Health care standards organization rolls out new requirements to reduce racial disparities in health outcomes.
Shalon Irving, an epidemiologist studying racial disparities in health care, died soon after giving birth to her first child. She died even though she had excellent insurance, a large support network, and a dual-subject Ph.D. in sociology and gerontology.
Irving is not alone. Maternal mortality rates remain high across the United States. These rates are highest for Black women such as Irving. Regardless of their income or education level, Black people’s risk of dying in childbirth is far greater than average. The COVID-19 pandemic has only exacerbated this racial disparity in maternal deaths.
And yet, according to federal public health experts, “most pregnancy-related deaths are preventable.” The leading hospital standard-setting organization, the Joint Commission, agrees. Over the summer, it adopted two new standards aimed at reducing maternal mortality. As of July 2020, thousands of hospitals have a choice to make: adopt the new standards or risk losing their accreditation from the Joint Commission.
The Joint Commission’s move to address maternal mortality arrives on the heels of older standards that hospitals and government agencies in California and New York devised over the past decade to help promote maternal health equity and address preventable deaths. Many of these older standards focus on reducing severe maternal morbidity—complications arising during labor or delivery that have significant health consequences.
Based on extensive research and guidance from medical practitioners, the Joint Commission concluded that focusing on two specific causes of severe maternal morbidity—maternal hemorrhage and severe hypertension (preeclampsia)—would have the greatest “potential impact.”
Existing standards targeting severe maternal morbidity are generally voluntary. Health care providers may miss out on incentives if they do not meet certain requirements or choose not to join a particular program, but they will not suffer any other penalty. The Joint Commission’s standards, by contrast, require hospitals to take action.
To be in compliance, each accredited hospital must draw up a comprehensive plan for ensuring that all maternal health staff and providers can identify and respond to a severe maternal morbidity event before it puts the patient’s life at risk.
Maternal or obstetric hemorrhage is the medical term for excessive blood loss during labor or the postpartum period. According to the Joint Commission, it is “the most frequent cause of severe maternal morbidity and preventable maternal mortality.”
Preeclampsia is a pregnancy complication characterized by abnormally high blood pressure. It can be fatal if left untreated. Since early symptoms of preeclampsia can overlap with common kinds of pregnancy discomfort, consistent blood pressure monitoring is essential to prevent the condition.
To address maternal hemorrhage, the Joint Commission identified seven elements of performance covering all stages of care. The six elements addressing preeclampsia call for similar measures.
As part of their comprehensive plan, hospitals must create their own evidence-based procedures which include criteria to identify patients with “severely elevated blood pressure.” When patients with high blood pressure are not monitored, their preeclampsia can go undiagnosed, leading to serious injury or death.
Multidisciplinary teams, comprising members from every hospital department that a patient suffering a severe complication might interact with, must develop these procedures.
To ensure that hospitals actually change their practices, the standards for both maternal hemorrhage and preeclampsia include elements of performance that call for annual emergency drills, case review, and patient education about the signs and symptoms of both conditions.
All of the elements of performance are universal: they apply to the care of all patients admitted to labor and postpartum wards. None are tailored to the specific needs of patients of color. Despite the general nature of the elements of performance, the Joint Commission acknowledges the racial and ethnic disparities in maternal health outcomes in a supplemental guide to the new standards.
In August, researchers from the New York State Health Foundation became the latest group to identify staggering discrepancies in health outcomes between white people and people of color, with the widest gap between Black and white people.
In their report, the researchers argue that a “growing body of evidence” indicates structural racism and implicit biases “have been ingrained into the societal and health care system culture for decades.” Based on this evidence, the researchers urge New York State and private stakeholders to complement quality-of-care standards with initiatives aimed at eliminating racial disparities.
In a 2019 interview, Dr. David Baker, the Joint Commission’s executive vice president for health care and quality evaluation, reportedly remarked that some hospitals will likely struggle to comply with the two new standards. Until compliance is widespread, Dr. Baker reportedly stated, the Joint Commission will not consider any further maternal health requirements.
While hospitals work on complying with the Joint Commission’s standards, health advocates seeking to address the effects of structural racism and implicit bias on maternal health outcomes will have to secure further voluntary measures and encourage more legislation.