In response to the growing awareness of racial disparities in health care, a group of midwives in Georgia launched a structured anti-racism strategy to prevent pregnancy complications in their state — and perhaps beyond.
In June 2020, several midwives, including Obstetrix®-affiliated Amy Kayler, CNM, MSN, midwifery director at Northside Women’s Specialists in Atlanta, looked at the pregnancy complications in their state with the most disparities in outcomes based on race. They chose hypertension during pregnancy for their quality-improvement project since high blood pressure can be a lifelong health issue with serious consequences during and after pregnancy.
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Discouraging disparities among people of color
During pregnancy, pre-eclampsia can cause hypertension and damage organs, including the liver and kidneys. It can develop after 20 weeks of pregnancy in women whose blood pressure had been normal.
Based on data obtained from the Centers for Disease Control and Prevention and Georgia’s Maternal Mortality Report:
- Black women develop pre-eclampsia/eclampsia at a higher rate than women of other races or ethnicities.
- Among women with pregnancy‐induced hypertension, Black and Hispanic women have a higher stroke risk than non‐Hispanic whites.
- Among expectant women with normal blood pressure, only Black women had an increased risk of stroke.
Why do these disparities exist? Kayler said pervasive racism within the health care system often leads to these uneven outcomes. The medical complaints of many people of color — including pregnant women — aren’t heard or acted upon by their health care clinicians. Studies have revealed clinician biases against people of color regarding pain management during labor and delivery. Some clinicians may not believe a patient of color’s assessment of their pain and therefore won’t offer pain-alleviating medication. When it comes to hypertension, Kayler said some health care professionals don’t refer patients of color for additional testing. Lack of insurance or lack of access to health care services compound these issues, she said.
“Like many other states, Georgia’s urban residents have access to care, but rural areas may not have any obstetrics clinicians,” Kayler said. “It’s every clinician’s job to educate their patients, know each patient’s level of risk and order additional tests if necessary.”
Building on bundles
The Alliance for Innovation on Maternal Health (AIM), a national data-driven maternal safety and quality-improvement initiative, developed inpatient clinical protocols called bundles to help reduce obstetric complications such as hypertension, sepsis and hemorrhage. While the bundles enforce best practices and help eliminate clinician variances, Kayler said the goal of the group’s quality-improvement initiative is to develop a hypertension bundle tool for the ambulatory setting — where the bulk of prenatal care is delivered.
“We’re doing a good job within the health care industry, but there are still many areas for improvement,” Kayler said.
The group of midwives want to give clinicians a roadmap to look at every patient the same, starting with her first visit. The bundle will include a checklist of signs and symptoms to look for based on the latest evidence-based research. For example, suppose a patient has a history of hypertension either during pregnancy or when she’s not expecting. Protocol in this case includes follow-up with a cardiologist, an order for an echocardiogram and an assessment of the patient’s future risk of hypertension. While the bundles are still being developed, they will likely also include collecting patients’ previous medical history (including blood-pressure data); starting patients on baby aspirin to reduce their risk if indicated; and monitoring blood pressure before, during and after pregnancy. To do this, the group suggests supplying clinicians with Bluetooth-enabled at-home monitors for their patients.
“As midwives, we feel it’s important to play a part in addressing health outcomes of mothers and babies in Georgia,” Kayler said. “Our goal is to develop a viable bundle, test it in groups, refine it if needed and disseminate it throughout the state.”
Many states have expanded Medicaid postpartum coverage for up to a year, so underserved women can now seek care for chronic illnesses such as hypertension after they deliver, which Kayler believes will help move the needle toward equity.
Next steps to close the gap
The group unveiled a poster presentation on the pilot project at the American College of Nurse-Midwives Annual Meeting & Exhibition in May. Since then, two members of the group submitted the project and were accepted to the Emory Rollins School of Public Health Innovation Summit, which took place in September. They plan to finalize the bundles and start the pilot project in the coming months. They are pursuing grants to help fund the pilot and the cost of blood pressure monitors. If the project is successful in Georgia, Kayler said the group’s mission is to expand it to other states.
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