Imagine a system where pregnancy, birthing, and postpartum environments are abundant with support, love, and trust and are free from disrespect, physical and psychological harm, and trauma.

Imagine a system that addresses social, emotional, spiritual, and physical wellbeing and builds trust among women, their support people, and clinicians.

Imagine a system where there are clear, reliable pathways to access that navigate emergency, acute, and advanced maternal services as needed, with a focus on strong, supported, and trusted handoffs.

It is long past time to go beyond picturing something better. It’s time to co-design such a system before more harm occurs.

A common narrative in the United States is that medical care is the dominant determinant of health outcomes. Out of this narrative grows a dangerous assumption that more care always leads to better outcomes, despite the well-documented evidence to the contrary. More medical care and unnecessary interventions can often lead to an increase in undesired outcomes.

This is particularly evident for maternal and infant health outcomes: The US has the highest per capita spending on maternal and infant medical care in the world while also seeing the poorest outcomes among high-income countries.

The current health care delivery system is failing mothers and families across the US, and these shortcomings are amplified among certain populations, including Black, Indigenous and people of color (BIPOC) and those living in rural communities. While it would be easy to assume that poor maternal health outcomes in rural areas are due to a lack of access to services, poor outcomes and dramatic inequities are the result of system failures. These include the overuse of interventions; a culture of fear and distrust; racism, sexism, and other explicit and implicit biases; poor coordination between social and medical care systems; inadequate access to community support; and inadequate support for other social determinants of health.

There is a growing understanding that redesigning systems to support those who are most marginalized by the current system builds stronger systems for everyone. The predominant barriers to better maternal and infant health outcomes are from the delivery system itself. The COVID-19 pandemic is increasing many of the barriers to positive health outcomes, particularly in rural communities. Given these challenges, now is a prime time for disruptive innovation and whole system redesign of maternal health care delivery.

One whole system redesign strategy is to shift the locus of control from the health care delivery systems to the community and focus it on BIPOC living in the rural US. This approach is based on the theory that medical resources aren’t being optimally leveraged and connected to community-based and other support resources. Working with BIPOC living in rural areas to co-design a new care and support system would drive toward better and more just maternal and infant health outcomes and serve as a model for other communities across the US.

An approach to whole system redesign would do the following:

• Use a culturally humble co-design and co-production process that centers on BIPOC with lived experience in the rural health setting. IHI has successfully used an “Equity Action Lab” (EAL) process to facilitate co-design across multiple stakeholders to improve maternal health outcomes. In the EAL, participants set an ambitious goal and designed a 100-day preliminary action plan. This is a highly adaptable model that uses proven strategies from quality improvement, design thinking, co-design, and behavioral economics.
• Start with gaining a common understanding of “what matters most” to those directly affected. 
• Be asset-based, focusing on identifying and mobilizing the unique individual and community assets within rural communities.
• Build trust among people who birth, their families, community supports social services, health care providers, and health care delivery system representatives. 
• Explicitly address structural racism, bias, and historical traumas that have led to the racial, social, and economic inequities seen today. IHI has found that doing this work upfront helps to build will for co-design of innovative care models with people with lived experience. 
• Acknowledge that racial inequities in maternal and newborn health outcomes are not caused by inadequate prenatal care and that race itself is not a risk factor for poor outcomes. Racial inequities in maternal health outcomes are caused by structural and institutional racism as well as implicit and explicit biases of clinicians.
• Use a reproductive justice framework.
• Challenge deeply held beliefs and shift power from health care toward people who birth. 
• Democratize data and see qualitative and quantitative data to guide decision making. 
• Leverage quality improvement methodologies to learn quickly and learn together. 

The US is in a unique moment. The COVID-19 pandemic is having both real and perceived impacts on the perinatal health care delivery system in rural communities. Many of us are taking part in a long overdue and growing national conversation about the stark inequities built within our current systems. Instead of trying to get back to normal, we can work together to imagine and build a “new normal.”

Catherine Mather, MA, is Project Director, Institute for Healthcare Improvement.

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