Recent reports have revealed a deeply concerning trend in maternal deaths in the United States: a 40% increase in just one year, from 2020 to 2021. While part of this increase is related to COVID-19, it began long before the pandemic. The U.S. also has persistent racial disparities in maternal health. Because an overwhelming majority of pregnancy-related deaths (84%) are preventable, it is imperative that both the public and private sectors come together to address these injustices.
The Association of Maternal & Child Health Programs (AMCHP) is a national resource, partner, and advocate for public health leaders who work and support state maternal and child health programs and others working to improve the health of women, children, youth, families, and communities. AMCHP hosts an annual conference with maternal and child health leaders from federal health agencies, state, tribal, and local health departments, community-based organizations (CBOs), and beyond. This year’s conference in New Orleans, Louisiana saw more than 1,300 participants both virtually and in person.
Because each state distributes federal Title V funding, which assures access to maternal and child health care services according to their state’s particular needs, the AMCHP conference offers a unique opportunity for leaders to gather and share ideas about how to make their Title V funding processes and decisions more efficient, impactful, and equitable. Three members of Palladium’s U.S. Health team attended the conference to join the critical conversations about equity and to speak about Palladium’s long experience in global maternal and child health.
Providing Sustainable Solutions and Differentiated Support
“Many of the conference’s sessions addressed an important barrier to maternal health equity: too often, birthing people, especially birthing people of color, are not being adequately listened to in clinical settings,” explains Chinwoke Isiguzo, Senior Technical Advisor at Palladium.
One commonly proposed solution to this barrier is doulas: professional (non-clinical) caregivers trained in childbirth and who provide physical, emotional, and educational support to a mother before, during, and after pregnancy. The significance of doulas’ role lies in how they facilitate communication between birthing parents and their medical team and empower families to navigate their care experience. “We know from our global health experience that similar birthing support, when well designed, can improve equity and maternal and infant outcomes,” Isiguzo adds.
"For example, in Nigeria, we found that one way to help increase the use of health facilities during labor and childbirth was to introduce companions (such as doulas). We supported the government's implementation of this program through the USAID-Funded Integrated Health Program."
The team also took part in important conversations about the role of data in maternal health inequities. Some data sets contain no racial information, making it impossible to quantify, describe, or analyze racial inequality.
Many of the data conversations looked at the concept of Evidence-Based Interventions (EBIs), those practices, procedures, programs, or policies that have been proven effective such as counseling interventions to prevent perinatal depression, doulas, and CDC's recommended strategies to prevent preterm birth. However, CBOs don’t always have the resources to evaluate their interventions in a way that meets the traditional standards required to be considered an EBI.
In a vicious circle of exclusion, this often means that CBOs may not receive further funding for their work, because of a lack of evidence. “The evidence behind some EBIs may have been generated with a different population from the CBO’s population, and EBIs will lack cultural responsiveness. So, insisting that CBOs must use EBIs may be impractical,” Isiguzo adds.
One solution to this circle of exclusion is community-defined practices. “While most of these community-defined practices generated in harder-to-reach communities may not meet the standards of EBIs, researchers and stakeholders need to understand that they are addressing the unmet needs of groups that have been marginalized and must be supported and funded,” Isiguzo adds. Similarly, inclusion of more qualitative information as “evidence” can also cultivate more equitable power and counter negative stereotypes.
“Ultimately, communities need to be involved in defining the problem and developing interventions; supporting community-rooted work leads to the development of programs that best meet the specific needs, values, and context of those participating in the interventions.”
Community and Localization are Critical for Equity
“We noticed synergies between this concept of community-defined evidence in the U.S. and Palladium’s shift towards localization in our global health work,” adds Ellen Smith, Palladium Senior Technical Advisor. “We heard Title V Directors from Indiana and other states discuss their efforts to simplify funding application processes to reach a wider net of more diverse CBOs than have been previously funded, thus improving access and equity in procurement processes.”
“As we know from our global work, prioritizing social inclusion and the local needs articulated by a community fosters increased innovation and increased likelihood of initiatives’ sustainability.”
While conference attendance was heavily from the public sector, which often finances the care and services that women and children receive, they cannot and don’t work on it alone. Smith explains that philanthropy and foundations also often care about community well-being, including outcomes, impact, systems change and equity. “To work on these topics effectively, philanthropy and other private sector partners such as employers should be working in conjunction with the care and services funded by Title V.”
Because both public and private sectors are actively engaging in conversations about how we define ‘evidence,’ they should be coordinating efforts, present in the same room, and engaging in conversation with one another to create collective impact. Without this, interventions will fall short and are likely to be unsustainable. “We’ve seen it clearly at work when both public and private sector partners are coordinated. For example, in the Utkrisht impact bond that Palladium designed and managed, we successfully led a multisectoral group of organizations to improve the quality of maternal-newborn services in India.”
Applying global lessons to U.S. public health is not something new and organizations such as the Robert Wood Johnson Foundation, the National Alliance of State & Territorial AIDS Directors, and others are making strides in the sector. “We were encouraged by the diverse perspectives presented at the conference, and to see the link between federal programs such as HRSA’s Title V and community perspectives,” Smith concludes.