Commentary by Cassandra Toscano, MBA Co-Founder, Principal Advisor & CEO, Health Transformation Advisor

As someone who has launched maternity programs across nearly half the states in a 30-year career, the recent NEJM Catalyst article on payer strategies to improve maternal health care resonates deeply — and leaves me with a lot more to say.

The article provides a solid foundation for what an integrated maternity program should include. But the fact that there is still this much left unaddressed says a great deal about the complexity of the challenge we face.

Data and technology integration go further than most programs realize. Effective early identification requires more than enrollment data — it demands integration with labs, pharmacy, eligibility files, AI-driven provider data, and the consumer-facing apps patients are already using. In a recent east coast analysis, 50% of Medicaid members were actively searching Babyscripts for pregnancy information. That kind of engagement is a data source and an access point that we need to be designing around, not just acknowledging.

Doulas are only part of the story — and we can fund them without new spending. We know that doula scholarships can be structured in a budget-neutral way, and that culturally concordant doula services meaningfully improve trust and openness to health information and social service support. More than paying for doulas, we need to fund access to them equitably.

Midwifery workforce gaps are one of the clearest predictors of poor maternal outcomes. When you compare the U.S. to countries with strong maternal mortality results, the difference in midwifery supply is a stark standout. Expanding midwifery access directly addresses both the shortage of providers and the “windshield time” — long travel to care — that drives worse outcomes in rural and underserved areas. Policies need to reflect that.

There are clinical practice gaps that are fully within our control. Consistent blood loss measurement during delivery remains inconsistently enforced. This is not a new problem, and it is addressable today.

We cannot discuss maternal health in 2026 without naming the regulatory environment. Restrictions on OBs providing full women’s health services are a real barrier that affects outcomes. Omitting that from any serious strategy is a gap.

Community-based, in-home, evidence-based programs exist and are underutilized. Full-family programs with strong evidence behind them should be widely supported and expanded — not left to compete for pilot funding.

Substance use treatment has a maternal health gap that rarely gets the attention it deserves. A large share of medication-assisted opioid treatment centers will not treat pregnant mothers. For patients already navigating limited access, this creates a compounding crisis.

Maternal health must be understood as a continuum — not a nine-month episode. The care model needs to extend well before and after the childbearing years. Behavioral health integration for both the mother and father, carried through the first year of life with birth spacing discussions included, is not a future aspiration — it’s a present gap.

And for commercial patients, the financial barriers are just as real. High deductibles, limited time off, and unpaid maternity leave are not peripheral issues. They are structural barriers to healthy birth outcomes, and any serious strategy needs to name them.

Amazingly, I could go on — and across different geographies and subpopulations, I often do. The point is not that this article falls short. The point is that we have more than enough evidence today to act, and we need to expand support for mothers and families, not retract it. The next ten years are not the timeline. The work starts now.

_____________________________________________________________________

This commentary is a response to: “Strengthening Maternal Health Research — Payer Strategies to Improve Maternal Health Care,“ NEJM Catalyst Innovations in Care Delivery, 2026.