Amid worsening health outcomes for Black obstetric patients, some hospitals are improving maternal care by offering midwifery support, remote monitoring of patients' vitals and educational resources.
Compared with white patients, Black obstetric patients are at disproportionate risk of life-threatening conditions, like preeclampsia and postpartum hemorrhage, as well as pregnancy-related complications like preterm birth. Both health systems and federal agencies such as the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services have increasingly turned their focus to reducing disparities in maternal morbidity and mortality rates.
Related: How Northwell closes maternal health disparities with an AI chatbot
Overall, maternal mortality in the U.S. has increased by 33% since the start of the COVID-19 pandemic, and more than 60,000 obstetric patients experience severe morbidity and long-term health impacts each year. Between 2020 and 2021, the maternal mortality rate for non-Hispanic Black women rose from 55.3 deaths per 100,000 live births to 69.9 deaths, according to the National Center for Health Statistics.
“What we're seeing in Black obstetric health is unnecessary and preventable deaths,” said Ndidiamaka Amutah-Onukagha, associate professor in the Department of Public Health and Community Medicine at Tufts University School of Medicine. “It’s a failure of the obstetric system when it comes to prioritizing Black birthing people and making sure that their needs, their wishes and their intentions are centered.”
Hospitals are looking for ways to combat this downward trend through several initiatives and, in some cases, with outside support. America’s Essential Hospitals, a nonprofit trade group, partnered with CVS Health Foundation to fund 12 hospitals’ obstetric care initiatives. Over the course of the 18-month program, which ran from September 2021 through March 2023, grant recipients concentrated on reducing conditions like hemorrhaging and hypertension among maternal patients, and dismantling elements of structural racism within their organizations.
Here are a few strategies hospitals have used to improve their Black obstetric patients’ morbidity rates and enhance birthing care quality.
BElovedBIRTH Black Centering's midwife strategy
At Alameda Health System, based in California, Black obstetric patients are invited to join prenatal care groups led by midwives and family support advocates. The participants attend regular check-ins and receive clinical care from midwives throughout their pregnancy and early postpartum period.
More than 200 patients have participated in the BElovedBIRTH Black Centering program since its launch three years ago in partnership with the Alameda County Public Health Department. The majority experienced better outcomes as a result of having their social and clinical needs consistently met, program director Jyesha Wren said.
While obstetricians are a necessary component of birthing care, using midwifery services has many benefits, said Wren, who is a certified nurse midwife at Alameda Health System.
Midwives are healthcare professionals with expertise in providing holistic antenatal care, educating patients about the labor and the birthing process, managing complications and pain and identifying high-risk pregnancies. Certified nurse midwives—individuals with a graduate degree in midwifery who attended nursing school and are credentialed by the American Midwifery Certification Board—are able to practice in every state. They can provide general reproductive care, prescribe medication, order lab tests and diagnose patients.
“We have a very medicalized maternity care system and we have really poor outcomes compared to other countries,” Wren said. “Using midwives in collaboration with doctors produces the best experiences and health outcomes for birthing families.”
Support and individualized care coordination from midwives—in addition to more than 15 two-hour group visits with other birthing patients and appointments with nutritionists, psychologists and other specialists—led to 88.8% of BElovedBIRTH Black Centering participants carrying their babies to full term and 89.4% having babies with healthy birth weights. Of the Black obstetric patients at Alameda Health System who were not part of the program, 86.5% carried their babies to term and 85.9% had healthy birth weights.
More than 80% of BElovedBIRTH Black Centering participants reported feeling less stressed than they were at the start of their pregnancy, better prepared to advocate for themselves and celebrated as a Black birthing person, Wren said.
To fund the BElovedBIRTH Black Centering program, Alameda Health System relies on financial support from the Alameda County Public Health Department, and leverages a number of donations and grants from the Alameda Health System Foundation and others, including $45,000 from America’s Essential Hospitals and CVS Health Foundation.
The program’s overall budget for 2024 is approximately $3 million. However, the health system is working to find alternative ways to bankroll the program.
“We’re looking at how some of the services that are supported through grant funds can be moved over to be reimbursable healthcare services,” Wren said. “We're going to be doing a lot of that work to have a guidebook to share with other communities, particularly those serving MediCal eligible people.”
Remote tracking of hypertensive disorders
Provider organizations like the American College of Obstetricians and Gynecologists recommend patients return for a postpartum visit between three and 10 days after giving birth. But coming to an in-person appointment with a newborn baby is a significant hurdle for many birthing people.
Missing this visit can be dangerous as blood pressure tends to spike in obstetric patients several days after delivery, and hypertension can cause strokes, cardiovascular collapse and death. One in five Black obstetric patients experience hypertensive disorders, compared with about one in seven white obstetric patients, according to data from the CDC.
Women and Infants Hospital is working to lower the barrier to postpartum care using technology.
“When you offer a remote blood pressure monitoring program, the rate of adherence to the recommended postpartum blood pressure screening increases dramatically,” said Dr. Adam Lewkowitz, an obstetrician-gynecologist specializing in high risk pregnancies at the Providence, Rhode Island, hospital. “The disparities in race in terms of receiving recommended screenings are also eliminated.”
Women and Infants Hospital launched its hypertension equity program in November 2022 to proactively track and treat patients experiencing hypertension, thus avoiding further hospitalization following delivery.
The health system’s electronic medical record identifies patients with pregnancy-related hypertensive disorders, who are then approached to join the program. Each month, around 100 patients enroll. The program is led by a nurse practitioner and bilingual community health worker.
About 19% of program participants are Black and 34% are Hispanic, Lewkowitz said.
Participants receive a blood pressure cuff, either through their insurance or donations given to the hospital. For the next six weeks, patients regularly communicate their blood pressure readings to the program’s lead nurse practitioner and community health worker through their electronic health record. They can also discuss any other symptoms.
Based on patients' vitals, the nurse practitioner may recommend they start on or increase their blood pressure medication.
Since implementing the program, the hospital's overall percentage of emergency department admissions among patients with the hypertensive disorders of pregnancy dropped from 5% to 2% within 42 days of delivery. Among Black obstetric patients with hypertensive disorders, postpartum emergency department admissions have decreased from 10% to 2%.
Women and Infants Hospital has also been piloting the use of Bluetooth-enabled blood pressure cuffs with a $45,000 grant from America’s Essential Hospitals and CVS Health Foundation. The cuffs automatically input patients’ blood pressure into their electronic medical records.
The pilot, which runs alongside the hospital's hypertension equity program, includes an artificial intelligence algorithm that flags high blood pressure readings for providers.
“We’re trying to figure out ways to make it easier for patients by making it more automatic,” Lewkowitz said. “So they don't [need] to open their EMR or have Wi-Fi at home—all of these things that might be barriers.”
Community support and patient education
Hospitals are also looking beyond medical intervention toward educational resources and social determinants of health to help Black obstetric patients.
Clinical intervention on its own is not enough to solve Black maternal health disparities. and social determinants of health and community support cannot be ignored, said Kalpana Ramiah, vice president of innovation and director of AEH's Essential Hospitals Institute.
“Connection to the community has really helped [hospitals] scale these programs and rebuild trust with their communities,” Ramiah said.
Initiatives focused on Black community health can make a world of difference when it comes to improving outcomes, said James Jackson, CEO of Alameda Health System.
“We have an opportunity to lean in and to be cutting edge, getting people out of thinking that hospitals just provide acute healthcare,” Jackson said. “We can be in the community. We can be actively working to improve the day-to-day health of all citizens.”
Along with midwifery services, Alameda Health System’s BElovedBIRTH Black Centering program distributes educational materials on childbirth that are culturally aligned and discuss issues that Black women and families face, Wren said.
The program also helps patients access locally available social services and targets poor nutrition by delivering fresh produce to participants’ homes.
BElovedBIRTH Black Centering is one of many initiatives looking to help obstetric patients access these kinds of resources. At JPS Health Network, for example, a screening tool embedded in the electronic health record system assesses individuals for various social determinants of health, connecting obstetric patients with social workers for nonclinical support and generating automatic referrals to local health, food and transportation services.
Broward Health, based in Fort Lauderdale, Florida, partners with a transportation company as part of its Every Mom, Every Baby program to ensure patients have rides to appointments. The program also offers group prenatal sessions to facilitate peer support and socialization.
MedStar Washington Hospital Center’s Mom HEART program educates obstetric patients about hypertensive disorders, as well as their potential impacts on long-term cardiac health. Participants can also join an online platform for virtual nursing support and information on subjects like mental health and common postnatal concerns.
Clarification: This story has been updated to note the Alameda County Public Health Department provides funding for the BElovedBIRTH Black Centering program.
