Governor Newsom Appoints First-Ever Surgeon General for California

By Xenia Shih Bion

https://www.chcf.org/blog/governor-newsom-appoints-first-ever-surgeon-general-california/

About a year ago, Nadine Burke Harris, MD, MPH, published her first book, The Deepest Well: Healing the Long-Term Effects of Childhood Adversity. The book chronicles her journey from San Francisco pediatrician to pioneer in the field of research on adverse childhood experiences (ACEs). On February 11, Burke Harris will take another momentous step on her career journey: She will be sworn in as California’s first-ever surgeon general.

Governor Gavin Newsom announced the appointment of Burke Harris on Martin Luther King, Jr. Day, describing her as a “pediatrician, entrepreneur, and nonprofit CEO” who has “dedicated her professional career to understanding the link between adverse childhood experiences and toxic stress in children, and the effect both have on future health outcomes.” As surgeon general, Burke Harris will “urge policymakers at every level of government and leaders across the state to consider the social determinants of health, especially for children.”

On the campaign trail, Newsom spoke often about the need to invest in early childhood education and health care, and he has worked quickly to propose early childhood investments in his initial acts as governor. During his inauguration speech he said, “California is our home. In our home, every child should be loved, fed, and safe. … We will support parents so they can give their kids the love and care they need, especially in those critical early years when so much development occurs.”

The Heart of the Issue

Burke Harris’ research has centered on the impact of trauma on children in early childhood. In 2008, she was working at the Bayview Child Health Center, treating children and adolescents who were growing up in one of San Francisco’s poorest neighborhoods. As she recounted a few years later to Paul Tough in The New Yorker, the clinic was making significant headway on health issues like asthma that are common among low-income children. Despite that, “I felt like we weren’t actually addressing the roots of the disparity,” she told Tough.

Then a colleague gave her a journal article about an ACE study conducted by Kaiser Permanente San Diego. The study of more than 17,000 Kaiser HMO members found that the higher an individual’s ACE score, the worse his or her health. There was a stunning range of negative health outcomes for which this correlation was found ­— likelihood of having an alcohol use disorder, of injecting drugs, of having diabetes, heart disease, or cancer ­— just to name a few. Lead author Vincent J. Felitti, MD, summarized, “The ACE study reveals a powerful relation between our emotional experiences as children and our adult emotional health, physical health, and major causes of mortality in the United States.”

The study was a revelation to Burke Harris and changed her approach to treating young patients in her clinic. In an interview with the Center for Youth Wellness, which she founded in 2013, she said, “When I first started my research into toxic stress, I had no idea that childhood adversity could change the way our DNA was read and transcribed. I never learned about that in medical school.” But she went on to pave the way for important local and national efforts to combat childhood trauma, leading the Bay Area Research Consortium on Toxic Stress and Health and serving as a member of the American Academy of Pediatrics’ National Advisory Board for Screening, among other appointments.

“We couldn’t be more proud of Nadine’s appointment as Surgeon General of California,” said Mary Pang, board chair of Center for Youth Wellness. “Nadine now takes the power of her voice and vision to Sacramento, working alongside policymakers to effect change and creating a healthier California for all of us.”

How California Is Caring for Those with Trauma

There is already some work underway at the state level to address childhood trauma. Former governor Jerry Brown signed two childhood trauma bills into law in late 2017. According to an ACEs Connection blog post, AB 340 “creates a statewide advisory body to review current screening protocols and make recommendations about how to improve trauma screening for children” in the Medi-Cal program. AB 1340 “requires the Medical Board of California to consider including in its continuing education requirements a course in integrating mental and physical health care in primary care settings, especially as it pertains to early identification of mental health issues and exposure to trauma in children and young adults and their appropriate care and treatment.”

Additionally, Medi-Cal has taken steps in recent years to focus on ACEs and trauma-informed care. For example, Medi-Cal’s Whole Person Care pilot program (PDF) in 26 counties coordinates health, behavioral health, and social services to improve vulnerable people’s health outcomes (CHCF is supporting the pilots’ Learning Collaborative). Some Whole Person Care pilots, including one in Marin County, use a trauma-informed approach to understand and address individuals’ complex needs.

Sandra R. Hernández, MD, president and CEO of the California Health Care Foundation, spoke at the Center for Youth Wellness’ 2018 ACEs Conference about the importance of health coverage for providing people who have experienced trauma with appropriate care. She praised Governor Newsom’s appointment of Burke Harris, saying, “Dr. Burke Harris is recognized nationally as a pioneer and advocate for understanding childhood trauma and building a foundation for lifelong health. I can’t imagine a better person for this role.”

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The U.S. Needs More Midwives for Better Maternity Care

https://www.scientificamerican.com/article/the-u-s-needs-more-midwives-for-better-maternity-care/

Despite the astronomical sums that the U.S. spends on maternity care, mortality rates for women and infants are significantly higher in America than in other wealthy countries. And because of a shortage of hospitals and ob-gyns, especially in rural areas, many women struggle to access proper care during pregnancy. Moreover, the rate of cesarean sections is exceedingly high at 32 percent—the World Health Organization considers the ideal rate to be around 10 percent—and 13 percent of women report feeling pressured by their providers to have the procedure.

Widespread adoption of midwife-directed care could alleviate all these problems. In many other developed countries, such as the U.K., France and Australia, midwifery is at least as common as care by obstetricians. In the U.S., certified midwives and nurse-midwives must hold a graduate degree from an institution accredited by the American College of Nurse-Midwives, and certified professional midwives must undergo at least two years of intensive training. This is designed to make midwives experts in normal physiological pregnancy and birth. Thus, for women with low-risk pregnancies who wish to deliver vaginally, it often makes sense to employ a midwife rather than a more costly surgeon. Yet only about 8 percent of U.S. births are attended by midwives.

The roots of America's aversion to midwifery go back to the late 1800s, when the advent of germ theory and anesthesia reduced much of the danger and discomfort associated with childbirth. The benefits of these technologies brought doctors to the forefront of maternity care and pushed midwives aside. Obstetricians helped to bar midwives from practicing in hospitals, which were now considered the safest birth settings. By the early 1960s midwifery was virtually obsolete.

It has made a comeback since then, with practitioners just as well trained as doctors to supervise uncomplicated deliveries. Studies show that midwife-attended births are as safe as physician-attended ones, and they are associated with lower rates of C-sections and other interventions that can be costly, risky and disruptive to the labor process. But midwifery still remains on the margins of maternity care in the U.S.

To bring it back into the mainstream, midwives must be fully integrated into the medical system. Some states currently refuse to recognize them as legitimate practitioners, and some severely limit what midwives are allowed to do, despite evidence that states with the most restrictive policies also have some of the highest rates of adverse birth outcomes, such as deaths of newborns. If midwives were allowed to work alongside other providers, patients would get the care advantages, and if difficulties arose, a woman whose home birth suddenly became complicated could be seamlessly transferred to a hospital.

Even when state laws are favorable, women who wish to work with midwives often face financial obstacles. Medicaid will cover all midwifery services, according to the Affordable Care Act, but the requirement does not extend to private insurers, many of whom lack in-network midwives or refuse to cover midwifery care at all. Half of planned non-hospital births are currently paid for by patients themselves, compared with just 3.4 percent of hospital births. Thus, a less expensive birth at home may paradoxically be out of reach for women who cannot afford to pay out of pocket. U.S. hospitals charge more than $13,000, on average, for an uncomplicated vaginal birth, whereas a similar midwife-attended birth outside of the hospital reduces that figure by at least half. Insurers would save money by embracing midwife-attended, non-hospital birth as a safe and inexpensive alternative.

A national shortage of birth centers further limits women's choices. These homelike settings are designed to support naturally laboring women with amenities such as warm baths and spacious beds and are consistently rated highly in surveys of patient satisfaction. Yet there are only around 350 existing freestanding birth centers in the entire nation, and nine states lack regulations for licensing such facilities. More government support for birth centers would help midwives meet a growing demand, which has already fueled an increase of 82 percent in centers since 2010.

Policy makers, providers and insurers all have good reasons to encourage a shift toward midwifery. The result will be more choices and better outcomes for mothers and babies.