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W.Va. Bucks Rising U.S. Maternal Mortality Trend

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Lauren Headley and her daughter Reese. Photo courtesy of Lauren Headley

The United States has some of the highest maternal mortality rates in the developed world — and unlike most other first-world countries, our rates are going in the wrong direction.

American women are three times more likely to die during or after birth than women in Great Britain and eight times more likely than women in Scandinavian countries.

But despite the prevalence of major risk factors such as low access to prenatal care, a high poverty rate and a largely rural population, West Virginia, is bucking the maternal mortality trend. Maternal deaths are not only low, they’re also stable.

Part of that may be due to statewide initiatives to improve outcomes.

Lauren Headley

When Lauren Headley was 35, she got pregnant. Her age categorizes her as high-risk, but she is a nonsmoker and was a Zumba teacher at a healthy weight at the time she conceived.

Headley in the hospital shortly before the birth of her daughter. Photo courtesy of Lauren Headley

About six months into her pregnancy, though, Headley was diagnosed with gestational diabetes. Her obstetrician was concerned that, as a result, her baby would be born large and wouldn’t fit through her birth canal. So at around 39 weeks, doctors induced labor. The baby girl was born healthy and neither mother or infant had any complications.

Then on the 10th day after she gave birth, Headley woke up bleeding.

“But this was like gushing and red clots of Jell-O,” she said.

She called her doctor’s office and her doctor told her that some bleeding was normal but, if it continued, to go to the emergency department or to call back. So she got into the shower to see if that would calm things down.

“As I’m in the shower, the blood just pours out,” she said. “I mean cups of red Jell-O is what it looks like and it’s just pouring out. And I get really weak and I sit down in the shower and yell for my husband, and he comes in and he looks in there and he’s like ‘Oh dear God, you need to call your doctor back. There’s no way this is normal.’”

Headley was taken by ambulance to the emergency department at Thomas Health, where she was diagnosed with a severe postpartum hemorrhage — which is one of the leading complications that causes maternal mortality in the United States.

Postpartum hemorrhage 10 days after birth is admittedly pretty rare, but how well a hospital is prepared to deal with obstetric emergencies can mean the difference between life and death for someone like Headley.

Which may be part of why West Virginia’s rates are so low.

West Virginia’s rates are low — but why?

West Virginia actually ranks 5th in the country — tied with Hawaii — for least number of maternal mortality deaths in the nation — behind California, Massachusetts, Colorado and Nevada, according to data from the Centers for Disease Control and Prevention.

Headley with her daughter shortly after giving birth. Headley badly hemorrhaged 10 days later, but the bleeding was stopped at the hospital. Postpartum hemorrhage is one of the leading causes of maternal death in the U.S. Photo courtesy of Lauren Headley

Maternal deaths in West Virginia related to pregnancy and childbirth have bounced between one to four deaths a year during the past 11 years. Even though West Virginia is a small state and has few births annually, this is a pretty low rate and surprising because West Virginia is poor, rural and has higher rates of comorbidities, which are all risk factors.

But when you try to dig into the numbers, “it’s hard to know exactly why our rates are lower,” said Amy Tolliver, director of the West Virginia Perinatal Partnership. She said over the last 10 years, they’ve been working closely with all of the hospitals in the state that deliver babies to improve the care they offer to moms.

“We have been implementing different training programs specifically around maternal hemorrhage — that is one of the bigger drivers that we see in regard to maternal morbidity and nationally in terms of maternal mortality,” Tolliver said.

Tolliver said every hospital in the state that delivers babies has a specific set of protocols they are supposed to adhere to in the event of complications like uncontrolled postpartum bleeding.  

“To have the crash carts available with all of the equipment necessary, to have trainings in place, and to continue doing those staff trainings — we think that’s one of the biggest factors in improving care is practicing for the high-risk patient.”

“I think we also do a good job in this state of accepting the fact that we have a lot of the risk factors that increase the risk for maternal mortality,” said Dr. Ally Roy, an obstetrician at Marshall Health.

Roy delivers babies at Cabell Huntington Hospital. When a patient is admitted there, she says there is a checklist the staff goes through with the patient. If they meet the criteria for moderate or high risk for postpartum hemorrhage, they receive intervention at delivery time aimed at reducing their risk. Anecdotally, she said, the protocols have greatly improved outcomes for patients with postpartum hemorrhage.

“When you have an emergency, you want people to be able to react smoothly and seamlessly,” said Tolliver. “There should be no downtime in trying to figure out what they need to do next. It needs to be very quick, very regimented, getting the process in place.”

In an email exchange with Thomas Health, the hospital Headley was taken to, a representative said that Thomas has protocols in place for how to deal with hemorrhages that were developed in conjunction with the statewide initiatives.

But experts working in this field in West Virginia say there’s still work to be done.

In 2008, West Virginia established a maternal mortality review committee made up of experts from across the state that basically looks at all of the data around deaths linked to pregnancy and childbirth and sees what happened. They then make recommendations based on the findings. About half of U.S. states currently have such committees.

“One of the first things that we did find was that some of our women who were postpartum may have presented in an emergency room with a severe headache and other symptoms, but they weren’t caught quickly enough in regard to understanding that that was preeclampsia, for example, that they may have been experiencing,” said Tolliver. “So there were some efforts put together to do some education with our emergency room staffing.”

Preeclampsia is a pregnancy complication that is usually characterized by high blood pressure and, if untreated, can cause organ damage and even death.

Last year, the committee recommended a renewal of those education efforts, so the Perinatal Partnership is getting ready to go out around the state to do more trainings.

Tolliver said the objective is to have caregivers “be prepared to be looking at the patient just a little bit differently [and] to ask the question, ‘Has she given birth recently?’ Those answers to those questions may drive the care in a different direction and get to the bottom of what is going on with her much more quickly,” she said.

So is there anything women could do to protect themselves against dying in childbirth? First, say experts, understand that women can experience life-threatening complications during childbirth, thus they recommend that women listen to their bodies, advocate for themselves, and talk about risk with their care team.

This article was originally published by West Virginia Public Broadcasting.

Appalachia Health News is a project of West Virginia Public Broadcasting, with support from Marshall Health and Charleston Area Medical Center.

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How Do You Fight High Rates of Cervical Cancer in Appalachia? Researchers Say By Showing Up, Building Trust

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Photo: Daan Stevens/Unsplash

It’s an enduring fact: You’re more likely to die from cancer if you live in rural Appalachia than if you live anywhere else in this country.

According to a 2016 University of Virginia study, between 1969 and 2011, the incidence of cancer declined in all regions of the U.S except rural Appalachia. And while the rate of people who died from cancer declined throughout the country, in Appalachia disparities persisted. Rural Appalachia has the highest cancer mortality rate; urban non‐Appalachia, the lowest. 

Saving lives that would be lost to cancer requires multidimensional strategies. A recently announced $11 million National Cancer Institute grant is facilitating one such effort. A team of researchers from four universities – Ohio State University, West Virginia University, the University of Kentucky and the University of Virginia – is poised to address a form of cancer that’s disproportionately high in rural Appalachia and one that’s entirely preventable: cervical cancer. 

The researchers will be collaborating with 10 health-care systems serving at-risk communities throughout Appalachian Kentucky, Ohio, Virginia and West Virginia.

“This region has one of the highest rates of cervical cancer and cervical cancer deaths in the United States,” lead investigator Electra Paskett, a professor in Ohio State’s colleges of Medicine and Public Health, said in a press release announcing the grant. “We know that smoking tobacco products, HPV infection and lack of timely cervical cancer screening play a significant role in these exceptionally high rates.”

The project will comprise three initiatives to be implemented through clinics and health centers in the region. They include at-home HPV screening, interventions to improve HPV vaccination rates among young people, and smoking-cessation counseling and nicotine-replacement therapy. 

Barriers to Care

“Cervical cancer is 100 percent preventable,” said Stephenie Kennedy-Rea, the West Virginia University Cancer Institute’s associate director for Cancer Control and Prevention and a recipient of the NCI grant. “We have a test that identifies pre-cancerous cells and we have a preventive vaccine. There’s no reason we should have people being diagnosed with late-stage cervical cancer.” 

Karen Winkfield, director of the Office of Cancer Health Equity at Wake Forest Baptist Comprehensive Cancer Center in Winston-Salem, North Carolina, agrees: “Cervical cancer is one of the cancers that we have done an amazing job at preventing.”

But rural Appalachians are being screened and vaccinated at lower rates than other parts of the country. Access to care is a primary reason.

According to a 2016 American Society of Clinical Oncology “State of Cancer Care in America” report, half of all hematologists and oncologists practice in just eight states, all with high percentages of urban residents: California, New York, Texas, Florida, Pennsylvania, Massachusetts, Ohio and Illinois.

“In places like Appalachia, we just don’t have that many providers who can care for individuals close to home,” said Winkfield, who recently served as chair of ASCO’s Health Disparities Committee. Access to transportation is often an issue; the cost of travel is another.

Education – unawareness of the care you need and the care that’s available – also plays a role, Kennedy-Rea said. 

The prevalence of smokers is another factor. Data for 2017 indicates that West Virginia has the highest adult smoking rate in the country, 26 percent, up a percentage point from the previous year, with Kentucky close behind, at 24.6 percent. 

“It’s hard to point to any one factor,” Kennedy-Rea said. “It’s often a combination.”

In many rural Appalachian communities, a strong tradition of individualism and a reluctance to admit to illness prevail, as do deeply ceded religious beliefs, a conviction that God will heal, or that cancer is God’s will and there’s nothing to be done about it. 

Winkfield acknowledges that traditions and beliefs are sometimes factors, but believes that it’s generally more complicated – that when such considerations do come into play, they’re often intertwined with the inherent challenges, the socioeconomic barriers.

“It’s almost putting blinders on, in some ways, because of the challenges. It’s more about, ‘What can I do about it?’” she said. “If you go and you get screened for a cancer and you’re diagnosed with cancer, then what?” 

‘Asking to Be Vaccinated’

Partnerships between academia and community-based health organizations, such as the one the NCI grant is now facilitating, are working to not only respond to that “then what?” but also at precluding the need for the inquiry.

The objectives of this multilevel initiative, Kennedy-Rea said, are to increase cervical cancer screening rates in at-risk communities, elevate HPV vaccination rates and decrease the rate of smoking.

“We’ve seen the ability of clinics to increase their screening numbers and the very positive outcomes from that,” she said. “And they’re able to sustain it.” 

The theory behind implementation science is that you reinforce systems that are already in place, helping them maintain sustainability of the desired interventions. 

Kennedy-Rea said that her office, Cancer Prevention and Control, has traditionally focused primarily on an individual’s behavior. They’re now moving more toward multi-level initiatives, whereby, while continuing to help that individual overcome barriers, they’re taking this systems approach.

“If I send a staff member to southern West Virginia to work for a day and identify people in need of screening, and navigate these folks to screening, we may successfully get 20 to 30 people into screening,” Kennedy-Rea said. 

“If we spend the same amount of time working with a health system, identifying patients within their system who are in need of screening and help them build interventions into their workflow, over the same amount of time we may be able to identify 6,000 people and impact the ability of that clinic to screen those 6,000 people.”

Among the initiatives funded in Appalachia through the grant will be helping parents understand the importance of the HPV vaccine. Kennedy-Rea believes that when the vaccine was introduced, it was understood as a means of reducing sexually transmitted diseases but not as a cancer-prevention measure.

“And I think in Appalachia, that may have hurt the uptake,” she said. “As we help people understand that this is a cancer-prevention vaccine, parents are more willing to have their children vaccinated. I also think that kids are asking to be vaccinated when they have all the information.” 

Long-term Commitment

Winkfield is bullish on such academia/community-based partnerships, most particularly when they’re undertaken in communities where there are only a half dozen or so primary care providers, as is often the case in rural Appalachia.

“If we can provide the support,” she said, “help lift those providers and provide them the resources they need so that it’s not an extra burden for them to do these things – that’s where those partnerships are really, truly invaluable.”

But, she cautions, “It’s a process; it takes a while.” The medical community, Winkfield avowed, is starting to better appreciate the importance of “taking time to understand the culture of the community and understand where people are so that we can meet them where they are.”

This is especially true, she said, in Appalachian communities that are “really tight knit. There’s a trust factor; people have to know that you’re there to stay, that you’re not going anywhere … You can’t pop in and out; you can’t do that type of helicopter research and expect to make a big difference.”

She points to the University of Kentucky and other universities throughout Appalachia as exemplars of long-term commitment. 

Kennedy-Rae and her colleagues anticipate arriving in the communities in the fall, conducting focus groups, gathering baseline data and laying foundations, with implementation launching next spring.

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VA Expands Coverage for Veterans Through Urgent Care Clinics

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A U.S. veteran attends the 63rd Anniversary of D-Day in Normandy, France, June 6, 2007. Photo: Dept. of Defense/ Cherie A. Thurlby

About 40 percent of veterans who receive medical care through the Veterans Health Administration are now covered at urgent care clinics. This expansion of benefits for veterans is part of the Mission Act, which went into effect last month. 

Veterans with a service-connected disability used to have to pay out of pocket if they went to an urgent care facility. Now, if veterans have been waiting for care for a long time, or if they live far from a VA hospital, they can receive care through private doctors in their local community. 

James McCormick is a veteran in West Virginia, and he’s recently been named the National Junior Vice Commander of the Military Order of the Purple Heart. He said the new expansion of benefits could have an especially big impact for veterans in the Mountain State. 

“In an area that’s rural, where the distance to a VA is often 100 miles or more, this is actually a really good thing,” McCormick said.

But he said, not many veterans he’s spoken to are aware that they can now use their VA benefits to go to urgent cares.

“It needs to be better communicated. Not all of them know about it. Very few in the mainstream know about it.”

According to a press release from the Beckley VA Medical Center, the new urgent care benefit is meant to give veterans “a convenient way to get treatment for minor injuries and illnesses such as colds, strep throat and pink eye.”

McCormick said that while this new benefit is very helpful, he hopes it doesn’t lead to a funding reduction, or loss of resources for the VA health system.

“We definitely don’t want that to distract or take away from the support or the funding of the existing medical system that we have in place. It’s very important to us as veterans that we have that,” McCormick said.

He said that overall, he’s been happy with the care he’s received through the VA. He suffers from chronic pain, a result of multiple gunshot wounds he received while in Iraq, and when he decided to get away from taking opioids, he was able to treat his pain with a specialized alternative type of pain management therapy at the VA in Huntington.

These types of innovative, alternative therapies are what he hopes the VA will continue to put resources into in the future, as well as increased access to local care, so veterans aren’t having to wait to receive medical care.

“So that’s why I was real excited to see this, you know, giving them access to an urgent care system, a local doctor, someone that they could go to and get assistance right away, I think that’s a good step in the right direction, but we still have a few more steps we have to take.”

Although the VA Mission Act passed through Congress with bipartisan support, some Democratic lawmakers say they hope it won’t set a precedent for more privatization of the VA medical system.

This article was originally published by West Virginia Public Broadcasting.

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Addiction Medicine Mostly Prescribed To Whites, Even As Opioid Deaths Rose Among Blacks

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Buprenorphine, better known as Suboxone, is used to treat substance use disorders. Extensive research has shown opioid-addicted people who are properly prescribed buprenorphine or methadone are much less likely to relapse and overdose than people who try to recover without medication. Photo: Craig F. Walker/The Boston Globe via Getty Images

White drug users addicted to heroin, fentanyl and other opioids have had near-exclusive access to buprenorphine, a drug that curbs the craving for opioids and reduces the chance of a fatal overdose. That’s according to a study out Wednesday from the University of Michigan. It appears in JAMA Psychiatry.

Researchers reviewed two national surveys of physician-reported prescriptions. From 2012 to 2015, as overdose deaths surged in many states so did the number of visits during which a doctor or nurse practitioner prescribed buprenorphine, often referred to by the brand name Suboxone. The researchers assessed 13.4 million medical encounters involving the drug but found no increase in prescriptions written for African Americans.

“White populations are almost 35 times as likely to have a buprenorphine-related visit than black Americans,” said Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School and the study’s lead author.

The dominant use of buprenorphine to treat whites occurred while opioid overdose deaths were rising faster for blacks than for whites.

“This epidemic over the last few years has been framed by many as largely a white epidemic, but we know now that’s not true,” Lagisetty said.

What is true, Lagisetty added, is that most of the white patients either paid cash (40 percent) or relied on private insurance (35 percent) to fund their buprenorphine treatment. The fact that just 25 percent of the visits were paid for through Medicaid and Medicare “does highlight that many of these visits could be very costly for persons of low income,” Lagisetty said.

Doctors and nurse practitioners can demand cash payments because there’s a shortage of clinicians who can prescribe buprenorphine, according to Dr. Andrew Kolodny, co-director of Opioid Policy Research at Brandeis University’s Heller School for Social Policy and Management. Only about 5 percent of physicians have taken the special training required to prescribe buprenorphine.

“The few that are doing it are really able to name their price, and that’s what we’re seeing here and that’s the reason why individuals with more resources — who are more likely to be white — are more likely to access treatment with buprenorphine,” said Kolodny, who was not involved in the study.

Kolodny wants the federal government to eliminate the required special training for buprenorphine and a related cap on the number of patients a doctor can manage on the drug.

Some physicians who’ve studied racial disparities in addiction treatment say the root causes date to 2000, when buprenorphine was approved. At that time, proponents argued that buprenorphine was needed to help treat suburban youth, according to Dr. Helena Hansen at New York University. Those young patients didn’t see themselves as addicted to heroin in the same way as hard-core urban heroin users who went to methadone clinics for treatment.

“Buprenorphine was introduced as private-office treatment, for a private market with the means to pay,” said Hansen, an associate professor of psychiatry and anthropology. “So the unequal dissemination of buprenorphine for opioid dependence is not accidental.”

Hansen added that the fix must include universal access to treatment in a primary care setting, an end to the criminalization of opioid dependence (which puts more blacks in prison for drug use than whites) and more federal funding to expand access to buprenorphine for all patients.

Several leaders in the fight to reduce opioid overdose deaths say the study results are disturbing.

“It really demands for us to be looking at equitable treatment for addiction for African Americans as we do for white Americans,” said Michael Botticelli, director of the Grayken Center for Addiction at Boston Medical Center and the former director of the Office of National Drug Control Policy.

Botticelli identified key issues that may contribute to the racial treatment gap and deserve further investigation. For example, he wants to know if Medicaid reimbursement rates are simply too low to entice more doctors to work with low-income patients, or if there are too few inner-city doctors prescribing buprenorphine or if African Americans themselves are somehow reluctant to seek this form of treatment.

Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health, called the findings surprising and disturbing. Surprising because the disparity is so large, and disturbing because her agency has prioritized educating doctors about the value of prescribing buprenorphine.

Volkow also expressed disappointment that federal parity laws, which are supposed to guarantee equal access to all types of medications, don’t seem to be working for buprenorphine.

“We need to ensure that we have capacity to provide these treatments,” Volkow said, “because if you say you have to pay for them, but there are no services that can provide the treatments, then the issue of paying for them is secondary.”

Volkow has noted that fewer than half of Americans with an opioid use disorder have access to buprenorphine or two other medications used to treat opioid addiction: methadone and naltrexone. Volkow said she’s glad that the use of buprenorphine is on the rise, but the U.S. needs to understand why this lifesaving treatment isn’t benefiting all patients who need it.

This story is part of a partnership that includes WBURNPR and Kaiser Health News.

This article was originally published by Kaiser Health News.

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