One in three counties in the U.S. is considered a maternal healthcare desert.
Since that statistic was dropped back in October 2022 by March of Dimes, care in corners of the country has only continued to dry up. In response to the crisis, providers are using every seed in their seed bag and looking to "multimodal" technology strategies to predict health emergencies before they happen.
Those multimodal approaches combine telehealth, remote patient monitoring (RPM) and text messages to identify high-risk patients. High blood pressure monitoring and hypertension screening are currently recommended for pregnant patients by the U.S. Preventive Services Task Force, as heart disease and stroke are two of the leading causes of maternal mortality.
Lucienne Ide, M.D., is the CEO of digital health company Rimidi. She sees the country teetering on an inflection point.
“We're at this fork in the road of looking at what we could do with technology, identifying high-risk women and getting them into the programs where we're proactively and earlier identifying something dangerous and doing something about it,” Ide told Fierce Healthcare.
“But the alternate narrative is really, really bad and it's going to get worse. It's not like, 'Here we are today, and we could do better.' No, here we are today and it's going to get worse, but we can actually do better,” she said
Since 2019, the country has gone from 20.1 maternal deaths per 100,000 live births to 32.9, a 61% increase. According to the Mayo Clinic, high blood pressure, obesity, diabetes, infection and heart or blood disorders increase the risk of pregnancy.
Multimodal methods of care and the power of prediction
Rimidi helps patients collect their own stats with tools like cellular-enabled tools like blood pressure cuffs to predict preeclampsia and glucometers to predict gestational diabetes. Results are automatically uploaded into Rimidi's platform, which are incorporated into electronic health record (EHR) system.
Ide believes that RPM pairs well with expanding holistic care models. Reactive fee-for-service models may not kick into high gear until a patient recovering from pregnancy shows up at an emergency room experiencing a stroke. She says RPM allows for a “preventative mindset [and] a proactive management mindset.”
While hospitals often aim to reduce costs by decreasing readmissions, Ide suggests a slight shift in mentality. Instead of avoiding readmission altogether, providers can readmit a high-risk person before something worse happens.
“A woman comes to the ER having a seizure postpartum due to eclampsia,” Ide said. “That's not how we want them coming back to the hospital. We want them coming back to the hospital because they have elevated blood pressure before it causes serious sequelae, like a seizure.”
Rimidi partnered with Boston Medical Center to use its software platform to manage chronic conditions. The medical center’s department of obstetrics and gynecology integrated the platform into its EHR system to monitor high-risk pregnancies. The collaboration began in the early months of the pandemic when creative solutions were necessary.
Kaiser Permanente Northern California took a similar approach by implementing telehealth visits for pregnant people. Senior Research Scientist Assiamira Ferrara, Ph.D., studied the resulting data to assess the virtual visits' effects on care.
She found that during the pandemic, telemedicine visits increased from comprising 11% of pregnancy appointments to 21%, according to the study published in JAMA Network open. While overall appointments did not increase, health outcomes did not take a hit. A multimodal approach led to similar rates of preeclampsia, eclampsia, severe maternal morbidity, C-section delivery or preterm birth compared to an in-office-only approach.
“We saw that you can use the telehealth without harming the patient,” Ferrara told Fierce Healthcare. “This may reduce some barriers for people who have less time to go to the doctor's office because they don’t have a flexible job, or do not have transportation, or they don't have childcare for the kids. It’s also had very good uptake in Northern California’s two maternal health desert regions.”
Despite California having a robust network of maternal care, Ferrara sees the results holding across the country. She calls the use of multimodality forms of healthcare a COVID-era “natural experiment" that fortunately panned out.
Meeting patients where they are in the postpartum danger window
As the country was forced to move to telehealth, the maternal mortality crisis is inviting in other creative models of care. Ferrara hopes to look at data for a current Kaiser Permanente pilot study implementing self-monitoring of blood pressure and fetal heartbeats during pregnancy.
While roughly 22% of maternal deaths occur during pregnancy and a quarter take place on the day of delivery or within a week after, over half take place between seven days to a year after pregnancy, according to the Centers for Disease Control and Prevention.
In response to the disproportionate number of deaths in the year following pregnancy, extending postnatal Medicaid coverage from six weeks to a full year has been proposed in Congress.
Suchitra Chandrasekaran, M.D., is an assistant professor in the Department of Gynecology and Obstetrics at Emory University School of Medicine. She moved to Georgia with the goal of addressing maternal deserts and now runs a postpartum cardio metabolic clinic where she meets with patients 12 weeks after giving birth.
“We don't have standardized care,” Chandrasekaran told Fierce Healthcare. “I think we're at the initial stage, and we're here to figure out what's best. I offer telemedicine, even in the local Atlanta region. Remote care is great in an urban center where getting a baby and a mom out of the house is not an easy feat for people.”
Chandrasekaran hopes to expand her practice to a regional clinic. Pregnant people can go to a partnered department of public health clinic, get their blood pressure taken, have blood glucose checked and then jump on a telehealth call with her Atlanta-based clinic. Other patients can receive remote patient monitoring devices and report back to her centralized office. This way, Chandrasekaran hopes to identify patients most at risk before a health emergency occurs.
Just as broad and varied are the experiences of pregnancy and birth, Chandrasekaran says solutions should reflect that multiplicity of experiences. Some programs might use text messages connected to blood pressure monitors, some ask patients to call in their stats, others might allow patients to come in person if they so choose.
“It's hard to really standardize immediate postpartum, because what if you have a baby in the NICU that changes your ability to do things? What if you live three hours away from your delivering hospitals?” Chandrasekaran said. “I think having options is the key.”