Maternal health disparities are deeply rooted and multifaceted, affecting public health, individual health and society — and they can be improved via the healthcare setting. Considering this issue’s close link to patient safety and quality, which have drawn a tremendous amount of attention and process improvement efforts in recent years, maternal health disparities continue to largely fly under the radar.
Becker’s Hospital Review recently spoke with Khadeja Haye, MD, TeamHealth’s national medical director of obstetrics and gynecology, about the causes and impacts of maternal health disparities, the role that implicit bias plays in reinforcing these disparities and how organizations can mitigate disparities and biases by establishing processes that standardize care for all patients.
The issues that Dr. Haye discussed exist within the context of broader health disparities, which are health differences between people rooted in social, economic or environmental disadvantage.
Maternal health disparities are growing.
Maternal health disparities refer to differences in health status among pregnant women that are often exacerbated by healthcare-related factors, such as lack of access to care, deficient care or inequitable treatment due to implicit bias.
The most adverse expression of this type of disparity is maternal mortality. According to the National Center for Health Statistics, in 2021 the maternal mortality rate in the U.S. was 32.9 deaths per 100,000 live births, a 38 percent increase from 2020 (23.8 maternal deaths per 100,000 live births) and a 64 percent increase from 2019 (20.1 maternal deaths per 100,000 live births).
“These rate increases are why the conversation around maternal health disparities is getting so much more focused,” Dr. Haye said. “We understand maternal health disparities have a direct impact on the rising maternal mortality rates in the U.S.”
The causes of maternal health disparities are multifactorial
There are many factors at play that impact maternal health disparities. Key among them are social determinants of health, which include transportation, food, economic stability, education, community and the healthcare system itself.
“If someone is subjected to food insecurity, it impacts how they work and live or — if they go to school — how they focus on their education, which impacts their ability to earn an income, which impacts their ability to get a good-paying job that has insurance, which impacts the care they receive and their access to care,” Dr. Haye said, tracing food insecurity’s chain of effects and impact on health disparities.
Economic discrepancies are another common reality for patients from disadvantaged backgrounds, which often cause many individuals to forego necessary care. This can have especially pernicious effects when it comes to maternal and prenatal care. “Women with fewer resources are less likely to access prenatal care early, and we know that early access to prenatal care has an impact in terms of outcomes,” Dr. Haye said. She noted that women with limited access to care tend to have more “catastrophic” presentations.
However, factors that contribute to maternal health disparities are not only on the patient side; they can also come from healthcare institutions and providers themselves. One example is implicit bias, which is a pervasive issue in healthcare and refers to deeply held beliefs that may cause one to act favorably or dismissively toward people of a particular gender, age, race or ethnicity. “Implicit bias shapes how we view and interact with patients, which shapes the care we provide to them and ultimately impacts outcomes,” Dr. Haye said.
Another healthcare variable that influences maternal health disparities is care quality. Research suggests that hospitals in communities with a higher percentage of Black residents tend to be associated with a higher risk of severe maternal morbidity compared to hospitals in communities with lower minority populations. In addition to minority women and women with low incomes, those in rural areas tend to be heavily affected by maternal health disparities.
There is a great deal that providers can do to address maternal mortality and maternal health disparities
For providers, the first step to mitigating the effects of health disparities on maternal health and maternal mortality is awareness in recognizing there is a problem. Becoming aware and educating themselves on the topic and all of the factors that negatively impact maternal health disparities is a must-do for providers who wish to do right by their patients.
The second step is for clinicians to recognize their own implicit biases and do what they can do to address them — on an individual level. Dr. Haye gave an example of how a physician who is conscious of existing disparities and his or her own potential biases might act: “Two patients can present the exact same way but if you have a bias for the one who might be uninsured or has less access to care . . . you may treat them differently, which ultimately impacts their clinical outcomes.”
The third step is putting measures in place to mitigate biases at the system level. This can be achieved by standardizing care through establishing protocols and procedures, as well as conducting drills and simulations aimed at hardwiring how a patient who presents a certain way should be treated every time. With this systemic approach, there should also be an emphasis on seeing the patient as a person and not just as a collection of medical symptoms and concerns.
“There are so many different contributing factors in patients’ lives that have brought them to this point, in which they are presenting in front of you,” Dr. Haye said. “Take the time to ask questions, take the time to avoid making assumptions and really delve a little deeper into them as a whole person so that you can address all of their needs — not just the medical.”
Clinicians should be asking patients who appear vulnerable whether they have stable housing or reliable transportation, so that it can be taken into account in treating the patient as a whole person.
Clinical education partnerships can help providers effectively address maternal health disparities
Despite growing awareness and a sense of urgency around addressing maternal health mortalities, progress has been slow. To move beyond raising awareness to taking action, healthcare organizations need a system that standardizes care and reduces variability in how vulnerable patients are treated. TeamHealth provides educational training and leadership development to clinicians committed to being part of the solution in addressing maternal health disparities.
“From an educational standpoint, the goal is to help physicians understand how best to treat these patients and how to help organizations improve communication between team members, so that when they are faced with a patient emergency in real time, it all functions like a well-oiled machine — they know what to do and they do the same thing every time,” Dr. Haye said.
The approach she alluded to, standardization of care processes, is a time-honored best practice in the healthcare industry and in the care quality movement, but it has not necessarily been applied to reducing maternal health disparities.
To that end, Dr. Haye said it is important to provide clinicians with practical tools to help them address disparities, which is the heart of what TeamHealth does in partnership with healthcare organizations. “We are giving a charge to all of our clinicians to address their own biases and consider what they can do with respect to health disparities on a personal level, just taking it one step at a time,” Dr. Haye said. “Ultimately, that is how we’re going to address health disparities — everybody being committed to doing just one thing, taking one step at a time.”
Dr. Haye added that TeamHealth also reinforces the importance of provider organizations hiring with diversity in mind; research has long established that patients’ health outcomes are correlated with being treated by clinicians who reflect their demographics. “When a patient is treated by a racially concordant physician, in particular in the Black community, it does improve outcomes around cardiovascular disease and infant mortality,” Dr. Haye said. TeamHealth practices what it preaches by being mindful and intentional in its own hiring practices and paying special attention to diversity, Dr. Haye added.
Conclusion
Maternal health disparities have plagued marginalized communities for decades. However, it is only now that healthcare organizations are looking at this problem critically and appraising the role and responsibility they have in reversing this trend.
“As clinicians, our goal should be to show up in the best way that we can to meet the needs of the patients and deliver the type of care they deserve,” Dr. Haye said. “Part of that requires taking ownership of ourselves and finding ways in which we can help to address health disparities one patient at a time. We all came into healthcare to do a great job by our patients, and part of that is combating health disparities.”
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