Delivering High-Quality, Equitable Maternal Care: Lessons from the Nation’s Largest Private Integrated Care Delivery Organization

Lori Potter
Lori Potter
By Lori Potter, Senior Counsel, Government Relations, Kaiser Permanente

Over the past year, National Public Radio has been reporting on the high rates of maternal mortality in the U.S. through a special series called, “Lost Mothers.” I’ve been following along on my commute to work, often distressed by stories like Shalon Irving’s — a woman who died from complications resulting from high blood pressure following the birth of her first child.

Shalon was an epidemiologist at the Centers for Disease Control and Prevention who focused on understanding how structural inequality, trauma, and violence made people sick. Tragically, she herself became a symbol of the disparities that she studied.

The CDC reports that U.S. maternal mortality and morbidity increased by over 50 percent between 1987 and 2013. America’s maternal death rate is now one of the highest among developed countries — and infant mortality rates are more than 70 percent higher than in comparable developed countries.

Like many other health outcomes, a woman’s risk of sickness or death during or immediately following pregnancy and childbirth is not spread evenly across the population. Women in some racial and ethnic groups face significantly higher risks; the rates are especially alarming for black women, who are 3 to 4 times more likely than white women to die from pregnancy or childbirth-related causes.

Even worse, over half of maternal deaths like Shalon’s are preventable. Adhering to evidence-based guidelines for providing care has proven to produce better outcomes for mothers and infants. Yet many U.S. hospitals do not implement these standards. (When it comes to racial disparities, there are no established health care toolkits or guidelines to target inequities — an opportunity for improvement in the health care system.)

Congress takes notice of the need to better care for mothers and infants

The preventable risks and disparities women face during pregnancy and delivery have prompted not only journalists but policymakers to start paying attention.

In June 2018, the U.S. Senate Appropriations Committee voted to request $50 million in new funding for programs aimed at reducing the rate of women who die in pregnancy or childbirth, with more than two-thirds of the funding going to expand evidence-based programs at hospitals and increase access to the Healthy Start Program for mothers and infants.

This past September, the U.S. House of Representatives’ Committee on Energy and Commerce held a hearing called “Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S.” to improve ways to collect data on pregnancy-related deaths.

Kaiser Permanente’s maternal-infant care delivery: What sets us apart

We at Kaiser Permanente have long recognized this problem and worked on many levels to protect women and children who are at risk. We believe it’s important to share our practices with the broader public in hopes that other policymakers, researchers, or health care and delivery systems might benefit from the lessons we’ve learned.

Kaiser Permanente is the largest private integrated health care delivery organization in the U.S. Our model combines care and coverage, which lets us provide affordable, comprehensive reproductive, prenatal, delivery, postpartum, and ongoing follow-up care. While our structure may be unique, we share examples that other health care delivery systems can replicate.

In Kaiser Permanente launched its National Women and Children’s Health Strategy, which includes several practices designed to improve quality of care, such as:

  • A national perinatal patient safety program to improve maternal health;
  • Universal screening standards and treatment for mental health and substance abuse in the perinatal period;
  • Access to immediate postpartum, long-acting, reversible contraception across all care settings to support family planning.

Addressing disparities in maternal and infant health outcomes

Kaiser Permanente is committed to integrating best practices for addressing equity, inclusion, diversity, and excellence into every aspect of clinical care, including maternal and infant health. Here are some of the steps we’ve taken.

First, our model of coordinated care lets us examine the health care delivery process — screening, office visits, and procedures — as well as outcomes, such as blood pressure, infection, maternal or neonatal injury, across several factors, including race. Knowing where these gaps exist is the first step in addressing them.

Our electronic health record system contains vast data stores that can help researchers identify where disparities exist, helping us reduce them and improve overall care.

We also actively involve and support our physicians, nurses, nurse-midwives, and staff with continual education around cultural competency, implicit bias, and health disparities.

Informing the evidence base through research

Kaiser Permanente’s research centers are continually studying the risks related to maternal and infant morbidity and mortality — and corresponding differences across racial and ethnic groups — to improve the care we deliver and to inform the broader field of maternal and infant health.

For example, one study of fetal growth during pregnancies in which the mother developed gestational diabetes found significant variation between racial and ethnic groups.

Kaiser Permanente is also actively studying:

  • Disparities in cesarean section rates among low-risk women
  • Effectiveness of treating mild to moderate hypertension in pregnant women and the racial/ethnic differences in outcomes
  • Infant feeding and type 2 diabetes following a pregnancy with gestational diabetes

This last study exemplifies our ability to leverage the size and diversity of our membership — 75 percent of research subjects were Latina, Asian, or African American, and 25 percent had household incomes at or below 185 percent of the U.S. federal poverty level. This population distinguishes this study from prior studies that included predominantly women of European ancestry.

Future directions for improving maternal and infant health

Kaiser Permanente understands the importance of strong policies to ensure that health systems, insurers, and providers work collaboratively and across sectors to identify and eliminate the drivers of poor maternal and infant health outcomes. We’re hopeful that by sharing our learnings, we can continue to drive the types of policies and practices we know to be successful.