In the wake of the recent release of the White House, Centers for Disease Control and Prevention (CDC), and Blue Cross Blue Shield reports underscoring the severity of the U.S. maternal mortality crisis, the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI) convened an October 14 virtual seminar of six OB-GYN experts to discuss potential solutions.

Opening the session, LDI Senior Fellow and moderator Sindhu Srinivas, noted that among all high-income nations, the U.S. is the most dangerous in which to give birth. The maternal mortality rate for 2020 was 23.8 per 100,000 live births; by comparison, Canada’s rate was 10 per 100,000. U.S. deaths among Black patients is three times higher than white patients, while deaths among Native Americans are twice as high, and in the maternal care deserts of rural America, the death rate is 60% higher.

80% of Deaths Preventable

The CDC report issued four weeks ago estimated that 80% of these pregnancy-related deaths were preventable. The CDC’s Director of the Division of Reproductive Health, Wanda Barfield, MD, MPH, said the findings highlight “the need for quality improvement initiatives in states, hospitals, and communities that ensure all people who are pregnant or postpartum get the right care at the right time.”

The White House Blueprint for Addressing the Maternal Health Crisis cites its vision of a future in which “the United States will be considered the best country in the world to have a baby.”

The six panelists in the LDI seminar panel agreed that dramatically improving the quality of the country’s maternity care was possible, but would require sweeping changes to overhaul a currently dysfunctional system. They were Victor Caraballo, MD, MBA, Chief Safety Officer at Independence Blue Cross (Ibx); Veronica Gillispie-Bell, MD, Medical Director, Louisiana Perinatal Quality Collaborative and Pregnancy Associated Mortality Review, Louisiana Department of Health; Rachel Hardeman, PhD, MPH, Director of the Center for Antiracism Research for Health Equity, University of Minnesota; Pooja Mehta, MD, MSHP, Women’s Health Lead at Cityblock Health and former Chief Clinical Innovation Officer for Louisiana Medicaid; Karen Scott, MD, MPH; Associate Professor of OB-GYN, University of California San Francisco and Founding CEO of Birthing Cultural Rigor; and moderator Sindhu Srinivas, MD, MSCE, Vice-chair for Quality and Safety and Physician Lead for Women’s Health Service Line, University of Pennsylvania Health System.

Barriers and Insufficiencies

Their discussions ranged across a number of barriers and insufficiencies in the current system that contribute to high maternal mortality rates. These included:

• Structural racism that substantially increases outcome risks for Black and Brown patients.
• Lack of access to care across many low-income urban and rural communities.
• Overall workforce shortages.
• Lack of workforce diversity.
• Quality and safety measures and data collection practices that fail to capture the reality of patients’ situations and needs.
• OB-GYN practices that provide insufficient care throughout the full year that defines a patient’s pregnancy, delivery, and postpartum care and monitoring requirements.
• Reimbursement models that thwart the widespread use of innovative local community birthing centers and services staffed by professionals including midwives, doulas, and community health workers.

Missing Periods of Greater Risk

One of the central aspects of the problem is that the current fee-for service, health system-centric OB-GYN led system often provides narrowly focused episodes of prenatal, perinatal, delivery and postpartum care that misses periods of greatest risk during a patient’s pregnancy experience.

The CDC reports that 22% of maternal deaths occur during pregnancy, 25% occur on the day of delivery or within seven days, and 53% — or the majority of all pregnancy-related maternal deaths — occur between seven days to one year after pregnancy.

The seminar participants noted that the rigidly siloed nature of the current systems of OB-GYN, primary care, and other areas of care, along with barriers to health care access in many communities, leave patients on their own during periods of highest risk.

“We are disconnecting our moms from care as soon as they deliver until an arbitrary six-week appointment after which they are really disconnected,” said OB-GYN physician and panelist Gillispie-Bell. “We know if they have a hypertensive-disorder pregnancy, we should be checking blood pressures; and we know hypertensive disorders and cardiovascular conditions are the leading cause of pregnancy-related death. We have to find ways to take care out to the mom in the community rather than having the mom come into the care because that’s such a barrier. We need to keep moms connected for a whole year of follow-up.”

Structural Racism

Another aspect of the problem that weighs so heavily on Black and other minority patients is the long-term reality of racism-driven health, economic, social, educational, and political exclusions and disparities that result in poorer overall health and higher vulnerability to potentially lethal pregnancy complications.

“Structural racism dictates if someone gets to live in a healthy community, if they have access to healthy foods, if they have access to safe green spaces,” said reproductive health equity researcher Hardeman. “It’s going to impact whether or not they live in a neighborhood with dense housing or poor air or poor water quality… Our health care systems are not immune from structural racism. They have been built and constructed within the racial ideology of white supremacy and structural racism. I would argue that we have not fully grappled with what that means and how that translates to low quality care, particularly for Black and Indigenous birthing people. What we see is our birthing people accessing a system that isn’t actually rooted in the idea or notion of them thriving.”

A major point of the panelists was that the current health care system is physically too remote and its access barriers often too daunting to benefit large numbers of vulnerable pregnant patients who have devised their own local neighborhood alternative fix for the problem. But those solutions can’t be scaled for effective national use because they don’t fit within the fee-for-service model and are, as one panelist put it, out of step with the “OB-GYN/industrial complex.”

These neighborhood solutions are largely focused on small community centers staffed by clinicians as well as a corps of midwives, doulas, and community health workers available for long-term monitoring and care services for pregnancy patients. Cited as some of the currently operating community center models were Mamatoto Village, Roots Community Birth Center, and Village of Healing.

The general idea of these community-based centers is to provide close-by, culturally relevant, patient-informed pregnancy care, and be a gateway to higher levels of medical care for those pregnant patients who require it. Conceptually, this provides long-term, easily accessible, ground-level care and monitoring for potentially huge numbers of local patients at the same time it eases the load on hospital OB-GYN departments.

Change the Quality Metrics Standard

“We’ve had data for a while that the utilization of doulas and midwives improves outcomes and experiences across the sexual reproductive and perinatal experiences,” pointed out Scott. “The question is why aren’t those types of data utilized as performance indicators?… Relying exclusively on (the current) outcome measures and claims data reinforces a false narrative.”

“We need to change the quality metrics standards,” Scott continued. “We need to recognize racism as an adverse event in a patient’s experience and we need health plans to be naming it as such. It’s a violation of patient safety. We need to be linking claims data to patient experience measures and community-driven measures of safety, quality, and value. And then, we need to be tethering those types of measures to a reimbursement system that recognizes their importance and value.”

Back to the Future with Midwives

Once the primary provider of birthing services, the field of midwifery faded out across the U.S. in the early 20th century with the rise of modern high-tech medicine as white male physicians dominated the emerging OB-GYN field. The Journal of Perinatal Education explained that “midwives survived in Europe, but in America, they were eventually usurped when birth began taking place in hospitals and as medical science and technology advanced. Midwives eventually rose again as educated nurse-midwives (but) are again in jeopardy because of rising malpractice insurance costs, women’s trust in technology, and, most recently, renewed efforts by physicians to once again prevent midwives from practicing autonomously and outside the hospital environment in the United States.”

Cityblock Health, headquartered in New York City with offices in six states and the Washington, D.C., is one of the innovators working to build out a scalable hybrid infrastructure that melds the local community center concept with connections to established local health care provider services.

“Cityblock Health is a value-based primary care organization that takes financial risk across populations,” explained Mehta. “Medicaid or other payers entrust us with both the primary care and the financial accountability for outcomes for populations that have been historically marginalized. And within that framework, we weave together all of the learnings from our perinatal quality collaboratives and our maternal mortality programs and many years of qualitative research that lifts up Black and Brown women’s voices around what’s missing in the traditional fee-for-service system.”

Five-to-Ten Minute Patient Visits

“I’m a general OB-GYN who has worked for years in safety net settings,” Mehta continued. “Why are the prenatal visits that I’ve traditionally provided typically five to ten minutes? What about someone’s life and the challenges they’re facing? How can that possibly be met in that typical ten to five-to-ten-minute prenatal interaction?”

“Instead, Cityblock gets a list of members from health plans who, based on claims data, are poorly engaged in care. We outreach to that member, find out what it is that they need, and work to build trust with them so that we can have an honest conversation about their unmet needs. We build trust by hiring our workforce from the communities where we serve — folks with shared life experience — and then [we do] a lot of investment in workforce development. Our community health worker intervention is then powered or enabled by a clinically integrated team, a nurse, a behavioral health specialist, an advanced-practice clinician or provider.”

In a different approach to improving maternity care on a different scale, Ibx has taken a number of internal and external steps, said Caraballo. “Within the health plan, our whole strategy is centered on improving whole person, equitable health. We recognize health equity as a quality-of-care issue, and we’ve embarked on a number of listening strategies across our stakeholders and signed on wholeheartedly to the Blue Cross Blue Shield Association’s National Health Equity Strategy (BCBSA).

A Major Insurance Company’s Strategy

“We also understand that you have to lay a strong foundation in order to combat these longstanding structural issues,” said Caraballo. “So, we’re investing heavily into being able to collect and deploy real data across our providers and our members. We’ve signed on to implement the National Committee for Quality Assurance (NCQA) Health Equity Accreditation in all our plans.”

IBX is working with Cayaba Care, a company headquartered in Newark, New Jersey, that offers a range of home-based pregnancy care services in that city and Philadelphia. Cayaba’s services are designed to fill in with the patient between OB-GYN visits. The company maintains direct patient care connections virtually as well as through home visits and patient visits to its local clinic.

“These are services that are not necessarily tied to specific codes or that are easy to build under the old-fashioned system,” Caraballo said. “So, we’ve developed a different payment model with them that’s very innovative. It’s a hybrid between a provider and a vendor and is a very comprehensive model that addresses behavioral health and the social determinants provided by people who reflect the community in which they’re serving. And to be able to finance these services, we must get creative around how we can do that, because the current infrastructure has not been designed to reimburse these types of services. I think we would all like to see more flexibility with our benefits so we could deploy them more discreetly and have reimbursement for all of this.”

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