Our mothers are dying. In 2021, the United States saw 32.9 maternal deaths per 100,000 live births. When stratified by race, those rates were two to three times higher for Black women.
The popular press has succeeded in sounding the alarm, resulting in more public and policy dialogue around the issue than preceding decades: most recently, Congresswomen Alma Adams and Lauren Underwood, and Senator Cory Booker, reintroduced the "Momnibus Act" to address maternal mortality, morbidity, and racial disparities in the United States.
Despite these positive strides, the issue persists. Maternal mortality rates have consistently worsened year over year. Significantly, maternal deaths attributed to hospitalizations related to birth declined in 2021.
What do those concurrent realities show us? Clinical variables are not the primary drivers of poor maternal health outcomes. In fact, these data show that social and environmental factors are more important to achieving optimal health than either clinical services or genetics.
The United States spends 17.8 percent of its GDP on health care, nearly twice as much as the average OECD (Organization for Economic Cooperation and Development) country. And the majority of this spending is going to a healthcare system that is designed to attend to clinical variables, which, according to some studies, impact only 20 percent of county-level variation in health outcomes. To put that into perspective, social determinants of health (SDOH) affect as much as 50 percent (1).
How did we end up here? Why is it that our system focuses on just part of what is needed to secure good health outcomes for our nation?
To start, our health system is divided into different sectors — primary care, specialty care, mental health, and public health, to name a few — each with its own set of providers, protocols, and data systems. These sectors typically operate in silos, though toward the same goal, which is inefficient at best and destructive at worst. As it stands, each healthcare provider operates directly with the patient in a 1:1 model, without any communication between provider and provider, creating the opportunity for conflicting diagnosis and treatment plans. Additionally, this model places the burden on the patient to be the medium of communication as well as their own data repository.
Add healthcare payers and regulatory bodies into the mix, and the opportunity for missteps and duplicative procedures triples. Plus, misaligned incentives add an extra layer of complication. Payers are typically concerned about managing financial risk, while providers are primarily focused on clinical outcomes; regulatory bodies require lots of paperwork, providers would rather focus their time on patients.
Examples of these perverse incentives are everywhere in the maternal health space, specifically around outcomes and revenue. Reducing C-sections and avoiding pre-term birth and low birthweight infants are primary goals for maternal health, yet hospitals lose money on vaginal births and make money on NICU admissions.
Maternity care is uniquely affected by fragmentation, and not just in this misalignment of incentives. For decades, we’ve been hyperfocused on pregnancy as a clinical episode, without considering the unique individual involved and the context of their lives. The result is an overmedicalized system that is isolated from the social environment of patients, and often rewards unnecessary utilization and obsessive risk management.
Rising maternal mortality rates reflect our urgent need to reexamine what constitutes medical care, and recognize that attending to social and environmental variables that harm health is part of clinical management. We need to place the patient back at the center of care, not just in a bi-directional relationship with each provider of care and healthcare stakeholder (OB/GYN, midwife, mental health specialist, health plan, care coordinator, etc), but as the center of an ecosystem that is interconnected. Collaborative care is the way forward for maternal health.
Anish and Loral have a lot to say about the power of healthcare ecosystems to improve maternal health outcomes. Keep an eye out for more content from these authors on this topic.