This new center is working to reduce deaths of Native mothers and babies during pregnancy

The National Institutes of Health recently awarded University of Utah Health a $14 million grant to establish a maternal health research center – one of 10 across the country investigating how to reduce pregnancy-related deaths. Dr. Torri Metz, an associate professor, vice chair of research and clinician who specializes in maternal fetal medicine, is leading the new Elevate Maternal Health Research Center. In this episode of U Rising, Dr. Metz talks about the center and its focus on improving pregnancy outcomes specifically for Utah’s Indigenous populations.

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Transcript

Julie Kiefer: Welcome to U Rising. I'm Julie Kiefer, associate director of Science Communications at University of Utah Health and host of this episode.

Torri Metz is an associate professor of obstetrics and gynecology and she's vice chair of research in that department. She's also a clinician who sees patients as a maternal fetal medicine subspecialist. Now, she's drawing from her expertise in both health care and in science to do research that will improve the health of pregnant people and their babies. Welcome to U Rising, Torri.

Torri Metz: Thank you. It's wonderful to be here. 

Julie Kiefer: Torri, I was surprised to learn that your science career actually started in chemistry. Can you tell us a little bit about how you went from the laboratory to the clinic?

Torri Metz: Absolutely. Honestly, I thought I was going to be a physician when I was six. I was one of those people that just throughout their whole life knew that they were going to be a physician.

Then I got into college and began to question that a little bit in terms of that career path and the extended nature of that career path, and did my degree in chemistry and went into the lab just to see if that was a better choice for me to spend more time in the lab and drink chemistry and not going to medical school.
 
But it turned out that no, I still wanted to go to medical school and still really enjoyed the person interaction of medicine and really wanted to pursue that career path. So, I took a year off between undergrad and medical school and was a medical assistant at a clinic for underserved communities called Salud Clinic in Longmont, Colorado, for a year and then started medical school.

Julie Kiefer: And now your subspecialty is maternal fetal medicine. What is that exactly? And what drew you to that in particular?

Torri Metz: Yeah, so maternal fetal medicine is basically OB for high-risk populations and so either the mother has a medical condition or, you know, something that makes their pregnancy more complicated or the fetus has some kind of complication, something like a birth defect that's recognized on ultrasound. So, we're following the pregnancy more closely than we typically would in a normal, low-risk pregnancy.

Julie Kiefer: And now your research touches on that area, and we'll get to that in a minute. But I just want to talk a little bit about this situation here in Utah. Utah is so well known for having had the highest birth rate in the nation. Is that something that's still true here?
 
 Torri Metz: Yes, it is still one of the highest, but as of the last time that they looked, it actually was not the highest. For a long time, Utah had the highest birth rate in the nation per capita. But the last stats I could find, it looked like we had dropped to number four, but still a very high birth rate per capita compared to other states.
 
 Julie Kiefer: And even though Utah has had this long history of having large families and lots of children, maternal mortality is still a problem here. And just to define it, maternal mortality is death during pregnancy or in the year following pregnancy. So, what's happening here in Utah?

Torri Metz: Overall, our maternal mortality rate is slightly below average, but it's still close to that average. And so, you know, we do worry about maternal deaths, obviously, as does everyone else. I think that this new grant that I know we're going to talk about, really, I think, draws attention to the issues that we have within Utah in terms of higher rates of maternal death among our Indigenous populations and that's where our focus is.
 
 But I would say that as a state, we've been thinking about this area for quite some time now. I have chaired the Maternal Mortality Review Committee at the state level for the past five years, and that's a committee where we review all of the maternal deaths that happen in the state and actually review deaths in conjunction with Wyoming as well, because initially they didn't have their own maternal mortality review because they just have a smaller population. And so together we'd review both Wyoming and Utah deaths. And I think that's where we all became interested, both as clinicians and investigators, in what are the causes of maternal death in Utah and how can we help prevent them?

Julie Kiefer: And some of our listeners might be surprised to know that substance use is the leading cause of pregnancy-related death for women in Utah. How do you think about that?

Torri Metz: Yeah, that's correct. And we do see nationally variation in the causes of death by state, but certainly here in Utah, our leading cause of death is substance use, and that's either from accidental overdose or intentional overdose. That's combining both of those categories, but I think that it really draws our attention to that as a state, that this is a real problem. This is a problem in our community. This is the leading cause of maternal death here and this is what we need to tackle.
 
 Julie Kiefer: And that's exactly what you're going to set out to do. You're leading a new Elevate Maternal Health Research Center is what it's called. This center is one of 10 to have just received federal funding from the National Institutes of Health and the University of Utah Elevate Maternal Health Research Center received $14 million in funding. What are your plans? How are you planning to use this funding and what's the research you're going to be doing?

Torri Metz: Yeah, so the Elevate Center is really trying to focus on reducing both maternal morbidity and mortality or death from substance use disorder in Utah specifically. And so one of the main aspects of this funding was that the centers were really trying to address the problem that's in their community. That was a huge emphasis of these applications, was really that community outreach component and making sure that we are doing something that's of value to our community. And I think that's what we as investigators are also very proud of.

Within the Elevate Center, we want to tackle that broadly, but we also have specific research projects embedded within the center that we'll be completing. We have a training component to the center where we'll be training other investigators to do research in the same area. So basically train sort of the next generation of clinician investigators here. And then there's a whole core that's dedicated to sort implementation science that's led by Dr. J.D. Smith here at the University of Utah, where we're really trying to look at ways to implement the work that we're doing both across the state and then ultimately nationally.

Julie Kiefer: And as far as I understand it, this center will have a focus on turning around those statistics around substance use in pregnancy. So, what are some of the ways that you'll be addressing that?

Torri Metz: Yeah, so we're going to start with two projects that have specifically been funded within the Elevate Center. The first of those projects is within Sacred Circle Healthcare, a partnership with them.

Julie Kiefer: Torri, can you tell us a little bit about this Sacred Circle Center and what that is?

Torri Metz: So, it is an urban clinic that primarily serves Native American populations. There is already prenatal care that's happening there. There's collaboration with the Confederated Tribes of the Goshute, and that's sort of where that relationship has built, honestly, between the Department of OB/GYN as well as the tribal leaders and that is something that's built over time, right? That's where we've done this qualitative work. That's where we have gone and tried to really build relationships with the tribal leaders so that they can understand that we truly want to bring culturally appropriate care to them. This is not a process where we're going to bring some sort of model that we have created that we think needs no adaptation for their community or their needs. Our goal is truly to partner with them and to address the barriers that they see in their communities.

Basically what we're doing there is taking an existing model that we have for caring for patients who have substance use disorder in pregnancy where we really bring everything they need to one place in a multidisciplinary way.

So bringing together obstetricians to do prenatal care, specialists in addiction medicine to help with treating patients who have substance use disorders, specialists in social work, people who are specialists in psychiatry and management of mental health disorders, and really bringing that all to one place for patients so that when they are coming for their prenatal and postpartum care that they can get access to all the resources they need.

We've been able to do that very successfully at University of Utah Hospital and have really built a clinic that exists both at our main hospital campus as well as our Daybreak campus, or South Jordan campus, where we have clinics where patients can be seen and have access to all those resources at the same time.

And this project that we now have funded is to take that same sort of model and help the team at Sacred Circle Healthcare implement it at their clinic, which is an urban clinic serving Native mothers who have substance use disorders so that they are not needing to leave the community environment that they trust.

Our goals will really be to implement a culturally sensitive and appropriate model of care for Native mothers so that we are eliminating barriers to care and really trying to work very closely with our community partners at Sacred Circle to implement this model. And then basically what we'll do is we'll take that implemented model, create basically a toolkit that we hope can then be used to expand even further this type of care to other clinics across Utah.

Julie Kiefer: What are the difficulties that are facing that are preventing them from getting the health care that they need?

Torri Metz: Yeah, I mean, I think some of that is just trust, comfort and environment. It's hard. Those are things that are built over time. Patients typically have a medical home where they feel like they can go and get care that's respectful, appropriate and that they feel that can trust the practitioners there. The goal is then to take the model to them, not change the people that they're seeing, but train the people that they're seeing to implement this same type of model.
 
 I think that the barriers that we've seen, and Dr. Michelle Debbink has done a lot of work in this area in terms of qualitative research asking Native mothers, which they have told us is their preference in terms of what they would prefer to be called, to talk about why don't you want to come to the medical center? What are barriers to you getting care that you think results in worse outcomes for your pregnancy or for your health?
 
 And what we hear is that people feel that they are stigmatized against or people see them in a different way. People aren't able to be culturally sensitive to their needs when they have requests surrounding the time of their appointments or surrounding the time of their birth and transportation and finances and all of those things that we just think we can eliminate a lot of by going into a community where patients are already seeking care and really being sensitive to culturally appropriate sensitive care and a trusted system.
 
 Julie Kiefer: I think, it seems like providing that culturally appropriate care, I mean, that's not a small issue, right? I think it's a real mindset change for a lot of health care providers out there. Can you talk about that aspect a little bit and how your center's going to address that? 

Torri Metz: Yeah, I mean, I do think that the first step is, honestly, just listening to the community and their needs. So, we have done some of that preliminary work through Dr. Debbink along with a lot of her partners to just think through what are these barriers and how can we address them? How can we be good listeners?

The Elevate Center, a big component of it is something I'll call the Community Advisory Board where we are going to have community members from both Sacred Circle Clinic, as well as people who have lived experience with substance use disorder, as well as people from more rural settings, telling us, like,   are we on the right track? Where are we missing the mark here? And how can we adapt what we're doing to better meet your needs? And that is a huge part of what Elevate is going to be doing. We have our first meeting with our community advisory board actually set up for early November, and we're really looking forward to that.

Julie Kiefer: So that back-and-forth communication seems to be a central part of it. I'm wondering if the center is leading out nationally in some ways. Is this something you're seeing elsewhere, too?
 
 Torri Metz: Yeah, we had an initial kickoff meeting of all the centers that have been funded by the NIH, and I would say there is a huge focus on reducing disparities in maternal mortality. And certainly within Utah, the disparities that we see are for patients who are Native American and Pacific Islander. There's just huge disparities that we see in populations that are non-white in Utah with maternal mortality rates. And so we are really hoping to close those gaps.

Nationally, that is also the focus of many of the centers and the disparity and the population focus is not necessarily the same everywhere, but the fact that there are disparities by race, by the community that people live in that just need to be reduced and ultimately eliminated by taking these interventions to the community is really the big focus of these NIH centers. They all have different projects. They all have different missions. We've kind of talked about our main project that we have here in terms of one of our projects. We actually have another one that focuses more on health care clinicians that we can talk about, but they all have this idea of collaboration with the community and bringing to the community with the community needs, whether that's community nursing, whether that's implementation of a program like this into Sacred Circle Healthcare. Everybody has different ideas and different things they're doing, but ultimately the goal is reduction of disparities in maternal mortality and overall reduction nationally.

Julie Kiefer: How do you hope things will be different in, say, 10 years from now?

Torri Metz: Yeah, so we'll be tracking, obviously, through the Maternal Mortality Review Committee. We will continue to track maternal deaths in the state of Utah and causes of death. When we review deaths, we actually also talk about opportunities for prevention and preventability. And so I think close partnership as well with the Utah Department of Health and Human Services is going to be critical in this work, and they are partners in this grant application and moving forward in terms of evaluation of impact.

I think the other piece of this is do we see reductions in maternal death? Certainly, that's a huge question. That's what ultimately we'd like to see. But do we also see reductions in substance use more broadly at the time of birth? We've been following for the past few decades, actually, just rates of substance use at births. So,   we can sample cord segments at the time of birth anonymously and just evaluate how we're doing related to population prevalence of substance use.

And that was started even way before my time that I came here. But every 10 years or so, we've just been kind of monitoring that. And most recently, we did it in 2020 and we have seen over time that rates of substance use has increased in Utah. Now, that's likely consistent with just population nationally, but if we can get the word out about substance use, if we can do more education surrounding this, if we can get more resources out to communities and clinicians about how to treat substance use disorder, which is another big part of what Elevate wants to do, can we reduce those rates of substance exposure at the time of delivery? And that's something that we can also monitor over time. So,  I mean, I think we have these more surrogates along the way markers of are we reducing use? And then ultimately, if we can reduce use, then we can hopefully reduce deaths.

Julie Kiefer: And, actually, this is a theme of your research that goes beyond this center, too. For a while you've been interested in investigating substance use during pregnancy. Specifically, I'm thinking about the work you've done around cannabis. What's the status of that research now?

Torri Metz: So, I do have some other research funding that's more focused on cannabis use and adverse pregnancy outcomes. We are getting very close to publishing that data, which I'm excited about, and hopefully we'll be able to bring to everybody soon as well. But really just looking at if there's cannabis exposure during pregnancy, do we see effects on pregnancy outcomes? And I think that's another question that's relatively pressing in the public health world. Just as cannabis legalization expands nationally and medicinal cannabis is legal in Utah, what effects do we have and how do we counsel patients about the effects of cannabis on pregnancy? So, working on that and results very soon.

Julie Kiefer: So, I look forward to hearing more about that and we'll be sure to have you on again so that we can update our audience on that work, too.

Torri Metz: Great! Thank you so much.

Julie Kiefer: Thank you for being my guest on U Rising.
 
Listeners, that's it for today's episode of U Rising. Our executive producer is Brooke Adams and our technical producer is Robert Nelson. I hope you'll tune in next time. I'm Julie Kiefer. Thanks for listening.