10 minute read
Rethinking Maternal Health Outcomes – Opportunities to Thrive
Kecia L. Ellick, PhD Research Scientist, The MayaTech Corporation
Introduction
Maternal mortality rates in the United States remain alarmingly high compared to other countries. In 2021, the U.S. maternal mortality rate was 32.9 deaths per 100,000 births rising from 23.8 in 2020 and 20.1 in 2019 (Hoyert, 2023). The significant racial and ethnic disparities reflected in these rates are well known. In 2020, Black women were more than two and a half times more likely to die from pregnancyrelated causes than White women (CDC, 2022) In fact, Black women are more likely to experience a pregnancy-related death in the U.S. than in any other developed country. American Indian/Alaska Native and Hispanic women are also at increased risk of pregnancy-related death compared to White women. These persistent disparities underscore the urgent need for interventions to address the root causes of inequities in maternal health outcomes. These rates are indicative of the significant impact of social determinants of health on maternal outcomes.
The disproportionate impact on communities of color underscores the systemic racism and structural inequities that perpetuate health disparities. Racial and ethnic minorities often experience barriers to accessing quality maternal health care, such as inadequate insurance coverage, geographic isolation, and lack of transportation (Kozhimannil et al., 2019). Additionally, issues such as poverty, inadequate housing, and food insecurity are strongly associated with poor maternal outcomes, highlighting the need for comprehensive interventions that address these social determinants of health that contribute to poor maternal health outcomes (Metz et al., 2017). These disparities must be addressed through culturally responsive care and interventions that are tailored to meet the unique needs of vulnerable populations, including people of color and lowincome people.
Although barriers to accessing quality maternal health care disproportionately impact women of color, it is important to note that even among people with access to quality care, significant racial disparities in maternal mortality persist. Furthermore, Black women with high levels of education and income had a higher risk of maternal death compared to their White counterparts with lower levels of education and income. For example, Creanga et al. (2018) found that Black women with college degrees were more likely to experience a pregnancy-related death than White women without a high school diploma.
Other studies have similarly reported that Black women with access to high-quality care experience higher rates of pregnancy-related complications, such as pre-eclampsia and preterm birth, compared to White women (Cavanaugh, 2021). These findings highlight the impact of systemic racism and structural inequities on maternal health outcomes, which can persist even in the absence of traditional barriers to accessing care. Comprehensive and multifaceted interventions that address both the social determinants of health and the systemic racism that perpetuate them are required in order to effectively improve maternal health outcomes.
Equity Birth Plans
One effective approach to improving maternal outcomes is the implementation of birth plans among all pregnant individuals. Birth plans are written plans that communicate a person's preferences and goals for labor, delivery, and postpartum care to their birthing team. Birth plans have been shown to increase patient satisfaction, improve patientcentered care, and lower rates of medical interventions during childbirth (Jennings et al., 2018). Equity birth plans (EBPs) utilize a health equity model to address social determinants of health that can impact maternal and infant health. Utilizing the socio-ecological model (Armstrong et al., 2007) as its framework, equity birth plans center the individual in the consideration of integrated patient-related and systems-related risks to achieve safe and equitable birth outcomes (Tyre et al., 2022). Such considerations include individual patient experiences, fears, and concerns, and access to clinical, familial, and community support resources (Tyre et al., 2022).
Equity birth plans are culturally responsive and have demonstrated the efficacy of birth plans in improving maternal and infant health outcomes among people of color. Howell et al. (2020) reported that the implementation of birth plans in hospital settings led to a significant reduction in preterm birth (from 13.8% to 9.9%), low birth weight (from 12.6% to 7.7%), and infant mortality (from 2.6% to 1.9%) among Black women. Kozhimannil et al. (2016) found that birth plans that included doula support and group prenatal care were associated with a 41% reduction in preterm birth and a 33% reduction in low birth weight among women of color. Moreover, equity birth plans that address the unique needs of Black people and other birthing people of color have been proposed as a promising approach to reducing racial and social inequities in maternal and infant health outcomes (Tyre et al., 2022).
Out-of-Hospital Births
As a component of their birth plans, a growing number of pregnant people are opting for alternative birth settings as another strategy to improve their birthing experiences and overall maternal health outcomes. Advocates for out-ofhospital births argue that these options can provide a more personalized and culturally responsive birth experience, as well as greater autonomy and control for the birthing person. In 2019, out-of-hospital births accounted for 1.61% of all births in the United States; a slight increase from 2018, when out-of-hospital births accounted for 1.5% of all births (Martin et al., 2021). Of the 64,504 out-of-hospital births that occurred in 2019, 35,426 occurred at home and 29,078 occurred in free-standing birth centers.
difficult to access out-of-hospital birth options (Tilden et al., 2014).
Despite these barriers, efforts are underway to increase access. As of 2021, several states have Medicaid programs that cover doula services, including Oregon, Minnesota, and New York (The National Partnership for Women & Families, 2021). These programs provide reimbursement for doula services, which can help to make these services more affordable for low-income women. Additionally, some nonprofit organizations and community groups are providing free or low-cost doula services to women in need (Hudson, 2018). In addition to doula coverage, some state Medicaid programs also cover midwifery services; Medicaid coverage of midwifery care has been associated with lower rates of preterm birth and cesarean delivery (Kozhimannil et al., 2014). In Oregon, Medicaid covers licensed midwives who provide care to pregnant women and attend home births (Oregon Health Authority, 2020). In New York, Medicaid covers midwifery services provided by certified nursemidwives (New York State Department of Health, n.d.).
Out-of-hospital birth can play a particularly important role in improving birth outcomes. Although the majority of these alternative settings have been experienced by non-Hispanic Whites, there is growing interest and demand for out-ofhospital birth options, particularly among women of color and those with a history of traumatic birth experiences or medical interventions (Pascali-Bonaro & Anderson, 2021). Planned home births attended by certified professional midwives are associated with good outcomes for Black women, including low rates of interventions and high rates of vaginal birth after cesarean (VBAC) and breastfeeding initiation and continuation (Cheyney et al., 2014). Black women who planned to deliver at home or in a birthing center with a midwife had lower rates of preterm birth and low birth weight compared to Black women who planned to deliver in a hospital with a midwife or physician (Grünebaum et al., 2017).
Despite their positive influence on maternal outcomes, access to midwifery care remains limited for vulnerable populations in the United States. (Stapleton et al., 2018; Kozhimannil et al., 2016; Kozhimannil et al., 2019). Midwife shortages exist in many parts of the country, and where available, midwives may not be licensed to practice or attend births (Groppe & Zuppa, 2019). Doulas, who provide emotional, physical, and informational support to pregnant women during labor and delivery, are also less accessible for some – people of lower socioeconomic status (SES) and people of color are less likely to have access to doula care compared to their counterparts with higher SES (Kozhimannil et al., 2016). This is due, in part, to the cost of doula services, which can be prohibitive for some families In addition, most insurers do not cover doula care Similarly, out-of-hospital birth options, such as home birth or birth center births, are less accessible to people of lower SES and people of color. This can be due to a lack of insurance coverage for out-ofhospital births, or limited options for out-of-hospital births in certain regions. Some pregnant people may also face barriers related to transportation or childcare, which can make it
Other efforts include increasing the number of midwives in underserved areas, providing education and information about midwifery care to women and healthcare providers, and promoting the use of midwifery care in healthcare policies and guidelines (Bingham et al., 2018; Snow et al., 2017). It is critical to prioritize the implementation of birth plans in a way that is equitable and accessible to all pregnant/birthing people, regardless of race, ethnicity, or socioeconomic status. While there is evidence supporting the effectiveness of developing and implementing EBPs, which may include the use of a doula or midwife, and/or the consideration of out-of-hospital birth settings, these interventions are less likely to be promoted among people of lower SES, people of color, or people who are of higher risk.
Role of Community-Based Organizations (CBOs)
Community-based programs can play an essential role in improving maternal health outcomes, particularly for pregnant people who experience social and economic disadvantage, by supporting the development of birth plans, promoting out-of-hospital births, and advocating for policy and systemic changes to improve access to equitable perinatal care and support. CBOs work to address the social determinants of health that impact maternal and infant health outcomes and improve access to healthcare, education, and other resources.
CBOs can support the development of birth plans by providing education and resources that empower pregnant people to make informed decisions about their care. A community-based program in Hawaii that provided group prenatal care and individualized support improved birth outcomes and increased maternal satisfaction with care. The program promoted the development of birth plans and empowered participants to make informed decisions about their care (Hsieh et al., 2020). A community-based, free standing birth center in Minnesota (Hardeman et al., 2020) utilized a culturally-centered model of pregnancy and postpartum care people to address the disparities in birth outcomes experienced in their community, resulting in zero preterm births experienced among the 284 families that participated in their programs.
CBOs can also play a role in promoting out-of-hospital births as a viable option for pregnant people. Holzman et al. (2020) found that a community-based program that provided group prenatal care and education increased the likelihood of planning an out-of-hospital birth among participants. The program also provided support and resources for those who chose to have an out-of-hospital birth, which contributed to positive birth outcomes.
CBOs can also advocate for effective policies that support pregnant people. The National Perinatal Association's Community-Based Doula Program works to improve access to doula care for low-income and marginalized communities, advocating for policies that support doula care and providing resources and training for doulas. The program has been shown to improve birth outcomes and increase maternal satisfaction with care (Nommsen-Rivers et al., 2021).
Policy Implications and the Federal Response
State Medicaid programs can impact access to perinatal care by covering non-OB providers and staff, such as certified nurse-midwives, doulas, and community health workers. The Oregon Medicaid program covers doulas as part of its maternity care package, resulting in reduced rates of preterm birth and cesarean section (Ward et al., 2019). Similarly, the Medicaid program in New York City provides reimbursement for community-based doula services, resulting in improved maternal and infant health outcomes among low-income women of color (Ickovics et al., 2020).
Public policies can also impact maternal health outcomes by addressing systemic issues such as racism, poverty, and lack of access to care. The Black Maternal Health Momnibus Act of 2021 is an example of federal legislation aimed at addressing racial disparities in maternal health outcomes by providing funding for various programs and initiatives, including maternal mental health services, perinatal quality collaboratives, and implicit bias training for healthcare professionals (Ely, 2021).
There are, however, concerns about the safety of out-ofhospital births. While planned out-of-hospital births were associated with lower rates of interventions such as cesarean section and epidural anesthesia, they also had a slightly higher risk of perinatal mortality and neonatal seizures compared to hospital births (Grünebaum et al., 2017). In addition to concerns about safety, there have been cases of criminal prosecution of families who experience complications during out-of-hospital births, particularly in cases where the family did not seek timely medical attention or did not disclose their plans for a home birth to their healthcare provider (Lavender, 2020). Funding from the Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC) can support workforce development and research on strategies to improve maternal health outcomes. HRSA provides funding for nurse-midwifery education programs and the National Health Service Corps, which places primary care providers in underserved areas (CRS, 2021). CDC funds the Pregnancy Risk Assessment Monitoring System (PRAMS), which collects data on maternal behaviors and experiences before, during, and after pregnancy to inform public health interventions and policies. By investing in research and workforce development, policymakers can improve access to care and support evidence-based practices that promote maternal health equity.
Summary
Efforts to improve maternal health and birth outcomes must address systemic issues such as racism and lack of access to quality care. Equity birth plans and out-of-hospital births are promising strategies for promoting maternal health equity and reducing disparities in birth outcomes, particularly among Black women and other women of color. By addressing social determinants of health and promoting patient-centered care, these strategies can improve access to high-quality care, increase patient satisfaction, and reduce the risk of adverse maternal and neonatal outcomes.
However, there is still a lack of awareness and education about the benefits and risks of out-of-hospital births, particularly among socially and economically disadvantaged populations. Public policy makers and public and private partners are increasing messaging, education, and awareness about birth setting options to ensure that individuals have the knowledge and resources to make informed decisions about their care. Funding for community-based organizations and programs that prioritize equity in maternal health can also help address these issues and improve outcomes for all communities.
As researchers, clinicians, and public health professionals, we have a collective responsibility to promote maternal health equity and ensure that all individuals have access to safe, high-quality care. We must continue to advocate for policies and programs that prioritize equity in maternal health, and work towards increasing messaging, education, and awareness about birth setting options, particularly among marginalized populations, if they are to thrive!
As a long-standing stakeholder in helping to advance U.S. public health outcomes, The MayaTech Corporation is deeply committed to our nation’s health – with a keen eye on addressing social determinants of health (SDOH) and reducing systemic barriers that result in health disparities and inequities. Tackling the coming weeks, months, and years will require dynamic partnerships among all sectors to ensure that Federal public health initiatives are effective, efficient, and reach the communities most in need.
The MayaTech Corporation addresses existing and emerging public health challenges through direct engagement with agencies, governments, foundations, institutions of higher education, the private sector, communities, and individuals. We provide a portfolio of research, training, evaluation, capacity-building, and other strategic support services - all aimed at reaching and impacting the most vulnerable populations, amplifying best practices, and innovating the practice of public health.
MayaTech's recent work has included support of Federal agencies and their grantees for stakeholder-engaged projects aimed at: identifying barriers to HPV vaccination in rural communities; advancing racial equity and researcher diversity in artificial intelligence and machine learning to reduce health disparities; evaluation of research infrastructure capacity at HBCUs to address maternal and child health, HIV/AIDS, and cancer disparities; and building workforce capacity among underrepresented minority researchers, health providers, and trainees.
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