Why It Matters
“Every system is perfectly designed to get the results it gets, and our system in the US is perfectly designed to get higher maternal mortality than almost every other developed country.”
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Maternal Mortality Isn’t Getting the Attention It Deserves

By Susannah Berlowe Binder | Thursday, June 27, 2019
Line of Sight
It’s good to see the mainstream media highlighting the problem of maternal mortality in the US. It’s also important that some prominent American political figures are starting to talk about race-based inequities around maternal and neonatal outcomes. The spotlight is long overdue, but still heartening.

However, I still don’t see enough health care leaders prominently featuring maternal health and maternal mortality in their discourse, strategic considerations, or organizational priority setting. More than 700 women die each year in the US because of pregnancy or delivery complications. Despite these appalling numbers, I don’t know of many executives or health system boards asking, “Is this a problem for our patients? What can we do?”

I know of a few honorable exceptions, but broadly speaking health care leaders are not giving these issues the focus they deserve.

Why not?

Any time you ask a leader why something is not on their priority list, you tend to hear variations of the same response: “We’ve got limited bandwidth.” That’s undoubtedly true, of course. We all have too many demands on our time, resources, and attention. And yet we manage to prioritize some things. So, why not maternal health and maternal mortality?

Part of the challenge is that these problems are widespread and complex. Maternal deaths are happening in both urban areas and rural communities. It’s not just poor black women who have a much higher maternal mortality rate than white women, but all black women. Education, income, and access to health care don’t seem to provide the “protection” from negative outcomes they often do. In fact, research indicates that a black woman in New York City with a college degree is three times more likely to die from pregnancy or childbirth complications than a white woman who has dropped out of high school.

So, what does it mean if poverty, educational attainment, and health care access are factors but not the real problems? It means that the contributors to maternal mortality go deeper in our society, and some of these issues are specifically about the experience of people of color in our health system.

Every system is perfectly designed to get the results it gets, and our system in the US is perfectly designed to get higher maternal mortality than almost every other developed country.

More Than a Lack of Representation

Women in the US are more than four times as likely to die in pregnancy or childbirth as women in Poland, Greece, or Iceland. The World Health Organization estimates that African American expectant and new mothers die at about the same rate as women in Mexico and Uzbekistan. Maternal health inequities exist in other parts of the world, but they’re not as pronounced as they are here in the US.

Would health care leaders pay more attention to these issues if more of them were women or people of color? I believe the short answer to that question is yes. But these issues go beyond a lack of health care leadership sufficiently representative of the communities that we serve.

Our colleague, Neel Shah, MD, MPP, Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School and co-founder of the March for Moms, summed this up well in an interview with the Harvard T.H. Chan School of Public Health. After reviewing investigative reporting on maternal deaths in the US, he said, “The common thread is that when black women expressed concern about their symptoms, clinicians were more delayed and seemed to believe them less,” he said. “It’s forced me to think more deeply about my own approach. There is a very fine line between clinical intuition and unconscious bias.”

Maternal Deaths Are Preventable Harm

Many health advocates, families, and researchers have been raising the alarm about maternal mortality in the US for decades. Yet, I suspect if we asked people in the general patient safety community if they were aware of the problem, we would get the same kind of inconsistent responses that we would get from most health care leaders.

Does it stem from a similar lack of representation among patient safety professionals? When you consider that research indicates at least 60 percent of maternal deaths are preventable, it would seem to be exactly the kind of issue crying out for focused patient safety attention.

And yet, while IHI has worked to improve maternal health for many years, we have historically not done enough to directly address the disproportionate share of harm experienced by African American women and their families.

Therefore, IHI has a duty to add our collective voice to those who have come before us to address what can only be called a tragedy in US health care. When more people who care deeply about preventing avoidable patient harm focus on this issue, I firmly believe they will feel as I do that we have a responsibility to use our improvement experience and expertise to end what should be a thing of the past.

IHI is attempting to do our part through our new learning networks. We’ve begun a large-scale, three-year project supported by a grant from Merck for Mothers — called the Better Maternal Outcomes Rapid Improvement Network — to improve outcomes for all women and babies in the US and reduce inequities in maternal health. The initiative’s goals are to spread the use of evidence-based care practices to reduce complications such as hemorrhaging, hypertension, and blood clots; reduce inequities in maternal outcomes; and partner with women, health care providers, and community organizations to better understand and address factors that improve health outcomes for mothers and newborns.

In addition, to focus squarely on the population experiencing the most harm, we will co-design improvement efforts in four communities to reduce inequities in care delivery and outcomes for black women. To do this, we will give women with lived experience the respect they deserve as experts with essential insights into how to improve women’s health care. We will also invite organizations with deep maternal health experience to work with us on testing, scale up, and collaborative learning.

What Health Care Leaders Can Do

We need to expand on the work we’re already doing to pursue the Triple Aim to ensure healthy pregnancies, safe deliveries, and thriving children in all communities. This requires greater commitment to co-designing with patients. More specifically, I recommend leaders:

  • Listen — We should always listen to patients and families as part of our efforts to improve health care. This is especially important when addressing maternal health inequities because the voices of African American women and their families have been underrepresented in the discourse about how health care systems engage with them. For this reason, IHI has been explicit about the need to partner with African American women who have much to teach us about how to improve maternal health.
  • Acknowledge and address implicit bias — Very few people in health care intend to discriminate against any of their patients, but the experience of many of our patients and years of research indicate that implicit bias is common and causes harm. The only way to address this is to admit it and take deliberate corrective action. As Child Trends and other organizations have noted, health systems can provide better and more equitable maternal health care by training all staff to recognize their implicit biases, providing tools to address inequities, ensuring access to proven clinical and social support interventions, and standardizing their responses to obstetric complications.
  • Support collection of standardized data — This past December, federal legislation was signed into law to provide funding to collect and analyze data on every maternal death in the US. The Preventing Maternal Deaths Act (HR 1318) is meant to create and support existing Maternal Mortality Review Committees (MMRCs) to reduce state to state variability regarding the types of data tracked and the collection methods used. Health care leaders have an opportunity to insist that this standardization occurs so that meaningful data is gathered and assessed. We won’t know if the changes we’re making to improve maternal health are leading to improvement without good data collection and analysis. MMRCs should also include women who have experienced life-threatening complications and the families of those who have died. They are the people whose stories helped create the momentum that led to passage of the Preventing Maternal Deaths Act. They deserve to directly contribute to its proper implementation.

Passing bipartisan legislation in these notoriously gridlocked political times is an indication of how much can be done when we work together to do the right thing. We can’t wait for more women and families to suffer to convince us to make preventing maternal deaths and eliminating health inequities our top priorities.

Editor’s note: Look for more from IHI President and CEO Derek Feeley (@DerekFeeleyIHI) on leadership, innovation, and improvement in health and health care in the “Line of Sight” series on the IHI blog.

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