Maternal mortality rates have been documented extensively. Data is available from U.S. government entities and from international entities such as the World Health Organization. Findings show that rates have decreased significantly worldwide, but preventable maternal deaths are still occurring — and even rising — for some marginalized populations, even in high-income countries like the U.S.
Less visible are the ways in which providers and educators are addressing the problem. Innovative approaches are happening globally through a range of resourceful and creative initiatives. These efforts are helping to reverse negative trends and provide models for greater change.
Educating to improve maternal mortality
For over 50 years, international nonprofit Jhpiego has launched projects to improve women’s and family health, prevent disease, strengthen health systems, and advance accelerators for health in low-income countries. One such initiative is the Helping Mothers Survive project, led by Cherrie Evans, DrPH, MSN, Senior Maternal and Newborn Health Advisor at Jhpiego.
Initially a midwife in the U.S. with expertise in assisting maternal surgical interventions for caesarean births, Evans now works internationally to help providers implement strategies to promote maternal survival. The Helping Mothers Survive educational initiative successfully helped reduce postpartum hemorrhage and other maternal complications in Uganda, Bangladesh, Nigeria, and many other countries.
Reformulating training for greater effectiveness
Jhpiego sought to leverage the finding that traditional two- or three-week intensive provider training did not have a lasting impact on maternal health challenges. Research indicated that training would be more effective in smaller doses — with a skills focus instead of lecture focus, with simulations instead of reading, and at the worksite with entire teams instead of in a workshop for only one or two providers from a hospital.
These adjustments led to Helping Mothers Survive, an initiative comprised of single modules targeting postpartum hemorrhage (the leading cause of maternal death in many regions), preeclampsia, and prolonged or obstructed labor. Along with a module on essential care for normal labor and birth, the modularized approach grew into a larger effort benefiting women and families around the globe through implementers such as United Nations agencies, faith-based organizations, Ministries of Health, and NGOs. The modules are available for free on Jhpiego’s website.
Applying improved training concepts to new settings
Evans is now leading a new project that uses the same modular approach. By bundling small amounts of information that providers need to know along with resources, the project provides portable, hands-on training directly to real-world settings.
“Watching this approach in action and seeing the difference between this and other very good training programs that did not change provider behaviors — that, to me, was the ‘secret sauce.’ Training teams together and solving problems where they work, with a ‘low-dose, high-frequency’ approach, really improves performance and health outcomes,” said Evans. “Many indicators improved dramatically when this training approach was used.”
Ensuring applicability of training in different contexts
When piloting educational approaches in new geographic areas, Evans explained that it is important to tailor approaches to their environments. Jhpiego used the Kirkpatrick Model to examine the applicability of an educational approach to its setting.
The Kirkpatrick framework encompasses four domains, the first of which is acceptability. For training to be acceptable, cultural sensitivity and an understanding of language, customs, and other cultural factors is critical. “All of those things must be reflected in the materials. In India and several African countries, we had focus group discussions and very targeted questionnaires to get feedback on images, technique, and anything that participants wanted to change. We tried to take what we learned and incorporate it as one of the keys of providing respectful care for mothers and newborns.”
Using technology to improve maternal health outcomes
In contrast to Jhpiego’s localized approach, Australia’s indigenous community has partnered with the University of Queensland to work more broadly. The Digital Infrastructure For improving First Nations Maternal and Child Health (DIFFERENCE) project seeks to improve maternal mortality rates by aggregating First Nations data.
Data linkage across health facilities will reinforce a higher standard of care for indigenous people. Anticipated outcomes are expanded awareness of how well the country is serving the indigenous community, supporting the enhancement of birthing services and capabilities, and improving care experiences.
The project, which is the recipient of A$3 million (Australian dollars) in funding, is part of a larger trend to leverage digital health technologies to improve care for indigenous people. This initiative joins another Australian project, the Digital Health Cooperative Research Centre (DHCRC), which seeks to evaluate how technology can help remote, indigenous communities in terms of virtual care models, patient and provider preferences regarding virtual care, and knowledge of digital tools.
The DHCRC project will also help connect groups providing health care in remote areas to improve care delivery. Researchers anticipate that the project will improve equity and access for disadvantaged groups, help narrow the digital divide, and reduce acute care demand over time.
Equity and access as approaches to improve maternal mortality
In higher-income settings such as the U.S., reducing maternal mortality requires different approaches. With the availability of high-quality learning opportunities for healthcare providers, lack of education is not as much of a factor. Nor is there a lack of technology to connect providers and patients.
However, the U.S. has equity and access issues for some populations, as surfaced recently in a March of Dimes 2022 report, which found that 2.2 million U.S. women of childbearing age live in maternity care deserts. In these areas, less than half of U.S. women living in rural areas are within a 30-minute drive to a hospital with obstetric services.
The American College of Nurse-Midwives advocates for training more certified nurse-midwives (CNMs) and certified midwives (CMs) to help bridge the care gap in these areas. Factors causing these care gaps are a maternity healthcare provider shortage and social determinants of health such as socioeconomic inequalities, bias, and a lack of access to care.
Other approaches to improve maternal mortality
Approaches to help overcome complex, nuanced problems in countries such as the U.S. include targeted efforts to reduce variation in care, the implementation of maternal safety bundles, increased governmental reporting requirements, and addressing the top causes of maternal deaths through specific, targeted action plans at the state level.
One successful approach is a Labor and Delivery Best Practices program initiated in 2008 by a New York City collaborative of hospitals to reduce medical malpractice claims. The collaborative developed a four-pronged program consisting of enhanced education, team-based training, simulation-based training, and documentation improvement, along with an audit program to reduce medical errors.
Facilitated through Healthcare Risk Advisors, the program achieved significant gains in patient safety and a reduction of adverse obstetric events collaborative-wide.
From the preceding exploration of some of the ways different organizations, countries, and regions are working to improve maternal care, we see that innovative approaches must target the varying circumstances, causes, and correlating factors that play a role for the involved populations. Their unique complexities may present obstacles, but they could also provide opportunities and solutions.
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