Second Opinion with Joan Lunden

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> Racial disparities in maternal health is a complex and very real issue.

Women are dying every day, and we all need to start talking about this issue so we can find solutions.

Joining us today on "Second Opinion," primary-care physician from the University of Rochester Medical Center, Dr. Lou Papa.

>> But still, there was a difference in the care that was provided, based entirely just on the race of the individual.

>> Expert in racial and ethnic disparities in obstetric and gynecological outcomes, Dr. Teju Adegoke from Boston Medical Center.

>> But we really also have to think about the direct effect of racism in healthcare and in the way we provide care based on skin color that is contributing to this issue, as well.

>> Professor of Emergency Medicine from the University of Illinois, Chicago, College of Medicine, Dr. Heather Prendergast.

>> The numbers are not being deceptive.

The health disparities are getting worse.

Women of color are dying.

>> And Wade Norwood, the C.E.O.

of Common Ground Health, an organization that brings together leaders to collaborate on strategies for improving health.

>> Dr. King was right -- racial inequity, of all the forms of inequity, when it comes to health, it's the most inhumane.

>> And I'm Joan Lunden, and it's all coming up, here on "Second Opinion."

Thank you all for being here today.

Wade, I want to start with you.

And welcome back to "Second Opinion."

>> Thank you.

>> I mean, you and your organization, you're always looking at population health and populations at risk.

So how do you define racial disparities?

>> We look to see, "Where are there differences in health outcomes, differences in access, or differences in population health status that are clearly associated with race and ethnicity?"

and then we carry that data into community conversation to try and make sure that we're elevating those inequities in health that are really salient and really pressing for members of our local community.

>> Dr. Prendergast, what are -- talk to us about some of the underlying causes of seeing racial disparities in health?

>> Yeah, so I'm gonna frame my conversation or answer through what I see in the emergency department.

And so, you know, we know that the emergency department, by default, has become the safety net of the healthcare system.

Right?

So, we take care -- Our doors are open for those who are under-insured, uninsured, have access to care.

And so, a lot of the social determinants of health, as a result of the inequities that we see around that, we see a lot of these patients in the emergency department.

And so it spans the entire gamut, but I'm particularly excited that we're focusing on maternal health, because that is one where we've seen significant widening of the disparities over time.

And as, you know, the pandemic and a lot of these other conditions have gone on over the last year, we see that the inequities are just getting larger.

And the lack of attention to addressing these social determinants of health are really manifesting, and we're seeing a widening of the gap, in terms of health outcomes around, particularly, minority women.

>> Well, Wade, we've talked about this before.

I mean, you can kind of go down that list.

I mean, access to good food sources.

I mean, a lot of times, it's just the zip code.

What are some of the real underlying -- >> Financial instability, educational opportunity, access to safe and affordable food, access to housing.

And, sadly, all of these social and economic factors are heavily influenced by structural and institutional racism that only exacerbates those differences and makes this such a very pressing conversation for us to be having.

>> Dr. Adegoke, you know, it's hard, because you look at these -- you know, these causes, which you can point to and put them in your research.

Biologically, of course, everyone's the same, so it begs that kind of question of, "What's missing?"

>> I am so happy that you said that, Ms. Lunden, that biologically, we are all the same.

The data really does not support anything intrinsic to black or brown bodies that makes them higher-risk for adverse outcomes during pregnancy and after pregnancy.

It's really what we're doing to black and brown bodies inside and outside of the healthcare system.

As Mr. Norwood and Dr. Prendergast said, social determinants of health tell us part of the story.

Access to adequate housing, food, transportation, being able to access medical care, all of these things influence birth outcomes and pregnancy outcomes, but the data over the last few years also really shows us that they do not adequately tell the story.

So, we know that black women are three to four times more likely to die during and around pregnancy compared to white women.

For Indigenous or Native American women, that number is two to three times the increased risk.

But even when you control for things like income, housing, education, we see that those disparities still exist.

Among college-educated women, black women are actually five times more likely to have poor outcomes during and after their pregnancy compared to white women.

So the social determinants tell us part of the story, but we really also have to think about the direct effect of racism in healthcare and in the way we provide care based on skin color that is contributing to this issue, as well.

>> So, when we're talking, Lou, you've talked about the "burden of illness"... >> Right.

>> ...you know, in people of color.

What are you t-- Like, what different kinds of illnesses would we say that it would affect?

>> Well, unfortunately -- and this kind of gets to Dr. Adegoke's point -- it's pretty much across the board, which would be really unusual for biology to affect almost every disease state.

So, almost every disease state for people of color, they have worse outcomes or they don't get the standard of care compared to people who are not of color.

And part of the problem with that, with even the big players, like diabetes and cancer and heart disease, is they get them younger, as well, and that impacts your maternal health.

So it becomes -- This structural description is really important because it's all built in.

It's not like you can just change a single thing and that's gonna fix it.

>> So, certainly, what we're hearing is, it's not about race, it's about racism, because it's about how doctors and healthcare system treat people of color and give different treatment because of that.

>> And as we've talked about before, it's difference that cuts across socioeconomic status.

So the point that Dr. Adegoke was making, I think, is an important point, that even college-educated, professional women of color, particularly black women, wind up experiencing far worse birth outcomes.

And this is a very personal subject for me, because our second pregnancy resulted in the stillbirth of one of our twin daughters.

The surviving twin was born with cerebral palsy and died at a very young, tender age of 8.

This is people's lives.

And these poor outcomes impact family systems and communities in a way that we must really recognize Dr. King was right -- racial inequity, of all the forms of inequity, when it comes to health, it's the most inhumane.

>> And Americans always want to think of the United States as, like, the best -- the best of anywhere in the world, the most technologically advanced and the wealthiest country, but it's almost embarrassing when you look at these statistics.

>> Morally reprehensible.

>> Like, we should really be ashamed.

I want to talk Dr. Adegoke about -- specifically about how big a problem racial disparity is in maternal health.

>> So, as we have seen in multiple publications over the past few years, three to four times the increased risk of death for black women compared to white women during and after pregnancy, two times to three times increased risk for women who are Indigenous or Native American.

Women who are Hispanic or Latinx also experience worse outcomes during their pregnancies compared to white women.

And these gaps have existed for as long as we have been measuring birth outcomes.

Over time, despite advancements in science and technology, despite the development of perinatal quality improvement collaboratives, those gaps actually are getting wider and not more narrow.

And as we said earlier today, the COVID-19 pandemic has just exacerbated these inequities.

>> Dr. Prendergast, I just want to know what it's like.

You're in the E.R., working kind of on the front lines and trying to lessen this disparity.

>> It's -- It's definitely challenging.

But one thing I can say is that, you know, I tend to look at things as, you know, where is the opportunity?

And so we know that there isn't as much opportunity because we know that there are gaps in this.

We know that housing instability for a pregnant woman increases their risk two to three times of having a complication.

We know that tradeoffs are being made when it comes to the social determinants of health, and as a result, we're seeing negative health outcomes.

And so what we need to do in the emergency department is not understand that there has to be a proper linkage.

We know that, yes, we're there for our community, for our patients, but we also know that there has to be linkage to primary care.

You know, individuals who rely solely on getting episodic care at the emergency department tend to have fragmentation of their care and it leads to poor outcomes.

If you look at the maternal deaths, about 2/3 of them occur in that postpartum period -- right?

-- a third in the first 30 days and then the other third over the rest of the year.

And so all of this contributes to the maternal death numbers that we're seeing.

So we have to pay just as much attention.

Our concern should not end as soon as the mother has the baby.

And so there are a number of things that we can do on not only a policy level, but structural level, institutional level, community level.

There's a whole -- you know, a multifaceted approach that needs to happen.

And I think that having conversations such as this sets the stage for us to do that.

>> Absolutely.

It's like we see so often today, somebody doesn't really use the medical profession until it's an emergency, and then they go to the hospital.

And, unfortunately, when you're looking at the statistics of people of color, that's how pregnancy is treated.

>> Exactly.

And most of the diseases, unfortunately, are treated, as well.

You know, diabetes is diagnosed later.

That impacts pregnancy.

Hypertension is diagnosed later.

That impacts their pregnancy.

>> Dr. Adegoke, what should the experience of perinatal care ideally look like in order to try to get fewer and fewer disparities?

>> I think we've touched on some of those things in our conversation so far.

You know, ideally, everyone is able to access good prenatal care.

We know that access just on its own is not enough.

Even people who have done all the right things and attended all their prenatal care visits, when you are a person of color, you still have higher risk for adverse outcomes.

I think about what I would want if I were pregnant, if I were having a baby.

Ideally, I would see the same provider throughout my pregnancy, somebody who knows my history and doesn't just know my medical history but also knows my personal history, someone who knows me well, somebody who's working from the assumption that I am a person trying to make the best decisions for me and for my family.

"Best" may look very different for me than it does for the provider.

The calculus of what I use to decide what's best for me may be very different than what they would be deciding based on our relative positions in society.

But, you know, having that baseline respect sets us up to be able to have open conversations about what the medical recommendations are at every point, what the options are, and then, how each of those options works best with or does not quite work with my goals so that we are always having shared decision-making, open conversations around care.

When I talk to my patients, you know, that they are afraid to go into a hospital to give birth.

They're worried that hospitals are not safe places for them and for their babies.

They're worried that healthcare providers and healthcare systems do not have their best interests at heart, and that is just a conversation that no one should have to have in 2021.

It's absolutely unacceptable.

>> And, of course, far too many women in disadvantaged areas go back to work within 10 days after having a baby.

And all of the numbers show us that this is not good for mother or for child, but they go back to work because they need the income.

>> Right.

Those are some of the other things, talking about what we can do at the policy level.

You know, if you don't have -- if you're not lucky enough to have good health insurance through your employer and you are on Medicaid, that coverage cuts out six weeks after pregnancy, even though, as we've discussed this morning, 50% of maternal mortality happens after the birth within either six weeks to a year, 20% happens after the six week period.

So not having access to coverage from six weeks is not helpful.

In addition to that, for people who are not able to access care routinely, sometimes that pregnancy is the only time that they're able to access medical care.

If they're diagnosed with diabetes or diagnosed with high blood pressure that, as Dr. Papa pointed out, has sort of gone uncovered prior to their pregnancy, and we take coverage away after six weeks, there's no opportunity for them to continue working on that medical problem, trying to get to a point where they're in a more healthy place, either before the next pregnancy or if they don't plan to get pregnant again for the rest of their lifetime.

So we're really missing an opportunity there to be able to give people access to care.

We need better legislation to support moms, not just to have time away from work right after they've given birth, but also to be able to breastfeed when they go back to work, if that's their choice.

We need better legislation that allows for investments in access to these social determinants of health that allows for things that data shows improve birth outcomes -- access to doula support and birth support, access to, again, primary care after that pregnancy is over, and access -- or, sort of setting up our quality measures so that we are -- our payment incentives so that we're not just looking at what care we provide, but how equitable is that care?

It's one thing to have good outcomes for some portion of your population, but if another portion of the population you serve is suffering at that same institution, that should also be considered unacceptable, and healthcare systems should be held accountable for that.

>> When I hear her say all this, Wade, I think we need that Family and Medical Paid Leave Act to be passed, which of course, is still hung up in Congress, which, you know, unlike what passed in '61, which just said you won't lose your job... >> Right.

>> ...now -- Like, we're one of the only countries in the world that doesn't give paid leave when you have to leave to have a baby or to take care of a loved one who's sick.

>> Joan, I had the same response listening to the doctor, and I could have listened to her go on for another half-hour, thinking of pregnant women who have to worry about eviction, who have to worry about their utilities being shut off.

And what we need to do is start investing in the protective factors before young women become of childbearing age, before women are pregnant, and through the perinatal experience because it is wrapping community, it is wrapping compassion, it's wrapping support around women as they bear life.

That gives us the best outcomes for the next generation of life.

It's really going to take our leveraging and rethinking the connection between the clinical, the community, the intervention, and the preventive care so that it really is person-centered, and provided at the place where the patient finds care is the most supportive, natural, and authentic.

>> But that place is where the doctors and the nurses are.

So that leads me to say, like, where do you start this process to change it?

Is it partly in medical schools?

Part of it is policy and government legislation, but is part of it also in medical schools?

>> It is a structural issue.

There was a study done where it looked at medical students and physicians and gave them a scenario of different patients.

And the only difference between the patients, the singular difference was the color of their skin.

And these were, what they consider themselves, aware, right?

That they thought that they were aware with their bias... >> And not biased.

>> ...and they would give the best care.

But still, there was a difference in the care that was provided based entirely just on the race of the individual.

If the individual was described as an African-American, they were assumed to be not compliant.

They were assumed to be resistant to a test.

They were assumed not to have follow-up.

There was a number of assumptions that were made that they weren't even aware of.

>> But as Dr. Adegoke said, this has been going on for decades.

This isn't anything that -- And it's been known for decades.

And yet I'm so struck by this report, the Health of America Report, that says -- you think things would be getting better -- since 2018, the rates of the morbidity, maternal morbidity, the rates are on the rise overall and that pregnant women in the United States are more than twice as likely to die from complications related to pregnancy or childbirth than those in most other high-income countries in the world.

I mean, it's almost hard to believe those statistics.

>> Right.

And part of it is, is that, you know, in our healthcare system, if you have money, you'll get really good care.

If you're white and you have money, you get really, really good care.

And a lot of it is, there's a lot of stuff that has to happen beforehand -- before you deliver that child, and that's not happening.

And there's not structure in place to support those individuals financially to get them the appropriate prenatal care that they need.

You know, we were talking about how if you don't have paid family leave, that affects the whole family.

I've had patients of mine where the mom has to go right back to work, so grandma, the mother of the patient, has to watch the kids, so she can't come in to see me.

And the children can't get in to see the pediatrician 'cause there's no one that can drive them there.

So it's this cascading effect.

>> Absolutely.

Dr. Adegoke, I mean, you're an OB-GYN.

Is part of this problem not only that we need to change the way we teach in medical school, but we need more doctors who are of color so that they have a better sense and certainly less bias, don't you think?

>> Absolutely, absolutely.

This is something that starts even before medical school.

I was listening to Dr. Papa talk about this study, where they had different providers look at clinical scenarios and the care they gave was different based on the color of their skin.

There's another similar study done recently where they asked young medical providers -- they were medical students, residents, fellows, you know about certain beliefs that they might have about people based on the color of their skin.

And the results are shocking.

There are people out there, early in their careers practicing medicine, who believe, for example, that black people have thicker skin, that they don't feel pain in the same way.

And so when you think -- when you realize that people have those beliefs, it makes it very clear why someone would present in labor and have their pain ignored by their healthcare team, because the team doesn't actually believe that they're suffering as much as they might think if the person looked different.

What we need to do as a healthcare system is stop denying the effects of racism on the care that we provide.

The patients are onto us.

They know this is happening.

There just really isn't a point trying to pretend it doesn't happen anymore.

>> Wade, you're, like, shaking your head yes to the whole thing.

>> I would have offered a hearty amen.

[ Laughs ] And I think it is the fact that the growing, diverse voices in healthcare are being heard, received by, and being responded to by other leaders within the healthcare community.

When in doubt, consult the experts.

It's the folks in the community who are experts on their care.

And I think that the engagement of the healthcare system with the non-health system, the fact that it is now common -- it was unheard of 15 years ago -- but now healthcare is stationed in barbershops and in beauty salons, in church basements and neighborhood-block associations.

We have the ability to restore a sense of the community and healing as principal to healthcare.

And I'm really excited about the prospect of making that real for the someday grandchildren of mine who will safely arrive.

>> And Dr. Prendergast, you're out there on the front lines.

Go ahead.

>> You know, I was just going to jump in and say that, you know, I think that it's important that we look at all of this in the -- in the context of health equity, right?

And understanding that the playing field is not level and everyone -- there's going to be different amounts required to get folks up to an adequate level, and that cuts across all the interventions and approaches that we can take.

So when we're talking about education among healthcare professionals, that's, you know, starting, as you know, with our medical students, residents, fellows, understanding that people are coming in, everyone has unconscious biases.

And so we have to get to a point where we're comfortable having those conversations and understanding, again, that, you know, we're -- we're doing this in the context of health equity, right?

And so you understand it's not about giving everyone equal amounts.

We're not talking about health equality, we're talking about equity, right?

So everyone's not at the same level.

And when we use that kind of approach to kind of use it to educate and to support, you know, not only -- Because there's a role for education because this is definitely, as Dr. Adegoke mentioned, a two-way street.

Right?

So we have to be engaged with the community in finding these solutions, finding these -- And they are things that are available.

They are there.

We just have to -- You know, you can't come with an ego.

You have to humble yourself and understand that, "You know what?

The numbers are not being deceptive.

The health disparities are getting worse.

Women of color are dying."

And so that is a reality.

And so we have to look at -- you know, across the entire spectrum.

Where's our opportunity, how do we go about this, and what is the framework in which we're going to operate?

>> Yeah, the numbers are unquestionable and unconscionable.

Dr. Adegoke, I'll let you end here.

Where is the hope?

>> I think the hope is in the fact that we are having this conversation.

10 years ago, you couldn't say openly that racism was directly affecting care for people of color.

So we are at that starting point.

It's not enough, but it's a good place to start.

I think the next steps are, again, engaging with black and brown communities, really going to them, asking them what their experience has been and what they need us to do differently to provide better care.

There is legislation that hopefully will come all the way through that process and provide investments in social determinants of health, investments to increase healthcare workforce diversity, doula support.

We need access to care that doesn't happen just within health-- hospital and clinic type of systems.

We know that that is not adequate to take care of our population.

I'm very excited to see where we go if we can just pay attention to the data and pay attention to the communities that are affected going forward.

>> Well, it certainly is incumbent upon everyone to try to provide health equity.

Doctors, thank you so much.

Thank you, everyone, for being here today.

And, also, thank you to all of our medical advisers who are with us every step of the way to ensure that we bring you evidence-based, accurate medical information.

And, of course, to all of you at home, thank you for watching.

From all of us here at "Second Opinion," we encourage you to take charge of your healthcare.

I'm Joan Lunden.

Be well.

>> Find more information about this series at SecondOpinion-TV.org.

You can also follow us on Facebook and YouTube.

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> "Second Opinion," with Joan Lunden, is produced in conjunction with UR Medicine, part of the University of Rochester Medical Center, Rochester, New York.