Perinatal partnerships: 10 tips for achieving maternal health equity
As a former clinical nurse in critical care and labor and delivery, I'm often asked health questions about what to expect during the hospital birthing experience.
The inquiries are ones of curiosity — but also fear.
Often, that fear is due to the awareness that Black women, Native women and women in rural communities experience maternal morbidity and mortality at significantly higher rates than white and urban women. In a time that brings much joy and excitement, anxiety and uncertainty linger.
Recently, a friend connected me with a mother expecting her second child. She requested my help with healthcare navigation and guidance during the perinatal period. Her first child was born almost 10 years ago, and she felt like she was starting over as a new mom. As a Black woman, she experienced a high-risk pregnancy with her first child, compounded by poor bedside communication and feelings of being dismissed and undervalued by her healthcare team.
She recalled the resulting battle with postpartum depression and other stressors, and decided this birthing experience would be different. That meant engaging a team of individuals committed to supporting her pregnancy goals and cultivating a safe space for a healthy pregnancy, delivery and baby.
As I assisted her with finding an obstetrician/gynecologist (OBGYN) and other birth workers, I often wondered how hospitals, clinics, healthcare providers and organizations could better serve high-risk patients and eliminate one of our nation's greatest healthcare crises. After all, data from Maternal Mortality Review Committees showed more than 80% of pregnancy-related deaths are preventable. Healthcare organizations are encouraged to be leaders in effecting change by providing respectful, equitable care for all birthing persons, promoting physical and emotional well-being for patients, and developing partnerships to provide high quality maternal and infant care to build healthier families and communities.
Below are 10 strategies to do just that:
1. Engage with a Perinatal Quality Collaborative (PQC): PQCs are state-level networks of teams who aim to improve the quality of care for mothers and babies. Comprised of clinicians and public health leaders, PQCs partner with hospitals, state agencies, families and communities to implement initiatives and share best practices to reduce maternal health disparities. The Centers for Disease Control and Prevention (CDC) currently funds 36 state-based PQCs. Engagement in a PQC is one factor in receiving the birthing-friendly hospital designation.
2. Implement obstetric (OB) patient safety bundles and emergency readiness protocols: The Alliance for Innovation on Maternal Health (AIM) at the American College of Obstetricians and Gynecologists (ACOG) developed safety bundles comprised of evidence-informed best practices that address common clinical conditions of pregnant and postpartum people. Quality initiatives such as maternal early warning sign protocols, obstetric rapid response teams, hemorrhage carts, and accurate and timely quantification of blood loss after birth provide clinical guidance to reduce maternal complications.
Furthermore, as OB units continue to close, rural communities with majority Black and low-income residents are disproportionately affected. As maternity deserts increase, it is essential that rural and non-obstetric facilities are equipped for obstetric emergencies. The Sg2 Women's Health Snapshot provides insights on women's health trends, including obstetric services and forecasting.
3. Create doula and midwife programs: Growing and diversifying the perinatal workforce in both the hospital and community setting allow for more support of the birthing person's physical, emotional and educational needs. Inclusion of doula care has shown to decrease birth complications and increase the likelihood of breastfeeding.
According to a Cochrane review, women with support in a doula role were 39% less likely to have an unplanned cesarean birth than those with no continuous labor support. Midwives assist in reducing labor interventions, cesarean sections, preterm births and low birthweight infants. Care models include hospitals providing doulas during labor and delivery to birthing persons who may not have access to a doula, Certified Nurse Midwives (CNMs) leading triage units or CNMs providing care for low-risk laboring patients in OB units.
4. Know data, recognize opportunities: Collecting and stratifying clinical data by race, ethnicity and language (REAL) allows hospitals to identify differences in health conditions based on patient demographics, enhance understanding of communities served and design interventions and quality improvement initiatives that are culturally sensitive and patient-centric to mitigate health disparities. The Vizient® Vulnerability Index™ assists healthcare organizations in gaining insights into their community's health to improve access to care and care delivery. The tool is now publicly available and aggregates 43 social determinants of health data points across nine categories such as education, housing, clean environment and transportation that affect quality outcomes like maternal morbidity and mortality. Awareness of vulnerabilities that may impact a community's health and targeting inventions to close gaps in care enhances overall healthcare outcomes and quality of life.
5. Facilitate implicit bias training and culturally competent education: Nearly 50% of all providers practicing obstetrics and gynecology admit to having some racial bias. Implicit bias contributes to healthcare inequities for communities of color. The March of Dimes offers continuing education courses to eliminate bias in maternal and infant healthcare. Culturally competent education is recommended to effectively deliver healthcare services that meet the social, cultural and linguistic needs of patients and families.
For example, addressing cultural and language barriers by including educational resources in various languages, incorporating professionally trained healthcare interpreters both in-person and by use of language telecommunications and technology in obstetric units could improve patient health outcomes and patient satisfaction. Engaging leaders & advocates in the community from certain diverse backgrounds may help enhance partnerships and culturally competent care within the hospital.
Being culturally aware and knowledgeable of the attitudes, beliefs and behaviors that may influence healthcare decisions for diverse patient populations empowers providers to improve patient-provider communication and build a trusting relationship during the healthcare delivery journey.
6. Monitor patients remotely: To remedy workforce shortages, telehealth for obstetric patients helps improve care access in areas of limited resources. In addition, provider home visits and monitoring vital signs such as blood pressure at home may assist in the management of high-risk OB populations.
7. Utilize innovation and technology: The Pregnancy+ and Baby+ apps are free educational tools that track pregnancy and baby development by providing animated illustrations, daily pregnancy and baby information, diet, exercise, baby growth and more, and provides support during pregnancy and after the baby is born. The Irth app allows patients to review prenatal, birthing, postpartum and pediatric care experiences and provides patient-reported insights on perceived bias and racism.
Irth offers a hospital pilot program to improve Black patient experiences, as well as a doula program and pregnancy resources. Huggies provides free articles, tools and insights for individuals and families preparing for pregnancy, during pregnancy and beginning parenting. And Pampers offers a free online, on-demand nine-part birthing education series from clinical childbirth experts.
Healthcare organizations can utilize various technological resources providing evidence-based information to help supplement education provided by clinicians and healthcare professionals to the patients and families.
8. Promote perinatal network support: Pregnancy and childbirth are experiences birthing persons should not have to figure out alone. The pregnant person should feel empowered to choose a team of health professionals such as an OBGYN, nurse, lactation consultant, doula, childbirth educator, midwife, family, spiritual advisor, trusted friend and more to support, care and advise during pregnancy and beyond. As the circle of care is formed, healthcare organizations and clinicians play an essential role in partnering with the team to provide optimal, patient-centered care.
9. Provide postpartum resources: Most states have expanded postpartum Medicaid coverage to 12 months after having a baby, which is a step in the right direction considering that among pregnancy-related deaths in 2020, 47% occurred 7 to 365 days postpartum. Furthermore, a recent Yale study suggests that ensuring access to breast pumps could help maintain breastfeeding, empower families to reach their breastfeeding goals, and address inequities in breastfeeding outcomes between U.S. racial and ethnic groups. Additionally, as mental health challenges arise during and after pregnancy, the National Maternal Mental Health Hotline is 24/7, free and confidential. Call and/or text 1-833-TLC-MAMA to receive resources and counseling for anyone in need.
10. Champion community relationships and partnerships: The health of individuals and families relies on the health of the community around them. Health organizations can influence the well-being of the community they serve by partnering with local and national organizations, community, advocacy and faith-based groups, birthing centers and clinics, and additional professionals passionate about enhancing maternal and infant care. Creating maternal support groups and utilizing perinatal navigators and/or community health workers help fill gaps in care, education and support for underserved populations. For example, creating a dads and doulas program engages expectant fathers in the birthing experience by equipping them with knowledge and skills to support their partners during and after pregnancy.
In addition, various organizations are partnering to make impacts in the community by increasing access to education, resources and supplies. Huggies has partnered with AWHONN to display the POST-BIRTH Warning Signs in diaper aisles in over 3,000 Family Dollar stores nationwide. Furthermore, the U.S. Department of Health and Human Services teamed up with nonprofit Baby2Baby and Huggies to provide newborn supply kits to help reduce the burden of immediate supplies needed after delivery. A true champion on and off the track, Olympian and mother Allyson Felix partnered with Pampers to provide a donation of 1 million preemie diapers to neonatal intensive care units (NICUs) across the country. Awareness by health organizations of these kinds of community partnerships and initiatives help them point patients to important resources — a progressive step toward providing the holistic care mothers, babies and families deserve.
Now for the best news: My friend delivered a beautiful, healthy baby girl with no complications (and I even had the pleasure of naming the baby!). I'm honored to have been chosen as a trusted advisor in her care — and all of us in healthcare should strive to build that level of trust with all those who come to us at one of the most exciting, scary and vulnerable times in their lives.
Related: Read our spotlight on maternal health, which details the efforts of providers, suppliers, nonprofits and Vizient experts in confronting the maternal mortality crisis.