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Pressing to Improve NJ’s Maternal, Infant Health and Reduce Racial Disparities

A multipronged approach to addressing New Jersey’s worrisome maternal mortality rate is underway

Doulas newly certified Nov 2018
Newly certified doulas are expected to help drive down the state's maternal mortality rate.

A street festival in Paterson focused on family services hosted by First Lady Tammy Murphy. State funding for doula programs in Newark and Trenton. Hospital collaboration to standardize proven clinical birthing practices. Initiatives to arm new mothers with better quality data, in both high-tech forms and more traditional ways.

These are just some of the approaches healthcare leaders in New Jersey are now using to address the state’s worrisome maternal mortality rate and to continue to drive down the number of infant deaths, particularly in communities of color.

Despite improvements in healthcare and medical technology over the years, as many as four in ten deaths of mothers are connected to pregnancy or childbirth, according to state data, and most of these are considered preventable by experts. For black women, the maternal mortality rate is more than four times what it is for white women.

Improving maternal and infant health, and the racial disparities involved, has been a priority for state Department of Health Commissioner Dr. Shereef Elnahal, who is seeking to make systemic improvements in maternal and infant health outcomes at hospital birthing centers statewide.

More power to doulas

He is also working to empower community-based clinics and doulas, or birth educators, to improve pre- and postnatal care; last summer the DOH invested $4.7 million to support maternal health programs statewide and in two doula pilot programs, in Newark and Trenton.

Shereef Elnahal
Credit: NJTV News
Health commissioner Dr. Shereef Elnahal

“It’s a tragic reality that race determines health outcomes for some New Jersey mothers and babies. Everyone — regardless of skin color — should be given an equal chance at a healthy, productive life,” Elnahal said this summer.

The state has also launched a promising collaboration with hospital leaders that Elnahal said could help improve outcomes, based largely on a model used in California. Birthing facilities there worked together to share data and best practices, involving women in the process, in ways that reduced maternal mortality by more than 50 percent over seven years.

“It’s a success story we can work from,” Elnahal said. Roughly 10 percent of maternal deaths occur during the birth process, he said, while some 60 percent happen in the period after a woman leaves the hospital, often because the new mother didn’t recognize a potentially deadly symptom — or others didn’t take her concerns seriously.

“Where you see the ball dropped, number one, is a lack of detection of complications during birth,” the commissioner said, “and number two, a lack of discharge planning and (education around) identifying symptoms and dealing with these.”

Importance of prenatal care

Connecting pregnant women with prenatal care is also essential in reducing maternal mortality, Elnahal added. These programs track the pregnancy and the mother’s health and can identify complications. They also help ensure the hospital has the necessary clinical information when the delivery date arrives, he said.

“Without having a (clinical) risk profile you don’t know how to take care of that patient when they come in. And things are intense when you’re in labor,” Elnahal said. “The risks are just off the chart — not just for the mother, but for the baby too.”

As of 2015, New Jersey’s overall infant mortality rate of 4.7 deaths per 1,000 live births was lower than the national rate (5.9) and down from where it had been in 2000 (6.3), according to the DOH. However, while white babies here have a death rate of three deaths per 1,000 live births, black infants have a mortality rate of 9.7.

But as infant deaths have declined, maternal mortality — death during pregnancy or within a year of giving birth, for related reasons — has more than doubled nationwide in the last 25 years, according the latest state report. Nationwide, there were 15.9 maternal deaths per 100,000 live births, as of 2013. In New Jersey, the rate was 12.8 for white women and 46.5 for black women that same year.

Jill Wodnick
Jill Wodnick

Jill Wodnick, a doula and childbirth educator at Montclair State University said reducing cesarean section births also must be a priority, especially in New Jersey, where the procedure is still used in roughly three in 10 births. (The target is less than 23 percent.) While it is sometimes medically necessary, the procedure carries extra risks of blood clots, cardiac complications and infections for the mother, and can lead to lifelong issues for the baby; still, it is sometimes used for reasons of convenience.

The C-section trend

A preference for C-sections is part of what Wodnick calls the “over medicalization of birth” in general, a trend she said has led to practices — like restricting women in labor to their beds — that are sometimes easier for providers, but not necessarily better for the mothers themselves. Empowering doulas and community birth programs can also help combat this, she said, noting that the DOH’s efforts to do so have given her “great hope.”

“Transforming maternity care in New Jersey is probably the most important and exciting way we are going to make a two-generation impact” on families’ health, Wodnick said. Doing this requires listening to women, including them in reforms, she added, and not criticizing them for complications related to chronic health conditions or a lack of prenatal care. “The maternal health crisis cannot be blamed on women,” she stressed.

The New Jersey Hospital Association, which represents the state’s 49 birthing centers, has also embraced efforts to better incorporate doulas — previously shunned at many facilities — and protocols to reduce C-sections. Hospital leaders are now using the same mechanism, the Perinatal Quality Collaborative, to improve other aspects of maternal and infant care, like reducing high blood pressure, bleeding risks and preterm births.

“There is a palpable determination to make sure all women in New Jersey can have safe births, healthy babies and problem-free recoveries,” said Cathy Bennett, the hospital association’s president and CEO — and former DOH commissioner — following a perinatal collaborative steering committee meeting last week.

A way to compare different birthing centers

Tammy Murphy
NJ First Lady Tammy Murphy, second right, at the recent Family Festival in Paterson

Other improvements will rely on new technology and better access to data, for providers and the general public. The DOH is working with First Lady Tammy Murphy and the New Jersey Innovation Institute, an NJIT corporation, to host a “tech challenge” event early next year. Elnahal said the goal is for tech experts, entrepreneurs and healthcare leaders to collaborate on projects — like building a new app — that provide user-friendly ways for the public to learn more about maternal and infant health and to connect with appropriate services.

In addition, the department is working with the NJHA to create the state’s first Maternal Health Report Card, based on legislation adopted last year, to ensure families have easily available information about how different birthing centers compare. Elnahal and Bennett said the goal is to create a product that is useful to the public and healthcare providers — and could help them to reduce racial disparities and other gaps in care.

The report card is good news to Wodnick, with Montclair State — if it includes useful data that can actually empower women to make good decisions about their healthcare. “It’s a paradigm shift,” she said, “but we need to put women at the center of this process.”

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