A Shared Mission and a Team Approach: A Prescription for Rewriting the History of Black Maternal Health in America |

Ms. S, a 33-year-old black woman living in Philadelphia, had an uncomplicated pregnancy until she was 38 weeks old. It was then that, during a visit to the practice, we learned that she was suffering from high blood pressure for the first time. Given the progress of her pregnancy and the risks of this new disease, we recommended inducing her labour. Her labor and the birth of her baby went well, but immediately after delivery she started bleeding profusely – she had a postpartum hemorrhage. A hemorrhage cart, carrying all the drugs and tools needed to respond, was rushed into the room. A coordinated and rapid response from our team got her bleeding under control, and she was safely sent home with her baby, while being enrolled in a remote blood pressure monitoring program to watch for any dangers that may arise even after returning home.

Sadly, this story is all too familiar to our county’s birthing hospitals. There is a crisis in maternal health care in the United States. Not only is the maternal mortality rate in the United States higher than that of any other industrialized country, but black women continue to die from pregnancy-related causes at alarming rates. The black-white mortality gap in pregnancy-related deaths has persisted for decades, with black women dying at rates three to four times higher than white women. For every maternal death, more than 100 women experience a serious complication during or shortly after pregnancy, and these events are much more likely to occur in black women. But that doesn’t have to be the case: the majority of maternal deaths are preventable.

While continuing nationwide efforts to improve maternal morbidity and mortality and working to eliminate disparities are essential, a specific focus on health care delivery is essential. We need to make changes that deliver care to patients when and where they need it – in hospital rooms, outpatient clinics, and even in their homes.

Mrs. S’s story is not unique, and it highlights the need for a coordinated team to recognize and respond to the most common postpartum complications. A hemorrhage like hers is one of the leading causes of maternal death. Additionally, pregnancy-related high blood pressure is one of the leading causes of illness among new moms, even after they return home.

Changes in healthcare have led to increased consolidation, with the formation of multi-hospital systems – 67% of US hospitals are now affiliated with a healthcare system in some way. The same model applied throughout our region. These organizational changes provide a unique opportunity to use a “systems” approach to address maternal morbidity and mortality and to embed equity into quality improvement efforts across multiple hospitals. This allows for a “learning lab” where we can quickly measure whether our efforts are working, and successes can be accelerated to help more women. In order to capitalize on this opportunity, health systems – large and small, urban, suburban or rural – must set expectations for a collaborative approach with a clear and common goal.

In 2020, our healthcare system – which spans a wide geographic footprint, including five hospitals that provide obstetric care and assist 20,000 births annually in Philadelphia and surrounding Pennsylvania and New Jersey – has set itself a bold goal that places women’s health as a central pillar of system success. This included a measurable, system-wide goal to reduce maternal morbidity and mortality among Black women, who account for 28% of the nearly 20,000 deliveries in our hospitals each year. The purpose of the framework was to create a “system,” a system-wide shared goal, to enable faster dissemination of best practices to reduce severe maternal mortality among black women much faster than any individual hospital could not do it alone.

This system-wide setup created a team culture that allowed each hospital to share best practices and learn from other proven approaches that they may not have yet implemented. Previously, for example, patients pregnant with twins who had large uterine fibroids might not have been identified as high risk for postpartum hemorrhage in a hospital in our system, but would have been identified as such in a another hospital. Together, we’ve standardized our approach with a bleeding risk assessment tool that ensures patients like this are identified as high risk across all of our hospitals and receive the right care in every location.

In addition to standardizing our methods for being prepared, recognizing and responding to patients with postpartum hemorrhage, we also shared research on strategies to reduce rates of cesarean delivery and birth complications in order to stimulate discussions on other interventions that may have an impact on maternal morbidity and mortality. For example, we made changes to the care of patients with anemia during pregnancy and standardized the processes used to induce labor to reduce cesarean delivery and other complications. And we’ve extended our care through text messaging and remote monitoring to monitor dangerous conditions that can arise even after patients return from the hospital. This text-based follow-up after pregnancy-related high blood pressure is the standard of care across our system.

The focus on equity is at the heart of all this work. We launched implicit bias training to eradicate discrimination that can impact patient care, conducted staff and provider surveys, conducted an education and awareness campaign, and invited guest speakers to expand our prospects. Above all, we have developed a dashboard to regularly monitor and communicate our progress to all members of the care teams.

In our first year, these efforts resulted in a 30% reduction in maternal morbidity and mortality among Black women system-wide, compared to the previous year. We have now expanded our efforts to focus on improving outcomes for all pregnant patients of color. We know that this work is a journey, that each year we will encounter new challenges, and even setbacks, which will remind us of the urgency and necessity of our work to overcome the sustained perils of giving birth as a black woman in America. . .

A patchwork of advocacy, good intentions, pilot programs and even new laws are not enough to reverse what has become a shameful part of American health care. We can make a difference through a deliberate, system-wide approach and quality improvement efforts that put equity first. Behind all of this, we must deploy a fundamental and unwavering commitment to breaking the cycle that too often costs the lives of black women while those of their children are just beginning.

Sindhu K. Srinivas, MD, MSCE, is the Physician Lead, Women’s Health Service Line and Maternal Fetal Medicine Clinician at Penn Medicine. Elizabeth A. Howell, MD, MPP, is chair of the Department of Obstetrics and Gynecology at Penn Medicine. Kevin B. Mahoney is the CEO of the University of Pennsylvania Health System.

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