap by comparing an inflated numerator with under-counted ones.
The omission that matters most is the one raised by the two new sections. The plan names cardiovascular disease as the leading cause of death and then proposes a workforce with fewer physicians in it; it never mentions maternal-fetal medicine, cardiology, anesthesia, hospital quality or levels of care, which are the only workforce and system variables with any mortality signal in the US literature and the recurring failures named by the European enquiries it cites as models. Universal coverage, which the plan supports through Medicaid, is the single policy with the strongest claim to a mortality effect, but the natural experiments of TRICARE, Kaiser, the NHS and France show that it narrows the Black excess without removing it. None of this means the money will be wasted. The evidence points clearly at where it would do the most: paying every delivering hospital to run hemorrhage and hypertension bundles with race-stratified outcome reporting, funding remote postpartum blood pressure programs and cardio-obstetric follow-up, supporting states to keep women insured for a year, building the enhanced surveillance that HMHBA says it wants (and accepting that the measured rate may rise when the counting improves), and funding rural transfer and readiness systems rather than propping up units delivering fewer than 100 births a year. Doulas and midwives belong in that system for the outcomes they have been shown to change. If the program’s own scorecard is the NCHS rate, it should say now which baseline it is using and how it will separate real change from measurement change; otherwise the result in 2031 will be unfalsifiable, and both success and failure will be claimed.
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