Author: Jillian Genereux

Being Unhoused is Not Neglect…Part II

Our National Perinatal Information Center Perinatal Database reveals that homelessness is one of the most reported social determinants of health (SDOH).

Elizabeth Rochin, PhD, RN, NE-BC | May 30, 2024

Posted under: Social Determinants of Health/Disparities

Two years ago, I wrote about a story I came across in the Los Angeles Times, Pregnant, Homeless, and Living in a Tent: Meet Mckenzie. I read the article with genuine interest, as our National Perinatal Information Center Perinatal Database reveals that homelessness is one of the most reported social determinants of health (SDOH). This continues to be the top viewed blog at NPIC.

In this news story, a young woman, Mckenzie, describes her experiences as a homeless teen during her pregnancy. She worries about having to disclose her housing situation to case managers and social workers at the hospital when she goes into labor, fearful that her baby will be taken into protective custody based on her housing status.
Based upon the most recent definition updates, I am changing this to Being Unhoused is Not Neglect.

According to Mckenzie, one of her social workers did not associate being unhoused with neglect, and merely the location of living.

According to the Child Welfare Information Gateway, neglect is frequently defined as “the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child's health, safety, and well-being are threatened with harm.” So, does living in a tent meet this definition if all other needs are satisfied? Should it? And do words matter? Homeless? Unhoused? Housing insecure?

Voices Across the Nation
When I I reposted that article on LinkedIn I received messages from across the United States regarding experiences working with unhoused mothers and the often kneejerk reactions to immediately contact Protective Services about their housing status:

“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 current 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 to make every effort to keep these newborns with their mothers”—Southeast US

“We assign blame to these mothers. Homelessness ‘must have been their choice.’ They did something to lose their home, their livelihood.’ With this kind of mindset, we will never help these women. We will simply continue to blame them”—West Coast US

“We make it impossible for women to seek help when they are experiencing homelessness. And too many care providers assume that homelessness is some permanent situation. There must be better answers”—West Coast US

“We treat convicted prisoners who deliver and give birth with more compassion than we do those who are homeless. We make great efforts to keep the mother and baby together during incarceration, but do not allow the same effort for the homeless mother. What does that say about us, and the value we place on those who are experiencing homelessness?”—Mid-Atlantic US

The Data Has Changed in Two Years…and Not for the Better
A recent 2023 JAMA investigation discovered the following data related to pregnancy and homelessness: Trends, Characteristics, and Maternal Morbidity Associated With Unhoused Status in Pregnancy | Equity, Diversity, and Inclusion | JAMA Network Open | JAMA Network
  • A prevalence rate of homelessness at the time of delivery: 104.9/100,000 deliveries.
  • Median age of 29.
  • Prevalence of unhoused patients grew 72% between 2016 and 2020.
  • Substance use disorders, mental health conditions, and patient characteristics (low income; Black/Native American; obesity) were all noted to be associated with a higher prevalence of homelessness.
  • Patients who were unhoused were 12 times more likely to experience cardiac arrest during pregnancy or delivery, 8 times more likely to require mechanical ventilation, and 5 times more likely to develop sepsis.
The National Perinatal Information Center collects social drivers of health (SDoH) data every quarter. Based upon the Z-codes for sheltered and unsheltered homelessness, within the period 10/01/2022 – 09/30/2023, NPIC member hospital SDoH reported data revealed a sheltered/unsheltered homelessness prevalence of 280/100,000.

One of the challenges of addressing homeless families is that there have been many definitions of what “homeless” means over the years. However, most states now are using the US Department of Housing and Urban Development definition, which is “an individual or family who lacks a fixed, regular, and adequate nighttime residence.”
The US Department of Housing and Urban Development (HUD) reported between the years 2022 – 2023 the largest increases in homelessness were experienced by families with children, by as much as 16%. Chronic homelessness increased by 31% of those who reported chronic challenges with shelter.

Seeking Safety, Seeking Refuge
So how do women become unhoused in the first place? Domestic and sexual abuse is the primary driver for women fleeing their homes, with children in tow, to escape abuse. Studies on homelessness report that nearly 90% of homeless women have experienced sexual or physical trauma. A Massachusetts report on homelessness reported that women are more likely to opt out of shelters for fear of their physical safety, and therefore are not counted and are underrepresented in many estimates of homeless women. Homeless mothers experience chronic and repeated traumas that can impact both the mother and the child in irreparable ways.

Menstruation is Expensive
A 2024 study exploring qualitative works revealed several studies surrounding women experiencing homelessness The homeless period: a qualitative evidence synthesis (tandfonline.com). One of the primary drivers of this work found the recurring theme of women experiencing homelessness, “menstruation is expensive.” The cost of menstrual supplies, the inability to wash blood-stained clothing, and access to facilities to maintain menstrual hygiene were few. Postpartum women experiencing homelessness face significant challenges in maintaining perineal hygiene, particularly if fresh pads and clean bathrooms are not available.

So, What Can You Do?
Advocacy for access to care is not a one-and-done event. Advocating for equitable, sustainable, and compassionate services to support homeless women and their families is of the utmost importance in our communities. Just as important is advocating for resources for those who are on the brink of homelessness…just one paycheck away from having nothing.

So, before you pick up the phone and call Child Protective Services to initiate a report for neglect, have you already made every effort to secure the unmet social needs of your pregnant patient? If not, why not? Do you initiate Child Protective Services reports equitably and equally? And if not, why not? Do you track the race and ethnicity of your Child Protective Services reports based on the rationale for the call? Do you share that data with your care teams?

"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 to make every effort to keep these newborns with their mothers."

So, I return to this statement. What could have been done differently? How could we have kept this pregnant woman in the hospital and connected her with the services she needs to take care of her newborn? How could we better engage? How can we reframe our biases and eliminate racism within our healthcare settings to provide respectful and dignified care to all patients?

Being Unhoused is Not Neglect…until you say it is.


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Creating the Case for Well-Newborn Care Simulation

Well-newborns are not often thought of as requiring additional support or expertise for their care. Research and literature, both medical and nursing, tend to support Labor and Delivery and Neonatal Intensive Care as opposed to the immediate postpartum period. Perhaps it is time to revisit this and build depth into these areas, including the care of the well-newborn.

Elizabeth Rochin, PhD, RN, NE-BC | May 22, 2024

Posted under: Other, Quality of Care

In 2022 and 2023, the National Perinatal Information Center partnered with GE HealthCare to explore the constellation of issues that exist within newborn falls. Many areas were identified by a nationally recognized expert team of nurse scientists, clinicians, and leaders.

Two important key measures were identified as part of this work:
  • A national framework and proposal developed to provide prevention and response guidance to quality, safety, and accrediting organizations.

  • Establish standardized, unit-specific simulation activities and drills that can be used in hospitals to promote readiness, recognition of risk, prevention of, and response to a newborn fall.
Simulation was described as an opportunity to create awareness and a safe space to facilitate in-situ opportunities for improving the quality of care for newborns. It was important to better understand the current landscape of simulation within obstetric spaces. The group performed a SWOT Analysis (Strengths, Weaknesses, Opportunities, and Threats) of overall simulation activities. Do these seem familiar to you?

Strengths:
Freedom to make mistakes
Safe space for failing
Repetition
Build teamwork and expectations
Identify repetitive errors

Weaknesses/Limitations:
Timing, time-consuming
Information overload
Availability of equipment
Availability of space
Staffing barriers
Lack of multidisciplinary commitment
Conflicting care priorities

Opportunities:
Encourage multidisciplinary engagement
Consistent messaging
Change culture/practice
Encourage simulation with lived experience experts

Threats:
Poor reputation
Budgeting constraints
Costs
Employee time
Lack of support/prioritization from providers for simulation experiences

With simulation becoming such an important factor in patient outcomes, safety, and risk reduction, how can we create opportunities out of these challenges? For organizations that continually struggle with the use of simulation (including challenges such as staffing, costs, and leadership support), what are some of the lessons learned from organizations that have embraced and enculturated simulation as a way of work? While our attention tends to focus on high-fidelity simulation, perhaps our attention needs to focus on high-quality simulation. High quality and low fidelity together can be just as effective.

There is a plethora of research and practice in the use of simulation for obstetric care, including simulations for postpartum hemorrhage, severe hypertension, sepsis, and others, including Obstetric Patient Safety (OPS, AWHONN), and Emergencies in Clinical Obstetrics (ECO, ACOG). Simulation activities are also included in programs such as Obstetric Advanced Life Support (OB ACLS), Advanced Life Support for Obstetrics (ALSO), Neonatal Resuscitation Program (NRP).

While these primarily focus on emergent events, is there an opportunity to simulate well-newborn activities that would seem to be routine, but have the potential to result in unintended harm? In some facilities, well-newborns/nursery beds are not counted in the daily census, which creates even more challenges in facilitating and supporting the costs of well-newborn simulation. While we often think of the mother/newborn dyad as a stable entity, are there potential threats that could leave a newborn exposed to a higher risk of a fall while in the hospital?

Here are just a few:

Postpartum/Well Newborn:
Bed position and bedrail management
Bassinette management and tipping risks
Unintended sleep and sleep education
Breastfeeding positions and fatigue
Cable management and ambulation
Teach-back and closed-loop communication

You will see that one of the overarching themes here is to ensure high-quality education for postpartum patients and their families. Education surrounding bassinette management, safe sleep, fatigue, and safety while ambulating are all critical for immediate postpartum patients. However, research has also shown that one of the most frequently reported missed care elements in obstetric and neonatal intensive care is that of patient education. It could be posited that patient education in well-newborn environments may be a missed care element as well, creating even more urgency for consistent and standardized care.

Most well-newborn simulation research and literature focuses on the academic setting, including the use of simulation for educational purposes before licensure, in both medical and nursing settings. Literature searches through PubMed, EBSCO, CINAHL, WorldCat, Google Scholar, and others show a dearth of information related to the use of simulation for well-newborn care in the hospital environment. Perhaps it is time to consider the use of simulation in well-newborn environments to ensure the highest quality of care.

What are some of the most important elements of well-newborn care that should be more defined? Highlighted? We’d love to hear from you.
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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.

Elizabeth Rochin, PhD, RN, NE-BC | January 23, 2024

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?

Elizabeth Rochin, PhD, RN, NE-BC | December 13, 2023

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.

Elizabeth Rochin, PhD, RN, NE-BC | November 16, 2023

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?

Elizabeth Rochin, PhD, RN, NE-BC | September 14, 2023

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.

Elizabeth Rochin, PhD, RN, NE-BC | August 10, 2023

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.

Elizabeth Rochin, PhD, RN, NE-BC | July 20, 2023

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.

Elizabeth Rochin, PhD, RN, NE-BC | June 29, 2023

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.

Elizabeth Rochin, PhD, RN, NE-BC | June 14, 2023

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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