Importance: American maternal and neonatal mortality rates are the worst of the world's high-income countries. These rates are particularly low among patients of color, who have higher Cesarean delivery rates (CDR), higher healthcare costs, and poorer outcomes than White patients. However, common economic analyses do not address interlinked issues and therefore underestimate both the hidden causes of health inequities and the resultant costs to taxpayers. We have therefore designed a more comprehensive health economic model and metric (DEVELOP) that incorporates population health, equity, and economic integration. Design & Measures: The DEVELOP model, a childbirth-specific model of the societal economic gain or loss related to healthcare outcomes, incorporates an individual's long-term economic contributions into its calculations of economic benefits. We first used our model to estimate fiscal outcomes if each state's CDR for Black patients was lowered to that of White patients. Second, we calculated the costs of "excess" CDR and mortalities among Black patients. Third, we incorporated the additional long-term economic contributions of mothers and their children. Results: In the U.S., maternal and neonatal mortality rates and associated costs were higher for Black patients than White patients, and states with the lowest per capita health expenditures showed worse maternal outcomes and higher continuing costs. If the Black patient CDR were reduced to the White patient CDR, taxpayer-funded healthcare programs would save $263 million annually. Reducing the Black patient MMR would improve economic output by $224 million per year, and reducing the Black patient NMR would save $3.1 billion per year, for a combined economic improvement of $3.3 billion annually. Conclusions and Relevance: The costs of improved prenatal care should be reconceptualized as investments for future economic growth rather than as short-term burdens. Policies blocking reasonable investments in health equity are counterproductive.

The authors have declared no competing interest.

This study did not receive any funding

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study used (or will use) ONLY openly available human data that were originally located at: https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D United States Department of Health and Human Services (US DHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics (DVS). Linked Birth / Infant Death Records 2007-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program, on CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/lbd-current.html on April 5, 2023. Maternal Mortality Rate by State 2024 (worldpopulationreview.com) Maternal Mortality Rates in the United States, 2021 (cdc.gov) https://www.kff.org/other/state-indicator/infant-mortality-rate-by-race-ethnicity/?dataView=1&currentTimeframe=0&sortModel=%7B%22colId%22 https://www.cia.gov/the-world-factbook/field/mothers-mean-age-at-first-birth/ https://data.worldbank.org/indicator/NY.GDP.MKTP.CD https://www.bea.gov/data/gdp/gdp-state

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Yes

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