Despite this progress, inequities remain in maternal health care coverage and access. According to 2020 data, 30 million nonelderly people are uninsured in the United States, and Hispanic, Black, American Indian and Alaska Native, and Native Hawaiians and other Pacific Islander people, as well as people with low incomes, are consistently more likely to be uninsured compared with their non-Hispanic white counterparts.8 Without high-quality health care coverage, many people forgo necessary and preventive prenatal and postnatal care. Even before the COVID-19 pandemic and subsequent economic crisis, women were more likely to delay or go without care, skip recommended preventive care, forgo filling prescriptions, or report problems paying medical bills as a result of health care costs.9 Access to comprehensive maternal and reproductive health care services has been shown to improve maternal health outcomes.10
Insurance coverage alone is not enough to achieve health equity—including maternal health equity. There has been an increased recognition of the need to move from traditional payment models, which pay providers per service, toward value-based care delivery, which attempts to pay based on quality. The ACA undertook reforms to incentivize providers to deliver high-quality care and improve care coordination, notably through the expansion of innovative payment models, patient-centered medical homes, and accountable care organizations (ACOs), among other changes.11 These reforms moved the U.S. health care system toward a value-based care model and ensured that public payers were rewarding quality—not quantity—in care delivery.12 However, there is evidence to suggest that not every community—particularly communities of color—is able to benefit from these reforms equally, and many of these innovative payment models have not been aimed at reducing racial and ethnic health disparities.13 Illustratively, a study published in Health Affairs found that providers who serve a patient base that has a higher concentration of Black, low-income, uninsured, or disabled people, or people with less than a high school degree, were less likely to participate in ACOs.14
Additionally, there are costs associated with not taking action to improve existing health care disparities. This cost of inaction on maternal health care—that is, the costs resulting from inadequate or inaccessible maternity care that negatively affects women, their families, and society at large—should provide a strong impetus to build on the ACA to improve maternal health outcomes. When pregnant people are unable to access affordable, high-quality care during pregnancy, delivery, or in the postpartum period, they may be forced to pay out of pocket, face financial uncertainty, or go without care altogether. Many of these issues stem from the high cost of pregnancy itself. The average charge for a vaginal birth is around $15,300, while a caesarean section (C-section) costs around $20,400.15 Complicated pregnancies can run exponentially higher. Given almost half of all pregnancies in the United States are unintended, it is frequently difficult for people to anticipate and build sufficient savings to cover maternal health-related costs. The Federal Reserve noted in a recent report that nearly 40 percent of people in the United States could not cover an unexpected $400 expense (a percentage that has almost certainly grown as a result of the current economic crisis).16 Pregnancy and childbirth are the most costly hospital-based health services, according to an analysis of hospitals charges conducted by the Agency for Healthcare Research and Quality.17 Notably, about two-thirds of all bankruptcies were the result of medical bills or illness-related work loss prior to the pandemic.18
The American Rescue Plan—federal legislation recently enacted to address the COVID-19 pandemic—includes provisions that represent a significant enhancement of the ACA. Relevant here, the law increases financial subsidies for people to purchase plans on ACA marketplaces, extends eligibility for these subsidies, provides federal financial incentives for states to expand their Medicaid programs, and creates a new option for states to further extend Medicaid coverage for pregnant people.19 The recently reintroduced Black Maternal Health Momnibus Act of 2021, a collection of 12 federal bills designed to address maternal health disparities, also includes provisions related to payment and delivery models aimed at improving the quality of care for Black birthing people.20
This issue brief focuses on administrative actions that the Biden-Harris administration, as well as state leaders, can take to build on these legislative developments and improve upon the gains made under the ACA. The recommended actions include:
- Creating a special enrollment period for pregnancy to allow people to enroll in coverage outside of the ACA’s limited open enrollment period.
- Establishing minimum coverage standards for maternal health to ensure that pregnant people and people who can become pregnant can access needed services across plans and geographic areas.
- Setting standards for network adequacy that guarantee meaningful access and choice of culturally competent providers and perinatal support workers, including midwives and doulas.
- Developing innovative payment and quality care models that, through focus and design, are aimed at eliminating maternal health disparities among Black and Indigenous people.
Create a special enrollment period for pregnancy
The ACA marketplaces—both the federally facilitated marketplace, Healthcare.gov, and the 15 state-based marketplaces—are online portals that give people the opportunity to compare and shop for plans that meet their care needs.21 Notably, the vast majority of people who purchase plans on the marketplaces receive federal financial assistance through premium tax credits, which assist with monthly premiums, and/or cost-sharing reductions, which help to lower out-of-pocket costs such as copays and coinsurance. However, consumers can generally only purchase these plans during a limited open enrollment period, which in recent years has been six weeks beginning in November.22 Those who have experienced qualifying life events, such as a recent move or job loss, may be eligible for a special enrollment period (SEP) that allows them to enroll in coverage outside of the open enrollment period.
While a person can also qualify for an SEP for giving birth, pregnancy alone does not similarly qualify. As a result, a person who was previously uninsured or who has a non-ACA compliant plan, such as a short-term plan, could find themselves without access to needed services such as prenatal, gestational diabetes, and maternal mental health care. The U.S. Department of Health and Human Services (HHS) and state-based marketplaces should deem pregnancy a qualifying life event for an SEP and allow pregnant people to enroll in coverage. Some states have already created an SEP for pregnancy. For instance, in 2016, New York became the first state-based marketplace to create an SEP for pregnancy, followed by Connecticut, the District of Columbia, Vermont, Maryland, and New Jersey.23 Still more could benefit from an SEP for pregnancy in every state: In 2018, 12 percent of women of reproductive age (15–44 years), or about 7.7 million women, were uninsured nationwide,24 and more are underinsured without coverage of needed services.25
In addition to the importance of improving access to coverage for pregnant people, there is a strong cost argument for making pregnancy a qualifying life event for an SEP. Without coverage, prenatal visits, which can be as many as 10 to 15 visits and may require additional services such as amniocentesis, can total thousands of dollars.26 Some pregnant people choose to delay or forgo prenatal care in the face of high out-of-pocket costs—a decision that, unfortunately, often leads to even greater costs down the road. Inadequate prenatal care carries numerous and costly risks, including an increased likelihood of preeclampsia, a pregnancy complication caused by high blood pressure, and gestational diabetes. For example, if left untreated, pregnancy-related hypertension can cost an uninsured patient more than $18,500, in addition to costs related to hospital stays.27
Women who do not receive prenatal care are also seven times more likely to have a preterm birth compared with women who attend the majority of their prenatal visits.28 The cost of preterm birth is staggering: For example, according to a seminal report published by the Institute of Medicine (now known as the National Academy of Medicine) in 2007, preterm medical costs accrued from birth to age 7 were an additional $43,500 over similar medical costs for a term birth.29 Meanwhile, excess maternal delivery costs due to preterm birth were approximately $5,200 more than the delivery costs associated with a term birth.30 Ancillary costs, including for early education services and special intervention services, can drive this figure even higher.31
Establish minimum coverage standards for maternal health
The ACA’s essential health benefits (EHB) requirement was intended to bring uniformity in coverage across plans, particularly in the individual and small group market, but there are still significant differences in services covered across states.32 In particular, maternity and newborn care coverage continues to fluctuate across states. Since 2011, HHS has allowed states to select a benchmark plan to define the specific services that must be covered under each EHB category, and the Trump administration issued guidance allowing even more flexibility among states’ selection of benchmark plans. When HHS initially issued this guidance, the agency stated that it would reassess “whether enrollees have difficulties with access for reasons of coverage or cost,” among other issues.33 In 2011, the Institute of Medicine recommended that states have flexibility but similarly stated that the committee’s solution at the time was to “build on what currently exists, learn over time, and make it better” and noted that “[t]he EHB package should be continuously improved and increasingly specific.”34
More than a decade later, the federal government has the opportunity to set a minimum standard for the maternity and newborn care benefit, among other EHBs.35 Indeed, state flexibility does not preclude the federal government from establishing a minimum federal standard, and HHS should issue regulations establishing a minimum standard for maternity care. Specifically, maternity care should be consistent with the services as recommended by medical experts, including the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics;36 this should include preconception care, prenatal care, ancillary services, mental health screening and services, labor and delivery, and postpartum services, among others.37 Even more, the number of prenatal visits and other services that are covered should be increased for complicated pregnancies. Before a federal standard is set, states can use its existing flexibility to incorporate these minimum standards independently.
Relatedly, HHS and state governments should enact regulations to fill gaps in the coverage of breastfeeding counseling and equipment. While most private and Medicaid expansion plans have to cover these services without out-of-pocket costs to the enrollee, traditional Medicaid plans—those plans for people who qualified for Medicaid before the ACA was implemented—are not subject to this requirement.38 State Medicaid programs should ensure that the benefits of those eligible for Medicaid through the traditional pathway align with the benefits of the Medicaid expansion population. Additionally, plans currently have discretion over the breast pumps they must cover. HHS and states should ensure that plans cover—at a minimum—one breast pump from each of the most common types, including electric, manual, and battery-operated.
Additionally, non-ACA compliant health plans, which are not required to cover maternal health care services, should be limited, and clear notice should be given to consumers when a plan is not ACA compliant.39 In particular, short-term plans should not last more than three months. These plans do not have to comply with the ACA benefit requirements, including stipulations to cover required preventive services such as well-woman visits or EHBs such as maternity care. Notably, a 2018 Kaiser Family Foundation analysis of short-term plans found that not one of the 24 short-term plans analyzed covered maternity care.40 These plans are not required to adhere to consumer protections, such as excluding or charging more or outright denying coverage to people with preexisting conditions, including pregnancy; these plans are also not prohibited from charging women more for the same coverage as men.41 Unfortunately, these plans are likely to attract younger, healthy people, including people of reproductive age, into purchasing individual plans due to their low premiums.42 People whose health plans do not include maternity benefits may find themselves in need of a maternity rider, or supplemental insurance. A rider has high premiums and requires enrollment prior to pregnancy, making it practically unworkable given that people would need to know in advance that they would need maternity services and the rider.
Similarly, health care sharing ministries—entities where people with common religious beliefs pay into a fund that pays for certain medical expenses for members—do not have, and frequently do not adhere to, ACA benefit and consumer standards.43 Indeed, health care sharing ministries can prevent certain women from joining their plans; for example, some plans do not allow single pregnant women to receive coverage, while others require that women enroll before becoming pregnant.44 These plans can also be costly to patients: A Commonwealth Fund analysis of five health care sharing ministries revealed that almost all plans imposed coverage caps.45 One ministry noted that members are responsible for maternity costs exceeding $4,000 for an uncomplicated delivery and $6,000 for a medically necessary C-section. This cost would be in addition to the monthly membership, which generally ranges from $500 to $5,000.46 Again, this may leave pregnant people in the lurch, as hospital charges for delivery can greatly exceed this limit. States can regulate health care sharing ministries beyond federal standards; however, 30 states have laws exempting health care sharing ministries from state insurance regulations.47 HHS and state administrators should ensure that this coverage, at a minimum, meets ACA standards.
Ensure the diversity of health plans’ provider networks
HHS should ensure that there is an adequate provider network for people seeking maternal health care. The ACA requires the secretary of HHS to issue regulations to ensure that health plans, at a minimum, have “a sufficient choice of providers,”48 and these regulations require sufficiency in both the numbers and specialties of providers.49 Additionally, health plans’ provider networks are required to be inclusive of essential community providers, who are defined as providers serving low-income communities and areas with a shortage of health professionals, including certain family planning providers and HIV/AIDs clinics.50 The Obama administration also previously issued guidance establishing more specific standards, such as time and distance standards, related to access to providers within certain specialties.51
An adequate provider network is necessary to ensure that having health coverage actually results in increased health care access and utilization. Specific to ensuring equitable access to maternal health services, it is necessary that health plans’ provider networks include nonphysician providers and a broad range of perinatal workers. Midwives and doulas, in particular, have been associated with better maternal health outcomes and lower rates of medical interventions during birth.52 Access to both midwives and doulas has also been shown to generate cost savings. A study from the University of Minnesota found that if the percentage of pregnancies (including births covered by both private plans and Medicaid) delivered at midwifery practices increased from 8.9 percent in 2018 to 20 percent in 2027, the 10-year cumulative cost savings would be $2.82 billion for private plans—benefiting both employers and employees—and $1.13 billion for state Medicaid programs—benefiting taxpayers as well as the federal and state government.53 This increase in midwife-assisted delivery would also result in 30,000 fewer preterm births between 2018 and 2027. Similarly, a recent study modeling the cost-effectiveness of doula services found that such services could save up to $884 per doula-assisted pregnancy and that if all low-risk pregnant women received doula services, this would result in $247 million in savings.54 Of course, cost savings alone should not determine birthing plans; however, access to a range of providers and birthing support is necessary for pregnant people to make meaningful decisions about their care.
While the ACA prohibits plans from discriminating against providers,55 the law does not require private insurance plans to contract with certain providers, such as midwives, or birthing support people, such as doulas. The ACA does not require private plans to cover care delivered by any provider at a birthing center, as required in the Medicaid program.56 In the absence of such a requirement, plan enrollees could find themselves without coverage for a midwife or doula, or their plan might cover these health care workers but not contract with any within their network.57 Illustratively, private insurance typically does not cover doula care, and only a few Medicaid programs cover doula services.58 Most private insurers and Medicaid plans cover certified nurse midwives (CNMs), but certified professional midwives (CPMs), who typically practice outside of the hospitals, are less frequently covered. CPMs are covered in only 13 state Medicaid programs, and six states require private insurers to cover these providers, according to 2017 data.59 The Center for Consumer Information and Insurance Oversight (CCIO) within HHS and states should establish minimum network adequacy standards for private plans. Such standards could require a minimum percentage of available providers in an area—which is inclusive of doulas and midwives, including CNMs, CPMs, certified midwives, and community-based midwives—as well as require coverage for deliveries in birth centers. If a plan does not have a midwife or doula within its network, enrollees should be able to access this care out of network at the same cost level as in-network services.
Additionally, standards related to a plan enrollee’s ability to access certain providers should explicitly include OBGYNs so as to ensure that people who do wish to access care from an OBGYN are able to do so. Studies have found that OBGYNs are among the most common providers from whom women receive care,60 and nearly 60 percent of women report visiting an OBGYN regularly.61 No matter the provider, there must be an adequate geographic distribution of providers as well as providers with flexible hours. This is particularly important for people of color, who are more likely to work in jobs with limited paid sick leave and thus need after-hours care.62 Additionally, there must be providers within the network who are trained to give culturally competent care, including providers trained on implicit bias and anti-racism. There must also be language access services to deliver care to people with limited English proficiency, which is particularly important for immigrants. Network adequacy standards alone cannot solve issues related to the provider workforce; however, these standards can encourage insurers to include available, qualified providers in their networks.
The Trump administration loosened the ACA network adequacy standards, including by shifting enforcement of these standards even more to the states.63 This essentially left no federal oversight of compliance for existing network adequacy standards. Notably, a 2014 study found that 23 states did not have quantitative standards for regulating plans’ networks, and states’ ability to regulate these plans varied.64 HHS should return to regulating plans’ network adequacy and enforcing standards at the federal level. Relatedly, the ACA requires marketplace plans to include a directory of the providers included in plans’ networks.65 Given the demonstrable effect that the care delivery team has on maternal health outcomes, plan enrollees who are pregnant or planning to become pregnant must be able to rely upon their plans’ provider networks as well as access these provider directories in order to make informed decisions when selecting a health plan. Unfortunately, multiple studies have found that provider directories are frequently inaccurate.66 HHS and state regulators can assist with improving this accuracy by monitoring plans’ provider networks and directories and holding the insurers that help to populate the directories accountable for inaccuracies.
Encourage states to adopt policies that expand Medicaid
As noted above, Medicaid expansion has been associated with lower maternal mortality rates, particularly among Black mothers,67 and can play an important role in achieving maternal health equity. Due to systemic oppression and inequities, Black, Indigenous, and Latina women disproportionately rely upon the Medicaid program.68 Furthermore, Medicaid funds nearly half of the nation’s births and pays for a greater share of births than private payers in rural areas.69 Following the ACA’s coverage expansions, including Medicaid expansions, the percentage of new mothers who were uninsured fell 44 percent, and those reporting not having their medical care needs met due to cost decreased 59 percent.70
However, not every low-income person has access to the Medicaid program. Twelve states have not expanded their Medicaid programs, as was contemplated under the ACA.71 Women who otherwise would not qualify for Medicaid except for their pregnancy status might be eligible for pregnancy-only Medicaid coverage, which entitles them to coverage for “pregnancy-related services” or services for “conditions that might complicate the pregnancy.”72 While access to these services can be lifesaving, women are only entitled to this coverage for around 60 days postpartum, unless their state elects to extend this coverage. The federal government should encourage states to extend pregnancy-only Medicaid coverage beyond 60 days postpartum, and states should adopt this extension. Specifically, the Centers for Medicare & Medicaid Services within HHS can issue guidance encouraging states to extend Medicaid pregnancy-only coverage to at least one year postpartum and provide the full scope of available Medicaid benefits. To be clear, this does not replace the need for states to also expand their Medicaid programs, as the ACA intended, which should continue to be encouraged and adopted by states.
In recent years, some states have embarked on legislative and regulatory efforts to extend postpartum coverage beyond 60 days. Currently, six states—Illinois, South Carolina, New Jersey, Georgia, Indiana, and Missouri—have pending Section 1115 demonstration waivers to extend postpartum coverage, although in some cases not for the full 12 months or only for specific populations. Illustratively, Illinois has proposed extending pregnancy-only Medicaid coverage from 60 days to 12 months for women earning up to 200 percent of the federal poverty level, and it projects that extending this coverage will result in an additional 62,932 postpartum women enrolling in Medicaid each month.73 This postpartum extension is in addition to the state’s Medicaid expansion in 2014, through which more than 600,000 additional people have gained coverage as of April 2020.74
Expanding Medicaid and extending 12-month postpartum coverage is in line with the ACA’s goal of creating affordable coverage and would also result in critical cost savings for pregnant and postpartum people. Analyzing one-year postpartum costs among birthing individuals with employer-based insurance, the Health Care Cost Institute found that the majority of postpartum spending occurs after two months.75 This illustrates that people enrolled in Medicaid are also likely to continue to have numerous, costly postpartum needs well after 60 days postdelivery. Furthermore, an Urban Institute study found that among its study population of newly uninsured mothers nationwide—almost half of whom had lost their Medicaid or other insurance coverage after pregnancy—1 in 5 reported experiencing postpartum depression, and 1 in 3 had received a C-section. These findings led the study’s authors to conclude that many of the women surveyed have unmet and sustained mental and physical health care needs during the postpartum period.76
Another negative yet common byproduct of inadequate postpartum Medicaid coverage is insurance churn, or changes in insurance coverage over time (either cycling between insurance and uninsurance or between health plans). A 2017 Health Affairs study reported that 70 percent of people who were uninsured, 55 percent of people enrolled in Medicaid or the Children’s Health Insurance Program, and 35 percent of people with private or government insurance at the time of delivery experienced at least one month of uninsurance in the six months following delivery.77 Multiple studies have highlighted the need for continuous and uninterrupted coverage for pregnant and postpartum people. Churning poses both health and financial costs to patients, insurers, the health care system, and taxpayers writ large. Churning can also lead to delays in receiving preventive care, reduced medication adherence, higher rates of emergency room visits, and increased hospitalizations.78 It is important to note that in states that expanded their Medicaid programs, there have been marked improvements in continuity of coverage as well.79
Create innovative care models that pay for quality and promote the equitable delivery of care
The ACA authorized the creation of the Center for Medicare and Medicaid Innovation (CMMI) within HHS to design and implement innovative health care payment models. The office has previously operated models focused on maternal health, including those aimed at reducing early deliveries,80 improving prenatal care,81 and caring for mothers with substance use disorders.82 There have also been state-based payment and delivery models aimed at improving maternal health. For example, state Medicaid programs have enacted maternity care homes, whereby patients are assigned a provider who coordinates their various medical needs, and the provider may receive payment incentives for delivering certain services or meeting specific quality metrics. In North Carolina, 70 percent of the pregnant people participating in the state’s pregnancy medical home received prenatal care starting in the first trimester.83 The Momnibus also includes bills that call on HHS to develop new care models: The Tech to Save Moms Act, introduced by Rep. Eddie Bernice Johnson (D-TX) and Sen. Bob Menendez (D-NJ), encourages the CMMI to consider developing a model that integrates telehealth services in the screening, monitoring, and management of pregnancy-related care.84 The Impact to Save Moms Act, introduced by Rep. Jan Schakowsky (D-IL) and Sen. Bob Casey (D-PA), would also create a new perinatal care alternative payment model.85 Additionally, the Data to Save Moms Act, introduced by Rep. Sharice Davids (D-KS) and Sen. Tina Smith (D-MN), would establish a Task Force on Maternal Health Data and Quality Measures. It would also require a review of existing quality measures, including a review of their effectiveness and the barriers preventing providers from implementing them, among other factors.86 The Momnibus would provide funding to enact these models, but HHS also has the authority to develop the models through administrative actions.
The CMMI should exercise this authority to design a demonstration project that is focused on addressing maternal health inequities, particularly for Black and Indigenous pregnant people. These models should incorporate maternal health quality measures, such as the National Quality Forum-endorsed measures on C-sections or early elective deliveries (i.e., induced pregnancies and C-sections before 39 weeks) to discourage these procedures when not medically necessary.87 Additionally, these models should incorporate reproductive health measures such as the patient-centered contraceptive counseling measure, which asks patients about whether they received the contraceptive care and counseling of their choosing. The CMMI should also include quality family planning guidelines, which provide evidence-based recommendations to help people decide when and whether to become pregnant and which are associated with improved maternal health outcomes.88 Such measures can also be incorporated into other insurance coverage requirements to ensure public and private plans are only paying for quality care.
It is also important that participating providers be racially and ethnically diverse and representative of the communities that they serve. Ensuring that providers receive cultural competency training has also been found to yield positive outcomes. A meta-analysis of 19 studies found that when providers received training in cultural competency, patients had improved health care access and utilization.89 Providers who predominantly serve communities of color have also been frequently excluded from participating in innovative models; it is important that the agency provide increased funding and technical assistance to allow these providers an equal opportunity to participate in the demonstration project. Specifically, demonstration projects should include safety-net providers such as family planning providers, rural providers, and other providers who have been historically underfunded.90 Additionally, nonphysician providers and birthing support such as midwives and doulas should be included given the known positive effect they have on maternal health outcomes. Within these models, participating providers, as well as other health care workers involved, should be required to receive implicit bias and anti-racism trainings.
Throughout and after the demonstration project, the participating entities should report patients’ disaggregated data based on race, ethnicity, sex, gender, gender identity, sexual orientation, disability status, immigration status, English proficiency, income, and geographic location. This information should be considered when evaluating the effectiveness of the innovation model. Additionally, the evaluation should conduct a proper risk adjustment to account for social and environmental factors that are outside of the providers’ control to ensure the quality of care delivered is properly assessed.91 Some experts have rightly raised a concern that without proper risk adjustment, an unintended consequence of a value-based payment model could be the unfair penalization of providers who serve communities that have historically been disadvantaged in the health care system and thus came into the demonstration with poorer health.92
Overall, however, there are substantial cost savings associated with care coordination and value-based payment models.93 This approach has been taken up in the maternity care context: A 2015 study in North Carolina showed that when women who were covered by Medicaid for at least part of their pregnancy were enrolled in the state’s Baby Love Maternity Care Coordination program—a home visiting program that coordinated prenatal visits, mental health counseling, and childbirth education, among other services—they experienced a decline in preterm birth risk compared with a control group.94 In regards to alternative payment models, Tennessee implemented a perinatal episode-of-care payment model that saved the state more than $4.7 million between 2014 and 2015 and led its C-section rate to drop from 31.4 percent in 2014 to 29.2 percent in 2015.95
There is a strong moral imperative as well as financial incentive to improve maternal health outcomes through federal and state administrative action. While there are costs associated with improving maternal health coverage and care delivery through coverage expansion and delivery system reform, they pale in comparison to the costs associated with the maternal health crisis itself. Diminished health and quality of life, loss of economic productivity, and, importantly, the ripple effects that a maternal death has on families, communities, and society at large highlight the urgent need to address this national crisis. This is of particular importance for Black and Indigenous people, who make up a disproportionate share of this human toll. By making investments to expand and improve comprehensive maternity coverage, diversify provider networks, and shepherd innovation in maternity care delivery and payment models, the United States will be better positioned to meet this crisis head-on, ensuring that all pregnant and postpartum people can experience healthy and safe pregnancies and continue to lead productive lives.
Jamille Fields Allsbrook is the director of women’s health and rights with the Women’s Initiative at the Center for American Progress. Osub Ahmed is a senior policy analyst for women’s health and rights with the Women’s Initiative at the Center.