Keelee Moseley knew something wasn’t right.
After an emergency cesarean section in February 2018, the Texas mom was in so much pain she couldn’t walk. She told doctors she wasn’t feeling well. Still, hospital staff sent her home.
In the following days, she only felt worse. Her heart rate rose, she nursed a fever and her stomach swelled, turning red.
A week after the C-section, Moseley noticed a black blister on her stomach. The 40-year-old IT professional wound up in the ICU. Her kidneys were failing. She had sepsis, and a flesh-eating, life-threatening infection at the incision site.
Moseley is one of about 25,000 women nationwide who develop severe complications during pregnancy each year, according to the U.S. Department of Health and Human Services. Approximately 700 die of those complications. Women of color are most at risk.
“I didn’t know that Black women were dying at the rate they were dying at—until it was almost me,” Moseley said.
Black women like Moseley die at three times the rate of white women from pregnancy-related causes, according to the U.S. Centers for Disease Control and Prevention.
In light of those troubling statistics, the U.S. Department of Health and Human Services announced Thursday morning an action plan to improve maternal health.
The road map outlines three targets to achieve in the next five years: reduce the maternal mortality rate by 50%; reduce the low-risk C-section delivery rate by 25% and control blood pressure in 80% of reproductive aged-women.
The department announced various objectives for a “life course approach” toward improving women’s health pre-pregnancy, during pregnancy and postpartum.
“We really need to create health along the life course. You’re not going to magically make someone healthy when they find out they have a positive pregnancy test,” said Surgeon General Dr. Jerome Adams,who released an accompanying call to action. “We want to make sure people are healthy before they become pregnant, while they’re pregnant and after they deliver.”
The coronavirus has magnified the disparities and health inequities that put moms of color at risk for pregnancy-related complications.
“It is incredibly important because we know that many women have foregone prenatal care out of fear of COVID,” Adams said. “We were facing what I consider an epidemic of maternal morbidity and mortality prior to COVID-19. But … there is a very real chance that these numbers are actually going to get worse because of COVID-19.”
This issue is personal to Adams, whose wife had several high-risk pregnancies and three C-sections. His sister, who lives in a rural area of St. Mary’s County in Maryland, also is undergoing a high-risk pregnancy.
“So, I very much understand the importance of having someone who can advocate on your behalf and having high-quality health care,” he said.
Interventions based on data
HHS cites a four-tiered approach to achieving its goal of reducing maternal morbidity and mortality, one of which is to improve data and bolster research on the issue. The department plans to allocate $3 million toward projects related to maternal health data collection and better connect the U.S. Centers for Disease Control and Prevention Pregnancy Risk Assessment Monitoring System and state hospital discharge data.
“It really does start with the data, and that data should inform our interventions and our policies so that we can truly give moms the best chance,” Adams said.
The plan also aims to “advance a nationwide paid family leave plan” so mothers can focus on their health and children, and a public-private partnership with the March of Dimes to implement evidence-based maternal health strategies in hospitals that serve mostly Black patients and provide obstetric care for Black moms. An HHS spokeswoman says the department hopes to improve care in at least 100 hospitals.
March of Dimes CEO Stacey Stewart said the program will implement strategies using patient safety tool kits developed by a national data-based initiative on maternal health improvement, the Alliance for Innovation on Maternal Health.
“These are bundles of maternal safety supports that have been proven to work,” Stewart said. “The issue is, are they being implemented in hospitals that are primarily serving Black mothers, and can we enhance the ability for those hospitals to implement those practices?”
Stewart said that along the way, she hopes the program also will help detect issues and barriers that individual hospitals have providing quality care to Black moms.
“One of the things and the areas that we know it’s really impacted Black maternal health is the issue of implicit bias,” Stewart said, adding that the March of Dimes has recently rolled out an implicit bias training program for health care providers.
Moseley says she thinks implicit bias may have been at play in her hospital experience.
“When I told my doctor, at the time of discharge and readmission, I was very clear and adamant about how I was feeling,” she said. “And I was dismissed. If they were listening to me, they could have responded faster.”
Focus on rural communities
The HHS plan also describes a Rural Obstetric Readiness program to begin in 2021 for rural Indian Health Services sites that lack labor and delivery services. The CDC reports Native American women are twice as likely to die from pregnancy-related complications than white women.
Maternal health outcomes are impacted by race as well as geography. HHS says fewer than half of women in rural parts of the U.S. are within 30 miles of a hospital with obstetric services.
Joy Anderson knows that struggle all too well. Anderson is the executive director of the Healthy Start Program in Florida’s Gadsden County, the state’s only majority-Black county. She often sees pregnant women with obesity and hypertension or diabetes, both of which plague the North Florida county, federally recognized as a health professional shortage area.
“Gadsden County doesn’t have in-county prenatal care,” Anderson explained. “There’s no full-time provider in Gadsden. Most of the moms have to seek their services outside the county … That wouldn’t be such an issue if it weren’t so transportation disadvantaged as well.”
As a result, women can miss their out-of-county obstetric care appointments, which is often a “daylong ordeal” through Medicaid-offered transportation from rural Gadsden to Florida’s capital city some 30 miles east, Anderson explained.
“It is a maternity-care desert,” she said. “Having a maternity-care desert where we already have a predisposition to higher poor birth outcomes is a great challenge for us.”
Looking back at her own postpartum complications, Moseley says if she hadn’t been her own advocate, she believes she may not have lived.
“I lived to share this story,” she said. “If I wouldn’t have been taking selfies … and I (hadn’t) discovered those blisters, I would have died. I think about all the women who spoke up and didn’t get listened to, didn’t get the attention that they need—they’re not here any more. … We shouldn’t have to die.”