Resources: 

Expectant mothers and their loved ones can find many ways to get support through pregnancy and beyond: 

Diversifying Doulas Initiative is a program of Patients R Waiting, in Lancaster, Pennsylvania. The goal is to provide greater access for women of color to doulas, and to provide training to those who want to become doulas.  

Learn more about doula services at UPMC Magee-Womens Hospital, or email thebirthcircledoulas@upmc.edu. 

Residents of Allegheny County can call Resolve Crisis Network, which provides crisis counseling for a variety of issues, at 1-888-796-8226.

UPMC Health Plan members can access support, education, and resources from maternity health coaches. This program is provided to members at no cost.

Transcript:

Dr. Ellen Beckjord: In this episode, we talk about pregnancy, reproductive health, and health disparities with two guests: Dr. Hy Simhan, maternal fetal medicine doctor at UPMC Magee-Womens Hospital, and professor and executive vice chair of the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Pittsburgh; Dr. Simhan, welcome to Good Health, Better World.

Dr. Hy Simhan: Thanks for having me.

Dr. Ellen Beckjord: And Dr. Sharee Livingston, ob-gyn department chair at UPMC Lititz and co-founder of the Diversifying Doulas Initiative. Welcome, Dr. Livingston.

Dr. Sharee Livingston: Thanks for having me.

Dr. Ellen Beckjord: Dr. Simhan, if I could start with you, please tell us about reproductive health at a high level and talk about trends and challenges that you’re seeing right now.

Dr. Hy Simhan: Thanks for that question. Reproduction is a really important domain for us to think about as a society. And it’s important to all of our members of our society. The notion that reproduction is a choice, that reproduction is intentional, that individuals can choose to reproduce when they choose to reproduce, and if they choose to do so, can do so in a healthy and healthful manner for themselves and for their offspring is incredibly important to us as individuals and is the ultimate measure of our health as a society. The trends that unfortunately we have seen over the last several years and now decades have been that there have been suboptimal outcomes for offspring and for mothers in this society, for all members of our society and, concerningly so, we’ve seen widening disparities in those outcomes among a variety along a variety of lines — rural versus urban across race, ethnicity lines, and across other elements of geography and socioeconomic status. 

And, so, I believe that we owe it to ourselves as individuals, as our society, as policymakers, as health care providers, to be part of the tide that rises to float all boats, to improve pregnancy outcomes that are intentional and optimal for mothers and offspring, and eliminate — not just narrow, but eliminate — disparities across all of these intersectional lines: race, socioeconomic status, education, and geography.

Dr. Ellen Beckjord: Dr. Livingston, can you please tell us about how the experiences of pregnancy and giving birth differ among various communities? And, I know that you’re involved with caring for some pretty diverse communities. I would love to hear your thoughts on how those experiences of pregnancy and giving birth differ, and what things might be common across those groups and what things might be unique.

Dr. Sharee Livingston: Thanks for that question. I’m glad I have the opportunity to focus on the similarities and the differences in birthing people and their experiences. As an African-American ob-gyn physician and as an OB in general, we get to see many great things happen on a day to day basis. Birth is a beautiful thing. We’ve been birthing babies for 250,000 years and actually we birth very well. With that said, there are times when bad things happen in our world and we see maternal morbidity and mortality. And over the past 20-something years, we’ve seen a significant uptick in mortality in the United States. 

And we have to ask ourselves, well, if we once birthed beautifully, what’s happening now? 

And those were the disparities that I heard you and Dr. Hy discussing, and we’ll dive deeper into that. So for birthing people of color, birth is not as great as it can be and should be. And I know that we can do better and we will do better. However, I think generally there is room for improvement in the birth experience in general. 

I think there’s room for improvement to make it a safer birth experience across all sectors, and that’s why we’re having this discussion today so that we can focus on the problem, but focus more on solutions and listening to the patients. One of the things that I do on a day-to-day basis and encourage all health care providers to do, is listen to the patients, bring them into conversations such as these so that we can focus more heavily on solutions and solutions that matter to them.

I have the pleasure of working at UPMC Lititz, where I see a diverse group of birthing people: urban, rural, Amish, Mennonite, city folks. And it’s a pretty cool environment to work in. And, so, I listen to them and hear what their wishes, wants and desires are. And the common theme across all of these birthing families is, “I want to know that my health care provider is listening to me. I want to know that my health care provider values this experience that I’m having.” 

And it’s important that we are hearing what they want their birth experience to be, and we build onto that and insert our medical knowledge and help make it a very safe birthing experience across the board.

Dr. Ellen Beckjord: Let’s talk a little bit more about disparities in maternal health and infant health outcomes, particularly for Black and Hispanic communities. 

I’d love to hear, and if I can start with you, Dr. Simhan, about how we’re approaching eliminating these disparities, especially locally here within the UPMC system. But also, if you care to comment, nationally in the United States. But, you know, these disparities have existed for a long time. They’re extremely well-characterized. What are we doing to, as you said earlier, not just narrow or decrease those disparities, but truly eliminate them? And what are we doing to, as you said, you know, use the rising tide [that] pulls all boats up. 

Overall, maternal and child outcomes in the U.S. are not as good as they are in other parts of the world. 

But in particular, what are we doing to address disparities for Black and Hispanic communities?

Dr. Hy Simhan: One of the features of our health care system that has developed — and I wouldn’t say it’s by design, but it’s by, I suppose, evolution and default — is that it is on one hand quite advanced and able to render incredibly effective care in acute and critical situations with a great deal of excellence, but on the other hand is quite fragmented and not all of the members of our society enjoy access to this care system. 

A population health approach integrated within a clinical care system aims to identify gaps and close those gaps for a population of individuals. At UPMC, in our women’s health service line, our clinical innovation team, called Hatch, has adopted a variety of strategies to try to bring a population health approach to our group of pregnant and postpartum people in our system, regardless of where geographically you might reside within our relatively large catchment area here at UPMC. 

So to that end, we have a degree of technological innovation which relies upon capturing and serving up health care gaps that are identified in the electronic health record from a population of pregnant people. And then serving those to a team of nurses and navigators, social workers, doulas, and other critical members of the health care team who can then do electronic or telephonic or face-to-face or virtual outreach to individuals to offer resources — to close gaps in care, and importantly, communicate with the frontline care team for those individuals. So the doctors and nurses who are part of the obstetrical or prenatal practice for those individuals.

This approach for us serves a range of use cases, whether it is the identification and management of anemia in pregnancy, screening for and referral for depression in pregnancy, gestational diabetes, hypertension in the postpartum period, and — most recently — social determinants or drivers of health. 

Each of these use cases has very legitimate reasons to be addressed and closed gaps for all people. And, in doing so, we aim to be the rising tide that floats all the boats, as I’ve said before, and in particular, focus on narrowing gaps in populations who have been subject to the widest disparities. And that’s our Black and brown patients and our patients in rural communities. So that approach, which is described as innovation, is empowered by technology, but really is a philosophical approach and driven by the humans on the clinical care teams and on our population health team working together to narrow these gaps in care. 

And that, I think, is an approach that can scale across a variety of health care systems in the United States. Certainly, we, at UPMC, have so many stakeholders who have helped us build this team and this approach, and for that I’m incredibly grateful. And, I do think that this approach can be spread to other communities and other health care settings, and I’d like to see it be more deeply integrated into women’s health care across the United States.

Dr. Ellen Beckjord: One follow-up question. It seems like implicit to this approach is a very data-driven approach to managing the health of a population. And so I’m wondering if you think one of the ways that data-driven approach positions the clinical innovation team to have a big impact on reducing and eliminating health disparities is that by being data driven, it reduces bias?

And I’m thinking of two kinds of bias, where people who are better equipped to come and get care then get more care and get more attention. If you’re using a data-driven approach — and some of that data is generated through the delivery of care, I understand that — but you’re less biased toward the population who shows up and have a broader view into the overall underlying population, some of whom may not be as equipped or empowered to come and receive care. So that bias is addressed and also implicit bias that can affect all of us, where the data are used to highlight certain people in the population that may have specific needs. And it’s not left up just to the judgment of the provider, which can be affected by bias, as we all can be. 

Are those two reasons that you think the approach you’re taking specifically help to combat health disparities and improve health equity?

Dr. Hy Simhan: It’s a really important point, I think that is a really clear example of how using data allows us to be more objective and be more equitable in our delivery of care. I’ll give two examples of why I think this data-driven approach has essentially shown the benefits for the reasons that you articulated in your question. 

Let me first talk about our approach for doula care here in Western Pennsylvania in UPMC. 

We offer a doula service that’s integrated within our women’s health service line to our patients who receive pregnancy care free of charge to those individuals. And we aim to improve health care outcomes for all of our patients and, in particular, see doulas as an important source of eliminating disparities. 

What’s important about our program is that there are many roads into receiving doula care for us. A provider might identify a patient as being eligible for doula care or benefiting from doula care, and so that’s a source of referral. A patient themselves might endorse based on their own knowledge of who a doula is and what a doula can do. She may say, “Well, I’d like a doula,” and that’s a road in. 

A third way in for our program, which is, I think, relevant for your question, is that we can use our electronic tools to identify patients who have risk factors for adverse pregnancy outcomes and disparities in those outcomes. So we can use race, socioeconomic status, and neighborhood deprivation, et cetera. We have a series of five characteristics where we can do specific targeted outreach, offering doula services to individuals who might not otherwise, for a variety of reasons, either know what a doula is or have some misconception around the cost of doula care, et cetera. 

I think it’s important to offer the service to all individuals. But an equitable approach  involves targeted outreach, presenting the program to those who we feel might benefit the most and yet are least likely to access it. That’s a data-driven, targeted approach to offering that service.

The second element of our population health approach that I think addresses the implicit bias element of what you’ve talked about is our approach to optimizing and maximizing initiation and sustained breastfeeding in the postpartum period. 

There are a variety of biases involved, unfortunately, in our society overall and in clinical care teams around who does or does not breastfeed, who should or should not breastfeed. And we make very specific efforts to offer lactation services, either face to face or in a virtual manner to patients regardless of geography and regardless of a care team’s biases. We certainly work hard every day, to minimize the effect of implicit bias on face-to-face clinical care. But as a safety net underneath that, our data-driven population health approach still offers education and lactation support for individuals who might receive care from a team who is biased against them initiating breastfeeding.

Dr. Ellen Beckjord: Those are great examples. Thank you. Dr. Livingston, if I could ask you to talk about efforts that are underway to improve health equity and reduce disparities, especially for Black and Hispanic pregnant people, and, in particular, if you’d like to tell us more about the Diversifying Doulas Initiative, would love to hear about that.

Dr. Sharee Livingston: I co-founded the Diversifying Doulas Initiative in 2020 when the COVID crisis hit us, and I did not want to see the health disparities gaps that we have discussed so eloquently here widened. 

And so the mission of the Diversifying Doulas Initiative (which around here we call it DDI, it’s very affectionately known as that), our mission is to decrease maternal morbidity and mortality in pregnant people of color through doula care. 

And for those in the audience who may not know, a doula is a nonmedical birth support person — and doulas pre-date doctors, doulas pre-date hospitals. And that’s why we learn and look to them to provide support to our birthing families. 

Doulas are really an integral part of the health care team. I don’t profess, and neither do doulas profess that there is some doula juice out there and they’re the only ones who can solve the maternal health crises that we’re seeing. But they are an integral part of the health care team and the perinatal workforce. We have two areas of focus with DDI, and that is to increase the number of Black and brown doulas, but also provide fully subsidized doula care to pregnant people of color. 

On average, the cost of a doula ranges between $800 and $1,200. That can be cost-prohibitive for the very people who need it most. There was a great study that came out in 2013 that showed that for vulnerable people who have a doula supporting their pregnancy, the maternal health outcomes such as C-sections and postpartum depression were decreased by nearly 56 percent. That’s significant. And that is the type of data that we must pay attention to.

Doctors alone will not solve the maternal health crisis — nor will nurses alone, midwives alone. But when we work together as a team and integrate doulas into that perinatal workforce, we will begin to see improvement of health care outcomes. And so therefore, I created — we created — the Diversifying Doulas Initiative, and Lancaster County had one Black doula. And after DDI came along, we now have 28 Black doulas, Black and brown doulas. 

And the benefit of that is the doulas and the support team look like the community that we are serving and cultural congruence matters. We know that health outcomes are improved, implicit bias is lessened when there is cultural congruence. So organizations like DDI are out there. We’re looking to duplicate our efforts in many cities. 

We have been recognized nationally. We received a Health and Human Services grant to duplicate our efforts nationwide. And so people are paying attention to the realities that we have to work together as a team to improve maternal health outcomes. And as the co-chair for the UPMC Health Equity Now Committee, whose mission is to decrease maternal morbidity and mortality in birthing people here at UPMC hospitals, we are working internally to solve the maternal health crisis, and we’re working with a committee of nearly 50 people. 

Some of those are committee community members and we are putting a true emphasis on the three Ps, which is people — we want to pay attention to the patient — policies, and processes. So I’m glad we’re having this conversation today.

Dr. Ellen Beckjord: Oh, well, that’s wonderful. Both hearing about the Diversifying Doulas initiative, the Health Equity Now Committee — Dr. Simhan, the population health approach that is being taken at Magee — are all such positive and really hope-inspiring things to know about. 

As we’ve had this conversation, and I’m hearing about all of the work and effort and attention that’s going into the perinatal period and to address what are some real problems we have to solve with respect to health outcomes for pregnant people and their offspring, I can’t help but think about current policy. You know, and I think maybe there are some exceptions, but on average current policy in the U.S. around paternal and maternal leave, it’s almost like the lack of any protected time for leave from employment after birth implicitly sends a message that the birth should itself be invisible, that there’s no reason to accommodate special needs that new parents might have after such a significant event.

And those two things then don’t really, they don’t really jive. Right. You’re sort of all of this attention paid to the perinatal period and big efforts underway to improve birthing experiences and birthing outcomes. 

And it certainly is not the responsibility of the health care system to solve what is current policy in the U.S. around leave. But I guess as two front-line health care providers who are putting in such extraordinary efforts to optimize birthing experiences and birth outcomes, how do you think about the lack of paid or protected leave for the most part — of paid leave in particular? 

I guess there are some, there are some protected leave — but what do you think about the lack of paid leave and the remarkable difference between what the U.S. landscape looks like as compared to other developed countries around the world? And Dr. Simhan, if I can start with you.

Dr. Hy Simhan: It’s a terrific point. I’m really glad you brought it up. I think it is excessively siloed to focus on pregnancy and birth alone, as important as it is, and then feel like, that’s placed in a box, wrapped, and put a bow on it, and fail to acknowledge the importance of the period, the year that follows pregnancy and its importance on the health of the mother and of the offspring. I think many other developed societies and governments have acknowledged that with their policies. Ours has failed to do so, as you identified. I’d like to point out two specific reasons that I think attention ought to be paid in the U.S. in this space and how that would benefit our society overall. First, we know the economic consequences in the postpartum period — absenteeism from work, loss of economic stability — contributes to a detriment in developmental outcomes for children. 

We know objectively with empirical data that school performance is affected by the economic and life circumstances throughout childhood, certainly, but really profoundly even in that first year of life. Even though a child may not go to preschool or kindergarten for anywhere between one and four more years. That economic circumstance in that first year of life has an effect that deleterious effects amplify over time. And to take a strength- and asset-based approach, improving economic and social circumstances in that first year of life, those effects amplify over time. 

The second point is that real health outcomes in terms of development for offspring and health for mothers, particularly for those who have some adverse pregnancy outcome — a preterm delivery, pre-eclampsia, gestational diabetes, to pick three — those all have really, really important consequences over the entire life course for both the mother and for the offspring. 

In that first year postpartum there are very specific care opportunities, prevention opportunities, assessments for both offspring and mothers that we know are effective, and yet we’re unable to effectively deliver them across our population for a variety of reasons. But one of the important reasons is what you’ve talked about now: the absence of paid and protected leave to allow those services to be rendered and to provide social and economic security during that first year after birth. Incredibly important. Other societies have recognized it. We know empirically this is not just because it feels like the right thing to do, even though it does. It’s because there are real clinical adverse effects that happen when you don’t do it. 

And on the other side, when policies change to support these, we know populations become healthier over the life course. We’re talking about not just immediate outcomes, but school performance, the ability to graduate from high school, and other actual functional offspring outcomes. And for mothers, chronic hypertension, cardiovascular disease, obesity, diabetes are all, you know, pregnancy and its experiences are a window of opportunity for risk identification and prevention. But we need the infrastructure to do that. And that year postpartum is so valuable at being able to do that. And I could not advocate more strongly for a focused effort to improve that here in the United States.

Dr. Ellen Beckjord: Thank you. Dr. Livingston, would you care to comment on the question?

Dr. Sharee Livingston: Essentially what we’re describing is reproductive justice. It’s a core framework that really describes the right to have a child, the right not to have a child, and essentially the right to parent a child in a safe and healthy environment. And, so, with that said, I think as we talk about preconception and conception and the labor and delivery process and the months and years beyond that described by Dr. Hy, I think it’s important that we understand that reproductive justice is essentially the human right to maintain bodily autonomy and we want to make birth safe. But looking at a bigger picture, if we emphasize reproductive justice and put the ability to control one’s reproductive destiny in the hands of families, then I think that the problem becomes easier to solve.

I mean, we have to ensure that the health care providers are diversified. For the past 40 years, the number of Black doctors has hovered around 5 percent. That is problematic, and there are ways that we can fix that. And the way that we can do that is creating pipeline programs. So, again, when you ask what solutions are, that’s it. We have to face systemic racism face on, address it, eliminate it, dismantle it, and reduce implicit bias, which we’re doing here at UPMC by educating our providers on what it is. Everybody has bias. Bias is the brain’s shortcut. But when we keep focus on implicit bias and how harmful it is, we can undo that path. So there are many solutions. We all just have to continue to listen to all of the ideas and implement and put action forth.

Dr. Hy Simhan: Yeah, I guess I would say the strategies that Sharee just discussed, having, you know, organizational commitment to that in a sustained way is important. The strategies we discussed. Doula care, a population health approach, are demonstrably successful at improving all outcomes and narrowing disparities. I think we’re not at a place today in the U.S. where those are widespread and sustainable.

And, so, in policies, you know, CMS and other entities who decide whether things are or are not covered as part of obstetrical care — paid leave, the expansion of Medicaid to include your postpartum — those are, you know, as a health care provider and as someone who is not just a one-on-one health care provider, but decides how, in part, how a health care system responds to these issues, I feel that there’s a lot that we can do to demonstrate that approaches are effective and we need other stakeholders — payers, our government, policymakers — to help make those approaches sustainable.

Dr. Ellen Beckjord: Well, I’d like to thank you both for a really wonderful conversation on such an important topic for this season of Good Health, Better World. Dr. Sharee Livingston. Thank you so much for joining us today.

Dr. Sharee Livingston: Thank you for having me.

Dr. Ellen Beckjord: And Dr. Hy Simhan, thank you for being on Good Health, Better World.      

Dr. Hy Simhan: Really a privilege. Thanks for having me.

Dr. Ellen Beckjord: Supporting diversity and inclusion in health care is key in helping communities thrive. Learn more about the Diversifying Doulas initiative and UPMC’s ongoing commitment to providing access to culturally competent care by visiting the show notes for this episode at postindustrial.com/goodhealth.