Guest Editorial

Fight for Improved Maternal Health Depends on FPs

July 03, 2019 01:16 pm Jessica Taylor Goldstein, M.D.

As a family physician and newly anointed fellow of the AAFP, I was proud to get a frontline view of the AAFP's advocacy work on a cause that's near and dear to my heart at the recent March for Moms(www.marchformoms.org) in Washington, D.C.

[headshot of Jessica Taylor Goldstein, M.D.]

Jessica Taylor Goldstein, M.D.

It was the second time I have added my voice to the rally. Last year, I went with fellow family medicine educators who were attending the Society of Teachers of Family Medicine Annual Spring Conference. I carried a banner that said "Fam Docs for Moms" because it's important for people to know that FPs recognize the need for better maternal health in this country -- and that we're doing something about it.

The United States has the worst maternal mortality rate in the industrialized world.(www.npr.org) In fact, moms today are more likely to die in childbirth than our mothers were, and among African Americans, Native Americans and those who live in rural communities, the maternity mortality rate can be more than three times greater(www.cdc.gov) than that seen in white mothers.

It doesn't have to be this way. More than half of these deaths are preventable if we address the risk factors associated with maternal mortality, such as health disparities, racial inequities, lack of access to family planning, and health care shortages in rural and underserved areas.

But, you may ask, can a family doctor do all that? Yes, by working together and collaborating with others, we most certainly can.

Family physicians, who often see moms and babies postpartum, are uniquely positioned to screen for maternal well-being well into the first year postpartum and beyond. This time period is crucial. Cardiac disease, one of the most important risk factors for maternal mortality, often presents after six weeks postpartum, and the traditional six-week followup without interim postpartum evaluation is often insufficient.

In addition, one in five women experience postpartum depression or anxiety, often presenting weeks or months after a baby's birth. I screen moms for depression and anxiety at every well-child visit throughout the first year, and in my estimation, these numbers are probably underreported.

When mothers are sick or gone because they don't get effective treatment, it doesn't affect just them; it affects everyone they touch -- their kids, their partners, their parents, everyone. It touched me. My mother had schizophrenia, and I was taken from her custody at age 8 and placed in the foster care system before I went on to be raised mostly by my sister and her husband. It is something that affects how I see the world almost every moment. If I can make one family just a little bit healthier by keeping moms healthy, that is priceless.

Now I'm the mother of three beautiful girls: Seraphina, 10; Samara, 8; and Sage, 5. My husband and I are both family medicine faculty at the Natividad Family Medicine Residency in Salinas, Calif. I am half Mexican, although I have never met my Hispanic father. I am also a veteran of the Iraq War, serving as a flight surgeon in the U.S. Navy. These experiences have given me a deep empathy with the underserved and those who face obstacles that seem insurmountable.

I now work with a mostly Hispanic migrant farm worker population at Natividad. In the 3 1/2 years I've been here, I have worked hard to make sure that patients have access to immediate postpartum contraception on the obstetrics floor and that resident physicians receive family planning education. I look for ways to improve informed consent for our patients, as well as to enhance collaboration among the nurses, midwives, doulas, obstetricians and family physicians in the hospital and in our wider community. In my individual practice, I serve all ages, and I maintain hospital privileges for cesarean section, delivery, and dilation and curettage. There are 10 family physicians who catch babies at Natividad and six who are C-section privileged. We are here because this community needs us.

The country as a whole needs us, too -- all of us family physicians.

When I got back from the March for Moms in 2018, I went on a mission. I co-chair STFM's Family Centered Maternity Care Collaborative, and one of our goals is to educate medical students, family medicine residents, family physicians and family medicine educators on how to help solve this country's maternal mortality and morbidity crisis. It's important to remember that any solution must include an education component because ensuring family doctors have the broad skill set this effort requires depends on their having received the necessary training and inspiration. It's critical that we reverse the declining number of family physicians who deliver obstetric and pediatric care, and we can do so if we train, support and advocate for those who do.

I spoke with a lot of people after last year's rally, and I tweeted, posted to Facebook and emailed about the event. I eventually connected with AAFP leadership and began working with the Academy on the 2019 March for Moms.

That work paid off on May 10, the day of advocacy before this year's rally, when I joined Team California for March for Moms in visiting the offices of Sens. Dianne Feinstein, D-Calif., and Kamala Harris, D-Calif., as well as those of members of my state's House delegation. We shared personal stories that clarified the need for legislation to improve maternal health, reduce disparities in health care, and increase support for perinatal and postpartum depression. The team included comedian Angelina Spicer, who is making a documentary about her personal battle with postpartum depression, and author/screenwriter Rachel Stuhler, a near-miss survivor who lost more than one-half of her blood volume after a scheduled C-section. Stuhler shared her belief that she might not have survived if she weren't white and from a middle-class background. That was hard to hear.

But even harder was hearing the stories of people who came to the rally to represent their mothers who had died in this maternal mortality crisis.

We urged legislators to pass several bills that would, among other important advances

  • make maternity and family leave more widely available,
  • address racial disparities in health care,
  • increase funding to state maternal mortality review committees, and
  • devote more resources to treating perinatal depression.

The next day, I took my place alongside medical students, residents and fellow family physicians, including AAFP President John Cullen, M.D., of Valdez, Alaska, in the March for Moms rally. Together we advocated for the well-being of mothers and families by pointing out the critical need for better maternal and postpartum health in the United States.

It was the third year in a row that many of us had gathered on the National Mall to hear mainstage speakers like Cullen, as well as other leaders and celebrities.

Cullen told the crowd(youtu.be) that primary care must play a vital role in reducing maternal morbidity and mortality. Family physicians are crucial to this work, but we know it's not a load we can lift alone. That's why so many family physicians traveled to Washington for the event -- to look for ways to coordinate our work with that of other professional organizations, consumer groups, health care professionals, policymakers and families, and together, secure the best possible health and well-being for all mothers.

The March for Moms is done for this year (although the 2020 march(www.marchformoms.org) is now in the planning stages, so save the date!), but the fight continues.

With collaboration between family physicians, midwives and obstetricians, we can win. Family physicians need to advocate to train and maintain scope of practice because we are vital to ensuring all families get the care they deserve. Together, we can solve this crisis. Please join us.

Jessica Taylor Goldstein, M.D., is an associate professor in the Department of Family and Community Medicine at the University of California, San Francisco, serving as faculty and RHEDI (Reproductive Health Education in Family Medicine) Director at the Natividad Family Medicine Residency Program in Salinas, Calif. She is also the medical director of the Monterey Birth and Wellness Center, the first free-standing birth center in Monterey County.