1181: Improving Maternal Care Systems

JOHN SHEEHAN: 

This is Public Health Review Morning Edition for Thursday, August 6, 2026. I'm John Sheehan with news from the Association of State and Territorial Health Officials.

 

Improving maternal health outcomes starts with ensuring every pregnant patient receives care at the facility best equipped for their needs. Today, senior analyst for Maternal and Infant Health at ASTHO, Lexa Giragosian, discusses ASTHO's latest research on implementing levels of maternal care across the country. Drawing on interviews with leaders in 13 states, she'll explain how risk-appropriate care can improve outcomes for mothers and infants while highlighting the barriers that remain, including rural hospital closures, workforce shortages, transportation challenges, and gaps in culturally competent care. Lexa Giragosian, welcome to the show.

 

LEXA GIRAGOSIAN: 

Thanks for having me.

 

SHEEHAN: 

So, Lexa, your recent article in the Journal of Public Health Management and Practice featured insights from key informant interviews. What were the themes that were coming out of those interviews?

 

GIRAGOSIAN: 

Yeah, so we've done a lot of previous project work in the risk-appropriate care space, and we really identified a need to better understand the systems and state approaches that states are taking to implement levels of maternal care. So, we did decide to conduct key informant interviews like you said. We spoke with 13 different states to understand the policies and processes, as well as challenges, and identified the themes of needing to address hospital closures, strengthen workforce capacity in public health and clinical settings, improving hospital leadership buy-in and increasing consumer awareness of levels of maternal care, improving the understanding of and assessing of using CDC LOCATE as a tool, and then also securing sustainable funding.

 

SHEEHAN: 

And I think one of the one of the points that comes across in your article is sort of matching maternal needs with the right kinds of care. Can you can you sort of illustrate that for us? What does that mean?

 

GIRAGOSIAN: 

So, that means that depending on the risk of your pregnancy, whether you have any kind of pre-existing conditions like hypertension or diabetes, or if you are low risk and going to have a safe delivery, that you are matched at the hospital that is equipped to manage your level of care. So, if you have a high-risk pregnancy with a high risk of having complications, that means that you need to be treated at a hospital of the corresponding level, and if you have a low-risk pregnancy with no preexisting conditions, no concerns, you can give birth at a lower-level facility or at a birthing center.

 

SHEEHAN: 

Okay. And so, when that goes right, what does it look like?

 

GIRAGOSIAN: 

So, when that goes right, simply put, there should be a safe delivery where all the necessary referrals are in place, you are delivering with the right capacities and capabilities in that hospital or facility for you, and mother and baby should have a safe experience. I can also talk about what happens when that doesn't go well. An example we like to use a lot is kind of this scenario when systems fail to match risk with facility capability. If we have a patient that comes in with known placenta previa and presents in labor at a small hospital without any necessary surgical capabilities, there has been no prior referral to a higher-level center. Unfortunately, an emergency hemorrhage may occur. This can lead to a delayed transfer, leading to urgent, high-risk transport during a period of instability. And this proven lack of access to risk-appropriate care in this case would lead to an increased risk of severe maternal hemorrhage and neonatal compromise. If the patient had received risk-appropriate care, their provider would have referred them to a higher-level facility. This maybe didn't take place because they weren't able to access prenatal care in the first place. There could have been transportation issues or other social factors that influenced access, but if they were able to access this risk-appropriate care, they probably would have given birth in a higher-level facility that would be equipped to manage this type of complication, would have created a safety plan ahead of time, ensured they were at the right place at the right time to deliver safely for mom and baby.

 

SHEEHAN: 

Yeah. You also identify challenges faced by tribal communities, by rural communities. What are some of the challenges that impact those communities?

 

GIRAGOSIAN: 

Yeah, so across the country, there have been really high rates of rural hospital, of hospital closures, especially in rural or underserved areas. This is also disproportionately affecting our American Indian and Alaska Native populations, with Indian Health Service facilities having services suspended or even being closed, and these gaps negatively affect maternal and infant health in terms of even just like accessing care, but also in terms of not having access to culturally competent care, which can be really important for positive maternal and infant health outcomes. There's kind of no size fits all in terms of addressing this. I know some states have tried to alleviate this burden by exploring other options or speaking with their, the communities directly to identify what their specific needs are to ensure that they can access care that's culturally conscious, whether that's, you know, increasing transportation systems, doing provider trainings, implicit bias trainings, there's a lot of opportunities to alleviate this burden.

 

SHEEHAN: 

Mm-hmm. And you also mentioned workforce shortages. What are states doing to try and combat that?

 

GIRAGOSIAN: 

Yeah. So, workforce shortages is a big issue in the terms of levels of maternal care implementation, as it spans both public health and clinical. So, in a public health capacity, there's just a lot of limited staff in order to manage levels of maternal care programs, and that really affects effective implementation across a region and across a state. So, trying to leverage partnerships, braiding and blending federal funding can be helpful to try and extend the public health workforce that already exists. On the clinical side, there is a very poor distribution of OB-GYNs, a shortage as well, but most of them are comprised in urban areas rather than rural or underserved areas. And there's also just an overall lack of maternal and fetal medicine specialists making accessing risk-appropriate care quite challenging. And so many states are exploring non-obstetric provider training, so improving the capacity of family medicine physicians, ER physicians, EMS, nurses to address maternal health emergencies in order to alleviate the rising rates of maternal mortality across the country.

 

SHEEHAN: 

Mm-hmm. Another finding from the article is that some hospitals are concerned that just the designations themselves can confuse patients. That you know, a low-level, lower-level of care doesn't mean less care. It just means a different level for a particular patient's needs. How can we get better at sort of explaining that?

 

GIRAGOSIAN: 

Yeah, that's a big thing where hospitals are hesitant to engage in levels of maternal care implementation in fear of become being a lower level and having the public or the community think that they are not a good hospital, when in reality, it's all based on your level of risk where a low-risk person receiving care at a lower-level hospital is perfectly safe and is the right place for them to deliver. So really engaging hospital leaders is important, the administrators, the C-suite, as well as engaging the community, both components are very interconnected and important for effective levels of maternal care implementation. There's been some success in states that have held webinars for hospitals outlining the levels of care and what this will look like in their facility. And there's also some success with the creation of like guides and marketing toolkits for hospitals about how to share their level of care broadly with the community with very value neutral messaging to ensure that there is no confusion and people know where they can safely deliver. Educating providers and clinicians on levels of maternal care is also very important, as they're the ones oftentimes having that one-on-one communication with patients and are able to ensure they're a trusted source of information to for patients, hospitals, for everyone involved to make sure risk-appropriate care can happen.

 

SHEEHAN: 

Yeah, absolutely. And it sounds like there's enough confusion all around with the kinds of messaging that that go into this. It sounds like there's more work to be done.

 

GIRAGOSIAN: 

Definitely. I know ASTHO's been involved in risk-appropriate care for for many years, and it is very important for we're improving maternity care systems, as well as reducing the like strikingly high rates of maternal morbidity and mortality in this country, ASTHO is currently running a community of practice called the Bridging Barriers in Maternal Health Access Community of Practice that's brought together of 15 states and territories in order to work together to advance levels of maternal care implementation in their jurisdictions, and we're hoping to continue this work to make this a nationally widespread effort to address maternal health. And there's also going to be a toolkit being published in the fall that's going to highlight specific scenarios that states may encounter in the pursuit of levels of maternal care implementation, highlighting some strategies they can employ, as well as other state case studies they can reference as they're addressing these factors. So, definitely a lot of work to be continued doing, and ASTHO is very excited to be a leader in the field and bring together all the cross-sector partners that are necessary.

 

SHEEHAN: 

Well, Lexa Giragosian, thanks so much.

 

GIRAGOSIAN: 

Thanks for having me.

 

SHEEHAN: 

Lexa Giragosian is senior analyst for Maternal and Infant health at ASTHO. You can find Lexa's recent Q&A with University of North Carolina Department of Obstetrics and Gynecology Professor Kate Menard on levels of maternal care state implementation at the link in the show notes.

 

ASTHO welcomes new member Amy Epkey, acting director of the Michigan Department of Health and Human Services. Epkey previously held the senior deputy director position for the Financial Operations Administration at MDHHS, and also held positions with Michigan's Department of Environment, Great Lakes, and Energy, Department of Agriculture and Rural Development. This has been Public Health Review Morning Edition. I'm John Sheehan for the Association of State and Territorial Health Officials.