This is not a new question in the health landscape of the United States, but while this issue has gained more media attention and funding as of late, statistics are not yet showing improved outcomes, especially for Black women in our country.
To give this problem more context, it pays to frame exactly how deep this problem goes and the populations who are most affected by it.
In a recent article published in Patient Engagement HIT on maternal mortality, the latest data from the CDC revealed the following:
"The United States still has the worst maternal mortality rates in the developed world, a factor largely driven by steep Black maternal health disparities, according to the most recent figures out of the Centers for Disease Control & Prevention. The data, prepared by the National Center for Health Statistics, showed the overall maternal mortality rate in 2020, the most recent year for which there is data, was 23.8 deaths per 100,000 live births. That is up from 2019 when the maternal mortality rate was 20.1 deaths per 100,000 live births.
And just as overall maternal mortality got worse in 2020, maternal health disparities likewise deepened. In 2020, the maternal mortality rate for non-Hispanic Black women was 55.3 deaths per 100,000 births, which is 2.9 times the rate for non-Hispanic White women (19.1 deaths per 100,000 births).”
We know the national trends are reflected in our Missouri communities. In a report we co-edited[1], compiled collaboratively with stakeholders across Missouri and published by the Missouri Hospital Association, the stark details and disparities were laid out in the introduction:
“Approximately 700 women in the U.S. die annually due to pregnancy related causes, and another 50,000 experience a life-threatening condition — often with long term sequelae — during labor and delivery… The quality and access to maternal care is uneven, particularly among rural and lower-income populations, and persons of color. In fact, Black women are four times as likely to die as white women, and they experience more than two times the risk of severe maternal morbidity (SMM) as white women in Missouri..., the rate of death among Medicaid beneficiaries was four times greater than the rate among mothers with private insurance.”
What is doubly worrisome is the number of maternal deaths that may be going unaccounted due to:
Access to coverage: Gaps in understanding the mother’s prenatal and postpartum course include a lack of interoperable electronic health records, incomplete data sources, and a lack of access to care for many once Medicaid coverage ends at 60 days postpartum.
Access to care: Through maternal mortality record reviews, it is understood that women are most likely to die from a pregnancy-related or associated event between 42 and 365 days postpartum — a time when many women have no provider access and rely on the emergency department for treatment.
But perhaps the most interesting sentence in the report is the following:
“Eighty-two percent of pregnancy-related deaths were determined to be preventable through a wide variety of stakeholder actions.”
Missouri’s Pregnancy Associated Mortality Review (PAMR) committee works painstakingly to review every maternal death, as well as to offer a report with recommendations rooted in action that can be implemented to prevent these deaths. And the more than 30 initiatives across seven content areas comprised in this report demonstrate the action-oriented efforts across Missouri, engaging families in both dense, low-resource, urban areas and diffusely populated, traditionally underserved, rural counties. Currently, these stakeholders are coalescing around support for legislative action to extend Medicaid coverage to one year postpartum for all Missouri mothers, a key recommendation of the PAMR report.
While each state is obviously different in terms of its demographics and healthcare policies, there is a lot of evidence that what was highlighted in the MHA report is mirrored across the US. There are indicators that the challenge is significant enough that stakeholders up and down the healthcare ecosystem, government, and patient advocacy groups are becoming galvanized for action.
At the Federal level, policy to impact Black maternal health disparities has gained attention and momentum, particularly over the past year. In February of 2021, Rep. Lauren Underwood, serving the Illinois 14th District in the US Congress (a nurse and the first millennial and person of color to represent her community in the US House of Representatives), along with Rep. Alma Adams (NC 12th district) and Sen. Cory Booker (NJ) and members of the Black Maternal Health Caucus, introduced the Black Maternal Health Momnibus Act. The Act includes a series of 12 bills to save moms’ lives and work to end racial disparities in maternal health outcomes. In the press release announcing their sponsorship of the legislation, Rep. Underwood was quoted:
"As maternal mortality rates continue to drop around the world, they are rising in the U.S., leaving behind devastated families and children who will grow up never knowing their moms. This crisis demands urgent attention and serious action to save the lives of Black mothers and all women of color and birthing people across the county."
There are other bright lights across the country demonstrating coalitions focused on the problem:
Aetna CVS Health has pioneered programs with the Society of Maternal-Fetal Health to support and integrate doula care for birthing people and to provide patient education regarding the symptoms and treatments for pre-eclampsia, a syndrome involving, in some cases, fatally high blood pressure, which is more common and severe in Black women.
Highly visible advocates like Cheryl Pegus, Executive Vice President of Walmart Health and Wellness, continue to bring awareness of the issue of Black maternal health to mainstream media, such as Oprah’s Own Your Health channel.
Kim Keck, President of Blue Cross Blue Shield Association, declared the group’s intention to make Black maternal health a priority as part of their National Health Equity Strategy, a “multiyear effort laser-focused on key health issues that disproportionately affect people of color. And as a first step, the Blues have committed to reducing racial disparities in maternal health by 50% in the next five years.”
For us at Simply Strategy, our work in maternal child wellness is one of the most rewarding health issues we encounter. Capturing the diversity and strength of work across our own state in one report was inspiring and hopeful. However, the ongoing, worsening statistics are a sobering reminder that the healthcare community has a long way to go to reverse the trends, eliminate racial disparities, and prevent more pregnancy-related deaths. And it underscores what we see in our overall healthcare research and strategy practice—the need to be collaborative, action-oriented, and patient-centered.
For all these initiatives to take hold and flourish, we see these three things as essential:
Collaboration: There are a lot of players in the healthcare ecosystem (payers, providers, non-profits, hospitals, patients/consumers, and those of us who serve them). But we all have the same goals—to improve the lives of moms, babies, and, therefore, communities. We know that to be effective, programs must be developed and implemented collaboratively with a variety of partners. No one funder will provide all the answers nor all the mechanisms to implement them; diverse program goals, funding streams, content experts, and organizational structures are essential to solving such a complex, multi-faceted problem.
Action: A report is only effective if it is taken off the shelf and used as a blueprint for action – an action that is tested and measured and refined and tested again. Some actions will be more effective than others. Some will be transferable across regions and across care settings, and some will have a limited impact depending on patient populations. Some will be controversial or difficult to implement (like moving to a value-based payment model). But only once we share even modest outcomes based on action can we convince those setting broader policies of the need to make them universal best practices.
Program design based on understanding: Many of the challenges caused by health disparities center around things we can address if we are willing to honestly endeavor to understand the lived experiences of disproportionately affected populations—in this case, Black mothers and families—AND consider the impact of our own biases and behaviors. Misunderstanding how and when to offer care can impact a patient getting the care she needs when she needs it. Missing the impact of provider bias can mask the instances in which critical symptoms are dismissed or overlooked, leading to complications that can be fatal. Without a clear understanding of the patient, the social determinants of health, and their relationship to the structure of the healthcare delivery system itself, through carefully executed research that uncovers their context and intersectionality, programs won’t be designed for optimal outcomes. Healthcare needs to take a page from consumer research by embedding the “voice of the customer” as a key holistic component in the efforts to combat maternal morbidity and mortality.
We’d love to partner with more organizations dedicated to this important and impactful journey—as strategists and moms, we can’t think of work more near and dear to our brains and our hearts.
[1] Kendig, S., Rideout, R. & Williams, A. (2021). Missouri Maternal-Infant Health: State and Regional Actions Care Delivery and Health Outcomes. Missouri Hospital Association. Available at www.MHAnet.com