Advancing Maternal Health
Equity and Reducing Maternal
Morbidity and Mortality
PROCEEDINGS OF A WORKSHOP
Joe Alper, Rose Marie Martinez, and Kelly McHugh, Rapporteurs
Board on Population Health and Public Health Practice
Health and Medicine Division
THE NATIONAL ACADEMIES PRESS
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by the March of Dimes, Merck & Co., Ronald McDonald House Charities Global, and the National Academy of Medicine. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-09354-5
International Standard Book Number-10: 0-309-09354-6
Digital Object Identifier: https://doi.org/10.17226/26307
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Copyright 2021 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Advancing maternal health equity and reducing maternal morbidity and mortality: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/26307.
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PLANNING COMMITTEE FOR A WORKSHOP ON ADVANCING MATERNAL HEALTH EQUITY AND REDUCING MATERNAL MORTALITY1
CLAIRE BRINDIS (Chair), Distinguished Emerita Professor of Pediatrics and Health Policy and Emerita Director, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, School of Medicine
ELENA FUENTES-AFFLICK, Professor and Vice Chair of Pediatrics and Vice Dean for Academic Affairs, University of California, San Francisco, School of Medicine, and Chief of Pediatrics, Zuckerberg San Francisco General Hospital
MELISSA A. SIMON, George H. Gardner, MD, Professor of Clinical Gynecology, Vice Chair of Research in the Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, and Founder and Director, Center for Health Equity Transformation
BROWNSYNE TUCKER EDMONDS, Assistant Dean for Faculty Affairs, Professional Development, and Diversity, and Associate Professor of Obstetrics and Gynecology and Pediatrics, Indiana University School of Medicine
ROSE MARIE MARTINEZ, Study Director and Senior Board Director, Board on Population Health and Public Health Practice
KELLY McHUGH, Research Associate
Y. CRYSTI PARK, Administrative Assistant
JOE ALPER, Consulting Writer
1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
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This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by MAXINE HAYES, University of Washington School of Medicine and School of Public Health. She was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.
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The National Academies of Sciences, Engineering, and Medicine’s Board on Population Health and Public Health Practice wishes to express its sincere gratitude to planning committee chair Claire Brindis for her valuable contributions to the development and orchestration of this workshop. The board also wishes to thank the other members of the planning committee—Elena Fuentes-Afflick, Melissa Simon, and Brownsyne Tucker Edmonds—for collaborating to ensure a workshop complete with informative presentations and rich discussions. Finally, the board would like to thank the speakers and moderators, who generously shared their expertise and their time with workshop participants.
Support from the many annual sponsors of the Board on Population Health and Public Health Practice is critical to the board’s work. The sponsors include the March of Dimes, Merck & Co., Ronald McDonald House Charities Global, and the National Academy of Medicine.
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Organization of the Proceedings
EXPLORING THE ROOT CAUSES OF POOR MATERNAL HEALTH OUTCOMES FOR BLACK AND INDIGENOUS PEOPLE
The Forces That Shape Inequities in Maternal Health Outcomes
Strategies to Reimagine and Disrupt the Root Causes of Poor Maternal Health Outcomes
Indigenous Reproductive Justice
EXAMINING THE BURDEN OF MATERNAL MORBIDITY AND MORTALITY
Factors Contributing to Maternal Morbidity and Mortality
The Burden of Maternal Morbidity and Mortality Among American Indian and Alaska Natives
BIRTHING EXPERIENCES IN CARE SETTINGS
Prioritizing Patient Narratives and Community Wisdom in Quality Improvement and Implementation Science
Centering Lived Experience and Expertise: Health Equity and Measurement
Maternal Mortality and Medical Misogynoir
Birthing Experiences in Care Settings: Pregnant People Experiencing Incarceration
MATERNAL HEALTH AND COVID-19: EXACERBATING VULNERABILITIES AND USE OF TECHNOLOGY
Maternal Morbidity with COVID-19 in Pregnancy and the PRIORITY Study
Maternal Health Inequities: Lessons Learned (and Re-Learned) from the COVID-19 Pandemic
Disconnects and Digital Divides: Black Women and Birthing People’s Maternal Telehealth Experiences During the COVID-19 Pandemic
MATERNAL HEALTH ISSUES RELATED TO THE FOURTH TRIMESTER
Establishing the Fourth Trimester
Post-Birth Warning Signs and Exploring Concepts of Implicit Bias Among Obstetric Nurses
Perinatal Mental Health: The Role of the Fourth Trimester
Improving Maternal Mental Health Outcomes for Women of Color
STATE EFFORTS TO REDESIGN MATERNAL HEALTH CARE
North Carolina’s Pregnancy Medical Home
Support Community-Based Doula Organizations Working Toward Bridging Racial Inequities in Maternal Mortality Rates
Perinatal Quality Collaboratives
IMPLEMENTATION OF STATEWIDE POLICIES AND MANDATES TO ADVANCE MATERNAL HEALTH EQUITY
Birthing People and Newborns Affected by Opioids: Universal Screening for Opiate Use Disorder with a Validated Tool Strategy
Building Capacity to Address Maternal Health Equity
California’s Dignity in Pregnancy and Childbirth Act and Maternal Health Policy
PROMISING STRATEGIES USING A REPRODUCTIVE WELL-BEING APPROACH TO ADVANCE MATERNAL HEALTH
Reproductive Justice Influence in Community Health: Midwifery Model in a Federally Qualified Health Center Birth Center
The Role Community-Designed Programs Play in Reducing Infant and Maternal Mortality for Indigenous Communities
Promising Strategies Using a Reproductive Well-Being Approach to Advance Maternal Health
FEDERAL POLICY APPROACHES TO ADDRESS MATERNAL HEALTH AND MATERNAL MORBIDITY
The Federal Policy Landscape for Black Maternal Health
Maternal Health Advocacy Efforts
RESEARCH AND FUNDING NEEDS TO INCREASE KNOWLEDGE GENERATION AND IMPROVE MATERNAL HEALTH OUTCOMES
National Institutes of Health–Supported Maternal Mortality Research and Opportunities
Increasing and Sustaining Investment in Research to Optimize Health and Outcomes
Funding Priorities at the Robert Wood Johnson Foundation
Discussion and Concluding Remarks
APPENDIX B: Biographical Sketches of Workshop Speakers, Moderators, and Planning Committee Members
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Box, Figures, and Tables
1 The many factors of the root causes of health inequities
2 Maternal mortality data, 2018 and 2019
3 Causes of pregnancy-related deaths between 1987 and 2013
4 Cause-specific, pregnancy-related mortality, by race/ethnicity, 2007–2016
5 Leading cause of pregnancy deaths from MMRC data
6 The state of maternal health care in the United States relative to other high-income countries
7 Participant responses to the question of whether they received various supports they needed and if they received help getting them from their physician or midwife
9 A structural framework for understanding how structural and systemic inequity produces inequitable health outcomes for Black birthing people
11 Incarcerated pregnant people in a 12-month period, 2016–2017
12 COVID-19 has a prolonged course of symptoms in 25 percent of pregnant patients
13 Black people as a share of COVID-19 vaccinations, cases, deaths, and total population, May 24, 2021
14 Large majorities of both Black and white seniors are eager to get vaccinated
15 Medicaid eligibility is much more restrictive for parents than pregnant women, particularly in states that have not expanded Medicaid
16 The factors influencing maternal health in the year following birth
17 North Carolina’s birth hospitals and urban and rural counties, 2019
18 Percentage of births born weighing less than 5 pounds 8 ounces, by state, 2019
19 The North Carolina Pregnancy Medical Home provider network
20 Entry to care rates in the first trimester among non-emergency Medicaid, Pregnancy Medical Home–attributed pregnancy
21 Rate of unintended pregnancy based on the initial risk screening among non-emergency Medicaid, Pregnancy Medical Home–attributed pregnancy
22 ImpactabilityTM score for pregnant people for a patient-centered task
23 Medication for opioid use disorder works to decrease overdoses in pregnant and postpartum patients
24 Challenges impacting maternal health outcomes and inequities in the District of Columbia
25 The percentage of U.S. births attended by certified nurse-midwives
26 Pregnancy-related mortality by race and Hispanic origin, 2014–2017
27 Leading causes of pregnancy-related mortality, 2014–2017
28 An expansive model reflecting the gaps, opportunities, and interconnectedness of issues along the research continuum
1 Maternal Outcomes for Pregnant Women Who Develop COVID-19
2 Perinatal Outcomes for Pregnant Women Who Develop COVID-19
3 Risk Factors for Severe COVID-19 Illness
Acronyms and Abbreviations
|ACA||Patient Protection and Affordable Care Act|
|ACOG||American College of Obstetricians and Gynecologists|
|AWHONN||Association of Women’s Health, Obstetric and Neonatal Nurses|
|CDC||Centers for Disease Control and Prevention|
|CMS||Centers for Medicare & Medicaid Services|
|FQHC||federally qualified health center|
|HHS||Department of Health and Human Services|
|ICU||intensive care unit|
|IHS||Indian Health Service|
|IMI||Institute for Medicaid Innovation|
|MADM||Mother’s Autonomy in Decision Making|
|MMRC||Maternal Mortality Review Committee|
|MMRIA||Maternal Mortality Review Information Application|
|MORi||Mothers on Respect Index|
|MOUD||medication for opioid use disorder|
|NASDOH||National Alliance to Impact the Social Determinants of Health|
|NBEC||National Birth Equity Collaborative|
|NCHS||National Center for Health Statistics|
|NICHD||National Institute of Child Health and Human Development|
|NICU||neonatal intensive care unit|
|NIH||National Institutes of Health|
|NVSS||National Vital Statistics System|
|OUD||opioid use disorder|
|PHQ-9||Patient Health Questionnaire-9|
|PMSS||Pregnancy Mortality Surveillance System|
|PQC||Perinatal Quality Collaborative|
|PREM-OB Scale||Patient-Reported Experience Measure of Obstetric RacismTM|
|PRIORITY||Pregnancy Coronavirus Outcomes Registry|
|PRMR||pregnancy-related mortality ratio|
|RWJF||Robert Wood Johnson Foundation|
|SDOH||social determinants of health|
|SWHR||Society for Women’s Health Research|
|USPSTF||United States Preventive Services Task Force|
|V-QPAC||Virtual Quality Improvement Prioritization by Affected Communities|
|WHO||World Health Organization|