An Unequal Burden: Reducing Racial and Ethnic Disparities in Maternal Health Outcomes
In the U.S., all pregnant patients are more likely to die from pregnancy-related complications today than they were in the 1990s. A recent CDC review of maternal morbidity and mortality concluded that of deaths reviewed, 80 percent had been preventable, and, relative to White patients in the U.S., Black patients are roughly three times and Indigenous patients are more than twice as likely to die from complications related to pregnancy. Because BIPOC patients bear the brunt of risks for maternal morbidity and mortality, improving maternal patient safety requires understanding the scope of racial and ethnic disparities in healthcare.
Amid this ongoing crisis in U.S. maternal healthcare, TDC Group hosted presentations and a panel discussion featuring three prominent physicians to address how medical professionals and organizations can make healthcare safer by making it more equitable. Strategies to reduce disparities in maternal morbidity and mortality include firm commitments from healthcare system leaders, standardizing key aspects of care, and taking advantage of community partnerships.
The panelists were Elizabeth A. Howell, MD, MPP, Harrison McCrea Dickson President’s Distinguished Professor and Chair of the Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania; Lakshmi Krishnan, MD, PhD, Internist and Cultural Historian of medicine at Georgetown University, where she is the Founding Director of the Medical Humanities Initiative; and Ronald Wyatt, MD, MHA, Senior Fellow at the Institute for Healthcare Improvement and Private Healthcare Consultant.
When Leaders Commit, Organizations Will Follow
Compensation for some leaders of the University of Pennsylvania Health System was recently tied to achievements in equity and patient safety, such as reducing maternal morbidity and mortality among Black patients. Accompanying this commitment by system leaders, Dr. Howell says, Penn Medicine’s widespread efforts to eliminate structural and institutional racism have pervaded all levels and branches of the system: “We really worked on hemorrhage initially and identified the areas of opportunity, talked about shared best practices among the group, met monthly. And we really focused on standardized practices, culture, and teamwork, and drills. We had dramatic declines in morbidity and mortality among Black women in the first year.”
Teamwork and Standardization Increase Safety for All
Like many other health systems, Penn Medicine has leaned into care bundles, which improve patient safety by promoting structured responses to postpartum hemorrhage and other life-threatening complications.
Looking back on recent successes, including efforts to standardize key aspects of care, Dr. Howell admits that at first, she wondered whether her Penn Medicine team could recruit enough support for a system-wide patient-safety initiative to succeed. But in fact, the very breadth of the effort contributed to its success: “People got excited to be a part of something . Here we are, five delivery hospitals, not as connected, and now we're sharing best practices.”
Dr. Howell describes a positive “spillover effect,” by which patient safety efforts in support of one population have elevated safety for all, noting “improved hemorrhage care across the board for everyone.”
Community Partnerships Distribute Safety Improvements
A program called Heart Safe Motherhood has decreased disparities in outcomes between Black postpartum patients and others. It has proven successful for patients at all five of Penn Medicine’s delivery hospitals, and is now being expanded to Philadelphia’s downtown delivery hospitals. Through at-home blood pressure cuffs and texting, patient participation has increased blood pressure measurements within the first 10 days postpartum, in accordance with recommendations from the American College of Obstetricians and Gynecologists (ACOG), and reduced ED visits and readmissions, Dr. Howell says.
Dr. Howell and Dr. Wyatt both spoke to the value of such at-home and in-community patient safety programs to improve maternal outcomes and overall maternal health. Many community programs operate in affiliation with CDC-sponsored State Perinatal Quality Collaboratives, which are up and running in some states, and still forming in others. Dr. Howell describes these Collaboratives as “an opportunity for not just health systems and healthcare providers and public health folks, but physicians from the community, physicians who are outpatient, ambulatory, who are not necessarily affiliated with an academic center or a large health system to be part of these efforts.”
Such efforts, Dr. Howell says, dig into “how bias might be playing a role in what we're doing and how we're approaching our patients and our decision-making. And here are some tools that we can think about utilizing to try to help us not do that.” A commitment to using these tools aligns systems and medical professionals with commitments from ACOG, as well other medical professional organizations and various states, to eliminate racial disparities in health outcomes.
Community Partnerships Run on Trust
Community Partnerships commonly lean on community health workers. Dr. Wyatt mentioned several collaborations that have succeeded this way, including West Side United in Chicago and the Kansas City Health Forward Foundation Equity Collaborative.
Considering positive precedents, Dr. Krishnan recommended centering conversations with community health workers when researchers and patient safety leaders are wondering, "Well, how do we even make this work at this place of worship or at this community center?” Dr. Krishnan emphasized, “We have to be very careful and thoughtful about those relationships,” which need to be a way to “consolidate trust.”
The Time Is Now
Dr. Wyatt described “pushback on these topics”—meaning the topic of equity improvements to increase patient safety— from some leaders in healthcare and government: “They say, ‘It's too much. It's too big. It's too fast. Give us more time.’” But given the longstanding, well-recognized discrepancies in maternal outcomes for Black and White women, he says, ”We need to fix the root causes.”
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.