Health Equity and Maternal Health
Redefining Maternal Safety
Maternal safety refers to the safety of a person during pregnancy, childbirth, and the postnatal period. Transitions through pregnancy and birth can pose complex safety challenges, and normal physiologic changes can result in signs and symptoms that make it difficult to recognize and diagnose serious illness. Additionally, patients may not receive timely or adequate information about their health or the healthcare system (and how to navigate the system in the postpartum period), making it challenging for them to advocate for themselves.1 The intersection of these factors results in missed opportunities for health and wellness, as well as preventable mortality and severe maternal morbidity. The actionable nature of these outcomes, as well as the significant disparities by patient race, ethnicity, and insurance type, indicates the need for more readiness, recognition, response, reporting, and respect.2
Maternal safety traditionally focuses on measurement and assessment of clinical processes and outcomes to ensure that mothers and their babies are receiving evidence-based, recommended care intended to avoid potential harm. These measures primarily include assessment of maternal mortality and morbidity, including outcomes such as preeclampsia, eclampsia, sepsis, and the need for blood transfusion.3 These measures index maternal care and can suggest where there may be room for improvements, particularly within specific patient populations. For example, from 2011 to 2014 the pregnancy-related mortality rate was more than three times higher among Black women than White women.4
These components of maternal safety demand accountability for critical clinical components of care. However, when assessing maternal safety, it is also essential to also take a whole-person view. In many ways, this viewpoint may be just as important to patients when it comes to defining safe maternal care. Of course, patients do not want to experience an adverse event, but for those giving birth and their companions, safety also includes more nuanced and individualized factors, such as effective, trusting, and respectful communication with their healthcare team. This perspective goes beyond discrete clinical outcomes and takes into consideration the interaction of multi-level factors that can affect clinical outcomes. These include concordance of patient-clinician race and ethnicity; the timing, methods, and pace of information exchange; and the context of care such as nurse-patient staffing ratios.5
Addressing the Structural and Social Determinants of Maternal Safety6
Given the importance of safety as a positive concept and the impact that structural and social determinants, including systemic racism, can have on safety outcomes, considering approaches to address and mitigate root causes of disparities in maternal safety has become an increasing priority in the United States, including within healthcare systems and among policymakers. There are several overarching approaches for the identification of patient-centered care needs and accommodation for people’s journeys to realize their health goals.
One approach is more closely aligned to traditional definitions of maternal safety. This approach seeks to identify where there are, or are expected to be, discrepancies and differences in clinical outcomes between patients or groups of patients and determine if there are differences in the quality of care that could contribute to those outcomes. A thorough analysis of disaggregated data can allow for the implementation of interventions targeting identified factors and can mitigate inequalities in care processes. However, while it can support a more direct link between intervention and outcomes, this approach can often be retrospective in nature, and rely on uncovering care inequities through intentional investigation of disaggregated data before a connection can be made between specific structural and social determinants of maternal safety and outcomes.
An additional approach is centering patient perspectives from the onset of their interaction in healthcare systems to focus on care as experienced by communities—to identify and mitigate threats to safety collaboratively. This approach is prospective and focuses on the provision of equitable care from the outset and offers new insights into traditional outcomes such as hospital readmissions. Relatedly, this approach of focusing on humanity in healthcare also allows for the opportunity to have patients and clinicians determining which outcomes constitute a complete assessment of safe, respectful maternal care.
Both quantitative and qualitative approaches can identify and mitigate structural and social determinants of maternal safety, but they have very different roles in the provision of safe and equitable care. The first approach provides direction for specific, targeted areas for action, whereas the second approach establishes a foundation for learning mechanisms by which to achieve whole-person care. By integrating these frameworks, we can optimally support equity and safety in patient care.
Example of Whole-Person Maternal-Infant Care—Reengineering Postnatal Unit Care and the Transition to Home
This integrated approach to whole-person maternal care is underway in work led by Drs. Alison Stuebe and Kristin Tully from the University of North Carolina (UNC) at Chapel Hill, in partnership with an interdisciplinary team funded by an AHRQ Patient Safety Learning Lab (PSLL) grant. The goals of this work are to advance just, effective perinatal care by identifying underlying factors contributing to maternal and infant morbidity and mortality and to use these findings to reengineer the delivery system to support the needs of birthing parents, their infants, and their dyadic relationships.7
Through their PSLL’s mixed-methods study, including qualitative interviews with patients and filming of interactions between and among healthcare team members, mothers, their partners, and infants, the UNC-Ohio State University-North Carolina State University team has identified communication, education, and information as areas of opportunity for providing more equitable care. These areas include eliminating language barriers and implementing sensitive approaches to education and follow-up care instructions. Additionally, the team found that the clinicians are not consistently transparent with patients about the purpose of postpartum pain assessments. Asking patients open-ended questions such as “How is your bottom feeling?” and “What’s helping?” can promote patient-centered care through listening to birthing parents and validating their experiences. This connection can translate into more meaningful tailoring of the variety of pain management strategies that are available. Further, the team noted that institutional and interpersonal trust can be earned through more intentional healthcare team and patient interactions, so the clinician hears more of what the patient is seeking to convey, and responds with more affirmation, clarity, and depth. This shift can promote patient comprehension and the perception of healthcare as a resource for individuals when they can benefit from it.
Moving forward, reengineering the system for transparency, inclusivity, and joy can ensure that mothers and infants are safe throughout the birth admission and postnatal care process. This can not only help to ensure the patient and family are well-prepared and informed regarding follow-up care and the warning signs for potentially serious events, but that they feel that the medical team is a reliable and worthwhile resource for help. Interventions to support this reengineering include guidelines for centering patient perspectives; revision of the after-visit summary; more asynchronous and open access to health information; using animations to promote clinician empathy around patient and family needs; strengthening of services for patients with limited English proficiency; patient-centered quality metrics, timing, and process; and more solutions, including a cultural shift that recognizes the importance of safety as encompassing what patients need to know, feel, and have happen.
Kristin Tully, Ph.D.
Research Assistant Professor, Department of Obstetrics and Gynecology
Collaborative for Maternal and Infant Health, School of Medicine
University of North Carolina at Chapel Hill
Alison Stuebe, MD, MSc
Professor, Maternal-Fetal Medicine and Director, Division of Maternal-Fetal Medicine, UNC Department of Obstetrics and Gynecology
Co-Director, UNC Collaborative for Maternal and Infant Health
Distinguished Scholar in Infant and Young Child Feeding, UNC Gillings School of Global Public Health
University of North Carolina at Chapel Hill
Amelia Gibson, PhD
Associate Professor, School of Information and Library Science
Carolina Health Informatics Program
University of North Carolina at Chapel Hill
Eleanor Fitall, MPH
Senior Research Associate, IMPAQ Health
Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health
Kate R. Hough, MA
Editor, IMPAQ Health
- Primers: Maternal Safety. Patient Safety Network (PSNet). Agency for Healthcare Research and Quality. September 7, 2019. https://psnet.ahrq.gov/primer/maternal-safety
- Patient Safety Bundles. Alliance for Innovation on Maternal Health. Accessed September 23, 2021. https://safehealthcareforeverywoman.org/aim/patient-safety-bundles
- Severe Maternal Morbidity. Reproductive Health. Centers for Disease Control and Prevention. Accessed September 23, 2021. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm
- Maternal Safety. PSNet. Agency for Healthcare Research and Quality. Annual Perspectives. December 22, 2018. https://psnet.ahrq.gov/perspective/maternal-safety
- Wang E, Glazer KB, Howell EA, Janevic TM. Social determinants of pregnancy-related mortality and morbidity in the United States: a systematic review. Obstet Gynecol. 2020;135(4):896-915. doi:10.1097/AOG.0000000000003762
- 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. J Womens Health (Larchmt). 2021;30(2):230-235. doi:10.1089/jwh.2020.8882
- Overview of Patient Safety Learning Laboratory (PSLL) Projects. Agency for Healthcare Research and Quality. December 2016. Content last reviewed September 2021. Accessed September 23, 2021. https://www.ahrq.gov/patient-safety/resources/learning-lab/index.html