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We are the Maternal Health Learning and Innovation Center, a network of maternal health equity experts and organizations working to make real change for women and birthing people in the U.S.
Our podcast is a series of episodes connecting around culture, lifting voices and stories, exploring innovations in maternal care and discussing ways we can center equity in the way we approach our health and wellness.
Learn more about us, explore our resource center and find support for all maternal health professionals at MaternalHealthLearning.org.
For more podcast information and content, visit MaternalHealthPodcast.org.
Vicki - 00:00:03:
Hi, everyone. Welcome to the Maternal Health Innovation Podcast, season three. I'm your host today, Vicki Curtis. I'm currently the Director of Women's Services at the University of South Alabama. Children and Women's Hospital in Mobile, Alabama. So coming to you today from the deep south. This podcast is created by the Maternal Health Learning and Innovation Center. Episodes are released weekly, so please be sure you're subscribed. And please share with your friends and colleagues. So that we can build a greater audience. On this podcast, we listened to Maternal Health Innovators. And we learn about ways we can implement change to improve maternal health. Eliminate inequities. And reduce maternal mortality and morbidity in the United States. In this episode, we'll be talking with Jessica Noble. From ECU Health Eastern Carolina University about the I gave birth bracelet initiative. That they started in 2021. And how these bracelets are creating better Maternal health outcomes by ensuring the most effective and tailored care. Or postpartum moms. Thank you so much for joining me, Jessica. Tell us about you and your program.
Jessica - 00:01:17:
So I'm so happy to be here with you today, Vicki, and to talk about how we can save our families and save our Mom's lives. I became a nurse when I was young. I went and got my bachelor's degree first thing and went straight into Maternal health. I worked on a rural facility floor. LDRP, labor delivery and postpartum for almost 18 years. And I loved it. I've always been very passionate about caring for our moms and babies and making sure that our birthing persons have the best care possible. What about you, Vicki? What brought you into, what made you passionate about maternal care?
Vicki - 00:01:54:
I had a similar path as you actually. I started with an Associate degree. Little embarrassing, but I graduated in 1985. So I have many years. On Maternal health and it's just always been a privilege for me. To be part of the community. Of such an important milestone in people's lives. On the happy occasion. And also on the sad occasions, but to be a part of that, to help and and hold hands has been something I've always enjoyed. And so I've been able to. Grow and find positions and further my education throughout the years and then ended up in this challenging role. As a director here.
Jessica - 00:02:35:
Absolutely. I can understand Administration being a difficult seat to sit in. I had the opportunity to sit in Administration in a rural facility for a couple of years and that was not for me. I currently serve with perinatal outreach in Eastern North Carolina, what we call Region 6 of our state, and I'm excited to get to work with all the individuals that I get to work with. Within the State Maternal Health Program innovation , as well as all of my other perinatal nurse champions. So currently that is the role that I serve in. And through East Carolina University supporting me, I've received my master's and received many certifications and also had the opportunity to now start as a clinical instructor for the College of Nursing for ECU undergraduates. And that's so exciting because I was an ECU undergraduate. And so to go back to that state has been exciting for me specifically. And so I know that we both have programs, Vicki, and I gave birth bracelets. We started in 2021, like you mentioned. And the biggest thing with that program is the education about what can happen in the postpartum period. We know that postpartum mortality in the state of North Carolina, 43% of those deaths occur in days one to 42. And so we know those people go home. One to two days after delivery. So majority of those deaths are occurring once they go home. Having the opportunity to bring awareness and education to not only patients, but their families and their support partners, as well as those specialties that may not see obstetrical patients routinely like emergency medicine has been enlightening as well as rewarding, because we've seen the return of patients knowledge and how they're receiving care before they get to those dangerous signs and symptoms.
Vicki - 00:04:31:
That's so awesome and congratulations on publishing that.
Jessica - 00:04:35:
Thank you.
Vicki - 00:04:36:
Here at Children's and Women's, we started our program. In May of this year, 2023. When we did a quick search, we were able to read about your program. And we just thought it was a wonderful idea. And so we also initiated I just delivered bracelets. And we are also using the preeclampsia still at risk. So our moms that have had any hypertension diagnosis during their pregnancy. They will also receive a bracelet that says preeclampsia. It's a purple bracelet. And then for our population that have a pregnancy or infant loss. We have a white bracelet and it also has rachelsgift.org on the bracelet which is the bereavement. Company that our services that we use a wonderful nonprofit. I wish I had some anecdotal stories to share. And we haven't received those yet, but what we have received. Is a lot of connection from hospitals across the nation. I'm sure you have too. You know, about starting something similar in their hospitals. And I just hope that. I mean, our goal is for outlying rural hospitals, just like you were talking about. 37% of the counties in Alabama are considered OB deserts. So the access to care is... Is limited. And that without question. Impacts mortality and morbidity. And then. We have 15 more hospitals that I read that are at risk for closing, also rural hospitals. This access to care problem. I mean, we have to do whatever we can.
Jessica - 00:06:18:
Absolutely. Absolutely.
Vicki - 00:06:21:
So, Mom is discharged if she shows up at a rural hospital, which is quite likely because she's had to travel for her OB care. We want her treated obstetrically and not medically. And we hope that these bracelets will serve as net alert. And we're also educating these outlining hospitals by sharing posters of the program. But that continuous outreach education is a challenge. Have you been able to address that in your region?
Jessica - 00:06:48:
So I was very blessed to come into a system that had outreach education built. So in 2010, when our outreach education through Eastern AHEC was, the funding was cut in the state of North Carolina, our director, Angela Seale, helped with rebuilding that program with nurses and providers. And when I stepped into this role, there were already three people serving and they go to the hospitals, they provide outreach, they provide simulations. So that gives more awareness to our program. We have the opportunity to teach our residents when they come in, our ER, Family medicine, midwifery and OB residents, when they start in the summers, we try to get them through advanced life support and obstetrics, which talks about a lot of those things that can happen in the labor and delivery period, but we also try to highlight the postpartum period as well. And the emergency medicine residents specifically, because just like you said, we send our moms to the emergency room. When you look at the A1 or help me Vicki, so I say it the right way now, Association.
Vicki - 00:07:52:
Yeah, that's okay. Association for Women's Health. Obstetric and neonatal nurses.
Jessica - 00:07:56:
Thank you, because I did not want to say that incorrectly. When we use their Post-Birth Warning Signs, it is a great graphic that talks about, you have pain in your chest, you have obstructed breathing, any of those things you wanna call 911. And so if we have the opportunity to educate our paramedics and our EMTs and help them understand their protocols better and how to best utilize their services that they provide, because like we said, the maternal mortality, a lot of that is occurring. And that came from our 2014 to 2016 Maternal Mortality Review Committee here in North Carolina, that 43%, we can help if we help those outlying folks who don't typically COB patients or postpartum patients understand that the care that they receive, just like you said, is gonna be vastly different than just someone who has a headache and high blood pressure that has not been in the postpartum period. The medications that you utilize, magnesium sulfate is something that they're gonna receive in that postpartum period to prevent the eclampsia that they may be suffering from preeclampsia postpartum. And a lot of people don't know that. So this helps serve the purpose to help that education and enhance that education if you go as a warning sign with the bracelet.
Vicki - 00:09:12:
That's so impressive. Your program is more robust than ours. I don't mind sharing that. And I know a lot of listeners are. I have the same opinion and I know we're all trying to grow and impact. Again, congratulations to your region and facilities for getting all those. Great processes in place. You and I talked a little bit before and believe it or not, Jessica and I don't know each other. We're meeting across this forum, but we have so much in common. These conversations are coming so easily to it. Because North Carolina has OB deserts as well, correct?
Jessica - 00:09:46:
Yes, ma'am, absolutely. So when you look at in region six, the 29 counties that I serve as nurse champion for. Many, many of those counties are OB deserts. And I cannot speak to a direct percentage because we've actually had quite a few closings recently of Family practice and a facility as well that had an emergency room in it and that has recently closed in our region. So looking at OB care deserts and how we can impact that and how, again, we can educate those who don't routinely come in contact with those obstetrical patients or those postpartum patients that, hey, this is how we can help them by showing the flyers and the posters, just like you were talking about, Vicki, going out and speaking to people in their space, going to bays and speaking to EMTs, speaking to paramedics, speaking to emergency room doctors, also talking about with the pediatricians what that looks like when they do their Enberg scales for their pediatrician visits and they can see those patients and those babies and moms come in, how can they best serve them? What resources do they have? We have a great program, NC MATTERS, in the state of North Carolina that is accessible to everyone and they are a hotline for our providers that only have an OB care desert, but maybe they also have a mental health care desert. Maybe there's not a lot of access to that. And when you look at 2022 MMRC data for the state of North Carolina, the number one leading cause of death was mental health diagnoses. So how can we serve that population as well? Hey, this pediatrician, we got a positive score for the EDPS, Enberg scale. How can we now address that? I don't know who they can go see. I don't have a listing. Maybe their obstetrician is in a whole nother county an hour away. So what does, what can NC MATTERS do? Hey, let me help you. Let me find you some care. Postpartum Support International is also a great program that is helpful for that as well. And we were gonna talk about a little bit, readmission rates. I know for us, our original thought process, our hypothesis was that our postpartum readmission rates within the Medical Center would go up. They actually went down by 0.77%. And when you look at our article in the North Carolina Medical Journal, it talks a lot about that and how we were able to impact that. The only processes that we changed were the Post-Birth Warning Signs education and the bracelets.
Vicki - 00:12:12:
I'm so glad you brought up the Post-Birth Warning Signs that A1 did put out because We also utilize those as part of our discharge education. We use the magnets and they're included in a discharge book that we give each patient. Because I believe that moms do like to read these books. Dad. You know, talk about what's happening with their bodies and caring for their babies. So I hope when they get home and they have this magnet on their refrigerator. And this discharge booklet in there. In their living room that they're able to read and educate themselves even more. Do you have ideas about? How are we going to impact these women? That are in these OB deserts. You know, I'd love to talk about. I'm happy that Medicaid did extend postpartum coverage to one year. Yes. It's not enough, but still we're grateful for that. Some states, I don't know how many, I want to say it was 12 for reimbursing for Doula Care. So I hope that we continue to. Advocate for that change. And I'd love your thoughts on this as well. I would love to see some special funding for midwifery training. With a repayment, you know, by getting midwifery services out to these communities that are lacking care, we've got to go to these women. They can't get to us.
Jessica - 00:13:33:
I totally agree with you. So I think that when you look at our state specifically, and you look at the lack of care providers, when you look at statewide, our region, the World Health Organization would love for it to be one provider to a certain number of patients, and ours is about triple that in our region. So how can we impact providers? I think those midwifery students, nurse practitioners as well, women's health nurse practitioners to take care of those in the postpartum period, when you look at our School of Medicine, our obstetricians are not graduating as many as we used to. But we have lots of midwifery students. In the three years that I've had the opportunity to serve and help educate these individuals going through school, our midwifery program has grown tremendously. And Doula Care is so important. When you look at bedside care and how that can impact our cesarean section rates, as well as how it impacts Mom's birth story, birth trauma is real. And that can affect that Mom and that child's relationship for the rest of that child's life. So having that one support person not only decreases your risk for cesarean, but it also increases and empowers Mom to speak up for herself. Sometimes when we don't think about it and we're at our most vulnerable, having an advocate is so important. And having a Doula that understands that we wanna be as natural as possible, but we also communicate well as a collaborative team. So interdisciplinary teams and interdisciplinary education are so important to enhance our Mom's care throughout interconception all the way to postpartum.
Vicki - 00:15:10:
Great point. I would like to see more focus on Community-Based Doula Program too, so that We train Doulas that live in the communities that need them. They can easily relate to and feel comfortable with. That they have that Family feeling. Of that intimacy, the relationship. That they really can share. And what they feel like their needs are.
Jessica - 00:15:36:
Absolutely. Yes, East Carolina University has started a program with our midway free students and some of our medical students that they train to help be Doulas while they're in school and they provide services on our Labor and Delivery floor. There's also many other programs in the state of North Carolina that are focused on Doula Care and how can we serve our population. There's a lot of work going into the state with the Institute of Medicine and how we can help expand coverage, just like you were saying. There are some of the primary health plans in the state of North Carolina that took over Medicaid. Do support Doula services. Unfortunately, there are some restrictions that can be difficult to follow for Doulas and patients alike. So there's still some barriers that we have to break through, but absolutely there's quite a bit of work. Going into the care and how Doulas can be incorporated into those mothers and families' lives throughout their pregnancy early on as well as postpartum.
Vicki - 00:16:33:
Right. It's so exciting and I agree with you that the future, to me, looks like. Advanced practice providers such as our PA, MDs, midwifery. Midwives. Being accessible to the more rural areas. Or in supportive providers that may already be there. I know. It's difficult to recruit providers and. One provider is not enough because. Everybody does have to have that. Life balance and that's understandable too. So we need to move groups. Into these areas so that the group is supporting each other. In their great work. To support the mothers. Who are supporting the babies, which is the future.
Jessica - 00:17:16:
Absolutely. And how we support our moms and our babies and our birthing persons and their families can certainly impact, like I said before, that relationship for that child. So when you impact a person who's pregnant in their pregnancy or their postpartum period, you are impacting not only that parent, but also that child. And that's vastly important in how we address that, as well as how we educate and help folks be aware. So when we talk about our bracelets, they're a great tool. They're such a great tool. Also, how can we increase that awareness? How can we increase that education and make sure that we're not using medical jargon, that we're talking on the same level? When you speak about the postpartum period and we have the bracelets that we give to them. So we have flyers that we did very similar to you guys. We did flyers and we did posters, and we try to put those flyers up in the offices. And it has a lot of the Post-Birth Warning Signs. It has a picture of the bracelet on a Mom and what that looks like. So it helps them see that before they have their baby and before they have that postpartum drain. And it's difficult for them to hear and listen and understand and remember. So they may read their books. Those books are so phenomenal. I actually make my students go through and read those books with the patients so that it helps them learn too. And when I bring awareness to that Post-Birth Warning Signs in the back, just like you were saying, the magnet, the sticker is great. But if you don't have those, tearing that sheet out of the book and putting it on your refrigerator, that helps remind you and your Family, hey, I've had a headache for three days. That's not normal. I should really seek some care. I need to call somebody. I need to go to the emergency room if I'm seeing spots. Those are the things that we want to make sure we bring awareness to. And in speaking to the demise piece and those moms who may or may not want to wear their bracelet, having the white bracelet is amazing. That's a great opportunity for them to still have their recognition and educating our folks on that. And one thing that we talk about for that barrier that we have encountered is just making sure they get the education. So even our books that we give to our moms that don't take home a baby, we use June's bouquets so she doesn't go home with her arms empty. And we also give a booklet that still has Post-Birth Warning Signs. And even if you don't want to wear that bracelet, put that on the refrigerator so you remember and make sure your support Family and support persons tell someone if you have an emergency that that's happened. And we want to make our patients better historians so they know to tell, hey. I had a baby like four weeks ago and I have a really bad headache. Sometimes you might get blown off and you really have to be able to speak up for yourself in a lot of different situations.
Vicki - 00:20:00:
I want to share a journey that We stumbled into. That even went to this podcast. So late last year, I subscribed to IHI. Just because I believe they have great information that I like to. Browse through. And I saw an opportunity. To apply for a program that they were offering that was eliminating inequities, reducing maternal mortality morbidity. And it just so happened I was going out of town that day. I was leaving on a vacation. And so I forwarded it to two of our quality members that I know are just always ambitious for a great project. And I said, hey, I think we should look at this, but I don't think we should. I can't, the deadline's tomorrow and I have to leave town. And so they took it on and we emailed back and forth and we got the application submitted. They were selecting five hospitals. We were one of the five. We rejoiced. We created a team and. Our team fully engaged. And then IHI was selecting one hospital to move forward. We did a six month project with IHI. And they were going to select one hospital to continue on this path. And they selected. USA Children's and Women's Hospital. So that application to that program led us to this podcast. It led me to making this connection with you. It reconnected us with the March of Dimes. Who is coming on site the end of September to do an implicit bias training. It has had so many hospitals reach out to us about our bracelet program. So I want to encourage listeners. Don't be. Intimidated. Be inspired. By all the great work that's out there because I don't consider myself an expert. I think I have great experience. But I don't have a strong. Academic background, you know, for research and Dad and... And laying it all out there. But the opportunities from these organizations, IHI. March of Dimes, A1. They're out there. So browse their websites and you will see opportunities to. Improve your team and ideas to improved patient outcomes.
Jessica - 00:22:25:
Absolutely. And so my position currently as nurse champion is a grant position through HRSA. And so it's a federally funded program and it is. It's amazing. So when we speak about how we can grow the program, for our nurse champions, for my region, like I said, I had the opportunity to come in to and. Outreach opportunity and they already had a team built. Don't feel as though this can't be done. When you don't have a team. This can be done. Even when you don't have a team, this can certainly be something that you can start. And looking at grant funding, what does that look like for your state? What does that look like for your region even? Where do you live? What are some opportunities? Going on your state websites, reaching out to your state representatives, those types of things can certainly help you find information on how to start it. We started very small. We started in our Medical Center. We began with doing Post-Birth Warning Signs education through the A1 site for all staff that would come in contact with anyone who was pregnant or postpartum. Once we had that education established, it took about six months. We started only for the first year in the Medical Center. And we pushed out education to our via flyers and posters, as well as emails and telephone calls to the region where our county, our Pitt County folks and our emergency medicine folks. And that took a lot of time. It was a lot of boots on the ground is going to see these individuals and speaking to them. The other piece of that is expansion and making sure that we have, you may have to build a team once you start in one spot. It very well may be just like you were saying, Vicki, you had the opportunity to build the team with bringing in the IHI training as well as implicit bias and understanding how do we recognize the way we work and grow and how what we were warmed by the way we were raised, how the thought process that we formed, how can we change that? How can we break that cycle, if you will, of is that really true or is that just something that I thought because that's what my grandmother told me and make those changes. It's so important to make those changes in ourselves so that we can provide our patients with the utmost quality care.
Vicki - 00:24:43:
Yeah, great points. In the next two years, what do you hope to see in North Carolina related to? Maternal wellness.
Jessica - 00:24:53:
Well, we know that for maternal mortality, it takes about 10 years, right, to see a huge difference. We are currently working on a study, applying for IRB right now, actually. Looking at how we have impacted moms, how they seek care, and what did they retain from post-birth morning signs. So you've got a bracelet, you received education, when did you see it? Do you remember it? Why is it important to wear the bracelet? So bringing in over the next year, looking at how our patients have truly been impacted and what that looks like. The goal would be for increased awareness, for not only seeing the decrease in maternal mortality, but also seeing increase in communities. In so many other countries, we have these communities that are already built. And unfortunately, where we live, we don't always have those communities. Maybe they're a military Family, how can we support them? Maybe they're here because someone's in medical school and they're here by themselves having their baby with their spouse who's busy, and how can we support that Mom? How can we support the Mom who this is her third baby and help her get those resources that she needs? In healthcare, and specifically in obstetrical healthcare, oftentimes we have siloed care. So we have a great program, but maybe this person over here doesn't know about it because they live in a different county or they're not in the same pathway. I think the care management for high risk pregnancies, what we call CMHRP in our state, which is moving to a different name, those care partners are amazing. They do great work with going in home, doing visits, as well as making sure patients have those resources that when we know social determinants of health, transportation is the biggest issue in our region.
Vicki - 00:26:35:
Yeah, I think home visits are certainly a key plan. I think. I had, it's many years ago, but I had the privilege of working in NICU in Cambridge, England. And you know, there are their health visitor home program is pretty amazing. And so supportive of moms. I wish that we could develop something similar. I think for, I may have shared, we're working on a postpartum. Home Blood Pressure Monitoring, a six-week monitoring program. We're going to call it Hero for Mom.
Jessica - 00:27:10:
Awesome
Vicki - 00:27:11:
and It's an acronym that I don't have right in front of me. My apologies. Or is definitely for the fourth trimester because we're trying to put more of a focus with this. Measure if we are going to see decreased admissions by this better and improved surveillance of moms hospital discharge. And to establish that connection with them for six weeks hospital discharge. You know, some really, I hope we can go live October 1, but. You know, the devil's in the details and it seems like every day it's an old we should probably think about that. I feel like we're going to have a lot of great success. I'm really excited about rolling it out. And see what the return is. Yeah, I'm incredibly proud of. Of South Alabama. We know we're usually in the lower. Quadrants of you know, impacting Maternal health. And so. We know we need to do better. And what I'm happy to say is. We are doing better.
Jessica - 00:28:10:
Yes.
Vicki - 00:28:11:
And we're taking the steps to do better. And we do care. We care so, so much. Yes. So we look forward to that.
Jessica - 00:28:19:
Absolutely. There's so many things that we can think about. There's a lot of work to be done when it comes to Maternal health. There's been a lot of work with neonatal health and how we took care of our babies and how we've improved in all that care. So now understanding that Mom is often medicine for babies. So how can we help support her and support the whole Family and support all of our birthing persons and make them feel appreciated and make them feel understood and not brushed off and all of those different things. So that's a great way to look at your program. I think other states that have tried to do bracelets just for preeclampsia, we just talked about that 43% of our deaths in North Carolina were postpartum. They were not sick. A lot of those people weren't sick in pregnancy. So having that equitable practice of providing the bracelet to all people after delivery of 20 weeks, That allows those persons to be incorporated and heard and listened to. If you've never heard of the Hear Her campaign, I encourage you to look that up. And it talks about how we need to listen to our patients, listen to our moms and understand what's going on and really spend that quality time. You mentioned the fourth trimester. That's really a lot of what the work is that we're doing is looking at how we can support. All those folks in that fourth trimester, that postpartum period up to that one year. Thank goodness for Medicaid expansion. But now we have to help our providers learn how to best care for these people because obstetricians are like, okay, it's been six weeks. You know, who are you gonna see? Do you have a primary care provider? A lot of our rural facilities in Eastern North Carolina, those obstetricians end up becoming PCPs because there aren't any. And so like we talked about, those nurse practitioners, those midwives, how can they support those smaller regions? How can we recruit them? You were talking about the midwifery program, we're growing it, but hey, we're gonna pay your loans off if you work here, not just three years, but five years. So you grow roots and you stay. And certainly that would be a good way to do that. That's exciting to hear that you're gonna be able to implement that program for you guys in Alabama too. I know that there's so much work and I wanna have the opportunity to share widely because just like you said, we've had quite a few folks reach out. I spoke to your health department folks a couple years ago. About bracelets and what that looks like. So I'm so excited to hear that Alabama is working on this. There are a couple other places that I've spoken to, actually spoke to a place in Northern California a few months ago. I was really excited about that because we bring all of our stuff for OB. We bring it out of the California Maternal Quality Care Collaborative. That's right. I had the opportunity to serve on our North Carolina Perinatal Quality Collaborative, we call it PQCNC, great initiatives in how we build those aim bundles and implement those aim bundles within the hospital. But then also how can we support them on the outpatient side? The lack of providers is a huge issue and providing that care in the postpartum period is challenging when you don't have enough providers to see the patients.
Vicki - 00:31:16:
Well, thank you for sharing your perspective on all of these items. It's just such a pleasure to get to know you and. I'd like to thank everybody. For listening. Probably didn't hear anything new. But you heard our perspective and maybe some things that we're doing that. That you may want to do or maybe you're doing something great and we'd love to hear from you. So we can do that also. It takes a village and. We want our village to be strong. You know, I will say that. One of our IHI representatives, Cleola Payne, who was here this week. She shared a story about shoulder strong. The things we're working on, we may not see in our lifetimes or in my lifetime. I may not see the end results. But shoulders strong and. And being the shoulders to carry it forward. So that it's better for our future. You know, don't ever be discouraged because everything that anybody does is making a difference. So. We appreciate all the efforts.
Jessica - 00:32:22:
Absolutely.
Vicki - 00:32:22:
Yeah, I'd like to read our package. And then we'll close. USA Health Children's and Women's Hospital cares about you. Wearing this bracelet for the next six weeks will alert anyone providing medical care for you. That your condition or illness may be pregnancy health. We are striving to improve Maternal health for our community. And so we thought that, you know, if we could share the why. When we give it to them that. That would inspire them to wear it.
Jessica - 00:32:52:
Absolutely. And if people know the why, they're more likely to do something than they would be if they didn't understand the why behind it, for sure.
Vicki - 00:33:01:
I agree. For more Podcasts, videos, blog, and Maternal health content. Visit the Maternal health Learning and Innovation Center website. At maternalhealthlearning.org. We want to hear from you. Tell us what you want to hear more of, review our podcast and share. With like-minded innovators. We've got some great episodes recording now. Be sure you're subscribed and please share.
Narrator - 00:33:30:
This project is supported by the Health Resources and Services Administration, HRSA, of the U.S. Department of Health and Human Services, HHS, under grant number U7CMC33636, State Maternal Health Innovation Support and Implementation Program Cooperative Agreement. This information or content and conclusions are those of the author and should not be referred by HRSA, HHS, or the U.S. Government.