case study maternal health

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• Published: 16 April 2020

Innovations in maternal and child health: case studies from Uganda

• Phyllis Awor 1 ,
• Maxencia Nabiryo 1 &
• Lenore Manderson 2 , 3 , 4  

Infectious Diseases of Poverty volume  9 , Article number:  36 ( 2020 ) Cite this article

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Nearly 300 children and 20 mothers die from preventable causes daily, in Uganda. Communities often identify and introduce pragmatic and lasting solutions to such challenging health problems. However, little is known of these solutions beyond their immediate surroundings. If local and pragmatic innovations were scaled-up, they could contribute to better health outcomes for larger populations. In 2017 an open call was made for local examples of community-based solutions that contribute to improving maternal and child health in Uganda. In this article, we describe three top innovative community-based solutions and their contributions to maternal health.

In this study, all innovations were implemented by non-government entities. Two case studies highlight the importance of bringing reproductive health and maternal delivery services closer to populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service, through task-shifting certain sonography services to midwives. Various health system and policy relevant lessons are highlighted.

Conclusions

The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Emphasis should be put on identification, capacity building and research to support the scale up of these community-based health solutions.

Every day, about 300 neonates and infants and 20 mothers die from preventable causes in Uganda [ 1 ]. Most of these deaths occur during delivery and within the first month of life. These deaths are mainly caused by complications to the mother and child in labour and during delivery, and in association with infectious diseases of poverty including malaria, pneumonia, sepsis and HIV/AIDS [ 2 ]. These statistics have remained almost the same over the past 10 years, while the Ugandan government (like others in low income countries) is grappling with low human resources for health, lack of medicines, equipment and diagnostics, weak governance, and limited funding for health [ 3 ].

In Uganda, maternal mortality is mainly attributed to the “three delays”: delay in making the decision to seek care; delay in reaching a health facility in time; and delay in receiving adequate treatment [ 4 ]. The first delay is attributed to the failure of the mother, her family, or the community to recognize a life-threatening condition; in this context, lack of awareness of pregnancy-related health risks is a major reason for the low uptake of maternal health services [ 5 ]. The second delay is associated with delays in reaching a health centre, due to road conditions, lack of or cost of transportation, or location of the facility: over 40% of rural women in Uganda report distance-related barriers to accessing healthcare [ 6 ]. The third delay occurs at the facility where, upon arrival, women receive inadequate care or ineffective treatment because most health facilities in Uganda, especially in rural areas, persistently lack the necessary medicines and equipment to care for mothers during pregnancy and at the time of and after delivery [ 7 ]. The ‘three delays’ model reveals the complexity of maternal health challenges. To tackle these issues, there is need for multi-disciplinary and inclusive approaches that engage various stakeholders, including community members, in solving these problems [ 8 ].

Communities often identify and introduce pragmatic and lasting solutions to challenging health problems. Little is known of these solutions beyond their immediate surroundings, but if some of these were scaled-up, they could contribute to better health outcomes for larger populations. In this article, we focus on community-based solutions for maternal health in Uganda.

Study design

The three case studies described in this article were identified through a six-week crowdsourcing call, in May and June 2017, which invited individuals and community organizations to share their community-based solutions to improve maternal and child health in Uganda. The call was launched through newspaper advertisements in the five main local languages in Uganda and through multiple seminars at Makerere University and with the Ministry of Health technical working groups on maternal and child health, e-health and monitoring and evaluation and operational research. The call was further disseminated through different online platforms, print media, and radio advertisements.

Twenty nine nominations were received from diverse implementers across the country. The submitted nominations were within the following categories: improving access to delivery care, for example, by providing maternal waiting homes; phone apps for pregnancy information and for sexual and gender-based violence reporting; improving neonatal care; ultra sound scanning devices; and creating better social and economic opportunities for disadvantaged women and children. Twenty one nominations were eligible and these were reviewed by an external independent panel of judges that included experts from academia, non-governmental organizations and the Ministry of Health. Five top solutions were selected for further case study research.

Data collection

To better understand the successful social innovations in health, we investigated for novel processes, products, policies, market mechanisms, and practices addressing the health challenges. A descriptive and explorative case study research approach was utilized to understand the selected projects better and to explore the role of social innovation in improving the lives of women and children in Uganda. Further, exploration of cross-case themes that have transferable properties within and between different contexts was undertaken.

Data collection followed the case study methodology as proposed by Yin and Eisenhardt [ 9 ] [ 10 ] This approach allows for an in-depth systematic exploration of a phenomenon via the collection and analysis of multiple forms of data. Yin proposed the use of six sources of evidence as a way to achieve construct validity in case study research. These include documentation, archival records, interviews, direct observations, participant observations, and physical artefacts [ 9 ]. The various forms of data enable an enriched, multi-dimensional layout of the phenomenon of query and supports construct validity.

In this research, data was both qualitative (in depth interviews, observations) and quantitative (evaluation data on the impact of the solution and existing disease and systems indicators on the local health context). Field visits were conducted, and implementers and beneficiaries of the solutions were interviewed. The interviews were recorded and transcribed, and supplementary information was received from the organizations’ records, including reports. This triangulation of multiple forms of qualitative and quantitative data enabled the research team to examine certain aspects in depth, to compare different forms of data around the same aspects, and to constitute or support the coding of a concept using multiple forms of data. Traingulation was also useful for quality control. The collected information was analysed to generate case study reports that reflect the innovative components of each case study and the key health system recommendations for policy makers and implementers.

To support the construction of the social innovation case, data collected through different methods was triangulated as per Table  1 below.

Case studies

Below, we describe three case studies of social innovation in maternal and child health, and provide health system and policy relevant recommendations. Two case studies demonstrate the importance of bringing reproductive health and maternal delivery services closer to recipient populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service. Figure  1 shows the location of the case studies in Uganda.

Map of Uganda showing locations of the case studies

Case 1: mothers’ waiting hostel at Bwindi community hospital

Bwindi Community Hospital (BCH) is a private not-for-profit health facility in South Western Uganda, that has sought to address some of the delays in women’s access to health care by providing a maternity waiting home for pregnant women from remote and hard-to-reach areas for about 1 month prior to expected date of delivery. BCH began as an outreach clinic without fixed facilities — it literally operated under a tree — but it has expanded to a 112-bed hospital which provides health care and health education to the surrounding population.

The hospital serves over 100 000 people, including the Batwa pygmies who lived in the Bwindi forest, and were evicted when the area was made a national park in 1991. The Batwa have been subject to systematic structural violence, with extremely poor health as a result of poverty and displacement. The hospital initially aimed to serve the Batwa, but then expanded to provide health care for other people also in the surrounding sub-counties of Kayonza, Kanyantorogo and Mpungu. The terrain is mountainous and settlements isolated; in consequence, women often walk for approximately 8 h to reach a health care centre [ 11 ].

The waiting hostel was established in 2008 within the BCH to provide pregnant women with a place to stay prior to delivery, so that they did not have to endure long journeys through difficult terrain when they were in labour. By its location within the hospital, the waiting hostel ensured that pregnant women would have access to a skilled birth attendant at delivery. It also ensures that women who are HIV infected are enrolled onto the prevention of mother to child transmission (PMTCT) program, to protect their children from infection. Women are required to make a one-time payment of United States Dollars (USD) 1.5 for the duration of their stay in the hostel. BCH leverages funding from other hospital programs and existing structures, such as sexual and reproductive health services and the Community Based Health Insurance Scheme (CBHI). These services have now been in operation for 10 years.

BCH utilizes existing hospital staff to take care of the women in the waiting hostel. A full time nurse checks each day women’s general condition and vital signs (blood pressure, fetal heart rate etc.). In case of emergency, the fully equipped hospital operating theatre is available and a full time obstetrician is on duty. At the hostel, women prepare their own meals and contribute to cleaning. They also receive basic health education, including on how to prepare nutritious meals for their infants and young children. First time mothers are also engaged in peer learning on how to care for a new-born. The nurses and midwives also conduct sexual health sessions on child spacing, the advantage of small families, and family planning methods, so that women make an informed choice about contraceptive use.

The community health worker outreach program

BCH has a community health outreach department with three community health nurses, who work with 502 community health workers in 101 villages to conduct health promotion activities and identify women with high risk pregnancies. Women in the high-risk category as per the WHO definition are especially encouraged to stay at the hostel a few weeks before their expected date of delivery.

Impact on health care delivery

From July 2006 to 2012, on average 106 deliveries occurred monthly and an estimated 30% of the mothers utilized the hostel. In 2014, there was a 10.5% increase in women’s utilization of the mothers’ waiting hostel by women from distant sub-counties; and a fourfold increase in the utilization of delivery services at BCH. By 2017, the hospital was delivering an average of 150 babies monthly, and approximately 45–60% of the women utilized the waiting hostel. Thus increasing numbers of women marginalized by location have been accessing the hostel, the antenatal care it provides, and the PMTCT program. In total, following the launch of the health insurance scheme March 2010, there has been a consistent increase in outpatient attendance, inpatient admissions, and deliveries at BCH. Further, about 150 children receive immunization services weekly and all new-born babies received. Bacille Calmette-Guerinand polio vaccines on the maternity ward.

The idea of a maternity waiting hostel is not new in African or other settings. Global guidance on waiting homes in hard-to-reach areas exit, and many countries have related policies [ 12 ]. However, in Uganda, there are no publicly run maternity waiting homes. Over 30% of women in rural areas deliver at home, because of continuing barriers to seeking, reaching and receiving quality maternal health care [ 13 ]. Distance to a health facility, limited transport services and the direct and indirect costs of travel all influence women’s delivery location, with women living the farthest away from facilities most likely to deliver at home [ 13 , 14 , 15 ]. Maternity waiting homes like this one in BCH can contribute to increased access to skilled birth attendants, timely interventions, and better delivery outcomes.

Case 2: imaging the world, Africa

Due to low income and lack of advanced medical imaging technology, rural women living in remote and under-served areas are unable to access diagnostic imaging, and so have difficulty in receiving timely diagnosis of pregnancy complications. This increases the risk of severe morbidity and mortality among pregnant women. Imaging the World Africa (ITWA) is a Ugandan-registered NGO which focuses on incorporating low-cost ultrasound services into remote health care facilities which routinely do not provide this service, which lack the standard infrastructure required of imaging systems, and where there is a shortage of radiologists. ITWA integrates technology, training and community participation to bring medical proficiency and high-quality imaging services to the population [ 16 ].

The imaging the world model

The ultrasound program was originally introduced in 2010 to identify high-risk pregnancies in one health facility in eastern Uganda, and expanded to six other districts and 11 facilities by 2016. The model incorporates point of care ultrasound imaging devices, task shifting, training and innovative real-time external radiological expert reviews, using telemedicine services. It combines these services with community awareness and pragmatic funding models that promote self-sufficiency. ITWA provides the program by training nurses and midwives at remote health centres to perform basic ultrasound scans. ITWA developed software to compress and transmit full ultrasound images via the internet to an offsite team of participating radiologists, both in Uganda and abroad, for real-time interpretation, enabling them to review the images, provide a diagnosis, and relay the results back to the transmitting centre.

Task-shifting training program

ITWA equips nurses and midwives with the skills and knowledge to conduct obstetric ultrasound scans. They developed a 6 to 8 week certified training program for non-specialist health workers located in rural areas, delivered at the Ernest Cook Ultrasound Research and Education Institute (ECUREI), a private for-profit sonography training centre located in Kampala. Selected midwives or nurses with an expressed interest in sonography undertake practical and theoretical training on how to conduct abdominal sweeps and transmit the images for interpretation. Once health professionals have successfully completed the training course, they are awarded a certificate of completion and ITWA then provides the health facilities in which they are based with ultrasound machines to perform scans.

E-health/telemedicine ultrasound radiology service

ITWA developed software (utilizing Digital Imaging and Communications in Medicine) that compresses and transmits full ultrasound images via the internet. During ultrasonography, the probe is passed across the abdomen of the pregnant woman in a series of six prescribed sweeps using a low-frequency transducer, so acquiring a series of static images. These images are de-identified and stored locally on a computer before being compressed and transmitted digitally via an internet connection. They can then be immediately viewed by participating radiologists, the majority of whom are local Ugandan radiologists who volunteer to interpret the scans. An abbreviated report of the findings is sent via SMS to the nurse/midwife’s cell phone, and a full report is sent by email, usually within an hour. In order for this to happen, there must be a laptop, a cell-phone, internet connection, and an ultrasound machine at the point-of-care.

ITWA has rolled out ultrasound services in 11 rural health facilities in Uganda and has trained 150 health workers to perform obstetric ultrasound. Since 2010, 200 000 ultrasound scans have been conducted, with each scan generating data to aid decision making. ITWA maintain that obstetric ultrasound results have helped change the management in 23% of pregnancies with complications. The others did not require imaging for decision making.

The availability of ultrasound scans has allowed pregnant women to receive timely care at the appropriate level of health facility, thereby reducing unnecessary delays and complications of delivery. This has led to an increase in the number of women seeking antenatal care, increased male involvement in ANC services and attendance, because of their interest in seeing an image of the unborn child, and improved birth planning.

Ultrasound sonography has been extended to include echocardiography through a cardiac ultrasound pilot program, with radiologists in the US usually viewing and supporting the interpretation of these images. The pilot program identified 58 pregnant women with heart disease, who were monitored and treated at the clinic close to home. Seven women were monitored for specialized delivery, and one had her first baby after multiple late pregnancy fetal deaths [ 16 ]. The US-based radiologists also provide support in interpreting other complex images, such as those taken to determine breast cancer.

Case 3: action for women and awakening in rural environment (AWARE-Uganda)

AWARE-Uganda is a non-governmental organization operating in three districts of Karamoja region in northeast Uganda: Kaabong, Kotido and Abim districts. Karamoja is the least developed region in the country, with low levels of employment, high levels of illiteracy, food insecurity, poverty and poor health care services, intimate partner violence, and a history of armed conflict, abduction and war-related gender-based violence [ 17 ]. The consequences of these challenges, coupled with unfavourable attitudes towards women’s education and community beliefs in the value of early marriage for wealth, have caused great suffering to women and girls in the area [ 18 , 19 ].

The AWARE holistic approach to women’s health and empowerment

AWARE Uganda was established in 1989 by a group of local women in Kaabong district with the aim of advancing the social, cultural and economic status of women in the region [ 20 ]. AWARE utilizes a holistic approach to address development issues through women’s empowerment and engagement to improve their own and others’ livelihoods in their community. AWARE provides supportive conditions for women to engage in small business enterprises and agricultural practices, and to increase their roles in leadership and decision making. Women are also sensitized about their rights.

With the establishment of a maternity waiting house, the organization has also improved access to maternal and child health care services, bringing pregnant women closer to Kaabong hospital. As a result, maternal and perinatal morbidity has been reduced.

AWARE-Uganda has engaged and empowered over 5000 women in its activities, including the delivery of an integrated package of services to address the health, economic and social needs of women. Most activities at AWARE are offered by local volunteers, often previous beneficiaries, contributing to the sustainability of the program. Working with men to address negative gender dynamics and to change beliefs around the value of women has been critical, illustrating how empowering and engaging with vulnerable groups and their communities is an effective approach to creating social change.

Impact on women’s health

AWARE has conducted community sensitization and capacity building on gender-based violence and intimate partner violence to police officers, health workers, elders, district leaders, and in schools, where child rights clubs have been established in Kaabong district. Community members, including children, are also sensitized on all forms of discrimination against women and human rights, case handling, and reporting procedures. Over 50 girls have been rescued from various forms of violence including gender-based violence and forced marriages, and have received counselling from AWARE staff who also link them to treatment at Kaabong hospital.

In 2016, AWARE Uganda conducted 28 training workshops for ten women’s groups on the use of modern farming methods, including the use of ox ploughs, crop spacing, and making and using composite manure to improve soil quality and crop yields. These skills were shared with over 370 households. AWARE purchased 25 ploughs and 25 ox chains, and 550 hoes, pangas and axes to assist women in agriculture. About 200 women from four communities were involved in chilli and honey production, improving their livelihood and those of their families.

AWARE also runs a mother’s waiting home in the semi-arid Karamoja region. The 20-bed maternal waiting home at the AWARE centre was established in 2010 and is the only one of its kind in the area. Since this date to time of writing (2019), over 500 women have received services at this facility per annum, including antenatal case, clinical monitoring when the pregnant women is resident at the home, and skilled delivery care; many more receive health education information. About 1000 people have utilized family planning services provided at AWARE.

With support from partners, AWARE distributed 12 040 home health care kits, including condoms, to community members in Kaabong district. AWARE registered and trained 32 Village Health Teams (VHTs) to operate in five sub-counties, with VHTs following up on those who need care at household or community level.

Leveraging community social capital as a resource for this organization was pivotal. The founders did not wait for funding opportunities to start organizing women, but rather, drew on women’s ideas, energy and time. Women asked for land from the district government and were granted this. They then bought and planted 150 fruit tree seedlings, and this marked the start of their activities.

Utilizing volunteers and beneficiaries was key to sustaining AWARE’s efforts, and it has operated for 30 years in these rural areas. Women have become empowered to support other women in similar situations. AWARE believes in working with partners to strengthen and advance work, and in this context, the police and Kaabong Main Hospital work together to support the organization in addressing gender-based violence, receiving and attending to referrals from the organization. One major challenge that AWARE had was to overcome negative attitudes towards women, and to change men’s mind set, AWARE started involving men in activities while working to empower women. AWARE has therefore shown that it is possible to overcome discriminatory cultural perceptions and practices through committed long-term involvement.

These three cases provide innovative and pragmatic solutions to the three delays in access to health care, which are known to significantly contribute to maternal mortality in Uganda. When pregnant women in remote and hard to reach locations access and utilize maternal waiting homes prior to the onset of labour and delivery, this immediately removes the problem of recognition of danger signs in pregnancy, as well as that of delayed health care decision making and lack of access to a skilled birth attendant. In addition, taking ultrasound imaging closer to pregnant women, also directly contributes to reductions in all the three delays. This is through early recognition of high risk pregnancies like multiple pregnancies and placenta previa and decision making related to birth planning and delivery.

Key health system lessons

Based on these case studies, three key health system lessons emerge:

The first is that while maternity waiting homes for high-risk pregnant women in remote areas are recommended in national and global health policies, they are almost non-existent in Uganda and other low income settings. Maternity waiting homes can contribute to increasing institutional deliveries, reducing obstetric delays and improving maternal and perinatal health outcomes in remote areas. In hard to reach areas, maternity waiting homes may contribute to reducing the high maternal deaths. As shown above, the waiting home can also provide opportunities for health education for mothers to improve the wellbeing of their new born children and families. For stronger effect, CHW outreach programs can contribute to identifying and getting women into hospital in remote and inaccessible areas.

The second health system lesson relates to the important role of shifting some acceptable health care roles from higher qualified to less qualified health workers (task shifting). The majority of community-based innovations identified within the SIHI involved some task-shifting activities. As we have illustrated for ITWA, task shifting can create an effective way to deliver ultrasound services to low resource settings. Trained midwives can conduct the ultrasound scan, reducing the cost of hiring a sonographer in low resource and remote settings. In addition, the integration of telemedicine for the interpretation of ultrasound scans is feasible and provides an opportunity to improve the quality of care to patients.

Thirdly, in order to contribute to effective social change for women experiencing discrimination and violence, full community and multi-sectoral action is necessary, including men’s participation in women’s empowerment and increased decision making. The bottom up approach utilised by AWARE is important for effective change. AWARE works to ensure that all community members (men and women) have skills to improve their livelihoods and to support gender equality. Past program beneficiaries, for example, women and girls who experienced GBV, can become active providers of services to new beneficiaries, sensitizing them about gender-based violence and contributing to sustainability.

Principles of social innovation

All these cases also demonstrate the principles of social innovation [ 21 , 22 ]. These are: strong community participation; multi-stakeholder engagement; addressing gaps in health and wellbeing (needs-based); and contribution to transformation in the health and lives of beneficiaries. Additional characteristics of the three case studies are that they are complementary to public health care provision and they focus on improving access to health care (affordability of services, bringing services closer to the people, and utilization of task-shifting mechanisms).

Affordability is a key component of these social innovation solutions, as services must be provided at an affordable price, so that communities can access them consistently, and sustainably. Two of the solutions request a user fee of about USD 1.5, while AWARE provides free services, sustained by the grants it receives.

Finally, availability of health services and geographical access are key components, which are addressed in these case studies through the utilization of lay community health workers to provide health services and through task shifting and training midwives for obstetric imaging service provision.

The ability of communities to identify and implement practical solutions to health care challenges in low income settings needs to be recognised and embraced. The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Stronger emphasis should be put on identification, capacity building and research, in order to support the scale up of these community-based health solutions.

Availability of data and materials

Original case studies are available online at https://socialinnovationinhealth.org/uganda/

Abbreviations

Antenatal care

Action for Women and Awakening in Rural Environment

Bacille Calmette-Guerín

Bwindi Community Hospital

Community Based Health Insurance Scheme

Chief executive officer

Community health worker

Ernest Cook Ultrasound Research and Education Institute

Gender Based Violence

Imaging the World Africa

Mothers’ Waiting Hostel

Non-governmental organization

Social Innovation in Health Initiative

Special Programme for Research and Training in Tropical Diseases

United States dollar

Village health team

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Acknowledgements

We acknowledge the individuals who supported the data collection and case study writing: Juliet Nabirye, Christine Nalwadda and Lindi van Niekerk. We also acknowledge input from participants from the case studies who provided input toward their individual case studies that are available online. They are: Grace Luomo, Birungi Mutahunga, Renny Ssembatya and Matovu Alphonse.

The Social Innovation in Health Initiative (SIHI) Uganda received funding from the Special Programme for Research and Training in Tropical Diseases (TDR) to conduct this research.

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Phyllis Awor & Maxencia Nabiryo

School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Lenore Manderson

School of Social Sciences, Monash University, Melbourne, Australia

Institute at Brown for Environment and Society, Brown University, Providence, RI, USA

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PA contributed to the development of the research protocol. PA and MN engaged in data collection and writing of the first drafts of the case studies. LM reviewed the drafted case studies and the manuscript and provided professional expertise that improved the writings. PA wrote the first draft of the manuscript. All authors provided input and endorsed the final version. All authors read and approved the final manuscript.

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Correspondence to Phyllis Awor .

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Ethical approval for this work was obtained from Makerere University School of Public Health’s Higher Degrees, Research and Ethics Committee (HDREC) – Number 498. Informed and written consent was obtained from all participants.

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Consent for publication was given by all co-authors and management of the case studies sited.

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The authors declare that they have no competing interest.

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Awor, P., Nabiryo, M. & Manderson, L. Innovations in maternal and child health: case studies from Uganda. Infect Dis Poverty 9 , 36 (2020). https://doi.org/10.1186/s40249-020-00651-0

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The Surgeon General’s Call to Action to Improve Maternal Health [Internet].

4 strategies and actions: improving maternal health and reducing maternal mortality and morbidity.

Given the importance of maternal health for our families, communities, and nation, addressing the unacceptable rates of maternal mortality and severe maternal morbidity calls for a comprehensive approach that addresses health from well before to well after pregnancy. A singular focus on the perinatal period would ignore upstream health factors associated with chronic conditions as well as other environmental and social factors that contribute to poor outcomes. 3 HHS has laid the framework by providing recommendations for preventive services that promote optimal women’s health. 79 , 80 , 81 The strategies and actions in this document are based on these recommendations as well as consensus statements and recommendations from other organizations. The following sections outline specific actions for addressing the conditions and risk factors outlined above as well as other factors that may impact maternal health. The opportunity for action exists across the spectrum of women and families; states, tribes, and local communities; healthcare professionals; healthcare systems, hospitals and birthing facilities; payors; employers; innovators, and researchers. Individuals, organizations and communities should select and implement actions as applicable to their needs. Regardless of organization or group, everyone can help to improve maternal health in the U.S.

EVERYONE CAN

• Recognize the need to address mental and physical health across the life course—starting with young girls and adolescents and extending through childbearing age. 3
• Support healthy behaviors that improve women’s health, such as breastfeeding, 82 smoking cessation, 83 and physical activity. 84
• Recognize and address factors that are associated with overall health and well-being, including those related to social determinants of health. 22
• Understand that maternal health disparities exist in the U.S., including geographic, racial and ethnic disparities ( Figures 3 – 7 ), and work to address them.
• Acknowledge that maternal age and chronic conditions, such as hypertension, obesity, and diabetes are risk factors for poor maternal health outcomes (See prior sections “ Differences in Maternal Mortality and Morbidity ” and “ Risks to Maternal Health ”).
• Learn about early ‘warning signs’ of potential health issues (such as fever, frequent or severe headaches, or severe stomach pain, to name a few 85 ) that can occur at any time during pregnancy or in the year after delivery.
• Work collaboratively to recognize the unique needs of women with disabilities and include this population of women in existing efforts to reduce maternal health disparities. 26 , 27 , 28
• WOMEN AND FAMILIES

Women can play a critical role in promoting, achieving, and maintaining their health and well-being, often with the support of fathers, partners, and other family members. Preventive health and wellness visits can provide women with screenings, risk factor assessment, support for family planning, immunizations, counseling, and education to promote optimal health. 79 Women can engage in healthy practices, monitor their overall health, and address conditions they may have such as hypertension, diabetes and obesity. Many resources in the form of books, mobile applications, social media, and guides provide information about what to expect before, during and after pregnancy as well as information on important health behaviors, preventive care, medications, and potential risks.

Prenatal appointments provide the opportunity for healthcare professionals to monitor pregnancy, perform prenatal screening tests, 85 discuss questions and concerns that women may have, including plans for delivery and infant feeding, and provide recommendations to promote a healthy pregnancy. 86 A statewide study of all live births in Pennsylvania and Washington showed that starting prenatal appointments in the second trimester instead of the first, or attending fewer prenatal appointments, was associated with a higher risk of unhealthy behaviors and adverse outcomes, including low gestational weight gain, prenatal smoking, and pregnancy complications. 87 Data also show disparities in initiating and/or receiving prenatal care, with non-Hispanic white (82.5 percent) and Asian women (81.8 percent) more likely to receive prenatal care in the first trimester than all other racial and ethnic groups, including Hispanic (72.7 percent), non-Hispanic black (67.1 percent), AI/AN (62.6 percent), and Native Hawaiian or Pacific Islander women (51.0 percent). 17

Women should also be supported after delivery to reduce the risk of adverse maternal and infant outcomes. For example, breastfeeding has demonstrated benefits for infants and can also be beneficial to mothers, including decreased bleeding after delivery and reduced risks of hypertension, type 2 diabetes, breast and ovarian cancer. 88 Black mothers are less likely to initiate breastfeeding than white or Hispanic mothers (74.0 percent versus 86.6 percent and 82.9 percent, respectively). 89 These data suggest opportunities for understanding and addressing these disparities.

WOMEN AND FAMILIES CAN

Focus on improving overall health 90.

Try to engage in healthy behaviors and practices by participating in regular physical activity, 84 eating healthy, 91 getting adequate sleep, 92 , 93 and getting ongoing preventive care that includes immunizations 57 and dental care. 94 Recognize that oral health is part of overall health and that pregnant mothers may be prone to gingivitis and cavities. 95 Abstain from tobacco 96 and other potentially harmful substances, including marijuana, 97 prior to and during pregnancy. As there is no amount of alcohol known to be safe during pregnancy or while trying to become pregnant, women should consider stopping all alcohol use when planning to become pregnant. 98 Follow medical advice for chronic health conditions such as diabetes and hypertension, learn family medical history, and adopt or maintain healthy lifestyles. Women who are planning or may become pregnant should take a daily folic acid supplement. 99 For women who are entering pregnancy at a later age or with chronic diseases or disorders, learn how to minimize associated risks through ongoing preventive and appropriate prenatal care.

PROMOTE POSITIVE INVOLVEMENT OF MEN AS FATHERS/PARTNERS DURING PREGNANCY, CHILDBIRTH, AND AFTER DELIVERY

Promote men’s positive involvement as partners and fathers. 100 Include men in decision-making to support the woman’s health, to the extent that it promotes and facilitates women’s choices and their autonomy in decision-making. 101

ATTEND HEALTH CARE APPOINTMENTS 79

Women should attend primary care, prenatal, postpartum, and any recommended specialty care visits and provide health information, including pregnancy history and complications, to their health care providers during all medical care visits, even in the years following delivery. 101 , 102 Know health numbers, such as blood pressure and body weight, and record them at each visit. If recommended, continue to monitor and record blood pressure in-between visits. 103 Those with diabetes should check and record your blood sugar regularly. 104

COMMUNICATE WITH HEALTHCARE PROFESSIONALS

Ask questions and talk to healthcare professionals about health concerns, including any symptoms you experience, past health problems, or concerns about potentially sensitive issues, such as IPV and substance use. 105 Be persistent or seek second opinions if a healthcare professional is not taking concerns seriously (See the Joint Commission “Speak Up” guide for ways patients can become active in their care 106 ).

LEARN HOW TO IDENTIFY PHYSICAL AND MENTAL WARNING SIGNS DURING AND AFTER PREGNANCY

Utilize resources that provide information about the changes that occur with a healthy pregnancy and how to recognize the warning signs 85 for complications that may need prompt medical attention. The CDC’s Hear Her campaign seeks to raise awareness of warning signs, empower women to speak up and raise concerns, and encourage their support systems and providers to engage with them in life-saving conversations. 107 Learn to recognize the symptoms of postpartum depression such as feelings of sadness, anxiety, or despair, especially those that interfere with daily activities, and seek support. 108

ENGAGE IN HEALTHY BEHAVIORS IN THE POSTPARTUM PERIOD

If electing to breastfeed, seek support as needed. Resources include healthcare providers, lactation consultants, lactation counselors, peer counselors, and others. Attend postpartum visits as they are the best way to assess physical, social, and psychological well-being and identify any new or unaddressed health issues that could affect future health. 109 Continue engaging in healthy behaviors after pregnancy, such as managing chronic disease and living a healthy lifestyle.

• STATES, TRIBES AND LOCAL COMMUNITIES

States, tribes, and local communities can create environments that are supportive of women’s health and tailored to local needs and challenges. They can create the infrastructure needed to engage in healthier lifestyles and to ensure access to high quality medical care.

Healthy People provides national goals to guide health promotion and disease prevention efforts in the U.S. and highlights the importance of creating social and physical environments that promote good health for all. 22 Often referred to as social determinants of health, the conditions into which people are born, live, work, play, worship, and age can strongly influence their overall health. 22 Examples of social determinants include access to educational opportunities, availability of resources to meet daily needs (e.g., healthy food options), public safety and exposure to crime. 22 Examples of physical determinants include natural and built environments (e.g., green space, sidewalks, bike lanes), and housing and community design, and exposure to physical hazards. 22 Case studies have demonstrated that health outcomes can be improved where there is a concerted and coordinated effort involving both healthcare systems and communities where their patients live. 110 , 111 , 112

Perinatal regionalization or risk-appropriate care 113 is a promising approach for improving maternal safety as it has been shown to be an effective strategy for improving neonatal outcomes, 114 though more research is needed to assess its impact on maternal health outcomes. States can explore this approach as well as other strategies to increase access to quality care, such as the adoption of telemedicine, and the review of the scope of practice laws (what health care professionals are authorized to do), licensure and recruitment policies. Perinatal Quality Collaboratives (PQCs) are state or multi-state networks of multidisciplinary teams that work to improve maternal and infant outcomes by advancing evidence-informed clinical practice through quality improvement initiatives. 115

States, tribes and local health agencies play a role in providing essential services to protect the health and promote the well-being of their communities through education, prevention, and treatment. They provide support for community-driven initiatives and evidence-based practices that address topics such as emerging infections (e.g., COVID-19), sexually transmitted infections, and immunizations. The role of public health is changing due to increased demands from chronic disease, new economic forces, and changing policy environment. 116 The National Consortium for Public Health Workforce released a Call to Action addressing the need for strategic skills in the public health workforce to enable collaboration across sectors to address the social and economic factors that drive health. 117

MMRCs Multidisciplinary committees that perform comprehensive reviews of deaths among women during and within a year of the end of pregnancy

Surveillance data can help to monitor trends and focus efforts to reduce maternal morbidity and mortality. States, tribes, and communities have the opportunity to assess maternal deaths, injuries and illnesses and identify strategies for preventing these adverse outcomes. The Centers for Disease Control and Prevention (CDC) supports states in establishing MMRCs to perform comprehensive reviews of deaths among women during pregnancy or within a year after birth, obtain better data on the circumstances and root causes surrounding each death, and develop recommendations for the prevention of these deaths. 117 However, MMRC reviews can lag by several years, and some states have not yet created MMRCs. Ensuring that MMRCs collect uniform data, such as through the Maternal Mortality Review Information Application (MMRIA), 118 will provide comprehensive national data on maternal mortality and result in more timely and detailed reporting to inform prevention efforts.

Representative population-based data on pregnancy and disability are lacking. 118 State health departments, researchers, and other stakeholders can work together to address gaps in surveillance and identify best practices for reducing health disparities, including among pregnant women with disabilities.

STATES, TRIBES, AND LOCAL COMMUNITIES CAN

Create social and physical environments that promote good health 22.

Improve factors that are associated with health and wellness, including safe communities, clean water and air, stable housing, access to affordable healthy food, public transportation, parks and sidewalks, and other social determinants of health. Support prevention of domestic violence and abuse. Consider addressing areas recognized as “food deserts” (areas with little access to affordable, nutritious food) or “food swamps” (areas with an abundance of fast food and junk food outlets). Encourage healthy eating initiatives tailored to the community such as community gardens, farmer’s markets, school programs, businesses’ support of healthy foods, as well as participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for eligible women.

PROVIDE BREASTFEEDING SUPPORT AT THE INDIVIDUAL AND COMMUNITY LEVELS

Establish policies to support women’s abilities to breastfeed, to reach their breastfeeding goals once they return to their communities and worksites, and thus achieve full health benefits of breastfeeding for their babies and themselves. 119 , 120

STRENGTHEN PERINATAL REGIONALIZATION AND QUALITY IMPROVEMENT INITIATIVES

Consider adopting a classification system for maternal care that ensures women and infants receive risk-appropriate care in every region utilizing national-level resources, such as the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) joint consensus document on levels of maternal care, 121 and other state-level guidelines. Develop coordinated regional systems for risk-appropriate care that address maternal health needs.

PROMOTE COMMUNITY-DRIVEN INITIATIVES 101 AND WORKFORCE DEVELOPMENT

Pursue promising community-driven initiatives, such as the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau’s Healthy Start program 122 and the Best Babies Zone Initiative, 123 funded by the W.K. Kellogg Foundation, that aim to reduce disparities in short-term (e.g., access to maternal healthcare), medium-term (e.g., breastfeeding and postpartum visits), and/or long-term outcomes (e.g., premature births and low birth weight infants). Develop or recruit a workforce that supports the maternal health needs of the community. Incentivize healthcare professionals with obstetric training to serve in rural, remote or underserved areas. 124

ENSURE A BROAD SET OF OPTIONS FOR WOMEN TO ACCESS QUALITY CARE

Examine scope of practice and telehealth laws to maximize women’s access to a variety of healthcare professionals, 125 especially in rural regions and underserved areas, 125 while ensuring procedures are in place to address obstetric emergencies. Engage and collaborate with federal and tribal health systems within states to avoid duplication of services and support access to a full range of care. Support partnerships between academic medical centers and rural hospitals for staff education and training and improved coordination and continuity of care. Support state and regional PQCs in their efforts to improve the quality of care and outcomes for mothers and infants.

SUPPORT EVIDENCE-BASED PROGRAMS TO ADDRESS HEALTH RISKS BEFORE, DURING AND AFTER PREGNANCY

Provide funding for local implementation of evidence-based programs, such as home-visiting, substance use disorder treatment, tobacco cessation, mental health services and other programs as recommended by the Community Preventive Services Task Force. 126 Support local efforts to prevent family violence and provide support for women experiencing IPV. Educate the public about risk factors for high-risk pregnancies, pregnancy-related warning signs, risk-reducing behaviors, and the importance of prenatal and postpartum care.

IMPROVE THE QUALITY AND AVAILABILITY OF DATA ON MATERNAL MORBIDITY AND MORTALITY

Address challenges with vital statistics and data reporting, 127 , 128 such as racial misclassification, 129 and misclassification and documentation of the causes of death, and improve the accuracy of maternal mortality and morbidity reporting for national comparison and analysis. Enhance data and monitoring of racial and ethnic disparities. Expand and strengthen MMRCs to review and assess all pregnancy-associated deaths (the death of a woman while pregnant or within one year of the termination of pregnancy, regardless of the cause) 130 and identify opportunities for prevention.

• HEALTHCARE PROFESSIONALS

While states, tribes, and local communities help to ensure infrastructure and programmatic support for maternal health, individual healthcare professionals provide education, support, and care for women before, during, and after pregnancy.

The full range of healthcare professionals and teams should understand factors that contribute to women’s overall health and work to identify and mitigate potential pregnancy risks. Every medical appointment or interaction with health care professionals is an opportunity to ensure that standards of care and the full needs of women are being met. Given the vast diversity in geography, economy, and racial and ethnic make-up of communities across the U.S., healthcare professionals can ensure that the care they provide is scientifically-sound and culturally appropriate to the individual and their respective community. 101

Fragmented care across healthcare settings may inhibit providers from having a full understanding of a patient’s medical condition(s) and risks. 131 , 132 Many opportunities exist across providers to improve communication, including through care coordination, adoption of mobile applications, and enhanced interoperability of electronic health records (EHRs). Even healthcare professionals who do not normally care for pregnant women play a role in reducing maternal morbidity and mortality. Engaging and coordinating care among a diverse set of healthcare professionals, such as primary care providers, emergency department providers, dentists, cardiologists, endocrinologists, psychologists, and social workers, can be challenging, but strengthens the ability to identify, address, and prevent harm.

Various professional associations play a key role in developing standards of care to provide guidance on screenings, preventive care, prenatal and postpartum care, and management of obstetric emergencies. Associations are valuable resources for developing evidence-based guidelines on areas important to maternal health.

HEALTHCARE PROFESSIONALS CAN

Ensure quality preventive healthcare for all women, children, and families.

Increase knowledge, awareness, and utilization of clinical practice tools such as those associated with recommendations from the USPSTF; 133 the Women’s Preventive Services Guidelines; 79 Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents; 134 and the CDC. Use preventive health care and wellness visits to conduct screenings, assess risk factors, provide support for family planning, offer immunizations, and provide education and counseling to promote optimal health. Include such topics as folic acid supplementation for all women who are planning or capable of pregnancy, 100 breastfeeding, nutrition, physical activity, sleep, oral health, substance use, and injury and violence prevention. 91

ADDRESS DISPARITIES SUCH AS RACIAL, SOCIOECONOMIC, GEOGRAPHIC, AND AGE, AND PROVIDE CULTURALLY APPROPRIATE CARE 110 IN CLINICAL PRACTICES

Increase self and situational awareness of and attention to disparities. Participate in research to determine if provider training may improve patient-provider interactions. Learn how to identify and work to address inequities within health systems, processes, and clinical practices using standardized protocols. Provide culturally and linguistically appropriate services that respect and respond to individual needs and preferences. 135

HELP PATIENTS TO MANAGE CHRONIC CONDITIONS

Reduce the burden of chronic conditions, such as hypertension, diabetes, and obesity, as well as mental health and substance use disorders (See prior section “ Risks to Maternal Health ”) on women’s health across the lifespan by helping them to manage these conditions. For example, refer women at risk to diabetes educators, nutritionists, and mental health professionals. Conduct cardiovascular risk evaluation, to include history of hypertensive disorders of pregnancy and gestational diabetes, 136 and provide risk reduction strategies for women of childbearing age before, during, and after pregnancy.

COMMUNICATE WITH WOMEN AND THEIR FAMILIES ABOUT PREGNANCY

Listen to women and their family members’ concerns before, during, and after delivery. Engage the family in creating a supportive environment. Discuss and make available options for traditional practices that may vary by culture and personal preferences. Educate about warning signs 85 during pregnancy and the postpartum period. 137 Use culturally acceptable and easily understandable methods of communication. 138 Link women with a substance use disorder to family-centered treatment approaches. 139

FACILITATE TIMELY RECOGNITION AND INTERVENTION OF EARLY WARNING SIGNS DURING AND UP TO ONE YEAR AFTER PREGNANCY

Track patient vital signs (e.g., blood pressure) across healthcare visits, including prenatal, initial hospital admission, and postpartum visits. Learn to recognize and react to signs and symptoms associated with hemorrhage, pre-eclampsia, hypertension, cardiomyopathy, infection, embolism, substance use, and mental health issues. Use screenings and tools to identify warning signs early so women can receive timely treatment. Coordinate care across obstetrician-gynecologists and primary care providers and consult with specialists, as needed.

IMPROVE HEALTHCARE SERVICES DURING THE POSTPARTUM PERIOD AND BEYOND

Communicate the importance of postpartum visits, including the ACOG recommendation for an initial assessment within the first 3 weeks postpartum followed by ongoing care as needed and a comprehensive visit within 12 weeks after delivery. 110 Non-obstetric providers can have an important role to play. For example, pediatricians could screen for maternal mental health during well-baby visits utilizing validated tools, such as the Edinburgh Postnatal Depression scale. 140 Other non-obstetric providers should ask about prior pregnancies when taking medical history and be aware of pregnancy-related morbidities that can occur up to one year post-delivery and those that raise life-time risks, such as gestational diabetes, 141 gestational hypertension, and preeclampsia, 34 , 35 , 36 , 37 and follow recommended guidelines. 102 , 103

PARTICIPATE IN QUALITY IMPROVEMENT AND SAFETY INITIATIVES TO IMPROVE CARE

Engage with state and/or national quality collaboratives and patient safety initiatives to improve maternal health. (See section “ Health Systems, Hospitals, and Birthing Facilities ”). Consider using resources, such as the Agency for Healthcare Research and Quality’s Toolkit for Improving Perinatal Safety 142 which includes patient safety bundles, TeamSTEPPS® (team strategies and techniques to enhance performance and patient safety 143 ) and simulation training.

• HEALTH SYSTEMS, HOSPITALS, AND BIRTHING FACILITIES

Health systems provide comprehensive care for the full range of women’s health before, during, and after pregnancy. Within these systems, hospitals provide the vast majority of delivery services. In 2018, approximately 98 percent of all live births occurred in hospital settings. 17 Over the past two decades, many rural counties have lost their hospital-based obstetric services. 144 In these areas, women are more likely to have out-of-hospital births and to deliver in hospitals without obstetric units, as compared to those living in rural counties that maintained hospital-based obstetric services. 145 Additionally, in rural or underserved areas, access to maternal care in the prenatal and postpartum period may be limited. 125

Hospitals and health systems can address this through strategies such as telemedicine and linking facilities that do not offer planned childbirth services with those that do, and facilitating prompt consultation and safe transportation to the appropriate level of maternal care. The designation of levels of care, as outlined in the ACOG/SMFM Levels of Maternal Care, helps to ensure that women receive care at facilities that are best equipped to address their needs. 122 The CDC developed the Levels of Care Assessment Tool (LOCATe) to assist states and other jurisdictions in assessing and monitoring levels of care. 146

Quality improvement strategies, such as participation in PQCs 116 and implementation of maternal “safety bundles,” may help hospitals and health systems to reduce maternal morbidity and mortality. 147 A safety bundle is a set of practices and policies designed to identify appropriate and timely actions the health care staff can take in response to maternal complications. The Alliance for Innovation on Maternal Health (AIM) is a maternal safety and quality improvement initiative that addresses preventable causes of maternal morbidity and mortality through the implementation of bundles to identify and swiftly respond to common pregnancy-related complications. 148 The President’s FY 2021 Budget proposes $15 million to expand the AIM Program. Adoption of safety bundles by hospitals requires leadership and clinical team commitment, as well as training and implementation support.

Offering diverse provider types for maternal care, such as family physicians, midwives and support personnel (e.g., doulas) in hospitals and other healthcare settings may support women’s preferences. Midwifery care is provided in hospital settings, birth centers, and home settings, and can be a valuable part of women’s health care. 148

Medical history associated with pregnancy and delivery does not always travel with women in their future medical records or across different types of providers. Addressing this is key to ensuring coordinated care across providers within and between health systems.

HEALTH SYSTEMS, HOSPITALS AND BIRTHING FACILITIES CAN

Ensure availability of risk-appropriate care across the healthcare system.

Ensure staff, equipment, and services are available to address the health needs of women with both low- and high-risk pregnancies. Implement guidelines for levels of maternal care at all birthing hospitals and facilities and work with states to adopt standardized criteria and uniform definitions for levels of maternal care (See prior section, “ States, Tribes and Local Communities ”).

IMPROVE ACCESS TO CARE AND COMMUNICATION WITH PATIENTS

Adopt methods for improving access to care and communication, especially in rural or underserved areas or when conditions limit face-to-face interactions, while ensuring patient safety and quality of care. These methods can include telehealth and remote monitoring, among others. Work with health insurers to address gaps in access to medical facilities, equipment, information, and transportation for women with disabilities. 149

IMPROVE THE QUALITY AND SAFETY OF PERINATAL CARE

Provide evidence-based clinical practice, including utilization of standardized protocols related to pregnancy, delivery, and the postpartum period. Consider other resources, such as the Agency for Healthcare Research and Quality’s Toolkit for Improving Perinatal Safety. 143 Participate in state, or regional PQCs to implement quality improvement efforts and monitor progress with standardized data. Consider routine surveillance and monitoring of “near misses” and other SMM events.

PROVIDE COMPREHENSIVE DISCHARGE INSTRUCTIONS

Ensure discharge processes include education for women and families about warning signs (e.g., Association of Women’s Health, Obstetrics and Neonatal Nurses’ Save Your Life discharge instructions 150 ), and the importance of postpartum visits. 110

TRAIN HEALTHCARE PROFESSIONALS IN NON-OBSTETRIC SETTINGS ABOUT OBSTETRIC EMERGENCIES

Standardize protocols and training to respond to obstetric emergencies in the emergency department 8 and other non-obstetric settings, to include transportation to the most appropriate facility for care. Train non-obstetric clinicians to consider and seek recent pregnancy history when assessing patients. 8

ENCOURAGE OBSTETRIC CARE-TRAINED PROVIDERS TO SERVE IN RURAL, REMOTE AND UNDERSERVED AREAS 125

Support additional training in obstetric care in residencies for family physicians, especially those who will practice in rural, remote or underserved areas.

OFFER A VARIETY OF HEALTHCARE PROVIDER AND SUPPORT OPTIONS TO FIT MATERNAL PREFERENCES AND NEEDS

Leverage and incorporate midwives into hospital obstetric care and other community programs. 126 Support maternal-infant home visiting and away-from-home programs/pre-maternal homes (where pregnant women from remote areas can stay before the birth of their child 101 ) to support care.

ADDRESS DISPARITIES AND PROVIDE CULTURALLY APPROPRIATE CARE IN HEALTHCARE SETTINGS

Provide education and training on disabilities. Identify and work to address inequities within health systems, processes, and clinical practices. Ensure the availability of culturally and linguistically appropriate services that respect and respond to individual needs and preferences. 136

SUPPORT BREASTFEEDING PRACTICES

Implement hospital or birthing center initiatives, such as the Baby Friendly Hospital Initiative, to help women successfully initiate and continue breastfeeding their infants. 151 Ensure access to lactation support providers for breastfeeding women.

COORDINATE WITH COMMUNITY RESOURCES

Consider coordination with resources, such as group prenatal programs, 152 WIC, 153 home visiting programs, 154 and others that address social determinants of health. Consider alternative approaches to expanding access and education, to include use of community health workers. 155

ENHANCE COMMUNICATION WITHIN AND ACROSS HEALTHCARE SETTINGS

Adopt methods to ensure the seamless transition of information between providers along the care continuum, including strengthening communication and care coordination among obstetrician-gynecologists and other health care professionals.

Health insurance coverage is a key determinant of health care access and utilization. 156 Payors – including private health insurers, state-based Medicaid and the Children’s Health Insurance Program (CHIP) -- can play a key role in addressing maternal health by helping to ensure affordability of and access to high quality preconception, prenatal, delivery, and postpartum care. 157 , 158

Reimbursement for, and access to, comprehensive care, such as preventive services recommended by the USPSTF (A or B rating), 134 Women’s Preventive Services Initiative, 79 and Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, 135 can ensure women and children receive recommended services. These services may include preventive screening (e.g., blood pressure, weight status, diabetes, infectious diseases, sexually transmitted infections, cancer) and vaccinations, breastfeeding support, mental health support, substance use screening and treatment, and screening for intimate partner and family violence.

Ensuring a wide range of healthcare professionals are included in a health plan’s network may broaden women’s access to comprehensive services that address the full spectrum of care. Coverage of programs, such as those that fund transportation to appointments, or technology, such as applications that facilitate chronic condition management and timely and convenient communication, can reduce barriers to care.

Overall, while there are many strategies that payors can consider for helping to improve maternal health, including those outlined below, more research is needed to assess the impact of these actions on maternal health outcomes.

PROMOTE ACCESS AND PAYMENT FOR WOMEN’S HEALTH SERVICES ACROSS THE LIFESPAN

Develop services and networks to provide care before, during, and after pregnancy, including pre-pregnancy counseling. Reimburse time spent with healthcare professionals to discuss healthy lifestyles, family planning, optimal management of chronic conditions (e.g., diabetes, hypertension, obesity), substance use disorders, and mental health conditions. Reduce cost barriers and ensure payment options are understood by women and their families.

ALIGN FINANCIAL INCENTIVES WITH THE FULL RANGE OF PERINATAL CARE

Provide financial reimbursement and quality incentives related to improving maternal care for women of all races and ethnicities and implementing standards of care. Implement value-based payment incentives for innovative ways of delivering high quality care. Support efforts to reduce barriers that patients may face when accessing healthcare, such as transportation, language needs, or geographic isolation. Promote telehealth, as appropriate, for women in underserved, rural or remote areas or under conditions that limit face-to-face interaction and support remote monitoring of highly prevalent and harmful conditions like hypertension and diabetes.

ENSURE A WIDE RANGE OF HEALTHCARE PROFESSIONALS ARE INCLUDED IN A HEALTH PLAN’S NETWORK

Also, consider coverage for supportive services, such as doulas, lactation support, and home visiting programs.

MONITOR POPULATION-LEVEL TRENDS AND IDENTIFY OPPORTUNITIES FOR IMPROVEMENT

Utilize data to inform strategies for improving maternal health and support provider participation in quality improvement efforts in states and local communities, such as PQCs. Track trends in quality of care and health care utilization and develop approaches that may reduce identified disparities.

Employers play a key role in establishing norms and expectations around the support of working mothers, including paid family leave and workplace policies.

The postpartum period is a crucial time for women to recover from birth, bond with their new infant(s), and firmly establish breastfeeding practices. Lawmakers have been working to prioritize parental leave for the American people. In 1993, the Family and Medical Leave Act (FMLA) 159 was signed into law to provide certain employees up to 12 weeks of unpaid leave, including after the birth or adoption of a child. 160 FMLA applies to public agencies (local, state, or federal government agencies), public and private elementary and secondary schools, and private-sector employers with 50 or more employees. 161 FMLA covers more than half of the workforce, however, some eligible women may be unable to take this unpaid leave for financial reasons. 161

In December 2019, Congress passed and the President signed into law a major improvement in the compensation and benefits package for the government’s 2.1 million Federal civilian employees as part of the National Defense Authorization Act (NDAA). 162 The Act provides Federal civilian employees with up to 12 weeks of paid parental leave to care for a new child, whether through birth, adoption, or foster care, beginning in October 2020.

In addition to parental leave, other federal worker protection laws have been enacted, such as the Fair Labor Standards Act (FLSA), which ensures that American workers receive a minimum wage. 163 In 2010, the FLSA was amended to require employers to provide reasonable break time and a space for an employee to express breast milk for her nursing child for one year after the child’s birth. 164

Employers have an opportunity to play a key role in supporting women during their pregnancies and in the postpartum period. Due to the recognized health and economic benefits, ACOG endorses paid parental leave, including full benefits and 100% of pay for at least six weeks after delivery. 165 In addition to paid leave 166 in the postpartum period, other family-friendly benefits such as flexible work schedules, preventive medical care, and childcare for sick children may improve recruitment of potential employees and greater retention of current employees.

Employers who offer health insurance are in a position to advocate for comprehensive care coverage to support maternal health. Effective workplace programs and policies can also reduce health risks and improve the quality of life for workers, including women and their families. 167

Overall, there are many strategies that employers can consider that may help to improve maternal health, including those outlined below, however, more research is needed to assess the impact of these actions on maternal health outcomes.

EMPLOYERS CAN

Adopt and support family-friendly policies.

Consider paid family leave 168 and other family-friendly policies, such as flexible work schedules and on-site or easy-to-access high quality childcare. These policies may also help with recruitment and retention of valuable employees. 167

SUPPORT BREASTFEEDING

Provide lactation spaces for breastfeeding mothers, including for those who do not qualify under the FLSA. 166 Consider going beyond what is required in the FLSA 164 (e.g., break time, private rooms) by providing hospitable and welcoming environments, including access to refrigerators, comfortable chairs, sinks and microwaves, for applicable employees.

ENSURE ROBUST MATERNAL CARE THROUGH EMPLOYER-SPONSORED COVERAGE

Negotiate with health insurers on behalf of employees for comprehensive care, including expanding options for receiving care (e.g., telehealth), reducing out-of-pocket costs, and implementing innovative approaches to monitor and manage risk factors (See prior section, “ Payors ”).

DEVELOP A WORKPLACE HEALTH PROGRAM

Develop or adopt workplace programs and policies that promote healthy behaviors, such as ready access to local fitness facilities, healthy vending or cafeteria options, tobacco-free environments and work settings free of environmental threats. Provide worksite blood pressure screening, health education, and lifestyle counseling to help employees control their blood pressure. 169

Innovative approaches across the health care arena can improve maternal health outcomes through policies, technology, systems, products, services, delivery methods, and models of care.

For example, while diabetes educators and nutritionists may already be included in some models of obstetric care, the inclusion of hypertension educators may be an innovative approach to further enhance comprehensive care in the obstetric setting. Technological innovation, such as mobile or computer-based applications, may help to monitor and/or manage women’s health during and beyond pregnancy. This could include mobile applications or monitoring systems that can help to manage conditions, such as diabetes or hypertension. For example, HRSA’s Remote Pregnancy Monitoring Challenge supports innovative-technology-based solutions to help providers remotely monitor the health of pregnant women while empowering these women to monitor their own health and healthcare. 170

Improvements and innovations in EHR technology offer an opportunity for improving maternal health. Interoperability between systems can allow providers to have a more complete view of a woman’s health by incorporating information from various clinical settings and systems. However, the demands of the current EHR systems may take time away from direct patient-provider communication. EHR systems should be improved to ensure they are provider-friendly and valuable to health care professionals. They should also incorporate improvements such as recommended care guidelines and clinical decision support tools, and facilitate linkage of maternal health records with infant health records.

Finally, innovation in delivery methods can address access issues for women who have barriers to care, such as those living in rural or underserved areas, or with limited transportation, or when conditions limit face-to-face interactions. Telehealth innovators can help states and providers identify opportunities for connecting women with a broad range of services to meet their needs. This could include providing remote access to obstetricians, maternal-fetal medicine and other specialists.

Listed below are some topic areas for innovators to consider that may improve maternal health. Innovations should be evaluated to assess their impact on maternal health outcomes.

INNOVATORS CAN

Improve communication between providers and women.

Decrease burden of EHRs on providers to allow more time for communication with patients. Develop mobile applications to facilitate communications during and after pregnancy so that women can conveniently raise issues or concerns to providers and providers can remotely monitor key vital signs. Such applications can focus on various aspects of prenatal and postpartum care and can involve a team of healthcare professionals. Consider developing applications tailored to a variety of cultures, health literacy levels, and racial and ethnic populations and incorporating human-centered design in the development of these applications.

PROMOTE COORDINATION OF CARE ACROSS HEALTHCARE PROFESSIONALS

Help to address a fragmented system by facilitating communication across different providers using innovative approaches.

DEVELOP AND/OR PARTICIPATE IN NEW MODELS OF MATERNAL CARE

Consider models of care that address maternal health risk factors, such as hypertension, diabetes, unhealthy weight, substance use disorders, mental health conditions, and IPV, to name a few. For example, the Center for Medicare and Medicaid Innovation’s Maternal Opioid Misuse (MOM) Model supports the coordination of care and integration of critical health services for pregnant and postpartum Medicaid beneficiaries with opioid use disorder. This, and other innovative payment and delivery models have the potential to improve quality of care for mothers and infants. 171

EXPAND DELIVERY METHODS FOR ACCESSING SPECIALTY CARE

For example, telehealth companies can better meet maternal health needs by designing technology that connects women to needed specialty care providers (e.g., obstetricians, maternal-fetal medicine specialists, cardiologists, endocrinologists, pulmonologists, nephrologists, nutritionists, and mental health professionals) and services.

• RESEARCHERS

A critical component of developing solutions and monitoring their impact is the ability to glean information from reliable and comprehensive data; however, there are substantial data limitations and gaps in existing research on maternal health. Further, clinical studies often exclude pregnant women due to an increased risk or concern for adverse outcomes in this population, particularly in research for therapeutic products. Researchers have opportunities to advance this area by adding to the field of evidence on clinical outcomes and by improving the quality of data that are available for analysis.

In clinical arenas, more outcomes-based research would be valuable for understanding the interaction of comorbidities during and after pregnancy and the effectiveness of selected interventions on improving maternal health. More research is needed on disease processes and clinical interventions, protective factors, demographic risk factors, racial disparities, and health system factors. 172

Research is also needed to fill clinical gaps in knowledge related to the defining and treating medical conditions that are known risk factors for maternal mortality, including preeclampsia, cardiovascular disease, peripartum cardiomyopathy, and hemorrhage. 173 , 174 , 175 Research on screening algorithms, risk assessments, and diagnosis involving biomarkers could help to improve timeliness of the identification of women with these conditions and their referral to treatment. 175 , 176 The National Institutes of Health (NIH) supports research addressing many aspects of maternal health.

Evidence has been provided throughout this document for many strategies and actions, however, more research is needed for others, particularly those in the “ Payors ” and “ Employers ” section. Researchers should consider examining those areas, as well as those listed below.

RESEARCHERS CAN

Identify biological, environmental, and social factors that affect maternal health.

Consider analyzing data from NIH’s PregSource®, a crowdsourcing research project designed to improve the understanding of pregnancy by gathering information directly from pregnant women via confidential online questionnaires. 177 The Pregnancy Risk Assessment and Monitoring System (PRAMS) 178 and the National Health and Nutrition Examination Survey (NHANES) 179 are examples of publicly available data sources that can be used for analysis. The Transformed Medicaid Statistical Information System (T-MSIS) also has data and research-ready files specific to Medicaid and CHIP information. 180

ADVANCE A RESEARCH AGENDA, SUCH AS DISCUSSED IN THE HHS ACTION PLAN 181 , TO IDENTIFY EFFECTIVE, EVIDENCE-BASED CLINICAL BEST PRACTICES AND HEALTHCARE SYSTEM FACTORS, INCLUDING RESEARCH ON REDUCING DISPARITIES

Conduct research to identify, develop, and rigorously test clinical interventions to address risk factors; identify healthcare factors (e.g., quality of care); and provide insights into healthcare delivery approaches (e.g., care coordination, innovative models of care) for improving access to high-quality maternal health care. Support research to understand, prevent, and reduce adverse maternal health outcomes among racial and ethnic minority women, those who are socioeconomically disadvantaged, and those in rural, remote and/or underserved areas. This should include exploring the potential effects of inequities within health systems, processes, and clinical practices on maternal health outcomes.

EXPAND RESEARCH TO DEVELOP SUFFICIENT EVIDENCE ON MEDICATIONS AND TREATMENT

Adopt recommendations made by the HHS Task Force on Research Specific to Pregnant Women and Lactating Women (PRGLAC), 182 to increase research for therapeutic products already in use by pregnant or lactating women and for existing therapeutic products not currently licensed for use during pregnancy, but with potential benefit for pregnant women and their infants, and to increase discovery and development of new therapeutic products for these populations.

ENHANCE MATERNAL HEALTH SURVEILLANCE BY IMPROVING THE ACCURACY, QUALITY, CONSISTENCY, SPECIFICITY, TRANSPARENCY, TIMELINESS, AND STANDARDIZATION OF EPIDEMIOLOGICAL DATA ON MATERNAL HEALTH

Improve data quality and timeliness; enhance data and monitoring of racial, ethnic and geographic disparities, and disparities among women with disabilities; and assess strategies to leverage and harmonize national data systems for monitoring maternal health.

Unless otherwise noted in the text, all material appearing in this work is in the public domain and may be reproduced without permission. Citation of the source is appreciated.

• Cite this Page Office of the Surgeon General (OSG). The Surgeon General’s Call to Action to Improve Maternal Health [Internet]. Washington (DC): US Department of Health and Human Services; 2020 Dec. 4, STRATEGIES AND ACTIONS: IMPROVING MATERNAL HEALTH AND REDUCING MATERNAL MORTALITY AND MORBIDITY.
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Monitoring childbirth in a new era for maternal health

WHO and HRP launch the Labour Care Guide to improve every woman’s experience of childbirth, and to help ensure the health and well-being of women and their babies.

The philosophy of labour and delivery care, and the recommended World Health Organization (WHO) approach, have developed significantly in the last decades.

The recognition that every birth is unique is now a cornerstone of the 2018 WHO recommendations on intrapartum care for a positive childbirth experience.

Over one third of maternal deaths, half of stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth. The majority of these deaths occur in low-resource settings and are preventable through timely interventions. Knowing when to wait - and when to take life-saving action - is critical.

What is the new Labour Care Guide?

The WHO Labour Care Guide  is a new tool, which puts the WHO recommendations on intrapartum care into practice. It helps skilled health personnel to provide woman-centred, safe and effective care and to optimize the outcome and experience of childbirth for every woman and baby.

Launched alongside the WHO Labour Care Guide User’s Manual , the tool promotes a person-centred approach to monitoring a woman’s and her baby’s health and well-being from active first stage of labour to end of second stage of labour.

This creates a positive feedback and decision-making loop, as health personnel are encouraged to regularly:

• assess the well-being of the woman and her baby
• record their observations
• check for signs that breach thresholds for health and well-being as labour progresses
• plan what care may be required, in consultation with the woman.

The Guide and Manual recognize that every birth is unique - from a woman’s personal experience of care, to the speed at which her labour progresses.

“ The new WHO Labour Care Guide strengthens the relationship between women and their healthcare providers during labour and childbirth, improving both individual experience and clinical outcome. It is a practical tool for a new era of maternal health, where women’s values and preferences are at the centre of their own care ,” says Mercedes Bonet, Medical Officer in the WHO Department of Sexual and Reproductive Health and Research, including HRP,  UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Beyond the partograph

The Labour Care Guide revises and replaces the traditional WHO partograph, a labour monitoring tool which is now inconsistent with the latest evidence about labour duration, triggers for clinical interventions and the importance of respectful maternity care.

Many women do not experience a labour that fits the expected rate of the original WHO partograph. For instance, there is no evidence supporting the use of a cervical dilatation rate of 1 cm/hour as a screening tool to trigger medical interventions or referral. 

Instead, the Labour Care Guide includes updated, evidence-based reference ranges of labour progress. By recording and reviewing their observations against these references, health personnel are encouraged to think critically, avoid unnecessary interventions and act on warning signs.

They can also include each woman in decision-making about her own labour, part of the Labour Care Guide’s emphasis on the importance of a woman and her baby’s experiences of childbirth .

A revolution in maternal health quality of care

The Labour Care Guide has been evaluated in six countries, using a mixed-methods study recently published in BIRTH . It was found to be feasible and acceptable for use across different clinical settings, promoting woman‐centered care and improving outcomes.

“ Using the Labour Care Guide, we show more care to our patients than before, we provided them what they needed. So we had less complications and less interventions [due to] early detection and decision makin g,” explained a midwife, who evaluated the tool in Nigeria.

Achieving the best possible physical, emotional, and psychological outcomes for every woman and child requires health systems to support a model of person-centred care which both empowers the user and enables health personnel.

In this way, the Labour Care Guide is much more than a technical tool for monitoring labour progress. It represents revolutionary steps towards evidence-based, individualized labour care.

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Innovations in maternal and child health: case studies from Uganda

Affiliations.

• 1 Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda. [email protected].
• 2 Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
• 3 School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
• 4 School of Social Sciences, Monash University, Melbourne, Australia.
• 5 Institute at Brown for Environment and Society, Brown University, Providence, RI, USA.
• PMID: 32295648
• PMCID: PMC7161188
• DOI: 10.1186/s40249-020-00651-0

Background: Nearly 300 children and 20 mothers die from preventable causes daily, in Uganda. Communities often identify and introduce pragmatic and lasting solutions to such challenging health problems. However, little is known of these solutions beyond their immediate surroundings. If local and pragmatic innovations were scaled-up, they could contribute to better health outcomes for larger populations. In 2017 an open call was made for local examples of community-based solutions that contribute to improving maternal and child health in Uganda. In this article, we describe three top innovative community-based solutions and their contributions to maternal health.

Main text: In this study, all innovations were implemented by non-government entities. Two case studies highlight the importance of bringing reproductive health and maternal delivery services closer to populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service, through task-shifting certain sonography services to midwives. Various health system and policy relevant lessons are highlighted.

Conclusions: The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Emphasis should be put on identification, capacity building and research to support the scale up of these community-based health solutions.

Keywords: Case study research; Community-based solutions; Innovations in maternal and child health; Maternal and child health; Social innovations; Social innovations in health; Uganda.

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Conflict of interest statement

The authors declare that they have no competing interest.

Map of Uganda showing locations…

Map of Uganda showing locations of the case studies

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