To address this shortage, we must incorporate midwives into obstetric care. Midwives are trained health care providers equipped to give prenatal care and deliver infants, allowing obstetricians to focus their care on patients who are at higher risk for morbidity and mortality. When midwives are involved in obstetric care, patients have lower C-section rates and decreased rates of preterm birth. However, among high-income countries, the United States has some of the lowest rates of midwives per 1,000 live births.
As an OB-GYN who has been practicing for 15 years, the way I was trained to treat many conditions, including hypertensive disorders of pregnancy, is no longer recommended. Doctors and other providers are not always aware of these changes. Much like the general population, pregnant women and new mothers need medical care that is evidence-based to ensure good health outcomes.
The Alliance for Innovation on Maternal Health, or AIM, is a quality improvement initiative designed to put in place and support best practices to reduce maternal morbidity and mortality. AIM in combination with state-based perinatal quality collaboratives, or P.Q.C.s, use patient safety bundles — evidence-based practices to ensure readiness, response and recognition for some of the leading causes of maternal morbidity and mortality — to ensure hospitals and providers are giving quality care. Through P.Q.C.s, states have seen fewer severe complications from hypertension and hemorrhaging and reduced rates of unnecessary C-sections. As of May, at least 27 states had C.D.C.-funded P.Q.C.s, and all states except Wyoming are enrolled in AIM. The Centers for Medicare and Medicaid Services has created the “birthing friendly” designation for hospitals participating in structured quality improvement programs and establishing patient safety bundles. To improve clinical quality of care, all birthing facilities should work to receive this designation.
Maternal outcomes are not determined by health care alone. What we call social determinants of health — where we live, work and play — also affect health outcomes. Social factors affect about half of health outcomes. When we think about maternal mortality, we should also look to economic stability, education access, health care access, neighborhood and the built environment and community.
Generations of racial residential segregation supported by unfair lending practices for home buying have perpetuated inequities for Black Americans. In minority neighborhoods, there is less access to health care and there are food deserts and environmental factors such as factories that have been linked to various negative health outcomes, including preterm births. Add to this decreased access to transportation, which leaves these mothers and families further removed from care.
Social determinants of health also play a critical role in the year after birth. A report from the Commonwealth Fund comparing maternal care in 11 wealthy countries found that the United States is the only one that does not guarantee home visits in the postpartum period. Ours is also the only high-income country that does not ensure paid maternity leave.