Maternal Health in ‘Crisis Mode’

The United States now has the highest rate of maternal mortality among developed nations. Here's what's underway to reverse the trend.

Many mysteries arise when a woman gets pregnant. What’s the baby’s sex? Will he or she look more like mom, or dad? What will the baby be like when he or she grows up?

Increasingly, moms-to-be in America are facing a darker mystery: Will I survive?

The United States now has the highest rate of maternal mortality among developed nations. The rate increased by 26.6 percent from 2000 to 2014, according to a 2016 analysis published in the journal Obstetrics & Gynecology. Now, about 700 women die annually from pregnancy-related complications, according to the Centers for Disease Control and Prevention.

“The nation is in crisis mode trying to ensure all women have equal opportunities to survive childbirth and the recovery period immediately following delivery,” says Jenné Johns, director of quality improvement and health equity with the Blue Cross and Blue Shield Plans of Illinois, Montana, New Mexico, Oklahoma and Texas.

Even more jarring, 60 percent of maternal deaths could be prevented, according to the CDC. Uncontrolled high blood pressure, which can lead to stroke, and hemorrhage are common causes of severe injury or death in pregnant women. Both can be controlled or prevented.

Maternal mortality highest among African-American women

Some women are more at risk than others of dying during or after pregnancy. For instance, African-American women are three to four times more likely than white women to die from pregnancy.

Johns cites chronic stress, historical and implicit bias within the health care system and clinical symptoms presenting differently before, during, and after pregnancy as probable causes for higher death rates among black mothers.

Women covered by Medicaid — which pays for nearly half of all births in America — are also more prone to have preterm and low birth-weight babies than women with private insurance. Many women covered by Medicaid also lose coverage shortly after childbirth, creating a gap in obtaining timely and important health care services.

“Among the health care community, there is a growing understanding of the importance of driving targeted solutions to meet the clinical, economic and cultural needs of these women,” Johns says.

Experts are focusing on two areas where the system appears to be failing mothers: care practices and access to care.

Rhonda King spent 30 years as a labor and delivery nurse for high-risk pregnancies. Now, as an employee of Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas, she reaches out to moms during and after their pregnancies to provide support, including help managing high-risk conditions such as gestational diabetes and preeclampsia.

 

Improving care

One of those experts is Dr. Carla Ortique, a family medicine and OB-GYN doctor working at Texas Children’s Hospital in Houston. She got interested in maternal health after her daughter-in-law went through a difficult pregnancy.

“It opened my eyes to some of the inequity in the delivery of health care,” she says of that experience.

Since then, she has worked to alleviate those inequities. She now serves as vice chair of the state of Texas’ Maternal Mortality and Morbidity Task Force.

This group reviews and determines the cause of maternal death and injury cases. It then makes recommendations to the hospital where the death occurred to help prevent similar cases in the future.

Ortique points to California as a beacon of this approach’s success.

The California Maternal Quality Care Collaborative developed evidence-based quality improvement toolkits around the state’s leading causes of maternal death and injury, like hemorrhage and preeclampsia.

The collaborative was formed in 2006. Between 2006 and 2013, the rate of maternal death in California fell 55 percent. Meanwhile, maternal mortality continued to climb in the rest of the U.S.

Access to care

Unfortunately, it doesn’t matter how much OB-GYN care evolves if women can’t access it.

Sometimes, women can’t get care because they don’t have health insurance.

In other instances, women don’t go to doctors when they’re pregnant.

Educating women on the importance of starting prenatal care early is “a big piece” of the problem, Ortique says. “Women feel pregnancy is a state of good health, that it’s natural, and don’t necessarily recognize the importance of taking care early.”

Even limited prenatal education about pregnancy, labor and birth has proved effective at improving outcomes for babies and moms, according to a study in the Journal of Perinatal Education.

OB-GYNs are seeing improvements in getting women timely and frequent maternity care care by offering group prenatal visits, says Johns, the health equity director for the five Blues Plans. Group visits demonstrated reductions in racial and ethnic disparities in pre-term delivery rates and seeking maternal care.

Expectant mothers participate in two-hour group educational sessions with women of similar gestational ages and learn how to care for themselves during pregnancy and how to care for their infants.

Group prenatal appointments are linked to longer gestations, higher birthweight babies and greater patient and provider satisfaction.

“Engaging groups of pregnant women in prenatal care is proving positive birth outcomes and positive birth delivery realities. There’s something magical about group support,” says Johns.

Between work and childcare responsibilities, it’s not always easy for women to make it to checkups, even if they are in a group setting.

So, it may be time to meet women in the communities where they live to provide health care, instead of requiring travel outside of their communities, says Dr. Anita Stewart, a pediatrician with the Blues Plans.

“There are populations that do not travel outside of their communities for many reasons,” Stewart says. “We have to re-envision how to provide health care in new settings in the communities we serve.”

The Black Barbershop Health Outreach Program could be a model for this. The program aimed to reach African-American men at risk of diabetes and heart disease by meeting them in a place they already go and trust: the barber shop. It offers education and has screened more than 30,000 African-American men for health issues.

Health plans can also help coordinate care for members experiencing a high-risk pregnancy. For example, a pregnant Blue Cross and Blue Shield of Texas member had poorly controlled Type 1 diabetes. A nurse care coordinator worked with the member’s doctors to set up home health care. That way, the member could finish her pregnancy at home instead of in a hospital bed.

The health care community, including OB-GYNs, hospitals and health plans, have a responsibility to “support healthy pregnancies, deliveries, and keeping women alive post pregnancy,” says Johns — and hopefully leave pregnant women facing only happy mysteries.

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