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It’s a simple, but important question now asked every time a woman of child-bearing age arrives at a New Jersey emergency room: Have you been pregnant within the last year?

As of January 2020, state law requires hospitals in New Jersey to ask all emergency department patients  about their recent reproductive history to help diagnose their condition and better identify post-partum preeclampsia, a rare but serious form of hypertension that requires immediate medical care.

This change is just one of many steps hospitals across New Jersey have taken to improve maternal health care and reduce what is one of the highest maternal mortality rates in the country. These efforts are part of a broad spectrum of reforms now underway, and planned, to improve birth outcomes. And they are starting to show results.

The 2020 law was informed by a program launched years earlier at RWJBarnabas Health, one of the state’s largest hospital systems, to try and improve care for new moms who came into the network’s emergency rooms with hypertension, or high blood pressure.

A team of doctors, nurses and other maternal health leaders worked with emergency room staff and IT experts to create an alert system designed to quickly flag these patients and ensure they get proper care.

Narrowing racial gap

“We really use this team to identify issues within our system, issues within each of our unique communities, and determine what changes need to be made,” said Suzanne Spernal, an advanced practice nurse and vice-president of women’s services at RWJBarnabas.

The maternal leadership collaborative, organized in 2015, is one of the tools RWJBarnabas is using to improve maternal health and narrow the gap in racial disparities. Black mothers die at nearly seven times the rate of white mothers in New Jersey, more than double what it is nationwide, according to the most recent state data available.

The collaborative also serves to advance the goals outlined by Nurture NJ, a campaign launched in 2020 by first lady Tammy Murphy to cut the state’s maternal mortality rate in half and eliminate the racial gaps within five years.

Nurture NJ’s work is proceeding well, Murphy told NJ Spotlight News last week, with dozens of legislative proposals signed into law by her husband, Gov. Phil Murphy, and a wide array of state agencies collaborating to reduce inequities, improve access to care and elevate the voices of mothers, particularly Black moms.

“We are just doing everything within our power to see that we are moving the needle,” she said.

The first lady’s office has also partnered with community organizations to host festivals, pop-up giveaways of food, diapers and other goods, and health clinics with COVID-19 testing and vaccinations. The work has been supported by hospitals, physicians’ groups and Horizon Blue Cross Blue Shield, the state’s largest health insurance company, among others.

Delivery can spell danger

The majority of maternal deaths occur during delivery or in the first few weeks after birth, often related to severe bleeding. Three in five are preventable, experts note.

Improving these outcomes has long been a focus of the New Jersey Hospital Association, which represents the roughly 50 hospital-based birthing centers that help deliver some 100,000 babies each year.

Through its perinatal quality collaborative, the hospital association has provided its members with maternal mortality data and benchmarking options, best-practice toolkits and checklists to help medical teams navigate emergencies, plus webinars and other educational opportunities. Last week the association posted an online video course focused on reducing implicit bias in maternal and child health, timed to coincide with Black Maternal Health Week.

“Understanding more about implicit bias is such a hot topic right now,” said Dr. Meika Tylese Neblett, chief medical officer at Community Medical Center, an RWJBarnabas hospital in Toms River, who is featured in one of the segments.

“It’s understanding how your unconscious self … that is creating this implicit bias has a direct effect on how you are caring for your patients,” she said.

Preliminary C-section data

New Jersey Hospital Association president and CEO Cathy Bennett said the perinatal collaborative aims to “achieve measurable, sustainable quality improvement, and we have data that shows the impact of this work,” starting with a significant reduction in births by cesarean section, or C-section.

In 2016, New Jersey had among the nation’s highest rates for C-sections, she said, with nearly 40% of births involving the major surgical procedure that is necessary in some situations but involves significant risk. Preliminary data for 2021 shows the rate for regular C-sections dropped to 27.8%, Bennett said, calling it “a pretty astounding reduction.” (Experts have set 23.6% as the nationwide goal.)

But Bennett said this is only a start, with the COVID-19 pandemic posing new challenges. “We know that more work remains to achieve further improvement, including reducing disparities in outcomes for women and infants of color and to address COVID vaccine hesitancy among expectant mothers and women of child-bearing age,” she said.

The hospital association is tracking the impact of the COVID-19 pandemic on maternal health outcomes and monitoring data to determine if an initial uptick in poor outcomes recorded at the start has continued in the years since, Bennett explained.

Pandemic complications

“Birthing hospitals had to address never-before-seen issues to keep mom, baby and staff safe,” she said. “If you think about it, even the very process of laboring was potentially a situation where the virus could easily spread to others.”

At RWJBarnabas, leaders are also evaluating their COVID-19 response and its impact on maternal health, Spernal said. At the pandemic’s start the system’s hospitals sought to release healthy new moms within 24 to 48 hours to lessen their infection risk, she said, but despite the “best of intentions” there were limited support systems set up to help them once they got home.

“For the right patient, that rapid discharge is completely safe. But in other cases, it might not be prudent to send these new moms home so quickly,” Spernal said, adding, “We probably could have done a better job” connecting them with telehealth follow-ups or other services after their release.

RWJBarnabas has also taken steps to better incorporate doulas into its birthing protocol, Spernal said, but these trained advocates for the mother can be hard to find in some communities. State officials have been working to increase the size and diversity of this workforce through various programs and partnerships.

The hospital system also hosted online support groups, thanks to telehealth technology, which Spernal said has enabled more than 3,000 participants to join sessions on breastfeeding, mood disorders and pregnancy itself.

‘No matter how far we think we’ve come, we haven’t come far enough.’

“Over the past year we’ve seen an increase in the number of Black women participating” in several of these groups, Spernal added. “You don’t necessarily get that in the brick-and-mortar setting.”

But despite these gains, maternal health experts agree more work is needed, particularly to reduce the racial disparities. This is especially true with unconscious bias, Neblett said. “No matter how far we think we’ve come, we haven’t come far enough,” she said.

“Some nurses still have the thought that a Black women’s body is different than a white woman’s body. So they still have the thought that the difference in care and the difference in outcomes is due to a biological or genetic difference,” Neblett explained, noting this is not the case.

Neblett said recruiting and training more Black and Hispanic health care providers will also help strengthen the connection with patients of color, allowing for better care.

“It’s a big push in all fields, not just maternal medical care, to ensure that Black women, when they are coming to this space, feel comfortable,” she said. “And it’s not just the doctors. It’s the nurses, it’s the technicians, it’s the frontline staff and the registration, every part of it, so they feel empowered and understood when they are coming here.”