- [Narrator] Conversations for the Common Good is made possible by the support of Maternal and Family Health Services.

(calming music) WVIA presents, Conversations for the Common Good Civil Discourse, Civic Engagement: A Regional Approach to Maternal Care.

And now, moderator, Tracey Matisak.

- Hello, everyone.

Welcome to Conversations for the Common Good: A Regional Approach to Maternal Care.

I'm Tracey Matisak.

Pregnancy is often viewed as a time of anticipation, even celebration.

But for far too many Pennsylvanians and their families, pregnancy can end in tragedy.

Maternal mortality rates have been increasing here and around the country for decades.

In fact, the United States has the highest maternal mortality rate among high income nations, and the rates of maternal death for Black women exceed that of entire nations.

Even worse, the vast majority of those deaths are preventable.

So why is this, what's causing these deaths, and what's being done here in Northeast Pennsylvania to ensure that as many pregnancies as possible have healthy outcomes?

To address these questions and more, we have assembled an expert panel well versed in this critical issue.

Dr.

Maria Montoro-Edwards is President and CEO of Maternal and Family Health Services, a nonprofit organization dedicated to meeting the health and nutrition needs of Northeastern Pennsylvania's women, children, and families with information, education and quality care.

Dr.

Amanda Flicker is Chair of the Department of Obstetrics and Gynecology at Lehigh Valley Health Network, part of Jefferson Health.

And Sara Goulet serves as Special Advisor to the Pennsylvania Secretary of Human Services, Dr.

Val Arkoosh.

Her work focuses on maternal health initiatives among other responsibilities, and on what's being done at the state level to promote healthy pregnancy outcomes for all Pennsylvanians.

So welcome, and thanks to you all for being here.

Dr.

Flicker, I wanna begin with you and ask you to just define what we mean by the term maternal mortality.

- Sure.

Maternal mortality is the death of a pregnant individual, either during the pregnancy or within a year postpartum.

And we usually further break that down into deaths that are associated with the pregnancy.

So either a condition that may have been made worse because of the pregnancy, or may have arisen because of the pregnancy, or those that are pregnancy-associated and may not be specifically related to the pregnancy itself.

- So there's maternal mortality, and there's maternal morbidity.

What's the difference?

- Morbidity are serious outcomes that may have short or long-term consequences for the individual, but don't result in death.

And they may be a, like a near miss or a precursor event that could have ultimately led to a maternal death.

- So for example, what might?

- So for example, things like fluid in the lungs, pulmonary edema, injury to the kidneys, need for admission to an intensive care unit, a hemorrhage that requires blood transfusion.

Those would be a couple of examples.

- Yeah.

Sara, what do we know about maternal morbidity or mortality, I should say, in Northeast Pennsylvania in particular?

How does Northeast Pennsylvania compare to the rest of the state?

- Well, let me start by saying, the Maternal Mortality Review Committee, the folks on that committee do a tremendous job in reviewing the cases.

We know that one maternal death is too many, but here in Pennsylvania, there's a really thorough solid review.

We fortunately don't have so many deaths that we do break them out by region.

So at this time we don't, we can't say, oh, there's been this many deaths either associated or related in Northeast PA.

I will say though, that the recommendations of the Maternal Mortality Review Committee are being implemented through coalitions, one of which Maria here heads up here in Northeast PA, which is focusing on the recommendations of the MMRC, or the Maternal Mortality Review Committee.

And that's where really some regionalization can take place by looking at those recommendations and saying, oh, this really does pertain to a situation we have here, whatever that may be, lack of access to care, a higher rate of behavioral health or SUD occurrences.

So things that allow regions to then look at their needs based on the recommendations of the MMRC.

- And I do wanna come back and talk more about that Maternal Mortality Review Committee, because that's important.

And that group has really been studying some of the numbers and getting a good sense of where we are.

So we will come back to that.

Dr.

Montoro-Edwards, what does the rate of maternal mortality tell us about the overall health of a given community?

What's the relationship?

- So it gives us an idea about the quality of care, the care linkages, what's available within the community, and maternal mortality and morbidity are good indicators of what's available in the community to support families, both prenatally and postnatally.

- Yeah.

Dr.

Flicker, I was struck by the fact that the United States has the highest rate of maternal mortality among high income nations.

I mean, in a country that prides itself on the quality of medical care that we have, that was stunning to me.

Why is that?

- There's a lot of reasons that go into that.

You know, one upfront is record keeping, and using standard definitions across various countries.

So it's really important that we're all speaking the same language when we're making the definitions that we shared early on.

But that aside, we also know that there are several factors in place.

One, as Sara mentioned, access to care.

So can patients afford care?

Can they get to care?

Is care available in their areas?

And I know we're gonna talk a little bit later about maternity care deserts, but just a little teaser for that.

And then there's the health that we bring to the pregnancy.

So in our country, people enter pregnancies now later, and sometimes less healthy than we should be or we ought to be with issues like obesity, and diabetes, and hypertension.

So those are just a couple of the things that contribute to why the United States stands out, unfortunately, in that way.

- Sara, I was reading that mental health has been cited as, at least by the Pennsylvania Department of Health, as the leading cause of pregnancy associated death, which surprised me.

Can you unpack that for us a bit?

- Sure.

Well, when you say mental health, we tend to use the term behavioral health, which includes mental health conditions as well as substance use disorder.

So people who have either of those, women who have found, either they've had a history of mental health, behavioral health prior to the pregnancy, during it, or potentially after.

And so we do tend to see those contribute to where the majority of our maternal deaths are, which is past that six week checkup.

So people, you know, finding out that they might have a need, and maybe not being able to be connected to care, or the longer they go past that six week checkup, they're just simply not getting care.

There are challenges too with people getting behavioral health and SUD care.

Connection to providers, it's tough, right?

There's not enough providers, there's not enough care.

And sadly, there's still a stigma associated with people who have behavioral health or SUD needs.

And so people are hesitant, particularly if you think about you've just had a baby, and you may have substance use disorder that you're dealing with, you might be very concerned about seeking care because you might worry that maybe that baby won't, you know, could be taken from you.

And so that's the last thing anybody wants to happen.

We want people to get care.

So it's a lot of that access to care, a lot of that is access to providers who might not be there.

And certainly there's things that we're doing to try to improve that.

A lot of things that we're doing with screenings, with connecting people to telehealth, even mobile care for people.

So a lot more ways to ensure that people can get the care they need.

But it's a challenge.

I think you would probably both agree from your experience in terms of people getting the care they need around behavioral health.

It's an ongoing challenge on a number of different levels.

- And when you talk about SUD, substance use disorders, would you say that that is the majority of the behavioral health concerns that we see in terms of being a key factor when it comes to maternal mortality?

- Yes.

- Yeah.

- It's a lot of self-medicating.

Postpartum anxiety and depression are real.

And there are so many fluctuations with hormones in the perinatal period.

And unfortunately, there are too few behavioral mental health providers, but also too few who are skilled or certified in perinatal mood and anxiety disorders.

- And Dr.

Montoro-Edwards, can you speak to that a little bit more in terms of what you might see, or what the clinics across the state might be seeing, particularly here in Northeast Pennsylvania when it comes to substance use disorders, and how well trained are medical professionals in the area to address those things?

- Well, medical marijuana is a challenge because it kind of conveys that it's not as detrimental as a street drug, but unfortunately it could be.

And so often we see folks who may be getting it from somebody else, or they're not getting it on the street and they think it's okay.

So that's certainly a challenge.

- You mentioned postpartum depression, huge issue, and how that may factor in as well.

- Sure, well, often, this happens several weeks to months after the delivery.

And so we find that Maternal Family Health Services, having those resources available to mom, maybe six months down the road when things might be a little bit more challenging than they were two weeks after the birth, having those resources available, having a place where mom knows that they can get those services and nonjudgmental.

- Yeah, and Dr.

Flicker, there was something you were about to add.

- Yeah, I was just going to add, I think also during the course of a pregnancy, asking multiple times about somebody's behavioral health needs and screening assessments.

We know that many people may not feel the trust related to stigma, or concern about outcomes for their family to be able to share that information about a substance use disorder that they had.

Maybe it's opioid dependence, maybe it's, you know, other substances that they're using.

And so more and more, we're screening people each trimester to be able to offer the help to them and their families so they can have a safe delivery, and keep their family unit together.

- One other thing to add too, we know that people prefer to get care from someone they trust, right, and someone that looks like them, or someone that they just, you know, entrusted with their care.

And so on a relatively new program is the Perinatal Tips Program.

So it's essentially an opportunity for a healthcare provider, it could be someone like yourself, like an OBGYN, it could be a doula, it could be a community health worker, someone, it's a hotline, if you will, for them to call that care provider, to speak to a behavioral health specialist and say, "Hey, I have a patient, or I have a client, "and we got something going on, what can I do?"

And so it allows them to take action on behalf of the person, the patient, or the person they're working with, again, in a really comfortable setting, and get some direction to care, some connection to care in a means that generally is much more, you know, amenable to the patient themselves, where they're hearing from that trusted provider.

- And where that's valuable, like Dr.

Montoro-Edwards was saying, some clinicians just don't have the expertise.

They might be behavioral specialists, but they don't have the expertise in perinatal mood disorders.

And so they can phone a friend, if you will, through this hotline, and get that advice for certain medications that might be safe for breastfeeding or other treatment modalities that might benefit somebody if the first line things aren't as effective.

And that's a new program.

- It is new.

There's a really cool program too that University of Pitt is doing the pharmacy school, which allows people, especially if you think of your community pharmacist, like some people are, you know, I don't actually have a small community pharmacy unfortunately.

But for those that do, there's a trust placed in that pharmacist, and they're doing a really cool program where pharmacists can work with pregnant and post-partum individuals to essentially say, "Oh, these medications might not go well together, "or you might want to think about this."

And just, again, that other trusted advisor or provider for them.

And I think that's a really cool program to bring pharmacists onboard somewhat.

- And it speaks to kind of casting a wider net, right, of people who are in a position to help prevent these kinds of outcomes, and just providing resources for the providers, right, to get extra input and assistance as they're trying to help women through this.

Is that something, is that widespread?

You said it's new.

Is this widespread throughout Pennsylvania?

Is it something we're seeing in other communities?

- Perinatal Tips is around the state now.

There's, I think there's four in each, like kind of the four regions, if you wanna divide the state into quarters kind of.

And then the pharmacy program is just a pilot now that the University of Pittsburgh is doing.

But yeah, and there are other programs, there's a Tips Program for children, and that's really what this sort of grew out of because it was a really successful program.

And each of the grantees who receive funding to start the perinatal tips are doing things, again, that are kind of regional, getting back to our regional conversation.

Well, we kind of feel like we need this here, and it might not be true in another part of the state.

So that really does allow kind of that customizing, if you will, for regional needs.

- Dr.

Montoro-Edwards, Dr.

Flicker mentioned rural moms and the difficulty of access.

- [Amanda] Yes.

- In many cases, you have health centers that are sprinkled throughout Northeastern Pennsylvania.

But can you speak to that, the difficulty for some women of just getting access to care at all because of their zip code?

- Well, sure.

The rural nature of so many of our communities makes transportation quite difficult.

And so if someone doesn't have that transportation themselves, we can sometimes provide a gas card, or Uber is sometimes an option, but it's a very expensive trip for a family to have.

And those things make it difficult for mom to keep appointments.

So there's often missed appointments.

And that really interrupts the continuity of care.

So one of the things we're doing at Maternal and Family Health Services to help address some of those challenges, we're piloting a program starting next month to screen, and refer, and treat mothers who are in our Women, Infants, and Children Supplemental Nutrition Program for Behavioral Health.

So you have that trusted relationship with your WIC nutritionist.

This is somebody that you'll be seeing every three months, and so they know you, and they can help identify that there might be a challenge, and then do that warm handoff to one of our care navigators and our providers so that we can take them to the next level.

- Yeah, and I wanna come back and talk more about WIC as well a bit later in our conversation.

Dr.

Flicker, I was also struck by the fact that Black women die at twice the rate of their white counterparts.

Why?

- We're really continuing to investigate and understand the causes for that.

Certainly I think we've thankfully moved from the phase of knowing that information through data collection, and now digging deeper into the whys.

So some of it is implicit bias.

Structural racism is part of the problem, as well as weathering, which is persistent stress that one may feel related to implicit bias or other things.

And then those can develop even into physical conditions, whether it be hypertensive disorders, whether it be diabetes and other conditions.

And then those things also predispose you to adverse pregnancy outcomes, - Right, so it's a vicious cycle.

And I was struck by a study that I read about that said that medical students were surveyed, this is maybe 10 years ago.

But medical students were surveyed about their beliefs about patients of color, and that many of them believe that Black people have a higher pain tolerance, which then means that also Black patients are not necessarily taken as seriously when they complain of pain and other issues, which then leads to them maybe not getting the same level of pain treatment.

How big a concern is that?

- I appreciate you raising that.

Sorry for interrupting.

The CDC has a campaign called Hear Her.

And so I think it's really paying attention to the need for healthcare providers to listen to our patients and acknowledge things like pain, shortness of breath, other symptoms that may be a sign of something more serious that's occurring.

And then managing that at the individual level.

Your pain is probably not the same as her pain, and so we can't make assumptions about any individual group or person based on that.

And I think that Sara also mentioned about the identity of your healthcare provider, and feeling that sameness and that connection.

And so increasing the diversity of our workforce can help with the trust component in that physician-patient relationship.

- You mentioned trust, and that's another factor I think, because in many communities of color, there is sort of an inherent distrust of the medical community, oftentimes with reason.

But that sounds like another sort of piece of the puzzle, right?

Addressing that sense of distrust, and also bringing in more doctors of color.

- Right, yeah.

I think it's the listening, and the acknowledgement and the affirmation, and then the response as well.

- Yeah.

There was an interesting quote from a doctor in the Philadelphia Public Health Department who said that the inequities are not biological, they are systemic, to your point about, you know, racism and so forth.

But also, I think if I heard you right, Dr.

Flicker, you said that there are just other factors, just the inherent stress, right, that can come with racism, that can come with all of these systemic factors that then manifest as health issues in pregnancy.

- Right, and in and outside of pregnancy as well, sure.

- I also wanna talk, Dr.

Flicker, while we're on this subject, another thing that surprised me as I was preparing for this conversation was, I read that more women die postpartum than leading up to and during labor and delivery, which surprised me.

Why is that?

What are the causes?

And we should talk about what that postpartum care should look like.

- Part of it is going, looking at the reason for it.

First of all, we mentioned that the most common cause or associated cause of maternal death or maternal mortality are behavioral health disorders.

And so they're exacerbated in the postpartum period often.

So that's part of it.

Additionally, if, you know, for those of us who have children, the period, the time after you give birth, you see a pediatrician or a pediatric care provider numerous times.

But how many times did you go back to the provider for yourself?

Very few.

So partnering together with our pediatric colleagues can be really important.

You know, Maria shared about using WIC as an avenue to screen for behavioral health disorders, but partnering with our pediatric providers, if I come into the office for my child, can you screen the mother as well, and look for some of those things?

So it's that.

And then, you know, we had periods of time where the six weeks was the end of your care.

Now we talk about the fourth trimester.

And so it's really giving more attention to that year beyond, whether it's behavioral health disorders, whether it's managing diabetes, whether it's managing blood pressure from a hypertensive disorder of pregnancy.

So for all of those reasons, that year is really critical, not just in the life of the newborn, but in for the mother as well.

- And Dr.

Montoro-Edwards, talk about what you see in the various health centers that you run across Pennsylvania as it relates to that postpartum care.

What you provide, what does that look like?

- So we have a fourth trimester program, and that provides additional support for mom in terms of postpartum anxiety and depression, additional nutrition, breastfeeding support.

So many times you might see the lactation counselor while you're in the hospital, and the pediatrician will often have a lactation counselor.

But those times in between, you know, there are a lot of questions, and so we provide those in person or via phone, and it's really just helpful to be able to take away some of the mystery of what's going on with your body.

And that's a lot of what we do.

- Sara.

- I just wanna add something too from the Department of Human Services.

So we're the Medicaid agency, and I know we're gonna talk a little bit more about some of the challenges Medicaid has been having.

But to Dr.

Flicker's point about postpartum care, and ensuring that people get the care they need, you know, we've extended Medicaid now to 12 months post end of a pregnancy for whatever reason that may be, so if you're covered under Medicaid.

And also I think going back even further, because you talked about earlier on, right, we know that a lot of women who enroll in Medicaid because of their pregnancy, they would be eligible and might not have been otherwise, don't start to get care till into the second trimester.

And we need people to get care earlier, because if there is a chronic condition, if there is a mental health or behavioral health condition, get them into treatment earlier so that they have a healthier full pregnancy, and especially postpartum.

And I think too, we're doing a lot more to ensure that that continuum of care happens so that they do see their physician, not just the pediatrician.

There's a lot of, pediatricians are great for like helping to do screenings and things for even for moms, but also, you know, the reproductive planning.

Like so are they, oh, do they wanna get pregnant again, or, right, or can we connect you to a primary care physician so that at the end of that 12 month post Medicaid, you know, you have somebody that's gonna continue to care for you, sort of interconception type care, and just your ongoing healthcare.

Somebody said at some webinar I was on that once you've had, you're postpartum forever, you know, like if you've had a child, you are postpartum, you know, for the rest of your life.

So really just ensuring that women know, you know, you gotta take care of yourself.

We all have, if you've had, you know, you have children, right?

We all have kids here, you start forgetting about yourself because you're focused on the children, and that's not necessarily a bad thing, but you gotta do both.

And so I think, you know, we're really trying, we work with a lot of community-based organizations that try to get to women, you know, kind of early on and be like, oh, are you not enrolled?

Let's help you enroll, and let's get you, you know, your first appointment so that people are like, get into that regular routine of care, and have that continue postpartum is incredibly critical.

- So since we're talking about Medicaid, and you said that the benefits have been extended.

- [Sara] Yes.

- But there's been so much confusion about that, right?

Because we've been hearing about cuts to this program and cuts to that program.

And I wonder if you've seen, has there been confusion where people are just assuming that they're not gonna have the benefits, and what does the effort look like to raise awareness and educate people that the benefits are there?

- Sure, and you hit the nail on the head when you said people are confused,, and we've had people say, "Oh, I thought Medicaid went away."

So typically if you're a Medicaid recipient, you annually have to renew, so to ensure that you're still qualified.

Now people will have to do that twice a year.

Not yet, but they will have to.

Same is true for SNAP, which is Supplemental Nutrition Assistance, formerly known as food stamps.

So there's a lot more barriers, a lot more hurdles, a lot more frustration for people who are already busy, and already living with some weathering I would say, is in some instance.

About 30% or more of births in Pennsylvania are Medicaid covered.

But it's a lot more hurdles for people, and it does create confusion.

We have a very robust campaign around advising people, you know, that Medicaid is still here, here's what you need to do, here's how we can help you do that.

And again, we work with a lot of community-based partners.

I'm sure you're doing a lot of navigation for recipients so that people know it is still here, and we're here to help you ensure that you, you know, get the benefits that you qualify for.

- Yeah, and Dr.

Montoro-Edwards, if you'd speak to that as well.

- We saw a lot of confusion during the federal and state shutdown this fall.

There were so many people who confused the SNAP program and the WIC program, and thought that their WIC benefits had ended.

There were also, we saw a drop in some of our clinical participants because people didn't think they had medical assistance anymore.

And so people were not taking care of themselves.

And so we know that something like that has a tremendous ripple effect in a family.

- Yeah.

Well, and there's also the concern that, as Sara pointed out, there are now more hoops to jump through.

The benefits may be there, but you have to actively do more, right, to be able to access them, which can be difficult in itself for people who may already be overwhelmed, especially if you've already got young children.

If you have a substance use disorder, if you have one of those sort of aggravating factors, and now you've gotta jump through more hoops, right?

And so I wonder if you, you know, kind of speak to what that means in terms of helping people through that, making sure that they're aware of that sort of thing.

- So that's where care navigation becomes very important.

We do have care navigators that can help clients apply for various programs, and to verify their eligibility.

And that's critically important for individuals who may have a low literacy level, or may be English language learners.

Also, you know, being tech savvy, and having access to the internet, and being able to do the forms online is sometimes a challenge.

- Yeah, for sure.

Dr.

Montoro-Edwards, one other question, because you mentioned WIC, and are you the largest WIC provider?

- Maternal, yes.

Maternal Family Health Services is the largest WIC provider in Pennsylvania.

We serve 17 counties, and approximately 50,000 infants, mothers, and children up to the age of five every month.

- Yeah, and Pennsylvania is a leader then in that respect as it relates to Pennsylvania.

- Certainly is.

Pennsylvania has been a leader in so many aspects of what is needed to prevent maternal mortality and morbidity.

We are very fortunate that the Commonwealth has advanced several initiatives, and we are, fortunately all of these initiatives are moving in the same direction, working with the same priorities.

And so that we are very strategic in the approach to make sure that there's no duplication of effort, and that the community is really involved.

- Yeah, Dr.

Flicker, let's talk a little bit about training and the way that medical professionals are trained to work with women particularly, I mean not just during pregnancy, but certainly during labor and delivery, and in the postpartum time as well.

And there are lots of different, you know, we know there are midwives, there are doulas, there are OBGYNs like yourself.

And I think for the lay person, that can be confusing, especially as you get into midwives and doulas and so forth.

So can you walk us through a little bit, I mean, first of all, talk about what it is to be a midwife, and what that entails and what the qualifications are, and what do we need to know?

- Right.

Well thank you for asking that question, 'cause I think there is some confusion about, you know, who's on your team when you're considering pregnancy and childbirth.

And so many people are familiar with what an obstetrician is.

But in order to continue to provide care with some of the workforce challenges that we're facing across the country, and certainly locally, investing in our team, building our village is really important.

And so family medicine physicians and clinicians can also provide prenatal care, and some of them will attend birth as well.

And then you mentioned midwives.

So within the state of Pennsylvania, midwives can be licensed to practice if they're a certified nurse midwife.

So people who've completed nurse training, and then they go on and do midwifery school after that, that's the pathway for licensure in Pennsylvania.

In other states, and maybe one day in Pennsylvania, there'll also be a pathway for a certified midwife.

So they don't do the nursing piece of it, but they do the same midwifery training.

They're certified by the same board, and then they might be eligible for licensure.

Another category is what's called a certified professional midwife.

They go through a different pathway for training, and a different certification board.

They tend to be, because they're not eligible for licensure in Pennsylvania, they tend to be more home birth attendants.

And then often people will use language like lay midwife, which are folks who may be attending home birth, and not necessarily certified by a governing body or eligible for licensure.

It's a little complicated, but it's, I think it's important for people to know and be informed when they're making decisions about who's going to provide their prenatal care, and who's going to attend their birth.

And then, yeah, I mean you mentioned about sort of other people, and we can talk about it, but when you come in to give birth, your team includes those people, but may also include nurses and anesthesiologists, and you know, pediatric providers to tend to the baby.

We mentioned a little bit earlier as we were discussing about doulas.

And so doulas are nonclinical folks who may provide advocacy and support for patients and their families.

So they are often trained, and I think Sara can probably speak a little bit more to what's happening in the state related to doulas, but they're really enhancing education and support, and often advocacy for birthing persons.

- So would you say that with that hierarchy that you just listed, would the doula have the least amount of medical training?

- Yes.

- Out of that group?

- That would be fair, yeah.

- And Sara, if you could speak to that as well.

- Sure, so in the Medicaid community, we now can enroll doulas, or I should say doulas can enroll as providers.

So they must be certified for this day.

You have to have some mechanism where you're showing your, that you've been trained.

And we do have, I think upwards of 200 doulas now enrolled.

Might be fewer than that, I don't know that exact number.

Yeah, we have more certified than we have enrolled.

It's a process, right?

I mean you can attest to like, no one's like, oh, it's so easy to do claims and be a provider.

You know, especially for someone who, for a lot of doulas are just like sole proprietor, right?

They're used to someone paying them out of pocket, and there will be plenty of doulas who will continue to do that.

But having them be able to enroll in Medicaid opens up the opportunity for anyone, you know, really to have a doula if they choose to.

Pennsylvania's also the first state, we think, in the country that now has a registered doula apprenticeship program, which is apprenticeship through just like you would think of a carpenter or an electrician, the same type of process to develop an apprenticeship.

It's a year long apprenticeship.

The beauty of that is you're paid while you train.

So it certainly opens up the profession to people who might have been like, well, I can't afford to go train, and I have to work, and I, you know, so it really does give more people opportunity to be a doula.

And it's a really robust training actually developed with an OBGYN who has a training program.

And now, because you have to work with somebody to develop the program, right?

So we're really excited about that.

So, you know, talking with some healthcare systems about, you know, bringing on doula apprentices, and helping them train so that they can be a part of that team, 'cause you do want people to have the team around them that they want.

And if a doula is part, you know, is something that they want, they should be able to be part of that team.

And so integrating that care, and having them sort of slot into the role they have.

I kind think of them as a coach for the birthing person.

You know, they can really be there to answer questions, and hopefully be helpful to the clinical staff.

- Yeah.

And just to drill down a little bit further, and maybe Dr.

Flicker, you can clarify for us, because you kind of gave us the hierarchy as it relates to midwives.

How do you advise your patients when it comes to, if a patient says, you know, "I'd like to have someone else here "as part of my support team", how do you advise them and what might those different levels of support, like practically speaking look like?

- I think one part is assessing the patient's level of risk in terms of selecting their care provider, like their healthcare provider.

But then what are their goals for their pregnancy and who do they already have, right?

Do they have a trusted sister, aunt, mother?

Do they have a family or community member?

Some people will bring somebody from their church.

So, who's already on your team?

And then what do you feel like you're missing?

Now, it's certainly beneficial where patients before might not have been able to access a doula because it was a cash only service.

Being able to have medical assistance pay for it opens that door for more people to access that.

And so, you know, there some patients will develop a birth plan, so they might think about the way they want their birth to be conducted.

And it's, while there's so much that's unanticipated in a birth, it's really, I think, an opportunity to have a discussion.

Usually the birth plan's brought up later in pregnancy, but it's a place where we can have a conversation about how do you want, what are some of the things that you would opt in for or opt out for?

Is that reasonable and appropriate for your level of risk and your medical condition?

And then who do you want there, what do you want the environment to look like?

So I think it's a really great time to talk about expectations for both parties.

- And then what does that look like for you as an obstetrician?

If you're working with, say, a midwife or a doula, what does that look, in an ideal world, because as you said, things can go any number of directions, right, once you get into labor and delivery.

But what does that look like in terms of the working relationship that you would have with those professionals?

- To clarify, do you mean for an individual patient or like within a healthcare system?

- Yes, as you're in the labor and delivery process, what sort of the, obviously you have the job of getting the baby out, but what is the sort of division of labor and what might that look like in a labor situation?

- Hopefully you've had that conversation up front, right?

Where we, if we've had the opportunity to chat with the patient, develop the birth plan, and understand who's gonna be in the room with them, is it gonna be their spouse and their sister, and maybe they have a doula or they don't.

And then often by that point, they've already chosen whether their care is gonna be provided by a midwife, a family medicine clinician, an obstetrician.

Maybe they even need more high risk and complex care from a maternal fetal medicine specialist, right?

We haven't even talked about them yet, but they're really an important part of the high risk care team.

And so, you know, we can set that stuff up in advance.

And that's where also choosing the facility where you give birth matters, whether you choose to up, you know, whether you're gonna choose an out of hospital birth, and you know, risk appropriate patients may choose that, then maybe you would choose a birth center.

Those tend to be lower intervention midwifery-led facilities.

And we have a couple, fortunately a dwindling number across the state of Pennsylvania.

Okay.

And then hospitals have different levels of care as well.

Most specifically defined by the care for the newborn.

You know, NICUs, people are familiar with intensive care units for premature or medically complex babies.

So identifying your level of risk upfront, your preferences, where your clinicians feel like you would get the best care, I think is really important.

And then if you choose a midwife, you know, finding a hospital that has midwifery services is important.

And there are a lot of them across the state of Pennsylvania.

- Yeah.

You talked about risk factors, and one of the factors that we really didn't talk in depth about in this conversation is age.

And how big a risk factor is that, at what point do you enter the high risk category, and what does that mean?

- Right.

Historically, it had been 35 was like the breakpoint, but that had to do with some like genetic risk.

Really, you know, there are women who are in their late 30s and early 40s having pregnancies who come in very healthy, and some women who are in their 20s who are medically complex.

But as we age, right, we have increased risk for things like blood pressure problems, diabetes.

I know I keep saying that, but those are two of the very common medical conditions that can complicate pregnancies.

Weight-related issues become a bigger problem often as we get older.

And those conditions can lead to abnormal fetal growth, can lead to issues, anomalies that the baby might develop.

Preeclampsia, which is a condition of pregnancy, where you have high blood pressure and can affect other body systems as well.

So screening for all of those things.

So as we age, those things become more likely to develop.

- But we don't call it a geriatric pregnancy anymore.

- We thankfully don't, yes.

- Which sounds awful.

- You're 35 for geriatric, right?

- Or elderly.

- Yes, we've done better.

- Yes, we're getting better.

We're doing better.

- That was a term that probably needed to go.

- [Amanda] Yeah.

- Dr.

Montoro-Edwards, do you see in your health centers, are there a fair number of women who choose to have at-home births if they are in a position to that in terms of their physical health?

- I can't say that we see our clients leaning that direction.

Primarily our clients will have, will give birth in one of the local hospitals.

One of the things that we so often see with our clients is that we're in much more isolated society now than we were just two, three decades ago.

And families don't have the support systems that we may have had when we were having our children.

And so maybe there isn't a mother, and a grandmother, and sisters, or brothers, whatever, to come around you and give you all that help that you need.

So there is definitely a role for a doula to provide some of those supports for mom.

But unfortunately it seems like we may be more electronically connected, but physically we may not have those familial connections.

- Yeah, are you seeing more women taking advantage of doulas to be part of their birthing process?

- We don't provide doula service at Maternal Family Health Services.

And so I can't say that it is increasing in Northeastern Pennsylvania.

There are some providers, but we are not at this point.

Dr.

Flicker?

- Another point, I think your point is valid about not necessarily having the familial community to support people during pregnancy, but group prenatal care programs can be a nice solution to that, where you have peer support.

So Centering Pregnancy is one of the most widely known models of that through the Centering Healthcare Institute, which really brings together a cohort of birthing persons, and or their families or support persons can also join, usually around the same part of their pregnancy.

And they have group visits, so they have a very brief visit that's centered on their own, checking their blood pressure and they're waiting and answering any specific questions they might have.

But then they have a group session where they get education, and there's a lot of peer support within that group.

And I think those are great.

Also, options for families who are a little less connected.

- Absolutely.

We use the maternity medical home model of care.

And so in our practice in Scranton, our circle of care practice, mom will have access to so many services in that one location.

So oral health, prenatal care, reproductive health of birth spacing, the women, infants and children program, nurse-family partnership, even maternity clothes and transportation support are all available.

So one of the things we try to do is take away that transportation barrier, that if you can get to us, and so many times, moms have to bring other children with them because they don't have anyone to watch them.

And so it's better if we can help them get what they need at that one visit.

- Yeah, it's one stop shopping.

- That brings up home visiting, which you mentioned some of those programs.

Home visiting is covered under Medicaid as well, or we keep saying Medicaid and medical assistance, it's the same thing.

It's an opportunity for someone to really help out a mom.

I know like in Europe I think they're like, oh, they'll be there tomorrow, and they'll do whatever you need, you know, like they essentially just like what maybe a family member might have done.

But you know, not everybody has that, to Maria's point.

And so home visitors can really come in and help a family just kind of get used to having a new child in the home, and you know, and can see things that, you know, maybe are a red flag about the mom's care.

So it's a really great program.

Unfortunately some people are hesitant to have someone come in their home.

I do know some providers of home visiting services will offer home visiting as telehealth to start, and so getting comfortable with the family, getting comfortable with the home visitor, and then they'll ultimately say, you know, how about we come out to the house, and I think they have like pretty good response to that.

- We do public locations as well.

Maybe a Dunkin Donuts or a playground.

- Yes, which is awesome.

- Things to work well.

- Just give people comfortable.

- It also makes me think of Nurse Family Partnership, which is probably the best to speak to that program.

- So Nurse Family Partnership is an evidence-based model, and it's been in existence over 40 years in the United States.

Pennsylvania, I believe it's been in existence here well over 25 years.

And it's an amazing program that pairs a pregnant mom with a personal nurse until the child turns two.

And this nurse can provide all kinds of support and help with parenting, health, even career goals for mom along the way.

But it's so often we hear from clients that say, I don't know what I would've done without my nurse.

It really changes lives.

- Yeah, yeah, that's incredible.

And it does keep people connected to care in some instances.

- It is, and it's an upstream program because so many of the studies have shown that for families who are engaged with the Nurse Family Partnership, so many other challenges are averted down the road.

And it's actually a cost saving program that there are fewer dollars spent on other supportive social services because of this early intervention.

- Yeah.

Dr.

Flicker, you mentioned that, you know, we never know until we get to the labor and delivery process, what may happen and things can go sideways sometimes.

What would you want women to know who are concerned about that, that what if I have an emergency during that process, like, you know, is the hospital equipped to handle that?

What should women know about what's in place for an unusual situation?

- I appreciate the way the Alliance for Innovation Maternal Health, AIMH Project, but listed out their recommendations for various severe obstetric issues.

One is readiness, then recognition, and then response.

They also include reporting, but we'll focus on the first three.

And so I think first we talk, before we talk about that, which is in the hospital setting, choosing the right clinician and the right facility is really important, and that's where the patient and the clinician need to work together to make the right decision, right?

So there, because there are lots of options, the setting where you might give birth, the clinician who's going to attend your birth.

But speaking specifically of birth centers and hospital settings, readiness is, do we have example would be like a hemorrhage box, which is basically a box that is kept together usually in your pharmacy system where all of the medications we might need to respond to an obstetric hemorrhage are already.

So the nurse can just get it, and we can use those medications, and she doesn't have to pick each one out individually.

That's an example of like readiness.

And then another example might be simulation training.

So many facilities, for a while, it was required by the Joint Commission to do simulation training for hypertension and for hemorrhage.

But certainly people do it for lots of other things where we simulate an emergency scenario, usually with your team members in ideally in your setting to practice those skills, not just the hands-on skills, but also our teamwork and communication.

And then the response is how do we mobilize that team when we need it, or recognition just to take a step back.

Recognition then is sometimes in the electronic medical record, it might flag somebody to say, look at this patient, her blood pressure is really high.

And so one, there's lots of challenges with electronic medical records, but that's certainly a benefit that we have seen.

And then the response, like I said, is what do we do to bring that team together?

Is it an overhead page?

Is it an emergency button?

And then do we have those resources together?

So I hope that people know that we prepare for emergencies that may arise every day, even when we don't have one that occurs.

- Sara, early on you mentioned the Maternal Mortality Review Committee, and I promised that we would come back to that.

How did that come to be, and what are we learning from the work of that committee?

- Well, in Pennsylvania-wide it was 2018.

I don't remember if it was like a statute, I honestly don't remember it.

- It was legislation that primarily sponsored by one of our state representatives.

- Maybe you should have.

No, I'm just kidding.

- It was one of the founding members of the MMRC.

- This is why she knows this.

- It was many years of work to get the legislation passed.

That's why I remembered.

- And Philadelphia has same, and Philadelphia, there's little bit longer for a long time.

So the MMRC meets monthly, reviews cases, and presents them to the full MMRC so they can decide if it's pregnancy associated, pregnancy related, what recommendations might be around that if it was preventable.

And you know, really what some of the factors were that led to the death.

It's a tough meeting.

I sit in on them, or as a subject matter expert, I'm not, I don't comment.

Sometimes I'll throw a webpage on that somebody might need to see, or a resource.

But yeah, it's very heavy work, especially for the people who are really spending the time reviewing the cases then presenting them.

But it is an opportunity to see what are the reasons why women are dying, and how do we address that, what can we do, what can those recommendations be?

And really coming to a consensus from that group, which is lay people, a lot of obstetricians or OBGYNs, people from all, from mental health care, all different levels of care.

And you know, folks from community-based organizations that are providing care, whether it's, what is it, Pennsylvania Coalition Against Domestic Violence, like organizations that, you know, there certainly are factors sometimes, or unfortunately, you know, that that is a factor in a woman's death.

So it's a really interesting opportunity, I think, to have a really comprehensive group review those cases, and put a real spotlight on the need for, to address the maternal health crisis for all the reasons we've talked about today.

- And make the recommendations for how do we do them.

And then that's where like the funding that went goes, the coalition that Maria and her team head up really can make a difference in the regions, which is sort of leads us back to what we started to talk about with that, yeah.

- And speaking of funding, certainly the state government has put some money behind.

- [Maria] We certainly have.

- Trying to understand maternal mortality, and to prevent it as much as possible.

And I know Dr.

Montoro-Edwards, that your particular health center, Maternal and Family Health Services, received money from the state for this specific purpose.

- We did.

I serve on the Pennsylvania MMRC, and I have learned so much about what our organization, MFHS, should be doing, should be focusing on, should be working toward as a goal.

And so when the opportunity came about to develop these regional maternal health coalitions using the recommendations from the MMRC as kind of our framework, but then developing a local response to local challenges.

So our Northeast Regional Maternal Health Coalition serves 14 county area, and we have representatives from healthcare, from payers, community providers, persons with lived experience, so important to the process, and so many of the supporting organizations that we work with.

And so we're doing an asset analysis to see what we have and what we need to work toward.

And we're also, you know, meeting on the collective recommendations that we've developed for this 14 county area, and then beginning to implement them as we go.

- I think too, it's important to mention infant mortality, at least briefly in this conversation, even though our focus has been maternal mortality.

And Dr.

Montoro-Edwards, I'm wondering about your thoughts about where we are in terms of that.

What I had read was that the March of Dimes tells us that the rate of infant mortality has actually decreased, but still highest to babies born to Black moms, 1.8 times the state rate.

And Pennsylvania got a grade of C from the March of Dimes as it relates to infant mortality and preterm birth rate.

So what do we need to know about that?

- Well, Pennsylvania may have gotten a C, but the United States got a D+.

So I'm happy to say the Pennsylvania is really one of the more forward thinking of states.

And in terms of infant mortality and its connection to maternal morbidity, mortality, mom's health, nutrition, healthcare access are all predictors of what's going to happen with the infant.

So the better mom is health wise, connection to resources, the infant mortality rate will be reduced.

- Yeah.

As we get ready to wrap up our conversation in these last few minutes, I'd like for each of you to just share a key takeaway.

Something that if our audience takes away nothing else from this conversation, what would you want them to remember as it relates to maternal mortality?

What do we need to know?

What is the most important thing on your mind?

And Sara, I'll start with you and we'll work our way.

- I just figured we were all probably gonna say maybe the same thing, but that's good because.

So I would say, and of course I'm looking at it from a state government perspective, and having a lot of my work, you know, focused on maternal health.

I think women, families should be confident that the state, whether it's state government, it's our clinicians, it's our community-based organizations, are really focused on this topic, and are doing everything they can in the ways they can, both individually and collaboratively to address it.

So we really are, I mean from the governor on down, Governor Shapiro's incredibly supportive.

You know, our Secretary of Human Services is an obstetric anesthesiologist, the Secretary of Health is a pediatrician.

And we really couldn't have a better team of people who are leading the work, and saying yes to everything that we wanna do to address the crisis.

So I feel like folks, Pennsylvanians should be confident that the people who are looking at this are committed to it, to making change, positive change, and really getting just better healthy outcomes from moms and babies.

- Dr.

Flicker?

- I think building on that, you listed a several different, like organizations and things like that, is it takes a village.

And so I think for individual patients, their village are their support system within their families, and their friend groups, and their church groups, or whatever it might be.

And then their care team, which we talked about.

Then at the systems level, right, we have a village of nurses, and physicians, and midwives, and doulas, and we are, that's our care team, or our village.

But then lastly, at the broader level, I think systematically, its government, and its insurers, and its pharmacy.

But within Pennsylvania, I think never have we ever seen the number of like synergistic organizations, where we have the Maternal Mortality Review Committee, we have the Pennsylvania Perinatal Quality Collaborative, we have regional maternal health coalitions.

And for a while, and then obviously some of our professional societies, they were all kind of working on different things, and I think now we're really in a more concerted way, all stroking our oars in the same direction.

We have a unified vision and goals.

And so while they might be enacted differently in different regions, whether, you know, the northeast of Pennsylvania is definitely not the same as the southeast of Pennsylvania.

And so the responses might be different, but we're really focused on the same priorities and outcomes.

- Dr.

Montoro-Edwards.

- Well, I would like to direct anyone to mfhs.org if you are interested in learning more about the Regional Maternal Health Coalition.

If you're interested in learning more about WIC, the Nurse Family Partnership, reproductive health, maternity care, we can answer a lot of your questions on our website, but also through our Care Navigator line.

- Well, on that note, that is all the time we have.

Dr.

Montoro-Edwards, Dr.

Flicker, Sara Goulet, thank you all for being with us, and for an insightful and informative conversation.

For all of us at WVIA, I'm Tracey Matisak.

Thanks for joining us for Conversations for the Common Good.

(calming music) (audience applauding) - [Narrator] Conversations for the Common Good was made possible by the support of Maternal and Family Health Services.