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Closing Care Gaps: The Impact of Digital Coaching on Maternity Outcomes

Dani Bradley, MS, MPH, Director of Clinical Services and Evidence
Lisa Richards, MSN, CNM,  Health Services Coordinator
Ovia Health

In their lifetime, women are rarely as engaged with their health as they are when they are working to start or grow their family. However, pregnancy can still be a confusing time for many women as lack of education and resources leave them with unanswered questions, unidentified risk and general confusion. The pandemic has only worsened these issues in many cases, as OBGYN appointments were cancelled, modified or moved to virtual settings, and it is often worse for BIPOC mothers. 

How can organizations combat worsening maternal health outcomes, improve maternal and infant care equity and close gaps in care that can lead to avoidable adverse events? Listen now to hear how digital coaching and early education can significantly reduce pregnancy complications and close common gaps in knowledge and care for women and children.

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If you enjoyed this podcast episode, check out the full OviaAsks podcast series, or other content, for more insights from leading employer organizations

Podcast Transcript:

Dani Bradley: Hello and welcome to another episode of the Ovia Asks podcast! I'm Dani Bradley, Director of Clinical Services and Evidence at Ovia Health. Today, I wanted to discuss a topic that's near and dear to everyone's heart at Ovia - women's health, women's health equity, and the power organizations have to impact and improve outcomes.

So, we all know that in their lifetime, women are rarely as engaged with their health as they are when they are starting to grow their family. But even though they're engaged, it can still be a confusing time with limited resources. Many women lack the information and resources that they need to really understand what they're at risk for and how they can best prepare for the best outcomes. Many are left relying on Google, social media, or friends and family for advice, instead of finding a trusted, accurate resource.

This is troublesome for many reasons, but certainly leaves them with unanswered questions, unidentified risk factors, and just a general sense of confusion and a lack of support. The pandemic has only worsened these issues in many cases, as a lot of OBGYN and midwife appointments were cancelled or modified or moved to virtual settings. Our research actually estimates that about 30% of prenatal visits were modified or cancelled during the pandemic. That number fluctuated depending on the geography and the stage of the pandemic, but as things slowly start to return to pre-pandemic care delivery, that virtual care component is here to stay and there will be long lasting changes to the way prenatal care is delivered.

When there are changes to care like this, it can lead to many feelings from patients about the care that they receive, including a perception of lower quality. They can feel like things are being missed or ignored, and that really brings a big risk for eventual adverse outcomes in birth outcomes. For those of you who don't know, maternity care is actually one of the largest medical cost drivers in the United States. What's more is that much of this spend is actually caused by avoidable adverse outcomes, yet somehow women's health and maternity care are still being labeled as niche by many.

So, while this is a lot of information to digest, you might be left wondering - what can my organization do to impact the lives of our members and improve their outcomes to reduce associated costs? Today, I am lucky enough to be joined by my colleague Lisa Richards who is not only a registered nurse and a certified nurse midwife, but also leads Ovia Health’s coaching team, so thank you so much Lisa for joining us!

Lisa Richards: Thank you Dani, I'm really happy to be here to talk about this today.

Dani: Wonderful - so Lisa and I are going to talk a little bit about how organizations can make really big impacts on maternal health and health equity for moms and babies through digital coaching and early education. Our research at Ovia shows that there are simple ways to significantly reduce pregnancy complications and close common gaps in knowledge and in care for women and families. 

Lisa: Thanks so much Dani! We've definitely seen some really amazing results with our programming, but before we dig in there, I want to make sure we're really setting the scene so our listeners understand why this is so critical to population health and the health of the next generation. So Dani, I’d love to hear your opinion on why you think women's health and specifically maternity care is so important for organizations to focus on and improve.

Dani: That's such a great question, and there are so many thoughts that come to mind. I think the first thing I'll say is that there's just such a massive opportunity here for improvement. Maternity care accounts for something like 10% of all healthcare spend in the United States and at the same time, the United States has the worst maternal mortality rate of any developed nation, so there's clearly a disconnect in the way that we're delivering care and what we're spending on it.

Not only is there room for dramatic improvement in healthcare for women and families, but investing in women more broadly has shown time and time again to boost communities and economies. So there's a clear opportunity to really be making an investment in women and babies.

The majority of the workforce right now is part of the millennial generation, and millennials care more about benefits than they do compensation. More and more research is starting to show that when millennials go out looking for jobs and they're part of the workforce, they're actually looking more at what the employer can provide to them from a benefit standpoint, including flexible work schedules and support with daycare and how can I balance the role of being a parent while also working. So, I think for organizations to be focusing on what women and families need to be successful in their personal lives will really show people that they care and allow people to show up in a big way in their professional lives as well.

In addition to being successful employees and being a contributing part of the workforce, it also influences overall health long-term. So, looking at population health outcomes, we can impact that if we start with maternity care. If an entire generation of women and children see adverse results or have less equitable care, that really adds up and compounds over time, so my biggest takeaway is just that there's an immense room for improvement. 

Lisa: Yeah, I think we're definitely seeing a culture shift there. Not only in the workforce, but in how people want to interact with their employers, healthcare providers, and health plans, and that willingness is certainly different than it may have been years ago. 

But even with the increase in technology and medical advances, things like preterm births are still really common. Preterm births account for 1 out of every 10 births in the U.S. today, and that's not the goal we want to be chasing.

So, as you said, the U.S. currently has the worst mortality rate for any developed nation, and there has to be something driving that. What would you say are the most common factors driving those poor maternity outcomes that we're seeing today?

Dani: It's a very, very complex issue with probably hundreds, maybe thousands of factors at play. I think cracking this is one of the biggest priorities for many organizations around the country right now, including some groups within the government.

There are countless factors that influence maternity outcomes. If I had to call out some of the most impactful, I would highlight the delivery of care. So, that includes the training of providers and provider philosophy, and the implicit bias and structural racism that exists in our healthcare system. When we're talking about health equity and maternity outcomes, we can't ignore the fact that Black women are four times more likely to die from pregnancy related complications compared to white women. These are things that there is clearly a need to address and many organizations are doing very important work to address these things, including Ovia. I think that’s an area for immense improvement over time.

One of the other things that I would call out is the social determinants of health, things like income and housing, education level, access to healthy food, transportation, safety at home - all of these things build up the environment in which somebody lives, which eventually impacts their outcomes. Addressing these things is the root cause; we need to go upstream and look at what is happening in people's environments and how can we make changes to the resources that they have and the access that they have to care that can eventually impact their longer-term outcomes.

And all of this really adds up to one big point which is healthcare outcomes aren't where they need to be, and disparities in birth equity just need to be addressed. So, like I said before, organizations are working on this, but there's much more work that needs to be done.

Lisa, you and your team speak with women across the United States daily as coaches at Ovia.  What do you hear most often that strikes you as one of the biggest gaps in care and what are women kind of needing support on the most?

Lisa: That is a really great question and I think women in general just need more support across the board at this time in their lives when they are trying to get pregnant, when they are pregnant, when they are new parents. We see that these women are hungry for information and so they're reading parenting blogs and joining Facebook groups and really, they want to know more and they don't always know where to turn. 

So, when they reach out to us, they're often reaching out just because they're uncertain, they're unsure. They don't know if what's going on in their body is normal or not, they don't know what info they can trust when they turn to the Internet, they don't know when it's important to go to their healthcare provider with their question or their concern, and so when all those questions come up, they don't feel like they have a trusted resource that they can really easily turn to in that moment. They may also not always feel comfortable going to their healthcare provider; they might feel embarrassed about their questions, or they may worry that they're going to be judged or have their concerns dismissed, and so that's the gap that we can really fill.

Even during pregnancy, when the average person is being seen by their healthcare provider much more often than she will ever be seen at any other time in her life, she's still not always getting her questions answered. And so, we can be there in between those doctor visits as a source she can turn to. Another factor is they just plain don't know what questions to ask sometimes; they don't know where to start.

Dani: Yeah that makes perfect sense. I think it sounds like the biggest gap is just the fact that there is a gap - there's room for more support and there's room to provide more access to resources and information for women around the country who are starting their families.

For many people, particularly those who are starting their families right now or having a child for the first time, there are just so many unknowns and there's a lot of anxiety around the experience with changes to your body, changes to your mental health. And we know that there are a lot of things that are either missed or skipped when patients don't feel prepared to advocate for themselves in an appointment with their OBGYN or their midwife. At no fault of their own, providers are extremely busy running from one patient to the next and there often isn't enough time to have your questions answered or to have an opportunity to ask for what it is that you're looking for in your care. So, what we do at Ovia is focus on what patients can do for themselves - how can they feel empowered and confident to go into their visits with their providers to ask for what it is that they know they need because they know their body and they know what's best for them in collaboration with a provider who can provide the care that's right for their risk factors. 

I think a perfect example is the risk for preterm birth and how that can be identified with a cervical length measurement. So this is not currently the standard of care, though there's mounting evidence to suggest that universal cervical length measurement would actually improve outcomes and reduce costs. At Ovia, we educate members on what a cervical length measurement is, what is the value of it, what can it tell you about your health, and what the next steps are if you do find out that you might be at risk for preterm birth. So, preparing women in that way to go into a visit so that they can ask for screenings that maybe they wouldn't otherwise be offered by a provider really allows us to bring patients into the decision making of their own healthcare.

Why do you think, Lisa, that most women aren't actually asking about factors that contribute to preterm birth and what could we do to improve women's confidence in doing that?

Lisa: Most patients aren't healthcare professionals themselves, they're not scientific experts. And so you said that there's this growing mountain of evidence out there about the importance of universal cervical length screening, but most patients aren't equipped to go out there and interpret all of that data. For many people, what they do is they just put their trust in their healthcare provider and assume their provider is doing what's best for them, and that their provider is staying on top of that evidence. While it's hopefully true in many cases that this is what's happening, we know it isn't always happening - certainly some providers are better than others at staying on top of evidence and updating their practice to reflect the most current and up to date guidelines. So there really is an opportunity for people to advocate for themselves in a way that could potentially improve their outcomes.

So Dani, I know that's something you recently studied and I think it would be great to dive in a little deeper there because I think the results are really interesting: can you tell us more about the study that you recently completed and presented at the 2021 ACOG conference on the impact of digital health coaching on cervical insufficiency education and how women/men uptake cervical length measurement?

Dani: Yes, I would be happy to! I’m very proud of this research that came out of the research group at Ovia that studied the program that you lead and that we built to support millions of women. So, we published a piece of research that looked at the role that digital coaching had on uptake of cervical length screening, as you mentioned. We presented it just this past spring in 2021 at the American College of Obstetrics and Gynecologists Annual Meeting and what we did was we looked at women who were enrolled in the Ovia pregnancy app over the last couple of years and we looked at their participation in our coaching program. What we actually found was that, among the women who engage with coaching compared to those who did not engage with coaching, they had a two times greater likelihood of having their cervical length screened to determine whether or not they have an insufficient cervix, which we know is a key factor in figuring out if they are at risk for preterm delivery and then likely to move on to use a medication called progesterone which is demonstrably effective at reducing the risk of delivering preterm. So connecting the dots to look at how we go from education, coaching people to be empowered to ask for what it is that they need, identification of risk early so that we can mitigate it with interventions that work, and then leading to those eventual outcomes like Ovia’s ability to reduce the impact or the incidence of preterm delivery. 

Given these outcomes and the importance of screenings like this and what you've heard, Lisa, from Ovia members in your work and coaching, what would you say are the main ways that women and members can get educated on how to advocate for themselves in their healthcare?

 Lisa: To me, the answer is really simple: every woman should have access to an Ovia health coach and should be reaching out to us for their guidance, but we know that's not always possible. There are a lot of other resources out there and it's really important to just look at the source and really understand where it's coming from and whether you can trust it and whether it's staying up to date. Things like a parenting and pregnancy book that you can buy online might be great, but it can take years for evidence that's coming out now to work its way into those pregnancy books, and so you want to make sure that you have a source that you trust that you can go to. 

Dani: Absolutely, I agree with you. I think not enough can be said about the power of having health specialists available to you through a coaching service like ours. There are many other resources, of course, but I think the feedback that we've heard from members who do have access to our services is just so powerful. I mean, we hear from people that say “I don't know what I would do if I didn't have access to this team of nurses who could answer my questions”. Members often feel like they have too small of a question that they don't want to bother their provider with, and just having access to somebody at the tap of a finger to be able to answer your questions or calm your concerns can make such a difference in what your pregnancy ends up looking like and the outcomes of your pregnancy.

You and I know so much about Ovia Health’s coaching program, but for those who aren't as familiar: how does coaching help and what are coaches able to assist with specifically? What do you think the people on your team - the nurses, lactation consultants,  sleep coaches, the registered dietitians - all of these specialists who are so important for the continuum of reproductive care, what kinds of gaps are they filling and what support do they provide to members?

Lisa: So as you just mentioned, we do have sort of a broad range of clinical specialties on our team so we can address all kinds of needs and questions for our members. And really, education and empowerment are the foundation of what we do to help each individual make the decision that's going to be the best fit for them and their family. We can help to answer those questions that come up between healthcare appointments and we can also really help to get our members connected to the right resources if and when they need them. We know that finding and accessing care can be a major barrier for a lot of people in a lot of cases. People just don't know what services exist, or what they qualify for, or what services are covered by their health insurance, or how to find those services, even when they want them. So we really do our best to close those gaps, to break down those barriers, and help people find the support that they need.

Dani: For somebody who's going through becoming a new parent and all the changes that come with that like lack of sleep, having someone in your corner to answer those questions and help you through those times is so reassuring and is such a relief for so many people. Not everyone has access to a health coach, so what advice would you give women who are starting this journey and how can they make sure that they're educated? 

Lisa: So I would say find a trusted resource like Ovia and our team of health specialists, and talk to your healthcare provider and ask your healthcare provider how they stay up to date on evidence and guidelines. And then, in terms of all the info out there, as I was saying earlier, not every mommy blog or parenting group can be trusted, so know who you're talking to - ask questions like who wrote the book that you're reading and what's their background, who's teaching that childbirth class you signed up for and what's their background. Really ask yourself why you can trust them to help you make the decisions that are right for you. 

Dani: That's fantastic, that's really great advice. I have the same question related to self advocacy: so where can women and families and how can women and families advocate for their care to ensure that their needs are met? What kind of tips would you give people?

 Lisa: So again, speak up! Don't be afraid to ask questions - that is your right in our healthcare system. You should always feel informed and like you're part of the decision-making process. Anytime you're considering what may or may not be right for your health, you can consider using the acronym BRAIN to try to help guide you before making any health-related decisions for you or your loved ones. So that acronym stands for:

  • B is for benefits: What are the benefits of this choice?
  • R is for risks: What would the risks of this choice be?
  • A is for alternatives: What other choices might you have in this situation?
  • I is for intuition: What feels right? What is your gut telling you to do?
  • N stands for nothing: What if you just did nothing in this situation and you didn't make this choice or you didn't use one of those alternative options?

You should feel like you can answer all of those questions before deciding whether or not you are going to make a healthcare choice. You should feel like you know the benefits, risks, alternatives, what your intuition is telling you to do, and what happens if you do nothing at all.

So I know we have a lot of health plans and organizations that are looking to help women and families and their members do exactly that, and have a safer family building pregnancy fertility journey. So Dani, what advice would you give to those organizations who are looking to improve maternal health outcomes?

Dani: It's a great question and I think that BRAIN acronym is something that I will be using moving forward; that's not something I was familiar with before! But when it comes to organizations and what they can do for their members and their employees, I think it’s first and foremost about meeting people where they are: what is it that your members or your employees need from you to feel supported in their decisions and in the changes that are happening in their lives as they grow or start their families?

When it comes to showing your members and employees that you support them, there's so much more weight behind actually taking action, and I think that providing benefits like Ovia and many other resources really show them that you care and that you want them to have the resources that they need in order to have the best outcomes possible. When you're selecting the benefits that you want to offer to your members, I think what's important to keep in mind is that you're not duplicating anything that they already have access to. You're not trying to add another provider through a telemedicine solution that's going to have the same gaps in care as the provider that your members are already seeing. Selecting benefits that fill those gaps and address other concerns beyond what's available to them in the healthcare system is one of the best ways that you can provide support to your members and your employees.

And I think finally, it's just important to call out what we discussed at the start of this conversation, which is that there are different outcomes for different groups of people. Women of color have worse maternal health outcomes than white women and they need additional resources. So I think selecting resources thoughtfully and in a way that will really impact the resources that all of your members have, but particularly people who have disproportionately worse outcomes, is important. One of the things that we're doing at Ovia is that we're building a birth equity program which I’m incredibly proud of and excited to release and, on top of that, we've built our coaching team to reflect the people that we serve.

Lisa: Absolutely Dani, thank you so much for sharing all of those tips.

Dani: Sure! Thank you so much for joining us today Lisa; I am so moved by all the work that you and the Ovia health coaches do every day to help guide and educate our members going through this really transitional time in their lives. I know you hear thanks from them every day, but I want to thank you as well. Your work is so important and critical to reducing birth inequities, as well as improving outcomes and education and advocacy for women and their families every day.

And if anybody is listening who has questions about Lisa's work or health coaching more generally, please feel free to reach out to Ovia! We are happy to discuss in more detail and thank you again! We hope you enjoyed the conversation and you'll join us next time.


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