Share This Podcast

Maternal and child health inequities by race are a blot on our national fabric. But fixing them isn’t about one silver bullet — it’s about systems coming together to do their part. Abdul reflects on the struggle for birthing equity. He interviews Dr. Natalie Hernandez, one of the authors of the “Practical Playbook” on maternal health inequities to understand how sectors can come together to save Black moms and babies.

TRANSCRIPT

[AD BREAK] [music break]

Dr. Abdul El-Sayed, narrating: Medicare is set to cover the weight loss medication Wegovy. The Supreme Court seems skeptical of limits on the abortion pill mifepristone. A total solar eclipse will take place next Monday. Please don’t look right at the sun. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] If you’ve been a listener to this show first, thank you. But you know that addressing the fact that some people get to live long, healthy lives while others don’t is a central preoccupation here. The people on the unjust side of that divide, they tend to be poorer, more urban or rural, and disproportionately they tend to be Black. There is no statistic that better captures the inequity or the fundamental injustice of it, than the fact that Black babies are up to two times as likely to die before their first birthdays, and even more astoundingly, that Black moms are up to four times as likely to die while birthing them. And that’s not because our maternal and infant mortality outcomes are particularly good. We rank 45th in maternal mortality worldwide and a shocking 54th in infant mortality. Those numbers are brutal on their own terms. We live in a country where our most vulnerable people die at stupefying rates. And where the color of your skin can make that up to four times worse. To add insult to injury, for most of our history, the public health and medical professions sought to wipe their hands clean of any wrongdoing. Instead finding simplistic answers to explain these inequities away. If it wasn’t inherently racist, genetic, or biological explanations with no scientific basis, it was behavioral. Blaming Black folks for bad outcomes. But the real answers are neither simple nor founded in anything about the individuals who suffer premature death themselves. They’re profoundly complex and structural. The problem never was what Black folks are or do. It’s always been what society is and does to Black folks. I started my career as an epidemiologist studying maternal and child health outcomes. How societal circumstances seemingly far away from the closure of a womb could alter the chemistry inside it, radically reshaping the circumstances of the most important hand off of life. There’s a conceit in science that answers are simple, direct, and easy to identify. It’s the basis of the entire Cartesian scientific tradition, that you can isolate individual variables one by one, and identify the way each of them shapes an outcome. But the real world is a lot messier. What happens when those variables interact with each other, or when the outcome you’re studying shapes the variables you’re so assiduously trying to hold constant themselves? That complexity matters because it turns out that society’s impact on the lives of moms and babies is really, really complex, and there’s no silver bullet answer to solving it. Instead, it requires us to pay attention to all the features of our society that shape the problem. Job access, housing, stability, air quality, water access, the availability of healthy foods, and  walkable communities. The way you’re treated by society at large, the people with whom you’re most intimate, and the caregivers you’re relying on. All of these shape the circumstances of a pregnancy, and the chances that it turns deadly for a mom or a baby. And that’s the point of a recent book co-written by my guest today, Doctor Natalie Hernandez. She’s been studying the circumstances of maternal mortality her entire career. She’s the executive director of the center for Maternal Health Equity at Morehouse School of Medicine, and coauthor of The New Practical Playbook three: Working Together to Improve Maternal Health. She joined me to talk about what it says about us, that we continue to allow moms and babies to die at such high rates. And what a whole of society approach to tackling the maternal mortality crisis could look like. Here’s my conversation with Professor Natalie Hernandez. 

Dr. Abdul El-Sayed: Can you introduce yourself for the tape? 

Natalie Hernandez-Green: Hi, my name is Natalie Hernandez-Green. I am an associate professor in the Department of Obstetrics and Gynecology at Morehouse School of Medicine, and the founding and executive director of the center for Maternal Health Equity. But most importantly, one of the editors for the practical playbook three. 

Dr. Abdul El-Sayed: All right, so I want to jump right in because, you know, you focus quite a bit on maternal and child health disparities and obviously that’s your work and that’s what you wrote about in the book. But we talk a lot about this, and I don’t think folks fully appreciate just how staggering the inequities are. So can you walk us through the state of uh maternal and child health inequities by race in this country? 

Natalie Hernandez-Green: Yeah, absolutely. So as a lot of us or may or may not know, the maternal mortality rates in the United States have worsened over the past three years. Um. Every year about 1200 women die of maternal causes in the United States. But what’s stark is that there are Black women and birthing people in particular in the United States, are three times more likely to die from pregnancy related causes than their white counterpart. And this disparity widens in various cities and states. So where I’m at in Georgia, Black women are three times more likely to die from pregnancy related causes. But in a state like New Jersey, Black women are almost eight times more likely to die from pregnancy related causes than um white women. And Black women in particular have a 53% higher risk of dying in a hospital setting during childbirth. And that’s maternal deaths, something that often doesn’t get talked about more often is severe maternal morbidity. And that is when women almost nearly die from pregnancy related complications or have pregnancy related complications that then turn into serious, more serious complications later on. And the severe maternal morbidity rate has increased about 75%. And the same inequities that we see in maternal deaths are the same inequities we’re seeing for severe maternal morbidity. Um. In fact, out of the, I think, 29 indicators of severe maternal morbidity, Black women have about 25 of those. 

Dr. Abdul El-Sayed: Wow. There’s so many pieces to dig in there. But, you know, I really appreciate you reminding us that mortality is usually a tip of an iceberg. And when you’re counting mortality statistics, you’re by definition missing all the people who survived a really terrible outcome that can leave scars, both physical and psychological, for the rest of a life. And, you know, a lot of that morbidity, um just doesn’t get counted as well. I want to ask you, just dig in the numbers. Why why do you see such huge disparities in a place like Georgia versus a place like New Jersey? What tends to account for that difference? 

Natalie Hernandez-Green: Yeah, there are multiple factors that contribute to it. For instance, the reproductive health of Black women have long been compromised by interpersonal, institutional, and structural racism. In addition to contending with a lot of social and economic drivers of poor health that really undermine Black and Brown Americans as they experience a lot of discriminatory healthcare practices and abuse from slavery to the present. We know that, you know, obstetrics um, was, you know, born out of, you know, experimentation on enslaved women, um who we, a lot of us knew as Anarcha, Lucy, Betsey, and then the failing to listen to patients or providing an adequate standard of care. Um. So health care itself is a driver of the inequities that we see around death and severe complications that Black women and other women of color face and the history of racism within our health care system um has to be understood in order for us to really dismantle institutional racism in health care systems. There’s also been um, hypotheses, um including one from Arline Geronimus called weathering, which is this, you know, impact of high level chronic stress just caused by living as a Black person in a racist society, which can cause weathering of the body. And this term, weathering describes how constant stress of racism may lead to premature biological aging and poor health outcomes for Black women in particular, like disproportionately high death rates from chronic conditions such as heart disease, stroke, diabetes, and cancers. And it’s a lot of this mental anguish and stress where you’re always fighting against larger structures and systems that really have an impact on your health. And then, you know, I work in a medical school and I’m very, you know, familiar with, you know, medical curricula. You know, there’s also a lot of inherent bias in medical education. And so providers, you know, are learning about race based medicine. You know, particularly in obstetrics and gynecology, you know, one of the commonly used textbooks, you know, demonstrate a lot of that bias, by the way it demon– you know, with pictures where 75% of the pictures of women were white or, you know, 100% of them that demonstrate a normal body were of white women, but 70% of them that demonstrated Black women show them nude. And so a lot of these inherent biases, whether they’re conscious or unconscious, really contribute to a lot of the drivers of what we see around maternal health inequities. 

Dr. Abdul El-Sayed: And I want to talk about each of these specifically. But why such a difference between a place like Georgia and a place like New Jersey? Like I’d expect, actually, that Georgia would have a higher rate of, of maternal morbidity and mortality, given that it is historically the Deep South. Um. 

Natalie Hernandez-Green: Yeah. 

Dr. Abdul El-Sayed: What what kind of explains those big geographic fluctuations, if there’s anything? 

Natalie Hernandez-Green: Yeah. I don’t know the complete answer to that. I think um, first of all, you know, 56% of the Black population lives in the southeast. And we know a lot of that is due to slavery. And so I think when you have this high concentration of of a community, you don’t see as many differences. But I think with, with Georgia, it’s just we just have really poor health care so we think all populations just really suffer from a lot of these inequities. And particularly like rural white women and Black women have almost similar um, you know, rates of maternal deaths or severe maternal morbidity because, you know, policies that were passed um for Black women, you know, we don’t realize the spillover effects it has on other historically marginalized communities like rural communities. And so I think white rural women sort of balance those inequities. You know, I’m from the South Bronx. And so, you know, I know, you know, redlining and a lot of these other things that happened in the northeast or in some cities that you see where there’s this wide variation of inequities. I think it’s in– inherent because of these segregated communities and neighborhoods, the systems of care that exist in Black versus white, you know, more affluent communities. Like I said, in the South Bronx, you know, I think until I left the Bronx, I didn’t meet another white person or saw someone that didn’t look like me. Um. So I think, I think a lot of the redlining and these other policies that segregate neighborhoods in the North or in some other cities contributes to a lot of these inequities. 

Dr. Abdul El-Sayed: Hmm. You said two really important points that I think are really valuable to to double click on. One of them is that when we measure inequities, by definition, we’re measuring a fraction. There’s a numerator and denominator. You’re looking at the rate of a particular outcome in one group relative to the rate of a particular outcome in the baseline population. And one of the important points you made is that when the rate in the baseline population of that outcome is itself really high, you might not see a huge inequity, but there still might be really high morbidity among everybody. So there’s a world in which, Black maternal outcomes in New Jersey could possibly be better than they are in Georgia, even if the inequity looks smaller, because the baseline risk of the outcomes that we’re talking about in Georgia are so high, even among white folk. And that’s a really interesting point, right? Because, Georgia remains one of these states that has been extremely laggard. You know, think about Medicaid coverage and who gets access to to to quality care and and who doesn’t. And uh you compare that to a place like New Jersey where, you know, northern racism is the racism of segregation. And you see it, you know, Detroit versus everybody, as they say, or as you talked about the South Bronx, where I did a little bit of my training in med school. Uh. And you get an experience of, okay, this is just very, very different than a place three miles away. When you talk about New York, like, literally three miles away. 

Natalie Hernandez-Green: Yeah. I mean, there was um, my colleagues at Morehouse School of Medicine did a study, and they did see just within five miles between north and south Atlanta, your life expectancy is about ten years. And that’s what, five miles you know, where we’re in South Atlanta and I go to Buckhead in North Atlanta, and my life expectancy significantly um increases if I live in North Atlanta. So, yeah, I think, you know, you have really valid points in how you’re explaining that and what we see happening across. And again, a lot of these are, you know, policies that were passed and, you know, in the, in the in the past really created these systems of dysfunction within certain communities. 

Dr. Abdul El-Sayed: The other point I wanted to pull out here is, is so much of the experience of mothering, of carrying a pregnancy is circumstantial. It’s the situation in which you are having and [?] this pregnancy and I think, you know, we’re going to work down to the specific health care system, but I think there’s something about the ubiquity of structural racism that tends to get washed away in the set of causes that we talk about. So a lot of folks um focus on and rightfully so inter individual bias in the health care system, which is rightfully so, but we tend to abstract away the situation in which you’re becoming pregnant. Right. Is this a pregnancy that was uh desired? In a relationship that um is healthy and could sustain long term uh this this infant? Is it a situation where you’ve got massive stressors around the ability to afford basic uh needs of a dignified life, whether it’s housing or food, or transportation? Is it a situation in which um the ability to uh focus in and engage in this pregnancy is possible? What is the nature of who else lives in a home with you? These are all situations that tend to show up um in statistical abstractions. But we don’t often think about the dynamics at play in these scenarios. And then the implication for the health of an infant. And I want to say this, to say that any of these scenarios I talked about often get demagogued by not well-meaning actors, you know, actors who want to lay blame at the feet of individuals rather than ask questions about patterns and how those patterns develop, um to blame people for poor outcomes rather than to be asking questions of why have we built societies with such vastly different opportunity sets that lead to the kind of patterns that we see? Can you tell us a little bit about some of the dynamics that tend to play out at the structural level, before anybody ever even sees a health care provider, in terms of the circumstances in which people get pregnant, that might be shaping some of the downstream outcomes?

Natalie Hernandez-Green: Yeah, absolutely. So, you know, you mentioned even before people get to the health care system, you know, in a lot of Black and Brown communities, we never get to a health care system. Right. Because again, of where communities are situated in Georgia, about 20% of women do not have access to care and the first time they’re ever seeing a provider is, you know, when they’re pregnant, right? When they get Medicaid and they finally get access to care. But prior to that, and, you know, I mentioned weathering. You know, you have, you know, a person who’s dealing and fighting these larger structures and systems. And this leads to, you know, heart disease, you know, as a Afro-Latina woman in an academic setting, you know, every single day when I’m outside of my, you know, safety net of a historically Black medical school, I’m faced with, you know, racist ideologies. You know, people look at me and automatically have these assumptions about who I am, and then I’m put in situations that cause me to weather where I’m always feeling stressed. And that has happened since I was a little girl growing up in the South Bronx. You know, I remember walking and my game was counting crack bottles on the floor that had different color caps. You know, how many red ones can you catch? You know, our systems of education and how, you know, and particularly in the Bronx and even in some places in Atlanta and other urban and rural communities where we lack access to quality education, where we are facing food insecurity and all of these other things that contribute to where we see some of the outcomes. But um, you know, one thing that people don’t talk about is that a lot of what we call the social determinants of health are still not protective factors for Black women and other women of color. For example, Black women who are college educated fair worse than women of all other races who never finished high school. Um. You know, there’s a lot of blame. Well, you know, I know why, you know, Black women are facing these inequities, they’re obese. Well, obese women of all races still have better birth outcomes than Black women who are of normal weight. And even Black moms who initiated prenatal care in the first trimester, because we always hear, again, like you said, that individual level blame, you know, well, they didn’t initiate prenatal care early on. Even Black women who initiated prenatal care in the first trimester still have higher rates of infant mortality um than white women. And so as you mentioned, you know, there’s just these legacies of racism, of gender discrimination, of income inequities integrated into the structures of society, including the public policies that we see that continue to happen, the cultural representations that reinforce racial inequality. It all pertains to maternal health and the the drivers of what we see with inequities in the rates. 

Dr. Abdul El-Sayed: Yeah, I really appreciate you sharing a lot of those uh differences and some of your own experience, because I think um it’s illuminating for us to appreciate the fact that folks who work on this problem have spent a long time having to dispel a number of myths that are built on this idea that we have more agency in a society whose structures tend to rob those [?] that agency than we really do. And that’s the thing about it, is that we’re often asking people to make up for it. To almost be superheroes against circumstances that tend to be incredibly hard. And so, you know, to lay an analogy here, it’s one thing to walk on a, on a flat pathway. It’s another to have to climb uphill. And then when people cannot make it all the way up the hill and they slide down to the bottom, we say, well, they just didn’t try hard enough. They’re just not working hard enough. They’re just not doing all the things right, except for exactly what you shared. You talk about the birth outcomes among college educated Black women, and they tend to be worse then, uh then then high school educated women, of of of other races. And that tells you how deep and profound a lot of these forces are. Now they start to get a lot more individualized when you think about institutions. We talked about Medicaid um, in particular. But it’s not just what happens when you get to a health care setting. And as you noted, too many people, particularly Black and Brown people in our country, do not have access at all. But it’s that space at which you actually think about the use of health care, right? So I think about this often when we talk about Medicaid. Now, I’ll be clear, I think the existence of Medicaid is substantially better than the nonexistence of Medicaid. And it’s very clear when you when you dig into the statistics, like, you know, thinking about a Georgia versus a New Jersey, but the nature of Medicaid is such that you are by definition, a second class citizen. You are a second class consumer of health care, and you’re told that by the health care system every single time. And so it changes the way in which you think about whether or not this institution is there to take care of me or this is an institution I’m going to have to battle every step of the way, and who’s going to treat me or talk to me in all of the ways that society implicitly treats me and talks to me as somebody of color. Can you talk a little bit about the struggle for health care access and the ways that health care access in our country and the system that we’ve assented to, shapes people’s trust in the health care system, and how that ultimately changes the kind of care that they get or whether or not they get care at all?

Natalie Hernandez-Green: Yeah, absolutely. You know, you mentioned Medicaid, a second class citizen. And that’s we see that even with numbers. Right. And numbers don’t lie. So when you look at pregnancy related complications, in fact, you know, it’s higher among women who are in Medicaid than it is with women who have private insurance. And we’ve seen that with cancer outcomes and all other disease and disaster areas. Right. And, you know, we had done at Morehouse School of Medicine through my center, we did a story collection because we really wanted to center and amplify Black women’s voices who nearly died from pregnancy related complications. And we knew that racism would come up. But the second most common theme was that they felt that they were discriminated against because they had Medicaid, and that the quality of care that they received was subpar, and that no one cared about them. Because exactly what you said they were treated like a second class citizen instead of individual who wants to experience what should be the most amazing moment in that person’s life. And here they are, you know, waking up ten days later in a coma because they didn’t have the private insurance that many of us, and actually not many of us, that some of us, you know, are powered and privileged to have in this country. So you’re speaking my language, and, you know, I wear a shirt um and I have it now where it says, listen to to Black mothers because no one’s listening to us. You know, no one’s listening to people who they’ve always seen as second class citizens. Or for a while, you know, Black women weren’t even called women. You know, Black women had to fight really hard to be considered a human being. Um. And that’s still perpetuated in in how society sees us, the policies that are passed. You know, I think about individual level interventions and they’re great, but they’re just Band-Aids to a larger problem that we need to solve. And so in my work and what we’re trying to do with the book and and I know we’ll get to that in a minute, is, you know, we really need to think about how even those individual level things can inform policy and advocacy, um so that we can change the system so we can reimagine a health care system that cares for all and doesn’t discriminate because of how you look, the type of insurance you have, and where you live. Um. So I don’t know if that answered fully your question. 

Dr. Abdul El-Sayed: Yeah. No, I really appreciate it and I think um, I think it’s so important to reflect on the fact that the minute you start seeing yourself as literally less than another patient because that’s how you’re treated. The trust that could be there is lost, right? And you know that that is before you even start talking about inter individual bias and racism. And I think about my partner Sarah and I, we just recently had a baby. Uh. Well, not recently anymore. She just turned one, but I remember I couldn’t make the first prenatal care visit, and um, I’d really wanted to be there. Something came up, and I just wasn’t able to be there. And, you know, I think about the way that my wife was interacted with because, you know, we walked through it afterwards and she’s a physician and I’m a physician. But when they asked about, you know, the situation, you know, of this pregnancy, there wasn’t a is dad in the picture? It was tell us about dad? Right. 

Natalie Hernandez-Green: Mm hmm yeah. 

Dr. Abdul El-Sayed: And that’s because she codes as upper middle income. Right. She codes in a particular way. And my, my wife is a is a woman of color. She wears a hijab. But there were assumptions made about her circumstances that are not made about others. Another assumption, you don’t use alcohol, right? Right? Rather than saying tell us how much you drink. And these questions show up in ways right that make assumptions about people. And in so many of the conversations I’ve had with Black mothers interacting with the the system, it’s those questions that tend to further the gap, right? It’s like after you’ve fought to get yourself in the room, that doctor, that nurse, that MA, whoever it is who’s asking these questions. They’re already making assumptions about the kind of parents you are. And you even you haven’t even had your baby yet, right? 

Natalie Hernandez-Green: At all, yeah. 

Dr. Abdul El-Sayed: And so I want to I want to I want to ask you, what do people report about their experience inside the health care system? That’s like after they’ve already been, you know, for the ones who get access, what are the kinds of experiences that people report and talk about? And how does that shape the way that they engage the health care system? And then the outcomes on the on the back end. 

Natalie Hernandez-Green: Yeah. So I think, you know, like you mentioned in your personal experience, you know, these stereotypes, right? These biases that people have, particularly with um Black women, you know, of the thing of the marital status, you know, why do we even ask that question? What purpose does it serve? I think, you know, a better question would be social support. But there are all of these assumptions made about that. You know, the fact that, you know, when you’re asking, as you mentioned about substance and alcohol use, you know, there’s an assumption that Black people are more likely to use drugs or abuse alcohol, or even if it’s reported, then they’re more likely to be criminalized, rather than given treatment. Right. And so the example that people always say is this opioid epidemic, now that a particular population is more affected by it, you know, people are getting treatment centers and there’s all these policies to decriminalize it. But as soon as a Black woman reports any type of substance use or mental health disorders, her children are taken away, she’s criminalized, she’s put away. And again, that breaks down a lot of the trust that people have in a health care system. Or if you really needed help, you’re less likely to report that you need the help because you’re afraid of the circumstances or the unintended consequences that come as a result of being honest and truly trying to seek the support and the needs that you have. And so, you know, a lot of that perpetuates through a lot of the socio demographic information that we ask when we see patients or we’re working with people. Um. The fact that, you know, even with a doctor’s visit, you know, a lot of women feel like they’re not listened to or that they’re explaining symptoms and they’re dismissed. And we’ve heard this over and over and over again and seeing terrible stories where Charles Johnson talks about his wife as Cedars-Sinai and what happened there, or Wanda Irving, who lost her daughter, who has two PhDs. Two, postpartum pre-eclampsia, um and studied health inequities. That was her life’s career and still succumb to, you know, a provider who dismissed her symptoms when she knew what she was experiencing. And so that has created a lot of mistrust and distrust of our healthcare system, of the types of information that people um receive. You know, people are seeking, you know, more holistic methods of care. You know, we see, you know, this exodus of Black women who don’t want to give birth in a hospital setting and want to do it comfortably in their homes, you know, alternatives to physicians where people are now, you know, more open to midwifery models of care um and seeking, again, alternative models of care because they don’t want to be in a health care system that undervalues them um, and doesn’t see them as human, but sees them as something else, as inhumane. So I think there’s a lot of work that we need to do. I think, you know, with new policies and and people speaking up, I think there are ways of delivering care in a respectful way. And then, you know, eliminating some of that, you know, bias that people have. It’s going to take some time because we still live in a society that functions in white supremacist ways. And so that’s really hard um to get around because, again, policy makes it really difficult. [music break]

[AD BREAK] 

Dr. Abdul El-Sayed: So you’ve co-edited a book about exactly this, called A Practical Playbook. Walk us through some of the key strategies that we need to pursue to take on all of these different choke points that tend to lead uh to these awful outcomes? 

Natalie Hernandez-Green: Yeah, well this is a huge book. And so um, you know, the one thing that we like, it is first of its kind, it’s a guide for practitioners, for researchers, for community activists and advocates of maternal health that are providing practical tools. And so these are, you know, a lot of books talk more theoretically. And this book really provides, you know, as we call it, the practical ways of really dealing with this maternal health crisis. And so it provides tools. It talks about multi-sector collaboration because, as we mentioned, it’s not just about a health care system, but there’s these broader structures that play into, you know, the maternal health crisis. This is the third in the DeBeaumont’s Foundations Practical Playbook collection, which again provides clear guidance for engaging in multi sectorial partnerships and supporting public health. So what people would look forward to in this book is leveraging new ideas and resources, the opportunity to maybe replicate a best practice that they’ve read about um in one state and see how it can apply to another state or in another type of setting. Um. It includes innovative approaches to gathering using data. Because one thing that we don’t have consistently is really great data about maternal health. I mean, you know, a lot of the maternal mortality review committees um, you know, function in different ways, collect data differently, or think about deaths differently, pregnancy related versus pregnancy associated. And then it provides, you know, strategies on how to scale up things. Right? A lot of us, and we know a lot of really great community based organizations have really good resources or programs, but, you know, they need to be scaled up or we need to provide evidence for them. And so these are opportunities for people to showcase their work and hopefully get in contact with someone else to say, hey, you have a great program. I know how to evaluate it. Let’s work together. And so I think, you know, we provide a lot of promising tools and strategies to improve maternal health in unique ways that are really um a instruction manual on how to be able to do it in your own community. 

Dr. Abdul El-Sayed: Can you can you tell us about one best practice that you find particularly meaningful that, like, if you could pick this one and say, I’m going to shake my magic wand and this is going to be everywhere. Do you have one that you you would put everywhere if you could? 

Natalie Hernandez-Green: Yeah, absolutely. So I think one of the things that we’ve been thinking about and something I think that people brought up and they call it in different ways is lay, lay models. Right. Because since there’s such a mistrust and distrust of the health care system, I think figuring out ways where people who are trusted in the community, like a community health worker, a promotora, or a you know, community based perinatal patient navigator, you know, these are people who have lived experiences who can work with the community to provide the social support and meet their unmet needs, in meaningful ways, and be an advocate for, you know, people when they’re engaging in a health care system, you know, people call these doulas. Um. There are many different ways that people call this, but these are models that have existed in our communities for a really long time. And they existed because these were the only ways that we were able to get really good health care. Um. And a lot of that are principles around community organizing. But then these are also models that provide economic opportunities for lay people who have a passion to do this work. And so as we’re providing care, um and meeting unmet social support needs, we’re also creating economic opportunities and breaking cycles of poverty that have existed in our communities for a really long time. And so this is a model that I’m currently using in my own work at a safety net hospital in Atlanta, and we’re already starting to see promising outcomes, not just maternal health outcomes, but really meeting people where they’re at. And I think sometimes when people think about innovation, you know, they think about technology, they think about oh training more physicians, diversifying the physician workforce. When innovation, for me means getting people what they want in the ways that they need it, in the amounts that they need it. And I think that we were thinking so much outside of the box when we’re not meeting basic human needs of our communities now. 

Dr. Abdul El-Sayed: Yeah. And from people who want to give it. Right. This is the hard part about it is that if you were to sort of think about all of this work as trying to build a wall against maternal mortality, and you were to build it with bricks. If you just piled a bunch of bricks together with no cement between. Right, you don’t have a very good wall. And not only that, but if you sort of think about these bricks as our institutions, these institutions are not focused on our lowest income folks. And that’s a set of choices we made about the institutions we built and about how we incentivize them. When we built a health care system that was focused on making folks at the very top of those systems a lot of money. We basically said that anybody who didn’t have money to spend in the system was going to be a second class citizen. That’s in part why Medicaid has the kind of outcomes it has is because it doesn’t reimburse the same way. I mean, this is like last one in kind of, health care, right? And it requires folks who can hold what’s left of those institutions together and be folks who are focused on the well-being of the person in front of them, independent of whether or not they’re going to be able to bill some amount of money for the service rendered. And the tough part about the way we’ve incentivized this is that, you know, it’s not only that that that lower income patients and because of structural racism, predominantly, Black patients reimburse at a lower rate. We’ve also created an extremely litigious healthcare system where bad outcomes are liable to get sued. And so folks end up wanting to run away from folks that they code is liable of having bad outcomes. So it’s a downward spiral, right? You end up having this situation where the reimbursement isn’t very high and then folks code as, quote, “bad patients,” which is a terrible, awful thing to say about anybody. Uh. And then–

Natalie Hernandez-Green: Yeah. 

Dr. Abdul El-Sayed: They do everything they can to push away. So you need somebody who’s willing to, invest in these individuals. And then the last part about this is that, you know, I remember sitting in my, medical school class about embryology and then again during my ob gyn rotation and being reminded that childbirth is a is a perfectly physiological thing. It’s like not a pathological thing. It’s not a failure of the body. It’s not a disease. It’s not a bad outcome unto itself. It’s like a glorious thing that that um is the way that humans create life. And it can go terribly wrong when the proper care is not shown to folks. And we don’t build a society that is promoting, of the way we procreate, um or at least promoting of the way we procreate for its most vulnerable people. And you can imagine a world where, okay, so how do you make sure that the people who need the, the tertiary quaternary health care get it? But folks who are having a relatively normal pregnancy, that they’re getting the kind of support, service and care that keeps them from falling into a potentially pathological pregnancy. And we get the whole thing mixed up, and this idea that everybody gives birth in a hospital where people go to get sick and die. Right is–

Natalie Hernandez-Green: Exactly. 

Dr. Abdul El-Sayed: –is is is normal, is is kind of a, a really problematic breaking of, of the way the system really ought to have been built. 

Natalie Hernandez-Green: Yeah. I remember being at the Governor’s conference and having, you know, one of the panel, this was one of our Indigenous Native American sisters. And, you know, she was just in tears and was talking about exactly what you said, this birthing experience and how, you know, with hospitals, it takes away a lot of these cultural nuances and identities that we have when you give birth, you know, particularly and I think in her tribal nation, you want to hear the sound of a fire crackling, not the beeping sound of the heart monitor. You want your child to come into this world smelling the sage and these other scents, not the, you know, anti-bacterial antiseptic that people here and then you want to be in a warm, soft space. And the hospital room just feel so cold. And so it’s a complete opposite, you know, this medicalization of what a birth should be that people have been doing for, you know, since the existence of time. We’ve taken those beautiful things away from people because we’re scared of what you said, you know, the litigation and all of these other things. Yes. There are times, you know, we have been able to save people, but the fact that we’ve had perinatal outcomes for over 100 years, and they continue to get worse and we continue to try to intervene, says that we’re not doing it the right way. And that’s why I say we need to reimagine a system that respects and appreciates, you know, us, particularly as women and birthing people, that our bodies know what to do naturally. Um. And um, and then at the time where we need, you know, care because we’re high risk, then that’s when people should intervene. But it should be a wonderful experience. And I’ve been blessed to have two beautiful births. Um. Because I was knowledgeable and I knew what to look for um when, when I, when I wanted to bring my children into this world, I knew that I wanted them to also hear Stevie Wonder when they came out, because he’s one of my favorite artists. Um. But yeah, there’s something inherently wrong about the systems that we’ve created to bring new life into this world. 

Dr. Abdul El-Sayed: Yeah, I really appreciate that. And I also love the idea of of you’re setting the bar high. It’s like, listen, listen, this is the height of things and it’s only downhill from here. [laugh] Um.

Natalie Hernandez-Green: Yeah. [laugh]

Dr. Abdul El-Sayed: I love that. I um, yeah, I really appreciate, that point. And, and that’s the thing about it is, like, it’s not to say that health care and modern medicine haven’t delivered. You know, you look at how far we’ve come over 100 years, but, like, it’s hard not to believe that the pendulum swung the wrong way and that the incentives we’ve created have made sure that where they are acting appropriately, they’re acting appropriately for a very particular group of people. And that tends to leave out–

Natalie Hernandez-Green: Yeah. 

Dr. Abdul El-Sayed: –Black folks, lower income folks, rural folks. And and we see the outcomes play out. And, you know, at this point, you know, you just look at the as you talked about the maternal and infant mortality metrics, and they’re not moving in the right direction. We don’t perform particularly well in this country. And so there’s a lot of rethinking we need to do. We appreciate you helping us to do that rethinking. Our guest today was Doctor Natalie Hernandez. She is an associate professor and she is the executive director of the center for Maternal Health Equity at Morehouse School of Medicine and, coeditor of the excellent, Guide to Taking on America’s Maternal Mortality Disparities and Inequities, the Practical Playbook three. We really appreciate you taking the time to join us. Thank you so much for your time, your insight, your wisdom, and your passion on this issue. 

Natalie Hernandez-Green: Thank you so much for having me on. 

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. The Centers for Medicare and Medicaid Services, better known as CMS, announced last week that they would cover the GLP one agonist medication semaglutide, sold under the trade name Wegovy, for people who meet both the clinical definition of obesity and have high risk for heart disease. As we’ve covered on the show, these medications really are, from a purely pharmacotherapy perspective, as close to miracle drugs as it gets, causing dramatic weight loss in regular users by acting in the brain to trigger satiety. But those who come off the medications tend to gain weight thereafter. Not to mention the staggering cost of the treatment. Over $1,000 a month for those paying out of pocket. Which is why the ruling is notable. Wegovy would not be eligible for Medicare drug price negotiation for some time, given how new it is, suggesting a massive cost burden on Medicare if the manufacturer, Novo Nordisk were to offer it at full price. So why is CMS making this move? Recent evidence found that Wegovy reduced the risk of heart attacks by 20%, which for those meeting criteria, puts it among the most effective heart disease medications around. In fact, Novo Nordisk was recently granted a label change for the medication as both a medication for weight loss and heart disease and stroke prevention in patients meeting criteria for obesity. Last week, the Supreme Court heard oral arguments in a case over the abortion medication mifepristone. The court took the case at the urging of the Biden administration, who challenged a ruling by a three court panel. That panel had themselves heard an appeal after a district court judge’s sweeping ruling to ban mifepristone outright. In effect, attempting to single handedly overrule the FDA’s approval more than two decades ago. The whole thing is absurd on its face, which thankfully, the majority of the Supreme Court seemed to think too. There were a couple of critical issues the justices raised. The first was the standing to even bring the case. The plaintiffs are doctors who claim that they’ve been hurt because they’ve seen people harmed by mifepristone. According to their lawyer, Erin Hawley, the wife of insurrection adjacent Senator Josh Hawley, they were forced to treat patients in quote, “life threatening situations in which the choice for a doctor is either to scrub out and try to find someone else, or to treat the woman who’s hemorrhaging on the emergency room table.” First, that’s dubious on its face, considering how safe mife is. Second, though, it’s a real stretch to say that because you’ve had to provide care for people, you’ve been harmed by its legality. Here’s Justice Kagan, somewhat incredulously. 

[clip of Justice Elena Kagan] What is the conscience objection. What what are the doctors objecting to, exactly? 

Dr. Abdul El-Sayed, narrating: Doctors treat people in terrible situations all the time. That’s kind of the job. If they’re so frustrated by the dangers of this drug, I’m wondering why the doctors don’t sue over, say, motorcycle helmet laws. The second was the broad, sweeping nature of the ruling. The justices notwithstanding, having created the space for this in their Dobbs ruling in the first place, seemed unwilling to allow a lawsuit to overturn the entire FDA. Take a listen to what conservative Justice Neil Gorsuch had to say. 

[clip of Justice Neil Gorsuch] And this case seems like a prime example of turning what could be a small lawsuit into a nationwide legislative assembly on on on a on an FDA rule or any other federal government action. 

Dr. Abdul El-Sayed, narrating: So all in all court watchers feel that the tone and tenor of the conversation suggests that the court isn’t likely to side with the doctors, but they’ve done crazier things. So we’ll keep watching. Finally, there’s going to be a total solar eclipse across parts of the US next Monday. These events occur when the moon passes directly between the sun and the Earth, blotting out for just a moment the entire sun. The breathtaking spectacle happens every 400 years, which is probably a good thing because people. Well, some of us can be, we’ll just say idiots who assume that because the moon is obfuscating part of the sun, that somehow looking straight into the sun can’t hurt you. Nope. It still can. You can buy a pair of eclipse glasses for pretty cheap online. So please, if you are in the path of the eclipse, go out and view the splendor. But don’t do it without a pair of eclipse glasses and don’t look right at the sun. Okay, that’s the end of my PSA. On your way out, don’t forget to rate and review. It goes a long way. Also, if you love the show and want to rep us, do drop by the Crooked Store for some America Dissected merch. And don’t forget to follow us at @CrookedMedia and me at @AbdulElSayed no dash on Instagram, TikTok, and Twitter. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Charlotte Landes mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, and me. Doctor Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice, and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests, and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human, and Veteran Services.