8 Ways Healthcare Attorneys Can Reduce Racial Disparities in Maternal Mortality

By: Marki Stewart, Coppersmith Brockelman PLC

Maternal mortality in the United States has more than doubled in the last 30 years—women living in the United States today are 50% more likely to die in childbirth than their mothers were a generation ago. Researchers estimate more than half of these deaths are preventable.

Alarmingly, the path to motherhood is significantly deadlier for women of color than it is for their white counterparts. Nationally, black women are three to four times as likely to die from pregnancy-related causes than white women, a disparity that has only widened in recent years.[i] Surprisingly, these disparities increase with age and education; data from the Centers for Disease Control and Prevention demonstrates that pregnancy-related deaths for black women with at least a college degree are five times higher than white women with a similar education.

Closer to home, the rates are likewise alarming. On October 22, 2021, the Arizona Society for Healthcare Attorneys (AzSHA) presented a panel discussion regarding the data in Arizona showing that women of color have higher rates of maternal mortality than their white peers. Native Americans have the highest maternal mortality rates in Arizona, at more than four times higher than white non-Hispanic women.[ii]

Although the causes of death vary—including cardiovascular diseases, hypertension, pulmonary embolism, and hemorrhage, among others—by and large, women die because they do not receive early, effective, and aggressive lifesaving treatment. Despite most preventable events being preceded by vital sign changes, structural racism and health care providers’ implicit biases may lead to delayed responses to clinical warning signs.[iii] A provider’s failure to quickly identify warning signs to rescue a pregnant woman or new mother can lead to catastrophic consequences.

Healthcare attorneys must help clients address this dire situation. Whether serving as general counsel for a hospital, counsel to a payor, or representing individual physicians or physician groups, attorneys can use their positions of power to influence key decisionmakers who directly impact this problem. Attorneys should impress upon their clients that increased maternal mortality for women of color is not only an issue of justice in healthcare, but any situation in which sub-standard care is provided also creates potential liabilities and must be urgently addressed.

Here are eight ways attorneys can leverage their influence to enact positive change:

1. Urge hospital leadership to participate in the Arizona Alliance for Improvement of Maternal Health Collaborative (AIM).
   
   Administered by the Arizona Hospital and Healthcare Association, AIM is a quality improvement initiative that helps hospitals implement Patient Safety Bundles, a series of evidence-based practices that reduce provider bias and ensure a timely and tailored response to a wide variety of objective clinical warning signs. In addition to addressing certain clinical symptoms, the Patient Safety Bundles address patient support, including standards for recognizing and treating perinatal depression and anxiety. Participating hospitals also provide valuable data to better understand the challenges in Arizona and track progress toward state and national goals.[iv]
   
   
2. Recommend that all hospital, physician, and physician group staff members interacting with patients receive implicit bias training on a recurring basis.
   
   Implicit bias training uses techniques to recognize and understand the magnitude of unconscious bias, helping to de-bias patient care. A variety of programs are available, and can be performed in-person or virtually, both free or for cost. The March of Dimes’ Breaking Through Bias in Maternity Care, a training session that can be done in-person or by virtual learning experience, provides an overview of implicit bias and personal assessment, strategies to mitigate racial bias in maternity care, and a plan for building a culture of equity within an organization.[v] Some healthcare organizations choose to perform internal implicit bias training sessions that are tailored to their needs.
   
   
3. Encourage hospitals and physician groups to hire health care providers of color.
   
   Tragically, as with their mothers, black newborns die at three times the rate of white infants in the United States. Research demonstrates that black newborns cared for by black physicians have 50% reduced mortality compared to black newborns treated by white physicians. Furthermore, racial concordance with one’s physician can increase health care utilization among under-resourced communities.[vi] If the hospital or physician group finds it difficult to recruit providers of color, encourage them to start a scholarship program to invest in young medical and nursing students of color.
   
   
4. Recommend hospitals and obstetric physician practices hire doulas and offer doula care to all pregnant women.
   
   Doulas are non-clinical professionals who provide physical, emotional, and informational support to mothers before, during, and after childbirth. Data shows doulas increase patient satisfaction with the birthing process, decrease the risk of C-section, and decrease the risk of newborns being sent to the NICU.
   
   
5. Advocate for hospitals and obstetric practices to consider offering group prenatal care, an alternative model of prenatal care delivered in a group setting for peer social support, skill building, and education.
   
   Women who participate in group prenatal care with other women at similar gestation ages receive approximately 20 hours of prenatal care over the course of their pregnancies, compared to approximately two hours in traditional individual care settings. The American College of Obstetricians and Gynecologists determined that group prenatal care resulted in reductions in pre-term birth and NICU admissions, increased birth weight for infants, decreased emergency department visits in the third trimester, and increased patient satisfaction.
   
   
6. Advise payors, such as private health insurers or AHCCCS, to adopt payment policies that are demonstrated to improve maternal care.
   
   Health insurers have a critical role to play because providers may not pursue necessary care if reimbursement will not follow. Payment policies that encourage good maternal care include an extension of AHCCCS coverage for pregnant women for up to one year after birth. Currently, when someone enrolled in AHCCCS gives birth, their coverage may expire just sixty days after their pregnancy ends, meaning that many low-income mothers are forced to forego necessary postpartum health care because they can’t afford the expense; indeed, almost 20% of maternal deaths occur 43 days to 1 year after delivery.[vii] Payors should also expand reimbursement for doulas, group prenatal care, home visits, and mental health treatment for pregnant and post-partum women. Some payors have begun to reimburse for implicit bias training, and others should follow suit. [viii] Payors can also provide outcome-based reimbursement incentives for providers to close gaps in maternal health.
   
   
7. Encourage hospitals and physicians to collaborate with the Native American community to address Native communities’ lack of access to care, and to offer care options that respect the community’s culture, values, and beliefs.
   
   The physical distance between Native American communities and hospitals makes it hard for Native women to access care; some studies show that Native American women have half as many prenatal visits as their white counterparts, making it difficult to identify health problems at an early stage. Hospitals and physicians can adopt a home visit program in which doulas, midwives, nurses, or social workers travel to the woman’s home to provide care and offer support on a wide variety of issues impacting social determinants of health.[ix]
   
   
8. Recommend physician and physician group clients participate in a variety of programs aimed at improving maternal care and eliminating racial biases.
   
   Excellent examples of existing programs and tools include:
   • The American College of Obstetricians and Gynecologists’ “Every mom. Every time.” program provides extensive training and guidance on clinical warning signs.[x]
     
   • The Association of Women’s Health, Obstetric and Neonatal Nurses’ Post-Birth Warning Signs Education Program teaches best practices on a variety of topics impacting maternal mortality, including disseminating information to patients to increase their recognition and response to life-threatening symptoms.[xi]
     
   • The Agency for Healthcare Research and Quality’s Toolkit for Improving Perinatal Safety aims to improve patient safety, team communication, and quality of care[xii], and its Guide to Patient and Family Engagement in Hospital Quality and Safety promotes better engagement between patients, families, and health professionals.[xiii]

The United States’ increasing maternal mortality rate, borne largely on the backs of women of color, has become a public health crisis that all players in the health care industry should work to improve, including health care attorneys. AzSHA is committed to continue addressing this issue, and we welcome our members’ feedback and insight into creative ways that attorneys can help. If you are interested in collaborating with other attorneys on this issue, please reach out to Marki Stewart, at mstewart@cblawyers.com.

[i] See Khiara M. Bridges, Racial Disparities in Maternal Mortality, 95 N.Y.U. L. Rev. 1229 (2020).

[ii] A 2017 report from the Arizona Department of Health Services’ Maternal Mortality Review Program

demonstrates that Arizona’s maternal mortality rate is at 25.1 deaths per 100,000 live births (2012-2015). This

ranks Arizona 25th in the nation. Native American/Indigenous women died at four times the rate (70.8

per 100,000 live births) compared to White non-Hispanic women (17.4 per 100,000 live births) despite

Native Americans representing only 6.0% of the births. The maternal mortality rate for Hispanic/Latina

women was 22.4 per 100,000 live births while the maternal mortality rate for Blacks, Asian, and Pacific

Islander women combined was 44.0 per 100,000 live births. See ADHS maternal Mortality Action Plan, June 2019, available at https://azdhs.gov/documents/operations/managing-excellence/breakthrough-plans/maternal-mortality-breakthrough-plan.pdf.

[iii] For additional information about health care providers’ implicit biases impacting their perception of pain and treatment plans for patients of color, see “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites,” Kelly M. Hoffman, et al., Proc Natl Acad Sci U S A. 2016 Apr 19; 113(16): 4296–4301, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/.

[iv] For more information about how to participate in AIM, see https://www.azhha.org/arizona_aim_collaborative.

[v] Further information about this training can be found here: https://ww.ahapac.org/system/files/media/file/2020/12/march-of-dimes-breaking-through-bias-maternity-care.pdf. Organizations can inquire about an in-person training session by completing this form: https://www.marchofdimes.org/professionals/implicit-bias-training-form.aspx.

[vi] “Physician-Patient Racial Concordance and Disparities in Birthing Mortality for Newborns,” Brad N. Greenwood, et al., PNAS September 1, 2020 117 (35) 21194-21200, available at: https://www.pnas.org/content/117/35/21194.

[vii] The Build Back Better package passed by the U.S. House of Representatives would mandate one year of postpartum Medicaid care. If enacted by the Senate without this provision, Arizona’s legislature would need to grant AHCCCS statutory authority to enact this change.

[viii] See https://www.forbes.com/sites/debgordon/2021/04/20/us-health-insurer-announces-new-plan-to-reduce-racial-disparities-in-maternal-health-by-50-in-five-years/?sh=3f6ad5b11ebd.

[ix] For more information on the benefits of home visits, see https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview. For information about reimbursement for home visits, see https://www.americanprogress.org/article/home-visiting-programs-vital-maternal-infant-health/.

[x] See https://www.acog.org/advocacy/policy-priorities/maternal-mortality-prevention.

[xi] See https://www.awhonn.org/education/hospital-products/post-birth-warning-signs-education-program/.

[xii] See https://www.ahrq.gov/hai/tools/perinatal-care/index.html.

[xiii] See https://www.ahrq.gov/patient-safety/patients-families/engagingfamilies/index.html.