The coronavirus pandemic brought the importance of public health to the forefront of national attention. While the Covid-19-related shutdowns at first significantly slowed the number of births in the U.S., the birth rate is expected to surge later this year. There will likely be close to 4 million births in the U.S. in 2021, the vast majority of which will be safe for both mother and child.
More than 700 mothers, however, die each year in the U.S. from pregnancy- and birth-related complications — and an astonishing two-thirds of these deaths are preventable.
More than half of these deaths occur the day after birth, while 19% occur during the following week. Data from the Centers for Disease Control and Prevention on maternal mortality for 2019, the last year with complete statistics, show striking 2.5-fold higher rate of maternal mortality in Black women (44.0 deaths per 100,000 live births) than white women (17.9 deaths per 100,000 live births). Rates among American Indian or Alaska Native women are also high, while those for Hispanic women are lower than for white women.
Health care providers, including obstetricians, midwives, and nurses, are increasingly attuned to these health disparities, yet it can be challenging to institute organizational change at the provider level. Managed care organizations — the overarching network of payers, plans, and providers that together coordinate patient care — can play a major role in preventing these heart-rending deaths by creating best practices for better health outcomes and incentivizing their use. For example, Medicaid, which contracts with managed care organizations in the U.S. to deliver care to eligible patients, was the source of payment for 42% of all U.S. births in 2018.
For this change to occur, however, managed care and other health care organizations must first recognize the inherent biases embedded into traditional health care practices.
As the medical director of operations for the Ob Hospitalist Group, a national organization that partners with hospital labor and delivery rooms nationwide, addressing racial and ethnic health disparities is a top priority of mine. Though the issue can at times be an uncomfortable one to navigate, the importance of integrating and addressing the existence of bias and the detrimental results it can have cannot be overlooked.
I see three main ways that managed care organizations can systematically approach improving care for Black and other minority mothers facing health disparities:
Acknowledge and address that racial bias exists. In a survey conducted by the Society for Maternal-Fetal Medicine, more than 80% of health care providers reported that health disparities affected their day-to-day practices, while 29% said their personal biases affected patient care.
Discriminating against patients and failing to provide quality care due to personal bias harms some patients and is ethically unacceptable.
While medical schools work to implement unconscious bias training, health care organizations can also implement protocols and training to help their staff examine and remediate their own personal biases. My organization, for example, formed a Diversity and Inclusion Committee that works to educate our clinicians and support team members in addressing bias and ensuring that all patients, regardless of race or income, receive care in a high quality and uniform way. Establishing a formal structure helps ensure that diversity and inclusion remain a priority and top of mind in all operational decision-making.
Eliminate “failure to rescue” deaths. One of the main contributing factors of childbirth-related deaths among Black and other minority mothers is the failure or delay in recognizing and responding to life-threatening complications such as eclampsia (severe high blood pressure), a blood clot in the lungs (pulmonary embolism), the blood infection known as sepsis, heart failure, and other problems. This is collectively known as “failure to rescue.” While most pregnancy-related complications are associated with patient characteristics like age, prior delivery by cesarean section, and a host of other factors, failure to rescue is often associated with characteristics of the actual health care setting, like daily patient volume, facility size, and provider-to-patient ratios.
Requiring clinicians to report data on care interventions and patient health outcomes can help create accountability for standardized, consistent, and unbiased care across patients, particularly in high-risk situations that involve intense monitoring and intervention, such as labor and delivery units. Managed care organizations can also play a role by strengthening linkages to other essentials needed for individuals to thrive, such as housing support or transportation. In January 2021, for example, the federal government encouraged states to incorporate value-based strategies as part of the managed care system for Medicaid patients by focusing on social determinants of health as a centerpiece for stronger population health outcomes.
Hire diverse health care providers. While patients may have preexisting health risks associated with their ethnicity, such as high blood pressure or diabetes, they are still considerably different from one another in terms of their experience with the medical system and access to care. When patients feel misunderstood or are unable to connect with members of the medical staff, it can be difficult for them to comfortably and confidently discuss their medical concerns.
The presence and visibility of physicians, midwives, nurses, and other providers of color in labor and delivery is important for patients, and is particularly necessary given that mothers’ survival rates are higher when they are cared for by providers of color. Yet according to the most recent numbers from the Association of American Medical Colleges, only 5% of the active physician workforce are Black, 5.8% are Hispanic, and 0.3% are Native American or Alaskan Native. By engaging in efforts to recruit, retain, and ultimately employ a diversity of physicians as part of the workforce, health systems can take a major step in creating a workforce reflective of the individuals being care for.
As hospitals and other managed care settings look to improve, evolve, and ensure positive outcomes for their patients, a paradigm shift is necessary to truly make a lasting impact when it comes to lowering the maternal mortality rate in the U.S. By acknowledging and incorporating implicit bias training, standardizing high-quality care for all patients, and committing to hiring diverse health care professionals across all fields of medicine, managed care organizations can position themselves to making a significant and positive impact — both clinically and culturally — that will save lives.
Alissa Erogbogbo is an OB-GYN and medical director of operations for the South Carolina-based Ob Hospitalist Group.