What The Rest Of The U.S. Can Learn From A Small North Carolina Maternal Health Program

Efforts to drive down the rates of maternal mortality in the U.S. tend to focus on how doctors and hospitals can change the way they administer medical care. Yet research shows that things like loving relationships, safe homes and being part of a fair and equitable community also play an important role in whether a woman has a positive experience with pregnancy and giving birth.

So experts were heartened by a pair of complementary bills, announced over the past week, that tackle this problem from both sides. The most recent national proposal, a bill from Sen. Kirsten Gillibrand (D-N.Y.) announced Tuesday, would give money to states and hospitals who need help standardizing their childbirth and postpartum treatment plans to evidence-based best practices, and would help maternal mortality review committees investigate deaths to figure out how they can be avoided in the future.

These kinds of quality improvements dominate the national debate about how to improve maternal care. California, for example, has managed to cut maternal deaths by more than half since 2006, while the rest of the country’s maternal mortality rate continues to rise. Experts attribute this to the state’s maternal quality care collaborative, a network of hospitals and public health agencies that share real-time data in the hopes of improving performance on preterm births, cesarean sections and other factors that can complicate a woman’s care.

But focusing solely on the medical care delivered at a hospital doesn’t address the nine months of prenatal care a woman typically receives during her pregnancy, as well as the postpartum period in which she is at a high risk of medical complications related to birth.

A different bill, proposed by Sen. Kamala Harris (D-Calif.) last week, takes an unusual approach by focusing on the community and social stressors that might make pregnancy more dangerous for women, especially women of color. It suggests that investing more money to improve the quality of these mothers’ lives may also help avoid birth-related complications and deaths.  

Given their late introduction in the legislative session and the lack of support from Republican senators, both bills have a slim chance of passing the Senate. But they could be poised to move quickly if the Democrats win a majority in Congress. If that happens, would Harris’ plan to focus on the social factors affecting pregnancy and childbirth work? One modest state program could give us a preview.  

Things like loving relationships, safe homes and being part of a fair and equitable community also play an important role in whether a woman has a positive experience with pregnancy and giving birth.

A portion of Harris’ bill relies heavily on the architecture of an innovative social program in North Carolina called a pregnancy medical home. It incentivizes doctors to screen every woman on Medicaid at their first prenatal appointment and assign them a pregnancy care manager if they’re deemed to be at high risk for a dangerous birth, whether for medical issues like a history of stillbirths, or for social issues like intimate partner violence or homelessness. Harris’ bill would replicate this by awarding $ 25 million to up to 10 states to create their own version of the pregnancy medical home.

When North Carolina’s Medicaid agency launched this initiative in 2011, it wasn’t even thinking about maternal mortality, said Dr. M. Kathryn Menard, one of the co-founders of the North Carolina program and the director of Maternal-Fetal Medicine at the University of North Carolina School of Medicine. Instead, the goal was to keep Medicaid costs down by preventing preterm births and cesarean sections.  

But one fascinating side effect of the effort may be that it helped to narrow the gap between black and white women in terms of maternal mortality.

Harris’ bill notes that in 2004, pregnancy-related deaths of black women in North Carolina were five times higher than those of white women. But by 2013, the latest year for which statistics are available, the gap disappeared. Black women’s maternal mortality rate declined to a rate of 24.3 deaths per 100,000 live births, while the maternal mortality rate for white women saw a slight uptick, to 24.2 deaths per 100,000.

Meanwhile, in the rest of the U.S., black women die from pregnancy-related causes at a rate that’s three times higher than that of white women.

These results caught the attention of Harris’ office, which confirmed to HuffPost that it mentioned North Carolina’s program because it’s the only statewide approach connecting the social issues affecting the health of mothers and babies to the prenatal care the mother receives. 

How The Program Works

Every woman who is on North Carolina’s Medicaid plan, a safety net health insurance program, is supposed to answer a short two-page questionnaire during her first prenatal visit about factors in her life that have been linked to riskier births. These could be medical, like a history of stillbirth, hypertension or substance abuse, or social, like questions about homelessness, domestic violence or recent sexual trauma.  

These social issues connect directly to maternal and infant survival. Going hungry could lead to intrauterine growth restriction, which is when the fetus doesn’t grow and thrive in the womb. Domestic violence endangers the lives of both mother and child. High levels of the stress hormone cortisol have been linked to premature birth and low birthweight. And studies suggest that a lifetime of racism could account for African-Americans’ poorer birth outcomes compared to those of recent African immigrants.

Doctors are reimbursed $ 50 for going through the questionnaire with patients at their first prenatal appointment ― an incentive that results in about an 80 percent screening rate, said Menard. 

Then women who score high on this risk assessment are paired up with pregnancy case managers, who meet with them monthly or weekly throughout their pregnancies to check up on them and try to help them surmount any barriers standing in the way of their prenatal appointments.

Care managers help connect women to counseling, sign up for food stamps or put them in touch with charities that give away cribs and car seats. They can also help them work on longer-term goals, like finding a new job, housing or going back to school before the baby arrives.

Finally, once a woman gives birth, the same care manager helps the woman make a postpartum appointment with her doctor, acquire any contraception she may need while adjusting to parenthood, and then transitions the woman to a primary care provider. Nationwide, only about 40 percent of women see their OB/GYN within three months of giving birth.

In all, more than 25,000 women ― almost 50 percent of all pregnant women on Medicaid in North Carolina ― were part of the pregnancy medical home program in 2017. 

I hope they’ll learn from our experience and call on us so that they don’t make the same mistakes along the way. Dr. M. Kathryn Menard, one of the co-founders of the North Carolina program

The program appears to have achieved some modest results. Unintended pregnancies among women on Medicaid have gone down slightly since 2012, from 52 percent to 45 percent, said Kate Berrien, a director at Community Care of North Carolina, the nonprofit that operates the state’s pregnancy medical home program. Preterm births were also down 7 percent from 2011 to 2014.

In other states that have run pilot programs, the results are similarly encouraging. A small, year-long experiment conducted with pregnant Medicaid patients in Texas found that hospitals were able to cut down on visits to the emergency room and inpatient hospital days for pregnant women, saving about $ 330,000 in ER services and almost $ 500,000 in inpatient care.

A final analysis of this experiment also found that these Texas mothers were also significantly less likely to deliver by C-section and that their newborns were significantly less likely to be admitted to neonatal intensive care.

Michael Lu, senior associate dean at the George Washington University School of Public Health and former director of the federal Maternal and Child Health Bureau in the Obama administration, praised North Carolina’s program but also said it would be prudent to wait for a more comprehensive evaluation before scaling it nationwide as Harris has outlined in her bill.

Still, he did agree that social issues can be a major stressor on bodies ― especially ones that are already experiencing the physical stress of a normal pregnancy.  

Lu compared the pressure of homelessness, unemployment and violence to the gunning of a car engine ― sooner or later, the engine is going to wear out.

“Unemployment, poor housing, family and neighborhood violence, the lack of partner and social support, and the experience of racism can affect pregnancy outcomes by causing chronic stress, which in turn can cause wear and tear on the body’s organs and systems,” Lu said. “That’s how these social determinants not only get under the skin but also get inside the womb to affect pregnancy outcomes.”

Harris’ office hopes that this moment in history, when the American public is galvanized around the issue of maternal mortality, will help pave the way for the senator’s bill and others like it.

It’s also really important to not overstate what one can see in statistics from uncommon events. Dr. M. Kathryn Menard

Menard cautions that North Carolina’s declining racial disparity in maternal deaths can’t be attributed solely to the program she helped create.

“The trend of narrowing the gap started before this program launched, and it continued in a positive direction,” she said. “It’s also really important to not overstate what one can see in statistics from uncommon events.” 

For the past 15 years, an average of about 22 women have died annually in North Carolina because of pregnancy-related causes. This means that a change of even just a handful of women in either direction could change the rates of maternal mortality and racial disparity wildly from one year to the next.

“It turns out that in 2013, the ratio of white to black was one,” Menard said of the racial disparity statistics cited in Harris’ bill. “But the next year it could be three again, just because these numbers are not that big.”

But she does allow that rates of maternal deaths among black women are going down. And pregnancy medical homes could be playing a role. 

When there’s no one else to count on, pregnancy care managers are there.

Public health experts may be waiting for more data before recommending that this program go nationwide. 

But LaTosha Scott, one of North Carolina’s 400 pregnancy care managers tasked with attending to women with the riskiest pregnancies, feels from the bottom of her heart that this program needs to be in “every state, every county and every area.”

It’s on social workers like Scott, 32, to help pregnant women surmount serious social issues so they can focus on the pregnancy at hand. Scott’s part social worker, life coach, fixer and friend for the approximately 50 women she’s responsible for at any given time as a pregnancy care manager in Orange County, North Carolina.

Scott remembers a recent patient who had become homeless and had all four children taken into the child welfare system until she could find a new home. Meanwhile, the woman was pregnant again and struggling to get everything ready for the birth.

Soon before her due date, she came to Scott with a problem: She had the car seat and newborn supplies, but couldn’t see herself being able to lug it all on the bus to the hospital once she was ready to give birth.

Scott took it all and stored it in her own office at the University of North Carolina Medical Center in Chapel Hill. And when the woman gave birth, she carried the supplies up to the postpartum wing of the hospital.

For more well-connected women, Scott’s role might be filled by a sister, best friend or auntie, while wealthier women might be able to employ a doula, nanny or concierge to help them get ready for the baby.

But for the women Scott sees, who may be struggling with homelessness or addiction, she is one of the few emotional supports they can count on throughout their whole pregnancy.

“She’s able to focus more on the pregnancy because she knows now she has support,” Scott said about her work. “It’s like, ‘I have Latosha to call on, and she can at least tell me where to go.’”

Menard says she was surprised to see that North Carolina’s pregnancy medical home program had caught the attention of a senator from California, as the initiative is still relatively young and still considered novel.

But she says that whether or not Harris’ bill passes, she hopes it sparks an overdue discussion about the social causes of maternal mortality in addition to the medical delivery component of maternal care.

Menard also thinks states should not wait for a federal law to pass before starting their own programs, and she invites anyone to contact her agency for insight into how to get something off the ground.

“I hope they’ll learn from our experience and call on us so that they don’t make the same mistakes along the way,” she said. “We can get them there a lot faster than we got there.”

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