Ending America's Maternal Mortality Crisis

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: a new CDC Vital Signs report calls attention to the hundreds of women who die each year during pregnancy, delivery, or soon after delivery.

We talk about the numbers and what's being done in response.

DR. WANDA BARFIELD:
I see this Vital Sign as a real call to action for healthcare providers, hospitals and health systems, states and communities, and women and their families to prevent these clearly preventable deaths.

DR. MICHAEL WARREN:
It's really important to think about how we optimize care in hospitals and birthing facilities. It's really important to think about how we get more women into prenatal care and how we get them in as early as possible during their pregnancy.

Those things are all necessary, but they're not sufficient. We have to think even earlier than that, because even the best prenatal care is not going to fix years—or even several decades—of poor health.

DR. NICOLE ALEXANDER-SCOTT:
We've spent many years now talking about these disparities. We know the numbers exist. They are heartbreaking, they are preventable, and need action driven towards doing something about it so that we cannot just focus on reporting out such negative numbers.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we examine a new CDC Vital Signs report about a troubling health concern. Each year 700 women in the United States die because of complications related to pregnancy or delivery. Even worse is the finding that Black women are three to four times more likely than white women to die from a pregnancy-related cause.

Our guests today are focused on finding ways to save the lives of women who all too often experience tragedy in a moment that should be filled with joy.

Dr. Michael Warren is the associate administrator of the Maternal and Child Health Bureau that is part of the U.S. Department of Health and Human Services’ Health, Resources, and Services Administration —also referred to as HRSA. Dr. Nicole Alexander-Scott is ASTHO’scurrent president and director of the Rhode Island Department of Health. They'll be along shortly.

But first, we hear from Rear Admiral Dr. Wanda Barfield, the director of the Division of Reproductive Health at the Centers for Disease Control and Prevention. She tells us what we can learn from the data found in the new report.

BARFIELD:
What we are understanding from this report is that deaths are occurring throughout the entire spectrum of pregnancy and postpartum period.

Again, we found that about a third of pregnancy-related Deaths happen during pregnancy, about a third happen at delivery or in the week after, and about a third happen between one week after delivery to one year postpartum.

And so, that's really an important issue that we need to understand that these deaths can occur in this period up to a year after delivery. And also, we found that three in five deaths could be prevented no matter when they occurred.

JOHNSON:
As if these numbers aren't bad enough, Dr. Barfield points out, the rates are worse for Black and Native women.

BARFIELD:
There are differences in deaths by race, ethnicity, and we know that Black women and American Indian, Alaska Native women are much more likely to die due to a pregnancy-related cause. And some of what we are seeing in includes the impact of structural racism and implicit bias on health. There has been a growing body of research that's documenting the role that structural racism plays in generating these disparities. For example, delayed prenatal care initiation has been associated with the endorsement of experiences of racism. We also see persistent disparities in maternal mortality, regardless of a woman's educational attainment.

We also know that there is variation in hospital quality, and there's evidence that some of the disparities that we're seeing in maternal mortality may be explained by variation in hospital quality. There've been several recent studies that have found that racial and ethnic minority women deliver in different and lower quality hospitals than whites. And hospitals that disproportionately care for Black women at delivery had increased poor outcomes for both Black and white women in those hospitals.

We also know that chronic diseases like hypertension and cardiovascular diseases are more prevalent in Black women; and so, these chronic conditions are associated with an increased risk of pregnancy-related mortality.

And then lastly, the issue of access to care, specifically quality care. We know that in individual cases there may be access issues related to the appropriate level of care. So, for example, we know that many Alaska Native, American Indian women are more likely to live in rural areas, where there could be challenges to accessing local, high-quality care.

JOHNSON:
She notes women have been facing these threats to a successful childbirth for decades, but that society has more focus now thanks to those who've come forward to share their experiences.

BARFIELD:
CDC has been monitoring maternal deaths through the Pregnancy Mortality Surveillance System since 1989, and this has been an important issue for us for quite some time.

But I think what's happened more recently that has increased this effort and interest has been the stories of women and their personal stories, as well as the stories told by their loved ones, that has been in the news and in the public. And I think the public has been incredibly surprised to find that this is even occurring. And I think—also from our report—we reveal that chronic diseases play a major role in many of these deaths. And I think that, too, has been very surprising to the public.

JOHNSON:
What, then, does Dr. Barfield hope will come of this new report?

BARFIELD:
I hope that the results of this Vital Signs will call to action many of the people who provide care to pregnant women and their infants in a way that reduces the large number of deaths that we're seeing in the United States.

I see this Vital Sign as a real call to action for healthcare providers, hospitals and health systems, states and communities, and women and their families to prevent these clearly preventable deaths.

JOHNSON:
The CDC wants to encourage women to talk about health concerns before they have problems. Later this year, the agency plans to launch a public service campaign to empower them to advocate for their health.

Dr. Michael Warren of HRSA leads a team that uses education and funding to improve women's health before, during, and after pregnancy.

Here's how they do it.

WARREN:
There are a number of ways that we go about that. One that we're particularly excited about right now is what we call AIM—the Alliance for Innovation on Maternal Health.

AIM started several years ago, recognizing that there are opportunities to improve the quality of care that's provided to women in this country. And so, AIM consists of a number of what we call bundles. Those are like toolkits of best practices or evidence-based guidelines that hospitals and birthing facilities primarily can implement.

And if they implement those, those have been shown to improve the quality of care. And so, those have been designed around things like a maternal hemorrhage or high blood pressure in the setting of pregnancy. There are a number of those that are being implemented across the country.

And so, thinking about how we increase the quality of that care in a reliable way is really important to us. That's one of the ways we're approaching that.

JOHNSON:
Do these look like training modules? Are they classes? Is it information?

When you're on the receiving end of these bundles and this guidance, what does it look like?

WARREN:
The bundles are a standardized set of resources. They are available online for folks to use. And one of the beauties of them is they can really be tailored to meet the needs of the particular hospital or birthing facility.

So, one of the things in public health that you realized early on is that every community is just a little bit different. Every facility is a little bit different. And while we want to make sure that there are standards in place and consistent protocols, you also want to have tools that are flexible enough to meet the needs of a particular community or a facility.

And so, hospitals and birthing facilities have the ability to tailor those bundles to meet their needs. They can identify what parts of those are the most important for their work and implement those as they need to.

JOHNSON:
Is this your approach to increasing consistency when it comes to the kind of treatment women receive, regardless of where they are, who they engage?

WARREN:
This absolutely is an approach to increasing the consistency of care across the country, and the AIM bundles allow us to do that because it provides, again, those standard recommendations and evidence-based practices to hospitals and birthing facilities can implement.

One of the things that's important to note as well is that there are a number of bundles that exist in hospitals, and birthing facilities can select what's most appropriate for their community.

And that really gets to another issue that we've really worked to support, is how do communities best know what are the leading drivers of maternal morbidity and mortality in their communities? And how do they tailor those solutions?

So, having a range of AIM bundles allows them to pick what is most relevant.

JOHNSON:
Can you give us an example of a tailored bundle, what that looks like?

WARREN:
Sure.

So, an example of a tailored bundle might be if a hospital or a birthing facility looked in to recognize that they had a number of women who've suffered hemorrhage during the time around the pregnancy, and that maybe the outcomes weren't as good as they would like.

They could go and look at this bundle and they can look at the practices that are there—and that might include everything from looking at your blood bank and what's the capacities there, how much blood do you have on any given day in storage, might include looking at your laboratory to say, “What's our ability in a hurry to be able to do typeing screens,” for example, “to make sure we know the recipient's blood type and it's going to be compatible?” And are those services available all throughout the day? We know that the babies come 24/7, and so, thinking about are those laboratory services are available. Making sure that, from an ordering standpoint, do the doctors and nurses understand the correct ways to order and have those protocols at hand, and then understand how to give that blood rapidly if needed? And are the tools there?

And so, all of those pieces go into play. When you start to think about changing the way we behave clinically, it's rarely just one thing. We know that those decisions and those actions happened in the context of a system. And so, those AIM bundles help you to look across the system. Again, it's not just as simple as giving a patient blood when they're hemorrhaging, but it starts to set a blood bank and the laboratory and do we have those basic needs available, and can we meet those when they occur?

JOHNSON:
What sort of feedback have you received from those who've used this information?

WARREN:
The feedback on AIM thus far has been very popular, and I would couch that in terms of the uptake.

So, just as of last month, we're up to 1300 birthing facilities across the country that have implemented AIM bundles. And right now, the AIM bundles cover about half of all births in the country. So, that's quite a spread, if you think about it.

We've just received funding from Congress in the past year to expand AIM, cover all 50 States. And so, our ultimate goal is that we'll be able to cover all or almost all of the births that happened in the United States.

JOHNSON:
How long will it take, do you think, to reach that goal?

WARREN:
You know, there's a lot of interest in this topic right now, and we've seen a rapid uptake over the last few years. So, we would hope that, over the next few years, we'd be able to meet that goal.

JOHNSON:
Let's switch gears and talk about block grants.

Give us an overview of that program and how it works.

WARREN:
The Maternal and Child Health Block Grant is our largest federal investment here in HRSA’s Maternal and Child Health Bureau. It's been around a long time. We talked about it as the oldest federal state partnership, and it's an opportunity for states to use federal funds to address what their most important priorities are in maternal and child health.

And so, there are a few features that we talk about when we talk about the block grant. One is flexibility. So, these funds, we call it a block grant for a reason. States gets this block of funds, and they are broadly charged with doing good things around the maternal and child health with it. There are relatively few strings.

They have to spend at least 30% of their funds on primary and preventive care for women and children. They have to spend at least 30% of their funds on services for children with special healthcare needs. And then, they are limited to no more than 10% of their funds that can be spent on administration. Otherwise, they really are free to meet the needs of their population.

So, states every five years do a comprehensive needs assessment looking at the needs and priorities of their state and their population. They look at their public health capacity and they develop an action plan that is responsive to their particular needs—because we know the needs of kids and families in Oklahoma, for example, may be very different than the needs of kids and families in Texas.

And so, states and jurisdictions can tailor their plan to meet their needs; and once they've done that, they use those federal funds and combination with the state funds that may be available to support whatever priorities they have. And so, all 50 states and all of the jurisdictions receive the block grant and they report annually on that to us on how they're doing based on the action plan that they set out.

JOHNSON:
I was surprised to learn that 86% of all pregnant women nationwide have somehow benefited from a program funded by the Title V grant.

WARREN:
That's an impressive statistic, absolutely—86% of all pregnant women served by the Title V Block Grant. And I think that speaks to the fact that the block grant really is the public health system for women, children, and families in this country.

Before I came to HRSA, I worked in a state health department, and we certainly leveraged our block grant department core public health services in many ways to women and children across the state, and that's the case for many of the states in the country.

So, it's not a surprise when you think about that, the block grant providing that kind of core infrastructure that so many women and children are, in fact, served by the grant.

JOHNSON:
Given that this is the granddaddy or grandmother of the programs you administer in this area, it's very likely everyone listening already knows about this. They know far more about it than I do.

How do we advance the conversation for them on this topic? Is there anything to look forward to in this area? Are there any changes coming?

What is the future for this program as it relates to how you deliver it, what it can do, what you're thinking in terms of funding levels— anything at all you can share as we lean forward into the rest of this year and beyond?

WARREN:
Well, there are a few great opportunities, I think, for your listeners to take action around this.

The first is that, right now, the states and jurisdictions are working on their five-year needs assessment for the block grant—those will be due in the summer of 2020. But those are quite comprehensive, and the states start on those a year, a year and a half in advance sometimes.

And so, it's a great opportunity for your state health officers, for your state public health staff, and their community partners to start thinking about what are the needs and priorities of the MCH population and how might those be discussed during the needs assessment process and how might those factor into the action planning that happens. And so, that's a great way that states can be involved in and take action.

The other is to think about funding opportunities that are either currently available or coming soon from HRSA. So, in the last year's budget, we were given additional money to support investments in improving maternal mortality and morbidity. And so, there very soon will be on our website posted funding opportunities related to reducing maternal mortality and morbidity.

Some of those will support the expansion of those AIM bundles that we talked about, but some of those will also support state innovation grants, where states can propose novel solutions that meet the needs of their particular population and actually receive funds for that.

So, those will be posted on our website and that's available at mchb.hrsa.gov.

JOHNSON:
When we look at this challenge and we hear that every year 700 women die because of a complication related to a pregnancy or a delivery, that's just startling.

And I assume that when you come to work every day, that figure is top of mind for you.

WARREN:
The notion that 700 women die in this country every year from pregnancy-related complications is absolutely top of mind, and it's one of the things I think that keeps me and many others awake at night. And I think, as we think here in the Maternal and Child Health [MCH] Bureau about how to approach that, those deaths are really the tip of the iceberg.

We know that for each of those deaths, there are many more women who will become very sick as a result of their pregnancy, and some of those will have lifelong complications. And so, the challenge is to think about what can we do about that? And once those deaths or severe illnesses occur, there's not a lot of opportunity to fix that, obviously. So, we want to think upstream.

We want you to think about how do we prevent those bad outcomes from ever happening in the first place. And in MCH, we talk a lot about the life course perspective. We know that everybody has a health trajectory, and events along our life course can improve our health trajectory. So, health promotion factors can improve our overall health trajectory, but risk factors can diminish that health trajectory.

And so, our work is really about how do we maximize those health promotion factors and reduce or mitigate those various risk factors so that all of us have that optimal health trajectory.

And when we think about maternal mortality and morbidity, we really want to think very early in the life course. And so, it’s really important to think about how we optimize care in hospitals and birthing facilities. It's really important to think about how we get more women into prenatal care and how we get them in as early as possible during the pregnancy.

Those things are all necessary, but they're not sufficient. We have to think even earlier than that, because even the best prenatal care is not going to fix years—or even several decades—of poor health.

So, then, we think in our population of young girls and adolescent women for example. How do we promote their health as early as possible? How do we give them the best possible start so, should they choose to become pregnant, they're as healthy as they can be going into that pregnancy, that gives them and their babies the best chance at a good start?

JOHNSON:
ASTHO’s president says she was shaken the first time she heard that so many women are dying from complications related to pregnancy and delivery.

We asked Dr. Nicole Alexander-Scott why the numbers are so high.

ALEXANDER-SCOTT:
Well, we certainly attribute a significant component of the unfortunate life expectancy trend that we've been feeling and experiencing in this country, ofa life expectancy decreasing for the first time in many decades, year after year for the last three years, to the fact that we need to readjust our investments.

That life expectancy trend has occurred in spite of significant investments in healthcare in the U.S., and yet other developed countries that have not had the same negative life expectancy trends has a much better ratio of spending on health.

And so, instead of two-thirds, 75% of funding going towards healthcare, there is a larger proportion of funding that goes towards community level factors, addressing prevention, affording ambulatory care, and tackling the determinants of health—social, economic, and environmental; where someone goes to school, what they're eating, what access to transportation they have, the type of housing or job opportunities they have—and we say that 80% of our health outcomes are actually determined by those types of community level factors.

And so, with this statistic, we are forced even more so to look at what are the surrounding environmental and social economic exposures that certain populations are experiencing and what changes and shifts in our current investments do we need to redirect to better be able to address that so that all mothers, families, and babies can be as healthy as possible on living the healthiest community as possible.

JOHNSON:
You've been working to change that focus in Rhode Island with your health equity zones, and also on a national stage with your colleagues across the states and territories.

How do they apply that thinking? How are you applying that thinking at home there in Rhode Island, however you want to address this?

How are you attacking this problem with that approach in your state and how should we do it nationally?

ALEXANDER-SCOTT:
Well, one of the changes we've acknowledged is we've spent many years now talking about these disparities. We know the numbers exist. They are heartbreaking, they are preventable, and need action driven towards doing something about it so that we can not just focus on reporting out such negative numbers.

And so, our health equity zones initiative in Rhode Island is the model and infrastructure we are choosing to say, let's do something about it. And it allows us to shift the over-investment in the healthcare setting to focus more on community level factors where we've seen other countries have done and receive better outcomes.

And by doing so, we've braided funding that we've received from federal partners, philanthropy, and others. And instead of having it focused on healthcare, diseases, and siloed approaches, we braided the funding and have invested in the community in a very organized and structured way through the health equity zones model.

We've applied public health principles, requiring communities to organize themselves, form a collaborative, do a data-driven needs assessment of their respective community in self-defined zone or area, and then put together an action plan that works towards shared goals with measurable targets and outcomes so that they can implement what they say needs to be done, and then evaluate it.

Those are all key public health principles that we know are affective; and it gives an opportunity for us to move from just talking about disparities—whether racial, ethnic, or geographics, or gender, or age-driven—and putting in place infrastructures that allow communities to lead the way in addressing them. And so, communities can work on policies and systems that lead to safer housing and develop opportunities for jobs and economic development and providing healthy and nutritious food, and access to transportation.

And that model of putting the community's voice first, letting them lead, and doing it in a structured way where we will get outcome becomes the basis for what we're talking about doing at the national level.

The ASTHO President’s Challenge is building healthy and resilient communities, and the first goal of that challenge is to mobilize community-led, place-based initiatives. Health equity zones is a ready-made example. There are plenty throughout the country that are similar and do the same thing. Put the community's voice first, use data and other public health principles to lead to sustainable change and improve policies and systems for better outcomes at the community level.

And the second goal of the president's challenge, building healthy and resilient communities, is to support public health in reaching across the non-traditional sectors—the business community, corporations, banks, the opportunity zones that are a part of the new tax bill nationally—and have those non-traditional sectors focus on investing in their local community. Understanding the importance of doing that in this way, help to sustain what we want to do, which has half of the community's voice to be placed first using a model like the health equity zone initiative.

So, it gives us an opportunity to not only talk about the numbers and the disparities that exist, but it puts structures in place that lead to sustainable change to address them.

JOHNSON:
Have any of the communities in your state launched a program through the health equity zone opportunity that seeks to help moms and babies?

ALEXANDER-SCOTT:
Absolutely.

Almost every health equity zone has a maternal child health element or focus to them, and wanting to create families and communities that are more supportive.

So, one of our health equity zones in Central Falls has been able to use their collaborative and the resources that are available as a result of the people sitting at the table to lead to a 24% decrease in teen pregnancy that has occurred in that area.

We have a Woonsocket health equity zone that has partnered with our sister agency, the Department of Children, Youth, and Family Services, to add a targeted objective or goal that focuses on reducing childhood maltreatment and neglect, so that there can be improvements in outcome.

We have several health equity zones that have walking school buses and partnered with education systems to improve attendance in school, test scores have improved, physical activity has improved, and parents being able to get to work and address the economic needs for their family has improved.

There has been an increase to access to fruits and vegetables, 36% in one of our health equity zones in Olneyville, and a 44% decrease in childhood lead poisoning in our Pawtucket health equity zone.

So, each of the infrastructures that have been built have been used in the way that works best for that local community to make the environment better for mothers, families, and for the children.

JOHNSON:
Is that how the dots get connected?

Is that how you lower Rhode Island’s share of this 700 number each year?

ALEXANDER-SCOTT:
Absolutely. That's the underpinnings for seeing the movement that's needed.

We know it's going to take an all-hands-on deck approach. We know it has to be place-based and that the community needs to lead the way with the support on how to make that structure and for there to be deliverables and outcomes that are being advanced towards and achieved. And with that, we know we will start to see improvements in the environment to which the pregnant women and mothers and families are able to raise their children

JOHNSON:
In Rhode Island,he number of Black women who receive delayed or no prenatal care at all is nearly double that of white women. And the numbers just keep going —I'm looking at a list here of all kinds of disparities.

Why is that? Is it economic? Is it education? Is it jobs? Is it all of these things?

What's going on there?

ALEXANDER-SCOTT:
It's a combination of all of them and a particular reason why we need to have the communities lea, is it also involves the structural and root causes. We cannot overlook racism or racist policies, discriminate policies that may be in place, whether explicit or unbiased. We cannot overlook the challenges for women that are increased more than others. And the challenges for those in low income or underserved communities.

When the structural factors related to that are exposed and addressed directly combined with adjusting the determinants of health that we've talked about, that's when you can start to see the improvement.

But you cannot ignore the role that the discriminate practices and policies can play, whether intended or unintended. There are institutional elements to that, and being able to identify and overcome structural and cultural barriers to care are key components of addressing such striking disparities as what you described.

JOHNSON:
The research says half of these deaths can be prevented. That's a big number, and it would seem to be a cause everyone could get behind.

What's the reaction when you hit the trail in Rhode Island with this message? How are people across your state responding?

ALEXANDER-SCOTT:
There is an understanding that it is not normal to have such deaths that are occurring during pregnancy and the discrepancy between race, ethnicity, and other population groups really emphasizes that. And there's really a need to help understand why it's important across the board.

There's still work to do to effectuate that, to help people recognize this can be preventable, and it should be prevented, and we need to care about the population disproportionately affected by this, and need to be willing to face some of the changes that are needed to help us address it, looking at overcoming structural and cultural barriers while also shifting investments to build better capacity and transformational change at the community level.

There needs to be a recognition and the courage to acknowledge and do something about it. And there's work to do there, which is why some of the disparities still persist.

But I'm encouraged that with our focus on it and keeping it judgment free and saying that these are just changes that we need to work on together that we, with time and persistence, I can get there.

JOHNSON:
You're a medical doctor, public health professional, you are leading the charge for your state in a high-profile position—but you're also going to be a mom soon.

Does this issue get more personal now that you can see that day coming very shortly when you'll have your own baby to take care of and keep you up all night?

ALEXANDER-SCOTT:
I'm very excited for that blessing to occur, and it is personal. I had to realize something I wasn't necessarily expecting, but how much I had to really process the data and actually prevent myself from getting consumed by it, in a sense, and to still stay positive in the midst of it. And that's an added level of work and effort and stress that other professionals, or soon to be working mothers, may not have to face or deal with it.

And it certainly highlights for me the importance of us caring about each other overall, whether or not there is any deliberate impact on the individual. Communities are facing these numbers in ways that are more stressful than what should be occurring during such a critical moment in life. And I've had to put extra energy into protecting against the negative outlooks that are reported.

And that's why we as a department and as a state really are putting our focus on the solutions. Instead of just discussing the numbers and the disparities—which are important to expose and make clear, we've been able to do that over the last couple of decades—it's now time to put in place infrastructures that allow us to act and do something about it so, it's not something that our children are still talking about the numbers with, you know, in the next 20, 30 years.

But we’ve set the stage for system transformation and policies to improve and discriminatory practices to be eliminated and better outcomes to occur. And that's what the health equity zones model is about.

That's what the ASTHO president's challenge is looking to do, put in place tools for people to begin to act so we can start to change these numbers instead of just talking about them.

JOHNSON:
Links to the CDC Vital Signs report, HRSA’s programs, the ASTHO President’s challenge, and Rhode Island's health equity zones approach can be found in the show notes for this episode.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And, if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.