Inform[H]er Roundup: Maternal Mortality — what’s working

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Maternal health interventions the Inform[H]er has covered over the last six months, now all wrapped up into one. Subscribe to The Inform[H]er here.

Nakeitra Burse will serve as program manager for a new maternal health program focused on partnering high-risk pregnant women in Jackson with birth and parenting support. It’s a simple idea, but more complex than it should be. Doulas, who serve as advocates before, during and after birth, are unregulated in Mississippi, and with that, lack infrastructure support needed to get their job done – payment and reimbursement models, their own workplace support and health care system connections. 

Part of a new grant – $295,000 over three years to Magnolia Medical Foundation from W.K. Kellogg Foundation will pair five doulas with 10 moms over 21 months – aims to improve birth outcomes by bolstering doula capacity across the city, and hopefully, the state. It’s a two-fold plan – support pregnant women by supporting doulas. The first step: start a doula registry.

“Doulas and breastfeeding have been shown to improve health outcomes for African American mothers and their babies. African American women are 3-4 times more likely to die from birth related complications than white women; and African American babies have the highest rates of infant mortality. This project will aim to decrease these grim statistics through a comprehensive strategy focused on evidence-based practice.”

– Dr. Erica Thompson, Executive Director of Magnolia Medical Foundation and lead investigator for the new grant

“We want to create a little bit more stability, structure and potentially upward mobility,” said Burse, who’s long partnered with Thompson to address maternal mortality risk factors in the state. “So we are hoping that we can either support doulas to become that type of collaborative for themselves or build the infrastructure to be able to be that. Most doulas are doing it part-time, and on top of that they have other jobs … so then that’s really a competing interest because you want to do the birth work, you want to help women, but you also have to have a (steady) income.”

Other pieces of the new program focus on education and support, both for moms and the community at large, like how to breastfeed successfully while going back to work – both for mom and her workplace. 

“It’s hard to operate in a system that wasn’t built for you. But how do we create systems and parallels that really help women navigate pregnancy and just bodily autonomy, while still understanding how and being able to navigate that bigger system that doesn’t always work for them,” she said. 

Burse is in a unique position to move this mission forward. Her company focuses on community-based public health strategies, communications and solutions. She’s built a career out of laying groundwork for a program just like this by starting and facilitating candid maternal health conversations – and then putting public health strategies in place across communities to effect change. 

As for why this moment is offering an inflection point – it’s a perfect storm of data and empowerment, Burse says. 

“I think part of it is the maternal and infant mortality numbers. But another part of it is liberation. Liberation in one part because people want to have bodily autonomy, they want to have autonomy to make decisions that they want to make for themselves and for their children,” she says. “We don’t always have that type of support and so having an advocate such as a doula who normalized that type of liberation is really solidifying your decision to birth in a way that you feel comfortable and to come out of that safely.”

Laboring With Hope

Burse’s background in public health education, communication and media

In the last two decades, Nakeitra Burse has lost three family members to pregnancy-related deaths — her aunt, sister-in-law and newborn nephew. Fed up with living through the grief without seeing change, she decided to take the narrative into her own — and her community’s — hands and produced a documentary about what it means to be a black woman giving birth in Mississippi. The outcome is a candid, deeply felt profile of community support, grief, fear, and ultimately, hope.

“Laboring With Hope” follows the stories of Burse’s family as they recover from and re-frame the grief that pervades their family and community. Burse is candid about the traumatizing effect of retelling these stories, but says it was also cathartic to name her family’s pain and their recovery process. She adds that, “It was too easy to cast this.”

For Burse, her family’s experience represents a snapshot into a bigger story, and begs the audience to reckon with inherent racism in the medical system that allows black women to die at a higher rate than their white counterparts. And forces the question: why? A crucial goal with her project is to stop talking about the problem and start looking at the causes and paths forward.

“As a public health professional who has done research, but who is really entrenched in the community, the narrative is important to me — for people to have their voice,” she says. “We know what the (maternal mortality) problem is, but we don’t want to talk about it. Part of it is racism in the health care system and that’s hard for people to talk about and it’s hard for people to address and grasp.”

 

Burse also prioritized putting a face to the devastating maternal mortality stats and trends we see, and says as a black mother herself, it’s important to have autonomy over the narrative, while lifting up voices of those most impacted. 

“It’s so important to me because being in public health in Mississippi you see all the dollars that come here. They (outside funders) come here to do all types of work and when its over they leave and there’s nothing left for the community,” she says. “Then there’s this narrative about Mississippi that continues to be perpetuated — poor, sick, all these things — but what people don’t get is the actual context behind it.”

That context is crucial, Burse argues. “You don’t see these local stories of women like my aunt, who was also an educated black woman who had a job and had insurance, or my sister-in-law who had the same story. (In the media) you’re not seeing all of the different types of women that this impacts,” she says, noting that it’s not just uninsured low-income women who die during childbirth. “There’s a broad spectrum of women that this impacts and it’s not just a small subset, it’s everybody.”

For audiences, the documentary is not just a tool to evoke emotion, but more of an action tool, she says. Each screening is accompanied by a discussion and her goal is to encourage conversation and impact maternal health policy. “This is an opportunity to do something, not just for my family, but for black women, period.”

See the trailer here and If you’re interested in learning more about the documentary or want to inquire about bringing a screening and discussion to your community, contact Nakeitra Burse.

 

Another doula-focused program

Doulas paired with women during pregnancy, child-birth 

A Jackson-based program is taking an innovative approach to improving maternal health outcomes in the capital city, hoping it embeds cultural, community-based change into the state’s birthing practices. Pharmaceutical giant Merck & Co. named ten cities last year to participate in their philanthropic “Merck for Mothers, Safer Childbirth Cities” initiative, including Jackson and regionally, New Orleans and Atlanta.

The Jackson program will pair pregnant women with doulas before, during and after birth for families that couldn’t otherwise afford the extra support throughout the process. Doulas act as non-medical birthing coaches, advocates, and support systems, walking women through everything from doctor’s appointments, social services, medical complications and birthing goals. Rising to the surface in recent nationwide maternal mortality conversations and research has been that women are not listened to in the exam room or during labor. A big part of doulas’ job is to bolster women’s voices in conversations with their medical team and advocate for open communication between all parties. 

Merck for Mothers’ goal — invest in local programs and community-based solutions to make city-specific goals that will foster more equitable birth outcomes and end preventable maternal deaths. (If you’re a regular to this newsletter, you know the stats — the U.S. is the only developed nation to see rising maternal mortality, and the burden is disproportionately bore by black women. Instead of focusing on those stats — here if you need a refresher — we’re looking at solutions.) Mississippi Public Health Institute will spearhead the program and manage the $875,000 grant investment over three years, with the goal of hiring five doulas to work with 15 women each the first year, and expanding from there. By building on the doula capacity that already exists in central Mississippi, the project hopes to normalize doulas into the birthing narrative across Jackson.

 “In a way we are working from scratch and doing a few things simultaneously — building knowledge and capacity among community members as well as doulas and providers, all at the same time.”

– Wengora Thompson, Jackson Safer Childbirth Experience director

The Jackson program goals are four-fold, based on city and state maternal mortality trends: 

  • Reduce medically unnecessary cesarean section births (Mississippi has the highest rate of C-sections in the country. Rankin and Hinds counties comprise fourth and seventh highest in the U.S. for low-risk births by C-section, at 39% and 37% respectively. Experts estimate about a quarter of births necessitate C-section and advise against the surgery for low-risk births due to the high risk of complication and recovery time for mother and baby.)
  • Use doulas to bolster community-based physical and emotional support for pregnant and post-partum women 
  • Reduce cardiovascular complications associated with pregnancy (Heart and blood pressure conditions are the two most common causes of pregnancy-related death in Mississippi.)
  • Collect and share more data about maternal health (Currently, state-collected data is lacking and limited to the new Maternal Mortality Review Committee, which reviews death certificates related to potential maternal mortality cases.)

“We need the medical community to be open and willing to be exposed to new things, where they can learn from families and their experiences,” Thompson says. “For policymakers and legislators, we need to place a focus on women and infant health in Mississippi — we have the stats, it’s time to collectively act.” A perfect example of a timely policy change that would immediately improve maternal health outcomes, she says? Extended Medicaid eligibility to post-partum women for one-year after birth. 

If you’re interested in learning more about the program, contact Wengora Thompson.

 

Taking on maternal health from the hospital perspective

Emergency departments exclusively for pregnant and postpartum women 

Dr. Lakisha Crigler’s obstetric patients are among the most high-risk in the country. That’s why she sees her role as an obstetrician hospitalist — meaning she only works at a hospital — in Southaven’s OB emergency department (OBED) at Baptist Memorial as a crucial piece to lowering the Mississippi Delta’s and the state’s overall high infant and maternal mortality rates. Dr. Crigler’s patients travel from across the state to get to the OBED, but she says it’s her Delta-based patients who especially stand to benefit from the service. 

In a recent study comparing two of the poorest regions in the U.S., the Delta and Appalachia, infants in the Delta were more likely to be preterm, low birth-weight and more likely to die during their first year of life. The report reiterates to researchers what Dr. Crigler and other OBs already know and see every day. Pregnancy risk goes beyond socio-economic status and even a woman’s health — it’s more often about lacking continuity of care, access and race. Half of Mississippi’s counties lack OB care, making follow-ups during pregnancy and postpartum even harder for many.

“Mississippi has clusters of health care — clusters here, clusters there. If you live close to a metropolitan area, you probably see whomever you want to see. If you live in a more rural area, good luck… And, we have to start having difficult conversations as to why economic status does not matter when it pertains to black women’s (risk). Education status does not pertain to them. Health status does not change their outcome. So it doesn’t matter if you have private insurance, you’re well educated and you’re in great health — your risk of dying is still greater than your white counterparts. We have to start looking into how to train for bias of all spectrums in health care. And that is a code that no one has cracked.”

– Dr. Lakisha Crigler, OB

The two-year-old OBED is part of a nationwide OB Hospitalist Group and offers a novel approach to disrupt the state’s maternal and infant mortality trends. If a pregnant or postpartum patient comes to the emergency room — no matter her symptoms — she is immediately sent to the OBED siloed off from the rest of emergency care. Emergency department physicians are not always trained in labor and delivery and might not be familiar with pregnancy and postpartum complications, Dr. Crigler says. The targeted approach to care sounds obvious, but the OBED is still catching on — currently operating at Jackson’s Baptist and Tupelo’s North Mississippi Medical Center, in addition to Dr. Crigler’s Memphis-metro location.

Dr. Crigler, who also serves as lead physician for the state’s Perinatal Quality Collaborative and works with the Maternal Mortality Review Committee, says extending postpartum access to Medicaid is among the most crucial steps in curbing the state’s maternal deaths. A few stats: Most maternal deaths happen post-birth and are related to preventable high blood pressure or cardiovascular complications, most births are covered by Medicaid in Mississippi, and that coverage usually cuts off about 60 days post-birth.

“Even if these diseases are found while they are pregnant … once they lose that (insurance) coverage, there’s no follow-up to continue high blood pressure medications or to continue seeing a cardiologist for cardiac disease that may present even after the pregnancy.”

That coverage gap really concerns Dr. Crigler and her colleagues on the Perinatal Quality Collaborative, which researches causes and solutions to maternal deaths. It’s imperative to diagnose high-risk pregnant women as early as possible, she says, but too often women are diagnosed, receive limited treatment while pregnant, then fall off the Medicaid rolls and lose lifesaving follow-up care for otherwise preventable diseases.

 

Most of these briefs appeared in the round-up section of our monthly women and girls newsletter, The Inform[H]er.