Legislation Could Better Address Georgia’s Black Maternal Health Crisis – Georgia Budget and Policy Institute

This policy brief is co-authored by Director of Economic Justice Ife Finch Floyd and Director of Health Justice Leah Chan.

The vision cast by Black leaders and scholars of “a world where Black women and birthing people have the rights, respect, and resources to thrive before, during, and after pregnancy” is attainable and fundamental to our state’s future. Currently, Georgia is one of the worst states in the country in which to give birth, especially if you are Black. A Black mother or birthing person in Georgia is twice as likely to die from pregnancy-related causes than their white counterparts. It does not have to be this way. More than 80 percent of pregnancy-related deaths are preventable, and state-level legislation can help create the conditions in which Black mothers and birthing people can thrive. Anti-racist economic and health policies and a state budget that supports Black women across the lifespan and addresses the root causes of health inequity can contribute to healthier pregnancies and more abundant futures for all Georgians.

In the past few years, Georgia legislators have taken some action to address maternal health, including enacting some legislative recommendations from the House’s 2019 Study Committee on Maternal Mortality. SB 338, passed during the 2022 session, extends Medicaid coverage for low-income mothers up to one year postpartum. On the other hand, the Georgia General Assembly has also restricted access to the full spectrum of evidence-based reproductive health care by passing laws like HB 481, which bans abortion once there is a detectable cardiac activity (usually around six weeks of pregnancy). Data shows that states with legislation to restrict abortion and reduce access to other reproductive health services, like family planning, have higher maternal mortality rates.

Given the maternal health crisis and the new limits on abortion care, some policymakers want to frame their proposals as positive measures to address maternal health. For example, a Governor Kemp spokesperson said HB 129, the TANF eligibility legislation, is “[l]iving up to [the governor’s] commitment to improve maternal health in Georgia. Governor Kemp is proud to push for the expansion of these benefits to expecting mothers.”

Although, individually, some legislation passed this year is significant, like removing the 5-year waiting period for Medicaid-eligible pregnant women and children who are lawful permanent residents, the collective impact on maternal health will be modest at best based on available research on the policies. These measures are considered modest because they have a narrow reach and/or ignore the severe health and economic circumstances contributing to the Black maternal health crisis.

Other legislation that would have provided incremental improvement, and in some cases, major improvement for Black birthing people’s health and economic well-being, did not pass this session. The piecemeal, unfocused approach to passing legislation to address this urgent crisis does not serve Georgia’s families. Our state needs a comprehensive, well-funded, sustained legislative effort guided by data and the lived expertise of those closest to the harm, specifically Black women and birthing people.

In the table below, GBPI assesses key bills from the 2023 Legislative Session and their potential impact on the Black maternal health crisis based on the best available research. The following is not an exhaustive list of all maternal health-related legislation introduced during the 2023 Legislative Session. Our assessment of each bill’s potential impact is based on data and available research.

How Will This Legislation Impact Black Women and Birthing People?

Significant evidence supporting this policy’s impact on Black women and birthing people – rigorous quantitative and qualitative research that demonstrates meaningful impact in reducing maternal mortality, maternal morbidity and/or poor birth outcomes among Black women and birthing people.
Significant evidence supporting this policy’s impact on women and birthing people in general – rigorous quantitative and qualitative research that demonstrates meaningful impact in reducing maternal mortality, maternal morbidity and/or poor birth outcomes among women and birthing people; no specific data or strong data on Black women and birthing people.
Growing evidence supporting this policy’s impact on women and birthing people – quantitative or qualitative research that demonstrates some impact in reducing maternal mortality, maternal morbidity and/or poor birth outcomes among Black or other women and birthing people.
No impact or unknown impact of this policy on women and birthing people – little to no research to understand the impact in reducing maternal mortality, maternal morbidity and/or poor birth outcomes among Black or other women and birthing people.

Health Care Coverage and Access

Remove the five-year waiting period for Medicaid-eligible pregnant women and children who are lawful permanent residents
HB 19 includes about $584,000 to allow pregnant women and children who are lawful permanent residents to enroll in Medicaid/PeachCare without waiting five years. Lifting this arbitrary barrier will provide Black immigrant women and birthing people with access to pregnancy and postpartum care. Providing Medicaid coverage to immigrant women during pregnancy and postpartum is cost-effective and has many benefits—like more women receiving adequate prenatal care and fewer infant deaths.
Pilot remote maternal and fetal monitoring among high-risk mothers
SB 106 creates a remote maternal and fetal health monitoring program for Medicaid-eligible, high-risk pregnant mothers, and HB 19 includes $1 million to support the pilot program. The program will use digital technology to perform remote monitoring—from tracking maternal heart rate to measuring blood pressure. More research is needed to understand the impact of remote monitoring on Black women and birthing people with lower incomes. Structural barriers, like lack of access to high-speed internet, could impact their ability to participate in telehealth programs like this one.
Close the Medicaid coverage gap without harmful restrictions (DID NOT PASS) Despite 71 percent of Georgians supporting Medicaid expansion, bills like HB 38 and HB 62 were not even given a hearing and did not progress. Expanding Medicaid eligibility to uninsured adults with lower incomes would benefit all Georgians. However, the largest reductions in uninsurance would be among Black people and  young adults 19 – 34 years old. This translates into greater access to health care coverage for Black adults of reproductive age. Medicaid expansion increases access to preconception care, which partly allows people to prevent or better manage conditions—like high blood pressure—that can lead to complications during pregnancy and postpartum. One study, comparing expansion and non-expansion states, found that the effect of Medicaid expansion on maternal mortality was greatest for Black mothers and birthing people. Another study found that Medicaid expansion in other states was associated with declines in death among Black infants.
Standardize care and breastfeeding policies for pregnant and postpartum people who are incarcerated
HB 235, which did not pass, would have set standards for carceral prenatal and postpartum care and established policies around breastfeeding and breast milk expression/storage for lactating women in state prisons and jails. Pregnant people who are incarcerated face dehumanizing and traumatizing conditions, including being separated from their newborns less than 48 hours after birth. The burden of mass incarceration, which builds upon a legacy of enslavement and codified racial segregation, falls heaviest on Black women compared to white women, and is linked to a higher risk of adverse birth outcomes like pre-term birth. One way to minimize harm is to establish evidence-based care standards and increase opportunities to provide  infants with breastmilk.
Increase Medicaid reimbursement rates for obstetric and gynecological services
HB 19 includes almost $19 million to increase select primary care and obstetrics and gynecology (OB/GYN) codes to 2021 Medicare levels. Unfortunately, the governor instructed the Department of Community Health to disregard this language. In Georgia, about 46 percent of all births are financed by Medicaid. However, low Medicaid reimbursement rates restrict people’s access to quality care during pregnancy. Each state decides the rate at which health care providers will be reimbursed for  Medicaid services, and physicians commonly cite low payment as one the main reasons  they do not accept patients insured by Medicaid.  Georgia reimburses for OB/GYN services at about 90 percent of the 2021 Medicare rate (which is set by the federal government). Bringing Medicaid reimbursement rates in line with Medicare rates could reduce more than two-thirds of disparities in access to care. This presents a missed opportunity to increase access to high-quality health care for Black women and birthing people with lower incomes.
Affirming reproductive rights and reducing barriers to abortion care
SB 15/HB 75, the Reproductive Freedom Act, which did not move this session, would protect abortion rights and expand access to abortion care. While abortion is very safe, the health risks of pregnancy are high, especially for Black people. This is largely due to racism in our health and economic support systems. Multiple research studies find strong associations between expanding abortion restrictions and worsening maternal health outcomes for all women. There is also some near-causal evidence that finds states that restrict access to abortion increase the maternal mortality rate for all races by 38 percent. Other studies find Black women  likely experience higher mortality rates and poor birth outcomes after implementation of a state abortion restriction.  Given the evidence of the connection between abortion bans and maternal mortality, restoring and expanding abortion access for all Georgians would likely reduce  poor maternal health outcomes among Black and other birthing people.

Community-Based and Culturally-Responsive Health Services

Expand home visiting in rural communities
SB 106 authorizes a Department of Public Health-led pilot project to provide home visits to at-risk and underserved rural communities during pregnancy and early childhood. HB 19 includes about $1.7 million to support the pilot program. Evidence-based home visiting models, such as the Nurse-Family Partnership, have demonstrated a range of benefits for women and their children—from fewer emergency room visits  to positive impacts on employment for the mother. A home visiting program in Tennessee reduced premature death among Black women across their lifespan. Investment in pregnancy-related programs in Florida—including home visiting—led to declining maternal mortality among Black women. For Black women and birthing people in rural Georgia, home visiting could also help overcome transportation barriers. However, more studies are needed to determine which home visit models specifically reduce deaths among Black women during pregnancy and postpartum. To get the greatest return on investment, the pilot should center the needs and experiences of Black women with lower incomes living in rural communities and consider the unique structural barriers  they face.
Certify community midwives (DID NOT PASS) HB 684, which did not pass, would have created a Certified Community Midwife Board to support the licensure and regulation of community midwives. About 35 percent of Georgia counties have no access to an obstetric provider and 75 percent have no access to a hospital with an obstetric or birth center. Certified community midwives could help expand our state’s shrinking maternal health workforce and build upon the rich history of Black community midwives. Although data on community midwives (without a nursing degree) are limited, midwifery care more broadly can result in higher  satisfaction among women and more cost-benefit compared to other care models. Future legislation could focus on  certification and ensuring certified community midwives can provide Medicaid -reimbursable services, as is the case in 18 other states.

Mental Health and Substance Use Disorder Prevention, Treatment and Recovery

Strengthen behavioral health services and supports
Although HB 520 did not pass, it will likely be taken back up in the 2024 Legislative Session. While the legislation has the potential to strengthen the behavioral health ecosystem broadly, it does not include any specific provisions related to pregnant or postpartum people. Mental health conditions—including suicide and drug overdose—are the second leading cause of pregnancy-related death in Georgia, and there is a great need for prevention, treatment and recovery services for women and birthing people. Black women are more likely to report postpartum depression and less likely to receive care compared to white women. Similarly, Black women are less likely to receive care for opioid use disorder during pregnancy than white women. Additional legislation is needed to focus on the behavioral health needs of pregnant and postpartum people, including Black women.

Economic Security

Temporary Assistance for Needy Families (TANF) eligibility expansion
HB 129 expands access to TANF for pregnant persons without children and repeals the family cap, which denied an increase to a TANF family who had another child while on the program. HB 565, which did not pass, would have allowed TANF applicants to keep their car and still be eligible for the program. It would have also expanded the total time limit on benefits from 48 months to 60 months.

The TANF program needs significant changes to be more robust. About two-thirds of Georgia’s TANF recipients are Black, but the program serves very few families in poverty overall. Benefits are extremely low and work and behavioral requirements are very restrictive. Further, there is evidence that monthly and periodic cash payments can improve birth outcomes but given these eligibility changes do not guarantee access to cash assistance is it unclear the extent to which these changes will impact birthing people.

Paid leave
SB 61 lifts the sunset on the Family Care Act which allows workers to use five sick days to care for a family member. HB 78 would require employers with 25 or more employees to implement a paid sick leave policy. Under this policy, workers can accrue at least 56 hours of paid sick leave each year. This bill did not move last session but would have been an important step in the right direction for pregnant workers and workers with infants. SB 61 will, and HB 78 could provide a small benefit to Black birthing people who need  time to care for themselves or their new baby when they’re sick. These policies could relieve some of the stress and some of the tough financial barriers between work and caring for a child.

However, the research shows that job-protected, family medical leave is what birthing people need to recover from birth, get postpartum care and bond with and care for their child. Paid parental leave of parents with a new baby. Job-protected paid parental leave also linked to lower infant mortality rates. Conversely, not having  at least 12 weeks of parental leave is linked to lower rates of child immunization.

Sales tax exemptions on diapers and feminine hygiene products
HB 211 would exempt the sales and use tax for diapers, and HB 123/SB 51 would do the same for menstrual products. If these bills had passed, they would have made these products more affordable and been an important step for gender equity. People with insufficient income to cover the essentials often experience period poverty and diaper need. In Georgia, Black and Latina women and Black and Latinx babies and toddlers are more likely to live in poverty than their white counterparts. Lack of access to these essential goods impacts people’s lives: Many menstruating people sometimes stay home from work or school when they do not have enough period products. An inadequate supply of diapers has been associated with increased maternal depression. The research on the impact of tax exemptions is  mixed. Tax experts find that good-specific tax exemptions may not be the best way to help low-income consumers who struggle to purchase diapers and feminine hygiene products. However, some studies show modest increases in purchase of diapers and period products. GBPI did not find tax exemption outcomes specific to Black mothers and birthing people.
Creating a state Earned Income Tax Credit and a Child Tax Credit
HB 79/SB 118, providing for a state earned income tax credit (EITC) and child tax credit (CTC), did not advance this session. However, both bills would help boost income for low-wage workers and families with children. Black families in Georgia are more likely to have very low incomes compared to white families. These circumstances phenomenon make it hard for these families to save or pay off outstanding debts. Boosting the federal EITC and CTC with state versions will help Black families  better plan and pay down debt. Several rigorous research studies also find that states with a refundable EITC have modest improvements in birth and mental health outcomes, especially for Black mothers.
Tenant protections
HB 404 would have offered protections for tenants and improved the quality of housing that families live in. This bill would have also established a few guardrails for the eviction process. With few, if any, statewide protections for tenants, those with low income can often only afford the lowest quality homes. HB 404 set a very low baseline for tenant protections and did not define what constitutes a home to be “fit for human habitation.”
Experts find housing to be directly related to health and is one of the primary social determinants of health. More specifically, studies find the historical and ongoing discrimination against Black families in the housing market continues to impact Black maternal and infant health outcomes. For example, Black women experience some of the highest eviction rates  often struggle to find decent housing after an eviction. While there is strong evidence that better housing supports Black maternal health, is it less clear if the modest protections in this bill would sufficiently support Black birthing people’s access to safe and affordable housing.
Increase the minimum wage statewide and index it to inflation
SB 25 did not pass this session but would increase the state minimum wage to $15 an hour and index it to inflation so it does not lose value over time. Raising the minimum wage in this way would improve economic security for Black and Brown people who disproportionately work jobs with meager wages. There little understanding on how  minimum wage increases improve Black maternal health and birth outcomes, but some research shows that giving low-paid workers a raise may contribute to modest reductions in pre-term birth, low birth weights and infant mortality. However, these studies do not focus on race.

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