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Office of the Surgeon General (OSG). The Surgeon General’s Call to Action to Improve Maternal Health [Internet]. Washington (DC): US Department of Health and Human Services; 2020 Dec.
Given the importance of maternal health for our families, communities, and nation, addressing the unacceptable rates of maternal mortality and severe maternal morbidity calls for a comprehensive approach that addresses health from well before to well after pregnancy. A singular focus on the perinatal period would ignore upstream health factors associated with chronic conditions as well as other environmental and social factors that contribute to poor outcomes.3 HHS has laid the framework by providing recommendations for preventive services that promote optimal women’s health.79,80,81 The strategies and actions in this document are based on these recommendations as well as consensus statements and recommendations from other organizations. The following sections outline specific actions for addressing the conditions and risk factors outlined above as well as other factors that may impact maternal health. The opportunity for action exists across the spectrum of women and families; states, tribes, and local communities; healthcare professionals; healthcare systems, hospitals and birthing facilities; payors; employers; innovators, and researchers. Individuals, organizations and communities should select and implement actions as applicable to their needs. Regardless of organization or group, everyone can help to improve maternal health in the U.S.
EVERYONE CAN
- Recognize the need to address mental and physical health across the life course—starting with young girls and adolescents and extending through childbearing age.3
- Recognize and address factors that are associated with overall health and well-being, including those related to social determinants of health.22
- Acknowledge that maternal age and chronic conditions, such as hypertension, obesity, and diabetes are risk factors for poor maternal health outcomes (See prior sections “Differences in Maternal Mortality and Morbidity” and “Risks to Maternal Health”).
- Learn about early ‘warning signs’ of potential health issues (such as fever, frequent or severe headaches, or severe stomach pain, to name a few85) that can occur at any time during pregnancy or in the year after delivery.
WOMEN AND FAMILIES
Women can play a critical role in promoting, achieving, and maintaining their health and well-being, often with the support of fathers, partners, and other family members. Preventive health and wellness visits can provide women with screenings, risk factor assessment, support for family planning, immunizations, counseling, and education to promote optimal health.79 Women can engage in healthy practices, monitor their overall health, and address conditions they may have such as hypertension, diabetes and obesity. Many resources in the form of books, mobile applications, social media, and guides provide information about what to expect before, during and after pregnancy as well as information on important health behaviors, preventive care, medications, and potential risks.
Prenatal appointments provide the opportunity for healthcare professionals to monitor pregnancy, perform prenatal screening tests,85 discuss questions and concerns that women may have, including plans for delivery and infant feeding, and provide recommendations to promote a healthy pregnancy.86 A statewide study of all live births in Pennsylvania and Washington showed that starting prenatal appointments in the second trimester instead of the first, or attending fewer prenatal appointments, was associated with a higher risk of unhealthy behaviors and adverse outcomes, including low gestational weight gain, prenatal smoking, and pregnancy complications.87 Data also show disparities in initiating and/or receiving prenatal care, with non-Hispanic white (82.5 percent) and Asian women (81.8 percent) more likely to receive prenatal care in the first trimester than all other racial and ethnic groups, including Hispanic (72.7 percent), non-Hispanic black (67.1 percent), AI/AN (62.6 percent), and Native Hawaiian or Pacific Islander women (51.0 percent).17
Women should also be supported after delivery to reduce the risk of adverse maternal and infant outcomes. For example, breastfeeding has demonstrated benefits for infants and can also be beneficial to mothers, including decreased bleeding after delivery and reduced risks of hypertension, type 2 diabetes, breast and ovarian cancer.88 Black mothers are less likely to initiate breastfeeding than white or Hispanic mothers (74.0 percent versus 86.6 percent and 82.9 percent, respectively).89 These data suggest opportunities for understanding and addressing these disparities.
WOMEN AND FAMILIES CAN
FOCUS ON IMPROVING OVERALL HEALTH90
Try to engage in healthy behaviors and practices by participating in regular physical activity,84 eating healthy,91 getting adequate sleep,92,93 and getting ongoing preventive care that includes immunizations57 and dental care.94 Recognize that oral health is part of overall health and that pregnant mothers may be prone to gingivitis and cavities.95 Abstain from tobacco96 and other potentially harmful substances, including marijuana,97 prior to and during pregnancy. As there is no amount of alcohol known to be safe during pregnancy or while trying to become pregnant, women should consider stopping all alcohol use when planning to become pregnant.98 Follow medical advice for chronic health conditions such as diabetes and hypertension, learn family medical history, and adopt or maintain healthy lifestyles. Women who are planning or may become pregnant should take a daily folic acid supplement.99 For women who are entering pregnancy at a later age or with chronic diseases or disorders, learn how to minimize associated risks through ongoing preventive and appropriate prenatal care.
PROMOTE POSITIVE INVOLVEMENT OF MEN AS FATHERS/PARTNERS DURING PREGNANCY, CHILDBIRTH, AND AFTER DELIVERY
Promote men’s positive involvement as partners and fathers.100 Include men in decision-making to support the woman’s health, to the extent that it promotes and facilitates women’s choices and their autonomy in decision-making.101
ATTEND HEALTH CARE APPOINTMENTS79
Women should attend primary care, prenatal, postpartum, and any recommended specialty care visits and provide health information, including pregnancy history and complications, to their health care providers during all medical care visits, even in the years following delivery.101,102 Know health numbers, such as blood pressure and body weight, and record them at each visit. If recommended, continue to monitor and record blood pressure in-between visits.103 Those with diabetes should check and record your blood sugar regularly.104
COMMUNICATE WITH HEALTHCARE PROFESSIONALS
Ask questions and talk to healthcare professionals about health concerns, including any symptoms you experience, past health problems, or concerns about potentially sensitive issues, such as IPV and substance use.105 Be persistent or seek second opinions if a healthcare professional is not taking concerns seriously (See the Joint Commission “Speak Up” guide for ways patients can become active in their care106).
LEARN HOW TO IDENTIFY PHYSICAL AND MENTAL WARNING SIGNS DURING AND AFTER PREGNANCY
Utilize resources that provide information about the changes that occur with a healthy pregnancy and how to recognize the warning signs85 for complications that may need prompt medical attention. The CDC’s Hear Her campaign seeks to raise awareness of warning signs, empower women to speak up and raise concerns, and encourage their support systems and providers to engage with them in life-saving conversations.107 Learn to recognize the symptoms of postpartum depression such as feelings of sadness, anxiety, or despair, especially those that interfere with daily activities, and seek support.108
ENGAGE IN HEALTHY BEHAVIORS IN THE POSTPARTUM PERIOD
If electing to breastfeed, seek support as needed. Resources include healthcare providers, lactation consultants, lactation counselors, peer counselors, and others. Attend postpartum visits as they are the best way to assess physical, social, and psychological well-being and identify any new or unaddressed health issues that could affect future health.109 Continue engaging in healthy behaviors after pregnancy, such as managing chronic disease and living a healthy lifestyle.
STATES, TRIBES AND LOCAL COMMUNITIES
States, tribes, and local communities can create environments that are supportive of women’s health and tailored to local needs and challenges. They can create the infrastructure needed to engage in healthier lifestyles and to ensure access to high quality medical care.
Healthy People provides national goals to guide health promotion and disease prevention efforts in the U.S. and highlights the importance of creating social and physical environments that promote good health for all.22 Often referred to as social determinants of health, the conditions into which people are born, live, work, play, worship, and age can strongly influence their overall health.22 Examples of social determinants include access to educational opportunities, availability of resources to meet daily needs (e.g., healthy food options), public safety and exposure to crime.22 Examples of physical determinants include natural and built environments (e.g., green space, sidewalks, bike lanes), and housing and community design, and exposure to physical hazards.22 Case studies have demonstrated that health outcomes can be improved where there is a concerted and coordinated effort involving both healthcare systems and communities where their patients live.110,111,112
Perinatal regionalization or risk-appropriate care113 is a promising approach for improving maternal safety as it has been shown to be an effective strategy for improving neonatal outcomes,114 though more research is needed to assess its impact on maternal health outcomes. States can explore this approach as well as other strategies to increase access to quality care, such as the adoption of telemedicine, and the review of the scope of practice laws (what health care professionals are authorized to do), licensure and recruitment policies. Perinatal Quality Collaboratives (PQCs) are state or multi-state networks of multidisciplinary teams that work to improve maternal and infant outcomes by advancing evidence-informed clinical practice through quality improvement initiatives.115
States, tribes and local health agencies play a role in providing essential services to protect the health and promote the well-being of their communities through education, prevention, and treatment. They provide support for community-driven initiatives and evidence-based practices that address topics such as emerging infections (e.g., COVID-19), sexually transmitted infections, and immunizations. The role of public health is changing due to increased demands from chronic disease, new economic forces, and changing policy environment.116 The National Consortium for Public Health Workforce released a Call to Action addressing the need for strategic skills in the public health workforce to enable collaboration across sectors to address the social and economic factors that drive health.117
MMRCs
Multidisciplinary committees that perform comprehensive reviews of deaths among women during and within a year of the end of pregnancy
Surveillance data can help to monitor trends and focus efforts to reduce maternal morbidity and mortality. States, tribes, and communities have the opportunity to assess maternal deaths, injuries and illnesses and identify strategies for preventing these adverse outcomes. The Centers for Disease Control and Prevention (CDC) supports states in establishing MMRCs to perform comprehensive reviews of deaths among women during pregnancy or within a year after birth, obtain better data on the circumstances and root causes surrounding each death, and develop recommendations for the prevention of these deaths.117 However, MMRC reviews can lag by several years, and some states have not yet created MMRCs. Ensuring that MMRCs collect uniform data, such as through the Maternal Mortality Review Information Application (MMRIA),118 will provide comprehensive national data on maternal mortality and result in more timely and detailed reporting to inform prevention efforts.
Representative population-based data on pregnancy and disability are lacking.118 State health departments, researchers, and other stakeholders can work together to address gaps in surveillance and identify best practices for reducing health disparities, including among pregnant women with disabilities.
STATES, TRIBES, AND LOCAL COMMUNITIES CAN
CREATE SOCIAL AND PHYSICAL ENVIRONMENTS THAT PROMOTE GOOD HEALTH22
Improve factors that are associated with health and wellness, including safe communities, clean water and air, stable housing, access to affordable healthy food, public transportation, parks and sidewalks, and other social determinants of health. Support prevention of domestic violence and abuse. Consider addressing areas recognized as “food deserts” (areas with little access to affordable, nutritious food) or “food swamps” (areas with an abundance of fast food and junk food outlets). Encourage healthy eating initiatives tailored to the community such as community gardens, farmer’s markets, school programs, businesses’ support of healthy foods, as well as participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for eligible women.
PROVIDE BREASTFEEDING SUPPORT AT THE INDIVIDUAL AND COMMUNITY LEVELS
Establish policies to support women’s abilities to breastfeed, to reach their breastfeeding goals once they return to their communities and worksites, and thus achieve full health benefits of breastfeeding for their babies and themselves.119,120
STRENGTHEN PERINATAL REGIONALIZATION AND QUALITY IMPROVEMENT INITIATIVES
Consider adopting a classification system for maternal care that ensures women and infants receive risk-appropriate care in every region utilizing national-level resources, such as the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) joint consensus document on levels of maternal care,121 and other state-level guidelines. Develop coordinated regional systems for risk-appropriate care that address maternal health needs.
PROMOTE COMMUNITY-DRIVEN INITIATIVES101 AND WORKFORCE DEVELOPMENT
Pursue promising community-driven initiatives, such as the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau’s Healthy Start program122 and the Best Babies Zone Initiative,123 funded by the W.K. Kellogg Foundation, that aim to reduce disparities in short-term (e.g., access to maternal healthcare), medium-term (e.g., breastfeeding and postpartum visits), and/or long-term outcomes (e.g., premature births and low birth weight infants). Develop or recruit a workforce that supports the maternal health needs of the community. Incentivize healthcare professionals with obstetric training to serve in rural, remote or underserved areas.124
ENSURE A BROAD SET OF OPTIONS FOR WOMEN TO ACCESS QUALITY CARE
Examine scope of practice and telehealth laws to maximize women’s access to a variety of healthcare professionals,125 especially in rural regions and underserved areas,125 while ensuring procedures are in place to address obstetric emergencies. Engage and collaborate with federal and tribal health systems within states to avoid duplication of services and support access to a full range of care. Support partnerships between academic medical centers and rural hospitals for staff education and training and improved coordination and continuity of care. Support state and regional PQCs in their efforts to improve the quality of care and outcomes for mothers and infants.
SUPPORT EVIDENCE-BASED PROGRAMS TO ADDRESS HEALTH RISKS BEFORE, DURING AND AFTER PREGNANCY
Provide funding for local implementation of evidence-based programs, such as home-visiting, substance use disorder treatment, tobacco cessation, mental health services and other programs as recommended by the Community Preventive Services Task Force.126 Support local efforts to prevent family violence and provide support for women experiencing IPV. Educate the public about risk factors for high-risk pregnancies, pregnancy-related warning signs, risk-reducing behaviors, and the importance of prenatal and postpartum care.
IMPROVE THE QUALITY AND AVAILABILITY OF DATA ON MATERNAL MORBIDITY AND MORTALITY
Address challenges with vital statistics and data reporting,127,128 such as racial misclassification,129 and misclassification and documentation of the causes of death, and improve the accuracy of maternal mortality and morbidity reporting for national comparison and analysis. Enhance data and monitoring of racial and ethnic disparities. Expand and strengthen MMRCs to review and assess all pregnancy-associated deaths (the death of a woman while pregnant or within one year of the termination of pregnancy, regardless of the cause)130 and identify opportunities for prevention.
HEALTHCARE PROFESSIONALS
While states, tribes, and local communities help to ensure infrastructure and programmatic support for maternal health, individual healthcare professionals provide education, support, and care for women before, during, and after pregnancy.
The full range of healthcare professionals and teams should understand factors that contribute to women’s overall health and work to identify and mitigate potential pregnancy risks. Every medical appointment or interaction with health care professionals is an opportunity to ensure that standards of care and the full needs of women are being met. Given the vast diversity in geography, economy, and racial and ethnic make-up of communities across the U.S., healthcare professionals can ensure that the care they provide is scientifically-sound and culturally appropriate to the individual and their respective community.101
Fragmented care across healthcare settings may inhibit providers from having a full understanding of a patient’s medical condition(s) and risks.131,132 Many opportunities exist across providers to improve communication, including through care coordination, adoption of mobile applications, and enhanced interoperability of electronic health records (EHRs). Even healthcare professionals who do not normally care for pregnant women play a role in reducing maternal morbidity and mortality. Engaging and coordinating care among a diverse set of healthcare professionals, such as primary care providers, emergency department providers, dentists, cardiologists, endocrinologists, psychologists, and social workers, can be challenging, but strengthens the ability to identify, address, and prevent harm.
Various professional associations play a key role in developing standards of care to provide guidance on screenings, preventive care, prenatal and postpartum care, and management of obstetric emergencies. Associations are valuable resources for developing evidence-based guidelines on areas important to maternal health.
HEALTHCARE PROFESSIONALS CAN
ENSURE QUALITY PREVENTIVE HEALTHCARE FOR ALL WOMEN, CHILDREN, AND FAMILIES
Increase knowledge, awareness, and utilization of clinical practice tools such as those associated with recommendations from the USPSTF;133 the Women’s Preventive Services Guidelines;79 Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents;134 and the CDC. Use preventive health care and wellness visits to conduct screenings, assess risk factors, provide support for family planning, offer immunizations, and provide education and counseling to promote optimal health. Include such topics as folic acid supplementation for all women who are planning or capable of pregnancy,100 breastfeeding, nutrition, physical activity, sleep, oral health, substance use, and injury and violence prevention.91
ADDRESS DISPARITIES SUCH AS RACIAL, SOCIOECONOMIC, GEOGRAPHIC, AND AGE, AND PROVIDE CULTURALLY APPROPRIATE CARE110 IN CLINICAL PRACTICES
Increase self and situational awareness of and attention to disparities. Participate in research to determine if provider training may improve patient-provider interactions. Learn how to identify and work to address inequities within health systems, processes, and clinical practices using standardized protocols. Provide culturally and linguistically appropriate services that respect and respond to individual needs and preferences.135
HELP PATIENTS TO MANAGE CHRONIC CONDITIONS
Reduce the burden of chronic conditions, such as hypertension, diabetes, and obesity, as well as mental health and substance use disorders (See prior section “Risks to Maternal Health”) on women’s health across the lifespan by helping them to manage these conditions. For example, refer women at risk to diabetes educators, nutritionists, and mental health professionals. Conduct cardiovascular risk evaluation, to include history of hypertensive disorders of pregnancy and gestational diabetes,136 and provide risk reduction strategies for women of childbearing age before, during, and after pregnancy.
COMMUNICATE WITH WOMEN AND THEIR FAMILIES ABOUT PREGNANCY
Listen to women and their family members’ concerns before, during, and after delivery. Engage the family in creating a supportive environment. Discuss and make available options for traditional practices that may vary by culture and personal preferences. Educate about warning signs85 during pregnancy and the postpartum period.137 Use culturally acceptable and easily understandable methods of communication.138 Link women with a substance use disorder to family-centered treatment approaches.139
FACILITATE TIMELY RECOGNITION AND INTERVENTION OF EARLY WARNING SIGNS DURING AND UP TO ONE YEAR AFTER PREGNANCY
Track patient vital signs (e.g., blood pressure) across healthcare visits, including prenatal, initial hospital admission, and postpartum visits. Learn to recognize and react to signs and symptoms associated with hemorrhage, pre-eclampsia, hypertension, cardiomyopathy, infection, embolism, substance use, and mental health issues. Use screenings and tools to identify warning signs early so women can receive timely treatment. Coordinate care across obstetrician-gynecologists and primary care providers and consult with specialists, as needed.
IMPROVE HEALTHCARE SERVICES DURING THE POSTPARTUM PERIOD AND BEYOND
Communicate the importance of postpartum visits, including the ACOG recommendation for an initial assessment within the first 3 weeks postpartum followed by ongoing care as needed and a comprehensive visit within 12 weeks after delivery.110 Non-obstetric providers can have an important role to play. For example, pediatricians could screen for maternal mental health during well-baby visits utilizing validated tools, such as the Edinburgh Postnatal Depression scale.140 Other non-obstetric providers should ask about prior pregnancies when taking medical history and be aware of pregnancy-related morbidities that can occur up to one year post-delivery and those that raise life-time risks, such as gestational diabetes,141 gestational hypertension, and preeclampsia,34,35,36,37 and follow recommended guidelines.102,103
PARTICIPATE IN QUALITY IMPROVEMENT AND SAFETY INITIATIVES TO IMPROVE CARE
Engage with state and/or national quality collaboratives and patient safety initiatives to improve maternal health. (See section “Health Systems, Hospitals, and Birthing Facilities”). Consider using resources, such as the Agency for Healthcare Research and Quality’s Toolkit for Improving Perinatal Safety142 which includes patient safety bundles, TeamSTEPPS® (team strategies and techniques to enhance performance and patient safety143) and simulation training.
HEALTH SYSTEMS, HOSPITALS, AND BIRTHING FACILITIES
Health systems provide comprehensive care for the full range of women’s health before, during, and after pregnancy. Within these systems, hospitals provide the vast majority of delivery services. In 2018, approximately 98 percent of all live births occurred in hospital settings.17 Over the past two decades, many rural counties have lost their hospital-based obstetric services.144 In these areas, women are more likely to have out-of-hospital births and to deliver in hospitals without obstetric units, as compared to those living in rural counties that maintained hospital-based obstetric services.145 Additionally, in rural or underserved areas, access to maternal care in the prenatal and postpartum period may be limited.125
Hospitals and health systems can address this through strategies such as telemedicine and linking facilities that do not offer planned childbirth services with those that do, and facilitating prompt consultation and safe transportation to the appropriate level of maternal care. The designation of levels of care, as outlined in the ACOG/SMFM Levels of Maternal Care, helps to ensure that women receive care at facilities that are best equipped to address their needs.122 The CDC developed the Levels of Care Assessment Tool (LOCATe) to assist states and other jurisdictions in assessing and monitoring levels of care.146
Quality improvement strategies, such as participation in PQCs116 and implementation of maternal “safety bundles,” may help hospitals and health systems to reduce maternal morbidity and mortality.147 A safety bundle is a set of practices and policies designed to identify appropriate and timely actions the health care staff can take in response to maternal complications. The Alliance for Innovation on Maternal Health (AIM) is a maternal safety and quality improvement initiative that addresses preventable causes of maternal morbidity and mortality through the implementation of bundles to identify and swiftly respond to common pregnancy-related complications.148 The President’s FY 2021 Budget proposes $15 million to expand the AIM Program. Adoption of safety bundles by hospitals requires leadership and clinical team commitment, as well as training and implementation support.
Offering diverse provider types for maternal care, such as family physicians, midwives and support personnel (e.g., doulas) in hospitals and other healthcare settings may support women’s preferences. Midwifery care is provided in hospital settings, birth centers, and home settings, and can be a valuable part of women’s health care.148
Medical history associated with pregnancy and delivery does not always travel with women in their future medical records or across different types of providers. Addressing this is key to ensuring coordinated care across providers within and between health systems.
HEALTH SYSTEMS, HOSPITALS AND BIRTHING FACILITIES CAN
ENSURE AVAILABILITY OF RISK-APPROPRIATE CARE ACROSS THE HEALTHCARE SYSTEM
Ensure staff, equipment, and services are available to address the health needs of women with both low- and high-risk pregnancies. Implement guidelines for levels of maternal care at all birthing hospitals and facilities and work with states to adopt standardized criteria and uniform definitions for levels of maternal care (See prior section, “States, Tribes and Local Communities”).
IMPROVE ACCESS TO CARE AND COMMUNICATION WITH PATIENTS
Adopt methods for improving access to care and communication, especially in rural or underserved areas or when conditions limit face-to-face interactions, while ensuring patient safety and quality of care. These methods can include telehealth and remote monitoring, among others. Work with health insurers to address gaps in access to medical facilities, equipment, information, and transportation for women with disabilities.149
IMPROVE THE QUALITY AND SAFETY OF PERINATAL CARE
Provide evidence-based clinical practice, including utilization of standardized protocols related to pregnancy, delivery, and the postpartum period. Consider other resources, such as the Agency for Healthcare Research and Quality’s Toolkit for Improving Perinatal Safety.143 Participate in state, or regional PQCs to implement quality improvement efforts and monitor progress with standardized data. Consider routine surveillance and monitoring of “near misses” and other SMM events.
PROVIDE COMPREHENSIVE DISCHARGE INSTRUCTIONS
Ensure discharge processes include education for women and families about warning signs (e.g., Association of Women’s Health, Obstetrics and Neonatal Nurses’ Save Your Life discharge instructions150), and the importance of postpartum visits.110
TRAIN HEALTHCARE PROFESSIONALS IN NON-OBSTETRIC SETTINGS ABOUT OBSTETRIC EMERGENCIES
Standardize protocols and training to respond to obstetric emergencies in the emergency department8 and other non-obstetric settings, to include transportation to the most appropriate facility for care. Train non-obstetric clinicians to consider and seek recent pregnancy history when assessing patients.8
ENCOURAGE OBSTETRIC CARE-TRAINED PROVIDERS TO SERVE IN RURAL, REMOTE AND UNDERSERVED AREAS125
Support additional training in obstetric care in residencies for family physicians, especially those who will practice in rural, remote or underserved areas.
OFFER A VARIETY OF HEALTHCARE PROVIDER AND SUPPORT OPTIONS TO FIT MATERNAL PREFERENCES AND NEEDS
Leverage and incorporate midwives into hospital obstetric care and other community programs.126 Support maternal-infant home visiting and away-from-home programs/pre-maternal homes (where pregnant women from remote areas can stay before the birth of their child101) to support care.
ADDRESS DISPARITIES AND PROVIDE CULTURALLY APPROPRIATE CARE IN HEALTHCARE SETTINGS
Provide education and training on disabilities. Identify and work to address inequities within health systems, processes, and clinical practices. Ensure the availability of culturally and linguistically appropriate services that respect and respond to individual needs and preferences.136
SUPPORT BREASTFEEDING PRACTICES
Implement hospital or birthing center initiatives, such as the Baby Friendly Hospital Initiative, to help women successfully initiate and continue breastfeeding their infants.151 Ensure access to lactation support providers for breastfeeding women.
COORDINATE WITH COMMUNITY RESOURCES
Consider coordination with resources, such as group prenatal programs,152 WIC,153 home visiting programs,154 and others that address social determinants of health. Consider alternative approaches to expanding access and education, to include use of community health workers.155
ENHANCE COMMUNICATION WITHIN AND ACROSS HEALTHCARE SETTINGS
Adopt methods to ensure the seamless transition of information between providers along the care continuum, including strengthening communication and care coordination among obstetrician-gynecologists and other health care professionals.
PAYORS
Health insurance coverage is a key determinant of health care access and utilization.156 Payors – including private health insurers, state-based Medicaid and the Children’s Health Insurance Program (CHIP) -- can play a key role in addressing maternal health by helping to ensure affordability of and access to high quality preconception, prenatal, delivery, and postpartum care.157,158
Reimbursement for, and access to, comprehensive care, such as preventive services recommended by the USPSTF (A or B rating),134 Women’s Preventive Services Initiative,79 and Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents,135 can ensure women and children receive recommended services. These services may include preventive screening (e.g., blood pressure, weight status, diabetes, infectious diseases, sexually transmitted infections, cancer) and vaccinations, breastfeeding support, mental health support, substance use screening and treatment, and screening for intimate partner and family violence.
Ensuring a wide range of healthcare professionals are included in a health plan’s network may broaden women’s access to comprehensive services that address the full spectrum of care. Coverage of programs, such as those that fund transportation to appointments, or technology, such as applications that facilitate chronic condition management and timely and convenient communication, can reduce barriers to care.
Overall, while there are many strategies that payors can consider for helping to improve maternal health, including those outlined below, more research is needed to assess the impact of these actions on maternal health outcomes.
PAYORS CAN
PROMOTE ACCESS AND PAYMENT FOR WOMEN’S HEALTH SERVICES ACROSS THE LIFESPAN
Develop services and networks to provide care before, during, and after pregnancy, including pre-pregnancy counseling. Reimburse time spent with healthcare professionals to discuss healthy lifestyles, family planning, optimal management of chronic conditions (e.g., diabetes, hypertension, obesity), substance use disorders, and mental health conditions. Reduce cost barriers and ensure payment options are understood by women and their families.
ALIGN FINANCIAL INCENTIVES WITH THE FULL RANGE OF PERINATAL CARE
Provide financial reimbursement and quality incentives related to improving maternal care for women of all races and ethnicities and implementing standards of care. Implement value-based payment incentives for innovative ways of delivering high quality care. Support efforts to reduce barriers that patients may face when accessing healthcare, such as transportation, language needs, or geographic isolation. Promote telehealth, as appropriate, for women in underserved, rural or remote areas or under conditions that limit face-to-face interaction and support remote monitoring of highly prevalent and harmful conditions like hypertension and diabetes.
ENSURE A WIDE RANGE OF HEALTHCARE PROFESSIONALS ARE INCLUDED IN A HEALTH PLAN’S NETWORK
Also, consider coverage for supportive services, such as doulas, lactation support, and home visiting programs.
MONITOR POPULATION-LEVEL TRENDS AND IDENTIFY OPPORTUNITIES FOR IMPROVEMENT
Utilize data to inform strategies for improving maternal health and support provider participation in quality improvement efforts in states and local communities, such as PQCs. Track trends in quality of care and health care utilization and develop approaches that may reduce identified disparities.
EMPLOYERS
Employers play a key role in establishing norms and expectations around the support of working mothers, including paid family leave and workplace policies.
The postpartum period is a crucial time for women to recover from birth, bond with their new infant(s), and firmly establish breastfeeding practices. Lawmakers have been working to prioritize parental leave for the American people. In 1993, the Family and Medical Leave Act (FMLA)159 was signed into law to provide certain employees up to 12 weeks of unpaid leave, including after the birth or adoption of a child.160 FMLA applies to public agencies (local, state, or federal government agencies), public and private elementary and secondary schools, and private-sector employers with 50 or more employees.161 FMLA covers more than half of the workforce, however, some eligible women may be unable to take this unpaid leave for financial reasons.161
In December 2019, Congress passed and the President signed into law a major improvement in the compensation and benefits package for the government’s 2.1 million Federal civilian employees as part of the National Defense Authorization Act (NDAA).162 The Act provides Federal civilian employees with up to 12 weeks of paid parental leave to care for a new child, whether through birth, adoption, or foster care, beginning in October 2020.
In addition to parental leave, other federal worker protection laws have been enacted, such as the Fair Labor Standards Act (FLSA), which ensures that American workers receive a minimum wage.163 In 2010, the FLSA was amended to require employers to provide reasonable break time and a space for an employee to express breast milk for her nursing child for one year after the child’s birth.164
Employers have an opportunity to play a key role in supporting women during their pregnancies and in the postpartum period. Due to the recognized health and economic benefits, ACOG endorses paid parental leave, including full benefits and 100% of pay for at least six weeks after delivery.165 In addition to paid leave166 in the postpartum period, other family-friendly benefits such as flexible work schedules, preventive medical care, and childcare for sick children may improve recruitment of potential employees and greater retention of current employees.
Employers who offer health insurance are in a position to advocate for comprehensive care coverage to support maternal health. Effective workplace programs and policies can also reduce health risks and improve the quality of life for workers, including women and their families.167
Overall, there are many strategies that employers can consider that may help to improve maternal health, including those outlined below, however, more research is needed to assess the impact of these actions on maternal health outcomes.
EMPLOYERS CAN
ADOPT AND SUPPORT FAMILY-FRIENDLY POLICIES
Consider paid family leave168 and other family-friendly policies, such as flexible work schedules and on-site or easy-to-access high quality childcare. These policies may also help with recruitment and retention of valuable employees.167
SUPPORT BREASTFEEDING
Provide lactation spaces for breastfeeding mothers, including for those who do not qualify under the FLSA.166 Consider going beyond what is required in the FLSA164 (e.g., break time, private rooms) by providing hospitable and welcoming environments, including access to refrigerators, comfortable chairs, sinks and microwaves, for applicable employees.
ENSURE ROBUST MATERNAL CARE THROUGH EMPLOYER-SPONSORED COVERAGE
Negotiate with health insurers on behalf of employees for comprehensive care, including expanding options for receiving care (e.g., telehealth), reducing out-of-pocket costs, and implementing innovative approaches to monitor and manage risk factors (See prior section, “Payors”).
DEVELOP A WORKPLACE HEALTH PROGRAM
Develop or adopt workplace programs and policies that promote healthy behaviors, such as ready access to local fitness facilities, healthy vending or cafeteria options, tobacco-free environments and work settings free of environmental threats. Provide worksite blood pressure screening, health education, and lifestyle counseling to help employees control their blood pressure.169
INNOVATORS
Innovative approaches across the health care arena can improve maternal health outcomes through policies, technology, systems, products, services, delivery methods, and models of care.
For example, while diabetes educators and nutritionists may already be included in some models of obstetric care, the inclusion of hypertension educators may be an innovative approach to further enhance comprehensive care in the obstetric setting. Technological innovation, such as mobile or computer-based applications, may help to monitor and/or manage women’s health during and beyond pregnancy. This could include mobile applications or monitoring systems that can help to manage conditions, such as diabetes or hypertension. For example, HRSA’s Remote Pregnancy Monitoring Challenge supports innovative-technology-based solutions to help providers remotely monitor the health of pregnant women while empowering these women to monitor their own health and healthcare.170
Improvements and innovations in EHR technology offer an opportunity for improving maternal health. Interoperability between systems can allow providers to have a more complete view of a woman’s health by incorporating information from various clinical settings and systems. However, the demands of the current EHR systems may take time away from direct patient-provider communication. EHR systems should be improved to ensure they are provider-friendly and valuable to health care professionals. They should also incorporate improvements such as recommended care guidelines and clinical decision support tools, and facilitate linkage of maternal health records with infant health records.
Finally, innovation in delivery methods can address access issues for women who have barriers to care, such as those living in rural or underserved areas, or with limited transportation, or when conditions limit face-to-face interactions. Telehealth innovators can help states and providers identify opportunities for connecting women with a broad range of services to meet their needs. This could include providing remote access to obstetricians, maternal-fetal medicine and other specialists.
Listed below are some topic areas for innovators to consider that may improve maternal health. Innovations should be evaluated to assess their impact on maternal health outcomes.
INNOVATORS CAN
IMPROVE COMMUNICATION BETWEEN PROVIDERS AND WOMEN
Decrease burden of EHRs on providers to allow more time for communication with patients. Develop mobile applications to facilitate communications during and after pregnancy so that women can conveniently raise issues or concerns to providers and providers can remotely monitor key vital signs. Such applications can focus on various aspects of prenatal and postpartum care and can involve a team of healthcare professionals. Consider developing applications tailored to a variety of cultures, health literacy levels, and racial and ethnic populations and incorporating human-centered design in the development of these applications.
PROMOTE COORDINATION OF CARE ACROSS HEALTHCARE PROFESSIONALS
Help to address a fragmented system by facilitating communication across different providers using innovative approaches.
DEVELOP AND/OR PARTICIPATE IN NEW MODELS OF MATERNAL CARE
Consider models of care that address maternal health risk factors, such as hypertension, diabetes, unhealthy weight, substance use disorders, mental health conditions, and IPV, to name a few. For example, the Center for Medicare and Medicaid Innovation’s Maternal Opioid Misuse (MOM) Model supports the coordination of care and integration of critical health services for pregnant and postpartum Medicaid beneficiaries with opioid use disorder. This, and other innovative payment and delivery models have the potential to improve quality of care for mothers and infants.171
EXPAND DELIVERY METHODS FOR ACCESSING SPECIALTY CARE
For example, telehealth companies can better meet maternal health needs by designing technology that connects women to needed specialty care providers (e.g., obstetricians, maternal-fetal medicine specialists, cardiologists, endocrinologists, pulmonologists, nephrologists, nutritionists, and mental health professionals) and services.
RESEARCHERS
A critical component of developing solutions and monitoring their impact is the ability to glean information from reliable and comprehensive data; however, there are substantial data limitations and gaps in existing research on maternal health. Further, clinical studies often exclude pregnant women due to an increased risk or concern for adverse outcomes in this population, particularly in research for therapeutic products. Researchers have opportunities to advance this area by adding to the field of evidence on clinical outcomes and by improving the quality of data that are available for analysis.
In clinical arenas, more outcomes-based research would be valuable for understanding the interaction of comorbidities during and after pregnancy and the effectiveness of selected interventions on improving maternal health. More research is needed on disease processes and clinical interventions, protective factors, demographic risk factors, racial disparities, and health system factors.172
Research is also needed to fill clinical gaps in knowledge related to the defining and treating medical conditions that are known risk factors for maternal mortality, including preeclampsia, cardiovascular disease, peripartum cardiomyopathy, and hemorrhage.173,174,175 Research on screening algorithms, risk assessments, and diagnosis involving biomarkers could help to improve timeliness of the identification of women with these conditions and their referral to treatment.175,176 The National Institutes of Health (NIH) supports research addressing many aspects of maternal health.
Evidence has been provided throughout this document for many strategies and actions, however, more research is needed for others, particularly those in the “Payors” and “Employers” section. Researchers should consider examining those areas, as well as those listed below.
RESEARCHERS CAN
IDENTIFY BIOLOGICAL, ENVIRONMENTAL, AND SOCIAL FACTORS THAT AFFECT MATERNAL HEALTH
Consider analyzing data from NIH’s PregSource®, a crowdsourcing research project designed to improve the understanding of pregnancy by gathering information directly from pregnant women via confidential online questionnaires.177 The Pregnancy Risk Assessment and Monitoring System (PRAMS)178 and the National Health and Nutrition Examination Survey (NHANES)179 are examples of publicly available data sources that can be used for analysis. The Transformed Medicaid Statistical Information System (T-MSIS) also has data and research-ready files specific to Medicaid and CHIP information.180
ADVANCE A RESEARCH AGENDA, SUCH AS DISCUSSED IN THE HHS ACTION PLAN181, TO IDENTIFY EFFECTIVE, EVIDENCE-BASED CLINICAL BEST PRACTICES AND HEALTHCARE SYSTEM FACTORS, INCLUDING RESEARCH ON REDUCING DISPARITIES
Conduct research to identify, develop, and rigorously test clinical interventions to address risk factors; identify healthcare factors (e.g., quality of care); and provide insights into healthcare delivery approaches (e.g., care coordination, innovative models of care) for improving access to high-quality maternal health care. Support research to understand, prevent, and reduce adverse maternal health outcomes among racial and ethnic minority women, those who are socioeconomically disadvantaged, and those in rural, remote and/or underserved areas. This should include exploring the potential effects of inequities within health systems, processes, and clinical practices on maternal health outcomes.
EXPAND RESEARCH TO DEVELOP SUFFICIENT EVIDENCE ON MEDICATIONS AND TREATMENT
Adopt recommendations made by the HHS Task Force on Research Specific to Pregnant Women and Lactating Women (PRGLAC),182 to increase research for therapeutic products already in use by pregnant or lactating women and for existing therapeutic products not currently licensed for use during pregnancy, but with potential benefit for pregnant women and their infants, and to increase discovery and development of new therapeutic products for these populations.
ENHANCE MATERNAL HEALTH SURVEILLANCE BY IMPROVING THE ACCURACY, QUALITY, CONSISTENCY, SPECIFICITY, TRANSPARENCY, TIMELINESS, AND STANDARDIZATION OF EPIDEMIOLOGICAL DATA ON MATERNAL HEALTH
Improve data quality and timeliness; enhance data and monitoring of racial, ethnic and geographic disparities, and disparities among women with disabilities; and assess strategies to leverage and harmonize national data systems for monitoring maternal health.
- STRATEGIES AND ACTIONS: IMPROVING MATERNAL HEALTH AND REDUCING MATERNAL MORTALIT...STRATEGIES AND ACTIONS: IMPROVING MATERNAL HEALTH AND REDUCING MATERNAL MORTALITY AND MORBIDITY - The Surgeon General’s Call to Action to Improve Maternal Health
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