Closing the Racial Divide in Maternal-Infant Health

The inaugural episode of The Princeton Pulse Podcast addresses maternal and infant health disparities, a serious and often overlooked public health crisis. The facts are startling. In the United States, Black mothers are three to four times more likely to die of pregnancy-related complications than white women, and Black babies are twice as likely as white babies to die before their first birthdays. Those statistics have captured the attention of both researchers and policymakers, especially in New Jersey, where the gaps are even more stark. What is causing such dire outcomes? How can we close the racial divide?

In this episode, New Jersey's First Lady Tammy Murphy discusses how the Garden State is tackling the issue head-on through policy and Nurture New Jersey, a collaborative endeavor aimed at making New Jersey the safest, most equitable place in the nation to deliver and raise a baby. She is joined by Princeton Professor Elizabeth Armstrong, who explores how racism drives maternal and infant health disparities and leads to adverse outcomes. 

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The Princeton Pulse Podcast is a production of Princeton University's Center for Health and Wellbeing (CHW). The show is hosted by Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health and Senior Services, produced by Aimee Bronfeld, and edited by Alex Brownstein. You can subscribe to The Princeton Pulse Podcast on Apple Podcasts, Spotify, or wherever you enjoy your favorite podcasts.

Transcript

PRINCETON PULSE PODCAST
EPISODE #1

Heather Howard  

Hi, and welcome to the Princeton Pulse Podcast. I'm Heather Howard, professor at Princeton University and former New Jersey Commissioner of Health and Senior Services. On campus and beyond. I've dedicated my career to advancing public health. That's why I'm excited to host this podcast and shine a light on the valuable connections between health research and policy. 

Our show will bring together scholars, policymakers, and other leaders to discuss today's most pressing health policy issues, domestically and globally. We'll highlight novel research at Princeton, along with partnerships aimed at improving public health and reducing health disparities. 

I hope you'll listen in as we put our fingers on the pulse and examine the power and possibilities of evidence informed health policy.  

On today's inaugural episode of the Princeton Pulse, we're addressing maternal and infant health disparities, a serious and often overlooked public health crisis. The facts are startling. In the United States, Black mothers are three to four times more likely to die of pregnancy-related complications than white women, and Black babies are twice as likely as white babies to die before their first birthdays. Those statistics have captured the attention of both researchers and policymakers, especially here in New Jersey, where the gaps are even more stark. New Jersey's First Lady Tammy Murphy has not only taken notice, but taken charge. After learning that Black mothers in New Jersey are seven times more likely than white mothers to die during pregnancy, and that Black babies are three times less likely to survive to one year of age, she launched Nurture New Jersey. Her goal is to make New Jersey the safest, most equitable place in the nation to deliver and raise a baby.  

What is causing such dire outcomes in maternal-child health here in New Jersey and across the U.S.? How can we close the racial divide? First Lady Tammy Murphy is here today to discuss those issues, along with Princeton Professor Elizabeth Armstrong, whose research interests include public health, the history and sociology of medicine, risk in obstetrics, and medical ethics. First Lady, Professor Armstrong, welcome to the show.

Elizabeth Armstrong 

Thank you, Heather.

Heather Howard  

Professor Armstrong, can we start with you? How would you define this problem nationally? Are we really facing a maternal health crisis?

Elizabeth Armstrong  

Well, the United States has experienced an increase in maternal mortality in recent decades, in distinction from almost every other developed country in the world. We are among the few countries that is experiencing rising maternal mortality rates. Maternal mortality, deaths during or after pregnancy, are really only the tip of the iceberg. There are around 800 maternal mortality deaths in the United States, but an estimated 68,000 near misses -- women who almost died during or shortly after pregnancy. And there are about 1.7 million serious maternal morbidity complications that occur every year in the United States. So looking at maternal mortality and maternal morbidity, yes, we are facing a maternal health care crisis. 

Heather Howard  

And First Lady, how is this playing out in New Jersey?

First Lady Tammy Murphy

Well, just to follow on what Professor Armstrong was saying, New Jersey is 47th in the country in terms of maternal mortality, which is appalling, given the high level of health care we have here in New Jersey. But you know, I just want to reiterate, the United States is in a very bad place. As Professor Armstrong just said, the numbers are tragic enough. But then you think about this: we are 55th in the world for maternal mortalities, which is stunning and clearly unacceptable, given the developments that we have in the United States. 

Here in New Jersey, a Black mother is seven times more likely than a white mother to die for maternity related complications. And a Black baby is more than three times more likely than a white baby to die before his or her first birthday, which is clearly unacceptable. So as you already mentioned, we launched Nurture New Jersey in 2019 to help us become the safest, most equitable state in the United States to deliver and raise a baby. We are very excited because we have a lot of momentum around what we're doing and a lot of work to do. But we've made some headway that I hope I can share with you today.

Heather Howard  

I'm looking forward to that. 

You mentioned some pretty startling statistics. How have you leaned into the research on this? What role does research play in your effort here?

First Lady Tammy Murphy 

Research is vital. We could not do anything, or honestly have a leg to stand on, if we were to go out in public and not have the research to gird everything that we're talking about. I will tell you that from day one of my husband's first administration, my team and I started meeting with stakeholders, both within the administration and outside of the administration, to really understand what was going on. I can tell you I naively approached this from the beginning thinking, oh, it's a lack of access to prenatal care. And sure enough, you know, after speaking to now thousands of stakeholders, and I truly mean thousands and thousands of stakeholders, it's pretty clear that the data indicates that we have a real challenge, particularly for our women of color. And it's taking into account all the social determinants of health. I mean, it is everything from transportation, to education, to nutritious food, to workforce development, to child care. It’s everything all bundled in one, and really the only way to define it, I hate to say it, is decades and decades, if not centuries, of institutional racism.

Heather Howard 

Professor Armstrong, do you want to jump in? Is that consistent with what you see nationally in the data?

Elizabeth Armstrong 

I think what First Lady Murphy is expressing in her focus on racism is a really important shift that's been taking place, more broadly, in how we think about public health policy in medical care. For a long time, we regarded race as a risk factor for adverse outcomes and for disparities that we observe in outcomes like infant mortality and maternal mortality. We have begun to recognize that it's racism, not race, that drives health inequalities and leads to adverse outcomes. So this is a very powerful reframing to how we understand the causes of adverse outcomes and disparities in those outcomes.

Heather Howard 

So Mrs. Murphy, can you give us an example of how you're seeing the social determinants of health play out in the New Jersey data? Education? Housing? What's a good example for our listeners?

First Lady Tammy Murphy 

How about if I give you a real live example, a woman. Her name is Ajanay. She lives up in Bergen, and she found out she was pregnant when she was in college. She found a great doctor that she was really happy with but found out that she couldn't stay on her mother's health care plan. So she got bumped off of the health care plan, which then meant that she had to go on Medicaid. And she ended up having to commute to Paterson because there are such limited choices. Many doctors don't accept Medicaid. So she went to Paterson and she would find herself not only having a much longer commute, but then on top of that, she had a long wait to get to the doctor because there were so few doctors and so many people who needed access to those doctors. Ultimately, she made it work. But then she started feeling unwell. She had abdominal pain and went to the hospital, and they didn't believe her. She ultimately delivered a baby boy who lived for three days. Ajanay is firmly of the opinion that had she had better access, had she been able to continue with the doctor that was closer to home and had more availability, then she would have had a different outcome. That brings it home for me. 

Heather Howard

Professor Armstrong, the research is pretty clear about insurance coverage, isn't it. But can you speak to this example, more generally, on the national trends in insurance coverage?

Elizabeth Armstrong 

Sure. We spent decades trying to expand insurance coverage as a solution to maternity care problems. Beginning in the 1980s, we expanded Medicaid coverage to include pregnant women. And, as First Lady Murphy indicated, the expanded coverage did not have the overwhelming effect that many policymakers and researchers hoped. We hoped that prenatal care would be a magic bullet, a solution to ongoing health disparities in the United States and high rates of infant mortality in particular. Unfortunately, things didn't play out that way, in part because expanded access alone, as First Lady Murphy's example demonstrates, doesn't necessarily guarantee that a woman can find a provider, can access quality care, and can receive care that is commensurate with her needs at that time. So expanded coverage is great. It's not sufficient. It's necessary but not sufficient as a policy solution.

Heather Howard 

Professor Armstrong, you mentioned that Medicaid has been a good source of coverage for many pregnant people, but Medicaid stopped covering many women three months after their delivery. The research shows that many of these maternal deaths were happening up to a year after. 

Elizabeth Armstrong 

This is such an important point, Professor Howard. When we hear maternal mortality, many of us have kind of these 19th century ideas about women dying literally in childbirth. What we know is that more than half of all maternal deaths happen after the baby is born, in the year following the birth. So we need to cover women for a longer period of time. Medicaid, for a long time, covered a single postpartum visit that usually took place six weeks postpartum. And that was it. Then the woman's coverage ended, and the baby's coverage would continue of course. That allocation of resources reflects a tendency in American health care policy to focus on children and pregnant women as vessels or producers of children, rather than focusing on women's health as an important policy goal in its own right.

Heather Howard 

First Lady, New Jersey was one of the first states to address this very issue that we've pinpointed. Right? Do you want to talk about that extension of coverage? 

First Lady Tammy Murphy 

Yes. Can I hit two things? 

 Heather Howard

Sure. 

 First Lady Tammy Murphy 

Okay, first of all, on the extension of coverage, I am so thrilled that you gave me the perfect layup, Professor Armstrong. My husband just signed into law an extension of Medicaid coverage for 365 days postpartum. That is something that is widely available across the United States. And I will tell you, it is heartbreaking for me to see that many states are not taking the federal government up on that offer, which is tragic. So yes, I'm really proud of my husband on that front and so excited for us here in New Jersey. 

There are two other things I want to say. I think also that Professor Armstrong's point about mortality happening any time up to a year postpartum is really important to understand. Because many people say to me -- and it goes back to your question about the data -- many people say to me, okay, when your husband came into office, we were 45th in the country in terms of maternal mortality rates. You've been working on this for several years now, and now we're 47th. What is going on? And I keep saying, you have to understand it's a lagging indicator. It's not as though you can fix something today and have the data immediately reflect those great changes tomorrow. We paid the price when we started out by having really bad policies that were in place, and we are basically making up for lost time right now. 

The other thing that I wanted to say -- and it goes back to both the economics of this as well as the racism piece -- is a very important point to make. It's not only people like Ajanay who need access to Medicaid, who are having disproportionate outcomes. There are people like Serena Williams, Beyoncé. These are powerful women who have incredible platforms, who can speak for themselves, who have access to the best doctors and the best medical treatment in the world. And no one believed their stories, and they had serious problems. So I just would say that it underscores the fact that this truly is a racism challenge. We have to rethink and transform the way we deliver care, and the way we think about community, and the way we support one another.

 Elizabeth Armstrong

I just want to stress that point, that we know that even the most advantaged Black women have worse outcomes than the least advantaged white women. Black mothers with a college education are at 60% greater risk of maternal death than white women with a less than high school education. So racism is playing a really important role in how women experience the maternity care system.

 First Lady Tammy Murphy

Yeah, I think that we have been so wrong about the direction we've been going in, for such a long time, that I think that we now need to change the conversation. We have been working really hard to do that for the last four and a half years. That's nothing in comparison to Professor Armstrong's depth and breadth of experience here. But I'm really so thrilled here in New Jersey because my husband signed 43 pieces of legislation in this space alone, which is pretty extraordinary, in just four and a half years. There's one particular piece of legislation that I have to tout, and that is universal home visitation. I really am so excited about this because it is a game changer in terms of disparities in income. 

 This law is enabling a nurse practitioner to go into the home of any mom -- whether the mom has delivered a stillborn baby, whether the mom has delivered a healthy baby, or whether the baby has been adopted. The nurse practitioner goes in to check on the mother and family. If you think about it, in the first six weeks of a baby's life, a baby is seen by doctors multiple times, and a mother may be seen maybe once. Think about the journey. You don't know if somebody has housing insecurity, has food insecurity, has taken five buses, is wearing her Sunday finest clothes to go to the doctor's office, which is a white room where no one can tell what's going on with this family. So now we send a nurse in to every single woman's home. And what will you find? You will find out if the mother is exhausted, if there is domestic abuse, if they don't have internet Wi Fi connection, if they don't have food. You'll see what other resources we can bring to the table that will help this family produce healthy children, healthy teenagers, healthy adults, healthy parents. Maybe the mother needs help with breastfeeding, or just needs somebody to hold the baby for 10 minutes so she can take a shower. You don't know what you don't know. 

 Heather Howard 

Professor Armstrong, the nurse-family partnership has been studied for a long time. Do you want to talk about what we know about the value of these programs?

 Elizabeth Armstrong 

I wanted to say two things in response to that. First of all, we know that this kind of home visitation works. Other countries have done this for a long time. This is the model in the UK. So we do have evidence from elsewhere that this kind of policy is effective. The other thing that I want to stress, that's so powerful about what First Lady Murphy is describing, is the fact that it's a universal home visit. Every mother and every baby receives this visit. This is not something that's targeted at women who are perceived as being at risk. It's not a stigmatizing policy. It's universal and powerful in that it helps to destigmatize the intervention. And it also helps to catch women who might not be visibly at risk in a physician's office.

 Heather Howard 

So that's one exciting initiative. Can you take us back and tell us about Nurture New Jersey?

First Lady Tammy Murphy

Absolutely. So from day one, my team and I started going both within the administration and outside the administration to really try and understand what was going, where the problems were, and what we can we do to fix this. Interestingly, on day one, back in 2018, I had two departments and agencies within the administration working alongside us to try and come up with a plan -- the Health Department and Family and Children's Services. Today, we have over 20 different departments that are working together with us to tackle this challenge. Outside, we traveled the state and met with stakeholders across every county in New Jersey. And I will tell you, the universal finding, both within the administration and outside the administration, is that there are some really great people out there who are genuinely trying to do the right thing. But everybody's working in their own little space and they don't pick up their head, they don't get out of their own silo to see what other people are doing that could possibly complement their work. 

So we started Nurture New Jersey, which is our statewide initiative to reduce maternal mortality rates by 50% over five years and to completely eradicate the inequities. Other states have done the 50% in five years, namely California, but they didn't pay any attention to the inequities. So we have built upon the work that they did already, as well as other states. We have worked together with literally the top experts in the country to try and tackle this challenge from all perspectives. We had over 100 stakeholders who were interviewed as part of this strategic plan. And at the end of the day, we unveiled the strategic plan in January of 2021. It is a 70 step, actionable plan. We have already, to date, tackled or started over half of these steps. We are just putting our heads down every day, and we are determined to move forward. I do think, by the way, that our plan could be a blueprint for other states and other areas across the country that might want to try and start fixing the challenges that they're experiencing in their own backyards.

 Heather Howard 

Professor Armstrong. First Lady Murphy mentioned California. Have you followed what California did? And are there any examples you would want to lift up nationally that give you hope?

Elizabeth Armstrong

California is a great example, California invested in something they call the California Maternity Quality Care Collaborative, which has reduced the maternal death rate in California by more than half, really impressive accomplishment. Some of the ways they did that are by developing toolkits for maternity care providers, so providing very clearly established protocols for dealing with certain kinds of obstetric emergencies, and also encouraging caregiving teams to engage in mock emergencies so that when an emergency happens, they know exactly what to do. CMQCC has also focused extensively on quality improvement in hospital settings and, as First Lady Murphy was stressing, collaboration and working with a variety of stakeholders. I think one of the strengths of the CMQCC has been exactly that -- their focus on working with a variety of stakeholders in developing these initiatives to reduce maternal mortality in California, rather than taking a top down approach and working only with obstetricians, for example.

Heather Howard 

That's great. So let's dig a little deeper. First Lady Murphy, one of the pillars of Nurture New Jersey is "building a safe, high quality, equitable system of care and services for all women during prenatal, labor and delivery, and postpartum care." Can you say more about that? You've got a bunch of different actionable items. But it all sort of sums up to creating and strengthening the workforce. Can you talk about that?

First Lady Tammy Murphy

Yes. So among other legislation that my husband has signed, we now give Medicaid reimbursement for doulas. I don't know if you're familiar with doulas, but they are something I wish I had known about when I was pregnant with any of my four kids. Community doulas, particularly, are people who are in the community, who are culturally sensitive and can counsel and provide support. Historically -- alongside midwives in certain environments and certain hospital situations -- I think that they've been treated as outsiders, as lesser parts of the support team. And I think that we have tried to expand our doula workforce. We have tried to ensure that they are being reimbursed by Medicaid. And we have also created a collaborative. We've done a lot of things just with the doulas specifically, and with the midwives. That is one area that I think is really important. During Covid, mothers were also given the ability to bring a doula into the hospital room because they were excluded. And that was really unfortunate. 

Heather Howard

Professor Armstrong, what do you see as the ideal workforce for achieving birth equity?

Elizabeth Armstrong

I'm really glad to hear First Lady Murphy's emphasis on doulas, which are an important component of the maternity care workforce. And I just want to stress that that is an evidence-based intervention. We know, from evidence, that continuous support during labor is associated with better outcomes for both mother and baby. In fact, studies have been done that show just having a person present in the room with the laboring woman improves outcomes. Unfortunately, the way hospital-based maternity care is structured in the U.S., that's often a luxury that women don't have. Labor and delivery nurses are caring for multiple women at a time. They're watching monitors, they're coming in and out of the room. So a doula is an important addition to the maternity care workforce. I think diversifying the maternity care workforce on a variety of dimensions is a key aspect of addressing the maternity care crisis in the United States. Making sure that maternity care providers look like the women and people that they're caring for is an important part of that diversification, but also diversifying the kinds of roles that are engaged in providing maternity care. We in the United States over-rely on obstetricians-gynecologists in the maternity care workforce. Ninety-four percent of all births in the United States are attended by an obstetrician. That's not as common in other developed countries, where midwives play a much greater role in maternity care. Obstetrics in the United States and elsewhere is a surgical subspecialty. So we need to diversify the workforce and look for people with different kinds of training, midwifery training, doula training, not just obstetric training, as an important component of how we think about who provides maternity care, and what the content of that care is.

Heather Howard 

You have also done a lot of thinking about birthing-friendly hospitals. Right? Can you say a little bit more about that? 

Elizabeth Armstrong 

Sure. In general, I think paradoxically people often assume that the solution to maternal mortality and morbidity is more medical care. Probably, de-medicalizing maternity care, overall, would be an important pathway to reducing maternal morbidity and mortality. There's no reason that every woman has to give birth in the hospital. We can develop alternative settings for women to give birth that are very safe. We can also think about supporting women who choose to give birth outside of the hospital by developing better systems for transfer and transport, in the occasion that a woman needs to move from a home or birth center into a hospital for more specialized care during her labor and delivery.

Heather Howard

That's a great segway. First Lady Murphy, I wanted to ask you about not just the medical response, but also the community-based response. You have a whole section of your Nurture New Jersey plan on community-based social supports for pregnant women and parenting? Can you talk a little bit about that?

First Lady Tammy Murphy

Well, we have a saying in our office, which is brought on by all the mothers who we have interviewed over time: Not about us without us. We say that the moms have to be at the table before the table is even built. That, I think, speaks volumes, because mothers' needs and mothers' comments and mothers' wishes are interspersed throughout the strategic plan. And I also will tell you that I'm really excited because, in the upcoming budget, my husband has allowed us to create a database where we are actually going to actively solicit input from mothers as to what's going wrong, what went well. And that will inform us as we move forward, as we continue to create policy and try and find creative ways and solutions to challenges that are out there.

Heather Howard

That's really exciting. Professor Armstrong, do you want to talk about how to include the people in research, and how to think about the people who we're worried about?

Elizabeth Armstrong 

One of the things I love about that community-based focus is that it's restoring attention to birth as a meaningful moment in individuals' lives and, quite frankly, in the foundation of our society overall. Academic researchers often use the concept of invisible centrality to describe reproduction and birth in particular. Birth is foundational to all of us. It is a universal experience. It's how we all got here to this planet. It is critical to the formation of families, societies, countries, nations, etc. But it's often marginalized or invisible or glossed over. It's rarely the center of attention for policy initiatives. So one of the things that I think is so powerful about Nurture New Jersey, and this entire initiative, is the way that it centers birth, and birthing women, as something important for all of us to think about all the time - not just a niche issue that affects only birthing women or affects only women, but something that is absolutely foundational to our communities and to our society. So I love restoring that focus on birth.

Heather Howard 

So let's look ahead. How can we all work together, as researchers and policymakers, to improve maternal-child health? And how can we ensure that New Jersey is a leader in building birth equity?

First Lady Tammy Murphy

Well, first of all, you're doing it by having this podcast. Because much of the challenge that we've faced is understanding and communicating with people, and telling them that there's a problem out there. I will tell you, there's something really exciting that we will be doing here in New Jersey, and I'm just really hopeful. One of the goals that we have is to create an innovation and research center in Trenton. Why Trenton? Because it's a birthing desert. It's a food desert. It's our capital. It has disproportionate outcomes both for moms and for infants. It's also the seat of government. We have already signed 43 pieces of legislation, and who knows what else there is to come. My thought is that this innovation research center will be the MD Anderson Cleveland Clinic of the space. We want to be able to bring services and research and everything under one roof, and make sure that it's accessible, make sure that we're delivering the correct services that are needed in the community, and also give policymakers around the country access to the laws that we have already signed - and an understanding as to where and how we got to where we are right now. My big hope is that a lot of the data that we have unearthed will be moved into the center, and will be protected for everyone to be able to study and understand and use for comparative purposes across the country. So I'm really hopeful in that space. And you know, we'd love your help down the road, as we are looking at architects and planning at this moment in time.

Heather Howard

That's exciting for us to hear, with the center being so close to Princeton and so central to our work. 

Professor Armstrong, you teach classes in reproductive justice, in the sociology of reproduction, and you and I both have advised numerous senior theses with students digging into these issues. What do you see as a way for researchers and policymakers to collaborate on pressing issues like this?

Elizabeth Armstrong

It's such an important question, Heather, because we need research to inform policy, but researchers also need to be attentive to what's happening in the "real world," which, of course, is just the world. And too often research agendas might be set by something other than the pressing needs in the community. So I think having this kind of center that will collect the experiences of people, as well as collect data, will be a really powerful way to address the maternity care crisis in New Jersey and, as First Lady Murphy suggested, provide models for other states and other regions to take up in their own attempts to reduce maternal mortality and morbidity.

Heather Howard

Well, this has been a wonderful discussion. I really appreciate both of your participation. Anything we should have addressed, or anything you wanted to raise?

First Lady Tammy Murphy

When I talk about there being a lot of good people out there who are trying to do the right thing, and sometimes you just get stuck in your space, I think about a lot of these very well-intentioned doctors, who might go into a very difficult area where they have challenges and they have clinics, and they don't have access to great health care. In the obstetrics space, what ends up happening is a situation in which the doctor is going to give his time on Friday, two weeks from now. The doctor would go in and say, okay, C-section, C-section, C-section, C-section, C-section -- and they would be not necessary, but necessary in the sense that they had the good doctor at the moment. But that's a serious piece of surgery, and many of these people would have children at home or they'd have to get back to work immediately. They wouldn't take care, they wouldn't go to their follow-up appointment. So, for example, in New Jersey we no longer authorize planned C-sections unless, of course, there is a medical reason for doing so. There are things like that -- like going to the hospital and asking someone if they have delivered in the last six to 12 months, if they appear to have no issues whatsoever. There are some really basic things we can do.

 Heather Howard 

Professor Armstrong, do you want to add to that or bring up anything that we missed?

Elizabeth Armstrong 

Well, just on the C-section issue, I think reducing the reliance on Cesarean surgery is critical to reducing maternal morbidity and mortality. And New Jersey is unfortunately high in C-section rates. The United States is high. New Jersey is just mirroring national trends. One in three babies in the United States today is born via Cesarean surgery. Best estimates suggest that an optimal Cesarean section rate is between 10 and 15%. So we're well above that optimal rate in the U.S. as a whole. And New jersey, again, mirrors that trend. We need to focus on ways to reduce primary Cesarean surgeries (the first Cesarean that a woman experiences), which will help to bring down the Cesarean rate overall. 

Heather Howard

Well, thank you again, both of you, for all the work you're doing in this area.

Elizabeth Armstrong

Thank you, Professor Howard. 

First Lady Tammy Murphy

No, thank you so much for having us. And thanks for the collaboration. Because it really is academia, business, health care. It's all of us coming together and accepting the fact that we can move the needle together, and we will here in New Jersey.

Heather Howard

Thank you for listening to the Princeton Pulse Podcast, a production of Princeton University's Center for Health and Wellbeing. The show is hosted by me, Professor Heather Howard, produced by Aimee Bronfeld, and edited by Eden Teshome, with additional support from Rose Huber, Dan Quiyu, and Casey West. We invite you to subscribe to the Princeton Pulse Podcast on Apple podcasts, Spotify, or wherever you enjoy your favorite podcasts. You can learn more about health-focused research led by Princeton faculty, students, and other Center for Health and Wellbeing affiliates by visiting our website at chw.princeton.edu and following us on Twitter, Instagram and Facebook. Search for Princeton CHW to find us. We hope you'll tune in to our next episode of the Princeton Pulse Podcast.