Black Women and Maternal Death
Black Women and Maternal Death
- Valire C. CopelandValire C. CopelandUniversity of Pittsburgh
- and Betty BraxterBetty BraxterThe University of Pittsburgh
The upward trend in the number of Black maternal deaths between 2005 and 2020 warrants an in-depth assessment of risk factors associated with the increased maternal mortality rate in the United States for this subgroup population. The risk factors are multifactorial and, in part, have been organized into several categories: demographics, social determinants of health (SDOH), medical conditions, and the quality-of-care interventions by health systems providers. In addition, the overall trends, causes, and solutions to decrease maternal mortality current rates reflect the social inequities in our society.
Black maternal deaths have been rising in recent years due to complex causes which stem from structural and systemic health inequities. In part, unvaccinated pregnant women were at greater risk of severe illness and hospitalization and even death if they were diagnosed with COVID-19. While Black Americans were disproportionately impacted by the pandemic, the disparities in maternal mortality predate and extend beyond the pandemic. In part, and together, the leading causes of pregnancy-related deaths include cardiovascular disease, other medical conditions and infections, cardiomyopathy, blood clots in the lung hypertensive disorders related to pregnancy, adverse pregnancy outcomes, racial bias of providers, and perceived racial discrimination from patients. In addition, an overview of nonmedical factors referred to as SDOH, which intersect with health status outcomes, will be discussed.
An overview of Black women’s maternal mortality and morbidity, factors contributing to poor maternal health status outcomes, and intervention strategies at the provider, health systems, and policy levels are provided. Social workers in health care systems function as health care providers and clinicians. Therefore, contributing medical and nonmedical issues are factors to consider for a holistic perspective during engagement, assessment, and intervention. The terms Black women and Black birthing persons are used interchangeably.
- Health Care and Illness
Mortality and morbidity rates for Black women in the United States reflect a major equity gap in our health care delivery system. According to the World Health Organization (Hoyert, 2019), maternal mortality is “the death of a woman while pregnant or within 42 days of termination of pregnancy irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” (Collier & Molina, 2019, p. 561). “Late maternal deaths occur 43 days to 1 year post pregnancy” (MacDorman et al., 2021, p. 1674). Maternal morbidity is defined as short- or long-term health events, challenges, and conditions resulting from being pregnant and giving birth.
Maternal mortality intersects with adverse pregnancy outcomes and is assessed as one of the leading indicators for measuring community public health. Despite the reductions in maternal mortality, for several decades, the rates for African American women have been three to four times higher than the rate for non-Hispanic White women (Chinn et al., 2021; Collier & Molina, 2019; Lister et al., 2019; MacDorman et al., 2021; Nagahawatte & Goldenberg, 2008; Singh, 2021), regardless of education and socioeconomic status (Riseborough & Adelman, 2008; Trost et al., 2022).
Today, our health care system is highly technological, and life expectancies for many subpopulation groups have improved. Nonetheless, non-Hispanic Blacks have a lower life expectancy than other racial and ethnic population groups in the United States (Liu et al., 2020). These higher mortality rates for Black women reflect the risk for a maternal death relative to the number of live births in a single pregnancy or a single live birth (Hunt, 2021). The causes of maternal deaths for non-Hispanic Black women are multifactorial (Joseph et al., 2021). There are several variables to consider when explaining and understanding the circumstances unique to each Black maternal death. While there are similarities such as sexism, health inequities, and systemic racism, there are differences when comorbid chronic health conditions must be taken into consideration (Lister et al., 2019). Variability in the risk of death by race/ethnicity is due to both medical and nonmedical factors (Bailey et al., 2017; Hall et al., 2015; Howell, 2018).
The overall trends, causes, and the lack of successful solutions in maternal mortality reflect the social and economic inequities in our society. Adverse pregnancy outcomes for Black women are long-standing and, according to the literature, started with enslaved women (Chinn et al., 2021; Crear-Perry et al., 2021; Owens & Fett, 2019). The different factors, in part, include access to care, quality of care received, prevalence of chronic disease, structural racism, and bias.
According to Lister et al. (2019) many Black pregnant women believe they are not valued to the same degree as their White counterparts. This thinking is reminiscent of their devalued status during slavery. Today, Black women describe differential treatment in health care as “based on public versus private insurance status, lower quality of prenatal care based on racism from providers . . . and their interactions with their doctors or supporting staff as prejudiced” (p. 3).
Black Maternal Health
Racial, structural, and sociocultural constructs have led to inequitable health care treatment of Black women for many decades (Chinn et al., 2021; Owens & Fett, 2019). The Tuskegee experiment (Jones, 1981) has been offered as a primary reason for mistrust in the medical system by many Black Americans. However, limited knowledge of the way in which enslaved Black women’s bodies were used to advance the medical specialty of obstetrics and gynecology has not been widely cited as an additional rationale. According to Owens and Fett (2019), as early as the 16th through the 19th century, Black women’s childbearing was a centerpiece of chattel slavery and gynecological experimentation. As the specialty of gynecology developed during the 1850s, without the protection on human subjects in research, “Black women were subjected to unethical experimentation without consent” (Chinn et al., 2021, p. 213). Francois Marie Prevost experimented repeatedly with cesarean section surgeries on enslaved women’s bodies; and James Marion Sims experimented with enslaved women in Alabama to create the surgical technique that repaired obstetrical fistula. Such advances in gynecology suggest Black women have had a precarious relationship with gynecological practitioners (p. 1343). Physicians used their open access to Black women’s bodies to expand and develop scientific innovations and knowledge for this unique medical specialty.
Provider Victim Blaming
The mistreatment of Black women during pregnancy and childbirth has continued through contemporary times, which includes, but is not limited to, being scolded, threatened, ignored, and receiving no response to request for help (Vedam et al., 2019). Some providers engage in victim blaming instead of acknowledging the systemic racism in obstetrics and gynecology practices (Nuru-Jeter et al., 2008; Owens & Fett, 2019). They discuss the ways in which Black pregnant women and non–gender binary folks are overweight, have advanced age, make poor dietary choices, and lack early prenatal care for their increased chances of maternal mortality.
Social Policies and Health of Black Women and Their Infants
According to Crear-Perry et al. (2021), policies and practices such as Jim Crow, the GI Bill, redlining, and mass incarceration are overt oppressive actions that have negatively impacted the health status of Black women and their infants.
Such practices prevent access to the health promotion resources and the opportunities necessary for optimal maternal health. Health care providers, practitioners, clinicians, and policymakers, concerned with creating a socially just and equitable health care system continue to be challenged by the way in which the health of Black women across most medical diagnosis lags that of non-Hispanic White women. African American health services researchers have come to expect the “twice as high, two time as likely” scenario. In part, the quality of care in hospitals with low quality ratings, medical care during labor, delivery, and clinical care facilitates the inequities in care we observe (Howell et al., 2016).
Prevalence of Black Maternal Mortality
The prevalence rate for Black maternal mortality is measured by the number of Black maternal deaths during a given time per 100,000 live births during the same time. The incidence of Black maternal mortality, in various parts of the United States is similar to the maternal death rates in some developing countries (Lister et al., 2019; Oribhabor et al., 2020; “Systemic Racism, a Key Risk Factor for Maternal Death and Illness,” 2021). For example, Georgia’s maternal mortality rate for Black women is 66.6 per 100,000 live births compared to 43.2 for White women, and for women between 35 and 44, with a rate of nearly 90 deaths per 100,000 live births. In Louisiana, the racial gap in maternal mortality is even more pronounced, with a rate of 72.6 per 100,000 live births for Black women and 27.3 for White women (Hunt, 2021; Leins, 2019). Non-Hispanic White women have a maternal mortality rate of 13.4% per 100,000 for Black women the rate is of 41.7% per 100,000, and for American Indian and Alaska Natives 28.3% per 100,000 (Oribhabor et al., 2020; U.S. Department of Health and Human Services Health Resources and Services Administration, 2019). Women of color, including Black, First Nations, and Alaskan birthing persons are two to three times more likely to experience a maternal death compared to non-Hispanic White birthing persons (Petersen et al., 2019).
Between 1969 and 1982, the maternal mortality was 7.8% for White women and 8.6% for Black women; from 1983 through 1998 no significant rate changes were record, they remained stable. During 1999 and 2017, the annual rates of increased, 5.4% for the overall population—6.4% for White women, and 3.8% for Black women. In 2017 and 2018, the rate declined by 19.6% for the overall population—21.9% for White women, and 19.0% for Black women. During the past five decades, maternal mortality remained 2.3–5.3 times higher among Black women than White women. Nevertheless, the 2018 rate for Black women was 33.5 deaths, 2.4 times higher than the 14.0 for White women (Singh, 2021).
Racial Disparities in Black Women’s Health
In part, the racial and ethnic disparities, across the life span, in our health and mental health systems reflect the inequities in the economic and social structures in our society. Quality of life commensurate with low socioeconomic status suggest African American women reside in demographic landscapes where they confront a disproportionate burden of chronic health conditions such as cardiovascular disease, obesity, diabetes, cancer, anemia, and chronic stress (Chinn et al., 2021; Crear-Perry et al., 2021; Hunt, 2021; Joseph et al., 2021). Women who live in deprived communities are at a higher risk for maternal mortality than women who live in our most-affluent areas (Howell et al., 2016; Singh, 2021). The health inequities observed in Black women are both structural and social. The social determinants which negatively impact health status outcome are linked to the environmental conditions where individuals are born, live, work, learn, and play. Their quality of life correlates substantially with these social and ecological environmental factors. As these conditions facilitate challenges to daily living, health disparities among the different population groupings based on the unique social determinants which impact their health are observed.
According to Crear-Perry et al. (2021), racism, classism, and gender oppression are at the foundation upon which unequal health outcomes manifest. In addition, the social transaction that occur within structural determinants are important to equation. Racial bias of providers and perceived racial discrimination from providers impacts Black patients’ trust in their providers and the medical community at large (Hunt, 2021; Lister et al., 2019).
The racial and ethnic health disparities which exist across health status outcomes for all Black Women living in the United States (Chinn et al., 2021) reflect the inequalities they confront in daily living. The risk for higher maternal mortality includes expectant mothers who are lower income, live in rural areas, experience an unequal share of underlying social determinants, likely to be obese, have multiple medical conditions, suffer from stress or depression, and engage in behaviors which negatively impact their health. Socioeconomic status alone does not explain the high risk for maternal mortality among Black Women (Lister et al., 2019). Nonetheless, the accumulation of chronic medical conditions, mental illness, and social determinants of health leads to adverse pregnancy outcomes and high maternal mortality risk for Black Women (Edwards et al., 2022; Nagahawatte & Goldenberg, 2008). Fifty to sixty percent of these deaths are preventable (Hunt, 2021; MacDorman et al., 2021; U.S. Department of Health and Human Services Health Resources and Services Administration, 2019). Black maternal mortality is not an isolate when it comes to life expectancy among for Blacks; overall life expectancy for Black individuals is lower than their White counterparts (Rivara et al., 2021).
Factors Contributing to Maternal Deaths
Demographic/Social Determinants of Health/Morbidity Factors
A recent systematic review found that race, ethnicity, insurance, and education are linked to pregnancy-related deaths. A Health Resources and Service Administration report on maternal mortality in the United States noted higher poverty rates were linked to higher mortality rates for all birthing persons (Singh, 2010). Within each poverty level, the maternal mortality rate was higher for Black birthing women compared to other counterparts. The link between race/ethnicity and poverty is not new with the intersection frequently cited in the burgeoning health disparities literature (Lin & Harris, 2008).
Non-Hispanic Black maternal mortality rates from obstetric embolism and obstetric hemorrhage were 2.3–2.6 times those for non-Hispanic White women, which together account for most of the disparity in between of the non-Hispanic Black–non-Hispanic White maternal mortality disparity (MacDorman et al., 2021). For non-Hispanic Black women, eclampsia preeclampsia, postpartum cardiomyopathy, obstetric embolism, obstetric hemorrhage, and ectopic pregnancy are leading cause of maternal death. For non-Hispanic Black women, the risk of dying from eclampsia, preeclampsia, and postpartum cardiomyopathy is about five to six times that for non-Hispanic White women (MacDorman et al., 2021).
Age is a maternal mortality risk factor. An increase in maternal mortality has been documented among adolescents and birthing persons over 35 years of age. A large international study involving 144 countries found a modest increased risk of maternal mortality among adolescents compared to birthing persons aged 20–24 years (Nove et al., 2014). Studies by Creanga (2018) and Creanga et al. (2015, 2017) reported 30% of deaths occurred among birthing persons 35 years of age or older. According to the weathering hypothesis developed by Geronimus (Chinn et al., 2021), as individuals age, stressful environments factor into the widening of health disparities: “Black–White disparities in health widen with age because of the accumulation of socioeconomic disadvantages and experiences with racism among Black women throughout the life course” (pp. 213–214). As adults age, their health status declines, and given the health risk presented, Black women’s mortality increases with age. Therefore, women who do give birth later in life may be at greater risk for maternal death than during earlier birthing years.
Another demographic factor targets the proportion of deaths associated with specific health conditions. Worldwide the most frequent cause of maternal death is linked to obstetrical hemorrhage followed by hypertensive disorders. Pregnancy-related sepsis, abortions, and embolism. The primary medical factors for disparities in Black and non-Hispanic White maternal mortality disparity are eclampsia and preeclampsia, postpartum cardiomyopathy, cardiovascular disease, and obstetric embolism. If the non-Hispanic Black maternal mortality rate for these causes could be reduced to non-Hispanic White levels, the overall maternal mortality disparity would be reduced by more than one-half (52.2%; MacDorman et al., 2021; a report from 13 Maternal Mortality Review Committees).
In contrast to the positive association between poverty level and maternal mortality, data supports education level as a protective effect for non-Hispanic White birthing persons (Decleroque & Zephyrin, 2020; Singh, 2021). However, education level does not protect Black birthing persons. A review of the literature suggests that a Black birthing person with a college education is more likely to experience a maternal death compared to a White birthing person with a high school education (Petersen et al., 2019). Although other racial/ethnic birthing persons experience adverse outcomes including maternal deaths, the disparities between non-Hispanic White birthing persons and Black birthing persons in the maternal health space are among the most severe.
The non-medical factors of care-systemic racism, discrimination, microaggressions, social determinants, and bias facilitate high rates of maternal morbidity and mortality among Black women in America. These influences, in part, continue to negate equity in health care for Black and Brown women, particularly hard. Accidental and incidental causes are not included in the World Health Organization definition of maternal deaths (Collier & Molina, 2019). These women continue have shorter life expectancies and higher rates of maternal mortality than their non-Hispanic White counterparts (Owens & Fett, 2019).
Structural racism has been linked to maternal health outcomes between White and Black birthing persons (Julian et al., 2020; Minehart et al., 2021; Nuru-Jeter et al., 2008; Williams et al., 1994). Confronting challenges of racism at both the individual and institutional levels can manifest etiological symptoms of stress, trauma, and depression which also trigger physical health complications; including but not limited to poor pregnancy outcomes. The relationship between a lifetime exposure of racism and health status outcomes is complicated. The social and economic inequities in society are systemic, institutional, and facilitate poor health outcomes, in general. As acknowledged, social determinants impact health and are assessed on an individual level. Structural inequalities are institutionally based and occur cumulatively over the lifespan. They are rooted in bias, discrimination, oppression, social injustice, and of course racism (Crear-Perry et al., 2021). Health status is negatively impacted, in part, through education, housing, employment, and access to quality health care. Structural and institutional racism are found in our political, social, and economic systems, and are present in communities where we live, play, work, and learn (Rivara et al., 2021; Weil, 2022).
Howell et al. (2016), using data from seven states, regarding obstetrics, found Black serving hospitals performed worse than other hospitals on many delivery-related indicators. The health care systems where obstetrics care is delivered vary in quality: “Blacks receive care in a concentrated set of hospitals and . . . these hospitals appear to provide lower quality of care” (Howell et al., 2016, p. 6).
Lack of Insurance
The Institute of Medicine(2002) published a report entitled “Care without Coverage: Too Little, Too Late.” With the use of data drawn from different studies, the report validated that lack of insurance is linked to adults experiencing poorer health and that insurance coverage would overall reduce deaths. Access to health care improved for African Americans a result of the Affordable Care Act of 2010, but this progress has stalled and has been eroding since 2016 (Baumgartner et al., 2020).
An increasing number of studies have also reported the effect of neighborhood environments (i.e., water, air, noise, temperature, and greenness) as a link to the development of hypertensive disorders during pregnancy. Unlike the study by Meeker et al. (2021) assessed the association between a neighborhood level factor (poverty, violent crimes, and housing violations) and maternal morbidity. The study’s finding showed a 2.4% increase in the rate of maternal morbidity for each 10% increase in the number of Black residents within a census tract related to violent crimes and percent of persons identifying as White.
Delay Models Framework
As the maternal mortality rate in the United States continues to increase, a long list of factors contributing to pregnancy-related deaths has emerged beginning with a couple of frameworks that are frequently referenced in the literature. One frequently referenced framework is the Three Delay model or 3Ds model of maternal mortality developed by Thaddeus and Martin (1994). The model is composed of three phases: delay to seek care associated with socioeconomic and cultural factors (Phase 1), delay to reach proper medical care associated with accessibility of the facility (Phase 2), and delay receiving quality care at a facility inclusive of appropriateness of referral system, and availability of supplies, equipment, trained personnel, and expertise of health care personnel (Phase 3). A fourth delay was added with the focus on delay in a community taking on the accountability for birthing persons and their offspring (MacDonald et al., 2018).
The 3D Model was modified in 2016 to a five-prong approach using a prevention framework:
Prong 1: Targets fetal and maternal issues with a focus on family planning, prevention of fetal infections in utero, and empowerment of birthing persons (e.g., women and girls) specifically addressing the needs of adolescent girls.
Prong 2: Targets delays in seeking care with a focus on providing education to birthing persons on danger signs during pregnancy and the postpartum period. Additionally, involves community activism using communication strategies that support an early response to the danger signs.
Prong 3: Targets reaching care after the birthing person decides to seek care and typically involves increasing the number of health clinics and health workers as well as offering financial incentives to birthing persons and health clinics to minimize the delays.
Prong 4: Targets delays in the provision of care that involves the interactions between a provider and the birthing person. Assumptions associated with the delay include a provider must be available and knowledgeable. To reduce the delay health care facilities must also have evidenced-based standards/protocols and processes for improving care.
To improve the maternal mortality rates for African American women and other women of color, planned changes across all systems of care are required (Joseph et al., 2021). The heightened concern by health care providers regarding safety, quality of care, equity of prenatal, delivery, and postnatal care are necessary to facilitate change.
Reducing Black maternal mortality rates requires a multitiered and multifactorial approach—within and across systems of care—involving patients, providers, hospital staff, health services researchers, and public health policy. A greater focus on preconception care, as a prevention strategy for optimal pregnancy outcomes, is necessary. By focusing on preconception care, as one strategy, we can improve Black women’s overall physical health as well as reproductive planning. Many nonlactating women are unaware of the way in which a chronic medical condition can impact their reproductive health (Oribhabor et al., 2020). Additionally, the adoption and implementation of safety bundles (i.e., evidence-based best practices) in health care facilities have been shown to reduce adverse outcomes (e.g., preeclampsia, postpartum hemorrhage) that often lead to death (Eppes et al., 2021; Main et al., 2017). All girls and women, especially Black women, given the purpose of the presentation, should be educated about all aspects of their physical, reproductive, and mental health. Age-appropriate women’s health curriculum can be taught in primary, secondary, and postsecondary education. Preparing our bodies for conception and pregnancy begins early in life. It’s important to understand the relationship between chronic and comorbid health conditions to pregnancy, prior to conception; and the way in which these conditions lead to pregnancy complications before and after delivery (Collier & Molina, 2019; Hunt, 2021; Lister et al., 2019; Oribhabor et al., 2020).
Black birthing persons can reduce the risks of experiencing adverse pregnancy outcomes by adopting healthy lifestyles (e.g., healthy diet, engage in physical activity, refrain from the use of substances, and prevent injury) prior to thinking about becoming pregnant. Additionally, birthing persons may schedule an appointment with their health care provider to initiate preconception counseling, an important step associated with a healthy pregnancy. During the preconception counseling appointment, family history, risk factors, medical conditions, and lifestyle behaviors are discussed (March of Dimes, n.d.).
Upon becoming pregnant, birthing persons should begin prenatal care as soon as possible. Early prenatal care will allow the birthing person and provider to begin to proactively plan and manage possible health problems if they emerge. During the prenatal/pregnancy period into the postpartum period, birthing persons and their support systems must be cognizant of warning signs linked to potentially life-threatening conditions and take appropriate actions that include reaching out to their health care provider. Health care providers play a critical role in providing health information for birthing persons and families to know what actions to take.
Monitoring disparities according to underlying social determinants is key to reducing maternal mortality as they give rise to inequalities in social conditions and health-risk factors that lead to maternal morbidity and mortality (Singh, 2021).
Health care providers (i.e., physicians, midwives, nurses) who participate in various programs and strategic decision making that are designed to improve knowledge and communication between health care team members including nurse midwives and doulas, enhance confidence to manage emergent problems, assess clients’ risks for the probability of an adverse response and in a timely manner initiate effective strategies. Most frequently used strategies include continuous educational trainings (drills) (Foo et al., 2019; Pattinson et al., 2019). The trainings help providers more quickly respond to emergent events. For their participation in the trainings (drills), providers may receive continuing education units (CEUs) or continuing education credits (CECs). CEUs or CECs are often required for health care providers to maintain a license.
Additionally, obstetrical emergency event simulations (e.g., postpartum hemorrhage, pregnancy-related hypertensive disorders) provide an opportunity for providers to respond to adverse conditions without placing patients at risk (Fransen et al., 2020). Simulations can also enhance providers’ confidence, promote team building; help determine knowledge gaps, communication problems, and concerns at the unit/system level; and have the potential to improve clinical outcomes (e.g., reduction in adverse effects of postpartum hemorrhage). Simulations and provider trainings are both designed to help reduce delays and to implement evidence-based strategies more promptly.
More interprofessional research is, however, needed to promote comfortable and effective communications between health care provider, social workers, and clients, specifically Black pregnant birthing persons. The Giving Voice to Mothers study by Vedam et al. (2019) shared information on the level of mistreatment voiced by Black birthing persons. Almost 28% of low-income birthing persons of color endorsed that they had experienced mistreatments compared to almost 19% of White counterparts. The mistreatments included scolding, being ignored, provider not responding to a help request in a timely manner, and failure of the provider to respond to the request. Furthermore, studies have found and health care organizations have cited that implicit bias exists within the maternal health space (American College of Obstetrics & Gynecology, 2017; Fitzgerald & Hurst, 2017; Kalata et al., 2022; Thomas, 2018).
Due to the experiences birthing persons of color often encounter in provider–client interactions, Black birthing persons have started to reach out to doulas, social workers in health care, and nurse midwives. Doulas are nonmedical providers, and they provide support services to birthing persons during pregnancy, labor, and delivery, and postpartum. Studies have found that the use of doulas helps to improve the maternal health of Black birthing persons. A 2017 Cochrane Review by Bohren et al. showed the health benefits associated with doula services include fewer cesarean sections, and more satisfaction with the birthing experience. Maternal health care provided by nurse midwives has also been linked to improvements in maternal care. Midwives are prepared to identify potential risk factors and to provide preventive care or care that mitigates the impact of the health problem. A nurse midwife also has the time to engage in a holistic assessment of a birth person, mindful of social determinants of health (SDOH) and cultural factors. A 2018 maternal mortality summit sponsored by the Health Resources and Services Administration highlighted the work of nurse midwives to reduce maternal mortality in the international arena. The summit also recommended that nurse midwives participate in health care initiatives designed to reduce maternal mortality in the United States (U.S. Department of Health and Human Services Health Resources & Services Administration, 2019).
Integrated health care teams for high-risk comorbid conditions during preconception, pregnancy, postpartum, and beyond; addressing structural racism and SDOH; developing and implementing hospital wide safety bundles with team training and simulation; provide health education and health promotion for warning signs to anticipate complications during pregnancy; establishing standard maternal levels of care to facilitate support for women with risk factors during labor and delivery (Collier & Molina, 2019).
Restructuring the way in which hospital systems prepare for the labor and delivery of Black women can reduce the maternal mortality rate (Hunt, 2021). The quality of care Black women receive should not depend on hospital location. According to the research, women of color, often deliver in hospitals where the quality of care is lower (Chinn et al., 2021; Collier & Molina, 2019; Hunt, 2021; Joseph et al., 2021; Oribhabor et al., 2020). Improving the quality of care within these hospitals systems will improve health care outcomes. Recommendations include standardizing maternal care to improve quality, strengthening maternal death reviews, addressing racial bias and racism among health care professionals, training to raise awareness of implicit bias held by providers, knowing the risk factor ahead of birth and delivery as well as the root causes of inequities in health care. We need health care policies to negate the negative impact of racism, SDOH, and cultural incompetence.
Within the systems of care, we need health communication training to enhance interactions—verbal and nonverbal—and treatment engagement between patients and providers. It’s important to instill the knowledge of “teaching clinicians and staff about racial and ethnic differences in maternal outcomes, the significance of mutual decision making cultural competence, and unconscious bias” (Oribhabor et al., 2020, p. 3).
Collaborative approaches to reduce maternal mortality and morbidity between providers, families, and lactating women include “creating review committees to examine cause of maternal death, sharing safety checklist at hospitals, clinics, and provider offices, improving access to high quality care, and alerting women about signs and symptoms of complications” (Petersen et al., 2019, p. 428).
Hospital systems are beginning to implement the use of safety bundles on obstetrical and postpartum units. A safety bundle is an organized method for improving the delivery of care and patient outcomes. A bundle typically targets four domains referred to as the four “Rs”: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. The American Hospital Association has worked with the Alliance for Innovation on Maternal Health, a cooperative agreement between the American College of Obstetrics and Gynecology and the Department of Health and Human Services Administration’s Child Health Bureau to disseminate patient safety bundles. Safety bundles are designed to improve care by targeting the leading causes of severe maternal morbidity and maternal mortality. A study examining the use of a quality improvement bundle initiative targeting obstetrical hemorrhage resulted in a reduction in severe maternal morbidity among hemorrhage birthing persons (Main et al., 2017).
Hospital systems/hospitals have also initiated the use of multidisciplinary health care team huddles (Brennan & Keohane, 2016). The huddles help reduce delays in providing care. During the huddle, health care team members assess each pregnant birthing person’s risk factors to plan and prepare evidence-based interventions.
Intergovernmental Policies: State and Federal Levels
Maternal Quality Care Collaborative/Perinatal Quality Care Collaborative
Most states, according to the Centers for Disease Control and Prevention (CDC), have or are in the process of forming a maternal quality care collaborative (MQC) or a perinatal quality care collaborative (PQC). MQCs/PQCs collaborate with varied stakeholders that include hospital systems, health departments, health professional associations, communities and families, academic institution, and health insurance organizations. The MQCs/PQCs address the health care needs of mothers and babies by (a) supporting collaborative learning, (b) providing rapid dissemination of data, and offering a platform for the implementation of quality improvement science initiatives. State MQCs/PQCs have led to major changes in the care delivery in the following states: (a) Illinois: an increased percentage of women treated with severe hypertension within one hour from 41% to 79% in year one; and (b) California: reduction in serious complications with severe bleeding during pregnancy or delivery from 22.75% to 18% during the ending of the project.
A policy intervention would include a reformulation of Title VI legislation to create a structure of legal accountability for implicit bias and unconscious racism. This would require critical reflection within the medical profession from a civil rights law perspective (Owens & Fett, 2019).
Guttmacher Institute (2022) reported that 49 states as well as the District of Columbia, New York City, and Philadelphia have a Maternal Mortality Review Committee (MMRC). MMRCs focus on improving health outcomes and reducing pregnancy-related death. The CDC defines a pregnancy-related death as a death during pregnancy or within 1 year post delivery. MMRCs are composed of members representing the interdisciplinary health care team (obstetricians, maternal–fetal medicine physicians, nurses, nurse midwives, forensic pathologists, mental, and behavior health providers), patient advocacy groups, and community-based organizations. If the death is not determined as pregnancy-related, the committee may also classify the death as: (a) pregnancy-associated—a death during pregnancy or 1 year of end of the pregnancy, regardless of cause; (b) pregnancy-associated, but not related—a death during pregnancy or 1 year due to a cause not related to the pregnancy; or (c) pregnancy-associated but unable to determine pregnancy-relatedness.
The goals of the MMRC are to determine the pregnancy-relatedness status of the death and to assess if the death was preventable. If the committee determines that there was some chance that the death could have been prevented, the committee lists contributing factors and develops recommendations for action. The recommendations for action are typically along five different levels: patient/family, provider, facility, system, and community. MMRCs have the potential to reduce maternal deaths 20%–50% because they look at the causes, identify data gaps, and make recommendations to prevent future deaths.
H.R. 959, the Black maternal Health Momnibus Act, is legislation that targets maternal mortality among racial and ethnic marginalized groups. Using a multiagency approach, the Act directs the Department of Health and Human Services to addresses SDOH within the maternal health space.
Implications for Interprofessional Collaboration: Social Work and Nursing
The collaborative roles of social workers and nurses represent an interprofessional approach to education, training, and health service delivery. Acknowledging the history of systemic racism in both our society and health care system. The lack of health providers of color within the system and inadequate cultural awareness training throughout medical education contributes to disparities in health care.
Health care provider can offer preconception, conception, prenatal, labor and delivery, postdelivery health education, and health promotion; emotional, social, and family support to mothers with dependent children; and cultural brokering and advocacy (National Center on Violence against Women in the Black Community, 2016).
The inequalities in health seem to emanate from origins like the social determinants of health. In part, but not exclusively, such factors include lifestyle behaviors, social characteristics, environmental conditions, and health services and health care (National Academy of Sciences, Engineering, and Medicine, 2021).
Faculty in Schools of Social Work and Schools of Nursing, who work collaboratively, agree with the need for a diverse health professional workforce. Strategic planning approaches for increasing diversity through community–university partnerships, faculty hiring and retention, admissions policies for students from diverse background. These structural changes must include diversity in curriculum content, faculty development and assessment. Our health care professionals should reflect the changing demographics of our society. We need to draw on the best practices for a comprehensive approach to educating health care social workers in interprofessional education, community-engaged learning, experiential education, and health-outcomes research (National Academy of Sciences, Engineering, and Medicine, 2021).
Our educational and training environments should reflect a climate that welcomes diversity in it many forms to mimic the diversity of our health care consumer population. According to the National Academy of Sciences, Engineering, and Medicine (2021) and as reported by the WHO (2008), moving toward equity in health care includes improving our daily living conditions and assuaging the inequitable distribution of power, money, and resources (WHO, 2008). The report offers three overarching recommendations for moving the world toward achieving equity in health care: public health policies to improve the well-being of girls and women; address the inequities between men and women regarding governance, financing, and the public sector; and develop and establish a system of accountability globally.
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