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MS. JOHNSON: Hello, and welcome to Washington Post Live. I’m Akilah Johnson, a national health reporter here at The Post.

Joining me today to talk about her organization and the path forward to improving maternal health is Adrianne Nickerson, CEO of Oula. Adrianne, welcome to Washington Post Live.

MS. NICKERSON: Thank you. I'm so happy to be here.

MS. JOHNSON: We are very happy to have you with us.

So before we get into what Oula does, let's talk about the genesis story of how Oula came about. Tell us a little bit about the creation of Oula.

MS. NICKERSON: I think, in many ways, Oula is the company I've wanted to build my whole career, and I say that because I started off getting a master's in global health focused on sexual reproductive health. And sort of in starting a company, you ask yourself a lot like why do this because it is a crazy journey. I think a lot of my initial passion for the space comes from growing up as one of four with three brothers, and so I'd say I've always been sort of uniquely attuned to things that are different for women because I'm so used to sort of watching my brothers' experiences in this world.

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And so it's an area I've loved, but I left grad school thinking, wow, so often this is the world, frankly, like politics in the U.S., and not quite sure how it's going to be able to build something that had an impact, and so I left grad school saying like if I'm going to be able to do anything in this space, like I really need to understand sort of the business side of it, since that seems to dominate so often how things get paid for, what gets built. And so I left, and I spent some time doing health care consulting, working with large health systems and insurers, and I spent some time actually working at a large health system in Long Island called Northwell and then actually building something in cancer.

And so, finally, when I got to my thirties and on a very personal level, got married and started thinking about having kids. I probably like thought about women's health again in a way that I haven't been able to focus since grad school and was honestly floored to hear the experiences that other women were having, as I was asking friends or talking to other women about what prenatal care, what birth looked like, and honestly, they described something that I'd say, at best, felt like a really impersonal and cookie-cutter and kind of like factory-line approach to care and obviously, worse than that, probably dangerous. It wasn't a system that I wanted to go through. So I felt like a sense of urgency to be able to build Oula, selfishly for myself, and then obviously for lots of other women and birthing people who needed a better experience and felt like at the core of what was broken and what we could fix was a care model problem, which we built the wrong system to deliver maternity care in this country.

MS. JOHNSON: And so as you're thinking about building another system, I'm curious about the name. How does Oula--you know, tell us what that means and how that is like part of the genesis story as well.

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MS. NICKERSON: So in building Oula, it was really important to us to create an experience that centered women's voices in their care, because that's so often what doesn't happen. In maternity care, in particular, there's so much of a focus sometimes on the baby at the expense of the mother, and so we picked the name "Oula" because it pays homage to doulas, and they're the one person, if you don't know, who's sort of entire job it is in the room, so to speak, or the delivery room to advocate for the mother or the birthing person. And so we love sort of paying homage to that in the company's name.

MS. JOHNSON: We will get to doulas soon in this conversation. Don't you worry. We will go over that territory.

But first, I wanted to kind of go back to something that was noted in the intro video, and that is that as soon as you opened your first location, you all were at capacity within three months, right? And so I'm wondering if we could talk a little bit more about the Oula model. You mentioned that you all are trying to break out of this kind of cookie-cutter approach to maternal care. So what are do folks get when they come to Oula? How do you all stand out from hospitals and other birthing centers?

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MS. NICKERSON: At the core of what we built was, as I say, a collaborative care model. So you want to be able to have the sort of the best of midwifery and obstetrics coming together, and so that means you're going to get a team-based approach to care. Majority of women are going to see midwives, but if they have something that means that there are a little bit riskier and they need a consult, they don't have to go outside the system somewhere else to have it. We have OB/GYNs, even maternal-fetal medicine specialists for part of that core care team to take care of women during pregnancy, and then in between appointments, we have this wonderful remote care team that is staffed by care coordinators who are usually doulas by background and training, RNs, NPs, and so you have a lot more touch points between visits. I say a lot of times that, you know, pregnancy doesn't happen in just 14 discrete moments over nine months. It happens in all the moments in between and definitely after they send you home with that baby, and so having those additional connections to your care team between visits is so important.

They're going to get connection to sort of classes and community, and so extra education, peer support by other women, for the people who are going through, this the same experience with them, and so they really get a more robust and supportive approach to care. And then they're able to deliver at a high-quality hospital where our providers sort of follow them in, catch the baby, so to speak, as we say for midwives, and then follow them along their journey. And so it does--your care and experience doesn't end with Oula at that sort of perfunctory six-week visit, we continue to offer additional support well into the first year of life after having a baby.

MS. JOHNSON: The fourth trimester, you all are still very much involved, it sounds like, you know, still catch the baby, six months, we're out. [Laughs]

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MS. NICKERSON: Yeah. We offer postpartum office hours that are facilitated by a lactation consultant and a doula from our team, and we did them at first in person. And then with the Omicron wave, we moved it all to virtual care and saw a ton more adoption, which makes sense. If you've had a small kid, the idea of like packing up and getting all of your stuff together to make it into your doctor's office to get sort of connection support in those first four weeks is really hard. And so people can continue to go to those classes for a year, for 6 months, for two visits. You know, it really is person by person, but we offer that support as a way to sort of extend the care experience and support well into the fourth trimester.

MS. JOHNSON: So who are the folks who are coming to seek out Oula? Talk to us about clients, patients? What term do you all use? Are these your--are they your patients? Are they your clients? And, you know, are they--age range, economic range, demographics. Just tell us a little bit about who comes to Oula to give birth and seek parenting help.

MS. NICKERSON: All sorts of folks come to Oula. I think--going back to--you mentioned that we got to full capacity in three months, and sometimes it's something we really highlight because I think there's this perception sometimes that midwifery care is like fringe or like it isn't something that every woman would want to choose. And we have, you know, everyone from, you know, your lawyers to your consultants down to your hairdresser to your social worker. I mean, really, it cuts across the gamut of folks who say this is the care model that they're looking for, and more and more really is what women are looking for, which is sort of best of both. They want connection to the known health care system that feels safe along with an approach that treats them like a whole person.

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And so it really is a wide swath. I mean, in terms of demographics, about half of our patients identify as not white. It's about a quarter of that identifies Black. We are predominantly commercially insured. About one in six rely on Medicaid and come through our doors. We have about 10 percent who identify as LGBTQ, and so we really do see a broader section that generally reflects the population in New York.

MS. JOHNSON: And so talk to us about your clinicians, right? Because you quite often hear, particularly when it comes to disparate care and the disparities that play out in maternal health, that it's really important that there's some racial concordance between, you know, patients and their clinicians. So tell us about who are your clinicians and who are providing the care at Oula.

MS. NICKERSON: So the majority of the folks who provide the care--I'd say we sort of have a flipped pyramid. Most people give birth with an OB in this country, and maybe 11 percent give birth with a midwife. It’s sort of flipped at Oula. So the majority of the providers that you're going to see if you come to Oula are midwifery or our midwifery team, because we really set out the midwifery model of care. Once again, you could see an OB. You could have an MFM consult in your care, just depending on the risk.

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In terms of the breakdown, I mean, you're right. Recently, concordant care has been proven time and time again to really improve outcomes. It's a challenge when the midwifery workforce is about 6 percent Black identifying. Our provider breakout, sometimes I hate sharing it because it feels like it's sort of putting them into a box in a way that like there's a lot more things that they bring to the table beyond obviously their identity, but about a quarter of our midwives identify as Black, maybe about 40 percent of our overall care team. So folks that are going to be interacting with the patients identify as non-white.

MS. JOHNSON: And so talk a little bit too about the philosophical differences--you touched on it a little bit--between midwifery and obstetrics and kind of what's the difference that one can expect in terms of types of care and the philosophical approach to birthing, difference between midwives and obstetrics, and then separate than that, I want to talk about what is a doula because I think quite often people, you know, conflate doulas and midwives. So first, difference between doulas and OB and then--I mean, sorry, hello--I just did it. Midwives and doulas, and then what midwives and OBs, and then what is a doula?

MS. NICKERSON: Okay. I'll do it. I'm not sure I'll do it in the right order, but I'll start off between--

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MS. JOHNSON: That's okay.

MS. NICKERSON: --midwives and OBs.

What we sort of say is everyone needs a midwife, and some people need sort of an OB too. Midwives very much focus on an approach to pregnancy that says it's normal until it's not. So they're focused on sort of natural physiological birth, where I'd say OBs are experts in sort of higher-risk care and they're the surgeon you want available if you need an emergency C-section or something operative. And so we really think of sort of both bringing a different skill set to the table. While we really like having midwives as part of our core care team is--what they do and they do really well is build a trusted relationship with patients. They spend honestly more time with the patients, and that's part of their ability to do that. They really uplift informed consent and autonomy in decision-making, something that I think is incredibly important for women in any health care setting, let alone sort of pregnancy and maternity is to feel like they're really a part of the decision-making process. And so I would say that they're complemented by OBs or really specialists at more of a high risk for that surgical-based care, but both can deliver and sort of catch babies.

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And then I'll contrast that with--so midwives versus doulas. So a midwife is, you know, a trained clinician, right? Often many of our midwives, the majority of them, have gone to nursing school first, and they get that degree, and then they go back for additional training in order to become a certified nurse midwife in particular. They've often honestly caught more babies than your average OB/GYN has because all they do is sort of in the business is focused on low-risk birth and broader sort of support for women's health. Whereas, your doula is going to be a trained patient advocate. So they're not a clinician by background. They're not going to give medical advice, but they are going to be a person who provides extra education, helps navigate to resources, both prenatally and postnatally, can honestly do some comfort and coping measures during labor and delivery and then as an advocate to help you have another voice in the room. Anyone who's been through labor, it's a lot. It's intense. You're not always sort of firing on all cylinders, and to have someone else in the room who knows what's important to you, communicating with the providers and other folks in the room is just a wonderful sort of asset to have as well.

MS. JOHNSON: Yeah. And so the CDC recently came out with a study not too long ago that was looking at respectful care and how about 30 percent of the women in the U.S. who have given birth or people who have given birth in the U.S. say they have felt somehow disrespected or mistreated during the course of their care, and another 40 percent, particularly of women of color, said they felt that they experienced discrimination while they were--during pregnancy, during childbirth.

And so, you know, you touched on trust and you touched on autonomy while we--while you were kind of talking about some of these differences in standards of care, and so I guess I'm wondering if we could talk a little bit about bias in delivery and how bias in delivery and bias in pregnancy care, how that affects outcomes.

MS. NICKERSON: It's a great question. I think--I mean, I don't know if I'm the expert in it, but what I'd say is like part of the reason why I think bias shows up is--or why it sort of impacts outcomes on some level is going back to sort of the trust piece, right? You need to trust that if you're raising a concern as a patient that your provider is listening to you and hears you and believes you.

And like many things in medicine, there's going to be a lot of gray space. There's going to be a lot of areas where we don't perfectly know what to do, and so I think if you rely on sort of--or I guess in that space, it's inherent for sort of bias to show up for the ability to sort of ignore the patient who's screaming and saying, you know, "This is wrong. This isn't what I should be experiencing," saying like, "Well, technically, your levels look just right." And so I think given that like medicine is always going to have some gray area, it is so important to build that like fundamental trust where when a patient speaks up and says this isn't right for me, like I know my body, but the person on the other hand of it--or on the other side of that conversation, first instinct is belief and trust. And, you know, inherently, with a racist health care system, too often that isn't what happens.

And going back to why do we think the midwifery model of care is so important is it's about building that foundation of trust, and, you know, it's not perfect. We do a lot of work, even as an organization, with our providers about bias in health care, how do we overcome that, how do we continue to train on it. We disaggregate our outcomes by race and ethnicity. We disaggregate even our experience data by that to make sure that we're not sort of becoming victims of that same bias and not understanding it by continuing to make sure we're looking at our data and keeping ourselves true to what we think is so important in delivering equitable health care.

MS. JOHNSON: Let's stay on that for a little bit in terms of what you all at Oula are doing to make sure that you are, like you said, delivering equitable care. How are you all, for lack of a better term, checking your biases outside of disaggregating data, you know, by race and ethnicity? What are some of the other things that you all as an organization are doing?

MS. NICKERSON: Yeah. I mean, we do a lot of just--I guess like training conversation, right? We did it across our whole organization, not sort of clinical versus not. Just if you come to Oula and you're going to be part of our team, we think it's really important that you have a fundamental understanding of racism in health care and how it shows up, that you have a shared vocabulary about how to sort of talk about and engage in those issues, that you, to become part of our team in the first place, think that it matters. And that's important to have those conversations.

Then we have a particular platform we work with on sort of systemic--or implicit--sorry--bias and how it shows up in health care settings in particular, and we work with that across our--any patient-facing member of our teams. That could be our clinician. That could be our front-desk person. That could be a medical assistant, right? Anyone who's going to have that interaction with the team goes through that training. What we like about it is it sort of takes an understanding of each individual and how they--where they sort of are at in their journey, assesses that, and then customizes, work together, and then we come together as a team to talk about it. And I've created spaces, particularly for white-identifying folks separate from our Black-identifying providers, and so we're really sort of working through it in those spaces.

Then as a leadership team, we've also done sort of separate coaching about how to create a more inclusive company, because I think it ultimately comes from the top, and then I think organization, we also have like a huge work plan. I sort of laugh at the work plan because I think there's this feeling of like I'm just going to check off the boxes, and it's not that it's a feeling like the work is never going to be done, but that we need to continue to sort of put it there and to put it on our priorities and things that matter and honestly have a wonderful team that holds us accountable to making sure we're doing it.

MS. JOHNSON: You know, so we've touched on what some folks might say are some of the key drivers when we think about maternal health outcomes in the U.S. You know, in the intro video, we talked about how the U.S. has one of the highest maternal mortality rates of high-income nations. But the flip side of that are the near-misses, you know, the maternal morbidity, which we don't quite talk about nearly as much, and so I guess I'm also interested, outside of trust issues or this kind of concept of respectful or disrespectful care, what do you think are some of the other key drivers in our nation's maternal morbidity crisis?

MS. NICKERSON: So it's interesting on the morbidity side, right? I would say like maternal death is like the canary in the coal mine, because for every like one that is like the worst outcome that you could ever imagine, there's at least a hundred of the severe, sort of morbidity events, and then a ton of folks honestly just have a pretty terrible experience. And I don't want to even like discount that last group, because I think everyone should have a great experience. People shouldn't walk away from birth with birth trauma, and honestly, if we just focus on maternal mortality, we sort of miss that broader picture that generally, when we're having a really poor experience--I think only maybe a quarter of women said they have very good or excellent care. So we're failing at every level.

I still think even in the sort of severe morbidity space, though, we're still talking about a lot of the same issues, and I'll talk about mortality, but it still is true for morbidity, which is I think there's this feeling like, okay, if you had a maternal death, it must have happened at the hospital, right, like during labor and delivery? And that's about one in five deaths, so about a third of them actually happened prenatally, and nearly half happened postpartum.

And we have a really poor infrastructure to support women and birthing people during that time, but I think most of our focus has been on how do we improve safety on labor and delivery. And that's obviously a key piece of it.

But if we send women home and we don't check on them again until the six-week visit, how do we think we're meaningfully going to change outcomes in that space where you have a huge risk for bleeding, for hypertension issues, for cardiac issues, for all of these things that are actually driving a lot of the morbidity we see, and we don't have that connection point and that continuity. And some of it's driven by a payment system that doesn't recognize the importance of support. Part of it's driven by, honestly, us still having a really antiquated health care system, right?

We do the vast majority of prenatal care appointments in this country in person and haven't leveraged technology as a meaningful way to connect with patients in between visits to get more information about how they're doing both physically and mentally and incorporate that into it. And so I think a lot of what we focus on at Oula is, absolutely, you should have a great birth experience, but we should be focusing as much time and energy and attention on prenatal and postpartum care, because that's where we're really failing women and where it's showing up in mortality and morbidity and honestly poor experience writ large.

MS. JOHNSON: Absolutely. Let's talk about the business side of Oula. So we're going to switch gears just a little bit here, and I know that you guys raised over $22 million to date between your Series A funding and seed funding. So what does that say about the appetite for investors to be included into potential solutions for the maternal health crisis?

MS. NICKERSON: You know, I think--so while it's a lot of money, it's still only a drop in the bucket of most venture capital dollars and where they're gone and where they're allocated.

I would say I think there's been more interest in the past few years generally about women's health and an appreciation that women not only are like the biggest consumers of health care, but they also control most of the dollars, which is they're making decisions for their parents or for their family. And so they sort of matter in that very, almost like a crude business sense. And so I think that has created interest on behalf of investors to sort of say what should they do here or should they be involved. Should they place a bet?

I think maternal care itself, a lot of investors are realizing they’re such an important moment in time to sort of build that relationship with women. If you think they're so valuable, because, you know, they control all of the spend and the $4.4 trillion health care industry, you have to find the right moment in time, actually, to build that relationship and engage in. Often, you know, maternity care, I'd argue, is sort of the best place to do it. It's, you know, quite honestly, a transformational moment. It's the first time you really deal with health care in this country because usually, hopefully, you're healthy until you get pregnant, and then are suddenly going to a lot of appointments and spending some time at the hospital. And so it's a really unique moment to build that. So I think that drives some of the interest.

That said, I've talked to many an investor who feel like it's too niche or like the TAM is too small for something in women's health, whether it's maternity or menopause or fertility or you sort of name it. And so I think it sort of cuts both ways still.

MS. JOHNSON: So interesting. Can you contrast what some of the early conversations were like? You know, where you're trying to elicit interest in this? And then maybe what the conversations are like now, has it changed, or is it still kind of that same skepticism of this is a niche market?

MS. NICKERSON: Oh, I think it's for sure changed, but part of it--I kind of laugh. My co-founder and I went to raise our seed round for this business April of 2020, and I don't know what you were doing April 2020, but most of the world was not going outside. And the idea that we were raising capital for a brick-and-mortar business was like almost laughable. And I laugh because I think, you know, it really felt like the world shut down--or at least New York City did towards the end of March, and we waited like a full two weeks. We're like, "Okay. Everything's going to be fine. You know, this is a great time to go out and start conversations." And, you know, it was a slog. I think it was a really hard time to be raising capital. Part of it was, you know, maybe not appreciation of the opportunity of women's health, and part of it was just a really sort of hard environment to be getting people excited. But I think, as a result, we have amazing ambassadors around the table who are really passionate as much for the business opportunity as for the mission and sort of the product that we're creating.

Fast forward to--and it probably--I think I talked to 70 investors, at least 70 conversations at the scene. Going to raise our Series A, I think I had two conversations, and so that talks a lot about how the market has changed but also what it means to have data. I think people when we were raising money originally for the business in 2020, it goes back to they had some skepticism of like, you know, do women really want this? Like okay, the care model sounds great. Yes, it's associated with better outcomes, fewer C-sections and fewer preterm births, and better satisfaction. But like is the U.S. consumer ready for this? And so to be able to show that, our first clinic reached capacity in three months. To be able to show that, we had a net promoter score of 94, so that women really loved it, that we had improved outcomes on C-sections, on preterm, on low birth weight, and you sort of name it, really changed the flavor on the tenor of our conversation.

MS. JOHNSON: And so do you think Oula is attractive to investors? Is it more attractive now that you've been able to change that? Like is this an attractive business model, do you think?

MS. NICKERSON: Oh, yeah. I think in health care, anytime you can combine three things, you can make a massive business, which is we have consumers with a much better experience. We have better outcomes, and we're doing it at a lower cost. And it's sort of a trifecta of building a really sort of defensible, huge business in health care.

MS. JOHNSON: So what's next? Like what's the next iteration of Oula? Are you all looking to expand? Talk to us a little bit about the future.

MS. NICKERSON: Yeah, I mean, we--there are women who need this great care and not just in New York, although New York has some of the worst outcomes in the country. So there is a good reason to start here. So we're going to continue to expand in New York, opening two more clinics here over the next year, and then expanding to two new markets also about over the next 18 months, so excited to continue to take what is working so well and sort of increase access and make sure that other women and birthing people are able to get access to this care in new markets. And then we get to sort of figure out where we go from there.

MS. JOHNSON: I was going to say, are there any other innovations in the maternal health space that you all are really excited about or thinking about integrating into what you all do or that just simply sound promising to you?

MS. NICKERSON: You know, I think we're always looking for how do we continue to make it better, and so one of the things we're focused a lot on right now is how to better incorporate mental health into our care model. And so one of the things that is so wonderful about midwifery care in the first place is they really take a whole-person approach to care. So realizing that it's not just the physical needs, but it's also the emotional needs, and so continuing to integrate that in a more meaningful way in our care is something that we're focused on going into the beginning of next year.

And also, there've been a lot of great innovation in that space. We've seen, you know, two new drugs become available in the postpartum space for depression, and so making sure that we sort of have an approach that takes it both and--which is like it's great and wonderful to have more medications available, but knowing a lot of women have, you know, a variety of needs, prenatal and postnatally that are mental health-related. So building out the right community and support and coaching along with access to the right pharmaceuticals is key to creating the right experience there, so excited to continue to sort of innovate in that space. And then, obviously, we'll have more to do after that point.

MS. JOHNSON: Ah, I feel like you're keeping a little bit of a secret there with that look, but I won't--I won't try to pry too much out of you right now.

[Laughter]

MS. NICKERSON: I had to come up with what is public actually, and I was like it might not be, so I'll hesitate and pause.

MS. JOHNSON: All right. Well, I will go to our final question then before we run out of time, and that is, in a single sentence, is there--what's your kind of hope for the future of maternal care? Maybe two sentences. Maybe not a single sentence.

MS. NICKERSON: You know, I hope that all women and birthing people have an experience that is transformative in the best possible way.

MS. JOHNSON: Absolutely. So we are just about out of time, and I want to say thank you so much for being so generous with your insights, even if you won't share that last secret with me.

MS. NICKERSON: [Laughs]

MS. JOHNSON: I will say we appreciate your time, and we're going to have to leave the conversation right there. Adrianne Nickerson, CEO of Oula, thank you so much for joining us here today.

MS. NICKERSON: Thank you so much. Talk to you soon. Take care.

MS. JOHNSON: Absolutely.

And thanks to all of you for watching. To learn more about our upcoming programs, head to WashingtonPostLive.com.

I'm Akilah Johnson. Thanks again.

[End recorded session

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