In the U.S., Black women are three times more likely to die from pregnancy-related issues than white women, according to the Centers for Disease Control and Prevention.1 Yet the CDC also determined that nearly two-thirds of pregnancy-related deaths can be prevented.2
To address maternal mortality and morbidity, the Health Evolution Forum Work Group on Leveraging Data to Improve Health Equity convened with Health Equity Pledge supporters to share lessons learned from executives working to advance equity with maternal health among their top priorities.
Prior to the meeting, the Work Group conducted a survey among Pledge supporters to gather insights about demographic data capture and experiences in addressing maternal health disparities. Responses revealed that at the aggregate level, Pledge supporter organizations are collecting Race, Ethnicity, Language and Sex (REaLS) data for more than 50 percent of their patients and members, but only a small number of supporters are stratifying and reviewing their REaLS data across their top business lines.3
“The results show that there are opportunities to increase collection through gold standard or voluntary self-reported methods as well as to increase collection for sexual orientation and gender identity data elements,” said Lesley Bristol, Manager, Forum, Health Evolution. “And, in terms of strategy, there are opportunities to increase stratification and review.”
To understand those opportunities, challenges and successes from work already underway, Tosan O. Boyo, MPH, Senior Vice President of Hospital Operations, John Muir Health and Carol Peden, MD, MPH, Executive Director for Clinical Quality, Blue Cross Blue Shield Association presented during the Forum convening dedicated to maternal health.
The health system side: John Muir Health
Black maternal health is the second equity strategy at John Muir Health. The only one of more pressing importance: distributing COVID-19 vaccines to populations that need them most.
“We decided to focus on Black maternal health for a couple of reasons, the first being that we have the largest rate increase of baby deliveries in the region,” Boyo said. Across nine counties spanning the San Francisco Bay Area, in fact, many hospitals have experienced a decline in births, Boyo said, but John Muir saw an exponential increase, making maternity a major service line. “Bringing equity work and performance improvement work together is important so we prioritized Black maternal health, especially when considering the statistic that Black Women are 243 percent more likely to experience morbidity and mortality compared to their white counterparts.”
As part of the initiative to advance maternal health equity, John Muir Health assessed severe maternal morbidity and found that its own rate was low when compared to the state of California.
“When you stratify data, solely because you do not see the initial disparity in the hypothesis you started with doesn’t mean you end there,” Boyo said.
To that extent, John Muir dug deeper by examining cesarean section births and uncovered a higher rate than counterparts across the health system.
“What we’ve started doing is educating the institution about why these metrics are important and why we are prioritizing Black maternal health and making sure everyone is on the same page,” Boyo said.
John Muir Health has also begun working with its health plan as well as Federally Qualified Health Centers in the region so the equity and quality work can span the entire continuum.
“We’ve built a coalition looking at these metrics from the inpatient side, ambulatory side, physician ancillary services. We have established the baselines and then we’ve established targets,” Boyo said. “My hope with this work is that we move from having a singular equity metric that we’re prioritizing and get to a place where every single department is stratified on the number one quality metric. We’re utilizing Black maternal health as the example for the rest of the institution.”
The health plan side: Blue Cross Blue Shield Association
Dr. Carol Peden provided a perspective from BCBSA. In April 2021 BCBSA CEO Kim Keck set what Peden described as the “bold goal” of driving a 50 percent reduction in maternal morbidity disparities within five years — not just within BCBS Plans but for all women in the U.S. — and outlined necessary actions to achieve that goal.4
“The reason we went for morbidity is because even though we know in the U.S. the mortality rate is much higher than other Western countries, mortality is the tip of the iceberg and going for morbidity allows us to address much greater numbers,” Peden said.
That decision was based on data published last year in BCBSA’s The Health of America report that shows differences in outcomes with greater morbidity in women of color than white women. Specifically, it found a 157 percent disparity relative to sepsis and a 190 percent disparity for pulmonary edema including heart failure.5
“We all know that the data drives improvements and these data highlight key areas for focus,” Peden said.
To achieve its bold goal, BCBSA established an advisory board of experts in maternal health and equity. In addition, each BCBS company created an equity lead with whom the Association holds monthly calls and conducts interviews to learn about what each Plan is working on and, in turn, the Association shares highlighted projects with the larger equity group on a regular basis.
BCBSA also set up a small working group of health plans that began generating ideas about what to measure, notably around person-centered care. “It’s very hard to collect that data from a health plan perspective,” Peden said. “So we came up with a menu of measures that the working group approved that were optional and a core set of data measures that we ask each Plan to collect.”
The core measures are HEDIS measures for pre- and post-natal care and post-partum depression screening and the Centers for Disease Control and Prevention’s 21 measures for Severe Maternal Morbidity.
BCBSA is now in analyzing ICD-10 codes from its national data warehouse for all its Plans for SSM and asking Plans to analyze local data to identify both the local and national picture of what is happening.
“You have to look at the data frequently to know what is going on,” Peden said.
Plans will convene on a regular basis to discuss what improvements each has made and what the various barriers and challenges encountered have been.
“Because we cover the whole U.S., we can see areas where there are known disparities and highlight what’s happening in those regional areas and when we get more data we will also be able to look at the bright spots and learn from them,” Peden said. “Part of our measurement strategy for the BCBS Plans is to extend the data and analysis period out to six weeks after the time of birth to make sure we capture the 40 percent of morbidity and mortality that happens during those six weeks.”6
What’s needed next
A new research study of high- and low-performing New York City hospitals found that when it comes to maternal morbidity, high performing hospitals are more likely to have senior leadership involved in quality initiatives than lower performing organizations.7
Indeed, as health care executives increasingly embrace the opportunities to increase REaLS and demographic data collection including sexual orientation/gender identity data, improve stratification and review of collected data, and implement evidence-based interventions for disparities identified through those data, it will be important to develop new partnerships, improve the patient experience and, ultimately, integrate equity work into quality initiatives.
Having served in safety-net hospitals in the Bay Area for a dozen years, Boyo has experienced firsthand the value of public health agencies, including Federally Qualified Health Centers, particularly since the implementation of the Affordable Care Act.
“More than anything, COVID-19 highlighted how necessary it is for public health departments to partner,” Boyo said. “Federally Qualified Health Centers in the region are going to know vulnerable populations more than we do, especially upstream vulnerable populations because people are more likely to trust them than the ED.”
Part of the reason for that trust is the reality that public health agencies have a better understanding of the population’s language and culture, which enable them to be proactive in ways that are more challenging for private enterprises.
Equity work will also require provider-payer partnerships. Boyo noted that such arrangements should enable payers and providers to understand what information the other has, how it has or has not been pushed upstream and what nuances are in that data. And they should help participating organizations learn from each other.
BCBSA, for its part, created a compendium of plan-based actions by reviewing the literature of best practices, looking at what the perinatal collaboratives are doing and interviewing all the BCBS Plans to understand work in their regions. Supportive actions include reinforcing maternal equity work, working to reduce bias, and establishing programs, such as food delivery to vulnerable women.
“We’re collecting a lot of data. When we actively measure disparities and work on improving things for all women, we can focus on the highest impact areas for disparity reduction using evidence-based based quality improvement programs,” Peden said. “One of our core metrics is postpartum depression screening and our next step in the equity work is to align and overlap behavioral and maternal health.”
BCBSA is also undertaking consumer experience work to understand how individual members feel about reporting race, ethnicity and Sexual Orientation and Gender Identify (SOGI) data.
Boyo urged the session attendees not to think of equity work as a project with a defined end-date but instead as a critical aspect of quality-related initiatives.
“Equity work is quality work. The reality is that equity work doesn’t really have a beginning and an end,” Boyo said. “To be successful in equity work, part of it is humility and knowing that there are absolutely things you don’t know.”
Health Equity Pledge
As a response to this challenge of addressing health disparities, the Health Evolution Forum has launched the Health Equity Pledge to meaningfully strengthen data foundations through the collection, stratification, and review of race, ethnicity, language, and sex data, with the ultimate goal to more effectively identify disparities, diagnose root causes, and instill accountability for eliminating them.
These actions, structured into three Pledge objectives, are a significant opportunity to embed equity into quality improvement and interventions across the health care industry, and to reduce disparities in care delivery, the patient and member experience, and outcomes.
To date, more than 50 health care organizations have signed the Pledge.
Sources & Citations:
1 U.S. Centers for Disease Control and Prevention, Working together to reduce Black maternal mortality
2 U.S. Centers for Disease Control and Prevention, Pregnancy related deaths in the United States
3 April 2022 Health Equity Pledge Data and Insights Survey
4 Blue Cross Blue Shield Association, Top ten maternal health equity actions
5 Blue Cross Blue Shield Association, Racial disparities in maternal health
6 Commonwealth Fund, Maternal mortality and maternity care in the U.S. compared to 10 other developed countries
7 MDEdge Ob.Gyn. News, Hospital factors tied to lower maternal mortality