Carole Johnson, the administrator of the Health Resources and Services Administration. (Kentucky Lantern photo by Sarah Ladd)

LOUISVILLE — Carole Johnson, the administrator of the Health Resources and Services Administration for the Biden administration, was in Louisville Thursday to discuss ways Kentucky can improve maternal health outcomes.?

After moderating a roundtable on the topic, Johnson discussed maternal health issues facing Kentucky with the Lantern. The conversation has been edited for length and clarity.?

Kentucky Lantern: Maternal health issues are very complicated, very intersectional, but in your work, do you ever see there is one domino issue, if you will, that, if you can tackle that, other things sort of fall into place??

Carole Johnson: It is a lifespan issue. That’s why we really think about it as: We have to support women of reproductive age in the community. We have to make the clinical setting as high quality and ready for complications as possible. We have to have a system that gets people connected to prenatal care as quickly as possible, and then postnatal.?

We have to make sure that — new parenting is hard — that people get the supports that they need, and that we’re tackling things like maternal depression. So, we really think about it as that continuum.?

I think sometimes with health policy problems, we tend to think about, ‘well, what happens inside the four walls of the clinic?’ And this is not one of those issues. This is an issue that’s about that, but it’s also about all the other ways that we make sure that pregnant women and new moms are healthy.?

KL: I know Kentucky is not alone in this, but in Kentucky, we see a lot of our statistics around maternal health impact Black women and other women of color more than white women. Does racism play a role in driving that fact? And if so, how do you tackle racism with policy??

CJ: What we know is what the data tells us, which is that Black and Indigenous women are dying at two to three times the rate of white women, and those disparities persist even when you control for things like education or income or the like. So there are systemic issues here that we have to address, but part of it is obviously about access … and being heard in the healthcare system.?

What we hear repeatedly when we do these roundtable sessions around the country is about women’s voices not being heard. Women know when something’s wrong or know when they need something, and their voices are not always heard.?

It matters that we center this work around women’s experiences, and that’s why we’re doing things like investing in community-based doulas so that women have an advocate and a voice in the healthcare system, particularly when they’re pregnant, when … all their energy should be about making sure they’re managing their own health, not about trying to fight for the access and services they need.?

That’s why we’re investing in more midwives. That’s why we’re investing in more (obstetricians) who come from the communities that we want them to serve in. That’s why we’re really focused on what does access look like? And access that isn’t just about checking a box on a map, but that actually is a trusted community provider that will listen to and support women’s needs.

KL: For the past few years, we’ve had a bipartisan debate in Kentucky on whether or not we should clear the path to have freestanding birth centers. Do those tend to help statistics around maternal mortality??

CJ: Sometimes the scope of services in freestanding birth centers can raise different levels of debate.?

Where there are freestanding birth centers that are able to manage less higher complexity deliveries, in a place where there’s a maternal health desert, … those are the kinds of things that we have to be thinking about.?

There are far too many counties in this country where access to maternal health services means getting on the road and driving for a very long time and and often ending up in the emergency room in a community hospital that may not have the preparedness and all the strategies that are necessary to have the healthiest deliveries.?

KL: Some of our debate revolves around the concern that rural hospitals could lose income as a result of people choosing to go to another facility. Do you see that as a problem, generally?

CJ: I actually think rural hospitals can be creative about thinking about what kind of partnerships in the community they can have. So I don’t know that it has to be an either or question if we can think about the kind of partnerships that would make it possible for rural hospitals to be part of that solution too.?

KL: We heard a lot today about mental health and substance use disorders. How key is it to talk about mental health when we talk about maternal mortality??

CJ: Mental health and substance use disorders are the leading cause of maternal mortality, and the data clearly shows about 80% of maternal deaths are preventable. That is a call to action for all of us around addressing maternal mental health and substance use disorders.?

It is heartbreaking, the stigma that still exists around these issues. A lot of times, when women are pregnant, … they think they have to be super women. We need to make sure that there’s a low barrier to entry to getting support and services for mental health and substance use disorders.?

We’re actually fighting right now in D.C. to make mental health and substance use disorder required services in our primary care settings, because that’s what we need to do. We need to make it part of the equation. We don’t want to be in a place where someone’s ready for help and raises their hand and what they get is a referral (to) ‘go call these numbers and see if you can find someone.’

KL: A key part of Kentucky’s Momnibus bill that became law this year is that the state made pregnancy a qualifying condition for insurance coverage in Kentucky. How important is it to have that insurance and to get that prenatal care??

CJ: We in the Biden Harris administration, one of our proudest accomplishments is getting health insurance to more people.?

It’s vital that we do that and we do everything possible so that people have coverage. We also need to make sure that there’s a place you can use that insurance card and we need to make sure that’s a high quality place that you can use that insurance card.

Coverage is critical, but it’s not sufficient. We need more.?