How can racial and socioeconomic disparities in North Carolina maternity and fetal mortality be addressed?

Addressing Racial and Socioeconomic Disparities in North Carolina Maternal and Fetal Mortality

To effectively reduce racial and socioeconomic disparities in North Carolina maternal and fetal mortality, implementation of the Pregnancy Medical Home model, extending Medicaid coverage to 12 months postpartum, providing implicit bias training for healthcare providers, and establishing standardized obstetric emergency protocols are essential interventions. 1, 2, 3

Current Disparities in North Carolina

• Non-Hispanic Black women face significantly higher pregnancy-related mortality ratios, with rates 3.2 times higher than non-Hispanic White women 2
• American Indian/Alaska Native women experience mortality rates 2.3 times higher than non-Hispanic White women 2
• Rural residents have approximately 9% higher probability of severe maternal morbidity during childbirth hospitalizations compared to urban residents 2
• White women in North Carolina have higher adjusted odds (aOR 1.33 to 1.18) of receiving adequate prenatal care compared to other racial groups 4
• Black women have lower odds of receiving adequate prenatal care (aOR = 0.75 to 0.85) during recent years 4

Evidence-Based Interventions

Pregnancy Medical Home (PMH) Program

• The North Carolina Division of Public Health developed the PMH program specifically for the pregnant Medicaid population with over 1,600 providers participating 5
• Key features include nurse/social work care managers providing case management services to high-risk patients, payments to providers at multiple milestones, and higher physician reimbursement for vaginal deliveries 5
• The program targets reduced primary cesarean delivery rates and decreased rates of very-low-birthweight and low-birthweight babies 5, 3

Addressing Healthcare System Factors

• Implement standardized approaches to emergency obstetric care through maternal safety bundles, which are evidence-based practices for maternity care 1, 3
• Expand telehealth services to increase access to care for high-risk pregnant women, especially in rural and medically underserved areas 1, 2
• Extend comprehensive care beyond delivery through the "fourth trimester" with multiple customized postpartum visits 1, 2
• Improve care transition communication between providers to ensure continuity of care 1

Combating Racial Disparities

• Implement implicit bias training for healthcare providers and culturally responsive care practices 1, 2
• Address systemic racism and discrimination that contribute to disparities through chronic stress and inadequate healthcare responses to expressed concerns 5, 2
• Develop peer educator programs similar to REACHUP, which trains peer educators on racial disparities in maternal outcomes 5
• Ensure diverse healthcare staffing and address social determinants of health 4

Policy and Insurance Coverage Interventions

• Extend Medicaid coverage to 12 months postpartum to improve maternal health outcomes and reduce fetal mortality 1, 3
• Expand insurance coverage before, during, and after pregnancy, as access to insurance allows women to initiate prenatal care, be identified as high-risk, and receive appropriate treatment 5
• Address factors associated with inadequate access to prenatal care, including having less than a high school diploma, being unmarried, and having Medicaid coverage 4

Risk Assessment and Early Intervention

• Implement continuous risk assessment throughout a woman's life course, starting before pregnancy and continuing through the postpartum period 5
• Identify women at greatest risk and initiate appropriate interventions early in the reproductive life course 1
• Connect patients in need of safe and affordable housing, transportation, and food with appropriate social services 1

Surveillance and Data Collection

• Enhance surveillance and data collection systems to better identify contributory factors to maternal mortality and inform targeted interventions 2, 3
• Utilize data from Maternal Mortality Review Committees to develop targeted interventions addressing specific causes of death 6

Common Pitfalls and Caveats

• Focusing solely on medical interventions without addressing social determinants of health will limit effectiveness 1, 4
• Failure to recognize the impact of neighborhood-level factors on birth outcomes can lead to incomplete interventions 7, 8
• Overlooking the confluence of infection and microvascular dysfunction during pregnancy among African American women may miss key pathophysiological pathways contributing to disparities 9
• Not extending care into the postpartum period is problematic, as more than half of all pregnancy-related deaths occur after birth 2
• Implementing interventions without addressing implicit bias and structural racism at provider and healthcare system levels will limit impact on reducing disparities 5