What we did was meaningful. I was drawn to start this publication because it presented an opportunity to break out of the typical crisis-driven flow and ebb of journalism about the field. Harvard wasn’t a publisher, but it was in the business of sharing knowledge, and I thought we could do for public health what Harvard Business Review does for business. I believed there was no public health without the public, and while it took some feints and half-steps to figure out what that meant for our journalism, we eventually settled on assessing every story idea with a simple question: “What would this story change?” Implicit was a corollary question: “And for whom?”

In the meantime, we relaunched the magazine as a digital publication, built out a social media presence, and launched a weekly newsletter. We co-sponsored a well-attended structural racism symposium and special issue, a series on public health data, a Public Health in Action collaboration with The Studio at the Harvard T.H. Chan School, and an event on artificial intelligence with Johns Hopkins Bloomberg’s Global Health Now. We had momentum—visitors to the site almost tripled in last year’s fourth quarter versus the prior year. Almost 15,000 people signed up for Harvard Public Health Weekly, close to 90 percent of them not connected to Harvard.

Readers ate up pieces on processed foods, the health effects of alcohol, and mental health. You also read our beautifully written and photographed narratives like the 10^th anniversary of the Flint water crisis or our look at Christian Happi’s bold aims for African science, and public health’s role in the recent Puerto Rican elections.

Our goal was to publish stories that would help improve health outcomes. That’s hard to measure in three-and-a-half years. But over 40 percent of you opened the newsletter in a typical week. In the last year, readers shared our articles more than 2 million times on social media. We’ve had at least 25 stories republished on other sites and 40 mentions in newsletters. Our stories have been cited in other publications and used in classrooms.

Public health outcomes change slowly, so it’s harder to measure real-world impact. I would love to hear from you about trying an idea you read about in HPH, or even if you just shared the idea with a colleague. Did you use an article from HPH in a class or a meeting? It would be great to hear from you at our inbox, magazine@hsph.harvard.edu. It will be live for a few more months. So will the site, and I encourage you to download articles you found useful.

The pandemic sparked a surge of public health journalism. These are the sites and newsletters I follow closely or scan regularly, and recommend to you:

• Axios Vitals
• Devex CheckUp
• The Examination
• Global Health NOW
• The Harvard Chan Studio
• KFF Health News
• MindSite News
• Public Health Watch
• The Healthiest Goldfish
• Your Local Epidemiologist
• ProPublica
• STAT Morning Rounds
• TradeOffs (podcast)

Also, the new Healthbeat is off to a promising start, focusing for now on Atlanta and New York City.

I have had a long and varied journalism career, much of it spent chronicling the vast impact of high technology. I have never done more meaningful and important work than what we were doing at Harvard Public Health. I am so thankful to the school, colleagues past and present and our fabulous advisory board, everyone who gave me informal counsel, and all the readers who reached out. I rue that we won’t be able to continue. But a wonderful thing about public health is its focus on the public. It is political with a small ‘p,’ rooted in communities.

What’s most important is that you in the public health community (and in the public) stay engaged in doing the good work you do. Keep telling your stories!

Onward,
Michael F. Fitzgerald

The post A farewell to HPH readers appeared first on Harvard Public Health Magazine.

Recent expansions to Medicaid—which covers about 41 percent of U.S. births—aim to address maternal health. Yet, these programs do not address stillbirth and infant deaths. Nor are they enough for mothers. Medicaid makes coverage decisions without prioritizing the data necessary to understand the problems, discouraging hospitals from providing care by pushing them into bankruptcy. Further, it fails to offer coordinated medical services, deliver urgently needed health care information to patients, or ensure the adoption of new life-saving technologies.

Replacing Medicaid’s maternal and child health coverage with a nationwide managed care program for pregnancy, birth, and infant care would align our national goals for healthier babies and mothers with a system that can deliver on them. Let’s call it “Medi-Mom.”

Medi-Mom would hold providers accountable for outcomes, promote modern technology to lower costs and improve quality, and enable access to all through public funding or private pay. It would operate similarly to Medicare Advantage plans that provide coverage to seniors through private insurance.

We have models for effective, evidence-based programs to manage complex conditions. The private companies and nonprofits that run them support community-based teams of primary care doctors, specialists, and social service providers, giving them autonomy to improve patient health outcomes and better manage costs.

One of these initiatives, the Program for All-Inclusive Care of the Elderly (PACE), has saved $6,000 on average per person compared to Medicaid expenditures for nursing facilities. During COVID-19, PACE providers moved quickly to educate patients, adopt telehealth, and coordinate with services such as meal and medication delivery. As a result, the infection rate among PACE participants was lower than comparable nursing home populations.

This approach shows so much promise for pregnant patients and their families that the Veterans Health Administration has recently expanded a similar program. It provides mothers and infants with comprehensive social, physical, and mental health support.

Focus on outcomes and access

Here are some ways Medi-Mom insurance plans would improve maternal and infant health:

Accountability. Medi-Mom would operate through a network of health care providers contracted by the Department of Health and Human Services, who would be paid a fixed amount per patient. They would be expected to use data to anticipate care needs, create goals for patients and performance targets for program leaders, and give interdisciplinary teams the authority to achieve them.

Medicaid metrics largely target processes like better care and smarter spending: Leaders are not accountable for specific patient or population outcomes. Medi-Mom would focus on pregnancy and infant outcomes based on actionable, reliable, representative data that Medicaid lacks today.

Focusing on outcomes would encourage providers to collaborate with the dozens of agencies that support families but are not considered to be health care, like the Supplemental Nutrition Program for Women, Infants, and Children (WIC). Care coordinators could be covered as a core service. Research shows that when new moms on Medicaid get help to access medical, social, public health, education, and other services, this reduces infant deaths.

Technology. Using remote monitoring and telehealth technology for postpartum care would help avoid costly and dangerous rehospitalizations. For example, 10 percent of breastfeeding mothers develop mastitis infections and visit the emergency room, when the condition can be easily diagnosed through a telehealth appointment and treated with antibiotics at home. However, Medicaid reimbursement for remote monitoring, telehealth, and other modern technologies in obstetrics is low compared to other conditions and varies by state.

Meanwhile, Medicaid continues to reimburse doctors for using a six-decade-old technology, electronic fetal monitoring, despite evidence that it does not reduce stillbirths. In addition, disproportionately low reimbursement rates for obstetrics create a financial strain for the 80 percent of providers whose patient caseload is primarily covered by Medicaid. They have little time and few resources to innovate.

One provider in Alabama observed in Time that Medicaid pays a total of $1,000 for nine months of pregnancy and postpartum care—and $1,600 for a one-hour joint replacement. In contrast, Medicare reimbursement rates are 30 percent higher on average for fee-for-service physician services than what Medicaid pays for similar services, both of which are lower than commercial plans. And Medicare’s New Technology Add-on Payment program, introduced 20 years ago, has increased providers’ utilization of new technologies by 134 percent.

Access for all. Medi-Mom eligibility would not have to be limited to low-income individuals. Privately covered and uninsured families could purchase a plan.

Small and medium-sized employers that struggle to provide health insurance could offer Medi-Mom to their employees. Expanding access beyond low-income patients may also reduce the overall cost per person of Medi-Mom in part by spreading risk across a broader patient population.

Further, Medi-Mom would be jointly funded by Medicare and Medicaid, reducing state program costs and expanding low-income patients’ eligibility to include at-risk mothers and infants. Like patients who have other life-altering and unique health conditions, these patients require more than routine care. (Medicare already funds some younger people with disabilities or complex chronic conditions—about 10 percent of Medicare recipients are under 65—including some people who are pregnant.)

Saving lives with comprehensive care

Providing comprehensive maternal and child health care can save lives and money. But it requires bold leadership and a willingness to hold program leaders accountable for performance.

Making Medi-Mom a reality will require champions at the federal and state levels to highlight gaps in the Medicaid system. The HHS secretary should start by convening a dialogue with policymakers, providers, philanthropists, insurers, and the real experts—families who can share their experiences with maternal and child health care or the lack of it. In addition, the secretary should create a “moonshot” team of private sector business leaders and public health leaders with proven track records as innovators to implement the program in the next year.

Political leaders say they want U.S. families to have more babies. If we are serious about ensuring mothers and babies survive and thrive, we need to stop accepting the status quo. It’s time to move past Medicaid and replace it with a program that prioritizes preventing infant, stillbirth, and maternal deaths. Done right, Medi-Mom can be a lasting legacy.

Image: FatCamera / iStock

The post How to reverse the decline in U.S. maternal health appeared first on Harvard Public Health Magazine.

That day, she says, she only noticed the stain as she arrived at the senate. She went inside the chamber anyway to draw attention to her cause: The lack of menstrual pads coupled with period shame is a reality faced by millions of girls and women in Kenya. But the first-term senator was ruled out of order by fellow legislators and castigated for violating the chamber’s dress code.

Even before this, Orwoba had been fighting against stigma—and “period poverty” more generally—through public service. In particular, she’d negotiated with government leaders to reduce corporate taxes that drive up the cost of sanitary pads. It’s one of the causes that paved her way to senate, where she holds one of the seats reserved for women’s affairs. Gender is the lens she brings to most of the bills she sponsors, and she works with peers in Uganda and Ghana on menstrual hygiene issues.

Orwoba sat down with Harvard Public Health contributor Lenny Rashid Ruvaga in Nairobi, Kenya to discuss three of her big ideas about periods. This interview has been condensed and edited.

Harvard Public Health: Recently, Parliament passed the Sanitary Towels Provision Bill you sponsored, ensuring an impressive funding increase for menstrual pads in public institutions, including schools and prisons. After a threat from the legislature to halve the budget for pads, you managed to get Parliament to double it, to 940 million Kenyan shillings (about $7.3 million). How did you do it?

Orwoba: You know, at the beginning of my advocacy, I was not so familiar with dealing with opposition. It really used to bring me down. For me, the most difficult moment was that the people that you are fighting for [sometimes say] that it’s not really an important [issue]: “Why are we talking about this?”

Now this is the beauty of moving from the civil society space into the public service space and into politics. From the civil society space, you are limited to public participation, demonstrations. You are outside. As a politician, you’re suddenly sitting in State House with the president, saying, “Mr. President, we are bleeding too much, and [the current budget] is not gonna cut it. We need one billion.” And, you know, those conversations for me are the highlight: This is what you can do with this position, as a woman in power. And I was so excited when those conversations behind the scenes materialized into [effectively] tripling the national budget allocation for pads. And now we have more girls receiving the free sanitary towels in schools.

HPH: You were an activist before you were a politician, and movement activism is often about working together. In your experience, do women parliamentarians also work together in the fight for more sexual reproductive health rights? Even across party lines?

Orwoba: I hate to be the person that says it. Women parliamentarians work towards the fight of representation, but they don’t work together. Most of my critics, of the people who have not really been supportive, have been women. I don’t know if it is inbuilt, but I would say as women parliamentarians of Kenya, we work towards representation of more women, but we don’t necessarily work together on it. That is the truth.

But why are women always being pushed to work together? Men are never being pushed to work together. Why should we always be united? As long as we are all working towards a common goal in our spaces, I don’t think the agenda should be uniting women for women. I think the agenda should be ensuring that every woman in a space of power and influence should be able to fight for more women.

HPH: What about male legislators?

Orwoba: Actually, male legislators have been more supportive towards the [sanitary towels] bill. For female legislators, it always feels like we are competing amongst each other. So it becomes a bit difficult to collaborate because it’s more about who is pushing the bill in terms of the mileage they get. Most of my partnerships are with the male legislators [for whom I] make it feel less awkward to …. just start talking about menstruation.

HPH: Last year, independent of your work as a parliamentarian, you launched something called “The Glo Pad Bank.” Tell us what that is.

Orwoba: After the stain incident, and all of the negative backlash and online bullying, I was, having a conversation with my sister and a couple of friends. And they said, you know what? I liked that you went and distributed pads. But, you know, you need to scale this up. You need to get a lot of people to bring you pads. And because we don’t want any kind of scandal related to money that is being sent to you.

HPH: Meaning, money is not always a useful tool in a country where corruption is high and rumors abound, right?

Orwoba: Exactly. So my friends said, how about we just, you know, station a 20-foot container somewhere, and people can just drop the pads? Simple. The next thing you know, one of the one of my friends said, I’m going to buy the container. There was no there was no working group. There was no think tank. It was really like, we don’t wanna deal with money. We want people to bring pads.

HPH: You want to launch Africa’s first menstruation museum. Can you share more about that?

Orwoba: You know, we take our kids to school. When they’re in school, they are going all the time to our museums. It doesn’t matter which country you come from; there is always a subject that will take kids in primary school, in high school, in universities to a museum, so that they can learn about history, or scientific things. You know, in Kenya, we are the cradle of mankind.

We show that in our museums. And I’m like—show where we came from, yes. And we all came from periods.

Back in the day, in Africa, there are many places where we had the period huts, where it was like a sacred place that you would be told to sleep and stay in because this is such a sacred time in your life. It’s like learning about how the world came about.

And over the years, we have had, such development in that space, you know? Like, who thought about a tampon? Why did they think about it? What informed that decision? All of that needs to be documented, displayed, for people to learn, understand, and appreciate So that by the time we are literally phasing off this stigma and this shame, it is not only because we have made loud campaigns over billboards about how you should be proud of your periods, but it’s also on the basis of the understanding of what the sanctity of menstruation is. And for me, that can only be done by educating our children from a very young age.

The post Battling period poverty in Kenya appeared first on Harvard Public Health Magazine.

—Leah Samuel

(Study in Health Services Research, September 2024)

The post Do Black women get C-sections more often than White women? It’s complicated. appeared first on Harvard Public Health Magazine.

—Sarah Muthler

(Study in Open Forum Infectious Diseases, September 2024)

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In the U.S., Hispanic women have been disproportionately affected by the HIV epidemic in recent years. Yet they’ve been less likely to take advantage of PrEP, a medication that significantly reduces the risk of getting HIV.

So we created a pilot intervention to inform more people about the medication by adding it to an existing and proven HIV-prevention program aimed at heterosexual Hispanic women. All of the participants in the pilot—none of whom previously were aware of PrEP—said they were satisfied with the intervention, and the vast majority learned a great deal. These results lead us to believe that this could be a good way to lower rates of HIV in the Hispanic community.

We are scientist nurses who research HIV prevention among Black and Hispanic women in South Florida.

Along with our team, we established SEPA+PrEP. It is an intervention that uses community engagement that is culturally tailored to Hispanic women to promote HIV prevention.

The program builds on the existing SEPA intervention, which was developed in 1999. SEPA, which in Spanish stands for health, education, prevention, and self-care, was created for Hispanic women 18–49. It has been shown to increase condom use and decrease intimate partner violence and substance abuse.

To create SEPA+PrEP, we adapted and updated the original SEPA intervention and added content about PrEP. We piloted the program with 44 Hispanic women in Miami-Dade County. The women attended three weekly sessions, each two hours long. Participants took part in discussions and role-playing activities, while practicing their communication skills and interacting with their peers.

None of the participants knew about PrEP prior to the study, and 70 percent had not used a condom for vaginal sex in the previous three months. More than half reported that they were not concerned about getting HIV before participating in the program.

After the intervention, we used questionnaires and focus groups to measure its acceptability and feasibility. All of the participants reported being satisfied with it, and 89 percent demonstrated comprehension of the information provided.

Overall, SEPA+PrEP was found to be an acceptable and feasible way to teach Hispanic women about PrEP and other forms of HIV prevention, such as condom use and HIV testing.

Why PrEP access matters

Although HIV infections in the U.S. have decreased by 12 percent since 2018, the rates among Hispanic women have remained steady.

Hispanics make up 17 percent of U.S. women but 21 percent of those living with HIV, according to the Pew Research Center.

In 2022, Hispanic women were almost three times more likely to be diagnosed with HIV than non-Hispanic white women.

Despite the high rates of HIV transmission among Hispanics, data shows that only 17 percent of PrEP users in the U.S. identify as Hispanic. This percentage is significantly lower than the proportion of Hispanics who are actually at risk for HIV.

Researchers have identified two main reasons for this disparity in PrEP use. First, social services providers that work with these communities don’t seem to realize that PrEP is readily available and effective. As a result, they rarely offer Hispanic women the drug as an option for HIV prevention. Second, Hispanic women—particularly immigrant Hispanic women—have limited access to health care due to financial barriers and a lack of health insurance.

What’s next?

Now that we know SEPA+PrEP can effectively teach women how to use PrEP, the next step is to determine whether the program actually compels women to start taking the drug.

Additionally, we aim to investigate whether SEPA+PrEP can address other issues related to HIV risk, such as intimate partner violence. Our team is also working on adapting SEPA+PrEP for Black women, who are also disproportionately affected by the HIV epidemic.

Image: klebercordeiro / iStock

The post Hispanic women are less likely to get PrEP treatment. A new intervention could change that. appeared first on Harvard Public Health Magazine.

Love was in the middle of moving back to her hometown of Greensboro, North Carolina, from Raleigh when she found out she was pregnant with her first child. It was 2020, and she and her husband had always wanted to start a family.

“I was happy,” she says. “We’ve been trying to get pregnant for a while.”

But when the mom-to-be began to navigate the local health care system, her happiness turned into frustration. In her first trimester, Love bounced from one OB-GYN to another, never truly landing on one who asked her about her wants and needs or discussed any risks. She was constantly being referred to other providers and doctors.

“I was told to go to one provider, and then another,” says Love, who agreed to share her story on the condition of anonymity. “And I always felt like I was having to explain myself over and over, so that provider could get to know me.”

The problem was with Love’s insurance. For some pregnant people, insurance does not cover enough expenses, or they don’t have coverage at all—which can have real medical consequences. But for the past two decades, a program in North Carolina’s Guilford County has been working to fill that gap and provide people like Love with high-quality care.

Widening the safety net

At the time of her first pregnancy, Love had a high-deductible plan through her job as a mental health professional. Though it covered her primary care well enough, it gave her few options when she became pregnant. From a lack of choice in providers to pricey co-pays for pregnancy-related services, her care was minimal, inconsistent, and expensive.

“I had a plan where I had to pay like $6,000 before they would pay for anything,” Love says. The price for maternal care [was] around $400 per month. In her second trimester, she routinely visited an OB-GYN working for the Guilford County Health Department. When she went to the receptionist, she was informed that her appointments were going to continue to come with a hefty price tag.

But there was help. They told her that Guilford County residents could receive financial aid from a program called Adopt-A-Mom, run by Every Baby Guilford County. The program could help cover her expenses for maternal care if she was ineligible for Medicaid. She was.

For Love, Adopt-A-Mom did more than help with expenses. It finally gave her the pregnancy and birthing experience she wanted.

Love is what the Guilford County Department of Health considers “underinsured.” According to the most recent Commonwealth Fund Biennial Health Insurance Survey done in 2022, people who are underinsured have access to health insurance all year “but their coverage doesn’t enable affordable access to health care.”

The same survey found that 43 percent of working age adults were inadequately insured: nine percent were uninsured, 11 percent had gaps in coverage, and the remaining 23 percent were underinsured. This is despite record highs in national coverage.

Being underinsured or not insured at all causes financial hardship for pregnant people. According to the Guttmacher Institute, the high costs of pregnancy hinders people from getting early care and therefore increases the chance of pregnancy complications—including infant mortality.

That’s something experts in Guilford County have known for decades. In 1988, a group of local medical practitioners studied the reasons behind the high rates of infant mortality and found that many pregnant people were either underinsured or didn’t qualify for Medicaid. And as is the case nationwide, Black people suffered the highest level of infant mortality.

To help eliminate disparities in prenatal care and parenthood, county officials created the nonprofit Guilford County Coalition on Infant Mortality in 1991. Three years later, they launched Adopt-A-Mom, a program which helps coordinate prenatal care for expectant parents who are ineligible for Medicaid and who are experiencing a low- to medium-risk pregnancy.

Jean Workman, the program director of Every Baby Guilford, defines a low- to medium-risk pregnancy as a pregnancy in which the birthing person has normal blood pressure and isn’t dealing with gestational diabetes.

“This means if they were able to get into early care, they’re not having to mitigate any issues,” Workman says. In other words, if the barrier to a safe pregnancy can be helped with regular appointments and financial support, Adopt-A-Mom can help. (Higher-risk pregnancies are usually defined by other health conditions and age.)

Adopt-A-Mom works by developing relationships with various OB-GYNs across the county, asking them to provide services to their clients at reduced prices. This year Adopt-A-Mom has contracted with seven providers.

Their clients get to choose from the list of providers, and the program covers the cost of the visit. They also negotiate discounted rates for lab work and ultrasounds on their clients’ behalf.

Although the first major racial disparity the county found was between Black and White people, Workman is also worried about another growing population of Adopt-A-Mom clients: uninsured Latinx people. Since 2020, Workman and her team found that there was an increasing need that she guesses might be from a general increase in the Latinx population as a whole.

Since the 2020 census, Guilford County has seen about a 10 percent increase in the Latinx population. As of 2019, there were about 15,000 people with an “unauthorized” status, the majority of which are from Mexico. About 42 percent were women and mostly of reproductive age. For Adopt-A-Mom, that figure is relevant because it means more people who are ineligible for Medicaid. The lack of a safety net like Medicaid creates a culture of reaction versus prevention. Elbia Altamirez, patient coordinator for Adopt-A-Mom, explains that when people lack insurance or are underinsured they’re less likely to attend regularly scheduled check-ups, or take over-the-counter medications for chronic symptoms, and they only interact with the local health care system in costly emergency room visits. And that same thinking doesn’t change with pregnancy.

“A lot of individuals that we serve, since they don’t have or they don’t qualify for Medicaid, they don’t have medical coverage and they don’t have the means to pay for that,” Altamirez says. “So 90 percent of the time they are not even enrolled in medical practices.”

Many states have some version of Medicaid or CHIP—the government-subsidized health insurance program for kids—or Medicaid expansion. Some [programs] are for “lawfully residing” immigrants, or there are some expansions just for pregnant undocumented immigrants, or only for undocumented children. Some states like Florida and Arizona have a limited waiver.

Just this year, California became the first state in the nation to expand health care to undocumented immigrants through their low-income state insurance program Medi-Cal. North Carolina also recently expanded its Medicaid coverage in December 2023, but only by income limits, which Wakeman says helped a lot more Black families find coverage.

“Unfortunately Medicaid expansions [in NC] have never covered undocumented immigrants,” Wakemen says. “But that’s why our programming needs more support than ever.”

Since its founding, Adopt-A-Mom has helped nearly 10,000 people. “And it’s only growing,” says Altamirez.

Improving outcomes for the most vulnerable

Love chose to have a home birth for both of her pregnancies—the most recent baby, another boy, came last October. For her, the choice came easily. Advocating for one’s own medical and mental health is something she helps her own clients do as a mental health professional.

“They were pretty open to it,” Love says about the program’s support. “I let them know pretty early on like, ‘Hey, I’m not a radical. If there’s something that you feel like I need, I’m always open and receptive to that.’ Whatever [clinicians] recommend, I’ll go back, do some research and when I come back, I have an answer as to if I would like to move forward with this or not, and I’ll tell you why.’ But I do like to make those informed decisions.”

She’s well aware that the experience for other pregnant people may not be as smooth.

“I’ve heard other stories with women who go to a provider and the provider is kind of against whatever it is that they want and so they don’t feel comfortable saying things like, ‘I’m having a home birth,’” she says. “Some people keep that a secret, when in reality is, you know, everyone’s on the same page or outcomes can be better.”

It’s a story that is common for a lot of people, but particularly for Black people. According to the Centers for Disease and Control and Prevention, Black women are three times more likely to die of pregnancy complications compared to White women even though 80 percent of pregnancy-related deaths are preventable.

Those statistics echo in Guilford County. Despite Adopt-A-Mom’s efforts, and the overall infant mortality rate trending down, Black babies still make up the majority of infant deaths in the county. Adopt-A-Mom’s 2022 Report shows that Black babies make up 52 percent of all infant deaths.

According to the Commonwealth Fund, things like lack of empathy, the failure to hire and retain Black doctors, lack of communication, poor outpatient follow-ups, a long racist history with unethical medical experiments on Black bodies (some of the most egregious are in the field of obstetrics and gynecology), and other elements contribute to the high rate of medical mistrust within Black communities. So Love isn’t surprised that Black maternal mortality is in the headlines these days.

“I can only imagine someone that doesn’t have my level of experience and knows how to navigate certain systems and do research,” she says. “They would probably feel very hurt [by the health care system].”

But there is a growing movement nationwide to change that. Democratic U.S. Reps. Alma Adams, from North Carolina, and Illinois’ Lauren Underwood, for instance, established the Black Maternal Health Caucus which aims to make improvements in Black maternal care and pregnancy outcomes a national priority.

“The statistics around Black maternal health are horrifying, and they haven’t improved in 30 years as maternal health outcomes overall have worsened,” Underwood said in a press release announcing the caucus’s founding. “But this issue extends beyond statistics for too many women and families, it’s their reality.”

Then there is the Black Mamas Matter Alliance, or BMAA. The group serves as a resource and podium that amplifies the work of their 40 partners which are locally-based organizations that provide various services. Atlanta Doula Collective for example, provides professional labor support and sometimes even at a discounted rate when funding is available.

Another BMAA partner is Black Health New Mexico. The organization is part practice, part health educator and part advocacy group. They’ve created a mental health program for new parents, contributed to a curriculum for young parents and have helped galvanize practitioners and organizations for equity in Black and BIPOC health. What all of BMAA’s partners have in common is they all work to advance Black maternal health, rights and justice.

As for Love, she’s grateful she had a local program like Adopt-A-Mom for both of her pregnancies. It allowed her to meet with her doula who introduced her to a lactation specialist. Her doula even began attending birth classes with her and her husband. Both of her pregnancies were healthy, and both went according to her plan.

“When it comes to birth, so many people are unprepared,” she says. “It’s not enough for it to be just you. You really need some people in your village to be a part of it.”

Image: shurkin_son / Adobe Stock

The post Adopt-A-Mom wants to eliminate pregnancy disparities in North Carolina appeared first on Harvard Public Health Magazine.

When Mana Parast was a medical resident in 2003, she had an experience that would change the course of her entire career: her first fetal autopsy.

The autopsy, which pushed Parast to pursue perinatal and placental pathology, was on a third-trimester stillbirth. “There was nothing wrong with the baby; it was a beautiful baby,” she recalled. We’re not done, she remembers her teacher telling her. Go find the placenta.

The placenta, a temporary organ that appears during pregnancy to help support a growing fetus, didn’t look as it should. Instead, it “looked like a rock,” said Parast. As far as they could tell, no one had ever examined this patient’s placenta through her pregnancy, and it was her fifth or sixth stillbirth, Parast recalled.

Every year, there are approximately five million pregnancies in the United States. One million of those pregnancies end in miscarriage, and more than 20,000 end in stillbirth. Up to half of these pregnancy losses have unidentified causes. Recent and ongoing research, though, suggests that the placenta may hold the key to understanding and preventing some pregnancy complications, such as preterm birth and maternal and infant mortality. A closer look at the placenta—including its size and function—may have a significant impact on stillbirth rates.
Still, the placenta and its pathologies have largely been understudied, some clinicians say. There are multiple reasons why: the difficulties in studying a fleeting and dynamic organ, the limitations in researching pregnant people, a lack of scientific consensus, few prospective studies, and the absence of standardized pathology reports on placentas.

Some groups are working to change that. The placenta “is this complex organ that’s critical to support fetal development, so you would think we know everything about it,” said David Weinberg, project lead for the Human Placenta Project, or HPP, an initiative by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The project has awarded studies more than $101 million from 2014 to the fall of 2023 to develop better assessment tools for the placenta while it is growing inside a pregnant person.

Placental research is an area of obstetrics that is sorely lacking, according to Weinberg. While limited research has been done on abnormal placentas after delivery, the HPP research teams realized in early meetings that if they wanted to improve outcomes, they’d need to know more about what a normal placenta does over the course of pregnancy. They are one of several U.S. based teams tackling this issue.

The shift in research is a welcome one for Parast, who is now director of the Perinatal Pathology Service and codirector of the Center for Perinatal Discovery at University of California, San Diego, and has received HPP funding for some of her work. But more should be done, she added, including adopting a more cooperative approach to applying new findings: “If we’re going to do this right, we have to come at it with this mindset.”

The human placenta does a lot of work for the fetus; it is, effectively, the fetal lungs, kidneys, and digestive tract. It’s also one of the only organs in the animal world that consists of two separate organisms—with tissues from both the mother and fetus—as well as the only temporary organ.

The placenta evolves across a pregnancy, too, continuing to support the developing fetus while interacting with the maternal environment, said Weinberg. The research has, so far, shown that issues with the placenta—its size, its placement, its microbiome—can signal health problems with both pregnant person and fetus, such as preeclampsia, gestational diabetes, preterm birth, and stillbirth.

As researchers have tried to develop ways to observe the placenta throughout the course of an entire pregnancy, they’re facing challenges, though. It’s difficult, for instance, to study the organ before a birth, due to potential risks both for the woman and for her developing fetus. Pregnant women have been historically excluded from medical trials, according to National Institutes of Health Office of Research on Women’s Health. The potential reasons include threat of legal liability should the study harm the fetus and the complex physiology of the pregnant body.

Because research on pregnant women faces so many restrictions, the largest body of placental research has been done after birth in a pathology lab. Here, the organ is typically only examined after a poor pregnancy outcome, such as stillbirth or placental abruption, in which the placenta pulls away from the uterus wall and causes heavy bleeding.

Placental pathology, though, has also long had limitations. “No one in their right mind was studying placentas,” said Harvey Kliman, director of the Yale School of Medicine’s Reproductive and Placental Research Unit, when recalling the early years of his pathology training in the 1980s when the organ was particularly understudied. As a medical student, he said, “I was discouraged from going into OB/GYN. I was told you can’t really do research on pregnant women. This is still basically true.” Conducting OB/GYN research can be particularly challenging compared to other fields of medicine, he added.

While the advanced pathology residents were working on cancer, Kliman said newer residents started in the basement morgue performing autopsies on placentas and fetuses. Even today, there is a hierarchy in pathology, and placental pathology is at the bottom, he said, akin to “scrubbing toilet bowls in the Navy.”

“A placenta review after loss can take up to six months because there’s no priority—there’s no patient on the table,” said Kliman. Most pathologists, he added, “don’t see the human side of this at all. I deal with patients every day. This is very real to me.”

Parast said that the culture of pathology is partly responsible for lack of placental recognition, because they [pathologists] often work in isolation from each other: “If there’s a perinatal pathologist, they’re the only one. So few people are doing this.”

Historically, getting pathologists to come together and agree on the details of placenta work is difficult; to change that, Parast has been working with PUSH for Empowered Pregnancy, a nonprofit that aims to end preventable stillbirths, along with other advocacy groups such as Star Legacy Foundation. Parast has also pushed the Society for Pediatric Pathology to come together and standardize the way placental autopsy reports are written. This a big complaint among obstetricians and advocates, she said, because when it comes to the reports as they are now, “no one understands them.” She added that clinicians also need more training on how to interpret them.

Placenta research is also hampered because of how science is done more broadly, said Michelle Oyen, an associate professor of biomedical engineering at Washington University in St. Louis. Competitive grant proposals and funding incentives tend to dissuade collaboration and methodology sharing. But building improved obstetrical outcomes requires collaboration between engineers and OB/GYNs, she explained. Historically, she added, there hasn’t been a relationship between those fields unlike other areas of medicine, such as orthopedics or cardiology.

Also at issue are shame and stigma around pregnancy loss—and women’s health in general. “It’s not just about the science, it’s about the fact that these problems are much bigger than most people understand,” Oyen said, referring to the systemic gender-based obstacles in medicine. And NIH funding, which supports biomedical and health research disproportionately goes to diseases that primarily affect men, according to a 2021 study published in the Journal of Women’s Health.

Furthermore, a 2021 study in the journal Science showed majority female teams of inventors are much more likely to pioneer new inventions in women’s health than majority male teams, said Oyen, “so it is a patriarchy issue.” With the majority of patents being held by men, “there is a balance problem there.”

That may be changing. “Women’s health is having a moment. Those of us who have been working quietly on this for 25 years are laughing about it,” she added. “Like we’ve been doing this this whole time, and suddenly, you’re really interested in it.”

Research efforts like the Human Placenta Project aim to build a new research base on the ephemeral organ. Now, 10 years into the HPP, researchers have a better understanding of the organ and its role in pregnancy outcomes. They are developing tools to monitor the placenta non-invasively, Weinberg said, such as advances in magnetic resonance imaging and ultrasounds, both of which can help better visualize the placenta and its blood flow.

“We’re at a point of clinical validation,” he said. “Researchers think they have a measure that can indicate whether or not a fetus may be a risk.” Prospective studies are the next step.

Unfortunately, none of these projects will be market ready in the near future, he said, although he argues that the project has brought national attention to the placenta.

“I do believe the HPP raised global awareness,” said Weinberg. “Things that seemed sci-fi not that long ago are now a possibility.”

Still, some clinicians and advocates are disheartened by what they feel is slow progress with big projects like the HPP, including Kliman and the advocacy groups PUSH and Measure the Placenta. Kliman’s placental research has highlighted the role of a small placenta as the leading cause of stillbirth. An unusually small placenta, he said, is a stillbirth risk because fetuses can grow too large for it; this may cause the fetus’s growth to stagnate, or make the organ simply give out.

Diagnosing a small placenta is “low-hanging fruit,” he said, estimating that it could prevent 7,000 stillbirths per year.

Lead image: Nastasic / iStock

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Rehri Goth is not an outlier. During my more than 30 years as a doctor, I have seen time and again how women’s health is overlooked. Women lack access to basic care, and they consistently eat least and last. These biases can create intergenerational ill health. That’s one of the reasons I jumped at the chance to lead the Bill & Melinda Gates Foundation’s gender equality work. I’m consistently frustrated at how little basic knowledge we possess about what to do to improve women’s health. Part of my work at the Gates Foundation is dedicated to filling these gaps.

The history of women’s health is one of neglect. For too long medical research has revolved around male physiology, despite clear sex and gender differences in health and disease. As a result, much of what is understood as fact about how to treat women’s health lacks a basis in science. For instance, the amount of blood loss needed to “qualify” as PPH was arbitrarily chosen decades ago. The ways in which conditions like asthma or cardiovascular diseases might manifest in women are often misunderstood, which can lead to misdiagnoses and delayed care. Research for conditions that specifically affect women, like endometriosis and menopause, receives a tiny fraction of funding compared to male-specific conditions like erectile dysfunction.

Systemic negligence—including the lack of effective treatments, poor care delivery, and the overall dearth of scientific research that centers women’s health—has driven gender disparities in health outcomes. A January report from the World Economic Forum and McKinsey Health Institute revealed that women spend 25 percent more of their lives in poor health compared to men. This is not because women live longer than men, on average; it’s largely a result of the systematic lack of sex- and gender-specific disease understanding. Billions of women and girls are thus denied the opportunity to be full and active participants at home and in society. Closing the health gap would infuse the global economy with an additional $1 trillion every year, as more women are able to join the workforce, according to the McKinsey report.

Everyone has a right to health care that is evidence-based and appropriate for our bodies. This is not a question of getting marginally better outcomes around the edges. It lies at the very core of gender equality and the well-being of communities around the world depends on it.

The good news is solutions are closer at hand than we may realize. PPH is the leading cause of maternal death worldwide in part because in the past 30 years, only two new medicines have been developed to manage such severe bleeding. In 2019, the Gates Foundation funded a large international clinical trial, called E-Motive, to determine what bundle of interventions would most effectively prevent maternal death from PPH in low-resource settings.

One of the most useful was serendipitous. Assessing PPH had previously been done by birth attendants eyeballing the size of the pool of blood on the ground. To standardize measurements, initial tests of treatments used a drape to funnel the blood into a container marked with volumes. This led to a clinical trial using a calibrated drape. The trial results, published last year, show the drape helped birth attendants keep better track of blood loss during deliveries, prompting quicker treatment for PPH. The tool was combined with other simple, readily available interventions, such as uterine massage and oxytocin, which together decreased cases of death due to severe bleeding by 60 percent.

Imagine what will happen when there are finally adequate resources devoted to addressing these challenges. 

We need more such research and development efforts, and I think we’re going to see them. I am optimistic that funders, policymakers, and researchers are finally seeing both the need and the opportunity to revolutionize women’s health. Recently, building on the launch of First Lady Jill Biden’s White House Initiative on Women’s Health Research, President Joe Biden signed an executive order that expands and prioritizes women’s health across U.S. federal research agencies—including with new funding. The U.K.’s Foreign, Commonwealth and Development Office committed new funding aimed to improve the health of women around the world.

In January, I became cochair of a World Economic Forum initiative, the Global Alliance for Women’s Health. This group brings 42 companies, NGOs, and foundations together to bring new resources and attention to women’s health. We’ve garnered more than $50 million in committed new funding to address women’s health by, for example, bridging gaps in menstrual health; increasing access to tools that reduce PPH; encouraging health innovations that meet women’s diverse needs, preferences and lifestyles; and exploring new financing models to increase funding for women’s health.

The Gates Foundation is hoping to make it easier for stakeholders to act. Last year, we partnered with the National Institutes for Health to develop the Women’s Health Innovation Opportunity Map, highlighting 50 high-return opportunities to advance women’s health research. Some, like promoting gender- and sex-specific health research and investing to equip the next generation of women’s health leaders, are already under way. Another way we’re working to make women’s needs and voices central to research and development is by supporting organizations like WomenLift Health, which recently hosted more than 800 people at an international conference in Tanzania focused on advancing women leaders in global health.

These signs of progress demonstrate that decisionmakers are finally starting to pay attention. Thinking about women’s needs, asking how new products and services will affect women, and testing novel medicines in women’s bodies will lead to a burst of progress. I saw this firsthand back in Rehri Goth: We developed a program tailored to the women and children there, and in four years maternal mortality dropped by 70 percent.

Change is possible. We must continue to push. The future health of millions of women and girls depend on it.

Top image source: miakievy / iStock

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Gender-based violence is a major public health issue globally. Survivors are at risk for injury, infection, and complications from pregnancy, as well as depression, post-traumatic stress disorder, and other mental illnesses. In some cases, family members can face physical and mental health impacts, too. As the first lady has seen firsthand, the health consequences of gender violence can be heartbreaking.

During Women’s History Month, Bio spoke at The Studio at Harvard T.H. Chan School of Public Health. She also sat for a Zoom interview with Jina Moore Ngarambe, managing editor of Harvard Public Health.

HPH: Fighting gender-based violence has been a personal commitment of yours. What’s the root of this commitment?

Bio: When I was 11 years old, I was married off to someone I had seen all my life as my uncle. [He was] someone I can run to for things I need, or if I have a problem in my family home; this is my go-to person.

I knew that my mother didn’t want me to be married off, but she was terrified of speaking up; she was very scared that my dad was going to leave her. The only thing that saved me is that when the war came to my town… [When] we became displaced, she was the one who encouraged me not to follow them. She told me: If you want to save yourself, this is the only chance you have—don’t come with us.

HPH: The gender violence in the story of your childhood is also intergenerational.

Bio: Absolutely. When a woman is in a marriage where you can’t speak up, you just have to go on with whatever is there—I lived through that. I saw my mom go through that for a very long time. That’s a reason why I refused to be silenced. We are all here for a journey, and if my journey is to save as many lives as possible, that’s what I’m going to do. I’ve been blessed that God gives me an opportunity to have a platform to speak to more people, to empower young girls to understand that our generation and their generation is totally different.

HPH: How do you see gender-based violence as a public health issue?

Bio: The bodies of young girls are not ready to carry a baby, and they become pregnant through early marriage, through rape, through early pregnancy. They don’t go for antenatal care—no checkup, nothing. When they’re due, they don’t know what to do, and they go to the hospital [too late]. For me, that’s the most obvious example.

HPH: Another issue that is often seen as a link between gender violence and public health is FGM, or female genital mutilation. I know it can also be a sensitive topic, but can you tell us a bit about the situation in Sierra Leone?

Bio: For me it’s not a sensitive topic. You have a lot of women who talk about FGM who will say a lot of [negative] things. That’s their own take. I was circumcised when I was a child. I don’t know how uncircumcised women feel because I’ve always been circumcised. I have three children; I never had any issue having a baby. Do I enjoy sex? I do. I am comfortable with my body. But you do have women who complain… I’ve never been to a hospital where they say these are victims of FGM. Until people can show me what FGM is doing in Sierra Leone, I’m not part of the conversation.

HPH: Where do you look for inspiration in your fight against GBV? Which activists do you look to, inside or outside Sierra Leone?

Bio: I’ve always drawn my strength from my mom—the things she does silently, without saying anything. I always go back to my mother for advice. Internationally, I see a lot of women trying to change the narrative. Do I imitate them? I don’t. I only want to do what I’m able to and capable of doing. What I do is from my heart. I’m not doing it because of my position; I’m doing it because I understand what victims go through—because I have been a victim before.

I have no diplomacy in my actions; it is just who I am… In some cases, my me is good enough. In some cases, my me is not good enough.

Top image: Fatima Maada Bio, the first lady of Sierra Leone, speaks at the U.S.-Africa Leaders’ Summit in Washington, D.C., in 2022. (AP Photo / Andrew Harnik)

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