everyone and welcome to the American Psychiatric Association. We are thrilled to have you all here today in person and virtually to kick off the More Equity in Mental Health Initiative. Since Congress dedicated the month of July as B.B. Moore Campbell National Minority Mental Health Awareness Month in 2006, APA established this initiative to promote mental health equity for young people of color. This year, this roundtable discussion is the first of our community activities this month focused on mental health equity. My name is Madonna Delfish and I'm a senior program manager in the Division of Diversity and Health Equity. Before we begin this evening, I would like to acknowledge the land on which we are gathered here this evening. This is the ancestral home of the Nakosh-Tonk people and Piscataway peoples who have served as the stewards of this land. As we pay our respects to their elders past and present, please take a moment to consider the many legacies of violence, displacement, immigration and settlement that bring us all here together this evening. I ask that you acknowledge this, that it is our collective responsibility to support and pursue policies and practices that respect this land and its First Peoples. Thank you. Now, to officially get this evening started, I want to introduce the Chief of the Division of Diversity and Health Equity and the Deputy Medical Director, Dr. Regina James. Please join me in welcoming Dr. James to the podium. So, good evening, everyone. Glad that you can all make it in person as well as virtually. So let me just start by saying, and I know you would all agree, there's no health without mental health. And physical health is intricately linked to mental health. So therefore it follows that maternal physical health is intricately linked to maternal mental health. So in general, overall maternal health in the United States, as we all know, unfortunately, is in a state of crisis. Compared to other countries in the developed world, the maternal mortality rate or the death rates in this country have persistently outpaced industrialized countries. There was actually an article recently published just July 3rd of this year in JAMA Network that outlined the maternal mortality rates, particularly for people of color, they were very high. And it was highest among American Indian and Alaskan Natives and the black community. Right here in the nation's capital, the maternal mortality rate is twice the national average, with 90% of the maternal deaths in D.C. occurring among black birthing people. Here is a part that I think is unthinkable, unconscionable, as a matter of fact. More than 80% of the pregnancy-related deaths were preventable. And this is based on a lot of data, but just recently I reviewed the Maternal Mortality Review Committee. So this is a multidisciplinary committee. It's convened at the state and local level, really looking at reviewing death information during and within one year of pregnancy. So they have experts from mental health, as we'll have this evening, obstetrics and gynecology, as we'll have this evening, as well as others including maternal fetal medicine, public health, et cetera. The committee noted the leading cause of pregnancy-related deaths. Some may think cardiovascular, hemorrhaging, infections, high blood pressure. No, no, no, and no. Mental health is the leading cause of pregnancy-related death, including deaths due to suicide and overdose, poisoning related to substance use disorder. That's 23% specifically of pregnancy-related deaths are due to mental health. Now the American Psychiatric Association has its finger on the pulse of this issue. And our colleagues in government relations and policy programs and partnerships have worked together and joined over 100 organizations in a letter to congressional committee chairs in support of legislation on maternal mental health. So for example, Mom's Matter Act, Into the Light of Maternal Mental Health and Substance Use Disorders Act, and Triumph for New Moms. So today, as was mentioned earlier, in recognition of B.B. Mark Campbell Minority Mental Health Month, we're going to start a conversation around maternal mental health. And to do this, we have two extraordinary physicians who will lead the discussion. Each will bring a unique perspective with a common goal, and that is bringing awareness and education around mental health. Again, with a focus on maternal mental health. Let's start with our first guest. Appointed by Governor Gavin Newsom as the second California Surgeon General and first Latina, Dr. Diana Ramos has more than three decades of experience and expertise with a focus on health equity and reproductive health. Under her leadership, the office of the California Surgeon General has established three key priorities. Reproductive health, mental health, and ACEs and toxic stress. Let me give you a few other wonderful tidbits about our special guest, Dr. Ramos. She's executive board member of the California Maternal Care Quality Collaborative, secretary of the National Hispanic Medical Association Executive Board, co-chair of the Women's Preventive Services Initiative Implementation Committee, chair of the American College of Obstetricians and Gynecologists District 9, co-chair of AMA's ACOG delegation, and this is the best part, as a fellow Bruin, she earned her MPH from UCLA, and her MBA from UC Irvine, and her Doctor of Medicine from USC. Let's please welcome with applause, Dr. Ramos. Dr. Ramos will be joined by APA's own Dr. Dionne Hart. Dr. Hart is board certified in psychiatry and addiction medicine. She's adjunct assistant professor of psychiatry at Mayo Clinic, medical director at Care from the Heart for almost two decades. In 2014, Dr. Hart was named Minnesota's Psychiatrist of the Year. In 2017, she received NAMI's Best Psychiatrist Award. She's the region four chairperson of the National Medical Association, president of the Minnesota Association of African American Physicians, inaugural chair of the AMA's Minority Affairs Section, currently serves as an APA delegate to the AMA House of Delegates. She's an AMA liaison to the National Commission on Correctional Health Care Board of Representatives, and in 2020, Minnesota Physician Journal named Dr. Dionne Hart one of the 100 most influential health care leaders in Minnesota. Please, let's welcome Dr. Hart. So we're going to start off this evening with opening remarks by Dr. Ramos, and then there'll be a conversation between Dr. Hart and Dr. Ramos, and then at the end, we'll open it up to questions for people here in the audience, as well as those who are here joining us virtually. So please, Dr. Ramos, the stage is yours. Thank you. Thank you so much for the opportunity to be here to share and highlight the amazing work that is happening in California. You may or may not be aware that one in eight babies born in the United States is born in California. So what we are doing in California really has a big ripple effect in terms of what is happening in the country. We've heard some sobering statistics, sobering information on the number of maternal mortality deaths. It's terrible. But I do want to highlight one thing, that California has the lowest maternal mortality rate in the country. We still have a disproportionate number of more maternal deaths in the black population and American Indian population, Alaska Native population. But overall, we have a lower rate. And I bring that up because we have implemented some what I think innovative solutions that have helped us create as being a Latina, I'd like to say the secret salsa for California. So we have some of the solutions and some of those are cross collaboration, in particular with community partners, because it is so critically important to listen to the voices of the community that are going to be able to provide the solutions for their homes where they live. You can't have a one size fits all solution for an issue for a problem. And so the work that is being done in California with maternal mortality, we were one of the first states to start maternal mortality review committee to really go through what were the causes of death for moms who were pregnant. But then more importantly, once you have that data, what do you do with the data? Because we know the data is gold. And that's what California has done through a cross collaborative initial funding from the California Department of Public Health. They created toolkits to focus on maternal hemorrhage, to focus on cardiovascular disease, to focus on sepsis. What are things that can be done by the whole health care team? As Dr. James highlighted, there really is an important need to address the issues. So we have toolkits that really have been implemented nationwide by many of our partners, state departments of public health, as well as the American College of Obstetrics and Gynecology. All of us have come and worked together. So I am thrilled to be here with Dr. Hart to share some of the solutions that we have developed and hope to share and look to know what is happening outside of California. Because I know when I speak with some of our national partners, there's some innovative work that is being done in the country that I would love to be able to take back to California and be the voice. But I can pretty much assure you that we've done a lot of innovative, resourceful work and hope to share some of that work with you tonight. Thank you. Thank you, Dr. Ramos. Because we've known each other for so long, I know that I'm going to often call you by your first name. Is that okay if we just say it? Absolutely, yes. So Diana is like my sister. So Diana, as California Surgeon General, Dr. James mentioned and you've emphasized the initiatives focusing on reproductive health, mental health, but the ACEs. So it's not often that we hear other people talk our language about ACEs and the impact, but you have made it a priority, recognizing that black women especially, regardless of their socioeconomic status, regardless of their education, have high rates of mortality and maternity as it relates to their maternal health. So these outcomes are often associated with adverse childhood events or toxic events. But as a perinatal mental health champion in California and the nation, you've discussed ACEs and you've discussed maternal health disparities, but everyone may not know what that means and what the extent of. So can you elaborate more when we talk about maternal morbidity and mortality, the exact numbers nationwide and not just in D.C. as we've learned, but nationwide, give us more information? Sure. So the recent report that just came out on July 3rd, as was stated, highlighted the fact that from 1999 to 2019, the maternal mortality rate pretty much doubled overall nationwide from 505 deaths in 1999 to 1,210 in 2019. We know that the rates also increased more also after COVID because of the fact that many of the moms are high risk, have comorbidities. And so it brought us an aha moment of, okay, we really need to focus nationally on improving these numbers. We saw that the recent report on July 3rd highlighted the fact that black women have overall a higher rate of maternal mortality along with American Indian and Alaska Native. Alaska Native had the highest increase overall. And I do want to share that California has the highest number of American Indian and Alaska Native birthing parents in the country. So when it goes back to, well, why does California care? Because we have a responsibility and part of that responsibility is coming up with those solutions. And so, you know, this was an even stronger call to action for us and we're already doing the work. I'm very pleased to highlight the fact that we are already have implemented some of the solutions that have been recommended to solve these disparities. And one of those is expanding the Medicaid coverage for moms up to one year after delivery, because we know that about 43% of deaths occur after seven days of birth. So let's just stop and think. So typically in the past, Medicaid ended six weeks postpartum if you had a vaginal delivery or eight weeks if you had a C-section. But now you have up to one year. So if a person had high blood pressure, diabetes, anemia, now they're being able to be cared for. Depression. So the resources are there. The other wonderful resources that now have been added as a benefit of Medicaid in California is doula services. So going back to the disparities, to have a voice from your community that looks like you, that knows your culture, knows the language. In California, 48% of the births are to Hispanic women. So to know the language and the culture really is a boom. And we're starting to hear in other places of the country where doula services are looking to be increased and covered. So a lot of different solutions are being created. We know that the causes of death also vary by ethnicity. For Asians, the most common cause of death was hemorrhage. For black women, it was cardiovascular. For white and Hispanic, it was the mental health substance use. So it really is different. So we need to know that data to tailor the solutions. So I hope that answered some of your questions. Thank you. So I think maybe even going back a decade, you can imagine the two of us having this conversation in this building. But the APA has prioritized collaborative care and working with primary care doctors. So one of the things in solution is that we know that perinatal mood and anxiety disorders contribute to negative outcomes. So tell me how you have been collaborating with psychiatrists in order to make sure they're comfortable not only recognizing when those disorders are happening, but treating them through their pregnancy. Yeah. So it's a collaborative partnership. And depending upon the psychiatrist, how comfortable they are in caring for a pregnant person, the partnership will vary. I've unfortunately had more personal experience with psychiatrists taking patients off of medication immediately because they were pregnant when a patient maybe had been on an antidepressant for years. And so I would realize that and say, why did you stop your medicine? And they said, my psychiatrist said to stop the medication. So again, it's this cross collaborative. And so it's educating the psychiatrist on it's OK. And the psychiatry clinicians, it's OK to be on medication. You look at the risk benefits. But then at the same time for obstetrician clinicians to say it's OK to start somebody on medication because they need it. But you need that collaborative partnership. And we have to remember that. And I say this often 80 percent of health happens outside of the health care setting. So maybe they're going to spend 10, 15 minutes with their OB. I mean, that's how long when I was seeing patients in clinic I had to see them. But the reality is that most of the care is going to be happening outside of the office. And I would hope that they fill their medication if there was one given because we know that about 25 percent of people don't fill their prescription. And to be able to have a resource for mental health, whether it's through the churches or schools or mom to mom support groups. So lots of cross collaboration is so needed. So we've mentioned that we're a collaboration a lot. And we definitely think that's important. We've emphasized it. But collaboration has to happen when you can have a psychiatrist and you have an OB doc. Oftentimes people don't have either or they don't have access to timely access to a culturally responsible or culturally responsive mental health professional. How do we make that happen? How do we expand our reach so that patients do get the care the right time from the right provider. So I asked that exact same question to a group of key opinion leaders that I convened in April from California. It was a cross collaborative group from physicians to business people to I.T. people voices from the community African-American Indian Hispanic Asian. And I asked them how can we improve the care. And we came up with three initiatives and they are one to be able to assess the risk of a patient in the health care setting as soon as they're admitted or in the health care setting because we know that 80 percent of the deaths are preventable. So if we can identify them early on that would be fantastic. The other is to empower and to enable a pregnant person to know their risk before they become pregnant. Right now what's happening is that people don't know their risk of complications until they're already pregnant or in the hospital in a situation where you can't do anything. But if you were to know beforehand right what your trajectory could be you can start to make a difference. And the third was trust. So going with trust and really it was American Indian and the black voices in the room that said we really need to make men's for all of the harm, the historical harm that has been, that has occurred throughout the ages. But more importantly, COVID has also brought in some mistrust. So using our trusted voices, whether those are community health workers, whether they're doulas, whether they're promotoras, to be the voice to say, this is the information, it is okay, and I encourage you to get the care that you need to help support and be that source of information for our patients is so critically important. I agree. And I think we've really talked about the impact of education, where an empowerment and education and making sure patients are aware. But oftentimes they're not aware of the trauma that they've experienced, they're not aware of what ACEs are. So they're just living their life and understanding what it means if you grew up and you didn't have housing or food security, and what that impact is, and they pass that on. So it trickled down to families, partners, communities. How can we collaborate to stop that, to make people aware of the impact of these childhood traumas, but also that we can stop triple down effect? So I think there's two things. One, it's educating the providers, right? Because many providers are not aware of what our adverse childhood experience is. And it's been primarily in the realm of the pediatric arena. It's the pediatricians that are doing most of the screening. But when we stopped to think, it really started in internal medicine in an obesity clinic by Dr. Filetti at Kaiser. That was the source of, wow, why is it that people who are obese gaining the weight? Why is it that they lose the weight and then they gain the weight? And it was when he asked a patient the reason why, and listen, right? Because we need to listen, that the patient said, you know, it's the weight that is protecting me. Because when I was a child, I was sexually molested by my father. And I was normal birth weight, normal weight when I was a toddler. But when I started to be abused, that's when I started to eat, because the weight was what was protective. And so it's knowing, you know, educating ourselves as to what ACEs are, and knowing that if we address the adverse childhood experiences early on as psychiatrists, and you would be thrilled about this, you can actually eliminate 44% of mental health conditions, 44%. That's better than any medication that you could possibly even provide, 44%. You also decrease the risk of chronic hypertension. So let's just start thinking about the causes of maternal death. You start to decrease also obesity, and you increase graduation rate, increase employment. So it's a whole trajectory. And the way that I thought about it is, when you have all of these negative experiences, you self-medicate, right? And that self-medication is going to be either alcohol, smoking, food. You start to do whatever you need to feel better. So educating the health care providers, then you can start to educate. Then you'll get that buy-in, and then the patients can be educated as to how it's going to impact their health. And more importantly, as an OB-GYN and now in the position, I'm really trying to include the reproductive arena. You alluded to it, but we know that the parents, the mother, is the first teacher for a child. So if the mom knows how to manage stress, even though it may be toxic stress, we know that toxic stress really is stress that goes on for prolonged periods of time and impacts and can actually change our epigenetics. If the mom knows how to manage that, then that child will be on a more positive trajectory, on a healthier trajectory, will know that, OK, these are the positive things that can be done to try and mitigate all the negative stuff that's happening. And I can tell you personally, having grown up in South Central LA in a single-parent household probably with many ACEs that I didn't know they were called ACEs until I started this position, I can look back and see all the positive stuff that was in my life and now read about it as to, oh, yeah, so this is what's going to make you resilient, having somebody there talking to you, having somebody there supporting you, going out into nature to try and just reconnect and remember to breathe. So all of these things really play a role for healthcare providers and for our patients. All of that is really built on trust between you and your physician. When, as we know, there's been so many valid reasons why minoritized communities do not trust their physician, how do we at the same time try to educate our colleagues, educate patients, but rebuild that trust so that you can have more of those conversations and they will feel empowered and educate people with the right information? So many people have Dr. Google as their number one doctor, right? How do we start to, like you said, they literally built a shelter around them. We need to try to penetrate those shelters and really do a lot of outreach to those communities who have been harmed by medicine. So how do we start working together to do that? Yeah, it takes a village, and I can tell you this is what's happening in California. So in California, we have a $4.9 billion investment, $4.9 billion with a B, in reimagining what mental health substance use treatment is, Children and Youth Behavioral Health Initiative, that's what it's called. But through that initiative, we are really redefining and reimagining the mental health, knowing that it's going to be done in the community. Our office specifically has just launched, and you can go online and look at it and take the course, Safe Space Curriculum, focusing on teachers who are, and there's three segments, zero to five, middle school and high school youth. How do you recognize adverse childhood experiences, toxic stress, and more importantly, what can you do? Because oftentimes, it's education first, and so that's just one of the initiatives. We also are going to be starting a campaign to educate the public, right, on what is toxic stress, what are ACEs, and where can you go for help? So the $4.7 billion investment is building up that network and the resources in the community so that we can then direct the public as to where to go. But it really is a cross-collaborative, and every opportunity, everybody needs to know so that if you recognize it, I mean, you may not be the one to provide the support, but you know where to send that person or to say, hey, you know, I just heard about this. You may want to check this out. So California sounds amazing, right? Come to California. Yes. But obviously, we all can't live there. So and you talked about this ripple effect that goes from California. So how do we, as patient advocates, make sure that we are part of that wave so that it comes to our state, that it comes to our community, comes to your workplace? Like, how do we help with that effort? So oftentimes, we are the test ground for what is happening nationwide. So you can use California as a resource. We have the largest number, you know. And so you can say, we are the beta testing. We are the pilot. And you can say, well, it was done in California, and this is how they did it, and this is what it cost. So now you have informed information, really a whole, the prescription, the recipe on how to implement a program. And you can tailor it to whatever your state's needs are and your state's budgets. You may not be able to implement the whole thing, but you could implement components of it and maybe start with the components that you need the most. So I would say use us as a test ground. Follow us on the social media. Follow what we're doing. And oftentimes, there's presentations in the APHA, in psychiatry organizations, and just sharing the best practices. So I'm going to switch gears a little, because it sounds like California is leading the way in many aspects that are positive. But the country as a whole, we are the number one jailers, number one prisoners, and women are a part of one of the fastest-growing cohorts of people who are in jails and prison. And we really don't talk a lot about moms. So it's like two-thirds of moms who, of women who are in prison are moms, and minor children. Four percent come into jails and prisons pregnant. Talk about trauma for moms and the children. How can we work together to not only stop that wave? We don't want to be number one in that, but to really make sure that people receive health care in a humane way in whatever setting. So you and I have talked about some of the experiences in working in the federal system. Some things have happened that are positive. Women no longer pay for just feminine products. That's a big barrier. Give you dignity. There are screenings and testing and treatment for STIs, because there's a lot of heavy burden there with sexually transmitted infections. But also, when women are pregnant and expecting, no longer being restrained while they're giving birth, which you can imagine. But also, there's longer periods of time with the baby. So that, again, we are trying to address some of the trauma that happens. So we have been advocating for this group of women. And I know that that is one of your priorities, to really address justice-involved women. But I'm just wondering, are there other ways that you perceive that we can continue to partner to bring dignity and culturally responsive treatment in whatever setting people are in? Well, I do have to acknowledge your leadership in the AMA for passing some of those resolutions has been amazing. So thank you so much. Dr. Hart is an amazing leader and voice for the correctional system and the inequities. So I think, one, you continue the work that you're doing, and ACOG will be there to support you. But the other thing, too, going back to the adverse childhood experiences, one thing that we do know is that the separation of a child from the parent, whether it's in the incarcerated system or divorced, really does play an impact. And it really is then pulling into the different systems from family members to help support that child, looking to see what are some ways that that trauma can be buffered and improved. The question that you're asking, really, there's no one specific answer. It really is multifactorial. And depending upon the state that you're in, the solution is going to be very different. But I think the one thing that we do need to address, the one thing that we can address is the stress that that child is experiencing because the mother has been separated. And so what can be done outside when the child comes back home, whether it's with the father or the grandmother, whatever relative is there to help support that child? I think that's the one thing that we can do. And then, obviously, continue supporting the mom so that she can be part of her child's life. Yeah. I think those are excellent suggestions. And I would think because we have so many people who are justice-involved, even if you don't work in corrections, you meet people who are justice-involved. And I think we should stop shying away from asking people about that. I know lots of times in training, when they showed up on the social history, nobody talked about it. It was kind of like, oh, we're not going to mention that. But that is another area where people get stigmatized. That's something that happened that was traumatizing, and then they can't talk to their physician about it. So I think we need to start asking questions about that. It doesn't mean that you are shaming someone. You're just bringing it up. It's a part of their history. So I think we really need to start talking about it. But also, there's a lot of advocacy to making sure people don't get criminalized for their health care issues, including substance use disorders. So we have a lot of area to work there to address that. So thank you for letting me share that. But I want to also say to the audience, if you don't have little kids, you might not know. On Sesame Street, there's now one of the characters has a dad in jail. So they start conversations and talk about it. So even if you don't have the language, you can give them resources so that they can have a discussion about it, and they can kind of see, it's not just me. So I think that is part of it, like having conversations and taking a lot of these things from just buried in the social history and starting to talk about it. So we have talked about moms, babies, but not partners and fathers. And a lot of times that they witness a lot of the morbidity, mortality happening, and even sometimes try to advocate for the moms during delivery. So they experience trauma, too. And we really don't talk about them a lot when we talk about maternal health. But I'm just hoping you can share some ideas on how we can support partners and prevent them from also having some of this trauma. Yes. No, partners are a critical voice, a critical component. There's been two near deaths that I can just always come to the top of mind. One was an Asian couple, and the wife had a postpartum hemorrhage. And I remember being in the anesthesia recovery area, and he was holding the baby, and his wife was in the gurney getting blood. And he just looked at me holding the baby, and he said, Doctor, please don't let my best friend die. Oh, you know. And what do you do? Yeah, I mean, absolutely, I'm trying my best and just hoping that things get under control. And then there was another one, another man, too. The same thing. The woman had a one in a million amniotic embolism that for all intents and purposes typically the patient does not survive, but she did. And he had two other children and then the baby also. And again, the same thing. Doctor, don't let her die. She's got so much to live for here. And we forget that the partner is traumatized, too. To be the witness, to have seen like a whole code be run right in front of their eyes, and to be holding that baby, we need to heal the partners, too, because we know in general there's about a 10% depression rate in partners. And that's for those partners that actually get screened, because I can guarantee you, I bet you it's even higher. Not only for the partners who the new mom had a near traumatic death, but just in general, right? 20% of the population has some type of depressive disorder. So we're not catching the dads and supporting the dads. So we need to remember the partner always needs to be acknowledged and asked, how are you doing? And I would do that in clinic. Both the partner and the patient would be there. And I would ask, I would look at the dad and how are you doing? And he would be surprised. He said, whoa, somebody's actually asking me how I'm doing. Because we know men are not going to typically go to an annual well visit. But to be able to be acknowledged is a gift. So we have to remember, it takes a village. It takes a village to raise a child to be that support for the mom that's going to go home. And if they're at risk for mental health disorders, if they've had a complication, it's going to be that partner that needs to be there and needs to be well. Now, if we acknowledge the partners and recognize that they do carry a risk, are there places or maternal health centers where they can also receive treatment? So as far as I know, no. The dad has to go to their primary care provider and go through that whole system. In general, we're not that sophisticated yet. We're trying to get the help for the moms and then hopefully come up with a program where the dads can be part of that. But right now, it's the mom and the baby, the dyad care. So lots of talk about families, about educating moms and educating families, supporting partners, supporting children. That's a lot of work, which is why there's so much collaboration. That's it. That is the key, the salsa, the cross collaboration, because 80% of health happens outside of that health care setting and the voices in the community know what they need and know what works for them. Thank you. And see if we have any questions from the audience. Thank you so much for this excellent discussion and the excellent interview. I would be interested in hearing your thoughts about the partnerships between the adult medical providers and the newborn intensive care units. And so, you know, I've come to learn that in a lot of the newborn intensive care units, which are predominantly minority women, there's not screening for trauma or depression for the mothers. And frequently, there's not continuity of those services for the mothers and the fathers. Thank you. Frequently, there's not- Do you want to say who you are? Should I start over? No, I just, you want to say who you are and then start your question? Yeah, so my question really is, I'd be interested in hearing your thoughts about what the future could look like for the care of families who have children who are in the newborn intensive care unit. They're frequently there for a very long time. They're not typically culturally, well, they're not typically sensitive places. They're places of crisis and the families are repeatedly traumatized over and over again. And I've not seen very many systems that were effectively providing support for the families during those experiences. And I'm sure you're familiar with those problems. I'd be interested in hearing your thoughts. Yes, I can tell you, being and working with the neonatologist, I love my NICU teams because they were the people that once I had the baby delivered I can just hand the baby over and I knew they were going to do a great job. But the thing to realize now, and we've overlooked it like you said, is that there is trauma. That is a stress. That is, depending upon the severity of the complication that that may be experiencing, that could be a lifelong stress, toxic stress. So with that in mind, the March of Dimes has actually developed a program for the NICU support. It's called NICU Support Moms. And many hospitals incorporate it and it's a support system for the parents of babies in the NICU. So that, and in conjunction with once the moms are going home, the recommendation is to do Edinburgh depression screening before they go home. And so to be able to connect them with the resources and the help that they need before they go home. And I know that not every system has that resource, but that's in the ideal model, in the best way that things are practiced, you know, that's one way to do it. We now have technology. We have AI. So we can predict, it's just a matter of programming it. We can predict who's going to be needing mental health resources. Gee, let's see, she was in the ICU, she had a preterm birth, she had hemorrhage. You know, you can start going through the algorithm and the AI program can detect which person is going to be needing the mental health support. So you can proactively identify before they're even leaving the hospital, who's going to be needing that support. Does it have to be somebody in the facility, in your hospital? No, it doesn't, because now you can provide care virtually, right? And so there's many systems. So we need to remember, and healthcare is oftentimes the last one to adopt, we're the slowest adopters, to adopt technology and AI. And I hear a lot of physicians and health systems say, oh, CHAT-GBT is going to replace us, and I would push and say, how can we use it to help improve the care that we are giving our patients? And that would be one way. And that's just with the NICU. You can do the same thing with maternal care. We can predict which moms are going to be the highest risk with an AI. And I can tell you, in California, if we did that, we can then deploy nurse-family partnerships program, so somebody that goes to the home of that patient, we can then assign a doula. We have the resources to be able to support what, just based on an objective way, is going to be a high-risk pregnancy. Diana, do you have suggestions for physicians who are in areas where they don't have the resources? So you might understand what to do and what they need, but if there are not resources to give them support to get it, for example, there's not transportation or daycare for the other kids to get those resources, do you have some novel ways where someone could make sure that they have the access to that care? So it's not novel, but I would say talk to your public health departments, because the public health departments have maternal child health divisions. And oftentimes, they're the ones that are overseeing the Medicaid programs, or along with the Department of Health Services for that state. And those are the partners. And again, in medicine, we oftentimes forget, who is it in the community that can help support us? And it's public health, Department of Health Services that have the resources, or more importantly can direct the providers where they can get that help. You mentioned Medicaid. So I know some of these services, there's actual ways you can build and get support for that work. Were you involved in making that happen? No, I wasn't. I can't take that credit. But I can say it is a great boom in California. Medicaid pays for transportation for some of the patients. And you just start to think of novel ways. I know some states use Uber to transport moms to their prenatal care. So if you're in a health desert, you start to think proactively, what are we going to do at the time of delivery? And we had a question. So we should go. Right. Yep. I want to second that. Thank you for the lovely discussion. We know that addiction and substance use disorders are often commingled or comorbid with mental health conditions and other health conditions. Can you sort of elucidate for us any specific successful strategies you've had with working with moms that have substance use disorder as a condition? So the American College of OB-GYN recommends screening for substance use disorder during prenatal care. And so the other thing, too, as Dr. Hart alluded to, is not being judgmental, not stigmatizing and try to build up that confidence so that the patient, if they are using, will be honest. The challenge comes now, though, is that if somebody is using, say, marijuana substance derived drugs, it's legal, right, depending upon the state. And so I can tell you many patients would use marijuana for nausea and vomiting in the first trimester because they said, well, this is natural. It's over the counter. And yes, you know, it's why am I being stigmatized? So again, it goes back to the education. We're having more and more information now that is indicating that there could be some negative repercussions in the developing embryo for those using even something as simple as marijuana. Unfortunately, though, to be able to say that everybody is going to be not going to be judged is not universal. Even in California, there are some regions in the state where if somebody is using substance abuse or some type of substance, they could be reported. And we don't want that because we know that is a negative impact for the mom, for the baby. And it just puts everything in a more negative trajectory. So there is no one solution, but it really is working with the health care systems and educating the providers and the counties, the regions as to what, you know, giving them the overall picture and potential. Hi. My name is Siobhan, and I am a local perinatal mental health clinician here in D.C. and in Maryland. And I have a two-parter. My first question is, what can be done to promote access between the hospital and then us private practice clinicians? Because here in D.C., there's a huge disconnect. Two, also here in D.C., it's amazing how median income can change from over the bridge on one side into the other. So one of the things that I've seen as a black perinatal mental health clinician is I've had – I see black clients of all socioeconomic status. And one of the things that I am seeing is that many of my clients, they will not either participate in certain services, they won't seek out certain services because they feel that they don't meet a certain socioeconomic status. So when they're hearing lots of things being pitched to Medicaid, there's a huge population that's also being missed because we also, here in our nation's capital, we have a lot of first-time moms that are 40, that are 42, and they're – so there's all these gaps in here, like gaps in care. So I guess my question is, what can we do to promote access from the hospital to the clinicians, and then also what can we do to promote access for moms of color of all socioeconomic status? So, from the hospital to the clinicians, I think it really depends upon the health system. Some systems are very well integrated so that it is the same hospital delivering the care during prenatal care. But more times than not, it's a disconnect. And so that is, I think, where your question comes in. Again, going back to the community, 80 percent of health happens in the community. So identify those community resources that can provide the support that is needed. Also, working with your public health programs to identify, are there any home visitation programs? Are there any doula programs that perhaps that person could be that trusted voice, the bridge to the resources that are needed in the community? If you can come up with a solution as to how you connect, I would love to hear it. But unfortunately, each system is so complex, as you know, and it's not a one-size-fits-all. But you bring up a good point, that if we would just start to share, how do you actually achieve it? How do you actually connect? I think that would be one solution. Moms, we know that social media is used the most by pregnant and new moms. So if we can elevate those resources, and just to say, wow, this system is actually providing all of these services, and the moms are sharing it with each other, what do you think is going to start to happen? People are going to want to go to that system that is being integrated. And the other systems are going to be forced to, uh-oh, they're leaving my system. We need to now adopt. But the power of the voices that we're serving is so critically important to include. And to let them know, look, this is what's happening, and ask them, what are some solutions that can be incorporated to improve that access? Hi. I'm Diana Clark, and I'm the managing director for research here at APA, and a PI on a CDC Foundation project. Now, I think it's a really great idea that we're promoting screening for mental and substance use disorder during the prenatal period. How do we guard against screening, even though they are positive results, clinicians are just putting it in the file, and nothing happens? So you have pregnant persons who have talked about that, that I'll go in, and every single prenatal visit, I get a screen, and I'm reporting my depression symptoms. I'm reporting my trauma. And yet, it goes in the file, and nothing happens. Because what that does is perpetuate that lack of trust again, right? So suggestions? Yes. Can I say something? Go ahead. I will say that it's not just OB or primary care docs who do that. I know outpatient people get PHQ-9s and never look at them, right? It just becomes a part of a box you check. So I think that we all, and this is the education piece, why are you asking those questions if you're not going to do anything with the information? So I think there has to be ways that we prompt each other, and I think it starts with training. So like when your residents do these screenings, ask them, okay, were there any positives? Did you expect, like have a dialogue about it, and now what's the next step? And then, and talk to the patient about it. But we also talked earlier about how can you do all those things you want to do in the time allotted? So it may not be the physician always who follows up, it may be another extender or another community partner, but I think we all get into that habit of taking this information and it goes right into the medical record and never to be seen again. Thank you, and I hear you about the, you know, when the residents are, you're working with the residents, but we have so many clinicians that are out there in the community, and they're seeing these pregnant persons, and they're doing this, and so who do they go to? Or who gives them that training? So I think- And it's each other. We have to do it. We have to educate each other. We have to hold each other accountable, and I think that's where the collaboration comes from. So if you know that that's the part of the medical record, and maybe you're covering for that person, so that's the time when you see it, you say, oh, maybe you didn't recognize it, but your patient called and said X, Y, and Z. I think we really have to start, like, gentle reminders to each other, but I mentioned the residents because if you train people to do it when they're learning all their skills, they do it automatic. We're usually the people who are, like, resistant, like, oh, I don't want to make, I don't want the epic. I don't want this, and, like, other people adopt and adapt, like, we're talking about AI. We get concerned about being replaced when it could be a tool. So I think some of it is just, like, taking down the barriers and say, you have the information. Let's work with it, but I also say on the flip side, some people don't talk about the information because they don't know what to do with it. If somebody screams positive, they're like, oh, no, this is awkward because I have no idea who to refer you to. So then they don't bring it up. So I think there's reasons why people neglect that part of the chart, but I think we can all do better. Yeah, and just to also say it also, you know, as the APA, I also think there's this responsibility to help to develop educational material that are free for access to individuals in the community who, so they can actually get these types of training. Yeah, one resource I would encourage you to look at is the Lifeline for Moms out of the University of Massachusetts. It's an outstanding, they have an app, and you basically put in, you know, your diagnosis. It gives you what you need to do, behavioral care, medication. If it gives you the medication and they're pregnant, what are the side effects? What can you expect? When will you see it work? It's fantastic. There's a question over there. So we have a couple questions from the audience. One of them wanted to know, how can we address the current legal prosecutorial approach to substance use in pregnancy, where women are reluctant to trust their health care providers, and as a result, they do not disclose their substance use disorders or abuse? There's a lot of advocacy work there. I know members of APA Foundation staff were here, so that SNMI is not a crime, that initiative. So we, criminalizing mental health disorders has been a problem for many, many decades. So I think that is probably what we have to start talking about and making changes locally. So like, if you ask the question and somebody tests, or somebody tests positive, if they're a certain number of weeks gestation, sometimes you automatically have to report, but not for treatment, but for criminalization of a mental illness. So I think that that's where advocacy comes in. Like, knowing your laws locally, knowing what you have to report, I mean, we have to do that. But also, once you know, just making changes so that your patients are not criminalized for seeking help. Lots of times, people are very vulnerable because their bodies are going through changes and they're more at risk for partner abuse. There's a lot of things happening when people are pregnant, and then they may relapse. So also, there's another opportunity for people to talk about prevention, like recognizing that this is another stressful period. It's a good thing. It's a good stress for most people, but it's also a stressful period. It makes people at risk. So I think there's a lot of ways that you can advocate, but also engage in discussion with patients to try to prevent some of those things. Good afternoon, and thank you so much for that wonderful dialogue. I'm Omar Escontrillas. I'm Senior Vice President of Equity Research and Programs with the National Council. So my question is a two-part approach. So having worked in state health department in the past, I understand also how strapped we are for funds. And even after COVID-19, that showed that a lot of state health departments plummet in terms of their funding. So how can we help address that reallocation of funds to address some of these concerns that are going on maternal health and mental health? And then my second question is, have you thought about using patient experience data in terms of helping with your dashboards or moving the needle forward into some of these initiatives and hopeful in preventing some of these mortality deaths in the future? So stories are powerful. So I'll take the second part of the question first. Stories are powerful. And yes, absolutely. When the stories are what drive the action, again, going back to not only the data, but the stories, now you build a full picture. And I can tell you there was one patient that I took care of who now has become an advocate. And she shares her story because she realizes that the power of her stories and the fact that by all intents and purposes, she could have died and those voices are really powerful. So I know that she belongs to policy and advocacy organizations that go to the state and sometimes go to the national level to inform and to educate those who are making decisions of, look, implementing these programs or funding these programs really makes a difference. In terms of how can we increase the funding in state programs, you got to talk to the feds. We're here in DC. So I would leave that to you. But again, you're never going to have enough money to do everything you want, right? It's got to be that partnership. So you may not have the money. And sometimes, too, when you have the money, you're restricted depending upon what that money was directed to do. But once you build that cross-collaborative partnership, then you're going to have one partner that can do one piece, another piece, another piece, and then together, you're going to be able to accomplish what you want. So even though you had more money, you probably wouldn't have been able to be so nimble and implement the initiatives that need to be implemented. But it's that partnership and the cross-collaboration that can. Thank you for the question. But also thank you for being a public health advocate. It's been a rough couple of years for you. So I appreciate all the efforts that people on the front lines of that work have been doing and doing way before people recognized that there were public health officials helping them. So thank you. And there was a question. Good evening, and thank you very much, Dr. Hart, Dr. Ramos. Phenomenal dialogue. Douglas LeBlanc, public health and public administration professional. I had a quick question just kind of in regards to the changing landscape when it comes to being a pregnant person here in the United States and a lot of the different laws, both at the local and federal levels, that have changed. With California being kind of like that catalyst of change during the integration of maternal and child care as well as mental health, how are you addressing those who may be coming from out of state looking to you all to receive that type of care and comprehensive approach to their journeys? So we lead by example. We have developed the programs and, you know, from reproductive health. so we have birth control pills that are available over the counter. You have emergency contraception as well. You don't need a prescription for basic reproductive, you know, for contraception, that's one thing. We provide Medicaid for those who need it starting in 2024. It's gonna be even if you're undocumented. So if you come in and you're pregnant to be able to receive that care. The other piece too along that whole reproductive spectrum is the abortion care. And I'm not sure if that's what you were referring to, but with the abortion care, you know, California has been leading the nation. We were one of the first to codify the abortion care being part of our state constitution. So the abortion.gov website that was initiated by Governor Newsom really is a comprehensive resource for abortion services that California provides. We are a leader in training as well in terms of providing information. So critically important, what I don't think a lot of people realize is that there is now gonna be disproportionate number of people practicing in certain states because of the fact that the abortion services are not available for those undergoing training. So I know there were more OB-GYN, family practice, residents applying to California because you have a whole spectrum of training. And so the resources are there. And the one thing I do wanna highlight is that the word abortion has been politicized. People forget that abortion is a medical term that if you were a medical student, and I remind the medical students when I'm teaching, you know, abortion could be a spontaneous, an elective. It could be a missed abortion. It could be in a topic. All of these fall under abortion. But it's been politicized to be one extreme, but it's not. And so California, like you said, we are leading. And I invite folks to go to the abortion.gov website and to look at all of the resources that are there. Sorry. We have another question from our virtual participants. Collaborative care mostly functions in primary care like pediatrics, et cetera. What are your thoughts on the prospects of the collaborative care model functioning in OB-GYN clinics? Collaborative care is an OB-GYN clinic. So I would say every single specialty has that opportunity to really be part of collaborative care. And especially with OB-GYN, I can remember, you know, doing a curbside consult with internal medicine, with emergency medicine, with anesthesia, with obviously pediatrics, but no, collaborative care, that's part of being, I think, a provider because we cannot know everything about everything, but we know I can call Dion and say, hey, Dion, what is this, you know, how do I manage this psychiatry or this substance use topic? And so that's what collaborative care is, is really being, pulling in on all of our resources that we have, our partners. And I think our, even though it was like, we had some resistance to adopting till COVID, but telehealth has really changed that. So you can dial up your colleague in just a matter of minutes, and then they'll pop up in the exam room with you. So, and I know that OB docs often want people to know that they are primary care physicians. So it's not a separate, we include them in primary care. Another question? Questions from the audience. Can you please comment on assigning a peer support person who shares the same language and cultural background as the pregnant person getting treatment and care? And what are your thoughts on the birth outcomes using peer support? Absolutely, I mean, ideally it would be wonderful if in California, we had half of the providers delivering half of the babies, which are all Hispanic, to be Hispanic, right? But the sad reality is that there's maybe only about 5% of all OBGYNs in the country that are Hispanic. And so what we do have though, is the resources to train the doulas, the promotoras, the community health workers that look like the patients that we serve. Absolutely, we have to keep on promoting our young people to go into medicine, the people of color to go into medicine to be those mentors and to be the support. But what we can do more immediately is train more doulas, more promotoras, community health workers, people in the community to help support our people of color that know the language. And I can tell you, I oftentimes was so happy, I would see more patients because they knew, I was very familiar with all the Mexican traditions in pregnancy, you know, you're coming in with the red ribbon or you're coming in, yes, you know. And it was interesting because many times the patient, I would ask them, so they were maybe 20 years old in East LA seeing patients and I would ask her, so why do you wear the red ribbon? And inevitably they would say, I don't know, but my grandmother said, I have to wear it. And I'm like, okay. So but understanding that and not saying anything disparaging but supportive and saying that's wonderful. Well, thank you both for sharing your expertise and all the work you've been doing over the years. I'm gonna ask a bit of a downer question. So there's this idea of covering or expanding the definition of healthcare to include things like transportation, include things like food security and other sort of additional services. We know that the healthcare spending as a percentage of our GDP has continued to go up. I'm sure that's the case in California. I was in San Francisco 10 years ago than I was in San Francisco a couple months ago. I think the particular street I was walking down was Geary Street. And you see sort of the percentage, just visually looking at it, the percentage or the number of people that are unhoused has gone up. The number of people that are unhoused within that, the proportion of those that are women significantly gone up. The proportion that are pregnant or with a young child in that situation has gone up. And this is not unique to San Francisco. This is happening in DC. This is happening in other cities. So number one, are we doing something inherently misaligned with what the needs are in healthcare? And is it actually a good idea to try to encompass all of these needs, whether it's transportation, food security, education within the umbrella of healthcare? Or is it sort of almost putting the attention on healthcare spending or healthcare investment when it is a larger social problem that we're not taking responsibility for? So what you just described are social determinants of health. And I've said it multiple times, 80% of health happens outside of the doctor's office. So if I have a pregnant mom who just had a baby and she's got two little ones at home, she may not have the transportation to go to her prenatal care appointment. She may not have somebody to help care for her little ones while she has to go to that postpartum appointment. So critically important, because it could be that she had severe preeclampsia, had diabetes, had medical problems that if we look at 43% of the time can kill a mom after one week of pregnancy, a new mom? Absolutely, we have to include that because we know that it's all of those external forces that are gonna drive the decisions to seek health and more importantly, to incorporate preventive solutions. So I'm glad you brought that question up because I think that is one of the most important questions. And I know many physicians were not trained in social determinants of health. A new generation of physicians are because I'm a faculty at Keck USC and they know social determinants of health and they realize that bigger picture. But we have to remind the public on how critically important it is that housing, if you can give somebody the medication that maybe needs refrigeration and guess what? If you don't realize that they are unhoused, they're not gonna take that medicine or that medicine is gonna spoil. So we need to look at the bigger picture. And I agree, I mean, I think it's well established that your zip code is more of a factor in your health outcomes than your genetic code. So I think we do have to address all of those issues, whether you call it part of the healthcare budget or social, like it has to happen. Before I was in medicine, I was a social worker. So that part of me has always been there and I can't turn it off. And I remember as an intern asking questions, like you said, like, if I give you this prescription, can you afford the co-pay? Can you get to the pharmacy? And one of my attendees said, are you a social worker or are you a resident? I said, yes, because you can't separate the two. So like you said, all of these things are really based on, are you in a stable place where you feel like you can take a medication that's sedating and not worry about your things being stolen? And like all of these things that we don't always think about come into play. So whether you put it under a health budget, whether you put it under public health or social services, it just has to happen. So I know that we kind of get into wars with other departments about who takes responsibility, but I think a lot of it is under healthcare because physicians have recognized the social determinants of health and said, you can't separate it. So that's why it's probably falling under our budget because we are advocates and we are scientists and we are seeing the whole picture and we are taking responsibility and saying we have to help our patients with their entire health and not just what the issue that walked into the office and what they said the chief complaint is, but under recognizing that that did not come in isolation. And only 10% of the care that is provided by physicians actually impacts the outcomes. The rest is a social determinants of health, 10% maybe genetics, but everything else outside where that person lives impacts the outcomes of health. So you talk about prevention, you talk about saving money, that would be the place to do it. Another question. Many psychiatrists may discontinue medication during pregnancy due to teratogenicity. Sorry if I butchered that word. So, for example, lithium may be stopped at six weeks of pregnancy. What are your thoughts on this? Tetragenicity. Say it fast. Teratogenicity. So, I mean, most of my, because of where I work primarily, my patients are mostly biological males. So, this doesn't come up often, but there are some medications that realistically you have to transition patients for because of the threat to the fetus. So, I think you just have to be thoughtful. But I also know that because I don't treat those patients very often, I'm going to consult Dr. Ramos. I'm going to consult one of my colleagues. I might consult somebody who is just more engaged in that part of healthcare and is a psychiatrist. But I think that's where you say, I need an expert consultation and I'm going to help the patient. But I think the problem that happens is people stop everything without a substitution or a plan. Like my grandma says, pray it away. Like that does not work. It does not work. So, I think just like especially like Dr. Ramos was talking about having the conversations preconception. So, like saying, okay, you're taking these medications, you're stable. If you talk about family planning, these are some of the things that we have to talk about. These are some of the things. So, like having those conversations in advance, like having that assessment tool, having, you know, discussions in advance so that you can come up with a plan of action and not just stop. Because an unstable mom, there's not going to be a good outcome for the baby either way. So, I think really having a discussion and really planning is the key. And the big takeaway, and this is in general, in OB, it's the risk and benefits. And the benefits of the mom always outweigh the benefits of the fetus. Because if you don't have a healthy mom, you're not going to have a healthy baby. So, always think of it that way in general. So, whenever we would have like neurologists asking us for a consult or whatever other specialty, it was always that, okay, the risk and the benefits. What's going to benefit the mom? Because you need that mom to be healthy. And again, going to Dr. Hart's recommendation of getting the consult that you need. But that Lifeline for Moms app, I highly recommend it because that's a good resource for that. Thank you. And one last question before we close out. Dr. Ramos, can you share some of the lessons learned from California in terms of what's being done there to promote maternal mental health equity and health equity in general with all of us that we can take back to our respective organizations and practices? Yes. So, there's a lot of work that is happening. As I mentioned earlier, the $4.7 billion that has been invested by Governor Newsom in reimagining what mental health substance use care is supposed to look like is one of those initiatives. If you stop to think about it, it goes up to age 25. And the really important thing to remember that by age 24, 75% of all mental health conditions would have been diagnosed. So, this is an opportunity. This is a game changer to really make a difference in the lives of a person. And the other things with perinatal mental mood disorders, we have wonderful cross-collaboratives throughout the state. When I was the president of the Orange County Medical Association, I worked in collaboration with a nurse practitioner who we developed a perinatal mental health toolkit that focused on the community because I kept on pushing back. The doctor oftentimes does not have the time or the resources to help, but here are the things that are available in the community. So, that's one resource. And again, focusing on resources that have been implemented by health plans on mental health. There's virtual appointments for mental health. The sky's the limit. California is really trying to become even more innovative. And when I pushed back on our partners, I said, we are in California where Silicon Valley lives, where Silicon Beach, which is Southern California, lives. We can come up with innovative solutions to address mental health. How about others that you had mentioned? Was the CDC Hear Her campaign? Yes. So, there's a Hear Her campaign that is listening to patients, right? Unfortunately, because of the limited amount of time that we oftentimes have, patients feel like they don't, are not heard. So, the Hear Her campaign is just one campaign that was put up by the CDC to provide some top of line messaging. There's also a maternal mental health helpline that's a national and that's 833-TLC-MAMA, TLC-MAMA. And that is specifically for pregnant women, pregnant people who need resources while they're pregnant or immediately postpartum. So, oh, this has been very, just very great, very wonderful. So, on behalf of our CEO and medical director, Dr. Saul Levin, and our APA president, Dr. Petrus Levinas, I'd like to thank our two extraordinary speakers, the California Surgeon General, Dr. Ramos, and APA's own, Dr. Dionne Hart. Let's give them both a hand. And in appreciation for what you have provided us in terms of awareness and education and things to think about, we have a little something for both of you. And it simply states, with our greatest appreciation for your commitment to achieving mental health equity presented to both Dr. Ramos and Dr. Hart. So, Dr. Ramos, if you can come. Oh, so beautiful. Thank you. Thank you so much. Thank you. It's so lovely. And Dr. Hart. Thank you. I can't get it out of there. All right. Oh, we can. Take a picture? Yes. Again, so that's the conclusion of our program. Thank you so much for coming out and thank you for those who attended virtually.

vaping

minority youth

challenges

comprehensive strategies

healthcare providers

substance use

COVID-19

social media

risks

More Equity in Mental Health Initiative

maternal mental health

maternal mortality rates

expanding Medicaid coverage

doula services

perinatal mood and anxiety disorders

adverse childhood experiences

trust-building in healthcare

justice-involved women

partners in the healthcare system

mental health of partners and fathers

collaboration