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Jessamy: Hello and welcome to The Lancet Voice. It's April 2021 and I'm Jessamy Baganal. And 

Gavin: I'm Gavin Cleaver. In the United States, black women experience 37. 1 maternal deaths per 100, 000 live births. The WHO lists the overall rate of maternal mortality in high income countries at just 11 per 100, 000 live births.

So why does this disparity exist? To find out, Jessamy and I spoke with Dr Rachel Bond, a cardiologist who recently consulted with the Biden Harris transition team on the subject of black maternal mortality. We're joined by Dr. Rachel Bond, who is the system director at Women's Heart Health at Dignity Health in Arizona, and is a member of the Association of Black Cardiologists.

Dr. Bond recently wrote a position paper in the AHA about a working agenda for black mothers that was on the best approach to better tackling black maternal mortality in the United States. Rachel, thank you so much for joining us. 

Rachel: Thank you so much. It's an honor. 

Gavin: How did you get interested in this particular area as a cardiologist?

Rachel: Oh, that's a wonderful question. So I get asked this quite often. And when we actually look at the disproportionate number of rates of mortality and morbidity for maternal health, we see that cardiovascular disease is the leading cause. About 26. 5 percent actually of the cause in the United States. And because of that was really a driver for me.

More importantly, knowing that 60 percent of these conditions are preventable through preconception counseling, through collaboration with cardiologists, obstetricians, high risk obstetricians, such as maternal fetal medicine providers. It really was a driver for me to educate not just my clinicians, but also the community.

about how common, unfortunately, a condition of the maternal mortality crisis this is, and more importantly, how it's disproportionately affecting women of different groups and cultural backgrounds. 

Gavin: These collaborations between cardiology and OBGYN, how common are they on this issue? 

Rachel: I am happy to say that they're actually a lot more common now than they had been in the past.

We now are realizing that the collaboration is necessary in order for us to tackle this crisis at hand. I myself in my health system have a maternal heart council where we meet monthly and address a lot of our higher risk mothers. Many of them that have traditional risk factors for cardiovascular disease that do place them.

At a higher risk of adverse pregnancy outcomes, such as hypertension, hyperlipidemia, diabetes, obesity, many risk factors that do disproportionately affect women of color. So by having this council and having this collaboration, we're able to figure out what is the best plan during pregnancy. but also what's the best delivery plan and more importantly what's the best postpartum plan because we do know that a third of the time a lot of these complications are occurring in the postpartum period.

So the reason this collaboration is more importantly key is because it's an easy seamless way for us to maintain a relationship with these mothers in the future to prevent any future cardiovascular outcomes that may be unfavorable. 

Gavin: So moving on to looking at overview of maternal mortality in the US So the figures as you say in the in your paper have been going in the wrong direction since 1990 and the statistics of course around black maternal mortality are really striking actually What are some of the reasons for the lack of progress in this area over the last 30 years?

I guess both overall and especially among black mothers 

Rachel: Absolutely. The United States is honestly the most dangerous country at this point in time in the developed world for a female to give birth. We know that rates are steadily rising, as you very nicely said, while in other countries, especially more industrialized countries, it seems to be dropping.

Weakness in healthcare is definitely a contributor that leads to misdiagnosis, delays in treatment, and lack of, more importantly, access to appropriate care. Beyond that, though, I think it's important for us to highlight that although this affects all women, the fact is that it's disproportionately affecting certain groups of women, especially women of color, especially black women.

And we know that biases in health care have led to stark racial disparities in maternal death. Black women are nearly three times more likely to die from a pregnancy event than a white woman. And it's important to note that race is not the driving factor. It's actually, at least from a biological or genetic sense, it's not, but it's more from a social sense where we know that chronic racism that Black women encounter, coupled with the possibility of misogyny due to their gender factors in.

This is a term that I like to use, which is called weathering, where we know that chronic racism and misogyny can lead to heightened vulnerability of chronic medical conditions and early deterioration of our health, and that is disproportionately affecting black women. Beyond that, access to care is also central in this issue.

We know that the quality of care that our patients receive is contributing. And we know that more importantly, that we see inequities in quality of care in minorities as well as low income and more rural areas. And those are other areas in vulnerable populations that are also highlighted in the position paper that I was able to lead.

We also know that inadequate access. More importantly to health insurance, as I mentioned earlier, the postpartum period is such a vulnerable period because a third of the time, that's where these complications arise. So it's important for us to realize that the majority of about 50 percent of our pregnancies are funded by Medicaid.

And most of the time after 60 days, the mother doesn't have access to that. So extending that at least up to one year could be so impactful and pivotal. And what I think is really interesting when it comes specifically to Black maternal health, is that although socioeconomic status broadly affects this, we know that a woman that is of a higher socioeconomic status or higher education, Being black and it doesn't actually protect her.

So that again centralizes the fact that it's a systemic problem. That's so deep rooted in our flawed structure of the United States with these microaggressions and biases. conscious or unconscious that are actually contributing at the core. 

Gavin: How many of these maternal deaths are preventable?

What are some of the biggest risk factors involved? 

Rachel: So nearly three out of five maternal deaths are preventable, so that's about 60 percent. And we know that the major risk factors a lot of time have to do with our Are just overall health traditional risk factors such as are we coming into the pregnancy ahead of the game with elevated blood pressure, elevated cholesterol, diabetes, obesity, physical inactivity or poor eating habits or possibly even smoking tobacco or do you having other?

negative vices. Beyond that, we know that the access to having affordable care and equitable care and resources is another factor that contributes. So this is why the emphasis on preconception counseling is so important. Because we can actually navigate a lot of these traditional risk factors, try to optimize them, and make sure that we educate the patient prior to her actual conception to ensure the success of the pregnancy and that we would, we won't necessarily have poor outcomes.

Beyond that, in the preconception period, that's really when Specialists like myself should come into the conversation where if the patient most likely is going to the obstetrician first, that obstetrician is being proactive and saying, you have a series of risk factors that do place you during your pregnancy as well as in the postpartum period for being at a higher risk of cardiovascular disease, let's get you into the hands of a cardiologist or at least a high risk obstetrician so they can work with us as a team centralizing that care, really focusing in on the patient.

Okay. We have a long way to go, but I am, again, very hopeful by the fact that larger health systems and even smaller health systems are really focusing in on that collaboration very early on between the cardiologists and the obstetrics care team. 

Gavin: What does the picture look like across different states?

Does it vary widely? 

Rachel: Yeah, that's a really important question because we know that the United States just overall has the highest rates of maternal mortality. And it's actually the highest we've seen in decades. But there are some states that unfortunately have even worse. We know that southern states like Georgia, Louisiana are at the very top, but even some eastern states like Indiana and New Jersey have very high rates.

And all of this has a lot to do with many of what we talked about, access to good quality care, equitable care, and more importantly, just having that Patient provider discussion. So there's a health literacy. That's, I think, a factor as well. We know, though, that all of these states that have the highest rates.

These are unfortunately amplified several folds. So we really maybe should be targeting these specific states by ensuring that we have improve federal funding and legislation just to improve outcomes and again, more importantly, expand access such as Medicaid coverage, et cetera, because clearly this is a life or death situation and depending on where you live, it may be much more amplified than others.

Jessamy: Thanks, Rachel. And this situation is obviously not unique to the US. We've seen similar data from the UK and from Australia. Very recently about, in the UK, I think it's four, black women are four times more likely to die during pregnancy and afterwards. What are the things that need to happen urgently?

And on the horizon, are there any international collaborations that are ongoing that might bring some light to this? 

Rachel: Oh, absolutely. These are all important questions and statements to highlight. We know that this is a global crisis. It's a global epidemic. And the fact is that at least in the United States right now, we are actively focusing on that access.

Making sure that women have ongoing, continued health care. And that's something that I'm very encouraged by with our new presidential administration, most recently passing the American Rescue Plan. This provides states with federal funding to extend Medicaid coverage. Illinois is the first state in the United States, which roughly a week ago announced that they would be providing this coverage from 60 days up to one year.

And we know that's going to make a large impact, because again, a third of these deaths and complications are occurring in that very vulnerable postpartum period. Beyond that, I do think it's important that we make it easier to access this care. We also need to make sure that we improve hospital protocols so they're standardized and they can be equitable examples of policy actions necessary to spark real change.

I think it's also important. That we hold clinicians that may have poor outcomes accountable, where we actually have a quality data assessment, and that's something that a lot of organizations are encouraging and looking at, not just in the United States, but also around the world. And I think when we're focusing on communities of color.

Regardless of if you're in the United States or other areas of the world, trust absolutely plays a major role. So for us, I think, thinking about who are the most trusted within the communities, and those are community members, community leaders. So I really do think it's important that we emphasize the collaboration with those leaders, be it faith based, be it other areas within the community where they can be the bridge between the community and the clinicians.

We know that collaboration is absolutely necessary. Beyond that, specifically, when we look at the data from the United States, we know that extending. The access and advocacy for women, including with the use of doulas or midwives, has also been really impactful, and particularly for doulas, we know that the vast majority of the time it may not be covered by insurance, access to doulas may not be covered by insurance, and I do think that's something that legislation really needs to look into, because they absolutely are part of the team, especially for these vulnerable populations, and they add such a large community.

a large part to the team in the sense to reduce these outcomes that we see. 

Jessamy: And in terms of kind of the longer term view, obviously this is a problem that needs to be dealt with and changed immediately, but it will take some time. What do you see as the necessary steps over the next five to ten years to try and level some of this out?

Rachel: I think the first step is to raise awareness. When we actually look at the data, we know that the vast majority of our communities, especially the most vulnerable communities, are unaware of the fact that pregnancy is something that they have to fear. And we want to make sure that's obviously not the case, but we also want to make sure that they're aware that pregnancy could be a very vulnerable period in time, dependent on what risk factors are coming into that pregnancy with.

Beyond that, even for me as a cardiologist, we know that awareness of heart disease in general is on a decline. The American Heart Association in 2019 actually did released a survey where about 10 years earlier, 66 percent of women knew that cardiovascular disease was their leading cause of death. And then 10 years later, that dropped to about 44 percent of the population.

And when they look specifically at who had the lack of actual knowledge of heart disease being the greatest threat, it was younger women, especially women of color that identified as black or his. And a lot of that we know when we look at the data, we're seeing higher rates of death and mortality in these black and Hispanic younger women.

And a lot of it is coupled with what's going on during pregnancy. So I think awareness needs to be improved. And I'm very fortunate to work with a series of societies from a cardiovascular perspective and other organizations that are trying to get that awareness out there. Beyond that, though, I really do think the structure of our health care system is what's feeding a lot of the disparities in care that we see, and that's a systemic thing that's going to take, as you mentioned, time.

It's not going to be something that overnight is fixed, but I'm hopeful by the fact that we're at least now passing some legislation that's providing the option for states to extend health care insurance. My hope is that with time, it will no longer be an option, but more of a mandate because we know that it's absolutely necessary to provide health coverage to all, because that is most probably the biggest driver of the disparities that we're seeing.

Gavin: So you're coming at this particular problem as we've talked about at the start there from a cardiology background, and you're a member of the Association of Black Cardiologists. Tell us about how the Association of Black Cardiologists came together and what some of its kind of main aims are.

Rachel: Absolutely. So the Association of Black Cardiologists is a non for profit organization, and the mission is actually that it's dedicated to promoting the prevention and treatment of cardiovascular disease in black communities, as well as other minorities to achieve health equity for all. Just mainly through the elimination of disparities, I'm fortunate to co chair the cardiovascular women and Children's Committee for the Association of Black Cardiologists, where we have the same mission, but our focus is on Children as well as women across their age continuum.

I think a big part of the discussion when we talk about maternal health in particular is that it's something we could prevent 60 percent of the time. And although access and structural things focus in on that, we also do know that it's important that we are making sure that these moms are coming into their pregnancy extremely healthy.

And one way to do that is to by educating them, making sure that they're aware of the possible risk factors that do place them at a higher risk. And we really want to make sure that we start that discussion earlier on during their childhood. So what's really unique about the ABC is that we don't just have adult cardiologists, we have pediatric cardiologists and also pediatricians.

that are part of the organization because starting with pediatricians is really the way to go to ensure that we provide tools for these younger children on how to maintain a healthy particularly healthy cardiovascular lifestyle so by the time they're considering pregnancy they're optimal and in ideal health.

Gavin: So as well, I noticed on your Twitter feed that you presented your work to the Biden Harris transition team earlier on in the year. So tell us a little bit about that, how that came about and what you talked about. 

Rachel: Yes, that was actually a wonderful opportunity that was presented to me through my leadership at the Association of Black Cardiologists.

At ABC, we are partnered with a organization, which is another non for profit organization. Created by women actually to help protect and advance the health and wellness of Black women and girls called Black Women's Health Imperative. They invited myself to talk about a lot of the efforts I'm doing centered around the Black maternal health crisis.

And I was among a few other predominantly Black led organizations, and I talked a lot about the position paper that was published in Circulation the American Heart Association Journal. Beyond that, we did talk about collaboration as separate organizations and how we could perhaps be a blueprint for the transition team to try to really focus their efforts on in terms of fixing this issue that we see at hand.

They were very, I think, welcoming in terms of the conversations that we had, so much so that the position paper, which it really, I think, opens the discussion for how to make sound solutions to this crisis, is now actually have a home in the Office of Minority Health Resource Center, which is their knowledge center for the U.

S. Department of Health and Human Service Office of Minority on their website. So I think it's a impactful reference. for other organizations from a government level or even local level to really focus in on how can collaborative care bringing in the community, bringing in even the media, bringing in other aspects of clinicians and subspecialists, how we all collectively could work together.

To fix this crisis and epidemic that we're seeing so I was extremely fortunate to have the opportunity to speak 

Gavin: Very exciting and We're similarly 

excited to have the opportunity to speak with you as well thank you very much for talking with us today Is there anything you'd like to add that you think we haven't covered?

Rachel: I think just in closing I can say that I know that there is a crisis and an epidemic that remains to be at the forefront, but I can say that with this new year, I do feel very hopeful that there will be change. We have a series of organizations, societies, as well as now government support of really highlighting the fact that this is an epidemic and there needs to be something done about it.

I am hopeful that all of the efforts will not go undone and I do hope that with everything that I have done and everything that organizations that I'm involved in have done, we will finally see improvements and I know we will, but I just wanted to really highlight the fact that all the efforts that we are doing this year have been very encouraging for me and very hopeful.

Gavin: That's great. What a positive note to end on. Dr. Rachel Bond, thank you so much. 

Rachel: Thank you.

Jessamy: When we discuss vaccine hesitancy, what structural aspects are we overlooking? Gavin spoke to Michelle Kahn about the use of language in international vaccination efforts. 

Gavin: I'm delighted to be joined by Dr. Michelle Kahn, who is Associate Professor of Health Policy and Systems Research at the London School of Hygiene and Tropical Medicine.

And Dr. Kahn, we're going to talk about your new comment, Lancet this week, which is called Rethinking Vaccine Hesitancy Among Minority Groups. Now it's such an interesting concept, and of course in this podcast we'd like to get a little bit philosophical, talk about the use of language, especially as it relates to health issues.

Tell us a little bit about this kind of reframing of vaccine hesitancy. What's the current framing of the issue and why, in your comment, do you say it needs a rethink? 

Mishal: Thanks. Thanks for having me here and for having this discussion. The kind of core issue that myself and my co authors highlight here is that there's a huge amount of responsibility being placed on individuals individual choices, individual attitudes which is associated with this.

term vaccine hesitancy, and the issue isn't being situated in the wider structural issues. And because here we're talking about vaccine hesitancy among minoritized groups, then for example, the wider issue of say structural racism and how that impacts people's choices or behaviors. So in essence, really too much focus on individual behaviors and choices.

And that gives, that sort of misses an opportunity for addressing some of the wider issues. 

Gavin: So when we're thinking about this conversation and kind of, as you said, shifting that responsibility in the language onto minority groups. Why does so much of the conversation, do you think, conflate these barriers that people face in accessing vaccines with the word hesitancy?

Why has hesitancy become this kind of catch all term? 

Mishal: The way it's often discussed or defined is vaccine hesitancy is when people will either be unsure, or actively not want to have a vaccine when there is access. And so the way I think about it is this idea of when there is access. I think we perhaps don't define that properly or simplify that too much.

And by that I mean that what does it, when you say when people have access, does that just mean that the vaccine is available for free? Is that enough? For one to say, yes, there's access. What about some of the other barriers that we see in such as, is it convenient? Is it is, are people able to physically reach the locations where vaccinations are being given?

Is it within their working hours? Are they going to have to lose a day of income owing to the sort of work they do? So I think that's one of the core issues as well as this idea of when there is access and what do we mean by access. 

Gavin: Yes, so as well as those kind of structural barriers, your comment goes into more detail talking about mistrust of governments and vaccine manufacturers among populations as also a kind of basis for hesitancy.

But, as we were saying, hesitancy that the language that places too much responsibility on these minority groups that might have these well founded fears. Tell us a bit about that, and does that kind of necessitate quite a tailored approach in terms of looking country by country or even like group by group?

Mishal: Yes, and I think Gavin, you hit the nail on the head, there is this, even within this issue of lack of trust, there's a lot of responsibility on individuals and often there's this conception, there's a, Irrational level of lack of trust for companies and governments. And I think that's unhelpful.

I think it is important to understand for individual communities what the sources of those concerns are and also consider that they might very well be very rational. So for example, A survey in the UK showed that people from black or Asian backgrounds were twice as likely to have faced discrimination when accessing public services, including such as the police.

And then that shapes that obviously shapes the experience and when, offered other services. And they also found a link between the people that had said they experienced discrimination being more likely to say that they were hesitant about taking the vaccine. So I think these are some of those concerns that we think are perhaps irrational but if it is based in their previous experiences of being treated differently when accessing public services then those need to be addressed without assuming that it's some sort of conspiracy theory that people are thinking about.

Gavin: So I, I guess that when we think about kind of solutions, then it requires quite a lot of contextual knowledge about a group's previous experience with the state. 

Mishal: Yes, exactly. And what is front of mind for different groups when they have concerns or the sorts of barriers they might be facing.

So I know it's not always easy to have a. group by group strategy. So I'm not claiming this is easy, but it might be necessary because assuming that the concerns are irrational and that it's the same concern for everyone misses some of the nuances that are needed in planning a strategy.

Gavin: So of course, as we've been talking about, there's so much nuance behind this kind of catch all term hesitancy that everyone's started using when talking about. People not receiving a vaccine. What would you like to see change around state led vaccine communication and as well distribution? And of course here, we should point out, we're talking about countries at the moment which are lucky enough to have a mass vaccination program because we need to acknowledge that almost all low and middle income countries have found vaccines extremely COVID 19.

Mishal: Yes, so certainly we are talking about those countries that are extremely privileged and there's a whole separate discussion about the sort of inequities around the world. But if we're focusing within countries here, and as we were just saying, one, I think one should. So stay away from having one size fits all solutions, but if we were to reflect on some broad principles that might be helpful.

So I think the first would be that focusing on the inequities and the broader structures that might disadvantage people in being able to Access vaccinations, thinking about that early, which I'm afraid hasn't been done in a lot of the higher income countries. So thinking about that upfront, not once one starts seeing the disparities, but predicting it's entirely predictable that this was going to happen, thinking about that early and having that upfront in, in strategies.

Number two again, perhaps sounds obvious, but I'm not seeing this so much is to base. The strategies to tackle the disparities on evidence data and where that's lacking, at least on insights from insiders within the community. So we're not assuming we know what the issues are. Number three would be to learn from other countries.

In our comment, we give Pakistan as an example of a country that's faced a lot of challenges with vaccinations and there's a lot to be learned from countries. And then finally the huge increase of, in misinformation and disinformation as the WHO and others are calling the infodemic being proactive also on, on tackling that.

So those would be my four sort of broad recommendations. 

Gavin: To pick up your third point there, of course many countries have been dealing with this problem for a long time. What are some of the other lessons that we can reflect on from other countries? 

Mishal: So from Pakistan, one of the broad lessons is that when there's been pockets of the population that have either had no or limited state services, then Suddenly expecting that providing vaccinations and saying that they're free will be sufficient that's not true.

It's obviously necessary to make things free, but when it's the case that there's been a tense or an absent relationship with the state, then a lot more needs to be done. And so we could possibly draw lessons. For such populations in higher income countries as well. It's somehow sometimes feels to me that we're saying, oh, we've ignored you for so long.

I'm, so I'm using pockets of populations of Pakistan where perhaps they haven't had primary healthcare, etc. And to say we haven't cared about you so far. for so long, but now that we as a country want to have high vaccination rates, here it is for free, and we'd like you to come. And to think that's suddenly just going to happen because a particular service is being made for free is naive.

Gavin: So finally then, do you think it will be difficult in future research to separate hesitancy? As we've been talking about, it seems so entrenched in the language. To separate hesitancy from inability to access and what kind of data you might think might be called for in the future? 

Mishal: I don't think it's I mean Along the line as a spectrum of difficult things that we're researching.

I actually don't think it is that difficult to separate these issues the data that's the initial data is actually very simple. In, in understanding, for instance, vaccine uptake divided up by ethnicity, age, and gender disaggregated also by local area to see how uptake might be varying in different parts of the country, having some understanding of vaccine availability and proxies for access to services, and then examining the reasons for refusal more deeply and being open to some of the greater sort of more can.

More complex issues. So for instance, differences between people actually having no trust or there being an inconvenience in terms of the timing or the location. So really look, looking into that and digging into it is what will allow us to have an evidence based strategy to address the disparities that we're seeing.

Gavin: Michelle, so much for talking with us. Is there anything that you'd like to add that you think we haven't covered in this area? 

Mishal: No, I don't. I think this has been a great discussion. So thank you. 

Gavin: No, perfect. Thank you so much.

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