Not long ago, a friend of mine died a week after delivering her baby. As her friend, I was devastated. As an obstetric nurse, I was baffled – my friend was black, over 35 years old, and had a pre-existing medical condition. To my knowledge, she (and her clinicians) did everything right during the pregnancy, so her untimely death was sad and shocking.
My friend’s story made a deep impact on me as a caregiver, and as our nation celebrates Black Maternal Health Week, I am compelled to reflect on the tragic outcomes that persist for Black women everywhere. When a mother dies during pregnancy, childbirth, or postpartum period, it has long-lasting and devastating effects on her children, family, and society. The rate of maternal mortality in the United States is alarming, with 20.1 deaths per 100,000 live births. These figures are even higher in the state of Georgia, where I practice; there are 26 deaths per 100,000 live births, and Black women are dying at 3 times the rate of white women. Sadly, this disparity in maternal mortality and perinatal outcomes has persisted for several decades. Factors that influence these disparities are complex and multi-factorial. In order to change the narrative, healthcare systems must take a comprehensive, team-based and patient-centered approach to improve outcomes for black women.
In my view, the key to reducing preventable maternal morbidity and mortality is implementation of evidence-based interventions, better screening, and focused efforts to decrease health disparities. A team-based approach to maternal care that includes the patient is critical. A big piece of this is work is to address racism and unconscious bias, which is a root cause of healthcare disparities. We are educating our clinicians and health care teams on how to recognize and mitigate bias and practice culturally competent and responsive care, in addition to addressing bias at the systems level. We also recognize that we cannot truly improve care without meaningfully engaging our patients and communities – the people we serve must be at the center of our efforts to redesign care. Leadership support at the highest levels and installing strong systems of accountability—ones that bake equity into quality goals and measurements—are also critically important.
Across the entire Kaiser Permanente system, we are committed to making broad changes to support optimal health for all patients of color. In 2019, Kaiser Permanente Georgia began an ambitious journey to improve black maternal health, with the goal of making our system the safest place for women to have a baby in Georgia. We envisioned creating a “cocoon” around our mothers to mitigate preventable morbidity and mortality. Our efforts to redesign perinatal care began with the creation of an obstetric database to better understand the population whom we serve. A small sub-group of physician and nurse leaders, data analysts, and quality and practice managers worked together to create the database. We created a regional Perinatal Patient Safety Program as a collaborative program between the Department of Women’s Services and the Department of Quality and Safety. A sub-group of the perinatal patient safety committee and and inter-disciplinary team of quality experts reviewed all maternal deaths over the last decade to get a better understanding of the causes and contributing factors and to determine if and how they might have been prevented. The aim was to use this information to inform our quality and safety initiatives.
Over the next two years, we established key practices that would improve maternal safety for all patients:
- All clinicians and nurses were educated on ACOG guidelines for acute hypertension, and copies of the guidelines were disseminated across the department.
- We introduced a best practice alert in the electronic health record (EHR) to notify clinicians about abnormal preeclampsia labs in a timely manner. The alerts enable earlier detection and interventions for preeclampsia.
Remote blood pressure monitoring was implemented in late 2019 as almost a quarter of our mothers had hypertensive disorders of pregnancy.
- We increased our perinatal screening program for depression, intimate partner violence, and substance abuse to 4 times during the perinatal period.
- We partnered with social services and behavioral health to create a clear referral path to our licensed clinical social workers and behavioral health for women who screen positive.
- We introduced a new postpartum visit within 1 week of hospital discharge to screen women for medical and psychosocial issues and educate mothers on post-birth warning signs. An evidence-based discharge education tool from the Association of Women’s Health, Obstetric, and Neonatal Nurses is used to educate our mothers.
- We are leveraging technology (telemonitoring) to manage hypertension and diabetes, standardizing evidence-based care across all ambulatory clinics, and learning and pivoting as we go.
- Weekly outreach calls to all mothers enrolled in our remote monitoring programs increases maternal awareness about their chronic condition, improves compliance with self-monitoring, and optimizes self-management at home.
We are proud of the strides we’ve made to improve Black maternal health at Kaiser Permanente. But we also know that individual actions by delivery systems are not enough to improve outcomes for Black women: we need state and federal policy leadership. Encouragingly, policymakers are increasingly prioritizing racial equity and maternal health. A landmark bill—the Black Maternal Health “Momnibus” Act of 2021—is making its way through Congress. The bill takes a comprehensive approach to addressing Black maternal health, with provisions that would address social determinants of health, grow and diversify the perinatal workforce, improve data collection and research, promote payment models that reward high-quality care, expand digital tools (such as telehealth), and invest in community-based organizations. We are also seeing a wide variety of maternal health bills at the state level. Kaiser Permanente is helping to shape these policies. We believe that establishing minimum benefits (such as for contraception, maternity and newborn/child care, and mental health and substance abuse services), expanding Medicaid and CHIP coverage, supporting data collection and reporting in delivery systems, investing in research on maternal health (including the role of structural racism and implicit bias in health care) and increasing public awareness about maternal health would go a long way in addressing disparities.
I will forever hold my friend’s story with me. While I will never make sense of what happened in her situation, I truly believe that with coordinated, national action, we can make great strides in preventing maternal mortality.