Beyond Birth: The Social Needs of New Mothers With Ascension

00:00:00:22 - 00:00:38:05
Tom Haederle
American health care has come a long way over the years and has much to be proud of today. But there is at least one glaring exception, and many people are surprised to learn what it is. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle, with AHA Communications. There are many medical complications that can accompany pregnancy and giving birth.

00:00:38:07 - 00:01:00:16
Tom Haederle
Most developed nations have achieved great progress in the mission of keeping new moms and their babies alive and well. The U.S.? not so much. In fact, we are losing ground. Why this is happening and what can be done about it are key questions in this new special podcast series from Advancing Health.

00:01:05:01 - 00:01:32:28
Julia Resnick
The United States has the highest maternal mortality rate of any developed country in the world. While most of the world has seen a steady decline in maternal mortality rates over the past 30 years, the United States has seen a steady increase. And just between 2020 and 2021, maternal mortality rates increased by 40%. Adding to that, black women are 3 to 4 times more likely than white women to suffer a pregnancy related death.

00:01:33:00 - 00:01:59:08
Julia Resnick
A college educated black mother has a 65% greater chance of a maternal death than a white woman with less than a high school education. There are myriad clinical and societal reasons for these disparities in outcomes. Across the country, hospitals and health care systems are launching initiatives to address some of the root causes for these outcomes. I'm Julia Resnick, director of Strategic Initiatives at the American Hospital Association.

00:01:59:11 - 00:02:29:02
Julia Resnick
This is Beyond Birth, a podcast series on how health care organizations can support the social and emotional needs of pregnant people and new parents. Today, we're going to talk about how societal factors influence pregnancy outcomes and hear what health care organizations can do to address the nonmedical factors that impact the health of their pregnant patients. I spoke with Dr. Stacy Garrett-Ray, senior vice president and chief community impact officer at Ascension about their Maternal Health Social Systems initiative.

00:02:29:04 - 00:02:47:15
Julia Resnick
I also spoke with a participant in the program, a mom of two X’Laodai Mack, We'll start with Dr. Garrett-Ray. So, Dr. Garrett Ray, thank you so much for being with us today. I'd love to start with some background about you and your health care system. So can you tell me about Ascension, your role there, and the communities that you serve?

00:02:47:18 - 00:03:17:15
Stacy Garrett-Ray
Sure. So for Ascension, we are a Catholic health ministry that focuses on how can we enhance the health in communities and individuals in which we serve and beyond. We tell people that really we started this ministry and it's rooted in over 2000 years. When you think about the work that we do, it started really understanding the needs of the community and building accordingly to address.

00:03:17:18 - 00:03:56:15
Stacy Garrett-Ray
So that's a little bit about Ascension. We're located mostly in the Midwest as well as in the South. So over 13 states and the District of Columbia at this point and and provide a magnitude of health care based on just the continuum of care. And so for me, I am actually from Baltimore, born and raised. I'm a family doc by trade who has always had a passion for being able to create change, not only at the individual level, but listening to the needs for those that are some of our most vulnerable populations and then creating initiatives to address.

00:03:56:18 - 00:04:14:09
Julia Resnick
Love that. And before we dive into the Maternal Health Social Systems Initiative, I just want to spend some time talking about the impact of social needs on pregnant people, particularly in the communities that you serve. So how can having social needs impact on this pregnancy or postpartum health care outcomes?

00:04:14:12 - 00:04:43:02
Stacy Garrett-Ray
So when you think about just postpartum in general, women's pregnancies or any pregnancy and overall, you have to understand that only 20% is impacted by access to care. And when you're at the door of either health care system, etc.. But that 80% that we're talking about, a lot of that stems from where we live, it has to deal with the community in which we live, our environment, our socio economic status.

00:04:43:05 - 00:05:06:11
Stacy Garrett-Ray
So when you don't really put all of those pieces into consideration that we all you're seeing a small portion of the individual not understanding the whole person. So when you're thinking about maternal health, you're caring for the mom or the, you know, the person who's pregnant as well as potential children that they're carrying. Right. It could be one.

00:05:06:11 - 00:05:24:19
Stacy Garrett-Ray
It could be multiple. And so you're really impacting so many lives through either food, nutrition, providing appropriate resources available, access to care and healthy birth weight. So it is critical that we address all of those social needs. But you got to ask the question.

00:05:24:21 - 00:05:31:17
Julia Resnick
So talk about those questions. How can clinicians be talking to their patients, to community members about what their needs are?

00:05:31:19 - 00:06:01:20
Stacy Garrett-Ray
Well, it's one having comfort and understanding that that's an important part. So it doesn't matter how great of a plan that you have as as a doc or as a health care provider, if you don't understand the full challenges that may come into place to address those needs. So it's asking the questions first. It's asking about food, access to care, transportation, housing, employment, having access to medications.

00:06:01:20 - 00:06:25:16
Stacy Garrett-Ray
It may seem very simple about prenatal vitamins, but that's not simple for everyone. It could be the choice between that and having a meal. So asking what is it that we want in terms of the goal and then backing in to understand and creating a space that people feel safe asking. I think one of the other things is that don't take a no show

00:06:25:21 - 00:06:55:10
Stacy Garrett-Ray
for a patient now coming in as being okay. We have to ask ourselves why is it that Ms.  Smith did not have transportation that day? Is it that Ms.  Smith is afraid of even having to pay for a co-pay because she can't afford it? And so that's what I think is going to be critical for providers for us to to understand that that is just as important and it's another vital sign.

00:06:55:13 - 00:07:22:27
Julia Resnick
Absolutely. You're speaking my language. I feel like we always have that that graphic about the social determinants of health are 80%, clinical care is twenty. But I don't see that applied to pregnancy as often. So I think it's really important to bring that framing back from just general health care to pregnancy. In a similar vein, you know who's at risk and are there any populations that are at a higher risk that providers should be particularly aware of?

00:07:22:29 - 00:07:53:12
Stacy Garrett-Ray
Yes. So we see significant disparity in terms of maternal health morbidity with black African-American communities. And the data has shown it doesn't matter what your socioeconomic status is, but we are seeing that is a significant challenge within the community. And I tell people that, you know, no one's asking you about your degree. No one's asking about those things.

00:07:53:12 - 00:08:29:25
Stacy Garrett-Ray
But when you're walking into a room, we do know that there is a lot of unconscious bias that is impacting for many communities. We also are seeing that seen in some of our Hispanic Latino communities as well. At the same challenges that are occurring. And it's unfortunate and I've lived through it myself too, that you know, that there are different things that people think when you're coming in a room as opposed to asking questions about pain or some of the challenges that you may be having.

00:08:29:28 - 00:08:49:09
Stacy Garrett-Ray
So for people to have the awareness, hopefully will bring in that, "Okay. Let me ask myself, am I really providing the care regardless of who comes in at the same level?" And if we can't and we're seeing differences in that, then we have to address that and ask ourselves why.

00:08:49:11 - 00:08:57:28
Julia Resnick
Absolutely. So how did maternal health equity become a priority for Ascension and specifically the Southeast Wisconsin Saint Joseph community?

00:08:58:00 - 00:09:25:01
Stacy Garrett-Ray
Sure. So there's a lot of work that has been done in this area, but it really stemmed from listening to the needs of the community and also looking at data and the disparities that were in front. And so specifically in Wisconsin, that team took opportunity to have focus groups come into place and have the voice of the community say, what is it that we are missing to meet the need?

00:09:25:04 - 00:09:53:06
Stacy Garrett-Ray
And so in Wisconsin, that's when they started the Maternal Health Social Initiative. This is work that is done, really boots on the ground. And when I was mentioning about no shows being an important signal, it's almost like another vital sign. You have to take it as that. And so that is really the key indicator for when a mother does not come in for an appointment.

00:09:53:09 - 00:10:15:09
Stacy Garrett-Ray
Guess what? You're receiving a phone call, and that phone call has really identified many challenges that we have seen based on those social needs. So, again, a lot of times we may not ask that. It may not be the way it's brought up at the first visit, or you got to think life changes for each of us every day.

00:10:15:15 - 00:10:38:09
Stacy Garrett-Ray
So you may have lost a job. You may need assistance with transportation. You may have some challenges with food or child care. And so that social initiative was put into place to ensure that we can get individuals to their door into the door, but also address the challenges that they may be having at home to ensure that mother and baby have best outcomes.

00:10:38:12 - 00:10:45:15
Julia Resnick
So can you walk me through the social system initiative? At what point in pregnancy did they start working with people and what happens?

00:10:45:18 - 00:11:12:29
Stacy Garrett-Ray
So they are able to start first visit with the mother. And what they do is for the first part of it is listening component. And so what is it pertaining to the social response? And it starts with social that we have to address in order to ensure that we can address the clinical needs. The other piece is that they're going to identify whether or not there are other conditions that we need to take into consideration.

00:11:13:00 - 00:11:48:18
Stacy Garrett-Ray
We know that anemia impacts outcomes as well. So we have found that this has really helped with identifying challenges and issues, transportation to assist with enhancing our I.V. iron infusion treatment that are essential for anemia. And so we have seen a significant increase. So moms were coming in 30 things started about 38%. And now we're seeing in some of the other locations where we have maternal health social initiative, 60 to 80% increase in coming in for the visits and improving those outcomes.

00:11:48:24 - 00:11:54:15
Stacy Garrett-Ray
And it all started by understanding what was holding you back from being able to come in.

00:11:54:18 - 00:12:15:12
Julia Resnick
Absolutely. So building that trust and that relationship is so important, and I know it can be uncomfortable for both the patient and the provider to screen for social needs and have those delicate conversations because of the stigma around having them. So how do you build that trust that patients feel open and comfortable sharing their challenges?

00:12:15:14 - 00:12:42:05
Stacy Garrett-Ray
So you know, I hate to use this term because I think there's a gym that uses this like no judgment zone, but it's like no judgment zone. And that's the beauty. I think, of our team members that come in. Our team members, of course, are also trained. I mean, we go through formation experiences, we go through training to ensure that we are able to come fully and accept and build that open environment.

00:12:42:05 - 00:13:05:29
Stacy Garrett-Ray
So team members are from the community, right? And I think that really helps as well. You see somebody who looks like you, is speaking your language. They know where you're from. There's that sense of familiarity that is there and comfort, but also knowing that that person, their sole job is to help you become your best.

00:13:06:01 - 00:13:25:26
Stacy Garrett-Ray
So they are truly angels. I have to say, all of our maternal health navigators, because they do this with their heart each and every day, knowing that they've got to create that space to ensure that moms feel like they want to come in. You know, it's it's like you got that. You got a trainer in the gym. They're going to say, come on, you got to do it.

00:13:25:26 - 00:13:42:02
Stacy Garrett-Ray
You got to do it. But you arrived, or have you arrived? It's it's that same type of concept and environment that's created. And that means a lot. Right. How many of us don't want to be just that next person on a visit? But they understand the whole being?

00:13:42:04 - 00:13:46:24
Julia Resnick
Absolutely. And no one wants to be medicalized, especially during pregnancy.

00:13:46:26 - 00:13:48:01
Stacy Garrett-Ray
Right.

00:13:48:03 - 00:13:53:25
Julia Resnick
So what kind of support can pregnant people and their families get from the program?

00:13:53:28 - 00:14:19:28
Stacy Garrett-Ray
Pertaining to navigation, we have assistance with transportation, finding out what are some of the needs there, food initiatives that we have in place. And those are condition specific as well. Some of the programs, so dealing with anemia, so iron, rich food, hypertension, diabetes and so there's the education, but also the assistance with support with food in that area.

00:14:20:01 - 00:14:46:04
Stacy Garrett-Ray
Housing is something that we also have been able to assist with, with some of our patients that are experiencing homelessness as well. Another key area is that not everyone is coming in and is their first pregnancy. They may have other obligations at home with other children, care giver, etc. So they also support with what are the resources available for child care as well.

00:14:46:06 - 00:14:57:26
Julia Resnick
Really that whole person care perspective. So when you're thinking about following up and closing the loop, how do you do that? How do you make sure that people are connecting with the resources that you're referring them to?

00:14:57:28 - 00:15:24:19
Stacy Garrett-Ray
So the maternal health navigators...they are making phone calls. They're the ones ensuring. And so it is it is important that they're making contacts. Our our our patients have that phone numbers of a lot of their community health workers. Some of our community health workers, they're even going to the home to to check out as well where they have their check-ins to ensure

00:15:24:26 - 00:15:47:18
Stacy Garrett-Ray
How are you doing, Ms.  Smith? Were you able to get the food bag that we that we provided to you? How did that work out? Or transportation as well? But they're also tracking and monitoring. Did Ms.  Smith come in that day? Right. And if Ms.  Smith didn't come in okay, and we've got to figure out what are some of the other challenges.

00:15:47:21 - 00:16:07:18
Julia Resnick
I spoke with a participant in the program, X’Laodai Mack. She's the proud mother of two boys, a ten year old and a three month old. When she got pregnant with her youngest, actually, X’Laodai knew getting to her appointments would be a problem. So when she learned that transportation assistance was available from the Maternal Health Social Systems Initiative, she took that opportunity.

00:16:07:21 - 00:16:20:21
X’Laodai Mack
That was one of the first problems I had very early on because my mode was transportation in electric bicycle. So as soon as I found out I was pregnant, I was like, Oh, I'm definitely going to need transportation.

00:16:20:23 - 00:16:29:04
Julia Resnick
It can be hard for people to ask for help. So when I asked her about what it took to accept help, she knew what was best for her baby and her family.

00:16:29:06 - 00:16:55:01
X’Laodai Mack
So when I did my check-in at the women's clinic, that's when I met Ms.. Peabody and I learned about all their programs for social help in for transportation. Also, if you need anything that you can't find. And that was one of the first things I was like, is transportation. I need that. They offered like if I needed any clothing or just even to talk to someone.

00:16:55:04 - 00:17:12:21
X’Laodai Mack
I felt good because it relieves a lot of stress from me because it's actually very stressful trying to find a job to get to appointments on time. It wasn't about me. It was about what my child that I was pregnant with needed. And I needed to hit that doctor's appointment to make sure that he was going okay

00:17:12:21 - 00:17:21:05
X’Laodai Mack
so I had to put anything to the side. I'll probably go to the side when it's about someone.

00:17:21:08 - 00:17:28:26
Julia Resnick
As health care providers consider how to engage with pregnant women about their social needs, X’Laodai shared some wisdom we can all live by.

00:17:28:28 - 00:17:53:19
X’Laodai Mack
Just have a smile. Ask him how their day is going because anything like that can just boost someone else's day and make it better. Just don't be afraid to self help when offered or be afraid to ask for help because you never know where you're going to need it. And even after my pregnancy, I'm still receiving help to get to my doctor's appointments as well as his doctor's appointments.

00:17:53:21 - 00:18:10:19
Julia Resnick
Back in my conversation with Dr. Garrett-Ray, I circled back to her earlier comment about how women of color are particularly at risk. So how is this program implementing a health equity lens and how does that connect with the broader Community Impact Team's work.

00:18:10:22 - 00:18:34:27
Stacy Garrett-Ray
In terms of having a broader health equity lens, I think that there are are really some critical components in this that have helped it to be a success. And that we have seen improvements in outcomes in morbidity and mortality and looking even at postpartum visit and prenatal visit completion rates. And it's because of a few things I would say.

00:18:34:27 - 00:19:01:27
Stacy Garrett-Ray
One, culture. Creating a culture where equity is at the forefront and that understanding the whole person in front of you is the only way that we are going to be successful. So that starts there. Being the structure is the other component, and that is of having a structure that requires that we look at equity and it's and it's data driven, right?

00:19:01:27 - 00:19:25:06
Stacy Garrett-Ray
I mean, we're able to look at data, but we also, like I said, view that no show as another vital sign. You have to look at that as another sign to let us know whether or not someone is in need of help. Right. If my systolic blood pressure were super high, guess what? It's going to raise a red flag.

00:19:25:08 - 00:19:52:27
Stacy Garrett-Ray
No show rate does with this. And so building that structure, the ability to be able to report and utilize the data. The other piece is that it's that they are ingrained and integrated into the team. So this is not something that is separate. But our maternal health navigators are part of the team. They are thought of just like everyone else that's 

00:19:52:28 - 00:20:20:00
Stacy Garrett-Ray
within women's health. And that's something that is important. I think some of the other things that we've put into place is that the tracking and utilization is key, but also listening to the voice of the mothers that we that we work with so that we understand what's working well, what's not and how do we improve? Otherwise, then it's an initiative that we've created, but it doesn't make the greatest impact

00:20:20:03 - 00:20:31:20
Stacy Garrett-Ray
if we'd all created to help those that we serve. So that's how I think that that's been helpful for us to be able to address it, move forward with health equity in this area.

00:20:31:23 - 00:20:39:04
Julia Resnick
So I want to pick up on that thread. What has the impact of the program been and how do you know you're making a difference and what has been working well?

00:20:39:07 - 00:21:08:19
Stacy Garrett-Ray
Yeah. Yeah. So a few things. So I will tell you some of the statistics that we have for our Wisconsin program that have been excellent. I've been really proud of that team. So when we looked at last year, just in July 2022, postpartum visit completion rates. At that point it was little lower, right? I mean, we had in some some of the groups, it was down as low as 22%.

00:21:08:25 - 00:21:40:12
Stacy Garrett-Ray
Right. By November with getting individual and ladies involved and our in our navigators, it went to 72.7%. That's a huge increase. Prenatal visit completion increased by 10% in just a few months. And looking at our healthy mom referrals, we just had just tens of these coming in over and over again because people were saying, okay, I'm hearing from my patients that 

00:21:40:12 - 00:22:05:24
Stacy Garrett-Ray
they really appreciate this. I'm seeing Ms.  Smith is coming in. So we've seen more and more referrals coming from providers over time as well. So those are some of the process metrics. But we have also seen a decrease in our missed appointments, increase in our infants born in full birth or full term as well as healthy birth weight and as well as the reduction in our neonatal ICU stays, too.

00:22:05:27 - 00:22:12:14
Stacy Garrett-Ray
So there is data to show that this improves and it's all about looking at that whole person.

00:22:12:17 - 00:22:22:10
Julia Resnick
That's amazing and really exciting early outcomes. What keeps your team motivated to keep doing this work? Other than that, they you're seeing these outcomes and you know what's working.

00:22:22:13 - 00:22:47:05
Stacy Garrett-Ray
The motivation comes from the passion to help others. I say this and I know it may sound really cliche, but it's the truth. I mean, they care. They care about making sure that people are living their best life and that they have that they and and their next generation have that opportunity to have the healthiest life available or possible.

00:22:47:05 - 00:23:17:21
Stacy Garrett-Ray
And so you cannot...when you have that type of passion and that joy in the team is very clear. Like if you don't have that passion or joy, maybe this isn't for you. Trust me. The love that is given from our team members, even in very challenging times. This is hard work. This is challenging work. But each day they celebrate those moments where they're creating improvement for Ms. Smith.

00:23:17:27 - 00:23:33:09
Stacy Garrett-Ray
And then when you see Ms. Smith coming in with her baby or she's saying, thank you so much, because the fact that you were able to to make sure I got here today, that right there is is priceless.

00:23:33:11 - 00:23:46:09
Julia Resnick
And I think for all of us in health care, that's such a beautiful thing to just remind us why we do what we do every day, because it's helping people. So what's next? Are there plans to grow this program? What's your vision for the future?

00:23:46:11 - 00:24:11:21
Stacy Garrett-Ray
Yeah, so so we have actually expanded the program already. So it's in Pensacola, Florida. We mentioned already about Milwaukee, Wisconsin, and as well as it's in southeast Michigan. So our our goal, of course, is to expand it even further. And we know that is something that is positive and can create change within the communities and within the lives of many.

00:24:11:21 - 00:24:14:15
Stacy Garrett-Ray
So our plan is to scale.

00:24:14:18 - 00:24:36:24
Julia Resnick
That's very exciting. And please keep us posted as you continue to do that, because we'd love to see how this program continues to grow and to support women across the country. Our country has a long road ahead to improve pregnancy outcomes. While we certainly need to focus on ensuring that all pregnant people can access high quality, equitable perinatal care

00:24:36:27 - 00:25:06:27
Julia Resnick
we can't lose sight of how social and emotional needs impact maternal health. As health care organizations work to make progress on maternal health equity, they'll need strategies that simultaneously address medical care alongside social and emotional support for pregnant people. For our listeners, you can access more tools for improving maternal health outcomes from our growing library of resources at www.aha.org/betterhealthformothersand babies.