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Derek van Amerongen, MD, MS: More than 50% of births in the United States are covered by Medicaid. Given your deep experience in Medicaid, what trends are you seeing, Dr Deans?
Sharon Deans, MD, MPH, MBA: I’m going to share some statistics, and then I’m going to give you some opinions and facts. As you mentioned, [even though the United States is] such a wealthy country, our maternal mortality rate is double that of most other high-income countries. Black women are 3 times more likely to die in childbirth. Medical coverage needs to be extended. As of October 2022, about half of the states have extended coverage past the typical 6 weeks; [otherwise] coverage ends at 6 weeks. Twelve states have extended it to 1 year. We know that maternal mortality occurs up to 1 year after birth. About 80% of those deaths are considered preventable. That’s the most important part.
One thing that Elvanse is doing is expanding doula coverage. Individuals ask me how we prevent NICU [neonatal intensive care unit] admissions. My answer is that it starts before you even get pregnant. It’s a long time before, so we need to go back to that point. But now we’re dealing with an immediate issue. There’s an IHI [Institute for Healthcare Improvement] model [about looking] upstream. What I like about the pandemic, it was a black swan that left this wake where it ripped off the Band-Aid and gave us permission to look at our data and talk about this. I’m very fortunate to be at a company that’s at the forefront of understanding what’s going on and paying attention to it. It’s an exciting time because when doctors transition from clinical practice to this kind of setting, they always say, “I want to have a bigger handprint.” Then you get there and you’re doing transactional work. But we’re truly getting this bigger handprint. We get to look at our data and zoom down on zip codes that tell us what the outcomes are and what we can do to affect that.
One big things—it’s not a magic bullet, but it’s extremely important as we talk about unconscious bias in the maternal child health setting—is giving these moms a voice by using a doula whothat can advocate for them. We’re finding a lot of outcomes are based on them not being heard. They’re trying to advocate for themselves, and their voices aren’t heard. We’re building our doula programs across the country to help give access to Medicaid moms, to make sure they have that voice. It’s not a magic bullet. There’s more than 1 thing going on, but that’s 1 of the major things we have.
We’re also doing population health initiatives with our providers. Traditionally, in OB-GYN [obstetrics-gynecology], with Medicaid, there are quality programs. If you get your primary care visit and your vaccinations, the primary care doctor has an incentive. If you get your mammogram and your Pap [Papanicolaou] test, which the obstetrician does, the primary care doctor has the incentive. We’ve pivoted that attention to our OB-GYN practitioners to help increase their awareness of population health. Not only the benign gynecologic screenings but also primary C-section [cesarean birth] rates—what does that look like for your practice? NICU admission rates—what does that look like? To increase that awareness by looking at the entire population and not just 1 person at a time.
Derek van Amerongen, MD, MS: Dr Wells, what are some of the tools and strategies you’ve used in your organization to address this issue?
Roxie Cannon Wells, MD: [I use] some of the things that have been discussed, but I go back to the frontline conversations that individuals have. For instance, we know a very famous athlete, a Black woman, who recently almost died because she was advocating for herself with the way she felt while she was in the hospital. Individuals weren’t necessarily listening. She had a PE [pulmonary embolism]. We need to get to the frontline nurses and doctors who are working with those moms, from the hospital perspective forward. You’ve already talked about the office and before they even become pregnant. But when they’re in the facility, it’s extremely important that we’re doing bias training. We need to make sure that we’re doing that.
One example is that I heard individuals refer to a laboring mom as a baby mama. That sets up thought patterns for others when they hear that. It sets up thought patterns that it’s got to be a Black woman,that, that she’s unmarried, that she doesn’t have the support that others have. But that’s not necessarily the case. We need to educate teams on appropriate behavior, verbiage, and interactions with families. Then [we need to address] not only a doula but training partners, not waiting until it’s time to go to birthing class to say, “Count to 10 while I’m pushing,” and those types of things. [We need to address] training partners, not only when a partner becomes pregnant but way before that. We’re going to have kids. We want to have kids. These are the things I need to learn so I can partner with you and help advocate for you while I’m in the room. I’m not feeling helpless because I don’t know what to expect during this. It’s more than cutting the cord. It’s support from the beginning. Those are some of the things that are extremely important, particularly educating partners for areas that don’t have doulas. My partner can be my doula if we educate them appropriately.
Sharon Deans, MD, MPH, MBA: Men can be doulas too.
Soyini Hawkins, MD, MPH, FACOG: Yes, they can.
Sharon Deans, MD, MPH, MBA: They absolutely can.
Soyini Hawkins, MD, MPH, FACOG: I’ll add 1 point about these statistics. When we adjust for socioeconomic status, even the wealthiest Black women and the most educated Black women are having poor outcomes. It can’t always be blamed on poverty, miseducation, and misunderstanding. Something is systematically not in tune with the outcomes we’re seeing in mortality and morbidity in this very affluent country that we live in.
You made a lovely point about doulas, coming up with programs, meeting patients where they are and building on their trust. That’s going to be a bridge between us as providers and them as a patient, so they feel they have an advocate. But they also have someone who can translate for them and help them understand what this doctor is saying and what jargon they’re [using]. What does that monitor say is happening with my baby? They’re not replacing the provider. They’re not making concrete medical decisions. But there’s a buffer so that there’s more compliance in the way the patients are able to take the care they’re receiving.
Transcript edited for clarity.
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