Initiatives to Reduce Maternal Mortality: Part 2


Experts expand on racial and social factors influencing maternal mortality.

Roxie Cannon Wells, MD: I’d like to share a personal example of such an experience. My daughter was born when I was in medical school. I was 29 years old when she was born. My mother was actually a midwife. And she was a midwife before there was actually a midwifery program. So the family doctor in the rural community taught her how to deliver babies, and she delivered babies for a lot of African American women. We’re talking about the South in the late 60s and 70s and in rural communities. That’s my passion, rural health. But I was at a major center when I delivered my daughter, and my mom was there with me, and I was struggling during the process. My mother advocated for me, and I actually think she saved the life of my daughter because she was there advocating and saying, “Listen, I’m not medical school trained, but I’ve done this, and this isn’t normal.” Had she not been there, I wasn’t in a space where I could advocate for myself from a perspective of pain or what have you. My husband was not in a space where he could advocate for me because this wasn’t a place [where he had] experience. But had she not been there sort of in a doula capacity, I don’t know what our outcome would’ve been. And I was a medical student, a third-year medical student who had some knowledge of what was supposed to happen. So, to your point, educated women are at risk for serious outcomes during pregnancy as well.

Sharon Deans, MD, MPH, MBA: Yeah, a recent New York Times article that came out about 3 weeks ago demonstrated that black women of higher socioeconomic status are dying at higher rates than poor white women. So there’s more to it than socioeconomic status. I think the most important thing is these kinds of conversations, so at the maternal and child health table there should be all the proponents for maternal and child health. The doula should be there right from the beginning. The health department. The private practitioner. The doula. The health plan. The hospital where they deliver, and they cycle back into that once they deliver. Everybody has to be at the table. We need to sort out the dance, what happens to these members at different times, and what everyone’s role is. Because I’m an old nurse as well and then an OB-GYN [obstetrician-gynecologist], and they’re very territorial. The nurses are the first advocates for that member, and then you get somebody else that comes in and says they’re the advocate. It can be a bit of a battle. And we need to get to the table, have these conversations sorted out, and established what that dance is for the safety of our patients with improved outcomes.

Soyini Hawkins, MD, MPH, FACOG: 80% preventable deaths…

Roxie Cannon Wells, MD: May I ask a question of the 3 of you? How early is too early to start talking about reproductive care and the potential of becoming moms or what have you for little black girls?

Soyini Hawkins, MD, MPH, FACOG: I would say that the conversation starts early because little black girls have little black baby dolls. So that whole thought of “One day, I want to be a mother” is something that is imprinted in little girls’ minds extremely early. So as the conversation goes into puberty and maturity, I think it’s a necessary conversation to have as soon as there’s a question of it in their mind. Because if we don’t have the conversation, they’re going to have it at school. They’re going to have it on social media. And the influence that those other areas might have on the way that our young ladies, very impressionable young ladies, think about things like sex, intimacy, and the difference between the two, and fertility and pregnancy, that’s a fragile thing that it would be nice if someone spoke with them before they had to figure it out on their own.

Roxie Cannon Wells, MD: I think for me, though, do you think that having conversations about advocating for yourself around female health or women’s health, how early is too early for that?

Sharon Deans, MD, MPH, MBA: I can give you a personal example. I have a 14-year-old granddaughter, an 11-year-old, and 7-year-old, and there are a few more. But the other day, the 14-year-old, [and I] had a conversation about menses, and my daughter took out her phone and gave a whole anatomy lesson to the 7, 11, and 14-year-old about the menses and sanitary products, the whole 9 yards. And then they go to Dunkin’ Donuts on the way to soccer practice and one of them wants bacon, and their dad says, “No. That’s not healthy.” So it’s those kinds of things, teaching them as soon as they start asking questions, but also the supportive things; how you eat, do you exercise regularly, do you take vitamins, avoiding smoking. It just goes down the cascade. And then being in a healthy relationship. What’s not a healthy relationship, and how you avoid that or how you get out of that if you find yourself in one. I think it’s never too early, as soon as they start asking questions. To have 6 healthy kids in a family is a blessing. How do you get to that? It’s a healthy lifestyle. It’s a supportive family environment. And that can happen for everyone. It doesn’t matter how much money you make.

Roxie Cannon Wells, MD: I ask those questions because I believe that, to your point, it starts very early. And if we expect to have better outcomes when women are of childbearing age or what have you, then it starts very early talking about the very things that you talk about.

Derek van Amerongen, MD, MS: Wonderful comments and great discussion, and ultimately based on a lot of the things we’re talking about today: transparency, trust, education, support across various age groups, and recognizing the issues of racial disparities, geographic, all of the socioeconomic issues are social determinants of health. Great discussion. Thank you very much, doctors.

Soyini Hawkins, MD, MPH, FACOG: I have a question just to expand slightly because I want to answer the question, I asked Dr Wells when it comes to teaching young women how to advocate for themselves and their bodies more specifically, not just about what their bodies are doing but the advocacy piece. Where is the line in the sand of making them rigid and feeling almost like they have to go and [protect] themselves and hard and “The doctor’s not going to have my best interests at heart” from the moment they walk in the door? I feel that from some patients. They almost come in with a door and a barrier up before they’re able to open up and even answer simple questions. So, in our young women, how do we teach them how to advocate for themselves, make sure that they’re able to simply give their symptomatology when they go to the doctor, but not at the same time block the care that is being offered to them? I think there’s a fine line there. We teach our young men to not be afraid to go out into the world and do things, but at the same time be afraid. It’s a fine line there even when it comes to health care.

Sharon Deans, MD, MPH, MBA: I think meeting people where they are. I have patients when I came in, they say to my staff, “I didn’t know she was black.” And I walk in, and I say, “Oh, I understand you didn’t realize I was black. Is that going to be a problem for you?” I would meet them exactly where they are. With the young folks, I’m talking about sneakers; I’m saying, “Your sneakers match your shirt. Could you save that money to apply to take an SAT review?” You just kind of meet them where they are and talk about the things. I think that breaks down the barrier and helps them understand that you’re on their side. But, even if I look like you and I tell you, “You need surgery. You need to go see somebody else for a second opinion.” And I’ll tell you that in a heartbeat. “You go see somebody else for a second opinion. Trust and verify. And if you consult Dr Google, print it out and bring it in so I can go over it with you, make sure to tell you why it’s true and why it’s not.” I think that bedside manner is key because folks are coming from all different walks. They’ve had all different kinds of experiences. We can’t take for granted because we look like them, they’re going to trust us immediately, just like you said. I think trying to find… like we all did this morning. We all found a commonality. OB/GYN, Atlanta, North Carolina. We all found a commonality. I think that’s important when you meet people, to kind of break down some of those barriers and gain their trust. They should go in guarded, quite frankly, based on what they’re reading in the newspaper and everything.

Soyini Hawkins, MD, MPH, FACOG: They do. Yeah.

Roxie Cannon Wells, MD: I think creating safe spaces for people to ask questions. I grew up in an era where it was “You do what I say. You don’t ask questions.” I have pivoted completely from that and try to give space for young people to ask questions. Now, sometimes I have to do that, [makes flat facial expression] when the question is asked…

Soyini Hawkins, MD, MPH, FACOG: Gather yourself inside.

Roxie Cannon Wells, MD: …and then kind of figure out how I’m going to respond to it. But I think giving that safe space to ask whatever questions they need to ask: “Oh, I didn’t know you were black.” Or questions about sex or what have you. But I think once you create that safe space, and I think it goes back to, again, community. Helping parents understand. Even being part of it. We want to be parents one day, helping them understand that it’s OK for kids to ask questions and to be curious and to display curiosity for a lot of different reasons. But it creates that trust space. Again, as a parent, sometimes you’re like, at least I have been in that situation. But I think it’s creating that safe space.

Sharon Deans, MD, MPH, MBA: I think that’s a great point. Absolutely.

Derek van Amerongen, MD, MS: Thank you, doctors.

Transcript edited for clarity.

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