“When I go into an individual patient’s room, I am the expert and they’re receiving the information. But within the group model, patients are not only asking questions, but also answering each other’s questions and providing their feedback.“ – Dr. Damali Campbell
Interview with Dr. Damali Campbell
We recently sat down with Dr. Damali Campbell to learn from her vast knowledge and deep passion about how to reduce maternal mortality, particularly for women of color. Dr. Campbell is a physician in Obstetrics and Gynecology and Addiction Medicine at University Hospital in Newark and an associate professor at Rutgers New Jersey Medical School. Her other affiliations include serving on the executive board of the New Jersey Medical Association and the New Jersey Black Women Physicians Association.
Here are some highlights from that conversation:
To start, what drew you to the field of medicine.
I grew up in Brooklyn. Nobody in my family is in medicine, so my decision was a quandary to everybody, but they were happy with my choice. I was always drawn to helping people and early on I was intrigued by illness. My grandmother had multiple myeloma and she would have to go into the hospital for treatment. I was pretty young, and I didn’t really know why she was going to the hospital, but I knew she didn’t like going. It was always a struggle for her to go and she was always happy to come home. So, I was intrigued by her reluctance to go and get help because I thought of medicine as something that was supposed to help people.
You are associated with so many innovative and important efforts around maternal health. We want to focus on your work with the Centering Pregnancy model. What is the model and what problems does it aim to solve?
Centering Pregnancy is a model that can be understood as group prenatal care. Simply put, we get together a group of women who all are going through their pregnancy and have similar due dates. That’s one of the hallmarks of the model. As a clinician, I wonder, “why didn’t anybody think of this earlier?” If I was spending an entire morning doing prenatal care, I’d go from room to room to room, repeating myself over and over again, saying the same things. Did I say this to this patient? Did I remind this patient about this? With the group model, I can tell everyone the same information at one time, number one. Number two, the setup helps debunk the myth that patients are not knowledgeable about pregnancy. Patients actually are knowledgeable. And I think part of increasing patients’ abilities to self-advocate and feel confident is allowing them to display the knowledge they have. When I go into an individual patient’s room, I’m the expert and they’re receiving the information. But within the group model, patients not only ask questions, but they answer each other’s questions and provide their feedback.
It takes time to change the way we, as clinicians, think about this because we’re used to a teaching setting. We learn that through school. There’s a teacher and there are the learners — teachers have all the knowledge and they impart it to students. In medicine, the patient is the student. But we know patients are experts at relating to their bodies and how they feel and, while I may have medical expertise and can explain some of their symptoms, I really want them to recognize the importance of their contributions. The last point I’d make is that it helps having a two-hour group visit. I’m still seeing the same number of patients, but instead of just spending 15 minutes with each patient, I’m spending two hours with everyone as a group. It allows us the time to increase our health literacy because I learn so much from the patients, just as they learn from me.
Are there studies that speak to long-term benefits of Centering Pregnancy, and have you been able to see an impact on patients in your own practice?
Studies support positive pregnancy outcomes from the Centering Pregnancy model, so the literature is there. On an anecdotal level, we’ve had patients come back to participate more than once, or who refer their sisters and other family members, so that’s a testament to the program’s value. I know it has allowed me to get to know patients on a more intimate level. We had a patient who was able to share with us that her mom had been diagnosed with cancer and that she personally was dealing with a lot. The patient’s father was taking her mother back and forth to New Brunswick [from Newark] for her cancer treatment, so the patient had to become the primary caregiver for her brother, who was two years old, and she also had an 11-year-old sister. With the more traditional approach to prenatal care, I wouldn’t necessarily have had time to talk to her at length beyond asking, “How are you? Is the baby moving?” and measuring her belly, and sending her for tests. I might not have had time for a conversation about what causes stress and to offer techniques for managing that stress. In the group setting when we go around the room, it’s not just the patients that talk about stress. Everybody has to participate and that includes the staff. I don’t think we would’ve found out about this patient’s situation and been able to offer her the additional support if not for group care.
New Jersey is committed to reducing maternal mortality, particularly for Black women and other women of color. What kinds of efforts can happen locally, citywide, or statewide to help decrease morbidity and mortality rates for Black women?
I think, number one, we have to increase awareness on all those levels. When I talk to friends with whom I work out or go out to dinner, I’m amazed they’re not aware that even Black women who are college educated have an increased risk of complications. So I think that, across the board, we still have work to do around increasing awareness. On a local level and citywide level, people need to know what questions to ask. They need to be aware of what services are provided at facilities they use in their service area.
If we’re trying to reduce morbidity and mortality, one of the things we should talk about is trying to avoid having a C-section unless it’s absolutely necessary. A C-section can be lifesaving, so it’s a tool, but I want that tool to be used only if it’s truly needed. And if you’ve had a C-section for one pregnancy, do you always have to have a C-section with future pregnancies? Women should be aware of whether the facility where they plan to deliver offers a trial of labor after Caesarean section, if that’s appropriate for them. Do they offer ambulation in early labor? What kind of labor support is available, especially if they don’t have a lot of familial, extended family or community support?
For high-risk women, if they’re anemic, what are their options in terms of treating their anemia? Not everybody wants to have a blood transfusion. What treatments are available? And if a blood transfusion is necessary, is that something the facility in their catchment area is able to provide? What’s the after-hours care situation in the place that provides their care? I wish that obstetrics was a 9-to-5 type of specialty, but I’ve learned that it’s not. I’m amazed when patients use a provider or partner who they can’t reach at night or on the weekends then they wind up in a facility that doesn’t know them and doesn’t even have their records. This can lead to fragmented care and emphasizes the importance of the use of electronic medical records but having access to them. These are the kinds of conversations patients and providers can have ahead of time to try to mitigate some of these circumstances.
As a member of the New Jersey Maternal Care Quality Collaborative, do you see it playing an important role in addressing maternal health disparities in the state?
Absolutely. The New Jersey Maternal Care Quality Collaborative is otherwise known as our state’s Maternal Health Task Force. The task force is legislated. With 34 members and multi-disciplinary in nature, it’s meant to promote buy-in from a variety of different stakeholders. I see this task force as instrumental in setting goals and priorities. We receive data from the Maternal Data Center and the Maternal Mortality Review Committee that reviews every death in the state of New Jersey of a woman who dies within 365 days of giving birth. There’s important information to be gleaned from reviewing those cases. Recommendations are made and actions are designed and prioritized.
As a physician, you’ve had to adjust how you provide care during the pandemic, such as relying more heavily on telehealth. How challenging is that for you and your patients?
Telehealth has been an extraordinary tool during this pandemic. And when in-person visits are not possible, I think it’s certainly a lifeline for physicians. But challenges remain, not only for patients, but also for providers. When the pandemic hit, in University Hospital we had computers, but not all our computers had cameras. We couldn’t all start telehealth right away because we lacked the ability to see our patients. It’s not only patients who have had difficulty with the technology, it’s also providers.
Patients may not have the ability or comfort level to go on camera. I’m here in the office. If I’m at home, maybe I don’t have any reservation about people seeing my background, but that’s not everybody’s circumstance, and we need to be sensitive to that.
OB is unique in that we need the ability to touch and feel the patient. For certain things, I can just ask a question, but for others I really do need to touch and feel the patient to adequately evaluate them. Also, a lot of what we do in obstetrics relates to prevention. We check blood pressure as a preventive measure and there’s a very specific way in which that needs to be done. The patient needs to be comfortable. The cuff has to be the right size. The patient has to sit in a comfortable position with legs uncrossed for five minutes. We do all of that in our office. So trying to tell a patient to do that at home and making sure they have the equipment to do it takes a lot of instruction. I’m not saying it’s impossible, but it takes a lot of work. And, again, you have to make sure the insurance companies have provisions to make it easy and seamless for patients to receive the durable medical equipment at home, including a scale to measure their weight gain, because if there’s rapid weight gain, you want to know.
We imagine that you’ve encountered vaccine hesitancy with some patients, such as pregnant women who fear the COVID-19 vaccine could harm their pregnancy or those who have a mistrust of the medical care system because of historical mistreatment. How do you handle those situations and what advice can you give?
I think what we all have to understand, and maybe some of us understand this better than others, is that we actually have relied on people’s trust or mistrust of doctors in the medical system too much. It’s a double-edged sword. Either patients trust us so much, almost blindly, or barely trust us at all. And so what I think we need to do is normalize the process of patients asking questions. I always try to end my encounters with patients with, “Are there any questions you need to ask me?” I think it’s easy for my patients to feel like I’m too busy; they don’t want to bother me because I’m running from room to room. They’ve been waiting a long time. So I try to remember to ask them, “Is there anything I didn’t answer for you?” Again, I just want to emphasize we really need to normalize patients asking questions. Because if we normalize that, then I don’t have to use the word “hesitancy,” because I don’t think asking me a question about a vaccine is being hesitant. It just means you want more information. And there’s nothing wrong with someone wanting more information. We should want everybody to want more information.
I think also what I’ve tried to focus on is high touch rather than high tech. I experienced a lot of patients who were interested in getting the vaccine, but they couldn’t navigate the computer system. They couldn’t navigate the appointments. And I did what I could to partner with them. I’m president of the New Jersey Medical Association so I partnered with the state, because I think it’s really important for groups to partner with trusted organizations who have ties to marginalized communities. And so we worked with churches, worked with smaller community doctors’ offices to get them to find out who of their patients wanted the vaccine and didn’t have appointments, and set up those appointments. It was hard. Now, there’s more vaccine availability. But in the very beginning, the vaccine wasn’t available in as many locations as it is now.
Our goal was to work with doctors and others (clergy, local politicians, etc.) that people trusted. They were already seeing those doctors, so they were much more likely to listen to them. Just as an example, if a person brings their child to a pediatrician and that person has let that pediatrician give their child all their childhood vaccines, they have become a trusted source on vaccines. It’s very easy for that pediatrician to turn to that parent and say, “It’s important that you get this COVID vaccination.” And that parent is much more likely to listen — and ask questions if they have any. Overall, I think it’s really important for us to focus on making sure people know it’s okay to ask questions.