The COVID-19 pandemic has had a disproportionate impact on Black and Indigenous communities, and people of color. This, along with racial justice protests, has focused attention on America’s long-standing racial health disparities and prompted calls for action to advance health equity. Systemic racism is a significant contributing factor impacting disparities in maternal and infant health outcomes. American Indian and Alaska Native (AIAN) and Black birthing persons are two to three times more likely to die in childbirth and postpartum periods than are white birthing persons.
COVID-19 presented serious challenges for an already-stressed prenatal and maternal health system. Limited access to in-person visits, restrictions on who could support a birth, and the broader stressors of the pandemic created challenges for birthing people generally and BIPOC birthing people in particular. Yet, while the pandemic has resulted in many hardships, it also has accelerated the pace of innovation in care delivery. Some innovations show promise as long-term strategies for expanding access to high-value, equitable maternity care for all and present a path toward addressing health equity.
To this end, the Maternal Health Hub1 published Maternity Care Delivery and Payment Changes During COVID-19: Assessing Equity and Sustaining Innovation, which examines innovative responses to the pandemic. The report highlights three case studies:
Prenatal Telehealth. Before the pandemic started, Michigan Medicine, an academic medical center at the University of Michigan, conducted a survey to gauge patient interest in virtual prenatal care. Results showed support for telehealth, prompting Michigan Medicine to redesign prenatal care for low-risk birthing individuals by implementing a “4-1-4” structure: four in-person visits, one obstetrical ultrasound, and four virtual visits, with additional virtual visits as needed. In addition, Michigan Medicine created an online program to provide birthing individuals with social connections and peer-mentoring support. While there are challenges regarding equitable device access and payment models to support this approach to care delivery, initial surveys from birthing individuals and doctors in the program show positive results. Specifically, individuals reported reduced barriers in accessing care, increased feelings of safety receiving care during the pandemic, improved counseling uptake, and increased sense of patient empowerment.
Virtual Doula Care. Doula care is a hands-on field. To adapt during the COVID-19 pandemic, Accompany Doula Care — a start-up that employs community-based doulas and contracts with accountable care organizations — implemented virtual care options. The organization worked with patients to determine whether in-person or virtual support was right for them and their families, developed COVID-19 training, tested innovative methods of reimbursement (e.g., reimbursing for cumulative time spent with the birthing person rather than single fixed rates), and distributed personal protective equipment. While the virtual model has been successful in providing continuous care during the pandemic, Accompany Doula Care continues to face challenges, including both patients’ and doulas’ concerns about comfortably using technology, inconsistent hospital policies, and most recently, hesitancy regarding COVID-19 vaccine uptake in the community.
Self-Advocacy Training. Effective advocacy during birth is critical to ensuring that a birthing person’s preferences, concerns, and needs are respected and addressed. While doulas are specifically trained for this role, most births in the United States do not include doula support. With pandemic restrictions limiting the number of people present during a birth, self-advocacy became a critical strategy to make sure birthing individuals’ voices were heard. The Black Coalition for Safe Motherhood designed a curriculum to provide birthing individuals and their families with tools to become strong self-advocates. It informs participants of their rights in a maternity care setting, including their right to informed consent and to vet maternity care services they receive.
These are just a few of the many innovations that have been implemented in response to the challenge of delivering maternity care during the pandemic. Identifying the innovations that are short-term band-aids versus those that should be kept and scaled up will require stakeholders to work with the communities they serve to assess efficacy and effects on health equity. A key step in growing these innovations into long-term solutions is to implement them in conjunction with strategies that acknowledge and address structural racism within health systems’ organizations and the communities they serve. Health systems can use what they have learned during the pandemic and invest in partnerships with community-based organizations to amplify efforts to address disparities. The models profiled on the Maternal Health Hub illustrate that it is possible to innovate and implement new delivery and payment models. With better financial incentives, federal and state policymakers could encourage adoption of such models to ensure all individuals have access to high-value, equitable care, including midwifery services and doula support.
