In the United States, 80 percent of maternal mortalities are preventable. Black and Native women are disproportionately impacted by maternal mortality, dying at up to three times the rate of White women. Most maternal deaths occur not immediately after birth but in the critical postpartum period.
To combat the maternal mortality crisis, over 150 maternal health experts came together to write The Practical Playbook III: Working Together to Improve Maternal Health. Throughout the book, the experts give insight on how to curve the alarming trend of maternal deaths.
The book was published by the de Beaumont Foundation in partnership with the Maternal Health Learning & Innovation Center and Oxford University Press. Among its seven editors is Dorothy Cilenti, a clinical professor at the UNC Gillings School of Global Public Health.
NPQ spoke with Cilenti to gain more insight into the book and its findings.
Rebekah Barber: How did you get involved in work around maternal health?
Dorothy Cilenti: I started out in governmental public health. I’ve worked as a local health director and worked at the state health department for about 17 years. My area of interest was women’s and children’s health. I did a lot of community-based work and state policy work in North Carolina to address disparities in infant mortality, maternal mortality, and women’s health. Then, when I went to UNC—to the Gillings School of Global Public Health—I continued to be interested in public health practice and wanted to continue to use the university’s resources to improve the practice of public health in the field.
In 2013, I was awarded funding to start a national Maternal and Child Health Workforce Development center. When the opportunity came up in 2019 to build our Maternal Health Learning and Innovation Center, we [schools of Public Health, Social Work, and Medicine] submitted proposals. My colleagues and I were successful in that competition. We’ve been implementing the Maternal Health Learning and Innovation Center for about the last five years. I’ve always been interested in maternal and child health, public health more generally, and how, in partnership with communities, we can address some of the determinants of health that are responsible for the health disparities we see in the US.
RB: How did the idea of the Practical Playbook III come to be?
DC: The Practical Playbook III: Working Together to Improve Maternal Health was organized, and writing began during the global pandemic. The idea for the book came from our Maternal Health Learning and Innovation Center, which is funded through the Health Resources and Services Administration [HRSA], to be a national repository of resources for people trying to improve maternal health in the United States.
I was familiar with the first two practical playbooks and the editors, Brian Castrucci with the de Beaumont Foundation and J. Lloyd Michener, who was at Duke then. I asked them if we could do a third edition focused on maternal health populations. This is the first book from the Practical Playbook series that was really focused on a population of interest—pregnant people and birthing people.
We met and got the support of the de Beaumont Foundation and Oxford University Press. We pulled together a diverse group of editors and began developing the outline for the book. We contacted over 150 authors to write on topics we thought were important to the field. It took about four years, maybe a little bit less, to get it published. It’s really been a labor of love.
RB: What are some of the recommendations that you propose in the Practical Playbook?
DC: We divide the book into sections. We have an introductory section. Then, we have a section on collaboration. Some of the recommendations in the collaboration section are really focused on the need to build partnerships and work across sectors.
“It’s really important to make sure that women have informed consent and are part of the decision-making process for their care.”
Then, we have a section on equity. How do we build programs and policies that are equity-centered and recognize the inequities in maternal and child health outcomes? We focus on innovation and quality improvement and look at how we can make improvements in both the clinical and community settings while centering equity.
We have a section on data and the importance of data to impact decision-making but also to understand people’s stories. We have an emphasis on collecting people’s experiences. Then, we have recommendations related to sharing resources and power with people from the communities that are impacted by the poor outcomes.
Our recommendations cross those main areas. For people who are reading the book and looking for suggestions within their area of work, we have a medical-legal chapter. We have a chapter on oral health. We have chapters on mental health, telemedicine, and policy. There’s really an array of information for many different readers. It’s meant to be more of a resource—maybe not to be read cover to cover—but to see where you, as a professional or a community advocate, can find information based on your perspective and where you work in this area.
RB: Were you able to uplift any resources that would specifically address the disparity that exists in the South, where maternal and infant deaths are even more pronounced than in other parts of the country?
“We really need to uphold the right to bodily autonomy and self-determination, which is being restricted in many states in the South right now.”
DC: We know that addressing disparities in the South means really focusing on holding the health systems accountable—addressing bias and promoting respectful care—regardless of race, ethnicity, or geography. We really focus on reproductive justice as a principle. Particularly in the South, which has a history of researching on women’s bodies and sterilization without consent, it’s really important to make sure that women have informed consent and are part of the decision-making process for their care.
In the South, we are also interested in wellness and preventive care. Many of our states don’t have expanded Medicaid services. Women may not be able to get preventive care until they are pregnant, and then they might lose coverage after they deliver the baby. Addressing gaps in access to health care and providing holistic care is important. It’s important to look at not only the pregnancy and the physical care of the mother but if she has any concerns with mental health or substance use, interpersonal violence, or oral health—any of those things that would contribute to her overall wellbeing would be very important.
Particularly in the South, where there is restricted access to a whole range of healthcare services, we really need to uphold the right to bodily autonomy and self-determination, which is being restricted in many states in the South right now.
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RB: Can you discuss additional recommendations to address racial disparities in maternal health?
DC: In our section focused on equity, we explicitly called out systemic racism and the importance of social determinants of health. We know we need to address social, structural, and political determinants of health through a reproductive justice framework. Unfortunately, Black women are two to three times more likely than White women to die of pregnancy-related causes. Determinants that contribute to that risk include economic stability, education, healthcare, and housing.
All those factors have to be addressed to address the disparities. In addition, for some of the reasons I mentioned—specifically the history of medical surgical experimentation and forced sterilization, there is a distrust of the medical system and medical providers. There needs to be an understanding on the part of the health systems of the history of this medical trauma and the need to address any bias that may be in the system.
Other populations that experience disparities include women who have disabilities, Indigenous women, and rural women—women who might not have access because they live in maternity care deserts, or they don’t have coverage for medical services. The solutions to address disparities must center on the community and have shared power in decision-making with the people who are impacted by the problems.
RB: Did the aftermath of the Dobbs decision shape the recommendations in the book in any way?
DC: When we started writing the book, we framed it around a reproductive justice framework—understanding that women should be able to decide if and when they will have a child, and if they do decide, they should be able to parent that child in a safe and healthy environment.
“There needs to be an understanding…of the history of this medical trauma and the need to address any bias that may be in the system.”
We were already recommending that policies continue to advance reproductive justice. When the Dobbs decision came out, and we started to see these restrictive policies around access to abortion care, we were able to strengthen our recommendations in that area and acknowledge how those kinds of policies are so detrimental to maternal and child health.
We see states that have very restrictive abortion policies—they also have high maternal mortality rates. We’re going to continue to research the impact of those kinds of policies on maternal health and family health and continue to recommend that women have access to comprehensive services, including abortion care, as necessary.
RB: Can you talk about any response you have received, especially from policymakers, since the Practical Playbook III was released?
DC: We have had a lot of interest in the book. In partnership with our Maternal and Child Health Bureau colleagues, we recently convened 35 states working to improve their maternal health systems. We provided each of them with a copy of the book.
We spent some time talking about some of the challenges they’re facing trying to implement some of these programs and policies in their states.
States are very different in terms of their context for doing this work, and it’s really helpful to give them an opportunity to meet with each other in these communities of practice and talk about some of the challenges they’re facing and how they are addressing those challenges.
We also are planning to participate in book clubs. The women’s caucus of the Public Health Association is interested in doing a book club and looking at some of the chapters in the book. We’ve gotten some interest from journals, podcasts, and others who are interested in hearing more about how this book can help transform the status of maternal health in the US.
RB: What role can philanthropists play in uplifting the recommendations in the Practical Playbook III?
DC: It is important for foundations and other donors to understand how to use their funding to drive quality improvement in clinical settings, require data transparency, and align payment with outcomes that engage women in their care.
The California Health Care Foundation, for example, has been partnering with the California Department of Public Health to address cesarean deliveries and has seen some good successes over time as they’ve been able to hold health systems accountable.
RB: Is there anything else you’d like to share about the book?
DC: Related to policy action, we have a section of the book that looks at the important role of policy. At the time the book was written, we were aware of the federal HHS [Department of Health and Human Services] action plan to improve maternal health in America. At the time that we were releasing the book, the White House Blueprint for Addressing the Maternal Health Crisis was also published.
There is awareness at the federal level about the importance of looking at Medicaid as a payer [for] half of the births in the United States—making sure that there’s presumptive eligibility. In 2020, there were only 31 states that allowed someone to go on Medicaid and then determine whether they were eligible afterward.
There’s also been a push towards postpartum coverage so that women don’t lose Medicaid 60 days after delivery. They now have 12 months of coverage. We know that half the deaths occur to women after they leave the hospital—after delivery. Then, we emphasize the need to cover services for midwives, doulas, community health workers, and home visiting services. We see Medicaid as a way to support those people as part of our workforce.
Then, in terms of workforce diversity, we know that we only have a small percentage of physicians, nurses, midwives, and lactation consultants who are representative of communities of color. For example, in 2018, only 6 percent of physicians and 8 percent of medical school applicants identified as Black, and less than 1 percent identified as American Indian or Alaska Native. In 2020, 80 percent of nurses identified as White, 7 percent as Asian, 6 to 7 percent identified as Black or Latinx, and less than 1 percent identified as American Indian. We need to invest in pipeline programs to expose a diverse community of young people to maternal health and use incentives and support to educate more diverse providers.
