Providers must look at their maternal health models to ensure patients are receiving the best care.
Mark Simon, MD
Look at virtually any news report on maternal health for women in the US over the last decade and you’re likely to see a dire picture. According to the latest numbers, the US maternal mortality rate climbed to nearly 30 deaths for every 100,000 mothers giving birth—double the mortality rate of other first world nations. What’s more, an estimated 60% of these deaths are preventable.
We must strengthen our resolve to improve maternal care. We can do better, and we know how to. Success is predicated on changing the fundamental structure of how care is provided at the policy, facility, and provider levels.
First, it is unconscionable that in 2020, there remain significant disparities in health outcomes for black women. Compared to non-Hispanic white women, African American women are three- to four-times more likely to die during or as a result of childbirth. Policymakers and health leaders should follow the lead of states like California in requiring implicit bias training for perinatal health professionals.
Additionally, states should take measures to ensure that all women have access to care at all phases of pregnancy, including the critical year after delivery. Cutting off Medicaid benefits a mere sixty-days postpartum increases the chances of missing delivery-related complications and potentially deadly conditions, such as hypertension, cardiomyopathy, and serious postpartum depression. California recently extended Medicaid benefits postpartum, while a handful of other states have extended benefits for specific postpartum intervention. Yet we know that > 50% of maternal deaths happen during the postpartum period.
Second, hospital and birth facilities must promote and strengthen maternal care protocols that work. Many hospitals have processes in place to address maternal hemorrhage and hypertension or preeclampsia, which are among the most common and deadly complications that occur among pregnant and postpartum women. Yet there are few mechanisms in place at these hospitals to ensure compliance.
Beginning next summer, the Joint Commission will require hospitals to meet 13 new “elements of performance” related to maternal health as part of its accreditation requirements. These requirements will help to provide teeth for enforcement, as hospitals that are unable to comply risk losing their accreditation. It’s a shame that fear of enforcement may force more hospitals to comply with protocols that are in place but not consistently followed, but that apprehension may save lives.
We also need to rethink the structures in which we deliver care. Traditionally, maternal care has happened in siloes, with women going to care facilities based on where their obstetrician has admitting privileges rather than which facilities are most appropriate for their risk level.
The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine recently updated their joint consensus document to provide guidance for how health systems can collaborate to provide regional, risk-appropriate care using a Levels of Maternal Care (LOMC) designation. The document ensures that women are provided the right care at an appropriately staffed and prepared health facility. A growing number of states are adopting and requiring the LOMC designation, including Georgia, Indiana, Iowa, and Texas, to encourage better coordination of care. Imagine how many complications could have been prevented if high-risk women were assigned to hospitals that were appropriately staffed (including obstetric staff onsite 24/7), and how many will be prevented when hospitals with high LOMC designations make these changes?
And finally, we need to reimagine the care team as 1 that both supports and supplements the role of the clinician. Labor and delivery can happen at any time, yet appropriate staffing levels are not always in place to accommodate this. The use of alternative care models can help with managing both physician burnout and improving care outcomes for patients.
For example, obstetrics hospitalists are being used more and more by hospitals to augment the role of community obstetricians and in-house staff. These hospitalists provide immediate, on-site availability in the case of an emergency, care for unassigned patients, and can manage the labor and delivery process on behalf of the community physician or until their arrival.
The use of a hospitalist can also help ensure standardized care is available, which has been shown to improve outcome, as well as help ease the burden of on-call obligations. Administrators should also recognize that not every patient presenting at the hospital requires an obstetrician. Maternal care should incorporate greater use of certified nurse midwives (CNMs), who can help obstetricians by providing skilled, efficient, compassionate care across the pregnancy spectrum, including in the Labor and Delivery suite.
While national efforts are underway, it will be up to healthcare providers on the ground level to ensure that these new regulations and recommendations are implemented and rolled out as intended. As we kick off 2020, it’s time for us as health practitioners and administrators to take a close look at our own models of care and make a resolution to ensure our patients are receiving the very best care available in the new year before us, and far beyond.
Mark Simon, MD, Chief Medical Officer at Ob Hospitalist Group (OBHG), is a board-certified OB/GYN and former head of the Department of Obstetrics and Gynecology for a U.S. hospital. The presented analysis reflects his views, not necessarily those of the publication.
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