Identifying Opportunities to Improve Maternal Health Outcomes in Outpatient Settings

By Jennifer Kawatu, BSN, RN, MPH, Meg Sheahan MSN, CNM, MPH, and Clancey Bateman, MS, MPH

“It started with swelling in my legs and a persistent ‘doom and gloom’ feeling,” Miasha Gillaim-El said. She had been at home just two days after giving birth when she realized she couldn’t catch her breath. She was rushed by ambulance to the emergency room where her heart stopped for 10 minutes, the result of pregnancy-induced cardiomyopathy. Miasha thought it could have been caught earlier and wished she had been aware of the postpartum warning signs to watch for up to 12 months after pregnancy.

The United States has the single highest maternal mortality rate among industrialized countries, and Black women are three times more likely to die of pregnancy-related causes than White women. The causes of inequity in maternal health are often structural and include economic, housing, and food insecurity, and environmental stressors, discrimination, and racism (1). However, according to recent reviews of maternal mortality across 36 states, more than 80% of all pregnancy-related deaths are preventable (2). As Fink, et al note, “Maternal mortality has been described as the ‘tip of the iceberg.’” For every pregnancy-related death, approximately 30 other individuals experience significant lifelong complications as a result of their pregnancy (3).

While pregnancy-related deaths continue to climb, delivery-related deaths in hospitals have decreased over the past 14 years, most likely as a result of national efforts to improve the quality of care during birth (4). However, related risk factors like obesity, gestational diabetes, hypertension, asthma, preeclampsia, tobacco use, and substance use disorder have increased over the same time period.

Intervening early in the outpatient setting to prevent and identify conditions that can lead to maternal morbidity and mortality can save lives. Sexual and reproductive health care providers who serve clients in outpatient settings (like Title X family planning clinics) have the opportunity to intervene before, during, and after pregnancy. With this in mind, the JSI-led Reproductive Health National Training Center (RHNTC) collaborated with the American College of Obstetricians and Gynecologists (ACOG) to adapt a subset of the Alliance for Innovation on Maternal Health (AIM) Patient Safety Bundles for use in the outpatient sexual and reproductive health setting. The resulting High Impact Practice Sets highlight evidence-based practices that sexual and reproductive health care providers can apply to address the leading causes of maternal mortality and racial disparities in maternal health.

The High Impact Practice Sets focus on hypertension, cardiac conditions, substance use disorder, mental health, and postpartum transition. Each set provides actionable steps in five core areas: 1) readiness; 2) recognition and prevention; 3) response; 4) reporting and systems learning; and 5) respectful, equitable, and supportive care. They emphasize the importance of mitigating social and structural drivers of inequity. Each set includes resources to support implementation and is accompanied by a measurement tool developed by ACOG to assist in collecting and using data for quality improvement. Practitioners will have the opportunity to learn about each set of high impact practices during a webinar series hosted by the RHNTC (sign up for the newsletter to hear about upcoming webinars).

Today, Miasha is thriving. By sharing her story (including with RHNTC webinar participants), she raises awareness about pregnancy-related cardiac conditions. She works with MoMMA’s Voices to educate health care providers on the importance of outpatient services as a critical juncture for the early identification and prevention of complications to improve maternal health outcomes.

The Reproductive Health National Training Center, managed by JSI Research & Training Institute, Inc., is a collaboration with the Office of Population Affairs and the Office on Women’s Health in the Office of the Assistant Secretary for Health to address the needs of Title X family planning service delivery grantees and Teen Pregnancy Prevention grantees through training and technical assistance.

1. https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf
2. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html
3. Fink DA, Kilday D, Cao Z, et al. Trends in Maternal Mortality and Severe Maternal Morbidity During Delivery-Related Hospitalizations in the United States, 2008 to 2021. JAMA Netw Open. 2023;6(6):e2317641. doi:10.1001/jamanetworkopen.2023.17641
4. Ibid