A new study of hospitals in New York City suggests ways to reduce severe maternal morbidity (SMM). The researchers interviewed health care professionals in four institutions with low performance and four with high performance, and identified various themes associated with good performance.
“Our results raise the hypothesis that hospital learning collaboratives focused on optimizing organizational practices and policies, increasing clinician and staff awareness and education on maternal health disparities, and addressing structural racism may be important tools for improving equity in maternal outcomes,” the authors wrote in the study, published in Obstetrics & Gynecology.
The researchers conducted 50 semistructured interviews with health care professionals at lower-performing and higher-performing New York City hospitals, which were selected based on risk-adjusted morbidity metrics. The interviews explored various topics, including structural characteristics like staffing, organizational characteristics like culture and communication, labor and delivery practices such as teamwork and use of evidence-based practices, and racial and ethnic disparities.
The analysis revealed six broad areas that were stronger in high-performing hospitals: day-to-day involvement of leadership in quality activities, an emphasis on standards and standardized care, good communication and teamwork between nurses and physicians, good staffing and supervision among physicians and nurses, sharing of performance data with health care workers, and acknowledgment of the existence of racial and ethnic disparities and that bias can cause treatment differences.
“I think this qualitative approach is an important lens to pair with the quantitative approach. With such variability in severe maternal morbidity between hospitals in New York, it is not enough to just look at the quantitative data. To understand how to improve you must examine structures and processes. The structures, which are the physical and organizational characteristics in health care, and the process, which is how health care is delivered,” Veronica Gillispie-Bell, MD, wrote in a comment. Dr. Gillispie-Bell is medical director at Louisiana Perinatal Quality Collaborative and the Pregnancy-Associated Mortality Review for the Louisiana Department of Health.
“We know that high reliability organizations are those who are preoccupied with quality and safety. That means accountability from leadership (structure) and stability in standardization of care (processes). However, none of this matters if you do not have a culture that promotes safety. Based on the key findings of the high-performing hospitals, there was a culture that promoted safety and quality evidenced in the nurse-physician communication and the transparency around data through a lens of equity,” wrote Dr. Gillispie-Bell.
She noted that the study should encourage low-performing hospitals, since it illustrates avenues for improvement. Her personal experience reflects that, though she said that hospitals need help. The Louisiana Perinatal Quality Collaborative addressed severe maternal morbidity at birthing centers by implementing evidence-based best practices for management of hypertension and hemorrhage along with health equity measures. The team conducted coaching calls, in-person learning sessions, and in-person visits through a “Listening Tour.”
The result was a 35% reduction in hemorrhage overall and a reduction of 49% in hemorrhage in Black women, as well as hypertension by 12% overall between August 2018 and May 2020. Not all the news was good, as Black women still had an increase in severe maternal morbidity, possibly because of the COVID epidemic, since it is a risk factor for hypertension during pregnancy and infection rates are higher among Black individuals. “We need support for state based perinatal quality collaboratives to do this work and we need accountability as we are now seeing from metrics being implemented by [the Centers for Medicare & Medicaid Services]. Hospitals need to stratify their data by race and ethnicity to see where there are disparities in their outcomes,” said Dr. Gillispie-Bell.
The improvements are needed, given that the United States has the highest rates of maternal mortality and morbidity among developed countries, “most of which is preventable, and we have significant inequities by race and ethnicity,” said Laurie Zephyrin, MD, vice president for advancing health equity at the Commonwealth Fund. The question becomes how to effect change, and “there’s a lot happening in the policy space. Some of this policy change is directed at expanding insurance coverage, including more opportunities, including funding for community health workers and doulas, and thinking about how to incorporate midwives. There’s also work around how do we actually improve the care delivered by our health system.” Dr. Zephyrin added that the Department of Health & Human Services has contracted with the health improvement company Premier to use data and best-practices to improve maternal health.
The new work has the potential to be complementary to such approaches. “It provides some structure around how to approach some of the solutions, none of which I think is rocket science. It’s just something that needs to be focused on more intentionally,” said Dr. Zephyrin.
For example, the report found that high-performing hospitals had leaders who collaborated with frontline clinicians to share performance data, and this occurred in person, at departmental quality meetings, and during grand rounds. In contrast, staff in low-performing hospitals did not mention data feedback and some said that their institution made little effort to communicate performance metrics to frontline staff.
“One of the key lessons from the pandemic is that we need to have better data, and we need to have data around race and ethnicity to be able to understand the impact on marginalized communities. This study highlights that there’s more to be done around data to ensure that we can truly move the needle on advancing health equity,” said Dr. Zephyrin.
The researchers also found that clinicians in low-performing institutions did not acknowledge the presence of structural racism or differences in care associated with race or ethnicity. When they acknowledge differences in care, they attributed them to factors outside of the hospital’s control, such as patients not seeking out health care or not maintaining a healthy weight. Clinicians at high-performing hospitals were more likely to explicitly mention racism and bias and acknowledged that these factors could contribute to differences in care.
Dr. Gillispie-Bell and Dr. Zephyrin have no relevant financial disclosures.