• Striving for Birth Equity: Family Medicine's Role in Overcoming Disparities in Maternal Morbidity and Mortality

    Executive Summary

    The maternal mortality rate in the United States is one of the highest in the developed world.1 Although data on maternal mortality rates in the United States have been largely inconsistent and unreliable, recent data show that U.S. maternal mortality rates have stagnated or even worsened over time, all while rates around the globe continue to fall.1,2 According to the World Health Organization (WHO), maternal mortality globally declined nearly 38% between 2000 and 2017.3 During roughly the same period, maternal mortality in the United States increased by over 26%.1 Significant disparities also exist in how these rates are distributed, with higher rates of mortality occurring among Black women, women with low income, and women living in rural areas. The factors driving these disparities are complex and intersect with clinical care, patient health, and public health on many levels. The American Academy of Family Physicians (AAFP) believes family physicians can play a significant part in addressing the disparities in maternal morbidity and mortality because they are trained to provide comprehensive care across the life course, including prenatal, perinatal, and postpartum care, for people in the communities where they live.4

    Call to Action

    Family physicians have a vested interest in policies and practices that advance the health of their patients and their communities. Several structural and institutional barriers to achieving better outcomes and equity in maternal morbidity and mortality exist, and solutions must be actionable and supported by broad-based policy changes. As medical experts and trusted members of their communities, family physicians can serve as effective agents in facilitating and advocating for change.

    Actions Family Physicians Can Take

    • Learn about the effects of implicit bias and develop an action plan for addressing personal biases
    • Work in a rural community to provide obstetrical services or partner with other clinicians providing obstetrical services in rural communities
    • Identify and encourage continuing medical education (CME) and other training opportunities on topics like patient safety bundles, implicit bias and health/birth equity
    • Participate in a local maternal health review committee
    • Advocate for policies to increase birth equity within their practice and the hospital system, including the standardization of mandatory data collection and reporting
    • Advocate for Medicaid expansion, payment parity and post-partum coverage to increase access to care for patients across their reproductive life course

    Actions Educators Can Take

    • Learn about the effects of implicit bias and develop an action plan for addressing personal biases
    • Develop best practice guides to help family physicians retrain and gain privileges to provide obstetrical care5
    • Support family medicine preceptorship programs for medical students and advocate for funding to expand opportunities into rural communities
    • Advocate for the funding of additional graduate medical education opportunities for family physicians and obstetricians to train in rural communities6

    Actions Policy Makers Can Take

    • Learn about the effects of implicit bias and develop an action plan for addressing personal biases
    • Advocate to expand Medicaid coverage and to extend coverage of mothers to one year postpartum and provide adequate reimbursement for obstetrical services
    • Advocate for the expansion of current loan repayment programs or incentives, including the National Health Service Corps (NHSC) and the federal Public Service Loan Forgiveness Program, to obstetrical care providers such as family physicians, OB-GYNs, certified nurse-midwives, labor and delivery nurses, and community health centers
    • Advocate to allow rural obstetrical care providers, and potentially rural hospitals, to be eligible for Federal Tort Claims Act (FTCA) medical malpractice liability protection

    Introduction

    Approximately 700 people die from pregnancy-related complications annually in the United States.7Among the maternal deaths for which timing is known, 31.3% occur during pregnancy, 16.9% occur on the day of delivery, 18.6% occur one to six days postpartum, 21.4% occur one week to 42 days postpartum, and 11.7% occur 43 days to one year postpartum.7 Data from 13 state maternal mortality review committees (MMRCs) during 2013 to 2017 indicated that more than 60% of pregnancy-related deaths were preventable.7 Many other individuals suffer pregnancy-related complications that do not result in death but place their health at significant risk. The leading causes of pregnancy-related morbidity and mortality include hemorrhage, infection, cardiovascular conditions, preeclampsia and eclampsia, and embolism.7

    In 2018, the maternal mortality rate in the United States was 17.4 deaths per 100,000 live births, which was more than double the rate of every other country in the developed world.2 The rates are significantly higher for pregnant people aged 40 and older (81.9 per 100,000 live births) and people of color. At 37.1 deaths per 100,000 live births, the maternal mortality rate for non-Hispanic Black people in the United States is more than double that of non-Hispanic white people (14.7) and more than three times the rate for Hispanic people (11.8). These reported rates notably exclude maternal deaths that occur more than 42 days after giving birth, which represent 11.7% of all maternal deaths, according to the Centers for Disease Control and Prevention (CDC).2,7

    Many of the disparities that exist in maternal morbidity and mortality are exacerbated by other social determinants of health.8 The closure of rural hospitals and obstetrics programs has led to enormous gaps in access to prenatal and perinatal services for pregnant people living in rural communities. Gaps in insurance coverage and availability of affordable care for people with low incomes also increase the risk of morbidity and mortality, particularly during the postpartum period.

    Evidence-Based Methods to Decrease Maternal Morbidity and Mortality

    Several evidence-based methods are being used to address maternal morbidity and mortality at the national and state levels. These methods include, but are not limited to, the following:

    • Alliance for Innovation on Maternal Health (AIM) maternal safety bundles
    • Maternal mortality review committees
    • California Maternal Quality Care Collaborative (CMQCC) toolkits

    The American Academy of Family Physicians (AAFP) supports the dissemination and use of existing evidence-based tools and resources within hospitals and physician practices, for both practicing physicians and those in training, to address disparities in maternal morbidity and mortality. In addition, the AAFP calls for standardization of data collection and reporting on maternal mortality (e.g., Maternal Mortality Review Information Application [MMRIA]) to enable stakeholders to better define data collection needs and identify gaps in existing research.

    AIM Maternal Safety Bundles

    The AIM program is designed “to equip, empower and embolden every state, perinatal quality collaborative, hospital network/system, birth facility and maternity care provider in the [United States] to significantly reduce severe maternal morbidity and maternal mortality through proven implementation of consistent maternity care practices” that are outlined in maternal safety bundles (action systems).9 The AIM maternal safety bundles represent best practices for maternity care and are developed and endorsed by national multidisciplinary organizations. The AAFP helps develop the AIM maternal safety bundles through its participation in the American College of Obstetricians and Gynecologists (ACOG) Council on Patient Safety in Women’s Health Care, a collaboration of professional organizations in women’s health care. The AIM program has been used concurrently with recent maternal safety initiatives, including MMRCs.

    Maternal Mortality Review Committees

    Maternal mortality review committees play an important role in collection and dissemination of maternal health data. Many U.S. states have begun the process of implementing MMRCs, with a goal of collecting information that will help researchers, policy makers, and medical clinicians identify the key factors found in maternal deaths. MMRCs study local maternal death cases to identify strategies for making pregnancies safer and preventing tragic outcomes. It is important for all stakeholders to support these committees and for family physicians to participate in these collective efforts.

    As MMRCs have emerged, it has become evident that defined data standards would allow better access to population health data across state lines. The CDC partnered with MMRCs and subject matter experts to create the Maternal Mortality Review Information Application.10 MMRIA provides standardized data that can be used for surveillance, monitoring, and research related to maternal mortality. It also provides a common data language to help MMRCs collaborate in case review and analysis.

    The AAFP supports the development, implementation, and sustainability of MMRCs and strongly advocated for the successful passage of the Preventing Maternal Deaths Act, which incorporated provisions of the Maternal Health Accountability Act. According to Health Affairs, “this legislation sets up a federal infrastructure and allocates resources to collect and analyze data on every maternal death, in every state in the nation. The bill is intended to establish and support existing [MMRCs] in states and tribal nations across the country through federal funding and reporting of standardized data.”11

    CMQCC Maternal Quality Improvement Toolkits

    According to the California Maternal Quality Care Collaborative, CMQCC Maternal Quality Improvement Toolkits “aim to improve the health care response to leading causes of preventable death among pregnant and postpartum women[,] as well as to reduce harm to infants and women from overuse of obstetric procedures. All toolkits include a compendium of best practice tools and articles, care guidelines in multiple formats, [a] hospital-level implementation guide, and [a] professional education slide set. The toolkits are developed in partnership with key experts from across California, representing the diverse professionals and institutions that care for pregnant and postpartum women.”12

    Barriers to Achieving Equity in Maternal Morbidity and Mortality

    Implicit Bias in Health Care

    The AAFP recognizes that the root causes of racial and ethnic disparities in maternal morbidity and mortality are institutional racism in the health care and social service delivery system, and social and economic inequities.

    Implicit bias is pervasive among all health care professionals and has deleterious effects on patient health.13 Implicit biases modify the physician-patient relationship by reducing trust, self-efficacy, understanding, and satisfaction. For patients, this affects their ability to manage their own health and adhere to treatment. For physicians, implicit bias limits their level of cultural proficiency, patient-centeredness, and job satisfaction. The academic medical community recognizes that to limit the impact of implicit biases on patient health outcomes, medical education and training must develop approaches rooted in both theory and research to change students’ and residents’ knowledge, behaviors, and practice.

    Formal medical education and training curricula are often void of content that provides a framework for identifying and mitigating implicit biases in clinical practice. Faculty who seek to incorporate this topic in training are often faced with barriers, such as the limited number of subject matter experts who can provide instruction; a lack of opportunities for participants to observe and demonstrate mitigation strategies in practice; and a lack of opportunities to engage with patients who can share experiences of encountering implicit bias in the delivery of prenatal care. Results from the 2017-18 Council of Academic Family Medicine (CAFM) Program Directors Diversity Survey indicated that only 64% of family medicine residency programs offered training for both faculty and residents on addressing implicit bias.14

    Studies examining the health outcomes of implicit bias have revealed significant effects. For example, studies have found that students harbor implicit biases toward minority patients when they enter medical school and that their level of bias remains constant or increases over time.15 In a sample group of white medical students and residents, half endorsed beliefs that there are biological differences in levels of pain for Black and white patients.16 As a result, they viewed the Black patients’ pain levels as lower than white patients’ pain levels and made less accurate treatment recommendations for Black patients. A study of gender bias among cardiologists revealed significant variability in simulated clinical decision‐making for suspected coronary artery disease.17

    The implicit biases of health care professionals toward people of color, particularly Black women, have been indicated as a contributing factor to racial/ethnic disparities in adverse maternal and child health outcomes. For example, studies have demonstrated that implicit bias of health care professionals affects rates of racial and ethnic disparities in contraception use18; access to and quality of prenatal care19-21; and clinical decision-making in the intrapartum and postpartum periods.22

    In addition, the implicit biases of health care professionals and discrimination against people of color stem from a long, sordid history of institutional racism perpetuated by the U.S. health care system. Institutional racism is a system that permits the establishment of patterns, procedures, practices, and policies within organizations that consistently penalize and exploit people because of their race, color, culture, or ethnic origin.23 The system of racism within organizations affects the attitudes, beliefs, and behaviors of one individual (the physician) toward another (the patient). Efforts aimed at addressing the implicit biases of health care professionals must also consider the historical and contemporary contexts of treatment toward people of color in the health care setting.

    The AAFP considers racism a public health crisis and continues to strongly advocate for addressing health disparities and negative health outcomes of racism in patients who are often at an increased risk of heart disease, stroke, diabetes, low birth weight, premature birth, and infant mortality.24 However, this will not be achieved without first acknowledging racism’s contribution to health and social inequalities, including inequitable access to quality health care services.

    Growing Loss of Rural Obstetrical Services

    Many challenges of living in a rural area may impact maternal morbidity and mortality. Access to rural hospital obstetrical services is of significant concern. In 1985, 24% of rural counties lacked hospital-based obstetrical services.25 As of 2014, 54% were without hospital-based obstetrics.26 More than 200 rural obstetrical units closed between 2004 and 2014, with additional rural units at risk.26 In addition to lack of facilities, there are complex issues such as lack of transportation, increased poverty, increased rate of chronic diseases, and difficulty recruiting and retaining physicians to live and work in rural communities.

    Levels of Maternal Care, a consensus document from ACOG and the Society for Maternal-Fetal Medicine (SMFM), seeks to address regionalization of services in which higher-level facilities support those that have fewer resources.27 This guidance calls for standards at each level of maternal care and a robust transfer network. The AAFP continues to collaborate with ACOG to ensure that the levels of maternal care are relevant to rural settings while providing high-quality obstetrical care at the local level. A key concern is the need for the levels of maternal care to address support and training for lower-resource hospitals and hospitals that have no obstetrical services.

    Through the introduction of the Rural Physician Workforce Production Act of 2019 (S. 289), Congress has also acknowledged the rising loss of rural health care providers. This bill would provide federal support for rural residency training, which will help alleviate physician shortages in rural communities. Evidence indicates that one of the most promising ways to recruit physicians to practice in underserved areas is through residency training that takes place in settings primarily associated with underserved populations (e.g., rural health clinics).28,29 Supported by the AAFP, ACOG, and the National Rural Health Association (NRHA), the bill would provide new, robust financial incentives for rural hospitals (including critical access hospitals) to provide the training opportunities that the communities they serve need.30 Currently, numerous incentives in the Medicare program discourage hospitals—even those in communities that desperately need new physicians—from providing such opportunities. The financial incentives specified in the Rural Physician Workforce Production Act would also extend to urban hospitals for the purpose of growing the number of residents in rural training tracks.

    Another major factor in the growing loss of obstetrical services in rural communities is the rising cost of liability insurance premiums.31 Higher premiums threaten the viability of some rural hospitals that have chosen to eliminate high-risk services (e.g., obstetrics, certain surgeries). As a result, patients must travel farther for this care or be transferred to a facility that provides needed services. High premiums can also make it difficult for rural areas to recruit or retain an adequate number and mix of physicians, especially in certain subspecialties.

    Through the Federal Tort Claims Act (FTCA), the federal government offers a way for certain rural health centers to lower their malpractice insurance costs. The FTCA affects rural health through the creation of a medical malpractice insurance program for federally qualified health centers (FQHCs). This program offers comprehensive medical malpractice protection at no cost to grantees who participate. Reducing the need for FQHCs to purchase private medical malpractice insurance makes more funds available for clinical services. Section 10608 of the Patient Protection and Affordable Care Act (ACA) expands FTCA protections to an FQHC’s nonmedical personnel.32 Malpractice demonstrations by the states are authorized in Section 10607 of the ACA. Expansion of the FTCA could help eliminate a major barrier for rural communities that are struggling to provide high-risk services due to the increasing cost of private medical malpractice insurance.

    According to the National Center for Health Statistics (NCHS), 43% of all births in 2017 had Medicaid as the source of payment for the delivery.33 In 19 states, Medicaid maternity coverage ends at 60 days postpartum, leaving people without access to care or support for problems during this critical time.34Some studies have found that more than 60% of maternal deaths occur postpartum.35 Statistics show a clear need to extend Medicaid coverage for up to one year after delivery.

    About 60 million people (i.e., 20% of the U.S. population) live in rural communities.36 The percentage of family physicians living and working in rural communities (15.7%) far exceeds that of any other physician specialty.37 More than 52% of all outpatient visits in the United States are to primary care physicians..38The AAFP is committed to eliminating health disparities in rural communities through several strategies, including supporting the retention of family physicians in rural areas and advocating for payment reform, medical malpractice reform, and loan repayment expansion.

    Educational Strategies to Support Family Physicians Providing Obstetrical Care

    Research findings published in the Annals of Family Medicine showed that physicians who graduated from residency between 2010 and 2013 had a narrower scope of practice than those who graduated between 1996 and 1999.39 While graduates feel more prepared than previous cohorts, family medicine graduates are providing significantly less OB care. A separate study showed that among recent graduates who intended to practice obstetrics, having lifestyle concerns and finding a job that did not include obstetrics were the most significant reasons that respondents did not end up with the scope of practice they intended.40

    Family medicine residency programs vary in the obstetrical training and opportunities they offer, as well as in how they meet the Review Committee for Family Medicine (RC-FM) requirements. There are opportunities to work with family medicine residency educators on models of training that provide core competency while also providing higher volume, acuity, and comprehensive obstetrical training.41

    One strategy to encourage medical students and residents to train in and provide OB care is to offer opportunities to experience the full scope of family medicine practice in a broad range of settings. State and local preceptorship programs have shown significant results in influencing medical students to choose primary care.42 However, over the years, these programs have suffered due to decreases in funding that limit the opportunities for exposure. Preceptorship programs, including the Society of Teachers of Family Medicine’s (STFM) Preceptor Expansion Initiative, have struggled to recruit family physicians who provide obstetrical care.

    AAFP Efforts to Address Maternal Morbidity and Mortality

    Striving for Birth Equity Policy

    The AAFP’s policy on striving for birth equity states, “The [AAFP] recognizes that significant disparities exist in the rates of maternal morbidity and mortality, with higher rates occurring among Black women, women who have a low income, and women living in rural areas. …

    The AAFP also recognizes that the root causes of racial and ethnic disparities in maternal morbidity and mortality are institutional racism in the health care and social service delivery system and social and economic inequities. Family physicians are well positioned to address these root causes as they are trained to provide comprehensive care including prenatal, perinatal, and postpartum care for women in the communities in which they live.

    The AAFP defines birth equity as the assurance of the conditions of optimal births for all people with a willingness to address racial and social inequalities in a sustained effort. The AAFP recommends educating physicians about inequities in maternal morbidity and mortality and supports strategies that integrate birth equity into the delivery of family-centered maternity care.”43

    Implicit Bias Training

    The AAFP supports physician education and development by creating and disseminating health equity-focused education and practice tools that are based on evidence and align with accepted educational standards. In 2020, the AAFP released its Implicit Bias Training Guide for use by members and other health care professionals. The training has also been expanded to 12 AAFP state chapters to facilitate the dissemination and implementation of training across the country. The primary goal of this training is to promote awareness of implicit bias among all members of the health care team and to provide resources for mitigating the negative effects of implicit bias on patient care.

    Training activities include self-assessments, application of skills to case-study examples, small-group discussions, and the development of an implementation plan. The training format incorporates both online modules and in-person activities. Learning objectives of this training include the following:

    • Increase self-awareness by reflecting on the results of the implicit bias self-assessment
    • Demonstrate conscious mitigation strategies to overcome implicit bias
    • Apply implicit bias reduction skills to case-study examples
    • Understand the effect of implicit bias on real-life patients

    Center for Diversity and Health Equity

    In 2017, the AAFP launched the Center for Diversity and Health Equity (CDHE) to support its strategic priority of striving for health equity by taking a leadership role in addressing diversity and the social determinants of health as they impact individuals, families, and communities across their lifespan. The CDHE provides education and training resources to AAFP members and other stakeholders to raise awareness and develop physician leaders who can provide solutions for patients and work to eliminate the social inequities that cause disparities. The CDHE focuses its work in four core areas: advocacy, workforce diversity, multisector collaborations, and education/training.

     Education on Recognizing Obstetrical Emergencies

    The AAFP and ACOG both have courses to provide education and build skills focused on recognizing obstetrical emergencies. These evidence-based, interprofessional, and multidisciplinary programs train medical staff and first responders through a blend of didactic learning and simulated obstetrical emergencies, with a focus on team-based care.

     The AAFP’s Advanced Life Support in Obstetrics (ALSO®) is a program that equips the entire maternity care team with skills to effectively manage obstetrical emergencies. This comprehensive course encourages a standardized team-based approach among physicians, residents, nurse-midwives, registered nurses, and other members of the maternity care team to improve patient safety and positively impact maternal outcomes.

     Basic Life Support in Obstetrics (BLSO®) is designed to improve the management of normal deliveries, as well as obstetrical emergencies, by standardizing the skills of first responders, emergency personnel, and maternity care providers. The BLSO curriculum is designed to train pre-hospital care providers; first responders and emergency personnel; and medical, nursing, and physician assistant students.

     Using the most up-to-date evidence-based literature, ACOG created its Emergencies in Clinical Obstetrics (ECO) course  to train health care professionals at all levels to work together during obstetrical emergencies. It features simulation stations that allow participants to get hands-on practice for individual skills and to practice the communication skills and critical teamwork required during an obstetrical emergency. Standardized lectures provide necessary background information, and participants also get clinical checklists for reference during the course and for use at their institutions.

     The AAFP believes it is vital to increase maternity care readiness for practice teams, first responders, hospitals, communities, and maternity care professionals so they are “OB ready.” Low-resource hospitals and communities where physicians no longer provide obstetrical services need adequate funding and the ability to connect with appropriate health care resources to become OB ready by building competencies in basic and advanced obstetrical care.

     In addition to training, rural medical professionals and first responders need access to necessary supplies and equipment to respond during obstetrical emergencies. This includes basic or prepackaged delivery kits, postpartum hemorrhage kits, and medications for both deliveries and/or common complications. The AAFP is eager to collaborate with public and private stakeholders on ways to further develop and implement the OB ready concept to better support communities in need.

    Investment in Rural Health

    The AAFP has invested directly in capacity building to eliminate rural health disparities by establishing a Rural Health Equity Fellowship through the CDHE. In 2019, the AAFP Chapter Health Equity Planning Grants program awarded grants to 10 AAFP state chapters to develop health equity plans by identifying specific tactics the chapters will use to advance health equity in their state and region.

     The AAFP further operationalized its efforts in 2019 by launching Rural Health Matters, an Academy-wide strategic initiative to improve health care in rural communities. Through this collaborative initiative, the AAFP seeks to establish itself as a leader for rural health and rural physicians by influencing policy and payment issues related to rural health; addressing educational needs and resources for family physicians practicing in rural areas; and creating policy, collaboration, and resources to help family physicians improve rural health disparities.

    Conclusion

    The factors driving the high rates of maternal morbidity and mortality in the United States are complex and highly relevant to the practice of family medicine. Limited access to quality prenatal and postpartum care, which is caused by workforce shortages and closures of rural hospitals and obstetrics programs and exacerbated by social determinants of health, creates disparities that family physicians are uniquely positioned to face. The AAFP is committed to working with stakeholders across the continuum of health care to implement evidence-based strategies aimed at achieving equity in maternal morbidity and mortality. Through continued engagement, learning, and a willingness to confront their implicit biases, family physicians can continue to serve as leaders to overcome this critically important public health challenge.

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    42. Primary Care Coalition. Primary care preceptorship programs work to build the physician workforce Texas needs. Accessed July 8, 2019. https://www.tafp.org/Media/Default/Downloads/advocacy/preceptorship.pdf

    43. American Academy of Family Physicians. Striving for birth equity. Accessed June 24, 2020. https://www.aafp.org/about/policies/all/striving-for-birth-equity.html

    (July2020BC) (2020 COD)