How the virtual ECHO model is boosting Black maternal health

Though maternal mortality rates in the United States have dropped slightly, Black birthing people are still twice as likely to die due to complications from pregnancy or childbirth as their white peers. This striking statistic underscores the need for significant improvements in maternal health equity. A program at the University of Indiana is working to achieve the needed improvements through telehealth-based medical education and clinical peer support.

Called the Black Maternal Health ECHO program, it aims to bring healthcare professionals together to explore clinical best practices and advancements that can curb Black maternal morbidity and mortality. The program is an adaptation of the Project ECHO (Extension for Community Healthcare Outcomes) model, which was developed by a University of New Mexico Health Sciences Center physician. The model was initially designed to provide virtual training and telementoring to primary care physicians using audio-visual technology, though it has been adapted in numerous ways.

The Black Maternal Health ECHO program aims to utilize the model to enhance Black maternal healthcare outcomes. Since its launch in 2023, it has grown to include participants not only from Indiana but also across state lines.

Understanding Black maternal health in the U.S.

Addressing Black maternal health in America is an intractable problem. Between 1999 and 2019, the maternal mortality rate in the U.S. more than doubled. During this period, the average Black maternal mortality rate jumped from 26.7 deaths per 100,000 live births to 55.4 per 100,000 live births.

The Black maternal mortality rate rose even higher to 69.9 deaths per 100,000 live births in 2021 before dropping to 49.5 per 100,000 live births in 2022.

Not only that, but Black birthing people born in the U.S. also experience higher odds of preeclampsia than Black women who immigrated from other countries, indicating that race is only one factor driving Black maternal healthcare gaps, among other social determinants of health.

According to Jasmine D. Johnson, M.D., assistant professor of obstetrics and gynecology at Indiana University School of Medicine, improving Black maternal healthcare is difficult primarily because there is a patchwork of approaches and strategies.

"The work is not synchronized," Johnson, who is also a member of the Black Maternal Health ECHO program's hub team, said in an interview. "One example of that is the Maternal Mortality Review Committee. We know that the government has allowed funding for most states to have those committees, but there's no standardized way in which those committees are set up, and who's on the committee, and how often they should be reporting the information. And so, I think that that's a lost opportunity to use collaboration in efforts."

Even at the health system level, there is little collaboration, she added. Healthcare provider organizations are employing various strategies to address racial disparities in maternal healthcare, including expanding access to digital health apps, mitigating implicit biases among physicians and establishing telehealth-based prenatal and postnatal care programs. However, the organizations tend to be siloed and are either unable or unwilling to share quality data and best practices to reduce Black maternal morbidity and mortality.

Exploring the Black Maternal Health ECHO program

The Black Maternal Health ECHO program was created to address the lack of collaboration. It launched as a partnership between the Indiana University (IU) Fairbanks School of Public Health and the Indiana Minority Health Coalition.

We got some grant funding to create a space where basically that siloed communication could be eliminated, and we could somehow connect people from around the state who felt passionate about ending health disparities and focusing on equity.

"[We] got some grant funding to create a space where basically that siloed communication could be eliminated, and we could somehow connect people from around the state who felt passionate about ending health disparities and focusing on equity," Johnson said.

The ECHO model is not new to the IU School of Public Health, which had previously launched ECHO programs for substance use disorder and LGBTQ health. When launching the ECHO program for Black maternal health, the institution already had a blueprint it could follow, starting with establishing a hub team.

Johnson explained that the hub team includes various maternal health experts, including doulas, public health experts and community health workers, who plan the virtual sessions twice a month.

These sessions focus on maternal health mortality and adverse outcomes data, the factors driving care gaps within the maternal health sphere and the latest research and resources to help improve these outcomes.

"What we've found is that there's a dearth of understanding about issues like what's the latest treatment for eclampsia? What do we need to do for major hemorrhaging during and post-delivery? What about postpartum depression? And there's new and evolving information about that that helps address the potential for mortality," said Velvet G. Miller, Ph.D., a member of the Black Maternal Health ECHO program's hub team and director of the Not 1 More Project, in an interview.

What we've found is that there's a dearth of understanding about issues like what's the latest treatment for eclampsia? What do we need to do for major hemorrhaging during and post-delivery? What about postpartum depression? And there's new and evolving information about that that helps address the potential for mortality.

Additionally, implicit bias among physicians is a significant driver of maternal health inequities, Miller noted. For instance, the idea that Black people have a higher pain tolerance than other races is still a commonly held bias that must be addressed.

"We are finding that comes up again and again and again," Miller said. "'They didn't hear me. They didn't pay attention to me. My wife kept saying she was in pain, and they ignored it, and she died, or my wife or my partner was bleeding out. And [they] kept saying, oh, that's normal, and she died.' So, really being present, in the moment with your patient, with the pregnant woman going through the process of delivery.... That's one of the main things that jumps out as a recurring lesson to learn."

The ECHO program helps those encountering or inadvertently perpetuating these drivers of poor Black maternal healthcare to address them. According to Johnson, the program has invited speakers with a wide array of expertise -- from trauma-informed care to culturally sensitive care -- to share their knowledge at the virtual sessions. In addition, the program highlights resources and social services for birthing people who might be experiencing postpartum depression or facing SDOH challenges, such as housing or food insecurity.

The session attendees include not only the healthcare professionals providing pregnancy and reproductive care to black birthing people but also the communities and teams that support them, including lactation specialists, community health stakeholders and people from payer organizations.

"[We also want to] engage those in the areas beyond the metropolitan area that may not have the opportunity to attend continuing education programs, get them informed on the latest trends and procedures, and have them be better equipped to provide the best care possible," Miller said. "Indiana has many healthcare deserts, particularly OB-GYN deserts."

Examining the program's progress

Since its launch, the Black Maternal Health ECHO program has expanded, nearly doubling its attendance and adding attendees nationwide.

Miller noted that the number of attendees has jumped from 30-40 at the beginning of the program to about 70-80. And the collaboration and learning that begin in the sessions stretch beyond them.

"The [attendees] have reached out beyond the sessions and have started connecting in a massively growing network," she said. "I call that network weaving. And that was not an objective of ECHO, but it certainly is an outcome. So, you have people in North Carolina that follow up and reach out to people in California with shared interests."

Further, the feedback from the participants has been overwhelmingly positive. Johnson noted that the program's hub team surveys session attendees about their impressions, and most feel that the information provided will help them enhance their practice.

Though the program's progress is currently measured by attendance and survey responses, Johnson hopes to develop a standardized approach to assessing how the ECHO program is influencing maternal care outcomes in Black communities.

The road to maternal health equity is long, but efforts like the Black Maternal Health ECHO program are essential to progress toward that goal. Telementoring ECHO programs can help provide a space -- albeit a virtual one -- where stakeholders can share the strategies, resources and medical education needed to achieve much-needed improvements in Black maternal health outcomes.

"I'm encouraged, but the barriers are still there, and we must remain vigilant and persistent.... I am inspired by a quote from Angela Davis from a long time ago where she said, 'I'm no longer accepting the things I cannot change. I am changing the things I no longer accept,'" Miller said.

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.