Improving Ambulatory Quality, Equity, and Collaboration for the Pregnant and Postpartum Patient

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Introduction

This presentation, featuring Jamie Morgan, M.D., Christina Marie Davidson, M.D., and Catherine Squire Eppes, M.D., M.P.H. addresses critical aspects of improving the quality, equity, and collaborative nature of care for pregnant and postpartum patients, with a significant focus on the ambulatory setting.

The discussion highlights alarming trends in maternal mortality, significant disparities, and the need for systemic changes across the continuum of care.

Key Challenges in Maternal Health

• Rising Maternal Mortality and Disparities: National data reveals disturbing trends of increasing maternal mortality rates in the US, with non-Hispanic Black women consistently bearing the highest burden. While delivery-related deaths in hospitals have decreased, overall maternal mortality continues to climb, indicating an increase in deaths occurring outside the hospital.
• Timing and Causes of Maternal Deaths: Half of pregnancy-related deaths occur between one week and one year postpartum. Leading causes vary by timing, with cardiovascular conditions, mental health disorders, and infection topping the list overall, while hypertensive disorders and stroke contribute more prominently postpartum. A critical point is that most of these deaths are potentially preventable.
• Health Inequity: Achieving health equity, where everyone can attain their full health potential by removing economic and social obstacles, is paramount. A one-size-fits-all approach to medicine is insufficient, as individuals have different needs based on their starting points.
• Barriers to Care: Women face numerous barriers to accessing timely prenatal and postpartum care, including structural factors like insurance coverage delays, difficulty finding Medicaid providers, transportation and childcare issues, and legal system concerns, as well as individual-level factors like limited support and conflicting priorities.

Strategies for Improvement

• Focus on the Ambulatory Setting: Recognizing that many contributors to maternal mortality and morbidity need to be addressed outside of the inpatient setting, the discussion emphasizes systematic improvements in both antepartum and postpartum ambulatory care.
• Patient-Centered Care: Implementing truly patient-centered care, where the patient is an active partner in decision-making and their goals, values, and preferences are respected and incorporated into care, is crucial. This includes collaborative, coordinated, and accessible care that addresses both physical and emotional well-being.
• Culture and Linguistically Appropriate Services (CLASS): Adhering to the CLASS standards, particularly the principal standard of providing effective, equitable, understandable, and respectful quality care that is responsive to diverse cultural beliefs, languages, and health literacy, is essential for eliminating health disparities. This necessitates offering communication and language assistance, including professional interpreters, and providing easy-to-understand materials in preferred languages.
• Clear Communication: Employing plain, non-medical language, using the patient's own words, slowing down, prioritizing key information, using visual aids and analogies, and the teach-back method are vital for ensuring patient understanding and engagement.
• Shared Decision-Making: Engaging patients in shared decision-making by seeking their participation, helping them explore treatment options, assessing their preferences, reaching a decision together, and evaluating their decisions fosters better outcomes and patient satisfaction.
• Minimizing Prescription Errors: Implementing strategies to minimize prescription errors in the ambulatory setting, such as providing clear instructions in the patient's preferred language and utilizing available resources like translated medication instructions, is critical for patient safety.
• Addressing Social Determinants of Health (SDOH): Recognizing the significant impact of non-medical drivers of health on maternal outcomes, universal screening for SDOH (food insecurity, safety, housing, transportation, utilities) is now a CMS requirement. However, the key is to develop clear pathways for acting on this information, including connecting patients with community resources and adapting medical plans to address identified barriers.
• Antipartum Risk Assessment and Reduction: Proactive risk assessment for conditions like hemorrhage and preeclampsia in the ambulatory setting allows for timely interventions such as aspirin prophylaxis for preeclampsia risk and patient education about potential complications. Remote blood pressure monitoring, particularly postpartum, shows promise in improving detection and management of hypertension.
• Mental Health and Substance Use Screening and Intervention: Given that mental health is a leading cause of maternal death, universal screening using validated questionnaires (e.g., Edinburgh, PHQ9, DAST) followed by brief intervention and referral to treatment (SBIRT) is crucial. Integrating these processes into the EMR with built-in support and billing codes can facilitate implementation.
• Optimizing Postpartum Care: Shifting from the traditional single six-week visit to a continuous period of engagement with contact and assessment in the early postpartum weeks and a comprehensive visit at 12 weeks is recommended. Addressing structural and individual-level barriers to postpartum care attendance is essential. Innovative models like text messaging, patient navigation, and complex care transition clinics hold potential for improving postpartum outcomes.
• Collaboration and Resource Utilization: Effective improvement requires collaboration among all stakeholders, including patients, families, communities, healthcare professionals, birthing facilities, payers, innovators, and researchers. Utilizing available resources such as the AIM safety bundles, the Fourth Trimester Project, and SMFM checklists can provide evidence-based guidance and tools for quality improvement initiatives.

Conclusion

Improving maternal health outcomes requires a comprehensive and multi-pronged approach that prioritizes quality, equity, and patient-centered care throughout the entire pregnancy and postpartum continuum, with a strong emphasis on the ambulatory setting. By addressing systemic inequities, implementing effective communication and shared decision-making strategies, proactively managing risks, and leveraging available resources, healthcare systems can work towards reducing maternal mortality and morbidity and achieving better health for all pregnant and postpartum individuals.

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