Chapters Transcript Keynote: Social Drivers of Health and Obstetric Outcomes Course: Health Disparities in Obstetrics and Gynecology: Approaches to Understanding and Improving Care It's a pleasure to be here and I'm honored to be able to be talking about this uh really important topic, cause I think uh you heard um someone just said the other day our world is on fire and um part of that are these dramatic inequities we have in this country, um, and so I think we together can think about what is driving them. Uh, and reflecting on that, what interventions we can use, of course, we won't be able to cover that in its entirety today, but at least um to get a start. So, uh Writ large, the objectives I want to talk about and tell you about what this talk will look like ultimately is that it'll be three parts. One will be to just describe the disparities in pregnancy care and outcomes that exist, and I suspect many of you know about these already, but I think it's worth it to center ourselves. And what those are and there are many, uh, disparities across many different domains that we could talk about, um, but uh what I want to do today within the context of this limited time we have is to focus on the racial and ethnic disparities that exist and how they intersect with uh a variety of socioeconomic factors. I wanna think about the origin then of those racial, uh, and ethnic disparities um really through the lens of structural racism and the. Social drivers of health that arise from that structural racism with very concrete examples of that. And then I wanna hopefully and on uh a a a note of hope as to the kinds of things that we can do to address uh those disparities, understanding the origin from which they arrive. So, uh, the first thing I think, and again I'm gonna take this for granted and go over this relatively quickly that that we all know is that racial and ethnic disparities exist and exist. Uh, with dramatically, uh, in a variety of levels in, uh, women's health, um, I'm gonna be focusing on obstetrics, um, the care that's provided, and I won't just say this, I'll give you examples, um, in the adverse pregnancy outcomes, things very specific to pregnancy that occur, uh, gestational diabetes, hypertensive disorders of pregnancy. And then of course, consequent to those things, the other uh uh uh end stages of severe maternal morbidity, uh, maternal mortality, and it's analog in the perinatal space, perinatal morbidity and mortality as well. And I think it's uh in these disparities have been long lasting and historically rooted and what should be alarming to all of us is that we are in many cases and probably in most cases, as I'll show you, not doing any better, but in fact we are doing worse. Um, so I told you I'd give you examples of this, and so I want to give you very discrete examples. Um, I could show you many examples of, uh, disparities in obstetric care, uh, through the lens of race, ethnicity. And, and I just want to pick out three from a paper, you know, this is sometimes hard to extract, for example, from admitted large administrative data sets, these kind of care that's provided isn't available, the ability to assess other things that are going on. This is a study that actually came from the MFMU networks looking at 115,000 deliveries across the country. And I want to point out to you just three aspects of care, um, and these are aspects that I, I pulled these out of the paper, um, just because there is no other reason and I think you, anyone can come up with to explain, uh, I, I don't think any good reason, for example, if you look at these, uh, self-reported race, ethnicities, non-Hispanic, black, Hispanic, and Asian. Um, for example, the differences, and this is um using as a statistical reference, uh, white, and the arrows indicate in the direction, uh, which is, so for example, the first row, more than one hour between complete dilation and pushing or delayed pushing, and we can have a debate about what what that is, but the bottom line is that shouldn't be systematically different by race ethnicity. I mean there's no reason for that, it may be different and different. But accounting for all of that, accounting for center, you can see that there are these dramatic, uh, you can't tell the magnitude of this, but I'm gonna tell you that there are dramatic differences by race, ethnicity. So for example, non-Hispanic black individuals are less likely, um, compared to white individuals to have greater than one hour between complete dilation and pushing and you can see that across these different things, the number of vaginal exams people get through the course of their labor, the chance of general anesthesia at the time of cesarean. That these And controlling for anything else that might account for these differences. There are these differences in care remain and something where again, I would say that there should be no reason ever that these differences exist. Um, these differences in care are reflected, uh, I should say, in, in differences in outcomes, and I also mentioned at the beginning in adverse pregnancy outcomes. So here we can see preterm birth, and these are data from the CDC, uh, 2019 and 2020. And uh once again you can see that across just a year, but if I showed you 10 years or 20 years, you would see a very similar pattern, which is to say that the Uh, difference across race ethnicity is dramatic, with the chance of preterm birth, for example, white compared to black, uh, nearly twofold greater. Um, and it, and that has not changed uh over time whatsoever. There are disparities in uh gestational diabetes. I'll point out two things from this slide that should be concerning to everyone. First off, that gestational diabetes across all race ethnicities are increasing dramatically, dramatically over time, uh, but that increase has not been shared. uh, let's see. But you do not see a finger. OK, well, the gray line is uh non-Hispanic white, you can see that largely that is the lowest uh chance and uh if you were to look at this statistically, the flattest line, um, and whereas increasing and increasing uh more rapidly among minoritized communities. And then if people have GDM as one example, um, again, racially and ethnically disparate, the chances of obstetric morbidity among the people who have GDM are different by race, ethnicity. So now you have a greater someone has a greater chance. Of having an adverse pregnancy outcome like gestational diabetes, and the consequences of that are magnified because the chances of an adverse outcome like cesarean delivery, intensive care unit admission or preterm birth are then greater as well. Um, and as we spoke about these things are on the path to, uh, maternal morbidity and events that are more proximate to maternal morbidity like postpartum hemorrhage and peripartum infection, and again adjusting for a variety of things we can see differences in race ethnicity with minoritized communities are generally having greater frequency of these adverse outcomes. And leading ultimately to disparities and severe maternal morbidity. Um, this, uh, again is from a large, uh, the study I mentioned before of 115,000 people, and you can see a 2 to 3-fold greater chance of severe maternal morbidity uh among individuals from minoritized communities. And then ultimately maternal mortality, um, which I think, you know, we all know and hear about and should be hearing about every single day in this country. Uh, where we have not maternal mortality rates that are embarrassingly high compared to the rest of uh high income countries typically at the lowest end of that sphere, and that's even overall, even in our best cases, our our lowest rates are higher than most other people, and then we have rates that are, uh, among, for example, as you can see the non-Hispanic black community that is 2 to 3 fold higher than among uh a non-Hispanic white community and Uh, once again, increasing year over year over year, except for the last year as the data were just released because of the COVID spike, um, but no one, depending on how that news was spun should misunderstand. Our rates are still terrible, they're just not as terrible as they were during COVID. We're just down to a baseline terrible rate. So then uh of course the question is for something that's a socially constructed uh um uh variable, if you will, why is that? And I think this is a really nice um Graphic from the Boston Public Health Commission and Racial Justice and Health Equity Initiative, which shows um racism but uh other uh isms and phobias. Uh, that lead to disparate care, um, and affecting health outcomes and the array of, uh, social drivers of health that that leads to, so this sort of font of structural racism, and again I'm gonna give you a very specific example, um, and the consequences of that in a second, and then the multiple and the plethora of uh drivers that arise from that with regard to social capital, education. The health behaviors that are facilitated or impaired by the structures in the built environment that surround us. um, and so let's take a uh an example of that and let's look at how that example uh ripples throughout time and leads almost imperceptibly today if you don't know it exists to this to the disparities that we see. So, um, redlining, uh, just a short history of redlining, um, which I think is a is a. Is there is such a concrete example of structural and legal racism um that it serves. A function to be able to look at it and then to see how this imposition. Uh, upon us leads to a myriad of health consequences, uh, years and decades, and even a century later. So housing shortages in the 1930s led to the development of the Federal Housing Administration. And the housing administration underwrote insurance for mortgages to make mortgages easier to get. Uh, what they, uh, did, however, was that that underwriting was based on a perceived neighborhood risk and this risk was not related in any direct way to finances or structures. It was related to the racial composition of that neighborhood. Uh, so redlining, so named, um, because as I'll show you in a second, uh, that housing administration came up with maps, and the neighborhoods that were deemed the greatest risk were uh colored red on that on those maps, uh, hence, hence the name redlining. Um, and so what happens when we take two neighborhoods. That are, they're not separated by mountains or rivers or countries or anything that are adjacent and essentially identical. They're not even neighborhoods, they're just streets next to one another. And then are identical for all reasons that anyone could imagine and then but just impose upon them. A legal framework that makes them different, so there's no natural, it's just a complete legal legal construct and what happens, and this is a really nice conceptual model from uh Doctor Krieger writing in the American Journal of Public Health in 2020. And so you can see on the left that we start out with this, these redlining maps, and then what happens is because the at-risk neighborhoods, people who are coming into those neighborhoods are not able to get loans as easily. So home ownership is less. Home ownership is less and regardless of the neighborhood that you're in as home ownership is less there's a I think we understand the trajectories of investment and disinvestment that differentially occur based on the on uh home ownership and other economic resources that accrue to particular neighborhoods and then generally over time this sets up just a a a very malicious cycle where there's disinvestment. And disinvestment breeds less home ownership, and you can see this on this conceptual model where this neighborhood trajectory of investment, disinvestment, racial and residential segregation and homeownership leads to a whole array of differential place-based resources. Whether that's a built environment like parks. And gardens, whether that's pollution, and again I'll give you very, uh, I won't to say this, I'll show you concrete examples of it. Um, and, and ultimately leads to great differences in embodied exposures, uh, that lead ultimately to different, um, physiologic transduction of, of these adverse uh environments. So, uh, material, biophysical, pollution, access to and quality of health care, the behaviors that are, again, facilitated by the environments we are surrounded by. And um psychosocial factors and stress. And for the for these of course lead to a myriad of health consequences for our purposes here today. What we're talking about are inequities uh in in in preterm birth in this study, uh, and but we're we're talking about our inequities are larger across um the obstetric domain. And so what I'll do through this next part of the talk is take us through concrete examples of this conceptual model and show you how this kind of concept of this is very real and very real consequences in our world. So here for example is um redlining of New York City. This is from the 1930s. So you remind everyone, this is a map from the 1930s. Of, of uh of essentially a zoning or a description of neighborhoods that was just imposed by a legal entity. Um, and so you could see, for example, on the Upper East Side, uh, next to Central Park, which is in in in the gray, and you can see that there's a, a green zone, green in this case is. The and I will, you know, the best, this is the terminology that was used, and then just north of that or or or just east of that, um there are red zones deemed hazardous. Uh, again, there's nothing right, I mean you live in New York, you know, these neighborhoods, there's nothing, there's nothing magical happening like right at that northern border of that green zone, but this is just an imposed construct, uh, completely artificial. And so what are the consequences of that, then one would ask, and Doctor Krieger asked that in this paper. So again, I'll just focus people. 1930s, this this legal imposition, um, and, and by the way, there are um there's a wonderful if you ever want to go back to it in terms of to really understand like histories and trajectories of any environment if people are not originally from New York and want to go, there are atlases. I'm happy to provide you the um website where you can go and put in any city that was. Um, had this happen to it, and you can go in and see uh the red lining that happened in that city, and if you're from that city, then you can, um, maybe reflect on the echoes that it has today. What does that mean for New York City? Well, you can see um this is preterm birth, and this is preterm birth nearly 100 years later. Right, so 100 years later, the um histogram, these bars are uh uh colored here to reflect the red lining that was done. So green in this case reflects the green neighborhoods and red reflects the red neighborhoods. And so just from this um Imposition Of a, uh, the structural approach to to mortgage conveyance. Uh, nearly 100 years later we end up with differences in preterm birth with the neighborhoods that were zoned red, uh, being nearly, well, so you can see here, over 7% in this case and less than 5% in the green neighborhoods, so 50% greater risk of preterm birth. So that sets the sort of, if you remember that conceptual model, the sort of the left and the right, we have preterm birth on the right, and we have on on the left, the red lining that originally occurred, and now what we are gonna need to do is to sort of fill in the middle of that model and to connect and the mediators um that explain why these things more proximately occur. Um, so this is a, uh, study from uh Chicago, really wonderful, uh, social epidemiologist, uh, Doctor Kerri Kershaw, looking at, uh, segregation. Remember on that Krieger model segregation was one consequence, um, a direct consequence and a uh perpetuating consequence of the of the red lining that occurred and, um, looked at just among black uh pregnant people in Chicago, so this is. Um, only looking at black pregnant people, and then looking at the neighborhood that they lived in. According to this segregate the degree of segregation that existed, and again segregation aligning with this investment related to this initial um redlining that occurred. The GI uh asterisk is a statistic that is used to quantify their different. Variables that can be used, but this is a variable Doctor Kershaw used to quantify the degree of segregation. And so for example, among black individuals, you can look and you can see that preterm birth. In the most highly segregated neighborhoods here, uh, deemed by a red is dramatically higher than in neighborhoods that are less segregated. Uh, as demonstrated in in intermediate by the yellow and by the green, and whether we look at spontaneous preterm birth, which is the middle set of bars, or medically indicated uh preterm birth, which is the the the most uh right sided set of bars, you see the exact same pattern. So then what is it then about these neighborhoods, since it clearly isn't race ethnicity per se, uh, which is again socially constructing a reason that that should lead to differences, that explains why this uh is why these patterns look like they do. Well one thing is again related to that red lining that occurred thinking back to that conceptual model, that uh Income, uh, it is and socioeconomic resources become differentially distributed across these environments. And so this is um uh looking at something called the index of concentration of the extremes. This was done by um uh folks up at Mount Sinai, uh, Doctor Yanovic and uh Doctor Liz Howell was the senior author on this. And done a tremendous amount of really interesting work in and around the um existence of an origin of uh racial and ethnic disparities. And um index of concentration of the extremes is a is a uh incorporates a couple different domains, both uh segregate segregation by race and ethnicity, but also the distribution of uh uh economic resources, um with the uh red bar again trying to keep a sort of a thematic code through this to make the reading of these multiple graphs easier. I acknowledge this is a lot of data, um. That individuals who have living in the most uh segregated neighborhoods with the most disinvestment and least economic resources, and all the things that that uh that those resources allow, having the greater risk of severe maternal morbidity. And there's things like the ambient environment. So here this is not looking at New York, but looking at California, but again it returning to this idea of the the historical uh ripple of of redlining, as it occurs, you can see on the left, um, and this is in California, looking at the Berkeley Oakland area, again the the redlining map colors that you've become accustomed to red, uh, the hazardous neighborhoods, green, the best neighborhoods. And um so on the left is that map from the 1930s, and again, uh, nearly 180 years later, looking at the overlay of pollution in this case from nitrogen dioxide, and how that overlays exactly on the red line neighborhoods. In terms of its so the the um greatest concentrations or the deepest purple in the middle with the gradient, of course, becoming less and less as we would have hypothesized um as as you move toward those green uh neighborhoods from 80 years ago, um, and, and then of course that overlays as we would have expected based on um Doctor Krieger's uh conceptual model, uh with the percent of people of color living in. In those neighborhoods um related to exactly what had happened, um, with the red lining from the 1930s, that pollution itself then is related to the chance of preterm birth. Um, the built environment in in neighborhoods that were redlined is, is because of disinvestment, uh, is, is structurally different, the proximity and the availability of parks, for example, walkable communities. Uh, so here's a study also by Doctor Kershaw looking um from the new mom to be study, which was a prospective study of over 10,000 lippers individuals um who had their address who gave their addresses and then had those addresses geocoded. Um, and for two things here, walkability index, which is like a quantification of the walkability of a neighborhood, and also the number of gyms and parks, things that would facilitate physical activity within 3 kilometers, and then there's self-reported physical activity from the individuals in this prospective study as well. And um bolded on this uh on this chart on on this table are a statistically significant association. So for example, the walkability index score, and it's not important what it is, it's just important to, you know, that it, as the as the index goes up, the neighborhood is more walkable. You can see that like look at the visits between 22 and 32 weeks as people reported their physical activity, and this is maybe not surprising. The more walkable a neighborhood was. The more physical activity people engaged in, the closer the proximity to gyms. The more uh uh uh physical activity people engaged in the same with parks. So this is a very concrete example then of the built environment in a neighborhood and how it facilitates health behaviors. That facilitate um better pregnancy outcomes. Why are does that facilitate pregnancy outcomes, better pregnancy outcomes because we know that for example, physical activity not unlikely to be associated with gestational weight gain and then if you now overlay this built environment, the things we talked about walkability, proximity to gyms, proximity to parks, types of grocery stores and concentr and food availability and nutritious food availability. What you see is that gestational weight gain, either in excessive or inadequate. is inversely related to, for example, the, so the more walkable your neighborhood is, the less likely it is that you are going to have excessive or inadequate gestational weight gain. That's true for the number of gyms and the number of parks that are available to you and proximate to you, nutritious grocery stores, um, and then. Without showing you the data, I'm just gonna say because I think you know that both inadequate and excessive gestational weight gain or associated with adverse pregnancy outcomes like hypertensive disorders of pregnancy, GDM, SGALGA and preterm birth. So we're seeing these mediators, right, that are related to the initial redlining. That then are related to the preterm birth or other adverse pregnancy outcomes that occurs. This relates to other aspects of the of the of our of our social environment. There's a really nice I think paper that people should go back and look at from uh Rachel Hardiman, uh, looking at the association of preterm birth with police contact, a highly stressful, uh, situation. Uh, the first slide I'll show you from her paper is, um, this is, uh, Columbia Heights, um, a neighborhood, um, in Minnesota, uh, I believe, and, um, you can see again the, the red line neighborhoods, um, and, uh, the, the colors that I'll just point out to you on this, on the right side of this slide are is the amount of police contact essentially. Um, that is overlaid on this neighborhood. So for example, you can see that the amount of police contact, um, is, is much greater years later in those red line neighborhoods. Now what Doctor Hardiman did was that she showed that regardless of who you are. If there is police contact, the chance or the increased risk of preterm birth is exactly the same. Right, so there's no statistical way to say this would be there's no interactions no matter who you are, if you are in a a a stressful environment where you're having police contact, uh, it frequently. Your chance of preterm birth is greater, doesn't matter if you're black, doesn't matter if you're white. The difference, of course, is, is that the chance of police contact is so much greater. In neighborhoods with greater proportions of black individuals. Which is related to the red lining that occurred. Now nearly 100 years ago, and of course then the chance of preterm birth is greater because we just said on the other slide that police contact for anyone is a risk factor for preterm birth to an equal degree. And it's not just the things that happen in pregnancy, and I think this is really what I want to drive home more than anything. I mean, it is incredibly important what happens in pregnancy, right? Incredibly important, but that is the that is just the acute phase of a chronic issue. And so the it is really the lifetime stress what people bring when they come into pregnancy, which is so um if such a driver. Of the adverse outcomes they occur and so what I want to show on this slide is just to explain, police contact in pregnancy, that's an acute. Issue, um, adverse childhood experiences is represented by the ACE score, well, as a childhood issue. And uh here what you can see in a really nice study um by a Drury, uh, published just a few years ago, is that the more adverse child experiences you have. The the shorter your telomeres are as an adult, and telomere shortening is a reflection of weathering and stress. And so, what are the consequences of that? Well, as people come into pregnancy, optimal pre-pregnancy, uh, and peri-pregnancy cardiovascular health is differential according to race ethnicity. And so first again, what should be concerning, and I'm, I don't exactly know what that um there's like a little random uh thing in the middle of this graph, uh, but, um, uh, one thing that should be concerning sort of an inverse to the GDM slide, is that for everybody over time, pre-pregnancy cardiovascular health has come into pregnancy is decreasing. So this is a widespread problem for everyone, but differentially. Uh, spread as well, and you can see that it not only is it decreasing for everyone, but cross sectionally, it is very different. In terms of the pre-pregnancy cardiovascular health um that that people have, uh, based on their race ethnicity, again related to the racism, uh, and, and the structural racism that has set the stage for this to occur. Uh, pre-pregnancy cardiovascular health is incredibly important in terms of pregnancy health. Uh, first off, I'll just remind people, even though that is, even though it's not a slide, that more than 50% of maternal mortality. Is related to cardiovascular and cardiovascular related events. That's a very direct thing. But pre-pregnancy cardiovascular health is related to uh adverse outcomes as well. So for example, this is looking at risk factors, 1 risk fact one adverse risk factor for cardiovascular health, 2 risk factors, 3 risk factors, 4 risk factors, and you can see the dose response, whether it's for the maternal ICU admission, preterm birth, low birth weight, or fetal death. The worst pre-pregnancy cardiovascular health that you have coming into pregnancy, which is set by a lifetime of adversity and or or differentially uh uh uh frequent depending on the adversity that people have had um is related to then the adverse outcomes that they have, um, the adverse outcomes for the people we care for in pregnancy, if they're pre if their pre-pregnancy or pregnancy cardiovascular health is bad. Has consequences for for them for the rest of their life as well. When I think of obstetrics, I think not just of the pregnancy event, but everything around that obstetric event, including what it means to future health. And this is a um slide again just to sort of um in all of this, it's not really supposed to be so much focusing on the numbers but focusing on the patterns. This is, for example, if your lipid levels are related in elevated in pregnancy, if you have GDM, if the sum of your glucose measures is greater, your chance of years later, 10 to 14 years later, of having elevated cholesterol, it's just one example of adverse cardiovascular health in the long term is greater. Now what about maternal cardiovascular health then? Well, maternal cardiovascular health in this uh nice study by Mandy Peric in JAMA is related to the cardiovascular health of your child. Right, so the cardiovascular health you have in pregnancy, so let's, let's maybe just look at the, at the graph. This is showing like um for every This is a cardiovascular health score, a lower score is worse. And then you can see that like as you go on these dots, um, the, the topmost dot is the most favorable cardiovascular health. So for people with the most favorable cardiovascular health, their children. And at 5 to 10 years of age, have the most favorable cardiovascular health, and every increment that you go down, if you have one intermediate score, if you have one poor score, if you have two poor scores. Your children have incrementally worse cardiovascular health, which again is setting, if we think about the life course perspective of health, is setting people from the start up for less less good health over their life course, including less good pregnancy health, less good pregnancy outcomes. Which then sets this cycle up again. So if we go back to the Krieger, I think, and I hope by this point, even though it's quick, that you would look and you say, yeah, we have shown how. As a structural uh racist event of redlining leads to inequities in the adverse pregnancy outcomes that we see today, and we see the mediators that connect that historical event to our present day uh disparity, whether it be the segregation that occurs as a consequence to it and the disinvestment related to that segregation. The different socioeconomic resources that are available, the access to and the quality of health care, and a variety of place-based resources, including pollution and the built environment, uh, grocery stores, parks. Uh, I've shown you, I, I hope, how these things lead to early life inequities, uh, how those early life inequities feed in to the chance of preterm birth, how that leads to greater long term health inequities, and that sets up a really problematic chain of adversity across generations. So it's completely depressing. Um, so what, so, so I wanna, what I want to end on though is how we can try and start thinking about to break this cycle. So the first thing I think that we have to uh reflect on is that there that any intervention that is going to do this is going to be multi-level. Uh, and this is critically important, um, because, as you've seen in these prior slides, the way, uh, these uh place-based disparities pervade health is fundamentally multi-level. It occurs at the individual, the interpersonal, the institutional, the community, and indeed at the societal level. And um I think as you're thinking about this, and as you're thinking about it, attacking this, and as you're thinking about what interventions am I going to come up with and work on, um, I think one thing is always really good to anchor in a conceptual model to frame how you're going to be doing this and doing this in a rational way. Um, I'll just show you on this slide, the social eco ecological model, because it feeds into what we've just been talking about, about multi-level influences and domains for intervention, but there are other models that you could use as well. Um, the first place I want to start is the central importance of community voices, that, um, although, uh, a, uh, Educational conference like this is incredibly important um that it cannot and should not end here uh and that is we're thinking about the interventions that we're gonna come up with and I really wanna use we in like a very big capital we um aspect that the first place to start is by going back to our community partners and working with them to think because we probably have very little insight into really the best ways to do this. Right, and so we have got to get out to our community partners and really work with them, and I have on this slide, um, up at the top a really a great example of someone, uh, Doctor Shockley Smith, uh working at Cradle Cincinnati, who's done a really amazing job and put together, and if I, if you ever get a chance to hear her talk about her experiences. Um, and, uh, I, I'd really be a huge advocate for it, and she, uh, spoke at a conference, uh, that I was at about, you know, the different strategies that you can use as you engage with your community partners to center their voices, uh, obviously focused on equity, using data to understand, as we've done a little bit, I hope today, um, how, how health is patterned by race, ethnicity, uh, and the racism underlying that and who's most affected. Um, listening and engaging, um, deeply and building and on what the community wants and needs, uh, and, and again I think that's always gonna be the place we start in any intervention. I think in the tools um that we can come up with as we sort of run up the chain, the sort of rainbow on the socio-ecological model, we can think of uh interpersonal or individual tools that are tailored to help overcome the adverse social determinants of health and the barriers to health that have been put. In our collective way. So here, uh, Doctor Lin Yi, a really wonderful health services researcher, MFM at Northwestern, um trying to think about how to we had to think about um. The care of individuals with gestational diabetes, which is a complex set of um newly learned behaviors and things that need to be done, that really challenging, particularly in low resource environments and how to put together tools that are specifically directed uh about overcoming social determinants of health. It's not just about can we get a better continuous glucose monitor, right, but it's because that is not gonna solve our problem. What is gonna solve our problem is understanding how to overcome the barriers that have been put in our way, and that's something Doctor Yee is trying to do um with tools like this, um, that are really directed to overcoming these adverse social terms of health in this specific setting of gestational diabetes. Um, other things, how we modify the health care system around us. Doctor Yees also looked at in the past and is now completing a randomized trial looking at postpartum navigation. We spoke about the connection between pregnancy health and long term health, and lapses in transitions of care are enormous, um, and which really compromise the ability to achieve long term health and seeing how postpartum navigation, uh, because look, I mean, for all of us navigating the health care system is a misery. I mean it is a misery if you're a clinician or if you're a patient. Um, is really a misery if you're a patient, um, just to get an appointment to get follow up, to understand what you're supposed to do. And a lot of times they're just, I would say most of the time, there's not time in the office you go to to take care of all of those things. So can a postpartum navigator navigation, which has been used in many other fields, um, a lay individual, but trained to navigate the health care system, how that can help. Uh, our patients, and so this is a retrospective, this is a just a a cohort study essentially people who happened at a demonstration project to get postpartum navigation or didn't, and in the green, you can see the people who did the greater likelihood that they actually come to their postpartum visit, the greater likelihood that they get, if desired, tier one or two contraception, the greater likelihood they get screened for depression. And so hopefully we'll have the results from her nearly 500 person randomized trial coming in the next year or two. I might go back to what you can do within your institution. Uh, and so here, I think, uh, led by Doctor Howell, uh, the, uh, Council on Patient Safety and Women's Healthcare, and they had lots of bundles for things like hemorrhage and infection, um, but put together a bundle for reduction of peripartum racial and ethnic disparities, both the framework to understand those disparities, some of which we've talked about today, uh, and the responses that we can have at an institution to try to overcome. The problems that we have, and it mimics the sort of bundle formula that other bundles like postpartum hemorrhage have in terms of readiness. I'm not gonna read this whole slide, but I'll, and I'm just gonna show you the four R's if you will, um, but I'm gonna point out one example from each slide. So it's. A system being ready to overcome these barriers. One example with that of that would be, for example, providing staff-wide education on racial and ethnic disparities in their root causes and best practices for decision making, something we're doing at least partially today. One would be recognition of the problems that an institution has. Um, providing staff-wide education on implicit bias and establishing mechanisms for patients, families, and staff to report in equitable care and episodes of miscommunication or respect. Of course it doesn't recognizing is not really all that useful if there's not a response. So a response would be, for example, to um find ways that when someone does report those inequities, to respond to them in a meaningful way. And then reporting in systems learning, which just as one example is building a culture of equity, including systems for reporting response which I just described. Uh, this is a really, I think, a great report, and I would really urge people to go back to it and think about how you can apply each of every one of these things to your institution and your department and question and ask yourself, are these things extant at the present time, and if not, why not? Um, when you're reviewing adverse events that you can have, that you, you will have and have had, do you review them through the lens of social determinants, uh, and, uh, structural racism? And here is an example in a framework, uh, again, really uh seminally, uh, driven by Doctor Howell and Doctor Hardiman, uh, for developing tools to for the CDC when they're doing um their maternal mortality reports. Uh, not just to say, well, like was this from hemorrhage, but what are the underlying causes of that, including the systematic and structured reporting of social determinants, uh, and, and, and interpersonal racism and discrimination. And so another uh paper I really recommend for people because it shouldn't just be the CDC who's doing it, should be that we're doing it as well and each and every one of our M&Ms and when we have them. At our professional organizations, we can be doing this. So, uh, I'll just put up I'm involved in the Society for Maternal fetal medicine, the strategic math that they came out with in 2022 and 2024, and I'm not gonna uh go over each and every one of those things. There's a few slides after this and I want to be respectful of time, but I wanna just, um, demonstrate that this is that if we saw a strategic map from 20 years ago, I can guarantee you it would not look like this. Uh, and that, you know, putting a nice graphic up certainly is not the end is not the end goal of this all, but it is important that, for example, in all the things advocacy and member engagement and knowledge, the recognition. That equity, inclusion and diversity that none of that is going to be possible without DEI work and and again not just putting up a a slide, but that that strategic map then drives if you're doing strategic planning correctly, the strategy actually that you employ, and I would say uh the SMFM has really tried to do that, whether it be in putting out in response to the strategic plan that they put forward, the focus of their publications, uh. The second bullet point, uh, special statement on race and maternal fetal medicine research dispelling myths and taking an accurate anti-racist approach. The annual, uh, events, uh, the events at the annual meetings, uh, President's workshop on social determinants and the anti-racism special interest group. The programs that they put forward, for example, a mentorship in a DEI annual award, uh, and the educational programs they uh put forth, which if you're on the website, you can still find using quality improvement and safety science to eliminate perinatal racial and ethnic health inequities. There's certainly policy that are beyond. The limits of our hospital walls, but that we should be tirelessly advocating for whenever we have the opportunity and even when we don't. Um, and here for example is the mmnibus set of uh uh uh policy uh desires, not all passed, um, but that were put forward several years ago in an effort to address. The structural, uh, racism and social determinants that have been operating and adversely affecting our population and again try to overcome those on a policy level. I want to show you that this isn't just like that these interventions matter and they make a difference in extremely concrete ways and we spoke about the and this will be the last little bit of this talk, we spoke about um. Early life course and how that is uh the life course and early events and how that can set the life course and the chance of adversity and adverse health from the very start. And here's a really lovely study I think called Baby first year study, where they took people who were um at um economic disadvantage historically rooted and just gave people cash transfers, they randomized people to cash transfers. Not an enormous amount of money, by the way. Randomize people to cash transfers or not getting cash transfers. Now these are the babies' brain waves. I will tell you I know nothing about babies' brain waves, so I am taking but from the article, gamma waves are the better ways. OK, we're just gonna accept that gamma waves are the better ways, and that gamma waves are are related to ultimate better um uh neuro development and uh neuro functioning. And in this randomized trial. With just relatively small cash transfers for economically disadvantaged individuals, there were already in the first years of life difference in uh in in neurologic development. And I think this is just an amazing example of how even just a a minimal intervention early on can change has the potential to change a trajectory. Uh, here is an example of looking at Medicaid expansion and how it affected, uh, hypertensive disorders of pregnancy. It didn't affect at all pre-pregnancy hypertension, but as more pregnant individuals had access, um, uh, to Medicaid uh across the country and earlier access, uh, and this is sort of interesting, so it's again a lot of information on the slide red line are non-expansion states over time. This is a difference and different study. Blue line is expansion states over time. And what you're seeing here is that actually the diagnosis of HDP becomes more frequent over time in expansion states. That should not be surprising to us. Everyone's having HDP. It's just in some people it's diagnosed well and timely and in some people it's not if you don't have proper access to care. So as you expand Medicaid, your ability to actually diagnose disease. Becomes more possible, but when you diagnose disease, what happens is you're able then to get better outcomes. So if you look at the chance of low birth weight among individuals who have HTP over time, what you can see is that the expansion states. Over time compared to their non-expansion counterparts actually begin to do better, because now you're having people who are diagnosed and cared for and some of those adverse outcomes that we discussed before are able to be mitigated. So, um, This has been such an unremitting, uh, Problem that I think we can have this sort of learned helplessness. And I think, you know, we just have to constantly be fighting against that, and we realized even from these last two brief examples, um, that we or or the other uh examples of interventions I showed you that at these multi-level, uh, that there are multi-level possibilities of influence and that they make a difference. And so, uh, Doctor Mayo, even back in 1926, just before redlining occurred, uh, the ills of today do not cloud the horizon of tomorrow, but act to a spur as greater effort, and I would hope that's something that we all can embody. And then then the last thing I will end on is a quote from a fireman on NPR in 2022. Uh, he had talked about um becoming of A fireman, um, because he was, he thought about it, he felt like the glory of it, running into burning buildings and saving people, and he finally become a fireman and then on the first day of becoming a fireman, he got called to a building and um it was on fire, and uh and the uh uh he was told to go in, there was a lady outside and he she was shoeless. Uh, because she'd run out of the house on fire, and he was told to go in and get her shoes. And he thought like, Oh my God, like here I had been thinking about this. Unbelievable, like running in and saving people, and I'm, I'm rescuing slippers. And he thought at first he was really down about it, and then he went out and the woman just said to her like how unbelievably grateful she was. He realized she had been standing there in the street, no shoes on, and just the act of giving shoes to her was so meaningful. Um, that it completely renovated his idea of being a fire person. And uh And he or someone on that. Uh, report said, do not let the fear of not being able to do the great, the big great thing dissuade you from trying to do the many small good things. Which I think is also incredibly important. If we think about this problem like in its largest aspect, it almost seems unremediable. um, but I think if we instead, you know, are just constantly and tirelessly chipping away at it, um, that we can make meaningful contribution, that's the only way we're gonna get to the finish line. Uh, so I'd leave you with those two quotes, and I don't know if we're taking questions now or later or. Sort of, whatever you want, what whatever Doctor Meta Lee wants. So thank you for your attention. Published May 3, 2024 Created by Related Presenters William Grobman, MBA, MD
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