Maternal Health Experience

Based on a tool originally developed in Washington state, The Health Equity Impact Assessment (HEIA) tool evaluates the impact of public policies, programs and administrative practices on health disparities in North Carolina. The HEIA uses data and community involvement to address health disparities and facilitate systems change and has been incorporated into the N.C. Perinatal Health Strategic Plan. The HEIA has also been adopted by Improving Community Outcomes for Maternal and Child Health, an initiative of the North Carolina General Assembly which allocates $2.5M in recurring funds for three years to implement evidence-based interventions in maternal and child health to age five health departments serving 13 rural and urban counties.

The Council on Patient Safety in Women’s Health Care produced a Patient Safety Bundle as part of their efforts to reduce peripartum racial and ethnic disparities. The Patient Safety Bundle is a structured way of improving care processes and patient outcomes and is built upon established best practices. It provides a framework to help providers reduce racial disparities in health care by focusing on the following four categories: 1. Readiness: Establishing systems to accurately document self-identified race, ethnicity, and primary language; providing staff-wide education on peripartum racial and ethnic disparities and their root causes and best practices for shared decision making; engaging diverse patient, family, and community advocates who can represent important community partnerships on quality and safety leadership teams. 2. Recognition and Prevention: Providing staff-wide education on implicit bias; providing convenient access to health records without delay; establishing a mechanism for patients, families, and staff to report inequitable care and episodes of miscommunication or disrespect. 3. Response: Engaging in best practices for shared decision making; ensuring a timely and tailored response to each report of inequity or disrespect; addressing reproductive life plan and contraceptive options not only during or immediately after pregnancy, but at regular intervals throughout a woman’s reproductive life; establishing discharge navigation and coordination systems post childbirth to ensure that women have appropriate follow-up care and understand when it is necessary to return to their health care provider. 4. Reporting/Systems Learning: Building a culture of equity, including systems for reporting, response, and learning similar to ongoing efforts in safety culture; developing a disparities dashboard that monitors process and outcome metrics stratified by race and ethnicity; implementing quality improvement projects that target disparities in healthcare access, treatment, and outcomes; considering the role of race, ethnicity, language, poverty, literacy, and other social determinants of health, including racism at the interpersonal and system-level when conducting multidisciplinary reviews of severe maternal morbidity, mortality, and other clinically important metrics; adding as a checkbox on the review sheet: Did race/ethnicity (i.e. implicit bias), language barrier, or specific social determinants of health contribute to the morbidity (yes/no/maybe)? And if so, are there system changes that could be implemented that could alter the outcome? Each of the four categories in the bundle is paired with resources to help carry out the mission.

A pilot program in Atlanta, GA sought to determine if maternal morbidity could be reduced with the implementation of a clinical pathway-specific Maternal Early Warning Trigger (MEWT) tool. The tool is designed to screen for sepsis, cardiovascular dysfunction, severe preeclampsia-hypertension and obstetrical hemorrhage. The primary goal was early assessment and treatment of patients suspected of clinical deterioration. The tool addressed the four most common areas of maternal morbidity and resulted in significant improvement in maternal morbidity.

Doulas can help reduce the impacts of racism and racial bias in health care on pregnant women of color by providing culturally appropriate patient-centered care and advocacy. Currently only two states, Minnesota and Oregon, provide doula care broadly for their pregnant Medicaid enrollees. The National Health Law Program’s Doula Medicaid Project seeks to improve health outcomes for pregnant Medicaid enrollees by ensuring that all pregnant individuals enrolled in Medicaid who want access to a doula, will have one. In 2018, New York State developed a Medicaid pilot program to cover labor support and home visits by doulas in order to address the discrimination and inequities in health care experienced by low-income communities and communities of color. The pilot focused on Erie and Kings Counties which have among the highest maternal and infant mortality rates and largest number of Medicaid births in New York State. The New York State Medicaid Program will reimburse participating doulas for up to four prenatal visits, support during labor and delivery, and up to four postpartum visits.

Health Connect One (HC One) in Chicago developed a Community-Based Doula Program, which provides support to young families during pregnancy, birth, and the early postpartum period. The populations served are primarily low-income Hispanic and African-American women. According to the Association of Maternal and Child Health Programs, “Community-based doulas provide culturally sensitive pregnancy and childbirth education, early linkage to health care and other services; labor coaching, breastfeeding promotion and counseling, and parenting education, while encouraging parental attachment. The peer-to-peer relationship and the continuity of care knit a fabric of support around the family, which has broad and deep impact on a variety of outcomes.” The principal outcomes include longer breastfeeding duration and less use of c-sections as well as immediate and long-term cost savings. HC One collaborates with community health agencies nationwide in establishing effective programs and securing community support to train and hire community-based doulas.

In 2005, Contra Costa County launched the Life Course Initiative, which addresses social determinants of health through its Building Economic Security Today (BEST) pilot project. The BEST project helps reduce economic inequities by providing financial education classes, one-on-one support to families, and asset development educational materials. The Life Course Initiative utilizes the 12-Point Plan to Close the Black-White Gap in Birth Outcomes as a framework for improving health care for African American women, strengthening African American families and communities, and addressing social and economic inequities. The 12-Point Plan is different from other approaches to addressing equity in health care in that it goes beyond the traditional medical model and prenatal care to address family and community systems, and social and economic inequities.

The Massachusetts Diabetes Prevention and Control Program (DPCP) identified missed opportunities for screening, managing, and follow-up of gestational diabetes and worked together to develop an action plan to realize those opportunities. The diabetes program launched a television and poster campaign to encourage Hispanic/Latino women who have been diagnosed with gestational diabetes to talk to their doctors about reducing their risk of developing Type 2 diabetes. The program also developed an informational poster in English and Spanish and a resource guide to educate women about the risks of gestational diabetes.

The First Steps Program works to assist mothers and infants in obtaining the health and social services they need by referring low-income pregnant women to comprehensive healthcare services. Women enrolled in Managed Care plans are eligible for enhanced services as part of this program, including Maternity Support Services (MSS) which offer preventive health messages, pregnancy education, referrals to resources in the community, and nutrition counseling. A multidisciplinary team approach is used and includes a nurse, behavioral health specialist, nutritionist and community health workers with services offered in an office, group or home setting. The enhanced services also include Infant Case Management (ICM) as well as Childbirth Education (CBE), which helps prepare the mother to develop self-advocacy skills as well as manage the changes experience during and after pregnancy. First Steps is administered by the Health Care Authority in Washington State.

The MotherWoman® Community-based Perinatal Support Model™ (CPSM) provides a comprehensive safety net for mothers at risk for/or experiencing perinatal depression. Implementation of the CPSM began in 2014 in Massachusetts communities that produced more than 21,000 births annually and other areas where the communities had high rates of teen births, minority populations, low birth weight and poverty – all factors which are correlated with an increased risk for perinatal depression. The objectives of the program are to expand resources, increase provider competence and promote mothers’ inherent resilience at all points of provider contact. The program aims to address barriers to care through multi-sector collaboration. Program outcomes included perinatal depression professional trainings to over 200 providers and universal screening implemented in OB, pediatrics, social services, and inpatient care, with more mothers engaged in education, screening and referral as needed.

To increase the knowledge of women of reproductive age on preconception health and wellbeing topics and to encourage them to initiate conversations with their healthcare providers and establish personal pregnancy planning goals, the Colorado Department of Public Health and Environment produced a Reproductive Life Plan booklet. Each page of the tool contains specific information about general health, reproductive health, personal safety, financial wellness, emotional health and self-esteem.

Delaware designed a guidebook to help women achieve maximum health before attempting to get pregnant by providing information about how to address the factors contributing to infant mortality in their state. It provides pregnant women with information on nutrition, best weight, vaccination, dental health, healthy lifestyle choices, sexually transmitted diseases, domestic violence, chronic diseases (high blood pressure, diabetes, gestational diabetes, HIV), the benefits of birth spacing, postpartum depression, prenatal care schedule, and more, as well as descriptions of Delaware’s Preconception Care program and Family Practice Team Model program

The Academy of Nutrition and Dietetics states that all women, particularly overweight and obese women, should have access to nutrition education and counseling regarding the potential maternal and fetal complications that can accompany obesity before and during pregnancy. The Academy recommends that during the preconception period, all women should be screened during routine care to determine their weight status with overweight and obese women offered counseling and interventions to assist in reaching a healthy body weight. It is further recommended that during pregnancy, all women should be provided with education about appropriate weight-gain goals and potential risks of excessive gestational weight gain. During the postpartum and interconception period, women should have access to nutrition education and lifestyle counseling to help reduce postpartum weight retention, with behavioral counseling focused on improving dietary intake tailored to the needs of postpartum women provided for the first 12 to 18 months postpartum. Since regular attendance at group sessions may be difficult for new mothers, the Academy suggests that alternative methods of education like text messages and online programs should be explored.

The Washington State Department of Social and Health Services (WSDSHS) has funded the Parent Child Assistance Program (PCAP) to assist with maternal substance abuse intervention. PCAP is a three-year home visitation model that helps to link women with substance abuse treatment, provide support for treatment completion and recovery, and help clients develop relapse prevention strategies. Case managers assist women with securing services such as family planning, safe housing, health care, domestic violence services, parenting skills, and mental health services and also offer transportation for important appointments. Numerous studies have demonstrated that the program produces positive outcomes for mothers, with many women completing substance abuse treatment, remaining abstinent from alcohol/drugs for at least one year while in the program, using a family planning method on a regular basis, and no subsequent birth or an unexposed subsequent birth three years after program entry.

The Health Foundation of Western and Central New York launched a program in 2009 that focused on areas with high poverty rates that have a high risk of poor maternal and child health outcomes. One of the grantees was a hospital that implemented the Centering Pregnancy model at their prenatal clinic in 2013. The Centering Pregnancy cohort had a higher attendance rate (92%) for their first postpartum visit compared to the clinic’s attendance rate (80%) as well as higher breastfeeding rates (50%) compared to their clinic counterparts (25%) at the postpartum visit. 92% of the women reported that they felt prepared for labor, birth and parenting. Centering Pregnancy is group prenatal care bringing women due at the same time out of the exam rooms and into a comfortable group setting. Women complete a conventional medical history and physical exam in a doctor's office or clinic and then are invited to join a group of eight to 12 women or couples who have similar due dates. The groups meet regularly throughout the pregnancy and continue to meet through the postpartum period, meeting every month for four months and then bi-weekly. Studies have shown that the program nearly eliminates racial disparities in preterm birth.

Oklahoma implemented the free Text4Baby mobile health service in 2014 by targeting pregnant women and mothers with infants under age one who are covered by Medicaid. Women enrolled in Text4Baby receive three personalized text messages per week, timed to their due date or baby’s birthday. The content includes Oklahoma-specific programs and resources.

The North Carolina Division of Public Health (NCDPH) created a new pregnancy-care model for Medicaid recipients that establishes Pregnancy Medical Homes (PMHs). The PMH initiative provides essential support to pregnant women, linking community resources with health care providers to provide the best chance for healthy pregnancies, deliveries, and newborns. The PMH program is an outcome-driven initiative monitored for specific performance indicators where practices agree to work toward quality improvement goals, such as eliminating elective deliveries before 39 weeks, using 17p to prevent recurrent preterm birth, reducing primary c-section rates, improving the postpartum visit rate, and more. Participating providers receive financial incentives from Medicaid for risk screening and postpartum visit completion, ongoing collaboration with a pregnancy care manager, local Community Care of North Carolina (CCNC) network support, data and analytics from CCNC’s Informatics Center, and clinical guidance materials and resources.

The Internatal Care Program (ICP) served women of childbearing age in the Phoenix Metropolitan area who were underserved and uninsured and who had experienced one or more of the following adverse birth outcomes: second trimester loss, intrauterine fetal death, preterm birth, and/or low birth weight. The ICP provides clinical care, care coordination, and health education/promotion to women with poor birth outcomes. The key objectives are to increase the number of women who deliver at term, improve birth intervals, increase access to quality preconception interconception, prenatal, and postnatal health care, and provide continuity from the postnatal period through subsequent pregnancies, which is accomplished by having the same provider perform health care services in the preconception and prenatal period. The program is a replication and an expansion of the Grady Interpregnancy Care Program at Grady Memorial Hospital, which is based on coordinated primary healthcare coupled with social support. The majority of patients had their mental health needs addressed, were consuming a folate supplement, were using contraception if they did not desire a pregnancy, and were engaging in physical activity. Of those who were pregnant, 87% had prenatal care in the first trimester. There were also demonstrated improvements in patient knowledge and attitudes about preconception health.

The What to Expect Foundation developed a Baby Basics program that aims to help get everyone – from physicians and staff, to patients and families – on the same page as a way to support vulnerable populations and strengthen the delivery of prenatal care. The materials and programs are designed specifically to provide lower-income and lower-literacy populations with crucial prenatal health information and support so they can become effective users of the health care system and advocate for themselves and their families. There are more than 11 active Baby Basics programs across the country and hundreds of health care providers purchase the Baby Basics book to use with their patients each year.

Ohio State University and other community social service organizations in the state offer a community-wide comprehensive prenatal and first-year-of-life program called Moms2B. The program provides weekly education and support sessions to promote healthy lifestyle choices and link women with support services. Using a multi-disciplinary team approach, health care professionals including doctors, nurses, social workers, dieticians, lactation counselors, and health care students educate women on topics including family planning, labor and delivery, maternal-infant health, reproductive health and more. The program is free to attend and women are offered a $5 Kroger gift card for attendance, transportation assistance, on-site childcare and a hot, healthy meal.

The American Hospital Association published a report in 2011 titled “Improving Health Equity Through Data Collection and Use: A Guide for Hospital Leaders.” The document lays out key strategies for collecting patient race, ethnicity and language data, including: 1. Engaging senior leadership 2. Defining goals for data collection 3. Combining disparities data collection with existing reporting requirements 4. Tracking and reporting progress on an organization-wide basis 5. Building data collection into quality improvement initiatives 6. Utilizing national, regional, and state resources available 7. Reviewing, revising and refining process and categories constantly. The report acknowledges that even though the majority of hospitals collect patient race, ethnicity, and primary language data, many organizations are challenged in using the data to provide equitable patient-centered care. Leading practices include: 1. Using an equity scorecard or dashboard to report organizational performance 2. Providing interpreter services 3. Reviewing performance indicators such as length of stay, admissions, and avoidable readmissions 4. Reviewing process of care measures 5. Reviewing outcomes of care 6. Analyzing provision of certain preventive care.

The Maternal Mortality Review Information Application (MMRIA, or ‘Maria’), reflects lessons learned from implementing a previous version of the system, the Maternal Mortality Review Data System (MMRDS), among 13 state maternal mortality review committees (MMRCs). MMRIA is designed to support and standardize data abstraction, case narrative development, documentation of committee decisions and routine analysis. MMRIA is available free of charge and jurisdictions interested in using MMRIA work in close partnership with the Enhancing Reviews and Surveillance to Eliminate Maternal Morality (ERASE MM) team at the Centers for Disease Control and Prevention (CDC). The team provides programmatic assistance and training to help committees use the system effectively and reduce duplicative processes during abstraction, case review, and analysis.

The American College of Obstetricians and Gynecologists (ACOG) is recruiting sites for their Birth Registry. The Birth Registry is the first national clinical data registry that is centered around labor and delivery outcomes in the United States. Its primary focus is capturing clinical data entered into the electronic health record (EHR) by providers. Through clinical performance measures and data quality metrics, the Birth Registry provides a unique opportunity for providers to better understand the overall quality of the maternity care provided within their institution. In order to enroll, the facility should complete the interest form and a member of the Birth Registry team will reach out within two business days. The complete onboarding process is dependent upon the signing of all required documents by the facility’s leadership and ACOG, and successful integration of the facility’s EHR with the registry vendor. There is currently no cost to enroll or participate in The Birth Registry for the first year.

In 2018, New York City announced a five-year plan to eliminate disparities in maternal mortality between Black and White women. One of the main components of the plan involves enhancing data quality and timeliness. To carry this out, the NYC Maternal Mortality and Morbidity Review Committee will drive data quality improvement by examining maternal deaths and analyzing and compiling data on severe complications experienced by expectant and new mothers. In order to address the challenge of data having historically been on a two to three-year time lag, the Health Department will provide preliminary estimates of mortality annually. The City will also request the NY State Health Department to release relevant hospital data within one year.

In 2007, all Massachusetts hospitals were required to begin collecting race and ethnicity data from every patient with an inpatient stay, an observation unit stay, or an emergency department visit. A standardized set of reporting categories was created and train-the-trainer sessions were held. The required data includes a detailed list of ethnicities, with 31 reporting categories that include 144 ethnicities or countries of origin. The effort has helped bring attention to reducing disparities in the quality of health care in policy discussions.

In May 2016, The Maternal and Child Health (MCH) Workforce Performance Center published a new guide entitled, “Diversity and Health Equity in the Maternal and Child Health Workforce: A Resource Guide to Key Strategies and Actions for MCH Training Programs.” The resource guide shares strategies and activities to support training programs’ efforts to increase diversity and integrate cultural and linguistic competence into training efforts. Each section includes resources and short vignettes highlighting strategies used by MCH Training Programs. The resources and vignettes are organized by three key themes: 1. Recruitment and retention of faculty, trainees, and program staff from racially and ethnically diverse and under-represented backgrounds 2. Raising awareness of disparities and inequities through curricula, research, learning, practice, and service environments 3. Integration of cultural and linguistic competence in all aspects of training, learning, practice, and service.

Evidence shows that community health workers (CHWs) improve access to care and improve health outcomes for vulnerable populations. Community health workers are uniquely qualified to work with vulnerable and high-risk populations, including pregnant and postpartum women and their children and families, because they are trusted members of the community. States have adopted a wide range of strategies to develop and support CHWs through defined roles and practices, sustainable funding, training and certification, and integration with the public health and healthcare system. For example, New Mexico and Massachusetts have established state CHW offices to perform functions such as coordinating CHW and other public health activities, certifying workers and trainers, approving training programs and curricula, and supporting the workforce through training and educational opportunities. Arizona established the Healthy Start Program, where CHWs educate and support pregnant women and new moms through home visits and group classes.

The National Center for Cultural Competence created a 90-minute video titled “Infusing Cultural and Linguistic Competence into Health Promotion Training” which discusses integrating cultural and linguistic competence into a health program framework. The video consists of six chapters which address the rationale and framework for cultural competence, with the last chapter including people who have experienced cultural competence issues as well as maternal and child health professionals’ work in the field around this topic. This resource was listed on the MCH Navigator website, which is funded by the Health Resources and Services Administration (HRSA) to provide free access to highly vetted trainings.

The Alabama Perinatal Excellence Collaborative (APEC) aims to improve pregnancy outcomes by equipping Obstetric providers with evidence-based guidelines and decision trees to assist them in the care of pregnant women. The APEC website provides easy access to the guidelines and direct contact with APEC leaders. The guidelines can be viewed on a personal computer, tablet or smartphone and there is an app designed to be compatible with iOS and Android devices.

The Colorado School of Public Health has been funded to develop and deliver graduate level Maternal and Child Health (MCH) courses to address the current educational needs of geographically-isolated MCH working professionals in the region. The School will offer courses, without charge to MCH workers in rural, frontier, and tribal underserved areas of the Rocky Mountain region. These credits can be directed toward a public health Certificate in Maternal and Child Health, and ultimately to the master of public health degree. The project addresses the target students' major barriers to higher education, namely distance and cost. The project will create educational opportunities that are distance-based, and as flexible as possible to respond to the needs of working people.

This brochure, developed by the Riverside University Health System Public Health Department, provides a user-friendly overview of pregnant and postpartum mood and anxiety disorders that affect the whole family. Warning signs, data, and guidance are all offered in both English and Spanish. Full brochure available here.