Improving health equity in maternal care

Published March 26, 2024

Article originally published in the April 2024 issue of Chicago Medicine Magazine

By Razia Hashmi, MD, MPH, FAAFP, Blue Cross and Blue Shield Association, vice president of clinical affairs

National centers of excellence program enhanced its criteria as part of a broad effort to address maternal health equity crisis 

At a time when Black mothers in Chicago are three times as likely as white mothers to die from pregnancy-related causes—with most of those deaths being preventable—the Blue Cross and Blue Shield Association (BCBSA) is leveraging its Blue Distinction Centers (BDC) for Maternity Care program to reduce racial and ethnic disparities in maternal care.

Since 2016, the Blue Distinction Centers for Maternity Care program has recognized hospitals that demonstrate expertise in delivering higher quality maternity care. Data shows that BDC designated hospitals outperform national averages for reducing cesarean births, elective deliveries and episiotomies. For 2023, BCBSA enhanced the program’s criteria to include new clinical processes that help hospitals address disparities in maternal health equity. These are evidence-based practices that respected medical authorities know improve health outcomes. I’m happy to say this commitment to taking measurable action to reduce disparities in maternal care is at the top of our CEO’s list of priorities.

“Our commitment to reduce racial and ethnic health disparities is rooted in action. The enhanced requirements for our Blue Distinction Centers will help mothers across the country gain improved access to higher quality, more equitable care,” said Kim Keck, BCBSA’s president and CEO. “Working with hospitals across the country means that we have an opportunity to bring about systemic change and impact millions of lives.”

Using the new criteria, BCBSA recently recognized more than 600 hospitals nationwide as BDCs for Maternity Care. They include 38 hospitals in Illinois.

Each hospital designated as a BDC for Maternity Care must meet all of the program’s quality criteria, which include new measures for maternal health equity. Every designated hospital must:

  • Collect a patient’s demographic data, including race, ethnicity and spoken language (REL), including having a system to document self-reported demographic data.
  • Hold drills or simulations to respond to adverse maternal events, such as obstetric hemorrhage, at least once a year.
  • Support doula participation in the maternity care team.

BCBSA developed the new criteria in close partnership with leading hospitals, the American College of Obstetricians and Gynecologists, The Joint Commission, and multiple state-based perinatal quality collaboratives (PQCs).

Our experts, Erin Barney, BCBSA’s vice president of Network Solutions and Rose Baez, RN, managing director of network quality innovation and measurement programs, worked in consultation with these partners to develop the new BDC health equity criteria. These three criteria rose to the top of the list because they are among the most powerful tools for providing a safer and more equitable maternity experience. 

“First,” said Barney, “we must be able to measure progress. Collecting REL data empowers us to measure the extent to which a hospital is actually closing gaps in care based on race, ethnicity and language.”

Second, regular drills to address adverse maternal health events are critical. In a hospital labor and delivery room, everyone has a role to play during an emergency and those roles and actions must become second nature. “Drills that reinforce roles and processes can help clinicians recognize signs of distress, listen closely to patients who report problems and respond efficiently with standardized clinical steps,” said Baez. “Using the same quality standards across the board, rather than judging on an individual basis, lessens the chance that race, ethnicity or language could be a factor in missing an obstetric emergency. Many Black patients who have experienced adverse maternal events report not feeling heard in the delivery room.”

The third criterion, being supportive of doula involvement, is one of the most important, in my opinion. As a physician and a woman of color, I was struck by this recent NEJM perspective1 about how the medical establishment must learn to share power in the delivery room with practitioners who can empathize with a woman’s real life experience. “By committing to collaborative partnerships with patients and doulas,” the authors write, “clinicians can participate in and appreciate the beauty of the birthing process while ensuring improved outcomes. When we honor birth as a collaborative experience, recognizing others’ expertise, the relationships created in that process contribute to both safety and success.”

Edward Hospital and Northwest Community Hospital, part of Endeavor Health system, are among the Chicagoland hospitals recognized as Blue Distinction Centers for Maternity Care this year. Dr. Lakshmi Halasyamani, Endeavor Health’s system chief clinical officer, said she appreciated payer partnerships like BCBSA’s BDC program. “It helps bring greater definition to the effort,” she said. “It’s like gasoline. It accelerates the journey, not just for us but for the patients who trust us.”

Halasyamani said the new health equity criteria also give hospital stakeholders a common approach for examining and improving their own systems and processes. “This allowed us to create a framework that not only helped us learn more about how we need to grow as professionals, to examine our own implicit biases, but also to examine our systems and address structural issues that result in inequitable outcomes.”

She said one of the most important lessons they’ve learned is that health equity isn't something you talk about at the end of a process. “It has to be built in from the very beginning,” Halasyamani emphasized, “using a helpful framework, such as the BDC’s criteria. So, as we are thinking about our performance, we have to start with: ‘Is it equitable?’ And then as we think about the nature of the interventions we're proposing, we have to ask, ‘Will those be equitable in their impact?’”

The Blues wanted to give hospitals the opportunity to deepen their impact across many areas of practice, and so BDCs’ framework also includes some optional criteria that many designated hospitals have incorporated. They include:

  • Using standardized protocols with checklists and escalation policies, including a standard response to early warning signs for adverse events, close listening to patients and investigating patient-reported and observed symptoms.
  • Assessing all pregnant patients for substance use disorders, using validated screening and connecting them to care.
  • Screening all patients for postpartum depression prior to discharge and follow up with those who screen positive.
  • Implementing trauma-informed protocols and anti-racist, implicit bias training to address health care team member biases and stigma.
  • Requiring ongoing physician and nurse education and training in fetal monitoring, obstetric hemorrhage and severe hypertension management.

Blue Distinction Centers for Maternity Care are just one component of our efforts to address and operationalize improvements in maternal health equity. In 2019, The Blues published a list of the top 10 maternal health equity actions that we believe will make the most difference in resolving the maternal health equity crisis. Making progress on these actions will not only impact the nearly 118 million lives that local BCBS companies cover, but, because we work with providers in every ZIP code across the country, will help raise the bar for every mom.

Moving the needle on health equity requires transformational thinking, and to do that we need all hands on deck. We all want the same outcome: healthy moms who feel supported during their birth experience. Structuring contracts with hospitals and recognizing their achievements are two ways that payers can fuel that transformation. Individual Blue Cross and Blue Shield companies across the country may also encourage hospitals to take additional action, tailored to the needs of their local communities, such as:

  • Incorporating nurse midwives and doulas in obstetric care. Many BCBS companies already cover these services or work with organizations that connect moms to culturally congruent, community-based care.
  • Establishing value-based care (VBC) arrangements with maternity care providers to reward their focus on delivering high-quality care—in contrast to fee-for-service arrangements that favor the quantity of care over its quality. Many BCBS companies offer VBC incentives to support the delivery quality care.
  • Boosting access to implicit bias training. This training, which many BCBS companies offer free of charge for network providers, helps health care team members recognize and change behaviors that could impact health outcomes.
  • Advocating for postpartum care that continues at least one year from delivery. Since a large percentage of maternal deaths occur within the first few months after delivery, it’s essential for mothers to have access to the preventive and acute care they need during what many call the “fourth trimester.”

And The Blues won’t stop there. We’re fighting for nationwide policy changes that we believe can end the maternal health equity crisis. That includes our support for the Black Maternal Health Momnibus Act of 2023. The act’s 13 individual bills include funding to grow the perinatal workforce, including doulas and nurse midwives, to give moms greater opportunity to receive quality care from providers they trust and to improve data quality processes and quality measures.

Together, we believe these commitments, from the community to its providers to The Hill, can help change the health trajectory for all mothers.

The Blue Cross Blue Shield Association is an association of independent, locally operated Blue Cross and Blue Shield companies.

To learn more about Blue Distinction, please visit or contact your Local Blue Plan.

1Dolly Pressley Byrd, Ph.D., C.N.M., Elizabeth Buys, M.D., Amanda Brickhouse Murphy, C.N.M., and Crystal Cené, M.D. (2023). Community-Based Doulas — Can Clinicians Share Power to Improve Maternal and Infant Health Outcomes? New England Journal of Medicine, 389 (26).