Strategies to Promote Maternal Health Equity

Perinatal quality collaboratives are associated with improvements in obstetric outcomes and strategies to advance equity.

Abstract

Perinatal quality improvement is a method to increase obstetric safety and promote health equity. Increasing trends of maternal deaths, life-threatening complications of pregnancy, and persistent racial inequities are unacceptable. This Narrative Review examines the role and strategies of perinatal quality initiatives and collaboratives to deliver safe and equitable maternity care and the evidence of demonstrated success. Key strategies to promote maternal equity through perinatal quality include communicating equity as a priority through leadership, leveraging data and enhancing surveillance, engaging in strategic partnerships, engaging community, educating clinicians, and implementing practice recommendations through collaboration.

Rapidly rising maternal morbidity and mortality rates and persistent racial and ethnic inequities reinforce a national call to action to prioritize improvements in maternal health, safety, and equity.^1,2 The number of perinatal quality initiatives, particularly those led by state collaboratives, have increased in response to worsening maternal outcomes as a key strategy to reverse worsening trends.^3,4 These quality initiatives focus on reducing the leading causes of preventable pregnancy-related deaths. More recently, inequities in outcomes have become an additional focus for many perinatal quality-improvement (QI) efforts.^4,5

The 2021 maternal mortality ratio in the United States was 32.9 deaths per 100,000 live births and 69.9 per 100,000 live births for non-Hispanic Black (Black) people.⁶ Maternal deaths in 2021 increased for all racial groups, with the largest increase among American Indian or Alaska Native people.⁷ This increasing trend in maternal deaths preceded the coronavirus disease 2019 (COVID-19) pandemic but worsened due to COVID-19–associated perinatal mortality. Maternal mortality ratios increased from 17.4 (n=658) in 2018 to 32.9 (n=1,205) in 2021.⁶ The United States has not seen maternal mortality ratios this high since the 1960s, with stable ratios from 1982 through 1996 at 7.5 deaths per 100,000 live births.⁸

Maternal deaths are largely preventable, and outcomes can be improved through quality initiatives. A report from maternal mortality review committees in 36 states determined that 84% of pregnancy-related deaths were preventable.⁹ Eliminating preventable causes of maternal death and addressing racial inequities is an urgent public health priority.² Rates of severe maternal morbidity (SMM), defined as severe pregnancy complications with significant health consequences, are also rising and show persistent inequities.¹⁰ People who have Medicaid insurance and those who are Black, Indigenous, and rural experience SMM at greater rates.¹¹ For every maternal death, an estimated 50 to 100 people experience SMM.^10,12 Targeting SMM provides a more expansive and upstream set of opportunities to intervene.

Modifying hospital characteristics, such as system and health care professional factors, is a suggested approach to recognizing, managing, and preventing obstetric complications and reducing racial inequities in SMM.^13–15 In response, a growing national movement to leverage QI-based approaches has introduced perinatal quality collaboratives as a solution.^16–20 Perinatal quality collaboratives take action-oriented approaches to address maternal death, SMM, and inequities through perinatal QI, aiming to modify clinical system structures and care processes. In fact, three perinatal quality collaboratives have published findings from QI initiatives to target morbidity and address racial gaps that demonstrate their success in improving both diagnosis-specific morbidity rates and racial inequities (Table 1).^21–23 The purpose of this narrative review is to describe perinatal quality collaborative strategies that promote maternal safety and health equity.

Table 1.

Perinatal Quality Initiatives Achieving Equity

PERINATAL QUALITY COLLABORATIVES

Perinatal quality collaboratives are state-based networks of stakeholders working to improve maternal and infant outcomes, with the goal of achieving population-level effects by advancing evidence-based clinical practice through data-driven QI initiatives and collaborative learning.^19,24 Perinatal quality collaboratives partner with hospital teams and clinicians and their leadership, health departments, public health professionals, state hospital associations, risk-management organizations, health insurers, community organizations, birth supporters, maternal health advocates, patients with lived experience, and families to improve outcomes (Fig. 1). Currently, there are active or emerging perinatal quality collaboratives in all 50 states and Washington, DC.¹⁹

Fig. 1. Perinatal Quality Collaborative stakeholders and strategic partners.

Meadows. Promoting Maternal Equity Through Perinatal Quality. Obstet Gynecol 2023.

To address rising maternal death rates in the United States and support state-led interventions to improve reproductive health, stakeholder groups from across the country formed the National Partnership for Maternal Safety and the AIM (Alliance for Innovation on Maternal Health) Initiative, funded by the Health Resources and Services Administration.^16,17,19,20 The efforts of the National Partnership for Maternal Safety served as a catalyst for perinatal quality collaborative development.¹⁶ This organization developed materials, tools, and resources that became the AIM patient safety bundles. AIM partners with professional organizations (the American College of Obstetricians and Gynecologists; the Association of Women's Health, Obstetric, and Neonatal Nurses; the American College of Nurse-Midwives) and other maternal health–improvement groups to support perinatal quality collaborative formation and activities to implement bundles, maintain safety bundle resources, and provide a centralized data system for participation and sustaining engagement.^17,20

The National Network of Perinatal Quality Collaboratives is a national collaborative of state perinatal quality collaboratives that provides expertise to sustain perinatal quality collaboratives and foster sharing of projects and findings.^3,25 The Centers for Disease Control and Prevention (CDC) provides funding to the National Institute for Children's Health Quality to coordinate the work of this national collaborative. National and state programs that align with and complement perinatal quality collaboratives include the AIM program, maternal mortality review committees, the CDC's ERASE MM (Enhancing Reviews and Surveillance to Eliminate Maternal Mortality) program, and the CDC's Levels of Maternal Care initiative.^26–28 Across these groups, there are increasing opportunities to address maternal equity through perinatal QI. In 2022, the CDC funded 26 state perinatal quality collaboratives to implement perinatal QI projects to address inequities in maternal and infant outcomes.

PERINATAL QUALITY INITIATIVES ARE ACHIEVING EQUITY

Three published articles highlight the success of perinatal QI to reduce or eliminate racial inequities (Table 1). In 2020, Main et al at the California Perinatal Quality Collaborative implemented a collaborative QI project across 99 birthing facilities in California to eliminate preventable morbidity related to obstetric hemorrhage. The team reported decreased rates of SMM-hemorrhage across all racial groups, with a reduction in the Black–White racial gap in SMM rates after adjusting for sociodemographic and clinical factors.²¹ Similarly, Davidson et al found a decrease in SMM for all groups and a reduction in the Black–White racial gap among SMM-hemorrhage rates after implementing an obstetric hemorrhage patient safety bundle.²² In this study, the reported findings are from one hospital that participated alongside other hospitals in the Texas Perinatal Quality Collaborative's obstetric hemorrhage initiative. Another study, by Hamm et al²³ in 2022, reported significant reductions in maternal morbidity for Black patients after implementing a perinatal QI project to target racial inequities in obstetric hemorrhage.

SIX STRATEGIES TO PROMOTE MATERNAL EQUITY THROUGH PERINATAL QUALITY

This narrative review explores the contribution of QI projects in hospitals, health systems, public health departments, or state perinatal quality collaboratives to address equity in maternal outcomes. From existing literature, we identified six equity-promoting QI strategies and characterize each using a classification system based on Bingham's ABCDE’S of QI Strategies and Tactics listed in Box 1 (https://www.perinatalqi.org/page/ABCDESImplementationStrategiesTactics).^29,30 A strategy is defined as a high-level plan to accomplish a goal, whereas a tactic refers to the specific actions taken to execute that plan and achieve the desired outcome. Bingham's ABCDE'S is primarily a reorganization of ERIC (Expert Recommendations for Implementing Change) in QI initiatives, with examples of how to implement tactics through a racial justice and equity lens. The strategy categories are A—Accountability, B—Buy-in (incentives or disincentives), C—Collaboration and Communication, D—Data, E—Education, and S-Structure Changes.³⁰ Table 2 summarizes the six maternal equity–promoting strategies, incorporating annotations from the ABCDE’S. These annotations serve to bring clarity to the significance and relevance of each strategy described.

Box 1. Bingham's ABCDE’S of Quality-Improvement Strategies and Tactics.

• A—Accountability

  • • Conduct cyclical small tests of change*

  • • Change accreditation or membership requirements*

  • • Create or change credentialing and/or licensure standards*

  • • Obtain formal commitments*

  • • Obtain and use patients/consumers and family ([and community] input and) feedback*

  • • Place innovation on fee for service lists/formularies*

  • • Provide performance reviews

  • • Provide clinical supervision*

  • • Revise professional roles*

• B—Buy-In (incentives/disincentives)

  • • Access new funding*

  • • Alter incentive/allowance structures*

  • • Alter patient/consumer fees*

  • • Develop disincentives*

  • • Increase demand*

  • • Change liability laws*

  • • Make billing easier*

  • • Use other payment schemes*

  • • Use capitated payments*

• C—Collaboration and Communication

  • Collaboration

    • • Co-create the solution(s) with the community or population that the initiative is trying to have a positive effect on

    • • Intervene with patients/consumers to enhance uptake and adherence*

    • • Identify early adopters*

    • • Identify and prepare champions*

    • • Involve executive boards*

    • • Involve patients/consumers and family members*

    • • Build a coalition (peer support and peer Pressure)*

    • • Conduct local consensus discussions*

    • • Develop academic partnerships*

  • Communication

    • • Meetings

    • • One-to-one discussions

    • • Academic detailing discussions

    • • Remind clinicians*

    • • Share information in a public and transparent manner

    • • Provide ongoing consultation*

    • • Arrange disciplinary discussions*

    • • Capture and share local knowledge*

    • • Centralize technical assistance*

    • • Develop a formal implementation blueprint*

    • • Mandate change*

    • • Model and simulate change*

    • • Organize clinician implementation team meetings*

    • • Promote adaptability*

    • • Promote network weaving*

    • • Use mass media*

    • • Involve executive boards*

    • • Use advisory boards and workgroups*

    • • Use an implementation advisor*

    • • Visit other sites*

    • • Create truth & racial healing circles

    • • Capture and share the experiences of the individuals who are interacting with the organizations or institutions

• D—Data

  • • Assess for readiness and identify barriers and facilitators*

  • • Complete audits and provide feedback*

  • • Use data sharing and benchmarking

  • • Use public release of data

  • • Provide data reports

  • • Conduct local needs assessment*

  • • Develop and organize quality monitoring systems*

  • • Use data experts*

  • • Facilitate relay of clinical data to providers*

  • • Involve executive boards*

  • • Use data warehousing techniques*

  • • Purposely reexamine the implementation*

  • • Stage implementation scale up*

  • • Tailor strategies*

  • • Collect and display race ethnicity data for all implementation efforts

  • • Make what is currently less visible more visible

• E—Education

  • • Conduct ongoing training*

  • • Set up classes, present at conferences and grand rounds, provide webinars

  • • Provide simulation training

  • • Present at competency fairs

  • • Use tests

  • • Provide demonstrations

  • • Provide on-line education

  • • Conduct educational meetings*

  • • Inform local opinion leaders*

  • • Use train-the-trainer strategies*

  • • Work with educational institutions*

  • • Conduct educational outreach visits*

  • • Develop an implementation glossary*

  • • Develop educational materials*

  • • Distribute educational materials

  • • Facilitation*

  • • Make training dynamic*

  • • Prepare patients/consumers to be active participants*

  • • Provide local technical assistance*

  • • Recruit, designate, and train for leadership*

  • • Shadow other experts* & individuals

• S—Structure Changes

  • • Change physical structure and equipment*

  • • Change record systems*

  • • Change service sites*

  • • Create a learning collaborative*

  • • Create new clinical teams*

  • • Develop and implement tools for quality monitoring*

  • • Develop resource sharing agreements

  • • Fund and contract for the clinical innovation*

  • • Start a dissemination organization*

  • • Power sharing and power building

Table 2.

Six Strategies to Promote Maternal Equity Through Perinatal Quality

1. Communicate Maternal Equity as a Priority Through Leadership

Leadership can empower health professionals to innovate and improve the quality of care they provide. Approaches include making equity a strategic priority within the organization; acknowledging the effect of racism on health outcomes; investing resources to educate staff and implement perinatal QI initiatives; fostering collaboration with health departments, hospitals, and community stakeholders; and developing performance data systems that accurately capture and report inequities.^5,23,31–34 In 2001, the Institute of Medicine named “equity” as an essential domain of quality, defining quality health care as safe, efficient, effective, timely, patient-centered, and equitable.³⁵ One approach to establishing and monitoring a culture of equity within health systems is to create a multidisciplinary, departmental health equity committee within obstetrics that engages members of the communities served.^34,36 Leadership-based, equity-focused strategies and tactics may be effective in increasing accountability, buy-in, communication, and collaboration, as well as improving data systems to monitor outcomes and experiences for all populations.

2. Leverage Data and Enhance Surveillance

An overarching goal of perinatal QI is to make measurable improvements in maternal care through collection and analysis of data. Leveraging data and enhancing surveillance of outcomes improves maternal health equity by identifying gaps in care among populations, particularly when stratified by demographic identifiers such as REaL (race, ethnicity, and language), SOGIE (sexual orientation, gender identity, and gender expression), SDOH (social determinants of health), and geographic locations.³⁷ For accurate accounting, data should be complete and demographic identifiers should be self-reported.³⁸ Presenting these data increases team awareness and accountability to people at risk for disparate outcomes, encourages targeted interventions, and helps track measures over time for progress. A data dashboard that includes run charts is a useful tool to visualize this information. In 2011, the California Perinatal Quality Collaborative established a real-time data system stratified by REaL using birth certificates, hospital discharge files, performance measures, and additional quality tools to engage teams and monitor performance and progress of QI initiatives.³⁹ Including patient-experience data could enhance data dashboards by identifying the needs of individual patients and ensuring that care is respectful.

In addition to data systems and dashboards, perinatal quality collaboratives can apply findings from state SMM data, maternal mortality reports, and other tools from the state health departments to inform project selection and strategies. Maternal mortality review committee reports can provide insights into risk factors associated with maternal deaths beyond clinical findings, with incorporation of a community context through SDOH and other indicators to inform policy recommendations.⁴⁰ In 2021, the Massachusetts Department of Public Health developed a Racial Equity Road Map (https://www.mass.gov/service-details/racial-equity-data-road-map) as a collection of guiding questions, tools, and resources to assist teams with taking actionable steps to better identify and address racial inequities.⁴¹ This tool includes recommendations to review data with historical, social, and structural context and creates a plan to act on health care practices that are unjust.

3. Engage and Collaborate with Strategic Partners

Partnerships are central to perinatal quality collaborative initiatives. By engaging a diverse set of partners (Fig. 1) in perinatal QI, perinatal quality collaboratives and stakeholders can collaborate to leverage resources, expertise, and networks to identify and address inequities, communicate efforts broadly, build capacity through education and trainings, and deeply engage communities to bring local knowledge and expertise to project success.^{4,5,32,39,40,42–48}

The California Perinatal Quality Collaborative described partnerships as a key to success through an example of partnership with the March of Dimes. This partnership allowed for nationwide dissemination of clinical toolkits created and published on their website.³⁹ Professional organizations also have been important for perinatal quality collaborative support. The Association of Women's Health, Obstetric, and Neonatal Nurses formed a strategic alliance with AIM to support nursing engagement in patient safety bundle selection, modification, implementation, data collection, and performance reporting.¹⁷

4. Collaborate With and Listen to Patients and Members of the Community

Engaging patients and communities in the design and implementation of interventions to improve maternal and infant health outcomes is crucial to addressing equity through perinatal QI. This includes incorporating patient feedback in QI-initiative selection, integrating lessons learned from patient-reported experience measures, and working with community organizations to enhance community resources to improve pregnancy outcomes.^{5,31,34,39–43,45–47,49} Engaging patients and families in project governance, including QI health equity committees, is also recommended.³⁴ Increasing opportunities for accountability, collaboration, communication, education, and changes in health care structures are merits of this strategy.

5. Educate Clinicians

Perinatal quality collaboratives provide education and training to clinicians to improve their knowledge and skills to provide equitable care. Trainings include 1) clinical updates on evidence-based practice; 2) QI tools and methodology; 3) data trends and roots of inequities in society, and 4) the effect of implicit bias, explicit bias, and racism on maternal outcomes.^{4,5,21–23,31–34,39,42,45,48–51} Often perinatal quality collaboratives provide educational opportunities through webinars and annual meetings. This education can also be integrated into traditional departmental education, such as continuing education series, trainee curriculum, morbidity and mortality rounds, and grand rounds.^36,52 In 2021, Arrington et al³⁴ reported an increase in health care professional attribution as a measure of readiness to address health inequities, after engaging 65% of the labor and delivery staff in events to raise awareness of health inequities and bias through social events, grand rounds, and synchronous and asynchronous learning.

6. Collaborate to Implement Best Practices

Perinatal quality collaborative initiatives are grounded in collaborative learning, team implementation of standardized protocols to improve care quality, and data systems for rapid collection and analysis of real-time data to track and compare progress. The goal of this combination is to drive rapid-cycle change. The collaborative approach allows optimal engagement of clinical teams, expands the knowledge base to assist clinical teams, unifies the project approach, and increases the opportunity to achieve clinical culture change.^{4,5,21–23,31,34,39,41,48,49}

Implementation of maternal safety bundles includes a prescriptive checklist for protocols, processes, trainings, and algorithms to minimize variation in practice. AIM patient safety bundles target the leading causes of maternal mortality. Each bundle contains five sections, each with recommendations and resources for implementation: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful Care.²⁰ Measures used to track progress are based on the Donabedian⁵³ conceptual model of structure, process, and outcome measures. Structure measures evaluate what hospital units have built, such as tools and processes. Process measures demonstrate the utility of the structures that have been built, such as rates of use or completion. Processes also measure what care is provided. The outcome measures are the results of interest, such as SMM. To target inequity, Howell and Zeitlin suggested criteria from the National Quality Forum to incorporate disparities-sensitive measures into perinatal QI (Fig. 2).^50,54

Fig. 2. Criteria for disparities-sensitive measures. Data from National Quality Forum. Healthcare Disparities and Cultural Competency Consensus Standards Technical Report September 2012. Available at:

https://www.qualityforum.org/Publications/2012/09/Healthcare_Disparities_and_Cultural_Competency_Consensus_Standards_Technical_Report.aspx. Accessed June 29, 2023.

Meadows. Promoting Maternal Equity Through Perinatal Quality. Obstet Gynecol 2023.

Open sharing of real-time measurement trends is an important component of improvement work. Perinatal quality collaboratives collaboratively review trends to encourage participation and motivate action.^4,39 The Institute for Healthcare Improvement's model for improvement is a QI process that is often used by perinatal quality collaboratives to guide implementation of QI initiatives.⁵⁵

LIMITATIONS OF PERINATAL QUALITY COLLABORATIVES AND PERINATAL QUALITY IMPROVEMENT FOR PROMOTING MATERNAL EQUITY

Although state perinatal quality collaboratives and perinatal QI projects have demonstrated success in improving perinatal outcomes and maternal equity, there are limitations. Perinatal quality collaboratives may have 1) limited funding to fully scale and sustain projects and 2) limited QI skill and knowledge among clinicians and stakeholders, both of which can hinder QI efforts.⁵⁶ In addition, few perinatal quality collaboratives have centralized data systems, and collaborating health care systems may have data sets with incomplete or inaccurate demographic information. Bias may be introduced into the project design and implementation if there is limited representation and participation among stakeholders from target communities and minoritized populations. As well, perinatal quality collaboratives are uniquely positioned to address the differential in care quality more so than the differential in access to care, which also contributes to health inequity. Perinatal quality collaboratives have dissemination limitations facing publication challenges, because implementation outcomes of QI projects often do not fit the traditional structure of scientific papers for publication in medical journals. As a result, the strengths of perinatal quality collaboratives, such as collaboration and data-driven population health improvement, go unrecognized, limiting opportunities to provide insights for future implementation efforts. To further highlight the potential benefits of perinatal quality collaboratives to achieve and sustain health equity, more published studies of implementation outcomes, particularly effectiveness, are needed.

CONCLUSION

Perinatal quality has emerged as a promising approach to reversing trends and promoting health equity, as evidenced by recent literature demonstrating reductions in diagnosis-specific maternal morbidity and racial disparities resulting from implementation efforts.^21–23 By implementing these described strategies, these initiatives and perinatal quality collaboratives have the potential to create a culture of equity. A culture of equity is established when health care systems, teams, and individuals share a collective commitment to value and actively ensure the provision of care and support necessary for all individuals to achieve optimal health outcomes. Continued investment and engagement may further amplify the clear and compelling value that perinatal quality collaboratives and perinatal quality initiatives bring to advancing equity.