By Avery Plough, MPH; Amber Weiseth, DNP, MSN, RNC-OB; Elizabeth Curtis; Joyce Edmonds, PhD, MPH, RN; Monica Christina Esqueda, PhD; Heather M. Young, PhD, RN, FAAN; Neel Shah, MD, MPP

The rapid and unyielding spread of the COVID-19 pandemic has radically changed how health care is administered, delivered, and experienced. While this is true across the entire spectrum of care, maternal health is particularly sensitive to these disruptions, with potentially far-reaching generational impacts.

The pandemic has exposed weaknesses and inequities in our maternal care systems, including fragmented care, anti-Blackness, and unconscionable racial inequities; however, it has also revealed unique opportunities to re-envision how our existing systems can be built to better serve the needs of people giving birth.

At the behest of Congress, in January 2020 the National Academies of Science, Engineering and Medicine (NASEM) produced a consensus committee report on Birth Settings in America that articulated the ways the current design of our maternity system “is fraught with inequities in access and quality and high costs, and there is growing recognition of the mismatch between the collective expectations of the care and support people giving birth deserve and what they actually receive.” It also provides the set of evidence-based solutions necessary for progress.

In June of 2020, we began convening virtual sessions to hear from people from across the country, including birthing people and those at the frontlines of care, in order to understand what lessons we can take from the shared challenges and promising responses. Over four sessions, we brought together 244 obstetricians, midwives, registered nurses, doulas, health administrators, investors, community leaders, and people who had recently given birth. Drawing on their combined insights and lived experiences, we were able to assess the shared challenges in providing high quality care, and began to form recommendations to address those challenges with high-impact innovations.

In a recently released white paper, we discuss how those findings can help leaders understand what investments and innovations have the potential to make the biggest and most sustained impact. In many cases, these innovations are not new. Rather, they are familiar, cross-cutting solutions that align with existing evidence-based recommendations, and we believe that makes them all the more powerful.

Our recommendations address the potential backslides in care resulting from the COVID-19 pandemic, while looking ahead for opportunities to make needed progress. Consistent with the NASEM report, we held a particular focus on approaches with the potential to eliminate or reduce racial and geographic inequities in maternity care. Our recommendations fall into three key categories:

1. Focus on investments that address challenges related to the continuum of care, family and support for birthing people, and patient-provider relationships.

In conversations with our participant community, these key themes were identified as priority areas likely to have the greatest potential for long-term impact on maternal health, particularly for people who experience racial and geographic inequities.

2. Identify the innovations that address these challenges and align best with both the needs of your community and the assets of your organization.

Participants identified six categories of innovations health system leaders should consider to specifically address high priority challenges. These include:

• Build trust & enhance communication between birthing people and clinicians
• Leverage virtual access to deliver clinical care, education, or support
• Customize care planning & support to meet birthing people’s unique needs
• Coordinate existing services & needs by integrating clinical and social services to minimize disjointed care
• Adapt roles & responsibilities to promote non-clinical and clinical capacity to address emotional, informational, and physical needs
• Utilize alternate care settings to facilitate the availability and accessibility of alternative settings

3. Accelerate existing momentum for your innovations by reinforcing the “demand” among birthing people or health system stakeholders and the “supply” of enabling factors.

Within each of our six priority areas, opportunities exist to capitalize on the momentum initiated by COVID-19 adaptations to further improve care and leverage this unique moment for change.

Throughout the process of building these recommendations, we witnessed how important it is to be inclusive of multiple perspectives, interrogate implicit biases, and practice cultural humility to find our way forward. During the course of this effort, clinicians had an opportunity to learn from the experiences of people who gave birth during the pandemic and reflect together. Participants could confer about key contextual differences in geography, access to resources, and service needs, bringing issues of equity, in all of its forms, to the forefront.

By revealing the gaps and inequities in our health systems, the COVID-19 pandemic has generated momentum for change. It has required providers and communities to not only adapt, but to innovate with courage and creativity. There is a window of opportunity to create a higher performing, more equitable, and just health system. By identifying and investing wisely in innovations with existing momentum that have the greatest potential impact, we can sustain this momentum toward better care for years to come.

Avery Plough, MPH, is the Design Lead for the Delivery Decisions Initiative at Ariadne Labs.

Amber Weiseth, DNP, MSN, RNC-OB, is the Associate Director of the Delivery Decisions Initiative at Ariadne Labs.

Elizabeth Curtis is a Research Assistant for the Delivery Decisions Initiative at Ariadne Labs.

Joyce Edmonds, PhD, MPH, RN is an Associate Professor at the Boston College Connell School of Nursing.

Monica Christina Esqueda, PhD, is a Program Manager at the Betty Irene Moore School of Nursing at University of California, Davis.

Heather M. Young, PhD, RN, FAAN is Professor and Dean Emerita at the Betty Irene Moore School of Nursing at University of California, Davis.

Neel Shah, MD, MPP, is the Director of the Delivery Decisions Initiative at Ariadne Labs.Illustration by Olga_Bonitas / iStock