Technology to Improve Maternal Health: Workshop summary

National Institute of Biomedical Imaging and Bioengineering

Virtual Workshop: Technology to Improve Maternal Health

January 18, 2022

Summary of the Workshop Discussion Organized by Common Themes From the Meeting

Disclaimer

This material should not be interpreted as representing the viewpoint of the U.S. Department of Health and Human Services, the National Institutes of Health (NIH), or the National Institute of Biomedical Imaging and Bioengineering (NIBIB). Names of companies and organizations are listed for information purposes only. Inclusion in this document is not an endorsement or promotion for any products or services. Refer to website disclaimers. All statistics reported in this document were stated at the workshop. The validity of these statistics have not been fact checked before publishing this document.

Overview: How Technologies Could Address the Maternal Health Crisis in the United States

The meeting—hosted by NIBIB and supported by National Institute on Drug Abuse (NIDA); National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); National Institute on Minority Health and Health Disparities (NIMHD); National Center for Advancing Translational Sciences (NCATS); National Human Genome Research Institute (NHGRI); the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD); National Heart, Lung, and Blood Institute (NHLBI); National Institute of Allergy and Infectious Diseases (NIAID); National Institute of Mental Health (NIMH); Office of Research on Women’s Health (ORWH); National Institute of Neurological Disorders and Stroke (NINDS); and National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)—convened representatives from multiple NIH Institutes and Center Operations, the research community, small business, the technology development field, and several community partners to share perspectives on essential technologies for all aspects of clinical care related to the health of Pregnant and Postpartum Women and People (PPWP), particularly those from underserved populations.

The past decade has seen an increasing awareness of the problem of maternal morbidity and mortality (MMM) in the United States. The Centers for Disease Control and Prevention (CDC) estimates 17 maternal deaths per 100,000 live births in the United States, and the trend is increasing. Rates of MMM are higher in the United States than in other high-income nations, and significant racial and ethnic disparities exist. In 2017, only two nations experienced an increase in maternal deaths: the United States and the Dominican Republic. Hospitals, the healthcare system, and society as a whole are failing pregnant women and pregnant people.

The World Health Organization defines maternal mortality in different ways, (e.g., pregnancy-associated mortality [deaths during pregnancy and up to 1 year postpartum from any cause], pregnancy-related mortality [deaths during pregnancy and up to 1 year postpartum that are associated with pregnancy], and maternal mortality [deaths during pregnancy and up to 42-days postpartum]). Some states and rural areas have much higher MMM rates than other states and urban areas.

Black and white maternal mortality disparities have existed for decades. These disparities have persisted and increased. They are not explained by socioeconomic or education status. Leading causes of pregnancy-related deaths among Black women include cardiomyopathy, cardiovascular conditions, preeclampsia/eclampsia, hemorrhage, embolism, and infection. Among white women, leading causes of pregnancy-related deaths include mental health conditions, cardiovascular conditions, hemorrhage, infection, cardiomyopathy, and embolism. Cardiovascular conditions are the main cause within the overall population. Maternal self-harm deaths are increasing. Opioid use disorder (OUD) contributes to MMM and poor infant health. More than 50 percent of maternal deaths occur postpartum. Up to 60 percent of MMM is preventable (both through proper screening and diagnoses and by improving care across the life course).

For every maternal death, 100 PPWP experience Severe Maternal Morbidity (SMM). SMM can involve life-threating diagnoses, life-saving procedures, organ failure, shock, amniotic embolism, ventilation, transfusion, or hysterectomy. Racial and ethnic disparities also exist in SMM. SMM, MMM, and related child outcomes are associated with enormous societal costs (i.e., the top nine causes of maternal morbidity alone account for over $30 billion in costs).

Systemic problems contributing to MMM in the United States include the fragmented health care system/processes and problems with continuity of care; a lack of access to care, especially in rural areas; a lack of culturally competent care; social determinants of health (SDoH) and structural racism, discrimination, and stigma. Inequitable delivery of health care services also results in racial and ethnic disparities in maternal health.

Better prenatal care improves birthing outcomes. Pregnancy and menopause represent two crucial stages in a woman’s life when clinicians can intervene to improve subsequent health. Technology could help clinicians provide better prenatal care and improve women’s health overall and thus maternal health, fetal health, and child health, which are central to NIH’s mission, particularly the mission of the IMPROVE Initative. By prioritizing healthy pregnancies, from preconception through the postpartum period, we can address maternal health disparities pertaining to racial, ethnic, geographic, socioeconomic, and other demographics. Many simple technologies could improve maternal health in low- and middle-income nations and could inform care in rural U.S. settings and throughout the current pandemic and future health crises. Such technologies could also improve health equity throughout the continuum of maternal health care.

Technologies could be meaningful and helpful when incorporated across the pregnancy care continuum to improve maternal outcomes, address social determinants of health, improve communication between patients and providers and between care facilities, and ensure quality of care. Technologies could assist with addressing many of the factors associated with maternal deaths by educating patients and providers; engaging patients in care; aiding in provider-patient decision making; improving clinical screens; and providing better prognosticators and predictive models. In addition standardizing care; reducing bias; and coordinating care across service locations to improve continuity of care and reduce care fragmentation can enable systems to communicate with one another (e.g., through data standardization, by interfacing electronic medical records [EMR] and Medicare systems). The integration of care from preconception to postpartum and beyond may help to improve quality of care overall.

Quality-of-care improvement efforts offer ways to reduce MMM and associated racial and ethnic disparities, and technologies could help to realize improvements in all these areas. Antenatal care could involve new models of care (e.g., group care, medical homes, models for high-risk care). Delivery and hospital care could improve with quality improvement initiatives, standardization, safety bundles, team training, simulations, review, protocols, and disparities dashboards. Postpartum care could include case management and patient navigators. More general solutions could involve eliminating bias, enhancing communication, and engaging communities. Improving public health across the life course, particularly in racial and ethnic populations, and addressing social determinants of health that lead to inequities in health outcomes, including maternal health outcomes, will help to address the overall problem of MMM.

Technologies Could Improve Health Communication, Access to Services, Continuity of Care, and Health Equity

• Technologies that thoroughly integrate EMR could help to ensure continuity of care and to integrate obstetrics care with mental health services, perinatal psychiatric care, and other specialty care services. Common technologies (e.g., phone, mail, broadband, social media) could be used to maintain contact with community partners and solicit patient and community input. Mobile applications could engage patients with easy access to resources, education, scheduling services, consultation, transportation, and insurance/reimbursement information to realize greater efficiency and improve access to and delivery of services and resources.
• Telehealth and related medical communications technologies have already addressed several health disparities and social determinants of health.
  • With more uptake, familiarity, and innovation, telehealth could improve maternal outcomes, increase patient engagement, correct misinformation (e.g., COVID-19 vaccine misinformation), and realize other benefits.
  • Telehealth technologies could reduce geographic barriers, pandemic-related problems, and “no shows” for medical appointments. Pending legislation may expand telehealth capacities in the near future.
  • American Medical Association (AMA) President Gerald Harmon, M.D., posited that telehealth services have improved maternal outcomes in rural America and that AMA has advocated for telehealth and its expansion before and throughout the pandemic. AMA has developed online resources, digital health “playbooks,” and other materials to support physicians and other clinicians providing telehealth services. AMA may solicit additional patient input about telehealth in the future.
  • Reimbursement mechanisms allow physicians to charge for telehealth services, which, studies show, ensure that telehealth is sustainable. A majority of physicians (75%) and patients (68-70%) surveyed approve of telehealth.
  • An American College of Obstetricians and Gynecologists (ACOG) spokesperson stated that telehealth could optimize and modernize healthcare by increasing connectivity and delivering services when and where they are needed. Two February 2020 ACOG publications outlined legal, licensing, and regulatory issues concerning telehealth and discussed the innovations of virtual visits, connected and wearable devices, and patient-generated data. ACOG and other research showed that telehealth services were not inferior to in-person visits and offered some advantages over in-person healthcare, such as greater accessibility and patient satisfaction.
  • Telehealth holds promise for treating remote and under-resourced populations as well as patients isolating in response to the pandemic. However, practices and policies related to telehealth run the risk of perpetuating health disparities.
• Several developers have produced digital maternal health platforms for patients and/or providers.
  • Maven Clinic has developed a digital health care delivery platform that promises a personalized experience for every member-patient, from preconception/fertility support to postpartum to early pediatric care. The platform addresses one of the biggest causes of health disparities—access to care—which is determined in part by economics/insurance status, language proficiency, geography, race/ethnicity, and other factors. Access to care represents the single biggest challenge to pregnancy care and whole-person care. Users of the Maven platform have 24/7 access to care providers from over 30 areas of specialization. Studies have shown that the digital platform has reduced newborn intensive care unit (NICU) admissions, cesareans, and emergency room visits and has improved mental health support and return-to-work measures of pregnant persons. The platform incorporates aspects of “digital inclusion” by matching patients with care that is both appropriate and timely (e.g., language compatibility, diverse providers, low wait times, low turnaround times).
  • Benten Technologies is developing a comprehensive, coordinated digital platform for PPWP and children from conception to up to two years postpartum. This Cloud-based platform serves pregnant and parenting people and health care providers. The platform supports or enables progressive care services, education, contingency management, gamification, customer behavior data, communication, and care coordination/continuity of care. Additional platform features include or will include lactation support, management of gestational diabetes, care for postpartum depression, prenatal care, and postpartum maternal monitoring for complications. The platform integrates wearable technologies and predictive models.
  • riskLD has developed an in-patient-oriented software platform for use in clinical obstetrics settings. This technology could monitor the birthing person and baby continuously, assist clinicians in diagnosing patients, initiate crisis alerts (based on abnormal vital signs, labor that is not progressing, and indicators of risk and distress), and support clinical decision making with real-time evidence-based recommendations. The “monitor-diagnose-alert-support” model of the software could avert adverse outcomes. This technology also has the potential to gather data to inform research and policy, to address ongoing MMM trends, and to mitigate hospital based SMM. Software tools could help to mitigate unconscious bias and racial disparities by providing evidence-based recommendations based on objective clinical criteria.
  • Digital platforms could follow the example of the Cayaba Care model, which involves multidisciplinary care, a maternity navigator, in-home and virtual visits, community partnerships, EMR, claims, questionnaires to stratify risks and inform personalized care, and more.
• Technologies could enhance efforts to address health disparities and SDoH. Equity, antiracism, inclusivity, and anti-oppression could be embedded in all biomedical technologies, particularly those designed to improve maternal health, a field in which racial, ethnic, social, and other disparities are profound and persistent. In today’s environment in which an elite minority hoard power and wealth, equity in general as well as birth equity and reproductive justice are under threat. Rather than a final goal, equity could be considered an ongoing concern, a principle that guides policy, clinical, research, and other decisions and initiatives.
  • If we prioritize the rights of all individuals (no matter their color, geography, income, gender, or sexual orientation) to choose if and when they will have children and the conditions in which they will give birth, technologies could help to ensure social support for parenting, healthy and safe environments for children, body autonomy, and other justice- and equity-oriented priorities.
  • Patient-oriented uses of technology could address some of the problems reported by Black PPWP (e.g., providing access to the Internet/Wi-Fi, telehealth training, making technologies like blood pressure cuffs available, respecting patient autonomy regarding technology [virtual vs. in-person clinical visits], and automating telehealth and EMR for direct referrals to specialist care and social services).
  • The Center for Maternal Health Equity at the Morehouse School of Medicine was established to address high rates of MMM in Georgia and elsewhere. The Center pursues equity; interdisciplinary translational research to understand and prevent MMM; team-based approaches to care and interprofessional training across the workforce continuum; and community outreach, engagement, partnership, advocacy, education, and technical assistance/evaluation for Black-led organizations. Center professionals have developed communication strategies and simulation models. The Center prioritizes a life course approach for Black PPWP; rethinks conventional research practices; involves Black, Indigenous, and People of Color (BIPOC) investigators; and incorporates the lived experience of patients. The Center and its community partners developed a mobile app to improve postpartum comorbidity self-management and professional follow-up care. Community members prioritized maternal mental health. Randomized controlled trials are forthcoming.
  • How individuals use technological tools could contribute to better health and greater equity but could have adverse effects as well. The people (e.g., midwives, doulas, nurses, public health lawyers) behind the technology are just as important as the technology itself, and we must prioritize supporting these individuals as we develop and implement new technologies. Technology does not ensure equity unless the people using it do so. To ensure greater equity, patients and community members should be encouraged to contribute to the development of maternal health technologies and may also include their own data as part of the process.

Using Technologies to Improve Patient Monitoring

Better patient monitoring—including continuous home monitoring of PPWPs, fetuses, and babies—through use of low-cost, wearable devices and other technologies could improve data collection for research as well as clinical assessment and decision making.

• Heart Safe Motherhood uses home postpartum blood pressure monitoring to improve outcomes.
• THEA is a text-message-based antenatal education and blood pressure monitoring program.
• Healing at Home is a two-way texting system for around-the-clock access to clinical guidance throughout the “fourth trimester[1].”
• Remote fetal monitoring could help to prevent the 26,000 stillbirths per year in the United States.
• Accel Diagnostics is developing a point-of-care test to screen for preeclampsia (as well as COVID-19 antibodies, heart failure, sepsis, and traumatic brain injury) from a single finger-prick drop of blood. This test can be performed in the home setting like a pregnancy test and does not require a laboratory.
• The Querrey Simpson Institute and the Sibel corporation are developing small, low-cost, wearable technologies for pregnant people. These small, unobtrusive devices could perform continuous vital sign monitoring (e.g., blood pressure, heart rate, oxygen saturation) much like current intensive care unit (ICU) equipment. These technologies could detect symptoms and vital signs that often precede hemorrhage (e.g., hypotension, tachycardia), eclampsia (e.g., hypertension), and sepsis (e.g., elevated temperature, hypotension, tachycardia). These wearable technologies could make ICU-style monitoring of maternal, fetal, and infant vital signs as convenient as wearing a Fitbit. These technologies are compatible with tablets, smartphones, and smartwatches. The “ANNE” vital signs monitoring system, which includes wearable “Band-Aid” style sensors, can monitor maternal heart rate, respiratory rate, temperature, SpO2, and continuous blood pressure; fetal heart rate; and uterine contractions. Additional technologies could provide continuous fetal echocardiogram and multichannel uterine electromyography monitoring. These systems could provide clinicians and researchers with timely long-term data, help detect vital-sign patterns that can be clinically informative, and predict and flag pregnancy risks. These technologies could also differentiate vital signs relevant to body position (e.g., standing vs. sitting blood pressure). A single set of software tracks all information. These technologies are low-cost compared with current standard-of-care technologies and could be used in low-resource areas in the United States and internationally.
• Bloomer Tech is developing noninvasive digital technologies and identifying new biomarkers for the health of PPWP. Women and other minoritized populations have been excluded from many major data sets, and as a result, many sex differences have been overlooked. Medical devices have not been designed for women’s physiologies and health needs. Bloomer Tech’s noninvasive digital fabric biosensors can be integrated into bras to collect valuable data. These data may help researchers identify digital biomarkers for health risks in PPWP, including those associated with pregnancy, postpartum cardiovascular risks, and later-life cardiovascular risks. Postpartum care after adverse pregnancy outcomes is often neglected, and additional monitoring through wearable devices could help. The bra-integrated monitors are compatible with smartphones.
• Rhia Ventures has invested heavily in maternal health to enable care beyond traditional clinical settings, including technologies like remote pregnancy monitoring. Rhia Ventures hopes to transform care with new technologies that monitor fetal heart rates and can detect fetal distress accurately and noninvasively. Additional business ventures can be profitable while addressing health equity and systemic failures (e.g., supporting culturally competent doula care).

Establishing Business Partnerships to Develop and Improve Maternal Health Technologies

• Partnerships between NIH, other biomedical funding organizations, the health care system, and/or commercial interests represent a practical way of developing maternal health technologies and preventing MMM. Many innovations occur at the intersection of business, entrepreneurship, technology, and healthcare.
• Success in these enterprises requires a large set of complementary skill sets. Not all physician-scientists are skilled businesspeople and may benefit from help from those with entrepreneurial expertise. Collaboration between STEMM (science, technology, engineering, mathematics, and medicine) experts, business, and the patients who will be served is essential to optimize technological development to address healthcare issues and maximize entrepreneurial investment.
• Businesses should not overlook the opportunity to integrate Medicare into their business models. Medicare serves a significant percentage of pregnant persons and represents an enormous business opportunity.
• The NIH Technology Accelerator Challenge series of prize competitions and similar mechanisms could stimulate the design of new maternal health diagnostic technologies.

Using Technologies to Treat Specific Maternal Complications and Improve Clinical Outcomes

New technologies could help to assess risk for, screen for, diagnose, treat, monitor, and follow-up for conditions and diseases that are common in PPWP and that contribute to MMM.

• Diabetes
  • PPWP with diabetes (including type 1 diabetes [T1D], type 2 diabetes [T2D], and gestational diabetes mellitus [GDM]) have stringent glycemic targets to reduce adverse pregnancy outcomes for the PPWP as well as the fetus and to prevent long-term maternal complications. Technologies enabling continuous glucose monitoring could help to hit those targets and improve outcomes.
  • T1D is associated with severe complications (e.g., congenital malformations, stillbirth/neonatal death, preterm birth, preeclampsia, large for gestational age, NICU admissions, neonatal hypoglycemia). These complications are costly emotionally and financially and are potentially preventable.
  • Pregnancy outcomes for patients with diabetes have improved with newer insulins but remain suboptimal.
  • Challenges in T1D and T2D include changing insulin requirements throughout pregnancy based on glucose target, delays in insulin’s onset of action, alterations in gastric emptying, increased risk of hypoglycemia, ketoacidosis, and others.
  • Challenges in GDM include glucose monitoring, food choices to improve glycaemia to reduce fetal risk, medications including insulin, glucose testing postpartum, management of ongoing glucose postpartum, and opportunities for T2D risk reduction.
  • Self-monitoring of blood glucose provides an incomplete glycemic picture. A1c lacks information about acute glycemic excursion and episodes of hypo- and hyperglycemia. Technologically enabled continuous glucose monitoring could reduce the risk of hypoglycemia; allow clinicians and patients to visualize day-to-day variations in glucose levels enabling more prompt insulin adjustment; and reduce risk of retinopathy, ketoacidosis, and preeclampsia.
  • Studies of insulin pump use during pregnancy have resulted in conflicting findings.
  • Studies with closed loop control insulin delivery (i.e., artificial pancreas) have shown improvements in glucose levels. This technology is not approved by the U.S. Food and Drug Administration (FDA), but an ongoing NIH-supported study with a closed loop artificial pancreas in pregnant women with T1D shows promise in helping patients control glucose within strict target ranges.
• Preeclampsia
  • Few drugs are currently in development to improve maternal health. A drug to treat or prevent preeclampsia would represent a major breakthrough for this common condition.
  • sFLT-1, a protein uniquely present in the placenta, is necessary and sufficient to initiate preeclampsia by causing an angiogenic imbalance. This protein represents a potential pharmaceutical target. A rise in sFlt-1/PIGF precedes preeclampsia symptoms, and assays currently in clinical use in Europe show a good negative predictive value by assessing the sFlt-1:PIGF ratio. The molecule is a good biomarker and correlates with adverse outcomes.
  • Technologies/pharmaceuticals involving RNA interference could potentially block the sFLT-1 pathway that leads to preeclampsia. Researchers developed a hydrophobically modified siRNA to create this interference. A study with a baboon model of preeclampsia showed a dose-dependent reduction in sFlt-1, improved blood pressure, and alleviation of proteinuria. Such a therapy could prevent or treat preeclampsia in humans and could dramatically improve maternal cardiovascular disease risk.
• Perinatal Mood and Anxiety Disorders
  • Perinatal mood and anxiety disorders are common, undertreated, and a leading cause of maternal mortality. Less than a quarter of PPWP with these disorders receive treatment.
  • Multilevel interventions that include use of technology have been shown to improve maternal psychiatric outcomes and to build obstetric units’ capacity to screen and refer PPWP to mental health services.
  • A multilevel intervention that includes patient education, clinician training, toolkits, systemic changes/workflow integrations has been shown to increase uptake of evidence-based practices (EBPs) for perinatal mood and anxiety disorders and improve outcomes.
  • An implementation protocol known as PRISM (PRogram In Support of Moms) tailors EBP implementation for each practice setting, from baseline assessment to action steps to implementing EBPs. PRISM resulted in higher treatment rates than screening alone. The multilevel intervention also involved patient navigators and other features to help patients access perinatal psychiatric care.
  • ACOG and researchers are evaluating the efficacy of the multilevel intervention’s e-modules, toolkits, and implementation protocols at several locations. These studies include antiracist implementation approaches and are also addressing SDoH.
• Substance Use Disorders (SUDs)
  • Digital tools and mobile applications offer recovery assistance and other support to PPWP with SUDs.
  • Currently, many U.S. babies are born after fetal exposure to opioids, and MMM is higher for PPWP with OUD. PPWP with OUD also have other risk factors for adverse outcomes. PPWP with OUD benefit from education, support, and advocacy to maintain connections with treatment and sustain recovery.
  • Technology and mobile apps could help with these efforts. For instance, the “uMAT-R” app supports PPWP recovering from OUD and stimulant use disorder with educational courses based on EBPs, listings of local resources, an event calendar for appointments and medications, in-app messaging, a goal tracker, pregnancy-specific features, and a curriculum library.
  • A study of uMAT-R’s efficacy showed that the app improved patients’ attitudes about treatment, recovery, and medication-assisted treatment for OUD. Participants overwhelmingly approved of the app and found it useful.
  • uMAT-R has been implemented in 19 facilities across Missouri and has served over 700 diverse patients. Recent findings showed that uMAT-R reduced anxiety symptoms and suicidal ideation, and improved medication adherence for OUD.
  • Recently, developers added features related to COVID-19 to the app.
  • Both in and out of the clinical setting, technology supporting PPWP with OUD or other SUDs may be able to address or avoid addiction stigmas as well.
  • Mobile applications like uMAT-R could help to mitigate the problem of MMM in the United States.
• Postpartum Hemorrhage
  • The Organon company has developed the Jada System, an FDA-approved medical device that helps to minimize postpartum hemorrhage and to regulate uterine contractions.

Areas for Future Research and Technological Development

• Additional research could further characterize and inform efforts to address those patient factors, community factors, clinician factors, and system factors that contribute to the quality of care.
• Future research could also further characterize and inform efforts to address the implicit biases and structural racism that affects all aspects of health care from preconception to postpartum care.
• Future research could help to identify additional systemic failures contributing to MMM, such as inadequate assessment of risks, communication failures, failures to screen, ineffective treatments, delays in diagnoses/treatment/follow-up, and a lack of coordinated care.
• Phenotyping preeclampsia could be an important step, as clinical assessments of preeclampsia can be unreliable.
• Artificial intelligence and machine learning also have the potential to help predict preeclampsia and other conditions and diseases associated with MMM.
• Research into automated technologies that assess glucose control for PPWP with diabetes could improve outcomes. Some NIH-supported studies are forthcoming.
• More research is needed to better understand peripartum cardiomyopathy (PPCM), to develop future screenings and treatments, and to develop related medical technologies. PPCM presents in late pregnancy or within the first few postpartum months and occurs in one in 2,000 live births in the United States. Most women recover from PPCM, but some are left with cardiomyopathy and chronic heart failure. Death and cardiac transplant occur in 5-10% of patients with PPCM. Black women have higher risk factors (e.g., hypertension) and poorer outcomes. Genetic background (i.e., truncation mutations in the TTN gene) affects risk and may predict outcomes and recovery. There may be a vascular component to PPCM. Antivascular biomechanisms in late pregnancy protect against hemorrhage; however, disruptions in this biomechanism may lead to PPCM. sFlt1 also plays a role in this biomechanism, and higher levels of sFlt-1 correlate with adverse outcomes. In murine PPCM models, inhibition of prolactin with bromocriptine rescued the cardiomyopathy phenotype. Additional studies with humans show that bromocriptine holds promise to prevent PPCM. Other research questions include:
  • Why do African American women have greater risks of PPCM and poorer outcomes?
  • What socioeconomic and genomic influences are there on myocardial recovery and clinical outcomes?
  • Is PPCM a vascular disease?
  • Can we develop targeted therapeutic interventions?
  • Might first-trimester interventions prevent or mitigate PPCM?
  • Can we improve screening for a rare disorder that has a large impact on MMM?
  • Can we better predict clinical outcomes in women with PPCM from biomarkers or genomics?
  • Can we use new diagnostics to refine risk assessment of recurrence PPCM in subsequent pregnancies?
• More research is needed to better understand risk factors and to develop screenings for sepsis in PPWP. Sepsis is the second leading cause of pregnancy-related mortality in the United States. Many maternal deaths from sepsis are preventable but were not averted because of delays in seeking care, in recognition/diagnosis, in treatment, and in escalation of care. Many physiological changes associated with pregnancy are similar to those associated with sepsis, creating diagnostic challenges. Although some patients have an elevated risk for sepsis, most cases of maternal sepsis occur in patients without risk factors. Thus, it is important to screen all patients. Many screening tools for sepsis exist, but none is perfect. All tools should be pregnancy-adjusted to be effective, and clear follow-up protocols should be instituted. Electronic screening tools for sepsis hold promise but should incorporate pregnancy adjustments, assess all vital signs, and initiate alert systems when sepsis is detected. Postpartum surveillance outside of the hospital (e.g., wearables) could be effective as a third of maternal deaths and 50% of sepsis cases occur postpartum. Technology for postpartum monitoring could also help to coordinate care and send alerts for potential sepsis cases (as well as other complications).
• Data analytics and data-driven modeling could help build biological models and improve prediction for risk assessment and informing interventions.
• Accessing biobanks, using technologies like mass spectroscopy and CRISPR, and conducting additional genomics research may help to identify new biomarkers for diagnoses, screening, and risk assessment.
• Technology could help to prioritize effective screenings and procedures and identify low-efficacy, low-relevance clinical practices that could be de-implemented to ease burdens on busy care providers.

Challenges to Use of Technologies to Improve Maternal Health

User-related Challenges

• Despite high access to mobile phones, individuals of color and those from lower socioeconomic status (SES) groups are less likely to engage in Internet health-seeking behaviors.
• Use of digital health management practices is low overall.
• Use of patient portals is associated with age, race, education, health literacy, and English language proficiency.
• Studies of Black birthing individuals resulted in several findings relevant to technology. Black PPWP reported several problems related to technology, such as impersonal technology, unavailable technology, and “digital redlining.” Black PPWP also identified other problems, such as a narrowing of the scope of services; a lack of cultural competence, compassion, and humility among providers; a diminished quality of care; barriers to communication and access to care; delivery without a partner or doula; and pandemic-related challenges.
• Interventions that fail to focus on equity, usability, and user preferences could function to widen racial and SES disparities.
• “Digital inclusion” must always remain a priority in developing new technologies.
• Some technologies could result in “alert fatigue” by flagging too many potential problems (and non-problems) to care providers. Provider input as to what type of information warrants an alert could be crucial to development of new technologies. Patient input is also crucial to inform what type of information is shared and flagged for patients.
• Broadband access and lack of access may create additional disparities. Equitable services provided via phone-only may be able to mitigate such disparities.

Business and Financial Challenges

• Limited funding exists to minimize entrepreneurial financial risks on new technologies.
• Good scientists and clinicians may not necessarily possess business experience, and there may be a lack of support for first-time scientist-entrepreneurs.
• Accessing community and clinical partners can be difficult for businesses.
• New technologies often involve regulatory uncertainty.
• Medicaid may not provide reimbursement for new technologies.

Other Challenges

• While continuous monitoring holds some promise for many clinical questions, these technologies currently have limited capacity for prediction. Predictive modeling based on continuous monitoring data is still in the nascent stages. Improvements are likely forthcoming, and new biomarkers could be identified with additional data collection.
• Technology raises security concerns and challenges.
  • HIPAA compliance and cybersecurity are challenges, particularly for Cloud-based platforms.
  • The risk of data breaches should be shared with patients prior to using such platforms.
  • Information available through EMR and other channels could enable unwanted surveillance and profiling, thereby diminishing health equity and justice.
  • Additional security for medical issues related to SUDs, other psychiatric issues, and other conditions may increase patient confidence to share information but could also function to increase stigma associated with these diseases.
• Often soliciting community input involves speaking to gatekeepers (e.g. spouses, family members, relatives, etc.) rather than individuals with lived experience (e.g., PPWP). How should biomedical professionals remain accountable to the communities?

Conclusion

New, in-development, and current standard-of-care medical technologies could help to address the increasing problem of MMM in the U.S. and associated racial and ethnic disparities. The technologies discussed at this meeting can be incorporated across the pregnancy care continuum to improve maternal outcomes, address social determinants of health, improve communication between patients and providers and between different care facilities, and ensure quality of care. Some of the technological systems discussed ensure continuity of care by facilitating care coordination/scheduling, record keeping, and secure information sharing. Other technologies could improve patient and fetal monitoring and provide clinicians with more information to guide treatment. Other topics addressed at the meeting include business opportunities for maternal health technologies; using technologies to treat specific maternal health conditions like gestational diabetes mellitus, preeclampsia, and postpartum depression; potential areas for development of new technologies; and challenges facing developers and clinicians in using technology to address maternal health issues.