Maternal Health Awareness Day 2024

Today is, National Maternal Health Awareness Day 2024. This year the focus is on Access to Care. Access in Crisis.

Posted under: Maternal Health, Quality of Care

The definition of “maternal health awareness” might depend on who you ask. And where.

This year the focus is on Access to Care. Access in Crisis.

And that is true. For many rural communities, closures of obstetric units and hospitals have created tremendous burdens in obstetric availability. Medicaid reimbursement has created significant voids in hospital budgets that are no longer sustainable. Insurance costs have created chasms in care, leading to a lack of obstetric specialists and delivery options in states least likely to afford lapses in care.

But there is more to accessing high-quality maternal care than we realize. Or recognize. Or care to admit. I will give you a few examples that create challenges to accessing even the most well-supported maternal care sites.

1. Racial disparities and racism: In April 2023, the Centers for Disease Control published Maternity Care Experiences that revealed troubling facts (survey methodology available within the CDC document):
  • 30% of Black, Hispanic, and multiracial mothers reported mistreatment (e.g., violations of physical privacy or verbal abuse) during maternity care.

  • 40% of Black, Hispanic, and multiracial mothers reported discrimination during maternity care.

  • 45% of all mothers reported holding back from asking questions or discussing concerns with their provider.
It is very easy to state, “That’s someone else,” or “That doesn’t happen here.” Are you listening to your patients? Are you able to hold space for the possibility that their experience is different from your own? Do ALL patients feel safe in accessing care in your facilities?

Researchers from the University of California at San Francisco found that “racialized pregnancy stigma may result in reduced access to quality health care; barriers to services, resources, and social support; and poorer psychological health”.
The experiences of Black women at the intersection of race, gender, and pregnancy | Bixby Center for Global Reproductive Health (ucsf.edu)

2. Obesity stigma: The stigma associated with obesity continues to impact a woman’s or birthing person’s choice of providers, or their willingness to seek out care. Obesity stigma is fueled by misconceptions and assumptions about people with obesity and continues to exist today. Have you ever seen a colleague or co-worker roll their eyes upon receiving the report of a pregnant patient with severe obesity? Have your own eyes rolled? What assumptions do you make about weight? And how are these assumptions keeping women and birthing people from accessing care due to obesity stigma from healthcare providers?

3. Mental health stigma: The stigma that continues to permeate healthcare is that of mental health disorders. “The bipolar patient in room 3…” Have you heard that recently? Ever? In 2019, researchers in California reviewed 300 records of women who died within one year of giving birth. The second leading cause of death was substance use disorder. Two-thirds of these women had at least one (1) interaction with the healthcare system. Are we seeing despair? Are we making assumptions about maternal mental health? Check out the Maternal Mental Health Leadership Alliance for more information.

4. Homelessness: Back in 2022, I wrote a blog entitled Homelessness is Not Neglect. There is incredible stigma that is associated with homelessness, and more particularly pregnant women who are homeless. Between assumptions, misconceptions, and other issues that can taint perception, homelessness can be a significant deterrent to seeking maternal health care. Here is a quote from the blog I wrote, and it is just as important now as it was then:

 “Members of our team immediately called CPS on a Black mother for being homeless. She left AMA during labor, and we do not know where she delivered. I was so distraught. Our policy directs us to contact CPS for homeless parents. Like they have not been traumatized enough already. We must change our policies to protect these mothers and families and make every effort to keep these newborns with their mothers.”

5. Incarceration: According to Knittel et al (2022), “We Don’t Wanna Birth It Here”: A Qualitative Study of Southern Jail Personnel Approaches to Pregnancy: Women & Criminal Justice: Vol 33, No 5, approximately 55,000 pregnant people are incarcerated in jails each year. As many of these people are of childbearing age, it would stand that some of these people would deliver while incarcerated. In 2018, Black women were incarcerated at twice the rate of white women (Equitable Care for Pregnant Incarcerated Women: Infant Contact After Birth - A Human Right (umich.edu)). This commentary by Franco et al provides a bleak picture of maternal health in our carceral systems. I would strongly encourage the review of this paper and learn more about how to advocate for maternal health patients who experience incarceration. Not only is there stigma of patients during their period of incarceration, but also upon release and their re-entry into their community.

Access to care can mean many things. But one thing is certain. Access to high-quality, affordable, and available care in the community can be life-sustaining and life-changing. Let’s improve maternal health everywhere. Every patient, every time, everywhere.

National Maternal Health Awareness Day 2024
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Creating Quality Improvement New Year Resolutions: Maternal and Newborn Care

Are you among the hospitals who are seeking to improve quality? Have you explored the Psychology of Quality Improvement?

Posted under: Maternal Health, Quality of Care

Hospitals across the country are looking forward to 2024 and sharing the vision of their strategic plans. If you are among the hospitals who are seeking to improve quality, have you explored the Psychology of Quality Improvement?

Last week, I joined others from across the United States at the National Institute for Children’s Health Quality (NICHQ) National Network of Perinatal Quality Collaboratives Annual Meeting. Rhode Island is fortunate to be one of many states funded to support its perinatal quality collaborative.

Many topics were consistently mentioned and I wanted to bring awareness to one of those topics here. Postpartum readmissions were one of the issues being addressed, and how we can continue to bring awareness to the key drivers of readmission.

According to the National Perinatal Information Center, between 2018 – 2022, the most frequently reported diagnosis related to postpartum readmission is preeclampsia. Severe hypertension and preeclampsia have continued to rise over the past five years, and that trend does not seem to be changing. Fortunately, there have been great strides in reductions in readmission due to infection, and postpartum hemorrhage has been relatively stable over the past five years.



Preeclampsia is not only the driver for postpartum readmission, but it has been a driver for cesarean birth as well. During the years 2018 – 2022, the NPIC Perinatal Database follows coded reasons for cesarean birth, and preeclampsia has had the highest increase over this same five year period.



Many hospitals are seeking resources to impact the rate of preeclampsia and hypertension that are being seen in obstetric units. Maternal morbidity and mortality discussions and review committees (MMRCs) continue to review maternal deaths associated with preeclampsia/severe hypertension/stroke and have finally begun to explore the impact that racism may have had in diagnosing/addressing/treating/responding to hypertension in Black women.

One of the most critical areas addressed during the NNPQC meeting was the Psychology of Quality Improvement. Yes, there is a foundational approach to QI projects that cannot be overstated. Dr. Veronica Gillespie-Bell (Louisiana) provided an outstanding primer on Creating Change and Managing Resistance (yes, managing the resistance to change). There are those who will embrace change. And there are those who will resist change. But there is a way ahead. And here are the secrets:

  • Define the change through an effective vision

  • Communicating the change

  • Building an improvement team(MUST include frontline staff)

  • Develop reinforcement strategies

  • Assess the climate for change—cultural, commitment, capacity readiness

  • Creating culture for change

  • Select the model for change

  • Understanding and managing resistance

  • Celebrate small wins


**normalization of deviance can completely derail change management**

It is very important to address normalization of deviance (NoD) within change management. NoD has been mentioned several times in these blogs over the past year. If you need a refresher, check out our previous discussions. Become familiar with the term. There are reasons that, on average, it takes 17 years to translate research to practice. This is one of them.

Are your frontline teams drivers or mere passengers in the quality improvement process? How can you leverage the bench strength of your teams to effectively create changes in patient care? If your frontline teams do not have an active role in your quality improvement initiatives, you are missing a critical voice in successful (and sustainable!!) change.

  • Are they ready to engage in QI work?

  • Did the team have any input in creating the QI project?

  • Are there identified champions and informal leaders who can contribute a diverse lens to the process?

  • Is there bandwidth available?

  • How many other projects and initiatives are underway?

  • Is this considered a priority among many others? Who is communicating that priority? (“This is something we have been told to do” versus “We have an opportunity to improve patient care and maternal outcomes”)

  • Is the team multidisciplinary and includes all facets of care?


It is important to include your patients and families in your quality improvement initiatives, particularly if the target population is patients. Let’s use maternal severe hypertension for a moment.

  • Do you have patients with lived experience on your Quality Improvement projects? How are you ensuring that diverse voices are a part of your work?

  • Have your patients reviewed your preeclampsia/hypertension discharge materials? Do they understand them? Are they in a language they understand?

  • Are you disaggregating your outcomes data by race and ethnicity? Are your time to treatment outcomes similar, or do you have glaring differences in treatment outcomes?


No matter your priority for this next year, whether it is maternal hypertension, postpartum hemorrhage, safely reducing primary cesarean birth, sepsis, maternal mental health, or other healthcare needs, creating a strategy to implement change in practice or process can take time. But let’s face it…our patients don’t have 17 years to implement change. They are relying on us now to provide the highest quality of evidence-based care.

As part of your New Year resolutions, think about adding sustainable change to your strategy. Change and sustainable change are two different concepts. Quality and patient safety are at or near the top of many hospitals’ strategic plans in 2024 and beyond, with many including high reliability as a metric of success. Achieving these goals are possible, but only with the cumulative efforts of data, knowledge, commitment to equity, and action. And yes, the psychology of quality improvement.

Here's to sustainable change and outstanding quality improvement in 2024. Happy New Year

If your team would like to incorporate sustainable quality improvement in your organization, NPIC can support your strategy. Reach out to us to learn more.
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Respectful Care in the NICU: Take Two

Racial and ethnic disparities continue to impact prematurity across the nation. The National Perinatal Information Center provides stratified race and ethnicity reporting for our member hospitals for both maternal and newborn outcomes.

Posted under: Other, Quality of Care

Last year, NPIC posted a blog about Respectful Care in the NICU, and how to apply the concepts that shape Respectful Maternity Care in the NICU setting. We are going to use some of that here, but there is more to do.

The Centers for Disease Control (CDC) reported that in 2022, 10% of babies were born prematurely, which was a slight decline from 2021. However, in 2022, the rate of preterm birth among African-American women (14.6%) was about 50 percent higher than the rate of preterm birth among white or Hispanic women (9.4% and 10.1% respectively).

Racial and ethnic disparities continue to impact prematurity across the nation. The National Perinatal Information Center provides stratified race and ethnicity reporting for our member hospitals for both maternal and newborn outcomes. In 2022, NPIC reported 312,840 neonatal discharges within the NPIC Perinatal Database. Of those discharges, Black newborns had the highest average length of stay (ALOS, 5.83 days vs White 4.22), highest APR DRG case mix index (CMI, 0.7479 vs White 0.4615), and the highest utilization of Medicaid (60.5% vs White 29.2%). Recognizing the real disparities and how to impact access to high quality, unbiased, and respectful care in the obstetric and NICU setting is critical to health and birth equity.

On September 29, 2023, the CDC released a report on mistreatment in maternal care, Many Women Report Mistreatment During Pregnancy and Delivery:
  • About 20% of women reported mistreatment while receiving maternity care.

  • About 30% of Black, Hispanic, and multiracial women reported mistreatment.

  • Almost half (45%) of women held back from asking questions or sharing concerns during their maternity care.
Now think about your NICU…what would these results look like if the CDC sought to evaluate care and interactions in the NICU?
  • How many women or parents would report mistreatment of their newborn? (“Rough” care, such as non-developmental care movement during diaper changes, daily cares, feedings?).

  • Would these reports be different if you stratified the results by race?

  • How many women or parents hold back questions or sharing concerns regarding their newborn during their stay in the NICU?
According to the CDC. “every mom deserves respectful and responsive care during pregnancy and delivery.”

So, let’s rewrite this for the NICU:
Every baby and their family deserve respectful and responsive care during their NICU journey.

Respectful Care…What is That?
Understanding the value and importance of respectful care in the neonatal care setting is and will be an essential conversation to engage. In pregnancy and obstetrics, Respectful Maternity Care (RMC) is defined as the preservation of a person’s dignity, choices, and preferences during birth and during the postpartum period. Respectful Care has been and continues to be a priority for maternal health outcomes, particularly with the continued disparities that are discussed within communities, including significant maternal and neonatal outcome disparities experienced by Black and Brown women, and other marginalized communities.

While the Respectful Care model typically focuses on the person giving birth, it is essential that these elements are applied to the supportive care of the mother/patient and newborn dyad in the Neonatal Intensive Care Unit. There are a few areas to focus on, including reducing stressors, provision of family navigators and support structures, and trauma-informed care. What are some of the elements of Respectful Newborn Care? Let’s dive in:


Reducing Stressors
The stressors that new parents experience with the birth of a premature newborn can be overwhelming. And supporting a new parent is critical in offering Respectful Newborn Care. Respect for the parent and their needs is an essential element of newborn care.

Imagine you have just given birth 2 months early, and you have two young children at home. Your spouse is ill and not able to visit with you and your newborn. You live an hour away from the hospital, and arranging childcare is uncertain. What is going through your mind? How are you going to be in two places at once?

NICU parents deal with these types of situations every day. Providing support to the mother and family to assure opportunities for bonding and care provision are essential. Transportation, food security, and the care of other dependent children as needed for frequent visitation to the NICU provides stability and a sense of control. Financial challenges compound these issues and further accelerate disparities that are found within neonatal care. Fully understanding social determinants and drivers of health (SDOH) speak to the promotion of dignity, autonomy, and the ability to care for a newborn amid turmoil, such as an unexpected admission to the NICU.

Trauma-Informed Care
Trauma-informed care is an essential principle of the Respectful Care model. Facets of trauma-informed care, such as previous experiences of trauma and subsequent response and reducing the impact of a current trauma (like an unexpected admission to the NICU) provide a meaningful foundation to the care of mothers and families during a stay in the NICU. Maternal/newborn separation can exacerbate trauma, and facilitation of visitation and information is key. Again, identification of environmental and social/structural determinants of health and their mitigation can ease the impact of further trauma to a family unit. These elements are cyclical, and all serve as conduits within a Respectful Care paradigm.

Part of reducing parental trauma in the NICU is assuring a shared decision-making approach for care. Encouraging involvement and supporting choices in the care of a premature baby can be empowering and motivating for a parent experiencing trauma during a NICU admission.

We’ve got this. We’ve all got this. Together, we can create intentional, meaningful and respectful environments for our babies, our moms, patients, families, and communities.

Learn more about Prematurity Awareness Month.
Interested in data that can support prematurity research? Connect with National Perinatal Information Center about research access to the NPIC Perinatal Database. NPIC has one of the oldest and most robust and dedicated linked mother/baby datasets in the US and provides key metrics for linked maternal and neonatal outcomes. To learn more, contact inquiry@npic.org.
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How Did We Get Here? Creating and Sustaining Supportive Team Environments

During Neonatal Nurses Week, not only should we be focused on the outstanding work of our neonatal nursing colleagues, but how can we promote collaborative teamwork that undergirds outstanding neonatal care? How can we best support our nursing teams in caring for the smallest and most fragile of patients?

Posted under: Other, Quality of Care

During this Neonatal Nurses Week, not only should we be focused on the outstanding work of our neonatal nursing colleagues, but how can we promote collaborative teamwork that undergirds outstanding neonatal care? Sometimes it is easier said than done, but one thing is sure: committing to and caring for our patients AND each other, should be our rallying cry.

Unfortunately, the news cycle of late has been rife with discussions of patient harm resulting from communication challenges and failures within teams:
  • April Valentine: Young woman who died while in labor. Nurses reported they could not call the doctor as they would “cuss them out.”

  • Lucy Letby: NICU nurse in the UK found guilty of murdering seven babies in a neonatal unit and convicted of trying to kill six others. Physicians and others came forward with their concerns, only to be told to “apologize to Lucy” for impugning her of wrongdoing.
As this is Neonatal Nurses Week, I thought I would briefly explore chain-of-command opportunities in the NICU. How can we best support our nursing teams in caring for the smallest and most fragile of patients? Instead, I found a litany of information related to bullying…nurse/nurse, nurse/physician, physician/physician. And I must say, I was not expecting that. While the majority of my work of late has been to support communication challenges in the obstetric setting, perhaps we should also focus on the NICU environment.

Committing to and caring for others, including each other, should be our rallying cry.

Here are two NICU examples I thought I would share, one from a nurse and one from a physician:

Nurse:
“Guess who just got bullied out of their new NICU job? It’s me. This is the most catty, cliquey, TOXIC work environment I have ever seen. I have been yanked off of orientation, belittled, completely unsupported, and now my preceptor says I need to ‘rethink if this is really for me.’ Like…. I have 4+ years of experience, have worked COVID ICU, charged, precepted, been asked to be House Sup…. I know I’m not dumb. But [gosh], they made me feel small. Anyone else go through this? Feeling pretty alone and discouraged right now. Luckily a past job is taking me back and I’m getting out of here.”

Physician:
“The presence of incivility is not new to medicine, and certainly not foreign to us in the NICU environment. Over the past two decades, I have seen several situations develop in different institutions that create an environment where it is uncomfortable, threatening, or unsafe to conduct oneself fluidly as part of a highly functioning team. Incivility can arise simply from people choosing to disregard or disrespect one another’s opinions, or it can manifest more blatantly in the form of harsh public criticism or the deliberate dissemination of misinformation that deteriorates trust levels.” https://www.medela.us/breastfeeding-professionals/blog/going-toxic-in-the-nicu-dealing-with-workplace-negativity

Think about that. Deliberate dissemination of misinformation. Deteriorating trust levels? The question is so timely…how did we get here?

And as I thought about this more, I kept coming back to the patient safety bundles developed by the Alliance for Innovation on Maternal Health (AIM). The 5 Rs, (readiness, recognition, response, reporting/systems learning/respectful interactions) create a consistent and standardized approach to improving patient care. And may even support team synergy and col
But what if there were a Team Communication Patient Care Bundle? What would that look like? How can we establish consistent, standardized ways of meaningful teamwork, enhancing communication, and improving patient outcomes?

So, the real question should be “where do we go from here?” and “How can we work collaboratively to create the best environment for patients AND our teams?”

Here is a start. I hope you will help me finish it.

Readiness
Every hospital Board/Trustees:
  • As part of Governance, routinely assess work environment/psychological safety and establish metrics to evaluate hospital leadership.
  • Expectations of transparency related to patient harm resulting from communication failures.
  • Understand the scope of Directors and Officers Insurance Liability (D & O)/General Liability (GL) in the event of serious maternal/neonatal harm/death that was the direct result of a documented/known team communication challenge (incivility/bullying/intimidation).
  • Yearly Board assessment that includes organizational psychological safety metrics.
Every hospital
  • Establish parameters, expectations, and accountabilities for team communication and share documents and reports openly.
  • Establish a definition of incivility/bullying/intimidation and hold all employees accountable to expectations.
  • Assess psychological safety within units and share findings with all team members, including between/within disciplines.
  • Establish a centralized and representative team to evaluate serious maternal/neonatal harm stemming from potential/real communication failures.
  • Train staff on team communication skills annually/per policy (TeamSTEPPS as an example).
  • Establish a chain-of-command system that is developed and agreed upon by all stakeholders and broadly communicates plans for escalation, including real-time communication tracking.

Recognition and Prevention
Every Unit
  • Provide ongoing education to all team members related to communication expectations and accountability.
  • As a team, identify high-risk and high-stress situations that may facilitate communication challenges.
  • Use simulation as a guide and teaching tool for critical conversations.
  • Collaborative physician/provide/nursing leadership that role models teamwork and open communication style.

Response
Every Unit
  • In the event of a serious communication failure, stabilize the patient as needed/supportive care for the impacted staff member(s).
  • Use a standard, facility-wide reporting system for potential/real patient care challenges related to team communication.
  • Establish a rapid response team/process that can be available to any unit to support communication challenges within patient care.
  • Consistent and equitable actions for behaviors/interactions requiring intervention.
  • Use of Employee Assistance Program (EAP) for support/counseling within serious communication failures/patient events.

Reporting and Systems Learning
Every unit
  • Celebrate improvements in team cohesion and communication at every opportunity.
  • Perform multidisciplinary reviews of any patient care errors that may be the result of team communication failures.
  • Monitor rate of event reports related to team communication issues/errors/failures.

Respectful, Equitable, and Supportive Team Cohesion
Every unit
  • Assess for and act upon real/perceived team communication challenges based on bias, discrimination, or racism.
  • Establish debriefing process for patient harm as a result of communication failures.
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Using Breastmilk Feeding Success to Support the CMS Commitment to Health Equity Measure

The Centers for Medicare and Medicaid Services launched the Commitment to Health Equity Core Measure. This Core Measure has five domains and should be on every hospital’s radar. We are going to use Breastmilk Feeding as an example of how these domains can work together to support hospital and community partnership and engagement.

Posted under: Maternal Health, Quality of Care

On January 1, 2023, the Centers for Medicare and Medicaid Services launched the Commitment to Health Equity Core Measure. This Core Measure has five (5) domains and should be on every hospital’s radar for action. This is a requirement for Inpatient Quality Reporting:

Domain 1: Equity is a Strategic Priority
Domain 2: Data Collection
Domain 3: Data Analysis
Domain 4: Quality Improvement
Domain 5: Leadership Engagement


August is National Breastfeeding Month. And what better time to show how these domains can work in action to provide support for your obstetric patients and care teams.

We are going to use Breastmilk Feeding as an example of how these five (5) domains can work together to support hospital and community partnership and engagement.

Implementing Quality Improvement within the Commitment to Health Equity Measure

Hospital Leadership/Boards of Directors
  • Is hospital leadership (yes, I mean the Board of Directors and the C-Suite) invested in improving maternal health?

  • Is maternal health and outcome disparities on the agenda of Boards of Directors/Trustee meetings? How often?

  • Do Boards of Directors/Trustees/C-Suite ask about QI projects on a routine basis?

  • Do they routinely ask about outcome disparities?

  • How often do they see the data? And is this data shared with Boards of Directors? Trustees?

  • How engaged is the Board in reviewing and understanding maternal health QI projects?

  • Do unit leaders have an opportunity to engage directly with the Board and share best practices and success stories of improved maternal healthcare, particularly through a racial and ethnic lens?

  • Do hospital Boards of Directors know which community health organizations are actively involved in patient care/transitions to home?

  • Does your Board of Directors reflect the community it serves?
Nursing and Physician Leadership/Unit Level
  • What does nursing leadership look like?

  • What does physician leadership look like?

  • Do they work well together?

  • Are they committed to the same outcomes and priorities?

  • Are they committed to including the voices of those most impacted in perinatal project planning?

  • In other words, are patients of color or others based upon identified social needs asked to participate in QI initiatives within the unit?

  • Is there a Patient Advisory Council that serves to facilitate connections between patients and care teams?

  • Are there routine communications/meetings between hospital teams and community organizations that support patient care after discharge?

  • Have they assessed the activation and readiness of their teams to engage in QI work?
Frontline Care Teams
Let's explore the teams themselves, the team members who will be doing the work.
  • Are they ready to engage in QI work?

  • Are Doulas considered part of the frontline care team?

  • Did the team have any input in creating the QI project?

  • Are there identified champions and informal leaders?

  • Is there bandwidth available?

  • How many other projects and initiatives are underway?

  • Is this considered a priority among many others?

  • Is the team multidisciplinary and includes all facets of care?

  • Are there identified naysayers?
What? Naysayers?
Believe it or not, naysayers are not only helpful, but can be very valuable to identifying barriers and real/potential pitfalls of a QI project. The "squeaky wheels," if you will, can be some of your most invested team members who sincerely want positive change. Or they have had enough of “one trick ponies” and QI projects that were not sustainable or implemented without frontline feedback. While it may be tempting to dismiss them, it is much more important to listen and hear their concerns.

The Patients Themselves
Earlier I mentioned the engagement of patients in QI project development. Yes, this is a critical component of successful QI implementation. As important as it is for your organization and team to be engaged and dedicated to QI, what if the project you are considering does not meet the needs of your patients?
  • Were assumptions made based upon conscious/unconscious bias rather than data?

  • Are the measures/objectives/metrics in line with the communities you serve?

  • How will patients react to and participate in a QI initiative? Are they passive or active participants?
So, let’s use breastmilk feeding as an example of how to engage the team and communities in supporting this important health initiative.

Hospital Leadership:
  • Awareness of the Commitment to Health Equity Measure?

  • View as a priority within public health initiative and health equity strategic plan?

  • Frequency and evaluation of racial/ethnic disparities in exclusive breastmilk feeding?

  • Rounding on units to assess for engagement? Barriers to implementation?
Nursing and Physician Leadership/Unit Level:
  • Awareness of the Commitment to Health Equity Measure?

  • Agreement on the importance of breastmilk feeding?

  • Mutual support from RN/MD leadership?

  • Awareness and involvement of all team members to support the initiative, including other care team members involved in care? And yes, this includes Environmental Services, Case Management, Food and Nutrition Services, Biomedical Engineering, Pharmacy, Respiratory Therapy, and anyone meeting a patient. Does everyone buy into the importance of breastmilk feeding?

  • Students part of the process and encouraged to participate in and lead QI activities?
Frontline Care Team:
  • Awareness of the Commitment to Health Equity Measure?

  • Does your frontline care team look like the patients you are serving? If not, what steps has your organization taken to diversify your team to ensure breastmilk feeding education is meeting the needs of your patients?

  • How are Doulas used in breastmilk feeding education?

  • Ongoing education? Is it Just-in-Time/bite size for ease of use?

  • Use of Lactation Consultants to promote real-time education?

  • How are QI Champions supported? Dedicated time for support of the QI project?

  • Understanding and appreciating the importance of evidence-based practice?

  • How are breastmilk feeding QI activities incorporated into daily processes? How are they communicated to teams? How do teams communicate initiatives and outcomes to each other?
Naysayers
  • Have they been heard? Have their concerns been addressed? Even if unable to meet the need, have the inability to provide (XXX) been discussed?

  • Are there not enough resources or supplies to support breastmilk feeding in the unit?

  • Are there personal biases against breastmilk feeding? Did a personal experience lead to anger or frustration surrounding breastmilk feeding? (VERY IMPORTANT!!)

  • Have any personal conscious/unconscious racial biases been addressed that may be creating negativity towards equity work?
And here is the important part: Community organizations know the important role they play in supporting patients in the community. Connecting hospitals and care teams with these critical resources is essential in safe and optimal transitions to home.

Patients/Community Organizations
  • Awareness of the Commitment to Health Equity Measure?
  • Have diverse patients been included in providing feedback related to their breastmilk feeding experience?

  • Has the breastmilk feeding QI project been introduced to patients with feedback elicited prior to implementation?

  • Is a Patient Advisory Committee or Team included in the QI project and process for improving breastmilk feeding?
  • Have patients been asked about resources, supplies, and other needs related to breastmilk feeding?

  • Have patients had an opportunity to review any hospital documentation related to Community Health Needs Assessment (CHNA) related to breastmilk feeding? Did they have an opportunity to contribute their experiences or findings?

  • Can patient advocates and community health workers (CHWs) serve as volunteer support to encourage and transition breastmilk feeding success to the community?
There are community partners throughout the US that can provide exceptional support and feedback to hospital teams to support breastmilk feeding after discharge. Creating awareness of the essential connections that hospitals and communities must have to ensure optimal outcomes is key.

But remember…Breastmilk feeding is but one area that community organizations can play a key role in perinatal care. Housing and food security, transportation, physical safety, and many other unmet social needs can benefit from the rich and vibrant hospital/community connections that can support optimal outcomes for new mothers, parents, and newborns.

**And remember…as you survey the unmet social needs of your patients, it is critical that this same exercise be conducted for your own hospital care teams. What community resources do they need to give their best to your patients?

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Creating a Use Case for Maternal Data and Quality Improvement

Every quarter, NPIC provides member hospitals with a plethora of data. Data that can be tremendously helpful in creating and sustaining quality improvement action plans to support optimal outcomes in maternal and newborn inpatient care.

Posted under: Data & Analytics, Maternal Health

Every quarter, the National Perinatal Information Center provides member hospitals with a plethora of data…a hospital’s own data and comparisons to their subgroup and the entire NPIC database. This data can be tremendously helpful in creating and sustaining quality improvement action plans to support optimal outcomes in maternal and newborn inpatient care across the United States. While real-time data access is critical for day-to-day patient care, quarter-over-quarter data analysis can be useful to assess interventions and programmatic shifts.

So, I decided to examine a few areas many hospitals focus on, particularly postpartum readmissions and cesarean birth. And I also wanted to look back to 2019 and come forward to 2022, as yearly trends can inform of areas of opportunity. And both postpartum readmission and cesarean birth allow for such reflection and calls to action.

Postpartum Readmission
Many hospitals focus on postpartum readmission and for good reasons. Readmission rates tend to be used as a proxy for quality but can also be bellwethers for population health opportunities.

NPIC Database 2019 – 2023, Delivery Readmissions coded with:


Observations:
  1. Severe maternal hypertension and hemorrhage continue to be areas of focus secondary to AIM patient care bundles and The Joint Commission Patient Care Standards.

  2. Not every readmission is a failure. Education on maternal warning signs and when to seek care may drive some of these readmissions. It is important to identify the drivers of readmission and any education or information that may have led to better recognition of serious maternal complications. Educational tools such as AWHONN’s POST-BIRTH Warning Signs and Save Your Life tools or the Centers for Disease Control Hear Her Campaign should be used with all postpartum discharges.

    AWHONN
    CDC Hear Her Campaign

  3. Major puerperal infections have decreased which is a good sign for postpartum patients. Consistent preventive measures and early identification of infection and sepsis can be lifesaving. Learn more about maternal sepsis at the Sepsis Alliance and the Tara Hansen Foundation.

    Sepsis Alliance
    Tara Hansen Foundation

Cesarean Birth:
Healthy People 2030 has set a cesarean birth target of 23.6% for low-risk women with no prior births. States across the US have participated in the Alliance for Innovation on Maternal Health Safe Reduction of Primary Cesarean Birth patient safety bundle. The original patient safety bundle was launched in 2015. So how are we doing?



Well, as a nation, and as a database, we are not hitting the target. There are some hospitals that are getting it done and doing it well! I hope we can celebrate your work and the work you are doing to promote intended vaginal birth, and to reduce the likelihood of future cesarean birth. We look forward to continuing to engage with our top decile hospitals and supporting their work and supporting other hospitals looking to reduce their primary cesarean birth. Here are a few suggestions from some teams across the country:
  1. Celebrate successes, even small ones. Publicly highlight physicians, providers, nurses, and other team members who consistently finish with a vaginal birth. If you don’t follow Dr. Tiffany Montgomery on LinkedIn, think about it. She is the Lead for Perinatal Quality at Parkland Hospital in Dallas, consistently posting about supporting her teams’ wins in reducing primary cesarean birth. Contacting Dr. Montgomery should be your next step if you are looking for ideas.

  2. Don’t bite off more than you can chew. How many quality improvement projects do you have running at the same time? Are the same team members being tapped every time? Creating space for QI is important, but sustainable change is the key. Take the pulse of your team routinely, and don’t forget that frontline team members AND patient voices should always be included in any QI planning and implementation. The Safe Reduction of Primary Cesarean Birth patient care bundle requires a multidisciplinary approach that includes prenatal and intrapartum teams.

  3. Stratify your data by race and ethnicity. Yes, this is important. Stratify your cesarean delivery outcomes by race and ethnicity. The literature for years, including the NPIC database, has shown that Black women historically have higher cesarean birth rates. There are numerous reasons for this, but lack of shared decision-making and continuous labor support, and bias/racism inside and outside hospitals have been found to contribute to higher cesarean birth rates. When you report that cesarean birth rates are “equitable,” your data can support your efforts.

  4. Understand quality improvement. No, really understand it. QI is not a “one-and-done” approach. A true QI project requires planning, data exploration, team readiness assessment, and an authentic approach to including the patient’s voice (as NPIC has termed #AuthenticQI). Quality improvement also requires an investment of time (= money) and inertia. Institute for Healthcare Improvement has an excellent QI framework for reducing primary cesarean birth.
NPIC is proud to provide this brief overview of key maternal outcomes. Our goal is for you to use your data in the best possible way to promote optimal health, well-being, and outcomes for mothers and newborns in your hospitals and communities, and we are proud to be your partner.
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Respectful Care in the Neonatal Intensive Care Unit

Respectful Care continues to be a priority for maternal and neonatal outcomes, particularly with the continued disparities described throughout the literature, including significant outcome disparities found within Black and Brown women and birthing persons, particularly maternal care and NICU care.

Posted under: Other, Quality of Care

In previous blogs, I have offered insight into the Alliance for Innovation on Maternal Health (AIM) patient care bundles, and their importance in maternal health.

It only makes sense to create newborn and NICU patient care bundles that are similar in nature to their maternal patient care bundle counterparts. After all, standardization and reducing variation are key to patient safety outcomes. The NICU is a natural next step in creating and cultivating patient safety bundles.

Patient safety bundles include the following domains:
  • Readiness
  • Recognition
  • Response
  • Reporting/Systems Learning
In 2021, a 5th bundle element was incorporated into the AIM patient care bundles, Respectful Care. This was the fifth element to be incorporated into all maternal patient care bundles. Respectful Maternity Care (RMC) is defined as the preservation of a birthing person’s dignity, choices, and preferences during birth and during the postpartum period. Understanding the value and importance of respectful care in the neonatal care setting is and will be an essential conversation to engage. Respectful Care has been and continues to be a priority for maternal and neonatal outcomes, particularly with the continued disparities described throughout the literature, including significant outcome disparities found within Black and Brown women and birthing persons, particularly maternal care and NICU care. While the Respectful Care model typically focuses on the mother/birthing person, it is essential that these elements are applied to the supportive care of the mother/birthing person and newborn dyad in the Neonatal Intensive Care Unit. Several of these elements are described below:
  • Alleviation of Environmental Stressors: Providing support to the mother/birthing person to assure opportunities for bonding and care provision are essential. Transportation, food security, and the care of other dependent children as needed for frequent visitation to the NICU provides stability. Financial challenges compound these issues and further accelerate the disparities that are found within neonatal care. The promotion of dignity, autonomy and the ability to care for a sick newborn amid turmoil, such as an unexpected admission to the NICU, cannot be overstated.

  • Provision of a NICU Family Navigator/Support Structures: The ability for a mother/birthing person to achieve the highest levels of autonomy during a NICU stay relies on the ability to fully comprehend and understand the course of care. A NICU Family Navigator or NICU Family Support Program can facilitate communication and ensure that every newborn and family are assured the same level of care and discharge planning. Lake and colleagues described disparities in NICU outcomes related to race, and failure to offer the same level of discharge care to all families is antithetical to the Respectful Care model. Any differences in care, specifically racial and/or ethnic outcomes discovered during inpatient care or during the discharge process should be immediately evaluated. The inclusion of postpartum doulas to offer support for the woman/birthing person during the NICU stay should be encouraged. (If you have not thought about using Postpartum doulas in your NICU as a support for your parents, now is the time).

  • Trauma-Informed Care: Trauma-informed care is an essential principle of the Respectful Care model. Facets of trauma-informed care, such as previous experiences of trauma and subsequent response and reducing the impact of a current trauma (such as an unexpected admission to the NICU) provide a meaningful foundation to the care of mothers/birthing people during a stay in the NICU. Maternal/newborn separation can exacerbate trauma, and facilitation of visitation and information is key. Again, identification of environmental and social/structural determinants of health and their mitigation can ease the impact of further trauma to a family unit. These elements are cyclical, and all serve as conduits within a Respectful Care paradigm.





How much does it cost to park in your hospital parking garage? How much is a bottle of water or a small meal in your hospital cafeteria? And if a baby is in the NICU for weeks, what does that cost? Childcare for those children at home? Lost hours at work? The trauma of an unexpected NICU admission can be but the very start of a perpetual traumatic experience for a family.

The Black Mamas Matter Alliance describes best practices for holistic maternal and neonatal care:
  • Addresses gaps in care and ensures continuity of care
  • Affordable and accessible care
  • Ensures informed consent
  • Confidential, safe, and trauma-informed
  • Provides wraparound services and connections to social services
Achieving a care model that not only supports but promotes and sustains Respectful Care should be considered requisite for any facility caring for women/birthing people and their newborns. Strategic planning should include a focus on equity and include the voices of those populations most impacted by disparate outcomes. Continuous quality improvement through an equity lens and self-reflection performed by individuals, departments and organizations is fundamental to the continued evolution of a robust and holistic care program. Respectful Care in maternal and neonatal settings will be critical to elevating both short and long-term outcomes, and supporting a strong foundation for autonomy, dignity, and a well-defined transition to home and equitable access to community resources.

So, let’s start a checklist for Respectful Care in the NICU:
Centering the baby and family for all care and decisions
Dignity and autonomy
Informed consent
Shared decision-making
Equitable access to pain management
Access to Postpartum doulas
Access to Community Health Workers
Postpartum depression assessment of mother and partner with appropriate referrals
24-hour access to baby
Parental presence during resuscitation
Assessment of childcare needs
Assessment of transportation availability
Assessment of nutrition
Equity in access to lactation support and donor milk
A home transition plan that respects and incorporates the culture, values, and lived experience of the family
Ability to measure Respectful Care and its impact on patient outcomes

Building respectful care into any NICU patient safety bundle should be a first step. I hope to hear from you and let’s continue to grow a new and emerging model of Respectful Care in the NICU.

References
1. Moridi M, Pazandeh F, Hajian S, Potrata B. Midwives’ perspectives of respectful maternity care during childbirth: A qualitative study. PLOS ONE. 2020;15(3):e0229941. doi:10.1371/journal.pone.0229941

2. Sacks E, Kinney MV. Respectful maternal and newborn care: building a common agenda. Reproductive Health. 2015;12(1):46. doi:10.1186/s12978-015-0042-7

3.Howell EA. Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol. 2018;61(2):387-399. doi:10.1097/GRF.0000000000000349

4.Harvey SA, Lim E, Gandhi KR, Miyamura J, Nakagawa K. Racial-ethnic Disparities in Postpartum Hemorrhage in Native Hawaiians, Pacific Islanders, and Asians. Hawaii J Med Public Health. 2017;76(5):128-132.

5.Km M, A K-D, R K, et al. Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care. Med Care. 2021;59(2):131-138. doi:10.1097/mlr.0000000000001461

6.Sacks E, Kinney MV. Respectful maternal and newborn care: building a common agenda. Reproductive Health. 2015;12(1):46. doi:10.1186/s12978-015-0042-7

7.Glazer KB, Sofaer S, Balbierz A, Wang E, Howell EA. Perinatal care experiences among racially and ethnically diverse mothers whose infants required a NICU stay. Journal of Perinatology. Published online July 15, 2020:1-9. doi:10.1038/s41372-020-0721-2

8.Sigurdson K, Morton C, Mitchell B, Profit J. Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of Perinatology. 2018;38(5):600-607. doi:10.1038/s41372-018-0057-3

9.Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women’s Health. 2020;30(2):230-235. doi:10.1089/jwh.2020.8882

10.Barfield WD, Cox S, Henderson ZT. Disparities in Neonatal Intensive Care: Context Matters. Pediatrics. 2019;144(2). doi:10.1542/peds.2019-1688

11.Davidson JE, Aslakson RA, Long AC, et al. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU. Critical Care Medicine. 2017;45(1):103-128. doi:10.1097/CCM.0000000000002169

12.Sanders MR, Hall SL. Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. Journal of Perinatology. 2018;38(1):3-10. doi:10.1038/jp.2017.124

13. Black Mamas Matter Alliance. Setting the standard for holistic care of and for Black women. http://blackmamasmatter.org/wp-content/uploads/2018/04/BMMA_BlackPaper_April-2018.pdf
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The Last Person You’d Expect to Die in Childbirth…Again…

The past few weeks have been very difficult for families within the United States. Communities are grappling with mothers who are dying on the day of childbirth, or within a day or two.

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

The past month has been very difficult for the maternal health community. Simply review the Go Fund Me accounts set up within the past month alone, and you will find the following posts of mothers who have died in childbirth, or before discharge home (not exhaustive):

32-year-old Justine Kostenbauder died of severe complications during childbirth (South Carolina).

Camylle Bowen died two days after childbirth (Texas).

28-year old Vanessa Dannecker died during childbirth (Long Island).

And social media erupted with disbelief this week upon hearing of Tori Bowie’s death during labor at her home, a track star and Olympic champion, the last person you’d expect to die in childbirth.

And that was the exact title of the NPR/ProPublica Lost Mothers Series in 2017. This piece described a white NICU nurse who died at the hospital she worked for due to complications of HELLP Syndrome. A long and detailed overview of the missed clues during labor and the immediate postpartum period was presented. Many other articles were published within this series and deserve another review.

And here we are, 2023, six years later, with the same scenarios playing out. Patients exhibiting signs and symptoms of distress. Patients verbalizing “something is wrong,” and those words falling on deaf ears, or onto team members who do not have adequate resources to support them. Or both. 80% of maternal deaths are preventable…at least.

13% of maternal deaths occur on the day of delivery. 13%.

Let’s do the math:
In 2021, it is reported that 1,205 women died of maternal causes. While that number is likely inflated due to COVID, let’s look at 2019, the last year without COVID diagnoses: 754. That is approximately 2 maternal deaths per day. 13% of 754 is 98. Approximately 98 women died on the day of delivery in 2019. That is approximately 2 per week.

In 2021, that number was 156, which reflects 3 maternal deaths on the day of delivery every week. An average of a maternal death, on the day of delivery, every 2 days, in 2021. That seems impossible in the United States of America.

Don’t Blame the Pregnant Person for their Own Death
There have been many discussions on social media this week about the death of Tori Bowie. Many of those continue the amplify and elevate the real issues of systemic bias, racism, and not listening to Black women’s concerns about their own bodies. But there is something that is looming in the background that needs to be immediately addressed: Blaming the patient. Did Tori use drugs? Did Tori seek early prenatal care? Was Tori compliant with her prenatal care? What? Are we back to blaming the patient?

In 2019, Dr. Monica McLemore and Valentina D’Efilippo published a piece in Scientific American, To Prevent Women from Dying in Childbirth, First Stop Blaming Them.

It is abundantly clear that this piece needs to be read and reread over and over. “Stop blaming women for their own deaths.” If it were only that simple. And trust me, it should be. No woman should be blamed for her own maternal death.

Here is a question you should ask yourself right now: If Tori were a white track star, would you have asked the same questions? Would you have assumed that by the color of her skin that she would be more apt to be compliant in her care? Seek out early prenatal care? Drug use even considered as a discussion point? These are questions that require very honest and deep self-reflection. Project Implicit can be a way to begin to create a pathway for self-reflection and an assessment of internal bias.

Data Speaks Volumes
The National Perinatal Information Center stratifies many maternal and neonatal outcomes by race and ethnicity for member hospitals. And in the aggregate, the following continue to be true, and follow the scientific literature very closely:
  • Black women continue to have the highest rate of cesarean delivery.
  • Black women continue to have the highest rate of severe maternal morbidity.
  • Black women continue to have the highest rate of preeclampsia.
There is a tremendous amount of work to do. Many organizations continue to work side-by-side to provide meaningful changes to the care of all women, but with an intentional focus on assuring the highest quality care for Black women.

Listen to Black women. Don’t make assumptions about Black women. But most importantly, support initiatives that support Black women in their communities.

And let’s all work towards a goal of reducing 13% of maternal deaths on the day of delivery to zero. No woman should lose her life by giving birth to a new life.

#13toZero
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Maternal Mental Health Awareness Month

May is Maternal Mental Health Month, which provides an opportunity for providers, patients, communities, and activists to engage in discussion and dialogue about the importance of recognizing maternal mental health as an unmet, urgent public health need.

Posted under: Maternal Health, Mental Health

“I couldn’t bring myself to tell my doctors or nurses, or the doctors and nurses in the NICU about the way I was feeling. I was already that “bipolar patient.” I had used opiates for a few years to cope with the pain that depression brought with the disease. I could feel myself becoming more and more depressed and desperate for help, but thought that if I asked for help, my baby would be taken away from me. My bipolar disorder had haunted me for most of my adult life, had labeled me, and now with a new baby, had no one to reach out to. Each time I left the NICU, I thought it would be the last time I would see my baby. That feeling was so traumatic, and even though my baby is now 1 year old, I still relive that fear every day.” –A.R., during a postpartum interview

Overview
May is Maternal Mental Health Month, which provides an opportunity for providers, patients, communities, and activists to engage in discussion and dialogue about the importance of recognizing maternal mental health as an unmet, urgent public health need. Compound this maternal mental health need with the public health crisis of racism and a stark picture emerges of women and birthing people in need of tremendous support. There are many facets that must be addressed within maternal mental health—access to care, transportation, stigma, insurance coverage, stable housing, to name a few. An area of concern that has been identified is that of opioid use disorder during pregnancy. A greater prevalence of comorbid psychiatric disorders, physical and sexual abuse, intimate partner violence, and chronic pain disorders likely contribute to disproportionate rates of opioid use and misuse in women and particularly women during pregnancy. Beyond opioid use are other substances that are used frequently to mask mental health symptoms that can be treated by other means. But that treatment costs money and access can be sparce depending on location and availability of providers.

The National Perinatal Information Center continues to track maternal mental health outcomes, including substance use disorder. In 2019, substance use disorder (ICD O99.3XX) was coded in 1.9% of patients (n = 334,402) and by September 2023, 2.3% were coded with substance use disorder (n = 325,195). While that number might not seem high, it continues to reinforce the need to remain vigilant in assessing patients in the prenatal, intrapartum, and postpartum period.

In the time period October 1, 2021 through September 30, 2022, 30-40 patient records were coded with postpartum psychosis (ICD -10 F53.1). In seeing this information, I thought about the patient behind the data. I wondered what their support systems were like. I wondered if they had support, or if they were alone in their suffering. I hope these women had what they needed to not only bring life into this world, but also had those to support them while they nurtured that new life.

Maternal mental health directly impacts the outcomes of a newborn. Perinatal mood disorders are some of the most identified maternal mental health concerns and are associated with increased risks of maternal and infant mortality and morbidity and are recognized as a significant patient safety issue. In addition to perinatal mood disorders, there are other mental health diagnoses that must be appreciated, including pre-existing psychiatric illness (major depression, bipolar disorder, schizophrenia, etc.) that often is underreported and undertreated due to stigma and fear of reporting. During the month of May, it is critical to recognize certain elements of maternal mental health that must be addressed:
  1. Destigmatize mental illness: Stigma is a complex phenomenon, that has three different types: public, self and institutional. Self-stigma develops from shame, blame and internalization of mental illness, which is most often fueled by public and institutional stigma. Supporting women and birthing people experiencing maternal mental health illness, and reducing shame and self-blame, is critical in achievement of treatment regimens and continued engagement with healthcare providers.

  2. Screening women for mental health during the postpartum period: NICU’s across the United States have begun to engage in various forms of screening and intervention to assist in reducing stress and depressive symptoms in mothers during newborn admission. In many cases, maternal mental health concerns remain under identified and undertreated during a NICU stay, which can have deleterious effects on the offspring, both in short-term outcomes while in the NICU as well as long-term neurodevelopmental and behavioral outcomes. Mendelson et al performed a systematic review and metanalysis of NICU programs designed to evaluate for postpartum depression and anxiety and found it increasingly important to evaluate maternal mental health during NICU admissions to assure engagement and understanding of treatment and discharge plans.

  3. Disparities in maternal mental health treatment: Overall, Black women are 3-4 times more likely to die during childbirth or within the first year after delivery. Increasingly, studies describe inequity in mental health screening, identification, and treatment for women of color and other vulnerable populations. Sidebottom and colleagues described the findings of their study in which African American, Asian, and non-white women were less likely to be screened for postpartum depression than their white counterparts. In addition, this study also revealed that women insured by Medicaid and other state programs were less likely to be screened than those women with private insurance.

  4. Access to care: Psychiatrists, psychologists, social workers, and others can be difficult to access, particularly in rural environments. Paying for these services can be difficult, if not impossible, as many providers may not accept Medicaid or patients may not have the means to cover services not covered by insurance. Credentialed/certified community health workers (CHW) can be an invaluable resource for supporting patients in seeking resources for maternal mental health care. Psychiatric Mental Health Nurse Practitioners (PMH-NPs) can also be a vital community resource for patients. Supporting legislation to provide avenues for advanced practice is key in further developing this critical community resource. Advocating for coverage for postpartum maternal mental health is critical to supporting mothers in our communities. Finding new and innovative ways of using and supporting telehealth and digital access to maternal mental health access is imperative. But this access to mental health is dependent upon providers, access to broadband, technology, treatment (medication/therapy) and the cycle begins anew.



Telehealth Access Wheel: Foundational Needs for Telehealth (NPIC, 2023).

This month, it is essential that we create space to discuss maternal mental health, and to develop sustainable strategies for treatment and maternal well-being. Whether that be in a prenatal visit, admission to Labor and Delivery, during a NICU visit, or in the community, as a nation we must be prepared to destigmatize maternal mental health, assure equitable care and access, and create a compassionate course of treatment for women and birthing people who continue to suffer in silence.


References
Devakumar D, Selvarajah S, Shannon G, et al. Racism, the public health crisis we can no longer ignore. The Lancet. 2020;395(10242):e112-e113. doi:10.1016/S0140-6736(20)31371-4

Ouyang JX, Mayer JLW, Battle CL, Chambers JE, Salih ZNI. Historical Perspectives: Unsilencing Suffering: Promoting Maternal Mental Health in Neonatal Intensive Care Units. NeoReviews. 2020;21(11):e708-e715. doi:10.1542/neo.21-11-e708

Patrick SW, Schiff DM, Prevention C on SUA. A Public Health Response to Opioid Use in Pregnancy. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-4070

Patrick SW, Barfield WD, Poindexter BB, Committee on Fetus and Newborn C on SU and P. Neonatal Opioid Withdrawal Syndrome. Pediatrics. 2020;146(5). doi:10.1542/peds.2020-029074

Kendig S, Keats JP, Hoffman MC, et al. Consensus Bundle on Maternal Mental Health. Obstet Gynecol. 2017;129(3):422-430. doi:10.1097/AOG.0000000000001902

Pescosolido BA. The Public Stigma of Mental Illness: What Do We Think; What Do We Know; What Can We Prove? J Health Soc Behav. 2013;54(1):1-21. doi:10.1177/0022146512471197

Mendelson T, Cluxton-Keller F, Vullo GC, Tandon SD, Noazin S. NICU-based Interventions to Reduce Maternal Depressive and Anxiety Symptoms: A Meta-analysis. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-1870
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Restoration of Black Autonomy and Joy in Perinatal Nursing Leadership

There is an important intersection between Black women and birthing people, Black perinatal nursing leaders, and maternal health.

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

Six years ago, the Black Mamas Matter Alliance launched Black Maternal Health Week, a week each April that would highlight and amplify the unacceptable and sustained increase in Black maternal deaths . Within the global COVID-19 pandemic, the outcome disparities within Black and Brown maternal health communities continued to grow and were impacted at greater rates. On April 13, 2022, Vice President Kamala Harris convened Cabinet secretaries to address the ongoing maternal morbidity and mortality crisis in the United States. The President’s FY23 budget included $470 million to address additional maternal disparities projects, including supporting the perinatal health workforce.

The perinatal health workforce has become an important discussion point, as the need for community health workers, doulas, and other Black maternal health advocates center conversations about the needs of Black mothers and parents. While there is a significant need for a community health focus, inpatient obstetric care requires intentional focus and strong leadership. As reported by the CDC and MMRIA report, 13% of maternal deaths occur on the day of delivery. Inpatient obstetric teams require experienced nursing leadership to support the infrastructure and care delivery required to provide high quality, respectful, and culturally competent care. Open nursing leadership positions within Women’s and Children’s service lines that were once rarely available or open now sit vacant for weeks, and in some cases, months. An area of healthcare leadership that is not often studied is that of frontline perinatal nursing leaders.

So how does this connect to Black Maternal Health Week? There is an important intersection between Black women and birthing people, Black perinatal nursing leaders, and maternal health.

Weeks ago, Synova Associates and the National Perinatal Information Center launched a white paper that reported on the effects of chronic stress on perinatal nursing leaders (Supporting Perinatal and Neonatal Nurse Leaders: Identification and Moderation of Chronic Stress, IRB #1321780). These nursing leaders represented inpatient settings throughout the United States such as neonatal intensive care (NICU), labor and delivery, postpartum, well-baby nurseries, lactation services, antepartum, and those nursing leaders who are responsible for multiple units. The findings of this study revealed significant racial disparities in many areas, including turnover intent (p < .001), job control (p < .001) and organizational constraints (p < .001).

Based on the results of this study, the following recommendations are suggested for hospital leadership to address:
  1. Healthcare leaders and communities must be made aware of the extrinsic stressors that exist for Black/African American and diverse perinatal nursing leaders. Within this study population, stressors were described as physical symptoms (chest pain, shortness of breath, p < .001) that cannot be ignored, and require additional research and development for strategies by and for those most impacted by these findings. We cannot discuss the physical impacts upon Black nursing leaders without recognizing racism and structural barriers that create environments that impact physical health.

  2. Turnover intention, particularly as described in this study (“I won’t be working here one year from now” p < .001) for Black and Brown perinatal nursing leaders must be more thoroughly explored, and the urgency of this finding addressed. It will be important to replicate this study within other service lines to establish if these findings are unique to perinatal services, or if these findings are more global to diverse nursing leaders regardless of setting.

  3. Job Control, or the perceived ability to make decisions or the freedom to decide how to work, was also significantly decreased for Black and Brown nursing leaders (p < .001). In addition, organizational constraints (hospital rules/procedures; adequate help from others) was also significant (p < .001), which continues to generate further need for examining systems and structures in place that create these real and/or perceived barriers to effective leadership. Exploring these differences is critical and may aid in better understanding turnover intent as well as the symptoms of chronic stress described within Black perinatal nurse leaders. #structuralbarriers
During Black Maternal Health Week, it is important to center the conversation around Black women and birthing people and the continued unacceptable outcome disparities that exist despite data saturation. While assuring the health, well-being, and bodily autonomy of our diverse patients and communities continues to be a priority in our healthcare systems, it is just as important to ensure that we are providing that same level of effort and intensity at assuring the health and well-being of Black nursing leaders within our systems. During Black Maternal Health Week this year, celebrate the richness and diversity of Black communities and Black perinatal leaders. Support the Black Mamas Matter Alliance and the Restoration of Black Autonomy and Joy. Commit ourselves to amplifying Black voices and experiences and follow their lead for innovative and sustainable solutions to eradicating Black maternal morbidity and mortality.


References
National Minority Health Month. NIMHD. Accessed April 9, 2022. https://www.nimhd.nih.gov/programs/edu-training/nmhm/

Black Maternal Health Week. Black Mamas Matter Alliance. Accessed April 9, 2022. https://blackmamasmatter.org/bmhw/

Trocado V, Silvestre-Machado J, Azevedo L, Miranda A, Nogueira-Silva C. Pregnancy and COVID-19: a systematic review of maternal, obstetric and neonatal outcomes. The Journal of Maternal-Fetal & Neonatal Medicine. 2020;0(0):1-13. doi:10.1080/14767058.2020.1781809

Di Mascio D, Khalil A, Saccone G, et al. Outcome of coronavirus spectrum infections (SARS, MERS, COVID-19) during pregnancy: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology MFM. 2020;2(2, Supplement):100107. doi:10.1016/j.ajogmf.2020.100107
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