This post is part of “Inequities in Maternal Mortality in the U.S.,” a blog series hosted by the MHTF.
While internationally maternal mortality rates have been falling, the sad reality is that the maternal mortality rate in the U.S. has doubled since 1990. Here in Philadelphia, the Maternity Care Coalition is working hard to address a maternal mortality rate that is significantly higher than the national average.
Maternal mortality is a multifactor problem. Many women are coming to pregnancy sicker, struggling to manage complex chronic diseases. These same women also face structural barriers such as fragmented health care and social service systems and poor access to quality transportation, child care, employment and housing. Many are further challenged by domestic violence, behavioral health and addiction issues.
The women we work with face many of these obstacles, often at the same time. One woman, Janet, got caught in the cracks of the fragmented health care system. She was determined to manage her diabetes, high blood pressure, obesity and other health conditions to ensure her and her baby’s health. Given her multiple comorbidities, she became a patient at the high-risk prenatal clinic at the Hospital of the University of Pennsylvania. Despite diligently logging her glucose readings and trying to take her medications, she struggled to get her neighborhood pharmacy to refill her medications. At the clinic, her providers worked to keep her health stable, but became frustrated when she did not appear to be taking her insulin and blood pressure medications. They were baffled as to why she was not complying with their instructions, unaware of the difficulties she faced in obtaining her medications.
Another woman, Cherise, was finishing her vocational education degree and had a part-time job, but no steady place to call home, when she learned she was pregnant. She quickly embraced her pregnancy and switched to the diabetes clinic for pregnant women. Having been in foster care as a teenager, Cherise was no stranger to challenges, but she did not anticipate the barriers she would encounter. Over five months she would live in four different places, including a shelter for people in recovery (the only emergency shelter available at the time). At the shelter, needle sticks were forbidden, including sticks to monitor her glucose. The tight curfew made it hard for her to go to her job in the evenings. She left the shelter to stay temporarily with a friend. How could she overcome these obstacles to take care of her own health and create stability?
Navigating pregnancy and the demands of high-risk prenatal care was overwhelming for these women. We have found that pairing community health workers (who we call “Advocates”) with women with chronic illness makes a huge difference in two critical ways. First, with the support of an Advocate, women are better able to address the countless challenges they face, and, as a result, are able to better manage their health. Secondly, systems critical to women’s well-being—hospital, clinic, insurance and social service—will develop a greater understanding of the person they are serving. This understanding, and subsequent adaptations, will strengthen communication between the different systems and improve their ability to meet critical needs of the woman. The Advocates do the following to integrate disjointed systems to better care for high-risk pregnant women:
- Connect women to their Medicaid Managed Care case manager and vital services (e.g. nurse visits, lactation support, and transportation) and supplies, such as breast pumps and cell phones.
- Update health care providers on their patients’ key non-clinical challenges through care review meetings
- Serve as doulas to support women through labor, delivery and breastfeeding initiation
- Connect women to many key resources, including behavioral health and addiction services through the behavioral health managed care agency
In Janet’s case, her Advocate helped her work with the pharmacy to autofill her prescriptions. Janet’s Advocate also alerted her healthcare providers to how prescription challenges had affected Janet’s adherence. Cherise’s Advocate helped her understand her housing options and accompanied her in her housing searches. With the additional support, Cherise was able to stay focused on her own health and diabetes management.
Fortunately, Philadelphia has a multi-disciplinary Maternal Mortality Review team that explores the causes of maternal deaths. This team has found that, primarily, inadequate health care is not the cause of these women’s deaths. These women are treated in world-class hospital systems and have access to a wide range of social service agencies. However, these systems and agencies are often not aware of each other’s efforts, which results in women tragically falling through what was supposed to be a safety net.
Cherise eventually found a room to rent, but continues to struggle with financial stability in her minimum wage job and inconsistent child care due to weak family support. But she has a strong handle on managing her diabetes, is connected to ongoing health care and feels a loving attachment to her son. As we celebrate our intervention’s first year, we must continue to ask ourselves and our system partners, “How do we acknowledge and address the social conditions challenging high-risk pregnant women so that women can successfully manage their own health and that of their babies and avoid catastrophic outcomes?”