There is no doubt that the United States is in the midst of a maternal health crisis. In fact, a new study found that the U.S. has the highest maternal mortality rate amongst 11 high-income countries. Further, we are one of the few developed countries where deaths related to pregnancy or childbirth are actually on the rise.
In fact, American women today are 50% more likely to die in childbirth than their mothers were. Moreover, there is a significant racial disparity in outcomes. According to the CDC, black women have a maternal mortality rate that is nearly three times higher than white women.
Despite these devastating statistics, providers are in a unique position to have lifesaving impacts on our pregnant patients, especially women of color, through more thoughtful education and support.
As an OB/GYN, I am acutely aware of the health care gaps that contribute to maternal morbidity and mortality in the U.S. A report from nine maternal mortality review committees estimated that over 60% of pregnancy-related deaths were preventable. Further, it cites better patient/provider engagement and empowerment as one of the main opportunities for improvement.
But how do we do this, especially in the midst of the COVID-19 pandemic that has added many outside stressors and barriers to consistent care?
Impact of COVID-19 on the maternal health crisis
Moms-to-be these days have a lot to deal with. They must manage their risks related to the novel coronavirus as well as the uncertainties related to the upcoming flu season. And, they must do it while also handling the usual pressures of being pregnant.
Moreover, patient/provider relationships have had to shift drastically. Many health care appointments have transitioned to virtual care or other forms of digital communication.
The usual course of prenatal care includes about 15 prenatal and postpartum visits, including services like ultrasound. The shift away from in-person visits drastically changes a woman’s pregnancy journey. Further, many Americans are outright canceling or postponing care because of fear of contracting COVID-19.
Related reading: Fear of COVID-19 Keeps Patients from Seeking Medical Care
The Path to Better Health Study by CVS Health found that 41% of respondents are not tracking their personal health information, such as weight, blood pressure, or cholesterol. In an environment where providers may not have regular contact with their patients, this is an alarming trend.
This suggests that many people who are, or may become, at risk for a chronic condition could develop complications that go undetected. This is especially concerning in maternity care because chronic conditions increase the risk of pregnancy complications.
Further, COVID-19 has highlighted longstanding and deep-rooted racial disparities within our health care system. The pandemic has disproportionately affected communities of color. This places our most at-risk patients in an even more vulnerable position.
Black women are also at an increased risk for chronic conditions. Further, the Path to Better Health Study revealed incidences of chronic disease in African American women more than any other ethnic group.
The maternal health crisis: identifying opportunities for intervention
Despite these myriad challenges, the pandemic has also provided an opportunity for adaption and change. As providers, we should embrace the critical role we play in our patients’ lives, specifically through better:
This is especially important when caring for those most at-risk for complications.
We know that focusing on empowering women works. For example, studies point to positive outcomes related to feelings of self-efficacy in pregnancy. These include:
- reductions in perinatal depressive symptoms,
- reductions in preterm birth, and low birth weight. 
As providers, we need a multi-pronged approach to ensure we are providing the kind of additional support women need along their pregnancy journeys:
1. Be ready to adjust.
Aetna initiated its “Time for Care” campaign in order to encourage patients to continue seeking health care during the pandemic. A national survey of 4,400 Americans was conducted to inform the design of the campaign.
It found that 50% of pregnant mothers are not confident that their primary care physicians have put the necessary measures in place to prevent the spread of COVID-19.
This suggests that we have work to do to help patients feel safe in health care settings. We have to adjust and provide new, safer, ways to care for patients.
This may mean implementing and encouraging the use of telehealth. It might also mean making sure proper protocols, such as the CDC recommended steps, are in place when in-person visits are necessary.
Changes, whether large (moving to virtual care platforms) or small (implementing masking and distancing guidelines) can have a positive impact on patients’ trust.
2. Listen to, advocate for, and empower patients
Women are often overlooked or underserved in health care. This is especially true for women of color.
For example, studies have found that Black female patients can experience racial bias when it comes to pain treatment. For example, African American patients who reported pain were 22 percent less likely than white patients to receive medication from their doctors.
We need to make sure that we actively listen to and advocate for our patients when they raise concerns about their health. That can help them feel encouraged and empowered throughout their health journey.
One way to initiate this approach is by learning about your patient’s status so you can ask questions relevant to their health. Also, when appropriate, encourage patients to bring outside support (e.g., a loved one, family member, or doula) into the clinical setting. This can help provide extra encouragement or advocacy in times of need.
Regardless of what steps you’re taking to do so, it’s imperative that moms-to-be feel empowered to speak up throughout their pregnancy. To create the kind of environment where that’s encouraged, we need to not only actively listen to our patients but believe them.
3. Be a champion of education and communication
Putting educational resources directly into expectant patients’ hands, either in-person or digitally, can be a great way to spark dialogue and encourage good decisions.
One way Aetna aims to help in this space is through a new initiative aimed at preventing preeclampsia. Preeclampsia is one of the leading causes of maternal death in the United States. The program consists of sharing kits containing educational materials on the risks of preeclampsia. It also provides information about the use of low-dose aspirin as a proven, low-risk intervention.
The initiative works to encourage and empower high-risk patients to start conversations with their providers about their pregnancies. The program is also notifying in-network OB/GYNs of this outreach and urging them to discuss risk factors with their patients.
By arming patients with education, we can empower them to ask informed questions and open those additional lines of conversation.
Leading the change in the maternal health crisis
Trust is critical when it comes to building better patient/provider relationships. We know that such relationships provide a solid foundation for effective treatments and better health outcomes.
There is no one, perfect solution to ending the maternity crisis in the United States. However, good communication and building trusting relationships with our expectant patients provide an opportunity to help our patients feel safe getting care during COVID-19.
Further, by prioritizing, empowering, and educating our patients, we can all play a part in improving patient/provider communication. At the end of the day, we all want to be part of a solution that ensures our patients are getting the care they need.
 Tikkanen R, Gunja, M, et al. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries, The Commonwealth Fund, November 18, 2020. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries – accessed 11/18/20.
 Weinstock M. The potential influence of maternal stress hormones on development and mental health of the offspring. Brain Behav Immun. 2005;19(4):296–308. doi: 10.1016/j.bbi.2004.09.006.
 Yim IS, Glynn LM, Schetter CD, Hobel CJ, Chicz-Demet A, Sandman CA. Risk of postpartum depressive symptoms with elevated corticotropin-releasing hormone in human pregnancy. https://pubmed.ncbi.nlm.nih.gov/19188538/
Published 10/19/20. Updated 11/18/20.
Joanne Armstrong, MD, MPH
Joanne Armstrong, MD, MPH is an obstetrician-gynecologist, Senior Director, and Enterprise Head of Women's Health and Genomics at CVS Health. In that capacity, she is responsible for women's health and genomics, clinical programs, policy, and strategy.
Dr. Armstrong earned her B.A. at Cornell University, a Master’s in Public Health (MPH) at the University of Michigan in Ann Arbor, and an MD at Rutgers New Jersey Medical School. She completed her residency training in obstetrics and gynecology at Brown University, Women and Infants’ Hospital of RI. She is board-certified in obstetrics and gynecology.
Dr. Armstrong has worked in a variety of direct patient care settings in academic, private practice, and public health care settings.
Aetna paid $500,000 in California for denying 93% of Emergency Visits. So let’s put this in perspective Dr. Armstrong. A woman has a headache during pregnancy and is at high risk of death and a stroke. Based on court documents, that woman would have her claim denied and would be told by your unit that she should have gone to an Urgent Care Center. Preemclapsia, risk of stroke, maternal mortality but no payment for Emergency Services. Thank You for this meaningless fluff piece. The fine was a pittance compared to what your “evidence based policies’ have done. This is outstanding Doublespeak. The reality is a Disgrace.
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