Maternal Morbidity and Mortality, Clinicians, and Public Health: An AJPH Supplement

There is increasing maternal morbidity and mortality¹ in the United States, and there are many reasons to be concerned. The CDC has reported that the maternal mortality rate increased from 17.4 deaths per 100 000 live births in 2018–32.9 in 2021. The CDC also reported that the maternal mortality rate for non-Hispanic Black women increased from 37.3 deaths per 100 000 live births in 2018–69.9 deaths per 100 000 live births, which is more than double the maternal mortality rate for non-Hispanic White women.² More than 20 nations reported maternal mortality rates in 2020 that were five to ten times lower than the US rate.³

Many factors may contribute to worsening health for pregnant people: the opioid epidemic, the Covid-19 pandemic, worsening income inequality, the emergence and growth of maternal care deserts in rural and densely populated urban areas, disparities in mortality among rural populations, intimate partner violence, and the persistence of health disparities by race, among other factors. More than 2.2 million women live in maternity care deserts in the United States.⁴

Public health outcomes and outcome improvement depend on factors beyond what we usually think of as public health science and practice. Public health science allows us to study how disease affects a population and identify interventions that improve measures of population health. Public health practice marshals resources at the local, state, and national level, in cooperation and collaboration with government, to identify and stop disease outbreaks, to prevent disease and injury, and to reduce morbidity and mortality.

However, public health outcome improvement also depends on clinical intervention and clinicians and their practices that bring evidence-based interventions to the individuals they serve. What clinicians do collectively matters. The type, training, number, and location of the clinical enterprises matter as well, and this has an impact on public health. This is true even though clinicians often do not consider themselves public health workers per se, and do not see themselves as using public health science or engaging in public health practice.

In this supplement of AJPH, prepared in collaboration with the Health Resources and Services Administration (HRSA), we begin to look under the hood of the clinical workforce as an engine of public health outcomes, focusing on maternal morbidity and mortality and on the public health science that will allow us to reduce maternal morbidity and mortality. These papers, drawn from the experience of individuals in the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services, examine interventions designed to test workforce and other approaches to reducing maternal morbidity and mortality.

The editorial by Sandvold et al. (p. S295) from HRSA describes the HRSA approach: under the authority of the federal Primary Care Training and Enhancement (PCTE) program, HRSA dispersed $16.1million in 31 awards during Fiscal Year 2021 for enhanced obstetrical training programs in the Primary Care Obstetrics and for Preventive Medicine residencies training primary care physicians in Community Prevention. This special section reports some of the results and findings of the awardees.

Meaningful studies of clinical interventions to reduce maternal morbidity and mortality need to address maternal health or related outcomes and not ancillary outcomes such as the satisfaction of clinicians or their confidence about their knowledge. Studies need a meaningful denominator if an intervention is to be meaningfully tested. They need rigorous designs, and we need to learn something useful and scalable to populations to be considered public health science.

Some of these interventions are early demonstrations of feasibility and have not yet been rigorously tested for population public health effectiveness and are published here as examples. Others are newly developed ways of measuring or modifying risk factors and have great promise if they can be scaled and delivered to the population of pregnant people.

James et al. (p. S330) used geographic information system (GIS) software to estimate driving distance (miles) from mothers’ residences in Conecuh County, Alabama to a hospital for 370 births, and found that most of these deliveries (81%) occurred 22–29 miles from mothers’ homes, but that 18% of deliveries occurred more than 70 miles from mothers’ homes, increasing the chance of adverse delivery outcomes.

Serpas et al. (p. S318) used a quality improvement process to increase from 23% to 80% the proportion of pregnant people screened for pre-eclampsia in a family medicine resident prenatal clinic. Results indicated that the proportion of patients prescribed low dose aspirin rose from 79% to 83% of the patients.

In a quality improvement study, Bakhai et al. (p. S322) showed an increase in COVID-19 vaccination rates over six months from a baseline rate of 30.8% to 60% among pregnant and six-months postpartum people in a marginalized population in a Federally Qualified Community Health Center in western New York.

Reported here are also examples of interventions that appear promising: an Extension for Community Healthcare Outcomes (ECHO) project provides ongoing professional development and support to health providers in rural and underserved areas of South Dakota (McCormack et al., p. S304); a family medicine obstetric track that was developed to train family physicians to provide maternity care services and address a maternity care workforce shortage in Oklahoma. (Charron et al., p. S314); a new training track for family medicine residents in Illinois prepared residents to provide evidence-based maternity care in rural and underserved communities, with an emphasis on higher-risk and surgical obstetrics (Khare et al., p. S312); added additional training in evidence-based care for substance use disorders to the usual course of study for family medicine residents providing maternity care (Squibb et al., p. S310); “Healthy Moms clinic” as a clinical practice site for a four-year combined Internal Medicine-Preventive Medicine (IM-PM) residency, with a focus on maternal health serving a high risk minority and often non-English speaking pregnant population, to facilitate the transition of these high risk patients to primary care in the IM-PM resident continuity clinic (Fuerdean et al., p. S316).

Also noteworthy, an interprofessional, multisituational, high-intensity simulations of obstetrical and neonatal emergencies was created for groups of family medicine residents and nursing students, training together in Texas (Garcia et al., p. S302); a Perinatal Resources for Opiate Use Disorder clinic staffed by family medicine-obstetric and Ob/Gyn attending physicians with backgrounds in addiction medicine, a clinic that included expanded perinatal and OUD treatment services provided by dedicated certified recovery specialists (CRS), behavioral health, social workers, pharmacists, and program coordinators, in which family medicine and Ob/Gyn residents, fellows in addiction psychiatry, family medicine addiction medicine, and medical students trained (DeMarco et al. created, p. S306); and physician trainees (family medicine obstetrics fellows and preventive medicine residents) deployed from four institutions to participate in Maternal Mortality Review Committees (MMRCs) to further their understanding of population maternal health (Miller et al., p. S308).

Much was learned from these HRSA-funded projects. Three studies used the quality improvement process to help expand the use of an evidence-based intervention to the population of a clinic or practice, taking a clinical process (quality improvement) and turning it into an effective public health intervention. This promising approach can be widely applied by clinical practices to help achieve meaningful but small-scale public health outcome improvements, understanding that we still need to find a way to scale these and other quality improvement interventions to all practices and all pregnant people to achieve meaningful population-level improvements.

There is no clear pathway to reduce maternal morbidity and mortality in a nation with a medical services marketplace but no organized health care system per se. To reduce maternal morbidity and mortality, we must identify risk factors for individuals as well as use the clinical enterprise to find individuals at risk and use evidence-based approaches to mitigate those risks. Moreover, we need clinical and public health workforces to address those risks, workforces that are adequately trained, supported, and sized. This includes clinicians, appropriately trained and supported, to identify the at-risk individuals in at-risk populations and bring adequately resourced evidence-based interventions to all who might benefit from intervention. These professionals, working in collaboration with an adequately trained and supported public health workforce, would be able to identify and arrest disease outbreaks and undertake public communication about risk factors and risk factor modification.

In the United States, we have many roadblocks to overcome before we can achieve these goals. An organized approach to bringing services to at-risk populations is wanting. Instead, we rely on a market-based approach and can only hope that purveyors of services have adequate financial or ethical incentives to encourage them to address the population at risk. In addition, we lack an evidence base that tells us which disciplines and clinical workforce sizes are effective in addressing the maternal risks the population encounters. Furthermore, we have no organized approach to workforce adequacy. No one is in charge of estimating the workforce we need to address the nation’s population, and no one is in charge of making sure we have enough students and trainees and enough places in health professions schools to ensure we have a right-sized workforce that can address the public health needs.

The United States has a long way to go to address its maternal morbidity and mortality crisis, and the many clinical challenges that face our population. In the United States, we often know what we need to do, but lack the workforce and logistical capacity to address the entire population with the public health science we have.