Women’s Health: Maternal Mortality & CVD

Welcome to Heart to Heart Nurses, brought to you by the Preventive Cardiovascular Nurses Association. PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management.  

Geralyn Warfield (host): Thank you so very much for joining us today where we are speaking with Dr. Ferranti and Dr. Khandelwal about maternal mortality and cardiovascular disease. We're going to be learning a lot, and Dr. Ferranti, I'm going to let you introduce yourself first.  

Erin Ferranti (guest): Sure. Thank you. I'm Erin Ferranti. I'm an Assistant Professor at the School of Nursing at Emory University. And I serve on the board of the Preventative Cardiovascular Nurses Association.  

Geralyn Warfield (host): We're so glad to have you here, Dr. Khandelwal, how about you?  

Abha Khandelwal (guest): Thank you for having us here today. I am an Associate Professor at the Stanford School of Medicine. I also am a board-certified cardiologist and echocardiographer, and I've been part of the Women's [00:01:00] Heart health program and lead our cardio-obstetrics program at Stanford. 

Geralyn Warfield (host): So, we've got some excellent experts at the table today and we're really looking forward to learning from you. Obviously, there are a lot of statistics around cardiovascular disease. Why don't we start with the basics.  

Abha Khandelwal (guest): You know, we've been seeing a decline in mortality from cardiovascular disease for some time. But, unfortunately, for any of us that work in the field, we've noticed over the last, you know, five, six years that that is now trending back up. And we know that it affects both men and women. Women are unique in that many of us experience pregnancy, and this is a unique time early in our life that we're around healthcare and healthcare providers. 

So, if we can identify certain factors or risk behaviors that we can modify, the hope is that we can prevent future disease. So, I think it's extremely important for all of us who take care of women to make sure that when we are meeting them, at that time, that we are really doing an [00:02:00] aggressive assessment of their risk factor profiles. 

Erin Ferranti (guest): Yeah, and just like cardiovascular disease is the number one killer of older women, it's also true for women during pregnancy and postpartum. So cardiovascular disease is the number one killer for women giving birth, which is, should never happen. You know, these are healthy reproductive-age women. And some come into pregnancy with risk factors that put them at higher risk, but mostly, you know, they're healthy enough to get pregnant, they shouldn't be dying as a result of giving birth. So, it presents a really unique opportunity, as Dr. Khandelwal said, because these are young women in their reproductive age years. And it gives us this window of opportunity to identify these risk factors which we know will impact them for their long-term health. 

Geralyn Warfield (host): Let's talk a little bit about the fact that it does not affect women equally.  

Erin Ferranti (guest): That is absolutely correct. We see incredible inequities and health disparities. [00:03:00] And, you know, it's been broadly in the news that, non-Hispanic Black women are disproportionately affected by both maternal morbidity and mortality. 

Native American women, or American Indian, and Alaska Native women are the other ethnic group that are hardest hit. And there are many reasons for this. There’s associated comorbidities, but there's also major social determinants of health, lack of access to healthcare, and just a lot of factors that go into why we see these disparities. 

But it’s absolutely solvable. There's no, you know, there's no good reason why we should have these disparities. So, our goal in this country right now is to really shore up those disparities and improve overall maternal mortality.  

Abha Khandelwal (guest): Yeah, I, I'm going to just echo what Dr. Ferranti said. It’s, we know that there is a discrepancy and a disparity. Part of that may be from the social determinants of health that is responsible, [00:04:00] but there's still a lot that we don't know. We still don't know why, even when African American women have gestational hypertension and have an adverse outcome, why their Caucasian counterparts with the same disease process doesn't. 

So I, I think that there's still a lot of work to be done to understand the true causes for why these discrepancies exist. But, it will take a big effort both by the science and activist as well as political community. 

Geralyn Warfield (host): So, let's talk a little bit about some of the solutions that might be on the horizon for us and what kind of actions we might take, either as individuals or within our healthcare organizations, or as a country, or in whatever regards we need to address this really serious issue. 

Erin Ferranti (guest): So, I mean, the issue is multifactorial, so any solution needs to also be multifactorial. You know, we touched on the social determinants of health. Those [00:05:00] certainly need to be addressed, one of them being access to care. We’ve gone through a process where some states have expanded Medicaid while others haven't. And by federal law, medic…states must require or must cover pregnant women up to 60 days postpartum. Some states have chosen to increase not only the federal poverty level by which women are eligible, but also extend that out to either six months or 12 months. Which makes a huge difference because we don't see maternal mortality only during pregnancy. It happens, you know, during pregnancy, around the time of delivery, and then up to one year postpartum. So having that access to care throughout that whole first year postpartum is really, really critical. And a lot of states are not offering that. 

42% of births in the country are paid for by Medicaid. And in some, in some states that are more [00:06:00] under-resourced, like where I'm from in Georgia, nearly 56% are covered. So those are women who are losing then coverage after 60 days.so that's a huge issue.  

Women are delaying pregnancy, so we're seeing women, you know, into the thirties and forties getting pregnant. And that comes with associated comorbidities, associated with age and overweight and obesity. So, we have a lot to tackle. 

Abha Khandelwal (guest): Yeah. I mean, when I see patients in, in the office, you know, it's, there's like you, like you said, there's a variety of levels on how to tackle this problem. So, you know, the first thing is even, forget about just women. If you look at the average American, most people, two-thirds of Americans actually don't meet the criteria for a heart healthy lifestyle, if you look at large population studies. So, first you have to know the risk.  

So, the AHA conducted a large survey asking women what their number one threat to their health was. That was before the Go Red Campaign came [00:07:00] out. And only a third of women knew that cardiovascular disease was their biggest threat. After this large Go Red Campaign, a lot of advocacy, a lot of work by a lot of people, they then did the survey again. And yes, there was some progress, but definitely not perfection, right? 

I mean, that number only went up to, I think it was still a little bit less than half. So, there's still a lot of work to do with education. So, the number one thing that we try to do with our female patients is to make sure they know what their risk factors are, so to educate them in a culturally-specific and really down to earth way so they can understand that. When I tell a patient to go outside for a walk, it has to be in a community where it's safe for her to do so. So, so that's I think number one, ground zero.  

I think the next thing is actually educating the people taking care of these women. So, I work at a women's heart health program. We are well [00:08:00] educated and in taking care of these women, but we know that when we survey hospitals, those that have more female doctors tend to do better. We know that when in cardiology—I can speak specifically to cardiology—that when there are female cardiologists in a group, you look at the patient's outcomes: in general, both, both genders, both sexes, have better outcomes.  

So, I think it's really about that education and awareness of our colleagues, whether it be midwives, physician assistants, NPs, pharmacists, RN coordinators, doctors, anyone who is actually taking care of patients needs to know what they have to look for. 

The state of California has created a free downloadable toolkit. It was in collaboration with the CDC and it’s called CMQCC. And in that toolkit there are a lot of resources both for patients and for their care providers. There's also data [00:09:00] there for health disparities for those who are interested to see where some of these disparities are. Because again, in the state of California we are, we have a large number of births in our state. So, it's really in our best interest to make sure that these women do, do well. And, I don't want to minimize, I've kind of talked about the clinical aspects of things, but one of the things that's extremely important is the stuff that Dr. Ferranti is doing, which is the research and the science and kind of making sure that people are aware of some of these disparities. 

Geralyn Warfield (host): Great information. We will be right back with even more.  

Geralyn Warfield (host):  And we're back with Dr. Ferranti and Dr. Abba Khandelwal, and we are so excited to continue our conversation on this most important topic of women and cardiovascular disease. And I'd love to have your, your input on care delivery models and how we might make some strides in tackling this really important issue. 

Abha Khandelwal (guest): Well, so infrastructure is critical [00:10:00] and really, the infrastructure has to be dynamic to the needs of the community. So, I operate in a coronary care academic center in a very specialized area of the country. So, I am very heavily resourced with a staff, including NPs, PAs, dieticians, exercise physiologists, behavioral therapists, nurse coordinator—I mean, we have an army of people taking care of patients that are coming from all over the state of California.  

But what I think is equally important and should not be forgotten, is the majority of people do not get their care at these type of institutions. The majority of people are going to their local family practice provider or, you know, whoever is in their community. So, I think, making sure the care delivery model that is developed for your area fits the needs of the community.  

I am in a very tech literate part of the [00:11:00] country where, you know, technology is everything. So, most of my women, regardless of their situation, have, have access to,wearable devices and remote patient monitoring. And they also drive a fair amount to come to see us. So, we're able to kind of deliver the care more locally to them postpartum with these devices. So, I think that that works for where we are.  

The American College of Cardiology is in the process of creating a toolkit that will also, again, be hopefully available to everyone to,help other areas of the country develop women's heart health centers, specifically cardio-obstetric centers that would fit the needs of their community. 

I think at bare bones, and minimum, is you need a, a physician or nurse practitioner in, ideally, cardiology, specifically trained (I'm maybe a little biased in that) as well as a,maternal fetal medicine [00:12:00] dyad. If we can bring in a family practice internist provider, and a behavioral therapist, that would be amazing. And again, adding dietician services again down the line could be good.  

But I do think that one of the things that pandemic taught our institution is technology makes things scalable. And it makes it accessible. And Dr. Ferranti's work, she'll describe about, kind of, these health deserts where there may not be care available. I think technology may be leveraged to, to bridge that gap.  

or as a country, or in whatever regards we need to address this really serious issue. 

Erin Ferranti (guest): Yeah, and just to add on to that, you know, women's health is not unique to the OB-GYN community. Just because these are reproductive age women, and they're often seeking their care with their obstetricians and gynecologists, but we need to have these strong partnerships with our specialty partners, with our cardiologists, with our primary, you know, primary care providers as well. With our endocrinologists for women who suffer from gestational [00:13:00] diabetes, to make sure that they're getting, you know, top of the line care. That they're getting, you know, guideline-recommended care. So that's huge.  

And, yes, with, there's many counties in this country where there are no OB providers, there are no delivery hospitals. There are no cardiologists. And so, we do have these huge, you know, healthcare deserts and maternity care deserts. And we really need to look at that more critically. I don't know what the solution is to that, but you know, getting a, a diversified, well-trained workforce to be in the rural areas is, is certainly one solution, which will take time, but it takes an investment in doing that. 

Geralyn Warfield (host): So, we've talked about that the issue of having access to care and being very attentive to women and their cardiovascular risk. And is there anything else that we should discuss that we have neglected to [00:14:00] talk about so far?  

Erin Ferranti (guest): I think wherever a woman seeks care, that any provider that's taking care of her must do a pregnancy history. That is not always on our H & P forms. And it needs to be. If it's not there yet, it needs to be. So if it's not an extensive pregnancy history, you know, did you have gestational diabetes? Did you have a preterm birth?  

So, we've talked a lot about these, you know, gestational diabetes and hypertension, but having a spontaneous preterm birth is also known to be a cardiovascular risk factor for that woman.Small for gestational age babies also; same kind of similar mechanism.  

So, those pregnancy histories are really important. And every care provider needs to be assessing that, no matter how old this woman is, she could be two months from pregnancy or five years from pregnancy. It's important to know those risk factors. 

Abha Khandelwal (guest): Yeah, I couldn't agree with you more, Erin. I think that, [00:15:00] obviously, during childbearing years, it's important to get that history because it may impact how you diagnose and treat her in the moment. But it's equally important for my postmenopausal women, because I need to know that she may have a risk-enhancing history. So I, I think that that's extremely important.  

And the other piece I will say is that, when looking at women's health and cardiovascular health, we, we put a lot of burden on, on the, the woman. But it’s equally important—some of the times I've seen my patients be the most successful at controlling their heart disease is when they have an engaged partner, and that partner supports them in the efforts that they're trying to do. 

And I think you're the one who told me that, you know, when you're taking care of a pregnant woman, you get a two for one. You're taking care of the pregnant woman and the baby. So, so though I, I like the term women's health, but it’s important for the community. And so I, I [00:16:00] would like to make sure that people understand it's not just on the woman, but the society and the community to support her too. 

Erin Ferranti (guest): Absolutely. And we know the two-for-one deal is...  

Abha Khandelwal (guest): I didn't say it right. You should say it. 

Erin Ferranti (guest): That's, it's probably not the right way to say it, but, you know, that baby that was part of a pregnancy that was affected by gestational hypertension or diabetes, we know that baby's at risk for their long-term health because they've been exposed to high glucose levels and, you know, mom having hypertension. 

So, you know, when you do take care of women, you take care of the whole family. So, I think that's really important.  

Geralyn Warfield (host): Well, on behalf of our listening audience, thank you so much, Abha and Erin, for being here today and sharing your knowledge and spurring us to action in what we're doing in the clinical practice setting. With that information well in hand, we are, we’ve got our marching orders. And thank you so much for encouraging us to be better practitioners. I'm Geralyn [00:17:00] Warfield, your host, and we will see you next time. 

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