Rae Woods: From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. We spend a lot of time talking about racism and equity on this podcast. In fact, we have an entire playlist dedicated to it that I'll link in the show notes. But today I want to talk about a specific component of health equity. One where the United States is actually woefully behind and that's maternal health. To do that, I've brought back Advisory Board health equity expert, Darby Sullivan. I also asked Callie Chamberlain to join us. She's the co-director of social responsibility at Optum, the co-host of their podcast, Until It's Fixed and she's a trained birth doula. Hey Darby. Hey Callie. Darby Sullivan: Hi Rae. Callie Chamberlain: Hi. Rae Woods: Darby, are you sick of coming on Radio Advisory yet? Darby Sullivan: Not at all. I love coming on and chatting with you about this stuff. Rae Woods: And Callie, you are our first-time guest, and we've had a few clinicians on the podcast before, but you are our first doula to come on, which is so cool. Callie Chamberlain: I love it. Thank you for having me. Rae Woods: Callie, you have a very interesting role. You actually co-lead social responsibility for Optum, which has this broad focus on health equity, but you yourself kind of had this aha moment. You realized somewhere along the line that organizations like Optum weren't actually doing enough for maternal health equity specifically. When did you have this personal aha moment? Callie Chamberlain: In my doula training, learning more about the experience of being pregnant and going through labor and delivery and postpartum, it really became clear to me how many gaps are in the system and also what the lived experience are of birthing people. And so being on the other side of that and training to essentially fill those gaps and work against some of what the system has set up amplified for me, the opportunity to really do something different here. So learning about the training and then also recognizing that Optum provides services to one in 10 children that are born in the United States. It just, Rae Woods: Oh wow. Callie Chamberlain: Became clear there was a major opportunity for us to actually change the way we do business. Rae Woods: And I think a lot of folks end up coming back to this firsthand experience. Although not many actually go to the point of saying I'm actually going to train to be a birth doula, but other people say, when I had a child, or when my partner had a child, or my sister, or my brother, that's what made me realize that maternal health is actually a problem here in the United States. And I want to spend some time just talking about how big of a problem this is. Darby, help level-set for me. Darby Sullivan: Yeah. So the US has the highest mortality ratio for pregnancy related deaths compared to all other similar nations. Rae Woods: Wow. Darby Sullivan: We're also the only country where our rate is actually increasing over time. So it's gotten 60% worse since the year 2000. Rae Woods: Since the year 2000? Darby Sullivan: Yeah. 60% worse. Most people know that maternal mortality, they've heard by now that it's a problem in the US, but I don't think many people realize how preventable the majority of these deaths are. So 60% of pregnancy related deaths that are measured could've been prevented with things like proper delivery at the point of care, proper care delivery during birth, prenatal care and more. Rae Woods: And you're speaking specifically about maternal mortality, Darby Sullivan: Yes. Rae Woods: But where do we stand when it comes to maternal health more broadly, or maybe even what does that term encompass? Darby Sullivan: Maternal health encompasses at least when we talk about it here at the advisory board, the mortality and also the morbidities that happen related to pregnancy. And so the mortality is really, really bad, but morbidities are also pretty severe. So I think every year between 60 or 80,000 patients in the US have a near miss or some severe pregnancy related morbidity, which does not lead to death, but can have really severe like clinical emotional implications. And the rate of those near misses are getting worse over time as well. And some folks are increasingly familiar with the maternal health problem. But what I think not as many folks realize is the disparate outcomes between racial groups in the US. Rae Woods: Ah, well, let's go there. Let's give it the platform that it deserves. What do we see when it comes to disparities within groups? Darby Sullivan: Yeah. So I guess first to zoom out, I want to emphasize that no matter who you are, in the US you are at risk of having a negative outcome just because you live in this country. But the problem is a lot more severe for specifically black and Native American patients. So Native Americans die at a rate of 2.5 times the rate of white people and black patients die at more than triple the rate. And really notably these disparities hold true when you account for education, when you account for income. One of the most striking facts that I've heard is that black women with a college degree are more likely to experience these morbidities than white women that don't have a high school education. Rae Woods: Callie, Darby, I normally have a lot to say on these podcasts. And I normally am quick to follow up with a question, but I actually kind of just want to pause on what you just said, because this is a really scary moment for a lot of people here in the United States. And you are describing a problem that is crisis level, a problem that has gotten and is getting worse. And perhaps most importantly, it's a problem that at least for a proportion of parents, is preventable. Let me go a little bit of a darker place. My guess is that COVID has not made things better. That its made things worse. Darby Sullivan: You would be right about that. And there are a few reasons for it. So we know that clinically the virus is more dangerous for pregnant people. We also know that the pandemic has made the adverse social determinants of health worse. So the things that folks need to stay healthy during their pregnancy are harder to come by like stable job, healthy food, prenatal care. But I mean, really heartbreaking, we've still seen, I think, news story after news story of some pregnant people not wanting to get vaccinated until after they give birth, Rae Woods: That's right. Darby Sullivan: Despite the fact that actually it's recommended that pregnant people get vaccinated, because then they can pass antibodies to their child. Rae Woods: Not to mention the fact that pregnant people are more likely to have severe disease and death from COVID-19. Darby Sullivan: Yes. Yes. So, I mean, we've just read story after story of parents dying before they ever meet their children, because they're not getting vaccinated. So that's sort of the individual stories that we're hearing, but we also know that Medicaid recipients are less likely to be vaccinated than the general public. And they're already a vulnerable population that are facing the adverse social determinants of health. So I think there's kind of no doubt that this will be a step in the wrong direction for maternal mortality. Rae Woods: And it comes back to your point that being a pregnant person in the United States puts you at risk period, Darby Sullivan: Right. Rae Woods: But that the level of that risk or the disparity that we feel among different groups gets worse when we actually are willing to peel back individual layers. Darby Sullivan: Yeah, absolutely. Rae Woods: Okay. Let me force myself to go to a slightly more positive place, right? This is a huge, huge problem, but the good news is that people like Callie and organizations like Optum have kind of realized with this spotlight that COVID has put on maternal health, that we actually need to do something about it. So Callie, my question for you is what advice do you have for organizations that are looking at this problem and saying, we need to take a bolder stance on maternal health equity? Callie Chamberlain: I mean, first of all, yes, absolutely. Just to underline something that Darby had mentioned earlier, when we think about equity in this context, the baseline is also not good, right? Like nobody wants to be there. Outcomes are terrible. There's a lot to be desired for everyone, regardless of what your race or ethnic background is. It's especially bad for people of color. And so I think that being able to center around that, to go into communities that are representative of your most vulnerable populations and asking them to help you solve the problems and being humble in that approach, being willing to amplify their voices and put resources behind them to ensure that you're truly understanding the complexity of the problem is so important. Rae Woods: This is really nuanced advice because you're saying on the one hand, this problem is bad for everyone, but we know that these disparities exist. But when it comes to the action steps that an organization takes, you actually want to orient your efforts at the portion of the population that has the worst outcomes, because you know ultimately it will benefit everyone. And that's a really specific nuance that I want to make sure people hear. Callie Chamberlain: Yes. Thank you for calling that out. And our belief is that when you solve for that group of people, you actually end up solving for everybody. Rae Woods: Exactly. Callie Chamberlain: Yeah. A lot of our work is centered around looking at pregnant people who are experiencing domestic violence, pregnant people who are incarcerated, pregnant people who never have their voices come into research that actually informs clinical practice. And so by wrapping our arms around those communities and ensuring that we're supporting people who come from those groups and working from behind them and integrating their insights and learnings into our organization and the way that we think about equity, I think that's the approach to be taking regardless of what you're focused on, but specifically around maternal health. The other thing I'd add here is that it's not just maternal health, right? When I have conversations with providers about how we got here, they'll also say things like, well, we don't talk about women's health. Callie Chamberlain: And in this country we don't prioritize women's health. And therefore it's not possible for actually, us to have reduction in maternal morbidity and mortality. And then you think about social determinants of health and how bad they are across this country. It's built on a foundation of race. And so kind of going back to something that was said earlier, when I was in doula training, we learned about the hospital gown for black women being the great equalizer. It doesn't matter how smart you are, it doesn't matter how much money you make, those things actually can work against you. And so we have to also in this context, talk about race. Rae Woods: I completely agree. And I want to get to these root causes in a moment, but I want to stay on practical advice for organizational leaders. As somebody who's actually advocated for change, what are the biggest things that you needed to armor yourself with? Were there people in the room? Was there specific kind of data that helped you kind of lobby in your own efforts? And how did you deal with the inevitable pushback that anyone who's dealing with a challenge like health equity will ultimately get? Callie Chamberlain: Yeah, I think in the answer that I just gave, which is very multi-dimensional, it really was looking at how the organization had oriented itself around those different topics and then pulling them together to say, we have a real opportunity here, and this is what we can live into. Right? We say that we're about health equity. We can actually lead in this space. Isn't that amazing? From a branding perspective, from a thought leadership perspective, isn't that where we want to go? And because this issue sits at the intersection of race and gender, there's a real opportunity for us to learn about our patient populations in a way that is not happening across the organization today. Rae Woods: So this is a real practice what you preach moment. Callie Chamberlain: Yes, exactly. And I think that really helped us get the right people in the room. We said, look, we've done work in this space before. We're just building on the legacy of what has happened before. And I think that also helped us to get some momentum. Rae Woods: And I think that same practice what you preach principle can help you, not in just making sure that an organization is advocating for optimal patient outcomes, but also so that we're actually addressing the root causes in the community, which Callie to your point is where we actually need to go if we are going to make progress. Let's make sure we understand why this problem exists. Darby, explain to me some of the root causes of maternal health and equity in the United States. Darby Sullivan: Yeah, sure. So according to the research, we see this crisis in part, because of kind of the intersection of two forces. So on the one hand, the legacies of structural systemic racism that we've been talking about for the past year and a half more and more, and on the other hand, like Callie mentioned, the sort of systemic deprioritization of women's health across the lifespan in favor sometimes of fetal outcomes. So those two things together, I think have uniquely led to the maternal health equity crisis. Rae Woods: Darby, those are two, I mean, they're humongous challenges to solve. And so part of me is thinking, no wonder folks focus on quick wins, or low hanging fruit, or aren't able to actually get to these root causes because you are talking about upending the structure of the United States. My question is how, how can organizations of all kinds start to chip away at these underlying issues? Callie Chamberlain: We are just beginning here to be clear. I think two things are really important. One is that each of our philanthropic organizations that we're supporting, which is out there in the world, not necessarily about us as the second largest healthcare company in the world, changing our business practices. Each of these grant partners has an executive sponsor. The intent of that is for the sponsor to serve as a senior advisor to the organization, to look for opportunities for Optum to even more deeply support their work. And also to think about the relationships and the communities, the insights that we're learning from our work to pull back into how we think about creating products and services within our organization. So that's one of the ways in which we're advancing, I think equity and deepening relationships with communities. That's really important because it's not just, again, out there. It's like coming into the organization as well. Callie Chamberlain: The second thing is thinking about how you align your priorities to what you say that you care about. One of the biggest things that I would love to see Optum do is to have really incredible best in class paid parental leave policies. I would love to see us lobby in ways that actually prioritize the things that we're doing externally and the things that we say that we care about internally. There's a gap there for a lot of organizations because we're in a capitalistic society, for profit environments. And also there's so much space to walk the line and I'd love to see us move closer to that in the future. Rae Woods: And this is not just a lesson about one organization or one major healthcare company. Every single person who is listening to this podcast needs to think, what am I doing now to make progress and how can I think bigger? How can I do more? How can I address every aspect of equity, not just my patient outcomes, but also my own people, right? My own workforce, as well as my community. And frankly, that's the message of equity period. I think it just plays out really, really specifically when we talk about maternal health. Darby, what do you think? How can organizations again, from across the industry, address some of these root cause issues? Darby Sullivan: Yeah, I think on the one hand leaders from organizations can sort of say, I'm actually making a change to my benefit structure in a way that will have far reaching impacts. That's relatively an easy step to make compared to sort of the other complex changes that orgs have to make. To stay at a high level, we recommend tactics that fall into three key categories. The first being primarily for provider organizations. So those are the ones that are actually owning that patient interaction. We recommend that they start with sort of these no regrets safety protocols because too often the standard evidence-based OB protocols that vastly reduce the instances of never events, those are not being used in a standardized way. Rae Woods: Meaning they're only used for say white pregnant people. Darby Sullivan: Or not, or maybe they're just sort of, some care teams know how to do it. Some care teams don't. Rae Woods: So just the basic way that we have care variation in general, Darby Sullivan: Exactly. Rae Woods: We're not focused enough on it in this particular space. Darby Sullivan: Exactly. And that's sort of like do that immediately. After those are in place, then I think you can start to build those feedback mechanisms to try to get a sense of, okay, what are the broader causes of this beyond just sort of the care variation that we might see. That means expanding an existing with maternal mortality review board to make it more of a perinatal review committee so that you catch problems that happen prenatal and postpartum, as well as during the delivery. In addition to sort of the basics of gathering data stratified by race, to see where disparities prop up. Rae Woods: And I would say that's the best practice for the patient outcomes piece. And then you pair that with what Callie was saying, which is how do we support our own workforce? How do we address this problem in the community? Rae Woods: Let me reveal to both of you, some of the pushback that I get and the pushback kind of centers around this idea that this is not my problem. This is not my problem to solve, or maybe this is not my problem because folks incorrectly think I have a pretty homogeneous patient population. So this isn't a problem for my organization, which Callie very eloquently said, Nope, it doesn't matter if you're a pregnant person in United States. This is a problem period. But the other kind of not my problem moment that we're having right now comes out of some very specific policy changes that have happened in the last several weeks. Of course, I'm talking about Texas and I get a little bit afraid that organizations, provider or otherwise who are not in Texas, are looking at what's happening and saying, see, it's bad there. They are the ones that need to focus on maternal health, perinatal care, et cetera, but we're actually okay, wherever we are in the country. What do you say to that pushback? Callie Chamberlain: I think that's part of the problem is that mentality that like the problems exist out there and they're disconnected from anything that has to do with me or the things that I care about. That's just simply not true. We live in the world together and the things that affect one group of people are affecting us all in some kind of way. And so I think one of the really incredible examples of social responsibility is Salesforce who offered the opportunity for their staff that were located in Texas to relocate as a result of this law. Rae Woods: Salesforce, the company. Yeah. Callie Chamberlain: The company. Yes, exactly. Thank you. So I think that's a really good example of an organization that's not in healthcare, but knows that they have a stake in the ground because they have people that work for them that are there. And they're saying, let me think differently about how I can show up in this moment. Darby Sullivan: Yeah. I think it's also important for all organizations in healthcare to realize just how tied abortion and maternal outcomes are or women's outcomes are. Zooming out a little bit. We know that pregnancy is more dangerous to health than an abortion is in terms of, Rae Woods: That's right. Darby Sullivan: Mortality, morbidity. We know that. And research shows that the people who are most likely to seek an abortion include people of color, low-income people, those with chronic conditions, those that are experiencing the adverse social determinants of health. Those are the people, the very same people that are most likely to have serious complications during pregnancy. So any restriction on abortions will inherently worsen outcomes for patients, especially patients of color, which is of course concerning from a preventative standpoint. If one of your goals is to improve maternal health and improve maternal health equity, you have to also keep abortion care as part of that strategy. Rae Woods: And this comes back to something that Callie said earlier, which is that to have a conversation about maternal mortality or maternal health, we just have to talk about women's health and you can't talk about women's health without addressing the fact that safe and legal access to abortion is a necessary part of women's health. And we need to be willing to have that conversation if we're actually going to get at some of these structural root causes that ultimately improve outcomes for pregnant people in this country. You both work with organizations of all different kinds about this issue. What's the biggest thing that those organizations tend to get wrong when it comes to addressing maternal health? Darby Sullivan: What a lot of organizations get wrong is that they think too narrowly both about the scope of the problem, but also about who should be involved in the solution. So we talked kind of specifically about the provider organization's role, but we know that health plans, life sciences companies, tech companies can also play a role. And so each stakeholder across the industry has to really think strategically about how they can partner within our own industry. And also even sometimes with competitors in order to sort of raise the bar for each other. Rae Woods: Do you have an example of that kind of partnership really playing out? Darby Sullivan: Yeah. So for example, we've been talking with health plans that are trying to think through how to hold provider organizations accountable for equitable care delivery in quality scorecards. And we are also seeing providers who are trying to work with plans to one day get reimbursement for referring patients to social care, those things that actually have a measurable impact on downstream outcomes. Callie Chamberlain: And I would add onto that and just say that I think being able to think about this issue more expansively is helpful for everybody. So like we're talking about with maternal health, it's also about women's health. It's also about reproductive justice and family planning. When we talk about birthing people, it's using that term birthing people, which is more inclusive. It's also, Rae Woods: That's right. Callie Chamberlain: Talking about people of color, looking at who's experiencing the worst kinds of disparities, looking at how our research is not inclusive enough because it doesn't encompass lived experience as a part of what's informing clinical practice. Rae Woods: Which comes back to those life sciences companies who are developing drugs and creating the technologies and all of that upstream work. Exactly. Callie Chamberlain: Yeah. And one of the things that I think was important for us at Optum was to recognize that we did not have relationships with the communities we wanted to work in. And so it required us to partner with uncommon allies and people who maybe we wouldn't have partnered with before to be able to rebuild that trust and work within communities to address this issue because it is complex, it's multidimensional. And thinking that we can just focus on providers or patient education, it's not enough to get us where we need to be. Rae Woods: I want to make sure that our listeners don't feel overwhelmed by the enormity of the problem here or that they feel let's say appropriately overwhelmed by the task at hand that every single person who's listening to this podcast needs to act on. And that's where I want to end our conversation. When it comes to maternal health, what is the one thing that you want to make sure our listeners do differently as a result of this conversation? Darby Sullivan: I've said this before on Radio Advisory, so I'll be a broken record, but it's really important that we understand we can't fix structural problems without structural solutions. So while we should be meeting patients in communities where they are, while we should be impacting our workforce, I also want folks to think even further, especially those that have government affairs arms, which is most organizations. How can you say, for example, I'm going to weave in my maternal health equity goals into my advocacy agenda, whether it's, I'm going to expand Medicaid coverage for pregnant people, or I'm going to try to advocate for our funding and reimbursement for traditional providers like doulas. What are the different policy choices that we already know will impact maternal health in a positive way that should be added to your agenda and also what needs to be taken off your agenda? So in what ways are we actually perpetuating the same problem that we're trying to address? Callie Chamberlain: Yeah. And I think to support that is my recommendation, which is to get closer to the ground all the time. It was so important for me to have the experience as doula to work side-by-side with people while they were in labor and delivery, to understand how broken this was. And I'm not recommending that everyone becomes a doula. Although, I think that would be amazing. There's needs to be much more of us. But it's just being in conversation to the people who are most vulnerable and thinking about how you leverage your power, your influence, your privilege, which all of us have in some sort of realm to think differently about the work that we're doing and to say what it is that needs to be said and make sure that our actions are aligning to that, right? It's not enough to say that we care about health equity. It's not enough to say that we really want to do something around maternal health. Get lower, like figure out how you do that and how you do that in community with the people that need to be most supported. Rae Woods: And you don't need to be a pregnant person or know a pregnant person specifically in order to have that more on the ground connection. Callie Chamberlain: Yes, that's right. Rae Woods: Well, Darby, Callie, thanks so much for coming on Radio Advisory. Darby Sullivan: Yeah. Thanks again. Callie Chamberlain: Thanks for having us. Rae Woods: It can be easy to think about maternal health and maternal mortality as purely a provider problem. But I hope you're convinced that this is absolutely not something that can be solved by any one part of the industry. We need all of you working together to solve these problems for your employees, for patient outcomes, and ultimately for the communities that you serve. That's the way that we are going to make progress on maternal health and on health equity more broadly. But remember as always, we're here to help.