I'M SAMIA NOURSI, THE SCIENTIFIC DIRECTOR FROM NIH OFFICE OF RESEARCH ON WOMEN'S HEALTH. IT IS MY PRIVILEGE TO WELCOME YOU HERE TODAY. LIKEWISE, TO THOSE WHO ARE VIEWING TODAY'S SESSIONS IN THE OVERFLOW ROOM AND VIA VIDEOCAST. THE VIVIAN PINN SYMPOSIUM WAS ESTABLISHED IN 2015 IN RECOGNITION OF DR. PINN'S LONG-STANDING LEADERSHIP IN WOMEN'S HEALTH RESEARCH. SHE WAS THE FIRST FULL TIME DIRECTOR OF ORWH AND FIRST PERMANENT NIH ASSOCIATE DIRECTOR FOR RESEARCH ON WOMEN'S HEALTH. THROUGHOUT HER 20 YEARS AS ORWH DIRECTOR, DR. CLAYTON -- DR. PINN LED NIH EFFORTS TO IMPLEMENT AND MONITOR THE INCLUSION OF WOMEN AND MINORITIES IN NIH-FUNDED CLINICAL RESEARCH. AMONG MANY OTHER INITIATIVES THAT WILL BE DESCRIBED BY DR. CLAYTON LATER ON. PERHAPS NOTHING IN HEALTHCARE IS MORE TRAGIC OR PREVENTABLE THAN THE UNITED STATES' RATE OF MATERNAL MORTALITY. RACIAL DISPARITIES AND HIGH PROFILE EXAMPLES OF MATERNAL MORBIDITY AND MORTALITY, HIGHLIGHT THE CHALLENGE WE FACE. THE TIMING IS RIGHT FOR ADDRESSING TODAY'S THEME: IMPROVING MATERNAL HEALTH, BEHIND THE NUMBERS. BY THAT, WE MEAN TODAY'S SPEAKER WILL EXPLORE THE CAUSES AND POTENTIAL SOLUTIONS TO THIS PUBLIC HEALTH CRISIS. I'D LIKE TO RUN THROUGH THE AGENDA REALLY QUICKLY. OUR FIRST SPEAKER, DR. JANINE CLAYTON, WHOM I WILL INTRODUCE IN A MINUTE, WILL PROVIDE AN UPDATE ON ORWH PROGRAMS. SHE WILL ALSO INTRODUCE OUR GUEST OF HONOR, DR. PINN. AFTER MY PRESENTATION ON MATERNAL HEALTH DATA, YOU'LL HEAR FROM OUR KEYNOTE SPEAKER, DR. LISA HOLLIER, THE PRESIDENT OF THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS. OUR FIRST PANEL IS CALLED "FRAMING A RESEARCH AGENDA TO ADVANCE MATERNAL HEALTH EQUITY: FROM BENCH TO BEDSIDE TO CURB SIDE." WE ARE FORTUNATE TO HAVE SUCH TERRIFIC PANELISTS. OH UR SECOND AND LAST PANEL WILL FOCUS ON FEDERAL UPDATES ON MATERNAL HEALTH ACTIVITIES. YOU'LL HEAR FROM THE TOP EXPERTS ON MATERNAL HEALTH FROM ACROSS THE FEDERAL GOVERNMENT, INCLUDING OUR COLLEAGUES FROM NIH INSTITUTES AND 16 IT AND CENTERS. WE'LL CLOSE WITH DR. CLAYTON AND STACEY STEWART, PRESIDENT AND CEO OF MARCH OF DIMES, THEY WILL OFFER THEIR FINAL THOUGHTS AND OBSERVATIONS. AFTER EACH PANEL, THERE WILL BE A FEW MINUTES FOR QUESTIONS. THOSE IN THE OVERFLOW ROOM CAN SUBMIT QUESTIONS THROUGH DR. MARGARET BEVENS WHO IS IN THE ROOM WITH YOU. THOSE OF YOU WHO ARE WATCHING AT HOME OR IN YOUR OFFICE MAY SUBMIT QUESTIONS BY SENDING AN EMAIL TO ORWH INFO AT NIH.COM. THAT IS ORWHINFO@NIH.COM. AS YOU CAN SEE, WE HAVE A FULL AND EXCITING LINEUP. THERE ARE NO SCHEDULED BREAKS, SO FEEL FREE TO EXCUSE YOURSELF ANY TIME YOU NEED A BREAK TO GET A SNACK OR JUST TO GO OUTSIDE FOR FRESH AIR. IN YOUR FOLDERS, YOU'LL FIND THE PROGRAM WHICH CONTAINS INFORMATION FROM ORWH, TODAY'S AGENDA AND SPEAKERS' BIOS. YOU'LL ALSO FIND A COPY OF OUR NEW MATERNAL MORBIDITY AND MORTALITY BOOKLETS, OUR LATEST PUBLICATION WHICH FOCUSES ON MATERNAL HEALTH, A CALENDAR OF UPCOMING EVENTS, AND THE INFOGRAPHIC OF THE TRANS-NIH STRATEGIC PLAN ON WOMEN'S HEALTH. THERE ARE MORE MATERIALS ON THE TABLE IN THE BACK OF THE ROOM THERE FROM ORWH, AS WELL AS SOME MATERIAL FROM THE EUNICE KENNEDY SHRIVER INSTITUTE ON CHILD HEALTH AND HUMAN DEVELOPMENT. HELP YOURSELF. PICK UP AN EXTRA COPY OF OUR MMM BOOKLET FOR A MOTHER YOU KNOW. BEFORE I INTRODUCE OUR FIRST SPEAKER, I WANT TO RECOGNIZE THAT WE WILL BE JOINED BY A VARIETY OF DISTINGUISHED GUESTS TODAY. WE WILL ACKNOWLEDGE AND WELCOME THEM AS THEY COME. IT IS NOW MY PLEASURE TO INTRODUCE OUR NEXT SPEAKER. DR. JANINE CLAYTON WAS APPOINTED NIH ASSOCIATE DIRECTOR FOR RESEARCH ON WOMEN'S HEALTH AND DIRECTOR OF ORWH IN 2012. A BOARD CERTIFIED OPHTHALMOLOGIST, SHE PREVIOUSLY SERVED AS DEPUTY CLINICAL DIRECTO OF THE NATIONAL EYE INSTITUTE. HER RESEARCH INTERESTS INCLUDE AUTOIMMUNE OCULAR DISEASES AND THE ROLE OF SEX AND GENDER IN HEALTH AND DISEASE. IN FACT, IT WAS HER DISCOVERY OF A NOVEL FORM OF DISEASE ASSOCIATED WITH PREMATURE OVARIAN INSUFFICIENCY THAT SET THE STAGE FOR HER EXPLORATION OF THE ROLE OF SEX AND GENDER IN HEALTH AND DISEASE. FINALLY, DR. CLAYTON LEADS THE IMPLEMENTATION OF THE NIH POLICY INITIATIVE THAT REQUIRES SCIENTISTS TO STUDY BOTH SEXES AS APPROPRIATE AT PRE-CLINICAL AND CLINICAL LEVELS. LADIES AND GENTLEMEN, IT'S MY HONOR TO INTRODUCE DR. CLAYTON. [APPLAUSE] >> THANK YOU, DR. YOUR SEE. WE ARE SO EXCITED ABOUT TODAY'S PROGRAM. WE HAVE AN AMAZING AGENDA LINED UP FOR YOU. AS YOU HEARD FROM DR. NOURSI. BEFORE I EVEN START THIS PROGRAM, I WANT TO ACKNOWLEDGE TEAM ORWH WHO DID ALL THE HARD WORK TO GET US WHERE WE ARE TODAY. AND IN PARTICULAR, DR. NOURSI, LEADERSHIP LEAD FOR THE VIVIAN PINN SYMPOSIUM THIS YEAR AS WELL AS OUR COMMUNICATIONS SUPPORT AND OUR CONTRACT SUPPORT. SO BEFORE WE EVEN START, I WANT TO ACKNOWLEDGE THEM UP FRONT. PLEASE JOIN ME IN THANKING THEM. [APPLAUSE] SO FOR US HERE AT NIH AND AT ORWH, MATERNAL HEALTH IS PERSONAL. THIS IS A PHOTOGRAPH OF DR. IRVING PROVIDED BY HER MOTHER, WANDA IRVING. SHE WAS A RESEARCHER WORKING TO ERADICATE HEALTH DISPARITIES. SHE HAS BECOME A SYMBOL OF ONE OF THE MOST TROUBLESOME HEALTH DISPARITIES FACING BLACK WOMEN IN THE U.S. TODAY. DISPROPORTIONATELY HIGH RATES OF MATERNAL MORTALITY. DR. IRVING WAS MORE THAN DR. IRVING. HER DISCOVERY IN IN MID 2016 THAT SHE WAS PREGNANT WITH HER FIRST CHILD HAD BEEN UNEXPECTED BUT THRILLING. THEN THE UNTHINKABLE HAPPENED. THREE WEEKS AFTER SHE GAVE BIRTH, SHE COLLAPSED AND DIED. SHALON'S LONG DIVORCED PARENTS HAD ALREADY BURIED BOTH OF THEIR SONS. SHE HAD BEEN THEIR LAST REMAINING CHILD. EVEN THOUGH WE HAVE AMAZING TECHNOLOGY, AND SCIENCE HAS ANSWERED SO MANY PROBLEMS, THERE IS SO MUCH WORK TO BE DONE IN THIS ISSUE OF MATERNAL MORTALITY. ON A PERSONAL NOTE, AS I MENTIONED, I'D LIKE TO HIGHLIGHT DR. IRVING'S IRVING'S NOT AS DR. IRVING BUT AS A MOTHER TO SOLEIL, A DAUGHTER TO WANDA, A FRIEND, COLLEAGUE, NEIGHBOR AND AFRICAN-AMERICAN WOMAN. BUT RECENTLY, I DID HAVE THE PLEASURE OF JOINING A GROUP AND THERE WERE SEVERAL OTHER FOLKS HERE TODAY THAT WERE SPEAKERS AT THE JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH AT AN EVENT DESIGNED TO ADDRESS THIS ISSUE IN HONOR OF DR. IRVING. I THINK THE TITLE IS JUST PERFECT. "THE FIERCE URGENCY OF NOW," ACCURATELY PORTRAYS THIS MOMENT IN TIME. AS PART OF A MORE AGGRESSIVE MEDIA OUTREACH THAT ORWH HAS UNDERTAKEN TO BRING VISIBILITY TO SOME OF THESE ISSUES, I WAS INVITED TO SPEAK AT A PODCAST LAST YEAR OR EARLY THIS SPRING, RATHER, AND THE TOPIC WAS WHY WOMEN GET OVERLOOKED IN HEALTHCARE. AND IT STEMMED FROM VENA SERENA WILLIAMS' OWN STORY OF HER EXPERIENCE AND COMPLICATIONS AFTER PREGNANCY. DR. IRVING'S AND SERENA WILLIAMS' CASES ILLUSTRATE THE BITTER REALITY THAT REGARDLESS OF INCOME, EDUCATIONAL ATTAINMENT, OR EVEN CELEBRITY STATUS, BLACK WOMEN ARE MORE AT RISK IN PREGNANCY. SO IT IS NO EXAGGERATION TO STATE, AS "U.S.A. TODAY" DID RECENTLY, THAT THE U.S. IS THE MOST DANGEROUS PLACE IN THE DEVELOPED WORLD TO DELIVER A BABY. MATERNAL MORTALITY IS RISING IN THE U.S. AT THE SAME TIME AS IT'S DECREASING IN OUR PEER COUNTRIES. AND TREND LINES ASIDE, OUR MATERNAL MORTALITY RATE IS THE HIGHEST BY A MAGNITUDE OF NEARLY THREE TIMES COMPARED, FOR EXAMPLE, TO THE U.K. AND SEVEN TIMES COMPARED TO FINLAND. SO REGARDLESS OF WHETHER THERE MAY BE ISSUES WITH THIS DATA, THIS IS VERY DISTURBING. THESE TWO SLIDES WILL GIVE YOU A SENSE OF WHY WE FOCUSED ON MATERNAL MORTALITY FOR THE VIVIAN PINN SYMPOSIUM THIS YEAR. AND MY COLLEAGUE, DR. SAMIA NOURSI, WHO YOU'VE HEARD FROM ALREADY, WILL BE SPEAKING LATER AND GIVING A LOT MORE DETAIL AT WHAT'S BEHIND THE NUMBERS. BUT LET ME PUT THE U.S.' ABYSMAL MATERNAL HEALTH IN PERSPECTIVE. THESE ARE JUST FIVE KIND OF TOP-LINE PIECES OF STATISTICS THAT UNDERSCORE THE SERIOUSNESS OF THE CRISIS THAT WE FACE. OUR AMAZING SPEAKERS WILL EXAMINE THESE NUMBERS IN MUCH GREATER DETAIL. TRAGIC REALITY OF MATERNAL HEALTH IN THE UNITED STATES IN 2019. THIS IS WHERE WE ARE NOT IN 1919, IN 2019. EACH YEAR IN THE U.S., ABOUT 700 WOMEN DIE AS A RESULT OF PREGNANCY OR DELIVERY COMPLICATIONS. THESE WOMEN ARE, OH OF , OF COURSE OH, DYING PREMATURELY. THINK OF THE HUMAN TOLL ON THEIR FAMILIES, FRIENDS AND COMMUNITIES. AS YOU KNOW, BLACK WOMEN BEAR A DISPROPORTIONATE BURDEN OF THESE DEATHS AND ARE THREE TO FOUR TIMES MORE LIKELY TO DIE OF PREGNANCY-RELATED COMPLICATIONS THAN WHITE WOMEN. AGE IS ALSO A FACTOR FOR MATERNAL DEATH. WOMEN AGED 35 TO 39 ARE TWICE AS LIKELY TO DIE IN PREGNANCY AS YOUNGER WOMEN 20 TO 24, AND THE RISK BECOMES EVEN HIGHER FOR WOMEN AGE 40 AND OLDER, AND WE KNOW THAT ADVANCED MATERNAL AGE IS AN ISSUE IN THE U.S. AND FINALLY, THIS STATISTIC IS TROUBLING, YET PARADOXICALLY MAY GIVE US A LITTLE BIT OF A REASON TO HOPE, AND THAT IS THAT 50% OF THESE MATERNAL DEATHS ARE PREVENTABLE. I'M SO PROUD TO ANNOUNCE TWO NEW RESOURCES THAT THE NIH OFFICE OF RESEARCH ON WOMEN'S HEALTH HAS CREATED IN COLLABORATION WITH OUR NIH PARTNERS. THE FIRST IS THE MATERNAL MORBIDITY AND MORTALITY BOOKLET THAT IS IN YOUR FOLDER. AND THE SECOND IS OUR NEW ORWH MATERNAL MORBIDITY AND MORTALITY WEB PORTAL. WE'RE REALLY EXCITED ABOUT THIS OPPORTUNITY TO BE ABLE TO SHARE INFORMATION MORE BROADLY AND TO HIGHLIGHT INFORMATION FROM YOU AND ACROSS THE FEDERAL GOVERNMENT. BEFORE I GO TO MY NEXT SECTION, I WANT TO THANK THOSE WHO WORKED ON THE MATERNAL MORTALITY AND MORBIDITY PORTAL, OUR COMS TEAM, DR. NOURSI, OUR INTERN JULIA MARCUS AND SEVERAL OTHERS IN THE MARCUS CONTRIBUTED TO THIS AMAZING NEW RESOURCE. PLEASE HELP US GET THE WORD OUT ABOUT IT, AND IF YOU HAVE MATERIAL THAT YOU THINK SHOULD BE ON THE PORTAL, PLEASE DO CONTACT US. BEFORE I GO ON TO MY NEXT ITEM AND INTRODUCE DR. PINN, I DO WANT TO ACKNOWLEDGE SOME OF THE SPECIAL GUESTS THAT ARE HERE WITH US TODAY. EVERY SINGLE ONE OF YOU IS SPECIAL TO US BECAUSE YOU'RE HERE TALKING ABOUT THIS WITH US TODAY, BUT I DO WANT TO ACKNOWLEDGE DR. ALICIA CHRISTY FROM JOHNS HOPKINS WHO'S HERE, I DO WANT TO ACKNOWLEDGE AS WELL -- I'M GOING TO SKIP OUR SPEAKERS -- ACTUALLY I'LL DO OUR SPEAKERS AS WELL. JACQUELYN CAMPBELL, JOIA ADELE CREAR-PERRY, DR. DANIEL FORD FROM HOPKINS, SARAH FOS IT TER FROM FOSTER FROM CDC, LISA HOLIER, KEYNOTE SPEAKER, SERENA FROM HRSA. TODAY'S WALS LECTURER DR. LUCILE ADAMS CAMPBELL. THANK YOU FOR BEING HERE, WE KNOW YOU'VE GOT TO SCOOT TO GIVE YOUR TALK AT 3:00, WE APPRECIATE YOU BEING HERE, AND REAR ADMIRAL DEPUTY ASSISTANT SECRETARY FOR HEALTH, WE'RE REALLY DELIGHTED TO HAVE YOU HERE AS WELL AS CONNIE NEWMAN, THE PAST PRESIDENT OF THE AMERICAN MEDICAL WOMEN'S SOAKS. WOMEN'S SOAX. WE ALSO HAVE LYNNE YAO FROM THE FDA HERE AS WELL SO THANK YOU VERY MUCH AND YOU'LL HEAR ABOUT OTHER FOLKS THAT JOINED US LATER IN THE DAY. BACK TO MY MAIN ASSIGNMENT FOR TODAY. I AM GOING TO -- IT'S REALLY MY OH PRIVILEGE TO INTRODUCE DR. PINN AND IT'S OFTEN SAID DR. PINN IS A WOSM MANY FIRSTS. SHE DOESN'T LIKE IT WHEN YOU SAY THAT, SHE DOESN'T WANT TO BE THE FIRST. SHE WOULD HAVE RATHER HAD THERE BE MANY WOMEN DOING THESE THINGS, BUT SHE'S THE FIRST IN MANY WAYS. YOU HEARD THAT SHE WAS THE FIRST FULL TIME DIRECTOR OF THE NIH OFFICE OF RESEARCH ON WOMEN'S HEALTH FROM 1991 TO 2011. SHE WAS THE FIRST PERMANENT NIH ASSOCIATE DIRECTOR FOR RESEARCH ON WOMEN'S HEALTH AND PRIOR TO THAT, DR. PINN BECAME THE THIRD WOMAN AND THE FIRST AFRICAN-AMERICAN WOMAN TO LEAD A U.S. PATHOLOGY DEPARTMENT AT HOWARD UNIVERSITY HOSPITAL AND COLLEGE OF MEDICINE IN 1982. SHE WAS THE SECOND AFRICAN-AMERICAN WOMAN TO ENTER THE UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE, WHERE IN HER CLASS, SHE WAS THE ONLY WOMAN AND THE ONLY AFRICAN-AMERICAN. THAT'S SOME RESILIENCE RIGHT THERE. NO DOUBT THAT BESIDES BEING A HEALER, RESEARCHER, LEADER AND PATHOLOGIST, I THINK OF DR. PINN AS A TRAIL TRAILBLAZER AND PIONEER. THROUGHOUT HER CAREER, SHE'S BEEN DEDICATED TO ENHANCING WOMEN'S HEALTH RESEARCH AND LED EFFORTS TO IMPLEMENT AND MONITOR THE INCLUSION OF WOMEN AND MINORITIES IN CLINICAL RESEARCH SUPPORTED BY NIH WHEN IT WASN'T A POPULAR CAUSE. SHE FOCUSED ON THE IMPORTANCE OF SEX DIFFERENCES BEFORE PEOPLE TALKED ABOUT SEX DIFFERENCES AND SPECTRUM, FROM BASIC THROUGH TRANSLATIONAL AND ALWAYS IMPLEMENTATION IN HEALTHCARE. DR. PINN ALWAYS KEPT THE PATIENT AT THE CENTER. SHE CREATED THE SPECIALIZED CENTERS OF RESEARCH ON SEX DIFFERENCES PROGRAM, THE FIRST SEX DRIRCHESES DIFFERENCES FUNDING OPPORTUNITY AT NIH AND LED THE EFFORT IN COLLABORATION WITH NICHD TO ENTER THE RESEARCH CAREERS IN WOMEN'S HEALTH PROGRAM AND WE ACTUALLY DO HAVE THE ARCHITECT, DR. VOGEL, HERE AS WELL. SHE ALSO CO-CHAIRED ON WOMEN IN BIOMEDICAL CAREERS AND SHE'S WORKED SUCCESSFULLY WITH MANY NIH INSTITUTES AND CENTERS IN A WIDE VARIETY OF PARTNERS AND STAKEHOLDERS OVER THE YEARS TO EXPAND WOMEN'S HEALTH RESEARCH ACROSS NIH AND BEYOND. IN CLOSING, THIS ANNUAL SYMPOSIUM NAMED IN HER HONOR IS FITTING FOR A WOMAN WHO HAS SPENT HER LIFE WORKING TO IMPROVE THE HEALTH OF WOMEN, ALWAYS ADDRESSING HEALTH DISPARITIES AND IMPROVING INDEED THE HEALTH OF THE NATION. LADIES AND GENTLEMEN, PLEASE JOIN ME IN WELCOMING DR. VIVIAN PINN. [APPLAUSE] >> OH, THANK YOU. THANK YOU VERY MUCH. I JUST FEEL AT HOME AND I MUST SAY, IT'S EMBARRASSING TO WALK IN THE BACK DOOR AND SEE YOUR PICTURE UP ON THE SCREEN. AND THEN FOR YOU TO STAND, YOU DON'T NEED TO STAND FOR ME. I'M JUST HAPPY TO SEE ALL OF YOU AND TO BE BACK AND ACTUALLY REALLY HONORED THAT JANINE AND THE OFFICE OF RESEARCH ON WOMEN'S HEALTH AND THE NIH, BECAUSE I KNOW YOU HAVE TO GET PERMISSION FROM NIH TO NAME AN EVENT AFTER SOMEONE. I'M JUST REALLY HONORED THAT MY NAME IS ATTACHED TO THIS WONDERFUL SYMPOSIUM DURING WOMEN'S HEALTH WEEK SO THAT IT KEEPS ME IN TOUCH AND MY NAME ALIVE, I GUESS, IN TERMS OF WHAT'S GOING FORWARD. AND IT'S IMPORTANT THAT THIS SYMPOSIUM TAKE PLACE BECAUSE ONE OF THE MISSION STATEMENTS FOR OUR OFFICE, WHICH WAS ESTABLISHED IN SEPTEMBER 1990, WAS TO NOT ONLY INCLUDE THE MAJOR FOCUS OF COURSE WAS THE INCLUSION OF WOMEN AND MINORITIES IN CLINICAL RESEARCH, BUT PART OF THAT MISSION STATEMENT WAS, AS WE DID RESEARCH ON WOMEN'S HEALTH AND PROMOTED AND EXPANDED RESEARCH ON WOMEN'S HEALTH, TO INTERACT WITH ADVOCATES, PUBLIC SERVICE GROUPS AND COMMUNITIES, AND THAT WAS ACTUALLY PART OF THE MISSION STATEMENT OF THIS OFFICE. SO WE CAN DO THAT BOTH FOR THOSE WHO ARE WITHIN THE NIH COMMUNITY AND THOSE WHO ARE FRIENDS OF THE NIH COMMUNITY, IT'S VERY IMPORTANT, AND SO THIS SYMPOSIUM REPRESENTS A WONDERFUL WAY TO DO THAT AS YOU KNOW, THIS IS THE 20TH YEAR OF CELEBRATING WOMEN'S HEALTH WEEK AND I REMEMBER WHEN THAT FIRST STARTED, ACTUALLY THE OFFICE OF WOMEN'S HEALTH AND THE DEPARTMENT STARTED THAT AND THEN WE ALL HAD BUTTONS AND LITTLE THINGS AND GIVEAWAYS, AND IN TURN, ACTIVITIES PICKED UP ACROSS MOST OF THE DEPARTMENT WITH MOST OF THE AGENCIES HAVING PROGRAMS OR PUTTING ON SOMETHING DURING WOMEN'S HEALTH WEEK, AND I THINK THAT HAS BEEN VERY GOOD. IN ADDITION, I'VE NOTICED THIS WEEK THAT MANY OF THE TV NETWORK SHOWS ARE MENTIONING WOMEN'S HEALTH WEEK BUT I WANT TO SAY A LITTLE ABOUT THAT IN A MINUTE. I WAS HAPPY BUT NOT SO HAPPY. I'LL COME BACK TO THAT. BUT I HAVE TO ALSO RECOGNIZE THAT IN ADDITION TO THE 20TH YEAR OF THE WOMEN'S HEALTH WEEK, THAT WE ARE FAST APPROACHING THE THRT 30TH THE ANNIVERSARY OF THE OFFICE ON WOMEN'S HEALTH. IT STRIKES ME BECAUSE WHEN PEOPLE SAY THEY WANT ME TO COME AND TALK AND I SAY, YOU KNOW, I'M NOT DOING RESEARCH ANYMORE AND I DON'T HAVE THE LATEST THINGS AND THEN THEY SAY, WHICH HAS COME TO REALLY BE TRUE, THAT WE REALLY HAVE A GENERATION THAT HAS COME ABOUT OVER THE PAST 30 YEARS, AND THEY ARE YOUNG WOMEN AND MEN WHO WERE NOT BORN OR WERE VERY YOUNG WHEN THE OFFICE STARTED AND WHO ARE NOT REALLY AWARE OF WHAT IT WAS LIKE BEFORE THE DEPARTMENT HAD ITS OFFICES OF WOMEN'S HEALTH AND ATTENTION WAS GIVEN TO WOMEN THROUGH RESEARCH AND THROUGH ALL OF THE OTHER ACTIVITIES OF THE OTHER AGENCIES. AND SO THERE RESLI A GAP, REALLY IS A GAP WHICH REALLY STRUCK ME YESTERDAY AND THIS MORNING AS I WATCHED TV. NOW THE EARLY FOCUS OF WOMEN'S HEALTH ADVOCATES WHO ARE ASKING FOR WOMEN TO BE INCLUDED IN CLINICAL TRIALS WAS TO EXPAND THE CONCEPT OF WOMEN'S HEALTH BEYOND THE REPRODUCTIVE SYSTEM, BUT I HAVE FIRMLY FELT THAT WE CAN'T GO AWAY FROM CALLING THIS WOMEN'S HEALTH RESEARCH FOR FEAR THAT AS WE PUT FOCUS ON ALL OF THE OTHER ORGAN SYSTEMS, WE'LL FORGET THE REPRODUCTIVE SYSTEM. AND THE REPRODUCTIVE SYSTEM HAS AND STILL HAS MANY AREAS THAT NEED RESEARCH JUST YOU AS AREAS LIKE HEART DISEASE AND PULMONARY DISEASE AND MENTAL HEALTH, ET CETERA. AND SO THIS SEMINAR TODAY IS REALLY, I THINK, QUITE TIMELY AS THESE SYMPOSIA ARE TO ADDRESS AN AREA OF CURRENT INTEREST, BUT I THINK THE POINT COMES ACROSS THAT AS WE LOOK AT THE EXPANDED CONCEPTS OF WOMEN'S HEALTH, WE CAN'T FOR FORGET THE ISSUES OF THE REPRODUCTIVE SYSTEM AND HOW WHEN THEY ARE -- I DON'T KNOW IF YOU WERE ACTIVE AT THAT POINT, BUT I CAN REMEMBER WHEN THE LEADERS OF ACOG CAME OUT TO MEET WITH THE DIRECTOR OF NIH WANTING AN INSTITUTE OF WOMEN'S HEALTH AND CLAIMED THEY DIDN'T RECOGNIZE THAT WE ACTUALLY HAD AN OFFICE OF RESEARCH ON WOMEN'S HEALTH AND I HAD TO REALLY CONVINCE THEM THAT WE WERE ADDRESSING REPRODUCTIVE HEALTH AND THINK WE'VE HAD A MUCH BETTER PARTNERSHIP SINCE THAT TIME. BUT AS TODAY'S SYMPOSIUM EMPHASIZES, THE IMPORTANCE OF NOT JUST EXPANDING THE CONCEPTS OF WOMEN'S HEALTH ACROSS THE LIFESPAN, IT'S ALSO IMPORTANT TO TAKE A LOOK AT REPRODUCTIVE HEALTH AND AS DR. HOLIER, HOLLIER, I REMEMBER REMEMBER THERE WAS THE FIRST WOMAN PRESIDENT OF ACOG SO IT'S NICE TO SEE 20, 30 YEARS LATER THAT WE'VE GOT OTHER WOMEN CONTINUING THAT TRADITION. BUT I HAVE TO QUOTE YOU AND I THINK JANINE HAS ALREADY REFERRED TO THAT, BUT YOU QUOTE IT AS SAYING THE UNITED STATES HAS THE WORST MATERNAL MORTALITY RATE IN THE DEVELOPED WORLD. AND IF YOU THINK ABOUT THAT WITH ALL OUR ADVANCES IN TECHNOLOGY, OUR SCIENTIFIC WORKFORCE, OUR MEDIA, HOW IS IT THAT THIS COULD BE THE CASE IN OUR COUNTRY TODAY, ESPECIALLY WHEN WE LIKE TO PRIDE OURSELVES ON WHAT WE'VE DONE IN HEALTHCARE AND WOMEN'S HEALTH RESEARCH. I'M SURE HER ADDRESS WILL PROVIDE MORE INFORMATION SO I'M NOT GOING TO QUOTE EVERYTHING I READ THAT SHE'S STATED BECAUSE I DON'T WANT TO INTRUDE ON HER REMARKS, BUT I THINK THAT'S REALLY IMPORTANT. BUT IN ADDITION, THE PREVALENCE OF MATERNAL MORTALITY DOES VARY BY RACE AND ETHNICITY, AS DR. CLAYTON HAS POINTED OUT AND AS OTHERS HAVE POINTED OUT. AND WE THINK ABOUT THAT, WHY? HOW CAN THESE DEATHS BE PREVENTED? WHAT ARE THE CONTRIBUTING FACTORS? WHAT HAS OUR RESEARCH SHOWN AND WHAT YOU FUTURE RESEARCH IS NEEDED TO ADDRESS THIS VITAL HEALTH COMPLICATION OF DISPARATE HEALTH OUTCOMES FOR WOMEN ACROSS THE RACIAL ETHNIC CATEGORIES? THAT'S WHAT THIS SYMPOSIUM WILL ADDRESSED TO. ACTUALLY I WAS THINKING WE PULLED OUT THE HECKLER REPORT THAT WE LIKE TO CALL THE TOM MALONE REPORT SINCE HE ACTUALLY PREPARED THAT REPORT FOR MARGARET HECKLER BUT I LOOKED AND ACTUALLY THAT REPORT REFERRED MORE TO LOW BIRTH WEIGHT BABIES AND FETAL MORTALITY AND NOT MATERNAL MORTALITY. I WAS HOPING TO HAVE A GREAT QUOTE FOR YOU FROM THAT, BUT I DIDN'T LUCK OUT ON THAT ONE. I DO HAVE TO ADD ANOTHER COMMENT GOING BACK TO WHAT I SORT OF REFERRED TO A FEW MINUTES AGO. WHAT HAS REALLY STIRRED MY SOUL FROM WATCHING THESE MORNING TV SHOWS. AND THAT IS THE IMPORTANCE OF CONTINUED EMPHASIS AND EXPANSION OF WOMEN'S HEALTH RESEARCH AND ITS IMPLICATIONS FOR CLINICAL CARE, BUT A RECOGNITION THAT WE HAVE MADE PROGRESS. AND IF WE KEEP STARTING OVER AND REINVENTING LIKE NOTHING'S TAKEN PLACE, WE'LL NEVER GET AHEAD. WE'LL JUST BE STUCK IN THAT RUT. SO IT'S IMPORTANT TO RECOGNIZE THE ADVANCES THAT HAVE BEEN MADE AND BUILD ON THOSE TO MOVE FORWARD. AS I'VE ALREADY STATED, ORWH IS APPROACHING ITS 30TH ANNIVERSARY NEXT YEAR, AND SINCE THAT TIME, THERE HAS BEEN MUCH PROGRESS NOT JUST AT NIH BUT IN THE ENTIRE MEDICAL AND SCIENTIFIC WORLD. ON THE IMPORTANCE OF WOMEN'S HEALTH, POINTS OF RESEARCH AND POINTS OF SEX AND GENDER DIFFERENCES FOR ALL AREAS OF HEALTHCARE AND ACROSS MEDICAL AND DENTAL SPECIALTIES. YOU'LL SEE I WROTE THIS OUT BECAUSE I WAS SO PASSIONATE I WANTED TO MAKE SURE I DIDN'T GO AD LIBBING SO I SORT OF PREPARED WHAT I WANTED TO SAY HERE TO KEEP ME IN CHECK, BUT MANY OF HAVE REFERRED TO THIS AS GENDER MEDICINE, GENDER-BASED MEDICINE, AND I THINK THAT'S AN IMPORTANT WAY TO THINK ABOUT IT BUT THAT'S NOT A NEW CONCEPT. WE'VE HEARD THOSE TERMS TOSSED AROUND FOR MANY YEARS. I SHOULDN'T SAY TOSSED AROUND, YOU SHOULD SAY EMPHASIZE THE IMPORTANCE OF RECOGNIZING SEX AND GENDER DIFFERENCES AS WELL AS RACIAL AND ETHNIC DIFFERENCES IN THE MANIFESTATION OF DISEASES, HOW THEY PRESENT THEMSELVES AND HOW THEY RESPOND TO THERAPY. THAT WAS REALLY THE BASIS OF THE INCLUSION POLICIES FOR HAVING WOMEN AND MINORITIES IN CLINICAL RESEARCH, SO THAT WE COULD UNDERSTAND IF OUR INTERVENTIONS WERE AFFECTING INDIVIDUALS DIFFERENTLY. BUT LISTENING TO THE PRESENTATION ON MORNING SHOWS HAS BEEN A SHOCKING REALIZATION THAT PERHAPS IN THAT 30 YEARS, WITH THE GENERATIONAL CHANGE, MANY TODAY DON'T KNOW ABOUT OR DON'T RECOGNIZE THE ADVANCES THAT HAVE BEEN MADE OR HOW OR WHY THEY EVEN CAME ABOUT. I REALLY HAD TO ALMOST FIGHT OFF A PANIC ATTACK, I WAS TRYING TO BE CALM THIS MORNING AS I LISTENED, BUILDING ON WHAT I HEARD YESTERDAY MORNING, AND I REALLY WAS CLOSE TO TRYING TO CALL THE NETWORKS TO SAY THAT'S NOT TRUE, AS I LISTENED TO COMMENTS SUCH AS, WOMEN'S HEALTH IS JUST EMERGING, IT'S A NEW AREA AND PEOPLE ARE JUST PAYING ATTENTION TO IT. SOMEONE ACTUALLY SAID WHO WAS PRESENTING FOR WOMEN'S HEALTH FOR MAJOR NETWORK ON A MAJOR MORNING SHOW THIS MORNING THAT MOST PHYSICIANS DON'T RECOGNIZE THAT MENOPAUSE IS DUE TO HORMONAL CHANGES, AND THAT THEY DON'T -- SO HELP ME! THAT WAS ON A MAJOR NETWORK THAT STARTS WITH AN N THIS MORNING. [LAUGHTER] AND THAT PHYSICIANS DON'T KNOW THAT MENOPAUSE IS RELATED TO HORMONAL CHANGES AND, THEREFORE, IT WAS DIFFICULT TO FIND A DOCTOR TO REALLY ENTERTAIN -- THAT DOCTORS JUST TREAT SYMPTOMS OF MENOPAUSE. ACTUALLY IF YOU LOOK AT MENOPAUSE, MENOPAUSE IS NOT A DISEASE SO YOU DON'T TREAT MENOPAUSE. THAT WAS TRUE, BUT I DON'T THINK SHE REALIZED THAT WHAT SHE WAS SAYING WAS TRUE, THAT WOMEN'S HEALTH IS NOT BEING TAUGHT IN MEDICAL OR HEALTH PROFESSIONAL SCHOOLS, AND THAT TEXTBOOKS DON'T HAVE IT, WHEN I THINK BACK TO HOW WE GOT OUT AND I REACHED A NUMBER OF AUTHORS OF TEXTBOOKS THAT I KNEW AND OTHERS I KNEW TO SAY YOU'VE GOT TO CHANGE, YOU'VE GOT TO CHANGE HOW YOU DESCRIBE THE PRESENTATION OF HEART DISEASE, THAT BACK IN '92, BY CONGRESSIONAL ORDER AND FOLLOWING THAT, ANOTHER REPORT WE DID ACROSS THE OFFICES, ESPECIALLY HRSA SORT OF TOOK THE LEAD BECAUSE THEY HAD THE OFFICE OF HEALTH PROFESSIONS EDUCATION, WHERE WE DID STUDIES LOOKING AT MEDICAL, DENTAL, PHARMACY AND NURSING SCHOOLS, OF WHAT WAS BEING TAUGHT ABOUT WOMEN'S HEALTH, AND I WANT TO SAY -- AND OF COURSE GOING BACK TO THE MENOPAUSE, I WANTED TO SAY, YOU KNOW, I WAS EVEN ON YOUR SHOW 30 YEARS AGO TALKING ABOUT MENOPAUSE. I WAS TRYING TO STAY CALM. [LAUGHTER] AND ALL OF THIS LANGUAGE LIKE THIS IDEA OF LOOKING AT SOCIAL AND BEHAVIORAL CHARACTERISTICS AND THAT THEY'RE IMPORTANT FOR HEALTH. WELL, DARN, WE WERE TALKING ABOUT THAT WHEN WE FIRST STARTED LOOKING AT THE AGENDA FOR WOMEN'S HEALTH RESEARCH, THAT WOMEN'S HEALTH AND IN FACT THE HEALTH OF WOMEN AND MEN RELATED TO OUR ENVIRONMENT, RELATED TO STATES OF POVERTY, RELATED TO OUR BEHAVIORS, SO THAT'S NOT A NEW CONCEPT, RIGHT, SABRINA? WE'VE BEEN TALKING ABOUT THIS FOR YEARS. AND THAT ALL OF THIS IS NEW, AND I'M THINKING, DID I JUST WASTE THE LAST 30 YEARS OF MY LIFE? BUT I HAD TO KEEP CONTROL BECAUSE I DIDN'T KNOW -- I DIDN'T WANT TO GET IN TROUBLE WHEN I HAD TO COME OUT HERE. SO I WON'T GO ON BUT I SURELY COULD. SO MY SUCCINCT MESSAGE IS I'M REALLY PLEASED TO SEE OBVIOUSLY IF YOU'RE HERE, YOU RECOGNIZE THE IMPORTANCE OF WOMEN'S HEALTH RESEARCH AND YOU'RE HERE TO CELEBRATE THAT WE DO HAVE A HISTORY IN WOMEN'S HEALTH. IT'S NOT A NEW OR EMERGING SCIENCE. BUT THERE'S STILL A LOT THAT NEEDS TO BE DONE. SO I WANT TO THANK YOU FOR APPRECIATING THAT WE STILL NEED TO GIVE ATTENTION TO WOMEN'S HEALTH AND SEX AND GENDER DIFFERENCES, OR OH SIMILARITIES BECAUSE RESEARCH IS IMPORTANT TO DETERMINE IF THERE ARE DIFFERENCES, AND I WANT TO PLEAD WITH YOU TO HELP GET THE MESSAGE OUT ABOUT THE ADVANCES THAT HAVE BEEN MADE. WE HAVE COME A LONG WAY. NOW WE CERTAINLY HAVEN'T ANSWERED ALL THE QUESTIONS, JUST LOOKING AT THE DATA ON MATERNAL MORTALITY WHICH POINTS IS THAT OUT, BUT STILL, IF WE'RE GOING TO REALLY MOVE FORWARD, WE NEED TO BUILD ON WHAT WE HAVE AND NOT IGNORE THAT AND START ALL OVER AGAIN LIKE THIS IS A BRAND NEW AREA. MAYBE IT IS FOR SOME. AND THE CONTINUING ATTENTION TO RESEARCH AND DISSEMINATING INFORMATION TO WOMEN SO WOMEN CAN PROTECT THEMSELVES AND THEIR HEALTH THROUGH SELF CARE AND BEHAVIOR MODIFICATION FOR LONGER AND HEALTHIER LIVES, AND I A WE HAD A POSTER ABOUT WOMEN LIVING LONGER AND BETTER AND IT SHOWED WOMEN ON BICYCLES. IT'S MY FAVORITE POSTER. IT WAS FOR A SEMINAR AS WE WERE HAVING THEN AND THESE WOMEN, BEAUTIFUL COLORFUL POSTER, AND I STARTED GETTING EMAILS FROM ACROSS CAMPUS SAYING, DR. PINN, THOSE WOMEN ON YOUR POSTER WILL NOT LIVE LONG IF THEY DON'T PUT ON HELMETS. [LAUGHTER] I TRIED TO GET THE ARTIST TO REVISE THE POSTER BUT YOU KNOW THE ARTIST SAID NO, AND SO I USED THAT SLIDE IN MY TALKS AND POINT OUT AT NIH WE DO KNOW YOU'RE SUPPOSED TO WEAR HELMETS TO PROTECT YOUR HEALTH. BUT HELP ME FEEL THAT THE LAST 30 YEARS HAVE NOT BEEN FOR NAUGHT, THAT WE NEED TO APPRECIATE WHAT WE'VE DONE, BUT NOT BE SATISFIED, AND WE NEED TO MOVE FORWARD. SO I WANT TO CONGRATULATE AGAIN DR. CLAYTON, THE STAFF OF ORWH, ALL THE OTHER HHS WOMEN'S HEALTH PROGRAM PERSONS AND OFFICES BECAUSE WE SPENT A LOT OF TIME WORKING TOGETHER AND A LOT OF MEETINGS AND A LOT OF PHONE CALLS, AND JANINE, I HOPE YOU'RE FINDING THAT SAME CAMARADERIE THAT I FOUND, BECAUSE NONE OF US COULD HAVE CON IT ALONE. DONE IT ALONE. BUT TO EACH OF YOU, AND AGAIN, TAKE MY PICTURE DOWN, PLEASE, THERE IS STILL MUCH TO DO. THANK YOU FOR BEING HERE, AND [APPLAUSE] TODAY I WANT TO SPEAK WITH YOU ABOUT THE KEY NUMBERS RELATED TO MATERNAL HEALTH IN THE U.S. I WILL FOCUS ON STATISTICS AND TRENDS IN U.S. MATERNAL MORTALITY AND MORBIDITY. AS YOU KNOW, TO ADDRESS ANY HEALTH PROBLEM, WE NEED TO UNDERSTAND WHO'S AFFECTED AND THE FACTORS THAT DRIVE THE NUMBERS. I HOPE TO PROVIDE YOU WITH SOME INSIGHT THE INTO THE WHO AND THE WHY OF MATERNAL HEALTH IN MY TALK. IN THE U.S., WE USE DEFINITIONS FROM THE CENTERS FOR CENTERS FOR DISEASE CONTROL AND PREVENTION, THE CDC. THE WORLD HEALTH ORGANIZATION, WHO, USES DIFFERENT DEFINITIONS AS YOU CAN SEE. THE CDC DEFINES PREGNANCY-RELATED DEATH AS: THE DEATH OF A WOMAN WHILE PREGNANT OR WITHIN ONE YEAR OF THE END OF A PREGNANCY, REGARDLESS OF THE OUTCOME, DURATION OR SITE OF THE PREGNANCY FROM ANY CAUSE RELATED TO OR AGGRAVATED BY THE PREGNANCY OR ITS MANAGEMENT BUT NOT FROM ACCIDENTAL OR INCIDENTAL CAUSES. YOU WILL ALSO SEE PREGNANCY RELATED MORTALITY RATIO, WHICH IS AN ESTIMATE OF THE NUMBER OF PREGNANCY-RELATED DEATHS FOR EVERY HUNDRED THOUSAND LIVE BIRTHS. THE CDC DEFINES SEVERE MATERNAL MORBIDITY AS UNINTENDED OUTCOME OF THE PROCESS OF LABOR AND DELIVERY THAT RESULT IN SIGNIFICANT SHORM TER OR LONG TERM CONSEQUENCES TO A WOMAN'S HEALTH. IT CAN ALSO BE CONSIDERED A NEAR MISS FOR MATERNAL MORTALITY. THE DATA GENERATED USING THESE DEFINITIONS HAS SOME LIMITATIONS, SO SOME CAUTION IS NEEDED IN ASSESSING MATERNAL MORTALITY OVER TIME. AND IN COMPARING PREGNANCY-RELATED MORTALITY AND MORBIDITY AMONG DEMOGRAPHICALLY DIFFERENT SUBPOPULATIONS OF WOMEN IN THE U.S. PEOPLE ARE WORKING, MANY OF YOU, TO IMPROVE MEASURES AND THE COLLECTION OF DATA, BUT THERE ARE -- THESE ARE THE DEFINITIONS THAT WE CURRENTLY WORK WITH. IN HER INTRODUCTION, DR. CLAYTON MENTIONED THIS BUT IT BEARS REPEATING. BLACK WOMEN ARE THREE TO FOUR TIMES MORE LIKELY TO DIE OF PREGNANCY-RELATED COMPLICATIONS THAN WHITE WOMEN. THE PURPLE LINE IN THIS GRAPH SHOWS CLEARLY THAT INCREASE IN MATERNAL MORTALITY IN THE UNITED STATES HAS BEEN MOST PRONOUNCED AMONG BLACK WOMEN. ACCORDING TO CDC, PREGNANCY-RELATED MORTALITY RATIO FOR WHITE WOMEN WAS 12.4 DEATHS PER 100,000 BIRTHS, COMPARED TO 40 DEATHS PER 100,000 BIRTHS FOR BLACK WOMEN FROM 2011 TO 2014. THAT'S A HUGE DIFFERENCE. NATIVE AMERICAN WOMEN ARE ALSO DISPROPORTIONATELY AFFECTED, AS YOU CAN SEE FROM THE TEAL LINE. THE REASON FOR THIS DISPARITY ARE COMPLEX, MULTIFACTORIAL AND NOT FULLY UNDERSTOOD. THEY RELATE TO MANY FACTORS SUCH AS HEALTH BEHAVIORS, GENETICS, THE PHYSICAL AND SOCIAL ENVIRONMENT IN WHICH WOMEN LIVE, AND ACCESS TO QUALITY HEALTHCARE. SO THAT IS AT LEAST IN PART THE WHO OF MATERNAL MORTALITY IN THE UNITED STATES. WHAT ABOUT THE WHY OF MATERNAL MORTALITY? WHAT ARE THE CAUSES OF MATERNAL DEATH IN THE U.S.? DR. HOLLIER WILL ADDRESS THIS ISSUE, BUT I WANT TO TALK ABOUT A PARTICULAR ASPECT OF IT. AS YOU CAN SEE, THE TRADITIONAL CAUSES OF MATERNAL DEATH SUCH AS HEMORRHAGE, INFECTION, SEPSIS, THROMBOEMBOLISM AND HYPERTENSIVE DISORDER OF PREGNANCY ARE STILL WITH US YOU. HOWEVER, ANALYSIS OF TRENDS FROM AROUND THIS PERIOD WHICH I HAVE NOT SHOWN HERE INDICATES THAT DEATHS FROM THESE TRADITIONAL CAUSES CONTINUE TO DECLINE. THEY ARE, OF COURSE, STILL VERY IMPORTANT TO ADDRESS. BUT IT IS IMPORTANT TO UNDERSTAND THAT THE DRIVERS OF MATERNAL DEATH ACTUALLY HAVE CHANGED DURING THE PAST TWO DECADES. I'D LIKE TO HIGHLIGHT ON THIS GRAPH CARDIOVASCULAR CONDITIONS AND CARDIOMYOPATHY, WHICH NOW REPRESENT A SIGNIFICANT PROPORTION OF ALL MATERNAL DEATH, 25% OF THEM. MOREOVER, DEATH FROM CARDIOVASCULAR DISEASES AND CARDIOMYOPATHY HAVE INCREASED AS DEATH FROM TRADITIONAL CAUSES HAVE DECREASED. THIS SUGGESTS THAT WE HAVE TO, ONE, EDUCATE CLINICIANS WHO PROVIDE CARE TO WOMEN ABOUT CARDIOVASCULAR DISEASES AND PREGNANCIES, AND TWO, IDENTIFY CARDIOVASCULAR DISEASE EARLIER, IDEALLY, BEFORE PREGNANCY. IT IS ALSO NOTABLE THAT FOR THE SECOND LEADING CAUSE OF PREGNANCY-RELATED DEATHS, OTHER MEDICAL, NON-CARDIOVASCULAR, THE CDC DOES NOT SPECIFY THE CONDITIONS IN THIS CATEGORY ON ITS WEBSITE. NOW I'M GOING TO TURN TO SEVERE MATERNAL MORBIDITY, OR SMM. DR. HOLLIER WILL ALSO ADDRESS THIS ISSUE, BUT I WANT TO GIVE A MORE GENERAL OVERVIEW FOR THIS CONTEXT. EACH YEAR, MORE THAN 50,000 WOMEN HAVE SEVERE PREGNANCY COMPLICATIONS SUCH AS HEMORRHAGE, INFECTION, HEART ATTACKS, BLOOD CLOTS, AND HYPERTENSION, ALSO KNOWN AS SEVERE MATERNAL MORBIDITY. SMM HAS BEEN STEADILY INCREASING IN RECENT YEARS AND THE RATE MORE THAN DOUBLED FROM 2000 TO 2010. A COMBINATION OF FACTORS IS PROBABLY DRIVING THE INCREASE IN SMM, AND THOSE INCLUDE OLDER MATERNAL AGE AND INCREASES IN PREVALENCE OF RISK FACTORS FOR PREGNANCY COMPLICATIONS THAT INCLUDE PREPREGNANCY OBESITY, PRE-EXISTING CHRONIC CONDITIONS AND CESAREAN OR OTHER COMPLICATIONS DURING DELIVERY. OF COURSE DATA ON SMM CASES ARE CRUCIAL FOR IDENTIFYING WAYS TO IMPROVE THE QUALITY OF MATERNAL I HOPE I'VE PROVIDED A GOOD OVERVIEW OF THE NUMBERS AS THEY SET THE STAGE FOR WHAT WILL FOLLOW AT TODAY'S SYMPOSIUM. MANY OF THE ORGANIZATIONS REPRESENTED HERE TODAY ARE WORKING TO IMPROVE MATERNAL HEALTH. THERE ARE MANY ACTIVITIES GOING ON ON THE NATIONAL AND STATE LEVELS. OF COURSE ACOG PLAYS A PROMINENT ROLE IN LEADING EFFORTS TO REDUCE MATERNAL MORTALITY AND SEVERE MATERNAL MORBIDITY IN THE U.S. WE ARE VERY FORTUNATE TO HAVE DR. LISA HOLLIER, THE PRESIDENT OF ACOG, TO PROVIDE THE KEYNOTE ADDRESS. TODAY'S PANEL DISCUSSION INVOLVE EXPERTS WHO ARE INTEGRAL TO EFFORTS TO IMPROVE MATERNAL HEALTH. THAT SESSION WILL PROVIDE MORE INFORMATION ON THE SPECIFIC PROBLEMS UNDERLYING MATERNAL MORTALITY AND MORBIDITY. WE HAVE PRESENTED THE DATA AND IT'S CLEAR THAT THERE ARE DESPAIRTS DI SPAIRTS ON MATERNAL HEALTH -- IN THE GENERAL HEALTH AND HOW WE CAN TAKE BENCH RESEARCH TO THE BEDSIDE AND THEN TO THE CURBSIDE IN OUR COMMUNITIES. FINALLY, FEDERAL PARTNERS WHO ARE LEADING THE GOVERNMENT EFFORTS IN THIS AREA WILL PROVIDE AN UPDATE ON THEIR ACTIVITIES TO ADDRESS MATERNAL HEALTH. I'M SURE WE ARE ALL LOOKING FORWARD TO STIMULATING DAY INFORMATION ON THIS CRUCIAL AREA ON DATA AND THE HEALTH OF WOMEN. IT THANK YOU VERY MUCH. [APPLAUSE] >> WELL, YOU ALL HAVE HEARD A LITTLE BIT ALREADY ABOUT DR. HOLLIER. SOME OTHER THINGS THAT YOU MAY NOT KNOW, I'LL SHARE, THAT SHE IS ALSO A PROFESSOR IN THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, AT THE BAYLOR COLLEGE OF MEDICINE. SHE SERVES AS CHIEF MEDICAL OFFICER FOR OB-GYN FOR TEXAS CHILDREN'S HEALTH PLAN AND THE MEDICAL DIRECTOR OF ON OH STE TRICKS AND GYNECOLOGY FOR THE CENTERS OF CHILDREN AND WOMEN. SHE ALSO CHAIRED THE TEXAS MATERNAL MORTALITY AND MORBIDITY TASK FORCE. SOMETHING ELSE I'D LIKE EVERYONE TO PAUSE AND THINK ABOUT IS, WHAT DID WE DO THREE DAYS AGO? THREE DAYS AGO, WE CELEBRATED MOMS, GRANDMOMS, AND MOTHERS-TO-BE. THIS TOPIC IS ALL SO IMPORTANT TO EACH ONE OF US IN THIS ROOM, BECAUSE ALL OF US HAVE A MOM. PERHAPS MAYBE GRANDMOTHER, DAUGHTERS THAT ARE IMPORTANT TO US. THE TOPIC TODAY AND THE PROGRESS THAT WE'RE MAKING AND THE PROGRESS THAT NEEDS TO BE MADE IS ESPECILLY IMPORTANT TO ME BECAUSE THIS LAST SUNDAY, I FOUND OUT THAT I'M GOING TO BE A GRANDMA. [APPLAUSE] SO PLEASE DO JOIN ME IN WELCOMING DR. LISA HOLLIER. [APPLAUSE] >> THANK YOU SO VERY MUCH. IT IS TRULY A PLEASURE FOR ME TO BE HERE TODAY AND I WILL TELL YOU THAT I AM SO HUMBLED TO BE STANDING HERE AT THE PODIUM IN FRONT OF DR. PINN. YOUR LEADERSHIP IS AND HAS BEEN ABSOLUTELY INCREDIBLE, AND I AM SO GRATEFUL FOR ALL THAT YOU HAVE ACCOMPLISHED. YOU HAVE ACCOMPLISHED A LOT THE LAST 30 YEARS, AND THERE HAVE BEEN TREMENDOUS, REMARKABLE IMPROVEMENTS, AND I HOPE THAT WE CAN CELEBRATE SOME OF THAT TODAY. THANK YOU FOR EVERYTHING. WE HAVE TALKED A LOT ABOUT THE CRISIS THAT WE'RE FACING. US A HEARD FROM DR. NOURSI EARLIER AND I WOULD LIKE TO SAY, IT HAS BEEN A PLEASURE TO WORK WITH DR. NOURSI, SHE HAS BEEN JUST TERRIFIC AND WE HAD FUN WORKING TOGETHER ON OUR SLIDESETS. PREGNANCY-RELATED MORTALITY IN THE UNITED STATES IS CLEARLY INCREASING. I WILL OFTEN SAY RATE. I UNDERSTAND THAT IT IS ACTUALLY A RATIO, BUT BECAUSE WE USE RATE SO COMMONLY EVERY SINGLE DAY, I WILL USE THAT TERM. WHILE RATES DO VARY FROM STATE TO STATE, THE OVERALL RATE IN THE UNITED STATES AS WE'VE SAID EXCEEDS THE RATE IN OTHER DEVELOPED NATIONS. NOW I'D LIKE TO PUT THIS IN CONTEXT AGAIN. WE'VE LOOKED AT THIS DATA IN SEVERAL DIFFERENT WAYS, AND WHAT I'D LIKE TO SHOW YOU TODAY IS THIS PLOT THAT HAS FOUR SPECIFIC AREAS. WHAT YOU CAN SEE IS THAT THE MAJORITY OF THE COUNTRIES REPRESENTED IN THE TRIANGLES OR SQUARES ARE IN THE LOWER LEFT-HAND CORNER OF THIS GRAPH, AND WHAT THAT AREA IS IS RATES OF MATERNAL MORTALITY THAT WERE FALLING IN NEAB 90 1990 TO 2003 AND RATES THAT WERE FALLING FROM 2003 TO 2013. ON THE OPPOSITE END OF THIS FOUR-QUADRANT -- IS RATES THAT WERE RISING IN BOTH OF THOSE DIFFERENT TIME PERIODS, AND YOU CAN SEE THAT THE UNITED STATES IS UP THERE WITH THAT RISING RATE IN BOTH THOSE TIME PERIODS ALONG WITH AFGHANISTAN AND BELIZE. AS WE SAID, WE HAVE THE MOST EXCEPTIONAL INFRASTRUCTURE, WE HAVE A STRONG COMMITMENT TO RESEARCH, SOME OF THE MOST BRILLIANT MINDS IN THE WORLD, AND YET WE FAIL OUR MOTHERS. WE'VE PRESENTED THIS DATA, AGAIN, IN MULTIPLE DIFFERENT WAYS, AND DR. NOURSI AND I TALKED ABOUT WHETHER I SHOULD TAKE THIS OUT AND I DECIDED TO GO AHEAD AND KEEP THIS IN BECAUSE EACH ONE OF US IS ADDRESSING THE RACIAL DISPARITY AND MATERNAL MORTALITY. BLACK WOMEN ARE DISPROPORTIONATELY IMPACTED. DRAMATIC DISPARITIES AND NOW WIDENING. RATES OF MATERNAL MORTALITY FOR AFRICAN-AMERICAN WOMEN ARE 3 TO 4 TIMES HIGHER THAN FOR WOMEN OF OTHER RACES, AND WHILE AGAIN THE DIFFERENCE IN THE RATE VARIES FROM STATE TO STATE, THIS IS INCREDIBLY SIGNIFICANT. IN DETAILED ANALYSES, YOU CAN SEE HERE THAT THE RATES OF MATERNAL MORTALITY FOR AMERICAN INDIAN AND ALASKA NATIVE WOMEN ARE ALSO SIGNIFICANTLY HIGHER. AND AS WE NOTE SIGNIFICANT REDUCTIONS IN MATERNAL MORTALITY AND MORBIDITY CANNOT BE ACCOMPLISHED WITHOUT ADDRESSING THE CARE GAPS FOR THESE WOMEN. SEVERE MATERNAL MORBIDITY PLACES A SEVERE BURDEN, A SIGNIFICANT BURDEN ON WOMEN, THEIR FAMILIES, AND OUR SOCIETY IN ECONOMIC, SOCIAL AND PERSONAL TERMS. FOR EVERY WOMAN WHO DIES, ABOUT 100 WOMEN SUFFER SEVERE COMPLICATIONS, SEVERE COMPLICATIONS. AND WHAT I WANT YOU TO REMEMBER, WHAT IS I THINK VERY IMPORTANT IS WE LOOK AT OUR PREVENTION STRATEGIES AND OUR INTERVENTIONS TO REDUCE MATERNAL MORTALITY, THERE IS A CONNECTION BETWEEN MORTALITY, PARTICULARLY PREVENTABLE ATERNAL DEATHS, AND SEVERE MATERNAL MORBIDITY. IF WE CAN IDENTIFY THESE WOMEN EARLIER, IF WE CAN INTERVENE SOONER ON THIS PATH, WE CAN PREVENT MORTALITY FROM EVER OCCURRING. THE PREVALENCE OF SEVERE MATERNAL MORBIDITY HAS BEEN INCREASING AND SIGNIFICANT RACIAL DISPARITIES ALSO EXIST IN SEVERE MATERNAL MORBIDITY. YOU CAN SEE HERE A GRAPH OF SEVERE MATERNAL MORBIDITY, THIS IS TAKEN FROM OUR COLLEAGUES AT THE CDC, AND IT SHOWS OVER TIME PERIODS THE CHANGE INSEVERE MATERNAL MORBIDITY USING THEIR DEFINITION. YOU CAN SEE THE OVERALL RATE WHEN IT INCLUDES BLOOD TRANSFUSIONS IN THE ORANGE LINE, IN THE BLUE LINE, THIS INCLUDES BLOOD TRANSFUSIONS ALONE, SO THE MAJORITY OF THE SEVERE MORBIDITY THAT WE'RE CALCULATING HERE IS ACCOUNTED FOR BY BLOOD TRANSFUSIONS BUT I DO WANT YOU TO RECOGNIZE THE SIGNIFICANT INCREASE IN THE GREEN LINE AT THE BOTTOM, SEVERE MATERNAL MORBIDITY WITHOUT BLOOD TRANSFUSIONS, ALSO INCREDIBLY IMPORTANT. THESE ARE 25 TO 40% INCREASES IN COMPLICATIONS FOR WOMEN OVER TIME. DR. PINN REMINDED US ABOUT HOW MUCH IMPORTANT WORK HAS ALREADY BEEN DONE, AND I WANT TO EMPHASIZE THAT WORK TODAY. PREVENTION IS POSSIBLE. THIS IS DATA TAKEN FROM THE CDC'S REPORT FROM NINE MATERNAL MORTALITY REVIEW COMMITTEES AND IT TALKS ABOUT OUR ABILITY TO PREVENT THESE DEATHS AND AS YOU CAN SEE, LOOKING AT THE MIDDLE ROW OF ALL OF THOSE COLUMNS, ABOUT 60% OF THESE DEATHS ARE CONSIDERED PREVENTABLE. WE ARE MAKING PROGRESS AND I WANT TO SHARE SOME OF THAT PROGRESS WITH YOU TODAY BECAUSE I THINK IT'S SO INCREDIBLY EXCITING. THE SOURCE FOR THIS IMAGE IS ALSO FROM THE CDC AND I'M GRATEFUL TO OUR PARTNERS THERE FOR THE OPPORTUNITY TO, A, WORK WITH THEM, BUT B, FOR THEIR INCREDIBLE PARTNERSHIP IN SO MANY OF THE THINGS THAT WE DO. I'D LIKE TO CALL ATTENTION TO THE PARTNERSHIP AND THE COORDINATION OF AT SO MANY LEVELS. THE MATERNAL MORTALITY REVIEW COMMITTEES IN THE LIGHT PURPLE CIRCLE CONDUCT DETAILED REVIEWS OF EACH MATERNAL DEATH, IDENTIFY CAUSES AND CONTRIBUTING FACTORS AND HELP US IDENTIFY WAYS TO PREVENT MATERNAL DEATHS. THE COLLABORATIVES YOU SEE HERE ALSO HAVE TOOLS AND TECHNICAL ASSISTANCE THAT IMPLEMENT SOLUTIONS BASED ON THE FINDINGS OF THE MATERNAL MORTALITY REVIEW SO WE GET THE DATA, WE DESIGN THE PROGRAMS, AND THEN WE IMPLEMENT THOSE PROGRAMS. THE ALLIANCE FOR INNOVATION ON MA IT TERNL HEALTH IS A PARTNER SHIM PARTNERSHIP OF A NUMBER OF DIFFERENT GROUPS AND WE HAVE SAFETY BUNDLES THAT I'LL TALK ABOUT A LITTLE BIT MORE IN JUST A SECOND. BUT IT'S THROUGH THE IMPLEMENTATION, THROUGH ALL OF THESE GROUPS WORKING TOGETHER THAT WE ARE ABLE TO IMPLEMENT PROGRAMS THAT REDUCE MATERNAL MORBIDITY AND MATERNAL MORTALITY. LET'S START WITH THE MATERNAL MORTALITY REVIEW COMMITTEES. WE HAVE 38 EXISTING REVIEWS INCLUDING TWO CITIES. RIGHT NOW THAT LEAVES US WITH ABOUT 14 STATES THAT DON'T HAVE MATERNAL MORTALITY REVIEW COMMITTEES. HOWEVER, WE DO HAVE CONTACTS IN EVERY ONE OF THESE STATES, THE CTC IS CDC IS WORKING AGGRESSIVELY TO ADD MORE COMMITTEES AND I BELIEVE WITH THE RECENT LEGISLATION PREVENTING MATERNAL DEATHS WITH THE SUPPORT AND THE INFRASTRUCTURE THAT IS PROVIDED THROUGH THAT LEGISLATION WITH THE NOTICE OF FUNDING OPPORTUNITY FROM THE CDC THAT RECENTLY CLOSED, WE'VE HAD THE BEST OPPORTUNITY WE'VE EVER HAD TO BUILD THAT INFRASTRUCTURE TO UNDERSTAND AND HELP PRIORITIZE THE SOLUTIONS THAT WE NEED TO PUT IN PLACE. SOME COMMITTEES ARE EVEN REVIEWING SEVERE MATERNAL MORBIDITY NOW, AND THAT PROVIDES US WITH EVEN BETTER DATA THAT WE CAN USE TO ENSURE THAT WE HAVE IDENTIFIED THE RIGHT INTERVENTIONS TO IMPLEMENT IN EACH PARTICULAR STATE. THERE ARE STATE-WIDE VARIATIONS, AND SO I THINK IT'S IMPORTANT THAT WE TAKE THE INFORMATION THAT WE HAVE TO PRIORITIZE THE BEST POSSIBLE ACTION. ONE OF ACOG'S PRIMARY FUNCTIONS IS TO DEVELOP OUR CLINICAL DOCUMENTS. OUR WORK GOES FAR BEYOND THE DEVELOPMENT OF CLINICAL PRACTICE GUIDANCE TO TRANSLATE THE CLINICAL DATA THAT WE HAVE FROM THE MATERNAL MORTALITY REVIEW COMMITTEES, THE GUIDANCE THAT WE HAVE FROM OUR ORGANIATION, AND COMBINE THAT INTO MEANINGFUL ACTION. THE ALLIANCE FOR INNOVATION ON MATERNAL HEALTH IS AN INITIATIVE BASED ON PROVEN IMPLEMENTATION APPROACHES THAT INCREASE MATERNAL SAFETY AND OUTCOMES IN THE UNITED STATES. IT WAS LAUNCHED IN 2015 AND FUNDED THROUGH A COOPERATIVE AGREEMENT WITH THE MATERNAL AND CHILD HEALTH BUREAU AT HRSA AND THE GOAL OF AIM IS TO ELIMINATE PREVENTABLE MATERNAL MORTALITY AND SEVERE MORBIDITY ACROSS THE UNITED STATES. AS YOU CAN SEE, I MENTIONED SAFETY BUNDLES. WHAT ARE SAFETY BUNDLES? THEY'RE A COLLECTION OF BEST PRACTICES THAT HAVE BEEN SHOWN TO IMPROVE OUTCOMES AND IMPROVE THE QUALITY OF CARE. THEY DON'T PROVIDE A SINGLE WILL PROTOCOL BUT INSTEAD THEY PROVIDE A STANDARD FRAMEWORK FOR EACH FACILITY TO DEVELOP A PROTOCOL THAT IS SPECIFIC FOR THEIR RESOURCES AND FOR THEIR PATIENTS. THE BUNDLES THAT WERE PRIORITIZED FOR ADOPTION ABOUT BY THE ALLIANCE FOR INNOVATION ON MATERNAL HEALTH WERE BASED ON DATA FROM THE REVIEW COMMITTEES. -- HEMIVAJ THE LEADING CAUSE OF MORTALITY THAT YOU SAW BUT ALSO HIGHLY PREVENTABLE. SO THIS CONDITION WAS PRIORITIZED IN THIS AND THIS BUNDLE WAS DEVELOPED. YOU CAN SEE AN EXAMPLE OF ONE PIECE OF INFORMATION FROM OUR BUNDLE THAT DESCRIBES THE DIFFERENT COMPONENTS OF READINESS, RECOGNITION AND PREVENTION, RESPONSE, AND REPORTING. WE HAVE A NUMBER OF THESE BUNDLES BASED ON THE DATA WE HAVE AGAIN FROM THE MATERNAL MORTALITY REVIEWS AND THESE BUNDLES INCLUDE MANAGEMENT OF CONDITIONS LIKE SEVERE HYPERTENSION, YOU SAW SEVERE HYPERTENSION AS A LEADING CAUSE OF MATERNAL MORTALITY WHILE IT WASN'T AT THE TOP, AGAIN, JUST DUE TO SEVERE HYPERTENSION ARE PREVENTABLE. THESE ARE -- THEY HAVE A HIGH DEGREE OF PREVENTABILITY SO IT'S REALLY IMPORTANT TO HAVE IMPLEMENTATION OF THESE BUNDLES TO PREVENT THOSE DEATHS. HYPERTENSIVE DEATHS ALSO DISPROPORTIONATELY AFFECT AFRICAN-AMERICAN WOMEN SO WE'RE PRIORITIZING BUNDLES THAT HELP US TO REDUCE DISPARITIES. A RECENT STUDY HAS SUGGESTED THAT IMPLEMENTATION OF A PROGRAM, A SINGLE PROGRAM REALLY ISN'T ENOUGH TO ACHIEVE MEANINGFUL SUSTAINED CHANGE IN OUTCOMES AND WE AGREE. AIM IS CHANGING HOSPITAL SYSTEMS AND HOSPITAL CULTURE. AIM IS CREATING A DIFFERENT CULTURE IN THOSE FACILITIES CREATING A CULL WILL TOUR OF PATIENT SAFETY. IT PROMOTES SAFETY BY USING MULTIDISCIPLINARY DRILLS FOR OB-GYNs, PEDIATRICIANS, ANESTHESIOLOGISTS, NURSING STAFF, OP RARITYING ROOM OPERATING ROOM S TAFF, IT BRINGS EVERYONE TOGETHER TO PRACTICE SO THAT YOU GET GOOD WF BEFORE YOU NEED TO BE GOOD AND YOU CAN REACT IMMEDIATELY IN THOSE CRITICAL, CRITICAL MOMENTS. WHILE CURRENT AIM STATES, AS YOU CAN SEE HERE IN THE DARK PURPLE COLOR, THEY MAKE UP ABOUT THREE QUARTERS OF THE TOTAL U.S. BIRTHING POPULATION. OUR GOAL, THOUGH, IS ALL 50 STATES, AND CONTINUED FEDERAL SUPPORT CAN HELP US ACHIEVE THAT GOAL. WE SPENT A LOT OF TIME TALKING TODAY ABOUT DISPARITIES IN MATERNAL MORTALITY. AND I WANT TO SHOW YOU SORT OF THE FIRST ITERATION AND THEN A SECOND ITERATION OF WHAT THE DISPARITIES WORK LOOKS LIKE FOR AIM. SO THE COUNCIL ON PATIENT A SAFETY IN WOMEN'S HEALTHCARE DEVELOPE A BUNDLE FOR THE REDUCTION OF RACIAL AND ETHNIC DISPARITIES WITH THE ASSISTANCE OF LEADERS LIKE ELIZABETH HOWELL, ALISON BRYANT AND KIM GREGORY. THIS WAS A START AND PROVIDED GUIDANCE ON THE COLLECTION OF DATA, THE UTILIZATION OF THE DISPARITIES DASHBOARD IN ALL BIRTHING FACILITIES, CLINICS, AND AN EXAMINATION OF THE BIAS OF THE PROVIDERS WITHIN THEIR HEALTHCARE SYSTEM. HOWEVER, LIKE ANY GOOD QUALITY IMPROVEMENT INITIATIVE, WE'VE RECOGNIZED THAT THIS WASN'T ENOUGH. IN FACT, WE NEED TO BE INCORPORATING MECHANISMS TO ADDRESS DISPARITIES IN ALL OF OUR BUNDLES. SO ACOG, A LOT IS CURRENTLY ADDRESSING THE DISPARITIES FOR BLACK WOMEN WITH THE HELP OF OUR PARTNERS, YEA, THANK YOU, JOANNE, THE NATIONAL BIRTH EQUITY COLLABORATIVE AND THE CALIFORNIA MATERNAL QUALITY CARE COLLABORATIVE. WE'RE IMPLEMENTING SOLUTIONS BY CENTERING BLACK WOMEN AND THEIR VOICES THROUGH MOTHERS' VOICES DRIVING BIRTH EQUITY, A PROJECT THROUGH THE ROBERT WOOD JOHNSON FOUNDATION. THIS WORK IS BEING LED BY BLACK SCHOLARS LIKE DR. KAREN SCOTT IN PURSUIT OF BLACK WOMEN'S BIRTH EXPERIENCES IN DIFFERENT GEOGRAPHIC REGIONS. THROUGH THIS PROJECT, WE ARE GOING TO BE ABLE TO INCORPORATE PATIENT VOICES AND THE LIVED EXPERIENCES IN METRIC AND MEASURE DEVELOPMENT THAT WE CAN USE IN THAT PATIENT SAFETY WORK. SO IT ISN'T JUST A BUNDLE ON DISPARITIES, DISPARITIES WORK IS INCORPORATED IN EVERY SINGLE THING THAT WE DO. IT'S INCORPORATED INTO HOW WE DELIVER OUR CARE. WE MUST ENSURE THAT THE METHODS THAT HOSPITALS AND CLINICIANS USE TO ADDRESS IMPLICIT BIAS AND RACISM ALIGN WITH BLACK WOMEN'S NEEDS, VALUES AND PREFERENCES. BLACK WOMEN'S FEEDBACK MUST BE USED AS A DRIVER FOR QUALITY IMPROVEMENT EFFORTS. AND THOSE QUALITY IMPROVEMENT EFFORTS ARE BEING SUCCESSFUL. IN FACT, THE AIM PROGRAM HAS HAD REMARKABLE IMPROVEMENT IN SUCH A SHORT TIME. THE INITIAL AIM STATES, ILLINOIS, OKLAHOMA, FLORIDA AND MICHIGAN, OBSERVED SEVERE MATERNAL MORBIDITY REDUCTIONS OF 7 TO 21% BETWEEN 2015 AND 2018. ONE AIM STATE AS YOU CAN SEE HERE ON THE SLIDE HAD A 21% REDUCTION IN HEMORRHAGE IN COMPLICATIONS FROM HEMORRHAGE, WHEN AIM BUNDLES WERE IMPLEMENTED IN THE HOSPITAL. AND INTEREST INTERESTINGLY, WHEN THE HEMORRHAGE BUNDLE WAS IMPLEMENTED IN A HOSPITAL, THE TOTAL NUMBER OF COMPLICATIONS WAS REDUCED IN THAT HOSPITAL, NOT JUST COMPLICATIONS FROM HEMORRHAGE, RIGHT, WHEN YOU CHANGE THE CULTURE, IT'S EXPANSIVE, IT'S THE BROADER THAN JUST THAT SINGLE BUNDLE THAT YOU'RE IMPLEMENTING. AND IN ILLINOIS, IT WAS ALSO PARTICULARLY EXCITING. THEY FOCUSED ON IMPLEMENTATION OF A SEVERE HYPERTENSION BUNDLE AND TIMELY TREATMENT FOR WOMEN THAT HAD SEVERE HYPERTENSION. WHEN THEY STARTED THIS WORK, THEY NOTICED THERE WERE MARKED DISPARITIES IN TIME TO TREATMENT. DISPARITIES BY FACILITY AND DISPARITIES BY RACE. WHAT THEY SHOWED EVERY TIME AFTER IMPLEMENTATION AT THE SEVERE HYPERTENSION BUNDLE WAS AN INCREASE IN TIMELY TREATMENT FROM 41% TO 85%. WHAT THEY WERE ABLE TO SHOW WAS THAT BY THE END OF THIS IMPLEMENTATION PROGRAM, TIMELY TREATMENT WAS THE SAME FOR ALL WOMEN AT EVERY HOSPITAL AND REGARDLESS OF THEIR RACE, AND THAT'S WHERE WE NEED TO BE IN THIS COUNTRY, THAT WE ALL HAVE THE SAME TREATMENT NO MATTER WHO WE ARE, NO MATTER WHAT WE LOOK LIKE, NO MATTER WHERE WE GO TO GET OUR TREATMENT. RIGHT CARE, RIGHT PLACE, RIGHT TIME. SO ACOG AND THE SOCIETY FOR MATERNAL FETAL MEDICINE WORKED TOGETHER TO DEVELOP LEVELS OF MATERNAL CARE AND WE'VE BEEN PARTNERING WITH THE CDC TO VERIFY THAT INFORMATION. WE'VE USED STANDARDIZED DEFINITIONS AND NOMENCLATURE FOR FACILITIES SO THAT A LEVEL 1 MEANS A LEVEL 1 MEANS A LEVEL 1, NO MATTER WHERE YOU ARE, RIGHT? THAT IDEA WOULD BE TO HAVE CONSISTENT GUIDELINES ACROSS THESE DIFFERENT LEVELS AND ULTIMATELY AN EQUITABLE DISTRIBUTION OF THESE FACILITIES SO THAT WE CAN HAVE AN APPROPRIATE NETWORK THAT PROVIDES RISK-APPROPRIATE ANTIPARTUM AND POSTPARTUM RESOURCES. WE HEARD CARDIOVASCULAR DISEASE AND CARDIOMYOPATHY -- I'M REALLY EXCITED TO SAY THAT JUST EARLIER THIS MONTH, ACOG LAUNCHED THE PREGNANCY AND HEART DISEASE PRACTICE BULLETIN, IT'S THE OUR NEW GUIDANCE FOR THE SCREENING, DIAGNOSIS AND TREATMENT OF WOMEN WITH HEART DISEASE IN PREGNANCY, BOTH IN THE PRE-PREGNANCY, PREGNANCY AND POSTPARTUM PERIOD. SO I'M REALLY EXCITED ABOUT THIS BRAND NEW CLINICAL GUIDANCE, BUT I WILL SAY THE MOST IMPORTANT THING AS DR. PINN HAS MENTIONED IS IMPLEMENTATION IS EVERYTHING. SO INCREDIBLY IMPORTANT. SO WE'VE HAD A LOT OF GREAT PROGRESS TOWARD OUR OUTCOMES. AND I'M REALLY EXCITED ABOUT THE INCREASING AWARENESS AND HAVING THIS HERE TODAY MEANS SO VERY MUCH. BUT I THINK YOU'VE NOTICED THAT WE'VE REALLY FOCUSED IN ON THE EFFORTS I'VE BEEN TALKING ABOUT ARE VERY MUCH AROUND THAT GREEN SECTION, THAT 36% AT THE BOTTOM. HOWEVER, WE HAVE AN INCREDIBLE OPPORTUNITY TO CONTINUE TO IMPROVE THE WORK THAT WE'RE DOING. THERE ARE A VARIETY OF DIFFERENT FRAMEWORKS THAT HELP US' VOOL WAIT US EVALUATE THE OPPORTUNITIES THAT EXIST TO IMPROVE THE HEALTH OF WOMEN OUTSIDE OUR TYPICAL CLINICAL SPHERE, OPPORTUNITIES THAT MUST BE ADDRESSED IN ORDER FOR US TO ACHIEVE OUR GOALS. THE FRAMEWORK THAT I PRESENT SEER ON THIS SLIDE HERE ON THIS SLIDE IS TAKEN FROM THE WORLD HEALTH ORGANIZATION IN 2010, AND I THINK IT'S REALLY IMPORTANT THAT WE ALL UNDERSTAND THAT WE NEED TO MOVE BEYOND THE INDIVIDUAL WOMEN, MOVE BEYOND THE HOSPITAL OR CLINIC, MOVE BEYOND THAT HEALTH SYSTEM, AND ADDRESS OTHER FACTORS, THE COMMUNITIES AND THE BROADER CONTEXTS IN WHICH WOMEN LIVE THEIR LIVES. WE NEED TO BE ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH AND IT ISN'T NEW. BUT IT REALLY -- WE REALLY NEED TO SEE THIS HAPPEN, WE NEED TO SEE CONTINUED WORK IN THIS AREA. ELIMINATION OF MATERNAL MORTALITY WILL REQUIRE CONTRIBUTIONS FROM ALL AREAS, INCLUDING NATIONWIDE POLICIES BEYOND HEALTHCARE. ELIMINATION AND MATERNAL MORTALITY WILL REQUIRE CHANGES IN OUR CULTURE AND CHANGES IN OUR VALUES. IF YOU LOOK AT THE STRUCTURAL DETERMINANTS, YOU CAN SEE OUR GOVERNANCE, OUR PUBLIC POLICIES, OUR CULTURE, SOCIOECNOMIC POSITION, GENDER, RACISM, EDUCATION, OCCUPATION, INCOME, THESE ARE ALL VERY, VERY IMPORTANT. THEN WE CAN SEE THESE OTHER DETERMINANTS THAT ULTIMATELY HAVE AN IMPACT ON WOMEN'S HEALTH BUT WE ARE GOING TO HAVE TO ADDRESS THESE SOCIAL DETERMINANTS AND ADDRESS THESE STRUCTURAL FACTORS THAT LIMIT OUR CARE. I'M GOING TO THROW UP A COUPLE OF IDEAS, DIFFERENT RESEARCH IDEAS AND HERE ARE JUST SOME OF THEM. AS WE LOOK AT SEVERE MATERNAL MORBIDITY, WE NEED TO BE ABLE TO HAVE BETTER RISK PREDICTION MODELS FOR SEVERE MORBIDITY AND MORTALITY, WE NEED IMPROVED MATERNAL EARLY WARNING SYSTEMS TO HELP US IDENTIFY THOSE WOMEN AND INTERVENE BEFORE A WOMAN LOSES HER LIFE. WE NEED TO BE ABLE TO MEASURE AND IMPROVE HOSPITAL QUALITY AND WE'VE TALKED ABOUT LEVELS OF CARE BUT WE DON'T HAVE ANY EVIDENCE LIKE YOU DO WITH NICU LEVELS THAT THIS ACTUALLY IMPROVES OUTCOME, SO WE NEED TO BE LOOKING AT THAT. WE NEED IMPROVED ASSESSMENTS OF COMMUNITY FACTORS, AS CONTRIBUTING FACTORS TO MATERNAL MORTALITY IN OUR MATERNAL MORTALITY REVIEWS. THIS IS SOMETHING THAT THE CDC HAS BEEN PROVIDING GUIDANCE ON AND WE'RE VERY EXCITED ABOUT THAT. THOSE WOMEN CENTERED OUTCOMES THAT I WAS TALKING ABOUT, WE NEED TO HAVE WOMEN CENTERED OUTCOMES IN EVERYTHING THAT WE DO, AND WE NEED TO USE THOSE. WE NEED TO UNDERSTAND WHAT ARE THE CONTRIBUTIONS OF THESE SOCIAL DETERMINANTS OF HEALTH AND WHAT ARE THE EFFECTIVE INTERVENTIONS TO ACTUALLY REDUCE THE DISPARITIES THAT WE'VE TALKED ABOUT, WHAT ARE OUR BEST STRATEGIES, WHAT ARE THE ROLES OF IMPLICIT BIAS TRAINING AND EDUCATION. IT'S SOMETHING WE TALK ABOUT A LOT, WHAT POLICY CHANGES CAN WE IMPLEMENT THAT TRULY MAKE MEANINGFUL CHANGE. CLINICAL RESEARCH AND THE ROLE OF NICHD IS VERY IMPORTANT IN HELPING US ADDRESS SOME OF THESE QUESTIONS, THOUGH CERTAINLY OTHER OPPORTUNITIES. I'M GOING TO CLOSE WITH JUST THIS IMAGE, THIS IS THE BUTTON THAT I'M WEARING TODAY. WE HAVE HEARD SO MANY TIMES THAT THE VOICES OF WOMEN ARE UNHEARD AND ACOG, BE THIS IS PART OF OUR NEWEST CAMPAIGN THAT WE JUST LAUNCHED THIS YEAR THAT REMINDS ALL OF US THAT WE NEED TO BE LISTENING, WE NEED TO GENUINELY LISTEN, WE NEED TO LISTEN TO WHAT WOMEN ARE TELLING US, WE NEED TO VALUE THEIR LIVED EXPERIENCES, AND WE NEED TO HEAR THEM, AND WE NEED TO ACT. SO THANK YOU VERY MUCH FOR GIVING ME THE OPPORTUNITY TO BE HERE TODAY. IT HAS BEEN A PLEASURE, AND I APPRECIATE YOUR ATTENTION. THANK YOU. [APPLAUSE] >> SO WE WOULD LIKE TO CARRY ON A TRADITION THAT DR. PINN STARTED QUITE SOME TIME AGO. DR. CLAYTON, DR. NOURSI AND I WOULD LIKE TO PRESENT WITH YOU THIS PLAQUE TO THANK YOU FOR COMING TO PRESENT THE KEYNOTE AND FOR ALL THAT YOU'RE DOING. [APPLAUSE] MY NAME IS -- I AM A TECHNOLOGY POLICY FELLOW IN THE OFFICE OF RESEARCH ON WOMEN'S HEALTH. FIRST I WOULD LIKE TO INTRODUCE TWO OF OUR VIPs THAT HAVE ARRIVED. STACEY STEWART, CEO, MARCH OF DIMES, AND ALSO DR. DOROTHY FINK, DIRECTOR OF WOMEN'S HEALTH AT HHS. WELCOME. QUICKLY I WANT TO REMIND THE AWTD YENS THAT WHILE I WILL PROVIDE A SHORT INTRODUCTION OF OUR PANELISTS, THE LONG BIOGRAPHIES ARE IN YOUR PACKET SO PLEASE LOOK THE A THOSE FOR MORE INFORMATION. NOW IT'S MY HONOR TO INTRODUCE OUR ESTEEMED PANELISTS TODAY, WHO I GUESS WILL BE COMING UP YOU SOON. OKAY. OUR MODERATOR, JACQUELYN CAMPBELL, PROFESSOR, JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING. WELCOME. DR. CAMPBELL'S MAY SCORE AREA OF RESEARCH IS VIOLENCE AGAINST WOMEN AND ASSOCIATED PHYSICAL AND MENTAL HEALTH OUTCOMES. OUR SECOND PANELIST, DR. JOIA ADELE CREAR-PERRY, IS FOUNDER AND PRESIDENT OF THE NATIONAL BIRTH EQUITY COLLABORATIVE. FOCUS -- WITH THE RECENT ADDRESS TO THE U.N. OFFICE OF THE HIGH COMMISSIONER FOR HUMAN RIGHTS TO IMPROVE MATERNAL MORTALITY. NEXT, WE HAVE DR. MICHAEL LU, PROFESSOR AND SENIOR ASSOCIATE DEAN FOR ACADEMIC, STUDENT AND FACULTY AFFAIRS AT THE MILL KEN INSTITUTE SCHOOL OF PUBLIC HEALTH AT GEORGE WASHINGTON UNIVERSITY. PRIOR TO JOINING GW, HE WAS CHILD HEALTH BUREAU FOR HRSA. OUR FINAL PANELIST, WHO ALSO SERVED AS OUR WONDERFUL AND ENGAGING KEYNOTE SPEAKER, DR. LISA HOLLIER, IS PRESIDENT OF THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS. ACOG. SO PLEASE HELP ME WELCOME OUR PANELISTS. [APPLAUSE] OUR PANEL, WHAT WE'RE SUPPOSED TO BE DOING, IS CONTINUING ON OUR WONDERFUL KEYNOTE DIRECTIONS IN TERMS OF SETTING OUT A RESEARCH AGENDA THAT WE HOPE ALL OF YOU IN THE ROOM WILL HELP TO EITHER FUND OR DO. [LAUGHTER] I'M GOING TO START WITH DR. CREAR-PERRY IN TERMS OF EXPLICATING A LITTLE BIT MORE WHAT KIND OF RESEARCH WE NEED TO EXPLICATE THOSE SOCIAL DETERMINANTS AND HOW THEY ACTUALLY AFFECT MATERNAL MORTALITY. >> THANK YOU. GOOD AFTERNOON, EVERYBODY. THANK YOU SO MUCH FOR INVITING ME, DR. CLAYTON, AND OF COURSE DR. PINN, SHE DOESN'T KNOW I MET HER AS A MEDICAL STUDENT AT THE 100TH ANNIVERSARY OF THE NMA, THEY WERE INTRODUCED AT THE HEAD OF THE CENTER, SO IT'S AMAZING TO BE HERE AND TO BUILD AND TO BE A PART OF THIS LEGACY, SO I APPRECIATE BEING HERE WITH YOU. SO, WHAT WE NEED -- A LOT OF TIMES WE TALK ABOUT SOCIAL DETERMINANTS, PEOPLE FEEL VERY OVERWHELMED, YOU KNOW, YOU SAW THAT LIST THAT LISA PUT UP ALL THE THINGS, WE CAN'T FIX POVERTY AND EDUCATION SO PEOPLE ALWAYS WANT LOW HANGING FRUIT, GIVE ME A LIST, GIVE ME SOMETHING MORE CONCRETE, THEY ASK. A FEW YEARS AGO, OUR ORGANIZATION DID -- WE LOOKED AT 50 DIFFERENT SOCIAL DETERMINANTS OF HEALTH TO SEE WHICH ONES HAD A POSITIVE PREDICTIVE VALUE FOR INFANT MORTALITY. I WOULD ARGUE BECAUSE THE LEADING CAUSE OF INFANT MORTALITY IS PREMATURITY, THE THINGS THAT CAUSE INFANTS TO DIE ARE SO MUCH OF THE THINGS THAT CAUSE MOMS TO DIE. UNFORTUNATELY WHAT WE SEE WHAT WE DID THIS LIST, THOUGH, IS THERE'S SO MANY THINGS THAT ARE MISSING. SO WE STARTED WITH ACTUALLY LISTENING TO MOTHERS TO SEE WHAT THEIR LIVED EXPERIENCES WERE. THEY TALKED ABOUT THINGS LIKE TRANSPORTATION AND NOT HAVING TRANSPORTATION. BUT THERE'S NO QUANTITATIVE DATASET ON ADEQUACY OF TRANSPORTATION IN THE UNITED STATES. I CAN'T SAY HOW DID TRANSPORTATION COMPARE IN DETROIT TO LOUISIANA. SO IF WE WERE GOING TO START THINKING ABOUT HOW THE SOCIAL DETERMINANTS OF HEALTH IMPACT OUR BODIES, WE FIRST HAVE TO LOOK AT COLLECTING DATA ACCURATELY ON SOCIAL DETERMINANTS OF HEALTH AND LOOKING AT THINGS LIKE TRANSPORTATION BECAUSE A LOT MORE DATA FOR HOUSING, SO WE KNOW HOUSING IS A BIG IMPACT, WE KNOW THAT THINGS LIKE RACIAL RESIDENTIAL SEGREGATION, WE HAVE SOME DATA AROUND THAT. WE KNOW THE HIGHER YOUR POE LEUTION RATE, POLLUTION, THE HIGHER INFANT MORTALITY RATE. SO LETTING THEM TELL US KIND OF WHAT HAPPENS, WHAT WE DON'T DO WELL IS LISTEN TO PEOPLE FIRST. WE JUST KIND OF MAKE IT UP BASED UPON WHAT WE THINK AND THEN DATA. SO MY OFFERING TO THIS AMAZING ESTEEMED CROWD IS PERHAPS WE SHOULD START WITH TALKING TO PEOPLE FIRST, AND THEN RUNNING THE DATA AFTER THEY TELL US WHAT'S GOING ON. SO ANYWAY, THOSE ARE JUST -- SO REALLY HOW ROBUST IT WOULD BE IF NIH OR OTHERS IN THE ROOM WOULD REALLY THINK ABOUT LOOKING AT THE DIFFERENT SOCIAL DETERMINANTS BECAUSE I CAN RUN AROUND AND SAY MARITAL STATUS, WE'VE YET TO PROVE THAT ACTUALLY IMPACTS MATERNAL MORTALITY. SO HOW DO WE PICK THINGS WE KNOW FROM THE WOMEN ACTUALLY IMPACT THEIR HEALTH. >> ONE OF THE THINGS I'M PARTICULARLY INTERESTED IN IN THIS REALM IS HOW EXACTLY STRUCTURAL RACISM AND EVERYDAY RACISM ACTUALLY AFFECT WOMEN'S PHYSIOLOGY AND HOW DOWNSTREAM WE SEE THESE MATERNAL HEALTH INEQUITIES. >> A GREAT OPPORTUNITY FOR US TO THINK ABOUT THAT IS THIS CARDIOMYOPATHY INCREASE, RIGHT? THINK ABOUT LIKE ERIKA GARNER DIED SIX MONTHS AFTER GIVING BIRTH FROM A CARDIOMYOPATHY. WE KNOW THE STRESS EITHER FROM STRUCTURAL RACISM, ERIKA SPENT HER TIME, HER FATHER WAS KILLED BY THE POLICE IN NEW YORK CITY, SO SHE WOULD GO BACK AND RELIVE THAT EXPERIENCE. WHAT THEY DO IN NIGERIA, WHICH HAS SIMILAR OR HIGHER RATES OF CARDIOMYOPATHY IS THEY HAVE A REGISTRY AND THEY'RE FOLLOWING PEOPLE. WHAT WE'RE LEARNING ON WHAT PEOPLE HAVE BEEN DOING FOR YEARS, RESEARCH IN GENETICS, RACE IS NOT JENNY TICK, GENETIC, WE ALL AGREE, RIGHT THE? BUT RACISM IMPACTS OUR TELOMERES, OUR HEARTS, SO THAT'S A REALLY IMPORTANT GROUP THAT INSTEAD OF LOOKING AT THEIR GENETICS TO SEE WHAT CHANGED, LOOKING AT WHAT OTHER LIVED EXPERIENCES AROUND THEM CAUSE HARM TO THEIR HEARTS AND WE CAN LOOK AT ALL THOSE KINDS OF THINGS. SO IT'S A GREAT, I THINK, LOW HANGING FRUIT TO START WITH THE PATIENTS WHO HAVE CARDIOMY OPATHY, DO SOME TYPE OF IMPACT, THE DIFFERENCE IN THEIR STRESS, VERSUS MOMS WHO DON'T HAVE CARDIOMYOPATHY, YOU COULD REALLY BUILD A ROBUST KAY DATASET FROM THAT CONCRETE GROUP OF INDIVIDUALS WHO WE KNOW THEIR NUMBERS ARE INCREASING. >> AND IF I CAN TAKE A LITTLE MODERATOR PRIVILEGE, I ALSO WANTED TO ADD IN TERMS OF BOTH ADVERSE CHILDHOOD EVENTS AND THE KIND OF CUMULATIVE EXPERIENCES OF VIOLENCE THAT WE SEE SO OFTEN IN AFRICAN-AMERICAN WOMEN AND ALSO NATIVE AMERICAN WOMEN AND SOMETIMES ON THAT GRAPH, WE FORGET HOW DISPARATE THEIR EXPERIENCES ARE OF MATERNAL MORTALITY ALSO. AND I KNOW DR. PINN WAS ONE OF THE PEOPLE THAT SAID WE HAVE TO WIDEN OUT WOMEN'S HEALTH TO INVOLVE THINGS LIKE INTIMATE PARTNER VIOLENCE. AND THAT PART OF WHAT WE NEED TO DO IN PRENATAL CARE IS DO THAT ROUTINE ASSESSMENT FOR INTIMATE PARTNER VIOLENCE AND NOW PEOPLE ARE THINKING ABOUT ALSO FOR ACES, BECAUSE IT IS THAT CUMULATIVE TRAUMA THAT HAS SUCH A DEVASTATING EFFECT ON ALL PART OF THE PHYSIOLOGY. ALL RIGHT. SO MOVING ON A BIT, DR. LU, WOULD YOU BE WILLING TO TALK ABOUT -- WE HEARD ABOUT SOME OF THE THINGS WE'RE DOING IN NIGERIA. ARE THERE OTHER PLACES AROUND THE WORLD THAT ARE DOING BETTER THAN WE ARE IN IT TERMS OF MATERNAL MORTALITY AND REDUCING IT, KEEPING IT LOW, THAT YOU COULD TALK ABOUT THAT WE NEED TO TRANSLATE RESEARCH FROM THERE? >> SURE. AND THIS IS WHERE YOU THINK YOU SAW THE GRAPH FROM DR. CLAYTON AND DR. HOLLIER IN TERMS OF WHERE THE UNITED STATES IS, WHERE ONE OF THE FEW DEVELOPED COUNTRIES THAT ACTUALLY SEE INCREASE IN MATERNAL MORTALITY. I DO THINK THAT IT'S IMPORTANT TO FOCUS THIS CONVERSATION AROUND SOCIAL DETERMINANTS BECAUSE I DO THINK A LOT OF THESE OTHER COUNTRIES GET -- THEY'RE REALLY HEAVILY INVESTED IN ADDRESSING SOCIAL DETERMINANTS THAT WE HAVEN'T INVESTED AS MUCH. SO I DO THINK THAT AS WE GO ON WITH A CONVERSATION TODAY, IT'S IMPORTANT TO TALK ABOUT MATERNAL MORTALITY -- IT'S IMPORTANT TO TALK ABOUT SAFETY BUNDLES, I THINK THOSE ARE ALL IMPORTANT LOW HANGING FRUITS, BUT IF WE DO WANT TO GET TO THAT ZERO MATERNAL DEATH, IF WE WANT TO COMPLETELY ELIMINATE DISPARITIES, WE REALLY HAVE TO TALK ABOUT SOCIAL DETERMINANTS. >> I ABSOLUTELY AGREE WITH YOU, MICHAEL. I DO THINK THE SOCIAL DETERMINANTS ARE REALLY IMPORTANT AND SOME OF THE THINGS THAT WE SEE IN OTHER COUNTRIES IS A SIGNIFICANT DIFFERENCE IN SOCIAL SUPPORT FOLLOWING DELIVERY. AND ACOG RELEASED GUIDANCE ABOUT A YEAR AGO ON OPTIMIZING POST POSTPARTUM CARE, AND I THINK IT REALLY WAS ONE OF THE FIRST TIMES WHERE WE SAID IT'S NOT A SIX-WEEK VISIT, RIGHT? THIS IS A TIME OF TRANSITION. THERE ARE A LOT OF CHANGES THAT ARE GOING ON IN YOUR BODY, AND REALLY RECOGNIZING THE IMPORTANCE OF CONTINUITY OF CARE, THOSE CARE CONNECTIONS, AND PROVIDING THAT ADDITIONAL SUPPORT, SO IS THE INTENT OF THE NEW CLINICAL GUIDANCE IS TO REALLY HAVE A CONNECTION BETWEEN THE MOM AND THE CLINICAL PRACTICE WITHIN A VERY SHORT TIME PERIOD FOR WOMEN WHO HAVE HYPERTENSION, WITHIN SEVEN DAYS AFTER -- SEVEN TO 10 DAYS AFTER DELIVERY, AT RISK FOR HEART DISEASE, AND HAVING THAT INITIAL TOUCH POINT EARLY FOR ALL WOMEN HAVING AN EARLY VISIT WITHIN THE FIRST THREE WEEKS AFTER A DELIVERY IS REALLY IMPORTANT AND THEN A COMPREHENSIVE ASSESSMENT AT 12 WEEKS. I THINK MANY OF YOU KNOW RIGHT NOW, OUR PAYMENT POLICIES FOR ABOUT HALF OF THE WOMEN IN THIS COUNTRY DON'T SUPPORT A VISIT AT 12 WEEKS POSTPARTUM, SO I THINK ONE OF THE THINGS THAT OTHER COUNTRIES ARE DOING RIGHT IS THE SOCIAL SUPPORT THAT THEY PROVIDE FOR WOMEN IN THAT POSTPARTUM PERIOD. >> SO IT WAS MENTIONED THAT I HAD THE GREAT PRIVILEGE OF PRESENTING AT THE U.N. IN GENEVA, WITH I IS VERY HUMBLING, BUT AT THAT MOMENT, WHAT WE WERE TALKING ABOUT IS HOW MATERNAL MORTALITY IS REALLY A HUMAN RIGHTS ISSUE AND WHAT THAT MEANS IS WHAT THEY'RE MENTIONING, THE COUNTRIES THAT DO HAVE BETTER MATERNAL MORTALITY RATES HAVE A HUMAN RIGHTS FRAMEWORK. WHEN YOU HAVE THAT, YOU BELIEVE THAT ALL INDIVIDUALS HAVE THE ABILITY TO LIVE TO THEIR FULL POTENTIAL, SO YOU DO THINGS LIKE, I DON'T KNOW, FREE CHILD CARE, IT WOULD BE NICE TO HAVE, SO THAT WHEN YOU HAVE A BABY, YOU DON'T HAVE TO WORRY ABOUT WHAT YOU'RE GOING DO WITH THE BABY AFTER BABY COMES. AND I WOULD SAY THE PANEL THAT I WAS ON, THE HEALTH MINISTER FROM UGANDA WAS ON THE PANEL WITH ME AND HE MENTIONED THAT IN UGANDA, THEY COUNT MOMS AND NOT BABIES BECAUSE THEY HAVE SIX BABIES HER MOM, AND SO THEY REALLY DON'T WANT MOMS TO DIE BECAUSE THEN THEY GOT 12 KIDS SOMEBODY'S TRYING TO RAISE AND IT'S A BIG ISSUE. HERE IN THE U.S. AS IS NOTED, WE HAVEN'T RELEASED OFFICIAL NUMBERS SINCE 2007 SH WE 2007, YOU COUNT BABIES, NOT MOMS. SO WHAT WE HAVE TO LEARN FROM OTHER COUNTRIES IS ALSO FRAMING THIS INSIDE OF HUMAN RIGHTS SO KNOWING THAT NONE OF US ARE GOING TO GET ANY IMPROVED HEALTH, INEQUITIES ARE STILL GOING TO EXIST, RURAL INEX-EAST COAST WITS, BLACK-WHITE INEQUITIES, NATIVE, ALL UNTIL WE HAVE A HUMAN RIGHTS -- SECONDLY IF WE DON'T COUNT THE DEATHS, SO THIS INVESTMENT FROM CDC WAS REALLY EXCITING, WE'VE WORKED SINCE 1010 TO 2010 TO GET THIS BILL PASSED, IT GOT PASSED THIS YEAR BUT IT'S IMPORTANT TO KNOW THAT NOW THAT WE'RE FINALLY GOING TO START COUNTING, HOW CAN WE HAVE ALL THE OTHER AGENCIES REALLY PARTICIPATE IN THAT AND WHAT CAN WE DO VERY DIFFERENTLY. >> JUST BUILDING ON THIS, I DO THINK THIS IS WHERE WE ALSO NEED TO BE TAKING THIS CONVERSATION UPSTREAM JUST FOR TOO LONG, FOLKS LIKE US, WE'VE TOILED DOWNSTREAM TO TRY TO -- THAT THE HARMS CAUSED BY DECISIONS MADE UPSTREAM. AS MUCH AS WE THINK THAT WE CAN FIX ALL MATERNAL CHILD HEALTH PRAWNS WITH PROGRAMS AND SERVICES, I THINK THAT REALLY -- TO ADVANCE EQUITY THE REQUIRE REAL LOCAL POLICY CHANGE. SO THIS THING WITH POSTPARTUM VISIT, RIGHT NOW MANY LOW INCOME WOMEN WILL LOSE THEIR MEDICAID COVERAGE AT 60 DAYS POSTPARTUM. SO CONSIDERING THE FACT THAT SOMEWHERE BETWEEN 12 TO 16% OF MATERNAL DEATHS ACTUALLY OCCUR IN THE LATE POSTPARTUM PERIOD, BETWEEN 43 DAYS AND 365 DAYS, SIMPLY EXTENDING MEDICAID UP TO ONE YEAR POSTPARTUM COULD BE AN IMPORTANT FIRST STEP IN TERMS OF ADDRESSING THESE LATE MATERNAL DEATHS. >> AND I JUST WANT TO ADD ON, TO A NUMBER OF POINTS, BUT FIRST OF ALL, ONE OF THE THINGS THAT'S HAPPENING IN CONGRESS TODAY, AND THIS IS NOT A POLITICAL STATEMENT, THIS IS A BIPARTISAN EFFORT THE AROUND THE BLACK MATERNAL MORTALITY CAUCUS LED BY ILLINOIS CONGRESSWOMAN LAUREN UNDERWOOD, AND ALSO NORTH CAROLINA CONGRESSWOMAN ALMA ADAMS. I THINK ONE OF THE THINGS WE CAN DO TO ADDRESS SOME OF THESE POLL WILL SEE ISSUES, IT NEEDS TO BE NATIONAL POLICY, IS TO HELP INFORM THEM OF OUR RESEARCH FINDINGS AND HELP INFORM THEM OF THE KINDS OF RESEARCH THAT'S NEEDED TO TRANSLATE FINDINGS. THE OTHER THING I WANTED TO MENTION ABOUT THE POSTPARTUM VISITS, THIS IS INCREDIBLY IMPORTANT, AND IT'S NOT ONLY IMPORTANT IN TERMS OF SOME OF THE HEALTH INEQUITIES THAT WE NORMALLY THINK OF IN RELATIONSHIP TO MATERNAL MORTALITY, BUT ALSO THE PREGNANCY ASSOCIATED DEATHS. THOSE ARE FROM HOMICIDE AND SUICIDE. AND OF COURSE SUICIDE IS OFTENTIMES ASSOCIATED WITH DEPRESSION DURING PREGNANCY AS WELL AS POSTPARTUM DEPRESSION AND SOMETIMES WE DON'T MAKE THE CONNECTIONS BETWEEN DEPRESSION DURING PREGNANCY AND HOW MUCH OF A RISK FACTOR THAT IS FOR POSTPARTUM DEPRESSION. WE ALSO KNOW NOT TO REPEAT A THEME THAT INTIMATE PARTNER VIOLENCE IS HEAVILY ASSOCIATED WITH POSTPARTUM DEPRESSION AND DEPRESSION DURING PREGNANCY, AND YET OUR NEWEST POSTPARTUM DEPRESSION GUIDELINES DON'T MENTION INTIMATE PARTNER VIOLENCE. SO NOT ONLY ASSESSING FOR VIOLENCE DURING PREGNANCY BUT ALSO AT POSTPARTUM VISITS IS INCREDIBLY IMPORTANT, AND OFTENTIMES THE PROVIDERS ARE NURSES AND NURSE PRACTITIONERS, AND IT'S IMPORTANT -- OR NURSE MIDWIES. IT'S IMPORTANT THAT THOSE ASSOCIATIONS WHICH I KNOW THEY ALREADY ARE, ARE WORKING WITH ACOG TO MAYBE SURE THOSE PROVIDERS ARE INCLUDED. I'M SUPPOSED TO MOVE ALONG OR WE'LL NEVER GET DONE. SO ONE OF THE QUESTIONS I WANTED TO ASK YOU AND I KNOW YOU TALKED ABOUT AIM, AND ONE OF THE THINGS THAT I WAS FACE FAST NATEED TO HEAR WHAT'S HAPPENING IN MICHIGAN AND HOW WELL THEY'RE IMPLEMENTING SOME OF THOSE THINGS. BUT I WONDERED IF YOU MIGHT TALK A LITTLE BIT MORE ABOUT EXACTLY WHAT KIND OF RESEARCH IS NEEDED TO MAKE SURE THAT WHAT'S HAPPENING IN ONE LOCALE, ONE STATE, GETS TRANSLATED TO THE REST OF THE COUNTRY WHERE IT'S NOT HAPPENING SO FAR. >> THANKS. I THINK THERE ARE A LOT OF OPPORTUNITIES FOR CONTINUED RESEARCH AROUND THE AIM PROGRAM, AND I THINK THE FIRST THING THAT YOU CAN SEE IS THAT WHAT I TOLD YOU WAS ABOUT OUTCOMES RELATED TO SEVERE MATERNAL MORBIDITY, I WASN'T TALKING ABOUT MATERNAL MORTALITY. SO AS WE FOLLOW THROUGH, AS MORE STATES ARE IMPLEMENTING THE AIM PROGRAM WHEN WE HAVE MORE PATIENTS WHO ARE BEING HELPED BY THE IMPLEMENTATION OF THE PROGRAM, WE NEED TO GET THAT MORTALITY DATA AS WELL. I THINK WE NEED ADDITIONAL WORK TO UNDERSTAND THE BEST IMPLEMENTATION STRATEGIES. WE NEED TO UNDERSTAND WHAT SUPPORTS PARTICULARLY RURAL OR SMALL HOSPITALS' NEED. I THINK ONE OF THE THINGS THAT WE'VE SEEN IN TEXAS, WE HAVE IMPLEMENTATION, WE LAUNCHED LAST JUNE AND WE HAVE IMPLEMENTED THE PROGRAM IN 210 OF OUR 230 DELIVERY FACILITIES, BUT THE ONES THAT WE'RE MISSING ARE OUR SMALLER RURAL FACILITIES, AND THOSE ARE THE ONES WHO REALLY PROBABLY NEED THE MOST ASSISTANCE. SO WHAT TYPE OF IMPLEMENTATION WORKS BEST IN SMALLER FACILITIES, WHAT IS THE POSSIBILITY FOR TEEMENT, ARE THERE IMPLEMENTATION NETWORKS THAT HAVE DEMONSTRATED BENEFIT ON THOSE TYPES OF PROGRAMS. SO THERE'S A LOT OF WORK THAT CAN BE DONE EVALUATING THE IMPLEMENTATION OF THE PROGRAM, THE ULTIMATE OUTCOMES OF THE PROGRAM BUT WHAT ARE THE INDIVIDUAL COMPONENTS OF THE PROGRAM THAT ACTUALLY DRIVE THE MOST BENEFIT, IS IT THE MATERNAL EARLY WARNING SIGNS, IS IT THE READINESS PIECE OR IS IT THE RESPONSE PIECE. WE'VE DEVELOPED THESE BECAUSE WE SAW DELAYS IN TREATMENT, AND WE'VE TRIED TO ADDRESS THE MOST IMPORTANT THINGS BUT I THINK WE NEED TO CONTINUE TO EVOLVE THE DIFFERENT COMPONENTS OF THE PROGRAM. ALSO IT WOULD BE HELPFUL TO EVALUATE THE DIFFERENT -- THE IMPACT OF DIFFERENT PROTOCOLS IN DIFFERENT FACILITIES BECAUSE IT ISN'T A SINGLE PROTOCOL, EVERYONE IS DEVELOPING THEIR OWN PROTOCOL, BUT WITHOUT HETEROGENEITY IN THESE PROTOCOLS, WHAT IMPACT DOES THAT HAVE AND HOW MUCH STANDARDIZATION IS NECESSARY VERSUS INDIVIDUALIZATION. SO I THINK THERE'S A LOT OF OPPORTUNITIES FOR RESEARCH AROUND THE BUNDLES THAT STILL REMAIN. I THINK, AGAIN, PART OF OUR PROBLEM -- I MEAN, IT'S WONDERFUL, IT IS WONDERFUL THAT WE HAVE THESE INCREDIBLE BUNDLES THAT ARE DEMONSTRATING GREAT RESULTS, THINK WE ALSO HAVE AN OPPORTUNITY LIKE WE DID WITH THE OPIOID BUNDLE TO MOVE AWAY FROM JUST THE DELIVER REEF DELIVERY FACILITY A ND INCLUDE THE CLINICAL PIECE IF YOU WANTED TO -- >> SO MY ORGANIZATION IS AN AIM PARTNER SO WE GET THE TO GO TO ALL THE MEETINGS AND WORK WITH ALL THE STATES AND WE WORK WITH CALIFORNIA AND MASSACHUSETTS AND OTHERS, AND REALLY ONCE -- THIS IS HOW DATA DRIVES INNOVATION, RIGHT? ONCE WE DISCOVERED THE MAJORITY OF THE DEATHS WERE NOT HAPPENING IN THE HOSPITAL, WE HAD TO MOVE TO MORE OF THE BUNDLES ADDRESSING THINGS LIKE WELL WOMEN CARE. I THINK ABOUT DR. PINN'S EARLIER COMMENTS ABOUT HOW IMPORTANT IT WAS TO ACTUALLY FOCUS ON WOMEN. SO LOOKING AT THE DIFFERENCE BETWEEN HOW WOMEN ARE TREATED VERSUS MEN. I REMEMBER LEARNING THAT HEART ATTACK SYMPTOMS, WOMEN PRESENTED DIFFERENTLY. THINK ABOUT HOW WE TREAT -- WE DON'T TREAT SPECIFICALLY BLACK WOMEN'S PAIN WHEN IT THEY COME TO THE HOSPITAL IN LABOR AND WHY THAT IMPATIENTS THEIR HEALTH. IF YOU'RE NOT EVALUATING MY CHEST PAIN, I'M MORE LIKELY TO DIE FROM MY CARDIOMYOPATHY BECAUSE YOU THINK I'M ONLY MAKING SOMETHING UP. SO THOSE ARE OPPORTUNITIES NOW THAT WE'VE MOVED KIND OF FROM THIS VERY -- WORKING ON LABOR AND DELIVERY, WHICH IS IMPORTANT, HEMORRHAGE, WORKING ON KIND OF PROTOCOLS AND SO REALLY THE NEXT ITERATION OF THE BUNDLES, THE LAST FOUR, I THINK, ARE REALLY MORE COMMUNITY-BASED AROUND THINGS LIKE OPIOIDS, AROUND POSTPARTUM, AROUND MATERNAL MENTAL HEALTH, AND REALLY THE PUSH IS THE DATA DROVE THAT. IF WE DIDN'T HAVE INFORMATION, THE ASSUMPTIONS WERE IT WAS ALL HOSPITAL, RIGHT? THE CREATION OF THE MATERNAL MORTALITY REVIEW COMMITTEE WAS CREATED BY THE AMA YEARS AGO AND IT WAS VERY DOCTOR-HOSPITALE FOCUSED, WE FIGURED IT WE COULD FIX THESE -- PULL BABIES OUT, EVERYTHING WOULD BE FINE. TURNS OUT IT DIDN'T WORK OUT THAT WAY SO NOW WE HAVE DATA TO SHOW THAT WOMEN ARE DYING BECUSE THEY CANNOT GET TO THE HOSPITAL, RIGHT, WHAT ARE WE DOING ABOUT ACCESS AND ASSESSING PEOPLE, MAKING SURE THEY HAVE TRANSPORTATION WHEN THEY LEAVE. WHAT ARE SOME WARNING SIGNS, HOW DO WE EXPLAIN TO PEOPLE WHAT YOU'RE SUPPOSED TO LOOK FOR WHEN YOU LEAVE THE HOSPITAL. SO ALL OF THESE ARE EXCITING THINGS YOU CAN RESEARCH, AND I'LL JUST END -- I'M ON A BUNCH OF THINGS. WE'RE ACTUALLY GOING TO PUT IN METRICS FOR HOSPITALS TO BE ACCREDITED BASED UPON MATERNAL OUTCOMES. SO WE NEED THE BUNDLES TO BE VALIDATED BECAUSE WE DON'T HAVE A LOT OF THINGS TO GIVE JOINT COMMISSION TO HOLD HOSPITALS& ACCOUNTABLE FOR. SO THOSE ARE REALLY IMPORTANT THINGS THAT WE NEED SUPPORT FROM RESEARCH RS AND FUNDING TO REALLY LOOK AT IMPROVED OUTCOMES. >> ONE OF THE OTHER THINGS THAT'S INCREDIBLY IMPORTANT IN THIS SPACE IS THE WHOLE LIFE COURSE KIND OF APPROACH, AND AS WE HEARD, THE FURTHER ALONG A WOMAN IS, THAT CAN INCREASE RISK, AND I ALWAYS THINK ABOUT THE ADOLESCENTS ALSO IN TERMS OF THEIR PARTICULAR HEALTH NEEDS AROUND ALL OF THESE ISSUES. AND WHAT KIND OF RESEARCH WE NEED TO SORT THOSE DIFFERENCES OUT. SO DR. LU, DO YOU HAVE ANYTHING IN THIS SPACE IN TERMS OF THE LIFE COURSE NOTIONS? >> SO THE WHOLE IDEA IS THAT PREGNANCY OUTCOME IS NOT THE END PRODUCT OF NOT JUST NINE MONTHS PREGNANCY BUT CLEARLY THE CUMULATIVE LIFE COURSE EXPERIENCE EXPOSURES THAT WE REALLY HAVE TO PAY ATTENTION TO. SO I DO THINK THAT THE LOW HANGING FRUIT GET US TO ABOUT HALFWAY TO ERADICATE MATERNAL MORTALITY, BUT IF WE REALLY WANT TO GET TO ZERO, WE REALLY HAVE TO START MUCH EARLIER THAN JUST DURING PREGNANCY. MY HOPE IS THAT IT WILL PROBABLY TAKE A GENERATION TO GET TO ERADICATE MATERNAL DEATHS FROM THE UNITED STATES BUT ONLY IF WE DO THE RIGHT THING AND ONLY CAN WE STRIVE TO MAKE SURE THAT WE CREATE CONDITIONS IN WHICH ALL GIRLS AND WOMEN CAN BE HEALTHY ACROSS THEIR LIFE COURSE. >> HOPEFULLY WE'LL HAVE A LITTLE TIME AT THE END TO TAKE QUESTIONS FROM THE AUDIENCE, SO IF YOU HAVE QUESTIONS FOR THE PANEL AND/OR RESEARCH STRATEGIES THAT YOU WOULD LIKE TO GET UP HERE, WE'D WELCOME THAT IN THE LAST FEW MINUTES OF THE PANEL. SO THE OTHER BIG ISSUE IS IN TERMS OF RESEARCH THAT WILL ACTUALLY TRANSLATE WHAT WE KNOW ACROSS DIFFERENT INITIATIVES. I WAS STRUCK BY WHAT YOU SAID ABOUT THE RURAL COMMUNITIES AND HOW MUCH WE NEED OH THOSE INITIATIVES TO GET TRANSLATED THERE AND THE RESEARCH THAT SAYS, YOU KNOW, WHAT ARE THE CORE COMPONENTS, WHAT ARE THE COMPONENTS THAT REALLY MAKE A DIFFERENCE FOR DIFFERENT COMMUNITIES. I WAS ON THE NAVAJO RESERVATION JUST A COUPLE WEEKS AGO AT SHIPROCK, WHICH IS THE BIGGEST HOSPITAL ON THE NAVAJO RESERVATION. AND THEY WERE TELLING ME, AND ONE OF THE THINGS THAT INTERFERE WITH WHAT WE WERE DOING WAS, THEY DO NOT HAVE STABLE ALWAYS HIGH SPEED INTERNET. IN THE BIGGEST HOSPITAL ON THE NAVAJO RESERVATION. AND WE OFTENTIMES THINK, WELL, YOU KNOW, WE'LL GIVE PEOPLE AN INTERVENTION ON THEIR SMARTPHONES, NOT THINKING ABOUT THAT THEY MAY NOT WANT TO PAY FOR THE MINUTES THAT IT TAKES FOR THEM TO DOWNLOAD SOME PROGRAM THAT WE WANT THEM TO GET OR THE TEXT MESSAGES WE WANT THEM TO GET, BECAUSE THEY'VE GOT LIMITED PENNIES TO SPEND ON THAT. PARTICULARLY IN SOME OF OUR RURAL AREAS WHERE WE ASSUME JUST BECAUSE WE HAVE HIGH SPEED AT HOME DOESN'T MEAN OTHER PEOPLE HAVE HIGH SPEED INTERNET AT HOME AND EVEN OUR LIBRARIES, I KNOW, IN BALTIMORE, YOU ONLY GET A HALF-HOUR ON THE COMPUTER BEFORE YOU HAVE TO GIVE UP YOUR STATION TO SOMEBODY ELSE. THEY JUST WANT TO MAKE SURE KIDS AREN'T GAMING THE WHOLE TIME, BUT ANYWAY, THAT'S WHAT IT IS PARTLY ABOUT. BUT WHAT IT'S ALSO PARTLY ABOUT IS IT REALLY LIMITS ACCESS TO THINGS THAT WE THINK ARE REALLY IMPORTANT FOR COMMUNITIES TO GET. SO I DON'T KNOW WHERE -- IF YOU WANT TO START IN TERMS OF THOSE TRANSLATIONAL COMPONENTS, WHAT KINDS OF RESEARCH. YOU TALKED ABOUT IT A LITTLE BIT BEFORE IN TERMS OF AIM, BUT ARE THERE OTHER RESEARCH AGENDAS THAT WE REALLY NEED TO ATTEND TO MAKE SURE THAT WE EVEN OUT THOSE INEQUITIES? >> AS SOMEBODY WHO WORKS IN THE MEDICAID SYSTEM, I THINK WE REALLY NEED TO EVALUATE THE EFFECT OR EFFECTIVENESS OF POLICY CHANGES AND WHAT TYPES OF IMPACT DID THOSE PARTICULAR POLICY CHANGES HAVE ON HEALTH AND LONG TERM HEALTH. SO I THINK THAT'S CRITICAL. WE DON'T HAVE ENOUGH OF THAT INFORMATION. WE ALSO NEED TO LOOK AT THE, AS WE'RE THINKING ABOUT SOME OF THOSE CRITICAL ACCESS AREAS, WHAT ARE THE POLICY CHANGES THAT WOULD HAVE AN IMPACT ON PRESERVING THAT REGIONAL FACILITY, KEEPING THAT FACILITY IN THE COMMUNITY AND AVAILABLE, BECAUSE IN MANY COMMUNITIES, THAT HOSPITAL OR THAT FACILITY SUPPORTS THE INFRASTRUCTURE OF THE ENTIRE COMMUNITY AND CLOSURE RESULTS AND A LOSS OF FAR MORE THAN ACCESS TO HEALTHCARE. SO THOSE TYPES OF POLICY CHANGES -- I'M HOPING THAT'S RELEVANT TO THE QUESTION BUT THAT'S SORT OF REALLY WHERE MY BRAIN GOES, AND JUST THE OPPORTUNITIES THAT WE HAVE TO HAVE BETTER INFORMATION THAT WOULD ALLOW US TO IMPLEMENT BETTER PROGRAM PROGRAMMATIC CHANGES WITHIN THE MEDICAID PROGRAM IT SELF, FOR EXAMPLE, WHAT OTHER TYPES OF THINGS DO WE NEED TO ADDRESS, WHAT IS THE IMPACT OF TRANSPORTATION PROGRAMS WITHIN THE MEDICAID PROGRAM, WHAT IS THE IMPACT OF DIFFERENT CARE MODELS AND WHAT IS THE IMPACT OF DIFFERENT PAYMENT MODELS WITHIN THOSE PROGRAMS. >> AND DR. CAMPBELL, YOU MIGHT NOTICE OUR HESITANCY A LITTLE BIT IS BECAUSE WHEN WE HONESTLY -- WHEN I THINK OF NIH, I THINK MORE OF BASIC SCIENCE RESEARCH. SO THAT'S WHY I BROUGHT UP CARDIOMYOPATHY. YOU SEE WE KEEP TALKING ABOUT POLICY AND THAT'S OUR LIMITATION, PERHAPS, THIS IS WHAT YOU ALL DO ALL THE TIME, BUT IT'S OUR LIMITATION AND WE PERCEIVE IT'S NOT, RIGHT? SO IN THAT PERCEPTION, WHEN WE -- THE THING THAT TRANSLATES IS THEN WE UNDERSTAND THAT WOMEN'S HEALTH, THE INEQUITIES AND WHY YOU SEE INEQUITIES IN WOMEN'S HEALTH AND WHEN YOU SEE INEQUITIES IN RACIAL DISPARITIES IT'S BECAUSE OF POLICY. THERE'S NO BASIC SCIENCE THING THAT'S GOING TO FIX THE DIFFERENCE BETWEEN HOW WE TREAT MEN AND WOMEN, RIGHT? THAT IS A GENERAL POLICY THAT WE PAY LESS FOR AN ENTIRE PRENATAL CARE AND DELIVERY, RIGHT, THAN WE DO FOR A KNEE SURGERY. THAT'S A POLICY DECISION. THAT IS A CHOICE ABOUT WHAT WE VALUE, WHAT WE'RE GOING TO PAY FOR, WHO WAS IN THE ROOM WHEN WE CREATED THE RVUs IN THE FIRST PLACE, HOW DO WE DECIDE THAT KNEE SURGERY WAS BETTER, HOW DO WE DECIDE THAT HOSPITALS WILL SAY OUT LOUD PREGNANCY IS A LOSS LEADER, WE WILL ASSUME WE WILL ALWAYS LOSE MONEY ON WOMEN BUT WE KNOW THAT THEY WILL BRING THEIR HUSBANDS HERE FOR THEIR KNEE SURGERIES AND THEIR FATHERS HERE FOR THAWR HERT THEIR HEART SURGERIES BECAUSE WOMEN LEAD THE HOUSEHOLD. SO INSTEAD OF INVESTING IN WOMEN, WE WILL UNDERFUND THAT PART SO WHEN YOU SEE RURAL HOSPITAL LABOR AND DELIVERY CLOSURES -- A HOSPITAL, A RURAL PLACE, CAN'T AFFORD A LOSS LEADER. THEY CAN'T WAIT FOR SOMEBODY TO BRING THEIR UNCLE TO THE DOCTOR. THEY NEED TO ACTUALLY BE PAID FOR THE VALUE OF THE CARE OF A WOMAN. SO WE ARE SO CONFLICTED IN THIS COUNTRY ON BELIEVING WOMEN ARE ON A PEDESTAL BUT ALSO SAYING WE DON'T REALLY NEED TO PAY FOR THINGS THAT HAPPEN TO THEM AT THE SAME TIME. SO I THINK IT WOULD BE EXCITING FOR US TO LEARN ABOUT HOW WE CAN DO POLICY THINGS AND POLICY STUDIES WITHIN NIH BECAUSE THAT FOR US IS SO MUCH OF AN IMPORTANT PART AROUND THE WORK FOR MATERNAL MORTALITY, I'M THINKING ABOUT WHAT WE COULD DO TO IMPROVE OUTCOMES. HOPEFULLY I DIDN'T MISREPRESENT YOU. >> SINCE I'M A PRIVATE CITIZEN NOW -- [LAUGHTER] -- SO I GET TO NUDGE YOU. I THINK BACK TO ONE OF THE FIRST TIMES I ACTUALLY CAME TO THE NIH CAMPUS, I WAS A JUNIOR FACULTY AT UCLA. AT THE TIME, I CAME FOR A WORKSHOP ON RACIAL DISPARITIES IN PRETERM BIRTH. AND SURE I WAS KIND OF ON THIS HALLOWE GROUND, SOME OF THE MOST BRILLIANT SCIENTISTS IN THE WORLD, AND OBVIOUSLY I WAS REALLY, REALLY ININTIMIDATED SO IN THAT TWO-DAY MEETING, THE FIRST DAY AND A HALF, SOME OF THE MOST BRILLIANT SCIENTISTS IN THE WORLD JUST KEPT TALKING ABOUT SHORT CERVIX, PROGESTERONE, ALL THE MECHANISMS OF PRETERM BIRTH WHICH I THINK IS REALLY IMPORTANT BUT AT THE -- BY SECOND DAY, I JUST FELT LIKE I HAD TO SPEAK UP, BECAUSE -- >> REALLY? >> BECAUSE A LOT WE WERE TALKING ABOUT JUST SEEMED SO REMOVED FROM THE REAL LIVES OF THE WOMEN THAT I WAS TALKING WITH IN A LOT OF THE COMMUNITY ENGAGED RESEARCH, I WAS -- AROUND THE DISPARITIES. SO I DO WANT TO NUDGE YOU ALL KIND OF A LITTLE BIT, I'LL BE PROVOCATIVE, LISA, YOU WERE TALKING ABOUT SOCIAL DETERMINANTS AND YOU LOOK AT THEM AND SAY THIS IS NOT YOU, RIGHT? I'M NOT SURE -- REALLY, NOT YOU, SO I WOULD HOPE THAT IN THE NEXT GENERATION OF RESEARCH, THAT WE TAKE ON THE BIG ISSUES, THE INTRACTABLE PROBLEMS, THE SOCIAL DETERMINANTS. AND LET'S ALSO CALL OUT THE ELEPHANT IN THE ROOM, WHEN WE'RE TALKING ABOUT DISPARITIES, RACISM IS THE ELEPHANT IN THE ROOM. THE CHRONIC STRESS OF RACISM NOPT ONLY NOT ONLY IN HEALTHCARE BUT ALSO IN EVERYDAY LIFE OF WOMEN OF COLOR CREATE THAT WEAR AND TEAR ARE OF WHAT WILL BRUCE CALLS -- WHAT IS OFTEN REFERRED TO AS WEATHERING, AND THAT MAY EXPLAIN WHY COLLEGE EDUCATED BLACK WOMEN STILL HAVE HIGHER INFANT MORTALITY RATES AS WELL AS A WHOLE LOT OF OTHER CHRONIC CONDITIONS COMPARED TO WHITE WOMEN WHO ARE HIGH SCHOOL DROPOUTS. SO THE PROBLEM IS NOW THAT WE'RE RECOGNIZING THE IMPACT OF RACISM ON THESE OUTCOMES ON DISPARITIES, WHAT DO WE DO ABOUT IT. SO WHEN WE'RE TALKING ABOUT TRANSLATIONAL RESEARCH, WHAT DO WE DO ABOUT RACISM AND AS A ROLE FOR NIH TO PLAY IN TERMS OF ADVANCING RESEARCH IN TACKLING SOME OF THE BIG, BIG PROBLEMS, THE INTRACTABLE PROBLEMS THAT REALLY HAS BEEN THE STANDOUT IN OUR NATION'S HISTOR. >> AND WE ARE GOING TO GIVE OUR FEDERAL PARTNERS A CHANCE TO HAVE A SAY IN THE NEXT PANEL. BUT I DO WANT TO MENTION, I KNOW THAT NIH -- IT'S NOT JUST NICHD THAT HAS RESPONSIBILITIES IN THIS REALM AND THE OFFICE OF WOMEN'S HEALTH RESEARCH, BUT YOU ACROSS NIH, THERE IS MORE FUNDING FOR IMPLEMENTATION SCIENCE FOR THAT KIND OF TRANSLATIONAL RESEARCH, FROM WHAT DO WE SAY NOW, FROM THE BENCH TO THE BED SIGN TO THE CURBSIDE, I THINK IS AN IMPORTANT ELEMENT THERE. BUT I ALSO WANT TO MENTION IN TERMS OF THE WHOLE MATERNAL MORTALITY PICTURE, THAT THE THESE PREGNANCY ASSOCIATED DEATHS, THE CDC PUTS ASIDE, AND MOST OF THE STATE MATERNAL MORTALITY REVIEW PANELS DON'T CONSIDER THOSE DEATHS FROM HOMICIDE AND SUICIDE. FOR HOMICIDE, THE GREAT STUDY THAT DIANE CHENG DID IN MARYLAND, WE FOUND THAT ACTUALLY HOMICIDE WAS THE LEADING CAUSE OF MATERNAL MORTALITY IN THE STATE OF MARYLAND. NOW, THERE HASN'T BEEN ANOTHER STATEWIDE STUDY THAT'S BEEN DONE ON THAT, BUT FORTUNATELY ILLINOIS AT THE STATE LEVEL PASSED A LAW THAT THEY HAVE TO HAVE TWO MATERNAL MORTALITY REVIEW PANELS. THEY HAVE THE REGULAR ONE FOR THE PREGNANCY-RELATED DEATHS, BUT THEY ALSO HAVE ONE NOW THAT THEY HAVE TO REVIEW THE VIOLENT DEATHS ALSO. ONE OF THE THINGS THAT DR. CHANG'S RESEARCH FOUND WAS THAT EVERY SINGLE ONE OF THOSE WOMEN WHO WAS KILLED AND THE MAJORITY OF THEM WERE KILLED BY PARTNERS BUT THEY WERE ALSO KILLED BY OTHER PEOPLE, EVERY SINGLE ONE OF THEM HAD BEEN TO PRENATAL CARE. SO IT WASN'T THAT THEY WERE OUTSIDE OF PRENATAL CARE, SO THAT REALLY HAS SOME IMPLICATIONS FOR US, AND THE KIND OF RESEARCH THAT INCLUDES THOSE PREGNANCY ASSOCIATED DEATHS AS WELL AS THE PREGNANCY-RELATED DEATHS. ALL RIGHT. WE'VE GOT 6 MORE MINUTES, I BELIEVE, IN THIS PANEL TIMING, SO DOES ANYONE IN THE AUDIENCE -- >> WHILE THEY'RE COMING FORWARD -- I JUST WANT TO ADDRESS WHAT YOU SAID BECAUSE -- AN ARTICLE IN LOUISIANA, HOMICIDE WAS THE NUMBER ONE PREGNANCY -- IT TENDS TO BE IN PLACES THAT HAVE HIGHER -- THE GUN LAWS ARE MORE LIBERAL, AND THERE'S NOT A LOT OF PROTECTION FOR DOMESTIC VIOLENCE PARTNERS, SO WE CAN DO A WHOLE NIH STING AROUND THAT FOR SURE. >> YES. >> I'M CONNIE NEWMAN, AMERICAN MEDICAL WOMEN'S ASSOCIATION. AS THE RATES OF MATERNAL MORTALITY ARE GOING UP, ALSO IN THIS COUNTRY WE KNOW THAT THE RATES OF OVERWEIGHT AND OBESITY AND DIABETES ARE GOING UP AND THESE INFLUENCE CARDIOVASCULAR DISEASE, SO -- AND THERE ARE MANY ENVIRONMENTAL FACTORS THAT IMPACT OBESITY. OBESE OBESITY AND OVERWEIGHT SO HOW DOES THIS CONTRIBUTE TO MATERNAL MORTALITY MORBIDITY AND WHAT CAN BE DONE? >> ACTUALLY THERE WAS AN NIH-FUNDED RESEARCH STUDY PUBLISHED PROBABLY WITHIN THE LAST TWO MONTHS THAT LOOKED AT COMORBIDITIES AND THE ABILITY TO PREDICT SEVERE MATERNAL MORBIDITY AND OBESITY THE WAS ONE OF THE COMORBIDITIES THAT THEY USED AS A PREDICTIVE VARIABLE, AND THEY REALLY DID NOT FIND THE RELATIONSHIP THAT THEY EXPECTED IN THE ABILITY TO PREDICT. JOIA, DO YOU WANT TO -- >> SO DESPITE INCOME, DESPITE OBESITY, BLACK WOMEN ARE STILL MORE LIKELY TO DIE IN CHILDBIRTH THAN WHITE WOMEN, SO WE CAN BE NORMAL WEIGHT AND WE'RE STILL MORE LIKELY TO DIE. SO I THINK WE DO BELIEVE THAT OBESITY IS A STRONG RISK FACTOR FOR A LOT OF THINGS IN THIS COUNTRY BUT WE'VE NOW KIND OF PLACED IT UPON EVERYTHING. WHEN WE UNPACK IT FROM MOST THINGS, WE DON'T FIND THE CORE LAYING THAT WE PERCEIVE TO HAVE. SO THIS WOULD BE ANOTHER GREAT OPPORTUNITY FOR US TO REALLY DIG DOWN BECAUSE WHAT HAPPENS IS PROVIDERS -- WHEN THEY SEE OBESITY THEY ASSUME SOMETHING IS GOING TO HAPPEN BECAUSE -- WHEN YOU SEE THE PICTURES OF THE PEOPLE WE SHOWED YOU TODAY, THEY'RE NOT OBESE. THE WOMEN WE MEET ACROSS THE COUNTRY, WE PERCEIVE -- >> WHAT OF DIABETES? >> SO THERE ARE -- IT DOESN'T SHOW DIRECT CORRELATION IN THE SAME WAY. THE NUMBER ONE -- IT'S JUST HARD FOR US YOU TO PULL AWAY FROM THAT BECAUSE IT'S REALLY THE NARRATIVE THAT WE HAVE CONSTRUCTED FOR THOSE. >> OKAY. THANK YOU. >> WE DO, HOWEVER, PHYSIOLOGICALLY FIND SOME ASSOCIATIONS WITH CHRONIC STRESS, AND INCREASED BMI. AND IT MAKES ME WONDER IF MAYBE THE PICTURE IS SOMEWHAT DIFFERENT FROM MATERNAL MORTALITY AMONGST NATIVE AMERICAN WOMEN BECAUSE WE HAVE THAT HIGH RISK FOR DEEB THERE, AND I DON'T THINK THAT'S BEEN SORTED OUT VERY WELL. >> HI, THANK YOU. JUST TO PIGGY BACK OFF OF THAT QUESTION, I HEARD A LOT OF TALK ABOUT STRUCTURAL RACISM AS LIKELY A CORRELATION TO THE INCREASING RATE OF MATERNAL MORTALITY. STRUCTURAL RACISM HAS BEEN AROUND A LONG TIME. IT'S NOT ANYTHING NEW, BUT YET THE MATERNAL MORTALITY IS INCREASING, SO IF IT'S NOT OBESITY AS THE FACTOR INFLUENCING MATERNAL MORTALITY, THEN WHAT OTHER SOCIAL OR ENVIRONMENTAL FACTORS THAT ARE CHANGING BOTH THE PAST 30 YEARS THAT COULD BE A FACTOR INFLUENCING THAT INCREASE? >> ONE OF THEM IS WE'VE STOPPED COUNTING, WHICH YOU IS WHAT I MENTIONED, AND THEN YOU DON'T PAY ATTENTION TO DO THINGS. NOW THE OTHER, WE CHANGED SOME OF OUR PRACTICE PATTERNS WHICH WE DON'T HAVE A LOT OF DAY TO SUPPORT, WE CHANGED OUR C-SECTION RATES WENT UP, WE CUT DOWN RURAL HOSPITALS SO WE'VE DONE SOME STRUCTURAL THINGS IN THIS COUNTRY THAT HAVE IMPACTED WOMEN'S HEALTH IN GENERAL. SO THAT MAKES IT VERY DIFFICULT. >> VERY GOOD QUESTION AND CLEARLY, THAT'S THE KIND OF RESEARCH QUESTIONS WE NEED TO HAVE ANSWERED. SO THANK YOU. >> SARAH FROM NINR. JUST A QUESTION THERE, WE TALKED ABOUT SOCIAL DETERMINANTS, AND IS THERE ANY DATA OR SOME INFORMATION THAT -- SPECIAL ANALYSIS SUCH AS, FOR EXAMPLE, FOR THE D.C. , PEOPLE WHO LIVE IN D.C. , THEY HAVE DIFFERENT PRIORITY THAN PEOPLE WHO LIVE IN KANSAS. IT'S LIKE AVAILABILITY OR THE TRANSPORTATION. SO IT'S BY STATE OR BY AREAS, MAYBE THEIR SOCIAL DETERMINANTS ARE DIFFERENT. SO DO YOU HAVE ANY INFORMATION FOR THAT? >> WE HAVE IT FOR INFANT MORTALITY. BECAUSE WE DON'T HAVE AS MUCH ROBUST DATA FOR -- STRUCTURAL RACISM POINTS OUT WHITE PEOPLE TO, SO IT'S NOT JUST IMPACTING US. IF YOU LIVE IN ATLANTA, YOUR INFANT MORTALITY RATE AS A WHITE WOMAN IS 6 PER THOUSAND WHICH IS MUCH BETTER THAN A BLACK WOMAN WHICH IS 13 PER THOUSAND BUT IF YOU LIVED IN PORE LAND OREGON AS A WHITE WOMAN, YOUR MORTALITY IS 1 FOR 1,000. SO WHEN YOU UNDERINVEST IN SCHOOLS, EDUCATION, WHEN YOU DON'T HAVE HEALTH INSURANCE EU MORE LIKELY TO DIE. IN NEW YORK CITY WHEN WE SAY MATERNAL MORTALITY RATES ARE -- THE REASON IT'S CLOSER IN TEXAS IS NOT BECAUSE WHITE WOMEN ARE DOING -- I MEAN BECAUSE BLACK WOMEN ARE DOING SO MUCH BETTER, THE RATES ARE REALLY BAD IN PLACES WHERE WE DON'T INVEST IN SYSTEMS AND THINGS AND THAT'S JUST THE TRUTH. SO OUR COUNTRIES THAT ARE DOING BETTER, THEY JUST DO THOSE INVESTMENTS. IT'S HARD FOR PEOPLE I THINK SOMETIMES TO -- WE -- WOMEN IN OUR BEHAVIORS FOR SO LONG THAT IT'S HARD TO SAY WELL, MAYBE WE'RE NOT -- MAYBE THEY DON'T NEED HIS TREK TOE MEES, MAYBE THERE'S OTHER THINGS GOING ON. >> THIS TIES INTO THIS A LITTLE BIT BUT HOW MUCH RESEARCH IS BEING DONE WITH AFRICAN-AMERICAN WOMEN WHO ARE HIGHLY EDUCATED AND HIGHLY INSURED AND STILL HAVING THESE BAD OUTCOMES? >> SO BALTIMORE, THERE'S A STUDY THAT SHOWED THERE'S A PROTECTIVE -- REALLY, REALLY POOR BLACK WOMEN, PEOPLE WHO DO REALLY POORLY, AND THEN WEALTHY BLACK WOMEN DO REALLY POORLY. IMAGINE THE LIFE OF A WILL BLACK MIDDLE CLASS WOMAN WHO WORKS AS A TEACHER WHO'S MARRIED -- THEY LIVE IN A BLACK NEIGHBORHOOD SO THERE'S SOME PROTECTIVE FACTORS THAT WE'RE NOW LOSING THAT WE CREATED TO SURVIVE FOR SO LONG. SO MAYBE THAT MIGHT BE SOME OF THE REASONS RATES ARE GOING UP. WE CAN LOOK AT OUR LATINO SISTERS AND BROTHERS AND RIGHT NOW THEY'RE STILL HOLDING ON TO SOME OF THOSE CULTURAL IDENTITIES. THERE IS DEFERL A NEED FOR RESEARCH AROUND WHAT ARE THE THINGS THAT HAPPENS FOR HIGH INCOME WOMEN AND WHAT ARE THE SPECIFIC THINGS. I DO JUST WANT TO SAY, MY FANTASY IS THAT WE DON'T HAVE TO KEEP PROVING THAT RACISM HAS A BIOLOGICAL EFFECT. I WOULD WISH NIH WOULD PUT OUT A STATEMENT AND SAY IT TELL MEARS SAY TELOME RES ARE REAL. IT'S NOT LIKE WE'RE GOING TO GET A PILL FOR OUR IT TELOMERES. >> NO, BUT IN A COUPLE OF SITUATIONS, I DON'T KNOW IF IT WAS IMPLICIT BIAS, BUT AGAIN, THEY WEREN'T HEARD, SO -- >> THAT'S ANOTHER THING WE NEED, I DO IMPLICIT BIAS TRAINING AND WE DON'T HAVE DATA TO SHOW THAT IT WORKS. I TELL PEOPLE I DON'T KNOW IF IT WORKS. I FEEL BETTER AFTERWARDS. I DON'T KNOW IF THERE'S ANY LESS RATISM RATISM BUT I FEEL REALLY GOOD. >> THANK YOU. >> AND I FIND IT VERY DIFFICULT TO BELIEVE THAT I'M TOLD I MUST DO AN HOUR ONLINE, AND PASS A TEST, WHICH I KNOW HOW TO GAME, AND THEN ALL OF A SUDDEN MY BEHAVIOR AND MY BELIEFS ARE GOING TO CHANGE? I DOUBT IT. BUT THAT'S JUST ME. BUT I THINK IF WE'RE GOING TO BE SERIOUS ABOUT ADDRESSING IMPLICIT BIAS IN THE HEALTHCARE SYSTEM, WE'RE GOING TO HAVE TO DO SERIOUS INTERVENTIONS AROUND IT. THAT ARE TESTED AND EVALUATED TO SEE IF WE REALLY SEE SERIOUS BEHAVIOR CHANGE. BECAUSE OTHERWISE I THINK IT'S A BIT OF A WASTE OF TIME. I ALSO WANTED TO MENTION IN TERMS OF THE EFFECTS OF RACISM AND STRUCTURAL RACISM AND HOW DO WE SORT THAT OUT. I THINK YOU'RE RIGHT, NIH HAS TO MAKE A STATEMENT, THIS IS HOW RACISM AIIVETS YOUR HEALTH AND IT'S BEEN SHOWN X, Y AND Z, THE BULLETED POINTS OF THE EFFECTS. BUT I ALSO THINK THAT WE NEED TO UNDERSTAND A LITTLE BIT MORE ABOUT HOW THAT STRUCTURAL RACISM MIGHT AFFECT, FOR INSTANCE, ENVIRONMENTAL TOXINS, ENVIRONMENTAL INFLUENCES. AND ALSO PARTICULARLY WHAT ARE THE RESEARCH THAT WOULD EE ELUCIDATE WHAT ARE THOSE PROTECTIVE FACTORS, WHAT CAN WE SHORE UP. YES, THERE'S OBVIOUS POLICY CHANGES BUT WHAT ELSE CAN WE ACTUALLY SHORE UP IN OUR COMMUNITIES, WHAT FACTORS CAN WE IMPROVE. WE'RE GOING TO GIVE OUR KEYNOTE BECAUSE SHE WANTED TO SAY ONE MORE THING. >> OKAY. SO I'D LIKE TO ALLOW FOR THE LAST QUESTION SO WE CAN STAY ON TIME. THANK YOU. >> THANK YOU. I'M AMELIA FROM NIAID. SO I DON'T KNOW IF THIS WAS MENTIONED SINCE I WALKED IN LATE SO PLEASE BEAR WITH ME. HAVE YOU LOOKED AT THE POTENTIAL OR THE IMPACT OF COMMUNITY-BASED OUTREACH TEAMS IN TERMS OF CIRCUMVENTING THE ISSUE AROUND LACK OF OR POOR ACCESS TO CARE POST NATELY FOR WOMEN? >> I THINK THAT THERE ARE SOME ONGOING STUDIES THAT ARE GOING TO BE EVALUATING, YOU MAY KNOW SOME OF THEM ALREADY. >> CERTAINLY THERE'S THE HEALTHY START PROGRAM WHICH REALLY KIND OF FOCUSES ON COMMUNITY-BASED COMMUNITY DRIVEN INTERVENTION. I ALSO WANTED TO MENTION THE HOME VISITING AND THERE WAS A STUDY THAT CAME OUT A FEW YEARS AGO THAT WAS DONE IN MEMPHIS, TENNESSEE IN PREDOMINANTLY LOW INCOME AFRICAN-AMERICAN WOMEN AS IT WAS FOUND OUT THAT WOMEN WHO RECEIVED HOME VISITING DURING REG SEE IN THE FIRST COUPLE YEARS OF LIFE ACTUALLY WERE THREE TIMES LESS LIKELY TO DIE FOM ANY CAUSE OVER THE NEXT 20 YEARS COMPARED TO WOMEN WHO DID NOT RECEIVE HOME VISITING IN RANDOMIZED CLINICAL TRIALS. WHAT WAS ALSO MORE STRIKING WAS THAT THEY WERE ABOUT EIGHT TIMES LESS LIKELY TO DIE FROM EXTERNAL CAUSES, CAUSES RELATED TO SUICIDES AND HOMICIDES AND DRUG OVERDOSE AND SO FORTH, SO THERE ARE PROGRAMS LIKE THAT, AND IT'S THE KIND OF COMMUNITY-BASED INVESTMENTS THAT WE OUGHT TO BE THINKING ABOUT AND I'LL JUST ALSO POINT OUT THE THAT SOME OF THE EARLIEST STUDIES THAT WERE DONE AROUND HOME VISITING WERE FUNDED BOTH BY HRSA BUT ALSO BY NIH, SO NIH DEFINITELY HAD A ROLE TO FIGURE OUT THAT NEXT GENERATION OF COMMUNITY-BASED INTERVENTIONS THAT'S REALLY GOING TO WORK IN TERMS OF ADDRESSING DISPARITIES. >> I THINK WE REALLY HAVE TO LOOK AT COST-BENEFIT RATIOS. WHAT ARE WE INVESTING IN THAT'S REALLY NOT DOING MUCH. YOU KNOW, WHAT KIND OF HEALTHY START PROGRAMS ARE NOT DOING MUCH VERSUS WHAT KINDS ARE DOING A LOT. THE NURSE HOME VISITATION MODEL IS AN EXCELLENT ONE BUT IT'S EXPENSIVE AND A LOT OF COMMUNITIES ARE RELUCTANT TO SPEND THAT MUCH ON IT. THERE'S ALSO BEEN A RANDOMIZED CLINICAL TRIAL THAT -- AN INTERVENTION CALLED DOVE, IT'S PARTLY FROM HOPKINS SCHOOL OF NURSING, DOES INCREASE THE RESISTANCE TO INTIMATE PARTNER VIOLENCE AND DOES HELP MOMS FIGURE OUT WHAT TO DO ABOUT THAT ISSUE, BESIDES LEAVING, WHICH OFTENTIMES PREGNANT WOMEN, THAT'S NOT WHAT THEY HAVE IN MIND. WHAT THEY HAVE IN MIND IS SOME INTERVENTIONS TO HELP ABUSIVE HUSBANDS. >> I WOULD BE REMISS IF I DIDN'T MENTION THE BLACK MOMS ALLIANCE -- WE JUST COMPLETED MA IT TERNL HEALTH WEEK, THERE'S A LOT OF RESEARCH THAT SHOWS THAT COMMUNITY -- HAS GREAT IMPACT ON MATERNAL OUTCOMES. WE KNOW WE STARTED THIS COUNTRY -- WE LOST OUT WHOLE MIDWIFERY WORKFORCE, I WAS AT THE NATIONAL ACADEMY OF SCIENCES, THERE'S A LOT YOU COULD YOU STUDY, A WHOLE LOT OF THINGS AND WE'VE BE HAPPY TO GIVE YOU A LIST, BUT WE HAVE A WHOLE BUNCH OF STUFF THERE THAT'S REALLY EXCITING. >> ALL RIGHT. I THINK WE'RE SUPPOSED TO EXIT STAGE LEFT. SO THANK YOU. [APPLAUSE] >> GOOD AFTERNOON. MY NAME IS DANA SIMMS, AND I WORK WITH THE OFFICE OF RESEARCH OND WOMEN'S HEALTH. I WOULD FIRST LIKE TO THANK OUR WONDERFUL PANEL, AND THANK DR. ELI SACHIN, DIRECTOR OF AMWA FOR BEING HERE TODAY. SECOND, I WANT TO TAKE A MINUTE TO POINT OUT SOME OF THE SLIDES THAT HAVE APPEARED AS SPEAKERS HAVE WALKED TO THE STAGE. EACH SLIDE DISPLAYS A SHORT STORY WE HAVE CHOSEN FROM THE LOST MOTHERS WEBSITE. THEY REMEMBER MOTHERS THAT WE HAVE LOST AND THAT ARE NO LONGER WITH US. THE NEXT SECTION OF OUR MEETING IS THE FEDERAL PARTNER UPDATE. DURING THIS TIME, CDC, FDA, HRSA AND NIH WILL GIVE EVERYONE AN OVERVIEW OF THEIR CURRENT ACTIVITIES ON MATERNAL HEALTH. AFTER THE LAST PRESENTER, THERE WILL BE APPROXIMATELY 15 MINUTES WHERE THEY WILL TAKE QUESTIONS FROM THE AUDIENCE. IT IS MY HONOR TO DO A SHORT INTRODUCTION TO THE PRESENTERS FOR THIS SECTION WE WILL FIRST HEAR FROM MS. SARAH FOSTER, THE ASSOCIATE DIRECTOR FOR POLICY PARTNERSHIPS AND COMMUNICATION IN THE DIVISION OF REPRODUCTIVE HEALTH FOR THE CDC. MS. FOSTER HAS BEEN WITH THE DIVISION OF REPRODUCTIVE HEALTH SINCE 2016 AND HAS LED EFFORTS TO BUILD, SUPPORT AND ADVANCE DCD'S EFFORTS IN TOPICS INCLUDING MATERNAL MORTALITY, PRETERM BIRTH AND OPIOID USE DISORDER IN WOMEN AND INFANTS. WE WILL THEN HEAR FROM DR. LYNNE YAO, THE DIRECTOR OF THE DIVISION OF PEDIATRIC AND MATERNAL HEALTH IN THE OFFICE OF NEW DRUGS AT THE CENTER FOR DRUG EVALUATION AND RESEARCH WITHIN THE FDA. IN HER ROLE WITH THE DIVISION OF PEDIATRIC AND MATERNAL HEALTH, SHE WORKS TO ADVANCE THE DEVELOPMENT OF SAFE AND EFFECTIVE THERAPIES FOR CHIRNL AS WELL AS FOR CHILDREN AS WELL AS PREGNANT AND LACTATING WOMEN. DR. MICHAEL WARREN, ASSOCIATE DIRECTOR OF MATERNAL AND CHILD HEALTH BUREAU UNDER THE HEALTH RESOURCES AND SERVICES ADMINISTRATION WILL PRESENT. DR. WARREN'S WORK WITH MCHB AIMS TO IMPROVE THE HEALTH OF AMERICA'S MOTHERS, CHILDREN AND FAMILIES. FINALLY, REPRESENTING NIH INSTITUTES CENTERS AND OFFICES, MS. MEGAN MITCHELL FROM THE NATIONAL HEART, LUNG AND BLOOD INSTITUTE AND DR. SARAH YOON FROM THE NATIONAL INSTITUTE OF NURSING RESEARCH WILL REVIEW WHAT ACTIVITIES ARE BEING DONE AT NIH. DR. SABRINA MA MADOFF WILL MODERATE THE Q & A SESSION. SO WE STAY ON SCHEDULE I WOULD LIKE TO ASK THAT ALL OF THE PRESENTERS BE READY TO COME UP TO THE STAGE BEFORE THEIR PRESENTATIONS AND BEFORE THE Q & A SESSION. >> GOOD AFTERNOON. I'M SARAH FOSTER FROM THE DIVISION OF REPRODUCTIVE HEALTH AT CDC, AND IT'S MY HONOR TO BE HERE TO TALK TO YOU TODAY ABOUT OUR WORK TO PREVENT MATERNAL DEATH IN THE U.S. IT'S A REALLY BIG HONOR TO BE HERE AS A PART OF THIS SYMPOSIUM. I'VE HEARD WONDERFUL THINGS ABOUT YOU, DR. PINN. I'M EXCITED BECAUSE A LOT OF WHAT I'M GOING TO TALK ABOUT IS A BUILT ON A BIG HISTORY OF WORK AND QUITE A FEW OF THEM ALL HAD A 30TH BIRTHDAY THIS YEAR OR LAST YEAR, I'D LIKE TO THINK WE'RE IN ANOTHER REALLY EXCITING TIME FOR MATERNAL HEALTH. CDC IN GENERAL APPROACHES MATERNAL MORTALITY IN THE CONTEXT OF OUR REPRODUCTIVE HEALTH WORK WHICH FOCUSES ON THREE AREAS, PREGNANCY HEALTH, WOMEN'S REPRODUCTIVE HEALTH AND INFANT HEALTH. BUT WE'LL FOCUS JUST ON THE MATERNAL MORTALITY PIECE TODAY GIVEN OUR TOPIC. AND REALLY WE LOOK IN TWO MAIN AREAS, ENSURING THERE'S ROBUST DATA WHICH AS YOU HEARD THERE ARE SOME GAPS THAT WE'RE WORKING ON, AND THEN IMOF PROVING ACCESS TO QUALITY CARE, AND REALLY THOSE TWO PIECES, WE SEE AS WORKING HAND IN HAND TO BETTER UNDERSTAND AND PREVENT MATERNAL DEATHS. WE'RE A RELATIVELY SMALL PROGRAM BUT WE REALLY ARE LOOKING FOR WAYS WHERE WE CAN MAKE A DIFFERENCE BECAUSE WE FEEL DCD DOES HAVE A CONTRIBUTION TO MAKE. SO I'LL START WITH OUR DATA, AND YOU'VE HEARD A GOOD BIT OF IT TODAY ALREADY. BUT WE HAVEN'T TALKED MUCH ABOUT THE CHALLENGES TRACKING PREGNANCY-RELATED DEATHS OR MATERNAL MORTALITY WITH VITAL STATISTICS AND THERE ARE MANY. SO TO OVERCOME THOSE, CDC BEGAN WORKING SOME TIME AGO WITH LOCAL MATERNAL MORTALITY REVIEW COMMITTEES TO STRENGTHEN AND STANDARDIZE THEIR EFFORTS. REVIEW COMMITTEES AS YOU'VE HEARD A BIT ABOUT ARE MULTIDISCIPLINARY COMMITTEES AT THE STATE OR CITY LEVEL TA REALLY BRING TOGETHER DATA FROM MULTIPLE SOURCES TO BETTER UNDERSTAND THE EVENTS THAT HE OH KURRED AND WHAT HAPPENS SO WE CAN BETTER PREVENT FUTURE DEATHS. SO THIS WORK HAD BEEN GOING ON FOR QUITE SOME TIME, WELL BEFORE 2011 EVEN THOUGH THAT'S WHERE WE HAVE A SNAPSHOT FROM BUT REALLY, THEY WERE VOLUNTARY BODIES, OFTEN VERY PATCHED TOGETHER FUNDING IF THEY HAD ANY FUNDING AND SO THIS WORK REALLY NEEDED TO SUPPORT AND WAS A PIECEMEAL APPROACH WHEN CDC STARTED TO DO MORE WORK IN THIS AREA. IF YOU LOOK AT 2011 WI IS JUST ONE SNAPSHOT IN TIME THAT WE HAD, THERE WERE 18 STATES AND ONE CITY THAT HAD A REVIEW COMMITTEE. CURRENTLY WE'RE EXCITED TO SAY THERE ARE 39 STATE-BASED REVIEWS AND TWO CITY BASED REVIEWS IN THE U.S. SO WREEF MADE A LOT OF PROGRESS IN A FAIRLY SHORT AMOUNT OF TIME. THAT SAID, THERE STILL IS A LOT OF WORK TO DO. OF THOSE 41 COMMITTEES, ONLY 14 HAVE PUT OUT ANY OF THEIR DATA OR REPORT OF THEIR DATA IN THE LAST FIVE YEARS. SO WE STILL HAVE A LONG WAY TO GO TO GET COMMITTEES KIND OF FULLY STOOD UP, ANALYZING AND REVIEWING ALL OF THEIR DEATHS AND THEN SHARING THEIR DATA TO MAKE A DIFFERENCE. SO ONE OF THE WAYS THAT WE'VE BEEN WORKING TO HELP STATES AND COMMUNITIES THAT ARE WORKING ON MATERNAL MORTALITY REVIEW IS REALLY TO HELP THEM STANDARDIZE THEIR DATA, SO BOTH THEY HAVE A STANDARD PROCESS BUT WE CAN ALSO THEN COMPARE DATA ACROSS JURISDICTIONS. AND SO ONE OF THE PIECES WE'VE BEEN WORKING ON IN PARTNERSHIP WITH THE CDC FOUNDATION AND THE ASSOCIATION OF CHILD AND HEALTH PROGRAMS IS THE MORTALITY REVIEW INFORMATION APPLICATION, WHICH REALLY WALKS THROUGH THE ESSENTIAL FUNCTIONINGS OF A REVIEW COMMITTEE INCLUDING DATA ABSTRACTION, CASE NARRATIVE DEVELOPMENT, DOCUMENTATION OF COMMIT DECISIONS AND THEN HELPING WITH ANALYSIS. I WANT TO SAY AS SOME OF THE CONVERSATION HAS HAPPENED TODAY, IT'S ALSO ADDRESSING SOME OF THE KNOWN GAPS IN THE DATA WE HAVE ON MATERNAL MORTALITY, SO WE'VE BEEN WORKING TO BUILD A GEOSPATIAL SET OF PIECES WITHIN -- THAT WILL LOOK AT COMMUNITY POVERTY LEVELS, COMMUNITY RESOURCES, TRANSPORTATION AND OTHER KIND OF NEIGHBORHOOD-LEVEL FACTORS. WE ALSO HAVE BUILT MATERNAL MENTAL HEALTH SCREENS TO COLLECT DATA IN A STANDARDIZED WAY IN MENTAL HEALTH CONDITIONS AND SUBSTANCE USE DISORDER SO WE CAN REALLY MAKE SURE THAT THOSE IMPORTANT CONTRIBUTORS TO MATERNAL MORTALITY ARE CAPTURED SYSTEMATICALLY BETWEEN COMMITTEES. AND WE KNOW FROM SOME OF OUR VERY EARLY WORK WITH REVIEW COMMIT OH S THAT ABOUT 7% OF MATERNAL MORTALITY, THE PREGNANCY-RELATED MORTALITY THE COMMITTEES HAVE DETERMINED IS CAUSED BY MENTAL HEALTH CONDITIONS, WHICH WE DON'T SEE IN PMSS BECAUSE IT'S HARDER TO LINK THAT DATA FROM JUST A DEATH CERTIFICATE ALONE AND MAKE A DETERMINATION ABOUT WHETHER IT'S PREGNANCY-ASSOCIATED OR PREGNANCY-RELATED. SO OH THIS IS ONE OF THE PLACES WHERE WE REALLY FEEL LIKE THIS DATA WILL MAKE A BIG DIFFERENCE IN OUR UNDERSTATING OF HOW TO SAVE WOMEN'S LIVES. SO NOW WE HAVE ABOUT 41 -- THE EXISTING 41 REVIEW COMMITTEES, ABOUT 33 ARE USING THIS TO WALK THROUGH THE PROCESS SO WE'VE MADE SOME REALLY BIG GAINS AND OVER TIME, WE REALLY FEEL LIKE THIS STANDARDIZATION IS GOING TO LEAD TO MORE COMPREHENSIVE DATA SO WE CAN WORK TO SOLVE THE PROBLEMS. SO WE'RE VERY, VERY EXCITED THIS YEAR, WITH 2019, WE GOT SOME NEW FUNDING, THE FUNDING OPPORTUNITY CLOSED LAST WEEK, BUT WE HOPE TO BE FUNDING ABOUT 25 STATES TO ACTUALLY SUPPORT -- DIRECTLY SUPPORT THE AGENCIES AND COORDINATIONS THAT ARE MANAGING THE REVIEW COMMITTEES IN THE STATES TO IDENTIFY AND CHARACTERIZE MATERNAL DEATHS SO THEY CAN IDENTIFY PREVENTION OPPORTUNITIES IN THEIR STATE. WE ANTICIPATE WE'LL BE FUNDING ABOUT 25 STATES AND THE AWARDS WILL BE MADE IN SEPTEMBER BUT IT'S REALLY GOING TO MOVE FORWARD TOWARDS A CONSISTENT COMPREHENSIVE ABILITY TO LOOK AT DEATHS. SO WE REALLY FEEL REVIEW COMMITTEES HOLD PROMISE FOR HOW WE MOVE FORWARD AND WE'VE RELEASED PROOF OF CONCEPT DATA FROM MMRIA OVER THE LAST FEW YEARS AND DR. HOLLIER TALKED ABOUT SOME OF THAT DATA. WE ALSO HAVE IT CONTINUED TO USE DATA FROM THE PMSS WHICH WAS PUT TOGETHER ABOUT 30 YEARS AGO BECAUSE WE KNEW WE NEEDED A BETTER WAY TO BE LOOKING AT MATERNAL DEATHS THEN, AND SO WE HEARD A LITTLE ABOUT THE OTHER CATEGORY. THE CATEGORIES THAT WERE DEVELOPED FOR PMSS WERE REALLY LOOKING AT WHAT ARE SOME OF THE CLINICAL OUTCOMES THAT WE NEEDED TO BE TRACKING, SO THAT'S HOW WE GOT KIND OF THE BIG OTHER BUCKETS THAT YOU SEE IN SOME SPOTS, BUT WHAT YOU SEE OVER TIME IS REALLY A BIG SHIFT IN SOME OF THE LEADING CAUSES OF DEATH, WHICH MEANS WE HAVE MADE PROGRESS, BUT WE ALSO HAVE A LOT OF WORK TO STILL DO. AS YOU SEE THINGS LIKE HEMORRHAGE HAVE GONE DOWN BUT CARDIOVASCULAR CONDITIONS AND CARDIOMYOPATHY HAVE BEEN GOING UP AS WE'VE DISCUSSED TODAY. AND SO LAST WEEK WE RELEASED SOME NEW DATA FROM PMSS THAT WAS LOOKING AT THE TIMING OF PREGNANCY-RELATED DEATHS AND THE LEADING CAUSES OF DEATH BY TIME, AND THAT'S WHAT YOU SEE HERE THAT REALLY KIND OF MAPS OUT PORE EXAMPLE THAT HEART DISEASE AND STROKE CAUSE THE MOST DEATHS OVERALL, CARDIOMYOPATHY CAUSES THE MOST DEATHS IN LATE POSTPARTUM PERIOD AND WE KNOW SOME OF THE THINGS LIKE THE HIGHER FREQUENCY -- IS DRIVEN BY THE CARDIOMYOPATHY DEATHS. SO AS WE TEASE APART THE PIECES, WE SEE PLACES WHERE WE NEED TO INTERVENE AND DO MORE OH WORK, WE ALSO SEE THAT THERE ARE A LOT OF DIFFERENT PLACES WHERE WE NEED TO INTERVENE AND DO MORE WORK. THE CHALLENGE I THINK IN MATERNAL MORE ISN'T THAT THERE'S JUST ONE EASY PIECE WE NEED TO GO IN AND FIX. YOU FIGURE IT OUT HOW TO -- SORT OF STRUCTURAL RACISM AND IMPLICIT BIAS. BUT THERE'S A BIG SET OF WORK AND A NUMBER OF DIFFERENT PLACES WHERE WE NEED TO BE TRACKING, MONITORING AND BE SURE THAT WE'RE MAKING A DIFFERENCE. SO -- CAUSES AND TIMING ARE BOTH REALLY IMPORTANT TO UNDERSTANDING THE DRIVERS OF MATERNAL MORTALITY. SO SWITCHING GEARS, TO TALK ABOUT ONCE YOU KNOW WHAT PART OF THE PROBLEM SAT LEE, HOW DO YOU IMPROVE ACCESS TO QUALITY CARE. THIS HAS BEEN TALKED ABOUT A LITTLE BIT BUT FOR US, ONE OF THE BIGGER EFFORTS IS REALLY SUPPORTING -- WE FUND PQC'S TO SUPPORT MULTIDISCIPLINARY TEAMS, TO IMPROVE OUTCOMES FOR MOMS AND BABIED, USING QUALITY IMPROVEMENT APPROACHES. AND REALLY IT'S IDENTIFYING WHAT NEEDS TO BE DONE, GOING IN, USING GOOD DATA TO INTENSIVELY ADDRESS AN ISSUE AND MAKE A DIFFERENCE. SO REALLY REDUCING VARIATION IN CARE AND OPTIMIZING RESOURCES TO IMPROVE CARE AND OUTCOMES. AND HERE ARE SOME EXAMPLES OF WHERE PQCs HAVE MADE A DIFFERENCE. IN A NUMBER OF CASES THEY'RE WORKING WITH ACOG AND HRSA ON AIM BUNDLING AS THEY'VE IDENTIFIED ISSUES THAT AIM HAS SOLUTIONS FOR AND SO IN MANY CASES LIKE ILLINOIS, YOU'LL SEE THAT THEY'VE BEEN ABLE TO ACHIEVE SOME SIGNIFICANT DECREASES IN SEVERE MATERNAL MORBIDITY, SO CONTINUED SUPPORT, PQCs ARE ONE KEY PIECE OF THE INFRASTRUCTURE TO IMPLEMENT SOME OF THE PREVENTION RECOMMENDATIONS THAT COME OUT OF REVIEW COMMITTEES. ANOTHER KEY PIECE FOR US IS REALLY MAPPING RISK-APPROPRIATE CARE WHICH DR. HOLLIER ALSO MENTIONED. ANOTHER AC/DC IS WORKING TO IMPROVE IS TO REALLY HELP STATES IMPROVE WHERE THEIR RESOURCES ARE AND WE'VE WORKED WITH ACOG AND THE SOCIETY FOR MATERNAL AND FETAL MEDICINE TO DEVELOP A TOOL THAT LOOKS AT THE RISK -- THE APPROPRIATE CARE LEVELS, SO THEY CAN LOOK AT THEIR MAPS TO ENSURE THAT HIGH RISK PREGNANT WOMEN AND INFANTS RECEIVE CARE IN A FACILITY THAT IS PREPARED TO MEET THEIR NEEDS AND REALLY MAKING SURE THAT MOM GETS CARE, THE RIGHT CARE AT THE RIGHT TIME IS ONE WAY WHERE WE FEEL WE CAN MAKE A DIFFERENCE. SO THIS IS ANOTHER -- LIKE OTHER SLIDES YOU'VE SEEN, THIS IS ONE THAT HAS A LITTLE BIT MORE STUFF ON IT. FOR US, YOU KNOW, WE'VE TALKED ABOUT SOME OF THE PIECES, YOU'VE HEARD ABOUT SOME OF THE OTHER PIECES AND YOU'LL HEAR MORE, THERE'S A LOT GOING ON RIGHT NOWS ABOUT ALSO A REALLY EXCITING TIME BECAUSE WITH ALL ARE WORKING REALLY HARD TO MAKE A DIFFERENCE THAT'S MAGNIFIED BETWEEN OUR WORK, SO WHILE MUCH WORK REMAPES, I THINK WE'RE REALLY EXCITED TO KIND OF CONTINUE ON AND TO LOOK FOR WAYS THAT WE CAN SAVE THE LIVES OF WOMEN GOING FORWARD. SO THANK YOU VERY MUCH. [APPLAUSE] >> GOOD AFTERNOON. MY NAME IS LYNNE YAO, AND I'M HERE AS REPRESENTATIVE OF THE FOOD AND DRUG ADMINISTRATION TO TELL YOU ABOUT SOME OF THE UPDATES ON ACTIVITIES WE HAVE GOING ON IN MATERNAL HEALTH AND ISSUES RELATED TO MATERNAL MORTALITY. I AM ACTUALLY VERY FLATTERED TO BE HERE AND I HOPE THAT I CAN GIVE YOU A FLAVOR FOR WHAT WE'RE DOING. IT DOES SEEM A LITTLE BIT SORT OF SKEWED OF ALL THE PRESENTATIONS THAT I'VE BEEN HEARING, BUT HOPEFULLY I CAN HELP PUT SOME PIECES TOGETHER AND EXPLAIN WHERE FDA IS IN THIS PUZZLE. THAT'S MY DISCLOSURE, SO JUST VERY BRIEFLY, I WANTED TO DESCRIBE WHO WE ARE OVER AT FDA, AND SOME OF THE WORK THAT WE DO THAT'S MAYBE AGAIN RELATED TO BUT MAYBE NOT RIGHT AT THE FRONT LINES OF FIGHTING MATERNAL MORTALITY. SO WE HAVE A GROUP IN THE OFFICE OF COMMISSIONER OR THE OFFICE OF WOMEN'S HEALTH WHO, BY THE WAY, IS CELEBRATING NOW 26 YEARS, ESTABLISHED IN 1994, SO WE'RE A LITTLE BIT BEHIND OUR COLLEAGUES AT NIH. WE'VE JUST HAD A CHANGEOVER IN LEADERSHIP, OUR ASSOCIATE COMMISSIONER, MARSHA HENDERSON, RECENTLY RETIRED AND WE HAVE AN ACTING ASSOCIATE COMMISSIONER WHO HAS TAKEN OVER. YOU IN THE CENTER FOR DRUG EVALUATION AND RESEARCH, THAT'S WHERE I WORK, WE HAVE THE DIVISION OF PEDIATRIC MATERNAL HEALTH AND DIT VISION OF BONE REPRODUCTIVE AND NEUROLOGIC PRODUCTS. I'LL BRING UP A LITTLE BIT ABOUT WHAT WE'RE DOING IN THE SPACE OF DRUG DEVELOPMENT TO TREAT DISORDERS OF PREGNANCY, BUT WE'RE REALLY -- THAT'S A REALLY HARD SPACE AND WE'RE WORKING VERY HARD TO TRY TO IMPROVE THAT BUT I BELIEVE THAT PROBABLY DOES IMPACT OUR ABILITY TO TAKE CARE OF WOMEN WHO ARE PREGNANT. WE HAVE A GROUP CALLED OB FDA, A NEW GROUP STARTED IN 2018 TO TRY TO BRING TOGETHER ALL THOSE NOOKS AND CRANNIES IN OUR ORGANIZATION WHERE EXPERTISE LIES IN THE CARE OF PREGNANT AND LACTATING WOMEN TO DISCUSS ISSUES RELATED SPECIFICALLY TO THAT AND THEN THE IDEA IS TO MAKE SURE WE UNDERSTAND WHAT EVERYBODY'S DOING SO THAT WE CAN DO IT MORE EFFICIENTLY AND MORE CONSISTENTLY. SO MY BRIEF TALK JUST GOING TO HIGHLIGHT THREE SPECIFIC AREAS THAT I THINK ARE IMPORTANT TO BRING UP TODAY RELATED TO MATERNAL MORTALITY AND MATERNAL HEALTH. SO ONE IS THE PROMOTION OF CLEAR COMMUNICATIONS OF THE EVENTS OF DRUGS TO PRESCRIBERS AND PREG NANTD WOMEN. THE SECOND IS TO OUR EFFORTS TO INCREASE THE AVAILABILITY OF QUALITY DATA TO SUPPORT THE SAFE AND EFFECTIVE USE OF DRUGS DURING PREGNANCY AND LACTATION, AND ALSO TO FUND RESEARCH TO SUPPORT OUR REGULATORY DECISION-MAKING IN THAT AREA. AND THEN FINALLY TO COLLABORATE WOULD OUTSIDE STAKEHOLDERS. SO I WANT TO TELL YOU A LITTLE STORY ABOUT -- IT'S BEEN VERY INFORMATIVE TO ME IN MY ROLE AT FDA. WE HELD -- AND I'LL TALK ABOUT IT A LITTLE BIT. WE HELD AN ADVISORY COMMITTEE TO TALK ABOUT HOW WE COMMUNICATE RISK. HOW IS FDA DOING IN COMMUNICATING RISK TO PRESCRIBERS AND TO WOMEN. AND WHAT I HEARD FROM BOTH PRACTITIONERS AND FROM PATIENTS AT THIS ADVISORY COMMITTEE WAS THAT IF FDA DECIDES THAT WE'RE GOING TO SORT OF ABDICATE OUR RESPONSIBILITY, IF WE WILL, AND JUST DESCRIBE VERY UNCLEARLY WHAT THE RISK IS OF A DRUG WHEN IT'S USED IN A WOMAN OR A PREGNANT WOMAN, BECAUSE WE DON'T NECESSARILY FEEL COMFORTABLE IN STATING THAT IT DOESN'T HAVE A RISK OR IT DOES HAVE A RISK, THEN THAT RESPONSIBILITY ROLLS DOWN. IT ROLLS DOWN TO THE PRESCRIBER WHO HAS TO COUNCIL THAT PATIENT COUNSEL A PATIENT ABOUT WHAT THE RISK IS IF USING THAT DRUG DURING PREGNANCY. IF THAT PRESCRIBER IS FEELING A LITTLE UNCOMFORTABLE ABOUT HOW THEY SHOULD BE EXPLAINING THAT RISK, THAT FDA FELT A LITTLE BIT UNCOMFORTABLE IN COMMUNICATING, THEN THE PRESCRIBER MIGHT SAY WELL, YOU KNOW, THIS IS WHAT IT MEANS, I'M NOT REALLY SURE WHAT IT MEANS BUT, YOU KNOW, THAT'S WHAT I THINK. THEN WHAT HAPPENS IS THAT IN THE FINAL ROLLING DOWN THE HILL, THE PERSON WHO ASSUMES ALL THE RISK AND ALL REQUIREMENT TO INTERPRET THAT INFORMATION IS THE PREG NANTD PREGNANT SO IN THINKING ABOUT HOW WE CAN CONSTRUCT STATEMENTS WHO WE GIVE TO PRESCRIBERS THAT THEN GIVE THEM TO PREGNANT WOMEN, THEY REALLY HAVE A HUGE RESPONSIBILITY IN TRYING TO COMMUNICATE THAT INFORMATION AS CLEARLY AS WE CAN, AND SO WE'VE UNDERSTOOD THAT IMPORTANT ROLE IN OUR JOBS EVERY DAY AT FDA. SO WE'RE TRYING TO DO A BETTER JOB IN COMMUNICATING THAT INFORMATION PRO, PRODUCT LABELING AND OTHER PRESCRIPTION PRODUCT, BIOLOGICAL COMMUNICATIONS. SO I'M GOING TO SPEND A LITTLE BIT OF TIME TO REMIND EVERYBODY ABOUT ONE OF THE INITIATIVES WE HAVE. SO THIS IS THE PREGNANCY LEVEL CATEGORIES, I DON'T NEED TO GO THROUGH IT, BUT IT WAS AN A, B, C, D, X, AND EVERYBODY UNDERSTOOD THAT THERE WAS A PROBLEM WITH THIS OVERSIMPLIFICATION OF THE DESCRIPTION OF RISK. IT WAS MISINTERPRETED AS A GRADING SYSTEM TO DRUGS THAT WERE CATEGORY A, THEY MUST BE GREAT TO USE IN PREGNANCY, AS OPPOSED TO CATEGORY G, WHERE THAT'S A BAD GRADE. IT REALLY DIDN'T MEAN THAT, IT WAS JUST TO TRY AND CATEGORIZE RISK ASSESSMENTS OR THE AMOUNT OF INFORMATION THAT WE HAD ON THE DRUG SO THAT PRESCRIBERS WOULD KNOW. SO WE TRIED TO DO A BETTER JOB BECAUSE THE LETTERS AS I SAY HERE CAN BE MISLEADING. SO WE CAME OUT WITH A NEW YOU WAY TO LABEL THAT WAS PUBLISHED IN 2014, WHEN OUR SECOND YEAR OF IMPLEMENTATION BECAUSE SPONSORS, DRUG COMPANIES, HAD A YEAR TO KIND OF FIGURE OUT AND WE HAD A YEAR TO FIGURE OUT HOW WE WERE GOING TO IMPLEMENT. SO YOU SEE THE LETTER CATEGORIES ARE REPLACED WITH DESCRIPTIONS OF WHAT WE KNOW ABOUT THE DRUG IN PREGNANCY, IN LACTATION, AND THEN IN FEMALES AND MALES OF REPRODUCTIVE POTENTIAL. WELL, HERE'S THE ADVISORY COMMITTEE WE HELD ABOUT A YEAR AGO NOW, AND IT'S HARD TO BELIEVE ILTS ALREADY BEEN A IT'S ALREADY BEEN A YEAR BUT WE ASKED OUR ADVISORS, HOW ARE WE DOING? ARE WE DOING AN OKAY JOB WITH THIS PREGNANCY LACTATION LABELING RULE? WE WANTED TO KNOW WHAT ARE THE FACTORS CRITICAL IN HEALTHCARE PROVIDERS' DECISION-MAKING AND ALSO HOW ARE WE DOING IN CONVEYING RISK. I DO POINT OUT THAT WE HAVE RECORDINGS OF MATERIALS SO IF YOU'RE INTERESTED IN WHAT THE ADVISOR SAID, IT WAS A VERY COMPELLING, I THINK, DAY FOR US. SO AS PART OF THIS DAY, WE ASKED A GROUP OF OUR COLLEAGUES FROM THE AMERICAN ACADEMY OF ALLERGY, ASTHMA AND IMMUNOLOGY, THEY DEVELOPED THIS ELECTRONIC SURVEY. THERE WERE 126 ALLERGISTS WHO RESPONDED. AGAIN, NOT ALL OF THEM -- OBVIOUSLY THEY'RE NOT OH OBSTETRICIAN GYNECOLOGISTS, BUT THEY DO TAKE CARE OF WOMEN, WOMEN OF REPRODUCTIVE AGE AND PREGNANT WOMEN. AS MANY -- YOU SHOULD GO BACK TO THE OLD SYSTEM, RIGHT, BECAUSE IT'S EASIER, AND BECAUSE IT'S EASIER FOR US TO COUNSEL, EVEN THOUGH WE UNDER STOOND IT WAS MISLEADING. MOST RESPONDERS, I WAS GLAD TO HEAR THAT MANY OF THEM FOUND THE INFORMATION THAT WE INCLUDED IN THE LABELING BUT IT DIDN'T REALLY BRING MORE MEANINGFUL INFORMATION TO THEM. SO I FELT THAT WAS WHERE WE'RE WORKING FROM THE BASELINE. SO WE ALSO HAD PRESENTATIONS FROM, AGAIN, VERY IMPORTANT EXPERTS IN THE FIELD ABOUT COMMUNICATING RISK. SOME OF THESE AREAS HERE, AGAIN, I THINK THIS CAN LEAD TO INCORRECT ASSUMPTIONS, INCORRECT CARE AND POTENTIALLY EXOWBD THE PROBLEM THAT COMPOUND THE PROBLEM WE'RE TRYING TO FIX, INCREASED -- PREGNANT WOMEN TEND TO OVERESTIMATE THE RISK TO THE BABY, THERE'S ALSO DISTORTED PERCEPTIONS ABOUT THE RISK EVEN WHEN THERE'S EVIDENCE BASED FACTS, ISSUES RELATED TO -- ARE LIMITED AND CONTRADICTORY. SO THE BOTTOM LINE IS WHEN THERE ARE SITUATIONS WHERE THERE ARE NO OR INADEQUATE DATA, YOU REALLY DO A GOOD JOB OF COMMUNICATING WE HAVE LITTLE DATA OR NO DATA. SO IN TERMS OF HIGHLIGHTS FROM THE RECOMMENDATIONS, I THINK WHAT WE'VE TAKEN BACK AND TRIED TO IMPLEMENT AND WE ARE STILL IN THE PROCESS OF DOING SO IS TO BENEFIT WHEN THERE'S A BENEFIT TO USING THE DRUG, WE FAIRLY STATE THAT, AND THERE ARE POTENTIAL RISKS IN NOT TAKING A DRUG. THE OTHER STORY I WANTED TO SHARE WITH YOU RELATED TO THIS MEETING WAS THAT WE HAD HEARD FROM PRESCRIBERS WHO IN THE SPACE OF WOMEN WHO ARE CHRONICALLY ILL, TAKE MEDICINES, WOMEN WHO ARE PREGNANT TAKE MEDICINES SO IN EITHER CASE, CHRONICALLY ILL WOMEN WHO WANT TO BECOME PREGNANT HAVE INCREASED RISK BECAUSE OF PREGNANCY. ONE AREA WAS A WOMAN WHO HAD MULTIPLE SCLEROSIS WHO UNDERSTOOD THERE WAS SOME RISK TO TAKING A DRUG THAT WAS HELPING KEEP HER M.S. IN CONTROL. WHEN SHE DECIDED TO BECOME PREGNANT AND EVEN THOUGH THE WARNINGS WERE THERE BUT THERE WAS NO CLEAR CONTRAINDICATION TO USE IN PREGNANCY, SHE SAID I CAN'T TAKE THAT DRUG BECAUSE IT WILL HARL MY BABY. SHE STOPPED THE DRUG, RELAPSED HER M.S. AND COULDN'T TAKE CARE OF THE CHILD SHE HAD. SO THERE ARE CONSEQUENCES THAT ARE -- I WOULD CATEGORIZE THAT AS SEVERE MATERNAL MORBIDITY BECAUSE THEY DON'T WANT TO TAKE A DRUG THAT IS KEEPING THEM HEALTHY BECAUSE THEY'RE WORRIED ABOUT THEIR BABY. SO WE HAVE A COUPLE OF AREAS WHERE I'M REALLY GLAD, I THINK THE ONLY THING THAT WE'RE GOING TO DO TO IMPROVE THIS SPACE OF UNDERSTANDING WHAT'S GOING ON, AT LEAST IN TERMS OF DURING PREGNANCY AND DRUG DEVELOPMENT IS TO INCLUDE PREGNANT WOMEN IN THESE CLINICAL TRIALS SO FDA LAST YEAR PUBLISHED GUIDANCE ON INCLUDING PREGNANT WOMEN IN CLINICAL TRIALS. I THINK IT'S GOTTEN SOME PRETTY GOOD UPTAKE ALL IN AN EFFORT TO DRIVE DRUG DEVELOPERS AND THE ACADEMIC AND SCIENTIFIC COMMUNITY TO INCLUDE PREGNANT WOMEN IN CLINICAL TRIALS AND WE HAVE CERTAINLY ETHICAL CONSIDERATIONS BUT NO PROHIBITION TO INCLUDING PREGNANT WOMEN IN CLINICAL TRIALS AND THERE ARE CERTAIN CIRCUMSTANCES AND GUIDANCE OUTLINES THIS. SO THE NEXT AREA I WANT TO BRIEFLY TALK ABOUT IS, SO WE HEARD THAT WE'RE NOT DOING A GREAT JOB COMMUNICATING INFORMATION WHEN WE HAVE IT, WE'RE DOING AN EVEN WORSE JOB WHEN WE DON'T HAVE QUALITY INFORMATION BECAUSE WHAT ARE YOU SUPPOSED TO SAY WHEN YOU DON'T HAVE THE INFORMATION? SO THE NEXT AREA I'M GOING TO FOCUS ON OF AREAS THAT WE'RE TRYING TO INCREASE THAT AVAILABILITY OF QUALITY INFORMATION. SO OWH, THE OFFICE OF WOMEN'S HEALTH, THEY SUPPORT A LOT OF FDA INITIATIVES BY AWARDING INTRAMURAL RESEARCH GRANTS. THERE ARE A COUPLE OF RESEARCH GRANTS THAT HAVE BEEN AWARDED IN 2018 AND ALL THESE GOAN AGAIN TO SUPPORT BETTER QUALITY INFORMATION THAT WE CAN USE TO SUPPORT OUR COMMUNICATION ABOUT DRUGS WHEN THEY'RE USED IN PREGNANT WOMEN. NATIONAL CENTER FOR TOXICOLOGIC RESEARCH OR NTCR, ANOTHER CENTER WITHIN FDA NOT LOCATED IN D.C. BUT LOCATED IN ARKANSAS, THEY ALSO HAVE ACTUALLY JUST SPEARHEADED THE FORMATION OF THE PERINAY WILL TALL PERINATAL HEALTH CENTER OF EXCELLENCE AND THEY'VE AWARDED ALMOST TWO MILL YONDZ FOR PROPOSALS TO RESEARCHERS AND ORGANIZATIONS WITHIN OUR GROUPS WITHIN FDA. WE ACTUALLY ARE RECEIVING AN AWARD FROM THE CENTER OF EXCELLENCE TO ACTUALLY DO SOME END USER TESTING IN THE MATERIALS AND LABELING THAT WE ARE PUBLISHING TO HOPEFULLY GET A BETTER IDEA OF HOW WE CAN IMPROVE THE COMMUNICATION INFORMATION THAT WE HAVE. THEN FINALLY I WANT TO TAKE A FEW MINUTES TO TALK ABOUT OUR COLLABORATION WITH OUTSIDE STAKEHOLDERS. I SOMETIMES HAVE TO WARN PEOPLE THAT I HAVE TO PUSH DOWN MY POINTY HEAD IN THIS AS A REGULATOR BECAUSE WE'RE NOT SCIENTISTS AT FDA, WE'RE ALL REGULATORS, SO I HAVE TO HIDE THE POINTY HEADEDNESS I STIEMENTS GET AS A REGULATOR BUT WE'RE TRYING HARD TO UNDERSTAND AT COLLABORATE WITH THE OUTSIDE COMMUNITY SO WE'RE NOT VIEWED AS SORT OF THE PROBLEM BUT PART OF THE SOLUTION, AND PART OF THAT WAS BEING INCLUDED IN THE PREGLAC TASK FORCE, THE RESEARCH SPECIFICALLY TO PREGNANT AND LACTATING WOMEN THAT WAS AN HHS LEVEL THAT MANY OF YOU KNOW ABOUT, SO WE WERE THERE AT THE TABLE, HEARD ABOUT THE NEED TO INCREASE THE AVAILABILITY OF QUALITY INFORMATION TO SUPPORT SAFE AND EFFECTIVE THERAPIES IN PREGNANT AND LACTATING WOMEN. YOU KNOW THAT THE RECOMMENDATIONS WERE PUBLISHED, AND JUST RECENTLY, JUST IN THE LAST COUPLE WEEKS, THE TASK FORCE CHARTER WAS REVIEWED BY CONGRESS TO CONTINUE THEIR IMPORTANT WORK. SO WE'RE VERY HAPPY ABOUT THAT. WE OBVIOUSLY ARE COLLABORATING WITH OTHER FEDERAL PARTNERS AND THAT'S HOPEFULLY WHY WE'RE HERE TODAY AND OF COURSE OTHER OUTSIDE ORGANIZATION. AND I WANT TO BRING UP VERY BRIEFLY IN MY LAST MINUTE COMING ATRACK SHUNS. I'M HAPPY TO REPORT THAT FDA HAS JUST PUBLISHED TWO DRAFT GUIDANCES, ONE THAT WAS VERY, VERY OLD AND PROBABLY NOT VERY HELPFUL, BUT CLINICAL LACTATION STUDIES, SO WE ARE INTENDING FOR DRUG DEVELOPERS TO DO A BETTER JOB IN CONDUCTING THESE CLINICAL LACTATION STUDIES AND WE HOPE THAT THIS GUIDANCE WILL HELP, AND WE'VE ALSO PUBLISHED RECENT GUIDANCE ON POST APPROVAL PREGNANY SAFETY STUDIES. THIS IS AN IDEA TO INCREASE THE QUALITY OF PREGNANCY REGISTRY STUDIES AND OTHER POST APPROVAL SAFETY STUDIES WHEN WE ASK SPONSORS TO EVALUATE THE SAFETY OF THEIR DRUGS WHEN USED IN PREGNANT WOMEN. WE'RE GOING TO FINISH HOPEFULLY IMPLEMENTATION OF PLOR AND ARE EXCITED ABOUT WHAT THE FUTURE HOLDS RELATED TO COLLABORATIONS INTERNALLY AND EXTERNALLY TO MOVE THIS FIELD FORWARD. I WOULD HOPE THAT THE BRIEF UPDATE THAT I GAVE TO ALL OF YOU TODAY DEMONSTRATES WE HAVE NOT BEEN SITTING STILL FOR THE FIRST 30 YEARS AND THAT WE HOPE IN THE NEXT 30 YEARS TO WORK MORE COLLABORATIVELY WITH EVERYBODY IN THIS ROOM TO GET IT DONE RIGHT FOR WOMEN. SO THANK YOU VERY MUCH. [APPLAUSE] >> GOOD AFTERNOON. I'M HAPPY TO GIVE YOU SOME UPDATES FROM HRSA'S MATERNAL AND CHILD HEALTH BUREAU. AT HRSA, WE HAVE A BROAD MISSION LARGELY FOCUSED ON PROVIDING HEALTHCARE TO UNDERSERVED COMMUNITIES. I'M GOING TO BE TALKING TO YOU A LITTLE ABOUT PORTFOLIO WORK WE'RE DOING SPECIFICALLY WITHIN THE MATERNAL AND CHILD HEALTH BUREAU. I WANT TO TELL YOU A LITTLE BIT FIRST ABOUT THE PARADIGM THAT WE'RE USING TO THINK ABOUT OUR WORK IN MCHB AND THAT'S ACCELERATE UPSTREAM TOGETHER. AND WE'LL SPEND SOME TIME TALKING THROUGH EACH OF THOSE SPECIFIC WORDS BUT FIRST WE'LL START WITH ACCELERATE, WHEN WE THINK ABOUT THAT, IT MEANS EXACTLY WHAT YOU THINK IT MEANS. GET A MOVE ON, HASTEN THE PACE OF THE WORK THAT YOU'RE DOING. THE CHILDREN'S BUREAU, OUR PREDECESSOR OF CURRENT DAY WAS FOUNDED IN 1912 AND IF WE THINK ABOUT THE IMPROVEMENTS THAT HAVE BEEN MADE IN MATERNAL AND CHILD HEALTH DURING THAT TIME, THERE ARE MANY. INFANT MORTALITY IS AN EXAMPLE THAT I COMMONLY USE AND IF YOU THINK ABOUT THE IMPROVEMENTS IN INFANT MORTALITY AT THE TURN OF THE LAST CENTURY, WHEN THREE TO 400,000 INFANTS DIED IN THIS COUNTRY EVERY YEAR, WE'VE MADE SUBSTANTIAL IMPROVEMENT EVEN IN THE LAST 30 YEARS, WE'VE CUT OUR INFANT MORTALITY RATE IN HALF. DESPITE THAT, 22,000 BABIES IN THIS COUNTRY STILL DIE BEFORE REACHING THEIR FIRST BIRTHDAY, AND SO WE'VE MADE IMPROVEMENT BUT WE HAVE TO DO BETTER AND WE HAVE TO MOVE MORE QUICKLY, WE HAVE TO ACCELERATE OUR PACE OF CHANGE, AND IF WE THINK ABOUT THIS TOPIC OF MATERNAL HEALTH, WE'RE ACTUALLY NOT IMPROVING AT ALL SO WE'VE GOT TO ACCELERATE OUR PACE OF INNOVATION, ACCELERATE THE WORK THAT WE'RE DOING TO START MOVING IN THE RIGHT DIRECTION. SO A COUPLE OF WAYS WE'RE DOING THAT IN THE SPACE OF MATERNAL HEALTH, WE'VE SPONSORED OUR GRAND CHALLENGES. THIS IS A NEW INITIATIVE WITHIN SIR IS A ACROSS H SH. LOOKING AT INNOVATIVE MODELS ENGAGING FOLKS THAT HAVE INNOVATIVE IDEAS, SO VERY DIFFERENT FROM PEOPLE WHO GRANTS WHERE WE ASK THEM TO WRITE 50, 70, 80 PAGE GRANT APPLICATIONS AND WE REVIEW IT AND THEN WE FUND IT. THESE ARE FEW-PAGE APPLICATIONS. THEY'RE SUBMITTED AND REVIEWED BY A PANEL OF SUBJECT MATTER EXPERTS AND JUDGES. WE THEN GO THROUGH A PHASED SERIES OF AWARDS SO PHASE ONE WINNERS ARE PICKED, THEY GET A SMALL AMOUNT OF SEED MONEY, WHICH IS USED FURTHER DRIVE THEIR INNOVATION, SO THEY GET TO FURTHER REFINE THEIR IDEA, THINK ABOUT HOW THEY MIGHT SCALE IT. WE THEN -- A SMALLER GROUP, THEY GET A LITTLE BIT MORE MONEY. WE BRING THOSE FOLKS TOGETHER AND HAVE THEM SHARE THEIR IDEAS. THINK ABOUT THE TELEVISION SCHOLL SHARK TANK WHERE YOU PITCH YOUR ADD YD AND YOU MAY GET SOME FUNDING FOR IT, SO VERY SIMILAR TO THAT. WE HAVE TWO CHALLENGES, ONE ON REMOTE PREGNANCY MONITORING, PARTICULARLY THINKING ABOUT CARE GAPS IN UNDERSERVED AREAS AND ALSO THINK ABOUT ADDRESSING OPIOID USE DISORDER IN PREGNANT WOMEN AND NEW MOMS. SO WE ARE IN THE MIDDLE OF PHASE ONE. WE HAVE ABOUT 10 WINNERS IN EACH OF THOSE CATEGORIES. WE'LL BE DOING DEMO DAYS AT THE END OF THE SUMMER, SEPTEMBER 12TH AND 13TH, WHERE WE'LL BRING THOSE WINNERS IN, HAVE THEM DEMO THEIR IDEAS, SHARE THEIR PRODUCTS THAT THEY'VE DEVELOPED TO DATE, AND THEN WE'LL MOVE INTO ANNOUNCING PHASE 2 WINNERS. WE ALSO ARE BEING A SELL RAIGHT THE PACE ATE WHICH WE'RE FUNDING INVESTMENTS IN COMMUNITY ACTIVITIES AIMED AT WILL IMPROVING MATERNAL HEALTH. SO WE HAVE HEALTHY START WHICH YOU HEARD DR. LU TALK ABOUT EARLIER, THAT'S BEEN AROUND FOR A WHILE. WE'VE JUST GONE THROUGH A NEW COMPETITION FOR HEALTHY START WHERE WE'VE ANNOUNCED -- SITES THAT START OND APRIL 1ST. THOSE ARE BY DESIGN IN COMMUNITIES WITH HIGH RATES OF INFANT MORTALITY BUT THINKING ABOUT THE LINK BETWEEN MATERNAL HEALTH AND INFANT HEALTH, WE KNOW THOSE ARE COMMUNITIES THAT WILL ALSO BENEFIT FROM ADDITIONAL FOCUS ON MATERNAL HEALTH SO THE CONGRESS GAVE US 12 MILLION NEW DOLLARS THIS YEAR TO PUT IN COMMUNITIES WITH HEALTHY START PROGRAMS SO THEY CAN BRING IN CLINICAL PROVIDER OHS SPECIFICALLY AIMED AIMENT PROVING MATERNAL HEALTH. WE LTION GOT ADDITIONAL FUNDING TO EXPAND OUR AIM EFFORT. THIS HAS BEEN GOING ON FOR A FEW YEARS FOR THE ALLIANCE FOR INNOVATION ON MATERNAL HEALTH, THOSE SAFETY BUNDLES YOU'VE HEARD TALKED ABOUT ALREADY TODAY AND THINKING ABOUT HOW WE EXPAND THOSE TO ALL STATES, AND SOME ADDITIONAL FUNDING FOR STATE INNOVATION AWARDS RERK NIEZING RECOGNIZING WE'VE GOT CHALLENGES, WE NEED TO THINK ABOUT HOW WE ACCELERATE THE PACE OF CHANGE, WE NEED TO SPARC INNOVATION SO GIVING STATES A SMALL A MONEY TO PULL TOGETHER STAKEHOLDERS TO USE THEIR DATA SO THINKING ABOUT WHAT OUR COLLEAGUE AT CDC TALKED ABOUT EARLIER, USING RELIABLE DAY TO UNDERSTAND WHAT OUR PROBLEMS ARE IN A VERY LOCAL WAY AND USE THAT TO DRIVE INNOVATIVE SOLUTIONS. THESE FUNDING OPPORTUNITIES WILL BE POSTED HOPEFULLY IN THE NEXT COUPLE OF WEEKS AND WE'LL BE AWARDING THOSE BY THE END OF THE FISCAL YEAR. I MENTIONED AIM. OUR PARTNERS AT ACOG ARE DOING TREMENDOUS WORK AT RECRUITING MORE STATES ALL THE TIME SO JUST LAST WEEKEND, I SAID 26 STATES, WE'RE UP TO 27, I DON'T KNOW IF THAT NUMBER IS STILL STABLE OR NOT, BUT 27 STATES, ABOUT 1300 1300 BIRTHING FACILITIES ACROSS THE COUNTRY SO REPRESENTING ABOUT HALF OF ALL BIRTHS IN THE UNITED STATES. WEEB WE'RE EXCITED TO SCALE THAT TO ALL THE STATES. SO WE'VE GOT OPPORTUNITIES TO ACCELERATE THE PACE OF CHANGE AND THINKING ABOUT SOME CARE INITIATIVES THERE, BUT WE ALSO HAVE TO THINK UPSTREAM AND WE KNOW IF WE THINK ABOUT THE ULTRAMALL DRIVERS OF HEALTH OUTCOMES, HEALTHCARE IS ONLY A PIECE OF THAT, 10 TO 20%, DEPENDING ON THE STUDY THAT YOU READ. SO THINKING ABOUT WHERE ARE THOSE OTHER OPPORTUNITIES TO IMPROVE HEALTH. DR. LU MENTIONED EARLIER THIS NOTION OF THE LIFE COURSE MODEL SO WE KNOW WE ALL HAVE THIS BASIC HEALTH TRAJECTORY AND THAT CAN BE IMPROVED OR WORSENED BY SPECIFIC FACTORS -- HEALTH PROMOTION FACTORS CAN HELP RAISE THAT TRAJECTORY BACK UP SO WE WANT TO WHERE WE CAN ENHANCE THE AVAILABILITY OF THOSE HEALTH PROMOTION FACTORS AND EITHER DECREASE OR MITIGATE THE IMPACT OF THOSE RISK FACTORS. SO WHEN HE WITH THINK ABOUT MATERNAL HEALTH, WE'RE TALKING ABOUT MATERNAL MORTALITY MORBIDITY BUT THOSE ARE THE END POINTS WE'RE FOCUSED ON, WE'VE MISSED THE BOAT. WE HAVE TO THINK MUCH EARLIER. I'M A PEDIATRICIAN BY TRAINING, I TALK TO COLLEAGUES THEY SAY THAT'S A PROBLEM FOR OUR O.B. COLLEAGUES. NO, IT'S A PROBLEM FOR US AS PEDIATRICIANS WHEN WE THINK ABOUT THE 6-YEAR-OLD, 8-YEAR-OLD, 13-YEAR-OLD WE'RE SEEING IN WELL CHILD CARE AND A THINKING ABOUT THEIR HEALTH ACROSS THE LIFESPAN SO WE HAVE TO LOOK UPSTREAM, WE CAN'T WAIT UNTIL PREGNANCY. IT'S ABSOLUTELY IMPORTANT TO THINK ABOUT PRENATAL CARE, WE HAVE TO THINK ABOUT THAT AND IT'S THE NOT SUFFICIENT WE'VE GOT TO LOOK UPSTREAM. WE ALSO HAVE TO THINK ABOUT THIS NOTION OF THE IMPACT ACROSS GENERATIONS, SO THINKING ABOUT A TWO-GENERATION APPROACH, THINKING ABOUT THE PATIENT THAT'S IN FRONT OF US AND THEIR FUTURE OFFSPRING BUT ALSO WHAT IS THE IMPACT OF THE HEALTH OF THEIR PARENTS ON THEM AND SO MANY OF OUR PROGRAMS WILL TAKE THAT KIND OF A LENS. JUST A COUPLE OF EXAMPLES OF WAYS WE'RE APPROACHING THAT, IN THE MATERNAL HEALTH SPACE WE'VE GOT WHAT WE CALL THE WOMEN'S PREVENTIVE SERVICES INITIATIVE. THIS IS A GUIDELINE FOR WELL WOMAN CARE. THERE'S A WELL WOMAN CHART THAT OUTLINES THE SPECIFIC ASPECTS OF CARE THAT SHOULD BE CONDUCTED ACROSS THE LIFESPAN, WHETHER THOSE ARE SCREENINGS OR PARTICULAR ASPECTS OF PHYSICAL EXAM, THAT HAVE BEEN SHOWN TO IMPROVE HEALTH. BUT I ALSO INCLUDED ON THIS SLIDE BRIGHT FUTURES. THAT'S THE GUIDELINES FOR WELL WILL CHILD CARE BECAUSE AGAIN, IF WE'RE THINKING UPSTREAM, WE HAVE TO THINK ABOUT THOSE PREVENTIVE SCREENINGS AND SERVICES EARLIER IN THE LIFE COURSE. SO THOSE ARE TWO INVESTMENTS AGAIN WE HAVE IN PARTNERSHIP WITH ACOG, THE AMERICAN ACADEMY OF PEDIATRICS. BUT WE AGAIN HAVE TO THINK JUST -- OR THINK BEYOND JUST CLINICAL CARE SO WE HAVE TO THINK ABOUT THOSE COMMUNITY FACTORS THAT INFLUENCE HEALTH, SO HEALTHY START IS A GREAT EXAMPLE. I MENTIONED THAT WE JUST ANNOUNCED THE HUNDRED WINNERS FOR THE CURRENT FUNDING CYCLE OF HEALTHY START, THOSE ARE DEPICTED HERE ON THIS MAP. THOSE ARE SPECIFICALLY FOCUSED ON WHAT ARE THE COMMUNITY DRIVERS OF POOR HEALTH OUT COME AND WHAT DO WE NEED TO DO TO ADDRESS THEM, SO THINKING UPSTREAM ABOUT HOW WE IMPROVE HEALTH. FINALLY I'LL END WITH TOGETHER. WE CERTAINLY DO NOT DO THIS WORK ALONE AND WE ARE FORTUNATE TO HAVE A NUMBER OF FEDERAL AGENCY PARTNERS WHO DO THIS WORK. WE ROUXLY TALK CDC AND SAY HOW DO WE ALIGN BEST, HOW DO WE THINK ABOUT MAXIMIZING THE IMPACT THAT WE INDIVIDUALLY HAVE AND THINK TOGETHER HOW WE PLAN OUR INITIATIVES. WE ALSO PLAN AND WORK WITH LOTS OF FOLKS IN THE OTHER PARTS OF THE PUBLIC SECTOR BUT ALSO THE PRIVATE SECTOR. LAST SUMMER WE HOSTED A GLOBAL MATERNAL HEALTH SUMMIT BRINGING TOGETHER REPRESENTATIVES FROM ACROSS THE UNITED STATES BUT ALSO SIX OTHER COUNTRIES, SOME OF WHO ARE DOING BETTER THAN US IN MATERNAL HEALTH, SOME OF WHOM ARE DOING WORSE BUT IMPROVING SO WE WANT TO SAY WHAT ARE THE LESSONS LEARNED FROM US, WHERE ARE THERE SIMILARITIES AND HOW CAN WE DO BETTER. ANOTHER EXAMPLE OF OUR PARTNERSHIP IS OUR WORK THROUGH TITLE FIVE. AND CHILD HEALTH BLOCK GRANT PROGRAM, OLDEST FEDERAL PARTNERSHIP THAT'S BEEN AROUND SINCE 1935 WITH THE PASSAGE OF THE SOCIAL SECURITY ACT THROUGH THIS PROGRAM, WITH HE GET BLOCK GRANTS TO STATES WITH VERY FEW STREAMS BUT WHAT WE KNOW IS THAT STATES USE THOSE FUNDS TO BE RESPONSIVE TO THEIR STATE-SPECIFIC NEEDS AND PRIORITIES. WE JUST DID A SURVEY LAST YEAR OF OUR STATE TITLE FIVE FUNDED PROGRAMS AND 56 OUT OF THE 59 JURISDICTIONS WERE USING TITLE FIVE FUNDS TO EITHER FULLY OR SPACIALLY SUPPORT ACTIVITIES ON MATERNAL HEALTH, THAT MIGHT BE SUPPORTING A COLLABORATIVE SO THEY'RE REALLY USING THIS TITLE FIVE MONEY TO INVEST IN IMPROVING MATERNAL HEALTH. SO JUST SOME EXAMPLES OF THE KINDS OF THINGS THEY'RE DOING, THE ONES I MENTIONED, BUTS BUT ALSO THINKING ABOUT PROMOTING HEALTH AND WELLNESS BEFORE, DURING AND AFTER PREGNANCY, SO SOME OF THAT IS IN DIRECT KERIK SOME OF THAT IS IN OTHER COMMUNITY-BASED INTERVENTIONS TO IMPROVE HEALTH. SO WE ARE EXCITED TO BE ONE OF THE AGENCIES THAT IS WORKING ON THIS. AGAIN, WE DON'T DO THIS ALONE. WE'RE EXCITED TO BE ABLE TO TALK A LITTLE BIT WITH YOU TODAY AND LOOK FORWARD TO ANY QUESTIONS THAT YOU MIGHT HAVE AFTER WE'RE DONE. THANK YOU. [APPLAUSE] >> GOOD AFTERNOON. EYE MEGAN MEGAN MITCHELL, HEART, LUNG AND BLOOD INSTITUTE, IT'S A REAL HONOR TO BE HERE TODAY. I'M GOING TO PROVIDE A HIGH LEVEL OVERVIEW OF MATERNAL MORBIDITY AND MORTALITY OR MMM ACROSS NIH AND I'LL BE FOCUSING ON FIVE INSTITUTES, AND MY COLLEAGUE SARAH YOON FROM NIMR WILL BE DOING THE SAME. SHE ALSO WILL BE TALKING ABOUT A NUMBER OF ICs AND OFFICES AS WELL AS ORWH. I'D LIKE TO NOTE THAT THIS IS NOT AN ALL-INCLUSIVE LIST OF ALL NIH I KRFLT Os ICOs INVOLVED IN MMM ACTIVITIES. SO THIS IS A LIST OF THE INSTITUTES THAT WE WILL BE COVERING TODAY AS WELL AS OFFICES IN ORWH. SO IN THE AREA OF MMM -- FOCUS ON THE USE OF MIND AND BODY APPROACHES TO PREVENT RELAPSE OF OPIOID USE AMONG PREGNANT WOMEN TO IMPROVE SLEEP QUALITY DURING PREGNANCY AND TO PREVENT POST-TRAUMATIC STRESS DISORDER SYMPTOMS AFTER CHILDBIRTH. NCCIH ALSO SUPPORTS FUNDAMENTAL WORK TO EXAMINE MECHANISMS OF ACTION OF MINDFULNESS BASED APPROACHES IN COGNITIVE THERAPY FOR PERINATAL DEPRESSION. SO IN THE CONTEXT MMM, NCCIH IS INTERESTED IN RESEARCH THAT ELUCIDATES MECHANISMS THROUGH WHICH MIND AND BODY APPROACHES AFFECT HEALTH, RESILIENCY AND WELL-BEING, RESEARCH THAT INCORPORATES NON-PHARMACOLOGIC INTERVENTIONS TO SUPPORT PREGNANT AND PARENTING WOMEN WITH OPIOID USE DISORDER AND STUDIES THAT UTILIZE MIND AND BODY APPROACHES TO PROMOTE WOMEN'S HEALTH DURING THE PERINATAL PERIOD AND PROPOSALS THAT SEEK TO IDENTIFY STRATEGIES FOR MAN MANAGING SYMPTOMS SUCH AS PAIN, ANXIETY AND DEPRESSION. SO I HAVE THE HONOR OF REPRESENTING AT NHLBI TODAY. THEIR BROAD PORTFOLIO OF HEART, LUNG, BLOOD AND SLEEP DISORDERS INCLUDES THE IMPACT OF PREGNANCY ON MATERNAL HEALTH DURING GESTATIONAL PERIOD AND MANY YEARS POST PAR TOM. MATERNAL WOMEN'S HEALTH PRIORITIES SPAN ALL OBJECTIVES OF OUR STRATEGIC VISION WHICH WAS DEVELOPED WITH EXTENSIVE INPUT FROM THE EXTRAMURAL RESOURCE COMMUNITY AND WAS PUBLISHED IN 2016. FOR EXAMPLE, UNDER OBJECTIVE 1 WITH NORMAL BIOLOGY, IT FOCUSES ON NORMAL BIOLOGY, WE LAUNCHED AN NICHE ITTIVE INITIATIVE IN 20 17 TO BETTER UNDERSTAND HORMONE INDUCED THROMBOSIS. AS WE DISCUSSED WITH A LOT OF OUR SPEAKERS TODAY IN THE U.S. CARDIOVASCULAR DISEASE IS NOW THE LEADING CAUSE OF DEATH IN PREGNANT WOMEN AND IN WOMEN IN THE POSTPARTUM PERIOD. NHLBI SUPPORTS CLINICAL RESEARCH TO IMPROVE PREVENTION AND TREATMENT OF PREECLAMPSIA AND HYPERTENSIVE DISORDERS OF PREGNANCY. WHICH EVALUATE THE EV QA EFFICACY AND SAFETY -- BLOOD PRESSURE TARGET RECOMMENDED FOR NON-PREGNANT ADULTS. WE ALSO SUPPORT WORK ON SLEEP AP KNEE AND TREATMENT AND VEECHES ON THE EVENTS OF PREGNANCY ON CARDIOVASCULAR HEALTH DURING PREGNANCY IN YEARS AFTER POSTPARTUM. SO I'D LIKE TO HIGHLIGHT OUR NEW MOM TO BE HEART HEALTH STUDY, NUT MOM TO BE SLEEP DISORDER BREATHING STUDY, WE ALSO HAVE OUR SAL PROGRAM DND SO NIAAA PRIMARY PLATFORM OF COLLABORATION ON MMM RELATED ACTIVITIES, THE COMMITTEE INITIALLY FOCUSED ON IMPROVING ALCOHOL PREVENTION AND TREATMENT FOR PREGNANT WOMEN. LATER IT WAS EXPANDED TO INCLUDE THE USE OF SUBSTANCES OTHER THAN ALCOHOL, HIV RISK AND OTHER INFECTIONS AND PRECONCEPTION WOMEN AND GIRLS. THE WORK GROUP IS HOSTING AN INVITED MEETING NEXT MONTH ON -- LIVING WITH SUBSTANCE ABUSE AND OTHER MENTAL HEALTH DISORDERS. THE WORK GROUP WAS AN INCUBATOR FOR THE MODEL CONTINUUMS OF CARE FOR WOMEN AND GIRLS INITIATIVE WHICH PUBLISHED IN 2017. IT SUPPORTS COMMUNITY-BASED PARTICIPATORY IMPLEMENTATION RESEARCH TO ACCELERATE THE TRANSLATION OF THE MOST PROMISING AND EVIDENCE-BASED WOMEN AND GIRL-FOCUSED HIV INTERVENTIONS. NIAAA IS ALSO CONSIDERING AN EXPANDED MODEL CONTINUUM OF CARE INITIATIVE THAT WILL HAVE A STRONG TRAUMA FOCUS AND INVOLVE PARTNERSHIP WITH NIAAA, NIDA, NIMH, NICHD AND OTHER PUBLIC HEALTH OFFICIALS FOR THREE OR MORE -- NIAID SUPPORTS STUDIES TO BETTER UNDERSTAND THE FUNCTIONAL INTERACTIONS OF IMMUNE CELLS PRESENT AT THE MATERNAL-FEE FETAL INTERFACE DURING PREGNANCY AS WELL AS INCLUDING MECHANISM RESPONSES. ALSO TO UNDERSTAND THE UNIQUE CONDITIONS DURING PREGNANCY TO PROMOTE PATHOGENESIS, TRANSMISSION AND THERAPY OF INFECTION. NIAID SUPPORTS SEVERAL PROGRAMS AND ACTIVITIES TO ADDRESS MMM IN THE FIELD OF HIV/AIDS AND HIV/AIDS-ASSOCIATED COMORBIDITIES, PARTICULARLY TUBERCULOSIS. THESEICALLY CLINICAL TRIAL NETWORKS SUCH AS THE IMPACT AND IMPACT CONDUCTS CLINICAL TRIALS TO EVALUATE THE SAFETY, PHARMACOKINETICS AND EFFICACY OF ANTI-RETROVIRAL INTERVENTIONS FOR HIV TREATMENT FOR PRE-EXPOSURE PROPHYLAXIS FOR PREVENTION OF HIV ASSOCIATED TUBERCULOSIS AND HIV INFECTED OR AT RISK PREGNANT OR LACTATING MOTHERS. IT'S IMPORTANT TO NOTE THAT NIAID ALSO SUPPORTS CLINICAL TRIAL PROGRAMS OUTSIDE OF THESE NETWORKS FOR THE SAME PURPOSES. SO LASTLY, NICHD SUPPORTS A LARGE NUMBER OF MATERNAL HEALTH PROGRAMS AND ACTIVITIES THAT SPAN ALL DIVISIONS OF THE IC EXTRAMURAL RESEARCH OR DER, WHICH IS HIGHLIGHTED IN GREEN, THE DIVISION OF INTRAMURAL POPULATION HEALTH RESEARCH OR DIPHR, WHICH IS REPRESENTED IN ORANGE HERE, AS WELL AS THE DIVISION OF INTRAMURAL RESEARCH WHICH IS DOWN IN THE BOTTOM THE IN BOTTOM IN THE PURPLE. IT ALSO EXPANDS THE NATIONAL CENTER FOR MEDICAL REHABILITATION RESEARCH. COORDINATING COMMITTEE, MHCC, IS COMPRISED OF APPROXIMATELY 30 STAFF MEMBERS INCLUDES INTRAMURAL AND EXTRAMURAL STAFF. ACCORDING TO THE NIH RESEARCH DISEASE CATEGORIZATION CODING, NICHD FUNDED 57% OF NIH'S MATERNAL HEALTH RESEARCH IN FISCAL YEAR 18. AN EXAMPLE OF NICHD MATERNAL HEALTH RESEARCH INCLUDES -- A CROWD SOURCING RESEARCH STUDY AND IT ALLOWS PREGNANCY EXPERIENCES TO BE EXIE LATED AND ACCESSED AND IT'S AN EXCITING CROWD SOURCING PROGRAM. I'D ALSO LIKE TO MENTION A COUPLE OF NICHD NETWORKS INCLUDING THE MATERNAL FETAL MEDICINE UNIT OR MMFU AND THE OBSTETRIC FETAL PHARMACOLOGY RESEARCH NETWORK OR OPRU. SO NICHD ALSO PARTNERS WITH OTHER -- WITH SEVERAL NIH ACOs AND OTHER FEDERAL AGENCIES TO HELP RO PROMOTE THE HEALTH OF MOTHERS, THEY PROVIDE EXAMPLES OF NIH MATERNAL RESEARCH COLLABORATIONS SUCH AS THE FINDING THAT RACIAL DIFFERENCES HAVE BEEN OBSERVED IN BLOOD VESSEL FORMATION AND PREECLAMPSIA. NICHD RECENTLY HELD TWO EVENTS, A COMMUNITY ENGAGEMENT FORUM ON MATERNAL HEALTH AND MATERNAL -- WORKSHOP DESIGN TODAY BROADEN PARTICIPATION AND ESTABLISH A NEW MATERNAL RESEARCH AGENDA TO ADDRESS SEVERE MATERNAL MORBIDITY AND MATERNAL MORTALITY. I'M GOING TO TURN IT OVER NOW TO MY COLLEAGUE SARAH. >> THANK YOU, MEGAN. I WOULD CONTINUE WITH THE NIDDK PROGRAM OF DATE. NIDDK MATERNAL HEALTH RESEARCH EFFORTS FOCUS ON GESTATIONAL DIABETES AND OH OBESITY DURING PREGNANCY. ALSO HAVE SHORT AND LONG TERM PREGNANCY -- LONG TERM WOMAN AND CHILDREN. ONE OF THE HIGHLIGHTS DURING PREGNANCY -- MEET DIAGNOSTIC CRITERIA FOR GESTATIONAL DIABETES HAS LONG TERM IMPACT ON MOTHERS AND OFFSPRING SUCH AS TYPE~2 DIABETES. AND NIDDK FUTURE RESEARCH EFFORTS INCLUDE THE STUDIES ON UNDERSTANDING THE NATURAL HISTORY OF GLYCEMIA DURING PREGNANCY, WHICH MAY INFORM DECISIONS ON -- DIAGNOSIS AND INTERVENTIONS AS A BENEFIT FOR MOTHERS AND CHILDREN, AND ALSO STUDIES ON OBESITY AND GESTATIONAL WEIGHT GAIN WHICH INFLUENCE ON INTRAUTERINE ENVIRONMENT OF THE FETUS. NEXT IS NIEHSMMM PROGRAM UPDATE, RESEARCH PORTFOLIO IN MATERNAL HEALTH INCLUDES A RANGE OF RESEARCH ON ENVIRONMENTAL INFLUENCE ON PREGNANCY RELATED OUTCOMES. NOTABLE FINDING INCLUDE THE PESTICIDES IN -- ASSOCIATED WITH GESTATIONAL DIABETES, SUPER FUND SITE, IMPAIRED GLUCOSE TOLERANCE. NIEHS AND NCI FUNDED BREAST CANCER AND THE ENVIRONMENTAL RESEARCH PROGRAM INCLUDE RESEARCH ON THE IMPACT OF EXPOSURE DURING PREGNANCY ON THE SUBSEQUENT RISK OF BREAST CANCER. SO NIEHS, FUTURE RESEARCH EFFORT IN THE FUTURE NIEHS HELPS TO PROMOTE MORE RESEARCH ON ENVIRONMENTAL IMPACT ON MATERNAL HEALTH. SOME STUDIES HAVE SHOWN THAT PREGNANCY IS CRITICAL WINDOW FOR ENVIRONMENTAL EXPOSURES. AND NOTABLE FINDINGS INCLUDE EVIDENCE THAT AIR POLLUTION EXPOSURE DURING PREGNANCY INCREASES THE RISK OF BREAST CANCER AND CARDIOVASCULAR DISEASES. NEXT SLIDE IS NIMHD, MMM PROGRAM UPDATE. THE PORTFOLIO ANALYSIS OF NIMHD EFFORTS IN WOMEN'S HEALTH IDENTIFIED ONE R01 STUDY, THEY HAVE A LOT OF STUDIES BUT JUST ONE EXAMPLE THAT INVESTIGATES WHETHER IMPROVING HOSPITAL CARE QUALITY IN NEW YORK CITY COULD REDUCE RACIAL/ETHNIC DISPARITIES IN SEVERE MATERNAL MORBIDITY. THE PROJECT INCLUDES PROCESSES OF CARE, ORGANIZATIONAL FACTORS, PATIENT PERSPECTIVES ON BARRIERS TO RECEIPT OF HIGH QUALITY CARE, DECISION-MAKING REGARDING DELIVERY HOSPITALS AND PERCEPTION OF RISKS. NIMH FUTURE RESEARCH EFFORT, NIMHD IS IN THE PLANNING PHASE OF ACTIVITIES AND INITIATIVES DISPARITIES AND MATERNAL MORBIDITY AND MORTALITY. THE HEALTH INFORMATION TECHNOLOGY FOA PUBLISHED BY NIMHD IN 2018 IS ONE FUNDING STREAM FOR EXAMINING HOW TO LEVERAGE HEALTH I.T. TOOLS TO IMPROVE HEALTH OUTCOMES FOR POPULATIONS DISPROPORTIONATELY AFFECTED BY MMM. NEXT IS MY INSTITUTE, NIMR, PROGRAM UPDATE, THIS SLIDE SHOWS SOME GRANTS RELATED TO MATERNAL HEALTH. NINR RESEARCH FOCUSES ON PRENATAL CARE IN THE CLINICAL SETTING AND THE COMMUNITY ON ADVERSE OUTCOMES AND PREGNANCY-RELATED COMPLICATIONS, ON HEALTH DISPARITIES EXPERIENCED BY WOMEN D MINORITY AND OTHER UNDERSERVED COMMUNITIES. MMM FUTURE RESEARCH PROGRAMS, NINR WILL CONTINUE TO STRENGTHEN RESEARCH SPECIFIC TO WOMEN, WHETHER AS A PATIENT, CAREGIVERS, OR COMMUNITY MEMBERS. AND ALSO RESEARCH WILL ALSO INCLUDE NON-PHARMACOLOGICAL APPROACHES TO IMPROVE THE MANAGEMENT OF PREGNANCY RELATED CONDITIONS, COPING BEHAVIORS, MICROBIOME, EXOGENOUS HORMONES RELATED TO MATERNAL HEALTH, AND FACTORS LINKED TO RESILIENCE IN MATERNAL MORBIDITY AND MORTALITY. SO THIS SLIDE SHOWS THAT OFFICE OF DIETARY SUPPLEMENTS, THE MMM PROGRAM UPDATE, THE ODS FOSTERS THE DEVELOPMENT AND DISSEMINATION OF RESEARCH RESOURCES AND TOOLS WHILE AIMING TO STRENGTHEN THE KNOWLEDGE OF DIETARY SUPPLEMENT USE FITS AND/OR HARMS. THE ODS PROVIDES LABEL INFORMATION ON OVER 76,000 DIETARY SUPPLEMENTS, 300 OF WHICH HAVE CLAIMS OR INTENTIONS FOR USE IN PREGNANT AND LACTATING. ODS -- WORKSHOP ON -- IRON SCREENING AND SUPPLEMENTATION IN IRON-REPLETE PREGNANT WOMEN AND YOUNG CHILDREN THAT WAS PUBLISHED IN 2017. THE NEXT SLIDE IS ODS FUTURE RESEARCH EFFORTS. ODS PROPOSES THE LAUNCH OF A NEW PROGRAM CALLED RESILIENCE AND HEALTH STUDIES. THE POTENTIAL MMM RELEVANT TOPICS WILL ADDRESS HOW RESILIENCE IS MANIFESTED DIFFERENTLY IN PREGNANT WOMEN AND HOW THESE DIFFERENCES MAY IMPACT PHYSIOLOGIC RESPONSES TO NUTRIENT OR PREVENTIVE INTERVENTIONS. NEXT IS ORWH. SO ORWH REQUESTED ICO, SO THIS IS NIH INSTITUTE AND OFFICES, TO IDENTIFY REPRESENTATIVES WHO WORK ON MMM, AND THESE REPRESENTATIVES PRESENTED RESEARCH SUPPORTED BY THEIR OFFICES AIMING AT SHARING THE KNOWLEDGE AND ENCOURAGING COLLABORATIONS. ORWH CREATED FACT AND INFORMATION BOOKLET THAT YOU HAVE NOW AND DEVELOPED A WEB PORTAL THAT DR. CLAYTON PRESENTED EARLIER TODAY. FOR FUTURE ORWH RESEARCH EFFORTS, THEY WILL CONTINUE COLLABORATIONS WITH NIH ICOs TO DISCUSS SHARED AGENDA AND ALSO LEADING A SPECIAL ISSUE OF THE JOURNAL ON WOMEN'S HEALTH IN THE VERY NEAR FUTURE, WE ARE VERY EXCITED. MY FINAL SLIDE IS THE ICO'S CONTACT INFORMATION. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT A PERSON ON THE LIST. AND THANK YOU FOR YOUR ATTENTION. [APPLAUSE] >> I WOULD LIKE TO ASK ALL THE FEDERAL PARTNERS, PLEASE JOIN US WITH DR. SABRINA, SHE WILL LEAD THE DISCUSSION. >> GOODS AFTERNOON, EVERYBODY. I LEAD THE OFFICE OF WOMEN'S HEALTH AND THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. AS WE'RE GETTING SETTLED HERE, A HUGE THANK YOU TO DR. CLAYTON œAND HER TEAM FOR INVITING ME TO BE HERE THIS AFTERNOON. I ALSO WANT TO GIVE A VERY, VERY SPECIAL SHOUT OUT TO DR. PINN. I HAVE BEEN AT HRSA SINCE 1998, AND DR. PINN HAS BEEN A MENTOR AND AN INSPIRATION TO ME FOR THOSE MANY, MANY YEARS AND IT IS SUCH A JOY TO HONOR HER AND TO BE HERE TODAY TO SEE HER, SO THANK YOU, DR. PINN. ALSO WHILE I'M HERE AT NIH, AND IT IS NATIONAL WOMEN'S HEALTH WEEK, SOME OF YOU MAY KNOW AND SOME MAY NOT KNOW THAT THERE IS A WOMEN'S HEALTH TIME CAPSULE BURIED ON THE NIH GROUNDS. TI STONE HOUSE. IT WILL BE OPENED IN THE YEAR 2100. I WON'T BE HERE, MAYBE SOME OF YOU WILL BE, BUT THIS WAS A PROJECT THAT MANY OF THE WOMEN'S HEALTH OFFICES BACK IN THE EARLY 2000s WORKED ON TOGETHER. IT REALLY WAS TO TRY TO SAVE FOR POSTERITY FOR THOSE GENERATIONS TO COME, WHAT WAS WOMEN'S HEALTH ALL ABOUT, AND SO I ENCOURAGE YOU TO LOOK THAT UP ON THE INTERNET AND READ MORE ABOUT THE WOMEN'S HEALTH TIME CAPSULE HERE AT NIH. JUST A COUPLE MORE INTRODUCTORY THINGS I'D LIKE TO SAY. I STARTED MY CAREER AT HRSA IN THE MATERNAL AND CHILD HEALTH BUREAU SO I HAVE A VERY STRONG AND PERSONAL CONNECTION TO THE MATERNAL CHILD HEALTH BUREAU, SPENT 10 YEARS THERE BEFORE MOVING ON TO LEAD THE OFFICE OF WOMEN'S HEALTH SO YOU MAY BE WONDERING WHAT THE OFFICE OF WOMEN'S HEALTH, SO WE ARE ONE OF THE CROSS CUTTING OFFICES WISM'S HEALTH ACROSS HHS, THERE ARE FIVE OTHERS, AND REALLY HAVE THE BIG PICTURE VIEW OF LOOKING ACROSS THE ENTIRE AGENCY AT HRSA, WHETHER THAT BE AROUND MATERNAL CHILD HEALTH, HIV/AIDS, TRAINING, RURAL HEALTH PROGRAMS, HEALTHCARE ACCESS PROGRAMS TO SEE HOW DOES WOMEN'S HEALTH REALLY INTERSECT AND INTERRELATE ACROSS ALL THOSE PROGRAMS, SO IT'S A REALLY BIG PICTURE VIEW AND WE'RE REALLY STRONG ON COLLABORATING AND BUILDING THOSE PARTNERSHIPS TO MAKE SURE THAT EACH OF OUR COLLEAGUES AND ENTITIES ACROSS THE AGENCY ARE TAKING THAT WOMEN'S HEALTH PERSPECTIVE AS APPROPRIATE. I'D BE REMISS TOO AND THIS IS MY LAST COMMENT BEFORE STARTING OUR CONVERSATION ABOUT IF I DIDN'T THANK DR. CAMPBELL FOR BRINGING YOU WANT CONNECTION BETWEEN INTIMATE PARTNER VIOLENCE AND PRETTY MUCH MOST EVERY HEALTH OUTCOME THAT WOMEN FACE TODAY AND MEN TOO. REALLY, IPV IS ONE OF THOSE REALLY PERVASIVE ISSUES FOR WOMEN'S HEALTH, 1 IN 3 WOMEN, 1 IN 7 MEN ACROSS THE U.S. ARE IMPACTED AT SOME POINT IN THEIR LIFE ABOUT IPV. IF WE'RE NOT TALKING ABOUT IT, WE SHOULD BE. WE SHOULD BE LOOKING AT HOW THIS REALLY, REALLY SERIOUS HEALTH ISSUE, SOCIAL DETERMINANT OF HEALTH IMPACTS WOMEN AND WHAT IS THE MEDIATING EFFECT ON WOMEN'S HEALTH OUTCOMES. I'M VERY, VERY EXCITED THAT HRSA IS THE PREMIERE AGENCY, I'LL SAY THAT, THAT HAS A HRSA STRATEGY TO ADDRESS IPV. SO PLEASE TAKE A MINUTE TO LOOK THAT UP AS WELL. WE'RE REALLY PROUD IT'S A REALLY WHOLE OF AGENCY APPROACH LOOKING AT IPV ACROSS ALL OF HIR VA'S PROGRAMS. SO TURNING TO OUR PANEL NOW, I THINK I'LL START WITH A QUESTION FROM MY COLLEAGUE DR. WARREN, ALWAYS A FRIENDLY FACE TO START WITH IN YOUR OWN AGENCY, RIGHT? SO WE HEARD A LOT TODAY, I THINK WE'VE HEARD A LOT ABOUT ACCESS TO CARE ISSUES AND REALLY THINKING ABOUT SOME OF THE CHALLENGES OF WOMEN WHO LIVE IN RURAL COMMUNITIES, WOMEN WHO LIVE IN SOME OF OUR MORE SMALLER COMMUNITIES, IT ISN'T JUST ABOUT THE CLINICAL ISSUES, IT'S ABOUT THE ACCESS ISSUES, IT'S ABOUT THE WHAT HAPPENS WHEN YOU -- THE HOSPITAL IS 100 MILES AWAY, SO I KNOW DR. WARREN AND SOME OF OUR OTHER COLLEAGUES IN HRSA HAVE REALLY PUT THEIR HEADS TOGETHER AND REALLY DONE SOME INNOVATIVE WORK ABOUT A NEW GRANT PROGRAM AND IT'S CALLED R MOMS, RURAL MATERNAL AND OBSTETRIC MANAGEMENT STRATEGY. SO I WAS WONDERING, DR. WARREN, IF YOU COULD TALK A LITTLE BIT ABOUT THAT AND HOW TELEHEALTH AND SOME OF THOSE OTHER TYPES OF INNOVATIVE STRATEGIES CAN HELP US IN MATERNAL HEALTH. >> SO WHEN WE THINK ABOUT THE CONTRIBUTION OF HEALTHCARE TO MATERNAL HEALTH OUTCOMES MENTIONED, CERTAINLY THERE ARE DISPARITIES IN ACCESS TO CARE SO OUR FEDERAL OFFICE OF RURAL HEALTH POLICY HAS DEVELOPED A FUNDING OPPORTUNITY CALLED RMOMS AND YOU JUST HEARD WHAT THAT STANDS FOR, AND THIS LOOKS AT THE ISSUE OF ACCESS TO CARE IN RURAL AREAS WHERE THERE HAVE BEEN A NUMBER OF RURAL HOSPITAL CLOSURES GENERALLY IN THE LAST FEW YEARS, BUT IN MANY AREAS, ADDITIONALLY, CLOSURE OF RURAL OR CLOSURE OF OB SERVICES WITHIN THOSE HOSPITALS EVEN IF THE REMAINDER OF THE HOSPITAL DIDN'T CLOSE. SO RMOMS LOOKS AT STRATEGIES TO THINK ABOUT NETWORKS OF CARE ACROSS RURAL AREAS AND THINKING ABOUT HOW THOSE NETWORKS MIGHT BE SET UP TO AGGREGATE CARE AND HOW YOU MIGHT DO THAT ACROSS THE CONTINUUM, SO NOT JUST PERIPARTUM CARE BUT PRENATAL CARE, THE CARE AROUND THE TIME OF THE DELIVERY, TRANSITION TO WELL WOMAN CARE, WHAT THAT LOOKS LIKE, SO NOT JUST TO STAND THOSE UP BUT HOW CAN YOU SUSTAIN THOSE. SO WE HEARD A LOT EARLIER ABOUT THE POLICY CHANGES THAT NEED TO BE IN PLACE TO SUPPORT THAT, WHAT ARE THE POLICIES THAT NEED TO BE IN PLACE TO SUPPORT THOSE KINDS OF NETWORKS OF CARE AND THEN ULTIMATELY DO THOSE IMPACT BOTH MATERNAL AND INFANT OUTCOMES. SO IT'S AN ACTIVE FUNDING OPPORTUNITY THAT'S ON THE STREET, IF YOU GO TO HRSA'S WEBSITE UNDER FUNDING OPPORTUNITIES, IT'S RMOMS, AND I THINK IT'S LATER THIS MONTH THAT THAT CLOSES. >> GREAT. THANK YOU, DR. WARREN. SO LET ME ASK OUR COLLEAGUES FROM CDC NOW, SO AGAIN YOU'VE HEARD A LOT ABOUT CDC AND THEIR SURVEILLANCE WORK. I WAS WONDERING IF YOU COULD TALK TO US A LITTLE BIT MORE ABOUT HOW THAT SURVEILLANCE WORK THEN TRANSLATES AGAIN AS WE SAYING THE SCIENCE TO THE BENCH SIDE TO THE CURBSIDE A LITTLE BIT MORE ABOUT HOW THAT TRANSLATES AGAIN TO HOW WE CAN IMPLEMENT THAT SO GOING INTO THE IMPLEMENTATION PART EVER ONCE WE KNOW THE NUMBERS, HOW DO WE USE THAT TO BUILD THESE KINDS OF PROGRAMS TO REALLY REACH THE WOMEN THAT WE'RE TALKING ABOUT, THE REAL WOMEN, THE FACE OF THE WOMEN THAT -- SUCH AS DR. IRVING OR SOME OF THE OTHER PEOPLE THAT WE'VE BEEN TALKING ABOUT, SO AGAIN, THE CURB SIDE, THE REAL STORY AFTER WE KNOW ALL THIS INFORMATION. >> WELL, TO START WITH, I THINK WE HAVE TO GET THE DATA AND SO THAT IS WHERE -- THAT'S THIS POINT WE'RE AT RIGHT NOW, BUT I DO THINK THAT'S ONE OF THE REASONS WHERE WE HAVE FELT MATERNAL MORTALITY REVIEW IS SO IMPORTANT BECAUSE IT REALLY DIGS A LOT DEEPER TO UNDERSTAND ALL OF THE DIFFERENT PEELS OF A STORY, SO WE KNOW THAT MOST DEATHS IN REVIEW COMMITTEES FINDINGS HAVE THREE TO FOUR CONTRIBUTING FACTORS SO THAT'S MULTIPLE LOCATIONS WHERE SOMEONE COULD HAVE MADE A DIFFERENCE AND PREVENTED THE OUTCOME AND PREVENT FUTURE DEATHS THAT ARE RELATED SO THAT REALLY LETS US LOOK AT THE LOCAL LEVEL, THE STATE LEVEL AND COMMUNITY LEVEL WHERE WE NEED TO MAKE INVESTMENTS, WHERE WE NEED TO MAKE CHANGES TO MAKE SURE EITHER THE HEALTHCARE PRACTICES OR THE COMMUNITY SERVICES OR LINKAGES BETWEEN HEALTHCARE AND COMMUNITY SERVICES ARE STRENGTHENED AND CHANGED TO BE SURE THAT WE CAN SAVE WOMEN'S LIVES. >> GREAT. THANK YOU FOR THAT. MAYBE WE CAN TURN TO OUR COLLEAGUES AT FDA WHEN WE TALK ABOUT DRUG DEVELOPMENT AND REALLY SOME OF THE CONCERNS, I KNOW THE LONG-STANDING CONCERNS ABOUT IS IT SAFE, IS IT SAFE TO TAKE MEDICINES WHEN YOU'RE PREGNANT AND HOW DO YOU BALANCE THE SAFETY OF THE MOTHERS HEALTH AND THE SAFETY OF THE BABIES'S HEALTH. IT'S AN ETHICAL QUESTION REALLY, IT'S A CLINICAL QUESTION BUT IT'S AN ETHICAL QUESTION SO AS I WAS LISTENING TO YOU, DR. YAO, I WAS LISTENING TO HOW CAN OR DOES FDA OR IS THERE ANY GUIDANCE THAT AS YOU'RE DEVELOPING AND PROVIDING THE DRUG APPROVALS AND CERTAINLY TRYING TO DO PERHAPS SOME POST MARKETING STUDIES, HOW DO YOU HELP WOMEN MAKE THOSE CHOICES? ANYTHING THAT FDA -- OB FDA DISCUSSION, I WAS INTERESTED TO SEE THAT, THAT YOU'RE THINKING ABOUT? >> WE HAVE VERY, I WOULD SAY, INTERESTING ROBUST CONVERSATIONS. WHEN YOU'RE PRESENTED WITH A SET OF DATA, YOU KNOW, WHEN YOU THINK ABOUT CLINICAL MEDICINE, RIGHT, YOU HAVE A PATIENT THAT YOU'RE ALL ROUNDING WITH, MAYBE YOU HAVE THREE DIFFERENT SPECIALISTS AT THE BEDSIDE, AND THEY ALL COME UP WITH A DIFFERENT PLAN. SO YOU CAN LOOK AT THE SAME DATA AND COME UP WITH A DIFFERENT DECISION ABOUT HOW YOU WANT TO -- WHAT CONCLUSION YOU DRAW AND HOW YOU COMMUNICATE THAT INFORMATION. EVEN WITHIN FDA, WE HAVE CLINICIANS OR SCIENTISTS, PHARMACOLOGISTS, TOXICOLOGISTS WHO HAVE A DIFFERENT LEVEL OF INTERNAL RISK, LIKE, WELL, I WOULD NEVER, EVER WANT TO IN ANY WAY EVER OF RISK THAT THIS DRUG BE USED IN A PREGNANT WOMAN BECAUSE A RAT GOT IT AND AT 20 TIMES THE DOSE THAT WAS MAXIMUM IN A HUMAN, THAT -- SO THERE'S A RISK THERE. YOU CAN'T HAVE A PREGNANT WOMAN EXPOSED TO THAT. AND YOU HAVE, YOU KNOW, SOME OF OUR OB COLLEAGUES SAYING, IF YOU DON'T WRITE THIS OR YOU'RE WRITING IT THIS WAY, NO PREGNANT WOMAN IS GOING TO USE IT AND THEY'RE GOING TO END UP IN TROUBLE, LOSE THE PREGNANCY, LOSE THEIR LIFE BECAUSE THEY DECIDE TO STOP A DRUG THAT WAS HELPING THEM. SO WITH HE HAVE THIS WHOLE SPECTRUM AND WHAT WE'RE TRYING TO DO IS CREATE A CONSTRUCT THE IN LABEL WILLING, WE DON'T WANT THE LABELING TO GO ON FOR VOLUMES AND VOLUMES. IT'S NOT AN ENCYCLOPEDIA, IT'S SUPPOSED TO BE ABLE TO FIT IN THE PACKAGE, RIGHT, IT'S SUPPOSED TO BE HELPFUL, BUT WE ALSO RECOGNIZE THAT THAT COMMUNICATION HAS TO BE ROBUST ENOUGH TO ALLOW A PRACTITIONER TO HAVE THAT CONVERSATION WITH THEIR PATIENT. AND ALSO RECOGNIZING THAT IN THE WORLD OF RISK AND THE WORLD OF SAFETY, THERE'S NEVER A WAY TO CONCLUSIVELY DECIDE AN ABSENCE OF A RISK, RIGHT? SO WE HAVE TO BE ABLE TO AT LEAST DEMONSTRATE THROUGH THE YEARS OF USE OF THE DRUG OR THROUGH ALL THE HUMAN EXPERIENCE AND IDEALLY IN WELL CONDUCTED CLINICAL TRIALS IN PREGNANT WOMEN, THAT WE DON'T SEE OR DO SEE SOMETHING. SO THAT'S HOW WE'RE TRYING TO MOVE FORWARD WITH THIS LABELING PROJECT, AND WE ARE SOLICITING FEEDBACK FROM THE END USERS, WE WANT TO HEAR FROM WOMEN, FROM PRESCRIBERS, WE WANT TO HEAR FROM PHARMACISTS TO SEE HOW CAN WE IMPROVE THAT. WE'RE WORKING WITH ALL SORTS OF WAYS TO COMMUNICATE INFORMATION, HEALTH LITERACY, HEALTH COMMUNICATION, SO WE HOPE THAT WE'RE GOING TO DO A BETTER JOB MOVING FORWARD. SUFFICE TO SAY IT'S A REALLY HARD SPACE, I'VE LEARNED A LOT, I'VE MADE A LOT OF, I THINK, MISTAKES BECAUSE I'M NOT THE EXPERT IN THAT AREA BUT WE'RE HOPEFULLY GETTING THAT INPUT SO WE CAN GET A BETTER JOB. BUT YOU'RE ABSOLUTELY RIGHT, IT'S A TOUGH PLACE. >> TURNING TO OUR NIH COLLEAGUES, I WAS JUST IMPRESSED OR MAYBE JUST INCREDIBLY AMAZED, STUDY AFTER STUDY AFTER STUDY AFTER STUDY, AND YET IS THERE ENOUGH, YOU KNOW, IS THERE ENOUGH PROMOTION, IS THERE ENOUGH DISCUSSION ABOUT HOW WE ARE ABLE TO -- PERHAPS IT'S THE PORTAL THAT WE KNOW WAS JUST LAUNCHED TODAY, HOW DO WE HAVE A DISCUSSION ABOUT THE AVAILABILITY OF ALL OF THOSE RESEARCH STUDIES IN ONE PLACE AGAIN OR IN SOME WAY THAT THE BREADTH OF PROVIDERS, PATIENTS, CAN REALLY UNDERSTAND THERE'S THIS HUGE AMOUNT OF STUDIES THAT ARE GOING ON. I'M NOT HERE AT NIH SO MAYBE AGAIN THIS IS MORE FAMILIAR FOR SOME OF YOU BUT IT JUST SEEMS LIKE THERE'S SO MUCH HAPPENING AND YET IS THAT KNOWN ACROSS ALL OF OUR FEDERAL SPACES THAT WE CAN TALK ABOUT THAT AND IN TURN, YOU KNOW, YOU CAN ALSO SHARE SOME OF WHAT WE'RE DOING. SO I THINK A LITTLE BIT MORE CROSS AS YOU WERE SORTD OF ALLUDING TO, A LITTLE MORE CROSS COMMUNICATION, CROSS SHARING. >> SO AT NHLBI, AM THE MMM . OF CONTACT. THIS IS A REALLY EXCITING TIME WITH US BECAUSE WE'RE WORKING WITH A LOT OF OUR OTHER I.C. PARTNERS AND WE HAVE THE ORWH-LED MMM . OF CONTACTS SUBCOMMITTEE THAT WAS JUST PUT TOGETHER. WE HAD MEETINGS IN DECEMBER AND JANUARY OF 2019. AND SO WE'RE ALL BEGINNING TO WORK TOGETHER AND LOOK AT THIS AS A BIG NIH PICTURE AND WE ALSO HAVE THE NEW WEBSITE THAT WAS DISCUSSED BY DR. CLAYTON TODAY AND A LOT OF THESE MATERIALS ARE BEING ROLLED OUT OOND I AND I THINK WE REALIZE WE ARE SEPARATE ICOs, 27 ICOs ACROSS NIH BUT WORKING TOGETHER I THINK CAN MAKE A REAL IMPACT AND WE'RE LOOKING AT THE DATA, I THINK, WITHIN EACH I.C. AND ACROSS I.C.s, AND IT'S EXCITING TO NOW HAVE THE RCDC CODING WHICH I MENTIONED HONESTLY UNTIL 2017 THAT WAS NOT AVAILABLE, MATERNAL HEALTH IS A NEW RCDC CODE, SO THAT IS REALLY ENLIGHTENING AND SOMETHING WORTH MENTIONING THAT IN 2015 AND 2016 AND PRIOR TO THEN, WE COULD NOT RUN ANALYSES AND LOOK AT MATERNAL HEALTH. SO NOW WE'RE LOOKING IT AT THE DATA AND AS I MENTIONED, NICHD DOES FUND 57% OF THE MATERNAL HEALTH PORTFOLIO, BUT ACTUALLY NHLBI IS JUST BEHIND THAT. WE'RE THE SECOND LEADING I.C. IN MATERNAL HEALTH RESEARCH, SO I THENG THAT WE'RE NOW AT A POINT WHERE WE REALLY WANT TO KIND OF PUT OUR HEADS TOGETHER AND THINK ABOUT WHAT IS THE MOST IMPACTFUL WAYS WE CAN MOVE FORWARD. >> I THINK -- MANUAL RECORDING SYSTEM TO CAPTURE MORE WOMEN'S HEALTH RELATED PROJECT THAT EACH IC HAS, AND THIS PILOT STUDY ACTUALLY SEVERAL ICs ARE PARTICIPATING, SO IN THE FUTURE, ORWH WILL BE ABLE TO CAPTURE HOW MUCH ACTUALLY MATERNAL MORBIDITY MORTALITY STUDIES WERE DONE FROM NIH WIDE, AND THEN ALSO THROUGH THE RCDC AND OTHER TOOLS THAT ARE REPORTED, ACTUALLY YOU CAN FIND THE PUBLICATIONS FROM OUR GRANTEES, WHAT THEY PUBLISHED, SO WE WILL BE ABLE TO UPDATE MORE NEW RESEARCH RESULTS. >> GREAT. I KNOW WE'RE RUNNING OUT OF TIME, SO I'M GOING TO -- I KNOW CHALLENGE EACH OF YOU IN 30 SECONDS OR LESS, 32ND OR LESS, RIGHT, YOU KNOW, WHAT DOES -- PRETEND LIKE WE HAVE -- WE'VE MADE THAT NEXT SMALL LEAP, RIGHT? IT'S NOT GOING TO HAPPEN IN A BIG LEAP OVERNIGHT, THE NEXT SMALL THING THAT YOU WOULD LIKE TO REALLY SEE HAPPEN TO TURN THE CORNER. WHAT WOULD THAT BE WHEN IT COMES TO MATERNAL HEALTH? NOT NECESSARILY MATERNAL MORTALITY. WE'RE GOING TO LOOK AT MATERNAL HEALTH AND WE'RE GOING TO THINK ABOUT ALL THOSE HEALTHY MOMS AND HEALTHY BABIES. SO WHAT IS THAT THING FOR YOU, WOULD YOU LIKE TO SEE? >> I WOULD BE HAPPY TO START. THIS PAST MOTHER'S DAY, I HAVE A 9-YEAR-OLD AND ALMOST 13-YEAR-OLD AND I LOOKED AT IT DIFFERENTLY THIS YEAR BECAUSE I WAS EXCITED ABOUT IT BUT I THOUGHT WHY DON'T WE PAY ATTENTION TO WOMEN 364 DAYS OF THE YEAR AS WELL. SO IT WAS EXCITING, I LIKED HAVING MY MOTHER'S DAY AND MY CARDS AND IT MEANT A LOT TO ME BUT I LOOKED AT IT DIFFERENTLY, THAT UNTIL WE TREAT WOMEN THIS WAY, 365 DAYS A YEAR, NOT JUST A ONE-DAY A YEAR HALLMARK HOLIDAY, WE ARE NOT GOING TO MAKE THE DIFFERENCE THAT WE NEED TO MAKE. AND SO THAT'S JUST MY THOUGHTS. >> I THINK I'M ALWAYS MORE INTERESTED IN HOSPITAL DATA AND USING TECHNOLOGY, I'M VERY EXCITED, NOW THE ELECTRONIC MEDICAL DATA IS AVAILABLE, SO IT'S MAYBE ACCURATE FOR LONG TERM PLANS. SHORT TERM PLAN RIGHT NOW, MAY BE ABLE TO USE THE NURSES NOTES AND TO FIND THEIR CLUSTERS OF THE SYMPTOMS THAT WE MAY BE EABL TO FIND WHAT IS THE FACTORS FOR THE PREECLAMPSIA, WE CAN PREDICT, OR WHEN MOTHER IS DISCHARGED FROM THE HOPTD, WE MAY BE ABLE TO PREDICT WHAT PROBLEM THEY HAVE THEN PHYSICIANS AND HOSPITAL MAY BE ABLE TO CONNECT TO THE COMMUNITY THE -- WHO MAY BE ABLE TO HAVE HOME VISITING OR THE LOCAL GROUPS CAN HELP THE MOTHERS. SO SINCE OUR COUNTRY THE MORTALITY RIGHT IS REALLY HIGH, SO RIGHT NOW WE MAY HAVE TO FOCUS ON ACCURATE INTERVENTION, NOW BUT I THINK AT THE SAME TIME, WE HAVE TO THINK ABOUT AS A LONG TERM, HOW ARE WE GOING TO PREVENT FURTHERMORE TALT AND FURTHER MORTA LITY AND MORBIDITY. >> I THINK A WIN WOULD BE, AS MY COLLEAGUE FROM NIH SAID, A REFRAMING THE CONVERSATION, SO WE TALK ABOUT MATERNAL MORTALITY/MORBIDITY, BUT HAVING THE BRODER CONVERSATION NOT ONLY ABOUT MATERNAL HEALTH BUT ABOUT WOMEN'S HEALTH AND SO THINKING THEN UPSTREAM, SO HOW DOES THAT TRANSLATE TO GIRLS' HEALTH, RECOGNIZING THAT GETTING THE DATA ABOUT WHY WOMEN ARE DYING AND WHY WOMEN ARE SUFFERING COMPLICATIONS DURING PREGNANCY IS AN ABSOLUTE AND NECESSARY FIRST STEP BUT WE CAN'T STOP THERE, WE HAVE TO THINK THEN, AS SARAH WAS SAYING, WHAT DOES THAT MEAN IN TERMS OF TRANSLATING THAT TRANSLATING INTO ACTION WHERE THOSE OPPORTUNITIES ARE FOR PREVENTION AND HOW WE LOOK UPSTREAM ACROSS THE LIFE COURSE TO THINK ABOUT HOW WE DO THAT. >> THE ONE THING THAT I WAS STRUCK BY TODAY IS THAT ADDED PHRASE, YOU KNOW, BENCH TO BEDSIDE TO CURBSIDE. AND I THINK THE ONE PLACE WHERE BACK AND I'VE BEEN THINKING ABOUT IS, THE PARTNERS THAT WE HAVE TO TURN ALL THESE IDEAS INTO SOMETHING THAT HELPS THAT WOMAN WHERE SHE IS. I THINK THAT'S THE ONE THING I'M TAKING AWAY FROM THIS, THAT WE'VE GOT TO TURN THAT IDEA INTO THE ACTION THAT LEADS TO THE CHANGE AT THAT LEVEL. >> I AGREE WITH WHAT'S BEEN SAID. I THINK ONE OF THE THINGS I WOULD ADD POTENTIALLY IS IF WE WERE LOOKING KIND OF BEYOND WHAT'S GOING ON NOW, ONE OF THE THINGS I WOULD LIKE TO SEE US DO MORE SYSTEMATICALLY POTENTIALLY IS LOOKING AT MEASURES OF RESPECTFUL MATERNITY CARE. WE'VE DONE SOME WORK INTERNATIONALLY THAT MEASURES THAT AND FINDS THINGS LIKE BIRTH ATTENDANTS CAN REALLY MAKE A DIFFERENCE AND I THINK SOME OF THE THINGS WE'VE HEARD TODAY TALK ABOUT SOCIAL SUPPORT AND OTHER ASPECTS, AND I THINK IT'S ONE PLACE WHERE WE HAVE SOME PLACES THAT ARE DOING IT AND MEASURING IT AND I THINK IF WE DID THAT MORE, WE MIGHT BE ABLE TO MAKE SOME MORE GAINS. >> OKAY. I THINK WE'RE OUT OF TIME. DR. NOURSI? >> THANK YOU. PLEASE HELP ME THANK OUR PANEL, HRSA, CDC, FDA, OUR COLLEAGUES FROM NIH, THANK YOU, EVERYONE. [APPLAUSE] WE'RE COMING UP TO THE END OF THE DAY, AND I REALLY APPRECIATE ALL OF YOU STAYS WITH US AND BEING SO FOCUSED ON THIS REALLY COMPELLING PUBLIC HEALTH ISSUE. IT'S MY PLEASURE TO INTRODUCE MS. STAY TEE STEWART. SHE STEWART. SHE JOINED THE MARCH OF DIMES IN 2017. IN THIS ROLE, MS. STEWART HAS THE ORGANIZATION LEADING THE FIGHT FOR THE HEALTH OF MOMS AND BABIES. SHE IS RESPONSIBLE FOR ALL ASPECTS OF THE ORGANIZATION'S STRATEGY, VISION AND OPERATIONS. SHE'S BEEN A SPEAKER HERE AT NIH IN THE PAST, AND PRIOR TO COMING TO THE MARCH OF DIMES, SHE WAS IN A SENIOR POSITION AS PRESIDENT -- THE U.S. PRESIDENT OF THE UNITED WAY. PLEASE JOIN ME IN WELCOMING TO THE PODIUM MS. STACEY STEWART FOR CLOSING REMARKS. [APPLAUSE] >> THANK YOU. IT IS GREAT TO BE HERE WITH ALL OF YOU ALL AND I AM PAINFULLY AWARE OF THE FACT I'M THE LAST SPEAKER SO I WILL TRY TO GET THROUGH THIS RELATIVELY QUICKLY. IT IS GREAT TO BE BACK HERE AT NIH AND THANK YOU, DR. CLAYTON, FOR HAVING ME. ALSO WANT TO SAY IT'S SO GREAT TO BE IN THE PRESENCE OF DR. PINN WHO I HAVE HEARD ABOUT AND KNOWN OF FOR MANY, MANY YEARS, OUR PATHS NEVER CROSSED SO IT'S VERY NICE AND QUITE MY HONOR TO BE HERE IN THE SYMPOSIUM NAMED AFTER YOU AND HAD IN HONOR OF YOU, SO THANK YOU FOR ALL YOUR WORK. ALSO HAVE SOME COLLEAGUES FEAR FROM THE MARCH OF DIMES, OUR CHIEF SCIENTIFIC OFFICER IS HERE, AND SHE'S BEEN VERY ATTENTIVE HERE, I'M SURE WE'RE GOING TO COMPARE LOTS OF NOTES. SHE HAS A VERY DISTINGUISHED BACKGROUND IN RESEARCH IN THIS SPACE AROUND MATERNAL AND INFANT HEALTH, AND IS A REPRODUCTIVE ENDOCRINOLOGIST AND OB-GYN AND AMAZING PHYSICIAN, RESEARCHER, AND THIS HAS BEEN REALLY A WONDERFUL DAY TO HEAR ALL OF THE THINGS. SO MY CHALLENGE RIGHT NOW IS HOW AM I GOING TO SAY SOMETHING THAT YOU HAVEN'T ALREADY HEARD, WHICH IS VERY DIFFICULT. ALSO IT MIGHT BE INTERESTING TO YOU THAT I'M THE ONLY ONE ON THE SYMPOSIUM TODAY THAT DOESN'T HAVE EITHER M.D. OR PH.D. AFTER HIS OR HER NAME SO YOU'RE ALSO WONDERING WHAT IN THE WORLD COULD SHE POSSIBLY SAY TO ME THAT WOULD BE WORTH MY WHILE. AND AS A FORMER WALL SREET INVESTMENT BANKER, BEFORE MY -- DAYS, IT WILL PROBABLY BE EVEN MORE PREPOSTEROUS THAT I'M STANDING HERE SPEAKING AT ALL. BUT I WILL SAY AS THE HEAD OF THE MARCH OF DIMES NOW FOR THE PAST 2 1/2 YEARS, IT'S BEEN REALLY AN HONOR TO LEAD THIS ORGANIZE AND TO DO SOME OF THE WORK THAT WE'RE DOING AND TO PARTNER WITH SO MANY OF YOU ALL ON MUCH OF THIS WORK AND I THINK IT'S BEEN SAID BEFORE THAT THERE'S NOT ONE SPEAKER HERE, ONE ORGANIZATION REPRESENTED HERE TODAY INCLUDING US THAT CAN TACKLE THESE CHALLENGES AROUND MATERNAL HEALTH BY OURSELVES. A LOT OF US WORK VERY WELL TOGETHER AND HAVE BEEN DOING SO FOR A NUMBER OF YEARS SO IT'S REALLY NICE TO ALSO GET CAUGHT UP ON A LOT OF WHAT ELSE IS GOING ON. AND SHARE IN SOME OF THE THINGS THAT WE'RE WORKING ON TOGETHER. LET ME JUST SAY THIS BECAUSE I THINK SOME OF YOU MAY NOT EVEN REALLY KNOW. WHAT IS THE MARCH OF DIMES TODAY? SOME OF YOU MAY ALL KNOW THE MARCH OF DIMES FROM YEARS AGO. HOW MANY OF YOU KNOW THE MARCH OF DIME FROM POLIO DAYS, RIGHT? PROBABLY MOST OF YOU. WELL, LET ME FAST FORWARD. IT'S 2019. AND WHERE ARE WE TODAY, WHAT ARE WE DOING, WHY ARE WE HERE, AND WHAT IS OUR WORK TODAY. AND PART OF THE REASON I CAME TO THE MARCH OF DIMES IS BECAUSE WE'RE DOING A LOT OF THIS VERY IMPORTANT WORK AROUND MATERNAL AND INFANT HEALTH, ESPECIALLY LOOKING AT THE ISSUES OF HE PROO MATURE BIRTH, MO TEARNL MORTALITY AND MORBIDITY, INCREASINGLY LOOKING AT THE ISSUES OF NEONATAL ABSENCE SYNDROME AND HOW THE OPIOID CRISIS IS AFFECTING MANY WOMEN BEFORE PREGNANCY, DURING PREGNANCY AND EVEN AFTER PREGNANCY, AND A LOT OF OUR WORK IS IN THE AREA OF RESEARCH, SIMILAR TO OUR DAYS FROM THE OLD POLIO DAYS, BUT IT IS MORE THAN JUST THAT ALONE. YOU'LL HEAR A LOT FROM ME IN THE NEXT FEW MINUTES AROUND OUR WORK IN ADVOCACY, BOTH AT THE FEDERAL AND THE STATE LEVEL, PROGRAMMATICALLY HOW WE'RE IMPACTING IN COMMUNITIES AROUND THE COUNTRY. WE'RE AN ORGANIZATION OF 900 PEOPLE ALL AROUND THE COUNTRY AND WE HAVE PROGRAMS EVEN OUTSIDE THE U.S. AS WELL. I SWRONT A CHANCE TO GO THROUGH A LOT OF THAT BUT I WILL TRY TO TOUCH ON SOME OF THE HIGHLIGHTS OF SOME OF THE THINGS THAT WE'RE DOING. ONCE THE ORGANIZATION GOT STARTED I WAS REALLY HONORED WHEN I CAME IN THIS BUILDING THAT THIS BUILDING WAS DEDICATEED ABOUT I PRESIDENT ROOSEVELT SO THAT WAS KIND OF A NICE WELCOME TO EVEN COME INTO THIS BUILDING. WE WERE STARTED BY PRESIDENT ROOSEVELT SOLELY TO WORK ON THE ISSUE OF POLIO. THE ISSUE OF POLIO, SURPRISINGLY, ONE OF THE BIGGEST HEALTH CHALLENGES OF ITS DAY, WAS FAIRLY STRAIGHTFORWARD. IT TOOK YEARS TO DEVELOP THE VACCINE BUT IT WAS PRETTY CLEAR WE NEEDED TO FIGURE OUT HOW TO ISOLATE, YOU KNOW, WHAT WAS CAUSING THE POLIO VIRUS, HOW TO FIGURE OUT HOW TO CREATE A VACCINE TO THEN MAKE SURE THAT EVERYONE COULD BE -- COULD HAVE WHATEVER PREVENTIVE CARE THEY NEEDED TO AVOID GETTING POLIO. WE ELIMINATED THE POLIO CRISIS AS FOR ALL INTENTS AND PURPOSES IN THIS COUNTRY AND IT WOULD BE ELIMINATE AROUND THE WORLD FOR ACCESS TO THE VACCINE. WHAT WE KNOW ABOUT THESE ISSUES AROUND MATERNAL AND INFANT HEALTH, ESPECIALLY MATERNAL HEALTH, IS THAT IT'S NOT THAT EASY. IT'S NOT GOING TO BE A VACCINE. IT'S NOT GOING TO BE A SHOT, IT'S NOT GOING TO BE A PILL. THERE MAY BE PILLS, THERE MAY BE THINGS THAT WE DO, BUT IT'S PROBABLY NOT GOING TO BE ONE THING, RIGHT? THERE'S NOT ONE THING THAT'S CAUSING IT IT SO THE LIKELIHOOD THAT THERE'S ONE THING THAT'S GOING TO SOLVE IT IS HIGHLY UNLIKELY. I COULD BE PROVEN WRONG AND IF I AM, THAT WOULD BE WONDERFUL BECAUSE IF THERE'S ONE SIMPLE SOLUTION TO THIS, WE'D ALL BE QUITE HAPPY. WHAT WE'RE LEARNING AT THE MARCH OF DIMES IS IT'S A VERY COMPLEX ISSUE. CAUSES ARE VERY COMPLEX, THE SOLUTIONS WILL BE MULTI-LAYERED, MULTIFACETED, AND THAT'S WHY AT THE MARCH OF DIMES, WITH HE FEEL LIKE IT'S SO IMPORTANT TO HAVE AN ORGANIZATION THAT REALLY SAYS WE FIGHT FOR THE HEALTH OF MOMS AND BABIES BUT WE EMPLOY DIFFERENT TOOL DOES THAT. WE HAVE A VARIETY OF PARTNERS. RESEARCH PARTNERS, POLICY PARTNERS, PROGRAMMATIC PARTNERS TO HELP GET AT SOME OF THESE ISSUES. BUT OUR GOAL IS TO MAKE SURE THAT WE REALLY IMPACT THE HEALTH OF ALL THE MOMS, WOMEN BEFORE THEY'RE PREGNANT, ALL THE MOMS WHO HAD BABIES AND THE 4 MILLION BABIES THAT ARE BORN IN THIS COUNTRY EVERY YEAR. I'M NOT GOING TO SPEND A LOT OF TIME ON THIS BECAUSE CERTAINLY WE HAVE BEEN THROUGH THIS PRETTY EXHAUSTIVELY TODAY, AND WE ARE PRETTY GROUNDED IN THE TRENDS THAT WE'RE SEEING AROUND MATERNAL HEALTH AND THIS IS JUST ONE CHART THAT WE COULD USE AS A PROXY FOR MATERNAL HEALTH, MATERNAL MORTALITY, MORBIDITY WHICH IS EVEN A MORE APPROPRIATE MEASURE WHEN YOU LOOK AT THE ISSUE OF MATERNAL HEALTH OVERALL BECAUSE DEATHS ARE ONE THING BUT THE NEAR DEATHS AND NEAR MISSES ARE ANOTHER EXPERIENCE ALL TOGETHER, WITH 50,000 WOMEN EACH YEAR EXPERIENCING NEAR DEATH EPISODES AND ALMOST DYING. JOIA, DR. CREA-PERRY AND I, HAD THE HONOR IN THE FALL OF LAST YEAR TO BE ABLE TO TESTIFY IN FRONT OF THE HOUSE ENERGY AND COMMERCE SUBCOMMITTEE IN SUPPORT OF THE BILL, PREVENTING MATERNAL DEATHS ACT VILLE FOR COMMITTEES TO BE ESTABLISHED IN ALL STATES. OF COURSE WE MADE A LOT OF PROGRESS TO GET A LOT OF THOSE STATES AS YOU'VE HEARD, ESTABLISHING THOSE MMRCs. WE STILL HAVE MORE TO GO BUT WE THINK THAT BILL WAS A FIRST STEP AT THE FEDERAL LEVEL TO ENSURE THERE WAS, ONE, THE APPROPRIATE FOCUS ON THE ISSUE OF MATERNAL HEALTH, BUT IT IS NOW FOLLOWED BY SEVERAL OTHER PIECES OF FEDERAL LEGISLATION THAT HAVE THE INTENT OF GOING EVEN FURTHER. AND LOOKING AT OTHER ISSUES THAT WE THINK CAN HELP TO PREVENT SO MANY MOMS FROM LOSING THEIR LIVES AND OF COURSE ALSO ADDRESS THE SIGNIFICANT RACIAL ANDETH THE NICK DISPARITIES THAT WE'VE SEEN AND HEARD ABOUT TODAY THAT ARE QUITE TROUBLING, AND THAT IS ALSO A CORE PART, THE ISSUE OF HEALTH EQUITY AND DISPARITY IS A CORE PART OF WHAT WE ARE WORKING ON AT THE MARCH OF DIMES, WE THINK PRESIDENT ROOSEVELT WOULD BE VERY PROUD OF OUR FOCUS ON THAT, BUT WE THINK ELEANOR WOULD BE EVEN HAPPY YEAR ABOUT HAPPIER ABOUT IT . SO I'M JUST GOING TO DO SOME SORT OF RAPID FIRE ON SOME OF THE THINGS THAT WE'RE DOING TO ADDRESS THE ISSUES OF MATERNAL MORTALITY AND MORBIDITY AND MATERNAL HEALTH. A LOT OF THINGS THAT YOU'VE ALREADY HEARD TODAY ARE EFFORTS THAT WE'RE ALL AT THE MARCH OF DIMES VERY INVOLVED IN. EVEN IF WE'RE NOT LEADING IT, THESE ARE EFFORTS THAT WE ARE EXTREMELY INVOLVED IN. ALL THE WORK AROUND MATERNAL MORTALITY REVIEW COMMITTEES, IN MANY, MANY STATES, WE ARE HELPING PROVIDING SUPPORT, WE'RE AT THE TABLE TO TRY TO MAKE SURE THAT THEY'RE FORMED, THAT THEY'RE FUNDED, AND THAT THEY'RE DOING ALL THAT THEY CAN DO IN ORDER TO GATHER THE RIGHT DATA, DESIGN THE RIGHT INTERVENTIONS. I'D ALSO SAY THAT PART OF OUR EFFORTS HAVE ALWAYS BEEN AROUND HEALTH ACCESS. FROM A POLICY PERSPECTIVE, THE REALITY IS THAT WE STILL HAVE TOO MANY WOMEN THAT ARE UNINSURED IN THIS COUNTRY. 10 MILLION WOMEN THAT ARE UNINSURED. HOW WOULD IT BE POSSIBLE AS WOMEN TO ACCESS THE RIGHT LEVEL OF CARE THAT THEY NEED, THE RIGHT LEVEL OF HEALTH AND WELLNESS THAT THEY NEED, IN HEALTHY BUT ALSO THAT THEIR BABIES ARE HEALTHY. WE HAVE A HUGE GAP. AND OF COURSE WE'VE SEEN IN 2017 AND EVEN CONTINUING A LOT OF BATTLES THAT WE'VE STILL GOT TO FIGHT TO MAKE SURE THAT WE HAVE ACCESS TO CARE FOR EVERYONE AND ESPECIALLY WOMEN, AND ESPECIALLY LOOKING AT ALL THE AREAS THAT WE NEED COVERAGE. NOT JUST HEALTH INSURANCE GENERALLY BUT REALLY LOOKING AT ALL THE EFFORTS THAT WE NEED TO PURSUE AROUND POSTPARTUM DEPRESSION SCREENING AND MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT, WHICH ARE SO CRITICAL. WE'RE SEEING ATTACKS RIGHT NOW AS YOU KNOW ON WOMEN'S RIGHT TO CHOOSE AND THAT IS TIED TO ALL KINDS OF CHALLENGES THAT WE STILL FACE WITH RESPECT TO AFFORDABLE CONTRACEPTION AND LONG ACTING REVERSIBLE CONTRACEPTION. WE ALSO NEED TO MAKE SURE AND I'LL TOUCH ON THIS IN SUCH A SEC ON MAKING SURE THERE IS RESPECTFUL AND ADEQUATE CARE FROM OUR CARE PROVIDERS. I'M GLAD TO HEAR DR. HOLLIER, WHO'S A LONG TIME VOLUNTEER WITH THE MARCH OF DIMES AND A FRIEND OF OURS, AS SHE'S BEEN LEADING ACOG TO TALK ABOUT THAT AS A KEY PRIORITY FOR ACOG. WE THINK THAT'S REALLY IMPORTANT, THAT ALL HEALTHCARE PROVIDERS ARE LENDING THE RIGHT KIND OF RESPECTFUL CARE TO WOMEN THROUGHOUT THEIR LIVES, AND ESPECIALLY WHILE THEY'RE PREGNANT TO MAKE SURE THAT THEIR& NEEDS ARE BEING MET AND THAT THEIR CONCERNS ARE BEING HEARD. WE ARE WORKING VERY MUCH ON THESE ISSUES OF HOW WE EXPAND CARE, SPECIFICALLY AROUND THESE ISSUES OF WHAT WE CALL MATERNAL CARE DESERTS. SO ON OUR WEBSITE AT MARCHOFDIMES.ORG WE DID A STUDY CALLED NOWHERE TO GO, MATERNAL CARE DEZ ERTS. HOW MANY OF YOU HAVE HEARD OF A FOOD DESERT? WHAT WE HAVE DONE IS LOOKED AT WHERE ARE THOSE PLACES IN THE COUNTRY WHERE WE LACK EVEN ACCESS TO THE BASIC OBSTETRIC CARE THAT WOMEN NEED. WE'VE TALKED ABOUT THE SHORTAGES IN RURAL HEALTHCARE WITH CLOSING OF RURAL HOSPITALS. WE LOOKED AT COUNTIES IN THE COUNTRY TO SAY HOW MANY COUNTIES DO WE HAVE THAT LACK EVEN ONE HOSPITAL THAT OFFERS OBSTETRIC CARE, EVEN ONE OB-GYN OR EVEN ONE CERTIFIED NURSE MIDWIFE. 35% OF ALL COUNTIES ARE CONSIDERED A MATERNAL CARE DID DESERT. THAT COVERS ABOUT 5 MILLION WOMEN AND THERE ARE ABOUT 10 MILLION WOMEN THAT ARE IN WHAT WE WOULD CALL THEY'RE ALMOST MATERNAL CARE DESERTS, THEY HAVE SEVERELY LIMITED ACCESS TO CARE. NOW IT'S NOT TO SAY THAT A HOSPITAL NEEDS TO BE IN EVERY SINGLE COUNTY, BUT I LOVE THE IDEAS AND WORK THAT'S BEING DONE AND WE'RE WORKING WITH MANY PARTNERS TOO TO LOOK AT ALTERNATIVE FORMS OF CARE. WHETHER IT'S AROUND TELEMEDICINE AND SOME OF THE THINGS WE ARE GREATLY U.S. PORE ITTIVE OF BUT ALSO LOOKING AT OTHER WAYS TO DELIVER CARE, BECAUSE MANY OF THESE MATERNAL CARE DESERTS ARE IN RURAL AREAS, ABOUT FOUR-FIFTHS OF THESE COUNTIES ARE IN RURAL AREAS BUT ABOUT A FIFTH OF THEM ARE ALSO IN URBAN AREAS. RIGHT HERE IN WASHINGTON, D.C., WE WOULD CONSIDER WARD 7 AND 8 A MATERNAL CARE DESERT WHERE THERE IS NO HOSPITAL IN 7-8, WITH THE CLOSING OF PROVIDENCE HOSPITAL IN WARD 5, WE'VE GOT A STRUGGLE FOR WOMEN WHO OFTEN -- ES PSHLY IF YOU'RE A HIGH RISK PREGNANCY, YOU MAY HAVE TO TRAVEL AN HOUR, HOUR AND A HALF ON METRO JUST TO BE ABLE TO GET TO THE NEAREST HOSPITAL TO DELIVER YOUR CHILD, MUCH LESS AROUND PRENATAL CARE AND THINGS LIKE THAT. SO THIS ISSUE OF HOW WE LOOK AT ALTERNATE FORMS OF CARE FOR WOMEN IN THESE MATERNAL CARE DEZ ERTS IS A BIG PART OF WHAT WE'RE ALSO WORKING ON. I WOULD ALSO SAY PROBLEM PROBLEM MATTICALLY HOW CAN WE ENSURE THAT. SO IESHES THAT YOU'VE HEARD RAISED TODAY AROUND HOW CAN WE CREATE A MORE SUPPORTIVE ENVIRONMENT AROUND WOMEN TO FEEL MORE SUPPORTED IN THEIR COMMUNITIES IS ALSO SOMETHING THAT WE'RE SCALING. WE'RE LOOKING -- A LOT OF YOU ALL MAY HAVE HEARD OF A GROUP CENTERING -- IT'S AN EVIDENCE BASED PROGRAM, RESEARCH SHOWS THAT GROUP PRENATAL CARE CAN REDUCE THE INCIDENCE OF PRETERM BIRTH, 35% FOR ALL WOMEN, 40% FOR WOMEN OF COLOR. WE HAVE ANOTHER MODEL AT THE MARCH OF DIMES THAT WE BELIEVE IS A MORE SCALABLE MODEL CALLED SUPPORTIVE PREGNANCY THAT SHOWS SIMILAR IF NOT EVEN BERT OUTCOMES FOR REDUCING THE RISK OF PREMATURE BIRTH, BUT ALSO SHOWS INCREASED INITIATION OF BREAST FEEDING AND SUSTAINING BREAST FEEDING OVER A LONGER PERIOD OF TIME. THE IDEA WITH PRENATAL CARE IS SIMPLY THAT THE SUPPORTIVE ENVIRONMENT THAT WOMEN FIND THEMSELVES IN WHERE THEY DON'T FEEL ISOLATED AND ALONE, ESPECIALLY IF THEY'RE IN A RURAL AREA BUT NEEFN AN URBAN AREA WHERE THEY DON'T HAVE ACCESS TO OTHER KINDS OF RESOURCES OR SUPPORTIVE SYSTEM OF COMMUNITY CARE AVAILABLE TO THEM, THIS GROUP PRENATAL CARE MODEL ACTUALLY PRODUCES RESULTS BECAUSE WE THINK IT REDUCES THE STRESS AND ANXIETY THAT OFTEN LEADS TO POOR OUTCOMES FOR MOMS AND BABIES, SO IT'S PROGRAMS LIKE THAT AT THE MARCH OF DIMES THAT WE'RE LOOKING TO SCALE, THAT WE'RE LOOKING TO ACTUALLY ENHANCE AND GROW OVER TIME AND WORK WITH MANY PARTNERS. I'D LIKE TO JUST TOUCH BRIEFLY ON SOME OF THE OTHER AREAS IN POLICY THAT WE THINK ARE SO IMPORTANT. A LOT OF YOU ALL MAY NOT KNOW, WE TALKED ABOUT FEDERAL POLICY BUT YOU MAY NOT KNOW THAT THERE IS A LOT OF ACTIVITY GOING ON AT THE STATE LEVEL THAT WE THINK IS VERY POWERFUL. THE MARCH OF DIMES THROUGH OUR ADVOCACY NETWORK, STAFF, ARE VERY INVOLVED IN MANY OF THESE ACTIVITIES. IN CALIFORNIA, FOR EXAMPLE, THERE'S A CALIFORNIA DIGNITY IN PREGNANCY AND CHILDBIRTH ACT LOOKING AT WAYS TO ADDRESS SPECIFICALLY AFRICAN-AMERICAN MATERNAL MORTALITY ISSUES. COLLECTING BETTER DATA AND GOING FURTHER. CALIFORNIA, YOU ALL KNOW, HAS HAD A LOT OF SUCCESS IN MOVING THE NEEDLE ON MATERNAL MORTALITY, BUT WE HAVEN'T SEEN DISPARITIES CLOSE IN CALIFORNIA. SO THERE IS A DOUBLING DOWN OF EFFORTS THERE. IN EFFORTS IN GEORGIA, FOR EXAMPLE, WHERE WE'VE BEEN WORKING SUCCESSFULLY WITH THE STATE LEGISLATURE THERE TO ADVOCATE FOR MORE MONEY TO ADDRESS MATERNAL MORTALITY, MORE FUNDING FOR MOREHOUSE SCHOOL OF MEDICINE, TO HELP EXPAND THEIR EFFORTS THERE. ALSO ESTABLISHING A CENTER OF EXCELLENCE AROUND MA IT TERNL MORTALITY. MORE MONEY TO THE DEPARTMENT OF PUBLIC HEALTH. THIS IS MONEY THAT'S NOT COMING TO MARCH OF DIMES, IT'S GOING TO MANY OF OUR PARTNERS BUT OUR ADVOCACY NETWORK IS PUSHING HARD FOR SOME OF THESE KINDS OF CHANGES. IN ARIZONA, AND TEXAS, IN STATES ALL AROUND THE COUNTRY, WE'RE SEEING A LOT OF PROGRESS BEING MADE ON THE POLICY FRONT, AND WE'RE REALLY PLEASED THAT WE'RE ABLE TO HAVE A VOICE TO MAKE SURE THE STATE LEDGE SLAY LEGISLATORS REALLY UNDERSTAND THE CRITICAL NATURE OF MATERNAL HEALTH TODAY, HOW IT'S IMPACTING THEIR RESIDENT IN THEIR OWN STATES AND THEN PRESENTING ACTIONABLE THINGS THAT THEY CAN PUT INTO POLICY AND LEGISLATION THAT WE THINK WILL MAKE A DIFFERENCE. ANOTHER THING WE'RE WORKING ON IN THE MARCH OF DIMES IS AROUND IMPLICIT BIAS TRAINING. I THINK THAT HAS COME UP MORE THAN ONE OR TWO TIMES HERE IN THIS CONVERSATION TODAY. GOING BACK TO THAT ISSUE OF RESPECTFUL CARE, THE MARCH OF DIMES, BECAUSE WE HAVE SO MANY HOSPITAL PARTNERS, PHYSICIAN PARTNERS, WHO REALLY ARE STRUGGLING IN THIS SPACE. WE HAVE GONE TO MANY OF THEM TO SAY, WHAT CAN WE DO TO HELP YOU, AND MANY OF THEM HAVE AGREED TO WORK WITH US ON GOING THROUGH MUCH DEEPER TRAINING AROUND IMPLICIT BIAS. WE ALL HAVE IMPLICIT BIAS. I'VE GOT IT, WE ALL HAVE IT, RIGHT? BUT IF IMPLICIT BIAS IS A FACTOR IN HOW WE DELIVER CARE TO ANYBODY AND WHETHER IT'S AROUND THEIR RACE OR THEIR ETHNICITY OR THEIR INCOME LEVEL, THAT'S SOMETHING THAT WE HAVE TO ADDRESS AS A SYSTEM AND AT THE MARCH OF DIMES, WE'RE HOPING TO BE THAT KIND OF PARTNER THAT CAN PROVIDE THE KINDS OF RESOURCES TO MAKE SURE THAT MORE OF OUR PARTNERS ARE PROVIDING RESPECTFUL, ADEQUATE CARE TO THE WOMEN THAT NEED IT. IN JUST THE LAST MINUTE I'LL SAY WE'VE GOT A LOT OF OTHER EFFORTS GOING ON WITH RESPECT TO FEDERAL LEGISLATION. SOME I'VE ALREADY TALKED ABOUT, BUT THERE ARE, I'M PLEASED TO SAY IN THE PRESIDENTIAL ELECTION, MANY OF THE PRESIDENTIAL CANDIDATES WHO HAVE MADE MATERNAL HEALTH A KEY PRIORITY. IT'S NOT JUST ELIZABETH WARREN WHO HAS A PLAN FOR EVERYTHING, THERE ARE A LOT OF THEM THAT HAVE A PLAN, ALTHOUGH I RESPECT AND APPRECIATE HER BEING A PART OF THIS CONVERSATION AS WELL, BUT WE'RE WORKING WITH MEMBERS OF CONGRESS IN BOTH THE SENATE AND THE HOUSE TO MAKE SURE THAT WE CAN HELP SHAPE LEGISLATION, PROVIDE THEM THE KIND OF INSIGHT AND INPUT THAT THEY NEED, AND PART OF THE -- THE LAST THING I'LL JUST MENTION IS THAT BECAUSE WE HAVE SO MANY MILLIONS OF PEOPLE THAT WE TOUCH THROUGH EDUCATION, THROUGHOUTREACH, THROUGH ADVOCACY, ONE OF THE THAINGS WE DON'T GET ENOUGH OF, WE THINK, ARE THE WOMEN WHO CAN COME FORWARD AND TELL THEIR STORIES. THE I REALLY APPRECIATED THOSE SLIDES, IN FACT, THE LAST ONE BEFORE I CAME UP, THE STORY OF CHARLES JOHNSON AND KIRA JOHNSON REALLY COMPELLING STORY, AND THEIR STORY WAS FEATURED IN AN EPISODE OF A FOX SHOW CALLED "THE RESIDENT," JUST A COUPLE WEEKS AGO, WHERE THERE IDEA OF MATERNAL HEALTH WAS FINALLY PUT INTO KIND OF POP CULTURE, IN OTHER WORDS, IN FACT, IT'S GOTTEN TO A LEVEL WHERE EVERYDAY PEOPLE ARE BEGINNING TO SEE THIS AS A REAL ISSUE AS OPPOSED TO JUST THE SUPER SMART PEOPLE IN THIS ROOM. ONCE WE CAN BRING THESE ISSUES AND TELL THESE STORIES IN A WAY WHERE IT BECOMES A MATTER OF EVERYDAY CONVERSATION IS WHEN HE WE THINK WE'LL REACH A TIPPING POINT OF MOVE WILLING ING THE NEEDLE EVEN FASTER THAN TODAY. SO WE HAVE A CAMPAIGN CALLED UNSPOKEN STORIES. IT AT THE VERY DIFFICULT FOR WOMEN, IT'S VERY DIFFICULT FOR FAMILIES TO COME FORWARD AND TELL THEIR STORIES OF A PREGNANCY THAT THEY HAVE HAD A CHALLENGE WITH, CHILDBIRTH THAT'S BEEN -- THAT'S NOT GONE EXACTLY AS PLANNED. WE'RE ENCOURAGING AND REALLY CHAMPIONING MANY WOMEN TO COME FORWARD AND TELL THEIR STORIES, OR DADS OR GRANDPARENTS. BECAUSE THE MORE AND MORE WE TELL THOSE STORIES, THE MORE WE CAN GET THIS OUT AND LET PEOPLE KNOW IN THIS COUNTRY, THE MOST DANGEROUS DEVELOPED NATION TO GIVE BIRTH THAT WE SIMPLY SHOULDN'T HAVE THESE KINDS OF OUTCOMES FOR MOMS AND BABIES. UNTIL WE TELL THOSE STORIES, THE WAY PARENTS HAVE AUTISTIC KIDS DON'T MIND TELLING THEIR STORIES, OTHER PEOPLE TELL STORIES OF HEALTH CHALLENGES THAT THEY FACE, THE MORE WE'RE BRAVE ENOUGH, HAVE COURAGE ENOUGH TO TELL THESE STORES, THE MORE WE'LL BE ABLE TO CHANGE THE PER SPEC ITTIVE OF THIS COUNTRY AND ONCE AND FOR ALL PROVIDE A BETTER SYSTEM OF CARE FOR ALL WOMEN, FOR ALL POINTS OF THEIR LIFE, BEFORE PREGNANCY, DURING PREGNANCY AND EVEN AFTER PREGNANCY AND HOPEFULLY MAKE BETTER OUTCOMES AND HEALTH OUTCOMES FOR MOMS AND BABIES FOR THE LONG TERM. SO I APPRECIATE YOU HAVE MEG HERE. THANK YOU SO MUCH. -- APPRECIATE YOU HAVING ME HERE. THANK YOU SO MUCH. [APPLAUSE] >> THANK YOU VERY MUCH, STACEY. COMPELLING CLOSING REMARKS. BEFORE I GO AHEAD AND GIVE MY CLOSING REMARKS, I WANT TO ACKNOWLEDGE DR. JIM ANDERSON, DIRECTOR OF THE DIVISION OF PROGRAM PLANNING, COORDINATION -- PLANNING IS SECOND, AND STRATEGIC INITIATIVES, WE CALL A DPCPSI, JIM, THANK YOU FOR BEING HERE. ALSO I BELIEVE THAT I SEE MS. MARSHA HENDERSON SOMEWHERE IN THE AUDIENCE, FORMER DIRECTOR OF THE FDA'S OFFICE OF WOMEN'S HEALTH. AND DR. MONICA FROM HEALTHY WOMEN, SO THANK YOU FOR BEING HERE. SO AS WE MOVE TO THE CLOSE, THERE ARE A COUPLE THINGS THAT HAVE COME THROUGH TODAY. THIS TERM BENCH TO BEDSIDE TO CURBSIDE, I'M NOT SURE DR. NOURSI WHO ORIGINALLY COINED THAT BUT I DO THINK IT'S GOTTEN SOME TRACTION TODAY, SO THANK YOU FOR BRINGING THAT TERMINOLOGY, AND DR. CAMPBELL, FOR CHALLENGING US WITH THAT TERMINOLOGY. YOU KNOW, AS WITH HE CAN SEE, THIS IS A REAL AND COMPLEX ISSUE. WE'VE HEARD ABOUT UNDERSTANDING WOMEN'S REAL LIVES, AND IT ISN'T ACCEPTABLE THAT THE UNITED STATES IS THE ONLY HIGH INCOME COUNTRY IN THE WORLD WHERE PREGNANCY RELIGHTED DEATHS ARE RISING. RELATED DEATHS ARE RISING, IT'S NOT ACCEPTABLE THAT AFRICAN-AMERICAN WOMEN ARE BEARING A DISPROPORTIONATE AMOUNT OF THIS BURDEN. IT'S NOT ACCEPTABLE. 50% OF THESE DEATHS WERE PREVENTABLE. SO WE HAVE LOTS OF QUESTIONS YOU HEARD FROM TODAY, AND AT NIH, WE'RE ABOUT ANSWERING QUESTIONS. IN FACT, WE BELIEVE SCIENCE IS THE BEST STRATEGY FOR ANSWERING THE DIFFICULT QUESTIONS AND I THINK ONE OF OUR PREVIOUS PANELISTS, IT WAS DR. LU, I BELIEVE, THAT CHALLENGED US TO TAKE ON THOSE REALLY INTRACTABLE, DIFFICULT QUESTIONS AND ADDRESS THEM ONCE AND FOR ALL. SO WHILE I HAVE EVERYONE HERE, BEFORE WE WALK AWAY, I WANT TO SAY THAT RESEARCH IS THE STRATEGY AND I WANT YOU TO SHARE THAT WITH ME. AND MANY OF THE TOPICS THAT WE TALKED ABOUT TODAY, WE NEED MORE DATA. WE HAVE SOME DATA BUT WE NEED MORE DATA. WE NEED TO FILL IN THOSE GAPS. AND WE NEED TO UNDERSTAND WHAT WORKS FOR WHICH WOMEN AND IN WHAT CONTEXT AND WHERE. WHETHER WE'RE LOOKING AT JUST POLICY CHANGE, CO-MORBIDITY ISSUES, IMPLICIT BIAS OR STRUCTURAL RACISM, WE NEED TO MAKE IMPROVEMENTS. I THINK WE ALL AGREE ON THAT. WHAT WE CARE ABOUT, WE HEARD, WE LIVES, ARE WORTH COUNTING. I HOPE THAT WE CAN ALL LEAVE HERE ENCOURAGED THAT WE ARE BUILDING ON OUR FOUNDATION. DR. PINN CHALLENGED US AT THE VERY BEGINNING OF THE DAY ABOUT ALL THE WORK THAT HAS BEEN DONE IN THE LAST 30 YEARS, THE AMAZING SCIENTIFIC ADVANCES THAT HAVE BEEN BROUGHT FROM THAT RESEARCH, BUT WE NEED TO BUILD ON THAT FOUNDATION AND RAISE AWARENESS AND DEVELOP NEW INITIATIVES AND GET THE WORD OUT MORE BROADLY. INITIATIVES IN PROGRAMS LIKE THE AIM BUNDLES, MMRCs, PREGLAC, THE PQCs AND MORE ARE NEEDED TO ADVANCE FORWARD AND IMPROFIT HEALTH OF IMPROVE THE HEALTH OF WOMEN BEFORE THEY'RE PREGNANT, DURING THE PREGNANCY AND AFTER THE PREGNANCY ACROSS THE LIFESPAN. IT'S CERTAINLY GOING TO TAKE A VILLAGE, IT'S GOING TO TAKE A COLLABORATION AND A MIGHTY EFFORT. IT'S GOING TO TAKE CREATIVITY THAT WE HAVEN'T APPLIED YET, AND WE ARE ALL GOING TO NEED TO GET BEHIND THIS AND CHANGE CULTURES, TO IMPROVE PROGRAMS AND TO ADVANCE EVIDENCE-BASED POLICY, ESPECIALLY FOR WOMEN OF COLOR. SO BEFORE I END, I JUST WANT TO SAY A SPECIAL THANK YOU TO THE ORWH TEAM THAT ORGANIZED TODAY'S MEETING AND OUR COMS TEAM, THEY HAVE DONE AN INCREDIBLE JOB AND I WANT TO ACKNOWLEDGE THEM AS WELL AS DR. NOURSI WHO LED THEM IN THIS PARTICULAR EFFORT, SO PLEASE JOIN ME IN THANKING THEM. [APPLAUSE] AND OF COURSE I'M GOING TO END BY ACKNOWLEDGING DR. PINN AND HER LEGACY OF LEADERSHIP. I WAS FORTUNATE ENOUGH TO ACTUALLY HAVE BEEN TAUGHT THE IN MEDICAL SCHOOL PATHOLOGY BY DR. PINN, AN TO HAVE HAD THE OPPORTUNITY TO BE HER DEPUTY, I LEARNED SO MUCH FROM HER, CONTINUE TO LEARN FROM HER, SO WE WANT TO THANK YOU FOR EVERYTHING YOU'VE DONE. PLEASE JOIN ME IN THANKING DR. PINN. [APPLAUSE] I'M GOING TO GO BACK TO ONE SLIDE, THOUGH. SO ANYWAY, WHEN YOU LEAVE HERE, I WANT YOU TO REMEMBER TO -- YOU'LL HELP ME? >> I APPRECIATE THAT. >> TO ASK QUESTIONS AND TO LEARN ABOUT YOUR HEALTH AND YOUR FAMILY'S HEALTH. THE ONE THING THAT'S MOST IMPORTANT IS TO ASK A MOTHER HOW YOU CAN HELP HER, BUT DON'T ACTUALLY ONLY WAIT FOR YOU HER TO ASK YOU FOR HELP, JUST ASK HOW SHE IS AND DO SOMETHING TO HELP HER. WE HEARD FROM MEGAN, WE ALL GOT LOVELY CARDS, SOME OF US GOT TEXTS ONLY THIS YEAR, THAT IS A PROBLEM I HAVE TO DISCUSS WITH MY DAUGHTER, BUT I DID GET A TEXT. N LAUGHTER] ANYWAY, WE FELT SPECIAL IN SOME WAY, THOSE OF US WHO ARE MOTHERS AND THOSE OF US WHO ARE NOT MOTHERS, THAT MAY HAVE BEEN A REALLY TOUGH DAY, RIGHT? SO I'D JUST ASK THAT EACH OF US TAKE A MOMENT AND DO SOMETHING NICE FOR THE MOTHERS IN OUR LIVES. AND THAT MIGHT BE JUST SAYING HI, HOW'S YOUR DAY AND ACTUALLY LISTENING, THAT MAY BE, WOW, I BROUGHT THIS, YOU KNOW, DINNER OVER, YOU DON'T HAVE TO COOK TONIGHT, THAT MIGHT BE, YOU KNOW, A GIFT CARD FOR A MASSAGE, WHO KNOWS WHAT THAT IS. BUT WE'RE DOING A LOT IN OUR LIVES, AND A -- OH, THANK YOU. ONE MORE. >> SOMEBODY ELSE DID THAT. >> HERE WE GO. ASK QUESTIONS AS A PATIENT, CITIZEN AND LEADER, BE HEARD IN YOUR FAMILIES, WE HEARD ABOUT WOMEN'S VOICES BEING HEARD. MAKE SURE YOU'RE HEARD. UNDERSTAND YOUR OWN HEALTH. YOU ARE YOUR OWN BEST ADVOCATE FOR YOUR HEALTH, AND I TELL EVERYBODY THAT WHO ASKS ME, BUT UNDERSTAND THAT HEALTH OF THE OTHERS AND ADVANCES, HOW SCIENCE ADVANCES HEALTH. PARTICIPATE IN CLINICAL RESEARCH. YOU DON'T HAVE TOO ACTUALLY BE SICK TO PARTICIPATE IN CLINICAL RESEARCH. WE HAVE STUDIES AT THE CLINICAL CENTER WHERE WE JUST NEED YOUR PLATELETS. YOU'RE THE CONTROL GROUP. SO YOU CAN PARTICIPATE IN CLINICAL RESEARCH. YOU CAN COMPLETE SURVEYS AND BE A PARTICIPANT. ENCOURAGE GIRLS TO STUDY SCIENCE TECHNOLOGY ENGINEERING MEDICINE AND MATHEMATICS, AND HERE'S THE LAST ONE, THE MOST IMPORTANT ONE TO ME, ASK A MOTHER HOW SHE'S DOING, AND DO SOMETHING TO BRIGHTEN HER DAY. SO THANK YOU FOR BEING HERE, AND FOR THE FOURTH ANNUAL VIVIAN PINN SYMPOSIUM, WE HOPE TO SEE YOU NEXT YEAR DURING NATIONAL WOMEN'S HEALTH WEEK. THANK YOU.