Our mothers are dying. In 2021, the United States saw 32.9 maternal deaths per 100,000 live births. When stratified by race, those rates were two to three times higher for Black women. While the popular press has succeeded in sounding the alarm, resulting in more public and policy dialogue around the issue than in preceding decades, the issue persists. Maternal mortality rates have consistently worsened year over year, yet maternal deaths attributed to hospitalizations related to birth declined in 2021. These concurrent realities highlight the central role of social and environmental drivers in maternity outcomes. In fact, these factors are more important to achieving optimal health than either clinical services or genetics.
The United States spends 17.8 percent of its GDP on health care, nearly twice as much as the average OECD country. Yet despite this spending, we currently have a health care system largely designed to attend to clinical variables, which, according to some studies, impact only 20 percent of county-level variation in health outcomes, while social determinants of health (SDOH) affect as much as 50 percent (1).
How did we end up here? Why is it that our system focuses on just part of what is needed to secure good health outcomes for our nation?
To start, our health system is divided into different sectors — primary care, specialty care, mental health, and public health, to name a few — each with its own set of providers, protocols, and data systems. These sectors typically operate independently, though toward the same goal, which is inefficient at best and destructive at worst, as lack of communication can result in conflicting diagnosis and treatment plans.
Add healthcare payers and regulatory bodies into the mix, and the opportunity for missteps and duplicative procedures triples. Plus, misaligned incentives add an extra layer of complication. For example, payers are typically concerned about managing financial risk, while providers are primarily focused on clinical outcomes; regulatory bodies require lots of paperwork, and providers would rather focus their time on patients.
Nowhere are the downstream negative effects of this fragmentation more observable than in maternity care. For decades, we’ve been hyperfocused on pregnancy as a clinical episode, without considering the unique individual involved and the context of their lives. The result is an overmedicalized system that is isolated from the social environment of patients and often rewards unnecessary utilization and obsessive risk management.
Rising maternal mortality rates reflect our urgent need to reexamine what constitutes medical care, and recognize that attending to social and environmental variables that harm health is part of clinical management.
To improve outcomes, the healthcare system needs to see individuals as the organizing principle of an ecosystem that includes all of the diverse sectors named above, and that ecosystem must be responsive to the range of variables that impact health and well-being. This vision invites a diversity of roles, decentralizes the power of traditional healthcare silos, and elevates the need for greater connectivity with ease in communication around the individual.
That’s easy to say but harder to accomplish. The U.S. is suffering from a massive shortage of healthcare providers and staff, making care coordination more difficult than ever. A non-clinical risk might be identified by an OB/GYN in an appointment, but communicating that risk to the appropriate care provider is more difficult ― with no guarantee that the resources are available to address that risk for the patient. With the traditional healthcare workforce crumbling, the urgency of providing maternity care within communities has never been more apparent.
Throughout pregnancy, labor, and postpartum, a patient will see (or should see) multiple healthcare providers, and likely multiple kinds of providers (OB, nurse, midwife, lactation consultant, doula, mental health specialist, MFM, social worker, among others). Often these providers of care exist in different medical groups or outside a single system of care, increasing the risk of communication issues and of vital information getting lost in transitions between providers. Continuity of care is especially an issue in the postpartum period, when the patient and new baby transition from maternity care to pediatric care, and Medicaid beneficiaries can be in danger of losing coverage depending on where they live.
This is where technology can make an impact. Connecting clinical, social and environmental inputs through a single digital ecosystem can automate the handoff from one professional to another, reducing friction and eliminating the coverage gaps that can occur with manual communication. In addition to improving the quality of care, this type of ecosystem also relieves the patient of some of the burden of being their record-keeper and the tedium of repeatedly detailing their medical history to each new provider. Importantly, by offering information plus connectivity, digital technology fosters personal agency within this complex system and provides more space for people to engage at the time and cadence they choose.
This solution can also automate interventions. Plugged into a single digital ecosystem, all stakeholders can input and access patient data and can make better-informed decisions to improve quality of care. With data analysis tools, a digital ecosystem has the potential to sift through these inputs and surface actionable data to the appropriate member of the care team, closing the intervention loop by providing the necessary follow-through.
Imagine that a patient comes into an OB appointment and records a blood pressure reading outside the recommended thresholds. The OB might give them some literature and advice on managing BP, and instruct them to self-monitor their BP from home, but their reach is limited — they can’t necessarily discover or address all of the factors that might contribute to high blood pressure: unhealthy eating habits, stress factors, lack of exercise, white coat syndrome, etc.
When that data is inputted into the digital ecosystem, it becomes available to every stakeholder and can activate a targeted response. Many health plans have benefits to support their members, but identifying eligible members is difficult with care silos. A digital health ecosystem can automatically identify eligibility, and direct patients to the services available to them through their health plan, such as nutrition counseling, fitness coaching, or behavioral health support as soon as their BP data is recorded.
This doesn’t solve the lack of human resources to support these interventions, but technology can assist there as well. There is a vast network of digital health tools specifically designed to address risk asynchronously at scale, with limited human oversight. These tools can be integrated into the ecosystem to facilitate interventions and remove some of the need for human support.
Imagine the above example, but in this scenario, the patient doesn’t make it to the OB appointment because they live too far away from the clinic or they can’t take the time off of work. Without identification, the risk that could have been treatable will worsen until it becomes a costly and potentially permanent issue with long-term health consequences for the patient and baby.
Now imagine that this patient has an internet-connected blood pressure cuff integrated with the digital health ecosystem. In this scenario, the BP data is still captured, and the response protocol can be activated, even without an in-person visit. Through the ecosystem, they can be connected to digitally supported interventions or management programs, sidestepping the barriers of access that led them to miss their appointment in the first place.
Innovators have responded to the call for better maternity care tools with a national network of patient-facing, digital solutions that address issues of access to care and labor shortages. Without integration with providers and health payers, however, these solutions are only compounding the problem of care silos. We need a digital bridge to connect the supply to the demand in a way that is sustainable, cost-effective, and scalable.
While a digital ecosystem might not be able to recreate the tangible sense of social safety and community intrinsic to a village; we can replicate its essence. By creating a unified digital ecosystem that connects all stakeholders, including healthcare providers, payers, and patients; we can bridge communication gaps, automate interventions, and deliver a more holistic, responsive, and communal approach to maternity care.
About Loral Patchen
Loral Patchen, Ph.D., MSN, MA, CNM, IBCLC, is the scientific director of health services research at MedStar Health Research Institute and a senior faculty midwife attending at MedStar Washington Hospital Center. Dr. Patchen leads several innovative research programs to promote improved health decision-making, address social drivers of maternal health outcomes, and optimize the use of digital technology in health care.
About Anish Sebastian
Anish Sebastian co-founded Babyscripts in 2014 with the vision that internet-enabled medical devices and big data would transform the delivery of pregnancy care. Since the company’s inception, they have raised over $40M. As the CEO of BabyScripts, Anish has focused his efforts on product and software development, as well as research validation of their product.