Pulling up a Seat to the Table: A Mixed Methods Study to Explore the Integration and Function of Social Workers in the Maternal Health Care of Women with Pregnancy-Related Cardiovascular Disease

Background: Cardiovascular disease is the leading cause of death for women before, during, and after pregnancy, accounting for 20% of female deaths and 30% of maternal deaths. Social workers are educationally and professionally trained to address social drivers of health that can impact risk for cardiovascular disease; however, they are grossly underutilized in healthcare delivery due to workforce shortages, generalized training, role ambiguity, and profession-related stigma. This challenge also exists within maternal healthcare despite the evident need. With mental health conditions as a correlate and consequence of cardiovascular disease accounting for a significant proportion of pregnancy-related deaths, the intersection of physical and mental health must be prioritized in maternal healthcare. To explore and expand the role of social workers in maternal healthcare, this mixed methods study uses an explanatory sequential design to address the following specific aims:

Aim 1: Identify if, when, and how clinical social workers (CSWs) are incorporated into the inpatient maternal health care of women with cardiac-related severe maternal morbidity.

• Q1: Among all patients with cardiac SMM, how many received referrals to a CSW, and how did receipt of referrals vary by patient race or ethnicity?
• Q2: Among all patients with cardiac SMM, how many had interactions with a CSW, and how did the frequency of interactions vary by patient race or ethnicity?
• Q3: Among cardiac SMM patients who were referred to or had interactions with a CSW, did the receipt of a CSW referral and frequency of CSW interactions vary by patient age, insurance type, delivery method, or cardiac history?
• Q4: Among cardiac SMM patients who had interactions with a CSW, how many received referrals from a CSW, and did the receipt of a referral and the referral type vary by patient race or ethnicity?

Aim 2: Explore perceptions of social worker integration into maternal health care among women with cardiac SMM, OB providers, and OB clinical social workers to identify how social workers can address psychosocial correlates and consequences of cardiac SMM (future presentation).

Methods: Based on retrospective cross-sectional cohort data from the CACHE Maternal Health Project (N=24,199), a REDCap sub-database and case report form were developed to conduct a chart review for patients with cardiac SMM who gave birth at Duke Hospitals between 2016-2021 (N=201). The study sample was limited to live births; patients with a cardiovascular composite event associated with pregnancy or delivery (e.g., congestive heart failure, cardiomyopathy, acute myocardial infarction, cardiac arrest, hemorrhage, eclampsia); and inpatient CSW visits during pregnancy-related hospital admissions.

Results: Among 201 patients, 80 patients (40%) received a CSW referral from their OB provider; 98 patients had CSW interactions with the majority (85%) with only one interaction. Black patients were less likely to receive a CSW referral, more likely to have a CSW interaction, and more likely to have multiple CSW interactions.

Conclusions and Implications: Further assessment of CSW interactions is needed to understand the underutilization of social workers and to develop strategies to leverage their potential to improve maternal health outcomes at the patient-, provider-, and system levels.