Elizabeth Howell, MD, MPP, Director of the Blavatnik Family Women’s Health Research Institute, testifies before a House subcommittee

“The United States is the most dangerous place to deliver a baby in the developed world,” stated Congresswoman Anna Eshoo from California in her opening remarks at the House Committee on Energy and Commerce hearing in Washington on improving maternal health, quoting an investigation by USA Today from 2018.

Approximately 700 women die from a pregnancy-related cause each year. The United States maternal mortality rate is higher than other high-income countries, and the numbers are far worse for women of color. In addition, for every death, more than 100 women experience a severe complication related to pregnancy and childbirth, resulting in thousands of women every year experiencing one of these events according to the Centers for Disease Control and Prevention.

For these reasons, on Tuesday, September 10, Elizabeth Howell, MD, MPP, Director of the Blavatnik Family Women’s Health Research Institute and a Professor in the Departments of Obstetrics and Gynecology and Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai, testified before the Subcommittee on Health of the Committee on Energy and Commerce.

Click here to watch Dr. Howell’s testimony before the House subcommittee

Dr. Howell emphasized six important action items to improve maternal health, which included elements of four proposed bills that were discussed in the hearing:

1. Develop quality of care metrics for maternal health that are patient-centered and address disparities
2. Authorize the Alliance for Innovation on Maternal Health (AIM) program
3. Extend Medicaid to cover up to one year postpartum
4. Develop and expand perinatal care quality collaboratives
5. Provide support for training in implicit and explicit bias to all health care providers
6. Support infrastructure to improve data collection and measurement

We do not know yet whether these bills or parts of these bills will be passed and signed into federal law. But there are things that the government and the health care system can do and should implement in order to address the problem of maternal death in this country. Dr. Howell ended her testimony as follows: “We have to value pregnant women from every community. We can and must do better.”

In addition to Dr. Howell, Patrice Harris, MD, MA, President of the Board of Trustees of the American Medical Association; David Nelson, MD, Chief of Obstetrics at Parkland Health and Hospital System in Texas; Usha Ranji, Associate Director of Women’s Health Policy at the Kaiser Family Foundation; and Wanda Irving, mother of Shalon Irving, PhD, provided testimony on the four maternal health bills that the House of Representatives is considering. The proposed bills aim to improve access to care for pregnant and postpartum women and to reduce severe maternal morbidity and mortality. All five of these experts instructed Congress that there are concrete steps Congress can take to improve maternal care before, during, and after delivery.

Wanda Irving is the mother of Dr. Irving who died after childbirth despite multiple visits to health care providers in the three weeks postpartum before her death. In her testimony, Ms. Irving declared, “What infuriates me is that Shalon’s death was a preventable tragedy. She was a 36-year-old woman of color who went to her health care workers again and again in distress–and she was not properly treated.” Later in her testimony she added, “It should not have happened.” We must do better. We can do better.

The following four bills address varied aspects of health inequity and current shortfalls in our health care system that impact maternal health.

The Quality Care for Moms and Babies Act (H.R. 1551)

H.R.1551 proposes to identify and publish a recommended set of core maternal and infant health quality measures. The legislation calls for a list of recommended measures including standardized processes, experience requirements, and outcomes of maternity care (including postpartum care) across a variety of healthcare settings and health plans by January 1, 2021. Additionally, this list of recommendations must also address disparities in maternal care, care coordination, and the importance of shared decision making between the patient and provider. By January 1, 2022, these measures are to be published, disseminated, and applicable to all Medicaid and Children’s Health Insurance Program (CHIP) eligible patients. By January 1, 2023 the government will standardize reporting information based on the initial measures, and this reporting will occur by January 1, 2024 and every three years thereafter. H.R. 1551 also includes the following:

• Establish a Maternal and Infant Quality Program that publishes maternal and infant health quality measures that will inform future recommendations and research studies that develop and test evidence-based measures
• Establish the Maternal Consumer Assessment of Health Care Providers and Systems Survey to measure health care experiences.
• Annual State Reports of specific maternal and infant quality of care measures for those under Medicaid or CHIP
• Expand quality collaboratives that facilitate performance data collection and feedback reports to physicians on performance and achieving benchmarks, create protocols and checklists to foster safe evidence-based practice, translate evidence-based science into clinical care, and to evaluate quality improvement (QI) programs and projects.

The Mothers and Offspring Mortality and Morbidity Awareness (“MOMMA’s”) Act (H.R. 1897)

H.R. 1897 proposes mandating the submission of the United States Maternal Mortality Rate to the international data repositories, as the U.S. has not since 2007. Due to a lack of standardization across state maternal mortality review committees as well as the lack of 100 percent state reporting, data has not been sufficiently reported to the CDC for them to do a proper analysis. The bill discusses the danger of underreporting maternal mortality and morbidity and the racial disparities in maternal death in the United States. This legislation discusses maternal death in the postpartum period. According to the CDC report of maternal deaths from 2011-2015, 21 percent of maternal deaths occurs 7-42 days postpartum and nearly 12 percent of deaths occurred between 43 and 365 days postpartum. Additionally, this bill focuses on oral health—some evidence that suggests women with periodontal disease during pregnancy could be at greater risk for poor birth outcomes, including preeclampsia. H.R. 1897 also includes the following:

• Establish state-based perinatal collaboratives to work with hospital-based, outpatient, and clinical teams, experts, and stakeholders to spread best practices and optimize resources.
• Provide CDC support to states to report severe maternal morbidity, oral health, maternal health, and breastfeeding data back in a standardized manner.
• Extend Medicaid and CHIP to 1 year postpartum and expand to include oral health.
• Make resources for pregnant and postpartum women publicly available on the Department of Health and Human Services website.
• Establish an accreditation of Regional Centers of Excellence Addressing Implicit Bias and Cultural Competency for hospitals, health systems, medical schools, and other health services education institutions.
• Establish a special supplemental nutrition program for women, infants, and children up to 2 years postpartum via SNAP.
• Tax the tobacco industry to pay for the measures in this bill.

The Healthy MOMMIES Act (H.R. 2602)

H.R. 2602 proposes to improve maternal and child health outcomes, health equity, and communication by providers and integrate support services in maternal and infant care. A unique aspect of this bill is that it has a focus on primary care and doula care for Medicaid beneficiaries. H.R. 2602 includes the following:

• Extend Medicaid and CHIP up to 1 year postpartum, requiring oral health services for pregnant and postpartum women.
• Establish the Maternal Care Home Demonstration Project, a five-year project to reduce severe maternal morbidity and to reduce avoidable mother and infant rehospitalizations.
• Require the Comptroller General to submit report to congress on gaps in Medicaid in CHIP no later than one year after the passage of this act to create recommendations on how to improve gaps, especially for low income, women of color in health care shortage areas.
• Use telemedicine to increase access to maternity care and increasing access to doula care to Medicaid beneficiaries.

The Maternal Care Access and Reducing Emergencies (Maternal CARE) Act (H.R. 2902)

H.R. 2902 proposes to reduce severe maternal morbidity in the United States through better quality health care. However, the scope of this act would only include 10 states. Several measures that would be enacted by the passage of this act are:

• Provide Implicit Bias Training for Health Care providers. This would be done by federal grants to health professional schools, prioritizing disparities in OB/GYN care.
• Establish the Pregnancy Medical Home Demonstration Project to deliver integrated health care services to pregnant women and new mothers. A care manager would be assigned to each patient and each patient will have a standardized medical, OB exam, and psychosocial risk assessment at their first prenatal visit.
• Collaboration with the National Academy of Medicine to study and make recommendations for incorporating bias recognition in clinical skills testing for accredited allopathic and osteopathic medical schools.

Amy Balbierz, MPH, is a program manager in the Department of Population Health Science and Policy and for the Blavatnik Family Women’s Health Research Institute.

Lying on a hospital bed after the birth of my first child, aware that the final stage of delivery had taken an unanticipated turn, I realized my research interests were both a blessing and a curse.

On the one hand, as a perinatal epidemiologist, I had a decent understanding of what was happening: a postpartum hemorrhage, or excessive bleeding, immediately following the delivery of my son. Only a few weeks before, I had defended my proposed dissertation research on pregnancy outcomes in New York City. My desk overflowed with data on the risks of pregnancy and childbirth. I was at least mildly equipped to combat the confusion and distress of an obstetric emergency.

On the other hand, I knew how bad it could get.

There are few events in life as salient as childbirth. That is true for me in all the conventional, wonderful ways one would imagine. However, I also recall with a vivid, visceral intensity those moments when the outcome felt suddenly uncertain. I remember the furrow in my obstetrician’s brow. I remember the realization that I was bleeding more than normal. I remember turning my head to watch a nurse examine my son, my husband radiating a unique blend of disbelief and joy as he took in the initiation rituals of modern medicine. I remember thinking “what a perfect picture” and “what is happening to me?” in the exact same moment.

I am fortunate that my complication was relatively minor. A quick injection of Hemabate—a synthetic prostaglandin, a hormone-like substance used to contract the uterus—stopped the hemorrhage. I was able to move on to recovery and new motherhood. But too often that is not the case. Missed opportunities to prevent the occurrence and escalation of obstetric emergencies have dire consequences for women, their infants, and their families. It is estimated that more than 60 percent of maternal deaths are preventable, and often attributed to health care quality failures including misdiagnosis, ineffective treatment, and poor coordination.

Two and a half years later, a slightly more experienced mother and newly minted PhD, I was back on the labor and delivery floor and my second son took his first breaths. But they were challenging breaths. Quick breaths. Shallow breaths. Again, within seconds I moved from the bliss of bringing new life into the world and of meeting my child for the first time, to the quiet suspicion that something was not quite right. The nurse lifted my newborn from my arms with a touch too much urgency and huddled over him for a bit too long. I do not remember the exact sequence of events but can hear my voice ask, “Is he ok?” on loop.

And I remember quiet. In that moment, I understood the phrase “deafening silence.” The void of chatter, of information, of assurances. A neonatologist arrived, assessed my son, and moved him into an isolette, one of those tiny plastic enclosed bassinets, for transfer to the hospital’s Neonatal Intensive Care Unit. With these few actions, the day I had anticipated for the previous 38 weeks was utterly changed. Settling somewhere between worry and frustration, I steeled myself for the journey.

I can happily report that my son is fine. He required a bit of extra TLC and a week in the NICU to acclimate to this big, wild world. Honestly, I cannot blame him.

Twice now, I can say that I tasted the stress and trauma of what too many women in this country and around the world experience in childbirth. A brief, passing taste – and for that good fortune I am eternally grateful.

But it is not just luck that allowed each of my birth stories to have a happy ending. I have insurance that affords me the choice of first-class medical providers and hospitals. I am more likely to receive high quality obstetric care, and to survive childbirth without significant short- or long-term health consequences, than women of other sociodemographic backgrounds because of differences in both where I receive my care and how I am treated in that facility. I benefitted from ready access to the medicine that got my bleeding under control, a team of providers able to step in quickly for my son, and an obstetrician who made extra efforts to support me postpartum until I could bring him home.

My experiences emphasize that there are two patients in childbirth. A recent commentary in the Journal of the American Medical Association (JAMA), discusses this unique feature of perinatal medicine—the “maternal-infant dyad”—as a priority area for clinical, epidemiologic, and health services research. The authors point out that few metrics track care and outcomes for moms and babies together or evaluate how policies and practices for one affect the other. Maternal and neonatal level of care designations, which aim to direct patients to appropriate health facilities by classifying hospital capacity for medical risk and complexity, were developed independent of each other and often do not align. We need to investigate the synergies between maternal and neonatal care and improve delivery systems to optimize resources, patient satisfaction, and outcomes.

Our team at the Blavatnik Family Women’s Health Research Institute is conducting qualitative research to understand the perinatal care experiences of women who suffered severe maternal complications or delivered high-risk infants. These analyses will provide insights into perceptions of care processes and barriers to quality when the primary concern is for a woman herself compared to when it is for her baby. Recalling the ways in which my family and I benefitted from access to comprehensive maternal and neonatal care fortifies my dedication to this work.

Kimberly Glazer, PhD, MPH is Assistant Professor in the Department of Population Health Science and Policy and the Raquel and Jaime Gilinski Department of Obstetrics, Gynecology and Reproductive Science. Dr. Glazer is a perinatal epidemiologist with research interests in obstetric care quality and perinatal health disparities. Her interdisciplinary research informs person-centered clinical practice and quality improvement across the pregnancy-postpartum continuum.

The research team at the Blavatnik Family Women’s Health Institute includes, from left: Mikhalya Brown, Ashaki Smith, Heather Reis, Amy Balbierz, and Naissa Piverger.

Childbirth is the number one reason for hospital admissions in the United States. As a result, postpartum care offers a window of opportunity to affect the current and future health of underserved women.

There are significant disparities in the receipt of postpartum care: Approximately 60 percent of Medicaid-insured women attend their postpartum visit, whereas approximately 80 percent of commercially insured women go to their visit. This postpartum visit is an important “check-in” for mom’s current health status, both physically and emotionally. But it is also a time to discuss long-term management for chronic conditions (such as hypertension, diabetes, and depression); improve health prior to future pregnancies; and link women to the primary health care system.

The Icahn School of Medicine at Mount Sinai partnered with Healthfirst (a Medicaid managed care organization and the largest insurer of Medicaid deliveries at the Mount Sinai Health System) and a multidisciplinary team of experts in obstetrics, health economics, and disparities to design an intervention to improve care and reduce disparities in care for high-risk women.

Amy Balbierz, MPH, is a program manager in the Department of Population Health Science and Policy and for the Blavatnik Family Women’s Health Research Institute.

The payment system redesign included a cost-sharing arrangement between the Health System and Healthfirst to cover the cost of case manager staff (social worker and care coordinator) and clinician education, and small financial incentives. After completion of this intervention, researchers concluded that it had a significant effect on postpartum visit rates among enrolled Medicaid-eligible mothers at The Mount Sinai Hospital. The project, “Reducing disparities in care for high-risk postpartum women through redesign of payment and delivery systems,” was funded by the Robert Wood Johnson Foundation.

Here are five reasons why the project was successful:

1.This care delivery project integrates evidence-based techniques. It prepares and educates women about physical and emotional symptoms of postpartum depression, gestational diabetes, and hypertension; bolsters social support and self-management; increases access to community resources; and reduces barriers to follow-up care. Our patient education materials, written in both English and Spanish, were simple and reinforced the importance of women’s health: “Remember, nearly all women will have some issue or problem after their delivery. Pregnancy and delivery demand a lot from you and your body. Go to your postpartum visit to check in on your health, to ask questions, to control issues, and to prevent issues from becoming problems.”

2. We tested the research materials prior to the rollout of the intervention. Material was pilot tested with women who were attending their postpartum visit. The new moms were asked to provide their understanding of the patient education materials and feedback on how to improve them. The materials were updated based upon the postpartum mothers’ feedback, and several of them stated they wished they had received this information during their own postpartum hospital stay.

3. The research team provided outreach to all clinical and non-clinical providers who came into contact with the patients, to ensure they knew about the who, what, why, and how of these reforms to the care delivery system. We also shared the specific aims of the intervention and stressed why it is important with staff at community health centers that provide obstetrics care. We met with everyone: obstetricians/gynecologists, maternal fetal medicine specialists, psychiatrists, nurse midwives, physician assistants, residents, postpartum nurses, lactation consultants, medical assistants, front desk staff, schedulers/registrars, obstetrics social workers, and administrative directors. We have found that staffs are very appreciative of this outreach because it acknowledges their critical roles in patient care. An informed and educated staff is much more likely to partner in the shared care delivery goals if they have a seat at the table.

4. We developed a dedicated multidisciplinary team of frontline staff through consistent and ongoing training. The personnel conducting the intervention truly cared about reducing racial/ethnic disparities in maternal and neonatal outcomes. Weekly team meetings allowed staff to discuss and monitor the status of recruitment and retention efforts, intervention delivery (including postpartum visit rates, home visits for high blood pressure, reminders for fasting glucose at the postpartum visit for mothers with gestational diabetes, and resources and follow-up for mothers with depressive symptoms), and patient outcomes. These regular check-ins reinforced the importance of the delivery change process and helped staff feel more confident and address challenges.

5.We followed up with patients and provided continuity in care. New moms are busy. They have many competing demands, including but not limited to, juggling physical and emotional postpartum symptoms with caring for their newborn, other children, and adult family members. They are often trying to do all of this while struggling with sleep deprivation, transportation challenges, and unstable home or work environments. For these reasons, the study had multiple touchpoints with postpartum women: during the hospital stay; a two-week follow-up call; a three-week survey call for data collection to assess various postpartum issues (such as physical and emotional symptoms, self-confidence/management skills, social support); postpartum visit reminder calls; and another survey at six-months. The team was sensitive to the patients’ time and energy constraints by providing options to complete the survey by phone at a time convenient to them; by email; by mail (providing a self-addressed stamped envelope); or in-person at their postpartum visits. In addition, the team care coordinator tried to meet in-person with new mothers who received their care at the hospital clinic. This familiar face and continuity built trust and patient engagement among a group of high-risk postpartum women.

In sum, it is very beneficial to implement a patient-focused program of health care starting at the mother’s hospital stay for delivery. This is a window of opportunity that should not be missed in order to set families on a positive course of health from baby’s day one.

Amy Balbierz, MPH, is a program manager in the Department of Population Health Science and Policy and for the Blavatnik Family Women’s Health Research Institute. She has worked alongside Elizabeth Howell, MD, MPP, the founding Director of The Blavatnik Family Women’s Health Research Institute at the Icahn School of Medicine at Mount Sinai, on her NIH and RWJF funded research for the last 10 years.

The United States is the only first-world country where maternal mortality rates are rising. The number of maternal deaths in the United States has risen from 674 in 1990 to 1063 in 2015, and the maternal mortality ratio, the number of maternal deaths per 100,000 live births, has increased from 16.9 to 26.4 in the same years. This trend is disproportionately affecting black and Hispanic women, with increased rates for both maternal mortality and severe maternal morbidity compared to white women.

The severity of the situation has been publicized in the media and grabbed the attention of elected officials in Washington, who last year passed the Preventing Maternal Deaths Act.

On December 21, 2018, this act was signed into law to establish a federal infrastructure to collect data on every maternal death in every state to carefully review each of the contributing factors leading up to the death and all the data on it to establish strategies and best practices for prevention. But questions remain, and the topic is bound to arise during the upcoming elections.

The Preventing Maternal Deaths Act allocated federal funds and directed the U.S. Department of Health and Human Services to establish a program that directs the funds to five crucial tasks:

1. Review all maternal deaths
2. Establish and sustain a Maternal Mortality Review Committee (MMRC) in every state
3. Develop for every state a plan for ongoing health care provider education to improve the quality of maternal care, the dissemination of findings, and the implementation of recommendations
4. Distribute Maternal Mortality Review Information Applications (MMRIA) to every state MMRC
5. Provide public disclosure of information found in these review committees in the form of state reports

The passage of this act occurred due to the increasing rate of maternal deaths, their high preventability, and a shortage of reliable data. The goal of the new law is to standardize how each state handles maternal deaths in order to collect the best data available to establish recommendations and policies to prevent maternal death.

Anna Kheyfets is a Clinical Research Coordinator in the Department of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai.

An example of standardization is the creation of the Maternal Mortality Review Information Application (MMRIA) by the Centers for Disease Control and Prevention (CDC). Many states already have review committees, but there is great variability across states, resulting in data that is missing or not comprehensive. Not all states use the same definitions of maternal death or the contributing factors, nor do they have a common source of contributing factors or causes of death available for selection in their reviews.

While contributing factors can range from comorbidities to delay in treatment on the part of the provider, the very definition of what classifies a maternal death is still up for debate. Some review committees, along with the general MMRIA form itself that has been implemented by 33 states thus far, divide these deaths into “pregnancy-related” and “pregnancy-associated.”

If a woman was pregnant at the time of her death, or died up to one year after the termination of the pregnancy, this would fall into the umbrella category of pregnancy-associated. (The duration post-partum that is considered pregnancy-associated is another contested factor across varied definitions of maternal death.)

If the death occurs from a direct pregnancy complication or a sequence of events that occurs from pregnancy, such as the aggravation of an unrelated condition by the physiologic effects of pregnancy, then this death is pregnancy-related. If the death is not related to her pregnancy, then it is still pregnancy-associated but not related.

However, there is variation as to how maternal deaths are classified as pregnancy-related or not. Due to the lack of standardization, opportunities for prevention are difficult to identify, though we know they exist. With the MMRIA and the federal infrastructure behind the MMRCs, the CDC can identify solutions to improve health care quality and outcomes for mothers.

Several 2020 Democratic presidential candidates have already spoken out on policies that could reduce maternal mortality. There will be much more on this topic to look out for during these primaries.

Anna Kheyfets is a Clinical Research Coordinator in the Department of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai. Her work focuses  on hospital quality and racism and discrimination in maternal and child health care.

Haiti is the poorest country in the Western Hemisphere and has one of the highest infant and maternal mortality rates. Naissa Piverger, MPH, a Clinical Research Coordinator in the Department of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai, was born in Haiti, speaks the languages, and understands what it means to live below the poverty line. In this post, she comments on the significant challenges many women in Haiti face obtaining proper health care for themselves and those they care for.

Naissa Piverger, MPH, is a Clinical Research Coordinator in the Department of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai.

I grew up on a farm in a rural area in Haiti with my grandparents. We had limited resources, including access to necessities, but my grandmother managed to not only feed us, but also her surrounding neighbors.

Fast-forward seventeen years later, my parents and I immigrated to the United States for a better life.

My early educational experience in Haiti was vastly different from what I experienced in the United States.  I appreciate having these diverse perspectives as it allows me to have a broader worldview. Unfortunately, through the years, I often watched helplessly from a distance, as natural and man-made calamities caused people in my birth country to suffer.

After the 2010 earthquake, I had the opportunity to visit Haiti and witness the aftermath of these natural disasters.

During my visit, I reconnected with one of my neighbors.  Marie – a mother of seven children, including three she adopted – came to pick up vegetables from my grandmother’s garden. Surprised to see me, she noted “My goodness! Look how tall you’ve grown.”

I smiled and hugged her, noticing that she was holding a baby in a shawl wrapped around her. In addition to her own children, Marie was now caring for the three children of a friend who trusted her to do so after her death.  She confided in me about the struggles to feed and maintain the health of her children.

She stated, “There are no jobs, no food, and no medical infrastructure. If I want to take my kids to see a doctor, I would have to have the money upfront or else they will not see them. Haiti is polluted by political vagabonds, and they are not doing anything to help us, and as mothers if we are not strong enough for our kids, then who will be strong for them?”

Marie’s eldest child is a 14-year-old named Jessica. Marie taught Jessica to cook as a young child because in Haiti, cooking is a means of survival. “If something happens to me, I want her to be able to help her brothers and sisters,” she explained.

She mentioned that there were hundreds of women in her position: uncertain of when their next meal will be.  Many of these women relied on the rainy season to help with the growth of their crops and fruits, never losing faith in God when things did not go as planned.

“Malnutrition in childhood and pregnancy poses a serious threat to childhood survival and long-term well-being. Given this reality, the pressure for many women in Haiti is great as they manage the health of themselves and those they care for,” says Naissa Piverger, MPH.

My experience with Marie was truly rewarding and valuable. I was fortunate to have learned about the perseverance that carried her and many others despite the challenges they faced over the years.

According to USAID, 22 percent of the population in Haiti, including 264,000 children under five, suffer from chronic malnutrition (stunting or low height-for-age) and 66 percent, or 792,000 children under five, suffer from anemia in Haiti. The country’s political instability and extreme poverty leave the residents vulnerable to disasters. The continued exposure to poor infrastructure, food insecurity, natural disasters, and communicable diseases continues to make the population of Haiti at risk for acute and chronic malnutrition.

Malnutrition in childhood and pregnancy poses a serious threat to childhood survival and long-term well-being.  Given this reality, the pressure for many women in Haiti is great as they manage the health of themselves and those they care for.

Naissa Piverger, MPH, is a Clinical Research Coordinator in the Department of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai, where she focuses on maternal and child health. She is working on a first author manuscript examining the barriers and facilitators of active surveillance for prostate cancer. She is among the top four individuals selected to present manuscripts at the American Public Health Association’s Annual Meeting and Expo in the fall of 2019.