The state’s first Assistant Commissioner for Health Equity lays out actions for improving maternal health
Hafsatou Fifi Diop, M.D., M.P.H., is the inaugural Assistant Commissioner of Health Equity at the Massachusetts Department of Public Health, a founding member of the Perinatal-Neonatal Quality Improvement Network of Massachusetts, and co-PI of the Massachusetts Maternal Mortality and Morbidity Review Committee. Dr. Diop received her medical degree from the University of Conakry, Guinea, studied epidemiology at the Center for Research (INSERM) in Paris, and received her master of public health degree with concentration in maternal and child health from the University of Hawaii at Manoa.
Patient Safety Beat: The Department of Public Health released a comprehensive Review of Maternal Health Services in November. Please describe the context and purpose of the report.
Dr. Diop: Governor Healey instructed Health and Human Services Secretary Kate Walsh, Undersecretary for Health Dr. Kiame Mahaniah and Department of Public Health (DPH) Commissioner Dr. Robert Goldstein to conduct a comprehensive review of maternal health services from prenatal care to birth centers to postpartum care, including reproductive and behavioral health care. She asked us to include a review of racial disparities and to consult and collaborate with community members in developing the report.
The Governor’s request came shortly after the closure of an inpatient maternity unit in Leominster, which heightened awareness about challenges some residents face accessing high quality perinatal care.
In addition, DPH released a Data Brief on severe maternal morbidity earlier in the year. It showed that rates of severe maternal morbidity for non-Hispanic Black people in 2011 were twice that of white non-Hispanics, and by 2020 the SMM rate was two and a half times higher — a 25% increase in 10 years.
Patient Safety Beat: The Review of Maternal Health Services includes 25 multi-part recommendations. Can you highlight some of the proposals you think are especially urgent?
Dr. Diop: Our goal was to present the Governor with actionable recommendations, and we indeed came up with 25. We are working on implementation, with some actions prioritized for immediate attention. One is to update DPH hospital and clinic regulations regarding birth centers to better align with national standards, including updates to staffing and supervision requirements.
The second action item is to work with the doula community to develop a pathway to certification, which currently does not exist in the state.
To be successful in my role, I need to foster collaborative relationships and develop partnerships with inter- and intra-agency heads, state and local community leaders, academics, local municipalities and other stakeholder groups committed to improving equity and health outcomes.
Third, we are working to integrate Levels of Maternal Care — a classification system used nationally to define “risk appropriate” care (lower levels of care do not deliver lower quality of care than higher levels) and help match patient needs with facility services — into DPH’s hospital licensure regulation’s perinatal section 105 CMR 130.600.
The fourth priority is to update guidance for health care providers to share best practices and document the establishment of a dual reporting system whereby substance-exposed newborns with no indication of neglect or abuse can be identified for support but not investigated. This will require collaboration of the Executive Office of Health and Human Services with DPH and the Department of Children & Families.
Also, we’re working with MassHealth to explore reimbursement of midwives at a level comparable to physicians for the same service and encouraging private insurers to do the same. And, to finish up this list, we are exploring ways to reimburse hospitals for remote blood pressure monitoring after individuals who had experienced hypertensive disorders during pregnancy or delivery are discharged to home. Pilot programs of remote blood pressure monitoring are already underway.
Patient Safety Beat: The state’s efforts to eliminate racial disparities in maternal care are part of a larger goal, to eliminate inequities in health generally. Your appointment as the first Assistant Commissioner of Health Equity is part of that effort. Please tell us about your new role.
Dr. Diop: I serve as a member of Commissioner Goldstein's executive leadership team, bringing a health- and racial-equity lens to DPH priorities. I am charged with helping to reduce disparities across racial, ethnic and socioeconomic groups while leveraging data to inform programs, resource allocation and policies to improve health outcomes. To accomplish this, I am collaborating with bureau heads to lead strategic planning initiatives across the department and to examine and devise strategies using equity-centered best practices. I am also working to ensure that social determinants of health and racial equity are factored into strategic plans, establishing short- and long-term objectives and providing adequate support to meet team and organizational goals.
Working with the Governor's office and Secretary Walsh, I may respond to initiatives that promote equity-informed public health legislation in coordination with legislative staff as needed. And to be successful in my role, I need to foster collaborative relationships and develop partnerships with inter- and intra-agency heads, state and local community leaders, academics, local municipalities and other stakeholder groups committed to improving equity and health outcomes.
Achieving equity is a journey, and it takes time to see tangible results. With that in mind, I think we are making progress.
Patient Safety Beat: You also served as DPH’s Director of the Division of Maternal and Child Health Research and Analysis, which included the Office of Data Translation that you led for a number of years. Could you talk a bit about that role and how it relates to your current work?
Dr. Diop: When I established the Office of Data Translation in 2008, my vision was to create a team of epidemiologists who would use data to inform programs and policies and make recommendations for The Maternal and Child Health Block Grant known as Title V, a federal-state partnership dedicated to improving family health and well-being across generations.
I chose the name “Office of Data Translation” because I wanted to use data for action, not just let it sit on the shelf. A lot of data is collected across DPH and elsewhere, but it’s pointless if we can’t use it to change or strengthen policies, programs and practices. From the start, we included data specifically related to equity in our work.
One of our primary projects was to establish the Pregnancy Risk Assessment Monitoring System or PRAMS in Massachusetts, a tool used across the country since 1987 to collect data on maternal attitudes and experiences before, during and shortly after pregnancy. Because we wanted to use the PRAMS survey to hear from marginalized communities, we decided to oversample by race and ethnicity. Massachusetts was the first state to include questions on the PRAMS survey specifically related to experiences with racism.
The Office of Data Translation also includes a population-based surveillance system, the Pregnancy to Early Life Longitudinal (PELL) data system, which allows us to examine the impact of prenatal and perinatal experiences on subsequent maternal, infant and child health. PELL offers public health practitioners and researchers the ability to study risk and protective factors and health outcomes longitudinally over the lifespan. Starting with deliveries in 1998 through 2022, we are able to link birthing parents to all their children and examine what happened around the time of delivery in relation to both maternal and child health outcomes over time. This is extremely important for equity, as experiences in utero can have lifelong effects.
No other state has longitudinal data of this sort.
Patient Safety Beat: Taking a long view of equity and maternal health issues, do you think we’re making progress? How would you describe where we are on the path toward equitable care?
Dr. Diop: Achieving equity is a journey, and it takes time to see tangible results. With that in mind, I think we are making progress. While it has been long recognized that racism — not race — leads to discriminatory beliefs and behaviors toward people of color, we did not explicitly call it “racism” until 2020 when the convergence of the COVID-19 pandemic and social activism in support of Black lives and against police brutality demanded action.
Massachusetts has made significant strides by enacting legislation, developing tools and using data to improve health equity. One example is the Racial Inequities in Maternal Health Commission established by a legislative act signed by Governor Baker in January 2020. Another is the Racial Equity Data Roadmap, a tool designed to help programs take concrete steps to identify, understand and act to reduce racial inequities. In addition, DPH has funded the SPEAK UP training offered by the Institute for Perinatal Quality Improvement. So far, we have trained more than 500 providers across 36 birthing hospitals to dismantle racism, provide respectful care that is equitable and high quality, and eliminate perinatal health inequities.
And last, but not least, earlier I mentioned the racial and ethnic inequities we see in severe maternal morbidity (SMM). DPH has transparently shared these new data about SMM rates and trends among people of color and is working on a number of initiatives to act on these findings as articulated in the maternal health report. Honestly, that's the only way we can begin to address the inequities we see in the data.