Our Take

Addressing the Root Causes of Maternal Health Inequity

15 Minute Read

The United States is the only industrialized nation where maternal mortality and morbidity rates are increasing. All U.S. demographic groups experience an elevated risk of adverse outcomes, but Black and Native American patients experience devastating rates of complications. Clinical leaders can advance equitable outcomes by embedding best practice obstetrics protocols into frontline practice, tracking performance and identifying care gaps, and tapping into system- and community-based resources.

 

The conventional wisdom

Most hospitals and health systems have made significant investments in maternal health. Those investments often include creating point-of-delivery care standards and emergency protocols for labor and delivery. This focus on labor and delivery—while mission-critical—solves only part of the challenge. In fact, 64% of pregnancy-related deaths occur during pregnancy and between one week and one year postpartum, also known as the “fourth trimester.” That is because inadequate access to prenatal and postpartum care leaves many patients at increased risk for clinical escalation and long-term complications.

Additionally, conventional efforts to reduce maternal morbidity and mortality operate mostly “colorblind,” without investments designed specifically to support the most at-risk racial groups. Similarly, quality reporting regulations do not require health care organizations to track or publish maternal health outcomes by race.

 

Our take

To adequately improve outcomes, clinical leaders must understand the root causes of health disparities and take appropriate actions at the system level.

Maternal health interventions are incomplete without addressing racial health disparities. That is because the U.S. maternal health crisis is, at its core, a crisis of inequity. Although all demographics are impacted by the poor performance of the U.S. in maternal health compared with other industrialized nations, women of color are disproportionately impacted. The pregnancy-related mortality rate for Black patients in the US is 3.3x the rate for white patients. For Native American patients, it’s 2.5x the rate. These trends are similar for morbidity rates. To improve outcomes, health care organizations must examine the root causes of inequities: the intersection of structural racism and sexism.

Root causes of maternal health disparities

1 Enduring legacies of institutional racism hardwired into policy, social institutions, and culture

2 Deprioritization of women's holistic health care across the life span, particularly in favor of fetal outcomes

Without an in-depth understanding of how these root causes manifest, interventions aren’t likely to make a significant or sustained impact.

The legacies of these structural underpinnings impact women of color across four levels: systemic, institutional, interpersonal, and individual.

The four ways inequities manifest in maternal health

Systemic

Restricted access to highly resourced communities

For example, Native American communities have a poverty rate of 25.4%, double the national rate. Poverty has a direct impact on health outcomes, reducing the ability to afford key social goods including healthy food, safe housing, preventive care, and medication.

Institutional

Insufficient access to affordable and quality clinical care

For example, Black women are more likely to deliver in lower quality hospitals with higher morbidity rates.

Interpersonal

Provider-held implicit biases and misinformation

For example, 40% of first- and second-year medical students wrongly believe that Black people have thicker skin than white people, leading to lower pain assessments and undertreatment of pain in Black patients.

Individual

Physical impacts of chronic stress

For example, the chromosomal markers of Black women in their 40s and 50s appear 7.5 years older on average than white women’s. This “biological weathering” is attributed to psychosocial stressors stemming from the intersectional impact of racism and sexism. Weathering leads to the shortening of telomeres and early physiological deterioration.

These multifaceted and interconnected inequities are deeply embedded within the U.S. health care system. That’s why true change is so challenging. Hospitals cannot solve structural racism and sexism on their own, but they do have a role to play in reducing maternal health inequities.

 

Three steps to improve maternal health

Clinical executives are uniquely positioned to champion maternal health equity investments at their organization. While investments should focus on addressing the needs of the most at-risk populations—Black and Native American patients—these changes will improve health outcomes for all maternal patients.

There are three immediate steps that hospitals and health systems can take to improve maternal health equity. First, all organizations should make best practice obstetrics protocols easy for frontline staff to implement. Then, organizations should institute ongoing feedback mechanisms to monitor adherence to care standards and assess gaps in maternal care. With that intel in hand, champions should tap into resources outside their traditional purview to expand their impact

  • Step

    Ensure evidence-based care standards are embedded into frontline practice

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    Track performance and identify care gaps

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    Tap into system- and community-based resources to expand impact

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Parting thoughts

The root causes of the U.S. maternal health equity crisis are complex and overwhelming, and the changes needed to reverse current trends will not be easy. But this is not the job of a clinical leader—or hospital, for that matter—alone. Success requires multidisciplinary, community-based action.

However, action shouldn’t be restricted to hospital/community partnerships. The most effective way to address the root causes of inequities is through government policy change. Hospitals and health systems already have policy advocacy efforts traditionally targeted at reimbursement rates, as well as the clout and scale to be effective. Leaders should direct resources to support government proposals designed to improve maternal access to care, quality outcomes, and workplace equity. Major proposals include:

  • Extend Medicaid coverage and increase Medicaid reimbursement
  • Improve funding and reimbursement rates for nontraditional providers
  • Offer pregnancy bundle payments
  • Introduce additional quality measures
  • Secure equitable leave for all parents
  • Reduce pregnancy discrimination in the workplace

To support hospital initiatives, Advisory Board will continue to identify tactical examples hospitals and health systems can implement to improve performance and advance equitable outcomes. For more on this public health crisis, review our Snapshot of Maternal Health Inequity cheat sheet.

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