Kysha Shaw lives with a lot of uncertainty. Among other things, the 42-year-old single mother of three worries about COVID-19, schools closing, and drug use and crime in her West Baltimore neighborhood.
“I love this community, but it can be really sad,” she says. “You see people begging for shoes and clothes. You might see someone slumped over with a needle in their arm. People sell drugs in front of the convenience stores.”
But Shaw is determined to keep herself and her children healthy, which she’s done thanks in part to an innovative effort called B’more for Healthy Babies Upton/Druid Heights (BHB U/DH). Founded in 2011, the program is part of a citywide initiative and is a partnership between the local community, the University of Maryland Medical Center, and the University of Maryland, Baltimore.
BHB-U/DH supports mothers and babies in West Baltimore, where 92% of residents are Black and 66% of children live below the federal poverty level. It provides prenatal education, support groups, smoking cessation, some rental assistance, and connection to a range of social services. Among other achievements, the effort has reduced infant mortality by 75%.
Experts believe that programs like BHB U/DH are essential if the United States hopes to address the inequities in maternal health found in so many crowded cities and remote rural towns.
The statistics are striking: Black and American Indian/Alaskan Native women are two to three times more likely to die from pregnancy-related causes than White women. Black women are twice as likely to experience serious perinatal complications. And early indicators suggest that COVID-19 is only exacerbating such inequities.
What’s more, advanced degrees and full bank accounts don’t close the gap. In fact, a college-educated Black woman faces a 60% greater risk of maternal death than a White woman with no high school diploma. Why is that? Experts point to the effects of subtle and explicit racism as well as weathering, the biological fallout of ongoing stress that can cause premature aging and related health problems.
Faced with this worrisome reality, researchers and providers are working to improve the health of vulnerable pregnant people before, during, and after childbirth.
“It’s incredible, some of the things I’ve heard our moms go through when they’re seeking care. It’s heartbreaking.”
Kamilah Dixon-Shambley, MD
Medical director of Moms2B
“Inequities are so pervasive and persistent that they require multisector efforts,” says AAMC Health Equity Research Analyst Funmi Makinde, MPH. “We need to address transportation, employment, and housing as well as physician shortages, and we need more diverse providers. We need high-quality data that are shared publicly to ensure accountability. The list goes on.”
Throughout all this work, it’s crucial to include the perspectives of patients who are often overlooked, experts say. In one recent survey, 20% of Black, biracial, and Latinx people felt their medical requests were refused or ignored, compared with 11% of White people.
“It’s incredible, some of the things I’ve heard our moms go through when they’re seeking care. It’s heartbreaking,” says Kamilah Dixon-Shambley, MD, medical director of Moms2B, an Ohio State University Wexner Medical Center program that provides yearlong supports and health education to low-income new and expectant mothers. “It’s crucial that patients and the community can trust their providers.”
Below, AAMCNews profiles multifaceted efforts to address maternal health inequities across the country.
Data that save lives
In 2006, California officials noted a worrisome trend: Maternal mortality was on the rise, even as the state recorded the most births nationwide.
Hoping to reverse the disturbing death rate, they turned to Stanford University School of Medicine to co-found the multistakeholder group that became the California Maternal Quality Care Collaborative (CMQCC).
Serious number-crunching has fueled much of the CMQCC’s work. For one, it collects and analyzes hospitals’ raw data to quickly identify areas ripe for improvement, including racial and ethnic disparities.
“We send hospitals back reports, and they are flabbergasted when data are broken down by race and ethnicity. They may see that their Black patients have 6 percentage points higher C-section rates than Whites,” says CMQCC Medical Director Elliott Main, MD. “That really spurs them on to look at addressing racism in labor and delivery.”
CMQCC experts also use data to identify the need for and then create step-by-step provider toolkits on key causes of birth-related complications. One on postpartum hemorrhage, which covers such crucial moves as measuring and effectively treating blood loss, reduced disparities between Black and White patients by nearly 80%.
“The standardized protocols in toolkits take away a lot of provider subjectivity,” Main says. “Subjectivity is the entrée for biases that impact patient care.”
And hospitals in the collaborative — there are more than 200 of them — can receive training on implementing the toolkits. “A toolkit that sits on the shelf does nothing,” he adds.
“We send hospitals back reports, and they are flabbergasted when data are broken down by race and ethnicity. … That really spurs them on to look at addressing racism in labor and delivery.”
Elliott Main, MD
Medical director of the California Maternal Quality Care Collaborative
All of these efforts have borne fruit: Since the launch of the collaborative, California’s maternal deaths have dropped by 65%.
Now, the CMQCC is crafting additional equity-related recommendations, such as handing expectant patients a staff-signed commitment promising to treat every patient with dignity and engage them in all birth-related decisions.
Also high on the CMQCC agenda is assessing the approaches of maternal mortality review committees, the bodies that study every pregnancy-related death.
“Often a problem is that review materials are medical-centric, and obviously the patient can’t tell her own story,” says Main. “We’re now exploring interviewing family members who lost a relative for their perspective. I think that’s going to be the future of committee reviews.”
Pregnancy always brings some stress, but the tension is much higher for patients who struggle to understand English and the intricacies of the U.S. health care system.
That’s why Crista Johnson-Agbakwu, MD, founded Valleywise Health’s Refugee Women’s Health Clinic in Arizona in 2008.
Since then, the Phoenix-based center has served more than 16,000 patients, many from countries across Africa. Arizona, which ranks high on the list of states resettling refugees, is now integrating evacuees from Afghanistan, says Johnson-Agbakwu.
“These are people who have escaped war and gender-based violence and other human rights atrocities,” she notes. “It’s important to understand the communities’ needs and meet the priorities they identify.”
To help do that, the clinic hires cultural health navigators (CHNs) — lay health care workers steeped in the culture and language of those they serve. “CHNs deeply understand patients’ background, religion, and lived experience and can interpret their health care through those lenses.”
CHNs offer patients ongoing supports, from accompanying them to prenatal visits to facilitating a smooth hospital discharge. And they can chart all interactions in electronic health records so that physicians know what’s been done or discussed.
“These are people who have escaped war and gender-based violence and other human rights atrocities. It’s important to understand the communities’ needs.”
Crista Johnson-Agbakwu, MD
Founder of Valleywise Health’s Refugee Women’s Health Clinic
Like Baltimore’s BHB, Ohio’s Moms2B, and similar programs, the clinic’s supports are accompanied by classes on perinatal health. But its offerings include a tour of the hospital labor and delivery unit — a crucial support for participants unaccustomed to Western, medicalized births.
“Things like IV lines and beeping noises and blood pressure cuffs can be very scary for this population,” says Johnson-Agbakwu. “They’re used to being mobile in labor and can interpret what we do as tying them to the bed. The tour helps demystify a lot of this.”
In all its work, the clinic strives to honor patients’ perspectives. “We try to go beyond checking the boxes of ensuring medical care,” she says. “We are engaging in care that’s anchored in mutual respect. That’s a piece that can be missing in achieving maternal health equity.”
Reaching rural patients
Many pregnant people in eastern North Carolina face significant health risks. More than half of women seen by Vidant Health and the Brody School of Medicine at East Carolina University (ECU) are overweight or obese, and many have diabetes or hypertension. The poverty rate of this population is twice the national average, and nearly all live in remote rural areas.
Black people — who comprise roughly a third of ECU and Vidant birthing patients — often fare the worst. In one recent nine-year period, they represented nearly 70% of maternal deaths in the region.
And Vidant Medical Center, based in Greenville, is the only large hospital in an expanse covering 29 counties.
Since 2017, ECU and Vidant have been working to support providers throughout the region in efforts to ensure high-quality care during obstetrical emergencies.
One major focus is drills in birth-related crises. These simulations — hundreds have been held in 18 hospitals over the past three years — cover emergency cesarean sections, maternal resuscitation, and more.
The scenarios unfold realistically: A Vidant staff member assumes the role of a patient, and the local team races to save her — calling for emergency assistance, rushing to get instruments, and suggesting necessary maneuvers.
“In a small hospital, these emergencies happen maybe once every two or three years,” which makes it tough to keep skills fresh, says James deVente, MD, PhD, an obstetrician-gynecologist at ECU and Vidant. “We give them a chance to practice skills over and over so that when something actually happens, they’re ready.”
Traveling to provide training is not always the best option, though. So ECU providers have also logged thousands of hours advising local providers on how to handle their toughest perinatal cases.
Now, in an effort launched in July 2020, ECU experts also remotely treat high-risk patients, working in collaboration with 15 local obstetricians.
“Patients often need to drive 60 miles or more each way to be seen [at Vidant Medical Center],” says Alan Sacks, MD, who heads ECU’s Maternal Outreach Through Telehealth for Rural Sites (MOTHeRS) Project. “Appointments can be a costly ordeal in wages lost for a day off from work, child care, and transportation. The project is patient-centered. We basically go to them.”
In addition to telehealth services like remote ultrasound, the effort screens all participants for food insecurity. Those in need immediately receive a food package and are connected to a local food bank. All patients with diabetes or obesity also receive ongoing nutrition counseling.
Sacks highlights another key component of the program: mental health care.
“Mental health disorders carry a 50% increase in severe maternal morbidity and mortality. Nearly 9% of maternal deaths are attributable to mental health disorders. All of these figures are higher in African American patients. The situation and statistics are tragic and can fuel a worrisome intergenerational cycle.”
Looking ahead, Sacks hopes to expand the MOTHeRS Project to additional remote locations. Meanwhile, the efforts so far have made a difference. For example, the infant mortality rate in the region dropped by 24% in recent years.
“There’s more work to be done,” says deVente. “But we set out to make this region a better place to give birth and be born, and I think we’ve succeeded in doing that.”