What are MMRCs?

In our first episode of BirthWork, your AMCHP hosts and two maternal health experts help to break down some of the responsibilities of Maternal Mortality Review Committees (also known as MMRCs). MMRCs are tasked with reviewing maternal deaths in their jurisdiction, determining “pregnancy-relatedness”, which is a key step of the MMRC process, and proposing recommendations to improve birth experiences and outcomes within their states and/or cities. Listen to this episode to learn more about how MMRCs provide insight and recommendations on how to reduce maternal mortality in the U.S. while helping to rewrite the narrative and transform conversations surrounding “BirthWork” across America.     

Guest Speakers: 

• Dr. Aasta Mehta is an OB/GYN and the Medical Officer of Women’s Health at the City of Philadelphia, Department of Public Health.  
• Teneele Bruce is a biologist and doula, and is serving as the Pathways Project Director at Baltimore Healthy Start.  

Episode Hosts: 

• Shaquelle Ballou and Kristina Wint, both former Program Managers at AMCHP, are the co-hosts for this episode. 

Resources: 

• Use our discussion guide for reflection and conversation. 
• Access our transcript for this episode here. 
• Check out Dr. Aasta Mehta and her work with OVA here.  
• Learn more about Teneele Bruce and Baltimore Healthy Start here. 
• You can find more information on Maternal Mortality Review Committees and the CDC’s ERASE Maternal Mortality initiative here.   

• Follow us @BetterBirthOutcomes on Instagram and don’t forget to like this episode!
• Learn more about the Association of Maternal & Child Health Programs (AMCHP) at our website.

Transcript

Episode 1: What are MMRCs?

F1 S1 0:03 

I'm an obstetrician. I like to have immediate satisfaction. Right. That's more like we get to deliver babies, like within less than a year. That's amazing. Like a human is conceived in and born. That’s the kind of stuff that I, you know, that's what I like. I like immediate gratification and the policy work is, you know, sometimes it's the whole, it’s your whole life you're working towards, like one accomplishment. And so when there's those moments of, Oh, we could do that like now or within a year or whatever, that's the stuff that I live for.  

0:43 

This is BirthWork. And that was Aasta Mehta, a physician, and the medical officer of women's health at Philadelphia's Department of Public Health.  

F1 S3 0:52 

I'm Kristina Wint, senior program manager at AMCHP. 

F1 S2 0:56 

And I'm Shaquelle. Also known as Shaq Ballou, a Program Analyst, also at AMCHP. 

F1 S3 1:01 

Today you are going to hear our conversations with two people working on the frontlines of maternal health. We are going to be talking about maternal mortality.  

F1 S2 1:10 

Maternal mortality in our nation is a pressing crisis. For a nation with so many resources and health care innovations, the rate that people die due to childbirth or pregnancy related causes is devastating.  

F1 S3 1:22 

And it's not getting any better. In 2020, 861 women were identified as having died of maternal causes in the United States, compared with 754 in 2019.  

F1 S2 1:35 

And black women and birthing people fear the worst off. Black women are three times more likely to die from a pregnancy related cause than their white counterparts.  

F1 S3 1:45 

In the second half of the episode, I was talking to Teneele Bruce, maternal health coordinator with Baltimore Healthy Start and doula, who has assisted over 20 births.  

F1 S2 1:55 

But for now, we will turn to my conversation with Aasta to better understand what is being done about the American maternal mortality crisis.  

2:10 

Aasta is a longtime OB-GYN and she has been practicing for over 14 years. She describes herself as on the shorter side with brown hair and brown eyes.  

Before we get into maternal mortality, I want to better understand what drew you into this work.  

F1 S1 2:26 

So I was actually it's funny, you know, my mom always is bugging me to clean out my stuff, Right. And so I was at my childhood home where I grew up, and I was looking through old, you know, applications for certain things, like college applications and stuff. And it was funny because I'm reading them, like man. I literally had it all figured out back then. In the sense of, I clearly had some kind of vision for where I wanted to go career wise and what I was interested in. Everything kind of had some policy or, you know collaboration and just sort of like a running theme in my college applications and then for medical school, like I was before I went to medical school, same right? It was very much like I didn't really talk about like women's health, but I was talking about policy and its intersection with medicine and how, you know, where's there's so much intersection that people don't even think about. And so that was my theme for med school.  

F1 S2 3:30 

Just so you guys know asked Aasta’s mom is also an OB/GYN so it just makes sense that asked to follow in her mother's footsteps right. Well, yes and no. 

F1 S1 3:40 

No. OB gyn was never really on the radar. My mom is an OB/GYN, and so. So that was an active kind of, I don't know if I want her life because my mom was a solo practitioner in a small town and was the only OB-GYN for miles and miles and miles. She delivered basically a whole generation of people in that town, which is incredible. But she was, with that, the other side of that is that she was always on call, always leaving in the middle of the night to go deliver babies. And so that was maybe not the lifestyle that I wanted to subscribe to.  

F1 S2 4:13 

After manifesting this very self, rather than because of her mother's influence, Aasta found her way to medical school and was surprised at how her mother's career did impact her choices when it came to applying for residency.  

F1 S1 4:25 

I did find myself in my OB-GYN rotation, just like, I don't know, like it was just, there's something like homey about it. It was just very familiar. Not that I ever shadowed my mom or anything, but it was just familiar. It was, you know, like the words Pitocin and vaginal bleeding. All these things that I grew up with, words that were just thrown around in my house. Adn then to see it in practice. Then it was like looked at my mom in a whole different way. And it was just, it was really cool. And then I was like, Oh, maybe I should go watch my mom deliver babies. And I remember I saw her deliver twins vaginally. And that was really like really cool.  

F1 S2 5:06 

Bringing life into this world is really cool. But not every delivery goes smoothly. Birth is a huge task for everyone involved. Aasta to share it the first time, something went wrong.  

F1 S1 5:19 

Yeah, you know, I've delivered so many babies in my lifetime now it feels like, so I've been practicing for 14 plus years. But I would say the one that stands out, as like one of the first times that it was like, wow, we're not in a good spot right now, is, we had a postpartum hemorrhage. I was an intern, so first year of residency, and a completely unexpected postpartum hemorrhage. First baby, so really not any risk factors to consider. And we, you know, took her back to the operating room and we're like doing all you know, doing all the things in terms of like giving her blood and, you know, giving her medication to help maybe stop the hemorrhage. And it was the first time where I looked at my attending and I looked at our chief resident, and they were both kind of like, anyone have any ideas? We had kind of run out of things and somehow, like someone thought about something called a bakri balloon, which was new at the time and an innovation.  

F1 S2 6:27 

I just want to take a quick minute to explain what this is. A bakri is a medical device that looks like a deflated version of those balloons you use to make the balloon animals that are twisted into shape, except it only expands at one end. It is used to temporarily control postpartum hemorrhage or excessive bleeding. To use it, the doctor will put it into the patient's uterus and then inflated by filling the balloon with saline. Bakri can remain in a person's body for 12 to 24 hours. This is a rather new invention, as it was created by Dr. Eunice Parker in 1992.  

F1 S1 7:03 

And we happen to have them. And so we were able to do it and stabilize her. But just like I look back, I mean, I think about that a lot, you know, like, thank God we had this innovation and thank God that someone decided that like women's health was like, worth it enough to, you know, to do new things because, I mean, my mom didn't have that when she was practicing. And, you know, the attending, this was the first time he was ever putting in the bakri. And we use them all the time now. But it was pretty new back then and just like, you know, thinking I'm so glad we have this because our next step it would have been a hysterectomy. And so obstetricians and midwives and those that we really had to think on our feet and I don't think people recognize that so much is that there is a lot of things that we're just like making decisions very quickly that are stressful and life changing.  

F1 S2 7:59 

Sadly, there are some patients who aren't as fortunate. Which brings us to our topic today of maternal mortality review committees or MMRCs.  

F1 S1 8:09 

So usually, I mean, MMRCs are composed of a multidisciplinary group of people. So yes, there's OBs, there might be cardiologists, there might be intensive care specialists, emergency medicine doctors, you know, a psychiatrist. So that would be like sort of the medical ones, people like that. But then like the sort of the non, I mean, well, actually and then within clinical like midwives, nurses, so within different disciplines within like medicine. Right. And then you would have sort of like community-based organizations. So that's like maybe your doula organizations or your home visiting programs, other like safety nets, like WIC, housing, you know, like those kinds of organizations. And then usually people have a medical examiner or like a or a coroner or something like that on the committee. And then, yes, I think there is more of a trend toward towards having people with lived experience so community members, beyond the, on these review teams as well. But so that's sort of like, some of the kind of people that you have, maybe like policymakers or people from government, insurance is another one. So you'd have people from all of the other arenas around the table and they would review these cases like through their own lens of being multidisciplinary and then make, yes, make a determination of whether they think the review was pregnancy related.  

F1 S2 9:48 

A Maternal Mortality Review Committee has the opportunity to review all deaths that happened during pregnancy and up to a year postpartum in their jurisdiction. For each case, they collect records and key information about that death to make a determination about whether or not the death was pregnancy related. This put simply means that the person would not have died had they not been pregnant. An easy example of this is if the person died in childbirth or due to eclampsia, a condition that is unique to pregnancy. Historically, MMRCs focused on pregnancy complications and medical causes of deaths. In the last decade, MMRCs have expanded the number and types of professionals on the committee to have the capacity to review cases such as those that involved suicides, homicides, and drug related deaths. Acknowledging that it can be argued that a substance use disorder was exacerbated by a person's pregnancy or that domestic violence in the home increased after a baby was born. MMRCs dive deeper into cases they categorized as pregnancy related in order to develop recommendations to prevent them from happening again. And so thinking back over your time. Was there ever a time that you disagreed on the review committee's decision?  

F1 S1 11:05 

I think that sometimes what happens and this is just one of the asterisks that every MMRCs should have by their by their data is that you're never going to have all the information available. Right? Like we're never going to have like the, first person account of that person walking through pregnancy and postpartum and then potentially like their death, right? They're never going to have like the whole video of all of that. So you're not going to know. There's some things that one is going to need to infer or, you know, to make a leap about in terms of like some of these determinations. And so that's where it's really important to have this multidisciplinary lens because as an obstetrician, like I'm going to be, you know, like there might be things that I'm an expert at, but I didn't think about, like the system and like the systemic racism or the the housing policy or the transportation, what have you. Right. I might not have thought about that. And so there are times and I think the ones that are really hard to really figure out about the pregnancy relatedness are the ones that maybe are suicides and the substance use deaths. The ones that are overdose related, especially if they happen like in the postpartum period, because you're just like never, unless like that person like it wrote out a suicide note and said exactly what they were thinking. There is some inference that one needs to make in order to decide if maybe this was related to the pregnancy or not. And that's where I would say like, um, there is more debate about those kinds of deaths. Traditionally in Philadelphia for a long time, we really didn't even, we would review all the deaths, but we really wouldn't make pregnancy relatedness determination on those kinds of deaths. We would only make them on those that were like medical causes and recognizing though that, and we don't do that anymore, we do them for everyone. But like, recognizing that there are a lot of substance use related deaths, there are a lot of suicides that are pregnancy related that we should be capturing in our data and looking at because that is just as important, if not maybe sometimes more important than some of like the medical co-morbidities. So are more pervasive, I should say not important, but more pervasive. So I think like, that's the so, you know, that's I would say it's been a shift in philosophy for us as an MRC over the last like three or four years. But I think that's where the committee kind of wrestles a little bit more. But the frustration again is always like kind of be really good. If we knew this one thing, you know, or we had this like information, but you just can't get all the information all the time.  

F1 S2 14:03 

So why is it important to look at maternal deaths? While the review was done one by one? The greater aim is to put together a picture of why the United States is failing birthing people. Our nation has one of the highest maternal mortality rates among industrialized nations. The hope is that MMR cases will lead to recommendations and direct actions.  

F1 S1 14:26 

Yeah, I mean, there's stuff that we're working on now that I think I remember more like because it's like stuff I know now. So we were talking about like we have a lot of patients that are that we review that don't have any prenatal care and we talk about, you know, like how do we access, you know, get increased access to prenatal care, increase people's engagement with prenatal care, all those things. And, you know, and it's kind of in relation to what when people deliver, they go home and they don't have like a place to, like, reach out to after that. Right. Like if something were to, you know, like they had like symptoms of some sort or, you know, something that was like maybe pointing towards a morbidity, etc., like they're less likely to like, engage with the health care system to get that taken care of. And so, you know, and we talk about these supports in the postpartum period and how do we increase supports and that sort of thing. And it was like something super simple, like why doesn't every person that doesn't have prenatal care, why don't we just engage them in home visiting? Like, it's like it seems so like, wait a second. Like, are we not doing that? Or it was just like, Oh my God, Like, that makes sense. Like, not just like, oh, like, you know, here are a bunch of resources or Oh, this is how you, like, apply for insurance, but like, we're going to do that warm handoff for like some kind of, like support in the in the postpartum period, you know, just to help you sort of, you know, like with things that you might need. Right. And it was just like something simple, like a blanket, like kind of like if this then that is a very easy thing to implement and doesn't take any more resources, can take extra funding or quality improvement or anything. It's just like a matter of like calling all the social workers and saying guys like this is what this is what we decided. Like, can you do this? You know? And again, we have five hospitals. It's easier to just implement that, right, because there's only five of them. And so, like, that's like an immediate like kind of like we can do that. Like, that's like, seems pretty straightforward. Like the least we can do. Is that right? And so it just it was kind of like a like a that would be the the example that comes to mind right now.  

F1 S2 16:34 

Speaking of putting recommendations into action, ASTA, among her many hats, also manages the OVA or organizing Voices for Action. The OVA is a community action team formed to carry out recommendations that come from the Philadelphia MRC. The goal of the community driven Coalition is to implement and support innovative citywide interventions that specifically address the leading contributors to maternal mortality in Philadelphia, the OVA builds upon existing collaboratives focused on target areas, infuses funding into pilot projects with the potential to improve maternal health and works across sectors, to integrate community voices and solutions into policies and programs.  

F1 S1 17:19 

We have a website. It's a birth to just justice Philly.com, so check it out. And that is so that's kind of what it is and, well.  

F1 S3 17:29 

What we're doing.  

F1 S2 17:31 

Beautiful. Asta is been a pleasure chatting with you, although this topic is not very pleasurable to discuss, but thank you for taking us back with you and sharing about your experiences in OPIS and what brought you to this work. And we are just hoping that our listeners can dive into that call to action that you shared with us. So thank.  

F1 S1 17:55 

You. Thank you. Shack And thank you, chef. You guys are such great partners and lucky to call you a friend as well. So thank you.  

F1 S3 18:09 

For the second half of this episode. I will be talking to two Neal Bruce, maternal health coordinator with Baltimore Healthy Start. She describes herself as a brown skinned black woman who wears glasses sometimes and has her hair in LOCs all the time. Tennille is also a biologist, certified breastfeeding specialist, birth doula, yoga instructor and herbalist who has assisted with over 20 plus births.  

18:38 

A lot of people assume that giving birth is the same no matter what city you live in. But as health professionals, we know that the experience can vary widely from one city to the next. So can you share with us what is unique about giving birth in Baltimore?  

F1 S4 18:57 

So giving birth in Baltimore out, you're talking about women that are possibly pregnant and experiencing homelessness or housing insecurity. You're talking about women that are pregnant and may be residing in what's considered a food desert or an area that is a considerable distance from a grocery store or fresh food items. You're talking about women that are pregnant and giving birth and may not have adequate transportation or child care. So as you can see from the examples that I've provided, there are a number of different things that are stacked up against women and families and birthing individuals here in the city of Baltimore.  

F1 S3 19:51 

So what I hear you saying is that the people of Baltimore face certain social determinants of health that affect birth outcomes for those who are listening. Social determinants of health are the conditions in the environment where people are born, live, learn, work, play, worship and age that affect a wide range of health, quality of life and health risk factors. And I know that people get into this work for all sorts of different reasons. I would love if you could tell us more about your position and what you do, and also tell us about the moment that you decided that you needed to be a part of this work.  

F1 S4 20:32 

So I decided to become a team member with Baltimore Healthy Start because I wanted to pursue work in maternal and child health full time. Prior to that, I was serving primarily as a birth doula in the DMV area, so I wanted to take the work that I was doing and continue to do and expand the reach.  

F1 S3 20:58 

Healthy Start is a federally funded initiative that provides grants to local education agency partnerships for program development and implementation. There are over 100 grantees across the nation, and Baltimore is one of them. What has it been like, Danielle Working with the Baltimore Healthy Start?  

F1 S4 21:16 

Baltimore Healthy Start welcomed me with open arms and I have been working in the area of maternal and child health here in the city of Baltimore, of course, wearing multiple hats. But all of those hats having a focus on decreasing infant mortality and also helping to mitigate and decrease the incidences of maternal mortality and also severe maternal morbidity. Mortality, of course, being when an infant or a mother dies and morbidity being when a death doesn't occur. But there's a very close encounter with a you know, with a fatality.  

F1 S3 22:04 

Is there any moment, especially since you have background as a Dula where you are like, This is why I need to do this full time or This is why I need to do this.  

F1 S4 22:16 

Just the stories. I am a treasure trove of stories at this current time. If you were to open me up stories from so many women, so many families would come spilling out. I just really felt the need to put those stories into action.  

F1 S3 22:36 

I kind of want to ask about one of these stories that you have because I would love to know about the first earth that you witnessed and specifically the first birth where you witnessed something that went wrong. What did that day look like? What did it feel like? And really, how has that impacted you.  

F1 S4 22:58 

As a Dula The first birth that I attended and participated in, where something went wrong, I would say the mother's labor wasn't progressing. She was at a bow. She was sitting pretty at about two centimeters and her labor wasn't progressing and she very much desired you'd a natural birth, a vaginal birth. And we tried everything to get her to relax and to open up and to make way for baby. And she just wasn't dilating her. Her labor was not progressing. So of course, the doctors were starting the conversations of Pitocin. They were starting the conversations of, well, if this Terry's on any longer, we're going to have to start exploring a C-section delivery versus AIDS original delivery.  

F1 S3 24:07 

Can you share with us that conversation in which Pitocin came up? What did that look like? Like what are the types of things that you discuss or how does that conversation go to make that decision?  

F1 S4 24:22 

So once the conversation about Pitocin came up there was immediate fear. There was immediate fear and a lot of tears and a lot of I don't want to and  

24:36 

understandably so, because a lot of folks, when they hear Pitocin, especially with regard to childbirth and labor and delivery, they they envision this medical intervention that takes otherwise pretty manageable contractions and taking them to a whole like level to where the pain is unbearable and you're ready to break stuff in the room because you're in that much pain. And the mother that I was serving, the mother that I was working with, her pain tolerance was pretty low. And she made that known very early on in our working relationship. And I took that in. But I also offer it to her. You think your pain tolerance is low now, but you really don't know what you're capable of until you're in the moment.  

F1 S3 25:31 

So what was the deciding factor for mom in this situation?  

F1 S4 25:35 

The mother got very upset because this was not what she had planned. This wasn't what she had envisioned for her birth. Also, her her blood pressure had started to spike a little bit. And, of course, this was more than likely attributed to to stress She had an otherwise healthy and uncomplicated pregnancy. But as we've seen, examples of high blood pressure can present itself at any point during pregnancy, during childbirth. And shortly after. So of course, we wanted to get her blood pressure to a level that was that was safe and that was healthy and suitable. So after having a conversation with the mother and getting her comfortable with pivoting from her birth plan, but still reaching the destination of a healthy mom, healthy baby, she opened herself up to the to the notion of Pitocin. So we got her started on the pitocin and right before it looked like she would need an epidural because mom was a champ.  

26:54 

Mom was a champ. She was taking these contractions like a true like a true warrior. And right before she was at the edge of, I can't do this, I need an epidural. She was checked and she was at about eight centimeters dilation. Her blood pressure was good at that point. And we were just like, Let's get ready to push. Let's hurry up and get this baby here. So although it looked like things were starting to go left rather quickly, we were able to turn things around. And, you know, that's what support looks like. Support looks like listening to the mother and hearing her concerns and addressing those concerns and being able to meet her where she is and being able to hold her hand through the experience, letting her know that she's not alone, letting her know that her voice isn't silent.  

F1 S3 27:52 

Your story is a great example of how viewers can partner not only with patients but with the medical team. Too often people think that having a Dula means that there will be someone in the delivery room forcing an intervention free birth, but that just isn't the case. You are amazing at weighing the options while calming the mom down and helping her navigate her choices. Can you tell me more about what was going on in your mind during that moment?  

F1 S4 28:18 

So in my own personal life, when things start to go left, I immediately start to panic. But when things start to go left for others, I remain very calm. And I think that's I think that's important. And that separates person because I have to be a support to others. I have to be a sounding board. I have to be that that that source of reason in another person's life, in another person's experience. I have to put myself aside what I would do if it were me. I have to put that aside and show up for for the person that I'm with. So I put that into practice with all of my birthing clients.  

29:08 

I tell folks that I provide non-judgemental support. So it's all about what what the mother wants with the mother needs what are her. Okay, I'll consider that and what are her non-negotiables? So when things started to go left, I definitely maintain a calm, maintained logic and maintained reason, and I think that was very helpful in being able to have a very real and a very objective conversation with the mother in that moment.  

F1 S3 29:42 

I would like to pivot a little bit because I want to know more about your work with maternal Mortality Review committees and specifically the one that you work with. How did you learn about the MRC and what made you engage with it?  

F1 S4 30:00 

So ironically, through Baltimore, Healthy starts work with the mark for mothers A safer childbirth cities Initiative. We were able to assist the Baltimore City Health Department in planning out and launching their newly established MRC, and it was definitely a unique lift considering that we did this in the midst of a pandemic. So it's been very rewarding being able to see the MRC in operation and also again just hearing the stories of these women, of these birthing individuals who unfortunately did not live to see motherhood, did not live to see parenthood. You have to be in the right mental space to hear those stories. You have to be in the right emotional and heart space to hear those stories and then looking deeper into those stories and really thinking actively of, okay, what went wrong here? Where was the ball dropped here? What could have been done differently here? How can we show up differently and more effectively and more holistically for mothers in the future so that way we don't experience these types of deaths repeating?  

F1 S3 31:37 

Absolutely. I like that component about providing accountability to the people who are providing services. I think we often missed that, and I believe something unique about the work being done in Baltimore is that you're also doing maternal mortality, morbidity to use review. Excuse me, can you tell us a bit about how that got started? Because the near misses are often not included in this conversation about maternal mortality.  

F1 S4 32:07 

You're right, Christina. The near misses really get glazed over, and yet they tend to make up a higher percentage versus the mortalities. So we're in the process of introducing severe maternal morbidity reviews to the MRA. See, it's definitely been an uphill climb, being able to get the information and the resources necessary in order to perform those types of reviews. So we're optimistic that we'll be able to have those types of reviews and look at those types of cases more closely in the future with the MRC And our organization is actively engaged in partnerships that have a focus on severe maternal morbidity. So we're able to, you know, we're still able to be focused on that particular that particular area and still be at service to two women who thankfully have not died and also thankfully have a story to tell that can help to inform maternity care delivery here in the city.  

F1 S3 33:23 

I'm thinking about that. I'm wondering if you can kind of paint a picture for us of what the Baltimore Review looks like, like how many people are around the table, Who are some of the specialties pregnant, really? How does the conversation go if you could be a fly on the wall.  

F1 S4 33:45 

So first of all, the individuals that sit on the committee come from a number of different backgrounds and experiences. So we have community members at the table. We of course, have maternal and child health individuals at the table. We have physicians at the table, nurses at the table,  

34:06 

individuals from the health department, from the Baltimore City Health Department. At the table we have fellow doulas at the table. We also have individuals that service different populations. So individuals that have experience serving women and mothers with a substance use disorder just as an example. So a number of different people at the table and the Congress sessions are very robust. So because our meetings have been  

34:40 

virtual due to the pandemic, it doesn't stop the conversations from being very engaging and again, very robust. The chair is usually going crazy. The chat feature is usually going crazy during these meetings, and it's because we have a lot to say. We're looking at these cases from a number of different angles and coming to a consensus of, okay, this is what happened, this is where things fell through the cracks and this is how we can endeavor to make things better.  

F1 S3 35:12 

Adding on to that question, have you had or deliberated over cases where racism or discrimination played a part, and how is that discussed on the committee?  

F1 S4 35:26 

So I can say that racism and discrimination more so, comes up in our Fetal Infant Mortality Review Committee, more so than the MRC. And that's because we have the benefit of having interviews from individuals who have experienced a pregnancy loss or an infant loss  

35:58 

with the with the maternal mortality review.  

36:04 

More times than not, we don't have the benefit of of an interview because that mother is no longer here with us. But in the in the femur committee meetings, yes, definitely have encountered cases where racism and discrimination were mentioned in the in the interviews with the mother.  

F1 S3 36:26 

Is interviewing a part of the morbidities review or do you see it being a part of the morbidities, the review? And do you think that there may be more instances of racism and discrimination coming up?  

F1 S4 36:40 

I definitely see racism and discrimination coming up in a future reviews that centers severe maternal morbidity. We were able to see racism and discrimination come up through our patients as partners initiative, where we were able to have focus groups that were made up of women who recently gave birth in the city and they were able to share their birth stories and experiences with us, both good and bad. And those stories helped to inform maternity care delivery here in the city with regard to quality improvement processes at local hospitals. So that was a that was like a small scale model of what I hope to see on a grander scale. Regarding assessment reviews.  

F1 S3 37:35 

Mm. I really like that that connection of the people with the experience to their actual work. Can you share a story that demonstrates how racism and discrimination plays out? Because I think in many people's minds it's explicit racism that is hostile and violent that often comes to their minds. But in birthing settings, it can often come in the form of microaggressions and more subtle actions and implications.  

F1 S4 38:02 

Sure. So one of the mothers she had just given birth, and so she's in the hospital room. She's she's exhausted, understandably. And she was experiencing some discomfort and just some difficulty with with using the bathroom. And she asked her nurse if she could assist her. And and the nurse was was a white woman. And the nurse told her, no, no, I cannot assist you right now. I'm busy.  

38:40 

However, there was a black nurse that was nearby and heard the mother and I agreed to assist her. I agreed to help her and to provide her with comfort because she was very tired. She asked her, you know, would you like me to take the baby into the nursery while you rest? And mother said, Yes, that would be great because I am so tired I can't even think straight. So that was just a small, yet powerful story. An example of how race and discrimination  

39:24 

plays a huge role in how a mother remembers and recalls her birth story, her birthing experience.  

F1 S3 39:34 

I would love to just give you some time to share any final thoughts that you want to leave us with about maternal mortality and maternal morbidity, Anything we didn't touch on that you want to ensure that we hear.  

F1 S4 39:52 

So in the immortal words of MHS MAXINE Reed Vance, who is the deputy director here at Baltimore, Healthy Start Health is in the community. Health is in the community. It's worth repeating. It's so true. A lot of the times when we you know, when we approach research and when we approach certain initiatives and projects that are concerned created in urban or rural areas or other areas of need, we're so driven by the data and we're so driven by a bottom line and that data loses its humanity. That bottom line loses its humanity.  

F1 S3 40:43 

Yes. Having to report back to funders or being asked about the numbers rather than thinking about the people.  

F1 S4 40:49 

When we're talking about maternal and child health, when we're talking about severe maternal morbidity, when we're talking about maternal mortality, when we're talking about infant mortality, we have to remember that there are faces and names behind the data. And we also have to be mindful that there are faces and names on the other side of that data and the individuals that are the ones in need. We have to make sure that the initiatives, the projects, these solutions that we're working towards, that we're proposing, we need to make sure that these things directly benefit and positively affect the individuals that are the most in need. So, you know, throughout this work, I want to keep not so much the data, but the people behind the data at the forefront. I want to always be mindful that these numbers have faces and they have names and they have lived experiences.  

F1 S3 41:56 

I love that so much.  

42:00 

You can connect with Danielle Bruce through Baltimore Healthy start dot org and find her via LinkedIn. Thank you so much for joining us today.  

F1 S4 42:11 

Thank you for having me.  

F1 S3 42:14 

Thank you for listening to our first episode of Breathwork. On behalf of Chack, my colleague Janina and myself, we are proud to be bringing you a series of episodes about cities across America thriving and striving towards better birth. Thank you to Ryan Truman from Story Center. This episode was produced in collaboration with Story Center, and you can learn more about them at Story Center. This work is funded by Merck for Mothers through the Safer Childbirth Cities Initiative. You can follow us on Instagram at better Birth Outcomes or through the Association of Maternal and Child Health Programs. Social media channels. Join us for more stories about what it will take for all families in the U.S. to have the best births.