December 17, 2020
When asked to describe the early days of the COVID-19 pandemic in New York City, Sascha James-Conterelli, DNP, CNM, LM, FACNM answered in three words:
“It was hell.”
Health care professionals went to work without personal protective equipment (PPE) due to lack of supply, and because of that, many of them became infected, too. “It has not been widely publicized, but health care workers, including nurses, have died as a result of the pandemic,” she said. “Our workforce was decreasing with folks getting sick. We were under-resourced with PPE and testing. We felt helpless. Aren’t we supposed to save folks and save people and have the answers? It was very eye opening in that we are all human. Letters after your name did not protect you from the virus. We are all vulnerable and all in it together,” she said.
James-Conterelli and her colleagues knew they needed to protect the most vulnerable: the elderly, those with comorbidities, and mothers and babies. To decrease the spread of the virus, hospitals limited the amount of people entering the hospital, including initially barring a support person at the bedside for laboring women. James-Conterelli and her colleagues wrote a letter to Governor Andrew Cuomo, and with many others, they advocated to allow a support person at the bedside. Later, doulas were also allowed. James-Conterelli was soon named to Governor Cuomo’s COVID-19 Maternity Task Force.
Disparities in care became crystal clear during the pandemic. Hospitals in the middle of boroughs, where populations are predominantly non-white, were the last to get PPE and point-of-care testing, but they had the greatest number of people affected by the virus.
“To see those numbers graphed on a daily basis showed the undeniable racial disparities. Pregnant women were dying in those hospitals because there were barriers to being tested and barriers to being protected. Forget not having a partner at the bedside—they couldn’t even get a test or a mask,” James-Conterelli said.
A GLOBAL ISSUE
James-Conterelli is quick to point out that maternal mortality was a global issue well before COVID-19. The reasons why pregnant and birthing women die are essentially the same across the world, but in the United States, “the issue of racism is even more of a problem,” she said. “When we really look at the bottom line, yes, access to care is an issue. However, a bigger issue is the fact that even when you have a well-educated Black person with access to care and means and money—this population is dying at an even higher rate than less educated, lower income, more marginalized folks.”
In discussing tennis legend Serena Williams, who suffered life-threatening complications after the birth of her daughter in 2017, James-Conterelli notes that someone like Williams, who is in peak physical condition and has access to the best medical care, still found that her complaints were ignored.
“So, then it leads you to ask what’s really the issue,” she said.
“It must be racism. There is nothing else, because when you start to drill down and really look at case-by-case scenarios, you see subtle holes in care that if it’s taken in one instance, it may not be anything, but when you line it all up, you will realize there is a huge systemic problem of how people view Black people, regardless of income, education, or socio-economic status.”
James-Conterelli’s work as co-chair of the Governor’s Task Force on Maternal Mortality and Racial Disparities has helped provide the research and the narratives that demonstrate racism as a public health crisis in this country. According to the CDC1, Black infants are more than twice as likely than white infants to die in the United States2, and Black women are more than three times as likely to die than white women.
Dr. Howard Zucker, MD, JD, the Commissioner of the New York State Department of Health and co-chair of the task force, held listening sessions across the state where Black patients spoke of assumptions that were made before any questions were asked. If a partner did not attend a prenatal visit, it was because he must be incarcerated, not just at work. It was assumed that patients were on Medicaid, but they were not asked what their insurance plan was. For many, it was assumed that the pregnancy was not wanted.
Two women, one from Brooklyn and one from Buffalo, were invited by Zucker to share their stories with the group. They bluntly told the task force, composed of a diverse group of providers, that they had failed, which James-Conterelli admitted was hard to hear.
“‘All of you failed me,’ they said. It was the most powerful and most hurtful thing that you could hear from people that you set out to help. We all enter this profession to do good; to make positive change. And we were not, collectively,” she said. “It was so eye opening. So, it was up to us to develop ways in which we could help women and birthing folks like those that stood in front of us to never become a statistic. How could we learn from and honor the women that gave their lives, basically, to tell us the story that our system is broken, not just in New York but across this country?”
“We talked about implicit bias at first,” she continued.
“Then we realized that this is actual racism, and we had to say the word, be okay with that, and understand that this is the long-standing history of a well-created system that we live and exist in. There are parts of the system that are glaringly in need of change, but overall, the system it is so intricate and there are so many layers to it, that many of us, even Black folks, would not get at first.”
The group’s first recommendation to the governor was to develop a maternal mortality review board that assessed the entire state. The trends and statistics show that greater than 60% of the women who die, die from preventable reasons. “Bottom line,” James-Conterelli said, “is not valuing birthing people. There is a lack of recognizing the holistic person; mental health issues; resources within the community, and follow-up and connection from community to provider to hospital to lead to recommendations.”
When there is a lack of Black providers, through both access and sheer numbers, often Black patients will not divulge information about themselves that may be important to their care because they worry they will be judged. “There is evidence to demonstrate that culturally congruent care decreases your rate of maternal mortality,” she said.
The Task Force made 10 recommendations, including reimbursing midwives at the same rate as physicians for the same care. Medicaid reimbursement for midwives in New York is 85% of the rate at which physicians are reimbursed for the same level of care.
Another recommendation was to increase the number of midwifery programs in state universities to provide another point of entry into the health care field that students may not be aware of. “When little kids only know about doctors and nurses, but they don’t know about midwifery, nurse practitioners, social workers, physician assistants, occupational therapists, or physical therapists, that’s a system failure. So, we need to make education more affordable for all,” James-Conterelli said.
Providers must also look at how they train new staff. Do they understand their own biases? Can they recognize them, and be ok? Can they work towards breaking down barriers and stereotypes?
“You have to change practice from the ground up, while also working from the top down,” James-Conterelli said.
THE TIP OF THE ICEBERG
“Maternal mortality is the tip of the iceberg,” James-Conterelli said. “Underneath is the big mountain of morbidity.” James-Conterelli uses University of Michigan professor Arline Geronimus’s theory of “weathering” to explain how the murders of George Floyd and Breonna Taylor, as well as countless others, affect Black and Brown people on a cellular level.
In an article in the American College of Nurse Midwives’ digital magazine Quickening, James-Conterelli writes, “Black and Brown people have a higher risk of comorbid conditions, such as diabetes and hypertension, but this is not because of their race or ethnicity. Rather, it is related to how people react to the color of their skin. Black and Brown people in the United States suffer from the generational effects of institutional racism that have altered their cellular reactions to life stressors such as pregnancy… . When a person is exposed day after day to harsh elements, they change, just as a wooden shingle becomes brittle after years of exposure.”
For example, if a pregnant Black woman is afraid every time she is near a police officer, the fear causes the fight-or-flight response, inciting a physiologic response that could potentially divert essential blood flow from the placenta to the mother’s heart, even if only for a brief period. As hormone levels rise, it affects the fetus in utero, increasing the possibility of deprivation of oxygen or the possibility of a greater risk of hypertension in the mother, which can cause an increased risk of intrauterine growth retardation (IUGR).
It is not that the woman had an underlying increased risk of high blood pressure; it is the physiologic response to fear that increases the hormones of reactivity, narrowing the blood vessels and leading to the onset of hypertension or diabetes, creating lasting effects on the unborn child and creating a generational effect. The baby is born “into a world that continues to repeat these effects, and they continue to repeat the cycle over and over again,” James-Conterelli said.
James-Conterelli notes that to begin to dismantle this kind of generational inequality, it must first be recognized and then attributed to racism. After that, you can address it and build solutions, which starts with education. “One of the reasons why I love that I’m in education is because you start with those that are most open to it: students ready and willing to learn that this is a problem,” she said.
In nursing and health care education, students can get the tools they need to recognize and stop perpetuating racism and gain the understanding that health care looks different for different people. “But it shouldn’t; it should be the same,” she continued.
“[Health care] can be tailored to the individual, but it must be equitable and treat the human and not the skin.”
FINDING HER CALLING
James-Conterelli’s journey to midwifery was not a direct line. “I actually wanted to model and do fashion,” she said with a smile, and did model for a little while before her mother, a physician, suggested she pursue something else as her major as a student at Howard University. James-Conterelli chose nursing and fell in love with it during her junior year. After graduation, she initially worked in oncology, but conversations with her mother and her grandmother, who birthed all eight of her children at home with a midwife, greatly informed her career choice. She also points to a pivotal interaction with a midwifery preceptor at Howard University who spoke about her work in Great Britain.
“I found that midwifery was my calling and what I wanted to do. What I do now feels more like part of my life than a job,” she said.
Earlier this year, James-Conterelli was named the first Black chair of the Graduate Entry Prespecialty in Nursing (GEPN) program at YSN. She serves as Chair-Elect for the 2020-2021 academic year and becomes Chair in the fall of 2021.
In the early stages of applying for the position, James-Conterelli spoke to Dean Ann Kurth ’90 MSN, PhD, CNM, MPH, FAAN. “[Dean Kurth’s] vision aligns with mine,” she said. “We want to move the school forward as a community. How do we better our entire community with the understanding that GEPN is the foundation for many of us? To me, that entrance is like the front desk staff in an office: it has to be the strongest because that is where folks encounter everything about your practice.”
GEPN students are a diverse, well-rounded group, and many of them worked in other professions before applying to YSN. “It’s not always that we are imparting knowledge,” said James-Conterelli. “We learn a lot from our students, and I hope that continues.”
James-Conterelli wants to help channel the students’ passion for advocacy into their learning by teaching them to be the best providers they can be first, while also learning how advocacy ties into their practice. “They are impatient, and I understand that. But I want them to realize this is a journey. I am impatient, too, but there is something to be learned in taking a deep breath and slowing down.”
She aims to make YSN’s GEPN program the strongest graduate entry program in the country with a student population that reflects the populations they serve.
“I hope that we have an even more diverse group of students that, when they click on the website and they see GEPN faculty like me and Dilice Robertson and Linda Ghampson, that they feel as though they belong by seeing our faces and reading our bios. I hope they see that they can do it, too,” she said.