Spotlight: Addressing Social Determinants of Health to Improve Maternal Outcomes
A new public health policy limiting the number of people allowed in the delivery room with a mother during labor to just one has introduced a new set of challenges in the era of COVID-19.
For many moms-to-be, this means — if they want a partner or family member to be there — their doula won’t be able to join them. While the immediate reaction to this scenario for many is likely to be disappointment, for others it could represent a serious risk factor to their outcome.
Women receiving doula care have been found to have improved health outcomes for both themselves and their infants, including higher breastfeeding initiation rates, fewer low-birth weight babies, and lower rates of cesarean sections.1 Doulas can also help reduce the impacts of racism and racial bias in health care by providing patient-centered care and advocacy.
More broadly, we know that income, racial and ethnic inequalities, educational attainment, and health insurance coverage drive major health disparities; these same disparities reveal themselves in pregnancy and birth outcomes. Mothers who did not complete high school had a 5% increase in maternal mortality when compared to women who completed high school. According to the CDC, African American moms in the US are more than three times more likely to die in childbirth than white Americans. 2
During 2011–2016, racial/ethnic disparities were correlated with up to 3.5x variation in pregnancy-related mortality:3
- 42.4 deaths per 100,000 live births for black non-Hispanic women.
- 30.4 deaths per 100,000 live births for American Indian/Alaskan Native non-Hispanic women.
- 14.1 deaths per 100,000 live births for Asian/Pacific Islander non-Hispanic women.
- 13.0 deaths per 100,000 live births for white non-Hispanic women.
Under current overload conditions stemming from COVID-19, we know that many health systems will be even more challenged than usual to address these risk factors as they evaluate their populations. We are here to help with that – please reach out.
A Look at Some Programming
Some of our clients are piloting promising support programs in this space, including interventions to promote further engagement with their pregnant populations at particular risk in facing socially driven risk factors. In addition to doula programs, we are seeing:
|Program Types||For Example…|
|Maternal nutrition programs||Free monthly delivery of pre-natal vitamins or weekly grocery supplements, reducing need to go out in the COVID-19 world. Evaluation: Reduction in low and very low birth weight.|
|Transportation campaigns||Transportation vouchers or Uber Health enrollment to allow for rides to and from pre-natal care appointments. Evaluation: Increased compliance with pre-natal screenings.|
|Enhanced care management programs||Enroll newly pregnant members in one on one care management for duration of the pregnancy and initial post-partum period. Evaluation: Decreased gaps in care.|
|Pregnancy medical home models||Comprehensive assessment and individually tailored services via ongoing collaboration with a pregnancy care manager Evaluation: Reduction in pre-term birth.|
So, Where to Start?
The hardest part is getting started. The battle against inertia is real, and more so than ever in the world of healthcare. If you want to see your programming succeed, make sure it’s measurable. Real politics apply here, and you need to be able to show the impact of the program.
Don’t set yourself up for failure – start small and identify highly specific metrics that are being tracked to evaluate the program. One of the critical things my team does in designing a pilot program is to ensure that we invite participation from people who are most impactable. This can mean a number of things depending on the core goal of the program, but most broadly it means that they have specific challenges that we can measure a change against. An unengaged person becomes engaged with a provider. A person with high ED utilization shows a decrease. Gaps in care are closed. Evaluating outcomes can sometimes be tricky when looking at different risk levels, so looking for opportunities to design a natural or randomized experimental population can ease long-term measurement.
Returning to maternal health, we might focus a pilot program to look specifically at pregnant moms in your Medicaid population who have additional social determinant stressors – high neighborhood stress, housing instability, transportation or food access challenges. We would focus evaluation metrics such as driving an increase in pre- or post-natal care visits.
The purpose of starting small and measurable here is to get the intervention off the ground and running, make iterative adjustments, and track the outcomes. We believe in a culture of active learning – we listen to what the data are telling us and build upon that foundation.