Featured topic and speakers
With the U.S. having the highest maternal mortality and morbidity rates among developed countries, the AMA continues to sound the alarm to policymakers that a multi-faceted approach is needed, one which includes addressing the leading causes of preventable maternal deaths and investing in the physician workforce to improve access to maternity care. During Black Maternal Health Week, April 11-17, it is particularly important to raise not only awareness of this issue, as it disproportionately affects Black and Native American/Alaska Native pregnant and postpartum individuals, but also to advocate for solutions.
Watch this webinar to learn about the AMA’s newly released recommendations on maternal health and what approaches are needed.
Moderator
- Willie Underwood III, MD, MSc, MPH, chair, AMA Board of Trustees
Speakers
- Maryanne C. Bombaugh, MD, MBA, MSc, member, Council on Legislation, American Medical Association
- Michael Rakotz, MD, vice president, Health Outcomes, American Medical Association
- Jennifer Brown, JD, health equity director, Advocacy, American Medical Association
Transcript
Dr. Underwood: Hello, everyone. Thank you for joining us for our webinar this afternoon on maternal health. And I apologize because I'm having a brief problem. All right. Look, we have a wonderful, wonderful program today. And I'm glad that all of you are able to join us. So we're going to get started.
But first, I'm going to give a brief background and see where we are. As those of you who don't know me, I'm Dr. Willie Underwood, board chair of the American Medical Association and urologist from upstate New York.
And it's my pleasure to be hosting for this wonderful session and recognition and honor for Black Maternity Health Week, which began on April 11, which we're going to take an in-depth look at the maternal and mortality crisis in America. And what we can do to do something about it.
So given the remarkable advancement in science and medicine over the last 30 years, it is shocking that women in the United States are at greater risk for pregnancy related deaths today than in 1990s. And their mortality rates for Black women is in fact significantly higher.
Black women are three and four times more likely than White women to die from pregnancy-related causes. Indigenous population are two to three times as likely. At the root of these disturbing statistics are widespread disparities that exist across our health care system.
Limited access to care for historically marginalized groups, chronic disease, a lack of pre- and postnatal care, and implicit bias on the part of clinicians have all contributed to this, as well as many other factors.
In fact, our nation suffered from the highest rates of mortality than any other well-resourced country. What's most disturbing is that a significant majority of pregnancy related deaths in our country are preventable. So that's why we're here this afternoon, to raise an alarm about these concerns, concerning trends, and to talk about what potential policy solutions could and should look like.
So this afternoon, we're going to have three awesome panelists. So with us today is Maryanne Bombaugh, an OB-GYN in Coastal Massachusetts and past president of the Massachusetts Medical Society. And an invaluable member of our AMA Councils on Legislation within our House of Delegates.
Also joining us today is Dr. Michael Rakotz, the AMA vice president for health outcomes. And Jennifer Brown, an attorney who leads the AMA federal advocacy work on health equity for our Washington office. Welcome everyone. And let's get started here. And let's jump right in. Jennifer, I would like to start with you. What is the current landscape of maternal morbidity and mortality in America? And what are some of the factors driving these trends?
Brown: So thank you Dr. Underwood. You mentioned that Black women are three to four times more likely to die from pregnancy related causes than White women. And American Indian and Alaska Native women are two to three times more likely to die than White women.
We know that Medicaid covers about 43% of all births in the United States. However, almost 66% of births of Black women and 67% of births of American Indian and Alaska Native women. More than 90% of women deliver in a hospital. And about 80% of these deaths are preventable.
However, this heightened risk, specifically for Black women, spans all income and education levels and insurance types. And I just want to ground our conversation by saying that these are not just statistics. Each tragic death matters, and it matters to the spouse, the partner. It matters to their family. It matters to their extended community.
And we know that severe maternal morbidity affect approximately 50,000 to 60,000 birthing people each year and the numbers are increasing. And as some of you may know, I am so passionate about this issue because I almost died during my second pregnancy due to a uterine rupture. I was about seven hours away from bleeding to death.
So I take this issue to heart and I'm very passionate and very committed to making sure that the AMA addresses this problem. We know that birth inequities, as you mentioned, arise at the intersection of discrimination by race and gender.
For Black and Native American women, we're talking about closures of maternity units in rural areas as well and urban areas as its also major factors. In addition to discrimination and bias and OB unit closures, which you mentioned, we know that some of the most frequent underlying causes of pregnancy are related to cardiac and coronary conditions, hemorrhage, infection, sepsis. So these are kind of—I just wanted to kind of lay the foundation and lay the groundwork for what we're talking about.
Dr. Underwood: Jennifer, thank you. So Michael, as Jennifer just mentioned, cardiovascular disease related to maternal mortality. So what impact does hypertension have on birthing people's health? And what are some specific areas in which you think we can improve the care and related to hypertension that birthing people receive during and after pregnancy? And what is the AMA doing to help improve the care of patients with hypertensive disorders of pregnancy?
Dr. Rakotz: All right. Thanks Willie. Well before I answer those questions, I want to quickly define the four categories of hypertension disorders of pregnancy just so everybody understands in case we have people who may not be as familiar.
Chronic hypertension is hypertension diagnosed before or in the first 20 weeks of pregnancy. Gestational hypertension is new onset hypertension that occurs after 20 weeks gestation. Preeclampsia is hypertension that occurs after 20 weeks with protein in the urine or low platelets or other organ involvement. And this can progress to eclampsia if seizures occur.
And the fourth category is chronic hypertension with superimposed pre-eclampsia, where pre-eclampsia occurs in a patient with existing hypertension. So those are the four categories. It's important to recognize that these disorders are common. As Jennifer mentioned, they occur nearly 1 in 7 deliveries in hospitals and they're increasing.
The number of people entering pregnancy with chronic hypertension often nearly doubled between 2007 and 2018. And importantly as Jennifer also mentioned, stark racial inequities exist with Black American, Indian and Alaska Native birthing people disproportionately affected.
So what's the impact on hypertension on birthing people's health? Well, the potential consequences of hypertensive disorders of pregnancy are that they're a leading cause of death in the early postpartum period, particularly in the first six days where they're literally the second leading cause of death in days one through six.
Hypertension is the leading cause for 30-day readmissions postpartum. And people with hypertensive disorders of pregnancy have higher risk of developing chronic hypertension and cardiovascular disease long term.
The risk of developing hypertension long term is two to three times higher. The risk of developing cardiovascular disease is nearly double. And I think it's also really important to note that people who have a hypertensive disorder of pregnancy have shorter lifespans.
So all really relevant and important information. So what can we do to improve the care for birthing people with hypertensive disorders of pregnancy before, during and after pregnancy? Before pregnancy, focusing on prevention and diagnosing conditions that lead to increased risk is critical.
So things like making positive lifestyle changes to prevent hypertension, focusing on nutrition, low sodium or salt intake, being physically active and tobacco cessation including e-cigarettes all extremely important. And these are all factors that contribute to optimizing cardiovascular health.
As is diagnosing and treating existing hypertension, which we need to improve on, and diagnosing and treating other medical conditions that can lead to poor cardiovascular health like obesity, diabetes and high cholesterol. So that's before pregnancy.
Release the Pressure
Release the Pressure (RTP) brings together a national coalition of likeminded health care organizations with a shared mission to reduce the incidence of heart disease in Black communities.
During pregnancy, focusing on monitoring, diagnosing and treating these conditions. So monitoring blood pressure throughout pregnancy, both in office and remotely, and using patient safety bundles of best practices like the AIM bundles which Jennifer is going to go into more detail are imperative for effective management with more equitable outcomes.
And using aspirin after 12 weeks gestation for those at high risk for preeclampsia to reduce preterm birth. That's during pregnancy. After pregnancy, continuing to monitor people closely and intervening quickly when indicated. This includes blood pressure monitoring starting immediately after discharge. Initiating and titrating medications when indicated. And importantly, transitioning to a primary care physician for follow-up and long-term monitoring.
And throughout all these phases—before, during and after pregnancy, education and support for both clinical teams and patients is essential. We need to provide education to physicians and clinical teams on the most current evidence and guidance, including all specialists involved in the care of these patients.
And increasing access to telehealth services is extremely important. And for patients, campaigns like the Release the Pressure campaign aimed at improving heart health for Black women, education on home blood pressure monitoring or self-measured blood pressure monitoring and how to perform it, and awareness of the risks of hypertensive disorders of pregnancy, symptoms and when to seek care.
And Willie, for the third question, what is the AMA doing to help improve care for patients with hypertensive disorders of pregnancy? In the AMA's Improving Health Outcomes Group where I work, we're working in two key areas—clinical quality improvement and multidisciplinary collaborations.
For clinical quality improvement, we're focusing primarily on postpartum because two-thirds of the mortality in patients with hypertensive disorders of pregnancy occur in the 12 months after delivery. All health care professionals, as I already mentioned, working with patients during that time need to be familiar with the ongoing risks and treatment recommendations.
And this provides us with an opportunity to impact both short and long term health. And as for multidisciplinary collaborations, and this includes with clinicians, health care organization leaders, advocacy and community-based organizations, we're convening experts to identify practical and effective clinical interventions to improve care for patients with hypertensive disorders of pregnancy postpartum.
We're learning from health care organizations who are already developing and implementing their own interventions. And we're collaborating with these health care organizations, researchers and experts from organizations like the CDC, ACC, the American College of Cardiology and ACOG to better understand opportunities and elevate existing resources. And the intent of all of these efforts really is to identify what works, and then focus on helping to scale those effective interventions.
Dr. Underwood: Wow. So we know that when we look at the total health of the human being, there is a financial or economic perspective to it. There is a physical overall health chronic disease aspect to it. So we've somewhat touched those.
So now Maryanne, please include what is the role of the mental health in pregnancy and postpartum period? And how does mental health contribute to maternal, morbidity and mortality? Please—come on, I can't get the words out today. Please tell us what the AMA is doing to support the mental health needs of pregnancy of pregnant and postpartum women, as well as—or pregnant individuals, as well as physicians caring for these patients?
Dr. Bombaugh: Those are such important questions, Willie. And as Jennifer mentioned in her review of the current state, we know that mental health conditions account for over 75% of pregnancy related deaths, deaths that are predominantly due to suicide or substance overdose or mental health conditions such as substance use disorder.
And from a morbidity standpoint, perinatal mental health disorders are also common. And they're a significant complication of pregnancy in the postpartum period. Up to 20% of women in the United States experience perinatal depression or anxiety.
And in community health centers funded by HRSA, such as the community health center in which I work, over 40% of our female patients of reproductive age report depression. But despite this knowledge, data shows that pregnant and postpartum individuals who have behavioral health conditions are less likely to receive sufficient behavioral health care compared to those who aren't pregnant.
See, you also asked really what's being done to improve the mental health care for patients in postpartum individuals? Well, it's now recognized that holistically integrating behavioral health into, excuse me, OB-GYN care practices and settings can improve and provide a true patient-centered experience of care.
This integration of physical and behavioral health breaks down the traditional care silos, and helps both pregnant and postpartum individuals receive treatment earlier when they need it and hopefully at the right level of care.
So knowing this information and recognizing the potential impact of an integrated care model, I'd like to mention two of the advocacy actions that the AMA is taking to help make it happen. First, the AMA has partnered with several members of the Federation of Medicine, including the American College of Obstetricians and Gynecologists, ACOG, to establish the Behavioral Health Integration Collaborative.
The mission of this collaborative is to equip physicians and their practices with the knowledge and support, to give integrated care to patients. To accomplish this mission, the Behavioral Health Integration Collaborative has called on payers and policy makers to join forces with OB-GYNS and other physician specialties to ensure that they have the necessary support to provide that integrated, equitable and whole person care for patients and families.
And the second advocacy action, the AMA Behavioral Health Integration Collaborative has accomplished is it's developed and is offering a free webinar series titled Behavioral Health Integration, which is a webinar series that specifically focuses on integrating mental health care into OB practices. Thanks.
Dr. Underwood: Thank you. So I'd like to shift the discussion to the social determinants of health. Now we know, again, that the social determinants of health impact every aspect of what we were just discussing. The physical, including the financial, including the mental health, the spiritual health, the emotional health of the individual.
So when we think about social determinants of health, which is the important part of the discussion. The social determinants of health are the conditions in which people are born, grow, work, live and age. And the wider set of forces and systems shaping the conditions of their daily lives.
These forces and systems include economic policies systems, development and agendas, social norms, social policies and political systems. As a result, determinants of health are often impacted by large and powerful systems that leads to discrimination, exploitation, and marginalization and exclusion and isolation.
So Jennifer, what is the AMA doing to impact how pregnant individuals from historically monitorized communities and rural communities and economic marginalized communities receive the support they need to have healthy pregnancies?
Brown: Thank you for that question. It's such an important one. We know that in this country, these historic and systemic realities are baked into structures, policies, practices and produce, exacerbate and perpetuate, quite frankly, inequities among the social determinants of health, and therefore affect health itself.
The question then is, once a physician identifies that a patient has a need, which could be a social determinant of health need, care coordination or even just help navigating the health care system, then what? So we want to help patients both navigate the health care system and address social determinants of health by enhancing medical legal partnerships.
Perinatal medical legal partnerships, MLPs, share responsibility across a diverse team, integrate legal care as needed, and leverage law and policies to help manage vulnerabilities that are exacerbated by an advancing pregnancy.
Encouraging the use of medical legal partnerships in more perinatal settings is warranted as obstetric visits often offer ideal time to discuss and intervene. Moreover, some very successful MLPs have been established across the country. We have one nearby our office, the Georgetown University Health Justice Alliance Perinatal Legal Assistance and Well-Being Law project, one of the first MLPs to focus specifically on perinatal needs.
These MLPs show a reproducible pathway to helping patients navigate the health care system and address social determinants of health. So as part of the AMA's outreach and advocacy, we are strongly encouraging both the administration and Congress to work together to provide funding, increased funding to expand MLPs across the U.S. so that every birthing person can have access to the benefits they are entitled to, to ensure a healthy pregnancy.
Dr. Underwood: Awesome. Maryanne, the ongoing overdose epidemic impacts all patient populations, including pregnant and postpartum patients. So what are specific considerations for pregnant and postpartum patients with substance use disorders? And what policy changes are needed to help support this patient population?
Dr. Bombaugh: Thanks Willie. Such a very important question. Certainly as a CDC data now shows, drug overdose deaths increased in the United States last year reaching a record of over 111,000 lives lost. And synthetic opioids accounting for over 70% of those drug overdose deaths.
Among pregnant and postpartum persons, drug overdose mortality increased approximately 81% from 2017 to 2020. And NIH data shows that the largest increase was observed in pregnant and postpartum persons between the ages of 35 and 44 whose overdose mortality ratios tripled from 2018 to 2021.
And mortality from substance use has increased for individuals who are pregnant or postpartum across almost all age, racial, ethnic, educational and marital status groups. And there is accumulating evidence that certain social determinants of health that were mentioned by Jennifer earlier, specifically poverty and lack of adequate health care, are also associated with substance use mortality.
But stigmatizing or penalizing pregnant and postpartum individuals with substance use disorder creates barriers to care. Barriers that are so significant that individuals don't seek treatment for their drug use and they don't receive prenatal care because of fear for themselves and for their families.
Data shows that pregnant individuals with substance use disorder are less likely to receive an appointment to an addiction treatment center, have difficulty finding child care to get there. And in many states, face punitive policies for their substance use, including fines, loss of custody of their children, involuntary commitment and even incarceration.
But there is advocacy work going on to try to make some positive changes. There are many evidence-based programs and efforts underway in states right now to extend Medicaid and the Children's Health Insurance Program, or CHIP, to extend coverage to pregnant individuals with substance use disorders.
The AMA has urged the administration to highlight those state expansion efforts and encourage states to continue to build on evidence-based practices to improve care and reduce inequities. And this includes support for removing harmful policies that stigmatize and punish pregnant and postpartum individuals who receive medications for opioid use disorders.
The AMA recently released an important document titled, Improving Access to Care for Pregnant and Postpartum People with an Opioid Use Disorder—Recommendations for Policymakers. And in this document, there's a comprehensive set of recommendations that can be used for advocacy.
And these recommendations are designed to enhance care for individuals with opioid use disorder who are pregnant or postpartum. And lastly, the AMA strongly, as we know, opposes criminalizing pregnant individuals who have substance use disorders. And sometimes our advocacy has had to go to court.
And on the judicial front, the AMA has signed on to an amicus brief in the state of Ohio versus Tara Hollingshead in last year, which concerned a pregnant person who was sentenced to a lengthy prison term for using illicit drugs during the third trimester of her pregnancy.
And the AMA joined with Ohio and other national organizations to file an amicus brief that urged the court to overturn the verdict that would have sent this woman to prison for 8 to 12 years. Unfortunately in May of last year, the court vacated that conviction. And the AMA will continue to be very active in this advocacy space on substance use going forward. Thank you.
Dr. Underwood: And I'm going to tell you, so far, I've heard some very alarming statistics. And I've also heard some very awesome solutions. And I look forward to working with you to move these things forward Michael, Jennifer, Maryanne and the rest of our AMA family.
Now having said that, let's bring this home to what's extremely important and significant here, because this we can fix. And this is what we're trying to solve as we think about it. So according to the CDC, 80% of maternal deaths in the United States are preventable. I'll repeat that again. 80% of maternal deaths in the United States are preventable. So Jennifer, what changes are needed to prevent these deaths? And what role should and what are the AMA planning?
Brown: Thank you so much Dr. Underwood for asking that question, because of the fact that 80% of these deaths are preventable, we're trying to focus on what can be scaled up nationally, and what can be implemented nationally to impact pregnant individuals across the United States, whether they're in urban hospitals or rural hospitals. And I say hospitals because we know that 99% of these births are in a hospital setting.
One of the things that the AMA has been really focused on is elevating these core AIM bundles. And these are the Alliance for Innovation on Maternal Health called AIM patient safety bundles. And we're encouraged, strongly encouraged that they're included in the White House blueprint that the administration has released.
However, it is important for states and the federal government to recognize that the biggest barrier to implementing these core AIM bundles is a lack of resources. And that additional funding beyond what has already been invested by the administration and Congress is desperately needed to adequately implement the AIM bundles, especially in smaller institutions and institutions that do not have vast resources.
The core AIM patient safety bundles that physician-led teams can implement to address the most common causes of maternal mortality are supported by specific quality metrics and measures through the AIM data center. And are the core building blocks of the AIM program's efforts to address the leading known causes of preventable, severe maternal morbidity and mortality in the United States.
Because 90% of these births, whether paid for by Medicaid or private insurance, occur in a hospital setting, the AMA believes it is uniquely positioned to kind of support all physicians, including non-OB physicians delivering babies in rural and historically marginalized communities to address these complex health issues.
And we know that by working with the administration and Congress to increase funding, we can elevate this and expand this, scale this up nationally, especially for as I said in rural communities. These are really pivotal in the work that we're doing.
And just to put a finer point on this, we're talking about obstetric hemorrhage. We're talking about severe hypertension and pregnancy. We're talking about cardiac conditions in obstetric care. We're talking about perinatal mental health conditions, postpartum discharge transition, and sepsis and care for people with SUD.
So those, as I mentioned at the beginning, are some of the leading causes of deaths. And those are also piggyback on and focus on the AIM bundles as well. So we want to do both. We want to focus on both. And these core AIM bundles really elevate that work if hospitals have the resources and the infrastructure to be able to implement those and the funding.
Dr. Underwood: So Michael, so what are some policy changes that could help support improving the care of patients with hypertensive disorders of pregnancy?
Dr. Rakotz: Well, we need regulatory and institutional policies that remove barriers. The ones we hear most often are coverage, reimbursement and a lack of system level support. So from talking with clinical and research experts and practicing physicians, we've identified a few barriers where policy change could help quickly.
And I'll just give you a few examples where we've seen some success and traction. So coverage for clinically validated or clinically accurate blood pressure measurement devices—home blood pressure monitors with no co-pay.
So we've had some success here with commercial payers and Medicaid. We're working on reducing barriers that limit access to these devices. For example, the process that patients have to go through to obtain the device even when there's coverage sometimes is not clear, sometimes is cumbersome.
So, for example, if there's a designated DME supplier or a designated retailer or the device is supposed to be prescribed and then mailed to somebody, these processes sometimes they work, sometimes they don't work well. But I think more importantly, often there's a gap in the understanding of physicians and clinical teams and patients for what those processes are even when there's coverage.
So there may be some level of coverage, but it just doesn't work. So we have to find a way to make sure that, that information is always understood by patients and physicians. But having said that, again we have seen success in creating the coverage. We just need to continue to work to make the quality of that coverage better.
And we also want to make sure it includes things like while it's great to have a validated blood pressure measurement device for remote monitoring during and after pregnancy, that device has to come with a cuff that fits the person that's using it. And often the devices come with a standardized cuff that doesn't fit large and extra large arms, which are increasing in frequency in the United States.
So we've got to also make sure that when there's coverage, that things like extra cuffs are available with those devices so that they can be used accurately because without them, none of it will matter because the cuffs won't be accurate and reliable for diagnosing and treating these conditions.
Another component here is coverage for clinical support services, which is really important as well to make sure that these get used. And we need clinical support services so that physicians and health care teams can better manage care for these patients.
The other area that we've seen traction is systemic level support policies. So we have been promoting a procurement policy for clinically validated BP measurement devices that health systems can adopt and have adopted to ensure that when they procure these home blood pressure monitors, these self-measured blood pressure monitoring devices.
For whenever blood pressure is measured within the organization or even at home from patients where they're providing devices, that it's measured with a device that is validated for clinical accuracy. So in other words, they adopt a procurement policy that says they will only purchase devices that have been validated for clinical accuracy.
Dr. Underwood: Thank you. I got to tell you. The work that the AMA is doing in our D.C. office regarding policy, working with the White House, working with regulatory agencies to address these issues, the work that we're doing in Chicago, what Mike is doing around the hypertensive disorders and trying to move this forward, the things that Maryanne has talked about. The mental health and moving forward.
But to do this, we have to have a physician workforce that has the resources and the tools that it needs to be able to implement this great policy and put these great programs together. And that Jennifer's hardwork in D.C. and other folks in D.C, that we're able to reach the goal of eliminating those 80% unnecessary, preventable maternal deaths.
So Maryanne, what is the current landscape of maternal health physician workforce? What policy changes do you think need to be implemented to support the maternal health physician workforce and ensure that patients everywhere have access to high quality obstetric care?
Dr. Bombaugh: Yeah. So what does a maternal health physician workforce landscape look like? I'll share it's concerning. And I'd like to share some data, but then also some solutions that are going forward to address it.
So in 2023, the number of medical student residency applications dropped in the relevant specialties that would deliver babies. We saw a 3% drop in family medicine residency applications, a 5% drop in OB-GYN applications and a 21% drop in emergency medical applications. And to add to this, the burnout rate among physicians in these specialties hovers around 60%. Furthermore, ACOG projects that there will be a shortage of up to 22,000 OB-GYNs by 2050.
These statistics are not sustainable if we are to improve maternal care and health outcomes in our country. So to answer your question, Willie, on what specific advocacy policy changes are needed to avert this impending maternal workforce crisis, I'd say we need a greater focus. A focus on increasing and retaining the number of physicians and maternal care to decrease maternal care deserts and improve health outcomes.
There are a number of innovative ways to start positive changes for the future and help improve the training and retention of physicians who provide maternal care. There are five maternal, or I should say, workforce advocacy items that we at the AMA are urging the administration to action to improve access for maternal care right now.
The first advocacy action is to expand maternal care education and training, especially for those physicians that are likely to give care to pregnant or postpartum individuals, but are not OB-GYNS or maternal fetal medicine specialists.
The second advocacy action is to increase funding for Teaching Health Center Graduate Medical Education or the THCGME programs. These programs are important, and they support the training of resident physicians and community-based ambulatory care centers.
And the programs prepare physicians to provide high quality care, and serve diverse populations in our rural and underserved communities. Since 2010, this program has helped 21 OB-GYNs complete their residency, and then enter the workforce to serve.
Though this is an excellent start, an additional funding is needed. And support for this program is needed, in particular for OB-GYN training. The third advocacy action is to increase funding for the national health service corps, and ensure that a higher percentage of physicians are accepted to the national health service corps loan repayment programs and scholarship programs.
Personally as someone who participated in a similar program, the Health Professions Scholarship Program or HPSP through the Department of Defense, I can't begin to tell you how essential that support was, that program was to enable me to attend medical school and then serve my country.
The fourth is to increase compensation for Indian Health Service physicians to a level that's competitive and equitable with other federal agencies. And additional funding should be provided to the IHS loan repayment program to increase the number of physicians that can be supported to serve these marginalized patient populations, especially in the maternal care space.
And the final action is to allocate additional funding for the Indian Health Service's Maternal Health Program. And this program should then ensure that the funds it receives are used to increase access to OB-GYNs and maternal fetal medicine specialists for American Indian and Alaska Native pregnant individuals. Many solutions there really.
Dr. Underwood: Yes. And we have to move them all forward. So now we're going to open this up to those who have put questions in the chat. But we also have some questions from our guests as well. So let's move forward with those. I think we have enough time.
Now here's a question that I often receive. And I'm going to answer it. Often receive the question—Willie, with all the stuff that physicians have to worry about, why are we talking about things like this? Why are we talking about substance use disorders in pregnancy, hypertension in pregnancy, social determinants of health, discrimination, inequities in health care and all these other things? Why should we focus on that?
Why? Because these are things that impact the very people who we set out to serve. But not only that, they cost our nation huge financial costs. But not only that, the cost of loved ones, because we're all—as me as who I am, I'm a son, I am a brother, I am a cousin, I am an uncle, I am all these other things as well as a physician. And I see the impact that this has on the families and on my personal family as well.
So this is why the AMA is in this space so that we can improve the health and the health care of the nation. And this is a major problem. It behooves us. They look at us if we have 80% preventable deaths. And then we don't stand up and saw that, someone else will and most likely will not be in our best benefit. That's why we need all of us, all physicians on deck, all medical organizations on deck. And this is a priority for us, as well as many other priorities.
So having said that, Maryanne, what are some ways we can advocate for maternal health at the state and local level? Also what are your thoughts on the Biden administration's effort to extend Medicaid coverage during the postpartum period?
Dr. Bombaugh: So these are two very big questions. And I'll try to answer them separately because they are so important. So you mentioned advocacy and how important it is to medical care. And I completely agree with everything that you have said.
Health care advocacy is very powerful. It uses data and recognizes the connection between patients and community health. And the social determinants of health and the structural systems that influence health. And it's really another indirect way perhaps in which we care for patients.
It can be done individually, as occurs often in our own practices. An example comes to my mind recently when I was working to obtain a prior oath for an MRI for a patient. And I spent almost 30 minutes on the phone trying to inform and persuade a benefits manager to change a policy so that my patient could obtain the study. So we do this individually.
But on a broader scale, advocacy can be even stronger when it's done strategically and has the support of organizations or groups that can help influence change improvements and assist especially with lobbying.
When advocating specifically for maternal health, as we're talking about at the state or locally, I would recommend that advocates get involved, and network and collaborate with state medical societies, specialty groups, get involved with state and local organizations that are focused on maternal health, such as the PNQINs, the perinatal/neonatal quality improvement networks in the state and local departments of public health.
And with state and quality and safety organizations. And in my state, for example, we have the Betsy Lehman Center, the Mass Consortium Coalition, rather, for the prevention of medical errors. MassHealth Quality Partners and others. Many of these organizations, you can work with them and collaborate with them to effect change.
Because maternal advocacy, it really needs to crosswalk with collaborators whenever possible to achieve the best outcomes. And supporting advocacy is so important to improve health and health care in maternal health. And I strongly believe it is so vital that advocacy education and involvement should even be part of medical training and included in considerations for academic promotions going forward.
Then you asked me also about my thoughts on the federal government's efforts to extend Medicaid coverage during the postpartum period. And before starting, I think it's important to know that right now, there are many different definitions for the postpartum period as there are for maternal mortality.
And this creates confusion and can create inequities as policies are applied. And at some point, we need to reach alignment on these definitions so that accurate data can inform health care and policy decisions on both postpartum care and maternal care for the future.
And that said, most individuals with pregnancy related Medicaid coverage typically lose their benefits 60 days after the end of pregnancy. The American Rescue Plan Act that was signed into law back in March of 2021 makes available an additional pathway that allows states to extend Medicaid pregnancy coverage from 60 days to a year postpartum called the state plan amendment.
And these efforts in the law extending Medicaid coverage to one year postpartum is critically important because over 50% of pregnancy related deaths occur between seven days and one year postpartum.
And additionally, many patients with hypertensive disorders of pregnancy that we've talked about or who have pregnancy related behavioral health issues or substance use disorder are likely to need treatment and care beyond the traditional 60 days of Medicaid coverage. So this expansion of Medicaid coverage through one year postpartum will very likely benefit the ongoing health of pregnant patients.
Dr. Underwood: Thank you. Jennifer, AMA supports Senate Bill 712, the Connect M-O-M, MOM Act. Can you explain what this bill would do and why the AMA believes it's important?
Brown: Yes. The Connected MOM Act, the AMA is a vocal supporter of the Connected MOM Act. The bill has bipartisan support, which is oftentimes rare in the current political climate. And if enacted, it would allow for the identification of both limitations and barriers to coverage of remote physiologic devices under state Medicaid programs.
And so you're saying, well, why is this important? Well, if you think about the statistics that I provided earlier, we know that about 43% of all births in the U.S. are covered under Medicaid. We know that for Black women, about 66%. For American Indian and Alaska Native women, about 67%. So this will be key in improving health outcomes for these populations.
And so identifying the limitations and barriers to coverage of remote physiologic devices under state Medicaid programs to improve maternal health outcomes. So not everyone understands what physiologic devices are.
We're talking about blood pressure cuffs. As we mentioned earlier, we're talking about weight scales. We're talking about blood glucose monitors and the like. So it's really important bipartisan legislation that we have been strongly supporting, both at our National Advocacy Conference, as well as the conference the medical students have. So we've been really active in this space and going on the hill and urging Congress to pass this important legislation.
Dr. Underwood: So to add to that. So what are some ways that medical students can make an impact with this issue?
Brown: So that's a great question. I talked briefly about the medical legal partnerships at the law schools and the medical schools. But I also want to talk about—and this is a very elementary kind of concept. But it's critical. And that is taking time to stay in the moment with the patient in front of you and listening.
The CDC has a national campaign called the Hear Her Campaign. The focus is to ensure that birthing people and their families know what warning signs to look for, and to be able to communicate that with their physicians and their health care providers.
But it also involves active listening on the provider side. And Maryanne talked about the burnout rate for physicians and certain specialty society—specialties, I'm sorry, specialties. And so we're talking about ER physicians. We're talking about family physicians. We're talking about OB-GYNs.
And so they have the highest burnout rates. And so it's really important when you're exhausted and you're burnt out, and you're dealing with other things that are going on in the hospital setting to be able to just take a moment and stay in the moment. So I would encourage the medical students to do that as well and focus on that. That's kind of a skill, an active listening skill.
But also staying connected with your state and federal public officials. Maryanne talked about it briefly. But as you all know, we work collaboratively in advocacy. I work with my colleagues, who are attorneys in the Advocacy Resource Center to navigate these spaces at the state level and with the state medical societies.
We also work here in the D.C. office with our federal affairs, lobbyists and our congressional lobbyists. So getting involved at the state and federal levels, knowing your members of Congress, knowing who represents your district, and being able to serve as a resource is key to moving this work forward.
The other thing that I wanted to add briefly because I know we're short on time winding down. But I wanted to note that we are producing, we have produced a larger document because I can see some of the questions coming through, it's about 30 pages that really details this work that we've been doing. And details—does a deep dive into our recommendations that we've produced and sent forth on policy recommendations at the state and federal level.
It also we're creating developed an appendix document. And this appendix document outlines cross business units across the AMA. So we've worked with a variety from the Center for Health Equity, Advocacy and IHO.
We've worked with PS2. We're really trying to make sure that we elevate all the great work that is being done across the AMA, across business units. And that will also help medical students and others to kind of understand where we are and what they can do and what legislation, what amicus briefs, what's going on. And we'll continue to update that and to keep them apprised of the path forward. And that will be on our maternal health website.
Dr. Underwood: Michael, so what are some solutions to AMA improving health outcomes you have to develop to help physicians and care teams improve blood pressure control? And also add this to it, what are some key pieces of education to share with patients diagnosed with hypertension in pregnancy, hypertension disorder of pregnancy?
Dr. Rakotz: Well, our team—the Improving Health Outcomes team is really focused on hypertension throughout all phases for adults in the United States. We have a portfolio of solutions that focus on helping improve the quality of care provided to patients with hypertension and to improve blood pressure control across all of these phases.
I'll mention three briefly here. Our AMA MAP Hypertension Program is a data-driven quality improvement program that focuses on the accurate measurement of blood pressure, timely and effective treatment, supporting patients to self-manage their hypertension. And all of this is done with a team-based approach across multiple disciplines.
We've got the AMA MAP SMBP, which is a practical seven-step approach for using home blood pressure monitoring to effectively lower blood pressure and improve blood pressure control, because that doesn't happen if you just hand out blood pressure monitors that really needs to be done in a specific way to really see the improvement that we want to see.
And finally, just the third one is the U.S. Blood Pressure Validated Device List, a website validatebp.org that lists devices that meet rigorous criteria for being validated for clinical use, including a subset of those devices that are validated for use in pregnancy.
The second part of that question, some key pieces of education to share with patients diagnosed with hypertensive disorders of pregnancy, know your blood pressure. Know your blood pressure numbers. And know what your treatment plan is. That includes both antihypertensive medications and aspirin if they're being used, or implementing the positive lifestyle changes that I reviewed earlier.
Knowing the warning signs and symptoms and what to do if you experience them, understand that your risk continues postpartum, and understand that your future risk of hypertension and cardiovascular disease is higher. And the absolute critical importance of following up with a primary care physician and any other health care professionals who help manage postpartum health long-term.
Dr. Underwood: Thank you. This is a question. I'm going to read it from the chat. So as noted, effective treatment and prevention of consequences of depression through an antepartum and postpartum depends on access to immediate treatment.
Most areas have long waiting period, especially those in economically and geographically disadvantaged areas, I think, can nationally-based telehealth access overcomes these obstacles? So I'm going to open this up to the group. I'm going to start with Jennifer, Michael, Maryanne. There's only if you can contribute, do you think you can contribute?
Brown: I'll let Maryanne and—I'll let the Maryanne and Mike.
Dr. Bombaugh: Sure. I can start. I think telehealth is incredibly important in providing any kind of mental health, behavioral health care for patients in pregnancy and not during pregnancy. I know in, for example, I'm in Massachusetts.
In Massachusetts, we have programs for where primary OB practices or others can—who have a patient with symptoms of postpartum depression can call into MACPAC for Mom's number and get help immediately to be able to treat that person while in the office or closely after the time that they're seen in the office.
So I think telehealth has tremendous, we need it. We need it because there is such a lack of services for behavioral and mental health care and substance use. So it's very—it is critical to have that available. It's wonderful to integrate behavioral health into practices.
But where that can't occur or cannot optimally occur for the patients being—populations being served, then telehealth serves an incredibly important function to be able to have access to that care, especially as we have maternal care deserts actually increasing in our country at this time.
Dr. Underwood: Yeah. And I want to add to that and just say regarding the maternal health deserts, I know you touched on it, and the impending worsening crisis in what's happening with OB-GYNs and access to care.
But currently, right now where telehealth could absolutely make a difference, 36% of counties in the United States do not have a practicing OB-GYN, do not have a hospital to deliver babies, and do not have birthing centers that do that.
So while telehealth won't solve all of those issues, that's a huge percentage of the United States that could benefit from telehealth to improve the quality of care where there isn't care. In addition—so in addition to the factors like transportation and for people who have basically access issues, for people that could tremendously benefit from having more ubiquitous telehealth available.
Brown: One of the things, if I could just chime in briefly, that we're doing at the federal level is that we are really pushing for reliable broadband connections at both the site of the physician and the patient to ensure that there's consistent, reliable maternal care that can be provided as well. And so I just wanted to elevate that work that we're doing, both on the telehealth front, but particularly talking about broadband connections.
Dr. Underwood: You just added at a point. And I think we have time to discuss it. But I guess there were 610 medical students who applied to OB-GYN programs this year that did not match. And I know the AMA is working diligently to increase residency spots with CMS and other programs, not just for OB-GYN, but across the board.
But by increasing those programs, we can hopefully impact the problem that Michael just laid out with all these areas of the country not having access to proper to care in this area. Now having said that, we're going to try to wrap this up quickly, like we're going to go with again Jennifer, Michael, Maryanne, give some closing remarks and take home statements that we want our audience to remember.
Brown: I think the one thing that I would want people to remember from this is that this is our—this is a major first step for the AMA to continue to move this work and work collaboratively across the business units on this work, to elevate it at the state and federal levels.
But this is our first step forward in this space. And we will continue this work, continue meeting with the administration, continue our work lobbying on the Hill, continue meeting with state officials. We have interviewed both state surgeon generals, perinatal quality collaborative folks, folks from hospital systems in urban areas that have high Medicaid populations.
And so we will continue to do this work. Continue to find recommendations. Continue to elevate those with our federal government and state government officials. And we just want to focus people back on our maternal health website that we will be posting with the recording of the webinar so that people have resources on our work as we continue this important and critical work and a path forward.
Dr. Underwood: Michael.
Dr. Rakotz: Most maternal deaths are preventable. We can do better by supporting physicians to optimize patients cardiovascular health in all phases of life, including pregnancy and postpartum. And for hypertensive disorders of pregnancy, specifically implementing best practices for treatment of people with these disorders, including AIM patient safety bundles.
Emphasize and improve continuity of care in the postpartum period. Ensure long-term medical care for patients with these disorders, including continued screening for cardiovascular disease and its risk factors. And supporting patients by making telehealth and remote physiologic monitoring available.
Improving coverage and access to clinically validated BP devices and cuffs to support home blood pressure monitoring. Increasing patient awareness about the risks and need for continued follow-up for medical care after pregnancy. Making sure people know how to optimize their cardiovascular health before, during and after pregnancy. And promoting programs like the Release the Pressure program to partner with Black women to support their heart health.
Dr. Underwood: Maryanne, you got the last few seconds.
Dr. Bombaugh: Thank you. So I would just say please stay active. Please stay involved. Please keep advocating for all of the issues that you've heard about today. They're all so important. We can do this. We can decrease maternal mortality in this country. We can solve these problems.
There have been absolutely excellent action items discussed today. And I'm sure there are many more that have to be discussed and can be thought of by all of you going forward. But it is really, really important that we do this, that we recognize this issue, and that we take interest and action to change it because it can happen. So thank you, Willie.
Dr. Underwood: All right. I think I'm going to get cut off. But thank you for being engaged today. Please join us in future AMA Advocacy Insights webinars, where we take you inside the most important policy issues affecting physicians and patients in our health care system.
Until then, God bless. And thank you very much for joining us. Please join us in our efforts. Please support the AMA. Please listen to these webinars and use this information and let's fix this problem because we can, we will and we must. Thank you. God bless.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
