Season 3, Episode 3: Support for pregnant people in marginalized communities
Some individuals and their babies are at a higher risk for complications during or after pregnancy — but what works to help them? In this episode, we’ll talk with Stacy Freeman-Pistella, a senior health manager in Magee-Womens Pregnancy and Women’s Recovery Center; and Tica Nickson, director of prevention of BirthRoot Community Doula Alliance, about support for pregnant people and new mothers in marginalized communities.
Are you or someone you know pregnant and struggling with substance abuse? UPMC Magee-Womens Pregnancy and Women’s Recovery Center offers services at five locations in Western Pennsylvania: Butler, Clairton, Natrona Heights, Erie, and Pittsburgh’s Oakland neighborhood. To learn more, call 412-641-1211.
The Substance Abuse and Mental Health Services Administration can provide information about treatment centers and resources throughout the country. Call 1-800-662-4357.
BirthRoot offers training to become a doula for those in Erie County.
Have you or a loved one experienced pregnancy or infant loss? Emma’s Footprints can help. Call 814-464-5989 today to connect with their support hotline.
Are you experiencing a crisis and are not sure where to turn? Call Resolve Crisis Hotline at 1-888-796-8226
Dr. Ellen Beckjord: In this episode, we talk with Stacy Freeman-Pistella, a licensed professional counselor and senior health manager who works in UPMC Magee-Womens Hospital’s Pregnancy and Women’s Recovery Center.
Welcome to Good Health, Better World, Stacy.
Stacy Freeman-Pistella: Thank you for having me today.
Dr. Ellen Beckjord: We’ll also talk with Tica Nickson, director of prevention at BirthRoot Community Doula Alliance, headquartered in Erie, Pennsylvania, about support for pregnant people and new mothers in at-risk communities. Tica, welcome to Good Health, Better World.
Tica Nickson: Thank you for having me today, Ellen.
Dr. Ellen Beckjord: This season of Good Health, Better World focuses on women’s health. And in this episode, we’re going to talk about pregnancy and the postpartum period.
Listeners may have an idea in their heads of what pregnancy and the postpartum period looks like, but one of our goals for this episode is to really specifically raise awareness of what those experiences can be like for at-risk communities. Such as women of color, who experience maternal deaths at a higher rate than other pregnant people. And we’ll also focus on women with substance use disorders, paying close attention to women with opioid use disorders during the perinatal period.
Tica, could you tell us about BirthRoot, your role there, and the communities you serve through this organization?
Tica Nickson: Yes, Ellen. I am a certified birth and bereavement doula, a postpartum doula, a childbirth educator, and a certified lactation counselor. But simply stated, I am a doula. And I always explain that doulas are nonclinical professionals that provide educational, physical, and emotional support to a birthing person, not just during the time of delivery, but throughout the entire episode of pregnancy. And I do that so that our clients can be the best advocate for themselves and their child.
BirthRoot Community Doula Alliance is the organization that I founded under the nonprofit Emma’s Footprints. Emma’s Footprints provides support to families suffering from pregnancy or infant loss up to 12 months.
They allowed me to develop BirthRoot under their nonprofit so that I could learn how to function as a nonprofit, and also get to my ministry of providing the evidence-based intervention of doula care in a community-centered model. This had not been done in Erie before and it was desperately, is desperately, needed.
I wholly believe that nothing can be done for us if it is done without us. And unfortunately, that is largely the case. So, my mission had to be making the doula workforce in Erie more representational of the Black and Brown community. As much as I would like to do all the mommies, I cannot.
So, building BirthRoot started and continues through removing the financial and logistical obstacles for Black and Brown people to become professionally certified doulas.
Dr. Ellen Beckjord: Can you tell us some more about the kinds of services and care that birth doulas deliver that results in, as you mentioned, better outcomes for pregnant people?
Tica Nickson: Sure. At BirthRoot, we are community-based doulas, which might be a little bit different from private pay doulas.
We really focus on meeting the needs, the basic care, the basic needs and necessities of the mother prior to delivery. Most people know doulas as the person that’s there when it’s go time, when it’s time to push the baby out. We as community-based doulas work with the mother throughout the entire episode of pregnancy, providing educational, emotional, and physical support that allows a mom to better advocate for themselves and for their babies.
Dr. Ellen Beckjord: And let’s stay with the idea of advocacy for a moment. Could you talk about the work that BirthRoot does — and you can talk about this in the context of Erie, which is where I believe you’re headquartered — how BirthRoot is supporting pregnant people from an advocacy perspective in Erie in particular?
Tica Nickson: So, in Erie in particular, we have pretty dismal Black infant mortality rates. What BirthRoot does is put the power back in the hands of the mothers and the families that we serve.
Building BirthRoot started and continues through removing the financial and logistical obstacles that many Black and Brown people have to becoming professional certified doulas. Because, if we’re being honest, those obstacles lead themselves to the gatekeeping of traditional doula training and certification programs. So in removing those barriers, BirthRoot, we’ve trained Black women to serve Black women as comprehensive and professional doulas, which helps to alleviate some of the stressors and build communication barriers between the medical community and our moms so that we can promote better birth outcomes.
Dr. Ellen Beckjord: And the evidence is, of course, entirely on your side that racial concordance in all kinds of health care matters so much. How many doulas has BirthRoot trained and how many doulas do you now employ?
Tica Nickson: So, BirthRoot over the course of three years, we’re closely approaching our third anniversary, we have trained and we have provided free doula training and certification for over 38 women in our community. Currently we have seven doulas that work for BirthRoot.
The purpose of providing doula training and certification was so that more people, women in general, would have access to doula care. So some of the people that we trained don’t actually work for us. They’re now more educated to provide doula support for whomever they choose and whomever they find available for the care.
Dr. Ellen Beckjord: That’s incredible, what tremendous growth over a short period of time, and what important work. Thank you for telling us more about BirthRoot and in particular the pipeline component of the work that you’re doing to bring more Black and Brown doulas into the workforce. It is very exciting to hear about. Thank you.
Tica Nickson: You’re welcome.
Dr. Ellen Beckjord: Stacy, could you please give us a high-level explanation of what the Magee Pregnancy and Women’s Recovery Center is and tell us about the work that you do there?
Stacy Freeman-Pistella: Sure, I’d love to do that.
So, the Pregnancy and Women’s Recovery Center opened on July 15 of 2014. When we first opened originally, we only saw pregnant women or pregnant parents. And the facility was the only facility in Western Pennsylvania that was actually dedicated to the treatment of pregnant women with the opioid use disorder. That was a population that even outside clinics really didn’t want to touch because of the pregnancy. So we wanted to specialize in that. So, the philosophy of our treatment was to focus around the pregnancy and then wrap the recovery services around this natural life event. So, ultimately, minimizing the fetal exposure to illicit substances and engaging the mother as the leader in her own recovery.
So, overall, we provide compassionate and comprehensive care to women with OUD, which is opioid use disorder. We provide MOUD, which is medication for opioid use disorder to pregnant and nonpregnant women.
In 2018, we expanded to also work with nonpregnant women so we could have that continuity of care, do family planning — all those special things instead of referring them out after working with them for this whole pregnancy and building rapport. And we wanted to keep having those relationships. And patients were verbalizing they wanted to stay with us so we added that component. And, so we provide medication, but we do it through an integrated team. So, we have doctors, we have nurse practitioners, licensed social workers, certified addiction RNs. And a very special component that we have is certified recovery specialists. And they are individuals in live recovery themselves and on maintenance medication and actually have delivered at our hospital.
So, they can really, it’s like full circle and amazing. So, when we bring that factor in which typically if someone would present to the E.D., her name is Cambria King, we’re going to send Cam in first, kind of like, “Hey, you know, I get it. This is how it is. You should try our program.” And then if someone’s open to that, because once again, they’re the leader of their recovery, then we would bring in the nurses and the doctors for the consults and then get them hopefully started and implemented on treatment.
The PRC provides a lot of different kinds of support outside of just the medication. We do resources for behavioral health. We do routine medical care, social service support, peer support, and lots of opportunities to participate in paid research, because a lot of these women have a lot of financial needs and a lot of different socioeconomic stressors. So that helps also. But the most important thing of our program is we are a harm-reduction program, so we don’t turn away anyone. We believe in meeting them where they’re at in their recovery. So, you know, if someone has a recurrence of illicit use, we’re not going to turn them away. We kind of look for the strengths perspective. So any decrease in use or even presenting to care, we see it as a positive for future change.
So our goal is to empower the women to own and be their own leaders in their recovery.
Dr. Ellen Beckjord: It’s interesting to hear you talk about how the center has expanded beyond just pregnant people, and I’d love to hear maybe just a little bit more from you, your perspective as working there as we think about this emphasis this season in Good Health, Better World on women’s health, it sounds like there was a natural evolution of, I guess, acknowledging or recognizing that providing this kind of recovery support in a way that is specific to women was important. Can you say a little bit more about that? And, if you’ve done this kind of work outside the context of this center with men and women, do you think that there’s something particularly valuable about doing recovery work for women specifically and keeping that kind of something that can be focused, or personalized, to some unique experiences that women have?
Stacy Freeman-Pistella: Absolutely. So, gender specific care is so important. Care for men is also just as equally important, but it’s different. So, with women, there’s a lot of different components that we have to look at. A lot of stigma in society, specifically towards mothers, a lot of stigma in the laws towards mothers and parenting and parenting people who use drugs.
So we have to take those factors into consideration. And with that being said, you know, it’s very common for women who use drugs to have CYF (Children, Youth and Families) involved. But a lot of times the partners do not have CYF involved. They don’t have the same kind of stigma because of the gender norms in the United States and the idealization of motherhood or the bias against single mothers, it’s very difficult. So, with that, there’s a lot of mistrust. So we really try to be genuine and authentic. Our whole team is like that to build that rapport, to work with women, to understand we’re here to empower you.
You know, you’re the driver of your recovery train. It can get off track. It does get off track. But, you know, we’ll help you get back on track. But, you’re, you know, you’re the driver of that. So, just supporting them.
Dr. Ellen Beckjord: Tica I do want to return to you in a moment with a question. But if I can stay with you just for one more follow-up, Stacy, about addiction. So addiction requires lifelong maintenance.
What do programs and follow-up support look like for people living with addiction or in the early stage of recovery who’ve just given birth, particularly if their baby shows signs of being affected by their substance use?
Stacy Freeman-Pistella: Well, the biggest part is education and understanding and educating individuals that they are not having moral failings. They’re not bad people. They’re not lacking willpower. This is a chronic health condition, just the same as asthma or diabetes. And, actually, the recurrence rates are very similar. There’s just a lot of stigma around that. Working with the woman who’s pregnant and working with their support network, because a lot of people are like, why would we just take her off of this med and put her on another med? They look at it as a replacement instead of something that’s going to help them maintain their health, right? And claim their lives back, reclaim their lives from addiction.
And, you know, once we explain to them the importance of being on medication with pregnancy, I feel like the families start to understand it a little bit more and they realize that we’re not just replacing one drug with another, you know. And there’s a lot of education because, specifically at any hospital, if you are delivering a child that’s been exposed to something that can make them considered affected, they have to stay for a few days to see if there is any kind of withdrawal.
And within my population specifically, it’s called NOWS, Neonatal Opioid Withdrawal Syndrome. One thing we can do really special for women that have just delivered or the baby may have those symptoms, is we have something called the PPU, which is the Parent Partnership Unit where the mother has been discharged from delivery. And the mother can stay there with her partner or whoever her support person is, have skin to skin, get education, have lactation consults, and really having that mother as medicine. And the rates have decreased so much from outside clinics that don’t have that kind of specialized … It’s like specifically, for buprenorphine. It’s like two out of three moms, the babies can have, you know, NOWS and our populations, it’s under 10 percent just by having those extra supports. So it’s a really cool program.
Dr. Ellen Beckjord: Tica I’d like to ask you about postpartum depression, sometimes called baby blues, and other mental health challenges that can often come with being a new parent.
And I’d love to hear your perspective on how these challenges might be different for people who are a part of marginalized communities and what some supports are in these areas. And maybe these are supports that are provided through the doulas that BirthRoot trains and the doulas that are employed by BirthRoot or other resources that you care to comment on in this area.
Tica Nickson: The challenges are exponentiated because there is a rightful mistrust of the health care system and other social care systems by marginalized communities. The weathering of Black women predisposes us to suffer from postpartum depression. But when our basic physical and tangible needs and rights and responsibilities are often overlooked and denied, why would we expect to receive compassionate and effective care for our mental and emotional needs?
So BirthRoot, our doulas, began a program of postpartum care. This provides our moms, after they’ve delivered their babies and have been discharged to the hospital, this provides our mothers with what is a luxury to most — postpartum doula care.
So they get, over the course of six to eight weeks, depending upon their mode of delivery, a representative, trained doula that comes into their home and makes sure that they have the things that they need to mother their babies. Which is rest, which is at a minimum when you first have a baby, nourishment, and an ear to listen to. They also do some light housekeeping. So our postpartum care and program helps to give the mother additional support.
We also offer lactation counseling through our certified lactation counselors so that the things that could depress a mom — not being able to feed the baby the way that you think you should be, not producing the milk — those women, those counselors come alongside our postpartum doulas, as well, to kind of build like a web of support. So between the mother’s birth doula, who still has interaction with her, her postpartum doula, and then if she’s breastfeeding, her certified lactation counselor, there’s a web of support that BirthRoot provides, in order to meet the needs of the mother, so that she can meet the needs of her baby.
Because really, I think the current focus in trying to elevate the levels of trust with medical providers is to train them to be more culturally competent. And I think that’s an honorable short-term goal. But I think the long-term goal has to be increasing the representation of the population in the mental health field.
I think representation is absolutely necessary if we are really looking to build trust with marginalized communities. But until we get that, it is important for current providers to align themselves with the communities and the community resources that are in the trenches with our moms now.
So that is how I think that trust can begin to be rebuilt by aligning with a mom, her support group, so that they feel supported, and they feel more comfortable with seeking mental health care.
Dr. Ellen Beckjord: I was thinking as you were as you were talking about just that and wanted to follow up with one more question. So, yes, absolutely. Increasing representation in the physical and behavioral health workforce so that there are more providers of color to be available as providers to people of color. Critically important, as you said, not something we can achieve in the short term. It’s going to take longer through lots of pipeline efforts, much like what you’re doing at BirthRoot to bring more doulas of color into the workforce.
But in the interim, do you find that the doulas who work through BirthRoot are, I’m assuming, that they’re equipped to recognize signs and symptoms of postpartum depression and then if they’re able to facilitate a conversation with a new parent, are those new parents more likely to disclose signs or symptoms that they may be experiencing and potentially accept a referral from BirthRoot to a provider that can address, for example, postpartum depression over a longer period of time?
Tica Nickson: Absolutely. What our doulas are, they’re trained on recognizing signs because they have such connected relationships with their mothers, they can tell when something’s a little bit off. And the mothers are receptive to their doula saying, “Hey, what’s going on?” And they’re more apt to be honest with what is really bothering them. As we at BirthRoot continue to connect with community resources and organizations, we have been able to make “warm referrals” to mothers and walk them through the process.
Dr. Ellen Beckjord: That’s fantastic.
Stacy Freeman-Pistella: So I would love to touch on this topic, too, if I can.
Dr. Ellen Beckjord: Absolutely. Go ahead, Stacy.
Stacy Freeman-Pistella: So with postpartum depression or Perinatal Mood and Anxiety Disorder, it’s huge for my population. And once again, very much like Tica is saying, it’s going along with that mistrust of the system.
There’s intense stigma against pregnant and parenting people. It’s written into our laws, CYF, our social supports, everything like that. Twenty-four states, including District of Columbia, consider substance use and pregnancy to be child abuse under the Child Civil Welfare Statutes. And three states consider it grounds for civil commitment. So this is literally written into the laws against them. So the biggest problem I see a lot of the time is someone not wanting to admit or trying to do their own version of a maintenance program with pregnancy. They don’t want to go to an actual clinic where there will be a hit on their insurance bill or they’ll know someone will know they’re getting this medication. So then when they finally come in to deliver and they may have something like a positive UDS, or urine drug screen, for like a buprenorphine, I know and other providers in the addiction field know they’re not taking that medication to get high — specifically something like buprenorphine because there’s a ceiling effect right around 16 mg — they’re doing that for their own treatment plan because they do not want to be in a formalized system because of the distrust of having CYF notified and having bad, maybe having other children, where they had that happen to them or removal of their children.
So, a big part of what we try to do is break down that stigma and encourage the trust with the patients. And we partner a lot with Nurse-Family Partnership, Early Intervention, here in Allegheny County Hello Baby Pittsburgh. So, you know, like Tica was saying, we know these providers. We can do that “warm” handoff. You know, a lot of the time we’ll have them come to the office and actually meet them there for the first time and kind of have a little session, a little chat together. And we do educate them throughout the trimesters because we’re lucky enough to have that rapport and work with them throughout the pregnancy. So we do formalize assessments also like the Edenburg and things like that also to just kind of quantify what’s going on.
Dr. Ellen Beckjord: One of the things that I think both of you are pointing to is that as we wait for longer term system change to happen, these kinds of services, like what’s provided through BirthRoot and what’s provided through the Magee Pregnancy and Women’s Recovery Center are just critically important to bridge that gap and help facilitate receipt of care that would otherwise be potentially out of reach for people due to a whole host of factors including stigma, including awareness, and including other barriers that that your services help people overcome.
I’d like to hear both of your perspectives on disparities in resources that may exist between people living in rural versus urban areas when it comes to getting help in communities with potentially smaller health care systems. And, Tica, if I could start with you. What disparities do you note that may exist between rural and urban areas? And if you care to comment on challenges that you observe, to actually be the same independent of whether you live in a rural or an urban area.
Tica Nickson: That’s a really, really good question because I don’t think that there’s that many differences between those resource disparities between rural and urban areas, because things like access to health care in an urban area with marginalized populations, there might be access, there might be doctor’s offices, but they don’t feel safe. We don’t feel safe in those doctor’s offices. We don’t feel heard in those doctor’s offices. Another disparity is transportation. In Erie, it gets really, really cold and there’s buses and things like that. But in order to get to where you’re going, you’re going to be out in the cold. And to do that with your baby, with your family, as a pregnant woman, that’s not something that is comfortable or acceptable, really. Another thing that our moms have issues with is time away from work.
So knowing the value and receiving value from those doctor’s appointments and other resource appointments is important for marginalized communities enough to take time off of work because that is how they live. There’s a lot of stigma in regards to receiving mental health care. As Stacy mentioned, there’s stigma just in being a pregnant woman, and the intersectionality of Black women as pregnant is dangerous. It affects everything that we do, everything that is done to us. So there are lots of disparities that keep women, keep families from the resources that are available. Erie, I like to say, Erie is very resource rich. There’s lots of opportunities to get health care, to do healthy things, to get healthy foods, but the navigation of those resources for marginalized communities is poor.
Dr. Ellen Beckjord: Stacy, if I could ask you the same question, and I’m thinking about how the Magee Pregnancy and Women’s Recovery Center is really the first treatment center of its kind in the region. And, so in this instance, we’re talking about a set of resources that are geographically unique, geographically limited. From your perspective, what are some differences that exist between rural and urban areas, or what have you seen with respect to the population that you serve? I assume some of whom live in rural areas and some of whom live in urban areas, that you care to comment on?
Stacy Freeman-Pistella: Absolutely. So, we actually have our main office embedded in Magee-Womens Hospital’s outpatient clinic, but we have satellites in more rural areas: Butler, Natrona Heights, Clairton. We just opened up in Hamot, so up in the Erie area. So we definitely have others, we have the urban and the more rural. But the barriers to care are the same no matter what. So a lot of barriers to care that we see specifically, and we do have the intersectionality of African American substance use and pregnancy, like we can get the trifecta on that, and we do. I have several patients that are of color. So, you know, it’s just one more barrier to care. But a barrier to care for our population specifically could be like, well, I’ve tried treatment in the past, it hasn’t worked. Or it’s intergenerational use where like, this is what people do, you know. Or fear of, once again, of CYF is a huge, huge barrier to care for us. But we have the same things. We have the lack of childcare, lack of transportation, lack of support, a lot of intimate partner violence or substance use coercion along with that, where they don’t want them to get, they want to be able to control and not have them on that medication, where they’re going to start feeling better and being more competent and more assertive. Or potentially, leave that abusive partner. So we have a lot of specific things in the realm of substance use that overcomplicate things even more. But like Tica said, it’s not just having that resource there. It’s them being able to trust that resource and come to that resource.
Dr. Ellen Beckjord: I’d like to ask you both and I’ll start with you, Stacy, and then and then Tica, I’d love to hear your thoughts on what you’re most hopeful about in the areas in which you work. So Stacy, starting with you, what are you most hopeful about in the context of the work that you do in the Magee Pregnancy and Women’s Recovery Center?
Stacy Freeman-Pistella: My most hopeful thing that I love, that I love the most, is seeing women go from coming in in active use and they don’t want to make eye contact — they’re very closed off, very shameful. And once they begin the medication treatment for their disorder, a month later, you know, they’re just a completely different person. They’re talking about, “Oh, I heard the heartbeat. Oh, I’m thinking about this name. Hey, that referral you gave me, I think I’m going to use that.” Just seeing them feel empowered in their parenting skills and empowered as a woman. I love that. That’s my favorite part. Another thing that I’m very hopeful for, for the future, is taking away the criminalization and the punitive values against women who use drugs. Truly, it is a chronic health condition and there is no other chronic health condition that has punitive laws against it. So whenever our society is able to recognize that this is truly a medical condition and not a moral failing, I think then, hopefully, our laws will change and that is going to be able to open up so many opportunities for these families and future generations.
Dr. Ellen Beckjord: Tica, how about you? What are you most hopeful about in the context of the work that you’re leading at BirthRoot?
Tica Nickson: Well, I got into this work because I wasn’t seeing the mothers that were having these poor outcomes. I wasn’t aware of them. When I started to research, I recognized that the PA Department of Health Statistics showed that between 2018 and 2020, Erie County had the second highest Black infant mortality in the state. So what I find — I see this as an opportunity. I see that as an opportunity to get better. I see this as an opportunity to save lives. So I think that these statistics, about the vulnerability of Black births in Erie, are in part caused by lower percentages of early prenatal care and inequitable access to other resources like nutrition, safe housing and transportation, things that we’ve been talking about. So I’m hopeful that through educational opportunities like this and being on this podcast, the growing buy-in that we’re getting from the community, and the medical community, as well as the Black and Brown community in Erie, and then continued investment into BirthRoot. We have, over the course of the time that we’ve been around, we have provided prenatal support for over 100 women in our county. We have attended and supported 60 births. So I’m hopeful that we can continue the work as we grow and develop and grow our program.
Dr. Ellen Beckjord: Well, pregnant women and pregnant people from marginalized communities and their babies are some of the most vulnerable members of our society. And the work that both of you are doing is just so critically important to bringing services, awareness to these people that they certainly deserve. And, so I just want to say thank you so much for the incredible work that you’re both doing. Stacy, thank you for being on the podcast today.
Stacy Freeman-Pistella: Thank you for having me.
Dr. Ellen Beckjord: And Tica, thank you so much for being with us on Good Health, Better World.
Tica Nickson: Thank you very much for having me.
Dr. Ellen Beckjord: All pregnant people and new parents deserve access to resources that help them build a healthy, fulfilling future for their families. Check the show notes for more information about how to get connected to BirthRoot in Erie, Pennsylvania, or the Magee Pregnancy and Women’s Recovery Center Program in Pittsburgh. Visit postindustrial.com/goodhealth.
Dr. Ellen Beckjord, MPH, is host of the Good Health, Better World podcast.
Ellen is a behavioral scientist, epidemiologist, and licensed clinical psychologist working at the intersection of population and digital health. A long-time member of the Society of Behavioral Medicine, Ellen currently serves on the board of directors as president-elect.
Her work focuses on promoting health, wellness, and health behavior change. She is vice president of population health and clinical optimization for UPMC Health Plan based in Pittsburgh.
Ellen trained at the University of Vermont, where she worked with cancer survivors and their families, at Vanderbilt University, and at the Johns Hopkins Bloomberg School of Public Health.
She completed post-doctoral research at the National Cancer Institute in the Health Communication and Informatics Research Branch within the Division of Cancer Control and Population Sciences. She spent nearly five years in academic medicine at the University of Pittsburgh and Hillman Cancer Center.
Ellen also is the co-author of “Porchtraits” in which she interviewed people in Pittsburgh during the early months of the COVID-19 pandemic about what they were learning, missing, enjoying, what surprised them, and what they felt hopeful about.
Ellen’s guiding principle: “Lead with love.”
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