Building Health Equity: Time to Combat Disparities in Maternal Health
Podcast Transcript

- [Intro Narrator] Welcome to Share Public Health, the Midwestern Public Health Training Center’s podcast, connecting you to public health topics, issues, and colleagues throughout our region and the country, highlighting that we all share in public health. Thank you for tuning in to Building Health Equity, the Institute for Public Health Practice, Research, and Policy’s series highlighting health equity practice throughout Iowa. Over the course of the series, we will be inviting speakers to dive deeper into their experiences in health equity practice to serve as a learning enrichment opportunity for health department staff and anyone interested in building health equity. As a heads up, these podcasts have been reformatted from the original Building Health Equity Webinar Series recordings.  

- [Tricia] Welcome to the 17th installment of Building Health Equity Webinar Series: Time to Combat Disparities in Maternal Health. Our objectives for today is to discuss the most pressing concerns and issues related to maternal health through a health equity lens, address certain populations that face barriers to maternal health, explore any potential partnerships or strategies to improve maternal health among diverse populations. I'm Tricia Kitzmann, I am faculty here at the University of Iowa College of Public Health. I work with the Institute for Public Health Practice at the University of Iowa, College of Public Health. I will now invite our guest speakers to introduce themselves. Bea, are you ready?

- [Bea Sanchez-Vazquez] Hi everyone, thanks for the invite. I'm Bea Sanchez from the Department of Health and Human Services. I'm a Project Planner and the PRAMSS Data Manager, so once again, thanks for having us.

- [Tricia] Awesome.

- [Nafla Poff-Dainty] Hello, my name is Nafla Poff-Dainty, I am the Maternal Health and Family Planning Executive Officer, so I lead our Title V Maternal Health Program, also known as the Healthy Pregnancy Program for the state and I'm very excited to be here. Been in this role for a little over a year, but I've been working in health equity for over a decade. So...

- [Tricia] Welcome Nafla and Bea, we are excited to have you with us today. So we'll kick off the presentation today, telling us a little more about yourself, what kind of got you into this work and what specifically do you do. Nafla, we'll kick it off with you first.

- [Nafla] Certainly, so like I said, I manage and coordinate our Healthy Pregnancy Program from the state level at Iowa HHS. I have always loved maternal health. It's always been a big part of my passions and reproductive health and the connection in between. I actually got my start in public health at Linn County Public Health way back in 2011 as an AmeriCorps Volunteer working on the Care for Yourself program. And there, I just realized even with that intersection, even though Care for Yourself isn't, you know, specifically reproductive health, classified as reproductive health or maternal health, women and mothers and the intersection of, is largely who we were serving. And so since then I got my Master's and then I've worked on a few different programs, but before I was at Iowa, I worked at the State of Wisconsin's Health Department in their Title V Maternal and Child Health Program as the Health Equity Consultant. So trying to think of how we can address the disparities in maternal and child health at the state level and then moved to Iowa and now I am in this role and very happy to be here.

- [Tricia] Wonderful, thank you, Bea we'll have you go next.

- [Bea] Yeah, so I spent nine years before coming to the department in Local Community Action Agency. So I was at the Title V agency for quite a while. And at that point I knew that's where I wanted my career to lead me. So a few years ago when I started at the department, I started as the PRAMSS Standard Manager, and PRAMSS is the Pregnancy Risk Assessment Monitoring Surveillance System. It's the survey that comes from the CDC to a vast amount of pregnant woman or women that have gave birth in the last several months. And that's data to better outcomes for infants and mothers and so we spend time looking through those results, analyzing PSEs and that sort of thing. And then through my journey at the department, I have also been lucky to be involved in the State's Doula Project.

- [Tricia] Fantastic, welcome. So what are the current issues and concerns related to maternal health from a health equity perspective?

- [Nafla] So a lot of the current issues and concerns are fairly broad but they all are major when it comes... They all see major disparities. So maternal mortality first and foremost, so looking at the deaths of people who have given birth within one year, and we look at both the pregnancy related and pregnancy associated. So say, we review all of the cases say of a car accident involving a postpartum person who's given birth or are currently pregnant. And then also, if we're talking about eclampsia, a death from eclampsia or a pulmonary embolism, looking at all of those. Unfortunately, our maternal mortality rate has been going up, so definitely of concern, and the fact that it is consistently higher among people of color. And then it is also continuing to grow so even though everybody is continuing to go up in maternal mortality, we're still seeing a broadening in this gap. And then alongside that, we also are seeing severe maternal morbidity, so not deaths associated with pregnancy but serious health issues, again, related to race and ethnicity. And the official kind of definition for severe maternal morbidity includes 20 different conditions. I'm not going to list them all, but just to kind of give you an idea of what might be included in that when we're having those conversations would be an aneurysm, eclampsia, sepsis, renal failure. Occasionally, we'll have conversations about needing a transfusion although that's kind of just a side to the maternal morbidity piece, so very large issues. I think within that we also see issues around prenatal care access, especially broken down by race and ethnicity. And so the ability to access care that fits your needs and then we're also seeing the same issue in our rural communities. And then, that it also goes hand in hand with the closing of birthing hospitals in our state. And so there are some areas of the state, which are more than one hour from a birthing hospital in Iowa. So how are we able to serve our communities there? What, you know, traumas and potential maternal morbidity are they facing? And again, this is all tied together, a decline in providers that are willing to or able to assist in birth. We've seen a decrease in family medicine providers that are able to provide obstetric care. And if we're also seeing the closing of birthing hospitals and then obviously the obstetricians that go along with a birthing hospital, where are people able to access their birthing help? Especially if they are having a high risk birth. And then we're also seeing a rise in out-of-hospital births. Not necessarily... I wouldn't say it was a concern but it's also just... It might be depending on who is giving birth out-of-hospital and what is necessitating that out-of-hospital birth. Because we do know that there are people who are trained and able to provide out-of-hospital care, but if they are in one of those spaces where you're an hour from a birthing hospital that's able to serve a pregnant patient in the way that is needed, then are we putting that person's life at risk by having an out-of-hospital birth?

- [Tricia] And even for clarification, I think we're seeing and hearing about this a lot in the nation, especially in the southern region, but this is happening in Iowa as well, correct?

- [Nafla] Yes, everything I said is specific to Iowa and our cases. So, all of these trends we're seeing nationally, but unfortunately we're also very much seeing in Iowa and Iowa's severe maternal morbidity rate has actually jumped significantly and it's higher in Iowa than the rest of the country currently. We have a very high rate of severe maternal morbidity. So luckily that hasn't translated into mortality quite yet, but something of major concern for us.

- [Tricia] Absolutely, Bea, do you have anything else to add?

- [Bea] I don't. I think Nafla did a wonderful job, thank you.

- [Tricia] Great. You touched a little bit on this already, but I'm gonna go ahead and ask it. Are there certain populations that are facing more barriers to maternal health? And if so, who are they?

- [Bea] Yeah, so based on our maternal health morbidity and mortality rates and reports, we see that the minorities are most at risk. Black identifying individuals in the Latino community, and then there's a rising concern of the indigenous population as well. Also, our rural populations when it comes to accessing services are vulnerable. So yeah, it's very unfortunate.

- [Tricia] Yeah. What resources are available to help support these populations?

- [Nafla] So I have to plug the local Title V agencies. I do see that there are a couple agencies that we contract with to provide the Healthy Pregnancy Program. And so these, they don't necessarily... We don't provide clinical care but it's more care coordination and then also screening for substance use, mental health disorders, intimate partner violence, and then obviously offering the support and referrals needed to address those throughout your pregnancy. Connection with a prenatal care provider. So then, then they can manage any medicines and obviously do all of the necessary prenatal care visits. So local Title V agencies, always highlighting them. As Bea mentioned, we do have a Doula pilot program, which is currently housed out of four of our local Title V agencies. So every step in the center of the state, Allen Women's Health out of Waterloo, Dubuque, VNA, and then Scott County Public Health and they are an invaluable resource. This pilot program is specifically focused on supporting black and African American pregnant people in those areas. And it also is using doulas of color and it's kind of a two part, so there's the pregnancy support piece. You receive three prenatal visits with a doula, birth support during the actual birthing process, and then three postpartum visits, and that's all covered by our program in those four spaces. Then there's also the training of black and BIPOC doulas who are interested in entering that space. And so we have kind of this... It's an increasing the workforce piece, but then also the supportive pregnancy piece. Community health workers and local public health, I see a lot of local public health on here, your local WIC office. And then also, I mean, I feel like you are all doing wonderful work, but then there are also organizations that are already serving the populations that are seeing disparities. They may not necessarily have maternal health programs, but maternal health is everything outside of just giving birth. And so they may be able to offer support in ways that are maybe not directly maternal health or prenatal care related, but support for everyday life and those, the care coordination and referral piece.

- [Tricia] Wonderful, Bea, do you have anything to add to that?

- [Bea] No, I don't.

- [Tricia] Fantastic. You've been very comprehensive so I appreciate that. So, what are some ideas to better reach these populations? The ones that are at greatest risk?

- [Bea] I think from being in the Doula Project, I think one of the best ways to reach these vulnerable populations is to hire culturally congruent staff. And if that's not possible, finding the populations' advocates within their communities to bring that information to them and that education. So, from my experience, I've found that building a relationship of trust, either from your staff members or from finding that community advocate within that population, that's gonna make a big difference in being able to help.

- [Nafla] I would also just add showing up in your community and in the spaces where these populations are showing up, not in a way where... With no intention, you're there to understand and learn, and coming as an invitee and as a guest to that space. Not necessarily as someone who's there to sell, you know, the maternal health program or tell them, you know, what disparities they are living in their everyday life.

- [Tricia] Wonderful. What methods have you seen be successful in helping these populations navigate and receive the resources to improve their health?

- [Nafla] So coming from the state, I feel like our role is slightly different, well, than say a local public health agency or a community access organization. We don't work directly with individuals or with the population of Iowa. So, in terms of the strategies from our purview that have seemed to work it's systems. Where are we missing, where are there gaps? Where are hospitals closing? What can we do to, as a state system, to increase our capacity and our ability to fund programs that are serving a diverse population and that are meeting the needs of a multitude of individuals. So, I just wanna kind of throw that out there in terms of methods and strategies. But I think, like Bea mentioned, culturally congruent care, if your space can reflect the people that are coming to receive services, that is key. Being able to see yourself as belonging, not necessarily fitting in a space but having a space where you feel heard and seen, and accepted is going to be greater than, you know, any baby shower at the county fair. And so how do you create that space? How is your public health department or community access organization serving a multitude of people and how do you show up? And this also allows for a stronger bond to form sooner with someone who doesn't necessarily look like you or doesn't have the same lived experience, or understanding of cultural differences that you may have. And especially for our populations who have English as a not primary language, entering these spaces is especially difficult because now it's not just a space where you don't feel like you belong, but you're also struggling to kind of process sometimes exactly what path you're supposed to go on. And then it's like, "Well, no, you can't get that here, you have to go over here." And how can we make that smoother? So, culturally congruent, but then also language access, as well.

- [Tricia] You touched on this and I don't... I wanna make sure I leave some space since our... A lot of our local public health agencies online today are looking for better resources. So, are there more resources or other things that local agencies could be exploring?

- [Nafla] I mean, to be honest, you are all doing wonderful work, so I would suggest working with one another and having the conversations about what is happening and what is working in your space. I do know there are programs like In Dubuque and Allen Women's Health that have had a lot of success with the native Hawaiian and Pacific Islander community in their spaces, not saying that everybody has solved the issue but they have built quite solid inroads with that community and have culturally congruent care within their staffing. So, learning from one another, also connecting with other counties or agencies that are seeing a lack in maternal health support. So I don't necessarily have a, you know, webpage or a training or anything like that to provide, but I think that you are all doing better than those webpages or a single resource can really provide you. Also connecting with other states, I know that we talk about Missouri and Nebraska and Kansas as being very... Their work reflecting ours quite a bit, but Minnesota and Wisconsin have also seen, you know, similar, maybe not same-same, but similar issues in terms of supporting health equity work outside of their major hubs and so what are they doing? And learning from one another. I feel like I would like to provide more, I wish I did have, you know, a nice webpage which would solve everything, but I don't.

- [Tricia] There's always a wish, right? Bea, do you have anything additional to add to that?

- [Bea] Yeah, so I would just add bringing the community champions, leaders, advocates, who also sit in to meetings, strategies. What are the barriers so that you are all able to identify if it's transportation, if it's clinic hours, you know, what is the barrier for accessibility to services. So that's all I have to add.

- [Tricia] Wonderful, thank you. You kind of touched on this, I think, you know, talking about sharing resources, identifying some of the barriers. Is there anything... And again, I think you both touched on this but is there anything else that public health agencies can do to help eliminate some of those barriers accessing maternal services outside of maybe the resources that we would providing them? Are there other avenues that they should be... Other agencies or other things that they should be connecting with to help eliminate those barriers?

- [Bea] I would suggest, you know, finding out what all their MCO offers as an additional service. Some MCOs offer transportation and so just being aware of what services are already available to the vulnerable community is very important. I also mentioned having non-traditional clinic hours or hours for maybe additional education opportunities, things like lactation information, having that be after work hours so that more people can have access to that. Having materials in different languages, as well. Yeah, that's what comes to mind.

- [Tricia] I'm gonna have you... I know most of us know what MCO stands for, but I'll go ahead and have you say what MCO stands for.

- [Bea] Yeah, so that's what the... What Medicaid provider they would have, right? So you have Iowa Total Care, Amerigroup just switched names and I can't think of it now, but that is their Medicaid provider.

- [Tricia] Wonderful, thank you. Nafla, do you have anything additional to add?

- [Nafla] I would also just add partnering with organizations that are already providing maternal health services in your area. So if you aren't funded by our Healthy Pregnancy Program, you know, who is serving your area of the state. So you don't necessarily have to duplicate services or efforts, especially if it's already available. But can you build a bigger partnership there? And then also just in understanding the... Or gaining hopefully a bit of an understanding of the disparities that are kinda more specific to you. We do have the Barriers Survey, which I can share the link to that report, which we run specifically focused on, what barriers are you experiencing? It is focused on certain areas of the state where we see most of our births but it does cover the, you know, pockets of the entire state. So there may be people who... From your area, even if you don't necessarily see your county listed on there, that are birthing in say Council Bluffs. And so what barriers are they experiencing to care and to accessing services in their space. And then we also have Bea's, wonderful survey PRAMMS, which is a federal survey so you're not likely to get, you know, county-specific data. But again, just gaining an understanding of the trends that we're seeing among different populations in our state related to pregnancy and the experiences that they're having during, but even before and after pregnancy. So just what data is already being collected that kind of gives us an idea of what's happening in your space? And I can put both of those in the chat for people to look at.

- [Tricia] Wonderful, thank you. What are some strategies that can be put in place to ensure all can access the supports that they need?

- [Nafla] So Bea mentioned some more kind of physical ideas for your space. So the having non-traditional clinic hours, so if people who are working a nine-to-five, Monday through Friday, have more options to access services. Having direct contact for commonly used resources and referrals. So if you do have a lot of people that are looking for transportation, you know, what resources are available in your county or through Medicaid, or their health insurance that you can offer? Is there someone who is offering a small grant for gas cards to kind of help support that transportation piece? Is home visiting an option that you can implement so you are meeting the patient or the client where they are? Hand-in-hand with that is having a seamless referral process. And so if you do need to have a warm handoff to a different program, what does that referral process look like? Are you sitting with the client and making the call with them to make an appointment for a time that works for them? Are you having the conversation between the three of you so that then you can also vouch for the referral space and they can also vouch for you? How involved is the patient in that? And I recognize that, that takes time and effort and we are short on time. We see a lot of people, we help a lot of people, but it really does go the extra mile in encouraging people to follow up on that referral. And then what needs are you seeing in your community that you may be able to help out with? So, do you have a needs list? So, are you again seeing food insecurity? Do you know that you live in a food desert? Is there... Are you in a child care desert? We may not be able to solve all of these, but if we can start addressing them in some way, again that takes off some of the burden of being a pregnant or parenting person. And then making it as easy as possible for the individual to access care. So is that allowing their child to be in that space? Do you have a little corner or some toys that their children can play with because for many Medicaid appointments, for instance, you're not allowed to have your child in transportation. And so, you know, that just is another barrier for people. And so if you are able to bring your child with you because you live in a childcare desert and don't have anyone to watch them kind of, how can we keep them entertained and make the space more conducive for everyone receiving care?

- [Tricia] Kimberly shared, "Another opportunity for collaboration is with stillbirth prevention organizations. Research shows a relationship with maternal morbidity, mortality, and stillbirth disparities exist with stillbirths rates across race and ethnicity, as well as within communities with challenges to accessing care." So, I wanted to make sure I shared that, as well. Kimberly, thank you for sharing that.

- [Nafla] I would also put in a plug for pre-conception health. A lot of the severe maternal morbidity that we see is related to common health factors that kind of become worse during pregnancy, and so if we can address some of those issues beforehand, before someone becomes pregnant, which obviously we know involves a lot of hormones and is not the happy golden, amazing, joy-filled time that it's always painted as, how can we address those things before someone becomes pregnant? So your Title 10 family planning clinics, any family planning clinics, even Care for Yourself programs. What can you do if you know that someone is planning on becoming pregnant or they're not planning on becoming pregnant, they do not want to, but are engaging in practices which may put them at higher risk for becoming pregnant? How can we manage their health beforehand? And so then it's not exacerbated during pregnancy as well.

- [Tricia] Wonderful. I think you've pretty much covered it, but I wanna make sure that I wrap around. Are there any other local or state partners that we should be considering collaborating with, both at the local and state level? Any that we didn't mention?

- [Bea] We mentioned the Managed Care Organizations, which were the MCOs, we would add Local Board of Health, school districts, population specific organizations. There's a lot of those that are starting or have been around or are, you know, in talks of becoming as more people come to Iowa. We mentioned WIC, obviously the Healthy Pregnancy Program and then your local federally qualified health clinics as well.

- [Tricia] Wonderful. For organizations or individuals who have not previously been involved in maternal health but are interested in contributing, where would you recommend them to start?

- [Nafla] So I would ask, what are you already doing? So like I said, I mean maternal health and a healthy pregnancy start well before a person becomes pregnant. So what are you already touching? If you're doing obesity work or anti-obesity work, can you do a little focus on, you know, preconception obesity work? So then, again, people are entering pregnancy in that space. If you're doing tobacco cessation work targeting maybe slightly younger women in their 20s as opposed to right when they become mothers, so, then, quitting tobacco becomes a little easier just because like I said, it's a stressful time, and we often go back to our vices and the things that bring us comfort. So quitting substances or tobacco, or alcohol, during pregnancy is actually harder than it possibly is before. If you're moving into health equity work, I would say self-awareness. So, where is your agency in its health equity journey? We do a lot of this within HHS and within the space that we currently touch, are we an equitable space? Are we culturally congruent? And the answer is no, but we're working on it. And so what can we do internally that will hopefully one day expand beyond like our proverbial four walls? And how can you become part of the solution? What's already happening in your community that is touching either the maternal health space or preconception space that again, you don't necessarily need to build yourself, but you can support and bring your perspective to? So how can you be a part of the larger solution, regardless of where your current passions lie. And so, I think really looking outside of maternal health itself to influence maternal health.

- [Tricia] I would say, really being actively involved maybe prior to working with these populations and getting to know some of the leaders within those populations before we're talking about either pregnancy but also sexual health, right? Talking about that as a whole, 'cause that also we know some of the Title 10 clinics, but also just general education about what sexual health is, that then can also lead to healthy pregnancies.

- [Nafla] Mhmm. Exactly. And with the community organizations, like we said before, showing up in their space for them. So, you know, it's not going to be we come in today and immediately have a partnership for our program, but what are the needs that we may have been missing in that population that they're working with? Would they like to see more doulas trained? How can we help support that? Is it access to prenatal vitamins that they're seeing a lack of? How can we support that? So, what do people need from the people who need it?

- [Bea] Right.

- [Tricia] Are there any volunteer opportunities or community-based programs you would recommend? I think you've kind of touched on some of these, but are there any that we wanna make sure we highlight and talk about today?

- [Bea] We have to mention Title V, of course. Most of the clinics have a volunteer program available to any individual that's interested in becoming a volunteer. We just, you know, recommend that they identify what area they wanna volunteer in, whatever their passion lays. And then federally qualified health clinics, as well. If you're interested in becoming a doula, I'm sure our contact information will be available for everyone, so if that is something that you would like more information about, please, please let me know.

- [Tricia] Tell me a little bit... I'm gonna have you explain just a little bit more on the Title V just in case folks are not really familiar with that.

- [Nafla] So, our Title V maternal health programs are based out of... We have 15 service areas, but currently 14 agencies serve those service areas and they provide education and referrals, and care coordination for pregnant people. It is free if you qualify for Medicaid or are living below that FPL. We do have the ability to do a sliding fee scale if you are above that FPL but it isn't used very often. And I would also say, if you do not qualify for Medicaid, say if your documentation status is not kind of in perfect order, we still offer free services, we're not going to turn you away because of that. But we do bill Medicaid if we are able to. And so when you become pregnant, you can come to one of our Title V maternal health programs, also known as Healthy Pregnancy Programs and they will get you set up with a obstetrician for your prenatal visits, warm referral there. Care coordination for dental visits since dental health and oral health are imperative during pregnancy. We screen for intimate partner violence, substance use, alcohol use, and mental health. So then we can provide proper referrals for those. We do offer listening visits at our funded agencies, so if you do score moderately high on our depression and anxiety screening, we do have services to kind of fill the... A little bit of the space between, you know, having these strong depressive and anxiety feelings, and finding a mental health provider because we do know that there's a lack of providers in the state and so a little bit of support there. And then connection to resources, referral to other spaces that you might need. So, when we're talking about transportation or childcare, we may not be able to fix that issue but offer referrals and that warm handoff to other spaces, so then we can better meet the needs of the population of Iowa.

- [Tricia] Wonderful. I wanna open it up to any questions from our audience. If you have any additional questions, feel free to put that in the chat and/or in the Q and A. And I'm gonna pause just for a minute to allow folks to either type in their questions or... In the chat or in the Q and A.

- [Bea] I will add that we do have a collaborative service area map that we can share with everyone, which identifies who the Title V clinic is in your area.

- [Tricia] That would be great, thank you so much. We'll make sure we get that information out as well when we send this out.

- [Nafla] And that'll also include our child and adolescent health services and then our First Five and WIC as well, so you can see who is serving all of our service areas from those programs.

- [Tricia] Wonderful, thank you, we appreciate that. All right, I am not seeing any additional questions. You guys, thank you so much for coming today and spending your afternoon or spending an hour with us and sharing your expertise. It's been a pleasure hearing about all the great work you're both doing. To our audience, I encourage you to subscribe to the mailing list on the Building Health Equity site. And all the resources that have been shared in the chat and ones that have been mentioned during the webinar, we will also send out and share. This was our second webinar this spring. We will have two more scheduled over the next several months. Topics will be about gender-based violence and community partnerships. Please be on the lookout for any additional webinars that we produce. We will post these on our website and send notification to our subscribers. Again, thank you so much for taking time today with us. I appreciate everyone's time and sharing again your expertise. Take care and have a wonderful afternoon.

- [Bea] Thank you.

- [Nafla] Thank you.

- [Tricia] Thank you.

- [Outro Narrator] Thank you for joining us today. Special thanks to Tricia Kitzmann, Tasneem Ali, Cynthia Maharani, Natalie Peters, Melissa Richlen, and the speakers who have shared their expertise with us. Theme music for the Building Health Equity podcast series was composed and produced by Dave Hoing and Roger Hileman. Funding for the Building Health Equity initiative is provided by the Iowa Department of Health and Human Services. Please see the podcast notes for an evaluation link and transcript. For additional resources and information, or to view the video webinar recordings, be sure to visit www.buildinghealthequity.com.