Maternal health leaders discussed the struggles they face in the field and ways to improve access at the 2023 Tennessee State of Reform conference last month.
Judith Nowlin, chief executive officer of Nest Collaborative and moderator of the panel, opened with some statistics.
“Over the past 15 years, maternal mortality has doubled in our nation,” Nowlin said. She also noted that the obstetrician shortage in the US is exacerbating the issue.
The Tennessee Department of Health’s (DOH) 2023 Maternal Mortality Report report revealed that pregnancy-related deaths rose significantly between 2017 and 2021. The pregnancy-related mortality rate grew from 27.2 deaths per 100,000 live births in 2017 to 64.9 deaths per 100,000 live births in 2021.
The report also said that in terms of pregnancy-related deaths, Black women were 2.3 times as likely to die as White women; women aged 30 to 39 years were more than twice as likely to die as younger women; women with TennCare were 1.8 times as likely to die from pregnancy as those with private insurance; and women in West Tennessee had a higher ratio of pregnancy-related deaths than those in other areas.
Danielle Tate, MD, the maternal medical director at the Tennessee Initiative for Perinatal Quality Care, referenced the statistics in the report and discussed why maternal health is a problem that should be included in all aspects of healthcare.
“Pregnancy-related talks are always appropriate for any level of care—when you talk about society, when you talk about community, because pregnancy is always going to be present. So how can we pull our resources together to make sure we’re taking care of the population?”
— Tate
Tate identified communication as an issue in the field, a lack of which leads to unawareness of services that are already available.
“There are so many great programs that are affiliated with our healthcare providers here, as well as our payers, that a lot of times are not known,” Tate said. Oftentimes, she added, providers may not even know of a new service, so they do not refer their patients to it.
Michael Poku, MD, chief clinical officer at Equality Health, said access is a leading issue in the maternal health space.
He told a story about a community health worker team at his organization that identified a woman in her third trimester of pregnancy who had not received prenatal care. Poku explained that the woman said, “I know I should be doing prenatal care but nobody is helping me with all these other pieces.”
“She really struggled to navigate the health and human services system,” Poku said. He explained patients are often educated on what they should be doing, but it can be difficult to access care because of the way the system is set up now.
Poku went on to emphasize the importance of care throughout the entirety of the pregnancy, as well as postpartum connectivity. The maternal mortality rate referenced in the Tennessee DOH maternal mortality report includes deaths occurring up to one year after pregnancy, showing the importance of continuation of care postpartum.
The most common reason for postpartum mortality is cardiomyopathy. Mental illness is also a factor—between 6.5 percent and 20 percent of women develop postpartum depression, and up to 20 percent of postpartum deaths are due to suicide.
Kate Condliffe, co-founder and chief executive officer of Diana Health, referenced her experience with a patient who had come into the clinic waiting room twice before her actual visit, but left before being seen. This happened because the woman had anxiety about seeing providers; she had not seen one in five years due to past sexual trauma.
Providers assessed the woman and connected her to social services in her community.
In the traditional system, Condliffe said patients often feel rushed and ignored, and providers do not have the resources to provide necessary follow-up care. The best way to improve the system, she said, is to have “care that starts with listening to women, care that is highly individualized, and care that takes a whole health approach.”
“We need to fundamentally restructure the way our care models are set up.”
— Condliffe
Tate said there is an “elephant in the room” regarding efforts to increase access to care, which she called the “business of medicine.”
“The business of medicine is going to tell me as a provider that I need to be somewhere that I can afford to pay my student loans back, or to be in a system that’s going to support me,” Tate said.
She said that means providers may not want to be in a rural area where they will not make as much money, or that they can only spend 10 minutes with a patient, even if they are in need of more time, because they have to move on to the next patient.
At Equality Health, Poku said they incentivize providers to spend more time with patients, rather than moving them quickly from patient to patient to get more money. “We’ll say, ‘You should actually be seeing the person and spending more time, and we’re going to actually pay you to be able to do that,” Poku said.
“Financial alignment with the ‘right thing to do’ is so critical.”
— Poku
Nowlin asked the panelists what they would ideally like to see in 2024 policy reform work.
Tate discussed the idea of “access for all.” It may look different depending on the person, she said, like telehealth, transportation, or a different type of provider, but ideally, everyone would have access to the healthcare they need.
Poku thought a combination of policy would be best, including a measurement framework and a reimbursement plan, so providers are incentivized and able to spend more time with their patients to meet their needs better. He also wants to start “migrating to a comprehensive, whole-person care approach.”
Condliffe said it would be ideal to have a shift in the mindset of policy workers so they are willing to invest in the long term. The long term, she said, includes implementing more preventative care.