Cheryl Martin (Host): Pregnancy among women of color can bring with it distinct challenges and health concerns. We explore the unique world of health care, race, identity, and culture with Dr. Donna Neale, Maternal Fetal Medicine Specialist, OBGYN, at the University of Maryland School of Medicine and UM Capital Region Health.

 Welcome to the Live Greater podcast series, information for a healthier you, from the University of Maryland Medical System. I'm Cheryl Martin. Dr. Neale, delighted to have you on to talk about pregnancy in women of color.

Donna Neale, MD: Cheryl, thank you for having me. I'm really excited to have this opportunity to share with you and your listeners, lots of information about, you know, being pregnant and being Black.

Host: Well, let's get started. First, what are some of the main health problems and challenges that pregnant women of color often face compared to other groups?

Donna Neale, MD: Well, I think if you ask me, you know, Dr. Neale, what are the top five? I would put them in this order; number one, obesity, number two, hypertension, number three, diabetes, number four, preterm labor, preterm delivery, and number five, uterine fibroids. And if you said further, are all these independent of one another, are they connected? I have to say there's some connectivity between some of them. And for example, obesity we know is a risk factor for both hypertension and diabetes, so just correcting the obesity problem would probably be really helpful in reducing some of the adverse outcomes that we see in women of color when they go through pregnancy.

Host: Talk about how that problem as well as others affect the health of both mothers and babies.

Donna Neale, MD: So, if we take each of those top five, there's a lot of crossover in terms of what are some of the adverse associations. So, for example, both obesity, hypertension, diabetes, all link with the following; preeclampsia, small babies, early delivery and stillbirth.. If you look at fibroids and preterm labor, preterm labor leads to preterm delivery, and there's so many sequelae of being born early, and probably the number one sequelae of that is an increased rate of neonatal death, so death within the first year of life.

And fibroids, very common in, in women of color cause an overdistension of the uterus, which then can lead to preterm labor, which can then lead to preterm birth. And then you end in that same place with those sequelae of prematurity. In addition to neonatal death, there's so many long life health challenges for those children who were born too early.

And most people know about the pulmonary or respiratory concerns where babies have a hard time breathing that can lead to asthma or reactive airway disease throughout a child's life. We also know that the brain needs the full pregnancy to develop. There are many neurologic developmental delays that can occur in the setting of prematurity. So it's a huge problem in our community.

Host: You mentioned this and I want to follow up. We know that more women of color die during childbirth. Why does this happen and what can we do to lower these rates and make pregnancy safer for them?

Donna Neale, MD: Unfortunately, that is correct. Women of color are three times more likely to die in childbirth than their non-Hispanic white cohorts. And in my mind, any woman who dies during childbirth, is one too many woman. So it's a problem across the board whenever a woman dies. But certainly when we see this disparity with women of color dying more frequently, it's alarming, it's shocking, and it calls us to action.

The question you asked me, I think, was why does this happen and what we can do to help reduce these disparities. Those both are challenging questions because when we think about why does this happen, it is certainly something that's multifactorial, multidimensional, and we've always known that, you know, women who work in this field, we, we've seen this. Over the last five to ten years, it's become more apparent to the lay population, so everybody knows about it now. And that's the first step, I guess, is to recognize that it's a problem, and everybody recognizing it, it's a problem.

And what I mean, everybody, I'm speaking, patients recognize it, families recognize it, institutions recognize it, individual hospitals recognize it, all providers recognize it, so not just OBGYNs, because some patients are cared for by midwives or family practitioners, or maybe receive a prenatal visit even in the emergency room.

So, it's important for all providers to recognize this, and it's important for each state to recognize what's happening on the state level; so that policies and procedures can be put in place from the state level. So it's, definitely something that's multifactorial.

Host: Well, money and where people live can make a big difference in pregnancy and having a baby. So how do financial problems, getting good health care and where people live, affect the pregnancy journey for women of color?

Donna Neale, MD: That's an excellent question. And I'm always, not that I'm excited to talk about this topic, but I am excited to share what we know about this. And this is what's so interesting. And that is typically we think those patients in general, so take pregnancy off the table, just patients in general, who are, have less financial resources, have less access to healthcare, and live in less resourced areas, have worse outcomes in their healthcare.

The interesting thing about some of the adverse outcomes in pregnancy is that when we look at women of color, even if you are highly educated, highly resourced, and living in a community that's highly resourced, highly educated, your outcomes for pregnancy mimic those of under resourced, under educated, non-Hispanic white women.

Host: Really? Why is that?

Donna Neale, MD: The short answer is we don't know. We have lots of hypotheses about this, and one of the big two hypotheses, really, is just the effect of what we call the weathering effect. What is the effect of being a person of color, just walking through society, and do those effects, this weathering effect, lead to what we call epigenetics, where there are changes on the genetic level that's secondary to the influences from the environment.

So this is a really exciting and evolving area of study. You know, we're just at the tip of the iceberg but it's certainly worth looking at, particularly when considering what I just shared about women of color, highly educated, highly resourced, living in highly resourced communities, still not having good outcomes in childbirth. And this is not to say that access to care is not an important piece and this is not to say that having some financial security is not an important piece because we certainly know that the social determinants of health definitely have an impact on outcome.

But this is, is more to the story. I just want to make sure our listeners recognize there's more to the story of this not going to the doctors or not having all the resources that patients may need in their community. There's a lot more to this story.

Host: So, is there anything an individual, a pregnant woman, can do to help with this problem if she's aware of it? What's in her tool house?

Donna Neale, MD: I love this question also. So, those who are listening, if you remember one thing I think from our discussion, hopefully you'll remember more, is that we really look at pregnancy as a stress test for life. Meaning how you perform in pregnancy is how you ultimately perform in life in terms of health issues.

And if you back that up a little bit further, we want you to be the best you can be when you enter the pregnancy. And so when you ask, what can patients do? I think one of the biggest things patients can do is have a pre-conceptual visit with their healthcare provider because that allows the patient to develop a relationship, rapport, trust with their provider, and that also allows the provider to optimize any underlying health conditions.

So we talked about in the beginning of our discussion, the role of hypertension, diabetes, obesity, and fibroids plays in adverse pregnancy outcomes. It's always preferable as a provider, if we have an opportunity to meet a patient with any of those conditions or anything else, and we have the opportunity to optimize those conditions; 100% of the time, those women are going to do better when optimized versus when they're not. So, what a patient can do is see a doctor before they're planning to get pregnant. We know not all pregnancies are planned, so then see a doctor as soon as you find out that you're pregnant. Take somebody with you when you go to your visits.

It's always important to have a second pair of ears to listen, to see what's going on and what the doctor is really sharing, what the provider is really sharing with you, as well as that second person being an advocate for you. Maybe there's something you forget, you tell your best friend and you forget to tell your provider and that something may be something really critical for the management of your pregnancy.

Host: So, you're talking about a woman getting a self-assessment even before she begins the journey to say, if I want to give my future child the best life possible and to be the best mother physically, if there are certain things that I need to do to get ready for this journey, let me work on everything that's within my control.

Donna Neale, MD: Absolutely. Perfectly said.

Host: Great. Now, we've been talking a little bit about this. People's experiences are different because of things like race, gender, socioeconomic status. Talk about how these things come together to affect how women of color experience pregnancy, and again, can we do anything to make things better? In other words, what are some tips to help women of color feel more comfortable talking to their providers, which you've just mentioned, to ensure they get the care that they need?

Donna Neale, MD: I'm going to pivot over to the role of the provider, the burden of the provider. So we recognize that all of us have implicit biases. And to be able to recognize how those biases may play out and how you care for a patient, how you respond to a patient, is really critical. It's become more in the forefront.

So I think in terms of what the provider owes the patient is to see the patient, to hear the patient, to listen to the patient, as the patient is, not as you expect the patient to be. So this again is where it's so critical for a patient to seek out providers and see, is that person listening to you?

Are they hearing your story? Are they telling your story for you? I just can't underscore how important it is, for that pre-conceptual visit or early visit to see whether this provider is going to be a good fit for you. In the end, the provider is the one who's going to be advocating for you, for managing you.

And so our role as providers is to see and take care of the whole patient. Hospitals are recognizing the importance of this. There's a lot of training going on now for all providers at all levels to be able to recognize things like implicit bias, recognize the impact of social determinants of health, recognize ACEs, childhood adverse events that may then impact an adult.

So it's important as a patient to feel the provider out. Are they are hearing you? Are they seeing you?

Host: That's a really, that's a really good point that it's not just selecting a doctor, but is this a right fit?

Donna Neale, MD: Correct.

Host: Is there a certain comfort level? Do you, do they really care about me? Now, let's talk about feeling well mentally is also very important during pregnancy. So, what are some of the most prevalent or challenging mental health problems for pregnant women of color and how can we give them better support?

Donna Neale, MD: We know that just across the board, mental illnesses are increasing in our communities. We know that across the board, and unfortunately with many disease processes, there's such a disparity in outcomes, access to care providers in the communities of color.

So we know depression's on the rise across our community, and we know that disproportionately less resources in communities of color to attend to these problems. And I point out depression because we know every pregnant woman is at risk for something called postpartum depression. But if you have a diagnosis of depression entering a pregnancy, your risk of postpartum increases even more. And then you add on any adverse pregnancy outcomes that we talked about earlier in the podcast, such as prematurity, preeclampsia, diabetes, small baby, and that increases your risk of postpartum depression, too.

If we have increased rate of hypertension, diabetes, obesity in women of color, and we know those outcomes often can lead to early babies and adverse birthing events, which can lead to depression. And we already have depression in our community where we're not attending to. We, as I say, collectively as a healthcare team, because of lack of resources and access; there's a burden of depression within our communities.

There's also a taboo for treatment of depression, often in many communities of color. So, people recognize they're experiencing episodes of depression, but are hesitant to speak out, seek help, because some of the taboos within the community.

Host: What can we do? What are your recommendations for supporting those that we think may be in that category?

Donna Neale, MD: I have many recommendations, but the first one is for our, when a woman embarks on pregnancy, as you alluded to earlier, it's a journey, and most of the time when we journey, we do journey with other people. So I think we need to start looking at pregnancy as that journey, and there are other people along the journey with us, and in the context of identifying mental health, it's important for family members, friends, hairdressers, as well as providers to recognize the signs and symptoms of depression, and being able to then refer the patient on to a provider, if the patient's willing.

I'm not advocating that we do things without the patient's permission, but if the patient's willing, we collectively as the community who's taking care of this patient, need to be able to recognize the signs and symptoms.

Host: And then offer support.

Donna Neale, MD: Correct.

Host: I wanted to have you expand on something that you touched on a little bit earlier about implicit bias. Because it is important for doctors and healthcare providers to understand and respect different cultures to give the best care. So how can they learn more about the cultural needs and wishes of pregnant women of color so they get better care?

Donna Neale, MD: That's an excellent question and luckily, because so much more attention has been paid to the role of implicit bias and how it may impact how patients are cared, there are many, many resources now, both online as well as on site certainly within the University of Maryland health system, most of the professional societies offer webinars that address implicit bias.

Many community groups now are offering, offering opportunities to learn about this. And I can tell you within the field of OBGYN, we have yearly, like a yearly credentialing that we all participate. And one of the areas that it's focused on is implicit bias.

Host: So there are plenty of tools out there for health care providers who want to be more sensitive to the journey of women of color.

Donna Neale, MD: Correct, and many states are going to a mandatory training session for all providers.

Host: You mentioned one key takeaway as we wrap up this conversation. Someone listening to this what would you say are the key takeaways you want them to remember?

Donna Neale, MD: The key takeaways from our conversation, again, is to be the best you can be when you enter the pregnancy. You want to be the best you can be when you enter the pregnancy because, again, pregnancy is a stress test for life. As you perform during the pregnancy is often how you're going to perform the rest of your life in terms of your health outcomes.

Bring, have an advocate, have a health buddy. Maybe it's your spouse, maybe it's a family member, maybe it's your best friend, maybe it's your doula, maybe it's a co worker, but have, I always advocate for patients, never come alone. Always bring somebody with you with your visit, again, to be that second pair of ears and to be your advocate.

As a patient, the value of the pre-conceptual visit is really enormous and so along the lines of being the best you can be is, seek care before you're planning to be pregnant. Understandably, not all pregnancies are planned, so, as soon as you know you're pregnant, seek care.

Go through your history, maybe there's something that you don't recognize that could be a problem for a pregnancy, but your provider does and has the opportunity to, to optimize before the pregnancy progresses even further. And it's important to find a physician, a provider that you're comfortable with.

And that's where, again, the pre-conceptual visit can be very beneficial or early pregnancy visit. And if all else fails, the one, the many things that are very important in pregnancy, but if you know you have a health condition and you're on medications and you're not sure if they're safe to use during pregnancy, before you just stop them, speak with a healthcare provider.

Every reproductive age woman should be taking folic acid daily. Because that helps protect the the spine as it develops very early in pregnancy. So any reproductive age woman listening to this call should be on folic acid. Pretty much all the multivitamins have the folic acid already included, so we, I advocate all reproductive age women to be just on a regular multivitamin.

It doesn't require a prenatal vitamin, just a multivitamin. And again, equally important, I think, don't be afraid to be pregnant if you're a woman of color. I've heard this too many times. Of course, it's we've just had a conversation about all the potential adverse outcomes that can occur, but certainly with regular, consistent, good care, a woman of color can have a very, very successful pregnancy.

Host: That's a great way to end our dialogue. Dr. Donna Neale, thanks so much for sharing your expertise on the pregnancy journey for women of color. Your passion is evident. The discussion very enlightening and enriching. Thank you so much.

Donna Neale, MD: Thank you for the opportunity to participate and thank you for listening.

Host: You can find more shows just like this one at umms.org/podcast and on YouTube. Thank you for listening to Live Greater, a Health and Wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this episode on your social media.