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The Ongoing U.S. Struggle with Maternal Mortality · Health Ethics Podcast

• 0:08
  Speaker 1: Welcome to Health Ethics, a series of conversations with leading
• 0:12
  Speaker 1: experts about ethical considerations associated with health and healthcare, both
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  Speaker 1: locally and globally. I am Brian Pilkington, Professor of Bioethics
• 0:21
  Speaker 1: in the Department of Medical Sciences at the Hackensack Meridan
• 0:24
  Speaker 1: School of Medicine. This series, like its predecessor, which focused
• 0:29
  Speaker 1: on the COVID nineteen pandemic, relies on the idea that
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  Speaker 1: challenging ethical issues are best addressed by folks from diverse
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  Speaker 1: backgrounds practically reasoning together, and complements the Health Ethics series
• 0:41
  Speaker 1: with its panel of leading experts from medicine, nursing, politics, economics,
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  Speaker 1: philosophy and the law. Thank you and enjoy the episode.
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  Speaker 2: It is my great pleasure today to speak with doctor
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  Speaker 2: James A. O'Brien. Doctor O'Brien began his medical education at
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  Speaker 2: the Royal College of Surgeons in Dublin, Ireland, who are
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  Speaker 2: first training at Brown as a fifth pathway student and
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  Speaker 2: then doing his residency at Women's in Infants Hospital in
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  Speaker 2: Rhode Island. He practiced in that area for about thirty
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  Speaker 2: years before accepting a physician as the medical director of
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  Speaker 2: Impatient on stetrics at the hospital in two thousand and eight,
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  Speaker 2: where he worked until his retirement. Just a couple of
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  Speaker 2: years ago, Doctor O'Brien did his undergraduate work at Notre
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  Speaker 2: Dame go Irish and Jay, it is such a great
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  Speaker 2: pleasure to have you on the podcast today and to
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  Speaker 2: talk about a very serious issue, maternal mortality in the
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  Speaker 2: United States.
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  Speaker 1: So, Jay, you written recently on the ongoing struggle with
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  Speaker 1: maternal mortality within the United States, and I'm curious, before
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  Speaker 1: we get into the details of the arguments of the
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  Speaker 1: work you've been doing, why was it important and to
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  Speaker 1: write this piece now.
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  Speaker 3: Well, thanks, Brian, I really appreciate the opportunity to speak
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  Speaker 3: to you and your audience today. For your audience who
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  Speaker 3: may not know the fine points, there are a couple
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  Speaker 3: of definitions out there for maternal mortality, just to frame
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  Speaker 3: our discussion moving forward. The one that is internationally used
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  Speaker 3: is a maternal death during pregnancy or within forty two
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  Speaker 3: days of delivery. But over the past several decades people
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  Speaker 3: have focused more on pregnancy related mortality, which extends beyond
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  Speaker 3: forty two days to a full year, and that's the
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  Speaker 3: working definition that we've used, especially when you consider that
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  Speaker 3: thirty percent of maternal deaths occur in that window between
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  Speaker 3: the forty third day after delivery and one year after delivery.
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  Speaker 3: So with that said, just to dive into the details,
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  Speaker 3: the focus here is that maternal mortality is really generally
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  Speaker 3: regarded as an indicator of overall population health, health, the
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  Speaker 3: status of women in society, and the overall function of
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  Speaker 3: the healthcare system. So when you look at our performance
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  Speaker 3: compared to other high income countries, it really is problematic.
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  Speaker 3: In addition to that, there have been i should say,
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  Speaker 3: significant efforts in the past two decades to look at
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  Speaker 3: maternal mortality rates. They have continued to rise and as
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  Speaker 3: I mentioned, when compared to other high income countries, or
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  Speaker 3: at least double to most other high income countries. We
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  Speaker 3: also have an issue with racial disparities and that black
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  Speaker 3: and American Indian Alaska Native women have rates that are
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  Speaker 3: two to three times higher than white women in the US.
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  Speaker 1: Thanks you. That's really helpful to frame things for the audience,
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  Speaker 1: and we have a diverse audience. Lots of folks from
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  Speaker 1: all walks of life listen to the show. But the
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  Speaker 1: group we're super interested in is medical students, so they
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  Speaker 1: have a lot of medical students who are who listened
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  Speaker 1: to the podcast, So would you mind being a bit
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  Speaker 1: autobiographical for a bit, especially for medical students who might
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  Speaker 1: be interested in b or other different fields sort of
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  Speaker 1: figuring this out. What led you to this kind of work?
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  Speaker 3: Absolutely, I really spent my entire medical career in women's health.
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  Speaker 3: I initially practiced as an obgion generalist and that was
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  Speaker 3: for twenty five years. Later in my career, I became
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  Speaker 3: the medical director of impatient Obstetrics at women in Infant's
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  Speaker 3: Hospital in Providence, rhightde Island, and it's one of the
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  Speaker 3: busiest obstetrical hospitals in the country. I've been acutely aware
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  Speaker 3: of the poor international status of the US based on
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  Speaker 3: that exposure and my reading through the years, and in
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  Speaker 3: my role as medical director, part of my work was
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  Speaker 3: to develop systems in protocol to improve patients safety and
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  Speaker 3: at the same time track our performance data. So it
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  Speaker 3: was this work that really piqued my interest in maternal
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  Speaker 3: morbidity and also maternal mortality.
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  Speaker 1: I think you're exactly the right person to have this
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  Speaker 1: conversation with. So with that background, with the framing of
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  Speaker 1: what how we think about maternal mortality now running up
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  Speaker 1: to a year. Why is the US's maternal mortality rate
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  Speaker 1: substantially higher than that of other high income countries, Like,
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  Speaker 1: what's going on?
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  Speaker 3: That's a complex question and there's not a clear single answer,
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  Speaker 3: but there are definite differences between the US and other
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  Speaker 3: high income countries. Although the US isn't the only high
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  Speaker 3: income country where this exists. One of the primary factors
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  Speaker 3: is the significant racial disparities that we see in maternal mortality,
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  Speaker 3: and that certainly impacts our overall rate. The most recent
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  Speaker 3: data available show that an overall maternal mortality rate of
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  Speaker 3: twenty two maternal deaths per one hundred thousand deliveries is
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  Speaker 3: our benchmark in the United States, and when you look
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  Speaker 3: at the racial breakdowns, there are nineteen maternal deaths per
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  Speaker 3: one hundred thousand deliveries for white women and twenty nine
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  Speaker 3: per one hundred thousand Black women, so a stark differential there.
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  Speaker 3: The US also suffers from a relative lack of ob providers.
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  Speaker 3: When you look at the total number of providers per
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  Speaker 3: thousand live births, we have sixteen obstetrical providers, which is
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  Speaker 3: broken down to twelve obgyns and four midwives in the
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  Speaker 3: United States. When you compare that with Chili, which is
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  Speaker 3: another high income provider which has the most robust workforce.
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  Speaker 3: Chile has a total of ninety two providers and again
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  Speaker 3: same as the US, twelve obqyans, but eighty midwives per
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  Speaker 3: thousand live births. Most other high income countries have at
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  Speaker 3: least double the overall number of providers that the US does,
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  Speaker 3: and in most cases at least six times the number
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  Speaker 3: of midwives. And one of the things that we've looked
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  Speaker 3: at our paper and looked at from an overall research
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  Speaker 3: perspective is the potential for expansion of the midwiffery workforce
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  Speaker 3: with a more robust and certainly a more diverse presence
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  Speaker 3: within that population. The other issue that plagues the US
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  Speaker 3: are geographic regions within the country, mostly in rural areas
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  Speaker 3: that don't have OBI coverage, and over a thousand counties
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  Speaker 3: in the US are considered maternity care deserts. The definition
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  Speaker 3: for the desert is areas in which there are no
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  Speaker 3: obstetrical facilities, nor obstetrical obstetrician gynecologists or certified nurse midwife providers,
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  Speaker 3: and this lack of coverage impacts nearly seven million women
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  Speaker 3: with resulting increased maternal morbidity and mortality.
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  Speaker 1: These numbers are staggering and shocking in many ways, and
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  Speaker 1: another familiar to you and your colleagues, and I think
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  Speaker 1: this topic is of special importance, I know to folk
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  Speaker 1: at the Hagenzec Marine in school medicine, where there's a
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  Speaker 1: great discussion of disparities, and also to folks who always
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  Speaker 1: tune in in my health ethics lab. Are actually doing
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  Speaker 1: some work on maternity care deserts. So one of the
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  Speaker 1: themes that you've mentioned so far connects up to both
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  Speaker 1: of those, and it's the racial disparities. So maternal mortality
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  Speaker 1: rates in the US seem to track significant racial disparities.
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  Speaker 1: Lots of folks are familiar, with some folks less familiar.
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  Speaker 1: For those who are less familiar, could you explain what's
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  Speaker 1: going on and why that's the case.
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  Speaker 3: Again, another difficult question to tackle, but one that certainly
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  Speaker 3: warrants a high level of focus. As I'd mentioned, Black
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  Speaker 3: and American Indian Alaska Native women continue to die in pregnancy, childbirth,
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  Speaker 3: and in their first year postpartum at certainly unacceptably high rates,
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  Speaker 3: and the data, as we discussed, suggests that that may
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  Speaker 3: be threefold higher. The CDC has identified several contributors of
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  Speaker 3: these disparities, and those include structural racism, implicit bias, variation,
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  Speaker 3: and the quality of health care and underlying chronic conditions.
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  Speaker 3: Social determinants of health also contribute to a lower likelihood
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  Speaker 3: of being ensured or receiving timely care, and there have
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  Speaker 3: been efforts to address this. The Center for Medicare and
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  Speaker 3: Medicaid Services now has hospitals screen for all social determinants
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  Speaker 3: of health, looking at health related social needs. The NIH
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  Speaker 3: also has a Social Determinants of Health Research Coordinating Committee,
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  Speaker 3: and their intervention is really to develop strategies that address
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  Speaker 3: these social determinants of health. I should add that the
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  Speaker 3: US is the only high income country in the previously
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  Speaker 3: mentioned studies that does not provide universal health care. This
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  Speaker 3: leaves about eight million reproductive age women uninsured time of
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  Speaker 3: their pregnancy. Racial and ethnic minority groups are the most
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  Speaker 3: likely to be impacted by this lack of health insurance
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  Speaker 3: and other costs related barriers to accessing care, and although
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  Speaker 3: there've been successful efforts to extend coverage to one year
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  Speaker 3: postpartum in some states, women ensured by Medicaid during pregnancy
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  Speaker 3: may face a loss of that courage after sixty days,
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  Speaker 3: and that's been referred to in other publications in the
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  Speaker 3: past as the postpartum cliff, where women get sixty days
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  Speaker 3: out and all of a sudden their resources are gone
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  Speaker 3: or dissipated.
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  Speaker 1: A very helpful framing for a very challenging issue, and
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  Speaker 1: folks who regularly listen to the podcast will be aware
• 10:42
  Speaker 1: of conversations around universal healthcare. Sometime we go on the
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  Speaker 1: Predecessor podcast with us listening, Professor Ruy Nuns from Portugal
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  Speaker 1: discuss sort of the challenges and had sort of philosophically
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  Speaker 1: of not having universal healthcare, and Jay yillmoan having trained
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  Speaker 1: in part in other places like the Royal College of
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  Speaker 1: Surgeons in Ireland. I mean, depending on where you go.
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  Speaker 1: At least when I've given talks elsewhere, it's viewed as
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  Speaker 1: a violation of human rights not to have this in place,
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  Speaker 1: and this is one of the bad consequences of that
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  Speaker 1: kind of practice.
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  Speaker 3: Yeah. Absolutely, Being in the British Isles for a period
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  Speaker 3: of six years looking at the healthcare system there, learning
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  Speaker 3: through the years about the National Health Service of the
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  Speaker 3: United Kingdom, I think as you look at models for
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  Speaker 3: national healthcare. Certainly the UK in terms of their National
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  Speaker 3: Health Service and also how they approach their maternal mortality
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  Speaker 3: issues is a nice model to look at. They really
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  Speaker 3: have a very dedicated infrastructure that looks at their problems.
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  Speaker 3: Having said that, I will note that their problems are
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  Speaker 3: very similar to ours and that they have higher than
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  Speaker 3: acceptable levels. They have racial disparities within their population as well.
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  Speaker 1: And so let's turn. Let's take it, and let's turn
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  Speaker 1: to something made more positive. You and your co authors
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  Speaker 1: in this excellent piece highlight that highlight maternal mortality review
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  Speaker 1: committees and perinatal quality collaboratives as effective or potentially effective,
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  Speaker 1: hopefully effective responses. For those listeners not familiar with these,
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  Speaker 1: could you detail what they are and sort of how
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  Speaker 1: they address address the issue.
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  Speaker 3: Maternal mortality review committees are state based and they're widely
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  Speaker 3: regarded as providing the highest quality data on maternal mortality.
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  Speaker 3: And this is when you compare them to the other
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  Speaker 3: current entities, one being the National Vital Statistics System and
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  Speaker 3: the other being the Pregnancy Mortality Surveillance System. The National
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  Speaker 3: Vital Statistics System is the entity that provides our international
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  Speaker 3: numbers for comparison to other countries throughout the world. But
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  Speaker 3: when you look at mmr c's and the resources they
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  Speaker 3: review with each maternal death, they use not only vital statistics.
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  Speaker 3: They go into individual medical records, they look at autopsy reports,
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  Speaker 3: they look at police reports, social media. In some states,
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  Speaker 3: they even interview family members because they really want to
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  Speaker 3: nail down the reason for each and every maternal death.
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  Speaker 3: They also use a CDC developed web based standardized tool
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  Speaker 3: for data abstraction, so that even with them being these
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  Speaker 3: separate statewide entities, the data collection process is to a
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  Speaker 3: degree standardized, and that mechanism was developed well over a
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  Speaker 3: decade ago, but they continue to tweak it to try
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  Speaker 3: to really get a standardized data stream, a better product
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  Speaker 3: for cross analysis, and something that is going to be
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  Speaker 3: useful producing strategies going forward. Turning the page to perinatal
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  Speaker 3: Quality collaboratives. They operate at a statewide and in some
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  Speaker 3: cases a regional level, and they really are a critical
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  Speaker 3: adjunct to MMRC. They develop and operationalize these solutions to
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  Speaker 3: address conditions and the system vulnerabilities that are identified with
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  Speaker 3: the Maternal Mortality Review Committee case reviews. I should mention
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  Speaker 3: California and the California maternal Quality Care collaborative. They really
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  Speaker 3: are the prototype for granadal quality collaboratives. When they were
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  Speaker 3: first instituted, over their first decade of work, they oversaw
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  Speaker 3: a fifty five percent decrease in maternal mortality at the
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  Speaker 3: same time as there was a sixty five percent increase
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  Speaker 3: in the US. And the way they've approached the problem
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  Speaker 3: is comprehensive. They've developed toolkits for several clinical entities that
• 14:43
  Speaker 3: are associated with maternal death. They have a data center
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  Speaker 3: that provides timely performance analysis to clinical institutions. They also
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  Speaker 3: have a robust clinical research arm that looks at this
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  Speaker 3: data and publishes in national journals that helps provide guidance
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  Speaker 3: for other states and other institutions trying to mirror their work.
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  Speaker 3: And they also have a very robust stakeholder network throughout
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  Speaker 3: the state that includes insurance, public interest groups, government entities, etc.
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  Speaker 3: The other thing I should mention is that forty eight
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  Speaker 3: states also coordinate with the Alliance for Innovation and Maternal Health.
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  Speaker 3: The acronym they use is AIM. They're a multi organization
• 15:27
  Speaker 3: group that's based in the American College of Obstetrics and
• 15:31
  Speaker 3: Gynecology and their programs also supported by the Health Resources
• 15:36
  Speaker 3: and Services Administration within the Department of Health and Human Services.
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  Speaker 3: Their primary work, like California Maternal Quality Care Collaborative, has
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  Speaker 3: been to develop evidence based bundles to address clinical conditions
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  Speaker 3: that are associated with maternal death. Using these efforts, they've
• 15:55
  Speaker 3: recognized that resources between individual institutions certainly will differ, and
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  Speaker 3: they encourage the standardization of care with algorithms that are
• 16:05
  Speaker 3: compatible with each individual institution with their resources and capabilities.
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  Speaker 3: There are current plans to expanding to fifty all fifty
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  Speaker 3: states and also to the US territories in the Indian
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  Speaker 3: Health Service. I should also mention before we close on
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  Speaker 3: this particular question that in the past two years, controversy
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  Speaker 3: has emerged with maternal mortality review committees in three states.
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  Speaker 3: Some suggestion was raised that these controversies were related to
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  Speaker 3: the enactment of strict laws limiting abortion in these particular states.
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  Speaker 3: In twenty twenty three, the state of Idaho became the
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  Speaker 3: only state in the US to not have a maternal
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  Speaker 3: mortality Review committee as the legislature declined to renew the
• 16:50
  Speaker 3: committee and let it disband. In twenty twenty four, they
• 16:55
  Speaker 3: reinstated the committee. I'm sure many of your listeners are
• 16:59
  Speaker 3: aware of the situation in Georgia where officials dismissed all
• 17:02
  Speaker 3: members of their MMRC after information was publicly disclosed related
• 17:08
  Speaker 3: to two maternal deaths that were determined to be preventable
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  Speaker 3: and were related to access to care that was restricted
• 17:14
  Speaker 3: by the state's abortion ban. And in Texas, the MMRC
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  Speaker 3: announced its intention not to review maternal deaths from twenty
• 17:24
  Speaker 3: twenty two and twenty twenty three. Recently, those happened to
• 17:27
  Speaker 3: correspond with the first two years of the state's very
• 17:30
  Speaker 3: strict abortion ban. Through local reporting, I've seen that they
• 17:34
  Speaker 3: also revealed that the original legislation for their MMRC in
• 17:39
  Speaker 3: twenty thirteen actually prohibited the review of abortion related deaths,
• 17:44
  Speaker 3: and in twenty twenty three, the state legislature allocated funding
• 17:49
  Speaker 3: with the intent of removing Texas from the federal death
• 17:52
  Speaker 3: tracking system. So problematic issues in all three of those states.
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  Speaker 1: The picture is grim and not report, investigate, try to
• 18:02
  Speaker 1: figure out what's going on. Seems especially disingenuous or I mean,
• 18:06
  Speaker 1: this is harrowing situations. You have a number of powerful
• 18:10
  Speaker 1: points that you raise. There at least ones that I
• 18:12
  Speaker 1: found especially waging and important, and in particular was the
• 18:15
  Speaker 1: claim that you made. And this connects up to what
• 18:18
  Speaker 1: you framed really nicely about mmr c's and other sort
• 18:21
  Speaker 1: of features that are in different places and moving in
• 18:24
  Speaker 1: different ways with different resources, so you want to pull
• 18:26
  Speaker 1: them together. So the claim, as I sort of ramble
• 18:28
  Speaker 1: through this, which you know, maybe it's a lofty goal
• 18:32
  Speaker 1: for the US of being one of the safest countries
• 18:34
  Speaker 1: in which to give birth, but you all note that
• 18:36
  Speaker 1: there will need to be national efforts across and I
• 18:39
  Speaker 1: think I'm quoting accurately here the entire prenatal, perinatal and
• 18:43
  Speaker 1: postpartum continuum. So the whole thing. Let's focus on that part.
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  Speaker 1: This is not simply an issue to be addressed in
• 18:50
  Speaker 1: labor and delivery. Can you say more about what's needed
• 18:53
  Speaker 1: across the continuum? So give us the positive move to
• 18:56
  Speaker 1: save moms in the US from your perspective.
• 19:00
  Speaker 3: You bet, that's a great question, Brian, And you know,
• 19:04
  Speaker 3: on a high note, we should note that over the
• 19:06
  Speaker 3: course of the last decades decades, there have been improvements
• 19:10
  Speaker 3: in the rate of maternal death during the prenatal and
• 19:13
  Speaker 3: intrapartum phases of care. In fact, during those two time windows,
• 19:18
  Speaker 3: the percentage of overall maternal deaths dropped from forty eight
• 19:22
  Speaker 3: percent to thirty five percent, and we have to look
• 19:26
  Speaker 3: at the work that's been done by groups like California
• 19:28
  Speaker 3: Maternal Quality Care Collaborative and other similar entities that have
• 19:32
  Speaker 3: developed across the United States. But concurrently, the bad news
• 19:38
  Speaker 3: is that deaths are up in the grouping up to
• 19:41
  Speaker 3: one year postpartum. In fact, postpartum deaths now constitute almost
• 19:47
  Speaker 3: two thirds of maternal deaths, and that window from seven
• 19:51
  Speaker 3: days to a full year after birth is now fifty
• 19:56
  Speaker 3: three percent of all maternal deaths that we see in
• 19:58
  Speaker 3: the US. The other concerning factor is that over this
• 20:03
  Speaker 3: period of time, the overall rate of death has continued
• 20:06
  Speaker 3: to rise in the US. A big spike was seen
• 20:09
  Speaker 3: during our COVID years. Understandably that's now leveled off and
• 20:13
  Speaker 3: come back into a little bit more acceptable range, but
• 20:18
  Speaker 3: certainly we're far from acceptable when you look at our
• 20:20
  Speaker 3: international comparators, When you look at the fact that sixty
• 20:24
  Speaker 3: to eighty percent of maternal deaths are considered preventable, we
• 20:28
  Speaker 3: should use the same approach to identifying and mitigating risk
• 20:32
  Speaker 3: in the postpartum period that we've used for pregnancy and
• 20:36
  Speaker 3: interpartum deaths. By doing that, the hope is that we'll
• 20:40
  Speaker 3: move into a closer alignment with other high income countries.
• 20:43
  Speaker 3: The other high income countries that were looked at in
• 20:47
  Speaker 3: the most recent Commonwealth Fund report, and for your listeners,
• 20:52
  Speaker 3: Commonwealth Fund, which uses data from the Office for Economic
• 20:56
  Speaker 3: Cooperation and Development, publishes regularly on maternal death They are
• 21:01
  Speaker 3: a fabulous resource. We used it extensively in developing our paper,
• 21:06
  Speaker 3: and they really in these other high income countries have
• 21:11
  Speaker 3: very comprehensive postpartum care programs which we in the US
• 21:15
  Speaker 3: currently lack. They have frequent home visits by midwives or nurses.
• 21:20
  Speaker 3: These visits are all in countries that are covered by
• 21:23
  Speaker 3: national Health insurance that we've discussed before, and they definitely
• 21:26
  Speaker 3: result in improved mental health and breastfeeding outcomes for these families.
• 21:33
  Speaker 3: All the other countries in the Commonwealth Fund report also
• 21:37
  Speaker 3: mandate at least fourteen weeks of paid maternity leave for
• 21:41
  Speaker 3: women after birth, which is again a factor that is
• 21:44
  Speaker 3: unfortunately lacking in the US. You'll see disparity state to state.
• 21:49
  Speaker 3: The highest level of coverage I've seen is usually in
• 21:53
  Speaker 3: the six to twelve week range, and when you look
• 21:56
  Speaker 3: at the models for postpartum intervention in the other countries
• 22:00
  Speaker 3: contrasts with single postpartum home visits that are sponsored by
• 22:04
  Speaker 3: some Medicaid entities. In the US, Medicaid covers roughly forty
• 22:09
  Speaker 3: three percent of births, and that's an interesting factor for
• 22:12
  Speaker 3: your listeners to focus on. These plans are all administered
• 22:16
  Speaker 3: by individual states, so that there is a wide variation
• 22:21
  Speaker 3: in services available in qualifying standards, and over the past
• 22:26
  Speaker 3: several years there have been concentrated efforts to extend postpartum coverage,
• 22:31
  Speaker 3: as we'd mentioned, from the sixty day benchmark to a
• 22:34
  Speaker 3: full year. We're in a good place right now in
• 22:36
  Speaker 3: that forty eight states in the District of Columbia as
• 22:40
  Speaker 3: of last week, now cover a full year of postpartum
• 22:45
  Speaker 3: care for patients, and the hope is that this change
• 22:48
  Speaker 3: will result not only in improvement in overall maternal mortality rates,
• 22:52
  Speaker 3: but also reflect progress in health equity. And the reason
• 22:56
  Speaker 3: that's important is that approximately two thirds of Black American, Indian,
• 23:00
  Speaker 3: Native Alaska, and Native Hawaiian or other Pacific Islander women
• 23:05
  Speaker 3: are covered by Medicaid for their prenatal care and postpartum care.
• 23:09
  Speaker 3: ACAG has supported this extension and for your listeners, ACOG's
• 23:14
  Speaker 3: the American College of OBQUIM. They've also supported the replacement
• 23:19
  Speaker 3: of the traditional single visit model with postpartum care to
• 23:25
  Speaker 3: a new patient specific process that transitions women with chronic
• 23:30
  Speaker 3: medical conditions and postpartum depression to a primary care provider
• 23:35
  Speaker 3: and or the appropriate specialists, and again leading the way
• 23:39
  Speaker 3: as the state of California, they've recently taken that step
• 23:42
  Speaker 3: with a Medicaid led redesign of postpartum care. Last thing
• 23:46
  Speaker 3: I'll mention is that we do definitely have work to
• 23:50
  Speaker 3: be done. The World Health Organization currently recommends at least
• 23:55
  Speaker 3: four health contacts in the first six weeks following birth,
• 23:59
  Speaker 3: but in the u US currently forty percent of women
• 24:03
  Speaker 3: skip their one postpartum visit, so implementation of these changes
• 24:06
  Speaker 3: are very much needed, and hopefully these are issues that
• 24:10
  Speaker 3: one by one will move the needle in the right direction.
• 24:13
  Speaker 1: Super helpful, and I appreciate you pointing to both the
• 24:17
  Speaker 1: medical features in play as well as the other kinds
• 24:19
  Speaker 1: of structural features which impact maternal mortality. And I think
• 24:25
  Speaker 1: such a high percentage occurs of maternal deaths occur after
• 24:30
  Speaker 1: seven days postpartum. It's just things that one would think
• 24:33
  Speaker 1: should be preventable, and framing this in terms of the
• 24:37
  Speaker 1: national international conversations, I think really helps to highlight what
• 24:40
  Speaker 1: the challenges are. Now, the positive suggestion of the paper
• 24:45
  Speaker 1: is to create a federal infrastructure to address issues of
• 24:49
  Speaker 1: maternal mortality. Now, given the work needed across the continuum
• 24:53
  Speaker 1: and in the disparities that you've noted, this makes sense.
• 24:57
  Speaker 1: Do you think it's plausible and practically and politically feasible? Like,
• 25:03
  Speaker 1: what are we going to do? And can it work?
• 25:05
  Speaker 1: Is this possible? Is the is the suggestion something that
• 25:08
  Speaker 1: you think could happen?
• 25:09
  Speaker 3: That's a great question. And you know, there's no doubt
• 25:12
  Speaker 3: that our current symptom systems and oversight have proven helpful
• 25:17
  Speaker 3: and driving improvement. But it's also fairly clear that greater
• 25:23
  Speaker 3: coordination and consolidation of the resources they're going to be
• 25:26
  Speaker 3: essential if we can are going to continue to make progress.
• 25:29
  Speaker 3: In the research that we did for our publication, it
• 25:32
  Speaker 3: really became apparent that they're already extensive resources that are
• 25:36
  Speaker 3: being employed, and they're coming from several different sources, but
• 25:41
  Speaker 3: at times they seem to lack synchronization. And given that,
• 25:44
  Speaker 3: it seems logical that we'd look to have a single
• 25:47
  Speaker 3: focal point for directing these resources, and that would have
• 25:51
  Speaker 3: profound advantages. The questions you raise about plausibility and feasibility
• 25:56
  Speaker 3: are really both fair and debatable. Like many questions related
• 26:00
  Speaker 3: to medical and societal change, political reality will probably drive practicality.
• 26:06
  Speaker 3: One ray of good news is that both prior administrations
• 26:10
  Speaker 3: have really acknowledged the issue of maternal mortality. The Trump administration,
• 26:15
  Speaker 3: in its later days in late twenty twenty, published a
• 26:18
  Speaker 3: lengthy review on maternal mortality in the US, and the
• 26:24
  Speaker 3: Biden administration developed potential legislation in the first two years
• 26:30
  Speaker 3: of his presidency. So in looking at both administrations having interest,
• 26:36
  Speaker 3: there is a possibility that will have an infrastructure to
• 26:40
  Speaker 3: further propel progress. But it's not going to be easy,
• 26:43
  Speaker 3: I know. Earlier in our discussion we highlighted mmrc's and
• 26:47
  Speaker 3: perinatal quality collaboratives. There has been the development of a
• 26:51
  Speaker 3: network of nationally integrated state and regional perinatal quality collaboratives,
• 26:56
  Speaker 3: and this grouping shares data, it shares processes as well
• 27:00
  Speaker 3: as their experience, and in twenty sixteen they formally united
• 27:05
  Speaker 3: to incorporate the National Network of Perinatal quality collaboratives. This
• 27:09
  Speaker 3: is really a major step forward, and Health and Human
• 27:13
  Speaker 3: Services has taken the lead in taking the raw data,
• 27:18
  Speaker 3: helping to standardize its collection process and the data linking
• 27:22
  Speaker 3: practices that are going to be essential to drive things
• 27:26
  Speaker 3: going forward. Other things to be considered when you look
• 27:28
  Speaker 3: at the numbers, Medicaid really needs to be central to
• 27:32
  Speaker 3: any maternal health redesign. And we mentioned before that forty
• 27:36
  Speaker 3: three percent of pregnancies are covered by Medicaid. Seventy percent
• 27:40
  Speaker 3: of Medicaid beneficiaries are under managed care plans. But again
• 27:46
  Speaker 3: these plans suffer from a lack of consistency due to
• 27:49
  Speaker 3: differences in contracting and plan design from state to state.
• 27:53
  Speaker 3: So this fragmented approach really needs to be addressed by
• 27:57
  Speaker 3: adopting national Medicaid standards that span the continuum of care.
• 28:03
  Speaker 3: And when you look at perennial quality collaborators, when you
• 28:06
  Speaker 3: look at Medicaid, bringing all these entities under a single
• 28:10
  Speaker 3: tent really should help move the process in the positive direction. Certainly,
• 28:15
  Speaker 3: the complexity of the problem and the diversity of the
• 28:18
  Speaker 3: resources that are expended at both the state and federal
• 28:21
  Speaker 3: levels is challenging, and to select a single position or
• 28:25
  Speaker 3: agency in coordinating these efforts really requires a lot of thought.
• 28:29
  Speaker 3: There certainly will the differences of opinion on whose best
• 28:33
  Speaker 3: position to drive this change. In our review, we proposed
• 28:37
  Speaker 3: that the Health and Human Service as Assistant Secretary for
• 28:40
  Speaker 3: Planning an Evaluation serve in this role. One of our
• 28:43
  Speaker 3: primary reasons was that the acronym for the position is
• 28:47
  Speaker 3: asp ASPE is operationalizing the work of the Office of
• 28:52
  Speaker 3: the Secretary for Patient Centered Outcomes Research and their trust
• 28:57
  Speaker 3: and again, looking at the clinical research to highlight areas,
• 29:01
  Speaker 3: looking at the social determined determinative health research to highlight
• 29:05
  Speaker 3: those areas as well is going to be a primary
• 29:08
  Speaker 3: goal going forward. So you know, in summary, I think
• 29:12
  Speaker 3: the ability to combine this focus within HHS with the
• 29:17
  Speaker 3: National Network of Perinatal Quality Collaboratives providing data, providing strategies,
• 29:23
  Speaker 3: it probably constitutes our best vehicle going forward to coordinate
• 29:27
  Speaker 3: these efforts.
• 29:28
  Speaker 1: A bold but sensible plan, if I might say, and
• 29:31
  Speaker 1: hopefully I mean, it gives us a little bit of
• 29:34
  Speaker 1: a light at the end of the tunnel, or whatever
• 29:35
  Speaker 1: the right metaphor is. And it was good to hear
• 29:39
  Speaker 1: that both previous administrations at the federal level at least
• 29:43
  Speaker 1: did work, which suggests there might be interest in addressing
• 29:46
  Speaker 1: this issue. Now, this is an utterly unfair question because
• 29:49
  Speaker 1: it asks you to pull out a crystal ball or
• 29:51
  Speaker 1: something like that. But I'm curious, in light of the
• 29:54
  Speaker 1: recent administrative change that just happened at the highest levels
• 29:59
  Speaker 1: of government in the US, do you anticipate your answer changing?
• 30:03
  Speaker 1: I mean, do you think anything will change in the
• 30:04
  Speaker 1: political realities in light of the switch.
• 30:07
  Speaker 3: It is requiring crystal ball, But although it shouldn't matter,
• 30:11
  Speaker 3: it really is never easy to predict. As you say,
• 30:14
  Speaker 3: my personal feeling is that the best way to address
• 30:16
  Speaker 3: maternal health would be by enacting legislation that included the
• 30:21
  Speaker 3: five goals of the White House Blueprint, which was the
• 30:25
  Speaker 3: Biden suggestion, and that looked at access to care. It
• 30:30
  Speaker 3: looked at raising all ships with a standardized quality of
• 30:34
  Speaker 3: care that's available to everyone. It looked at hearing the
• 30:37
  Speaker 3: individual patients concern, addressing social determinants of health, really having
• 30:43
  Speaker 3: a standardized data focus. And each of the five points
• 30:48
  Speaker 3: had several great suggestions and subdivisions within it to help
• 30:54
  Speaker 3: make improved outcomes of reality. But given the fact that
• 30:59
  Speaker 3: this legislation wasn't approved during Biden's first two years in office.
• 31:04
  Speaker 3: The chances for enactment during the next presidential term, i'd say,
• 31:07
  Speaker 3: in reality.
• 31:08
  Speaker 2: Is poor.
• 31:08
  Speaker 3: The fact that the Trump administration did produce that comprehensive,
• 31:13
  Speaker 3: moretuneral mortality summary that we discussed is encouraging. But at
• 31:19
  Speaker 3: this point, the leadership at Health and Human Services hasn't
• 31:22
  Speaker 3: been determined, and it remains to be seen if maternal
• 31:26
  Speaker 3: health will remain a priority within HHS even with a
• 31:30
  Speaker 3: lack of legislative action. However, the same policies and programs
• 31:34
  Speaker 3: that we've used and have proven successful up to this
• 31:37
  Speaker 3: point we should continue to employ and expand upon.
• 31:40
  Speaker 1: Do you anticipate additional benefits or challenges to addressing maternal
• 31:45
  Speaker 1: mortality in the coming years in light of these changes?
• 31:48
  Speaker 1: And I know waiting for some determinations with respect to
• 31:51
  Speaker 1: leadership and HSS and others may impact that, But at
• 31:55
  Speaker 1: quickly any thoughts, and then I'll get you out with
• 31:57
  Speaker 1: one more question.
• 31:58
  Speaker 3: You know, there is that we will continue to make strides,
• 32:02
  Speaker 3: but there's also data to suggest that the existing situation
• 32:07
  Speaker 3: may worsen it. And this again reverts to the abortion questions.
• 32:11
  Speaker 3: With the enactment of trigger laws and new legislation in
• 32:14
  Speaker 3: many states after the reversal of Roe v. Wade with
• 32:17
  Speaker 3: the Dobbs decision in twenty twenty two, the data shows
• 32:22
  Speaker 3: more limited access to care and abortion restriction states and
• 32:26
  Speaker 3: fewer maternal care providers and differences in maternal health outcomes
• 32:30
  Speaker 3: in those states as well. And I think because of
• 32:35
  Speaker 3: the severity of some of those laws, you're seeing this
• 32:38
  Speaker 3: reflected in applications to residency programs. In certain abortion restricting states,
• 32:43
  Speaker 3: you see providers that are seeing the landscape change beneath
• 32:47
  Speaker 3: their feet, making it more difficult for them to practice
• 32:51
  Speaker 3: in the way they've been trained to and they're accustomed to,
• 32:54
  Speaker 3: and that may drive migration from those states to other
• 32:58
  Speaker 3: more care friendly states. They're definitely our challenges moving.
• 33:02
  Speaker 1: Forward, grimm and well put, I mean, and returns back
• 33:04
  Speaker 1: to the earlier point that you raise, which we didn't
• 33:07
  Speaker 1: just we didn't spend a lot of time on about
• 33:09
  Speaker 1: some challenges in rural locations relative to care. So the
• 33:12
  Speaker 1: big resource the ethics of resource allocation kinds of questions
• 33:16
  Speaker 1: might be exacerbated sort of further down the line. I
• 33:18
  Speaker 1: really appreciate the time, I mean, the detail in this
• 33:21
  Speaker 1: research is super helpful. I know we have a number
• 33:23
  Speaker 1: of medical students interested and potentially being OB's interested in ethics,
• 33:27
  Speaker 1: and I know this was super helpful, but for that
• 33:30
  Speaker 1: segment of our audience, any advice for students interested in
• 33:33
  Speaker 1: ob who may or may not be interested in ethics
• 33:36
  Speaker 1: as they sort of work through their medical training. You've
• 33:39
  Speaker 1: been going at this for a few years, so you know,
• 33:42
  Speaker 1: stage on the stage, if you have to, you know,
• 33:44
  Speaker 1: a minute to tell them, what would you say?
• 33:46
  Speaker 3: Well, thanks, I appreciate the opportunity. And you know, for
• 33:49
  Speaker 3: any of your students that are considering a career in
• 33:53
  Speaker 3: obstetrics and gynecology, I would wholeheartedly endorse their pursuing it
• 33:59
  Speaker 3: and investigating it to see if it's a lifestyle that
• 34:02
  Speaker 3: would suit them. I've practiced for over forty years and
• 34:06
  Speaker 3: I feel my career was incredibly rewarding and probably one
• 34:10
  Speaker 3: of the most rewarding feels within medical care. It's such
• 34:14
  Speaker 3: a privilege to be able to provide care to a
• 34:16
  Speaker 3: woman in our family as they anticipate the delivery of
• 34:19
  Speaker 3: a child, and you know, with so many difficult areas
• 34:24
  Speaker 3: within medicine where you're dealing with death, severe illness, the
• 34:29
  Speaker 3: birth of a child, is such a joyous moment that
• 34:32
  Speaker 3: it really does resonate for everyone.
• 34:34
  Speaker 1: In the room.
• 34:34
  Speaker 3: You know, as we've discussed, and I've truly enjoyed the
• 34:37
  Speaker 3: opportunity to really look into our research, look into what
• 34:41
  Speaker 3: we found, highlight areas where we may move progress forward.
• 34:46
  Speaker 3: The next generation of healthcare providers is definitely going to
• 34:49
  Speaker 3: be challenged with maternal mortality and the accompanying morbidity. They're
• 34:54
  Speaker 3: also going to be challenged with the health disparities that
• 34:57
  Speaker 3: we've discussed today. So for them, as for me and
• 35:01
  Speaker 3: other current providers, there is a lot of satisfaction in
• 35:05
  Speaker 3: working both at your institution and beyond in healthcare organizations
• 35:09
  Speaker 3: at a statewide and federal level to really try to
• 35:13
  Speaker 3: push the needle forward. I do think there are clear
• 35:17
  Speaker 3: areas where we can continue to improve, and that challenge
• 35:20
  Speaker 3: will definitely fall to the next group of dedicated healthcare
• 35:23
  Speaker 3: providers to get out there and practice among all our
• 35:28
  Speaker 3: populations and especially, as we've mentioned, those underserved by race
• 35:33
  Speaker 3: or by their geographic location.
• 35:35
  Speaker 1: Thanks you really helpful advice for the students. Again, everyone,
• 35:39
  Speaker 1: thanks for listening. This is the Health Ethics Podcast on
• 35:42
  Speaker 1: Brian Pilkington and I've been speaking with doctor James A. O'Brien, who,
• 35:46
  Speaker 1: along with Adam Lakowitz, Elliot Maine, and Eli A. Dashy,
• 35:51
  Speaker 1: wrote an excellent paper in the American Journal of Perinatology
• 35:54
  Speaker 1: titled the Ongoing US Struggle with Maternal Mortality. Jay, thanks
• 35:58
  Speaker 1: so much for joining me today. I appreciate it.
• 36:00
  Speaker 3: I really appreciate the opportunity to talk. A pleasure meeting
• 36:02
  Speaker 3: you and pleasure talking to your audience. Thank you.
• 36:05
  Speaker 1: This podcast series is a production of the Health Ethics Lab,
• 36:08
  Speaker 1: and I am grateful to colleagues in the Department of
• 36:10
  Speaker 1: Medical Sciences, the IHS Library, and the Hackensack Bridy in
• 36:13
  Speaker 1: the School of Medicine for making this collaboration possible. To
• 36:17
  Speaker 1: learn more about our work or to engage with the
• 36:19
  Speaker 1: series content, reach out to me Brian Pilkington at Brian
• 36:23
  Speaker 1: dot Pilkington at hmh N dot org.