Posted: 11 Oct. 2022 8 min. read

Can office staff help improve maternal mortality rates?

By Heather Nelson, senior manager, Deloitte Consulting LLP.

In the US, pregnancy-related deaths have increased steadily over the past 30 years, and in 2020 the maternal mortality rate reached 23.8 deaths per 100,000 live births.The maternal health crisis affects Black women and birthing people more than other groups—regardless of their economic, social, or political background.

While access to quality prenatal care can increase positive maternal health outcomes, social barriers such as racism, socio-economic factors, and drivers of health (e.g., limited education, inadequate transportation, poor access to healthy food) can contribute to late or inconsistent prenatal care. It is imperative to understand and expand our understanding of what quality prenatal care looks like for Black women and birthing people. By evaluating the full prenatal experience—including interactions with front office staff—we can start to understand the full experience of Black women and birthing people and determine where non-traditional interventions could have a positive impact.

8 Questions for J&J’s Dr. Susan Nicholson

In January of 2017, an executive at Johnson & Johnson (J&J) asked Dr. Susan Nicholson to attend a patient-safety meeting—sponsored by the American College of Obstetrics and Gynecology (ACOG)—in Washington, D.C. Although Dr. Nicholson is neither a gynecologist nor an obstetrician, she agreed to attend as the head of medical safety within the company’s Consumer division. The session, which focused on the maternal mortality crisis in the United States, changed her perspective, the trajectory of her future work, and J&J’s involvement in maternal health.

During the session, Dr. Nicholson heard that more people die giving birth in the US each year than in any other developed country. Even more striking was the fact that Black people—regardless of economic or social status—are three to four times more likely than white people to die during pregnancy or childbirth. Dr. Nicholson recalls being stunned by the numbers. Even more shocking, she recalls, was the feeling that she was the only attendee who seemed astonished by what she had heard. (Most of the attendees were likely all too familiar with this crisis.)

J&J has been working with Deloitte to design a care model that reimagines the role of the front office staff as patient connectors, advocates, and critical members of the care team. I recently spoke with Dr. Nicholson (now J&J’s vice president of Women’s Health within the Office of the Chief Medical Officer) about her research into the root causes of maternal mortality and J&J’s efforts to reverse a troubling trend. Here is an excerpt from that conversation:

Heather: What happened once you returned from that ACOG meeting in 2017?

Dr. Nicholson: I tried to educate myself about why so many people were dying, what is causing it, and why is there such a large gap between white people and Black people. Once I started to dig into the data, I thought maybe there is something I can do here. A few months later, I sat down with our chief medical officer and explained the situation—the crisis and causes. I knew J&J had the ability and could make a difference. A year later, this became my fulltime job. (Click here for Dr. Nicholson’s perspective as a white woman researching Black maternal health).

Heather: What did you learn from your research? And why did you look so closely at the front office of health care organizations?

Dr. Nicholson: Our first step was to listen to women from across the country. Many of them told us that they sometimes felt they weren’t being heard by the front-office staff when they arrived for a medical appointment. Some of them felt disrespected by the office staff. As a result, some patients might choose not to return for care. I can understand why someone might make that decision. I have felt disrespected in a doctor’s office, and I’m a white-haired white woman who is also a doctor. But deciding not to return for future appointments during a pregnancy could lead to unaddressed medical issues. We decided to look at how we might be able to improve encounters between patients and front-office staff.

Heather: In your research, you heard from patients and front-office staff. What did you learn in talking with these two groups of people?

Dr. Nicholson: The front-office workers we interviewed didn’t really know anything about the maternal mortality crisis. And they generally didn’t have any first-hand appreciation for what a pregnant person might experience just to get to the doctor’s office. Maybe that patient had to take several busses, take time off from work, or find childcare. Front-office staff might not be aware of any of those challenges. I believe that if we can help these employees appreciate what some patients go through, I think they will want to be part of the solution. But you can’t ask someone to be part of the solution without providing them with an understanding of the problem and a way to be constructive.

Heather: You’re saying that we need to redefine the role of the front office and bring in a culture of humility. How can training and education be a catalyst for both centering cultural humility and improving the patient experience?

Dr. Nicholson: We need to educate staff about intentional or unintentional microaggressions [the casual degradation of any socially marginalized group] and how they might be perceived by a patient. People are often unaware that the words they use could be offensive to some people or perceived as dismissive. It is important not to blame anyone, either the patient or the staff. It is also important to understand that microaggressions are built into our language and our interactions. Front-office staff might be willing to adopt a new language if we provide them with that language.

Heather: The front office staff usually instructs all patients to sign in, have a seat, fill out forms, and wait to be called. What could they do differently?

Dr. Nicholson: It can be as simple as beginning the encounter by greeting the patient and asking how they are feeling today or offering the patient some water while they wait. Asking the patient if they encountered any challenges getting to the office might also provide some useful information. If the patient seems stressed, the front office staff might ask if they’d like a little time to decompress before the appointment. Consider asking the patient how they would like to be addressed. For example, ask the patient if they prefer to be called by their first name, or last name. These simple questions convey the message ‘I see you and I want to respect you.’ Those little things can change the calculus and demonstrate to the patient that someone respects them and cares about them.

Heather: Just the slightest change in intonation and the use of different words can create a much different environment and a sense of belonging for the patient. It can be powerful. What about the physical environment at a medical office? How can that be changed to improve the patient experience?

Dr. Nicholson: When I go to a doctor’s office and I see pictures on the walls of people who look like me, I feel like I’m amongst friends, I feel like I belong there, and I feel that I’m welcome. The physical environment can lower the patient’s defensiveness and could make them more willing to openly discuss some of the challenges they might be experiencing. A doctor’s office might have medical images of the human body, but if all those images are of only white women, a Black woman might not feel welcome.

Heather: Are clinicians aware of the impact their front-office staff might have on the patient experience, and on determining whether a pregnant patient will continue to seek care?

Dr. Nicholson: Our research absolutely has shown that physicians usually are not aware that there is a potential for microaggressions, or implicit bias, when their front-office staff interacts with Black patients. It is not socio-economic. It is about skin color. Based on available research, we know that all Black maternity patients are at higher risk for morbidity and mortality—regardless of whether the patient is a high-powered, college educated executive, or someone on Medicaid. (Click here for Dr. Nicholson’s experience explaining patient perceptions to a physician.)

Heather: Let’s say a medical office implements all these great interventions. Front office staff goes through training, and they come out more aware of their impact on the patient experience. They are more empathetic, and they have better interaction skills. Then how do we know that these changes have had an impact on patients?

Dr. Nicholson: There are a few tools we can use to measure improvement around inclusiveness, like the Mothers on Respect (MOR) index. But these are not enough. We also have to talk to the women who seek care at medical practices where staff has undergone this training. We have to compare those experiences to the experiences of patients who seek care in practices where staff hasn’t undergone this training. Did the patients feel they were treated with respect? Did the front office staff ask how they preferred to be addressed? Did the front-office staff offer the patient a glass of water or ask about the trip to the office?

(Click here for Dr. Nicholson's thoughts on how virtual reality could be used to train front-office staff.)


1 Maternal mortality rates in the United States, 2020, Centers for Disease Control and Prevention, February 23, 2022

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