Addressing the Root Causes of Maternal Health Inequity

All organizations should ensure their obstetrics patients receive the highest quality, evidence-based care throughout their delivery. To do this, organizations must ensure that staff are aware of best practices and can easily follow them.

Adopting evidence-based care standards

Organizations must start with adopting best practice safety protocols if they haven’t already. The Alliance for Innovation on Maternal Health (AIM) has developed open-access, data-driven maternal safety bundles for hospitals and health systems to adopt, including bundles on:

• Depression and anxiety
• Maternal venous thromboembolism
• Obstetric care for women with opioid use disorder
• Obstetric hemorrhage
• Postpartum care basics
• Prevention of retained vaginal sponges after birth
• Severe hypertension in pregnancy
• Reduction of peripartum racial/ethnic disparities
• Safe reduction of primary cesarean birth

To review these protocols, visit the Council on Patient Safety in Women’s Health Care here.

Facilitating frontline implementation

After reviewing evidence-based safety protocols, leaders must ensure clinicians are able to easily and consistently incorporate them into workflows. To do so, engage a multidisciplinary group of leaders, including physician, nursing, and administration, to design and roll out care standards system-wide.

Maternal health champions should:

• Use simulation training to prepare care teams for rare, severe, and timesensitive complications. Hold training sessions to unearth unanticipated barriers to protocol implementation. Then, engage the team in brainstorming how to address them. Emphasize that emergency communication procedures are evidence-based and must be as regimented as clinical procedures.
• Hardwire channels for regular intra- and inter-team communication to keep everyone accountable for sharing timely information. Schedule regular meetings for leaders to update staff on new programs or educational materials. Publish provider adherence data and highlight the impact of protocol changes to encourage behavior change.

It can be deeply unsettling for frontline care teams to hear that their practice could lead to unnecessary maternal death—or worse, that is already has. It’s likely that you’ll face pushback rooted in these difficult emotions, as well as general resistance to logistical change. To overcome these barriers, approach conversations with care teams, departments, and facilities as equal partnerships and identify the structural—not individual—challenges to ensuring patient safety.

For more guidance on designing easy-to-implement care standards, review our Create Care Standards Your Front Line Will Embrace research report.

Once organizations have no-regrets safety protocols in place, maternal health champions should institute ongoing feedback mechanisms to monitor adherence to care standards and identify other gaps in maternal care. Champions should:

• Expand maternal mortality review boards to become multidisciplinary perinatal review committees
• Use race-stratified data and community input to identify and address care gaps

Expand existing maternal mortality review boards into multidisciplinary perinatal review committees

The first step is to launch a multidisciplinary perinatal review committee to unearth the root causes of clinical escalation. Many organizations already have maternal mortality review boards, but these should be expanded beyond instances of mortality during delivery to include all complications before, during, and after birth. This expanded charter emphasizes that it’s important to prevent “near misses” as well as mortality, since morbidities can lead to long-term health complications and emotional trauma. Reviewing all unexpected complications, no matter the outcome, also ensures that successful responses to these complications are a matter of planned processes, not luck.

Committees should be made up of a truly multidisciplinary group, including a range of clinical and administrative leaders as well as patients and community members. A wide perspective allows the committee to use a broad definition of morbidities. It should include clinical complications, downstream mental health impacts, and subjective measures including whether patients felt respected and were owners in the medical decision-making.

Use race-stratified data and community input to identify and address care gaps

Multidisciplinary perinatal reviews surface critical gaps in care delivery after a serious complication has occurred. In addition to these reactive improvements, leaders should task data analysts and community health staff with collecting quantitative and qualitative data to proactively identify blind spots and next steps.

Common metrics to track, stratified by race, include:

• Number of prenatal care appointments
• Number of postpartum care appointments
• Self-reported patient satisfaction
• Social needs

Three tips for designing an effective data-gathering strategy

With this intel in hand, clinical leaders should make targeted investments by tapping into resources outside their traditional purview: across the system and in the community. Design solutions in partnership with the most impacted groups to advance equity. Prioritize partnerships that achieve the following:

• Connect community health leaders with frontline staff to offer ongoing cultural humility and clinical training. Cultural humility training must cover topics of power and privilege, structural inequities, and how injustice manifests in health care. Implicit bias training is an important first step, but education should extend to how staff can identify their own biases and mitigate them using patient engagement tactics. Demonstrate how staff can fit tactics into their workflows and make the most of limited time with patients. In addition, leaders should offer clinical education to dispel misconceptions that lead to disparate care (for example, the fallacy that Black people have thicker skin).
• Normalize and refer patients to perinatal-specific behavioral health care. Patients can experience a range of behavioral health challenges before and after delivery, including anxiety, depression, hypomania, and substance use. Many patients are only familiar with postpartum depression and may feel shame for not adhering to societal expectations of motherhood. Staff should screen for behavioral health needs during and after the pregnancy to normalize perinatal mood disorders and connect patients to care before severe escalations. Care should be perinatal- specific, including a specialized focus on building confidence in parenting skills, identifying support networks, and supporting infant bonding.
• Proactively identify and address social needs by connecting patients to community partners. As with any condition, a patient’s social needs before and after the pregnancy can reduce access to care, interfere with selfmanagement behaviors, and cause significant stress. Comprehensive prenatal and postpartum care must include social support to overcome barriers around food, housing, transportation, financial stability, and more. Community health workers can help unearth and address these needs by building trusting relationships and connecting patients with community-based organizations and social services.
• Partner with midwifery and doula groups to integrate additional patientcentered support into the care team. Some hospitals and health systems have employed midwives, but few have doulas. Both types of staff can help serve as a patient’s advocate throughout the pregnancy and delivery. Increasing evidence indicates that midwives and doulas can have a significantly positive impact on health outcomes and patient satisfaction. Contract with community-based midwifery and doula groups to support patients at highest risk of complications, including Black and Native American patients. Ensure these staff can easily enter care settings and have access to the patient during the delivery.
• Invest in telehealth capabilities to extend the care team’s reach to patients who face access barriers—particularly those in rural settings Geographic spread, the cost of transportation, and reduced wages from missed work reduces patients’ ability to come to frequent obstetric appointments. Tele-visits and outpatient remote monitoring can help overcome access barriers and mitigate patient risk. In rural areas, some providers may help relocate high-risk patients in their third trimester to a maternity home or other short-term housing to be closer to specialty care upon delivery.