If one of the barometers of health system performance is how well women are supported during pregnancy, childbirth, and after delivery, something is terribly amiss in the U.S. The strongest indicator is the maternal mortality rate. While it has been falling in much of the world, deaths during pregnancy and the year after among U.S. women have been rising: from 7.2 deaths per 100,000 live births in 1987 to 17.2 deaths per 100,000 births in 2015. Maternal mortality rates have increased for both white and black women, but there are persistent racial disparities: black women are three times more likely to die of pregnancy-related causes than white women. While many explanations have been put forth to explain these trends — better reporting, a rise in the prevalence of chronic conditions, and the impact of structural racism and poverty — experts agree the majority of maternal deaths are preventable.
Rising maternal mortality highlights problems in our nation’s approach to maternal health, including lack of medical oversight and social support during the postpartum period and inadequate coordination among obstetric and primary care providers. Interruptions in coverage also place women at risk. This problem is acute in the Medicaid program, which covers more than 40 percent of childbirths. In states that have not expanded eligibility for the program to low-income, non-childbearing adults, many women find themselves without coverage just 60 days after giving birth.
In this issue of Transforming Care, we examine efforts to redress these shortcomings by wrapping more supportive services around women who are at heightened risk due to their social or medical needs, and by stepping up support for months or even years after childbirth. We do not focus on efforts to reduce complications during childbirth itself, though the Alliance for Innovation in Maternal Health and the American College of Obstetricians and Gynecologists are leading important work to promote safer deliveries through “bundles” of best practices. Instead, we explore what happens before and after childbirth.
Using Pregnancy as Opportunity to Intervene
While childbirth is often a normal and even empowering experience, for a subset of women it’s a stress test on the body and spirit that puts them and their babies at risk. Many of those working to improve maternal health see pregnancy as on opportunity to engage women in regular care, particularly those who haven’t visited a doctor since they were children or have put their jobs, families, or others ahead of their own health. Frequent prenatal visits serve as an opportunity to identify and address what may be undiagnosed chronic conditions, including hypertension and diabetes, or behavioral health issues that may be exacerbated by pregnancy.
Group Prenatal Care and the Women-Inspired Neighborhood Network
One of the most successful models for supporting women during the prenatal period is CenteringPregnancy, a program organized around group prenatal visits that include between six and 12 women at similar stages of pregnancy. The visits, which can last up to two hours and are typically facilitated by obstetric physicians, midwives, or other clinicians, offer health education, anticipatory guidance about common postpartum challenges, and links to community supports. Each woman also has a private exam with her obstetrics provider.
The groups create opportunities for women to trade ideas for coping with the stresses of pregnancy and parenting, and this bonding helps keep women engaged, says Erin Conklin, M.P.A., CenteringPregnancy’s state program manager in Michigan. “If a patient misses an appointment, other members of the group will check in, saying, ‘We missed you. Are you coming? Do you need a ride?’”
Now in nearly 600 sites across the U.S., including many federally qualified health centers and other clinics serving low-income women, CenteringPregnancy has been linked to improved patient and provider satisfaction and reduced racial disparities in infant and maternal outcomes. (For examples of other group prenatal classes and their results, see this opinion from the American College of Obstetricians and Gynecologists.)
In 2016, the Women-Inspired Neighborhood Network: Detroit (WIN Network), founded by four of Detroit’s major health systems in an effort to reduce infant mortality rates, began offering CenteringPregnancy classes. In a first among Centering programs, community health workers (CHWs) help lead the group classes (along with certified nurse midwives from Henry Ford Health System), facilitating discussions on healthy lifestyles and nutrition, how to navigate the health care system, and other topics.
Most of the women who take part are African American and nearly all are Medicaid beneficiaries. While they tend to be relatively healthy (those with medically complex pregnancies are referred to traditional prenatal care), many have financial problems and lack resources to cover basics like diapers and strollers; some live in shelters or boarding houses. “Housing is the biggest need,” says Jaye Clement, M.P.H., M.P.P., director of community health, programs, and strategies at Henry Ford Health System, one of the four founders. “We see 10 people living in two-bedroom apartments.” The CHWs make multiple home visits, as many as 12 for those deemed at highest risk, to assess women’s needs and help them tap into sources of stable housing, childcare, transportation, or other support.
The CHWs work with women during their pregnancies and through their babies’ first year. “We are all about empowerment,” says Nada Dickinson, a CHW team leader. “A lot of women in low-income communities, especially African-American women, feel judged, not just by medical professionals. They don’t think they have value. We tell them they are intelligent and know their bodies. We encourage them to challenge things if they feel something isn’t right.”
Across Detroit’s Wayne County, 14 percent of black babies are born at low birthweight and nearly 12 percent of all babies are premature. In contrast, only 7 percent of the 172 babies born to women who’ve participated in WIN Network’s CenteringPregnancy since 2016 had babies with low birthweight or born prematurely.
New Jersey’s Healthy Women Healthy Families Initiative
New Jersey, which has the fifth highest maternal mortality rate in the country, is working to expand access to the CenteringPregnancy model and other maternal health programs — using a centralized referral system to identify the most vulnerable women and then surrounding them with extra support through their pregnancies and their baby’s first three years. Funded by federal and state maternal and child health block grants ($4.7 million annually) and philanthropic support ($2 million), Healthy Women Healthy Families, launched last year and focuses primarily on African-American women living in eight New Jersey cities with the highest black infant mortality rates. Health care providers and community health workers screen women to identify those who may be at risk. Cities are also enlisting churches, schools, libraries, and soup kitchens to identify women who may need help. An intake specialist then reviews women’s medical and social needs and connects them to CenteringPregnancy groups, nurse home visits, food pantries, job/employment services, benefit programs, or others.
The program was informed by the New Jersey Department of Health’s survey and focus group research, which found that pregnant black women are twice as likely as pregnant white women to report stress, and they point to different sources: white women most often mention the illness or death of a loved one, while black women mention more frequent arguments with their partners, moving, and problems paying bills. When asked the root causes of New Jersey’s high infant and maternal mortality rates, community health workers and other staff who work directly with low-income women pointed to the lack of culturally competent maternal health care providers and difficulty accessing care in a timely way. They also cited insufficient access to housing, childcare, and transportation.
In addition to community health workers, some cities are fielding doulas to support women through childbirth and help them with breastfeeding and other infant care. Program leaders hope that doulas and CHWs will stay in regular contact with women so they can help identify any red flags after delivery. “Doulas and CHWs will see women earlier after delivery than the doctors may see them and may communicate with them more often,” says Lisa Asare, M.P.H., assistant commissioner in the Division of Family Health Services at the New Jersey Department of Health. “They can teach women how to recognize danger signs … and act upon them.”
Engaging Women in Substance Use Disorder Treatment
Clinicians at St. Monica’s, an addiction treatment facility in Lincoln, Nebraska, find that pregnancy often opens a window of opportunity to engage women in addiction treatment. Most of their patients are pregnant or already have children, and they come from across the state seeking help for addictions to alcohol and drugs, mostly methamphetamines. Their treatment approach is informed by the research of Stephanie Covington, Ph.D., L.C.S.W., which suggests men and women need different approaches to addiction treatment because the underlying trauma that often fuels addiction may have different roots.
St. Monica's seeks to build women’s support networks by creating a home-like environment, with women sharing responsibility for cooking and cleaning and participating in group counseling sessions that enable them to recognize common experiences. “Where they turn that corner is learning that they often experience similar things in terms of the trauma, sexual abuse, or trafficking,” says Mary Barry-Magsamen, St. Monica’s CEO. “They realize everyone in the room experienced something like that and they are more alike than different.” And while many programs require women to complete treatment before reuniting with their children, St. Monica’s allows younger children in the homes, so their mothers can have support, oversight, and practice with parenting skills.
There have been other efforts to address substance use disorder in the context of pregnancy. For example, Ohio State University’s Substance Abuse Treatment, Education and Prevention Program Clinic partners with a local treatment center to offer co-located obstetric and addiction care for women with opioid use disorder. And the Horizons Program at University of North Carolina School of Medicine offers prenatal and postpartum care to pregnant women with substance use disorder.
Enhancing Support During the "Fourth Trimester" and Beyond
New Jersey’s Healthy Women Healthy Families initiative places as much emphasis on the postpartum period as the prenatal one in recognition that after childbirth women are still at risk as they undergo major physical and psychological adjustments in addition to adapting to life with a newborn. During this vulnerable period, the onus is often put on women to ask for help. Along with New Jersey’s state-led initiative, there are several efforts underway to offer more continuous support to women after childbirth, beyond the typical six-week postpartum visit.
Brigham and Women’s Cardiometabolic Clinic in Maternal-Fetal Medicine
One effort is being led by clinicians at Brigham and Women’s Hospital, which in 2011 created the Cardiometabolic Clinic in Maternal-Fetal Medicine to offer closer oversight during the postpartum period to women who experienced preeclampsia during pregnancy. (Preeclampsia involves high blood pressure and potentially changes in a mother’s kidney, liver, or blood-clotting systems.) They were motivated by growing evidence of the long-term risks of preeclampsia, which were documented in a startling study that followed more than 1 million women for eight years after childbirth. It found that women’s risk of developing premature cardiovascular disease doubled if they had experienced preeclampsia or related complications during pregnancy. Risks tripled among those who’d experienced poor fetal growth, quadrupled among those who’d had a stillborn baby, and were seven times greater if they smoked and had other preexisting risk factors. “If we had a better lens on women’s health, this news would be on the front page of USA Today,” says Ann Celi, M.D., M.P.H., an internist and pediatrician who leads the clinic.
Celi works with a team of maternal-fetal medicine specialists, internists, and nutritionists who provide intensive follow up in the weeks and months after delivery for women who experienced preeclampsia — about 2 percent of the women who deliver at the Brigham each year. They focus on proactively stabilizing women’s blood pressure through medication management, provide nutrition and lactation counseling, and engage in other efforts to set women on healthier courses. All women receive home blood pressure monitors as well as mental health and social referrals as needed. A study of 412 women who received care at the clinic found nearly half required medication adjustments. It also found high rates of engagement with nutrition consultations (86.8% attended) and primary care referrals (79.5% kept scheduled appointments.)
Northwestern’s Navigating New Motherhood
Clinicians at Northwestern Memorial Hospital’s Prentice Ambulatory Care Clinic, which provides prenatal and postpartum care to low-income women (nearly all are covered by Medicaid, 55% are African American, and 30% are Hispanic), in 2015 developed the Navigating New Motherhood program to offer enhanced support to women through the postpartum period. Based on the model of oncology navigators — who help cancer patients overcome barriers and find the resources they need to receive timely treatment — Northwestern’s navigator meets with women in the hospital after childbirth to offer services. In the first year, only seven of 218 women declined. The navigator then helps women schedule postpartum and any other medical visits and uses texting to check in on women regularly, answer their questions, and remind them of upcoming appointments. The navigator may also attend postpartum visits with women and help connect them to housing, nutrition, or other benefits.
Compared with patients who received treatment at the clinic the previous year, a study found those who received navigation support were more likely to attend postpartum visits (88% vs. 70%) undergo depression screening, and receive influenza and HPV vaccinations. “One of the things we found was that prior to meeting the navigator women didn’t appreciate the importance of the postpartum visit. They felt healthy and well and prioritized the baby and getting back to work,” says Lynn Yee, M.D., M.P.H., who developed the model and serves as an assistant professor at Northwestern’s Feinberg School of Medicine. The navigation program is now being expanded, and its effects will be tested in a randomized control trial.
Alison Stuebe, M.D., associate professor in the Department of Obstetrics and Gynecology at the University of North Carolina School of Medicine, has helped define ideal postpartum care. In a Q&A she describes what it will take to get there.
“I think there is a sense that once the candy is out of the wrapper, we’re done with the wrapper.”
Promoting Continuity of Care
Federally qualified health centers and other clinics that provide both primary and obstetric care are another model for supporting women’s comprehensive needs. Community of Hope, a federally qualified health center in Washington, D.C., has evolved a suite of services to support women of reproductive age that ramps up when they become pregnant. In addition to nine midwives (five full-time equivalents), the health center has perinatal navigators who work with pregnant women through pregnancy and six months after delivery to help them find social supports and make sure they find ongoing primary care. A group care coordinator leads group prenatal care sessions and a reproductive care coordinator helps women develop contraception and pregnancy plans. The health center also partners with Mamatoto Village, which trains community health workers to support women through pregnancy, childbirth, and the first months of parenting.
The fact that women can see Community of Hope clinicians before, during, and after delivery promotes continuity and helps ensure problems don’t get missed, says Ebony Marcelle, C.N.M., M.S., director of midwifery for the health center. “When women come for the early postpartum group and the baby needs a weight check, we will see the baby,” she says. “If she comes in with a baby and the [pediatric] provider sees she has not had a postpartum visit, we try to get her seen that day.”
Lessons and Policy Implications
Uninterrupted access to insurance is the greatest lever for change.
While these programs illustrate the benefits of increasing clinical oversight and social supports during the prenatal and postpartum periods, their spread may be hampered by states’ differing rules governing Medicaid eligibility. In states like Texas, many women who qualify for Medicaid while pregnant (because their income is less than 203 percent of the federal poverty level, or $52,273 for a family of four) will not meet the much narrower eligibility requirements for coverage after giving birth (income at 17 percent of the federal poverty level, or $4,378 for a family of four).
Changes in payment could help.
In addition to expanding coverage, states can modify Medicaid reimbursement to promote adoption of supportive maternal services. South Carolina’s Medicaid program has enhanced reimbursement for CenteringPregnancy programs, while New Jersey’s Medicaid program will reimburse doulas per client, Asare says.
Health plans can also pay for services such as maternal health navigator programs or blood pressure monitors for women at risk of hypertension. Technology platforms could be leveraged to scale promising approaches. Penn Medicine has used text messaging to collect blood pressure readings and educate women about the risks of hypertension in the postpartum period.
Expanding the workforce could help address unmet needs.
The success of these programs to date suggests that community health workers, doulas, navigators, and other nonmedical staff play critical roles in supporting women throughout their pregnancies and in the months and even years after childbirth. Understanding which approaches work best and finding sustainable funding sources will encourage their spread.
Greater focus on the quality of care offered to women is needed.
Maternal mortality reviews are one way to understand the root causes of maternal deaths and identify potential gaps in health care quality. While only about half of states and some cities conduct these reviews, the Preventing Maternal Deaths Act, signed into law in December 2018, establishes a federal infrastructure for collecting and analyzing information on every maternal death. In addition, there is a proposed revision of Healthcare Effectiveness Data and Information Set (HEDIS) measures for 2020 to measure receipt of early postpartum visits (between one and 21 days after delivery) in addition to later postpartum visits. But aside from these measures, data gauging the quality of maternal care are generally lacking.
To expand measurement and improve performance, Beth Israel Deaconess Medical Center in Boston recently established a population health program for women of reproductive age. Chloe A. Zera, M.D., M.P.H., who heads the effort, plans to focus on high-frequency, high-variability conditions, including hypertension and behavioral health. “We want to encourage all of primary care to prioritize reproductive health,” she says. To spur improvement, the health system may look at measures of quality that aren’t tracked elsewhere. “Something we care about — screening for diabetes after pregnancy with gestational diabetes, for example —is not a recognized quality metric. It hasn’t percolated up to that level,” she says.
Better training of primary care and obstetric providers is needed.
For example, internists and specialists need to be aware of the long-term cardiovascular risks among women who had preeclampsia or other pregnancy complications and work together to ameliorate them. A recent survey found that gynecologists were significantly more likely than internists to recognize the risk, but less likely than internists to know how to follow up.
In addition, obstetric and primary care clinicians need to be incentivized to work together to ensure women make safe transitions from postpartum to ongoing care. “The handoff is almost ceremonial, even though it’s incredibly important to a person’s well-being,” says Neel Shah, M.D., M.P.P., assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School.
In addition, pediatricians can play a key role by assessing how mothers are doing during well-baby visits and creating opportunities for parents to support one another.
To make meaningful progress, health care professionals need to address implicit bias and acknowledge the role of structural racism in maternal health.
While programs intended to educate women about their health and encourage them to speak up are important, they can only go so far in a health care system with a long history of racial and gender bias. Research has found that clinicians spend less time with black than white women, more frequently discount their symptoms and complaints, and undertreat their pain.
Reducing racial disparities will require an intentional focus on structural racism and implicit bias. In our September 2018 issue on Reducing Racial Disparities in Health Care by Confronting Racism, we shared several examples of how health care organizations are partnering with patients to identify problems and taking concrete steps to address them. Laurie Zephyrin, M.D., the Commonwealth Fund’s vice president for health care delivery system reform, outlined other strategies in her recent Stat op-ed, Pregnancy-Related Deaths Reflect How Implicit Bias Harms Women. We Need to Fix That.
And as the programs featured in this issue illustrate, the path forward must include a comprehensive and longitudinal approach to maternal health that does a better job of identifying when and how women may need additional support. “If we in health care can send a message to women that we care about them and that we are there to help them, that will go a long way,” says Celi of Brigham and Women’s Hospital.
