B.I.R.T.H. Equity Maryland
INITIATIVE
Why This Work Matters
Half of pregnancy-related deaths occur in the year postpartum. Reducing pregnancy-related morbidity and mortality depends on changing the way healthcare providers recognize and respond to obstetric and postpartum emergencies, especially Black mothers who are disproportionately impacted. Postpartum patients have often been seen in an emergency department, primary care office or other health setting where their early symptoms are not recognized as urgent maternal warning signs, are underappreciated or dismissed.
B.I.R.T.H. Equity Maryland includes tools for non-obstetric providers to address the substantial disparity in maternal morbidity rate for Black—and all-- birthing people in Maryland.
The Urgency
in the Data
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Pregnancy-related issues are the 5th most common reason for ED visits among women aged 15–65.
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Postpartum complications affect an estimated 5–12% of births in the first 6 weeks.
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Common symptoms: fever, abdominal pain, headache, bleeding, wound issues, and high blood pressure.
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53% of pregnancy-related deaths occur between 7 days and 1 year postpartum.
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The CDC reports that 80% of pregnancy-related deaths are preventable.
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Black women are 3–4x more likely to die from pregnancy complications compared to white women.
This initiative was a joint effort between the Mid-Atlantic Patient Safety Center (MPSC) and the Maryland Hospital Association, guided by an expert advisory group across maternal health, emergency medicine, family practice, and health equity. Participation in B.I.R.T.H. Equity Maryland was offered to any ED in the State of Maryland. Primary Care offices and community organizations were also provided participation. Participation was free of charge. The program was funded by grants from the France Merrick Foundation, the Maryland Hospital Association, and the Mid-Atlantic Patient Safety Center.
The primary aim of B.I.R.T.H. Equity Maryland is to educate non-obstetric providers to recognize early warning signs of obstetric complications, leverage teamwork and communication strategies, and identify and mitigate personal biases through implicit bias training and personal reflection. The program will also provide patient and family education resources to promote awareness of obstetric complications and self-advocacy.
Seventeen sites enrolled in the program: 2 Primary Care Offices and 15 Emergency Departments. Sites were organized into three cohorts: April 2023, July 2023, and August 2023. Approximately 1,000 healthcare professionals working in Emergency Departments across the State of Maryland completed the program.
The program reinforced that the work in this space must continue and that hospitals need to commit resources to supporting emergency department personnel in identifying and treating pregnant and postpartum people and eliminating disparities in maternal health outcomes.
Based on the program implementation, we recommend the following solutions implemented by hospital emergency departments across the state:
1. Update Emergency Department Policy
Revise the Emergency Department policy to explicitly cover care for both pregnant individuals and those who have given birth within the past 365 days.
2. Embed Hard‑Stop Triage Questions into the EHR
Design triage workflows in the electronic health record that embed mandatory questions about pregnancy and postpartum status in the triage navigator, functioning as a hard-stop before proceeding.
3. Automate Assessment for Urgent Maternal Warning Signs
Implement EHR workflows that require evaluation of urgent maternal warning signs for pregnant and postpartum patients. Embed these warning signs directly—so providers can reference them without relying on memory.
4. Align Vital Sign Triggers with ACOG Severe Hypertension Guidelines
Integrate vital sign alerts in the EHR for people identified as pregnant or postpartum, aligned with ACOG criteria for severe hypertension (e.g., systolic ≥160 mm Hg or diastolic ≥110 mm Hg), to ensure prompt recognition and intervention.
5. Provide Guideline‑Aligned Antihypertensive Order Sets
Ensure ED providers have access to order sets that align with ACOG-recommended antihypertensive treatments, such as intravenous labetalol or hydralazine and oral nifedipine, for pregnant and postpartum populations.
6. Include Urgent Maternal Warning Discharge Instructions
Embed discharge instructions describing urgent maternal warning signs into the after‑visit summary for all pregnant and postpartum patients seen in the ED.
7. Generate EHR Reports for Quality Review and Monitoring
Support and develop electronic reports to enable ED teams to quantify pregnant and postpartum patient visits and associated diagnoses. This data will facilitate case review and benchmarking against policy and evidence-based practices.
8. Facilitate Interdepartmental Case Review and Safety Evaluation
Establish regular collaboration between labor and delivery and ED leadership to review cases, shared safety reports, and continual improvement opportunities.
9. Ensure Timely Notification and Transfer to Obstetric Care
Create systems that ensure obstetric care providers are notified promptly when urgent maternal warning signs are identified—and that transfer to labor and delivery occurs immediately when safe and appropriate.
10. Develop Joint Training and Simulation Programs
Have labor and delivery leadership and educators collaborate with ED teams to deliver targeted education, including simulation exercises and drills for both ED nurses and providers.
11. Foster Collaborations with Birthing Centers
For non-birthing hospitals, urgent care centers etc. encourage and maintain collaborative relationships with birthing hospitals—especially those routinely involved in transfers of birthing patients—to ensure coordinated, seamless care.
Why These
Changes Matter
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They institutionalize standardized, evidence-based workflows, minimizing reliance on memory and enhancing patient safety.
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The vital sign triggers and order sets are backed by ACOG guidance, emphasizing immediate action for severe hypertension to reduce maternal stroke and morbidity
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Structured triage protocols and interdepartmental and interhospital coordination are essential to improve outcomes and ramp up timely, appropriate responses.
Access our B.I.R.T.H. Equity Maryland Patient Education video series
Topics include fetal movement counting, patient self-advocacy, urgent maternal warning signs, postpartum depression, safe sleep, and the roles of each member of the maternal care team. We encourage healthcare professionals to save and share these videos with pregnant and postpartum patients and their families.
Educational materials for non-obstetric clinicians
Quick-reference guides for urgent maternal warning signs
Resources that promote patient self-advocacy and equitable postpartum follow-up
Implicit bias and clinical awareness training materials
As a follow-up from the B.I.R.T.H. Equity initiative, Maryland Institute of Emergency Medical Services and MPSC began to collaborate and design education on the role of EMS in identifying obstetric emergencies, especially in the postpartum period. The education was rolled out to emergency services professionals across Maryland in the spring of 2024.
B.I.R.T.H. Equity continues as the Emergency Readiness in Non-Obstetric Settings workgroup, which brings together the Mid-Atlantic Patient Safety Center, Maryland Institute of Emergency Medical Services, and leaders from Obstetric and Emergency Department settings from across the state to improve and ensure readiness for the care of pregnant and postpartum persons who present for emergency or unscheduled care. The workgroup meets quarterly and focuses on promoting best practices, sharing resources, strengthening care coordination, identifying gaps, and supporting systems-level improvements to reduce maternal morbidity and mortality across Maryland.
