This is Rosie Talaga with the Becker's Healthcare
podcast.
I'm thrilled today to be joined by Melissa
Hassler, director of certified nurse midwifery at Fairview
Health Services.
Melissa, it's a pleasure to have you on
the podcast today.
Thanks, Rosie. Glad to be here. We have
a super important and interesting conversation in store
where we're gonna dive into black maternal health
crisis, what's driving disparities in care, and how
mHealth Fairview is working to create more equitable
outcomes for all patients.
Before we get into it, Melissa, can you
please introduce yourself and just tell us a
bit about your background?
Sure. Absolutely.
So I'm, Melissa Hassler. I'm a certified nurse
midwife. I've been in practice for twenty one
years now,
and I actually have been in practice at
Fairview that whole time. So I,
have had a really wonderful experience with the
health care system and had the opportunity to
really get to know some of the really
wonderful things that that system is doing in
our state of Minnesota. So,
I am in full clinical practice,
and also have an administrative role. So get
the opportunity
to really,
tie together what happens in clinical practice and
what we're actually doing within our health care
system to support optimal outcomes,
specifically for
pregnant people and
birthing people in our state.
That's wonderful. Thank you so much for the
introduction.
It's, particularly important and interesting that you have
both the clinical practice side and the administrative
role to really, like you said, tie the
two together.
Yeah. Exactly.
It's really you know, it's one thing to
sort of hear,
talking points about what is happening in maternal
health, but to be able to actually experience
it both with the patients and also the
providers,
the obstetricians and the midwives that I support
within our system, really figuring out what are
we doing, and are we doing the best
we can, and how can we structure our
system
to actually support and improve
maternal health. There is absolutely no question we
have a maternal health crisis in our entire
nation. It is a problem,
and it has been sort of there's been
a rising
swell of awareness,
particularly over the past five years. But now
we're really at a point where
we see it. We know it's there. What
are we gonna do about it? And how
do we, within our health care
system, structure our tools and our resources to
help try and make an impact in that,
maternal health
crisis?
That's really powerful. Thank you. And I'd like
to talk more about that crisis.
Such an important call out, especially coming off
the heels
of black maternal health week, which is an
important moment for reflection and in the community.
First, what is the black maternal health crisis
in The US, and what factors are contributing
to this?
So in 2023,
the maternal mortality rate in The US overall
was about eighteen point six deaths per 100,000
live births.
That's quite high, particularly for a developed nation.
And then when we break it down further,
people who identify as black, that mortality rate
is even higher. It's fifty point three deaths
per 100,000
live births in 2023.
That's more than double the national rate.
That is
a problem.
That is a stark reminder
that we are not actually getting to the
root of the problem of
maternal mortality
and then also identifying the fact that there
have to be some factors that are contributing
to that,
increasing rates and very high rate for particularly
black and brown birthing people.
Absolutely. That is, like you said, a tragic
tragic crisis that the black maternal mortality rate
will be more than double the national rate.
And like you said, that that does mean
that there are factors contributing to this. This
doesn't just happen naturally. So like I was
saying, what are some of those factors that
you,
think are some of the highest causes for
this?
So there are a lot it's a very
complex and complicated
problem.
But, really, what we've identified,
particularly within our system, having an opportunity to
reflect and see what is happening and really
look at evidence based care and literature
and evidence from our public health researchers and
from our,
clinical researchers and more,
maternal care,
looking at what is the evidence showing us.
And what we do know for a fact
is that race is often used
as a proxy
for biologic or genetic differences.
And we know that race is actually
not that. It's a social and societal construct
that cannot be used as a proxy for
biologic differences. So when we use race to
determine a risk factor, we're really eliminating
or over identifying people who are at risk
for adverse income outcomes.
So when we filter things inappropriately,
that really changes the course of care for
the pregnant person.
And when that happens, we miss opportunities to
intervene when we can.
And it also obscures the true underlying cause
of the adverse pregnancy outcomes, such as systemic
racism.
There are socioeconomic
factors that play into this.
And all of this really just exacerbates the
health disparities by misattributing
risk factors and failing to address the really
true underlying causes
that lead to these adverse outcomes.
I can give you a couple of examples
of, you know, things that we've done in
our system
that we are trying to sort of target
the why
of the outcomes that we're seeing.
One thing we're able to do is in
2023,
we created,
internally a birth justice initiative
that was a cross,
system
sort of collaborative
of all sorts of different people and employees
to talk about and really explore
what are the issues that are impacting this
maternal mortality
and how can we bring,
justice and,
you know, appropriate care for everybody that we
care for. So in this birth justice initiative,
we also were able to align looking at
our
systematic
prenatal care that's provided to all pregnant people
in our system and figure out what can
we look at in that care provision
that may be causing or perpetuating some of
these adverse outcomes
particularly
related to race.
So using
both the birth justice initiative and all also
our internal system and drive and commitment to
our community
and to equitable care,
using those two powers
to look at our own care and our
care map is actually what we call it,
which is the care map is sort of
the process by which we,
build our tools and provide care universally to
all pregnant people within our system. So how
do we use this birth justice initiative,
our internal Fairview values and mission
and focus on equity,
and target that prenatal pregnancy and birth care
to improve outcomes.
And we found some opportunities,
particularly with our screening tools that we were
utilizing in pregnancy to determine
how we,
provide either additional care or different care for
folks who have increased risks.
And so a couple of strategies. We've looked
at,
genetic screening. We've looked at maternal serum screening,
lead screening, preeclampsia
screening, diabetes screening,
all of these different aspects of care to
determine
what are we doing right and what can
we how can we eliminate the race or,
the social construct of race from that risk
assessment and really get down to the biologic
and physiologic factors
that may contribute to an outcome.
And so and in addition to that piece,
we're we're reconstructing things internally, providing care differently
for people universally, and also advocating
nationally
for other,
laboratory
places that we send off our samples to
to also
eliminate race based screening to really get down
to the root of how we need to
care for pregnant people,
for better outcomes.
So it's sort of an internal move and
then also a national move to try and
make some change with this.
Absolutely. And there's so much importance in what
you just said, especially,
I think, that call out for race being
used often as a proxy, but it really
being a social construct and getting back and
getting down to those real biological
factors.
It's really nice to also hear about that
birth justice initiative and,
Fairview's internal drive and commitment. I particularly like
how you called those your two powers, your
drive and commitment to your mission.
Yep. I'd like to hear with that context
in mind a little more about how this
issue
kind of initially resonated with your organization, how
it still is. So what motivated Fairview to
address racial and ethnic disparities in maternal care?
So, couple of years ago, I think it
was 2022
and the beginning of 2023,
our organization
just really made a focused intentional
call out of bringing equity to all health
care.
And a part of that was intentionally
evaluating
all of our care maps,
so our packages of care,
evaluating them from a lens of equity
and making sure that we are addressing
every aspect that potentially
could lead to
inequity in outcomes
or inequity in care.
And that intentionality
really,
you know, the system provides resources and incredible
people within our system who are subject matter
experts on equity,
within health care, particularly.
Those resources
helped,
inform
our new care map. And so that kind
of it was a synergy between this really
internal focus from Fairview on equity,
the birth justice initiative,
and then also kind of that national spotlight
on what's happening with maternal morbidity and mortality.
And it just came together
really
nicely in the end of twenty twenty three,
that allowed us to really dig into this
prenatal care map and and make sure you
know, it was a call to action from
our,
internal
employees and also
our organization to say, what are we doing
for maternal health care? And this was our
answer. It was to break down our prenatal
care process
and rebuild it in a way that was
really central to
equity and care, but also equitable outcomes.
And figuring out how do we provide that
care within the pregnancy journey
that leads to that equitable outcome.
And it's different from standardizing care. We're not
standardizing things across the board. I mean, in
a sense, we are. We are providing,
the highest evidence based care we can to
every single person that steps through the door
that's pregnant,
but also understanding that within that care, we
need to individualize it to meet the end
goal
of equitable
outcomes. Right? So what's great for one person
in the beginning might not be great for
everybody. And so how do we build a
system
that takes that into consideration
that lands us with the equitable outcomes and
improved maternal and fetal outcomes at the end.
Totally. I think that's a great call out
too about it's not exactly standardization. I think
that goes back to the difference just between
equality
being equal or being equitable. You know, standardization
might be the same across the board, equal
across the board, whereas your intentional,
lens of equity for your care maps is
more of that
equitable,
way of looking at things. Exactly.
I know you did mention,
specific steps that your organization is taking to
confront this bias such as the birth justice
initiative. I was hoping you could either talk
about other strategies or go in more to
depth for the birth justice initiative
that you're implementing to reduce this bias in
pregnancy and delivery care?
Absolutely. I've got a couple of examples I'd
like to focus on.
One first example is
our screening for preeclampsia risk in pregnancy.
Preeclampsia
is is a condition that's unique to pregnancy,
and postpartum that results in high blood pressure
and then end organ damage that can be
potentially fatal for some people,
and have long term effects on the pregnant
person and for the fetus.
And previously,
our screening for identifying people who are at
risk for this utilized,
things such as,
identifying
risk factor for developing
preeclampsia.
We know now that that actually is not
a specific
risk factor for developing preeclampsia.
What we wanna focus on is
the pieces of the
biology,
the pieces of the genetics,
and the conditions of the body that would
lead to preeclampsia.
Hypertension
disorders of pregnancy, a history of diabetes,
multifetal gestation, or, you know, multiple
fetuses,
twins, triplets, and so on,
kidney disease and autoimmune disease.
So those are examples of specific
conditions that would lead someone to
have preeclampsia potentially be at risk for preeclampsia.
And by identifying those, we can then take
interventions that help decrease those risks throughout the
pregnancy.
Another example is gestational diabetes screening.
Previously, we utilized,
screening high risk qualifiers as people who identified
as African American,
Latino,
Native American,
Asian,
Pacific Islander.
We know now that that race based screening
is actually not comprehensive
enough and is not accurately reflecting the folks
who are at risk for gestational diabetes.
So now we've pivoted to a universal
hemoglobin a one c testing, which is,
everyone who's pregnant and enters care in our
system will receive that blood work
that tells us their stratifies their risk for
developing diabetes.
So really
moving away from
those social constructs of race
and pivoting to the actual biologic and physiologic
factors that would play into increasing those risk
factors.
But it doesn't end there. It's not enough
to just eliminate race and screen for everything
else because we know the root of the
problem
is deeper than that.
So we have added screenings.
We've added social determinants of health screenings.
We have added screening for transportation
barriers.
We've added,
screening for food insecurity,
housing stability.
Those are pieces that we know actually
influence
and contribute
to maternal outcomes that are negative.
So not only are we identifying
those risks from social determinants of health aspect,
but then also creating wraparound services and access
to resources
that help intervene in those social determinants that
can impact that pregnancy.
Absolutely.
That's really important again to go back to
that idea of moving away from the social
constructs of within the screening processes and risk
identifying processes.
I'd like to dive into that a little
bit deeper,
and have you talk about how these race
based screenings and calculations
negatively impact care and outcomes.
Yeah. So so when we
eat there's a couple of different ways. Number
one, it's if you focus on the race
based screening, you miss an opportunity for interventions
for folks
who
may not have self identified as a specific
race. For example,
many of us,
have many different ethnic backgrounds,
and many of us don't actually know what
our specific
ethnic or, you know, specific genetic risk factors
are. And so if we don't know to
identify ourselves as a specific
race or or count ourselves in that specific
race, it really is not capturing anyone who
potentially could be at risk.
In addition,
it obscures the true underlying cause of the
adverse pregnancy outcomes, like racism
within
the health care system or socioeconomic
factors.
And then it just also
exacerbates the health disparities
by misattributing
risk factors
And then again, not addressing those true underlying
causes, which which we think are more likely
related to
socioeconomic
and social
constructs versus
actual biologic,
contributing factors for the outcome.
So it can really impact both missing people
and
actually adding people to,
a risk based profile that is actually misattributing
their risk,
and that can can really
change the course of their care and hinder
and in addition, hinder efforts to address the
root cause of what's really
the reason for the health disparity.
Absolutely. It is so important
to really be focusing on the root cause,
and I think that that's a really powerful
note
to say that, you know, patients maybe can't
put themselves into a box or quite literally
check a box that they identify with one,
self identify with one particular race because, you
know, as
as time progresses, that's just getting trickier and
trickier for everyone. So
zooming out a bit for our last question,
I'd like to connect this maternal care work
to the broader organization. So I'm wondering how
this initiative and this mission
aligns with the organization's
broader commitment
to health equity.
This is a great question and something I'm
really passionate about because I
I have stayed in this organization for a
long time for a reason and continue
to choose to stay here because
of the focus on
patient centered care
that evolves from dignity
and respect,
but also providing
the highest quality of care we can. And
it doesn't happen
alone. It happens within our communities.
And our our Fairview Health System is really
focused on not just
caring for the people within the doors of
our health care facilities,
but the community in which we live. We
do not just
aim to keep people,
to fix people's pathology. Right? We aim to
really provide whole person care that keeps people
out of our facilities
and promotes health and well-being within the community.
So making sure that we are
really looking at how we provide that care,
pulling the customer, the consumer, or the patient
into that process,
and better understanding
how we can do that within the walls
of our hospital and also within our community.
So we have a lot of initiatives related
to community advancement
and, ensuring that the voice of the the
community member and the customer is a part
of the care that we build and provide,
but also internally really changing
the barriers, the systemic barriers that we've been
seeing historically in health care.
We can't do it overnight. It's a huge,
long
initiative that we are so committed to and
continue to commit to
year after year after year because that we
know that when we keep our patients healthy,
we keep our communities healthy. And particularly with
pregnancy,
pregnant people
have babies. Right? And these babies are members
of our community, and those babies
grow up in these communities and become adults.
And the more we can provide
health and well-being at the root of that,
the healthier communities are, the healthier our state
is. And hopefully,
you know, we can have a national impact.
But we've gotta start somewhere. And Fairview has
really driven home a commitment
of health equity
and getting to the root cause and making
sure that what we're doing
is, you know, again,
from from the patient centered aspect of dignity,
respect, and highest quality of care.
That's a great point. I love the idea
of, you know, you have to start somewhere.
Where's the root cause and what better place
to start than maternal care where these Right.
Humans are entering the world. I mean, talking
about whole person care.
That's great. And it's so great to hear
your passion for this mission that is so
clearly a big part of Fairview's purpose.
Absolutely.
Yep.
Well, thank you so much, Melissa. That is
all the time we have for today, but
it's been an absolute pleasure,
hearing your insights about all the important work
happening at Fairview.
These conversations are truly vital as we work
towards a more equitable maternal care. So it
has been a pleasure,
and thank you all for listening.
Thank you, Rosie.