Fighting for maternal health
The US has the highest maternal mortality rate of developed nations. An innovative postpartum care model from Notre Dame can save mothers around the globe.
From Ghana to Indiana, Notre Dame researcher Joyce Adams wants to ensure new mothers have adequate care long after they give birth. (2 min watch)
I stared at the ceiling through a veil of tears. I heard the doctors and nurses debating whether I was at greater risk for a stroke or a dip in blood pressure as blood seeped onto the sheets beneath me. I thought of my newborn baby, crying in the emergency room lobby, and his two siblings, who were thankfully unaware of the sudden danger their mom was in. A chaplain held my hand as I prayed that doctors could stop the bleeding, could get me home.
I'm Tara McMullen. I am the coordinating producer of the What Would You Fight For? videos, and I write the accompanying stories you see here each week. For more than a decade, I've assumed roles including interviewer, story hunter, copy editor, writer, prop stylist, and even an occasional stand-in, but this year, I lived a story firsthand.
In January, our story team met Professor Joyce Adams as part of our annual interview process. We were immediately struck by both her passion for her work and the subject of her research—maternal health. I was pregnant at the time of our meeting. I knew the United States lagged woefully behind its Western peers, and that women of color have higher risks of complications and mortality. I had read the terrifying stories of Olympians Allyson Felix and Tori Bowie. So I was struck by Adams, who is both a researcher and nurse, and who had implemented a trial in four clinics in her native country, Ghana, to improve health outcomes for postpartum mothers. It was so successful, she has brought those care practices to the United States to improve outcomes for American moms. But I never thought I would be one of those moms she helped save.
Weeks after our meeting, I gave birth to my third child, a beautiful, healthy baby boy. Twenty-four hours after delivery, I was discharged from care. As a third-time mom, I knew what to expect. I knew sleep would be limited. I knew to increase my food and water intake to keep up with a nursing infant. I knew not to overexert, even when my two older kids wanted to play or there were chores to be done. I didn't lift anything that weighed more than my infant. I knew the rules, until the rules changed.
Eleven days after giving birth, while snuggling my newborn on the couch, I suffered a postpartum hemorrhage. As blood seeped through my clothes, I recalled Adams's research mentioning severe bleeding as a warning sign of urgent complications—I had reviewed her website just hours before as I was editing the script for the “Fighting for maternal health” video. Because of good information provided by Adams, I knew I needed to get to the hospital immediately. That information saved my life.
Featured voices:
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Joyce Adams
Associate Professor of the Practice and the Global Maternal Research Lead for the Eck Institute for Global Health at the University of Notre Dame
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Dr. David Haas
Robert A. Munsick Professor of Obstetrics and Gynecology at the Indiana University School of Medicine
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Kimberly Green Reeves
Vice President of Community Impact and Partnerships for Beacon Health System in Indiana and Michigan
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Tara McMullen
Coordinating Producer of What Would You Fight For?
Inadequate postpartum care
Adams is an associate professor of the practice and the global maternal research lead at the Eck Institute for Global Health, concurrently appointed in the Keough School of Global Affairs. She's also a faculty fellow of the Kellogg Institute for International Studies and the Pulte Institute for Global Development. Her work focuses on maternal health disparities that lead to mortality, with a focus on postpartum health. Adams has an undergraduate degree in nursing, which is where her interest in this field began.
As an undergraduate at Calvin University, Adams studied abroad in India. There she worked with a community organization that was devoted to improving maternal and infant mortality rates.
“I remember sitting down and reflecting on everything that I had seen and learned during that time period and telling myself this is the kind of impact that I want to make,” she said.
And so she pursued a doctorate in nursing science at Michigan State University. It was there that she noticed a gap in the research.
“I realized that a lot of studies were focused on antenatal care,” she explained. “It appeared as if when the mom gives birth and she's fine, that was the end of care for mom. But then an article showed up around that time that began to see that the data is showing that more women actually died after delivery, during the postpartum period, than during pregnancy or even childbirth. And I was like, wow, this is an often neglected area or aspect of maternity care and we need to be able to focus on this time period, the postpartum time period. And that's what I've done since.”
Adams explained that traditional postpartum care focuses on the six weeks after childbirth because that is how long the uterus needs to return to its pre-pregnancy state. While newborn babies have regular medical appointments throughout their first year of life, in the US, most women have a six-week postpartum checkup and little else. That is where Adams's research comes in.
Adams has developed an innovative group care, education, and support model called Focused Postpartum Care (Focused-PPC). The program provides women with follow-up visits with providers, education on warning signs, and various postpartum health topics, and it unites women with other mothers in a peer-support group for a year following birth.
“Although we used to focus on just that six-week time period, we now know that that is not sufficient for the postpartum period. We need to be able to provide care and support to women up until one year after delivery because issues linger up until that time point, especially with blood pressure cases, mental health issues,” Adams said. “There's a lot of complications that can happen or show up unexpectedly after mom delivers, such as severe bleeding, infections, mental health issues.”
Maternal care in sub-Saharan Africa
To put her research into practice, Adams partnered with Savana Signatures, a nongovernmental organization in the information and communication technologies for development space that is committed to improving the lives of girls, women, youth, and vulnerable populations in Ghana. Together they implemented Focused-PPC across four health facilities in Sagnarigu Municipality in Ghana's Northern Region, an area where new mothers historically receive minimal postpartum care or education.
Postpartum mothers and their babies gather for a session with Focused-PPC in Tamale, Ghana. (Photos by Michael Caterina/University of Notre Dame)
“Sub-Saharan African countries account for 70 percent of global maternal mortality, so if we are to make an improvement or begin to move towards meeting our sustainable development goals, we need to be able to focus on countries in sub-Saharan Africa,” Adams explained. But her motivation was also personal. “I've always wanted to give back to my community. And growing up in Tamale, I grew up in a home where my mom was an elementary school teacher and my dad was a pastor, and I watched how they worked in the community and served the people around us. My home was always a welcoming environment for the people around us, and that idea of social justice really resonates with me. And so working in Tamale in the same community where I was born and raised is something that is very dear to my heart and meaningful, because I'm giving back to the community.”
The program enrolled 12 intervention groups and 12 control groups with eight women in each group, for a total of 192 women. Interventions included clinical assessments of maternal health risks by specially trained midwives, who also offered structured education sessions about warning signs and other postpartum health topics, and a peer network of mothers who could encourage one another to implement healthy behaviors and seek help if needed.
The results showed overwhelming success. About 99 percent of the women in the intervention groups better understood signs of danger and were willing to seek help for postnatal complications. The program demonstrated that regular postpartum follow-up visits, consistent contact with health care providers, and strong community support contribute to early detection and management of complications such as hypertension and postpartum depression, and that standardized education enhanced women's knowledge of self-care, nutrition, and warning signs of postpartum complications. The training for the program increased the capacity of midwives to provide quality postpartum care and created a sustainable avenue for more midwives to be trained in the future. The model proved replicable, and a standardized education guide for Focused-PPC was adopted by the Ghana Health Service in the Northern Region. Together, these outcomes highlight the model's effectiveness in improving outcomes and confirm its potential for nationwide scalability as a reliable framework for safeguarding mothers' health.
“Our work with the Focused-PPC model demonstrates clear evidence: Women who receive regular postpartum contact and standardized education are more likely to detect and address complications early. These results confirm that investing in postpartum care is not just effective—it is essential if we are serious about reducing maternal mortality,” said Stephen Agbenyo, the executive director of Savana Signatures.
Lessons learned
Now, the program is being implemented back in the United States.
“One of the things that we've always thought about is that innovations can be developed in high-income countries and then what we learn, we take it to low- and lower-middle-income countries. But it is also possible that innovations can start in low- and lower-middle-income countries, and we take lessons from there and apply them to high-income countries like the United States,” Adams said. “We were able to design a program to address gaps in practice in Ghana. And once we implemented it and it was successful, we took that program and the lessons that we learned and adapted it for the United States context and to implement it here to be able to improve those same postpartum outcomes.
“Although we have the medical care, we have advanced technology, we have lots of health facilities, some of the issues that persist in low- and lower-middle-income countries are also prevalent in the United States. For example, access to care issues. There are so many women here who do not have access to OB-GYN services in the United States. We have what we call maternity care deserts, where women living in these areas do not have access to hospitals that can provide deliveries, and they have to travel long distances in order to be able to access maternity care services, just like we have in sub-Saharan Africa. Racial disparities in maternal mortality are a big issue in the United States with non-Hispanic Black women having two to three times a greater risk of maternal mortality than non-Hispanic white women. And so there is room to be able to work both in sub-Saharan Africa and in the United States and be able to improve outcomes in both worlds because we do have similar issues that can be solved with reciprocal innovation interventions.” Reciprocal innovation is a term that was coined by the Indiana Clinical and Translational Sciences Institute, a collaboration among Notre Dame, Indiana University, and Purdue University to create better health opportunities for people in Indiana.
Dr. David Haas '93, the Robert A. Munsick Professor of Obstetrics and Gynecology at the Indiana University School of Medicine, has worked with Adams for several years. He was excited about her research because he was seeing firsthand that patients were at-risk and dying, even in the United States.
“I think that it is important for people to understand that getting pregnant and then giving birth, while usually a wonderful experience, can be a dangerous thing,” he said. “I absolutely think people are shocked. We feel like we've come so far, and we're so technologically advanced. How in the world could it be that our moms are dying?”
But it's not outlandish, he said. He has seen that women don't always have the care they need in big cities like Indianapolis, where he practices at Eskenazi Health, and in rural obstetric deserts where women lack access to quality health care during and after pregnancy. But Adams's Focused-PPC provides something very doable, even in low-resource settings, that can have a real impact not just on moms, but on entire families.
“When a mom dies, it impacts the entire community,” he said, explaining that family members then need to step in to raise the child, that health outcomes for that child are forever impacted, that there are transgenerational consequences. “The life trajectory of people changes.”
He said Focused-PPC is currently working on regional expansion in Indiana, from his base in Indianapolis up to South Bend.
Adams shares resources like infant weight stations with families at a Pop Up Pregnancy & Family Village event at the Charles Black Center in South Bend. (Photos by Matt Cashore/University of Notre Dame)
Kimberly Green Reeves is the vice president of community impact and partnerships for Beacon Health System in Indiana and Michigan. She oversees the community health division that focuses on health promotion and disease prevention. Her team and Adams have collaborated for the last four years on projects ranging from hypertension to Pop Up Pregnancy & Family Village, a one-stop shop for pregnant and postpartum mothers to receive health services and community support.
“This idea of postpartum care support has also been an ongoing project for us over the years,” Green Reeves said. “The ultimate goal for this particular project is to address maternal mortality. We know at a national level that it is a problem that exists, and that there are disparities that exist for Black and African American mothers who are giving birth.” She noted that the Indiana government is currently collecting maternal mortality data, but data have already proven that infant mortality is a health concern in St. Joseph County.
“Infant mortality is an indication of how healthy the community is,” she said. “Ultimately, what we want to ensure is that there is a healthy mom to have a healthy baby.”
Green Reeves said Beacon is eager to implement the Focused Postpartum Care project and to be able to make on-the-spot adjustments based on the findings.
“The value of partnership here, particularly with Dr. Adams, is just invaluable to better health care outcomes,” Green Reeves said. “I'm grateful that we can collaborate.” Green Reeves noted there are challenges with implementing any postpartum model. The first is awareness, and the second is that new mothers have enough on their plates, she said. New mothers are in a vulnerable state and are unlikely to stop and seek help for themselves because their focus is on the new baby and their growing family.
Green Reeves is right. In my case, there was a real temptation to ignore the bleeding and see if it improved. It would not have, and the ramifications could have been deadly.
In the emergency room, I was given medications to try to stop the bleeding, but ultimately, I needed surgical intervention. I'm fortunate—I knew to act quickly, I had a hospital and knowledgeable providers within a quick drive, I had insurance, I had a partner and a community to care for our children. Thousands of women in America alone don't have access to those benefits, which can be the difference between life and death.
“In a perfect world, no woman should be sacrificing her life to give life,” Adams said. “We hope to be able to expand and scale up Focused Postpartum Care to everywhere in the world, be it high-income countries or low-income countries, so that every woman would have the opportunity to receive the quality care that she needs, and that will be able to decrease maternal morbidity and mortality rates.”