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How the US maternal mortality crisis is rooted in inequality (and 4 ways to combat it)

August 14, 2019

    The United States is the only industrialized nation where the maternal mortality rate is increasing. Black and Native patients are four times more likely to die from pregnancy-related complications compared to white patients. Transgender men report discrimination and insufficient care when pregnant. And 60% of these deaths are preventable. Researchers directly attribute these worsening trends to a few factors—insufficient access to care, miseducation on the warning signs of complications, and missed or delayed diagnoses.

    Download the slides: Health Equity 101

    Moreover, the underlying root causes of access and quality errors are structural inequities and deprioritized maternal care. For example, significant research and the American College of Obstetricians and Gynecologists acknowledge that implicit provider bias can result in under-treatment and exacerbate access challenges in Black communities. Further, care and coverage are primarily designed to ensure positive fetal outcomes, rather than maternal outcomes. For some communities with severe infant mortality rates, maternal mortality rates are even worse. Maternal care and Medicaid coverage often drops off post-delivery, despite the fact that one-third of deaths occur in the "fourth trimester," or the first three months after delivery.

    How to address inequities undermining maternal care

    This complex problem requires collaborative solutions. Here are four ways to get started:

    1. Bolster Maternal Mortality Review Committees to identify underlying root causes of preventable deaths. Although such committees aren't a new concept, its popularity has waned in recent years. These committees collect provider input to add nuance to mortality data that may often be limited in scope (e.g., missing information on social needs, behavioral health challenges, implicit bias).

    2. Implement in-depth training for care teams to improve communication skills, build patient trust, and mitigate implicit bias. Implicit bias training helps staff identify any unknown biases that can result in differential treatment of patients. Staff also need to cultivate communication and relationship-building skills to effectively work with patients from different backgrounds. Such training can include ongoing sessions on cultural proficiency, listening, and patient engagement basics, like shared decision making.

    3. Partner with community organizations to expand the care team with roles that foster relationship building. Midwives are an effective and lower-cost option for supporting patients from pregnancy through birth. Midwifery services can be offered across settings (e.g., in the hospital or in the patient's home) to improve comfort and access to care. Pregnancy-specific community health workers, advocates, or navigators offer high-touch support to meet non-clinical needs, support healthy behaviors, and increase access to care. These community-based staff are skilled in trust and relationship building. Doulas offer continuous education and affirmation to patients throughout their pregnancies to improve health knowledge and support self-management techniques.

    4. Form a community-wide, multi-stakeholder collaborative to improve maternal care quality and outcomes. According to CDC, on average, three to four different factors contribute to an individual maternal death. Combating multiple factors requires champions to address challenges across providers (e.g., poor access to care, low care quality), communities (e.g., gaps in social services) and patients (distrust of the health system, limited health literacy) are addressed. To plan for comprehensive solutions, providers must partner with health plans, the local government, and community-based organizations.

    Are you using these principles at your organization? We'd love to learn more! Reach out to Darby Sullivan at to share your efforts.


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