AHA Statement: Overcoming Racial Disparities and Social Determinants in the Maternal Mortality Crisis

Statement of the
American Hospital Association
for the
Committee on Ways and Means
of the
U.S. House of Representatives
“Overcoming Racial Disparities and Social Determinants in the Maternal Mortality Crisis”

May 16, 2019

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) commends the Committee on Ways and Means for examining the maternal mortality crisis and the role of racial disparities and the social determinants of health.

Maternal health is a top priority for the AHA and our member hospitals and health systems as we seek to eliminate maternal mortality and reduce severe morbidity. The causes of maternal mortality and morbidity are complex, including a lack of consistent access to comprehensive care and persistent racial disparities in health and health care. As hospitals work to improve health outcomes, we are redoubling our efforts to improve maternal health across the continuum of care and reaching out to community partners to aid in that important effort.

A recent Vital Signs report by the Centers for Disease Control and Prevention (CDC) noted that about 700 women die each year from complications related to pregnancy, and more than half of those deaths are preventable. An estimated 31 percent of pregnancy-related deaths occur during pregnancy, 36 percent during delivery or the week after, and 33 percent one week to one year after delivery. The national pregnancy-related mortality rate for 2011 to 2015 was 17.2 per 100,000 live births, with rates for American Indian/Alaska Native women and black women two to three times higher than rates for white women.

AHA Activity on Maternal Health

The AHA has been active in improving maternal health by working to reduce early- elective deliveries, unnecessary caesarian sections, obstetric hemorrhage and preeclampsia, and substance use disorders. We also partner with national organizations to safeguard mothers and babies, both before and after delivery. For example, we are an active member in the Alliance for Innovation on Maternal Health (AIM), a national, data-driven maternal safety and quality initiative with proven implementation approaches to improving maternal safety and outcomes.

Within the AHA, our Better Health for Mothers and Babies initiative serves as the organizational framework for addressing maternal morbidity and mortality. We recognize that mothers are at risk from the first days of pregnancy through the postpartum period, and know that hospitals and their community partners want to do more to improve their care.

The AHA provides a number of resources to our members, including:

• Evidence-based tools that can be implemented by hospitals of all sizes, such as AIM patient safety bundles, California Maternal Quality Care Collaborative toolkits, the Centers for Medicare & Medicaid Services’ (CMS) Maternal Opioid Misuse Model, and recommendations from maternal mortality review committees (MMRCs);
• Information for patients and families about the mental health conditions associated with pregnancy and screening recommendations, as well as initiatives from the March of Dimes, Merck for Mothers and others; and
• Links to clinical organizations, including the CMS Strong Start for Mothers and Newborns Initiative and the Council on Patient Safety in Women’s Health Care.

Recently, we developed an Action Plan and Checklist (attached) to help our members meet the goal of eliminating maternal mortality and reducing severe morbidity. They include recommendations for providers and toolkits reflecting best-practices to help hospitals and health systems evaluate and act on their data.

The Action Plan recommends that hospitals:

1. Evaluate and act on data.
2. Examine disparities.
3. Engage mothers and families.
4. Partner with clinicians and stakeholders in your community.

This Action Plan is being implemented in partnership with the AHA Physician Alliance; American Organization for Nursing Leadership; Institute for Diversity and Health Equity; the state, regional and metropolitan hospital associations; and AIM.

In addition, we developed a Discussion Guide to help hospital-based clinicians – working with community-based providers and other stakeholders – improve access to care and reduce health inequities for expectant and new mothers. The guide is designed to facilitate discussion and information-sharing within a hospital or health system’s practice and among providers across the continuum, covering prenatal care, labor and delivery, discharge protocols and the postpartum period.

In addition to the resources outlined above, the Better Health for Mothers and Babies website features podcasts, webinars and case studies focused on the field’s ongoing work to improve maternal health.

Given the committee’s interest in overcoming racial disparities and the social determinants of health, we offer a few examples of the work hospitals and health systems are doing in their communities to address these factors and improve maternal outcomes. For more examples, we encourage you to visit www.aha.org/bhmb.

Samaritan Health Services, Corvallis, Ore. Samaritan Health Services (SHS) recognized the need to improve birth outcomes of high-risk pregnant women in the region. In collaboration with various community and state partners, Good Samaritan Regional Medical Center established a program to ensure that the most vulnerable pregnant women had access to care and to screenings for medical, obstetrical and psychosocial concerns. Today, the Samaritan Maternity Connection (MC) program is at all five SHS hospitals and operates with three county health departments.

The program offers culturally relevant and age-appropriate programs that employ bilingual and bicultural local maternity care coordinators to support Latinas. Written materials are updated frequently to ensure that the social, cultural and linguistic needs of patients are met.

Adventist Health White Memorial, Los Angeles. The community that Adventist Health White Memorial (AHWM) serves has high rates of poverty and overcrowding. Health care funding cuts have reduced women’s access to prenatal and postpartum services, as well as pediatric care for their newborns. To increase access to care, AHWM launched the Welcome Baby Program.

The Welcome Baby Program is part of a community network of programs that provide supportive services to families with newborns. Developed in partnership with First5LA, an organization that seeks to prepare children for kindergarten, the Welcome Baby program is a voluntary, free hospital and home-visitation program for pregnant and postpartum women.

Welcome Baby works with families to maximize the health, safety and security of the baby and parent-child relationship and facilitate access to supports and services through nine points of contact: three prenatal visits; a hospital visit; and five postpartum home visits.

The Welcome Baby team provides individual support and information on parenting, early child development, bonding and attachment, health care, nutrition, breastfeeding and home safety. Mothers are seen as early as the first trimester of pregnancy and followed through the newborn’s first nine months. The program has three overarching goals: (1) increase breastfeeding; (2) increase access to health care; and (3) increase connections to local community resources. The caregivers help mothers make and keep all necessary pediatric or OB/GYN appointments, as well as track immunizations and other health needs for their infants. Through the program, new mothers are connected to other community and government resources as well, such as Special Supplemental Nutrition Program for Women, Infants and Children (WIC), food banks and educational programs.

Sinai Hospital, Baltimore. In 2003, Sinai Hospital of Baltimore launched the Perinatal Depression Outreach Program (PDOP) to improve infant and maternal well-being through the identification and treatment of maternal mental health struggles. Services specific to perinatal mental health are sparse in Maryland, and those that exist often are difficult to access.

With the launch of PDOP, Sinai became the first Maryland hospital to provide post- hospitalization services facilitating access to mental health treatment and social support for mothers at risk for perinatal mood and anxiety disorders (PMADs). PDOP provides free services to high-risk mothers who may otherwise not have access to care. To reach the most women, and to provide a forum for education, referral and peer socialization, the social workers offer a group intervention for clients. Group counseling is offered once a week, providing support and education to women adjusting to the postpartum period. Sessions help women understand PMADs, identify symptoms, discuss treatment options and learn new coping skills.

Other topics include parenting; creating a plan for transition and adjustment to a new baby; self-care while attending to a newborn; and the importance of accepting support and asking for help.

Henry Ford Health System, Detroit Medical Center, Beaumont-Dearborn Healthcare System, St. John Providence Health System, Detroit. Detroit’s infant mortality rate has been among the highest in the nation for years. In 2008, area hospitals and health systems commissioned the Detroit Regional Infant Mortality Reduction Task Force to develop an action plan to help more babies celebrate their first birthdays. The result was the Women-Inspired Neighborhood (WIN) Network.

The WIN Network empowers mothers and their support partners (significant others, grandparents, sisters and friends) to help babies thrive beyond first birthdays. Using innovative strategies, community health workers (CHWs) guide new and expecting mothers through a safety net of social, emotional and clinical supports. In groups clustered by gestational age, participants learn the CenteringPregnancy® curriculum with an added focus on social determinants of health. CHWs conduct home visits through babies’ first birthdays and continuously guide women to resources.

As part of the Detroit Regional Infant Mortality Reduction Task Force, WIN is a learning collaborative. With formal health care equity training at its foundation, data and participant stories are discussed regularly at quarterly meetings. CHWs inspire understanding between patients and providers by helping women improve their health literacy.

Supporting Changes in Legislation and Accreditation

At the federal level, a number of legislative initiatives specific to maternal mortality have been introduced. The AHA supported legislation enacted last year, the Preventing Maternal Deaths Act, which provides funding through the CDC for states and other entities to develop MMRCs. While some states and cities already have established MMRCs, participation by all states will allow for the collection of additional data that will aid in better understanding the causes of maternal mortality and ways to improve treatment.

We support several provisions of this Congress’ Mothers and Offspring Mortality and Morbidity Awareness (MOMMA’s) Act (H.R. 1897), including those that would:

• Improve data collection by establishing federal initiatives to assist states with reporting comprehensive data on maternal mortality and encourage uniformity in reporting and data sharing among states;
• Disseminate best practices to hospitals, professional societies and perinatal collaboratives regarding how to prevent maternal mortality;
• Fund an AIM grant program to promote the widespread adoption of maternal safety bundles at the state level;
• Fund state-based perinatal collaboratives to improve outcomes for pregnant and postpartum women and their infants;
• Extend postpartum coverage for women enrolled in Medicaid and the Children’s Health Insurance Program for up to one year, allowing providers to better coordinate services for mothers across the continuum of care;
• Address implicit bias and cultural competency by improving training for health care professionals regarding implicit bias and cultural competence; and
• Extend WIC for two years postpartum, an increase from the current standard of one year.

The AHA will continue to evaluate maternal health legislation as it is introduced.

In addition, the Joint Commission, which accredits more than 21,000 U.S. health care organizations and programs, including hospitals and health systems, recently proposed standards for perinatal safety. The AHA supports the Joint Commission’s focus on evidence-based procedures and responses that will ensure the most medically appropriate and effective course of treatment for women diagnosed with either maternal hemorrhage or severe hypertension/preeclampsia. In addition, we support the proposed requirement for education of staff, and believe conducting complication-specific training and drills will better prepare providers to act effectively and efficiently when these situations arise. Further, we support the proposed standards to provide patients and their families with the necessary educational materials to recognize symptoms that require immediate care as another important safeguard in this process.