Maternal Mortality

Maternal mortality in the United States has been rising for several decades, but actions taken at the community level, as well as larger public health initiatives, have the potential to slow this trend, according to experts at a webinar sponsored by the National Institute for Health Care Management.

Maternal mortality in the United States increased by 14% from 2018 to 2020, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.

However, more than 80% of pregnancy-related deaths are preventable, according to 2017-2019 data from the Maternal Mortality Review Committees published online by the CDC. MMRCs include representatives of diverse clinical and nonclinical backgrounds who review the circumstances of pregnancy-related deaths.

In a webinar presented on Sept. 20, the NIHCM enlisted a panel of experts to discuss maternal mortality, the effect of changes to reproductive rights, and potential strategies to improve maternal health outcomes.

Maternal mortality is defined as “death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to pregnancy or its management,” according to the CDC.

Importantly, mortality rates in the United States are approximately three times higher in Black women compared with White women, said Ndidiamaka Amutah-Onukagha, PhD, MPH, of the Tufts University Center for Black Maternal Health & Reproductive Justice. Dr. Amutah-Onukagha addressed some of the potential issues that appear to drive the disparity in care.

The lack of diversity in the health care workforce has a significant effect on patient outcomes, Dr. Amutah-Onukagha said. Overall, Black newborns are more than twice as likely as White newborns to die during their first year of life, but this number is cut in half when Black infants are cared for by Black physicians, she emphasized.

Other factors that may affect disparities in maternal health care include limited access to prenatal care, discriminatory hospital protocols, and mistreatment by health care professionals, said Dr. Amutah-Onukagha. She cited data showing that maternal mortality rates were higher in rural compared with urban areas. “According to the American Hospital Association, half of rural hospitals have no obstetric care, leaving mothers in maternity care deserts; this exacerbates existing disparities,” she said.

In the webinar, Sindhu Srinivas, MD, a maternal-fetal medicine specialist at the University of Pennsylvania, explained how patient, community, and system factors play a role in the disparities in maternal care.

Overall, Black women have to travel further to receive care, which has implications for high-risk pregnancies, and patients on Medicaid have to wait longer for care, and are less likely to be referred, she added. Black women also have higher rates of preexisting conditions compared with other populations that put them in the high-risk category, such as high blood pressure, diabetes, obesity, or being HIV positive, she said.

Other factors contributing to persistent disparities in maternal care include sociodemographics, patient beliefs and knowledge, and psychological issues including stress, said Dr. Srinivas. Community factors, such as social networks, safety, and poverty, also play a role, as do clinician factors of implicit bias and communication skills, she said.

Strategies to reduce disparity

Dr. Srinivas presented several strategies to reduce disparities at various levels. At the policy level, interventions such as establishing a Maternal Mortality Review Committee, establishing a perinatal quality collaborative, and extending Medicaid for a full year postpartum could help improve outcomes, she said. Dr. Srinivas also encouraged clinicians to report maternal mortality data stratified by race and ethnicity, and to participate in the Alliance for Innovation on Maternal Health program (AIM), an initiative in partnership with the American College of Obstetrics and Gynecology.

Dr. Srinivas also proposed maternal health policies to develop payment models “to sustain and scale innovative solutions, and “preserve access to contraception and abortion care.”

For clinicians looking to have an immediate impact, the panelists agreed that working with community health centers can make a significant difference by improving access to maternal care. Consider opportunities for partnership between hospitals and health care delivery centers in the community, said Dr. Srinivas.

Also, don’t underestimate the value of doulas in the birthing process, Dr. Amutah-Onukagha said. She urged clinicians to advocate for doula reimbursement and to take advantage of opportunities for doulas to work with pregnant individuals at the community levels. Data suggest that doulas are associated with increased maternal care visits and with breastfeeding, she noted.

Adam Myers, MD, of the Blue Cross Blue Shield Association, also contributed to the webinar discussion with a key point: Having financial means and commercial coverage is not a buffer against adverse maternal outcomes for racial minorities.

Dr. Myers cited the latest Health of America Report, which included data up to April 2021 with surveys of Medicaid members and their experiences. According to the report, rates of severe maternal mortality (SMM) increased by 9% for commercially and Medicaid-insured women between 2018 and 2020.

Among commercially insured women, SMM was 53% higher among Black women than White women; among Medicaid-insured women, Black women had a 73% higher rate of SMM, compared with White women.

In addition, the report showed that significantly more mothers of color were not able to complete the recommended series of prenatal visits, mainly for reasons of scheduling and transportation, which were greater barriers than COVID-19, Dr. Myers said.

Based on the data, one specific risk profile rose to the top: “We believe women of color aged 35 or higher with comorbid conditions should be treated as very high risk for SMM,” Dr. Myers emphasized. He stressed the need to focus on transportation and scheduling barriers and expressed support for partnerships and health care delivery centers in the community to mitigate these issues.

Finally, Dr. Srinivas encouraged clinicians to have confidence in their expertise and make themselves heard to help their patients and improve maternal health for all. “Use your voice,” said Dr. Srinivas, “As physicians we don’t think of that as an important aspect of our work, or that we can’t articulate, but remember that we are experts, and sharing stories of patients who are impacted is incredibly powerful,” she said.

The presenters had no relevant financial conflicts to disclose.

Maternal mortality in the United States has been rising for several decades, but actions taken at the community level, as well as larger public health initiatives, have the potential to slow this trend, according to experts at a webinar sponsored by the National Institute for Health Care Management.

Maternal mortality in the United States increased by 14% from 2018 to 2020, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.

However, more than 80% of pregnancy-related deaths are preventable, according to 2017-2019 data from the Maternal Mortality Review Committees published online by the CDC. MMRCs include representatives of diverse clinical and nonclinical backgrounds who review the circumstances of pregnancy-related deaths.

In a webinar presented on Sept. 20, the NIHCM enlisted a panel of experts to discuss maternal mortality, the effect of changes to reproductive rights, and potential strategies to improve maternal health outcomes.

Maternal mortality is defined as “death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to pregnancy or its management,” according to the CDC.

Importantly, mortality rates in the United States are approximately three times higher in Black women compared with White women, said Ndidiamaka Amutah-Onukagha, PhD, MPH, of the Tufts University Center for Black Maternal Health & Reproductive Justice. Dr. Amutah-Onukagha addressed some of the potential issues that appear to drive the disparity in care.

The lack of diversity in the health care workforce has a significant effect on patient outcomes, Dr. Amutah-Onukagha said. Overall, Black newborns are more than twice as likely as White newborns to die during their first year of life, but this number is cut in half when Black infants are cared for by Black physicians, she emphasized.

Other factors that may affect disparities in maternal health care include limited access to prenatal care, discriminatory hospital protocols, and mistreatment by health care professionals, said Dr. Amutah-Onukagha. She cited data showing that maternal mortality rates were higher in rural compared with urban areas. “According to the American Hospital Association, half of rural hospitals have no obstetric care, leaving mothers in maternity care deserts; this exacerbates existing disparities,” she said.

In the webinar, Sindhu Srinivas, MD, a maternal-fetal medicine specialist at the University of Pennsylvania, explained how patient, community, and system factors play a role in the disparities in maternal care.

Overall, Black women have to travel further to receive care, which has implications for high-risk pregnancies, and patients on Medicaid have to wait longer for care, and are less likely to be referred, she added. Black women also have higher rates of preexisting conditions compared with other populations that put them in the high-risk category, such as high blood pressure, diabetes, obesity, or being HIV positive, she said.

Other factors contributing to persistent disparities in maternal care include sociodemographics, patient beliefs and knowledge, and psychological issues including stress, said Dr. Srinivas. Community factors, such as social networks, safety, and poverty, also play a role, as do clinician factors of implicit bias and communication skills, she said.

Strategies to reduce disparity

Dr. Srinivas presented several strategies to reduce disparities at various levels. At the policy level, interventions such as establishing a Maternal Mortality Review Committee, establishing a perinatal quality collaborative, and extending Medicaid for a full year postpartum could help improve outcomes, she said. Dr. Srinivas also encouraged clinicians to report maternal mortality data stratified by race and ethnicity, and to participate in the Alliance for Innovation on Maternal Health program (AIM), an initiative in partnership with the American College of Obstetrics and Gynecology.

Dr. Srinivas also proposed maternal health policies to develop payment models “to sustain and scale innovative solutions, and “preserve access to contraception and abortion care.”

For clinicians looking to have an immediate impact, the panelists agreed that working with community health centers can make a significant difference by improving access to maternal care. Consider opportunities for partnership between hospitals and health care delivery centers in the community, said Dr. Srinivas.

Also, don’t underestimate the value of doulas in the birthing process, Dr. Amutah-Onukagha said. She urged clinicians to advocate for doula reimbursement and to take advantage of opportunities for doulas to work with pregnant individuals at the community levels. Data suggest that doulas are associated with increased maternal care visits and with breastfeeding, she noted.

Adam Myers, MD, of the Blue Cross Blue Shield Association, also contributed to the webinar discussion with a key point: Having financial means and commercial coverage is not a buffer against adverse maternal outcomes for racial minorities.

Dr. Myers cited the latest Health of America Report, which included data up to April 2021 with surveys of Medicaid members and their experiences. According to the report, rates of severe maternal mortality (SMM) increased by 9% for commercially and Medicaid-insured women between 2018 and 2020.

Among commercially insured women, SMM was 53% higher among Black women than White women; among Medicaid-insured women, Black women had a 73% higher rate of SMM, compared with White women.

In addition, the report showed that significantly more mothers of color were not able to complete the recommended series of prenatal visits, mainly for reasons of scheduling and transportation, which were greater barriers than COVID-19, Dr. Myers said.

Based on the data, one specific risk profile rose to the top: “We believe women of color aged 35 or higher with comorbid conditions should be treated as very high risk for SMM,” Dr. Myers emphasized. He stressed the need to focus on transportation and scheduling barriers and expressed support for partnerships and health care delivery centers in the community to mitigate these issues.

Finally, Dr. Srinivas encouraged clinicians to have confidence in their expertise and make themselves heard to help their patients and improve maternal health for all. “Use your voice,” said Dr. Srinivas, “As physicians we don’t think of that as an important aspect of our work, or that we can’t articulate, but remember that we are experts, and sharing stories of patients who are impacted is incredibly powerful,” she said.

The presenters had no relevant financial conflicts to disclose.

Maternal mortality in the United States has been rising for several decades, but actions taken at the community level, as well as larger public health initiatives, have the potential to slow this trend, according to experts at a webinar sponsored by the National Institute for Health Care Management.

Maternal mortality in the United States increased by 14% from 2018 to 2020, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.

However, more than 80% of pregnancy-related deaths are preventable, according to 2017-2019 data from the Maternal Mortality Review Committees published online by the CDC. MMRCs include representatives of diverse clinical and nonclinical backgrounds who review the circumstances of pregnancy-related deaths.

In a webinar presented on Sept. 20, the NIHCM enlisted a panel of experts to discuss maternal mortality, the effect of changes to reproductive rights, and potential strategies to improve maternal health outcomes.

Maternal mortality is defined as “death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to pregnancy or its management,” according to the CDC.

Importantly, mortality rates in the United States are approximately three times higher in Black women compared with White women, said Ndidiamaka Amutah-Onukagha, PhD, MPH, of the Tufts University Center for Black Maternal Health & Reproductive Justice. Dr. Amutah-Onukagha addressed some of the potential issues that appear to drive the disparity in care.

The lack of diversity in the health care workforce has a significant effect on patient outcomes, Dr. Amutah-Onukagha said. Overall, Black newborns are more than twice as likely as White newborns to die during their first year of life, but this number is cut in half when Black infants are cared for by Black physicians, she emphasized.

Other factors that may affect disparities in maternal health care include limited access to prenatal care, discriminatory hospital protocols, and mistreatment by health care professionals, said Dr. Amutah-Onukagha. She cited data showing that maternal mortality rates were higher in rural compared with urban areas. “According to the American Hospital Association, half of rural hospitals have no obstetric care, leaving mothers in maternity care deserts; this exacerbates existing disparities,” she said.

In the webinar, Sindhu Srinivas, MD, a maternal-fetal medicine specialist at the University of Pennsylvania, explained how patient, community, and system factors play a role in the disparities in maternal care.

Overall, Black women have to travel further to receive care, which has implications for high-risk pregnancies, and patients on Medicaid have to wait longer for care, and are less likely to be referred, she added. Black women also have higher rates of preexisting conditions compared with other populations that put them in the high-risk category, such as high blood pressure, diabetes, obesity, or being HIV positive, she said.

Other factors contributing to persistent disparities in maternal care include sociodemographics, patient beliefs and knowledge, and psychological issues including stress, said Dr. Srinivas. Community factors, such as social networks, safety, and poverty, also play a role, as do clinician factors of implicit bias and communication skills, she said.

Strategies to reduce disparity

Dr. Srinivas presented several strategies to reduce disparities at various levels. At the policy level, interventions such as establishing a Maternal Mortality Review Committee, establishing a perinatal quality collaborative, and extending Medicaid for a full year postpartum could help improve outcomes, she said. Dr. Srinivas also encouraged clinicians to report maternal mortality data stratified by race and ethnicity, and to participate in the Alliance for Innovation on Maternal Health program (AIM), an initiative in partnership with the American College of Obstetrics and Gynecology.

Dr. Srinivas also proposed maternal health policies to develop payment models “to sustain and scale innovative solutions, and “preserve access to contraception and abortion care.”

For clinicians looking to have an immediate impact, the panelists agreed that working with community health centers can make a significant difference by improving access to maternal care. Consider opportunities for partnership between hospitals and health care delivery centers in the community, said Dr. Srinivas.

Also, don’t underestimate the value of doulas in the birthing process, Dr. Amutah-Onukagha said. She urged clinicians to advocate for doula reimbursement and to take advantage of opportunities for doulas to work with pregnant individuals at the community levels. Data suggest that doulas are associated with increased maternal care visits and with breastfeeding, she noted.

Adam Myers, MD, of the Blue Cross Blue Shield Association, also contributed to the webinar discussion with a key point: Having financial means and commercial coverage is not a buffer against adverse maternal outcomes for racial minorities.

Dr. Myers cited the latest Health of America Report, which included data up to April 2021 with surveys of Medicaid members and their experiences. According to the report, rates of severe maternal mortality (SMM) increased by 9% for commercially and Medicaid-insured women between 2018 and 2020.

Among commercially insured women, SMM was 53% higher among Black women than White women; among Medicaid-insured women, Black women had a 73% higher rate of SMM, compared with White women.

In addition, the report showed that significantly more mothers of color were not able to complete the recommended series of prenatal visits, mainly for reasons of scheduling and transportation, which were greater barriers than COVID-19, Dr. Myers said.

Based on the data, one specific risk profile rose to the top: “We believe women of color aged 35 or higher with comorbid conditions should be treated as very high risk for SMM,” Dr. Myers emphasized. He stressed the need to focus on transportation and scheduling barriers and expressed support for partnerships and health care delivery centers in the community to mitigate these issues.

Finally, Dr. Srinivas encouraged clinicians to have confidence in their expertise and make themselves heard to help their patients and improve maternal health for all. “Use your voice,” said Dr. Srinivas, “As physicians we don’t think of that as an important aspect of our work, or that we can’t articulate, but remember that we are experts, and sharing stories of patients who are impacted is incredibly powerful,” she said.

The presenters had no relevant financial conflicts to disclose.

“Anytime you have a maternal death, it sticks with you for life,” said Elliott Main, MD, a maternal fetal medicine specialist at Stanford (Calif.) University and one of the nation’s leaders in combating maternal mortality.

Courtesy Dr. Elliott Main

Dr. Main has had two maternal deaths in his career, years ago. One woman had a fatal stroke because of severe hypertension, and another died of cardiac complications. “We tried to do everything we possibly could, but you scrounge your memory for years and years [afterward]. To have a young healthy person go into labor and delivery and not come out is a tragedy at all levels. It charged me to not ever want to see that happen again,” he said.

Today, Dr. Main is the medical director of the California Maternal Quality Care Collaborative (CMQCC), a wide-ranging group of clinicians, state officials, hospitals, and others who have come together to address the issue. About 30 states have similar perinatal quality collaboratives (PQCs), and other states are forming them.

They work in collaboration with maternal mortality review committees (MMRCs), state-level groups that review maternal deaths, identify problems to address, and make recommendations to the quality collaboratives on how to prevent maternal deaths.

About 600-800 women die in the United States each year due to pregnancy-related complications, which ranks the United States behind other industrialized nations. Leading causes include hemorrhage and hemorrhagic strokes secondary to hypertension. It’s estimated that the majority of maternal deaths could be prevented with proper care.

To that end, states are enacting safety bundles from the Alliance for Innovation on Maternal Health (AIM), which was established by the American College of Obstetricians and Gynecologist several years ago. There are bundles that address obstetric hypertension, hemorrhage, mental health, venous thromboembolism, opioid use, racial disparities, and other problems. They were developed by experts in the field and published in multiple journals. California and other states have issued toolkits on how to implement them based on local circumstances.

The goal is to standardize best practices nationwide to prevent maternal morbidity and mortality, Dr. Main said.

AIM bundle implementation is “what’s happening in New Mexico and a lot of states, mostly through the efforts of state level quality care collaboratives. Some [states] are further ahead than others,” said Eve Espey, MD, professor and chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, and president of the New Mexico PQC.

“Most states now have a [MMRC] that collects maternal mortality and near-miss data. Those data are used by the action arm,” which is the PQC. “If the review committee says” opioid use disorder is a significant contributor “like in our state, the collaborative rolls out the opioid use disorder bundle,” she said.

Beginning next January, the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, will require that accredited hospitals enact key elements of the AIM bundles for both obstetric hemorrhage and severe hypertension. “Everyone’s [now] motivated to get on that bandwagon,” Dr. Espey said.

“The bundles are here to stay,” and the Joint Commission requirements are “a really important step for sustainability and basic implementation. We really want to get them adopted everywhere,” said Dr. Main, who is also the national implementation director for the AIM initiative.

“The key thing is to work on implementing the hemorrhage and hypertension bundles in your hospital. I would suggest contacting [your] state” PQC, he said.

The California model

California, which has been working to reduce maternal mortality and morbidity since the mid 2000s, has produced among the strongest evidence to date that the efforts make a difference.

By 2013, the state had halved its maternal mortality rate to a 3-year average of 7 deaths per 100,000 live births, which is comparable with the average Western Europe rate of 7.2 deaths. Nationwide, the rate was about 17.4 deaths per 100,000 live births in 2018, according to the Centers for Disease Control and Prevention

The reasons are multifactorial, but “we think” the quality improvement efforts have been “an important contributor,” Dr. Main said.
 

Improvements especially for Black women

Among the success stories has been California’s implementation of the AIM obstetric hemorrhage bundle about 5 years ago. Among other steps, the 17 evidence-based recommendations included early recognition, immediate access to oxytocin and other medications, immediate access to a hemorrhage cart with instructions for intrauterine balloons and compression stitches, the establishment of a hemorrhage response protocol and team, and regular unit-based drills with debriefing sessions afterward.

Mentoring teams consisting of a physician and nurse with maternal quality improvement experience were created to help hospitals come on board, with each team working with five to eight hospitals. Efforts included monthly telephone calls and face-to-face meetings, and providers were held accountable for progress. Hospitals shared data and tips on implementation, under the aegis of the CMQCC.

When the baseline period of 2011-2014 to the postintervention period of October 2015 to December 2016 were compared, the rate of severe maternal morbidity from hemorrhage fell from 22.1% to 18.5% across 99 hospitals and 73,476 women.

The benefit among Black women exceeded that among White women, with a 9% absolute rate reduction versus 2.1%. “If you adjusted for risk factors, [we found] you could eliminate [racial differences] completely,” which is something that hadn’t been shown before. “This is a really big deal,” Dr. Main said, because the risk of maternal morbidity and mortality is three to four times higher among Black women, compared with White women.

Dr. Main and his team found that the biggest clinical risk factor that accounted for racial differences was a higher rate of cesarean deliveries among Black women, followed by higher rates of anemia at hospital admission. “If you have a C-section when you are anemic, you are going to have a transfusion,” he explained.

More recently, there’s been a push in California to reduce the rate of primary cesarean deliveries by enacting the associated AIM bundle with use of the same approach as with the hemorrhage bundle. Dr. Main and his team recently reported a rate reduction from 29.3% to 25% without compromising birth outcomes.

However, “some changes are easier than others. Hemorrhage was an easy one to change because it didn’t deal with physician autonomy as much, and you saw more immediate results” with fewer hemorrhages. Reducing cesarean delivery rates is “a bigger lift” because “it’s really changing the culture of labor and delivery. It involves more group pressure and more reinforcing, but we were able to do that,” he said.
 

Problems in the Show Me State

“We’ve patterned a lot” of what’s being done in New Mexico “after California,” Dr. Espey said.

The AIM hemorrhage bundle, for instance, is being rolled out to New Mexico hospitals, with the help of virtual meetings and mentoring programs, plus outreach to the Navajo and others reservations because, as with Black women, rates of maternal morbidity and mortality are higher among Native American women.

It’s been tougher going, however, in states such as Missouri, which recently ranked 44th in the country for maternal mortality.

“We started a little bit late, and we are a little bit behind,” said ob.gyn. Karen L. Florio, DO, at the University of Missouri–Kansas City and also a leader of the state MMRC and member of its PQC.

The main problem is money. California’s efforts are funded by the Centers for Disease Control and Prevention, the state health department, and hospitals, among others.

But Missouri is “not as well funded as California for our mortality review board, and our [PQC] is mostly not funded. If we could get that funding, we would have more resources to implement these AIM bundles,” she said.

In addition to the issue, Missouri didn’t expand Medicaid under the Accountable Care Act – something that’s been linked to reduced maternal morbidity and mortality – and there are entire rural areas with no maternity care. Plus after generations of mistreatment, “our African American population has a valid distrust of the medical system that contributes to maternal mortality,” she said.

Obesity-related heart disease is also prevalent in Missouri, even among young people. “I cannot tell you how many women I have had who have had a heart attack at the age of 30 and who have had stents placed,” Dr. Florio said.

Dr. Florio and her colleagues are currently using teleconferences and other means to roll out the AIM hypertension bundle but can do so only selectively. “We don’t have the resources to reach every single rural hospital all over the state,” she said; they are working to address the funding issues.
 

For rural hospitals, implementation is “daunting”

Meanwhile, rural hospitals have been a particular concern in South Dakota, said Kimberlee McKay, MD, an ob.gyn. who is the clinical vice president of the ob.gyn. service line at Avera Health, a hospital system based in Sioux Falls, S.D.

She’s been overseeing Avera’s implementation of the hypertension, hemorrhage, and venous thromboembolism bundles. “What’s hard is that” the AIM protocols come “out of academic centers. Implementation of complex algorithms is daunting” for hospitals that only do a couple hundred deliveries a year, she said.

For small hospitals, the approach she’s found that works is to first assess what they can offer, and then have them “do what’s reasonable” for their resources. The second part is making sure high-risk women get to a regional center – with an adequate blood supply, in the case of hemorrhage, for instance – for complications. Dr. McKay and colleagues are working on a system by which regional centers can monitor smaller hospitals for potential maternity problems, and contact them proactively before they emerge.

They’ve also made access to hemorrhage and hypertension drugs easier on labor and delivery units with the help of close-by dedicated medicine boxes, and standardized protocols and order sets across Avera. “We try to make the right thing the easy thing to do,” Dr. McKay said.

Dr. Espey is an editorial adviser for Ob.Gyn. News. The physicians have no relevant financial disclosures.

aotto@mdedge.com

“Anytime you have a maternal death, it sticks with you for life,” said Elliott Main, MD, a maternal fetal medicine specialist at Stanford (Calif.) University and one of the nation’s leaders in combating maternal mortality.

Courtesy Dr. Elliott Main

Dr. Main has had two maternal deaths in his career, years ago. One woman had a fatal stroke because of severe hypertension, and another died of cardiac complications. “We tried to do everything we possibly could, but you scrounge your memory for years and years [afterward]. To have a young healthy person go into labor and delivery and not come out is a tragedy at all levels. It charged me to not ever want to see that happen again,” he said.

Today, Dr. Main is the medical director of the California Maternal Quality Care Collaborative (CMQCC), a wide-ranging group of clinicians, state officials, hospitals, and others who have come together to address the issue. About 30 states have similar perinatal quality collaboratives (PQCs), and other states are forming them.

They work in collaboration with maternal mortality review committees (MMRCs), state-level groups that review maternal deaths, identify problems to address, and make recommendations to the quality collaboratives on how to prevent maternal deaths.

About 600-800 women die in the United States each year due to pregnancy-related complications, which ranks the United States behind other industrialized nations. Leading causes include hemorrhage and hemorrhagic strokes secondary to hypertension. It’s estimated that the majority of maternal deaths could be prevented with proper care.

To that end, states are enacting safety bundles from the Alliance for Innovation on Maternal Health (AIM), which was established by the American College of Obstetricians and Gynecologist several years ago. There are bundles that address obstetric hypertension, hemorrhage, mental health, venous thromboembolism, opioid use, racial disparities, and other problems. They were developed by experts in the field and published in multiple journals. California and other states have issued toolkits on how to implement them based on local circumstances.

The goal is to standardize best practices nationwide to prevent maternal morbidity and mortality, Dr. Main said.

AIM bundle implementation is “what’s happening in New Mexico and a lot of states, mostly through the efforts of state level quality care collaboratives. Some [states] are further ahead than others,” said Eve Espey, MD, professor and chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, and president of the New Mexico PQC.

“Most states now have a [MMRC] that collects maternal mortality and near-miss data. Those data are used by the action arm,” which is the PQC. “If the review committee says” opioid use disorder is a significant contributor “like in our state, the collaborative rolls out the opioid use disorder bundle,” she said.

Beginning next January, the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, will require that accredited hospitals enact key elements of the AIM bundles for both obstetric hemorrhage and severe hypertension. “Everyone’s [now] motivated to get on that bandwagon,” Dr. Espey said.

“The bundles are here to stay,” and the Joint Commission requirements are “a really important step for sustainability and basic implementation. We really want to get them adopted everywhere,” said Dr. Main, who is also the national implementation director for the AIM initiative.

“The key thing is to work on implementing the hemorrhage and hypertension bundles in your hospital. I would suggest contacting [your] state” PQC, he said.

The California model

California, which has been working to reduce maternal mortality and morbidity since the mid 2000s, has produced among the strongest evidence to date that the efforts make a difference.

By 2013, the state had halved its maternal mortality rate to a 3-year average of 7 deaths per 100,000 live births, which is comparable with the average Western Europe rate of 7.2 deaths. Nationwide, the rate was about 17.4 deaths per 100,000 live births in 2018, according to the Centers for Disease Control and Prevention

The reasons are multifactorial, but “we think” the quality improvement efforts have been “an important contributor,” Dr. Main said.
 

Improvements especially for Black women

Among the success stories has been California’s implementation of the AIM obstetric hemorrhage bundle about 5 years ago. Among other steps, the 17 evidence-based recommendations included early recognition, immediate access to oxytocin and other medications, immediate access to a hemorrhage cart with instructions for intrauterine balloons and compression stitches, the establishment of a hemorrhage response protocol and team, and regular unit-based drills with debriefing sessions afterward.

Mentoring teams consisting of a physician and nurse with maternal quality improvement experience were created to help hospitals come on board, with each team working with five to eight hospitals. Efforts included monthly telephone calls and face-to-face meetings, and providers were held accountable for progress. Hospitals shared data and tips on implementation, under the aegis of the CMQCC.

When the baseline period of 2011-2014 to the postintervention period of October 2015 to December 2016 were compared, the rate of severe maternal morbidity from hemorrhage fell from 22.1% to 18.5% across 99 hospitals and 73,476 women.

The benefit among Black women exceeded that among White women, with a 9% absolute rate reduction versus 2.1%. “If you adjusted for risk factors, [we found] you could eliminate [racial differences] completely,” which is something that hadn’t been shown before. “This is a really big deal,” Dr. Main said, because the risk of maternal morbidity and mortality is three to four times higher among Black women, compared with White women.

Dr. Main and his team found that the biggest clinical risk factor that accounted for racial differences was a higher rate of cesarean deliveries among Black women, followed by higher rates of anemia at hospital admission. “If you have a C-section when you are anemic, you are going to have a transfusion,” he explained.

More recently, there’s been a push in California to reduce the rate of primary cesarean deliveries by enacting the associated AIM bundle with use of the same approach as with the hemorrhage bundle. Dr. Main and his team recently reported a rate reduction from 29.3% to 25% without compromising birth outcomes.

However, “some changes are easier than others. Hemorrhage was an easy one to change because it didn’t deal with physician autonomy as much, and you saw more immediate results” with fewer hemorrhages. Reducing cesarean delivery rates is “a bigger lift” because “it’s really changing the culture of labor and delivery. It involves more group pressure and more reinforcing, but we were able to do that,” he said.
 

Problems in the Show Me State

“We’ve patterned a lot” of what’s being done in New Mexico “after California,” Dr. Espey said.

The AIM hemorrhage bundle, for instance, is being rolled out to New Mexico hospitals, with the help of virtual meetings and mentoring programs, plus outreach to the Navajo and others reservations because, as with Black women, rates of maternal morbidity and mortality are higher among Native American women.

It’s been tougher going, however, in states such as Missouri, which recently ranked 44th in the country for maternal mortality.

“We started a little bit late, and we are a little bit behind,” said ob.gyn. Karen L. Florio, DO, at the University of Missouri–Kansas City and also a leader of the state MMRC and member of its PQC.

The main problem is money. California’s efforts are funded by the Centers for Disease Control and Prevention, the state health department, and hospitals, among others.

But Missouri is “not as well funded as California for our mortality review board, and our [PQC] is mostly not funded. If we could get that funding, we would have more resources to implement these AIM bundles,” she said.

In addition to the issue, Missouri didn’t expand Medicaid under the Accountable Care Act – something that’s been linked to reduced maternal morbidity and mortality – and there are entire rural areas with no maternity care. Plus after generations of mistreatment, “our African American population has a valid distrust of the medical system that contributes to maternal mortality,” she said.

Obesity-related heart disease is also prevalent in Missouri, even among young people. “I cannot tell you how many women I have had who have had a heart attack at the age of 30 and who have had stents placed,” Dr. Florio said.

Dr. Florio and her colleagues are currently using teleconferences and other means to roll out the AIM hypertension bundle but can do so only selectively. “We don’t have the resources to reach every single rural hospital all over the state,” she said; they are working to address the funding issues.
 

For rural hospitals, implementation is “daunting”

Meanwhile, rural hospitals have been a particular concern in South Dakota, said Kimberlee McKay, MD, an ob.gyn. who is the clinical vice president of the ob.gyn. service line at Avera Health, a hospital system based in Sioux Falls, S.D.

She’s been overseeing Avera’s implementation of the hypertension, hemorrhage, and venous thromboembolism bundles. “What’s hard is that” the AIM protocols come “out of academic centers. Implementation of complex algorithms is daunting” for hospitals that only do a couple hundred deliveries a year, she said.

For small hospitals, the approach she’s found that works is to first assess what they can offer, and then have them “do what’s reasonable” for their resources. The second part is making sure high-risk women get to a regional center – with an adequate blood supply, in the case of hemorrhage, for instance – for complications. Dr. McKay and colleagues are working on a system by which regional centers can monitor smaller hospitals for potential maternity problems, and contact them proactively before they emerge.

They’ve also made access to hemorrhage and hypertension drugs easier on labor and delivery units with the help of close-by dedicated medicine boxes, and standardized protocols and order sets across Avera. “We try to make the right thing the easy thing to do,” Dr. McKay said.

Dr. Espey is an editorial adviser for Ob.Gyn. News. The physicians have no relevant financial disclosures.

aotto@mdedge.com

“Anytime you have a maternal death, it sticks with you for life,” said Elliott Main, MD, a maternal fetal medicine specialist at Stanford (Calif.) University and one of the nation’s leaders in combating maternal mortality.

Courtesy Dr. Elliott Main

Dr. Main has had two maternal deaths in his career, years ago. One woman had a fatal stroke because of severe hypertension, and another died of cardiac complications. “We tried to do everything we possibly could, but you scrounge your memory for years and years [afterward]. To have a young healthy person go into labor and delivery and not come out is a tragedy at all levels. It charged me to not ever want to see that happen again,” he said.

Today, Dr. Main is the medical director of the California Maternal Quality Care Collaborative (CMQCC), a wide-ranging group of clinicians, state officials, hospitals, and others who have come together to address the issue. About 30 states have similar perinatal quality collaboratives (PQCs), and other states are forming them.

They work in collaboration with maternal mortality review committees (MMRCs), state-level groups that review maternal deaths, identify problems to address, and make recommendations to the quality collaboratives on how to prevent maternal deaths.

About 600-800 women die in the United States each year due to pregnancy-related complications, which ranks the United States behind other industrialized nations. Leading causes include hemorrhage and hemorrhagic strokes secondary to hypertension. It’s estimated that the majority of maternal deaths could be prevented with proper care.

To that end, states are enacting safety bundles from the Alliance for Innovation on Maternal Health (AIM), which was established by the American College of Obstetricians and Gynecologist several years ago. There are bundles that address obstetric hypertension, hemorrhage, mental health, venous thromboembolism, opioid use, racial disparities, and other problems. They were developed by experts in the field and published in multiple journals. California and other states have issued toolkits on how to implement them based on local circumstances.

The goal is to standardize best practices nationwide to prevent maternal morbidity and mortality, Dr. Main said.

AIM bundle implementation is “what’s happening in New Mexico and a lot of states, mostly through the efforts of state level quality care collaboratives. Some [states] are further ahead than others,” said Eve Espey, MD, professor and chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, and president of the New Mexico PQC.

“Most states now have a [MMRC] that collects maternal mortality and near-miss data. Those data are used by the action arm,” which is the PQC. “If the review committee says” opioid use disorder is a significant contributor “like in our state, the collaborative rolls out the opioid use disorder bundle,” she said.

Beginning next January, the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, will require that accredited hospitals enact key elements of the AIM bundles for both obstetric hemorrhage and severe hypertension. “Everyone’s [now] motivated to get on that bandwagon,” Dr. Espey said.

“The bundles are here to stay,” and the Joint Commission requirements are “a really important step for sustainability and basic implementation. We really want to get them adopted everywhere,” said Dr. Main, who is also the national implementation director for the AIM initiative.

“The key thing is to work on implementing the hemorrhage and hypertension bundles in your hospital. I would suggest contacting [your] state” PQC, he said.

The California model

California, which has been working to reduce maternal mortality and morbidity since the mid 2000s, has produced among the strongest evidence to date that the efforts make a difference.

By 2013, the state had halved its maternal mortality rate to a 3-year average of 7 deaths per 100,000 live births, which is comparable with the average Western Europe rate of 7.2 deaths. Nationwide, the rate was about 17.4 deaths per 100,000 live births in 2018, according to the Centers for Disease Control and Prevention

The reasons are multifactorial, but “we think” the quality improvement efforts have been “an important contributor,” Dr. Main said.
 

Improvements especially for Black women

Among the success stories has been California’s implementation of the AIM obstetric hemorrhage bundle about 5 years ago. Among other steps, the 17 evidence-based recommendations included early recognition, immediate access to oxytocin and other medications, immediate access to a hemorrhage cart with instructions for intrauterine balloons and compression stitches, the establishment of a hemorrhage response protocol and team, and regular unit-based drills with debriefing sessions afterward.

Mentoring teams consisting of a physician and nurse with maternal quality improvement experience were created to help hospitals come on board, with each team working with five to eight hospitals. Efforts included monthly telephone calls and face-to-face meetings, and providers were held accountable for progress. Hospitals shared data and tips on implementation, under the aegis of the CMQCC.

When the baseline period of 2011-2014 to the postintervention period of October 2015 to December 2016 were compared, the rate of severe maternal morbidity from hemorrhage fell from 22.1% to 18.5% across 99 hospitals and 73,476 women.

The benefit among Black women exceeded that among White women, with a 9% absolute rate reduction versus 2.1%. “If you adjusted for risk factors, [we found] you could eliminate [racial differences] completely,” which is something that hadn’t been shown before. “This is a really big deal,” Dr. Main said, because the risk of maternal morbidity and mortality is three to four times higher among Black women, compared with White women.

Dr. Main and his team found that the biggest clinical risk factor that accounted for racial differences was a higher rate of cesarean deliveries among Black women, followed by higher rates of anemia at hospital admission. “If you have a C-section when you are anemic, you are going to have a transfusion,” he explained.

More recently, there’s been a push in California to reduce the rate of primary cesarean deliveries by enacting the associated AIM bundle with use of the same approach as with the hemorrhage bundle. Dr. Main and his team recently reported a rate reduction from 29.3% to 25% without compromising birth outcomes.

However, “some changes are easier than others. Hemorrhage was an easy one to change because it didn’t deal with physician autonomy as much, and you saw more immediate results” with fewer hemorrhages. Reducing cesarean delivery rates is “a bigger lift” because “it’s really changing the culture of labor and delivery. It involves more group pressure and more reinforcing, but we were able to do that,” he said.
 

Problems in the Show Me State

“We’ve patterned a lot” of what’s being done in New Mexico “after California,” Dr. Espey said.

The AIM hemorrhage bundle, for instance, is being rolled out to New Mexico hospitals, with the help of virtual meetings and mentoring programs, plus outreach to the Navajo and others reservations because, as with Black women, rates of maternal morbidity and mortality are higher among Native American women.

It’s been tougher going, however, in states such as Missouri, which recently ranked 44th in the country for maternal mortality.

“We started a little bit late, and we are a little bit behind,” said ob.gyn. Karen L. Florio, DO, at the University of Missouri–Kansas City and also a leader of the state MMRC and member of its PQC.

The main problem is money. California’s efforts are funded by the Centers for Disease Control and Prevention, the state health department, and hospitals, among others.

But Missouri is “not as well funded as California for our mortality review board, and our [PQC] is mostly not funded. If we could get that funding, we would have more resources to implement these AIM bundles,” she said.

In addition to the issue, Missouri didn’t expand Medicaid under the Accountable Care Act – something that’s been linked to reduced maternal morbidity and mortality – and there are entire rural areas with no maternity care. Plus after generations of mistreatment, “our African American population has a valid distrust of the medical system that contributes to maternal mortality,” she said.

Obesity-related heart disease is also prevalent in Missouri, even among young people. “I cannot tell you how many women I have had who have had a heart attack at the age of 30 and who have had stents placed,” Dr. Florio said.

Dr. Florio and her colleagues are currently using teleconferences and other means to roll out the AIM hypertension bundle but can do so only selectively. “We don’t have the resources to reach every single rural hospital all over the state,” she said; they are working to address the funding issues.
 

For rural hospitals, implementation is “daunting”

Meanwhile, rural hospitals have been a particular concern in South Dakota, said Kimberlee McKay, MD, an ob.gyn. who is the clinical vice president of the ob.gyn. service line at Avera Health, a hospital system based in Sioux Falls, S.D.

She’s been overseeing Avera’s implementation of the hypertension, hemorrhage, and venous thromboembolism bundles. “What’s hard is that” the AIM protocols come “out of academic centers. Implementation of complex algorithms is daunting” for hospitals that only do a couple hundred deliveries a year, she said.

For small hospitals, the approach she’s found that works is to first assess what they can offer, and then have them “do what’s reasonable” for their resources. The second part is making sure high-risk women get to a regional center – with an adequate blood supply, in the case of hemorrhage, for instance – for complications. Dr. McKay and colleagues are working on a system by which regional centers can monitor smaller hospitals for potential maternity problems, and contact them proactively before they emerge.

They’ve also made access to hemorrhage and hypertension drugs easier on labor and delivery units with the help of close-by dedicated medicine boxes, and standardized protocols and order sets across Avera. “We try to make the right thing the easy thing to do,” Dr. McKay said.

Dr. Espey is an editorial adviser for Ob.Gyn. News. The physicians have no relevant financial disclosures.

aotto@mdedge.com

This is the second of a two-part article on the role of racism and bias in the U.S. maternal mortality crisis and part of an ongoing Ob.Gyn. News feature series on the crisis. Part one of the story explored existing data, societal factors, and patient experiences related to structural racism, overt racism, and implicit bias as factors contributing to racial disparities in maternal outcomes. Here we explore potential solutions for addressing the inequities as proposed by thought leaders and key stakeholders.



The emerging racial disparities in COVID-19 incidence and outcomes in the United States are on a collision course with long-standing racial disparities in U.S. maternal care and mortality.

Maternal health advocates are bracing for the impact, but in the spotlight that the pandemic is training on the inequities and the health system changes taking shape in its wake, some also see hope for a shift in at least one important driver of the racial health disparities: access to care.

Non-Hispanic black women are at least three times more likely than Hispanic women and non-Hispanic white women to experience pregnancy-related death, and indigenous women are more than twice as likely, according to the latest data from the Centers for Disease Control and Prevention’s National Center for Health Statistics. The added strain COVID-19 is putting on the system stands to further limit the access to care that many pregnant women of color experience and to exacerbate racial disparities, panelists agreed during a recent National Maternal Health Patient Centered Outcomes Research Network webinar entitled “The Impact of COVID-19 on Black, Brown, and Native Pregnant People.”

“The saying is that ‘the virus doesn’t discriminate,’ but it understands our biases, right? So, the virus takes advantage of the weaknesses in our system,” said panelist Joia A. Crear-Perry, MD, an ob.gyn. and founder and president of the National Birth Equity Collaborative (NBEC), a New Orleans–based research, training, and advocacy organization working to optimize black maternal and infant health.
 

Hope for solutions from the ashes of a pandemic

The weaknesses in the system that Dr. Crear-Perry spoke of are in many ways a product of structural racism as described in a conceptual report in The Lancet, titled “America: Equity and Equality in Health,” which dug into the entrenched and tangled historical roots of racist sociological and political factors that formed a foundation for health inequity over time.

Today, people of color remain more likely to be excluded from access to health insurance and adequate health care. The authors defined structural racism as “the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice.” Today, largely as a result of these “reinforcing systems,” people of color remain more likely to be excluded from access to health insurance and adequate health care. At the same time, and for the same reasons, they are more likely to work in the service industry, be essential workers, and use mass transit, each of which increases the risk of exposure to COVID-19, Dr. Crear-Perry explained.

“It’s important for us to know that, for maternal mortality, it’s the same thing that happens,” she said. That means the focus on COVID-19–related disparities helps magnify and elevate the conversation regarding similar disparities in maternal outcomes.

It also means that some of the care delivery solutions embraced and facilitated amid the pandemic, such as extension of Medicaid coverage for up to a year after giving birth and broader use and insurance coverage of telemedicine, could finally gain traction; those are solutions long-sought by advocates like Dr. Crear-Perry and others as a means for alleviating racial disparities in maternal outcomes and addressing the maternal mortality crisis.

Therein lies the hope, she explained in an interview. “Some of the policies that we know would have been helpful prior to COVID-19 now are being seen as really important.”
 

Solution: Extending coverage

During a May 7 virtual Congressional hearing on “America’s Two Public Health Crises: The Impact of COVID-19 on Racial Inequities and Maternal Mortality in the U.S.,” cosponsored by the American College of Obstetricians and Gynecologists, the March of Dimes, and the NBEC, Dr. Crear-Perry further explained the importance of extended coverage and care access.

Asked what Congress could do immediately to “ensure that the pandemic does not compound the nation’s maternal mortality crisis, including unacceptable rates among black women,” she didn’t hesitate.

“Well, it would be amazing if we could get Medicaid extended for 12 months post delivery,” she said. “As you can imagine right now, we have moms who are birthing in hospitals where they have to worry about, 2 months later, not having coverage for themselves.”

If that mom is exposed to COVID-19 and has no insurance coverage and a newborn at home, the likelihood that she will call a provider if she develops symptoms is low, Dr. Crear-Perry said. “This is a great opportunity for us to really rethink some of those policies that we know are barriers, that we have created for people to be able to thrive after they have a baby and during child birth.”

Current policies are centered around an arbitrary cutoff of about 6 weeks for postpartum care, but the CDC reports that a third of all postpartum deaths occur between 1 week and 12 months after birth.

“We need our policies to reflect the current knowledge and the science,” she said. “Just like babies have automatic insurance coverage for a year later, mothers should have the same.”

Medicaid finances nearly half of all births in the United States, according to a 2019 Kaiser Family Foundation brief, which explained that federal law requires Medicaid coverage for only 60 days post partum for women who are eligible. Decisions regarding coverage after 60 days are determined by individual states; those that expanded Medicaid under the Affordable Care Act typically allow extended coverage – but only with reapplication at 60 days.

Many women in nonexpansion states become uninsured after pregnancy-related coverage ends, as do some in expansion states for whom reapplying is a hurdle too high to clear with a newborn baby to care for at home, Dr. Crear-Perry said.

Addressing these coverage gaps is key to improving access, and it is a core component of the Black Maternal Health Momnibus Act of 2020, a nine-bill package introduced in March by Rep. Lauren Underwood (D-Ill.), Rep. Alma Adams (D-N.C.), Sen. Kamala Harris (D-Calif.), and members of the Black Maternal Health Caucus to “fill gaps in existing legislation to comprehensively address every dimension of the Black maternal health crisis in America.”

One bill in the package addresses extended coverage with a goal to “promote innovative payment models to incentivize high-quality maternity care and continuity of health insurance coverage from pregnancy through labor and delivery and up to 1 year post partum.” Another focuses on promoting alternative ways to access care, such as through telemedicine.

Solution: Expanding care access

“There is a need for the democratization of care,” Dr. Crear-Perry said. “There is a need for people to have more ways to get care. This idea that the only way you can get prenatal care is you have to come to me at my office, has been a burden for working people for a long, long time.”

The COVID-19 pandemic necessitates increased use of telemedicine, but building blocks to allow patients to use it effectively must be put in place, she said. That means expanding broadband access, providing patients with blood pressure cuffs and other tools for use remotely, and expanding reimbursement to include not just video, but also phone calls.

Heart Safe Motherhood, a University of Pennsylvania text-based intervention developed to address postpartum hypertension – a leading cause of maternal morbidity and mortality, and at the start of the program, the leading cause of 7-day readmissions among obstetric patients, demonstrated the value of such approaches to care.

The program involves remote blood pressure monitoring using a digital monitor provided to at-risk patients at discharge. Text-based monitoring reminders encourage patients to check their blood pressure twice daily for the first 7 days.

“In our randomized, controlled trial, we saw our ability to meet ACOG guidelines on postpartum blood monitoring leap from 0% to 82%, compared to in-person office visits and 7-day readmissions from hypertension drop from 3% to 0%,” an update at the program website states.

ACOG

Rebekah Gee, MD, an ob.gyn. and director of the Louisiana State University Health System in New Orleans, also noted the importance of finding ways to deliver care “that are outside the traditional norm.

“Telemedicine, home visiting ... I think there are a wide variety of ways,” she said, noting that these kind of approaches not only help circumvent roadblocks to care, such as lack of transportation, but also can feel more personal and approachable for some women.
 

Solution: Measuring, investing, diversifying, respecting

The aims of other bills in the Momnibus Act also mirror several solutions proposed by maternal health advocates interviewed for this article. Among them are:

• Development of improved data collection processes and quality measures to better understand the factors that contribute to the crisis overall and among special populations, and to inform solutions for addressing them.
• Investments in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition.
• Commitment to the growth and diversification of the perinatal workforce to ensure that every mom receives maternity care and support from people she can trust to provide quality care and treat her with respect.

The latter is one that Dr. Gee, Dr. Crear-Perry, and others particularly emphasized.

“We need patient advocates like doulas, midwives and others who are better listeners and better able to advocate for patients,” Dr. Gee said. This would better allow for women’s desires in the childbirth experience to be addressed appropriately, she said, adding that this is something that “frankly, a lot of doctors do not have the time to do.”

That’s why the efforts to address maternal mortality have to focus on the health care system, not just on doctors’ behavior with respect to bias, she said.

Dr. Gee also said there is a need for culturally appropriate literacy and numeracy communications “that respect how people seek and understand information.” This varies by population, which is why it’s important to provide the same approach to care “no matter what the patient looks like,” while also understanding that different patients communicate in different ways.

A 2019 study published in Social Science & Medicine underscored how communication differences can affect outcomes; using a national sample of women who gave birth in U.S. hospitals, the authors found that those who had declined care for themselves or their infant during their childbirth hospitalization were more likely to report receiving poor treatment based on race or ethnicity. They concluded that, in the context of childbirth care, women – particularly black women – pay a penalty for what is perceived as uncooperative behavior.

This is another area where doulas and other patient advocates can help, Dr. Gee said.

Doulas have long been an integral part of the birthing process for many women, particularly women of color, and evidence suggests the supportive care they provide helps to improve outcomes. In fact, several states – including Oregon, Minnesota, and New York, among others – have expanded or have proposed expanding Medicaid coverage to include doula services for pregnant beneficiaries, a move cheered by doula associations and other maternal health advocates.

In many ways, it’s about “respectful maternity care,” which is something Dr. Crear-Perry has been working to promote through the NBEC in partnership with ACOG and the Robert Wood Johnson Foundation. It’s also something the World Health Organization has promoted by establishing global standards for such care.

“We’re hoping to socialize that as a norm in United States ... to really see what it would look like to value what birthing people want and to see them as partners in their birth,” she said.

However, the 2019 Giving Voice to Mothers study demonstrating consistently higher rates of mistreatment during obstetrical care for women of color than for comparable white women shows that the United States is falling short of those standards. The national study of 2,700 women examined how race, ethnicity, and place of birth interact with the experience of receiving maternity care in the United States, and showed that 1 in 6 experienced one or more types of mistreatment – with consistently higher rates among women of color, even after adjusting for interactions between race and other maternal characteristics, Saraswathi Veda, MD, of the Birth Place Lab and professor of midwifery at the University of British Columbia, Vancouver, and colleagues reported in Reproductive Health.
 

Solution: Listening, learning, reflecting, partnering

Timoria McQueen Saba, birth trauma survivor and maternal health advocate, has described experiencing instances of mistreatment throughout her obstetric care, and like Dr. Crear-Perry, she said trust and collaboration in care is imperative for improving outcomes.

“I think the most important thing you can do is really consider a patient a partner in the care you give them,” she said during a panel discussion at the 2019 ACOG annual meeting. “You’re not experts in their lived experience ... center a patient’s voice or the voice of a patient’s family. Incorporate that into your learning.”

During a virtual workshop held May 19-20 by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Judette Louis, MD, chair of the department of obstetrics and gynecology at the University of South Florida, Tampa, and president of the Society of Maternal-Fetal Medicine, provided practical guidance for addressing racism and implicit bias in practice and in research to reduce disparities in outcomes.

In an interview, she summarized her key points, reiterating solutions proposed by Dr. Gee and Dr. Crear-Perry and addressed in the Momnibus Act, and also offering a few others:

First, put aside the notion that disparities are genetically driven. For a variety of reasons, that just doesn’t make sense. For one thing, not all blacks are African American.

“My family is from the Caribbean,” she said. “Is it really conceivable that we’re all so similar?”

Look also at the disparities among Native Americans, she said. “How can you take 500 distinct tribes that live across a wide geographic area and lump them into one group and assume that they are similar?”

The problem is racism, not race. “When you keep saying ‘it’s about race, it’s about race, it’s about race’ – that sends a message to the person who is of that race that there is something inherently broken about [them],” she said.

Recognize that the roots of the problem run deep. Learn about and support efforts to address the underlying structural factors that contribute to the problem, Dr. Louis emphasized, and recognize your own bias. “We all have it. The key is to recognize [biases] and mitigate them when taking care of patients.”

That’s easier said than done, at least judging by one survey of maternal-fetal medicine specialists in which 84% of respondents agreed that disparities impact practice, but only 29% agreed their own personal biases affect how they care for patients, she noted.

Tools are available to help individuals identify implicit bias, and training programs for health care providers can help, as well, she said. Implicit bias tests and training programs that help to identify and address bias and racism on individual and organizational levels are increasingly available through academic centers, health systems, and advocacy organizations.

Hope for solutions: Progress and promise

Like Dr. Crear-Perry, Dr. Louis sees hope for reducing disparities and improving maternal outcomes.

In another survey of SMFM members to identify the practice issues most important to them, racial disparities ranked in the top three.

“It says a lot that our [maternal-fetal medicine specialists] really see this as a problem and they want it fixed,” she said. “And I think it says that a lot of people need to work on this, not just us.”

Indeed, many are engaged in that work. Veronica Gillispie, MD, medical director of the Louisiana Perinatal Quality Collaborative and Pregnancy-Associated Mortality Review, has been instrumental in recent initiatives to improve maternal outcomes in Louisiana, and she too said she feels optimistic.

“I am hopeful and I do see signs of hope,” she said in an interview.

Teams that she works with and trains seem invested, institutions are increasingly implementing faculty training on racism and bias, and Oschner Health, where Dr. Gillispie practices as an ob.gyn., appointed its first chief diversity officer in February.

Medical students she works with are attuned to the issues of racism, bias, and disparities, and they show a desire to enact change, she said. “They already get it, and they are working to make it better.”

Dr. Crear-Perry also predicts practice-changing results from studies looking at the delivery of obstetrical care and the role of supportive care, and she pointed out another aspect of the COVID-19 crisis that provides an important lesson for health care providers who care for birthing people: the scarcity of personal protective equipment amid the pandemic.

“My friends who are ob.gyns., who are now not getting access to the things they need to stay safe to practice medicine and who are feeling very marginalized at this moment, feeling not valued – that’s how birthing people [of color] feel,” she said. “I’m hoping that builds a sense of empathy.

”I’m hoping at the end of this crisis, that those ob.gyns. will think of patients as allies in fighting for more access to health for everybody and for more resources to do their work,” Dr. Crear-Perry said. “We’re all in this together.”

sworcester@mdedge.com

This is the second of a two-part article on the role of racism and bias in the U.S. maternal mortality crisis and part of an ongoing Ob.Gyn. News feature series on the crisis. Part one of the story explored existing data, societal factors, and patient experiences related to structural racism, overt racism, and implicit bias as factors contributing to racial disparities in maternal outcomes. Here we explore potential solutions for addressing the inequities as proposed by thought leaders and key stakeholders.



The emerging racial disparities in COVID-19 incidence and outcomes in the United States are on a collision course with long-standing racial disparities in U.S. maternal care and mortality.

Maternal health advocates are bracing for the impact, but in the spotlight that the pandemic is training on the inequities and the health system changes taking shape in its wake, some also see hope for a shift in at least one important driver of the racial health disparities: access to care.

Non-Hispanic black women are at least three times more likely than Hispanic women and non-Hispanic white women to experience pregnancy-related death, and indigenous women are more than twice as likely, according to the latest data from the Centers for Disease Control and Prevention’s National Center for Health Statistics. The added strain COVID-19 is putting on the system stands to further limit the access to care that many pregnant women of color experience and to exacerbate racial disparities, panelists agreed during a recent National Maternal Health Patient Centered Outcomes Research Network webinar entitled “The Impact of COVID-19 on Black, Brown, and Native Pregnant People.”

“The saying is that ‘the virus doesn’t discriminate,’ but it understands our biases, right? So, the virus takes advantage of the weaknesses in our system,” said panelist Joia A. Crear-Perry, MD, an ob.gyn. and founder and president of the National Birth Equity Collaborative (NBEC), a New Orleans–based research, training, and advocacy organization working to optimize black maternal and infant health.
 

Hope for solutions from the ashes of a pandemic

The weaknesses in the system that Dr. Crear-Perry spoke of are in many ways a product of structural racism as described in a conceptual report in The Lancet, titled “America: Equity and Equality in Health,” which dug into the entrenched and tangled historical roots of racist sociological and political factors that formed a foundation for health inequity over time.

Today, people of color remain more likely to be excluded from access to health insurance and adequate health care. The authors defined structural racism as “the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice.” Today, largely as a result of these “reinforcing systems,” people of color remain more likely to be excluded from access to health insurance and adequate health care. At the same time, and for the same reasons, they are more likely to work in the service industry, be essential workers, and use mass transit, each of which increases the risk of exposure to COVID-19, Dr. Crear-Perry explained.

“It’s important for us to know that, for maternal mortality, it’s the same thing that happens,” she said. That means the focus on COVID-19–related disparities helps magnify and elevate the conversation regarding similar disparities in maternal outcomes.

It also means that some of the care delivery solutions embraced and facilitated amid the pandemic, such as extension of Medicaid coverage for up to a year after giving birth and broader use and insurance coverage of telemedicine, could finally gain traction; those are solutions long-sought by advocates like Dr. Crear-Perry and others as a means for alleviating racial disparities in maternal outcomes and addressing the maternal mortality crisis.

Therein lies the hope, she explained in an interview. “Some of the policies that we know would have been helpful prior to COVID-19 now are being seen as really important.”
 

Solution: Extending coverage

During a May 7 virtual Congressional hearing on “America’s Two Public Health Crises: The Impact of COVID-19 on Racial Inequities and Maternal Mortality in the U.S.,” cosponsored by the American College of Obstetricians and Gynecologists, the March of Dimes, and the NBEC, Dr. Crear-Perry further explained the importance of extended coverage and care access.

Asked what Congress could do immediately to “ensure that the pandemic does not compound the nation’s maternal mortality crisis, including unacceptable rates among black women,” she didn’t hesitate.

“Well, it would be amazing if we could get Medicaid extended for 12 months post delivery,” she said. “As you can imagine right now, we have moms who are birthing in hospitals where they have to worry about, 2 months later, not having coverage for themselves.”

If that mom is exposed to COVID-19 and has no insurance coverage and a newborn at home, the likelihood that she will call a provider if she develops symptoms is low, Dr. Crear-Perry said. “This is a great opportunity for us to really rethink some of those policies that we know are barriers, that we have created for people to be able to thrive after they have a baby and during child birth.”

Current policies are centered around an arbitrary cutoff of about 6 weeks for postpartum care, but the CDC reports that a third of all postpartum deaths occur between 1 week and 12 months after birth.

“We need our policies to reflect the current knowledge and the science,” she said. “Just like babies have automatic insurance coverage for a year later, mothers should have the same.”

Medicaid finances nearly half of all births in the United States, according to a 2019 Kaiser Family Foundation brief, which explained that federal law requires Medicaid coverage for only 60 days post partum for women who are eligible. Decisions regarding coverage after 60 days are determined by individual states; those that expanded Medicaid under the Affordable Care Act typically allow extended coverage – but only with reapplication at 60 days.

Many women in nonexpansion states become uninsured after pregnancy-related coverage ends, as do some in expansion states for whom reapplying is a hurdle too high to clear with a newborn baby to care for at home, Dr. Crear-Perry said.

Addressing these coverage gaps is key to improving access, and it is a core component of the Black Maternal Health Momnibus Act of 2020, a nine-bill package introduced in March by Rep. Lauren Underwood (D-Ill.), Rep. Alma Adams (D-N.C.), Sen. Kamala Harris (D-Calif.), and members of the Black Maternal Health Caucus to “fill gaps in existing legislation to comprehensively address every dimension of the Black maternal health crisis in America.”

One bill in the package addresses extended coverage with a goal to “promote innovative payment models to incentivize high-quality maternity care and continuity of health insurance coverage from pregnancy through labor and delivery and up to 1 year post partum.” Another focuses on promoting alternative ways to access care, such as through telemedicine.

Solution: Expanding care access

“There is a need for the democratization of care,” Dr. Crear-Perry said. “There is a need for people to have more ways to get care. This idea that the only way you can get prenatal care is you have to come to me at my office, has been a burden for working people for a long, long time.”

The COVID-19 pandemic necessitates increased use of telemedicine, but building blocks to allow patients to use it effectively must be put in place, she said. That means expanding broadband access, providing patients with blood pressure cuffs and other tools for use remotely, and expanding reimbursement to include not just video, but also phone calls.

Heart Safe Motherhood, a University of Pennsylvania text-based intervention developed to address postpartum hypertension – a leading cause of maternal morbidity and mortality, and at the start of the program, the leading cause of 7-day readmissions among obstetric patients, demonstrated the value of such approaches to care.

The program involves remote blood pressure monitoring using a digital monitor provided to at-risk patients at discharge. Text-based monitoring reminders encourage patients to check their blood pressure twice daily for the first 7 days.

“In our randomized, controlled trial, we saw our ability to meet ACOG guidelines on postpartum blood monitoring leap from 0% to 82%, compared to in-person office visits and 7-day readmissions from hypertension drop from 3% to 0%,” an update at the program website states.

ACOG

Rebekah Gee, MD, an ob.gyn. and director of the Louisiana State University Health System in New Orleans, also noted the importance of finding ways to deliver care “that are outside the traditional norm.

“Telemedicine, home visiting ... I think there are a wide variety of ways,” she said, noting that these kind of approaches not only help circumvent roadblocks to care, such as lack of transportation, but also can feel more personal and approachable for some women.
 

Solution: Measuring, investing, diversifying, respecting

The aims of other bills in the Momnibus Act also mirror several solutions proposed by maternal health advocates interviewed for this article. Among them are:

• Development of improved data collection processes and quality measures to better understand the factors that contribute to the crisis overall and among special populations, and to inform solutions for addressing them.
• Investments in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition.
• Commitment to the growth and diversification of the perinatal workforce to ensure that every mom receives maternity care and support from people she can trust to provide quality care and treat her with respect.

The latter is one that Dr. Gee, Dr. Crear-Perry, and others particularly emphasized.

“We need patient advocates like doulas, midwives and others who are better listeners and better able to advocate for patients,” Dr. Gee said. This would better allow for women’s desires in the childbirth experience to be addressed appropriately, she said, adding that this is something that “frankly, a lot of doctors do not have the time to do.”

That’s why the efforts to address maternal mortality have to focus on the health care system, not just on doctors’ behavior with respect to bias, she said.

Dr. Gee also said there is a need for culturally appropriate literacy and numeracy communications “that respect how people seek and understand information.” This varies by population, which is why it’s important to provide the same approach to care “no matter what the patient looks like,” while also understanding that different patients communicate in different ways.

A 2019 study published in Social Science & Medicine underscored how communication differences can affect outcomes; using a national sample of women who gave birth in U.S. hospitals, the authors found that those who had declined care for themselves or their infant during their childbirth hospitalization were more likely to report receiving poor treatment based on race or ethnicity. They concluded that, in the context of childbirth care, women – particularly black women – pay a penalty for what is perceived as uncooperative behavior.

This is another area where doulas and other patient advocates can help, Dr. Gee said.

Doulas have long been an integral part of the birthing process for many women, particularly women of color, and evidence suggests the supportive care they provide helps to improve outcomes. In fact, several states – including Oregon, Minnesota, and New York, among others – have expanded or have proposed expanding Medicaid coverage to include doula services for pregnant beneficiaries, a move cheered by doula associations and other maternal health advocates.

In many ways, it’s about “respectful maternity care,” which is something Dr. Crear-Perry has been working to promote through the NBEC in partnership with ACOG and the Robert Wood Johnson Foundation. It’s also something the World Health Organization has promoted by establishing global standards for such care.

“We’re hoping to socialize that as a norm in United States ... to really see what it would look like to value what birthing people want and to see them as partners in their birth,” she said.

However, the 2019 Giving Voice to Mothers study demonstrating consistently higher rates of mistreatment during obstetrical care for women of color than for comparable white women shows that the United States is falling short of those standards. The national study of 2,700 women examined how race, ethnicity, and place of birth interact with the experience of receiving maternity care in the United States, and showed that 1 in 6 experienced one or more types of mistreatment – with consistently higher rates among women of color, even after adjusting for interactions between race and other maternal characteristics, Saraswathi Veda, MD, of the Birth Place Lab and professor of midwifery at the University of British Columbia, Vancouver, and colleagues reported in Reproductive Health.
 

Solution: Listening, learning, reflecting, partnering

Timoria McQueen Saba, birth trauma survivor and maternal health advocate, has described experiencing instances of mistreatment throughout her obstetric care, and like Dr. Crear-Perry, she said trust and collaboration in care is imperative for improving outcomes.

“I think the most important thing you can do is really consider a patient a partner in the care you give them,” she said during a panel discussion at the 2019 ACOG annual meeting. “You’re not experts in their lived experience ... center a patient’s voice or the voice of a patient’s family. Incorporate that into your learning.”

During a virtual workshop held May 19-20 by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Judette Louis, MD, chair of the department of obstetrics and gynecology at the University of South Florida, Tampa, and president of the Society of Maternal-Fetal Medicine, provided practical guidance for addressing racism and implicit bias in practice and in research to reduce disparities in outcomes.

In an interview, she summarized her key points, reiterating solutions proposed by Dr. Gee and Dr. Crear-Perry and addressed in the Momnibus Act, and also offering a few others:

First, put aside the notion that disparities are genetically driven. For a variety of reasons, that just doesn’t make sense. For one thing, not all blacks are African American.

“My family is from the Caribbean,” she said. “Is it really conceivable that we’re all so similar?”

Look also at the disparities among Native Americans, she said. “How can you take 500 distinct tribes that live across a wide geographic area and lump them into one group and assume that they are similar?”

The problem is racism, not race. “When you keep saying ‘it’s about race, it’s about race, it’s about race’ – that sends a message to the person who is of that race that there is something inherently broken about [them],” she said.

Recognize that the roots of the problem run deep. Learn about and support efforts to address the underlying structural factors that contribute to the problem, Dr. Louis emphasized, and recognize your own bias. “We all have it. The key is to recognize [biases] and mitigate them when taking care of patients.”

That’s easier said than done, at least judging by one survey of maternal-fetal medicine specialists in which 84% of respondents agreed that disparities impact practice, but only 29% agreed their own personal biases affect how they care for patients, she noted.

Tools are available to help individuals identify implicit bias, and training programs for health care providers can help, as well, she said. Implicit bias tests and training programs that help to identify and address bias and racism on individual and organizational levels are increasingly available through academic centers, health systems, and advocacy organizations.

Hope for solutions: Progress and promise

Like Dr. Crear-Perry, Dr. Louis sees hope for reducing disparities and improving maternal outcomes.

In another survey of SMFM members to identify the practice issues most important to them, racial disparities ranked in the top three.

“It says a lot that our [maternal-fetal medicine specialists] really see this as a problem and they want it fixed,” she said. “And I think it says that a lot of people need to work on this, not just us.”

Indeed, many are engaged in that work. Veronica Gillispie, MD, medical director of the Louisiana Perinatal Quality Collaborative and Pregnancy-Associated Mortality Review, has been instrumental in recent initiatives to improve maternal outcomes in Louisiana, and she too said she feels optimistic.

“I am hopeful and I do see signs of hope,” she said in an interview.

Teams that she works with and trains seem invested, institutions are increasingly implementing faculty training on racism and bias, and Oschner Health, where Dr. Gillispie practices as an ob.gyn., appointed its first chief diversity officer in February.

Medical students she works with are attuned to the issues of racism, bias, and disparities, and they show a desire to enact change, she said. “They already get it, and they are working to make it better.”

Dr. Crear-Perry also predicts practice-changing results from studies looking at the delivery of obstetrical care and the role of supportive care, and she pointed out another aspect of the COVID-19 crisis that provides an important lesson for health care providers who care for birthing people: the scarcity of personal protective equipment amid the pandemic.

“My friends who are ob.gyns., who are now not getting access to the things they need to stay safe to practice medicine and who are feeling very marginalized at this moment, feeling not valued – that’s how birthing people [of color] feel,” she said. “I’m hoping that builds a sense of empathy.

”I’m hoping at the end of this crisis, that those ob.gyns. will think of patients as allies in fighting for more access to health for everybody and for more resources to do their work,” Dr. Crear-Perry said. “We’re all in this together.”

sworcester@mdedge.com

This is the second of a two-part article on the role of racism and bias in the U.S. maternal mortality crisis and part of an ongoing Ob.Gyn. News feature series on the crisis. Part one of the story explored existing data, societal factors, and patient experiences related to structural racism, overt racism, and implicit bias as factors contributing to racial disparities in maternal outcomes. Here we explore potential solutions for addressing the inequities as proposed by thought leaders and key stakeholders.



The emerging racial disparities in COVID-19 incidence and outcomes in the United States are on a collision course with long-standing racial disparities in U.S. maternal care and mortality.

Maternal health advocates are bracing for the impact, but in the spotlight that the pandemic is training on the inequities and the health system changes taking shape in its wake, some also see hope for a shift in at least one important driver of the racial health disparities: access to care.

Non-Hispanic black women are at least three times more likely than Hispanic women and non-Hispanic white women to experience pregnancy-related death, and indigenous women are more than twice as likely, according to the latest data from the Centers for Disease Control and Prevention’s National Center for Health Statistics. The added strain COVID-19 is putting on the system stands to further limit the access to care that many pregnant women of color experience and to exacerbate racial disparities, panelists agreed during a recent National Maternal Health Patient Centered Outcomes Research Network webinar entitled “The Impact of COVID-19 on Black, Brown, and Native Pregnant People.”

“The saying is that ‘the virus doesn’t discriminate,’ but it understands our biases, right? So, the virus takes advantage of the weaknesses in our system,” said panelist Joia A. Crear-Perry, MD, an ob.gyn. and founder and president of the National Birth Equity Collaborative (NBEC), a New Orleans–based research, training, and advocacy organization working to optimize black maternal and infant health.
 

Hope for solutions from the ashes of a pandemic

The weaknesses in the system that Dr. Crear-Perry spoke of are in many ways a product of structural racism as described in a conceptual report in The Lancet, titled “America: Equity and Equality in Health,” which dug into the entrenched and tangled historical roots of racist sociological and political factors that formed a foundation for health inequity over time.

Today, people of color remain more likely to be excluded from access to health insurance and adequate health care. The authors defined structural racism as “the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice.” Today, largely as a result of these “reinforcing systems,” people of color remain more likely to be excluded from access to health insurance and adequate health care. At the same time, and for the same reasons, they are more likely to work in the service industry, be essential workers, and use mass transit, each of which increases the risk of exposure to COVID-19, Dr. Crear-Perry explained.

“It’s important for us to know that, for maternal mortality, it’s the same thing that happens,” she said. That means the focus on COVID-19–related disparities helps magnify and elevate the conversation regarding similar disparities in maternal outcomes.

It also means that some of the care delivery solutions embraced and facilitated amid the pandemic, such as extension of Medicaid coverage for up to a year after giving birth and broader use and insurance coverage of telemedicine, could finally gain traction; those are solutions long-sought by advocates like Dr. Crear-Perry and others as a means for alleviating racial disparities in maternal outcomes and addressing the maternal mortality crisis.

Therein lies the hope, she explained in an interview. “Some of the policies that we know would have been helpful prior to COVID-19 now are being seen as really important.”
 

Solution: Extending coverage

During a May 7 virtual Congressional hearing on “America’s Two Public Health Crises: The Impact of COVID-19 on Racial Inequities and Maternal Mortality in the U.S.,” cosponsored by the American College of Obstetricians and Gynecologists, the March of Dimes, and the NBEC, Dr. Crear-Perry further explained the importance of extended coverage and care access.

Asked what Congress could do immediately to “ensure that the pandemic does not compound the nation’s maternal mortality crisis, including unacceptable rates among black women,” she didn’t hesitate.

“Well, it would be amazing if we could get Medicaid extended for 12 months post delivery,” she said. “As you can imagine right now, we have moms who are birthing in hospitals where they have to worry about, 2 months later, not having coverage for themselves.”

If that mom is exposed to COVID-19 and has no insurance coverage and a newborn at home, the likelihood that she will call a provider if she develops symptoms is low, Dr. Crear-Perry said. “This is a great opportunity for us to really rethink some of those policies that we know are barriers, that we have created for people to be able to thrive after they have a baby and during child birth.”

Current policies are centered around an arbitrary cutoff of about 6 weeks for postpartum care, but the CDC reports that a third of all postpartum deaths occur between 1 week and 12 months after birth.

“We need our policies to reflect the current knowledge and the science,” she said. “Just like babies have automatic insurance coverage for a year later, mothers should have the same.”

Medicaid finances nearly half of all births in the United States, according to a 2019 Kaiser Family Foundation brief, which explained that federal law requires Medicaid coverage for only 60 days post partum for women who are eligible. Decisions regarding coverage after 60 days are determined by individual states; those that expanded Medicaid under the Affordable Care Act typically allow extended coverage – but only with reapplication at 60 days.

Many women in nonexpansion states become uninsured after pregnancy-related coverage ends, as do some in expansion states for whom reapplying is a hurdle too high to clear with a newborn baby to care for at home, Dr. Crear-Perry said.

Addressing these coverage gaps is key to improving access, and it is a core component of the Black Maternal Health Momnibus Act of 2020, a nine-bill package introduced in March by Rep. Lauren Underwood (D-Ill.), Rep. Alma Adams (D-N.C.), Sen. Kamala Harris (D-Calif.), and members of the Black Maternal Health Caucus to “fill gaps in existing legislation to comprehensively address every dimension of the Black maternal health crisis in America.”

One bill in the package addresses extended coverage with a goal to “promote innovative payment models to incentivize high-quality maternity care and continuity of health insurance coverage from pregnancy through labor and delivery and up to 1 year post partum.” Another focuses on promoting alternative ways to access care, such as through telemedicine.

Solution: Expanding care access

“There is a need for the democratization of care,” Dr. Crear-Perry said. “There is a need for people to have more ways to get care. This idea that the only way you can get prenatal care is you have to come to me at my office, has been a burden for working people for a long, long time.”

The COVID-19 pandemic necessitates increased use of telemedicine, but building blocks to allow patients to use it effectively must be put in place, she said. That means expanding broadband access, providing patients with blood pressure cuffs and other tools for use remotely, and expanding reimbursement to include not just video, but also phone calls.

Heart Safe Motherhood, a University of Pennsylvania text-based intervention developed to address postpartum hypertension – a leading cause of maternal morbidity and mortality, and at the start of the program, the leading cause of 7-day readmissions among obstetric patients, demonstrated the value of such approaches to care.

The program involves remote blood pressure monitoring using a digital monitor provided to at-risk patients at discharge. Text-based monitoring reminders encourage patients to check their blood pressure twice daily for the first 7 days.

“In our randomized, controlled trial, we saw our ability to meet ACOG guidelines on postpartum blood monitoring leap from 0% to 82%, compared to in-person office visits and 7-day readmissions from hypertension drop from 3% to 0%,” an update at the program website states.

ACOG

Rebekah Gee, MD, an ob.gyn. and director of the Louisiana State University Health System in New Orleans, also noted the importance of finding ways to deliver care “that are outside the traditional norm.

“Telemedicine, home visiting ... I think there are a wide variety of ways,” she said, noting that these kind of approaches not only help circumvent roadblocks to care, such as lack of transportation, but also can feel more personal and approachable for some women.
 

Solution: Measuring, investing, diversifying, respecting

The aims of other bills in the Momnibus Act also mirror several solutions proposed by maternal health advocates interviewed for this article. Among them are:

• Development of improved data collection processes and quality measures to better understand the factors that contribute to the crisis overall and among special populations, and to inform solutions for addressing them.
• Investments in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition.
• Commitment to the growth and diversification of the perinatal workforce to ensure that every mom receives maternity care and support from people she can trust to provide quality care and treat her with respect.

The latter is one that Dr. Gee, Dr. Crear-Perry, and others particularly emphasized.

“We need patient advocates like doulas, midwives and others who are better listeners and better able to advocate for patients,” Dr. Gee said. This would better allow for women’s desires in the childbirth experience to be addressed appropriately, she said, adding that this is something that “frankly, a lot of doctors do not have the time to do.”

That’s why the efforts to address maternal mortality have to focus on the health care system, not just on doctors’ behavior with respect to bias, she said.

Dr. Gee also said there is a need for culturally appropriate literacy and numeracy communications “that respect how people seek and understand information.” This varies by population, which is why it’s important to provide the same approach to care “no matter what the patient looks like,” while also understanding that different patients communicate in different ways.

A 2019 study published in Social Science & Medicine underscored how communication differences can affect outcomes; using a national sample of women who gave birth in U.S. hospitals, the authors found that those who had declined care for themselves or their infant during their childbirth hospitalization were more likely to report receiving poor treatment based on race or ethnicity. They concluded that, in the context of childbirth care, women – particularly black women – pay a penalty for what is perceived as uncooperative behavior.

This is another area where doulas and other patient advocates can help, Dr. Gee said.

Doulas have long been an integral part of the birthing process for many women, particularly women of color, and evidence suggests the supportive care they provide helps to improve outcomes. In fact, several states – including Oregon, Minnesota, and New York, among others – have expanded or have proposed expanding Medicaid coverage to include doula services for pregnant beneficiaries, a move cheered by doula associations and other maternal health advocates.

In many ways, it’s about “respectful maternity care,” which is something Dr. Crear-Perry has been working to promote through the NBEC in partnership with ACOG and the Robert Wood Johnson Foundation. It’s also something the World Health Organization has promoted by establishing global standards for such care.

“We’re hoping to socialize that as a norm in United States ... to really see what it would look like to value what birthing people want and to see them as partners in their birth,” she said.

However, the 2019 Giving Voice to Mothers study demonstrating consistently higher rates of mistreatment during obstetrical care for women of color than for comparable white women shows that the United States is falling short of those standards. The national study of 2,700 women examined how race, ethnicity, and place of birth interact with the experience of receiving maternity care in the United States, and showed that 1 in 6 experienced one or more types of mistreatment – with consistently higher rates among women of color, even after adjusting for interactions between race and other maternal characteristics, Saraswathi Veda, MD, of the Birth Place Lab and professor of midwifery at the University of British Columbia, Vancouver, and colleagues reported in Reproductive Health.
 

Solution: Listening, learning, reflecting, partnering

Timoria McQueen Saba, birth trauma survivor and maternal health advocate, has described experiencing instances of mistreatment throughout her obstetric care, and like Dr. Crear-Perry, she said trust and collaboration in care is imperative for improving outcomes.

“I think the most important thing you can do is really consider a patient a partner in the care you give them,” she said during a panel discussion at the 2019 ACOG annual meeting. “You’re not experts in their lived experience ... center a patient’s voice or the voice of a patient’s family. Incorporate that into your learning.”

During a virtual workshop held May 19-20 by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Judette Louis, MD, chair of the department of obstetrics and gynecology at the University of South Florida, Tampa, and president of the Society of Maternal-Fetal Medicine, provided practical guidance for addressing racism and implicit bias in practice and in research to reduce disparities in outcomes.

In an interview, she summarized her key points, reiterating solutions proposed by Dr. Gee and Dr. Crear-Perry and addressed in the Momnibus Act, and also offering a few others:

First, put aside the notion that disparities are genetically driven. For a variety of reasons, that just doesn’t make sense. For one thing, not all blacks are African American.

“My family is from the Caribbean,” she said. “Is it really conceivable that we’re all so similar?”

Look also at the disparities among Native Americans, she said. “How can you take 500 distinct tribes that live across a wide geographic area and lump them into one group and assume that they are similar?”

The problem is racism, not race. “When you keep saying ‘it’s about race, it’s about race, it’s about race’ – that sends a message to the person who is of that race that there is something inherently broken about [them],” she said.

Recognize that the roots of the problem run deep. Learn about and support efforts to address the underlying structural factors that contribute to the problem, Dr. Louis emphasized, and recognize your own bias. “We all have it. The key is to recognize [biases] and mitigate them when taking care of patients.”

That’s easier said than done, at least judging by one survey of maternal-fetal medicine specialists in which 84% of respondents agreed that disparities impact practice, but only 29% agreed their own personal biases affect how they care for patients, she noted.

Tools are available to help individuals identify implicit bias, and training programs for health care providers can help, as well, she said. Implicit bias tests and training programs that help to identify and address bias and racism on individual and organizational levels are increasingly available through academic centers, health systems, and advocacy organizations.

Hope for solutions: Progress and promise

Like Dr. Crear-Perry, Dr. Louis sees hope for reducing disparities and improving maternal outcomes.

In another survey of SMFM members to identify the practice issues most important to them, racial disparities ranked in the top three.

“It says a lot that our [maternal-fetal medicine specialists] really see this as a problem and they want it fixed,” she said. “And I think it says that a lot of people need to work on this, not just us.”

Indeed, many are engaged in that work. Veronica Gillispie, MD, medical director of the Louisiana Perinatal Quality Collaborative and Pregnancy-Associated Mortality Review, has been instrumental in recent initiatives to improve maternal outcomes in Louisiana, and she too said she feels optimistic.

“I am hopeful and I do see signs of hope,” she said in an interview.

Teams that she works with and trains seem invested, institutions are increasingly implementing faculty training on racism and bias, and Oschner Health, where Dr. Gillispie practices as an ob.gyn., appointed its first chief diversity officer in February.

Medical students she works with are attuned to the issues of racism, bias, and disparities, and they show a desire to enact change, she said. “They already get it, and they are working to make it better.”

Dr. Crear-Perry also predicts practice-changing results from studies looking at the delivery of obstetrical care and the role of supportive care, and she pointed out another aspect of the COVID-19 crisis that provides an important lesson for health care providers who care for birthing people: the scarcity of personal protective equipment amid the pandemic.

“My friends who are ob.gyns., who are now not getting access to the things they need to stay safe to practice medicine and who are feeling very marginalized at this moment, feeling not valued – that’s how birthing people [of color] feel,” she said. “I’m hoping that builds a sense of empathy.

”I’m hoping at the end of this crisis, that those ob.gyns. will think of patients as allies in fighting for more access to health for everybody and for more resources to do their work,” Dr. Crear-Perry said. “We’re all in this together.”

sworcester@mdedge.com

April 11-17 marked the third annual national Black Maternal Health Week, an event launched in 2017 by the Atlanta-based Black Mamas Matter Alliance (BMMA), in part to “deepen the national conversation about black maternal health.”

Around the same time, emerging data showing higher mortality rates among black patients versus patients of other races with COVID-19 opened similar dialogue fraught with questions about what might explain the disturbing health disparities.

ACOG

Facing hard numbers, harder conversations

The U.S. maternal mortality rate in 2018 was 17 per 100,000 live births – the highest of any similarly wealthy industrialized nation, the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) reported in January. That’s a striking statistic in its own right. Perhaps more striking is the breakdown by race.

Hispanic women had the lowest maternal mortality rate at 12 per 100,000 live births, followed by non-Hispanic white women at 15.

The rate for non-Hispanic black women was 37 per 100,000 live births.

Numerous factors contribute to these disparities. Among those listed by the American College of Obstetricians and Gynecologists’ chief executive officer Maureen G. Phipps, MD, in a press statement on the NCHS data, are care access issues, lack of standardization of care, bias, and racism. All of these must be addressed if the disparities in maternal and other areas of care are to be eliminated, according to Dr. Phipps.

“The NCHS data confirmed what we have known from other data sources: The rate of maternal deaths for non-Hispanic black women is substantially higher than the rates for non-Hispanic white women,” she wrote. “Continued efforts to improve the standardization of data and review processes related to U.S. maternal mortality are a necessary step to achieving the goal of eliminating disparities and preventable maternal mortality.”

However, such efforts frequently encounter roadblocks constructed by the reluctance among “many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse” to identify racism as a root cause of health disparities, according to Zinzi D. Bailey, ScD, former director of research and evaluation for the New York City Department of Health and Mental Hygiene, and colleagues.

In the third of a three-part conceptual report in The Lancet, entitled America: Equity and Equality in Health, Dr. Bailey and colleagues argued that advancing health equity requires a focus on structural racism – which they defined as “the totality of ways in which societies foster racial discrimination via mutually reinforcing inequitable systems (e.g., in housing, education, employment, earning, benefits, credit, media, healthcare, and criminal justice, etc.) that in turn reinforce discriminatory beliefs, values, and distribution of resources.”

In their series, the authors peeled back layer upon layer of sociological and political contributors to structural racism throughout history, revealing how each laid a foundation for health inequity over time. They particularly home in on health care quality and access.

“Interpersonal racism, bias, and discrimination in healthcare settings can directly affect health through poor health care,” they wrote, noting that “almost 15 years ago, the Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, documented systematic and pervasive bias in the treatment of people of color resulting in substandard care.”

That report concluded that “bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers” likely play a role in the continuation of health disparities. More recent data – including the NCHS maternal mortality data – show an ongoing crisis.

A study of 210 experienced primary care providers and 190 community members in the Denver area, for example, found substantial evidence of implicit bias against both Latino and African American patients. The authors defined implicit bias as “unintentional and even unconscious” negative evaluation of one group and its members relative to another that is expressed implicitly, such as through negative nonverbal behavior.

“Activated by situational cues (e.g., a person’s skin color), implicit bias can quickly and unknowingly exert its influence on perception, memory, and behavior,” they wrote.

In their study, Implicit Association Test and self-report measures of bias showed similar rates of implicit bias among the providers and community members, with only a slight weakening of ethnic/racial bias among providers after adjustment for background characteristics, which suggests “a wider societal problem,” they said.

A specific example of how implicit bias can manifest was described in a 2016 report addressing the well-documented under-treatment of pain among black versus white patients. Kelly M. Hoffman, PhD, and colleagues demonstrated that a substantial number of individuals with at least some medical training endorse false beliefs regarding biological differences between black and white patients. For example, 25% of 28 white residents surveyed agreed black individuals have thicker skin, and 4% believed black individuals have faster blood coagulation and less sensitivity in their nerve endings.

Those who more strongly endorsed such erroneous beliefs were more likely to underestimate and undertreat pain among black patients, the authors found.

Another study, which underscored the insidiousness of structural racism, was reported in Science. The authors identified significant racial bias in an algorithm widely used by health systems, insurers, and practitioners to allocate health care resources for patients with complex health needs. The algorithm, which affects millions of patients, uses predictions of future health care costs rather than future illness to determine who should receive extra medical care.

The problem is that unequal care access for black patients skews lower the foundational cost data used for making those predictions. Correcting the algorithm would increase the percentage of black patients receiving additional medical help from 17.7% to 46.5%, the authors concluded.

This evidence of persistent racism and bias in medicine, however, doesn’t mean progress is lacking.

ACOG has partnered with numerous other organizations to promote awareness and change, including through legislation. A recent win was the enactment of the Preventing Maternal Deaths Act of 2018, a bipartisan bill designed to promote and support maternal mortality review committees in every state. A major focus of BMMA’s Black Maternal Health Week was the Black Maternal Health Momnibus Act of 2020, a nine-bill package introduced in March to comprehensively address the crisis.

But efforts like these, whether they aim to elucidate the contributors to health disparities or to directly target structural and overt racism and root out implicit bias in medical care, are nothing new. As Dr. Bailey and colleagues noted, a challenge is getting the message across because efforts to avoid tough conversations around these topics are nothing new, either.

Dr. Gee attested to that during a maternal mortality panel discussion at the 2019 ACOG meeting where she spoke about the resistance she encountered in 2016 when she was appointed secretary of the Louisiana Health Department and worked to make racism and bias a foundational part of the discussion on improving maternal and fetal outcomes.

She established the first Office of Health Equity in the state – and the first in the nation to not only require measurement outcomes by race but also explicitly address racial bias at the outset. The goal wasn’t just to talk about it but to “plan for addressing equity in every single aspect of what we do with ... our case equity action teams.”

“At our first maternal mortality quality meetings we insisted on focusing on equity at the very outset, and we had people that left when we started talking about racism,” she said, noting that others said it was “too political” to discuss during an election year or that equity was something to address later.

“We said no. We insisted on it, and I think that was very important because all ships don’t rise with the tide, not with health disparities,” she said, recounting an earlier experience when she led the Louisiana Birth Outcomes Initiative: “I asked to have a brown-bag focused on racism at the department so we could talk about the impact of implicit bias on decision making, and I was told that I was a Yankee who didn’t understand the South and that racism didn’t really exist here, and what did I know about it – and I couldn’t have the brown-bag.”

That was in 2011.

Fast-forward to April 24, 2020. As Dr. Gee shared her perspective on addressing racism and bias in medicine, she was preparing for a call regarding the racial disparities in COVID-19 outcomes – the first health equity action sanctioned by Louisiana Governor John Bel Edwards (D).

“I think we really set the stage for these discussions,” she said.
 

Addressing equity to enact change

The efforts in Louisiana also set the stage for better maternal outcomes. At the 2019 ACOG meeting where she spoke as part of the President’s Panel, Dr. Gee said Louisiana had the highest maternal mortality rates in the nation. The NCHC data released in January, however, suggest that may no longer be the case.

Inconsistencies in how the latest and prior data were reported, including in how maternal mortality was defined, make direct comparison impossible. But in the latest report, Louisiana ranked seventh among states with available data.

“Ninety percent of the deliveries in the state happen at hospitals that we worked with,” Dr. Gee said, highlighting the reach of the efforts to improve outcomes there.

She also described a recent case involving an anemic patient whose bleeding risk was identified early thanks to the programs put in place. That enabled early preparation in the event of complications.

The patient experienced a massive hemorrhage, but the preparation, including having units of blood on hand in case of such an emergency, saved her life.

“So we clearly have not just data, but individual stories of people whose lives have been saved by this work,” she said.

More tangible data on maternal morbidity further show that the efforts in the state are making a difference, Dr. Gillispie said, citing preliminary outcomes data from the Pregnancy-Associated Mortality Review launched in 2018.

“We started with an initial goal of reducing severe maternal morbidity related to hypertension and hemorrhage by 20%, as well as reducing the black/white disparity gap by Mother’s Day 2020,” she said.

Final analyses have been delayed because of COVID-19, but early assessments showed a reduction in the disparity gap, she said, again highlighting the importance of focusing on equity.

“Definitely from the standpoint of the Quality Collaborative side ... we’ve been working with our facilities to make them aware of what implicit bias is, helping them to also do the Harvard Implicit Bias Test so they can figure out what their own biases are, start working to acknowledge them and address them, and start working to fight against letting that bias change how they treat individuals,” Dr. Gillispie said.

The work started through these initiatives will continue because there is much left to be done, she said.

Indeed, the surprised reactions in recent weeks to the reports of disparities in COVID-19 outcomes further underscore that reality, and the maternal mortality statistics – with use of the voices of those directly affected by structural and overt racism and bias in maternal care as a megaphone – speak for themselves.

Hearing implicit bias from patients’ perspective

Just ask Timoria McQueen Saba, a black woman who nearly died from a postpartum hemorrhage in 2010. At ACOG 2019, she spoke about how she had to switch ob.gyns. three times during her first pregnancy because she felt she had not received quality care – one doctor neglected to tell her she had placenta previa. She also experienced excessive wait times at prenatal appointments and had been on the receiving end of microaggressions and degrading questions such as “Are you still married?” and “Is your husband your baby’s father?” – and these are all things her white friends who recommended those physicians never experienced, she said.

“The health care system has just sometimes beaten people down so much, just like the world has – people of color, especially – to where you’re dismissed, your concerns are invalidated,” she said. “Some doctors don’t even think black people feel pain [or that] our pain is less.”

Mrs. Saba also spoke about how her health care “improved a billion percent” when her white husband accompanied her to appointments.

Just ask Charles S. Johnson IV, whose wife Kira Dixon Johnson died in 2016 during surgery for postpartum bleeding complications – after he and other family members spent 10 hours pleading for help for her.

Speaking at the ACOG panel discussion with Mrs. Saba, Mr. Johnson described “a clear disconnect” between the medical staff at the hospital and the way they viewed and valued Kira. He shared his frustration in wanting to advocate for his wife, but knowing that, as an African American male, he risked being seen as a threat and removed from the hospital if he didn’t stay calm, if he “tapped into those natural instincts as a man and a husband who wants to just protect his family.”

He fought back emotions, struggling to get the words out, saying that’s what haunts him and keeps him up at night – wondering if he should have “fought harder, grabbed the doctor by the collar, raised his voice, slammed on the counter.

“Maybe they would have done something,” he said.

Such experiences cross all socioeconomic boundaries. Ask U.S. Track and Field Olympic gold medalist Allyson Felix, who testified at a U.S. House Ways and Means Committee hearing on May 16, 2019 after developing severe preeclampsia that threatened her life and that of her baby. Ask tennis champion Serena Williams, who demanded assessment for pulmonary embolism following the birth of her child; she knew the signs, but her health care providers initially dismissed her concerns.

Their experiences aren’t just anecdotal. Data consistently show how racism and bias affect patient treatment and outcomes. Dr. Gee, for example, shared findings from a retrospective assessment of 47 confirmed pregnancy-related deaths in Louisiana between 2011 and 2016 that looked specifically at whether the deaths could potentially have been prevented if blood was given sooner, cardiomyopathy was recognized sooner, hypertension was treated on time, or other changes were made to care.

The answer was “Yes” in 9% of cases involving white patients – and in 59% of cases involving black patients (odds ratio, 14.6).

The study, reported in February in Obstetrics & Gynecology, showed that 27 of the deaths (58%) occurred at level III or IV birth facilities and that those deaths were not less likely than those at level I or II facilities to be categorized as preventable (OR, 2.0).

Findings from the Giving Voice to Mothers study, published in Reproductive Health in 2019, showed how mistreatment during childbirth might contribute to such outcomes.

In an online cross-sectional survey of more than 2,100 U.S. women, one in six reported at least one type of mistreatment, such as loss of autonomy, being yelled at or threatened, being ignored or having requests for help ignored, Saraswathi Vedam, SciD, of the Birth Place Lab at the University of British Columbia, Vancouver, and colleagues reported.

Race was among the factors associated with likelihood of mistreatment, and the rates of mistreatment for women of color were consistently higher – even when looking at interactions between race and other characteristics, such as socioeconomic status (SES). For example, 27.2% of women of color with low SES, compared with 18.7% of white women with low SES, reported mistreatment. Having a partner who was black, regardless of maternal race, was also associated with an increased rate of mistreatment, the authors found.

“I often get the question, ‘Do you think Kira would be alive if she was white,’ ” Mr. Johnson said. “The first way I respond to that question is [by saying that] the simple fact that you have to ask me is a problem.

“When this first happened, I was in so much pain that I couldn’t process the fact that something so egregious and outrageous happened to my wife because of the color of her skin, but as I began to process and really think about it and unpack this scenario, I have to be really frank ... do I think that she would have sat there for 10 hours while we begged and pleaded? Absolutely not.”

He stressed that his words aren’t “an indictment of the profession.”

“This is not an indictment saying that all people are racist or prejudiced,” he said. “But here’s the reality: If you are in this profession, if you are responsible for the well-being of patients and their families, and you are not able to see them in the same way that you see your mother, your wife, your sister, you have two options – you need to find something else to do or you need to take steps to get better.”
 

Fixing systems, finding solutions

Dr. Gee acknowledged the work that physicians need to do to help improve outcomes.

“The average time we give a patient to talk is 11 seconds before we interrupt them,” she said, as one example. “We have to recognize that.”

But efforts to improve outcomes shouldn’t just focus on changing physician behavior, she said.

“We really need to focus, as has the U.K. – very effectively – on using midwives, doulas, other health care professionals as complements to physicians to make sure that we have women-centered birth experiences.

“So, instead of just blaming the doctors, I think we need to change the system,” Dr. Gee emphasized.

The disruptions in health systems caused by COVID-19 present a unique opportunity to do that, she said. There is now an opportunity to build them back.

“We have a chance to build the systems back, and when we do so, we ought to build them back correcting for implicit bias and some of the systemic issues that lead to poor outcomes for people of color in our country,” she said.

Solutions proposed by Dr. Gee and others include more diversity in the workforce, more inclusion of patient advocates in maternal care, development of culturally appropriate literacy and numeracy communications, measurement by race (and action on the outcomes), standardization of care, and development of new ways to improve care access.


We will focus more specifically on these solutions in Part 2 of this article in our maternal mortality series. Previous articles in the series are available at mdedge.com/obgyn/maternal-mortality.

sworcester@mdedge.com

April 11-17 marked the third annual national Black Maternal Health Week, an event launched in 2017 by the Atlanta-based Black Mamas Matter Alliance (BMMA), in part to “deepen the national conversation about black maternal health.”

Around the same time, emerging data showing higher mortality rates among black patients versus patients of other races with COVID-19 opened similar dialogue fraught with questions about what might explain the disturbing health disparities.

ACOG

Facing hard numbers, harder conversations

The U.S. maternal mortality rate in 2018 was 17 per 100,000 live births – the highest of any similarly wealthy industrialized nation, the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) reported in January. That’s a striking statistic in its own right. Perhaps more striking is the breakdown by race.

Hispanic women had the lowest maternal mortality rate at 12 per 100,000 live births, followed by non-Hispanic white women at 15.

The rate for non-Hispanic black women was 37 per 100,000 live births.

Numerous factors contribute to these disparities. Among those listed by the American College of Obstetricians and Gynecologists’ chief executive officer Maureen G. Phipps, MD, in a press statement on the NCHS data, are care access issues, lack of standardization of care, bias, and racism. All of these must be addressed if the disparities in maternal and other areas of care are to be eliminated, according to Dr. Phipps.

“The NCHS data confirmed what we have known from other data sources: The rate of maternal deaths for non-Hispanic black women is substantially higher than the rates for non-Hispanic white women,” she wrote. “Continued efforts to improve the standardization of data and review processes related to U.S. maternal mortality are a necessary step to achieving the goal of eliminating disparities and preventable maternal mortality.”

However, such efforts frequently encounter roadblocks constructed by the reluctance among “many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse” to identify racism as a root cause of health disparities, according to Zinzi D. Bailey, ScD, former director of research and evaluation for the New York City Department of Health and Mental Hygiene, and colleagues.

In the third of a three-part conceptual report in The Lancet, entitled America: Equity and Equality in Health, Dr. Bailey and colleagues argued that advancing health equity requires a focus on structural racism – which they defined as “the totality of ways in which societies foster racial discrimination via mutually reinforcing inequitable systems (e.g., in housing, education, employment, earning, benefits, credit, media, healthcare, and criminal justice, etc.) that in turn reinforce discriminatory beliefs, values, and distribution of resources.”

In their series, the authors peeled back layer upon layer of sociological and political contributors to structural racism throughout history, revealing how each laid a foundation for health inequity over time. They particularly home in on health care quality and access.

“Interpersonal racism, bias, and discrimination in healthcare settings can directly affect health through poor health care,” they wrote, noting that “almost 15 years ago, the Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, documented systematic and pervasive bias in the treatment of people of color resulting in substandard care.”

That report concluded that “bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers” likely play a role in the continuation of health disparities. More recent data – including the NCHS maternal mortality data – show an ongoing crisis.

A study of 210 experienced primary care providers and 190 community members in the Denver area, for example, found substantial evidence of implicit bias against both Latino and African American patients. The authors defined implicit bias as “unintentional and even unconscious” negative evaluation of one group and its members relative to another that is expressed implicitly, such as through negative nonverbal behavior.

“Activated by situational cues (e.g., a person’s skin color), implicit bias can quickly and unknowingly exert its influence on perception, memory, and behavior,” they wrote.

In their study, Implicit Association Test and self-report measures of bias showed similar rates of implicit bias among the providers and community members, with only a slight weakening of ethnic/racial bias among providers after adjustment for background characteristics, which suggests “a wider societal problem,” they said.

A specific example of how implicit bias can manifest was described in a 2016 report addressing the well-documented under-treatment of pain among black versus white patients. Kelly M. Hoffman, PhD, and colleagues demonstrated that a substantial number of individuals with at least some medical training endorse false beliefs regarding biological differences between black and white patients. For example, 25% of 28 white residents surveyed agreed black individuals have thicker skin, and 4% believed black individuals have faster blood coagulation and less sensitivity in their nerve endings.

Those who more strongly endorsed such erroneous beliefs were more likely to underestimate and undertreat pain among black patients, the authors found.

Another study, which underscored the insidiousness of structural racism, was reported in Science. The authors identified significant racial bias in an algorithm widely used by health systems, insurers, and practitioners to allocate health care resources for patients with complex health needs. The algorithm, which affects millions of patients, uses predictions of future health care costs rather than future illness to determine who should receive extra medical care.

The problem is that unequal care access for black patients skews lower the foundational cost data used for making those predictions. Correcting the algorithm would increase the percentage of black patients receiving additional medical help from 17.7% to 46.5%, the authors concluded.

This evidence of persistent racism and bias in medicine, however, doesn’t mean progress is lacking.

ACOG has partnered with numerous other organizations to promote awareness and change, including through legislation. A recent win was the enactment of the Preventing Maternal Deaths Act of 2018, a bipartisan bill designed to promote and support maternal mortality review committees in every state. A major focus of BMMA’s Black Maternal Health Week was the Black Maternal Health Momnibus Act of 2020, a nine-bill package introduced in March to comprehensively address the crisis.

But efforts like these, whether they aim to elucidate the contributors to health disparities or to directly target structural and overt racism and root out implicit bias in medical care, are nothing new. As Dr. Bailey and colleagues noted, a challenge is getting the message across because efforts to avoid tough conversations around these topics are nothing new, either.

Dr. Gee attested to that during a maternal mortality panel discussion at the 2019 ACOG meeting where she spoke about the resistance she encountered in 2016 when she was appointed secretary of the Louisiana Health Department and worked to make racism and bias a foundational part of the discussion on improving maternal and fetal outcomes.

She established the first Office of Health Equity in the state – and the first in the nation to not only require measurement outcomes by race but also explicitly address racial bias at the outset. The goal wasn’t just to talk about it but to “plan for addressing equity in every single aspect of what we do with ... our case equity action teams.”

“At our first maternal mortality quality meetings we insisted on focusing on equity at the very outset, and we had people that left when we started talking about racism,” she said, noting that others said it was “too political” to discuss during an election year or that equity was something to address later.

“We said no. We insisted on it, and I think that was very important because all ships don’t rise with the tide, not with health disparities,” she said, recounting an earlier experience when she led the Louisiana Birth Outcomes Initiative: “I asked to have a brown-bag focused on racism at the department so we could talk about the impact of implicit bias on decision making, and I was told that I was a Yankee who didn’t understand the South and that racism didn’t really exist here, and what did I know about it – and I couldn’t have the brown-bag.”

That was in 2011.

Fast-forward to April 24, 2020. As Dr. Gee shared her perspective on addressing racism and bias in medicine, she was preparing for a call regarding the racial disparities in COVID-19 outcomes – the first health equity action sanctioned by Louisiana Governor John Bel Edwards (D).

“I think we really set the stage for these discussions,” she said.
 

Addressing equity to enact change

The efforts in Louisiana also set the stage for better maternal outcomes. At the 2019 ACOG meeting where she spoke as part of the President’s Panel, Dr. Gee said Louisiana had the highest maternal mortality rates in the nation. The NCHC data released in January, however, suggest that may no longer be the case.

Inconsistencies in how the latest and prior data were reported, including in how maternal mortality was defined, make direct comparison impossible. But in the latest report, Louisiana ranked seventh among states with available data.

“Ninety percent of the deliveries in the state happen at hospitals that we worked with,” Dr. Gee said, highlighting the reach of the efforts to improve outcomes there.

She also described a recent case involving an anemic patient whose bleeding risk was identified early thanks to the programs put in place. That enabled early preparation in the event of complications.

The patient experienced a massive hemorrhage, but the preparation, including having units of blood on hand in case of such an emergency, saved her life.

“So we clearly have not just data, but individual stories of people whose lives have been saved by this work,” she said.

More tangible data on maternal morbidity further show that the efforts in the state are making a difference, Dr. Gillispie said, citing preliminary outcomes data from the Pregnancy-Associated Mortality Review launched in 2018.

“We started with an initial goal of reducing severe maternal morbidity related to hypertension and hemorrhage by 20%, as well as reducing the black/white disparity gap by Mother’s Day 2020,” she said.

Final analyses have been delayed because of COVID-19, but early assessments showed a reduction in the disparity gap, she said, again highlighting the importance of focusing on equity.

“Definitely from the standpoint of the Quality Collaborative side ... we’ve been working with our facilities to make them aware of what implicit bias is, helping them to also do the Harvard Implicit Bias Test so they can figure out what their own biases are, start working to acknowledge them and address them, and start working to fight against letting that bias change how they treat individuals,” Dr. Gillispie said.

The work started through these initiatives will continue because there is much left to be done, she said.

Indeed, the surprised reactions in recent weeks to the reports of disparities in COVID-19 outcomes further underscore that reality, and the maternal mortality statistics – with use of the voices of those directly affected by structural and overt racism and bias in maternal care as a megaphone – speak for themselves.

Hearing implicit bias from patients’ perspective

Just ask Timoria McQueen Saba, a black woman who nearly died from a postpartum hemorrhage in 2010. At ACOG 2019, she spoke about how she had to switch ob.gyns. three times during her first pregnancy because she felt she had not received quality care – one doctor neglected to tell her she had placenta previa. She also experienced excessive wait times at prenatal appointments and had been on the receiving end of microaggressions and degrading questions such as “Are you still married?” and “Is your husband your baby’s father?” – and these are all things her white friends who recommended those physicians never experienced, she said.

“The health care system has just sometimes beaten people down so much, just like the world has – people of color, especially – to where you’re dismissed, your concerns are invalidated,” she said. “Some doctors don’t even think black people feel pain [or that] our pain is less.”

Mrs. Saba also spoke about how her health care “improved a billion percent” when her white husband accompanied her to appointments.

Just ask Charles S. Johnson IV, whose wife Kira Dixon Johnson died in 2016 during surgery for postpartum bleeding complications – after he and other family members spent 10 hours pleading for help for her.

Speaking at the ACOG panel discussion with Mrs. Saba, Mr. Johnson described “a clear disconnect” between the medical staff at the hospital and the way they viewed and valued Kira. He shared his frustration in wanting to advocate for his wife, but knowing that, as an African American male, he risked being seen as a threat and removed from the hospital if he didn’t stay calm, if he “tapped into those natural instincts as a man and a husband who wants to just protect his family.”

He fought back emotions, struggling to get the words out, saying that’s what haunts him and keeps him up at night – wondering if he should have “fought harder, grabbed the doctor by the collar, raised his voice, slammed on the counter.

“Maybe they would have done something,” he said.

Such experiences cross all socioeconomic boundaries. Ask U.S. Track and Field Olympic gold medalist Allyson Felix, who testified at a U.S. House Ways and Means Committee hearing on May 16, 2019 after developing severe preeclampsia that threatened her life and that of her baby. Ask tennis champion Serena Williams, who demanded assessment for pulmonary embolism following the birth of her child; she knew the signs, but her health care providers initially dismissed her concerns.

Their experiences aren’t just anecdotal. Data consistently show how racism and bias affect patient treatment and outcomes. Dr. Gee, for example, shared findings from a retrospective assessment of 47 confirmed pregnancy-related deaths in Louisiana between 2011 and 2016 that looked specifically at whether the deaths could potentially have been prevented if blood was given sooner, cardiomyopathy was recognized sooner, hypertension was treated on time, or other changes were made to care.

The answer was “Yes” in 9% of cases involving white patients – and in 59% of cases involving black patients (odds ratio, 14.6).

The study, reported in February in Obstetrics & Gynecology, showed that 27 of the deaths (58%) occurred at level III or IV birth facilities and that those deaths were not less likely than those at level I or II facilities to be categorized as preventable (OR, 2.0).

Findings from the Giving Voice to Mothers study, published in Reproductive Health in 2019, showed how mistreatment during childbirth might contribute to such outcomes.

In an online cross-sectional survey of more than 2,100 U.S. women, one in six reported at least one type of mistreatment, such as loss of autonomy, being yelled at or threatened, being ignored or having requests for help ignored, Saraswathi Vedam, SciD, of the Birth Place Lab at the University of British Columbia, Vancouver, and colleagues reported.

Race was among the factors associated with likelihood of mistreatment, and the rates of mistreatment for women of color were consistently higher – even when looking at interactions between race and other characteristics, such as socioeconomic status (SES). For example, 27.2% of women of color with low SES, compared with 18.7% of white women with low SES, reported mistreatment. Having a partner who was black, regardless of maternal race, was also associated with an increased rate of mistreatment, the authors found.

“I often get the question, ‘Do you think Kira would be alive if she was white,’ ” Mr. Johnson said. “The first way I respond to that question is [by saying that] the simple fact that you have to ask me is a problem.

“When this first happened, I was in so much pain that I couldn’t process the fact that something so egregious and outrageous happened to my wife because of the color of her skin, but as I began to process and really think about it and unpack this scenario, I have to be really frank ... do I think that she would have sat there for 10 hours while we begged and pleaded? Absolutely not.”

He stressed that his words aren’t “an indictment of the profession.”

“This is not an indictment saying that all people are racist or prejudiced,” he said. “But here’s the reality: If you are in this profession, if you are responsible for the well-being of patients and their families, and you are not able to see them in the same way that you see your mother, your wife, your sister, you have two options – you need to find something else to do or you need to take steps to get better.”
 

Fixing systems, finding solutions

Dr. Gee acknowledged the work that physicians need to do to help improve outcomes.

“The average time we give a patient to talk is 11 seconds before we interrupt them,” she said, as one example. “We have to recognize that.”

But efforts to improve outcomes shouldn’t just focus on changing physician behavior, she said.

“We really need to focus, as has the U.K. – very effectively – on using midwives, doulas, other health care professionals as complements to physicians to make sure that we have women-centered birth experiences.

“So, instead of just blaming the doctors, I think we need to change the system,” Dr. Gee emphasized.

The disruptions in health systems caused by COVID-19 present a unique opportunity to do that, she said. There is now an opportunity to build them back.

“We have a chance to build the systems back, and when we do so, we ought to build them back correcting for implicit bias and some of the systemic issues that lead to poor outcomes for people of color in our country,” she said.

Solutions proposed by Dr. Gee and others include more diversity in the workforce, more inclusion of patient advocates in maternal care, development of culturally appropriate literacy and numeracy communications, measurement by race (and action on the outcomes), standardization of care, and development of new ways to improve care access.


We will focus more specifically on these solutions in Part 2 of this article in our maternal mortality series. Previous articles in the series are available at mdedge.com/obgyn/maternal-mortality.

sworcester@mdedge.com

April 11-17 marked the third annual national Black Maternal Health Week, an event launched in 2017 by the Atlanta-based Black Mamas Matter Alliance (BMMA), in part to “deepen the national conversation about black maternal health.”

Around the same time, emerging data showing higher mortality rates among black patients versus patients of other races with COVID-19 opened similar dialogue fraught with questions about what might explain the disturbing health disparities.

ACOG

Facing hard numbers, harder conversations

The U.S. maternal mortality rate in 2018 was 17 per 100,000 live births – the highest of any similarly wealthy industrialized nation, the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) reported in January. That’s a striking statistic in its own right. Perhaps more striking is the breakdown by race.

Hispanic women had the lowest maternal mortality rate at 12 per 100,000 live births, followed by non-Hispanic white women at 15.

The rate for non-Hispanic black women was 37 per 100,000 live births.

Numerous factors contribute to these disparities. Among those listed by the American College of Obstetricians and Gynecologists’ chief executive officer Maureen G. Phipps, MD, in a press statement on the NCHS data, are care access issues, lack of standardization of care, bias, and racism. All of these must be addressed if the disparities in maternal and other areas of care are to be eliminated, according to Dr. Phipps.

“The NCHS data confirmed what we have known from other data sources: The rate of maternal deaths for non-Hispanic black women is substantially higher than the rates for non-Hispanic white women,” she wrote. “Continued efforts to improve the standardization of data and review processes related to U.S. maternal mortality are a necessary step to achieving the goal of eliminating disparities and preventable maternal mortality.”

However, such efforts frequently encounter roadblocks constructed by the reluctance among “many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse” to identify racism as a root cause of health disparities, according to Zinzi D. Bailey, ScD, former director of research and evaluation for the New York City Department of Health and Mental Hygiene, and colleagues.

In the third of a three-part conceptual report in The Lancet, entitled America: Equity and Equality in Health, Dr. Bailey and colleagues argued that advancing health equity requires a focus on structural racism – which they defined as “the totality of ways in which societies foster racial discrimination via mutually reinforcing inequitable systems (e.g., in housing, education, employment, earning, benefits, credit, media, healthcare, and criminal justice, etc.) that in turn reinforce discriminatory beliefs, values, and distribution of resources.”

In their series, the authors peeled back layer upon layer of sociological and political contributors to structural racism throughout history, revealing how each laid a foundation for health inequity over time. They particularly home in on health care quality and access.

“Interpersonal racism, bias, and discrimination in healthcare settings can directly affect health through poor health care,” they wrote, noting that “almost 15 years ago, the Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, documented systematic and pervasive bias in the treatment of people of color resulting in substandard care.”

That report concluded that “bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers” likely play a role in the continuation of health disparities. More recent data – including the NCHS maternal mortality data – show an ongoing crisis.

A study of 210 experienced primary care providers and 190 community members in the Denver area, for example, found substantial evidence of implicit bias against both Latino and African American patients. The authors defined implicit bias as “unintentional and even unconscious” negative evaluation of one group and its members relative to another that is expressed implicitly, such as through negative nonverbal behavior.

“Activated by situational cues (e.g., a person’s skin color), implicit bias can quickly and unknowingly exert its influence on perception, memory, and behavior,” they wrote.

In their study, Implicit Association Test and self-report measures of bias showed similar rates of implicit bias among the providers and community members, with only a slight weakening of ethnic/racial bias among providers after adjustment for background characteristics, which suggests “a wider societal problem,” they said.

A specific example of how implicit bias can manifest was described in a 2016 report addressing the well-documented under-treatment of pain among black versus white patients. Kelly M. Hoffman, PhD, and colleagues demonstrated that a substantial number of individuals with at least some medical training endorse false beliefs regarding biological differences between black and white patients. For example, 25% of 28 white residents surveyed agreed black individuals have thicker skin, and 4% believed black individuals have faster blood coagulation and less sensitivity in their nerve endings.

Those who more strongly endorsed such erroneous beliefs were more likely to underestimate and undertreat pain among black patients, the authors found.

Another study, which underscored the insidiousness of structural racism, was reported in Science. The authors identified significant racial bias in an algorithm widely used by health systems, insurers, and practitioners to allocate health care resources for patients with complex health needs. The algorithm, which affects millions of patients, uses predictions of future health care costs rather than future illness to determine who should receive extra medical care.

The problem is that unequal care access for black patients skews lower the foundational cost data used for making those predictions. Correcting the algorithm would increase the percentage of black patients receiving additional medical help from 17.7% to 46.5%, the authors concluded.

This evidence of persistent racism and bias in medicine, however, doesn’t mean progress is lacking.

ACOG has partnered with numerous other organizations to promote awareness and change, including through legislation. A recent win was the enactment of the Preventing Maternal Deaths Act of 2018, a bipartisan bill designed to promote and support maternal mortality review committees in every state. A major focus of BMMA’s Black Maternal Health Week was the Black Maternal Health Momnibus Act of 2020, a nine-bill package introduced in March to comprehensively address the crisis.

But efforts like these, whether they aim to elucidate the contributors to health disparities or to directly target structural and overt racism and root out implicit bias in medical care, are nothing new. As Dr. Bailey and colleagues noted, a challenge is getting the message across because efforts to avoid tough conversations around these topics are nothing new, either.

Dr. Gee attested to that during a maternal mortality panel discussion at the 2019 ACOG meeting where she spoke about the resistance she encountered in 2016 when she was appointed secretary of the Louisiana Health Department and worked to make racism and bias a foundational part of the discussion on improving maternal and fetal outcomes.

She established the first Office of Health Equity in the state – and the first in the nation to not only require measurement outcomes by race but also explicitly address racial bias at the outset. The goal wasn’t just to talk about it but to “plan for addressing equity in every single aspect of what we do with ... our case equity action teams.”

“At our first maternal mortality quality meetings we insisted on focusing on equity at the very outset, and we had people that left when we started talking about racism,” she said, noting that others said it was “too political” to discuss during an election year or that equity was something to address later.

“We said no. We insisted on it, and I think that was very important because all ships don’t rise with the tide, not with health disparities,” she said, recounting an earlier experience when she led the Louisiana Birth Outcomes Initiative: “I asked to have a brown-bag focused on racism at the department so we could talk about the impact of implicit bias on decision making, and I was told that I was a Yankee who didn’t understand the South and that racism didn’t really exist here, and what did I know about it – and I couldn’t have the brown-bag.”

That was in 2011.

Fast-forward to April 24, 2020. As Dr. Gee shared her perspective on addressing racism and bias in medicine, she was preparing for a call regarding the racial disparities in COVID-19 outcomes – the first health equity action sanctioned by Louisiana Governor John Bel Edwards (D).

“I think we really set the stage for these discussions,” she said.
 

Addressing equity to enact change

The efforts in Louisiana also set the stage for better maternal outcomes. At the 2019 ACOG meeting where she spoke as part of the President’s Panel, Dr. Gee said Louisiana had the highest maternal mortality rates in the nation. The NCHC data released in January, however, suggest that may no longer be the case.

Inconsistencies in how the latest and prior data were reported, including in how maternal mortality was defined, make direct comparison impossible. But in the latest report, Louisiana ranked seventh among states with available data.

“Ninety percent of the deliveries in the state happen at hospitals that we worked with,” Dr. Gee said, highlighting the reach of the efforts to improve outcomes there.

She also described a recent case involving an anemic patient whose bleeding risk was identified early thanks to the programs put in place. That enabled early preparation in the event of complications.

The patient experienced a massive hemorrhage, but the preparation, including having units of blood on hand in case of such an emergency, saved her life.

“So we clearly have not just data, but individual stories of people whose lives have been saved by this work,” she said.

More tangible data on maternal morbidity further show that the efforts in the state are making a difference, Dr. Gillispie said, citing preliminary outcomes data from the Pregnancy-Associated Mortality Review launched in 2018.

“We started with an initial goal of reducing severe maternal morbidity related to hypertension and hemorrhage by 20%, as well as reducing the black/white disparity gap by Mother’s Day 2020,” she said.

Final analyses have been delayed because of COVID-19, but early assessments showed a reduction in the disparity gap, she said, again highlighting the importance of focusing on equity.

“Definitely from the standpoint of the Quality Collaborative side ... we’ve been working with our facilities to make them aware of what implicit bias is, helping them to also do the Harvard Implicit Bias Test so they can figure out what their own biases are, start working to acknowledge them and address them, and start working to fight against letting that bias change how they treat individuals,” Dr. Gillispie said.

The work started through these initiatives will continue because there is much left to be done, she said.

Indeed, the surprised reactions in recent weeks to the reports of disparities in COVID-19 outcomes further underscore that reality, and the maternal mortality statistics – with use of the voices of those directly affected by structural and overt racism and bias in maternal care as a megaphone – speak for themselves.

Hearing implicit bias from patients’ perspective

Just ask Timoria McQueen Saba, a black woman who nearly died from a postpartum hemorrhage in 2010. At ACOG 2019, she spoke about how she had to switch ob.gyns. three times during her first pregnancy because she felt she had not received quality care – one doctor neglected to tell her she had placenta previa. She also experienced excessive wait times at prenatal appointments and had been on the receiving end of microaggressions and degrading questions such as “Are you still married?” and “Is your husband your baby’s father?” – and these are all things her white friends who recommended those physicians never experienced, she said.

“The health care system has just sometimes beaten people down so much, just like the world has – people of color, especially – to where you’re dismissed, your concerns are invalidated,” she said. “Some doctors don’t even think black people feel pain [or that] our pain is less.”

Mrs. Saba also spoke about how her health care “improved a billion percent” when her white husband accompanied her to appointments.

Just ask Charles S. Johnson IV, whose wife Kira Dixon Johnson died in 2016 during surgery for postpartum bleeding complications – after he and other family members spent 10 hours pleading for help for her.

Speaking at the ACOG panel discussion with Mrs. Saba, Mr. Johnson described “a clear disconnect” between the medical staff at the hospital and the way they viewed and valued Kira. He shared his frustration in wanting to advocate for his wife, but knowing that, as an African American male, he risked being seen as a threat and removed from the hospital if he didn’t stay calm, if he “tapped into those natural instincts as a man and a husband who wants to just protect his family.”

He fought back emotions, struggling to get the words out, saying that’s what haunts him and keeps him up at night – wondering if he should have “fought harder, grabbed the doctor by the collar, raised his voice, slammed on the counter.

“Maybe they would have done something,” he said.

Such experiences cross all socioeconomic boundaries. Ask U.S. Track and Field Olympic gold medalist Allyson Felix, who testified at a U.S. House Ways and Means Committee hearing on May 16, 2019 after developing severe preeclampsia that threatened her life and that of her baby. Ask tennis champion Serena Williams, who demanded assessment for pulmonary embolism following the birth of her child; she knew the signs, but her health care providers initially dismissed her concerns.

Their experiences aren’t just anecdotal. Data consistently show how racism and bias affect patient treatment and outcomes. Dr. Gee, for example, shared findings from a retrospective assessment of 47 confirmed pregnancy-related deaths in Louisiana between 2011 and 2016 that looked specifically at whether the deaths could potentially have been prevented if blood was given sooner, cardiomyopathy was recognized sooner, hypertension was treated on time, or other changes were made to care.

The answer was “Yes” in 9% of cases involving white patients – and in 59% of cases involving black patients (odds ratio, 14.6).

The study, reported in February in Obstetrics & Gynecology, showed that 27 of the deaths (58%) occurred at level III or IV birth facilities and that those deaths were not less likely than those at level I or II facilities to be categorized as preventable (OR, 2.0).

Findings from the Giving Voice to Mothers study, published in Reproductive Health in 2019, showed how mistreatment during childbirth might contribute to such outcomes.

In an online cross-sectional survey of more than 2,100 U.S. women, one in six reported at least one type of mistreatment, such as loss of autonomy, being yelled at or threatened, being ignored or having requests for help ignored, Saraswathi Vedam, SciD, of the Birth Place Lab at the University of British Columbia, Vancouver, and colleagues reported.

Race was among the factors associated with likelihood of mistreatment, and the rates of mistreatment for women of color were consistently higher – even when looking at interactions between race and other characteristics, such as socioeconomic status (SES). For example, 27.2% of women of color with low SES, compared with 18.7% of white women with low SES, reported mistreatment. Having a partner who was black, regardless of maternal race, was also associated with an increased rate of mistreatment, the authors found.

“I often get the question, ‘Do you think Kira would be alive if she was white,’ ” Mr. Johnson said. “The first way I respond to that question is [by saying that] the simple fact that you have to ask me is a problem.

“When this first happened, I was in so much pain that I couldn’t process the fact that something so egregious and outrageous happened to my wife because of the color of her skin, but as I began to process and really think about it and unpack this scenario, I have to be really frank ... do I think that she would have sat there for 10 hours while we begged and pleaded? Absolutely not.”

He stressed that his words aren’t “an indictment of the profession.”

“This is not an indictment saying that all people are racist or prejudiced,” he said. “But here’s the reality: If you are in this profession, if you are responsible for the well-being of patients and their families, and you are not able to see them in the same way that you see your mother, your wife, your sister, you have two options – you need to find something else to do or you need to take steps to get better.”
 

Fixing systems, finding solutions

Dr. Gee acknowledged the work that physicians need to do to help improve outcomes.

“The average time we give a patient to talk is 11 seconds before we interrupt them,” she said, as one example. “We have to recognize that.”

But efforts to improve outcomes shouldn’t just focus on changing physician behavior, she said.

“We really need to focus, as has the U.K. – very effectively – on using midwives, doulas, other health care professionals as complements to physicians to make sure that we have women-centered birth experiences.

“So, instead of just blaming the doctors, I think we need to change the system,” Dr. Gee emphasized.

The disruptions in health systems caused by COVID-19 present a unique opportunity to do that, she said. There is now an opportunity to build them back.

“We have a chance to build the systems back, and when we do so, we ought to build them back correcting for implicit bias and some of the systemic issues that lead to poor outcomes for people of color in our country,” she said.

Solutions proposed by Dr. Gee and others include more diversity in the workforce, more inclusion of patient advocates in maternal care, development of culturally appropriate literacy and numeracy communications, measurement by race (and action on the outcomes), standardization of care, and development of new ways to improve care access.


We will focus more specifically on these solutions in Part 2 of this article in our maternal mortality series. Previous articles in the series are available at mdedge.com/obgyn/maternal-mortality.

sworcester@mdedge.com

Nearly 700 women died from pregnancy-related complications in the United States in 2018, and almost a third of those deaths were associated with cardiovascular disease, according to the latest data from the Centers for Disease Control and Prevention.

Strikingly, studies suggest that up to half of cardiovascular disease–related maternal deaths are preventable, yet CVD remains the leading cause of maternal morbidity and mortality – and the incidence has been rising steadily for 2 decades.

The American College of Obstetricians and Gynecologists says that acquired heart disease is the likely culprit in the rise in incidence of maternal mortality as women enter pregnancy with an increasingly heavy burden of CVD risk factors, including older age, obesity, diabetes, and hypertension.

“They are entering pregnancy while already at risk, and that has led to an increase in morbidity and mortality during pregnancy,” Renee Patrice Bullock-Palmer, MD, a cardiologist and director of the Women’s Heart Center at Deborah Heart and Lung Center in Browns Mills, N.J., explained in an interview. “Unfortunately, among developed countries, the U.S. has the highest rates of maternal morbidity and mortality, and that’s shocking.”

It’s a problem that requires collaboration between obstetricians, cardiologists, and others involved in the care of pregnant women, she said.
 

The data and the depth of the crisis

The maternal mortality rate in 1987 – the year the CDC’s Pregnancy Mortality Surveillance System was implemented – was 7.2 per 100,000 live births. The rate in 2016 was more than double that at 16.9, and the rate in 2018, the most recent year for which data are available, was 17.4 – and significant racial and ethnic disparities in those rates have persisted over time.

In an August 2019 article published on the American Heart Association website, Dr. Bullock-Palmer addressed the cardiovascular state of health for pregnant women and the role of the cardiologists in their care, noting that there is a “role for increased collaboration between the cardiologist and the obstetrician with regards to a pregnancy heart team.”

“It is vital that mothers who are at increased risk for CVD or have established CVD be referred to a cardiologist for cardiovascular assessment and management,” she wrote, adding it is important to raise awareness among ob.gyns. and to improve cardiologists’ recognition of women at risk when they present for care for the first time.

These referrals should be made in the antepartum and early postpartum period, she said in an interview. More attention also must be paid to racial and ethnic disparities, and the role of cardiologists in addressing these disparities.

The CDC has emphasized racial and ethnic disparities in maternal mortality, noting in a 2019 Morbidity and Mortality Weekly report that, compared with white women, black and American Indian/Alaskan Native women aged over 30 years have a 300%-400% higher rate of pregnancy-related deaths (Morb Mortal Wkly Rep. 2019 Sep 6;68[35]:762-5).

With regard to disparities, Dr. Bullock-Palmer said the causes are multifold and may be related to a higher prevalence of CVD risk factors like obesity and hypertension in non-Hispanic black women.

“There may also be limited access to adequate postpartum care in this patient population,” she wrote, adding that some attention has been paid to addressing disparities, but that “there is a lot of work left to be done in resolving these inequities in maternal health care.”

Partnerships across specialties will help in addressing most of the factors associated with CVD and maternal death, she said.

The urgent need for these partnerships is underscored by the latest findings on CVD-related complications in pregnancy. A study published in March 2020 in the Journal of the American College of Cardiology, for example, looked specifically at the incidence of serious cardiac events (SCEs) in pregnant women with heart disease, and whether the events were preventable.

In a prospective cohort of 1,315 pregnancies among women with heart disease, Birgit Pfaller, MD, of the University of Toronto Pregnancy and Heart Disease Research Program, and colleagues found that SCEs occurred in 3.6% of cases (47 women) – most often during the antepartum period – that 49% were preventable, and that 74% were related to provider management factors.

The most common SCEs were cardiac death or arrest, heart failure, arrhythmias, and urgent intervention, and they were more likely to occur in women with acquired heart disease, severe aortic or mitral stenosis, mechanical valves, and systemic ventricular dysfunction. Adverse fetal and neonatal outcomes more than doubled in cases involving SCEs, compared with those without (62% vs. 29%), and adverse obstetric events occurred most often in women with severe preeclampsia.

“The majority of the preventable events occurred due to provider management factors, including: failure to identify the patient condition prior to pregnancy, failure to identify the patient as high risk, late recognition in cardiac deterioration, delay in treatment/intervention, inappropriate treatment, and lack of preconception counseling,” Melinda Davis, MD, of the University of Michigan, Ann Arbor, wrote in a summary and editorial published in the Journal of the American College of Cardiology.

Some preventable events were attributable to patient failure to seek care, noncompliance with care recommendations, and lack of access to care, Dr. Davis noted.

“These findings suggest that provider training, patient education, and health care advocacy are all important interventions to improve outcomes among pregnant women,” she wrote, adding that “the development of multidisciplinary cardio-obstetric clinics at tertiary care centers may also be helpful.”

Dr. Bullock-Palmer added the need for greater risk-prediction tools to the list, explaining that these are needed to assess CVD risk in the prenatal, antenatal, and postnatal period.

“The recently concluded Cardiac Disease in Pregnancy [CARPREG II] study indicated that there were 10 predictors that could be utilized to asses maternal CVD risk,” she noted.

The CARPREG II authors identified five general predictors (prior cardiac events or arrhythmias, poor functional class or cyanosis, high-risk valve disease/left ventricular outflow tract obstruction, systemic ventricular dysfunction, no prior cardiac interventions), four lesion-specific predictors (mechanical valves, high-risk aortopathies, pulmonary hypertension, coronary artery disease), and one delivery-of-care predictor (late pregnancy assessment), and incorporated them into a risk index.

“It is hopeful that these new initiatives will assist providers in improving their ability to appropriately risk stratify women,” Dr. Bullock-Palmer said.

 

Ongoing efforts

Efforts also are ongoing to develop the types of cardio-obstetric clinics mentioned by Dr. Davis and to establish collaborations and “pregnancy heart teams” as attention is increasingly focused on the U.S. maternal mortality crisis.

In fact, such teams are a cornerstone of ACOG’s guidance on pregnancy and heart disease. In May 2019 the college released a Practice Bulletin with 27 specific recommendations and conclusions relating to screening, diagnosis, and management of CVD for women during the prepregnancy period through the postpartum period.

Pregnant women and postpartum women with known or suspected CVD should undergo evaluation by a “pregnancy heart team that includes a cardiologist and maternal-fetal medicine subspecialist, or both, and other subspecialists as necessary,” according to the bulletin.

In a recent interview, Lisa Hollier, MD, immediate past president of ACOG and an instrumental figure in the push to better address maternal mortality – and in particular the cardiovascular contributors to the crisis – said she is “seeing a strengthening of that” with numerous organizations establishing pregnancy health teams.

Dr. Bullock-Palmer said she also is seeing progress, and added that collaboration should be prioritized even in the absence of dedicated pregnancy heart teams and clinics.

“Heart disease in pregnancy requires a multidisciplinary approach. You can’t just see the patient from the cardiac perspective – you also have to interact and team up with the obstetrician who is handling the pregnancy,” she said, adding that, without a dedicated team, coordination takes more effort, but is imperative for improving outcomes. “You have to collaborate at times when it is beyond the expertise of the institution or the physician; you have to know when to refer these higher-risk patients, particularly women with adult congenital heart disease.”

This referral should occur early – preferably in the antenatal period, she added.

The most important thing, however, is “recognizing these women ... even before the pregnancy,” Dr. Bullock-Palmer said, explaining that this can facilitate the necessary management – and in some cases, postponement – of pregnancy for women whose cardiac issues need to be addressed first.

Among other efforts to address maternal mortality are several programs developed by ACOG, and the Heart Outcomes in Pregnancy: Expectations for Mom and Baby Registry (HOPE) project of the Saint Luke’s Health System in Kansas.

“Hopefully the [HOPE] research collaborative ... which aims to address key clinical questions surrounding the preconception period, antenatal care, delivery planning and outcomes, and long-term postpartum care and outcomes of women will help to address the knowledge gaps and disparities in the care of women with heart disease in pregnancy,” Dr. Bullock-Palmer wrote in her article.

CVD-related risks in the post partum

Dr. Bullock-Palmer has particular concern for postpartum follow-up, given the increased risk for future heart disease among women with CVD-related pregnancy complications and the heightened risk of certain CVD-related events in the postpartum period.

That’s a component of the crisis that also was addressed during a press briefing at the 2019 ACOG annual meeting when the Pregnancy and Heart Disease Practice Bulletin was released.

Sharon Worcester/MDedge News

James Martin, MD, chair of ACOG’s Pregnancy and Heart Disease Task Force and a past ACOG president, explained during the briefing that CVD-related risks may accelerate and persist in the days and weeks after delivery, underscoring the need for follow-up and postpartum care.

Cardiomyopathy is a particular concern during this time – it’s the major cause of maternal mortality after 42 days, he noted. An emphasis on postpartum care also is especially important given that some data suggest up to 40% of women don’t return for that care.

“That is a very sad statistic and perhaps it reflects on our need to change payment models so that physicians and patients realize the importance of coming back for continuing care, because this really may be the end of pregnancy, but it is the beginning of the rest of their life,” he said. “And if they have cardiovascular disease or the risk factors ... they are going to possibly become worse over the course of their lifetime.”

sworcester@mdedge.com

Nearly 700 women died from pregnancy-related complications in the United States in 2018, and almost a third of those deaths were associated with cardiovascular disease, according to the latest data from the Centers for Disease Control and Prevention.

Strikingly, studies suggest that up to half of cardiovascular disease–related maternal deaths are preventable, yet CVD remains the leading cause of maternal morbidity and mortality – and the incidence has been rising steadily for 2 decades.

The American College of Obstetricians and Gynecologists says that acquired heart disease is the likely culprit in the rise in incidence of maternal mortality as women enter pregnancy with an increasingly heavy burden of CVD risk factors, including older age, obesity, diabetes, and hypertension.

“They are entering pregnancy while already at risk, and that has led to an increase in morbidity and mortality during pregnancy,” Renee Patrice Bullock-Palmer, MD, a cardiologist and director of the Women’s Heart Center at Deborah Heart and Lung Center in Browns Mills, N.J., explained in an interview. “Unfortunately, among developed countries, the U.S. has the highest rates of maternal morbidity and mortality, and that’s shocking.”

It’s a problem that requires collaboration between obstetricians, cardiologists, and others involved in the care of pregnant women, she said.
 

The data and the depth of the crisis

The maternal mortality rate in 1987 – the year the CDC’s Pregnancy Mortality Surveillance System was implemented – was 7.2 per 100,000 live births. The rate in 2016 was more than double that at 16.9, and the rate in 2018, the most recent year for which data are available, was 17.4 – and significant racial and ethnic disparities in those rates have persisted over time.

In an August 2019 article published on the American Heart Association website, Dr. Bullock-Palmer addressed the cardiovascular state of health for pregnant women and the role of the cardiologists in their care, noting that there is a “role for increased collaboration between the cardiologist and the obstetrician with regards to a pregnancy heart team.”

“It is vital that mothers who are at increased risk for CVD or have established CVD be referred to a cardiologist for cardiovascular assessment and management,” she wrote, adding it is important to raise awareness among ob.gyns. and to improve cardiologists’ recognition of women at risk when they present for care for the first time.

These referrals should be made in the antepartum and early postpartum period, she said in an interview. More attention also must be paid to racial and ethnic disparities, and the role of cardiologists in addressing these disparities.

The CDC has emphasized racial and ethnic disparities in maternal mortality, noting in a 2019 Morbidity and Mortality Weekly report that, compared with white women, black and American Indian/Alaskan Native women aged over 30 years have a 300%-400% higher rate of pregnancy-related deaths (Morb Mortal Wkly Rep. 2019 Sep 6;68[35]:762-5).

With regard to disparities, Dr. Bullock-Palmer said the causes are multifold and may be related to a higher prevalence of CVD risk factors like obesity and hypertension in non-Hispanic black women.

“There may also be limited access to adequate postpartum care in this patient population,” she wrote, adding that some attention has been paid to addressing disparities, but that “there is a lot of work left to be done in resolving these inequities in maternal health care.”

Partnerships across specialties will help in addressing most of the factors associated with CVD and maternal death, she said.

The urgent need for these partnerships is underscored by the latest findings on CVD-related complications in pregnancy. A study published in March 2020 in the Journal of the American College of Cardiology, for example, looked specifically at the incidence of serious cardiac events (SCEs) in pregnant women with heart disease, and whether the events were preventable.

In a prospective cohort of 1,315 pregnancies among women with heart disease, Birgit Pfaller, MD, of the University of Toronto Pregnancy and Heart Disease Research Program, and colleagues found that SCEs occurred in 3.6% of cases (47 women) – most often during the antepartum period – that 49% were preventable, and that 74% were related to provider management factors.

The most common SCEs were cardiac death or arrest, heart failure, arrhythmias, and urgent intervention, and they were more likely to occur in women with acquired heart disease, severe aortic or mitral stenosis, mechanical valves, and systemic ventricular dysfunction. Adverse fetal and neonatal outcomes more than doubled in cases involving SCEs, compared with those without (62% vs. 29%), and adverse obstetric events occurred most often in women with severe preeclampsia.

“The majority of the preventable events occurred due to provider management factors, including: failure to identify the patient condition prior to pregnancy, failure to identify the patient as high risk, late recognition in cardiac deterioration, delay in treatment/intervention, inappropriate treatment, and lack of preconception counseling,” Melinda Davis, MD, of the University of Michigan, Ann Arbor, wrote in a summary and editorial published in the Journal of the American College of Cardiology.

Some preventable events were attributable to patient failure to seek care, noncompliance with care recommendations, and lack of access to care, Dr. Davis noted.

“These findings suggest that provider training, patient education, and health care advocacy are all important interventions to improve outcomes among pregnant women,” she wrote, adding that “the development of multidisciplinary cardio-obstetric clinics at tertiary care centers may also be helpful.”

Dr. Bullock-Palmer added the need for greater risk-prediction tools to the list, explaining that these are needed to assess CVD risk in the prenatal, antenatal, and postnatal period.

“The recently concluded Cardiac Disease in Pregnancy [CARPREG II] study indicated that there were 10 predictors that could be utilized to asses maternal CVD risk,” she noted.

The CARPREG II authors identified five general predictors (prior cardiac events or arrhythmias, poor functional class or cyanosis, high-risk valve disease/left ventricular outflow tract obstruction, systemic ventricular dysfunction, no prior cardiac interventions), four lesion-specific predictors (mechanical valves, high-risk aortopathies, pulmonary hypertension, coronary artery disease), and one delivery-of-care predictor (late pregnancy assessment), and incorporated them into a risk index.

“It is hopeful that these new initiatives will assist providers in improving their ability to appropriately risk stratify women,” Dr. Bullock-Palmer said.

 

Ongoing efforts

Efforts also are ongoing to develop the types of cardio-obstetric clinics mentioned by Dr. Davis and to establish collaborations and “pregnancy heart teams” as attention is increasingly focused on the U.S. maternal mortality crisis.

In fact, such teams are a cornerstone of ACOG’s guidance on pregnancy and heart disease. In May 2019 the college released a Practice Bulletin with 27 specific recommendations and conclusions relating to screening, diagnosis, and management of CVD for women during the prepregnancy period through the postpartum period.

Pregnant women and postpartum women with known or suspected CVD should undergo evaluation by a “pregnancy heart team that includes a cardiologist and maternal-fetal medicine subspecialist, or both, and other subspecialists as necessary,” according to the bulletin.

In a recent interview, Lisa Hollier, MD, immediate past president of ACOG and an instrumental figure in the push to better address maternal mortality – and in particular the cardiovascular contributors to the crisis – said she is “seeing a strengthening of that” with numerous organizations establishing pregnancy health teams.

Dr. Bullock-Palmer said she also is seeing progress, and added that collaboration should be prioritized even in the absence of dedicated pregnancy heart teams and clinics.

“Heart disease in pregnancy requires a multidisciplinary approach. You can’t just see the patient from the cardiac perspective – you also have to interact and team up with the obstetrician who is handling the pregnancy,” she said, adding that, without a dedicated team, coordination takes more effort, but is imperative for improving outcomes. “You have to collaborate at times when it is beyond the expertise of the institution or the physician; you have to know when to refer these higher-risk patients, particularly women with adult congenital heart disease.”

This referral should occur early – preferably in the antenatal period, she added.

The most important thing, however, is “recognizing these women ... even before the pregnancy,” Dr. Bullock-Palmer said, explaining that this can facilitate the necessary management – and in some cases, postponement – of pregnancy for women whose cardiac issues need to be addressed first.

Among other efforts to address maternal mortality are several programs developed by ACOG, and the Heart Outcomes in Pregnancy: Expectations for Mom and Baby Registry (HOPE) project of the Saint Luke’s Health System in Kansas.

“Hopefully the [HOPE] research collaborative ... which aims to address key clinical questions surrounding the preconception period, antenatal care, delivery planning and outcomes, and long-term postpartum care and outcomes of women will help to address the knowledge gaps and disparities in the care of women with heart disease in pregnancy,” Dr. Bullock-Palmer wrote in her article.

CVD-related risks in the post partum

Dr. Bullock-Palmer has particular concern for postpartum follow-up, given the increased risk for future heart disease among women with CVD-related pregnancy complications and the heightened risk of certain CVD-related events in the postpartum period.

That’s a component of the crisis that also was addressed during a press briefing at the 2019 ACOG annual meeting when the Pregnancy and Heart Disease Practice Bulletin was released.

Sharon Worcester/MDedge News

James Martin, MD, chair of ACOG’s Pregnancy and Heart Disease Task Force and a past ACOG president, explained during the briefing that CVD-related risks may accelerate and persist in the days and weeks after delivery, underscoring the need for follow-up and postpartum care.

Cardiomyopathy is a particular concern during this time – it’s the major cause of maternal mortality after 42 days, he noted. An emphasis on postpartum care also is especially important given that some data suggest up to 40% of women don’t return for that care.

“That is a very sad statistic and perhaps it reflects on our need to change payment models so that physicians and patients realize the importance of coming back for continuing care, because this really may be the end of pregnancy, but it is the beginning of the rest of their life,” he said. “And if they have cardiovascular disease or the risk factors ... they are going to possibly become worse over the course of their lifetime.”

sworcester@mdedge.com

Nearly 700 women died from pregnancy-related complications in the United States in 2018, and almost a third of those deaths were associated with cardiovascular disease, according to the latest data from the Centers for Disease Control and Prevention.

Strikingly, studies suggest that up to half of cardiovascular disease–related maternal deaths are preventable, yet CVD remains the leading cause of maternal morbidity and mortality – and the incidence has been rising steadily for 2 decades.

The American College of Obstetricians and Gynecologists says that acquired heart disease is the likely culprit in the rise in incidence of maternal mortality as women enter pregnancy with an increasingly heavy burden of CVD risk factors, including older age, obesity, diabetes, and hypertension.

“They are entering pregnancy while already at risk, and that has led to an increase in morbidity and mortality during pregnancy,” Renee Patrice Bullock-Palmer, MD, a cardiologist and director of the Women’s Heart Center at Deborah Heart and Lung Center in Browns Mills, N.J., explained in an interview. “Unfortunately, among developed countries, the U.S. has the highest rates of maternal morbidity and mortality, and that’s shocking.”

It’s a problem that requires collaboration between obstetricians, cardiologists, and others involved in the care of pregnant women, she said.
 

The data and the depth of the crisis

The maternal mortality rate in 1987 – the year the CDC’s Pregnancy Mortality Surveillance System was implemented – was 7.2 per 100,000 live births. The rate in 2016 was more than double that at 16.9, and the rate in 2018, the most recent year for which data are available, was 17.4 – and significant racial and ethnic disparities in those rates have persisted over time.

In an August 2019 article published on the American Heart Association website, Dr. Bullock-Palmer addressed the cardiovascular state of health for pregnant women and the role of the cardiologists in their care, noting that there is a “role for increased collaboration between the cardiologist and the obstetrician with regards to a pregnancy heart team.”

“It is vital that mothers who are at increased risk for CVD or have established CVD be referred to a cardiologist for cardiovascular assessment and management,” she wrote, adding it is important to raise awareness among ob.gyns. and to improve cardiologists’ recognition of women at risk when they present for care for the first time.

These referrals should be made in the antepartum and early postpartum period, she said in an interview. More attention also must be paid to racial and ethnic disparities, and the role of cardiologists in addressing these disparities.

The CDC has emphasized racial and ethnic disparities in maternal mortality, noting in a 2019 Morbidity and Mortality Weekly report that, compared with white women, black and American Indian/Alaskan Native women aged over 30 years have a 300%-400% higher rate of pregnancy-related deaths (Morb Mortal Wkly Rep. 2019 Sep 6;68[35]:762-5).

With regard to disparities, Dr. Bullock-Palmer said the causes are multifold and may be related to a higher prevalence of CVD risk factors like obesity and hypertension in non-Hispanic black women.

“There may also be limited access to adequate postpartum care in this patient population,” she wrote, adding that some attention has been paid to addressing disparities, but that “there is a lot of work left to be done in resolving these inequities in maternal health care.”

Partnerships across specialties will help in addressing most of the factors associated with CVD and maternal death, she said.

The urgent need for these partnerships is underscored by the latest findings on CVD-related complications in pregnancy. A study published in March 2020 in the Journal of the American College of Cardiology, for example, looked specifically at the incidence of serious cardiac events (SCEs) in pregnant women with heart disease, and whether the events were preventable.

In a prospective cohort of 1,315 pregnancies among women with heart disease, Birgit Pfaller, MD, of the University of Toronto Pregnancy and Heart Disease Research Program, and colleagues found that SCEs occurred in 3.6% of cases (47 women) – most often during the antepartum period – that 49% were preventable, and that 74% were related to provider management factors.

The most common SCEs were cardiac death or arrest, heart failure, arrhythmias, and urgent intervention, and they were more likely to occur in women with acquired heart disease, severe aortic or mitral stenosis, mechanical valves, and systemic ventricular dysfunction. Adverse fetal and neonatal outcomes more than doubled in cases involving SCEs, compared with those without (62% vs. 29%), and adverse obstetric events occurred most often in women with severe preeclampsia.

“The majority of the preventable events occurred due to provider management factors, including: failure to identify the patient condition prior to pregnancy, failure to identify the patient as high risk, late recognition in cardiac deterioration, delay in treatment/intervention, inappropriate treatment, and lack of preconception counseling,” Melinda Davis, MD, of the University of Michigan, Ann Arbor, wrote in a summary and editorial published in the Journal of the American College of Cardiology.

Some preventable events were attributable to patient failure to seek care, noncompliance with care recommendations, and lack of access to care, Dr. Davis noted.

“These findings suggest that provider training, patient education, and health care advocacy are all important interventions to improve outcomes among pregnant women,” she wrote, adding that “the development of multidisciplinary cardio-obstetric clinics at tertiary care centers may also be helpful.”

Dr. Bullock-Palmer added the need for greater risk-prediction tools to the list, explaining that these are needed to assess CVD risk in the prenatal, antenatal, and postnatal period.

“The recently concluded Cardiac Disease in Pregnancy [CARPREG II] study indicated that there were 10 predictors that could be utilized to asses maternal CVD risk,” she noted.

The CARPREG II authors identified five general predictors (prior cardiac events or arrhythmias, poor functional class or cyanosis, high-risk valve disease/left ventricular outflow tract obstruction, systemic ventricular dysfunction, no prior cardiac interventions), four lesion-specific predictors (mechanical valves, high-risk aortopathies, pulmonary hypertension, coronary artery disease), and one delivery-of-care predictor (late pregnancy assessment), and incorporated them into a risk index.

“It is hopeful that these new initiatives will assist providers in improving their ability to appropriately risk stratify women,” Dr. Bullock-Palmer said.

 

Ongoing efforts

Efforts also are ongoing to develop the types of cardio-obstetric clinics mentioned by Dr. Davis and to establish collaborations and “pregnancy heart teams” as attention is increasingly focused on the U.S. maternal mortality crisis.

In fact, such teams are a cornerstone of ACOG’s guidance on pregnancy and heart disease. In May 2019 the college released a Practice Bulletin with 27 specific recommendations and conclusions relating to screening, diagnosis, and management of CVD for women during the prepregnancy period through the postpartum period.

Pregnant women and postpartum women with known or suspected CVD should undergo evaluation by a “pregnancy heart team that includes a cardiologist and maternal-fetal medicine subspecialist, or both, and other subspecialists as necessary,” according to the bulletin.

In a recent interview, Lisa Hollier, MD, immediate past president of ACOG and an instrumental figure in the push to better address maternal mortality – and in particular the cardiovascular contributors to the crisis – said she is “seeing a strengthening of that” with numerous organizations establishing pregnancy health teams.

Dr. Bullock-Palmer said she also is seeing progress, and added that collaboration should be prioritized even in the absence of dedicated pregnancy heart teams and clinics.

“Heart disease in pregnancy requires a multidisciplinary approach. You can’t just see the patient from the cardiac perspective – you also have to interact and team up with the obstetrician who is handling the pregnancy,” she said, adding that, without a dedicated team, coordination takes more effort, but is imperative for improving outcomes. “You have to collaborate at times when it is beyond the expertise of the institution or the physician; you have to know when to refer these higher-risk patients, particularly women with adult congenital heart disease.”

This referral should occur early – preferably in the antenatal period, she added.

The most important thing, however, is “recognizing these women ... even before the pregnancy,” Dr. Bullock-Palmer said, explaining that this can facilitate the necessary management – and in some cases, postponement – of pregnancy for women whose cardiac issues need to be addressed first.

Among other efforts to address maternal mortality are several programs developed by ACOG, and the Heart Outcomes in Pregnancy: Expectations for Mom and Baby Registry (HOPE) project of the Saint Luke’s Health System in Kansas.

“Hopefully the [HOPE] research collaborative ... which aims to address key clinical questions surrounding the preconception period, antenatal care, delivery planning and outcomes, and long-term postpartum care and outcomes of women will help to address the knowledge gaps and disparities in the care of women with heart disease in pregnancy,” Dr. Bullock-Palmer wrote in her article.

CVD-related risks in the post partum

Dr. Bullock-Palmer has particular concern for postpartum follow-up, given the increased risk for future heart disease among women with CVD-related pregnancy complications and the heightened risk of certain CVD-related events in the postpartum period.

That’s a component of the crisis that also was addressed during a press briefing at the 2019 ACOG annual meeting when the Pregnancy and Heart Disease Practice Bulletin was released.

Sharon Worcester/MDedge News

James Martin, MD, chair of ACOG’s Pregnancy and Heart Disease Task Force and a past ACOG president, explained during the briefing that CVD-related risks may accelerate and persist in the days and weeks after delivery, underscoring the need for follow-up and postpartum care.

Cardiomyopathy is a particular concern during this time – it’s the major cause of maternal mortality after 42 days, he noted. An emphasis on postpartum care also is especially important given that some data suggest up to 40% of women don’t return for that care.

“That is a very sad statistic and perhaps it reflects on our need to change payment models so that physicians and patients realize the importance of coming back for continuing care, because this really may be the end of pregnancy, but it is the beginning of the rest of their life,” he said. “And if they have cardiovascular disease or the risk factors ... they are going to possibly become worse over the course of their lifetime.”

sworcester@mdedge.com

This article is the first in a series on maternal mortality.

“You’re in really bad shape, kid. I don’t know if you’re gonna live through the night. I’m going to do everything I can to save your life, but the truth is you might die.”

If Timoria McQueen Saba imagined the words she would hear in the moments after she gave birth, those likely weren’t among them. But then she started to bleed. The energy around her shifted; she felt the urgency and intensity in the room, and she could see it – reflected from the television monitor over her bed – in the faces of her care team. After her husband and newborn daughter were led from the room, she did, in fact, hear those words.

They were spoken by a surgeon called in after efforts to control the bleeding failed – emetic words that joined forces with her hemorrhaging and confusion and fear, and as she began to vomit, her eyelids felt heavy. She fought to keep them open, sensing that if she closed them they might never open again.

In 2018 alone, similar words perhaps were spoken to the 658 U.S. women who suffered maternal complications and whose eyes never did open again. This is the latest official maternal mortality data from the Centers for Disease Control and Prevention.

Ms. Saba’s eyes, however, remained open through her birth trauma and through the PTSD that followed. A fierce advocate for maternal health, she shares her story often, as she did during a panel discussion at the American College of Obstetricians and Gynecologists’ annual meeting in May 2019, in an effort to improve outcomes for other women and families.

But her story unfolded nearly a decade ago and those eyes still are seeing women die from childbirth. Despite her efforts and the efforts of countless other individuals and organizations working to improve maternal outcomes, the new CDC data show that the United States has the highest maternal mortality rate of any similarly wealthy industrialized nation.

“I cannot believe I’m still talking about this issue,” Ms. Saba told a standing-room-only crowd and her copanelists Neel T. Shah, MD, and Charles S. Johnson IV, whose wife, Kira, died in 2016 during surgery for bleeding complications following the birth of their second child. “If all the people who I’d written to had just listened maybe once and tried to propel my message forward back then, Charles would be in a much better situation and so would his children.”

Mr. Johnson said that for 10 hours he and other family members pleaded for help for Kira, a healthy, vibrant women he described as “sunshine personified.”

She showed signs of postpartum bleeding after delivering a healthy baby boy by C-section, but a “STAT CT” order went unheeded for hours before she was finally taken for surgery.

“You’re walking down this corridor, you get to this point, these double doors open, and you just can’t go any further – and that was the last time I saw my wife alive,” he said. “When they took Kira back into the operating room, there were three-and-a-half liters of blood in her abdomen, and her heart stopped immediately.

Kira Johnson died April 13, 2016.

“I’m not here to tell you what I think, I’m here to tell you what I know, and that’s that Kira deserved so much better, and that Kira’s not alone, and that women all over this country deserve so much better.”

The U.S. maternal mortality crisis

Dr. Shah, an ob.gyn. at Beth Israel Deaconess Medical Center and director of the Delivery Decisions Initiative at Harvard Medical School’s Ariadne Labs, both in Boston, where he has “been on this mission to improve safety in childbirth for years now,” echoed Ms. Saba’s dismay regarding the pace of progress.

“It’s not just about the present, it’s about the future, it’s about the pact that every generation ought to have with the next one to leave things at least as well as they found them. And when it comes to the health of our moms in this country, we are not doing that,” he said. “An American mom today is 50% more likely to die in childbirth than her own mother was, and 3-4 times more likely to die if she’s black than if she’s white.”

Indeed, the data released Jan. 30 by the CDC’s National Center for Health Statistics (NCHS) – the first on maternal mortality released by the agency since 2007 – show a U.S. maternal mortality rate of 17.4 maternal deaths per 100,000 live births in 2018.

The rate is higher than the 12.7 per 100,000 live births reported in 2007, but the increase is attributable mostly to changes in data collection and reporting methods. In 2003, “a consensus process recommended that all states add a standardized ‘checkbox’ to improve the identification of maternal deaths,” and implementation wasn’t complete until 2017 as “funding, technology, and state laws allowed,” meaning 2018 was the first year that data were reported in a standardized fashion across states, the CDC explained in a press release.

The data demonstrate ongoing wide racial/ethnic disparities: the maternal mortality rates for non-Hispanic black women, non-Hispanic white women, and Hispanic women were 37.1, 14.7, and 11.8 per 100,000 live births, consistent with earlier data.

Further, the rates for women aged 40 years and over were nearly eightfold higher than for those under age 25 years (81.9 vs. 10.6 per 100,000 live births).

CDC officials noted, however, that inconsistencies in reporting still leave some question about the accuracy of the data, stating in the release that “NCHS has identified instances where application of the checkbox information according to coding rules led to misclassification of maternal deaths.”

The agency is making changes in rules and reporting to ensure greater accuracy, but the numbers nevertheless reveal a startling truth: “The United States is the most dangerous place to deliver a baby in the industrialized world.”

 

Progress and challenges

Rebekah Gee, MD, an ob.gyn. who served for 4 years as Secretary of the Louisiana Department of Health before leaving the position in January, made that statement during another panel discussion at ACOG 2019 – The President’s Panel: Maternal Mortality: Progress Toward Prevention – which was moderated by Lisa M. Hollier, MD, now the immediate past president of ACOG.

Texas Children's Hospital

That’s not to say progress hasn’t been or can’t be made, Dr. Gee said.

In fact, quality improvement measures she facilitated in Louisiana led to a 25% reduction in infant mortality and a 10% reduction in neonatal intensive care unit admissions, demonstrating the potential for improvement with such initiatives, but addressing maternal issues is a greater challenge, she said.

“I think part of the sad truth is that we really focus on babies first, not moms ... and that needs to change,” Dr. Gee said.

Dr. Hollier focused much of her attention during her tenure as ACOG president on doing just that, particularly through an emphasis on heart disease, which is the leading cause of U.S. maternal deaths in pregnancy and the postpartum period.

In an interview, she shared her thoughts on the progress achieved and the work that remains.

ACOG was instrumental in the enactment of the Preventing Maternal Deaths Act of 2018, which appropriated funding for Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM), a CDC initiative to support state-based maternal mortality review committees, said Dr. Hollier, professor of obstetrics and gynecology at Baylor College of Medicine, Houston.

“The really great news is that almost immediately after passage of the legislation, the CDC put out the notice of the funding opportunity, and they were able to provide 24 awards supporting 25 states,” she said.

ERASE MM will enhance state data collection and availability and enable a level of data sharing that “will really add strength and depth to reporting from the maternal mortality review committees, which really provides us with the best information we have to truly understand the causes, the contributing factors, and the strategies that can be put in place to prevent future maternal deaths.”

Further, the Alliance for Innovation on Maternal Health (AIM) program, a cooperative agreement with the Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau to improve safety and outcomes through evidence-based patient safety bundles, was extended, and in May 2019, ACOG updated its guidance on managing cardiac contributors to maternal mortality, releasing its “Pregnancy and Heart Disease” Practice Bulletin, she said.

Dr. Hollier continues in her quest for improved maternal outcomes. She is slated to deliver a keynote address at the American College of Cardiology/World Congress of Cardiology conference March 28 in Chicago.

“I’m so excited ... to talk about the new guidelines that we’ve put out and to really talk about how cardiologists and ob.gyns. can work together to improve women’s health outcomes,” she said, adding that she already is seeing a strengthening of such partnerships.

A number of academic institutions are developing “pregnancy heart teams” to identify and care for women who have or develop heart disease during pregnancy.

“This type of collaboration ... is going to be essential to address mortality from cardiovascular causes and from cardiomyopathy, which accounts for about 25% of all maternal mortality,” she said. “The next area where we really need some buy-in is from our emergency physicians.”

Enhanced collaboration with emergency physicians and other specialties present opportunities to better identify and address pregnancy-related complications and sequelae, she said.

“Women are dying because they’re not being diagnosed,” she added. “We have to raise that level of awareness – it’s just absolutely critical.”
 

Identifying and addressing drivers of the crisis

Dr. Gee further emphasized the importance of addressing maternal health, noting that for every woman who dies from maternal causes, 100 experience maternal morbidity.

“It’s startling and it’s scary,” she said. “We are looking at this not just as a problem of outcomes, but a problem of racial inequity and racial bias and implicit bias.”

When she and her team assessed maternal mortality in Louisiana, they looked specifically at whether each death could have been prevented if, for example, blood was given sooner, cardiomyopathy was recognized sooner, or hypertension was treated on time.

“When we looked at these numbers ... when we looked at white women, 9% of the time we could have done better with our medical care; with black women, 59% of the time we could have saved her life with better care,” said Dr Gee, who is a gratis assistant professor of obstetrics and gynecology at Louisiana State University, New Orleans. “And if that doesn’t convince you that racial bias is an incredibly important thing to address – that we need to have a conversation about and address at a national level – I don’t know what would.”

In fact, numerous health, societal, socioeconomic, and other factors – some known, some yet to be identified, and many inter-related – are among the drivers of the U.S. maternal mortality crisis. In the coming months, an Ob.Gyn. News team will examine several of these drivers in depth. We’ll look specifically at the role of racism and bias, and at urban-rural disparities in access and outcomes – especially for women of color and indigenous women. We’ll address the scope and impact of each, successes and failures in addressing the problems, and ongoing initiatives.

Follow us for insights from experts, researchers, practicing physicians, and patients and families affected by the maternal mortality crisis, and stay with us through coverage of ACOG 2020 for perspective on what, specifically, ob.gyns. can do about it.

Mr. Johnson proposed a starting point:

“Here’s the good news – you guys ready for this? We can fix this,” he said, adding that the solution starts with “speaking Timoria’s name ... speaking the name of Kira Dixon Johnson ... speaking the names of these women and then asking the people that are around you, ‘What are we prepared to do to make sure that this doesn’t happen to other women.’ ”

sworcester@mdedge.com

This article is the first in a series on maternal mortality.

“You’re in really bad shape, kid. I don’t know if you’re gonna live through the night. I’m going to do everything I can to save your life, but the truth is you might die.”

If Timoria McQueen Saba imagined the words she would hear in the moments after she gave birth, those likely weren’t among them. But then she started to bleed. The energy around her shifted; she felt the urgency and intensity in the room, and she could see it – reflected from the television monitor over her bed – in the faces of her care team. After her husband and newborn daughter were led from the room, she did, in fact, hear those words.

They were spoken by a surgeon called in after efforts to control the bleeding failed – emetic words that joined forces with her hemorrhaging and confusion and fear, and as she began to vomit, her eyelids felt heavy. She fought to keep them open, sensing that if she closed them they might never open again.

In 2018 alone, similar words perhaps were spoken to the 658 U.S. women who suffered maternal complications and whose eyes never did open again. This is the latest official maternal mortality data from the Centers for Disease Control and Prevention.

Ms. Saba’s eyes, however, remained open through her birth trauma and through the PTSD that followed. A fierce advocate for maternal health, she shares her story often, as she did during a panel discussion at the American College of Obstetricians and Gynecologists’ annual meeting in May 2019, in an effort to improve outcomes for other women and families.

But her story unfolded nearly a decade ago and those eyes still are seeing women die from childbirth. Despite her efforts and the efforts of countless other individuals and organizations working to improve maternal outcomes, the new CDC data show that the United States has the highest maternal mortality rate of any similarly wealthy industrialized nation.

“I cannot believe I’m still talking about this issue,” Ms. Saba told a standing-room-only crowd and her copanelists Neel T. Shah, MD, and Charles S. Johnson IV, whose wife, Kira, died in 2016 during surgery for bleeding complications following the birth of their second child. “If all the people who I’d written to had just listened maybe once and tried to propel my message forward back then, Charles would be in a much better situation and so would his children.”

Mr. Johnson said that for 10 hours he and other family members pleaded for help for Kira, a healthy, vibrant women he described as “sunshine personified.”

She showed signs of postpartum bleeding after delivering a healthy baby boy by C-section, but a “STAT CT” order went unheeded for hours before she was finally taken for surgery.

“You’re walking down this corridor, you get to this point, these double doors open, and you just can’t go any further – and that was the last time I saw my wife alive,” he said. “When they took Kira back into the operating room, there were three-and-a-half liters of blood in her abdomen, and her heart stopped immediately.

Kira Johnson died April 13, 2016.

“I’m not here to tell you what I think, I’m here to tell you what I know, and that’s that Kira deserved so much better, and that Kira’s not alone, and that women all over this country deserve so much better.”

The U.S. maternal mortality crisis

Dr. Shah, an ob.gyn. at Beth Israel Deaconess Medical Center and director of the Delivery Decisions Initiative at Harvard Medical School’s Ariadne Labs, both in Boston, where he has “been on this mission to improve safety in childbirth for years now,” echoed Ms. Saba’s dismay regarding the pace of progress.

“It’s not just about the present, it’s about the future, it’s about the pact that every generation ought to have with the next one to leave things at least as well as they found them. And when it comes to the health of our moms in this country, we are not doing that,” he said. “An American mom today is 50% more likely to die in childbirth than her own mother was, and 3-4 times more likely to die if she’s black than if she’s white.”

Indeed, the data released Jan. 30 by the CDC’s National Center for Health Statistics (NCHS) – the first on maternal mortality released by the agency since 2007 – show a U.S. maternal mortality rate of 17.4 maternal deaths per 100,000 live births in 2018.

The rate is higher than the 12.7 per 100,000 live births reported in 2007, but the increase is attributable mostly to changes in data collection and reporting methods. In 2003, “a consensus process recommended that all states add a standardized ‘checkbox’ to improve the identification of maternal deaths,” and implementation wasn’t complete until 2017 as “funding, technology, and state laws allowed,” meaning 2018 was the first year that data were reported in a standardized fashion across states, the CDC explained in a press release.

The data demonstrate ongoing wide racial/ethnic disparities: the maternal mortality rates for non-Hispanic black women, non-Hispanic white women, and Hispanic women were 37.1, 14.7, and 11.8 per 100,000 live births, consistent with earlier data.

Further, the rates for women aged 40 years and over were nearly eightfold higher than for those under age 25 years (81.9 vs. 10.6 per 100,000 live births).

CDC officials noted, however, that inconsistencies in reporting still leave some question about the accuracy of the data, stating in the release that “NCHS has identified instances where application of the checkbox information according to coding rules led to misclassification of maternal deaths.”

The agency is making changes in rules and reporting to ensure greater accuracy, but the numbers nevertheless reveal a startling truth: “The United States is the most dangerous place to deliver a baby in the industrialized world.”

 

Progress and challenges

Rebekah Gee, MD, an ob.gyn. who served for 4 years as Secretary of the Louisiana Department of Health before leaving the position in January, made that statement during another panel discussion at ACOG 2019 – The President’s Panel: Maternal Mortality: Progress Toward Prevention – which was moderated by Lisa M. Hollier, MD, now the immediate past president of ACOG.

Texas Children's Hospital

That’s not to say progress hasn’t been or can’t be made, Dr. Gee said.

In fact, quality improvement measures she facilitated in Louisiana led to a 25% reduction in infant mortality and a 10% reduction in neonatal intensive care unit admissions, demonstrating the potential for improvement with such initiatives, but addressing maternal issues is a greater challenge, she said.

“I think part of the sad truth is that we really focus on babies first, not moms ... and that needs to change,” Dr. Gee said.

Dr. Hollier focused much of her attention during her tenure as ACOG president on doing just that, particularly through an emphasis on heart disease, which is the leading cause of U.S. maternal deaths in pregnancy and the postpartum period.

In an interview, she shared her thoughts on the progress achieved and the work that remains.

ACOG was instrumental in the enactment of the Preventing Maternal Deaths Act of 2018, which appropriated funding for Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM), a CDC initiative to support state-based maternal mortality review committees, said Dr. Hollier, professor of obstetrics and gynecology at Baylor College of Medicine, Houston.

“The really great news is that almost immediately after passage of the legislation, the CDC put out the notice of the funding opportunity, and they were able to provide 24 awards supporting 25 states,” she said.

ERASE MM will enhance state data collection and availability and enable a level of data sharing that “will really add strength and depth to reporting from the maternal mortality review committees, which really provides us with the best information we have to truly understand the causes, the contributing factors, and the strategies that can be put in place to prevent future maternal deaths.”

Further, the Alliance for Innovation on Maternal Health (AIM) program, a cooperative agreement with the Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau to improve safety and outcomes through evidence-based patient safety bundles, was extended, and in May 2019, ACOG updated its guidance on managing cardiac contributors to maternal mortality, releasing its “Pregnancy and Heart Disease” Practice Bulletin, she said.

Dr. Hollier continues in her quest for improved maternal outcomes. She is slated to deliver a keynote address at the American College of Cardiology/World Congress of Cardiology conference March 28 in Chicago.

“I’m so excited ... to talk about the new guidelines that we’ve put out and to really talk about how cardiologists and ob.gyns. can work together to improve women’s health outcomes,” she said, adding that she already is seeing a strengthening of such partnerships.

A number of academic institutions are developing “pregnancy heart teams” to identify and care for women who have or develop heart disease during pregnancy.

“This type of collaboration ... is going to be essential to address mortality from cardiovascular causes and from cardiomyopathy, which accounts for about 25% of all maternal mortality,” she said. “The next area where we really need some buy-in is from our emergency physicians.”

Enhanced collaboration with emergency physicians and other specialties present opportunities to better identify and address pregnancy-related complications and sequelae, she said.

“Women are dying because they’re not being diagnosed,” she added. “We have to raise that level of awareness – it’s just absolutely critical.”
 

Identifying and addressing drivers of the crisis

Dr. Gee further emphasized the importance of addressing maternal health, noting that for every woman who dies from maternal causes, 100 experience maternal morbidity.

“It’s startling and it’s scary,” she said. “We are looking at this not just as a problem of outcomes, but a problem of racial inequity and racial bias and implicit bias.”

When she and her team assessed maternal mortality in Louisiana, they looked specifically at whether each death could have been prevented if, for example, blood was given sooner, cardiomyopathy was recognized sooner, or hypertension was treated on time.

“When we looked at these numbers ... when we looked at white women, 9% of the time we could have done better with our medical care; with black women, 59% of the time we could have saved her life with better care,” said Dr Gee, who is a gratis assistant professor of obstetrics and gynecology at Louisiana State University, New Orleans. “And if that doesn’t convince you that racial bias is an incredibly important thing to address – that we need to have a conversation about and address at a national level – I don’t know what would.”

In fact, numerous health, societal, socioeconomic, and other factors – some known, some yet to be identified, and many inter-related – are among the drivers of the U.S. maternal mortality crisis. In the coming months, an Ob.Gyn. News team will examine several of these drivers in depth. We’ll look specifically at the role of racism and bias, and at urban-rural disparities in access and outcomes – especially for women of color and indigenous women. We’ll address the scope and impact of each, successes and failures in addressing the problems, and ongoing initiatives.

Follow us for insights from experts, researchers, practicing physicians, and patients and families affected by the maternal mortality crisis, and stay with us through coverage of ACOG 2020 for perspective on what, specifically, ob.gyns. can do about it.

Mr. Johnson proposed a starting point:

“Here’s the good news – you guys ready for this? We can fix this,” he said, adding that the solution starts with “speaking Timoria’s name ... speaking the name of Kira Dixon Johnson ... speaking the names of these women and then asking the people that are around you, ‘What are we prepared to do to make sure that this doesn’t happen to other women.’ ”

sworcester@mdedge.com

This article is the first in a series on maternal mortality.

“You’re in really bad shape, kid. I don’t know if you’re gonna live through the night. I’m going to do everything I can to save your life, but the truth is you might die.”

If Timoria McQueen Saba imagined the words she would hear in the moments after she gave birth, those likely weren’t among them. But then she started to bleed. The energy around her shifted; she felt the urgency and intensity in the room, and she could see it – reflected from the television monitor over her bed – in the faces of her care team. After her husband and newborn daughter were led from the room, she did, in fact, hear those words.

They were spoken by a surgeon called in after efforts to control the bleeding failed – emetic words that joined forces with her hemorrhaging and confusion and fear, and as she began to vomit, her eyelids felt heavy. She fought to keep them open, sensing that if she closed them they might never open again.

In 2018 alone, similar words perhaps were spoken to the 658 U.S. women who suffered maternal complications and whose eyes never did open again. This is the latest official maternal mortality data from the Centers for Disease Control and Prevention.

Ms. Saba’s eyes, however, remained open through her birth trauma and through the PTSD that followed. A fierce advocate for maternal health, she shares her story often, as she did during a panel discussion at the American College of Obstetricians and Gynecologists’ annual meeting in May 2019, in an effort to improve outcomes for other women and families.

But her story unfolded nearly a decade ago and those eyes still are seeing women die from childbirth. Despite her efforts and the efforts of countless other individuals and organizations working to improve maternal outcomes, the new CDC data show that the United States has the highest maternal mortality rate of any similarly wealthy industrialized nation.

“I cannot believe I’m still talking about this issue,” Ms. Saba told a standing-room-only crowd and her copanelists Neel T. Shah, MD, and Charles S. Johnson IV, whose wife, Kira, died in 2016 during surgery for bleeding complications following the birth of their second child. “If all the people who I’d written to had just listened maybe once and tried to propel my message forward back then, Charles would be in a much better situation and so would his children.”

Mr. Johnson said that for 10 hours he and other family members pleaded for help for Kira, a healthy, vibrant women he described as “sunshine personified.”

She showed signs of postpartum bleeding after delivering a healthy baby boy by C-section, but a “STAT CT” order went unheeded for hours before she was finally taken for surgery.

“You’re walking down this corridor, you get to this point, these double doors open, and you just can’t go any further – and that was the last time I saw my wife alive,” he said. “When they took Kira back into the operating room, there were three-and-a-half liters of blood in her abdomen, and her heart stopped immediately.

Kira Johnson died April 13, 2016.

“I’m not here to tell you what I think, I’m here to tell you what I know, and that’s that Kira deserved so much better, and that Kira’s not alone, and that women all over this country deserve so much better.”

The U.S. maternal mortality crisis

Dr. Shah, an ob.gyn. at Beth Israel Deaconess Medical Center and director of the Delivery Decisions Initiative at Harvard Medical School’s Ariadne Labs, both in Boston, where he has “been on this mission to improve safety in childbirth for years now,” echoed Ms. Saba’s dismay regarding the pace of progress.

“It’s not just about the present, it’s about the future, it’s about the pact that every generation ought to have with the next one to leave things at least as well as they found them. And when it comes to the health of our moms in this country, we are not doing that,” he said. “An American mom today is 50% more likely to die in childbirth than her own mother was, and 3-4 times more likely to die if she’s black than if she’s white.”

Indeed, the data released Jan. 30 by the CDC’s National Center for Health Statistics (NCHS) – the first on maternal mortality released by the agency since 2007 – show a U.S. maternal mortality rate of 17.4 maternal deaths per 100,000 live births in 2018.

The rate is higher than the 12.7 per 100,000 live births reported in 2007, but the increase is attributable mostly to changes in data collection and reporting methods. In 2003, “a consensus process recommended that all states add a standardized ‘checkbox’ to improve the identification of maternal deaths,” and implementation wasn’t complete until 2017 as “funding, technology, and state laws allowed,” meaning 2018 was the first year that data were reported in a standardized fashion across states, the CDC explained in a press release.

The data demonstrate ongoing wide racial/ethnic disparities: the maternal mortality rates for non-Hispanic black women, non-Hispanic white women, and Hispanic women were 37.1, 14.7, and 11.8 per 100,000 live births, consistent with earlier data.

Further, the rates for women aged 40 years and over were nearly eightfold higher than for those under age 25 years (81.9 vs. 10.6 per 100,000 live births).

CDC officials noted, however, that inconsistencies in reporting still leave some question about the accuracy of the data, stating in the release that “NCHS has identified instances where application of the checkbox information according to coding rules led to misclassification of maternal deaths.”

The agency is making changes in rules and reporting to ensure greater accuracy, but the numbers nevertheless reveal a startling truth: “The United States is the most dangerous place to deliver a baby in the industrialized world.”

 

Progress and challenges

Rebekah Gee, MD, an ob.gyn. who served for 4 years as Secretary of the Louisiana Department of Health before leaving the position in January, made that statement during another panel discussion at ACOG 2019 – The President’s Panel: Maternal Mortality: Progress Toward Prevention – which was moderated by Lisa M. Hollier, MD, now the immediate past president of ACOG.

Texas Children's Hospital

That’s not to say progress hasn’t been or can’t be made, Dr. Gee said.

In fact, quality improvement measures she facilitated in Louisiana led to a 25% reduction in infant mortality and a 10% reduction in neonatal intensive care unit admissions, demonstrating the potential for improvement with such initiatives, but addressing maternal issues is a greater challenge, she said.

“I think part of the sad truth is that we really focus on babies first, not moms ... and that needs to change,” Dr. Gee said.

Dr. Hollier focused much of her attention during her tenure as ACOG president on doing just that, particularly through an emphasis on heart disease, which is the leading cause of U.S. maternal deaths in pregnancy and the postpartum period.

In an interview, she shared her thoughts on the progress achieved and the work that remains.

ACOG was instrumental in the enactment of the Preventing Maternal Deaths Act of 2018, which appropriated funding for Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM), a CDC initiative to support state-based maternal mortality review committees, said Dr. Hollier, professor of obstetrics and gynecology at Baylor College of Medicine, Houston.

“The really great news is that almost immediately after passage of the legislation, the CDC put out the notice of the funding opportunity, and they were able to provide 24 awards supporting 25 states,” she said.

ERASE MM will enhance state data collection and availability and enable a level of data sharing that “will really add strength and depth to reporting from the maternal mortality review committees, which really provides us with the best information we have to truly understand the causes, the contributing factors, and the strategies that can be put in place to prevent future maternal deaths.”

Further, the Alliance for Innovation on Maternal Health (AIM) program, a cooperative agreement with the Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau to improve safety and outcomes through evidence-based patient safety bundles, was extended, and in May 2019, ACOG updated its guidance on managing cardiac contributors to maternal mortality, releasing its “Pregnancy and Heart Disease” Practice Bulletin, she said.

Dr. Hollier continues in her quest for improved maternal outcomes. She is slated to deliver a keynote address at the American College of Cardiology/World Congress of Cardiology conference March 28 in Chicago.

“I’m so excited ... to talk about the new guidelines that we’ve put out and to really talk about how cardiologists and ob.gyns. can work together to improve women’s health outcomes,” she said, adding that she already is seeing a strengthening of such partnerships.

A number of academic institutions are developing “pregnancy heart teams” to identify and care for women who have or develop heart disease during pregnancy.

“This type of collaboration ... is going to be essential to address mortality from cardiovascular causes and from cardiomyopathy, which accounts for about 25% of all maternal mortality,” she said. “The next area where we really need some buy-in is from our emergency physicians.”

Enhanced collaboration with emergency physicians and other specialties present opportunities to better identify and address pregnancy-related complications and sequelae, she said.

“Women are dying because they’re not being diagnosed,” she added. “We have to raise that level of awareness – it’s just absolutely critical.”
 

Identifying and addressing drivers of the crisis

Dr. Gee further emphasized the importance of addressing maternal health, noting that for every woman who dies from maternal causes, 100 experience maternal morbidity.

“It’s startling and it’s scary,” she said. “We are looking at this not just as a problem of outcomes, but a problem of racial inequity and racial bias and implicit bias.”

When she and her team assessed maternal mortality in Louisiana, they looked specifically at whether each death could have been prevented if, for example, blood was given sooner, cardiomyopathy was recognized sooner, or hypertension was treated on time.

“When we looked at these numbers ... when we looked at white women, 9% of the time we could have done better with our medical care; with black women, 59% of the time we could have saved her life with better care,” said Dr Gee, who is a gratis assistant professor of obstetrics and gynecology at Louisiana State University, New Orleans. “And if that doesn’t convince you that racial bias is an incredibly important thing to address – that we need to have a conversation about and address at a national level – I don’t know what would.”

In fact, numerous health, societal, socioeconomic, and other factors – some known, some yet to be identified, and many inter-related – are among the drivers of the U.S. maternal mortality crisis. In the coming months, an Ob.Gyn. News team will examine several of these drivers in depth. We’ll look specifically at the role of racism and bias, and at urban-rural disparities in access and outcomes – especially for women of color and indigenous women. We’ll address the scope and impact of each, successes and failures in addressing the problems, and ongoing initiatives.

Follow us for insights from experts, researchers, practicing physicians, and patients and families affected by the maternal mortality crisis, and stay with us through coverage of ACOG 2020 for perspective on what, specifically, ob.gyns. can do about it.

Mr. Johnson proposed a starting point:

“Here’s the good news – you guys ready for this? We can fix this,” he said, adding that the solution starts with “speaking Timoria’s name ... speaking the name of Kira Dixon Johnson ... speaking the names of these women and then asking the people that are around you, ‘What are we prepared to do to make sure that this doesn’t happen to other women.’ ”

sworcester@mdedge.com