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Proceedings of a Workshop
Pages 1-166

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From page 1...
... In addition, severe maternal morbidity, which includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a birthing person's3 health (Kilpatrick and Ecker, 2016) ,4 has been steadily increasing in recent years (Ahn et al., 2020)
From page 2...
... Recognizing the urgency of this growing problem, the National Academy of Medicine Council expressed great interest in addressing this issue, and as a result, the Board on Population Health and Public Health Practice convened a 1.5-day virtual workshop, Advancing Maternal Health Equity and Reducing Maternal Mortality, to examine the current state of maternal health in the United States and explore the factors needed to enable communities and health care systems to be more effective in reducing maternal morbidity and mortality and in improving outcomes for pregnant people through the fourth trimester. The Statement of Task for the workshop, held June 7–8, 2021, is presented in Box 1.
From page 3...
... ; • the factors shaping maternal health and outcomes, includ ing social determinants, and the role early life events play in shaping health trajectories, and access to and the safety and quality of maternal health care; • current promising evidence-informed practices for improv ing maternal health and reducing maternal mortality from selected states/health systems (and discuss the potential to scale the approaches) ; • promising models and approaches that apply a life course approach to advance maternal health including the health of the child through the fourth trimester; and • research needs across the life course to improve outcomes for mother and child including preconception through the fourth trimester.
From page 4...
... She explained that her organization, NBEC, operates from the perspective that "all Black mamas, babies, and their villages thrive" by supporting the well-being of all birthing people and those with capacity for birthing.7 The core values of the organization start with what she called radical joy, and include leadership, freedom, wellness, Black lives, and sisterhood, with a particular emphasis on utilizing collective power to end the inequities that Dzau described in his opening remarks, which affect Black birthing people. "We are going to use our collective power to push for all people being able to thrive in the future," said Crear-Perry.
From page 5...
... It also requires putting assurances in place that include both "capital P" policies, such as Medicaid expansion, and "little p" policies, such as those that ensure birthing people have the flexibility to see their physicians on the weekends or at night, because they may have hourly jobs without paid leave. These policies are critical to achieving birth equity, she explained, because they address the conditions that cause health inequities and create the conditions that will enable all birthing people or people with the capacity for birthing, and not just those who have wealth,9 to do more than just survive pregnancy -- it will allow them to have an amazing experience and thrive.
From page 6...
... To address that, public health and health care systems are providing birthing people with ride-share vouchers, which Crear-Perry regards as a positive step. "But if we really want to undo the root causes, we would acknowledge the history of redlining, acknowledge the history of neighborhood covenants, and we would understand that segregation was by law," she said, and it was because of this 10 For more information, see https://www.who.int/health-topics/social-determinants-of-health (accessed August 17, 2021)
From page 7...
... ? Crear-Perry noted that when she first learned that Black birthing people were dying at three to four times the rate of their white counterparts, or at 8 to 12 times the rate of their white counterparts in New York City (Boyd et al., 2010)
From page 8...
... . In fact, obese women of all races had better birth outcomes than Black women with normal weight, and Black women who initiated prenatal care in the first trimester still had higher rates of infant mortality than nonHispanic white women.
From page 9...
... She emphasized the importance of health care providers stepping up to mitigate and address both implicit and explicit biases.11 She added that to address maternal mortality, it is paramount that "care originates from, and is defined by, Black women led organizations, practitioners, and community members." To get an idea of what it would look like to have respectful maternal care in the United States, NBEC staff interviewed Black birthing people across the country for their ideas. Birthing people want accountability, empathy, and safety, which requires undoing the racism that devalues them.
From page 10...
... With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care." See https://nursing.vanderbilt.edu/news/ florence-nightingale-pledge (accessed August 19, 2021)
From page 11...
... With that idea as the foundation for her remarks, McLemore went on to list what she views as the three root causes of poor health outcomes for birthing people of color: mistreatment and disrespectful care, reproductive injustice, and a lack of diversity in the health care workforce. She noted that in 2019, she wrote a piece for Scientific American titled "To Prevent Women from Dying in Childbirth, First Stop Blaming Them."13 In that article, she summarized existing knowledge about the root causes for maternal morbidity and mortality in the United States and carefully explained that many of these deaths were preventable, with symptom surveillance, early symptom recognition, and reporting being critical components of prevention.
From page 12...
... For example, Crear-Perry says that research has shown that the burden of maternal morbidity and mortality is greater among Black birthing people, regardless of routine prenatal care, socioeconomic status, education, insurance types, and rates of preexisting clinical conditions. In addition, data from a recent study that examined the dual burden of severe maternal morbidity and preterm birth show that these combined clinical experiences have the potential to disrupt maternal role attainment, lactation and breastfeeding, the transition of families, and postpartum mental health (Lyndon et al., 2021)
From page 13...
... Meanwhile, 93 percent of licensed nurses or certified midwives are women but only 34 percent of physicians are women, and while there are more Black women physicians than men -- 54.7 percent compared to 45.3 percent -- in all other racial and ethnic groups there are more men physicians than women physicians (AAMC, 2017; Sullivan Commission on Diversity in the Healthcare Workforce, 2004)
From page 14...
... . She also highlighted the need for partnership across the spectrum of disciplines who serve birthing people and pregnant-capable people.
From page 15...
... that is often inaccessible for reasons of geography or financial considerations, and that is frequently staffed by non-Indigenous individuals who lack cultural comprehension or cultural compassion. Farrell said that, in fact, Indigenous birthing people, more than of any other race, report the highest level of mistreatment, another cause of maternal health outcomes.
From page 16...
... Indian Health Service when it comes to providing reproductive health care and abortion care." Farrell proposed a few practical solutions to this problem. First would be to support the traditional or professional midwife in this country as an autonomous provider.
From page 17...
... Measuring Maternal Mortality Presented by Rear Admiral (retired) Wanda Barfield, Centers for Disease Control and Prevention "Because maternal mortality is a multifactorial problem, we need to think about robust and more detailed data to better understand and prevent these deaths," said Wanda Barfield.
From page 18...
... A third data source is the Maternal Mortality Review Information Application (MMRIA)
From page 19...
... The birthing people who die during pregnancy or their postpartum period are just the tip of the iceberg, however. "We know that there are many women, about 50,000, who suffer from severe complications of pregnancy each year, and even more have chronic conditions during pregnancy that give us a window to their future health," said Barfield.
From page 20...
... . "We need to consider these differences in equitable efforts to reduce maternal mortality," said Barfield.
From page 21...
... SOURCES: Workshop presentation by Barfield on June 7, 2021; Petersen et al., 2019.
From page 22...
... . The data also show that pregnant people with COVID-19 have an increased risk for adverse pregnancy outcomes such as preterm birth (Galang et al., 2020)
From page 23...
... Factors Contributing to Maternal Morbidity and Mortality Presented by Laurie Zephyrin, The Commonwealth Fund Until around 1998, said Laurie Zephyrin, maternal mortality had been gradually decreasing, before beginning to rise again. During the decades when maternal mortality fell and as birthing people started to experience healthier living conditions and better maternity services, there was a great deal of focus on improving surgical procedures and access to antibiotics, as well as an additional focus on improving maternity services within hospitals.
From page 24...
... As Barfield explained, maternal mortality falls into three buckets: during pregnancy, around the time of delivery, and up to 1 year after giving birth, with the latter bucket accounting for a little more than half of maternal mortality. These data show the critical importance of, when thinking about interventions, not just focusing on the delivery or birthing aspects or prenatal aspects, but continuing to focus help through the first year after giving birth.
From page 25...
... 25 SOURCES: Workshop presentation by Zephyrin on June 7, 2021; Tikkanen et al., 2020.
From page 26...
... "We cannot separate maternal mortality and morbidity from the systems in which they arise." Also important, said Zephyrin, is the need to address unequal treatment that women and birthing people of color receive and their unequal experiences in the health system, such as the disrespect they endure and the lack of autonomy they are granted over their care. In short, addressing unequal outcomes in morbidity and mortality requires addressing this unequal treatment and unequal experiences.
From page 27...
... The Burden of Maternal Morbidity and Mortality Among American Indian and Alaska Natives Presented by Abigail Echo-Hawk, Seattle Indian Health Board and Urban Indian Health Institute After noting that Native people have been storytellers for many generations, and that it is part of their scientific methodology, Abigail Echo-Hawk started her presentation with a story about an 18-year-old woman who found herself pregnant in a large city. Having never been outside of the IHS system 18 Group prenatal care models are those in which individuals receive both standard, individual prenatal care from a health provider, and also attend group sessions with other pregnant patients in which a health care provider facilitates discussions on relevant prenatal health topics (Zephyrin et al., 2021)
From page 28...
... As a result of this outwardly racist visit, this young woman did not return to receive prenatal care until she was well into the second trimester of her pregnancy. This is not an unusual story, said Echo-Hawk; 28 percent of American Indians and Alaska Natives in urban areas typically do not initiate prenatal care until the second trimester, which research has shown increases the risk of both infant and maternal death.
From page 29...
... In addition, American Indian and Alaska Native people cannot access many other systems that would help to address the SDOH. Her team has collected data on maternal mortality in urban areas where there are IHS facilities and found that at a national level, American Indian and Alaska Native birthing people were 4.2 times more likely to die than nonHispanic whites as a result of pregnancy-related complications.
From page 30...
... "Until we address inwardly the research and science field and the research enterprise, we will not make the changes we are attempting to do," she said, "because I will publish every single inflammatory paper I possibly can if it saves one more woman like Stephanie Snook." Discussion The first question for the panel came from an audience member, who asked Barfield if the data on maternal mortality also include statistics on abortion morbidity and mortality. The answer, said Barfield, is yes, the data include deaths occurring during any condition related to pregnancy.
From page 31...
... She noted that this is especially important in light of the fact that the majority of deaths are occurring in the later postpartum period. BIRTHING EXPERIENCES IN CARE SETTINGS The workshop's third session featured four presentations on the experiences that birthing people have in care settings and how those experiences contribute to maternal health outcomes.
From page 32...
... , hospitals do not keep Black birthing people safe. Rather, a hospital's primary drivers, she said, include a lack of ethical boundaries, the perpetuation of white leadership, and a hierarchy of knowledge construction that is grounded in anti-Black and misogynistic ideologies and practices.
From page 33...
... "Thus, we also argue that the perinatal quality improvement epistemology reproduces misogynistic misconceptions about Blackness, Black womanhood, and Black people that undermine our humanity and justice." The SACRED Birth study, Scott explained, applies Black feminist anthropological theories and methodologies to make an "unapologetic and fierce" declaration of two truths of resistance: (1) "the lives of Black women and people with the capacity for reproduction and pregnancy-related experiences are worthy," and (2)
From page 34...
... As of the date of this workshop, the SACRED Birth study had validated this instrument through field testing among more than 800 Black mothers and birthing people during the COVID-19 pandemic. Together with Black women–led community-based organizations, SACRED Birth developed a "community-centered, people-focused, hospital-based quality improvement toolkit." The next priority, Scott said, is examining the association between the PREM-OB ScaleTM, COVID-19 pandemic hospital responses, and birth outcomes and experiences.
From page 35...
... As part of this effort, SACRED Birth developed the Virtual Quality Improvement Prioritization by Affected Communities or V-QPAC protocol. V-QPAC applies Black feminist ethnographic methodology to identify and describe different forms of resistance and resilience that Black women and community leaders adopt in order to mitigate obstetric racism and power inequities that emerge from supporting Black mothers and birthing people during hospital births.
From page 36...
... While the survey questions used the terms Native American and Alaska Natives, the results listed those individuals as Indigenous. Half of those in the sample gave birth in hospitals, with the other half giving birth in birth and home centers.
From page 37...
... Nulliparous participants -- birthing people or the people who have the capacity for birthing who had never given birth to a child or who may have lost a child -- were 1.4 times as likely to seek postpartum mental health support. When asked how important is was for them to lead decision making, 91 percent of the participants said it was very important, whereas only 1 percent felt it was not important.
From page 38...
... • My doctor or midwife told me that there are different options for my maternity care. • My doctor or midwife explained the advantages/disadvantages of the maternity care options.
From page 39...
... . Vedam noted that WHO has found that birthing people or people with the capacity for birthing in marginalized communities globally, among low- and middle-income countries, experience similar rates of mistreatment (see Figure 8)
From page 40...
... Among respondents from the southeast United States, the odds of any mistreatment, low autonomy, or low respect were higher among Black birthing people and birthing people from other communities of color. Irrespective of participant race, midwifery care in community birth settings was protective against mistreatment, low autonomy, and low respect, compared to giving birth in the hospital.
From page 41...
... " Maternal Mortality and Medical Misogynoir23 Presented by Brownsyne Tucker Edmonds, Indiana University School of Medicine To open her presentation, Brownsyne Tucker Edmonds reiterated that the United States is one of the most dangerous industrialized nations to give birth in. For Black birthing people, who experience three to four times the rate of maternal mortality compared to white birthing people, the risk of dying in or after pregnancy rivals that of low-income or developing nations.
From page 42...
... 42 FIGURE 9  A structural framework for understanding how structural and systemic inequity produces inequitable health outcomes for Black birthing people. SOURCES: Workshop presentation by Tucker Edmonds on June 7, 2021; from Geronimus et al., 2020.
From page 43...
... In 1662, Virginia adopted the legal doctrine of Partus Sequitar Ventrum, which stipulated that the enslavement status of the child would follow that of the mother, making enslavement an inheritable status. Once Black children were legally born into slavery, Black childbearing became central to the enterprise of slavery, and society came to monetize, commodify, and exploit Black women's labor on three fronts: their physical labor, their reproductive labor, and their emotional labor, explained Tucker Edmonds.
From page 44...
... This results in a greater number of social work consultations, and referrals by providers to child protective services and the criminal legal system. Medical misogynoir also manifests in the challenging of the validity of Black birthing people's pain complaints, which result in inadequate pain management during and after delivery.
From page 45...
... The development of patient-centered models of care will need to integrate frameworks for trauma-informed care and reproductive justice into the manner in which the health care system delivers reproductive health care across the life course. Within the realm of obstetrics, this will require integrating medical and midwifery models of care to ensure that Black birthing people are afforded the full spectrum of supports they need.
From page 46...
... SOURCES: Workshop presentation by Sufrin on June 7, 2021; adapted from The Sentencing Project, 2020; Bureau of Justice Statistics: Historical Corrections Statistics in the United States 1850–1984 (1986) ; Prison and Jail Inmates at Midyear Series (1997–2018)
From page 47...
... She echoed Abigail Echo-Hawk's suggestion that multiyear aggregation of data should be done. She then turned her attention to the care that birthing people receive while incarcerated.
From page 48...
... 48 ADVANCING MATERNAL HEALTH EQUITY FIGURE 11  Incarcerated pregnant people in a 12-month period, 2016–2017. SOURCES: Workshop presentation by Sufrin on June 7, 2021; originally posted to https://arrwip.org (accessed August 18, 2021)
From page 49...
... With no mandatory standardization of care and no system of accountability or oversight, the care provided in prisons and jails is highly variable and inconsistent, said Sufrin. In fact, 12 states have no prenatal care policy for incarcerated birthing people (Daniel, 2019)
From page 50...
... . Incarcerated birthing people who give birth in a hospital cannot have visitors in most cases, and they may be shackled during labor, said Sufrin.
From page 51...
... MATERNAL HEALTH AND COVID-19: EXACERBATING VULNERABILITIES AND USE OF TECHNOLOGY The workshop's fourth session discussed the experiences of birthing people during the unprecedented period of COVID-19, and the experience with technology to provide and receive services. The three speakers in this session were Stephanie Gaw (University of California, San Francisco)
From page 52...
... There was also a 17 percent increase in preterm birth for pregnant people (6 percent of which were spontaneous) , versus for birthing people without COVID-19.
From page 53...
... NOTE: CI = confidence interval; NICU = newborn intensive care unit; OR = odds ratio. SOURCES: Workshop presentation by Gaw on June 8, 2021; Allotey et al., 2020.
From page 54...
... reproductive health equity and birth justice, and (4) biospecimen collection results.
From page 55...
... In closing, Gaw listed some of the forthcoming data that the project will release on maternal and neonatal outcomes, including neurodevelopment sequelae in the infants. One member of the research team is heading a side project, PRIORITY-VOICE, in which she interviewed 40 birthing people to explore their perceptions of and experiences with engaging in maternity care.
From page 56...
... id=70408044 (accessed August 14, 2021)
From page 57...
... Adding to the disparities, the comorbid conditions that are risk factors for severe COVID-19 illness are differentially distributed in the United States as a result of long-standing inequities in access and quality care, a result of structural racism. In obstetrics, as other speakers have noted, these concerns overlay the backdrop of the maternal morbidity and mortality crisis in the United States, particularly for Black birthing people.
From page 58...
... They also examined what their data systems were collecting and reporting and how they could make best use of that to serve the communities in greatest need. Thinking about community health and issues of reproductive justice were particularly important to her department of obstetrics and gynecology.
From page 59...
... However, Bryant said that her institution did not always meet the metric of having patient-centric maternity care, particularly at the height of the pandemic. She credited the work of the Massachusetts COVID-19 Maternal Equity Coalition for elevating the voices of birthing people who gave birth during the pandemic.
From page 60...
... • Conducting social media campaigns • Increasing awareness that the vaccine is available at no cost • Clarifying that the vaccine can be given regardless of immigration status • Publicly reporting vaccination data by race/ethnicity 31 The complete data set, updated regularly, is available at https://www.kff.org/coronaviruscovid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity (accessed August 14, 2021)
From page 61...
... FIGURE 13  Black people as a share of COVID-19 vaccinations, cases, deaths, and total population, May 24, 2021. SOURCES: Workshop presentation by Bryant on June 7, 2021; https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19vaccinations-race-ethnicity (accessed August 14, 2021)
From page 62...
... . Disconnects and Digital Divides: Black Women and Birthing People's Maternal Telehealth Experiences During the COVID-19 Pandemic32 Presented by Nia Mitchell, National Birth Equity Collaborative In the panel's final presentation, Nia Mitchell discussed the results of a study that she, Ayanna Robinson, and Isabel Morgan conducted on telehealth during the COVID-19 pandemic.
From page 63...
... The listening sessions also produced several recommendations to improve care provided to Black women and birthing people that fell into three categories: quality of care, decision making, and education. Discussion To start the discussion, Melissa Simon, posing a question from the audience, asked the speakers if any of the research they conducted or knew of unpacked or disaggregated Arab, Asian, Native Hawaiian, and Pacific Islander identity groups, given the socioeconomic and other inequities that exist among these ethnoracial subpopulations.
From page 64...
... The challenge in breaking down huge demographic categories is having a large enough population to get representative samples for small subpopulations of people. Another audience member commented that Black birthing people in the United Kingdom, where midwifery is standard, have worse outcomes when compared to Black birthing people in the United States, and noted that the midwifery workforce in the United States is also less diverse than that of the United Kingdom; the audience member asked the panelists, many of whom recommended the expansion of midwifery in the United States as a solution, to comment on these assertions.
From page 65...
... However, while human evolution has created a dependence on the village, modern life has stripped the village away from newborn care. As Stuebe said, "if a mama and baby are alone, or even if there is a mama, a support person, and a baby, that is not enough to help women and their babies recover during this time period and help birthing people to thrive." Steube said she wanted to frame the discussion around the question of what is needed as a culture and society to create an environment where infants and birthing people can thrive.
From page 66...
... "That was 46 years ago, and I would argue that we still have a lot of work to do to really create an environment where birthing people and infants can thrive," said Stuebe. In addition to those maternal mental health experiences, the fourth trimester is a critical time for survival: more than half of pregnancy-related maternal deaths occur after delivery.
From page 67...
... "When we think about who the women are who do not have access to paid leave, they are those in the lowest income brackets and those with the least accumulated wealth." She suggested that this might be yet another consequence of racist redlining that prevented the grandparents of birthing people of color from being able to buy a home in the 1930s; in turn, this prevented wealth from being passed down across generations, ultimately resulting in a birthing person today being unable to take unpaid leave. "When we think about the kinds of policies we need to consider to truly achieve health equity, we need universal paid parental leave so that one's income and one's life history do not determine whether or not
From page 68...
... SOURCES: Workshop presentation by Stuebe on June 7, 2021; Artiga et al., 2019.
From page 69...
... Toward that end, the Fourth Trimester Project at her institution has established two websites: newmomhealth.com and saludmadre.com, in order to provide honest, accurate, clear, and high-quality health information based on the latest science. These websites, she said, reflect and value the fact that birthing people are resilient, strong, and capable of making quality decisions for themselves and their families.
From page 70...
... Regarding reproductive justice, she echoed the organization SisterSong's call to action to ensure that every individual has the "human right to maintain personal bodily autonomy, to have children or not, and to parent those children in safe and sustainable communities;"33 she states that it should be ensured that society protects and values every parent and every child. 33 See https://www.sistersong.net/reproductive-justice (accessed August 17, 2021)
From page 71...
... . While she noted that there are many oversights that contribute to these deaths for all mothers, for Black mothers and birthing people in particular, racism, discrimination, and distrust from medical providers contributes significantly to the deaths during the postpartum period.
From page 72...
... Comments about pain management 36 See https://www.awhonn.org/birthequity (accessed August 15, 2021)
From page 73...
... These comments came in the form of "dog whistling," which is coded language they used to describe their experience working with Black mothers versus others. Harris then provided what she characterized as the most profound and jarring quotes.
From page 74...
... Perinatal Mental Health: The Role of the Fourth Trimester Presented by Karen Tabb Dina, University of Illinois at Urbana-Champaign Perinatal mental health disorders are the leading cause of maternal morbidity and mortality in the first 12 months postpartum, said Karen Tabb Dina. In fact, up to 20 percent of birthing people will experience a perinatal mental health problem during or after the time of giving birth.
From page 75...
... There are also significant disparities in perinatal suicidality among Black and Asian birthing people after giving birth (Tabb et al., 2020)
From page 76...
... This, she explained, is a community-based organization's approach to improving maternal mental health outcomes for women of color,39 and shifting the culture around maternal mental health. Noting that her colleagues at the workshop had highlighted many of the troubling statistics around racial inequities already, she shared that one in four women of color will experience postpartum depression, compared to one in seven white women.
From page 77...
... They created what she calls a "nontraditional approach" to addressing postpartum depression in women of color. She highlights that it comes from the community.
From page 78...
... By decreasing the stigma associated with maternal mental health challenges, the I.N.S.P.I.R.E. method normalized getting help in the fourth trimester and helped the participants understand that having a mental health issue postpartum has no bearing on who they are or who they hope to be.
From page 79...
... method is brilliant and hoped that the next step will be to figure out what its essential ingredients are so that it can be used for people in other contexts. Tabb Dina commented that in this discussion, she saw many of the themes of the day running together: unlearning and "decolonizing" our minds, providing respectful care, focusing on listening, and centering community and patients.
From page 80...
... Tabb Dina replied that collaborative care works and that one consultation center can help an entire state, and saves cost at the same time. Simon, who serves on the task force, stressed that USPSTF's decision to issue a recommendation statement for collaborative care helped to push the growth of that framing; she noted that more such recommendations could be beneficial for accelerating responses to maternal health crises.
From page 81...
... In 2019, 35 percent of birthing people with Medicaid identified as non-Hispanic Black, 23 percent as
From page 82...
... . Over the same time spans, the maternal mortality rate among white birthing people increased from 9.2 deaths per 100,000 live births to 15.9 deaths per 100,000 live births (CDC, 2020)
From page 83...
... The aims of this public–private partnership were to improve quality of care for pregnant Medicaid beneficiaries, improve birth outcomes, and reduce health care costs for the Medicaid population. A primary focus of the Pregnancy Medical Home program is to prevent preterm births, and there were two main strategies to addressing this: engaging maternity care providers serving the Medicaid population in quality-improvement efforts, and introducing community-based care management that targets those at greatest risk for preterm birth.
From page 84...
... As those needs arise, she noted, the clinical leadership collaborates to develop evidence-based clinical pathways, with supporting materials and resources for quality improvement. The topics that have arisen have included • hypertensive disorders of pregnancy • perinatal tobacco use • substance use in pregnancy • postpartum care and the transition to well woman or primary care for the birthing person • progesterone treatment and cervical length screening • obesity in pregnancy • reproductive life planning/postpartum contraception • multifetal gestation • COVID-19 care and resources In the Pregnancy Medical Home program, Medicaid beneficiaries receive a standardized risk assessment during their first prenatal visit.
From page 85...
... SOURCES: Workshop presentation by Menard on June 8, 2021; Community Care of North Carolina.
From page 86...
... She credits the work of the care managers who engage with birthing people to remove barriers to adherence to the postpartum visit, discuss the health benefits of birth spacing, review contraceptive choices, and inform patients of the availability of family planning services. All of these data can be stratified by race and ethnicity to identify meaningful differences in trends.
From page 87...
... FIGURE 20  Entry to care rates in the first trimester among non-emergency Medicaid, Pregnancy Medical Home–attributed pregnancy. SOURCES: Workshop presentation by Menard on June 8, 2021; Community Care of North Carolina.
From page 88...
... 88 FIGURE 21  Rate of unintended pregnancy based on the initial risk screening among non-emergency Medicaid, Pregnancy Medical Home–attributed pregnancy. SOURCES: Workshop presentation by Menard on June 8, 2021; Community Care of North Carolina.
From page 89...
... Implementing this system produced marked reductions in low-birthweight births in both Black and white high-risk groups that received five face-to-face encounters with a care manager, compared to those who did not receive the intervention. However, Menard noted that despite the intervention, Black birthing people still delivered low-birthweight infants at higher rates than white birthing people.
From page 90...
... • Data sharing and collaborative learning across the provider community can promote provider engagement and accountability in this work. • Practice support for program implementation and quality improvement can make a significant difference in the lives of birthing people.
From page 91...
... She added that in obstetrics, it is unusual to find effective infrastructure for broadscale quality improvement in the community and outpatient settings. She noted, too, that the leading cause of pregnancy-related death in Black birthing people is cardiovascular disease, which cannot be addressed by hospital-based quality-improvement efforts alone.
From page 92...
... To 41 For more information about New York A.364B, relating to the professional certification of doulas, see https://www.nysenate.gov/legislation/bills/2019/a364 (accessed August 18, 2021)
From page 93...
... She noted that many people in the community were unaware of these bills until their passage, despite the legislation's direct impact on community-based doulas and the families and communities they serve. Her organization has now started the #BeyondBirthWork campaign to support community-based doulas who go beyond the interpersonal relationships they develop to provide holistic, culturally relevant care to birthing people of color and low-income birthing people who would not otherwise be able to afford care.
From page 94...
... Rather, said Porchia-Albert, doula access is about helping birthing people have full autonomy in their human rights and their birthing experience. Doula access is about creating a cultural humility framework that lessens the power dynamics in the exam room, and understanding that episodes of care do not end at 6 weeks postpartum, and that pregnancy and postpartum are "forever." In terms of recommendations, Porchia-Albert said it is important to understand that community is a foundation for everything, and that people inform policy, not the other way around.
From page 95...
... Black birthing people, for example, deliver in different and lower-quality hospitals than do white birthing people, and the quality of care received during childbirth may differ by race and ethnicity even within individual hospitals. To address some of these hospital-based quality issues, PQCs have been working in states to specifically improve the quality of care provided to mothers and their infants.
From page 96...
... Henderson noted that while many organizations, hospitals, and hospital systems may take on various quality-improvement initiatives and projects, PQCs have a unique role: They take on the responsibility of improving outcomes for the entire population of the region's birthing people and infants. As she explained, they understand the regional network of perinatal care, can collaborate among teams from both the hospital and in the community, and can compare the performance of hospitals that are operating within similar contexts in terms of demographics, socioeconomics, and health services availability.
From page 97...
... PQCs in Alabama, Illinois, and New York are also engaging in initiatives that specifically target inequities and improve outcomes for communities of 43 See https://www.nichq.org/project/national-network-perinatal-quality-collaboratives (accessed August 17, 2021)
From page 98...
... "There are many opportunities for expanding this work, and I hope that by facilitating these types of partnerships and advocating to support these networks, states will help create the infrastructure and the capacity that lead to improvements in perinatal care and outcomes," said Henderson. IMPLEMENTATION OF STATEWIDE POLICIES AND MANDATES TO ADVANCE MATERNAL HEALTH EQUITY The next session of the workshop featured three presentations that provided further examples of the type of work that Henderson spoke about in the previous session.
From page 99...
... With that, she turned to the focus of her work in Illinois, which is addressing substance use disorders in birthing people and their newborns, which affects maternal morbidity and mortality. She began her presentation with a description of the Illinois PQC, which started in 2013.
From page 100...
... Illinois began its initiative to help birthing people and newborns affected by OUD in May 2018, with 107 participating hospitals. The initiative focuses on identifying pregnant individuals who have an OUD and connecting at least 70 percent of them to MOUD and recovery treatment services.
From page 101...
... We talk over and over again that it's a life-threatening chronic disease with life-saving treatment available." If providers can identify patients early in pregnancy and link them to treatment, they can reduce maternal overdose deaths, improve pregnancy outcomes, and help more patients and babies stay together after birth. Optimal care for all pregnant and postpartum persons with OUD comes down to several elements, said Borders: Screen every patient for OUD with a validated screening tool, assess their readiness for MOUD, link them with MOUD and recovery treatment services, provide them with naloxone counseling, screen and prescribe for hepatitis C, complete a warm handoff for MOUD and recovery services, schedule a close obstetric follow-up with navigation help, provide patient education on OUD and neonatal abstinence syndrome, reduce stigma, and promote empathy across the clinical team.
From page 102...
... Lastly, Borders commented on the outcomes of the program's focus on lessening the treatment inequities between Black and white birthing people in their care settings. She noted that they decreased what had been significant disparities in rates of linkage to MOUD programs -- improvements were seen for all races, but the greatest improvements in linkages were found among Black patients.
From page 103...
... More than 65 percent of the state's births are covered by Medicaid, and Mississippi has the highest cesarean section rate in the country, at 38.5 percent of all live births, as well as the nation's highest preterm and infant mortality rate. The greatest disparities, said Collier, fall on Black birthing people.
From page 104...
... They asked whether the committee was using data sources that had been evaluated for racism and bias themselves, or that adequately included the perspective of pregnant and birthing people and their families. They also wondered about the makeup of the committee itself: Did it have representation and inclusivity in its committee members; did its members have any knowledge about health equity, the SDOH, and racism as underlying causes of Black maternal health inequities; were they aware of Black community strengths, solutions and scholarship?
From page 105...
... Collier said that a question about whether discrimination contributed to a death has also been added to the review process, and its scope has broadened to capture cases that might be considered to be pregnancy related, such as suicide, drug overdose, and most recently, homicide. She added that they had noticed a particularly large disparity in pregnancy-related homicides, with Black birthing people being the most impacted.
From page 106...
... However, she explains that "buried" in these positive trends are persistent inequities; there has been no reduction in the inequities Black women and birthing people are experiencing. Between 2011 and 2013, for example, the death rate for Black women was 26.4 per 100,000 live births, almost 3.8 times higher than that for white women, and in Los Angeles County it was 4.5 times higher for Black women compared to white women.
From page 107...
... Collier noted, too, that California has not published updated statewide data on maternal mortality since 2015 and does not have a codified MMRC, PQC, or any requirement codified in legislation to address racial inequities in maternal and infant outcomes. Moreover, California has an obstetrics/gynecology workforce shortage, particularly in parts of the state with large populations.
From page 108...
... As a result, 48 See https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml? bill_id=201920200SB464 (accessed August 17, 2021)
From page 109...
... She and her colleagues are now exploring ways to provide funding through the state budget process to incentivize smaller hospitals to provide the rigorous and robust training that the law's sponsors envisioned would occur. Going forward, Flint said that SB 464 is just the beginning of addressing maternal mortality and morbidity in California.
From page 110...
... Henderson said she would like to see accountability extended to transparency with data and collecting data stratified by race, ethnicity, and other demographic factors so that birthing people can make informed choices as to where they want to go to give birth. She also stressed the importance of including the patient voice in the process of both developing programs and disseminating them.
From page 111...
... As an example, she noted that there are only a few obstetric and gynecology programs that offer exposure to midwifery training and vice versa. A significant facilitator of collaboration, then, would be to provide additional exposure during training to different members of the maternity care team.
From page 112...
... Borders agreed and noted that, as part of the Birth Equity Initiative, the Illinois PQC is going to help hospital teams provide patients with a QR code, an image they can scan with their phones, before delivery discharge that will send them a patient experience survey. This survey will assess whether the patient was listened to and received respectful care during labor and delivery.
From page 113...
... Nedhari said, This is a framework that helps us acknowledge that the methods and com pensatory behaviors that Black birthing people use for survival in a system of racism and white supremacy deserve understanding, curiosity, and grace, not judgment or repackaged respectability narratives to appease those who say, "I support Black women" except only in certain cases or only for certain Black women. She noted that her organization focuses not only on Black women, but also on all Black birthing people regardless of gender identity.
From page 114...
... Nonetheless, the program was able to maintain the zero maternal mortality rate that it has maintained since it started. Other statistics Nedhari cited from 2020 include 91 percent of the birthing people they served achieved a full-term delivery, 90 percent initiated breastfeeding, and 80 percent of its clients gave birth to a baby of healthy birthweight.
From page 115...
... "We are shifting the dynamics of community engagement toward community ownership," said Nedhari. In that respect, she said, Mamatoto has always been a conduit of resources that amplifies the voices of Black women and their families to be witnessed, funded, and elevated as subject-matter experts of the lived experience at the intersection of multiple oppression identities and the change agents who identify and evaluate the implementation of justice and are community solutions.
From page 116...
... conducted interviews with women in the regions of the city that have some of the worst birth outcomes. DCPCA found that these birthing people, most of whom were Black, reported not being listened to by their providers and not having great experiences overall with their providers (Russell et al., 2018)
From page 117...
... Women No high risk ob No hospital east reporting poor services east of of river experiences at river all hosptials STILL HAVE A LONG, A Food deserts High rates of Police brutality homelessness concerns LONG, A LONG WAY TO GO Unresolved and unaddressed COVID…… trauma FIGURE 24  Challenges impacting maternal health outcomes and inequities in the District of Columbia. SOURCE: Workshop presentation by Marcelle on June 8, 2021.
From page 118...
... "I think that has been one big pill to swallow for different individual systems and organizations, but it is true," she said. Marcelle also contended that there are many punitive elements in the current maternal health system which prevent the creation of a space in which birthing people feel they are safe.
From page 119...
... This community-designed, culturally responsive, full-spectrum Indigenous doula program arose out of the need to address the disproportionately high maternal mortality rates of Indigenous people in King County, Washington, and throughout the Puget Sound area. She noted that Native American, Alaska Native, and American Indian pregnant people have the highest maternal mortality rate in Washington State, where they die at almost 11 times the rate of white parents and about four times the rate of Black birthing people.
From page 120...
... Another doula is supporting a family through an ectopic pregnancy, and they offer abortion support. Goldhammer said that all of her organization's clients have to identify as Native American, Alaska Native, First Nations, Pacific Islander, or Native Hawaiian.
From page 121...
... She saw the need for such an organization when she herself went through the process to become an Internationally Board-Certified Lactation Consultant. During 2 years of training, she felt that she learned from white mentors how to serve white birthing people well, which did not align with her career goals, as she planned to serve the Indigenous community.
From page 122...
... They used a socioeconomic framework and chose to focus on the Black population, birthing people with previous negative birth outcomes, and populations living in poverty. "We wanted to make sure we did understand our community context, especially as we address systematic racism, as we speak about systemic racism, and address racial equity and racial inequalities that exist in our community," said Lubwama.
From page 123...
... Lubwama felt that this indicated that the community saw the YWCA as "an agency that understands racial justice and creates an environment in which people feel safe and valued." FEDERAL POLICY APPROACHES TO ADDRESS MATERNAL HEALTH AND MATERNAL MORBIDITY The workshop's penultimate session switched gears from promising state and local interventions to policies that are being considered and implemented at the federal level, and how they can contribute to advancing maternal health equity. The session's three speakers were Jamila Taylor (The Century Foundation)
From page 124...
... , as well as lack of empathy and respect for Black birthing people. In order to address maternal health outcomes, Taylor emphasized that solutions must be rooted in social justice and seek to address these inequitable power dynamics.
From page 125...
... The COVID-19 Safe Birthing Act would ensure that pregnant and birthing people could have a doula or other support person and a loved one in all health care settings. It would also expand access to maternal telehealth services for Medicaid beneficiaries, extend Medicaid and Children's Health Insurance Program coverage to 1 year postpartum, and ensure access to free testing, treatment, and vaccination for all pregnant and birthing people, regardless of their insurance status.
From page 126...
... • Ensure proper implementation of, beyond just passage of, laws and policies that center the health and social needs of Black women and birthing people. • Invest in antiracism training -- for both explicit and implicit bias -- for health care providers.
From page 127...
... (Aspen Health Strategy Group, 2021) Because Medicaid policies are determined at the state level, there is a great deal of variation in the experience of birthing people by state.
From page 128...
... Despite the overwhelming evidence demonstrating improved outcomes and lower cost, the midwifery-led model of care is underutilized in the United States. The ratio of midwives to obstetricians in the United States is 0.34, compared to 8.19 to 1 in Australia, 8.27 to 1 in the United Kingdom, and 3.46 to 1 in The Netherlands, with significantly lower maternal mortality rates in those three countries (Kennedy et al., 2020)
From page 129...
... SOURCES: Workshop presentation by Moore on June 8, 2021; IMI, 2020; Moore et al., 2020.
From page 130...
... : 1. The ability of other developed countries to have lower maternal mortality rates demonstrates that better outcomes are achievable.
From page 131...
... Going forward, she said, it is imperative that every Medicaid stakeholder conduct a self-assessment to identify their individual role before they can establish an action plan to support the collective effort to advance high-value, evidence-based perinatal models of care to serve all birthing people. For each stakeholder, Moore pointed to the need to look broadly outside of individual space, to identify opportunities and challenges, and to elevate the identified facilitators and mitigate barriers to achieve birth equity.
From page 132...
... "Each of us knows that change is not easy," she said. "It will take every Medicaid stakeholder to address birth equity for the Medicaid program." She also pointed out that, as the nation considers how to tackle alarming maternal mortality rates, the obvious option is to choose solutions that are already known to be innovative and cost effective.
From page 133...
... It is also important, said Godbolt, to understand that disparities in maternal and infant health outcomes are manifestations of racism, which is their root cause. For example, as Moore just shared, Black birthing people are more likely than white birthing people to live in maternity care deserts and as a result have difficulty accessing comprehensive reproductive health care services (March of Dimes, 2020)
From page 134...
... NBEC believes that the federal government should support health care transformation efforts that include health equity as an explicit goal, that are grounded in the needs of communities of color, and that seek to provide care that is equitable, trauma informed, reflective of the health care needs of communities of color, and include a fully integrated reproductive health care agenda. The federal government should also prohibit laws, policies, and practices that cause preventable inequalities in health outcomes, regardless of their intent.
From page 135...
... She noted that 15 organizations received funds from the project to enhance the telehealth infrastructure for maternal health services provided by doulas, nurse midwives, and childbirth education services to Black birthing people across the country and U.S. territories.
From page 136...
... She noted that there is broad cross-sector support for the development of this office, including support in both chambers of Congress and more than 150 different organizations that represent the maternal and child health field and the reproductive justice movement. If established, the Office of Sexual and Reproductive Health would develop a national sexual and reproductive health strategy that would include a framework for integrating sexual and reproductive health equity into federal processes.
From page 137...
... Godbolt agreed, pointing to the many studies that demonstrate that having a provider that looks like their patients does improve outcomes, particularly 58 Additional information is available at https://maternityneighborhood.com (accessed August 15, 2021)
From page 138...
... RESEARCH AND FUNDING NEEDS TO INCREASE KNOWLEDGE GENERATION AND IMPROVE MATERNAL HEALTH OUTCOMES The workshop's final session focused on looking forward, to how to advance the area of maternal health equity. Specifically, it focused on how research and funding mechanisms might help to develop a deeper understanding of the issue and achieve the desired outcomes that the workshop's presentations and discussions had highlighted.
From page 139...
... FIGURE 26  Pregnancy-related mortality by race and Hispanic origin, 2014–2017. SOURCES: Workshop presentation by Chinn on June 8, 2021; https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality 139 surveillance-system.htm#trends (accessed August 15, 2021)
From page 140...
... As other speakers throughout the workshop had noted, Chinn said that access to quality care is critically important for reducing maternal mortality and morbidity. Data from New York City show that birthing people from racial and ethnic minority groups give birth in hospitals with lower overall quality and higher rates of severe maternal morbidity (Howell and Zeitlin, 2017; Howell et al., 2020)
From page 141...
... FIGURE 27  Leading causes of pregnancy-related mortality, 2014–2017. SOURCES: Workshop presentation by Chinn on June 8, 2021; https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality 141 surveillance-system.htm#trends (accessed August 15, 2021)
From page 142...
... Meanwhile, the Implementing a Maternal Health and Pregnancy Outcomes Vision for Everyone initiative is funding research through NICHD and other NIH institutes aimed at reducing preventable causes of maternal death and improving health for birthing people before, during, and after delivery. A critical goal of this initiative, said Chinn, is to resolve health disparities and attain equity in maternal health.
From page 143...
... Increasing and Sustaining Investment in Research to Optimize Health and Outcomes Presented by Kathryn Schubert, Society for Women's Health Research To start her presentation, Kathryn Schubert explained that SWHR was founded more than 30 years ago to address the lack of inclusion in research of women. Today, SWHR promotes research on biological sex differences and women's health through science, policy, and education.62 She noted that, ultimately, research is one part of the puzzle to addressing maternal mortality and morbidity and the inequities that birthing people of color experience; a combination of coverage, access, cultural, and societal support will need to accompany research.
From page 144...
... It will improve outcomes for a woman's life across the lifespan," she said. "It will also inform maternal health prior to pregnancy." What is needed, she said, is increased and sustained investment in research to optimize health and outcomes for both mother and child, as well as basic, translational, clinical, and public health services and policy research, along 63 See https://orwh.od.nih.gov/about/mission-history (accessed August 17, 2021)
From page 145...
... She reiterated that these are rooted in systemic and structural racism and perpetuate conditions where birthing people, particularly birthing people of color, lack access to quality, affordable, culturally appropriate, respectful, and relevant care. The foundation does not have a specific strategy that focuses on maternal health at this time; however, in recent years it has initiated discussions with grantees, field experts, and other funders in order to gain insights about the role of maternal health and well-being in achieving an overall "culture of health," which is a foundation priority.
From page 146...
... The foundation, along with many other funders, is also supporting a nationwide study of the impact of COVID-19 during and after pregnancy. The study is looking at a racially and ethnically diverse group of birthing people and their babies across a variety of practice settings in the United States.
From page 147...
... She also said in closing that the foundation is looking introspectively at interrogating its own funding practices to make sure that its programs are part of the solution and are not furthering inequities and disparities. Paradigm Shifts for Funders Presented by Tenesha Duncan, Tara Health Foundation In the workshop's final presentation, Tenesha Duncan started by restating the definition of birth equity developed by NBEC and by providing a definition for birth justice, which several speakers had mentioned during the course of the workshop.
From page 148...
... "Sovereignty and self-determination are the outcomes that we are seeking when we talk about pregnancy, birth, and health outcomes over the life course," she stated. As a funder, the Tara Health Foundation organization starts from the perspective of three paradigm shifts that acknowledge the role of racism, sexism, misogyny, white supremacy culture, and how those create challenges for people within those institutions that are trying to advance birth equity and justice.
From page 149...
... The foundation also supports quality improvement efforts that seek to measure and dismantle systemic and institutional racism in care; they do this by supporting quality improvement by building research that centers the experiences of Black people. The final area of emphasis is on building community birth infrastructure.
From page 150...
... Another project they funded developed the IRTH app, which allows birthing people to connect with each other to share their experiences in health care settings; it aims to empower them to choose where they birth, who their clinicians are, and to understand the hospital or clinical setting that they might enter. Together, these projects span a range of topics that are centered on birth equity, birth justice, and economic justice.
From page 151...
... . The next question asked the speakers to identify the biggest gaps and data needs in the field that need to be filled to advance equitable, high-quality care for all birthing people.
From page 152...
... Additional information is available at https:// www.fda.gov/science-research/science-and-research-special-topics/real-world-evidence (accessed August 15, 2021)
From page 153...
... Shaw added that advocates have a crucial and essential role to play in pushing an agenda for change. She asked, however, that advocates not only elevate the problems faced by birthing people, particularly those of color, but also elevate solutions and the assets these communities have.
From page 154...
... She then commented on how the discussions focused on how to begin capturing the wealth of knowledge that already exists. Yes, there are gaps, she said, but there is an opportunity to build on what is known and the challenge is to find different ways with partners, funders, advocates, and community members to leverage what is known to advance the cause of maternal health equity.
From page 155...
... 2020. Initiatives to reduce maternal mortality and severe maternal morbidity in the United States: A narrative review.
From page 156...
... New York: Bureau of Maternal, Infant and Reproductive Health, New York City Department of Health and Mental Hygiene. https://www1.nyc.gov/assets/doh/downloads/pdf/ms/pregnancy associated-mortality-report.pdf (accessed August 11, 2021)
From page 157...
... Maternal Mortality Review Committees, 2008–2017. Atlanta, GA: Centers for Disease Control and Prevention, Department of Health and Human Services.
From page 158...
... 2021. The cycle to respectful care: A qualitative approach to the creation of an actionable framework to address maternal outcome disparities.
From page 159...
... 2021. Maternal mortality rates in the United States, 2019.
From page 160...
... 2019. Changing the conversation: Applying a health equity framework to maternal mortality reviews.
From page 161...
... 2021. Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 2016‒2017.
From page 162...
... Health Equity 4(1)
From page 163...
... Health Equity 4(1)
From page 164...
... 2020. Maternal mortality and maternity care in the United States compared to 10 other developed countries.
From page 165...
... 2021. Community-based models to improve maternal health outcomes and promote health equity.


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