Using an Equity Lens to Reduce Maternal Mortality in Louisiana
Louisiana has one of the highest maternal mortality rates in the country. And troublingly, Black women are dying from pregnancy-related deaths at over four times the rate of white women. According to a recent report, more than half of these deaths could have been prevented by making a system change, either at the patient, community, or hospital level.
“These findings illustrate the enormous potential that quality improvement initiatives have, not only for reducing maternal mortality in Louisiana, but for eliminating the Black-white disparity in maternal deaths—a disparity mirrored by states across the country,” says NICHQ Executive Project Director Pat Heinrich, RN, MSN, CLE. “By using an equity lens to identify system gaps and errors, Louisiana can test changes that lead to improvement, and then implement and scale these changes across the state. Shared broadly, other states can learn and adapt successful changes for local improvement across the nation.”
Louisiana is one of 47 state teams participating on the National Network of Perinatal Quality Collaboratives (NNPQC), a CDC-funded initiative seeking to improve maternal and infant health outcomes by advancing evidence-informed clinical practices. As the coordinating center, NICHQ provides state perinatal quality collaboratives with quality improvement technical assistance and communication and coordination support. The Louisiana Perinatal Quality Collaborative (LaPQC) launched in August of 2018, and now works with 40 birthing hospitals across Louisiana, covering 92 percent of births in the state.
Committed to addressing the alarming disparities in their state, the LaPQC is pursuing a dual aim that focuses equally on changing overall pregnancy outcomes and advancing equity. Specifically, they’re seeking to reduce maternal mortality among pregnant and postpartum women who experience hemorrhage and hypertension, two leading causes of maternal death, as well as to narrow the Black-white disparity in those same outcomes.
“Not only are women in Louisiana more likely to die from hemorrhage or hypertension, but we also know that those deaths disproportionately affect Black women,” says Kerrie Redmond, RN, the LaPQC’s perinatal improvement advisor. “And because of this, we know we needed to prioritize equity. We can’t only focus on responsiveness for hemorrhage and hypertension; we also need to make sure that we are giving equitable care to our patients, and that’s why we ingrained equity into our main aim statement rather than have it be a secondary piece.”
In the past 18 months, the LaPQC has made significant strides in identifying opportunities to support equitable maternity care in hospitals across the state. Below, Redmond and her colleague, Amy Ladley, PhD, perinatal quality program manager for Louisiana’s Bureau of Family Health, elaborate on successes and opportunities for improvement.
Seven Strategies for Promoting Equity
Encourage equity-focused staff trainings:
To kickstart a conversation about equitable care, the LaPQC asked all participating hospital teams to take one of Harvard’s implicit association tests (IATs) in advance of their January 2019 in-person Learning Session. There are 14 different IATs, each of which measure the attitudes or stereotypes people subconsciously associate with different concepts like age, skin tone, disabilities, religions, gender, race, and sexuality. By having hospital teams take the IATs, the LaPQC gave them a foundation for engaging in conversations about implicit biases and how they might impact health care delivery.
The LaPQC also encourages hospitals to host staff trainings on equity-focused topics, such as providing respectful patient care, treating patients as partners, eliminating stigma, dispelling myths, and addressing implicit bias. “We’re really trying to empower hospitals and build their capacity to deliver trainings that will be most relevant to their own staff and patients,” says Ladley.
Stratify data by race and ethnicity
Quality improvement projects collect data to help determine whether changes are leading to improvements (e.g., whether adding a new process results in a decrease in maternal hemorrhage or hypertension). This includes data on outcomes measures (the measures tied to the overall aim of the project, like the example above) and process measures (measures related to the processes teams work on as part of the improvement effort, such as measuring blood loss during delivery and completing risk assessments on mothers). However, unless data is stratified by race and ethnicity, teams can’t determine whether changes made are reducing disparities, explains Redmond. “Collective data show whether we are improving things overall; stratified data shows whether we are improving things for all groups and races.”
The LaPQC is implementing multiple strategies to ensure quality data collection: they are urging hospital teams to collect self-reported data on race and ethnicity; teaching them how to annotate run charts and track changes relevant to disparities; and encouraging teams to stratify data on process measures as well as outcome measures, so that they have a comprehensive view of who is affected by process changes.
Use patient stories as a catalyst for equitable change
While process and outcome data are essential to tracking the impact of changes in practice, there is a need to bring that data to life through patient stories. Sharing these stories makes the data real, personal, and unavoidable, which can prompt reflection and energize individuals around the need for change. And importantly, these stories also help ensure that improvement efforts are centered around those giving birth.
“Sometimes we get so focused on the mechanics of patient care—on the processes—that we’ll get a little nearsighted and forget that we're doing these procedures on humans with stories and backgrounds. And when you forget that, it exacerbates inequities,” says Ladley. “Patient stories take you out of that procedural mindset and back into that patient-centered care mode, so that birthing persons and their families are at the heart of the work that we're doing.”
Prioritize patient partnerships
Patient-centered care also depends on engaging patients as equal partners, says Ladley. Talking with families about their care plan, being transparent about what protocols you’re following and why, and making sure their voices and opinions count all help promote equitable care.
Similarly, on quality improvement initiatives, patient partnerships help ensure that patients’ lived experiences inform all improvement efforts, which is vital for change. After all, they are the only ones who understand what it is like to navigate health systems while dealing with bias and discrimination, and so, they can best identify opportunities for improvement. Ladley and Redmond recommend that all hospitals on the LaPQC engage patients as partners on their quality improvement teams, and ask them for their input and perspective on any potential improvement plans.
Talk to patients about equity and disparities
The media has brought needed attention to Black maternal mortality in the U.S., and specifically in Louisiana. Because of this, Ladley has heard many stories about women who enter hospitals frightened to give birth. Rather than skate over the media attention, Ladley recommends bringing it up and using it as an opportunity to acknowledge the problem and reassure families that you hear their concerns and will do everything you can to provide equitable care.
“We need to be honest that this is a problem,” says Ladley. “There’s this really profound fear, so we have a duty to provide extra reassurance and go that extra mile.”
Engage community partners
“We want to do everything we can to honor birthing persons and their experiences,” says Ladley. “One way to do that is by engaging with people who know these families best—those working directly in their communities.”
Ladley recommends seeking partnership with perinatal community health workers and community birth activists, including doulas, midwives, and lactation consultants. These community partners are an active part of the LaPQC, serving as faculty experts who regularly provide feedback on improvement approaches and opportunities, attend events, and share their knowledge and ideas. As community partners, they are uniquely tuned in to the systemic barriers that families face and have established trusting relationship with families most affected by disparities.
Remember, approaches to equity aren’t one-size fits all
“Hospitals are part of a larger system that's still greatly affected by systemic racism that was put into place decades ago,” says Ladley. “Having to negotiate that systems- and culture-change is going to mean different things for different hospitals: what works in a hospital that delivers 7,000 babies a year is not necessarily going to work for a hospital that delivers 500. We need to start by assessing each hospital individually to figure out where they are and what's their readiness, and then work with each to figure out the appropriate starting place.”
Looking for more strategies that address racial disparities in maternal and child health? Watch the recording of our recent webinar, From Awareness to Action: Strategies for Combating Racism in Health Systems.
Exploring a Nonbinary Approach to Health
NICHQ is not abandoning the traditional use of the terms “mother” and “maternal.” We are embracing the inclusive language of “birthing person/people” across our work. A move toward inclusive language does not force us to stop using language that so many people identify with; at its core, inclusion is about creating more space for one another. We are taking care to expand the use of these terms in our communications, on our website, in our resources, and eventually, in all our projects.
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