A holistic and collaborative approach, gathering reliable data and building patient trust are key to improving poor and unchanging statistics on maternal mortality and morbidity in the US, according to maternal health experts.
“At a macro level, women are 51% of the population, and they birth 100% of our future, so, if we’re not paying attention to maternal health, I don’t know what we’re doing as a society,” said health law attorney, and Nyoo Health founder and CEO Priya Bathija. “Then, if you look beyond that, women are making 80% of health care decisions. They’re making decisions for themselves, their parents, their children, their pets. Maternal health and women’s health in general, is a market opportunity. If you can provide positive patient experiences, those patients will come back to your organization when they or their family members need care.”
The current state of maternal health
The panel discussion “Reimaging Maternal Health Access, Innovations and the Future of Care,” organized by the American College of Healthcare Executives, began with a CDC report that shows the US is at the bottom for maternal mortality compared with other developed nations. There are persistent racial disparities, with Black, American Indian and Alaska Native women three times more likely to die of pregnancy complications than white women.
The CDC report “painted a clear picture of the causes of pregnancy-related deaths, and notably, behavioral health issues, including those from substance use disorders, that account for up to 20% of the maternal mortalities,” said panelist Brittany Bogan, associate chief operating officer at Von Voigtlander Women’s Health Hospital and C.S. Mott Children’s Hospital, Michigan Medicine. “The CDC review found that 4 out of 5, or 80% of these pregnancy-related deaths are preventable.”
Bogan, referencing a Commonwealth Fund policy brief, also pointed out that “maternal health is more than whether mothers die.” She said it also concerns morbidity, with about 8% of all pregnancies including complications. She said 60,000 women experience severe maternal morbidity annually. “Just because there are no deaths does not mean that things are going well,” she added.
Panelists described the difficulties many women have accessing needed care due to a lack of providers in many areas of the country. A March of Dimes report found that by 2035, all but six states are projected to experience inadequate numbers of obstetrician-gynecologists, with a particularly severe shortfall in rural areas.
Bathija said that to achieve better outcomes, addressing women’s health holistically may make the most positive difference in maternal morbidity and mortality.
“Women’s health is more than maternal and reproductive health,” she said. “Women’s health starts with primary care, including prevention, immunization, nutrition and weight management. But it also includes specialty care, including cardiovascular health, cognitive and brain health, autoimmune diseases, oncology, aging and bone health and endocrinology.”
Despite ongoing conversations and efforts among health systems, local and federal policymakers and community organizations to address the data, the national maternal mortality numbers have held steady for about the past decade, according to Bathija.
“There isn’t going to be just one single solution. It’s going to take multiple solutions and a multifaceted approach… this isn’t really a problem that one entity or one organization can solve,” she said, and added that the CDC study on maternal deaths had also evaluated the timing of those deaths and found “a majority of them were happening between seven and 365 days after delivery. So that’s likely when a mother is at home.”
She called for addressing maternal health from pregnancy, delivery and the postpartum period, and even before pregnancy occurs. Because no one provider or entity can handle all of that care, public health is important, including hospitals, payers, clinicians, governments, community-based birth and maternity organizations and policy makers.
Making positive change
Breaking down silos between organizations, working across the continuum of care, collecting and analyzing patient data to know where the gaps are, and then developing programs to address those gaps are needed to see a positive change, panelists agreed.
“It’s really easy for us to…say, collect the data and stratify it, and then you’ll know your path forward,” Bathija said. “It is not easy to do those things, and it takes work year after year to…evolve your process and make sure that the data that you’re collecting is valid and trustworthy…and that it reflects what’s happening in your patient populations. Once you have that data, there’s a lot of things you can do with it.”
Panelists offered examples of programs that have moved the needle on maternal health including:
- Quality improvement collaboratives like The Alliance for Improved Maternity Care, nationally coordinated through the American College of Obstetricians & Gynecologists. This initiative has rolled out bundles for conditions like sepsis, hypertensive disorders and postpartum hemorrhage, Bogan said. “We’re seeing a really wide-scale adoption of those bundles at hospitals all across the country.”
- Deploying care teams in new, innovative ways. MLK Community Hospital in Los Angeles has redesigned care teams to include a nurse midwife, with an obstetrician always available if there’s an emergency. “The hospital’s C-section rate is now half the state and national average. It topped their state’s maternity honor roll for seven years running, and the hospital is one of only 13% of hospitals to receive a CMS five-star rating for excellence,” Bathija said.
- The cocoon model at Kaiser Permanente in Georgia, which places the pregnant woman in the center surrounded by support for not just her physical needs, but also her mental and social needs from preconception to postpartum care.
- Building trust between patients and care teams. “The way to build trust is by being competent, reliable and affirming patients’ lived experiences,” Bathija said, encouraging everyone to listen to the Retrievals podcast Season 2, which addresses women’s pain during cesarean section deliveries.
“[T]his is a problem that is happening globally. In the United States alone, 8% of women report feeling pain during C-section, and some believe that rate is even higher, it’s just not reported or documented. And we’re not talking about minor pain. If you listen to the podcast, women describe that they feel everything, including the scalpel cutting through their flesh and organs being moved around. So, it’s… it’s horrifying.”
On a more promising note, the podcast talks about how a team at the University of Illinois Health changed its culture around C-sections. “They took that bad outcome and used it as an opportunity to build trust,” she said. “So, they have improved competence by educating teams on pain during C-sections, and they’ve empowered care teams to speak up on behalf of patients. And…doctors are trained on how to affirm patients, including the language and tone they can use to make patients feel safe, listened to and respected.”
The role of public policy
Panelists also pointed to public policies, including expanding Medicaid coverage for up to a year postpartum for women.
“To get all but two states to commit to [expand postpartum Medicaid coverage] is huge in this time,” Bathija said. “We’re also seeing the government still…trying new things. There’s the Maternal Health Transformation Model, they’re piloting with 15 states… that could improve outcomes and experiences for women throughout their pregnancy journey.”
Also, there is the CDC’s Hear Her campaign, which seeks to raise awareness about physical and mental health warning signs before, during and after pregnancy.
At the state level, Bogan said she sees a variety of approaches and how different groups are coming together. “So, it’s not just the health care systems and the state government,” she said. “What do we have for community-based organizations, policy makers, clinical and social interventions that need to be accounted for, and how do we bring all those partners together to come up with some comprehensive solutions that improve the health of women, infants and families overall?”
Bogan acknowledged that coordinating efforts across organizations can be challenging, especially when it comes to social needs. She offered an example of a woman who lives in a health care desert having to travel a long distance for health care.
“We’re asking a woman to travel four, six, eight hours away from home to receive her care, and perhaps elongating that care if there’s an antepartum admission, for example,” Bogan said. “Who is caring for her family, for other children, while she’s away? We don’t have any great systems in place for that ongoing support.”
Technology may offer some answers
Technology may help to fill some gaps. Bathija said virtual doulas can support mothers during pregnancy. BabyScripts offers a remote patient monitoring tool to diagnose and treat preeclampsia early. Lunajoy provides virtual access to mental health therapy, counseling and medication management to women without access to the services.
“They are focused on states that don’t have enough mental health providers, and they fill those gaps digitally,” Bathija said, and added that while she was not endorsing any particular product, there are hundreds of companies in this area.
Panel moderator Jhaymee Tynan, Aging Services Practice co-lead and principal for Healthcare Services at Korn Ferry, said the trend to have workers return to the office can have a profound impact on women.
“Flexible hours of work, flexible location for work, just that alone can be life-changing when you can design your work schedule around your life, and make them work together instead of against each other,” Tynan said.
Tynan said organizations may feel pressure to adopt a return-to-office policy, because people may feel “a little antsy about continuing to allow people to work remotely, but the flexible work option “is one of the most important benefits you can offer to working mothers.”
While maternal health challenges remain, including better coordination of efforts, consistent and uniform access to care, the conversation continues since better maternal health benefits everyone. “A healthy mother typically correlates to a healthier family, better contributions to society,” Bogan said.
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