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Hello and welcome to Louisiana.

Spotlight on Kerosene Sear your host for tonight's show.

Maternal mortality in the United States has been on the rise for decades, with over 23 deaths per 100,000 births.

The World Health Organization ranked the United States 55th in maternal health outcomes, among other high income nations falling behind countries like Russia, Spain and Japan.

In Louisiana, the maternal mortality rate far exceeds the national average, with 39 deaths per 100,000.

And for women of color, the risks are even greater.

With two and a half times as many black women dying during or after childbirth than white women.

Tonight, we'll look at what's driving these inequities, as well as speak with doctors and experts to hear some of the solutions.

But first, we'll hear from two mothers who have been directly impacted by Louisiana's poor maternal health care system.

To give us a better understanding of these issues at hand, here's our story.

Good morning.

My name is Nancy Davis.

My significant other and I have three children and we live here in Baton Rouge, Louisiana.

In August of 2022, my family and I had a very life altering experience.

The Supreme Court's decision to overturn Roe versus Wade in 2022 had dire consequences for women across the country.

But for Caitlin, Joshua and Nancy Davis, the decision altered their lives forever.

My name is Stacey Davis.

I'm from Baton Rouge, Louisiana.

At first, I thought I was pregnant around seven weeks.

I was extremely excited.

It was actually a planned pregnancy.

And when I told everyone else inside the house, the mood was like Christmas time.

I started stating my appointment the following week, or maybe the week or two following after I found out that I was pregnant and they actually scheduled it maybe three weeks later.

So whenever I went in, I was actually ten weeks pregnant and I received my very first ultrasound and that's when we realized something was wrong.

I knew from looking at the images on ultrasound, you know, I have previous kids, so I know exactly what the images are supposed to look like.

And whenever I saw those images, I literally saw part of the head cut off.

So I knew something was wrong.

I was told to take state it, you know.

I'll be right back.

Most people who have children know when you're an ultrasound appointment and it six states.

I'll be right back or leave out the room.

Something is terribly wrong.

And the doctor?

I'll never forget it.

She came in in a white coat, and when she stepped foot in a room, it was like her gasping.

Like you could hear her gasp for air.

And she told me at that very moment, you know, this is one of the one of the reasons that you can have an abortion.

Nancy met with a specialist who told her her baby had a cranio, which caused the skull to not fully develop a fatal prognosis.

He said if he or she makes it to birth, meaning if the baby doesn't died during delivery, he or she would die within minutes.

And he also told us that it would be $6,000 for him to perform the abortion.

So he referred us to Delta Clinic and they were closed.

We started calling different clinics out of state, seeing what the qualifications were, in a sense, because each state was different.

The very last clinic I contacted, which probably was weeks after I had those appointments scheduled, was Planned Parenthood of Greater New York.

And the doctor actually contacted me back and she just assured us that we would receive top quality health care.

After I received the abortion, I felt 100% better.

And not only that, I felt a sense of reclaiming my power by reclaiming something that was ultimately taken away from me, which was my bodily autonomy.

You know, So, yeah, like, I felt empowered.

Honestly, I founded the Nancy Davis Foundation after going through a person who struggled with Louisiana's health care system.

That's one of our main goals, is advocacy to evoke change and to help other birthing people who are in the same or similar situations as myself.

One mother in a similar situation as Nancy's was Caitlin, Joshua.

So I'm here to tell my personal story, similar to Nancy's experience and this idea that women are not being turned away from hospitals is absolutely false.

We are two just examples of unintended consequences of the abortion ban.

My name is Caitlin Joshua.

I am a community organizer for the Power Coalition and I do environmental organizing for an organization called Earthworks.

I currently live with my husband and our two kids, my daughters, five years old.

Lauren and my son is two months.

Liam.

So let's talk a little bit more about your pregnancy in 2022.

So when did you first find out that you were pregnant?

I first found out I was pregnant in 2020 to the very beginning of July of last year.

Wow.

How did you feel?

my God.

I was so excited.

My daughter was about to turn four years old, so we figured it was the perfect time to add to the to the family.

And so we were pretty excited about bringing home a new baby.

I immediately called my physician's office the same office I used with my daughter and tried to schedule an appointment at about five week mark.

I wanted to go ahead and get a series of appointments on the on the calendar, and so that's what I did.

And what happened?

Unfortunately, I was met with pushback and was told that I cannot be seen until the 12 week mark, which was very disappointing for me, just because I like to be on top of my health, especially when I'm expecting.

And so I decided to do a little bit more research and find another doctor's office that would take me before 12 weeks.

Most women don't wait until three months gestational age to go to the doctor's office for their first appointment.

Typically with physicians I've used in the past, everyone has said the same thing.

It's right around the latest eighth week, eight weeks.

And so 12 was very off putting.

But the secretary at the Women's Health Care Center that I usually go to, she straight up told me we are not going to see you until the 12 week mark.

I'm sure you've seen the news and we're trying to mitigate some of those potential risk.

And she was referring to abortion bodies, abortions or miscarriages within that first 12 week period.

And that's why I had to wait.

But the risk is for the hospital, not for you.

Absolutely.

Because the risk in that moment was something a very will happen to me or my life if I'm not seen.

And, you know, given the proper care that someone should be seen at that time.

Yeah.

So did anything happen in between the time that you were told, we're going to see you at 12 weeks and at 1212, we are absolutely.

So.

I didn't make it to 12 weeks.

I made it to right at 11 weeks when I started experiencing some cramping.

And I called my husband last September, September 12th to be exact.

And I said, hey, like I woke up this morning in a pool of blood out of tons of cramping going on at that time, what should I do?

And he said, Well, you need to go to work and go to the doctor's office.

And so, you know, I told my boss at that time she knew I was expecting.

And so she, you know, wish me luck.

And she said, go ahead and go.

So I went to women's health care assessment Center to see if someone could figure out what was going on with me.

In that moment, I was pulled into a room by myself with a registered nurse on staff, and she said, You know, I reviewed your ultrasound and if you are, in fact 11 weeks gestational age, your baby's at about five weeks, which means he or she is not growing.

And I said, So this is a miscarriage.

And she said, Well, I can't tell you that.

I don't know.

And I said, Well, I came here for just, you know, kind of a definite answer as to what's going on with my body.

Am I going to leave here with that?

And she said, I'm going to send you off with prayers and praying for you.

But in this moment, I cannot give you a definite answer as to whether or not.

But you can return and come back if things worsen.

So she sent you home with thoughts and prayers.

Q How does that make you feel when you're searching for answers and you're not getting one and then you get sent home with prayer?

And I honestly, like as a Christian woman, it was a slap in the face because I knew in that moment it just felt dismissive of like, we're not going to have a serious conversation about what's happening or what's at play in this moment.

But instead, you know, I'm just going to pray for you and the best.

Good luck is basically what she told me.

Where do you go from here?

I waited all of another 12, 14 hours before going to another doctor's office the next day.

At this point, I was passing such large clots that I was getting nervous and knew that this wasn't something I could manage myself.

And so I nudged my mother lines ahead.

And you watch, kid, and I'm going to go to be our general and see if someone will see me there.

So what did they say?

They say anything different?

The emergency room physician came in and she, you know, came in the room, you know, didn't even really introduce yourself, which is like, hey, I looked at your chart, I looked at your ultrasound.

This just doesn't look like a baby to me.

Are you sure you were pregnant?

This just looks like a cyst.

And at this point, my mother's there, my husband's there, and we all look at each other.

We're like, God.

Like, here we go again.

We're not going to get real answers.

It's going to be another gaslit situation.

And my response to her was like, Mama was absolutely pregnant.

I was right at 11 weeks.

I wouldn't be here if I wasn't.

And my mother proceeded to ask her, okay, can we just get paperwork then?

Like, at this point, they're frustrated.

I'm frustrated.

We're like, we're just going to go home.

We're not going to get anywhere here.

And at that point, I was just like, okay, guys, we're just packed things out.

We're just going to head home.

And so when do you actually find out that this is a miscarriage?

So it wasn't until the very end of the week, it was late evening, Friday, almost Saturday, and I done some research on a midwife and I went to Ochsner and she was amazing.

She was very honest and transparent that she could not offer me any procedure just because, you know, she could.

It is what she said.

But she said, I will give you closure.

And she'd say that this is, in fact, a miscarriage.

I'm surprised you, you know, gone to so many facilities and nobody could tell you that.

But she's like, I'm here to tell you that's what's happening and this is not going to be a baby that you're going to be holding in your arms.

And she was very kind about it.

I always tell folks I'm forever grateful to her.

But then I also just have a whole new, profound respect for the profession of midwifery because they do such great work and oftentimes don't get that recognition.

And she was able to give me that closure more than anybody that week.

So why do you think the hospitals reacted the way that they did whenever you came in saying, Hey, I think I may be miscarrying, I'm bleeding?

2022 was a very profound year in terms of where we are around reproductive health and how that's regulated from a government perspective.

And I can't help but know in that moment when no nurse, no physician could look me in the eye and have this conversation around miscarriage or spontaneous abortion.

The reason being was the overturn Roe versus Wade or the doctor's decision.

As someone who lives in Louisiana, you know, you and your family, you love living here, what are your expectations going forward?

Or better yet, what are your hopes?

What do you want to change here?

Yeah, absolutely.

In terms of reproductive health care, I'm hoping and I'm praying that this next year brings about some type of change as it relates to the law and acceptance of those laws.

This topic is complex and there are clearly many factors at play when it comes to Louisiana's poor maternal outcomes.

Joining me now is Dr. Veronica Gillespie.

Bell, who is a board certified OB-GYN and is the medical director of the Louisiana Perinatal Quality Collaborative and Pregnancy Mortality Review at the Louisiana Department of Health, which works to improve outcomes for birthing persons, families and newborns in Louisiana.

Thank you so much for joining us.

So I'd like to get to I'd like to start by getting to know more about the work that you do and the goals that you have for the collaborative.

So thank you so much for having me here today.

We really, in the Department of Health, try to honor the public health cycle.

And what I mean is we do data review through our pregnancy associated mortality review that we call PAMA, where we review all deaths of individuals that are pregnant or within one year of the end of pregnancy.

And not just to look at the numbers, but we look at these deaths to determine what could have been done different to prevent prevented that death.

Our committee that reviews deaths are combined of OB-GYNs, of cardiologists, of E.R.

physicians, but also community advocates, midwives, nurses, social workers, addiction specialist.

We try to do a real comprehensive 360 review of that individual's death.

So, again, we can make recommendations for prevention.

When we make these recommendations, we make them by the level of the the person that can implement the intervention.

So what can policymakers do?

What can health care systems do?

What can providers do?

On the action side, the Perinatal Quality Collaborative, we take those recommendations that are for health care, health systems and for health care providers.

We combine those recommendations with what we know from evidence based practices, mainly patient safety bundles that come from the Alliance for Innovation in maternal Health.

And we work with birthing facilities to implement those best practices and hoping.

And our desire is that every family will have a safe, equitable and dignified birth here in Louisiana.

So, so far, based on your research, how does Louisiana's maternal health care system compare to other states?

So in terms of our health care system itself is very similar, but our health outcomes are worse in the Gulf South region compared to the rest of the United States.

In general, we have a worse pregnancy related mortality rate in the United States.

In general, our pregnancy related deaths are worse than any other high income country.

But if we start looking at different parts of the United States here in the Gulf South region, including Louisiana, we do have some of the worst rates.

Has Louisiana always had poor outcomes?

Have we always had a high maternal mortality rate or is this something that's more recent?

So I'll say as a country, we have not always done the best job at measuring maternal mortality.

There have been some advancements that help us to detect when a death is of an individual that was pregnant.

One thing in the United States in 2003, they added the pregnancy checkbox to the death certificate.

So we primarily identify those individuals that have died from death certificates and now having that pregnancy checkbox will allow us to determine if they were pregnant.

But if we look at the numbers from 2003 onward, we have seen an increase across the country and Louisiana is no different.

Are we improving since then or are we continuing to go downward?

You know, unfortunately and there are many factors, but unfortunately we're not improving.

Now, I will say that when we look at the timing of deaths, we are seeing less deaths occur in the hospital.

And at the time of pregnancy, the majority of deaths, actually 53% across the United States.

And again, we see this reflected in our data in Louisiana occur from the time of delivery up to one year postpartum.

Now, you did just say that there are many factors that are contributing to the maternal mortality rate.

Would you mind telling us a little bit about that?

Sure.

So if we look at the factors, there are clinical factors and again, that's what we do with the perinatal quality Collaborative.

Collaborative is to make sure that in the hospital we are making sure we're implementing evidence based practices to help improve those clinical factors.

But overall social factors, social determinants of health, about 80% of our clinical outcomes come from our social factors and social determinants of health.

And so those factors are things like health care and health care access, economic stability, housing, the built environment.

Is it safe in your neighborhood?

Do you have access to fresh fruits, fresh vegetables?

Do you have a safe space to play?

Are there environmental factors like dumping grounds, factories, things like that?

Those are the social determinants of health.

We do know that for minorities, black and brown individuals, because of some historical factors, those social determinants of health tend to be more negatively impacted.

So we're going to talk a little bit more about how race can impact maternal health.

But before we get to that, I did want to talk a little bit more about what we saw in this video.

So clearly, you know, the dismantling of Roe versus Wade had unintended consequences for some women in Louisiana, as we just saw from Caitlin and Nancy.

What effect, if any, have you seen from last year this decision to overturn Roe versus Wade?

I think the biggest thing I've seen is ambiguity and ambiguity is never a place that we want to be as health care providers is never a place that we want to be in as patients.

And so I think there's a real lack of understanding of what is allowable, what is not allowable.

And I think what we've seen in this piece is the concern for the ramifications if you do violate the law.

The fact that as a physician, I may go to jail, not just not not from doing something that is inappropriate or not, that's not medically aligned.

But the fact that that I could go to jail, I think that has created a lot of fear.

And so I think for a lot of providers in health care systems, they they're not acting because they don't know what they can act on.

Well, circling back to the previous answer that you had given earlier, and it was focusing on race, both Caitlin and Nancy, they're African-American women, and it's known that this demographic is more likely to experience higher incidences of maternal mortality, infant mortality as well.

So why does race impact these outcomes?

So that's such a big question.

So it to boil it down and to break it down into two big things.

Structural racism and implicit bias, those are going to be the two factors that we always see as to why we have disparities.

When I speak of structural racism, I mean the systems that have been put in place either through public policy or other policies that have disenfranchized different racial ethnic groups and these systems are put in place to perpetuate the racial inequities.

So that systemic racism.

When I speak of implicit bias, our implicit biases are unconscious bias and our unconscious way we feel and we think about individuals is unconscious.

So it makes it that much harder to address.

And so it's a natural process that our brain does.

We're inundated with the amount of information that's coming in at one time.

We can't process all that information.

So our brain takes shortcuts.

They take these cut short is based on social conditioning.

The unfortunate thing in America is black and brown women in particular, and black birthing persons have not been portrayed in a very positive way.

And so the social conditioning and the bias that forms is a negative one.

And so as health care providers, if we don't address that bias, it then affects how we deliver care to black women.

So I think you've done a really good job of defining implicit bias.

But can you give me an example of something that maybe a black woman may face, one who's an expectant mother?

Yes, I can give you many examples, but I will tell you one in particular that I think has impacted not just black mothers, but black families, black individuals in general.

There have been studies where they have looked at one in particular where they surveyed about 200 white residents, white medical students, and they asked them, do black people feel pain in the same way?

Over 50% said no.

Black people have thicker skin, they have different nerve endings.

And the higher that belief was, the less likely they were to offer them pain medicine.

And so that is just an example of how a bias becomes a belief and then gets implemented into how we deliver care.

Well, we're running out of time, but I do want to ask this question, this last question.

So in a report you presented to the Maternal Mortality Task force at a hearing this year, you said that Louisiana is facing an OB-GYN shortage.

Why are we losing health care providers?

So the United States in general is facing a win shortage.

It is estimated that by 2030 that across the country we will be short about 5000 OB-GYNs, thousand OB-GYN, and compared to the supply, 5000.

And I think there's a number of factors.

I think that is a field that as medical students are choosing which field they're going to go into, not as many are choosing ob gyn.

So that's a factor when we have laws that will that impact the physician patient relationship and how we are able to practice that is turning physician medical students and physicians from from being in the field as well.

And then, of course, we have attrition because we have providers that are retiring.

And I think that we've not done a great job in fill in that space.

So, yes, we do need to encourage more OB GYNs to are more medical students and physicians to choose ob gyn and to practice, especially in our rural areas where we're seeing the greatest deficit.

But we also need to think about our systems of care and how else can we bolster our system?

How can we make the practice of midwife midwives incorporated into our obstetric practice so that we can be enough providers for the number of patients that need us?

Well, thank you so much.

This has been enlightening.

Dr. Gillespie.

Val, thank you for joining us and thank you for helping us better understand what's driving Louisiana's maternal health crisis.

Coming up, I'll sit down with three maternal health experts to discuss some of the other factors driving our poor maternal health outcomes and what changes they hope to bring to maternal health in the state.

But first, we'll hear from two midwives and how they believe midwifery will help improve the health of mothers in Louisiana.

I'm Tiffany Dietrich.

I'm a licensed midwife.

We are at Sage Birth Center in New Orleans.

It's the first freestanding birth center.

We've been here for about two years.

I had a birth center in California for about 13 years, and I started doing birth work in the nineties.

I was initially licensed in Washington State and then practicing in California, and then most recently here, Louisiana.

Midwifery model of care is very focused on education.

It's informed consent driven.

We have a very specific demographic of clients that we take that are appropriate to birth in an out of hospital setting.

In reality, that most women in pregnancy.

We provide all of the prenatal care.

We do the birth, we do all of the postpartum care and education and the amount of time that we spend in visits is a big part of improving birth outcomes in the South are outcomes are very poor for mothers and babies, particularly for women of color.

And we know that if you look statistically at outcomes with midwifery based care, it's much better.

Louisiana has a lot of challenges.

One of the bigger challenges is just the sheer amount of people that need care and the amount of providers that are available for that part of starting off pregnancy on a good foot is getting someone in for their first visit as as soon as you can.

And because there is a shortage of the amount of providers available, then you're looking at several months into a pregnancy before anybody can even get in.

And that sets the tone for other risk factors in pregnancy.

If we aren't getting women in early on in the process.

Louisiana's also very litigious.

We do a lot of inductions here.

Pregnancies are seem to be managed in the same way.

No matter who the client is.

And I think a lot of that is because it is so litigious and the doctors don't want to get sued.

And so they're doing everything they can and practicing in a very conservative way because of the risk for them.

I mean, if we look historically at how did we get here, we have a C-section rate of about 37%.

It's not drastically different from other developed countries.

But if we look back to what our C-section rate was previously in the 1980s, it was about 50 15%.

The primary provider for maternity care back then were family practice doctors.

When the malpractice rates got so expensive in the eighties, then a lot of those physicians no longer were in the birth business.

And the only provider pool that was left were OBIS and obstetricians or surgeons.

And in the 40 years since that period of time, the C-section rate has more than doubled.

A lot of it is a reflection of who the main provider type is.

Other countries have primarily midwives, nurse midwives and hospital bills.

Typically, about 80% of births in a lot of countries in Europe are with midwives.

And so their C-section rates do tend to be lower.

But more importantly, the outcomes are better.

Contrast that to the US, where our rate is about 4%.

And if we move in geographically from the south, from the east to the West Coast, we know that the amount of midwives here per capita is about a fourth of what it is in the West Coast.

And you see that as you track that, as you track the amount of midwives that are available for pregnant clients, the outcomes are better as we move to places where they have more midwives.

And so we're at this point, particularly in the South, because the risk of mortality with mothers and babies is so high.

We're trying to figure out how to fix a problem within a system where we need additional providers and midwives in particular.

It's challenging in Louisiana because we don't have a pool of midwives to draw from and that will involve training more midwives and recruiting midwives from other states to come in and practice and just getting more programs to educate midwives and getting more midwives into the hospital system as well.

LSU School of Nursing is one of those programs trying to bring more midwives into the system.

I spoke with the Director of the Midwife program to figure out what can be done to increase access.

So I'm Dr. Shannon Things Stack.

I am a certified nurse midwife and I am the director of the Nurse Midwifery Program here at LSU Health Sciences Center.

I've been a nurse midwife since 1996 and I have worked in a number of different settings.

I've attended births in hospitals, birth centers, provided care in the community through mobile health.

And for the last two years, I've been here creating a program to train more nurse midwives for pregnant women, especially first time pregnant women.

This seems like it would be a very attractive type of care to receive, but is it easy to access for everyone?

So it's not in Louisiana.

In Louisiana, only about 3% of births are attended by nurse midwives.

In other states, it's up to 20% and sometimes I think even a little higher in some states.

The there are a lot of reasons why it's harder to find a nurse midwife or a midwife to attend your birth here.

And one of them is just that we don't have the schools to train the nurse midwives, which is part of why I'm doing what I'm doing today in terms of training more people.

You know, so in Louisiana, you can you can find a nurse midwife practice in some of the bigger cities in New Orleans and Baton Rouge and Shreveport, up in Hammond.

But you can't find a nurse midwife in more rural areas or some of the areas that really need additional care.

And even in these cities, there might be one nurse midwife practice, there might be two.

There aren't enough midwives for everybody.

In the future, do you see Louisiana making it easier for women to access midwives?

I absolutely do.

I think there are a number of things going on right now and and the maternal health crisis has reached a proportion where people are paying attention.

We have to nurse midwifery schools in the state now.

So there's also there's Loyola.

We also have a task force that is meeting talking about ways to provide to increase access to midwifery and to increase access to the midwifery model.

So that task force is coming up with legislative recommendations that hopefully in the next session they'll take a look at.

So what can Louisiana do going forward to improve access to midwifery and also just improving health outcomes for maternal health care in general?

Know, to improve access to midwifery, we need hospitals, physicians and health care systems to buy into the model and to hire midwives.

We need, you know, rural health clinics, federally qualified health centers, health systems that are in the underserved areas to see the value of it.

Essentially, we need to get the word out about who we are and what we do so that these health systems will meet, bring us on and allow us to do the work that we can do.

We are lucky to have maternal health experts here with us in the TV studio.

Leighton Aguila is a dual registered nurse and is the co-founder of the birth Mark Dula Collective in New Orleans.

And Esther De is a certified nurse midwife with over 38 years of midwifery practice.

I'd like to start hearing a little bit, start by hearing a little bit more about your work as it relates to maternal health in the state.

So, Mr.. TONER, I'm going to start with you.

Thank you.

And so I am a Dula, a registered nurse and an international board certified lactation consultant.

I started my work as a doula first, actually, because I was working with homeless youth.

And what I found and was surprised that this was in my twenties was that a huge percentage of homeless youth were pregnant or parenting.

And so that really got me asking, how is it that we live in a society where pregnancy, instead of elevating you to a place where you're being cared for and protected, actually puts you at risk?

And I Googled how to support pregnant women, and I found the concept of a doula.

So I did my first doula training.

And from the beginning, for me, this work was about justice and about improving outcomes for families.

I started the birth Mark Dula Collective in New Orleans in 2010, and my co-founder and I had two aims.

We wanted to one, increase access to do list services because at the time the majority of doula services and how they were conceptualized was about luxury as a luxury service for high income families, mostly white families.

And I that's not how we believe Dula services should operate.

They should be an essential service and part of everyone's care.

And the second aim was to support doulas themselves.

It's really hard to be an independent solo practicing doula.

You need backup, you need benefits, you need child care.

And so we thought if we came together and organized together, we could create something that worked for both doulas and families.

And I did want to make sure that everyone knows the difference between a doula and a midwife, because that's a common misconception that that we do the same thing.

So as you all have learned, a midwife is a clinician like an obstetrician or a family physician.

They're the ones providing your clinical health care during pregnancy and birth, a do as a community health worker and a patient advocate.

We are caring for the pregnant person and their family prenatally during birth and in the postpartum period emotionally, physically, spiritually and informational.

And Esther, what about you?

How did you get started in this field?

So I came from midwifery from a women's health perspective when I was in my twenties.

The women's health movement was very strong, and almost every town I lived in had a women's collective.

So I went to midwifery school.

I worked for ten years in Gainesville, Florida.

I had a birth center and did home first there and Florida at that time and still does.

Just had a lot of midwives, hundreds and hundreds of midwives, licensed midwives, a licensed midwife school started while I was there.

There were at least a half a dozen first centers.

And when I moved here because my husband got a job here, which is how a lot of midwives, I think, get to Louisiana, there was I could hardly find midwives.

There were a few midwives.

Nobody was doing no nurse midwives for doing births.

There was one licensed midwives doing births at the time and that there was a midwife that was doing prenatal care at St Thomas Health Services and.

She gave me half of her job and then because she was married to an OB, she was able to start a practice in New Orleans East and that was a wonderful little practice.

People came from Mississippi and the North Shore and Canada and everybody came for that type of care.

But that that practice closed because the hospital was sold and they just closed the practice with no no explanation at all.

So Kathy Bardo, another nurse midwife, and I started a practice at Touro because she had a friend that was a physician and that was a wonderful little practice until the backup became a little unstable.

One, some of the physicians that worked with this particular position, their husbands didn't want them to back midwives.

Were afraid of the liability.

And then another doctor said he would be involved, but he wanted $2,000 a month to to be our backup.

So we were really happy when Ochsner Baptiste recruited us to be in their new birth center, in the hospital center.

But just a pattern of of how practices start and end and our reliance on doctors and hospitals for cooperation.

So I've got a lot of questions to get to.

But I did want to ask this one question to the both of you.

So like you said, doulas and midwives, they do completely different things, but sometimes you guys have the opportunity to collaborate.

You work together often.

Often.

And I would say that when we saw that one of our clients had hired a dual look, we were very happy and relieved.

And I think to also encourage our clients to work with midwives.

But you know, ideally the pregnant person is in the middle of this circle of support.

It's a team.

There's a midwife, a do, an OB who can assist if the pregnancy becomes high risk or surgery is needed.

Mental health professionals, family members and lactation consultants, we need all of that to have a healthy pregnancy.

Something that I wanted to touch on is that earlier, whenever you were explaining your role and how you got into this, you talked about how services like doulas and midwives.

It's something that I guess the stereotype is that it's for that are rich or of means and it discourages people from asking for a midwife or doula while they're pregnant.

But I want to know why is it important to prioritize these alternative forms of care and make it accessible to regular people?

Yeah, absolutely.

Well, the research is very clear that midwife led care gives better outcomes.

There was an example.

It was a while ago, but a small town in California had a county hospital and they needed maternity services.

They didn't have people to do prenatal care, so they got a grant to have nurse midwives into the town, deliver at the hospital, provide prenatal care.

The the infant mortality rate went down.

The pre-term rate went down.

The outcomes were much better with the midwives there, but the grant ran out and so the program was discontinued and the rates went right back up.

And in parallel for July's, you know, the most recent Cochrane Review shows.

But doulas reduce preterm rates by as much as 22%, which is huge, especially in a state like Louisiana, where we have a failing grade and our preterm rates are increasing.

We reduced the C-section rate.

Studies show between a 20 and 50% reduction in C-sections.

The Cochrane showed 39 and we improve of positive feelings postpartum, reduce postpartum depression and increase breastfeeding.

So both of these interventions have been well documented.

So what are some of the barriers in access to midwives and doulas?

A huge barrier for doulas is cost.

Right.

So in a state like Louisiana, up until recently there was no insurance reimbursement for do care.

So you either had to pay out of pocket or organizations like mine accepted grant funding and did do a sliding scale to make the services affordable.

But it's hard to scale those services to reach everyone.

There are efforts happening in Louisiana around insurance reimbursement, private insurance reimbursement just passed this year, and Medicaid is in the works.

So there is movement in this direction.

But right now, birthing families still are struggling to figure out how to pay for doula services.

And then, do you have anything to add?

One of the big barriers to nursing midwifery care is the current requirement to have a collaborative practice agreement in order to practice.

So certified nurse midwife CVS and nurse practitioners cannot.

We cannot practice our profession unless we find a doctor to sign this legal agreement, which there very hesitant to do.

And I was hoping in my story of my particular journey, that you could see that it's difficult to maintain those relationships.

So we are in the minority of states that still have that requirement.

28 states have full practice authority for nurse midwives.

And if we had that, we know from experience states that have more practice authority, have more midwives, have more access to care, have better outcomes, and also have more nurse midwives practicing in rural areas.

So bottom line, access, affordability and just knowledge in general that people, they don't understand what's available to them.

And structurally I think a lot of what Esther is saying is that the health maternal health care system is not structured in a way where folks can access midwifery and doulas when OBS are considered the default care and these other things, as you know, we could have on we could not.

Then there all of these barriers exist, but if we assume that this is default care, we would structure it differently.

Well, like all of the other topics that we've been talking about, this one is definitely a complex one.

And there's a lot of different directions that this conversation could go.

But unfortunately, we are running out of time.

But I want to say thank you so much for coming in and talking about this.

And, you know, collecting data is crucial to improving maternal health outcomes.

One aspect of maternal health that is rarely considered is health care for incarcerated women.

I spoke with Dr. Andrea Armstrong at Loyola Law School about what childbirth looks like in our prisons and jails and the lack of data being collected for these facilities.

Here's what they had to say.

My name is Andrea Armstrong.

I'm a professor of law here at Loyola University, New Orleans, and I study incarceration, law and policy.

You were a part of the task force that was created to study the conditions of incarcerated pregnant women in Louisiana.

What did the task force study specifically and also what came out of it?

The task force was led by the Louisiana Public Health Institute, and it included people who were formerly incarcerated women.

It included doctors and included advocates.

It included research teachers.

And our mandate was to study reproductive and maternal health for incarcerated women, as well as the implementation of three specific laws that impacted women's health here in Louisiana.

We did find that there were 71 deliveries of babies over a five year period.

There were four miscarriages and that over 600 women had been admitted into either a prison or a jail when they were pregnant.

Over the last five years, but I couldn't tell you today, for instance, how many pregnant people we have behind bars because we don't track it.

One thing that Louisiana is relatively unique for, though, is that we have a significant number of incarcerated women in local jails.

So two thirds of women who are serving a conviction who in any other state would likely be in a prison are actually doing their time in a jail in Louisiana.

And that has implications for their health care.

Jails are designed for short term.

They're designed for people who have been arrested, who are going before a judge for their arraignment or their trial.

And so everything is designed around somebody being there for, you know, 24 hours to 3 to 6 months.

They're not designed to hold people for years on end.

Their health care systems aren't designed for that.

Right.

And so what we've recorded is 71 births over a five year period.

The overwhelming majority of them were in a hospital, and it included caesareans as well as marginal deliveries.

But we did note that several did happen in facility as well at at four different locations.

There's definitely an undercount around the number of women who are pregnant and who are admitted.

There's an undercount around the number of women who delivered.

But we only received reports of four miscarriages out of a universe of over 600 admissions of pregnant women in five years.

And just thinking about the prevalence of miscarriages nationwide and in the general and free population for miscarriages over five years seems improbable.

Are there any solutions going forward that the task force recommends for prisons and jails in Louisiana to, you know, bring everybody up to speed?

There's a couple of things that are in progress that I'm hopeful for.

One is this legislative session.

The Louisiana legislative auditor is going to look at compliance with three laws that have been passed since 2012 affecting the health care for incarcerated women.

One of the issues with the task force report is that facilities in some cases didn't provide any information or only partial information.

But the Louisiana legislative auditor has the power of subpoena and so should be able to compile a deeper, more substantial record about compliance with pass laws.

So that's already in progress.

And we're excited to see what that brings.

We are back with our esteemed panel, the town of and Esther DeLong.

And joining us is Dr. Mae Wallace, who is a reproductive and perinatal epidemiologist at Tulane University in New Orleans.

Thank you so much for joining our panel.

I'm going to start with you with this first question.

So can you tell us a little bit about your work as an epidemic ologist?

And what are some of the areas you study as it relates to maternal health?

Yeah, So thanks for having me.

My my goal as an epidemiologist is to identify sort of trends and patterns in health across population and understand reasons underlying those trends.

So as it relates to maternal health.

I've been studying maternal and infant mortality rates here in Louisiana, nationwide, and sort of trying to understand reasons why they've been increasing in recent years, why low in Louisiana might be so much higher than other states.

Why There is so much difference across states in terms of these rates.

Why the US is so much higher than any other high income country on earth in terms of our national rate of maternal mortality.

And why is it that black and indigenous and other women of color are disproportionately experiencing these these types of death?

And so my second goal is to, of course, identify ways to reverse these trends and to promote maternal health.

And so these are programs and policies that we can show promote the health of people from the time that they are babies themselves through their life course so well before they become pregnant if and when they become pregnant.

Of course, during pregnancy.

And in that first critical year postpartum.

So we've heard experts categorize maternal deaths into two categories, and that's pregnancy related and pregnancy associated.

Can you help us understand the difference between these two terms?

Sure.

So the CDC defines pregnancy related mortality as death of a person during pregnancy or up to one year after the end of pregnancy from a cause related to the pregnancy or its management.

So think of these as obstetric causes of death, things like hemorrhage, hypertension or preeclampsia.

Obstetric embolism.

Pregnancy associated mortality is sort of a broader classification of deaths, and it's by definition the death of a person who is pregnant or up to one year from the end of pregnancy due to any cause.

So that includes all of those obstetric causes of death that are pregnancy related, as well as things like homicide, suicide, drug overdose, car accidents, cancer.

Literally any cause of death.

So while they're related and overlapping, it's really important to have both because so, for example, when you see a maternal mortality rate, the CDC publishes our national maternal mortality rate every year.

That includes only pregnancy related deaths.

So those obstetric causes of death.

But what our work and others have shown is that these other causes of death, homicide, suicide, drug overdose, are happening with alarming frequency in this population as well.

And so we need this concept of pregnancy associated death to be able to count those deaths, to monitor how we're doing in terms of our efforts to prevent them for pregnancy associated deaths.

You were talking about homicides and drug overdose.

Is there something that's more common?

We've shown nationally that homicide is among the leading causes of pregnancy associated death.

And here in Louisiana, we found that homicide rate, in fact, exceeded the rate of deaths due to the three top three pregnancy related causes.

So obstetric embolism, hypertension and hemorrhage.

So why is violence so prevalent among birthing people?

Yeah, so a few really key important pieces of information to know about maternal homicide.

First is that most of these cases are involved domestic violence so that the it's the victim perpetrator relationship is typically that they're intimate partners.

Second is that the vast majority involve firearms.

And the third is that pregnancy and postpartum is really a time of increased risk for violence, where our work and others has shown for many, you know, across decades at this point that homicide rates are higher in pregnant postpartum people than they are among women of reproductive age who are not pregnant and postpartum.

This is true in Louisiana.

It's true in states across the country.

And it's true when you look nationally as well.

And so I think, you know, mostly we think of pregnancy and the birth of a new baby as a really joyous time.

But that's just not always the case.

And I think in especially vulnerable relationship ups, where there's already a lot of ongoing stressors, where there's a history of or ongoing violence, pregnancy can just really exacerbate the stress folks are dealing with.

Research has shown that abuse can escalate in severity during pregnancy and that injuries inflicted on violence on pregnant women are more likely to be fatal.

What can be done to identify mothers who might be experiencing violence and are dual, often midwives better suited to identify potential victims?

Or are they better at this than, say, a physician?

I'm going to start with you.

So there are evidence based screeners in pregnancy that we can use to see if intimate partner violence or other types of violence are a factor for someone.

And I'm sure Esther can speak to that as well.

I know that when I served on the Pregnancy Associated Mortality Review Board, we often found when we were looking at a case where someone had died violently, that there was no record of that screening being done in the physician's office, which is a really unfortunate missed opportunity as to as we are meeting with clients in their homes or meeting their family members.

And so we do often the opportunity both to observe and to build trust with clients where they might disclose something like that and ask for resources.

Right.

You guys are there from every step of the way, doulas as well.

So it's easier for you guys to spot these things.

Definitely.

One study showed that on average, doulas spend about 45 hours with their client from pregnancy to postpartum, and the typical physician spends about 6 hours.

And so we spending much, much more time and really building a relationship.

And midwives visits are much longer as well.

And Dr. Wallace, I wanted to ask you this question.

So are there any policies that can be implemented to help curb, you know, these alarming numbers of violent crime against pregnant people?

Yeah.

So as I mentioned, most of these cases, the vast majority of them involve firearms.

And so, you know, removing a gun from a dangerous and violent situation is likely going to prevent a fatal injury.

And so Louisiana is actually one of about half of states in the country that have firearm laws that prohibit possession among people who have been involved with domestic violence.

So if you're under a domestic violence restraining order, you're no longer allowed to possess a gun in the state.

Our research has shown that that can be a really effective state law to reduce domestic abuse homicide, including in the pregnant postpartum postpartum population.

However, what we've seen, especially recently in Louisiana, is problems with the implementation of that law.

So it's on the books, it's in effect, but it's not really being put into practice.

So I think what's needed here is just efforts to shore up the provisions of the law and the processes through which we can successfully transfer firearms out of dangerous situations.

And then as a public health perspective on just the root causes of violence itself and how do we prevent violence.

It's about ensuring that families can afford safe and stable housing, can put food on the table, that they have economic and employment opportunities, that we support new moms and new families by providing paid family leave, by ensuring they can earn a livable wage and these sort of other more broad, upstream public health approaches to violence prevention.

There's another aspect of this that I don't think that we've talked much about, and it has to do with mental health.

So what role does mental health have on the impact of maternal maternal health outcomes and the ability to have a healthy pregnancy?

Of course, mental health plays a big role in both the pregnant person and the baby, and the whole family has experience of birth in the postpartum period.

We know that a significant number of maternal deaths are related to mental health, such as deaths that happen.

Bias, suicide.

And we also know that a huge percentage of maternal deaths happen in the postpartum period when mental health is a very significant concern.

And I and so many people have pointed out that in this country and in this state, we practice postpartum neglect.

So if you have a baby in the hospital, under the typical care system, you're there for maybe 48 hours and then you're shipped on your way with a newborn.

And we tell that mother, see you, in six weeks when this is actually the most vulnerable period probably of your life.

Right.

And so when I think about mental health, of course, you know, throughout the entire first year, postpartum and during pregnancy is important.

But that window where we just leave families on their own is absolutely crucial.

And if you have a doula, you're going to receive postpartum home visits.

If you have a community based midwife, you're going to receive multiple visits during that period.

If you have other ancillary services like nurse home visiting, you'll receive care.

And all of that forms a protective circle during that vulnerable window that does influence postpartum mental health outcomes.

And Esther, do you have anything to add?

Just one that again, there's a tool, there's a screening tool that's evidence based.

And and it should be part of every postpartum visit.

And I think midwives try to bring people back sooner.

But you're right.

Midwives from other countries are appalled at how we just leave our are new moms by themselves.

But that screening tool is very effective.

We found in our practice that it was just hard to find good referrals, that there aren't a lot of practices, nurse nurse practitioners or physicians who are doing mental health for postpartum women.

And, Dr. Wallace, I'm going to come back to you.

Do you have anything that you want to add on the mental health conversation and how that influences maternal health outcomes?

Well, I do want to just underscore access to maternity care and maternity care providers and support people like midwives and doulas as just a critical window of opportunity to identify someone who's in a mental health crisis or experiencing violence or experiencing substance use.

It's just this opportunity to connect to someone who might not otherwise be in care, if not for the fact that they're pregnant and be in touch with people who can identify that they have needed and wanted services.

So I think just to really underscore the importance of access for for mental health crises.

All right.

Well, everybody has contributed something very interesting.

I think this was a very compelling conversation, but I'm afraid we have run out of time for our discussion tonight.

So I want to thank Dr. Gillespie, Bell, Toni, Esther and Dr. Wallace for sharing their knowledge on these issues.

So what do you, our viewers, think?

We encourage you to comment on tonight's show by visiting LTB Dawgs Louisiana Spotlight and clicking on the Join the Conversation link.

We'd love to hear from you.

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