Fact Sheet: HHS Secretary Becerra’s Postpartum Maternal Health Collaborative Effectively Mobilizes State and Local Partnerships to Improve Outcomes

Quotes from Participants:

• “Participation in the Collaborative has sparked a sense of urgency and stimulated stakeholder engagement across the continuum of care.”
• “Using a simple tool like the PSDA has kept the team focused, prevented drift, kept the improvements manageable and produced results.”

Background

The United States has the highest rate of maternal mortality of any developed country in the world, with over 60% of pregnancy-related deaths occurring after delivery up to one year postpartum and most of these deaths considered preventable.ⁱ Although data show significant decreases in in-hospital maternal mortality since 2008—likely due to national and local initiatives and investment—the challenge of demonstrating effective approaches to improve postpartum health remains.ⁱⁱ, ⁱⁱⁱ

In February 2024, the US Department of Health and Human Services (HHS) launched the Secretary’s Postpartum Maternal Health Collaborative, a one-year quality improvement sprint to specifically address improving outcomes in postpartum health. This initiative, in support of the 2022 White House Blueprint for Addressing the Maternal Health Crisis, built upon HHS’ many longstanding and continued investments in improving maternal health including the extension of Medicaid coverage to one year postpartum, now in 47 states plus the District of Columbia and US Virgin Islands. 

The HHS Secretary’s Postpartum Maternal Health Collaborative federal team partnered with states and local providers to change the trajectory of postpartum maternal morbidity and mortality. State teams consisted of collaborators across sectors, including Governor’s offices, state and local health departments, Medicaid agencies, health plans, providers, and community organizations. The state teams used data to identify opportunities and metrics, deployed interventions to impact key drivers of maternal health, and strengthened state systems and leadership to propel the work forward. Six states participated in this quality improvement learning collaborative: Iowa, Maryland, Massachusetts, Michigan, Minnesota, and New Mexico. Three states (IA, MN, NM) focused quality improvement efforts on postpartum morbidity related to behavioral health, including both mental health and substance use disorder, and three states (MA, MD, MI) focused on addressing postpartum morbidity related to cardiovascular conditions. 

This work yielded lessons that will be shared with other states and collaborators seeking to improve postpartum health and will be further detailed in a forthcoming report from the January 10, 2025 Milbank Memorial Fund convening of the US HHS Secretary’s Postpartum Maternal Health Collaborative.

Secretary’s Collaborative Approach

To provide a framework for quality improvement efforts, HHS subject matter experts articulated key factors to decrease postpartum morbidity and mortality using a driver diagram (see Table 1). Postpartum hospital readmission rate was selected as a proxy metric for postpartum morbidity. Based on each state’s own data, teams defined project aims and utilized quality improvement methodology (e.g., piloting change ideas across health care, social services, and public health systems using rapid, iterative cycles of testing and implementation guided by measurement). Throughout this process, HHS provided states with technical assistance from a team of quality improvement, clinical, and policy experts, including subject matter experts from across HHS. All state teams met monthly to share learning and provide support to each other.

Key Learnings about Drivers of Postpartum Health

1. Using standards-based transitions of care that meet individual needs

The postpartum period generally includes numerous transitions in care setting including transitioning from birthing location to home, as well as transitioning between various clinical providers in primary care, obstetrics, and other specialties. Evidence- and standards-based transitions of care could reduce care fragmentation and improve postpartum health outcomes.

Change ideas that emerged from the collaborative included: creating clear protocols for transitions from hospital to home and from obstetric (OB) to primary care; establishing clearer, universally accepted clinical guidelines for referral to specialists; and making postpartum primary care appointments early in the prenatal period to help ensure follow-up. Some states working on improving cardiovascular outcomes emphasized self-measured blood pressure monitoring (SMBP) programs as an effective way to reduce hypertension-related morbidity and identified key features leading to positive outcomes, e.g., utilization of nurse- and pharmacist-led protocols for medication titration and cellular-enabled blood pressure measuring devices.

• The Maryland team applied quality improvement (QI) methods to improve care for women^iv diagnosed perinatally with hypertension at University of Maryland Capital Region Medical Center by scheduling outpatient follow-up appointments within three days of hospital discharge, discharging each patient with a blood pressure cuff and education on self-monitoring, referring those eligible to a private third-party home blood pressure monitoring service using cellular-enabled cuffs, and referring patients to a nurse-led home visitation program offered by the public health department that could provide hypertension-related support.
• The Massachusetts team addressed two key transition points: hospital to home, and OB to primary care. Boston Medical Center clinicians leading an existing postpartum self-measured blood pressure (SMBP) program that ended at six weeks postpartum coordinated with NeighborHealth, a large federally-qualified health center, to launch a new SMBP program lasting several more months. This program was managed by the outpatient OB clinic with the goal of transitioning blood pressure management to primary care providers.
• The Michigan team worked with clinical leadership at Detroit Medical Center sites to establish clear, evidence-based criteria for referral of postpartum women to specialty cardiology services to ensure continued management of cardiovascular conditions beyond the transition to home, and conducted physician education on the topic.

Some leading practices state teams explored included a Brigham and Women’s Hospital transition clinic for postpartum people with hypertensive disorders and postpartum self-blood pressure monitoring programs at Boston Medical Center and the University of Pittsburgh Medical Center. Other resources included the CDC’s Hypertension in Pregnancy Change Package that launched in May 2024 and Million Hearts Hypertension in Pregnancy Action Forum.

2. Ensuring women and families are seen and heard and their concerns are acted on

Designing services with patients and their families at the center is a hallmark of high-quality care.^v

Change ideas that emerged from this collaborative included: creating electronic flags in the patient chart to clearly indicate postpartum status up to one year for all providers; and creating and leveraging trusted relationships with service providers (e.g., through peer support specialists, social workers, and community-based care coordinators).

• The Massachusetts team solicited and acted on feedback from patients that text-based messaging was the preferred way to receive reminders to take blood pressure measurement at home, and found that women may prioritize well-child visits over their own postpartum medical care.
• In light of the New Mexico Medicaid Agency’s new requirement for contracted health plans to delegate care coordination functions to community agencies, the New Mexico team partnered with experts from the U.S. Substance Abuse and Mental Health Services Administration to provide technical assistance to local care coordinators on effective relationship building, substance use screening, and service referral with a focus on establishing trust.  

The CDC Hear Her® Campaign is an example of a national effort to address this driver by sharing potentially life-saving messages on urgent maternal warning signs with pregnant and postpartum people, their friends and family, and providers.

3. Increasing access to and utilization of mental health and substance use care

Mental health and substance use conditions are leading causes of pregnancy-related death.^vi States identified the need for early and repeated screening at each transition and touchpoint, coupled with linkages to high-quality services.

Change ideas that emerged from this collaborative included: increasing awareness and understanding of treatment of mental health conditions and substance used disorder (SUD) for postpartum women among all health care and service providers; expanding system capacity for referral and treatment for mental health and SUD; and pairing neonatal withdrawal treatment programs with support for maternal SUD treatment.  

• The Iowa team collaborated with providers in two different counties, St. Anthony’s Regional Hospital and Siouxland Community Health Center, to enhance perinatal mental health screening, standardize screening with pregnancy-specific tools, and develop tools for providers to view screening outcomes in electronic health records across time for better clinical assessment and care. They also trained health care and service providers across various disciplines to increase their capability to address postpartum behavioral health needs.
• The Minnesota team partnered with its perinatal quality collaborative leadership to identify ways to augment existing Eat, Sleep, Console care approach implementation with maternal mental health assessment and linkage to services while babies are still in the hospital.
• The New Mexico team partnered with a Medicaid managed care plan and its contracted care coordination agency to ensure robust service networks with warm referrals to treatment and service providers, and to address potential barriers to care for mothers with substance use disorders, such as provider and patient misperceptions on requirements for reporting to child protective services.

States explored strategies and resources such as technical assistance from the National Center for Substance Abuse and Child Welfare and promising practices from states working to use Plans of Safe Care to support the family and achieve better health outcomes.

4. Ensuring access to whole family-integrated care that addresses social needs

Change ideas that emerged from this collaborative included: improving quality and timing of screening for social drivers of health (SDOH); and ensuring warm referrals to quality services.

• The Massachusetts team tested cross-disciplinary, workflow-integrated protocols for SDOH screening and referral in the setting of a federally-qualified health center with obstetrics, pediatric and adult primary care services. Each patient was screened for SDOH needs when returning to primary care services after a pregnancy.
• New Mexico implemented a new requirement for Medicaid managed care plans to contract with community organizations to provide care coordination services in an effort to facilitate greater access to screening and referral for social support services.
• The Maryland team integrated referrals to a nurse care management program that addresses social needs based at Prince George’s County Public Health Department into the hospital discharge process for all postpartum patients.

Additional Learning on Methods and Care Systems

The structure and methods of a quality improvement learning network proved applicable and useful for cross-organization, cross-sector efforts to improve postpartum outcomes. Participants commented that the Secretary’s Collaborative provided both momentum and a framework to help mobilize state teams to establish new partnerships with payers and local providers that resulted in synergistic relationships to test and implement improvement ideas. The state teams found ways to utilize existing staff and funds to conduct the work, e.g., staff supported by a health system, hospital, or clinic, or staff funded by HRSA grants such as the Title V Maternal and Child Health Services Block Grant or the State Maternal Health Innovation Program. The learning network model provided a forum for states to share experiences and learn from each other.

Teams analyzed postpartum health metrics at both the state and provider levels. Different types of data served different purposes, e.g., states used data from maternal mortality review committees to define QI aims, while claims data, closer to real-time, were utilized to produce metrics that could potentially inform policy and program decision-making. States explored a new population measure of severe obstetric complications launched by the ARPA-H HEROES Program that expanded the definition of morbidity to also include suicide, self-harm, and substance use up to 60 days postpartum. In addition, states and their provider partners leveraged epidemiologist teams to learn about capabilities and challenges of existing data systems for building state or systems-level measures of postpartum health (e.g., postpartum readmission rate, postpartum emergency department visit rate, and postpartum care rate).

Insights on care systems emerged that helped to inform the state teams’ work. Because the postpartum period involves health care for both mother and infant that is rarely integrated, improvement efforts require collaboration among multiple entities that may lack established communication channels or inter-operable electronic health records systems designed to support better care. There is generally no single health care delivery system “owner” of the postpartum period of health when payment is fragmented. The extension of Medicaid coverage to 1-year postpartum could present opportunities for payment redesign, and the Transforming Maternal Health Model of the Centers for Medicare and Medicaid is an effort to support state Medicaid agencies in development of a whole-person approach including value-based alternative payment models for maternity care services. Clear protocols and working relationships among the various individuals and systems involved in the care transitions, as well as robust care navigation support by trusted professionals, seemed to be requisite conditions for postpartum health improvement.

Endnotes

ⁱ  Pregnancy-Related Deaths: Data From Maternal Mortality Review Committees in 38 U.S. States, 2020 | Maternal Mortality Prevention | CDC. May 28, 2024.

ⁱⁱ  Fink DA, Kilday D, Cao Z, et al. Trends in Maternal Mortality and Severe Maternal Morbidity During Delivery-Related Hospitalizations in the United States, 2008 to 2021. JAMA Netw Open. 2023;6(6):e2317641. doi:10.1001/jamanetworkopen.2023.17641

ⁱⁱⁱ  A Report from the Federal Partners Meeting of the NIH P2P Workshop: Identifying Risks and Interventions to Optimize Postpartum Health. National Institutes of Health Office of Disease Prevention. Oct 23 and 25, 2023.

^iv   While this fact sheet generally refers to women, the content is inclusive of every person giving birth, irrespective of gender identity or demographic background.

^v   Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine (US) Committee on Quality of Health Care in America. Washington (DC): National Academies Press (US);2001.

^vi  Pregnancy-Related Deaths: Data From Maternal Mortality Review Committees in 38 U.S. States, 2020 | Maternal Mortality Prevention | CDC. May 28, 2024.