Leadership and Faculty Development Program Conference – Panel

– As you guys know, this panel, this topic is maternal fetal health, but we’re focusing in
on the maternal piece, which is important. And I appreciate Dr. Declercq’s commentary to show the difference between
the maternal mortality rates and that of the fetal,
and perinatal loss rates, which are important. So, welcome to our panel discussion, which we will start to think about something that Joan Reid
has really instilled in us when we were fellows, which is to start thinking
about disparity solutions. How are we gonna address these
inequities through policy? How do we then lead to
measurable, demonstrable solutions to tackle these issues that are so great and really lead to what we call right now, human health crisis? So with that said, I
wanna introduce our panel that we’ve brought up to look
at systematic interventions of how we can address
maternal fetal issues, but specifically looking at
this maternal mortality rate and the issues related
to maternal mortality. So, welcoming to our discussion,
we have Dr. Fifi Diop who is not only our State
of Massachusetts Director of the Office of Data Translation for DPH, but she’s also an MCH Powerhouse. Dr. Diop is a practicing,
has been a practicing OBGYN, serves as the state maternal
child health director, an epidemiologist. Also is the director of
the Massachusetts Pregnancy to Early Life Longitudinal project, which is a linked database system, very important to understand and learn because not all states have that system. In addition to that, Dr. Diop has her MPH and is a champion for public health. She has been our person
who has conceived of our state perinatal quality collaborative. And what makes our quality
collaborative different from other state perinatal
quality collaboratives is we take a very strong
life course approach by connecting the work that we’re doing in the neonatal side to the maternal piece to areas of intervention and public health such as Early Intervention and Head Start. And we have that because of
the great foresight of Dr. Diop and all that she brings to us. I wanna also let you know that not only is she is colleague and a friend, she’s also a phenomenal dancer. So I enjoy attending conferences
and meetings with Dr. Diop. She’ll talk to you
today a little bit about using public health data to
inform clinical practice. And I’d like to bring up Dr. Diop. (applauding) – Thank you, Dr. Meadows, for
that wonderful introduction. I wanna say that the worst
thing that happens to me at conferences is to have
to speak after Dr. Declercq. (laughing) He’s stolen all my lines. You can see when I talk. But the worst part is, he’s a white man against a black woman. What type of equity is that,
(laughing) when we’re talking about it? That’s not fair. When it comes to talking
about the intersection of public health and clinical practice, there is a lot to be said. And of course, I’m not gonna have time in 10 minutes to do that, but I’d like to give a very brief but high level overview of three things. One is perinatal regionalization, which Dr. Declercq
alluded to a little bit. The other one is maternal
mortality reviews in the U.S. And then the third one is guidelines and circular letters that come out of the Department of Public Health. Because it’s been saying
that we have to do the work. You guys are doing your job. So, with that, I’m gonna start with
perinatal regionalization. In Massachusetts, in 1985,
we developed and implemented regulations for perinatal services to ensure that appropriate
but also safe care is provided at appropriate locations. And since then these guidelines
have been updated twice. Once in 2006 and recently in 2017. The challenge with these guidelines is that they are primarily related to the care of the newborn,
which he also mentioned. We care more about babies
than we care for mothers. So currently in Massachusetts, there is no system that designate levels of care for pregnant women. At the national level,
given in response to the increases in maternal morbidity and mortality in the past decade, ACOG and SMFM have developed and published maternal levels of guidelines in 2015, and these guidelines are
designated to promote collaboration between maternal facilities
and healthcare providers with the goal that pregnant
women will receive care at facilities that
appropriate for their risk. To support implementation
of the guideline, the CDC developed the levels
of care assessment tool known as LOCATe to allow
state and jurisdictions in assessing not only
maternal levels of care but also neonatal levels of care in alignment with the
national recommendations and guidelines from
ACOG, SMFM, and the AAP, the Academy of Pediatric,
American Academy of Pediatrics. The proposed levels of care includes four. One is basic care for level ones, and then the second one is a level two, which would include level
one and specialty services, and then level three, which
will include level ones and two plus subspecialty services, and then the highest level, which is the regional pyramid
of healthcare centers, which would include all of the levels but provide the highest level
of specialized services. The goal being that when
pregnant women at risk are seen. They are seen at facilities
that are readily prepared to respond to the levels
of specialized care, the need level of specialized care. And by the same talking, reducing maternal mortality and morbidity. Now, I wanna talk a little bit about maternal mortality reviews. In Massachusetts, maternal death review is authorized under Mass
General Law chapter 111, section 24 A and B. And the goal is really
to identify and review all pregnancy associated death from any cause during pregnancy or up to one year following
the end of pregnancy. And you heard the definitions of pregnancy-associated
mortality from Gene Declercq. We’re not gonna go into that. But essentially, the goal is
to get inside into the factors that contribute to both maternal
morbidity and mortality, and to inform the strategies to reduce the incidence of this tragic event. And a lot of us in the room here are members of the Maternal
Mortality Review Committee. In Massachusetts, we review all deaths. But before that, between 1941 and 1985, the Maternal Welfare Committee
at the Mass Medical Society reviewed maternal deaths
voluntarily reported by hospitals. The Department of Public
Health sanctioned the process but were not involved. And in the late 80s,
this process kinda waned for two reasons. One was medical liability concerns, and then the other one was perception that maternal mortality
was no longer an issue. And Gene showed that in the data. At some point we weren’t even
collecting the data anymore. So, in the 1990s, the
Mass Hospital Regulations were adopted and hospitals
were now required to report maternal deaths within 45 days to the Department of Public Health, but only few hospitals were in compliance. They were not reporting to us. And in 1997, there was a
very high profile death in a wealthy suburb in Newton, which was highly publicized by the media. And of course, anything that
gets the media attention, then gets the legislative attention, and then everybody’s attention. So, at that point, the Maternal
Mortality Review Committee was established by the Massachusetts Department of Public Health. And now, hospitals were not
only required to report to the Department of Public Health, but the Department of Public Health was chairing the committee, and we review, like I said,
all pregnancy-associated death, make recommendations and strategies that we determined back to the providers. I thought I was gonna
impress you with this slide to tell you that case
identification was difficult, but I think Gene Declercq did a good job at telling you how complicated is it. Of course, we don’t know all
the pregnancy-related deaths. We don’t know about all the
pregnancy-associated death because A, we don’t
know, when a woman dies, we don’t necessarily
know if she’s pregnant because our reporting system right now allows us to know if
there was a fetal death. In case of a fetal demise
at 20 weeks or greater, we know that, but anything that happens below 20 weeks, is not reportable to the vital statistics. So, we are missing a
great deal of pregnancies, losses, and women who died
while they had like less than, they were pregnancy
and less than 20 weeks. But in order for us to pick up on that, we do do some data linkages, and we conduct data linkages with our Pregnancy to Early
Life Longitudinal Data to pick up on some of the data. And the added pregnancy checkbox, which Dr. Declercq also mentioned in 2014 was also helping us identify
some of these cases. Back in the days when we
talked to the medical examiner about adding pregnancy
tests to, when women die, we were told that it was
violating confidentiality, so we didn’t do it, but with the new revision in 2014, the checkbox allows us to
pick up on some not all. We’re still missing a great deal. Now, instead of just looking
at pregnancy-related deaths, like Gene said, Massachusetts
actually, it’s a rare event. We’ve decided as a community
to collectively look at pregnancy-associated death, pregnant severe maternal
morbidity, which in these events, conditions for which women
could have that but didn’t. And our data indicated
that starting in 2000, 1998, there is a really sharp increase in severe maternal morbidity. Regardless of how we calculate it, there are a number of definitions related to including transfusion,
excluding transfusion, the rates are going up. If women are not dying, they’re sicker. They’re getting sicker and sicker, and we see that in the data. As a result, and of
course when we look at it by race/ethnicity, no surprise, big gap between black and white. And in fact, in the latter years, the gaps between blacks
and whites are increasing. And these are some of the
recommendations we make for Department of Public Health. Each maternity hospital should
have clinical guidelines and protocols for the
recognition and the management of maternal hemorrhage
including standard timing and criteria for implementation of massive transfusion protocols. The guidelines and the
protocols should include procedures that effectively
address the clinical risk and management of peripartum
maternal hemorrhage. And then as part of our Quality
Improvement collaborative, we launched the QI project focused on maternal hemorrhage with 28 hospitals and then maternal hypertension
with 10 hospitals. We provided Quality Improvement
training to 18 hospitals to be able to make some progress in related to severe maternal morbidity. And here’s the slide
that Dr. Declercq showed. We’ve been monitoring
pregnancy-associated deaths related to substance misuse. Again, a lot of new trends going just between 2005 and 2014 from 8% to 41%. The recommendation for these
coming of of department were to screen all pregnant
women through interviews using a standard tool at
the beginning of pregnancy at 28 weeks and at the time
she presents for delivery. And then developing
training on mental health, maternal mental health for
providers to demonstrate proficiency in screening
and referring women. And a lot of work with the Mass Perinatal Quality Collaborative around toolkits and best practices. We’ve been also monitoring oral health. As you can see, we haven’t
made a lot of progress here, but the recommendations included adding oral health questions to our
perinatal care recommendations in collaboration with Mass health. And we published an oral
health guideline for pregnancy. In 2016, we’re still
working with providers around implementation, which
has been very challenging. And we do issue circular letters when there are emerging trends. The last one we had was related to substance exposed to the newborn. We have several before that
related to HIV or H1N1. That’s part of what the department does. We share the data, and then we
come up with recommendations. And that’s my last slide. This is the contact info for DPH. Thank you. (applauding) – Thank you, Dr. Diop. Next among our panel of experts, I’d like to introduce
you to Dr. Rose Molina. Dr. Molina’s an assistant professor of obstetrics, gynecology,
and reproductive biology at Harvard Medical School
and is a practicing OB at Beth Israel Deaconess
Medical Center as well primarily in the Dimock Center in Roxbury. Dr. Molina completed her Global
Women’s Health Fellowship at Brigham and Women’s Hospital and obtained her MPH here
at the Harvard Chan School of Public Health as well. I have the pleasure of
having worked with Dr. Molina as a resident when she trained
at Brigham and Women’s, and she was a powerhouse
and a dynamic person there with a beautiful heart
who’s definitely zoned in on this need to focus in on
what we can do as clinicians to improve care for women. And so, she’s gonna give you
a clinician’s perspective about how we can begin to address bias and the impact of bias on care delivery. I do wanna add that I’m introducing
these personal anecdotes because it’s important to know that is really sobering statistics
about the health of women and potentially our infants,
especially for black women. And it’s nice to know
that the people that were, that are doing this work, that we’re working closely together, that are colleagues and friends, also have really nice human
sides about them that we enjoy. And so, I’d like to say that
Dr. Molina is a avid traveler and a foodie whose favorite
destination is Italy because of the food. And so, I’d like to bring out Dr. Molina to talk a little bit more
about some interventions that she believes would
be really impactful for us to address, impact of bias with clinicians
in the healthcare system. (applauding) – Thanks so much, Dr. Meadows. I’m so excited to speak to you all today about some potential solutions at least from a clinician’s perspective. I have no disclosures. However, I do wanna
start with a few caveats. The following solutions that
I’m gonna discuss are not easy. They require heart and
mind, time and effort, resources, commitment, and grit. Even though our panels
today focus on system and community solutions, we need to acknowledge that racism exists at multiple levels, personal, interpersonal,
institutional, and structural. And we need to define
solutions to dismantle racism in all of these spaces, but my brief focus today will
be on the clinical encounter and looking particularly
around patients, providers, and their interactions. I also wanna say upfront that overall we have very limited
data about effectiveness of solutions specific to
maternal health inequities, which are differences that are systemic, avoidable, and unjust. As we talked about earlier today, there’s a larger body of
evidence around birth outcomes, but less specifically
about maternal health, which likely signifies the
structural deprioritization of women’s health specifically, but the solutions that I present today are likely applicable to inequities across many medical fields. So I just wanna start
briefly of the story of how I came to this work. I grew up in San Diego on
the busiest point of entry between two nations in an
interracial, immigrant family. And my parents instilled
in me from a very young age the value of learning other languages to connect with people, whether it’s family,
friends, or strangers. From a young age, I felt
compelled to strive for equity in the global South when I
realized the stark differences in the opportunities people are afforded just because they happen to be born 15 miles South of where I was born, a circumstance that we all have no, absolutely no control over. This led me to work
with partners in health when I was a medical student
here at Harvard Medical School. And it was my experience
in supporting midwives in rural Chiapas that taught
me what it really means to believe that all people are worthy of high quality health care
no matter where they live simply because their lives matter. So solution one is to apply
a lens of health equity to daily clinical encounters. We need to see our patients, hear them, and validate their lived experiences. Our purpose as physicians
is to create a safe space in our clinics to build
trust with our patients by connecting with them
through our shared humanity while also recognizing
the intersectionality of their own identities. We need to prioritize our
communication with them, particularly in shared decision making. And this means we must
listen to understand and not always to respond. Recently, I met a 41 year old in my clinic who had a recent miscarriage and wanted to talk to me
about birth control options. In our short visit, she
described how she feels othered in nearly every moment of every day as a recent immigrant who
doesn’t speak English. She said to me, (speaking
in foreign language), which means, Dr., I’m not dumb. She went on to describe how she feels the sting of discrimination every day and being treated as if she were dumb just because she does not speak English. She went on about how
she pours out her time trying to navigate through life, and even just to find a doctor like myself who can speak to her in her own language. The solution lies in being
humble, compassionate, and inquisitive about our patients who come from all walks of life, and I encourage that
all of ask our patients about their lives and
just think for a moment what it may be like in their shoes. I’m proud to work at Dimock, a federally qualified community
health center in Roxbury where I’m able to screen
for patient’s daily needs and link them to appropriate resources such as health leads. I’m also able to connect
patients to the medical care that they need with wraparound services such as warm handoffs to
behavioral health providers or a referral to our detox unit on campus for someone who needs it. For our postpartum patients, one of the most important things I can do is to effectively transition their care to a primary care provider
in the same building, especially those with elevated risk of cardiovascular disease and diabetes because of pregnancy complications. This is particularly important, as we saw earlier in the key note, that cardiovascular disease
is now a leading cause of pregnancy-related death, especially cardiomyopathy
among black women. At Dimock we embrace new models of care that center women of color,
such as group antenatal care that allows women to build social support as they experience pregnancy together. And most importantly, we
must incorporate equity as a process and not just a, a process in our daily encounters
and not just an outcome. Solution two is to recognize implicit bias and build accountability to mitigate it. With regard to maternal mortality, we have seen differences
in preventable pregnancy related deaths by race, which have also been paired with the pundit stories in the media which call into question the role of bias. We need to recognize how implicit bias saturates all of our lived experiences and daily interactions. Yes, skin color is
certainly an important one, as is obesity, appearance, age, gender, among others listed here. The good news is that research shows that doctors are no more
biased than other human beings. The bad news is that doctors
occupy a place of power, and their biases can
have important impacts on their patient’s health. But the good news is that implicit bias is a habit that can be broken. We have to recognize that this is a lifelong journey for all of us. The goal is not necessarily
to stamp out bias but to be sensitive to it, name it, and hold each other
accountable for mitigating it. This requires daily self-awareness, self-reflection, and transformation, and we need to role model this behavior for each other and for our students. It requires humility and a commitment to do better every day. In response to the
outpouring of public stories of women of color who felt
that their healthcare team did not listen to their concerns, this past weekend ACOG, the American College of
Obstetricians and Gynecologists, announced its public awareness campaign. I’m wearing the pin here. It says, I’m listening,
every mom, every time. Additionally, there’s several bills at the state and federal levels about mandatory and
implicit bias trainings to address inequities in
maternal morbidity and mortality, but they need to be more than a checkbox. We need to identify best practices and content for these trainings so that they actually have an impact on behavior change and patient outcomes, and then we need to identify
how to scale those up. Solution three is to ensure diversity in the healthcare workforce. We need to build and
support a diverse workforce that reflects the patient’s we serve. A recent study found that
black men seen by black doctors receive more effective preventative care than those seen by non-black doctors, and this effect seemed to be driven by better communication and more trust. The medical field is
making strides in closing the gender gap with 39% of
full-time faculty being female, but only 4% of full-time
faculty are females of color. In 2015, only 6% of all
medical graduates were black, and 5% were Hispanic, that 13% of the U.S.
population identifies as black, and 18% as Latinx or Hispanic. The need for a diverse workforce extends beyond just medical schools but also to other health
professional schools such as nursing, and the pipeline needs to begin early, as early as middle school. Secondly, we need to
center and support patients through interdisciplinary and culturally congruent care teams. As the result of the many stories of mistreatment during child
birth among women of color, as we mentioned Serena Williams and in the Lost Mothers series, some women now are actually
scared to deliver in hospitals and are seeking alternative birth options. This can, at some times, lead
to strained relationships among the healthcare team
between lay midwives, professional midwives,
doulas, obstetricians, and other healthcare providers. We need to change the narrative that sometimes depicts
maternal health professionals as blaming each other for bad outcomes, and we need to move forward together as a truly integrated team as shown here with the
patient at the center and surrounded by a team of providers with different levels of expertise. To that end, we need to
recognize a just culture that essentially no one comes
to work trying to harm people. And we also need to see
that, just like our patients, healthcare providers also
function in a structural context that may constrain their behaviors. We are seeing an epidemic
of physician burnout as published by many of our colleagues right here at Harvard. Nearly 45% to half of OBGYNs nationally report symptoms consistent with burnout, and this is also true among midwives. We know that burnout is associated with major medical errors. This is not an excuse. It simply means that we need
to find a system solution for the physician work
environment in parallel. We in the United States can
learn a lot from other countries regarding the positive impact
of culturally congruent doulas and community health workers. Until our workforce reflects
the patients we serve, we need patient advocates like them who can come from the same communities and help our patients navigate transitions between home and hospital and back home. Solution number four
is to foster inclusion and belonging in the healthcare workforce. We need to build an inclusive environment to support and retain people
of color in our workforce, and that may mean developing
programs such as mentorship, coaching, and sponsorship
that really allow the healthcare workforce to feel valued and supported in their work. John A. Powell is professor of law in African American
studies at UC Berkeley, and he argues that we need to go beyond inclusion to belonging, a radical idea that is
much more than being seen and being included. He writes that belonging is not just how we treat each other, but it is how we actually
organize our economy, our structures, our schools, our faiths so that everyone belongs and recognizing we still have differences. Lastly, solution five is
to integrate health equity and advocacy training in undergraduate and graduate medical education. We need to teach that
structural competency to understand the
underlying power structures that shape the social
determinants of health that we all know about. Structural competency has been defined as the trained ability to
discern how a host of issues defined clinically as symptoms, attitudes, or diseases also represent
the downstream implications of a number of upstream decisions about such matters as healthcare,
and food delivery systems, zoning laws, urban and
rural infrastructures, medicalization, or even
about the very definitions of illness and health. This graphic comes from the
Boston Public Health Commission, which illustrates how racism is the driver of the variation and social
determinants of health, which we all know impact health outcomes. We need to ensure
diversity of clinical cases that do not perpetuate stereotypes, and we need to stop
racializing illness and disease when we teach our medical students. We need to teach the history
of racism in medicine to medical students and residents and acknowledge our profession’s mistakes so that we can better
understand the distrust patients have in our profession. For example, in my own
profession as an OBGYN, I had not heard the story of Marion Sims until I was an attending. He is considered one of
the fathers of gynecology, and his name is
commemorated on a retractor that gynecologists use on a daily basis. It was not until after
I became an attending that I learned that he
practiced surgical techniques to treat obstetric fistula on slaves without their consent
and without anesthesia. This is his statue in New York City that was only taken down
one year ago in April 2018, and the other statue that was commemorating him still exists. We need to teach our students about the history of redlining in Boston and the decades of the
Federal Housing Authorities disinvestment and explicit racist policies that impact where people live and their health and
well-being to this day. We need to tell the
story of Henrietta Lacks whose cervical cancer
cells were taken from her without her consent and used to develop the most commonly used human
cell line called HeLa cells. We also need to acknowledge that there were four
sterilization campaigns that occurred in the 1970s among the Mexican immigrant community. We should also teach about the
history of social movements and contemporary frameworks
that are relevant to the practice of medicine
such as obstetric violence, which originated in the
human rights movement in Latin America, the
White Ribbon Alliance, and Reproductive Justice. Lastly, we need to
infuse advocacy training into medical schools and residencies by telling our patient’s
stories in the places of power and using our platform
and status in society to speak out for what
matters to our patients, such as expanding Medicaid
and paid parental leave. Thanks. (applauding) – Thank you, Dr. Molina. I’d like to introduce our third speaker who is a colleague as well,
also another practicing OBGYN, Dr. Jackie Grant. Dr. Grant is practicing
maternal fetal medicine doctor and the Director of
Regional Perinatal Center in Columbus, Georgia. She also received her medical
degree from Emory University, and I’m sorry, her residency
at Emory University and maternal fetal
medicine practice training was at UNC Chapel Hill. And she had completed her MPH prior to coming to our fellowship, but then also completed an MPA
here at Harvard University. Something she and I
share in common is that this interesting love for the
idea of group prenatal care. And so something that Dr. Grant worked on across the state the
Georgia was implementation of Centering Pregnancy
Programs across the state, and received an awarded for such. Importantly, her humanism
in medicine is obvious in the fact that she was
invited here as a panelist, and the work she’s done, but also, her humanism
extends to really interesting pieces of art and her skill for antiquing. And so, you can definitely have a conversation with her about that. I have a beautiful brooch that
she brought with her today. But with no further ado, I’d
like to bring up Dr. Grant. (applauding) – Thank you, Audra, for
that kind introduction. I am one of two MFMs
and the Director of the Regional Perinatal Center
in Columbus, Georgia. And for those of you who
aren’t familiar with Columbus, Columbus is about an hour
and a half South of Atlanta. The demographics are about,
it’s about 50/50, black/white, about 6% Hispanic, and about 2% Asian. We actually boast some of the worst perinatal outcomes in the state, and that was one of the reasons
why I chose to go there. In fact, in the last two and a half weeks, I have had personal experience
with two maternal deaths. So, let me just say that we are, being in Georgia and in South Georgia, we are located in the belt
buckle of the Stroke Belt. It is very, very uncommon for us to see hypertensive emergencies. I can’t tell you how many
times just from my office I have actually sent patients, my office is right across
the street from the hospital, via ambulance because a
blood pressure is 215/115. It is so common to see just
extremely high blood pressures that I think our physicians and our nurses on the hospital side
are just desensitized. So I would be rounding,
doing antepartum rounds, and just be stunned the next day by these just ridiculous blood pressures that went untreated during the night. And it just became so concerning to me that I took it to the
Executive OBGYN Committee, which I am a member of. And I said, we need to do something about this failure to treat. It’s the standard of care
to treat blood pressures of 160/110 or greater, and we’re not following that standard. And what is going on? And so, to my surprise, I thought, ’cause I was like, we need to be actually, and how do I advance this slide? This one. So that was our hospital. So I said, we need to
be practicing in line with the Council on Patient
Safety in Women’s Health Care hypertension bundle, which is, has been, is evidence
based and endorsed by ACOG, of treating these blood pressures that are consistently or
persistently elevated, 160 systolics over 110 diastolics. And why aren’t we doing that? And to my surprise, I
actually got push back. (laughs) And the push back actually
mostly came from nurses, the nursing directors and the nursing. And the concern was that,
well, if our nurses, it was like, part of this
hypertensive bundle is notifying, a mandate to notify the physicians. And we aren’t even
consistently doing that part. The other part of that response is to treat within 30 to 60 minutes. So surely we’re not doing that either if we’re not consistently notifying. So some of the nurses on
the committee said that, well, our nurses are not going to call these physicians at
night because they’re afraid, and they’re afraid they’re
gonna get yelled at, and they’re afraid of this, and the doctors aren’t gonna treat anyway because these blood
pressures are commonly seen. And so they’re not going to, the doctors aren’t going to treat, and we don’t really want
our nurses being yelled at by the doctors in the middle of the night. And, I was just floored by this. I mean, I think my head
was about to explode. And I’m a very sort of passionate person, and my voice started to get high-pitched, and I was like, all it’s gonna take. I said, this is a
quality and safety issue, and this committee is charged with that, and all it’s gonna take is one
15 year old that strokes out, and we won’t have a leg
to stand on as a hospital. So, at that point, I think
I got their attention. And so, there was some
agreement around the fact that it was in fact a
quality and safety issue, and that we needed to
properly address the issue. So we basically sent out a letter to all of the practicing physicians, and we posted the letter
on Labor and Delivery, and we attached that to the
recent ACOG Committee Opinion that came out in February about
treating acute hypertension. And I think we have really
gotten some good response. I’m no longer seeing this
issue as much as I was on antepartum rounds. And in fact, most recently
in our Executive Committee, the nurses were actually bragging about one of the nurses that had
to check one of the residents who had an outburst when the nurse called, and said, don’t call me
about that blood pressure. I only want you to call
me if the blood pressure is greater than 180, a systolic of 180. And I might add that the
hospital has standing orders and have had those standing
orders for quite some time, but a lot of the doctors had personalized their standing orders and had changed their standing orders to tell the nurses to not to call them unless the blood pressure
was over 180 systolic. So anyway, the nurse basically
put the resident in check, and the blood pressure
was properly treated. So, I say all of this about
these, for most doctors, most doctors really
wanna do the right thing and the best thing for their patients. And just by giving them the guidance and putting it out there, the majority of people are
gonna fall in line with that. But there are always
gonna be some that’s not, and for that reason, you do
need a system-wide approach. And from my experience
working in public health and now working in a hospital system, is that you have to identify a problem. You have to make that
problem be understood as to why that’s a problem
and what the solutions are. And then you have to empower the people. The leadership has to do that power, that front the empower. And then you have to empower the people, and in this case, it was
to the nurses really, to speak up and to report. And then you have to have a
committee that responds to it, and monitors it, and
gives feedback about it. So, I think that’s just one
example of what we’ve done at Piedmont Columbus Regional
from a system’s perspective. The other thing we’ve done is that a lot of our patients that are candidates for low-dose aspirin therapy, so one of these upstream solutions. Low-dose aspirin therapy has been shown to decrease preeclampsia. And while it only decreases
preeclampsia by 10-30%, it’s all we basically have, but it has been shown to decrease their rick of severe preeclampsia or pregnancy induced hypertension resulting in pre-term births,
less than 34 weeks, of 60%. So what I found in my
consultative practice is that a lot of our patients are coming to me well after the time where
it would be most effective. And aspirin is most
effective before 16 weeks. So we’ve done an outreach,
and similar outreach, and in the Committee Opinions, and in a letter to the physicians, and we are seeing some improvement. We’ve got a long way to go there. We don’t have a systematic approach that we can deal with
community physicians on that, but we are seeing some improvement. So again, I just wanted to close by saying that sometimes it does take these overarching system-wide changes to really kinda effect practices. Thank you. (applauding) – Thank you, Jackie. That very near and dear
to her heart as well. So, our state PQC is working similarly to implement guidelines related to the safe, the Council on Patient Safety
in Women’s Health Care, Safe Motherhood Initiative through AIM. So there are bundles of
safety bundles called the Alliance for Innovation on
Maternal Health, AIM bundles, that our state is working
on implementations. So I think that’s really appropriate and important to discuss. I wanna just quickly encapsulate some of the things we’ve hard today just with our panel of
obstetricians and gynecologists talking about systemic
interventions to address this trend that we saw from Dr. Declercq’s slides on maternal mortality and the rising rates and disparity related to that. And so for those of you
with a MPH background, who remembers this
social ecological diagram that shows the interrelationship
between starting at human, a individual, out to the greater
systems of your community, out to greater systems related
to public policy, etc.? And so, with that said, it’s
important for us to think about where these interventions lie and a relationship between them. And so, importantly, we’re hearing about what we can talk about with our patients, and how clinical providers
can be selective, for lack of a better word, and to engage with a
provider that would be someone they could relate
to through language, through an experience of
feeling like they belong in their healthcare system. We’ve also heard a little
bit about how around that, within our hospital systems, there are evidence based safety bundles that we can start to put in
place to start this interplay, or conversations and
communication around patient care, and standardizing and bringing quality to the way that we offer that care. And then greater than that, we also have these state policies and state activities that happen like our Maternal Mortality
Review Committees, the work on those maternal levels of care. So designating hospital designations. And then greater than
that, we’ve got these areas related to public policy. And so, you’d heard in
Dr. Declercq’s slides the policy that was passed related to funding Maternal Mortality
Review Committees. But as you can see, there’s
one to four examples maybe on each of those
areas, and potentially five, and with that, there’s more to go and more activity for us to grow within. And so, with that, I’d like
to allow folks to stand up and bring some questions to our panelists ’cause this is an interesting area of multidisciplinary teaming
that we can start to engage in across disciplines, across
areas within pubic health, and across our diversity of thought so that we can really start
to tackle this problem. Because I don’t see anyone
standing up just yet, and we have some more time, I’d like to take the liberty
to ask the first question. I think that what’s really
interesting here to hear about, and something that Dr. Molina brought up, and I think interesting for all panels, so the four of us are all OBGYNs, and that is this, who is
having the conversations? A lot of what’s been in the media has actually focused in
on other professionals related to obstetrics care, and those would be out
doulas and our midwives more so than our obstetricians. And I’d like to actually add that there seems to have been a
little bit of attention created between the two groups of practice in terms of having this conversation and how we can work together. One of them from a recent conversation that was hosted at
another university system during maternal mortality
and maternal health week came up, and the person
asked a question about, why would somebody who
had a maternal hemorrhage deliver again in a hospital? Why wouldn’t you go to a birth center? So we’re creating this assumption that delivering in a hospital leads
to these negative outcomes, and delivering in a birth center will lead to positive outcomes. I wanna throw that toward you guys and hear your thoughts on care delivery and the types of facilities that women are allowed to have babies, and what you think about the, how that plays into that conversation between the groups of people
that deliver obstetrical and prenatal care to women
when they’re pregnant. – I’m happy to maybe say
a few comments about that. I think, I certainly feel
that tension a little bit, at least how some of the stories are being portrayed in the media, that there’s this dichotomy between hospitals and other options whether it’s community
places, birth centers. And I think the important thing is a lot of the work around regionalization and maternal levels of care. So ACOG is doing a lot
of work around defining what sort of risk
stratification categories are appropriate for
different levels of care. So an independent birth center being like a level one level of care up to like a tertiary or
quaternary level of care. So I think it really
needs to be individualized based on a woman’s preferences and then what her potential risks for having a complication
during child birth really are. But I think it goes back to
that relationship between whether it’s a midwife and a patient, or a obstetrician, or
a nurse practitioner. I think what really matters is that there’s trust in that relationship and that these can be open conversations about what a woman’s potential risks are knowing that in obstetrics
there’s so much uncertainty, and we cannot guarantee
any particular outcome for any particular person. And so, I think that we need to move the sort of narrative
over into thinking about how can we engage patients
in these conversations and talk about these risks
that we are uncertain about, and how to help them sort of
navigate that decision making about where is most appropriate
for them to give birth. – I’ve had the privilege to
work with some excellent levels, and nurse practitioners,
certified nurse midwives, and I admire a lot of
the work that they do. I, myself, have just taken care of so many high-risk patients, even before I became MFM. So, that’s always been an
issue that I struggled with, especially with home births. While that’s a good
alternative for some women, I don’t know not many of
the women that I serve that would be a good alternative for. So I think we have to be very careful in the selection of people
that’s doing home births, again. And I think most midwives do really screen their patients very well and work with obstetricians
to make sure that’s happening. So, but again, a lot of the people, just the people that I work with, certainly aren’t good candidates for that, and that’s why I’m in this
specialty that I’m in. – I want to add that as I showed, most of the pregnancy-related
deaths are preventable, and pregnancy itself should be a wonderful and beautiful event and experience, and it shouldn’t be
ending in a tragic manner. And most of the time, the
hypertensive crisis we see are related to extremely
elevated stress levels, which could be sort of managed with someone who may not be a clinician, but if helping decrease that stress level is brought up in the hospital setting in addition to the medication we give, I think that’s the key. Because standard of care
alone will not do it. We know that clinicians do
deviate from standard of care, and sometimes that is what
leads to tragic event. That is what leads to all
the complications we see. Women should be treated
based on their needs not just what standard of care. It is in addition to standard of care. And what what we’ve learned that is doulas and nurse midwives
tend to give the patient more attention than they would ever get in a hospital setting. That alone can completely
drop your blood pressure, put you in a comfortable mindset that could improve your outcome. And I think it should be
a combination of the two. So we should really sort
of bring that relationship. In most countries, deliveries
are done by midwives not obstetricians. This is the only country where the majority is done by the obstetricians. And we do see that in other countries they do tend to have better outcomes based on again, really the care. You provide that compassion, how the woman is views as
important, and listened to. Like Gene Declercq said, we really don’t do a good job
at listening to our patients. A lot of women who died, it’s not because the care wasn’t there. It was there, but they’re
just not being listened to. – And that’s what I loved
about the Centering model, I love about the Centering model. I was in public health for 10 years prior to going back
and doing a fellowship, and we actually administered
in my health district the first Public Health
Administer Centering Program in the state of Georgia. And I wish that even for providers that didn’t have centering care, the one thing that I loved about it was that you spend more time with patients. You got to know them more per, you really knew them personally after doing two hour
session for each visit. But part of the experience
that we had in public health with our Centering Program was we had a multi-specialty
team of facilitators. We had a social worker in
there during our sessions. We had nurse practitioners, and we didn’t have midwives,
but we had nurse practitioners that provided most of the care, and sometimes I was in the sessions too. And then we had other providers that came at different
times into the session. I believe that a lot of
the care in this country, prenatal care, and care
beyond the prenatal care, and even postpartum extension would be so much better
if our patients were, if that care was delivered
by multi-specialty teams because different people are
gonna see different things and address different needs that a provider, a busy
provider will not address. And so, I mentioned about the
maternal deaths that we had just in the last two weeks. Well one of those deaths was in a patient that I consulted on the hospital, and I think she had no prenatal care, came in with premature
ruptured membranes, delivered. She was homeless. Well while she was homeless,
she was under an alias because of some domestic violence issues. She had a C-section, was discharged, and within two weeks of her, two to three weeks of her discharge, she was murdered in a park. Now that was a system that didn’t. We provided excellent medical care, but that was a system’s
issue that was not addressed prior to her delivery
and going back out there in a situation she came
from and was actually, we were protecting her
from in the hospital. So, again, I think it’s crucial, and I think that not only doctors but all levels of
providers, social workers, if we could provide that kind of care then we would have a much, we would have much
better perinatal outcomes here in the United States. – [Audra] Thank you for that. I agree with that. Do we have time for additional question? We have one standing and
one Loud Chat question. So we’ll keep our responses brief to this. The question reads, so much of what is prioritized in Massachusetts Healthcare Policy is focused on value-based care, return on investment, and
demonstration of cost containment. How can providers lead the
culture shift in systemic values? Admittedly, that’s a tough question. (laughing) It is from the state perspective. I don’t know if you’d have comments. – I can speak from a local
back in my public health issue. I mean, we identified
the need in South Georgia where we had contiguous counties
with no prenatal providers. We didn’t have prenatal
providers in public health, but I trained actually
two nurse practitioners on how to do prenatal care. We started our Centering Program. And we actually, we were
able to get grant dollars. There was no money from the state, and we actually went to different funders and went to community obstetricians ’cause we don’t do deliveries. We had to have their partnership. And so, we got to, I don’t know if this is
answering that question, but I think it is, that
we’ve got to show people what the states, where the states are and how that everybody can
be a part of the solution. And we partner with a lot
of non-traditional providers to bring Centering
Pregnancy to South Georgia. – [Audra] Thank you. – [Maureen] Yes, hello. Thank you for a great panel. I’m Dr. Maureen Paul. I’m the Director at Family Planning at Beth Israel Deaconess Medical Center. And in the interest of talking
about interdisciplinary teams I just wanted to urge us
to include Family Planning as part of our teams. I recently attended a
conference in Las Vegas that was sponsored by the new President of the Society of Maternal-Fetal
Medicine along with ACOG, and for the first time the
Society of Family Planning was part of that, and it had to do with reducing
morbidity and mortality just in women with high-risk
medical conditions. And we know that pregnancy intention as well as interpregnancy intervals, effect birth outcomes as
well as infant outcomes, and that it’s important to think
in the preconception period and have pregnancy planning as well as at the time
of discharge, right, for your next pregnancy, have pregnancy planning
be an important element as well as pregnancy
termination being an option for women with high-risk
medical conditions, which often is not offered, or the method of choice may not be offered because Family Planning people are not included in the conversation. So, I just wanted to bring
that into our conversation. And the question is, how much
is this kind of preconception and kind of planning
perspective being talked about in the conversation that’s
happening across the state around maternal, reducing
maternal mortality? – Not enough. (laughing) – I would say, there’s
been a renewed interest, in particularly from ACOG
around postpartum care, and optimizing postpartum care, and thinking about it as a continuum and not just a single visit at six weeks. And certainly comprehensive
family planning counseling actually belongs in prenatal care to optimize the choices for postpartum, and then to, as you just mentioned, get to an ideal birth spacing sort of plan for all of the positive impacts of that. I think that there is also, interestingly, I think it’s at APHA, the sections around maternal health and then sexual and reproductive
health were separate, but from what I understand
the President Elect who I believe is Monica McLemore from UCSF is deliberately and intentionally
integrating those two because it’s kind of a false dichotomy that they shouldn’t be in separate camps, that they really need to
be considered holistically and sort of on a continuum given
that there’s preconception, there’s interconception, as many people in this country
have more than one pregnancy. And so, I think there
is a growing interest in bringing those two fields together. – Something that I’d also
like to add for our state, for Massachusetts, is our state Perinatal
Quality Collaborative as we’re doing work implementing
the safety bundles for AIM. We’re starting with opioid, and looking at this
maternal mortality issue and the rates there. We are also actively engaged in the state of Massachusetts PICCK Program, which is the Partners in
Contraceptive Choice and Knowledge. That’s being led by
Kate White through BMC. And through that program
that’s state funded, the focus is not just
simply about contraceptive or contraceptive methods, and
training physicians on how, or the providers on how
to place long-acting reversible contraceptives
immediately after delivery and those kinds of issues. It’s really more about how
do we engage in communities and populations of women
so that they understand what their contraceptive choices are and raise the knowledge in a
way that is culturally humble as we have those conversations. And so something that
we are thinking about on the state level and
actively engaged in as well. With that said, I think
I’m gonna start getting an eyebrow raise from Dr. Kaplan if I don’t wrap our session up so she can moderate her next group. I wanna offer profuse thank
you to the panel that’s here. Again, a collection of
people who are not only experts in their areas
and leading the charge, but also dear colleagues and friends. And so thank you again. I’d like to give them a round of applause. (clapping)

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