Addressing the Drivers of Maternal Mortality

12:00 p.m. – 12:10 p.m.     Welcome and Introductions

• Sarah J. Dash, MPH
  President and Chief Executive Officer, Alliance for Health Policy, @AllHealthPolicy
• Laurie Zephyrin, M.D., MPH, MBA
  Vice President, Delivery System Reform, The Commonwealth Fund, @commonwealthfnd

12:10 p.m. – 12:45 p.m.     Panelist Opening Remarks

• Shanna Cox, MSPH
  Associate Director of Science, Division of Reproductive Health, Centers for Disease Control and Prevention

• Jennie Joseph, L.M., CPM
  Executive Director, Commonsense Childbirth Inc., @jenniejoseph

• Elizabeth A. Howell, M.D., MPP
  Director, Blavatnik Family Women’s Health Research Institute, Icahn School of Medicine, Mount Sinai Health System, @LizHowellMD

• Eugene Declercq, Ph.D.
  Professor and Assistant Dean for DrPH Education, Community Health Sciences Department, Boston University School of Public Health;
  Professor, Department of Obstetrics and Gynecology, Boston University School of Medicine

12:45 p.m. – 1:30 p.m.       Question and Answer Session

(Note – This is an unedited transcript. Please refer to the video of the event for accuracy.) SARAH DASH:  Good afternoon, thank you so much for joining us today.  I am Sarah Dash and I’m the President of the Alliance for Health Policy and we’re really thrilled to have all of you here today.  For those of you who have perhaps not been to an Alliance event before, we are a non-partisan organization.  We are here as a resource for policy makers and the policy making community on a wide variety of health policy topics.  And today we are really honored to be bringing, in partnership with the Commonwealth Fund, this briefing on maternal mortality and what the drivers are, and what the potential solutions are.   About 24 hours after I had my own baby, I got a small glimpse into some of the disparities that we’re going to talk about.  I decided to walk her down the hall in her little bassinette and all of a sudden heard on the intercom, a code being called.  And all of a sudden, all of the medical personnel started running down the hall and of course I got out of the way and they all ran down to the emergency room and of course I was incredibly concerned about what was going to happen.  And a few minutes later, saw some of them walking up and walking back up, and then a few minutes after that, saw an African-American woman being wheeled up on a stretcher with a newborn baby on her chest.  And was relieved that they were both — they seemed to be alive and hopefully well.  And then a minute or so after that, as I was walking my own baby back to my recovery room, overheard a couple of medical personnel saying, yeah, there was a “stop and drop” down in the ER.  And that phrase stuck with me and I don’t know any more about that woman’s story, I don’t know anything about her background, but it was one glimpse into the wide differences that can occur when it comes to childbirth in this country.  And today, we’re going to hear some hard facts and hard statistics about maternal death and major morbidity, or serious injury.  What’s driving it and what’s driving some of the very, very serious and tragic disparities in our country.  So I hope that all of you will take away some new learning, some new insights, and some new ideas for how you can all go back to your day-to-day work and take steps towards solving this very, very important problem.   So with that, I’m very honored today to introduce a guest moderator for today’s panel.  Today’s panel will be moderated by Dr. Laurie Zephyrin.  She is the Vice President of Healthcare Delivery System Reform at the Commonwealth Fund, where she leads their portfolio on vulnerable populations.  She’s a certified Ob/Gyn and has spent her career implementing evidence-based policies and programs to improve healthcare delivery across the nation.  From 2009 to 2018, she was the first National Director of the Reproductive Health Program at the Department of Veteran’s Affairs, spearheading their strategic vision and leading systems change through the implementation of evidence-based policies and programs to improve the health of women veterans nationwide.  So I want to thank Dr. Zephyrin for moderating today’s discussion.  She’s going to go ahead and introduce our panel.  Thanks, Laurie.  

1. ZEPHYRIN: Thank you so much. And thanks everyone for being here.  It’s amazing to see a packed room and an audience on such an important issue.  As you know, there are shocking statistics in this country.  Women are dying during childbirth and in a country of this size and wealth and innovation, it is an injustice.  We know what to do and we know there’s a role for policy and I’m so glad all of you are here today to discuss and hear those options.

  I’m a physician, an Ob/Gyn, and a mother, and have engaged in transformation efforts locally and globally, and this issue is near and dear to my heart.  We’ve really created, and we have a healthcare system that too often fails women.  And so today we’re going to address some drivers and understand why, and share some solutions.  This is also about race.  Black women and Native American women are more likely to die when experiencing what should be a special journey for moms and their families.  And most of these maternal deaths are preventable.  At the Commonwealth Fund, I lead the vulnerable populations work there.  And when I’m talking about vulnerable populations, I’m talking about people that are vulnerable to inequity, and that this vulnerability is created by systemic disadvantages and we’re going to address some of those disadvantages today because we know what to do.  We know how to address this.  Racism and implicit bias are really linked to these maternal outcomes and black women are severely impacted.  We hear about the 700 plus deaths every year as a result of pregnancy and mortality.  We need to talk about the near misses, severe disability from pregnancy.  There are over 60,000 of them a year — of these women a year.  What happens to these women?  The trauma of having a complicated birth and how this impacts trust and well-being.  And how it impacts cost to the healthcare system.  We know what to do, we can intervene.  It’s about decreasing maternal deaths, eliminating the disparities and also decreasing severe maternal morbidity.  These deaths are occurring during pregnancy, at the time of delivery, and the majority after delivery when for many women, support is lacking.  Imagine going home with a newborn without that support.  Medicaid expires and they are left alone while they may be getting closer to death.  This risk doesn’t end when the child is delivered.  Moms matter even after birth.  And we can prevent this.  We see higher costs when we don’t prevent this; when we don’t intervene, and we know how to intervene.   So today we’ll explore how policymakers and health system leaders can shape solutions to get better outcomes for women.  We’re incredibly fortunate to have this panel of nationally recognized leaders who’ve been working to advance maternal health for decades, and they are joining us today in our discussions.  We will start with a patient-centered approach, Jennie Joseph, creator of the JJ Way.  And she coined the term “returner toxic zones” and I have had the pleasure of hearing her speak and hearing about her work.  She’s the Executive Director and founder of Common Sense Childbirth.  Then we’ll share data and trends — Miss Shanna Cox, Associate Director of the Division of Reproductive Health at the Centers for Disease Control and Prevention.  Then we’ll talk about why maternal health is the canary in the coal mine and the public health approach, Dr. Eugene Declercq, Professor and Assistant Dean of Community Health Sciences Department at Boston University School of Public Health.  And then we’ll talk about health systems and patients and address solutions addressing racism and bias.  Dr. Elizabeth Howell, Director of the Balvatnik Family Women’s Health Research Center Institute at the Icahn School of Medicine in Mt. Sinai.   So thank you very much for all of you sharing your work with us today.  And, Jennie?   JENNIE JOSEPH:   Thank you and good afternoon, everybody.  I am really glad to be able to speak today and I’m thrilled that you’re here.  Yeah, so I’m a midwife.  I’ve been in this field for 40 years.  I’m a British trained midwife, but I’ve lived in the United States in Orlando for 30 of those years.  I want to talk a little bit today about maternal toxicity — maternal toxic zones and why that’s a big problem for the United States.  Even as Sarah made her introduction and she talked about her experience as a newly delivered mother, how her experience looked really different to the woman that she described to us.  But she also talked about the fact that the terminology that was applied to that situation — the “stop and drop”, there’s some connotations there.  There’s some relevance there to using that type of terminology, because when we’re talking about equity, that terminology is key.  And I’ll explain a bit more as I go along.   As far as I’m concerned, in America, what we’re dealing with, is maternal toxicity is zip code specific.  It’s area specific.  But it can also pop up.  And so by that I mean, you could be, for example, like Serena Williams in the hospital and suddenly be surrounded by maternal toxicity because of who you are perceived to be.  All right?  So I’ll go back to the “stop and drop” example:  Women who are under that terminology, that means something.  Women who aren’t under that terminology, the term might be, oh, she had a precipitous birth and we implemented the precipitous birth protocol to support her.  See the difference?   So what’s going on?  Well, we’ve got our goals.  We make them every ten years, and the government says, you know, look, what we’re up to is eliminating health disparities.  In fact, for 2020 we are really ambitious, we are going to go ahead and achieve health equity.  I’m just noticing this 2019.  So not to be naughty, but just I’m pointing out that we have goals, but I wonder if we are really clear about how we are going to get there.  So we know what’s going on.  Our babies are dying.  In terms of African-American black babies die twice as often.  They are born too soon, they are born too small, they are born too sick to survive that first year of life.  This is America.  And of course, our women are dying.  And I’ve got 50,000 on my slide, I’ve heard 60,000 for the women who nearly died.  But I’m going to say it’s way higher than that.  Because you know what?  In America, women don’t talk about their experiences.  We stuff that right down really deep and we try to manage, we try to go on.  So I think that number could be doubled and we still might not be close.  Because you — if you have had a birthing experience in this country, you know what I’m talking about.  Whether you were a near miss or not.  But think about your girlfriends, your family, your neighbors.  They will have a near miss story for you.  That’s how many we’re dealing with.  So the social determinants of health play a part in the maternal toxic zones and environments.  Just know this:  Women and families are suffering whether it’s pregnancy — prenatally, during their actual delivery in the hospital environments or even out of hospital environments.  Or post-partum.  And the biggest problem we have is post-partum.  We abandon women in this country, once the baby is out, two days after the delivery, they are tossed out of the hospital, and it’s like, “Take this child and go home, figure it out. And maybe we’ll see in six weeks for a post-partum exam.”  And if any of you have ever had a post-partum exam, you know it’s a PAP smear.  What’s a PAP smear going to do for you when you’re newly delivered, possibly already suffering post-partum depression, struggling with breastfeeding, or worse yet, already back in the workforce.  We have a problem.   So it seems odd to me in a developed nation — the most developed nation in the world, that we have to talk about making pregnancy safer for women.  Particularly women of color.  I’m in Orlando, Florida.  I arrived 30 years ago and I’m still there, and I’m still trying to figure out why.  But in the meantime, what we did was we worked on how can we make it more accessible so that the care that’s missing — which is really a support that’s missing, right?  You know, medically, we’re sound.  Medically we’re great.  We spent a fortune on medical practice.  But the support that is missing is what’s causing the danger.  I’m a midwife, so I use the Midwifery Model of Care, but the Midwifery Model of Care is simply a patient-centered care.  Women-centered care.  It’s culturally correct.  It’s cultural humility.  It’s using the senses that we typically don’t bring into medical practice — compassion, listening, responding in a humanistic way.  Those are the things that keep things safe.  I have a birthing center where women have an option and choice for natural birth if that’s what they want.  The majority of my patients actually choose hospital birth because American women deliver in hospital, and that’s fine.  I don’t have any problem with that.  But what I do know is that having access to prenatal care with midwives, having post-partum care with midwives, means that you have somebody who’s paying attention to you across the entire experience.   The other thing we know is that we’re doing trauma informed care.  Why?  Because like I just said, American women are traumatized around this issue and we are trying very hard not to retraumatize the women that we see.  So it’s safe care, it’s respectful care, compassionate, culturally sensitive and non-judgmental — back to that terminology.  Right?  Terminology is really, really rife in our work in obstetrics.   So we created the safety from providing access to what we call “perinatal safe spots”.  And a perinatal safe spot is essentially going to operate from these four cornerstones.  Always, first and foremost is access.  You have no barrier to care.  There is not one single reason you can think of, why we will tell you, no, you can’t come in.  The immediate access, unrestricted access, allows them to build trust and connections.  And once you do that, once you connect with a woman and she sees that you care about her, she is going to disclose, she’s going to be open, she’s going to be compliant, and she’s going to be able to thrive.  Once she’s in that role, we can go ahead and give her the information that gives her the knowledge to move through her pregnancy in post-partum with much more power and agency.  And the empowerment is always what we see as the end result.   But here is something else:  We applied the same principles to our staff.  That’s a big shift.  The women that delivered this kind of care are empowered to do it in the way that’s best for them, but in the way they also are fulfilled in their job.  These are some of the women from our clinics.  These are women from the community who move on now into medical course practices.  They move into the pipeline for care.  And they also deliver the care in a culturally congruent way.  Our stats prove that what we’re doing is working.  This is a study from 2006.  We’ve been doing this a very long time.   But even though it’s not easy to see on the graph, essentially what happened when we took 100 women, we enrolled them in this study, we were able to see that the women that were in our care compared to the county and the state of Florida, were absolutely blowing it out of the water.  We had zero prematurity amongst the African-American women and Latinas in our practice, in that study.  Zero.  Zero low birth rate babies.  Compared to our county at the time, was nearly 20 percent of prematurity in 2006.  So it wasn’t dropped a couple of points, it wasn’t just when we moved it along and you know what, we made a little difference here, a little dent there.  No, we eradicated prematurity out of a population of women who were at high risk for a premature birth.  This is what they look like.  These are women from the practice.  These are women that represent who we’re serving.  Who would not normally — you will not see pictures of black women looking so healthy, so strong, so empowered, and so robust.  And at the end of the day, even though my population of women are choosing midwifery care, they have realized that this the safest way, the most expeditious way to get to the other end of this experience alive and healthy, and thriving.  So absolutely the difference between regular care and patient-centered midwifery model care, saves lives.  Thank you.     SHANNA COX:   Good afternoon.  And so I’d like to thank you, Jen, for engaging us with that presentation and the work that you do with the communities for moms and babies.  And so I’m going to take a high level national picture of maternal mortality, what the data tells us, and what the gaps in the data are.  So we have apps that can deliver groceries to our homes and the hottest gadgets to your front door.  But for all of our improvements and technology, maternal mortality in this country is not improving.  So while it’s important to understand this data that I will present to guide us towards understanding these tragic events, it is important to acknowledge that each of these counts are heart wrenching personal stories.  These are women, partners, valued family and community members, who are owed the best possible outcomes as they engage on their childbirth journeys.  And so we need to better understand what the drivers of maternal mortality are, and how we can prevent them.   I want to start with some data from our pregnancy mortality surveillance system, or what we call the PMSS.  The PMSS is the best current source of national information on maternal mortality.  It improves on just looking at death records, because we do additional linkage with birth and fetal death records, and we review pregnancy related deaths up to one year after pregnancy.  All 50 states, D.C. and New York City, voluntarily share their information with the CDC, where we summarize it and review it with medically trained professionals to determine the cause and timing of death.  The PMSS allows us to understand patterns in the data and identify populations that are most impacted.  So here we share the differences in pregnancy-related deaths by race, ethnicity, and calling out the higher rates of maternal deaths among African-American and American Indian Alaskan Natives who are three to four times more likely to die of pregnancy related causes than white women.   We also see differences by age with increasing rates in pregnancy related death as women get older.  But what I want to particularly call out here is that the disparities that is the gap between white and black and African-American women, or American Indian Alaskan Native women, actually increases as age increases.  It is hypothesized that this may be due to what we call “weathering”.  That is chronic stress and exposure to implicit instructional racism increase the risk of maternal mortality due to age at a greater pace among black and African-American women and Alaskan Native American women, than among white women.   We also see differences in maternal mortality rates by education.  This slide is striking because it shows generally the rates are lowest among those with at least some college education, but I would like to point out that African-American, and again, American Indian Alaskan Native women with a college degree have a higher maternal mortality rate than white women with less than a high school education.  The traditional factors that should be protective for these groups of minority women are not.   There is also wide variation in maternal death rates by state.  Due to PMSS data agreements, we cannot release identified state estimates, but the geographic disparities are striking.  And even when we group states from lowest to highest pregnancy related death rates, there are still disparities by race.  So while a state may look better overall when compared to other states, things are not equal for all women within the states.   So early last month, CDC released a vital signs report that documented the leading causes of death by time period, where it showed that heart disease and stroke caused the most deaths overall.  Obstetric emergencies such as severe bleeding, amniotic fluid embolism, caused the most deaths at delivery, and the week after delivery, severe bleeding, high blood pressure, and infection are the most common.  Cardiomyopathy causes the most deaths one week to one year after delivery.  However, when we further look at that late post-partum period, the proportion of deaths among black women is higher than those among white women, and that’s likely due to a higher burden of these cardiomyopathy deaths.  So that’s why it’s important for us to really evaluate the data in a way that helps us tease apart what the drivers of the disparities are.  So there are some limitations to the pregnancy mortality surveillance system.  It is built upon vital statistics, and so it’s limited in its ability to describe why these deaths are happening.  So for any problem to be solved, we know that strong data is needed.  And what is old is new.  The maternal mortality review process is not a new process, but support for these review committees have waned over time, resulting in a very piecemeal approach.  These multi-disciplinary committees review both clinical and non-clinical data about a maternal death, to provide a deeper understanding of the circumstances that surround each maternal death.  One of the unique abilities of the maternal mortality review committees is the ability to determine preventability.  And also, contributing factors, so we can prevent future deaths.  So CDC is working to support these review committees to ensure that we have robust data to better understand and prevent maternal mortality.   The data that I noted earlier from the PMSS does not capture data due to mental health conditions very well.  But review committees are able to dig deeper into the data and find that mental health conditions contribute to about seven percent of pregnancy related deaths mainly in the post-partum period.  But I also want to point out differences in the leading causes by race.  Whereas mental health and substance abuse are leading causes of death for white women, they have a much lower impact for African-American women.  So we have to be careful that we do not shift our focus to one cause, without looking holistically at all of those drivers of disparities, because in some ways, while it may be well-intentioned, we may end up exacerbating disparities.   So maternal mortality review committees, again, can help us identify opportunities for prevention.  There is not one thing or magic bullet, but the data shows us that pregnancy related deaths are a multifactorial issue.  In fact, review committees identify about three to four contributing factors per pregnancy related death.  These contributing factors are found at the patient, provider, facility, health system, and community levels, and so are the recommendations of how we can prevent them.   So one of the essential pieces that was identified through technical assistance to CDC, was the need for a common data platform to review committee abstraction and review.    So CDC developed a common data system called Maria, to support these review committee functions.  We’ve built out a mental health and substance abuse module to help states review and capture this data better.  We are funding five states as part of the response to the opioid epidemic to review all pregnancy associated overdose deaths, and identify opportunities for prevention, and we hope to leverage these lessons learned for other topics including collecting data on social determinants of health.   All in all, with more robust data, we can better understand and prevent maternal deaths and ultimately improve access to quality care.  One strategy to improve clinical care are perinatal quality collaboratives, or PQCs, which are a multi-disciplinary teams working to advance the evidence and inform clinical practices and processes and address gaps in care.  With buy-in from hospital leadership providers, and a wide variety of stakeholders including patients and families, these successful projects can be scaled up statewide.  The culture of care is shifted in participating facilities with the ultimate goal of population improvement in maternal and infant health.   So to close, I just want to mention the value of partnerships — clinical, public health, policy makers, non-profits and community-based organizations can all play a role in supporting the collection and use of timely data and translating these recommendations into action.  Thank you.  

1. DECLERCQ: Hi, I’m here not just as a researcher, but I’m also a member of the Massachusetts Maternal Mortality Review Committee, and the Perinatal Quality Collaborative. So these aren’t theoretical issues.  And I’m basically here to say that we don’t have a maternal mortality crisis in the United States.  We have a women’s health crisis in the United States of which maternal mortality is an important piece of, and sort of the thing we’ve drawn our attention to.  But it’s a much bigger problem than that.  So let me get into this.

  Clarifying some language around this first.  There’s three terms that get thrown around interchangeably — pregnancy associated mortality — that’s the death of any woman in pregnancy out to a year afterwards for any reason.  Hit by lightning, any reason.  It’s the place that maternal mortality review committees begin.  And then the determination gets made of this:  Which of those are related to pregnancy?  And what Shanna was talking about, the work that’s done at the CDC, focuses on pregnancy related mortality.  That’s an important piece.  And the description of the data set at CDC is the best data set, is completely accurate.  But there’s also maternal mortality, and that’s an international standard.  And that has the same criteria.  A death of a woman during pregnancy, during birth, or up to a year afterwards, is the definition of the pregnancy related mortality.  Maternal mortality goes out to 42 days.  And keep in mind those terms get used interchangeably and they are not the same thing.  They refer to different things in many instances.   So let me get into five points I’m going to try to make in six and a half minutes.  First, the persistence of racial disparities.  This is just to illustrate the fact that this isn’t a new phenomenon.  This has been going on for decades and decades.  There’s two lines on this graph — one, the blue line, shows the disparities in maternal mortality.  The red line shows disparities in infant mortality.  The infant mortality ones are embarrassing enough at two to two and a half times higher.  The maternal mortality ones are inexcusable at three to four times higher.  And in the most recent study that came out, it’s about three point three times higher for black mothers, compared to white mothers.   Shanna thoughtfully has covered some of my things, so I can go through them very quickly.  The manifestation of those are in key areas of cardiomyopathy, embolism, issues associated with hyper tension.  Now, let’s put this in context:  This is a comparison of the United States to other countries.  And you see these familiarly.  Oftentimes they’ll say we’re 40^th or something, but that comparing us to countries that have no actual births in them — Andorra and San Marino and Iceland.  Let’s look at countries that are comparable:  300 thousand births and wealthy countries.  And when we do that, we’re no longer 40^th, we’re simply last.  Among all of those countries, the issue of disparities arises because it’s often said, well, the issue in the United States, we’ve just said, is profoundly disparities.  And so maybe that accounts for the difference.  Well, if you look at this data and you say, what if we did the same comparison for just the white mothers in the United States?  Let’s do that.  If you did that, then instead of ranking last, United States would rank last.  And that’s important.  Both pieces are important.  This is not to underestimate the importance the disparities, but it’s to remind us that there are deep systemic problems in the United States that go beyond disparities, that are exacerbated by racial animus, but are not solely about racial animus.   Next point to consider:  We need to think about this from a public health perspective, more than a clinical perspective.  Why?  This breaks out when mothers die.  And Shanna presented a little bit of it.  This is another way to look at it.  About a third of the deaths are actually occurring during pregnancy.  About a third occur at birth and in the week after birth, and about a third occur between birth and a year afterwards.  When you think of it that way, then it’s really important that the efforts we’re making to improve hospital care are going on, but they won’t solve all of the problem.  The only way we solve the problem is by having integrated systems of care that care for women, comparable to what Jennie was talking about, from the beginning of pregnancy all the way through post-partum.  And the only way we do that is by thinking of this as a women’s health problem, as opposed to a pregnancy-only problem.  This has more data than you would ever want.  I will gladly discuss it afterwards with people.  But it just shows, if you look at it, on the left-hand side, this is causes of death over time.  And on the left-hand side, what you see are the factors that are going down, are almost all of those that are related to clinical care.  And the causes of death that have been going up in recent years are almost all associated with more public health oriented kinds of issues, of post-partum care.  So again, this is not to underestimate the wonderful efforts that are going on led by ACOG and the American College of U.S. Midwives, to try to improve clinical care, but it won’t be the end of the problem if we only do that.   I’m actually not going to talk about this one, Shanna talked about this, but look at the differences in the timing of death.  We have different problems at different points in time.    The reasons that women die in pregnancy is not the same as the reason women die at birth.  It’s not the same reason that women die post-partum.  So again, you need a system that covers all of those things.  And it’s more than maternal mortality.   So this is my take home one.  This is deaths of women.  Overall deaths.  It’s not pregnancy related, just overall deaths of women between 2010 and 2016 for women 25-34.  And what you see is those rates are going up.  Especially in the last three years that we had data.  And again, this isn’t just maternal mortality, it’s all causes of death.  And they are going up rapidly.  They are going up — overall, they are going up 22 percent in the last six years.  Why?  Well, this is the leading causes of death.  And at the top, you see that overall difference about 22 percent, and you see the reasons related to pregnancy and this measure does not capture all the maternal deaths.  But you see that the overall death rate is actually going up faster than the rate for pregnancy alone.  What is going up fastest — three areas — accidents — and I can’t read that from here, but I’m sure it says chronic liver disease.  Public health issues.  And violence.  These are factors that need to be considered.  Again, better clinical care will help, but it won’t end it.   So what can we do about this?  I have a minute and a half to solve this.  One of the ways to think about this, I think this is a critically important slide, in that it shows the coverage women have, and the lighter blue line is the proportion of women who are uninsured.  Now, this is pre-ACA, but what it is, prior to being pregnant, about 25 percent of the women at that point had no insurance coverage.  As they become pregnant, you see that line goes down, and the Medicaid, the dark blue line, goes up.  Once they have their babies, that 25 percent figure falls to about 10 or 11 percent.  Look what happens after.  Within two or three months, those rates are back up to 20 percent.  Why is that, you say?  Since you asked, this is the breakdown in how states apply Medicaid.  The blue lines represent what is necessary to be below the proportion of the poverty level you need to be below in order to qualify for Medicaid if you are not pregnant.  The orange lines are the levels that are necessary to qualify if you are pregnant.  And what you see is, states have done a nice job of incorporating women into the system if they’re pregnant.  But at the same time, what will happen is typically 60 days afterwards, the other rates kick in, and they are thrown out of the system.  But keep in mind, we just said that about a third of the deaths are happening after pregnancy, that we’re talking about.  And so one of the ways to think about this, is if we’re going to address the problem, maybe we need to keep these women in the system