Tatyana Kushner

In recognition of Hepatitis Awareness Month, Tatyana Kushner, MD, MSCE, a member of the Blavatnik Family Women’s Health Research Institute, a hepatologist by training, an Assistant Professor in the Departments of Liver Diseases with a joint appointment in Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine answered questions on hepatitis and we decided to share them on our blog. Dr. Kushner, an expert in liver disease, is also the Associate Medical Director of the Hepatitis C and Drug User Health Center of Excellence for the Clinician Education Initiative, which is a program funded by New York State that provides education to providers about hepatitis C.

What is hepatitis?

Hepatitis broadly means inflammation of the liver. Hepatitis has several potential causes. Most commonly we think of viruses that cause hepatitis such as hepatitis A, hepatitis B, hepatitis C, hepatitis D, and even hepatitis E. In addition, there are other causes such as autoimmune conditions that can cause hepatitis, which is called autoimmune hepatitis, as well as nonalcoholic steatohepatitis, or NASH, which is also called “fatty liver disease” and reflects inflammation caused by fat accumulation in the liver.

 What are the different types of hepatitis? How do you distinguish them?

The different types of hepatitis include viral hepatitis, autoimmune hepatitis, alcohol hepatitis, and nonalcoholic steatohepatitis—all of which reflect inflammation in the liver caused by different entities. In viral hepatitis, there are five types, which includes hepatitis A, B, C, D, and E. We can distinguish between the types by assessing the patient with a careful history as well as blood tests. For example, blood tests are needed to diagnose hepatitis A, B, C, D, and E to detect virus replication, as well as the presence of some specific viral proteins in the blood. To help diagnosis alcohol hepatitis or NASH, a liver ultrasound may be done that would demonstrate signs of fat in the liver. Rarely, we may also perform a liver biopsy if the blood tests are not definitive—for example, with autoimmune hepatitis, blood tests are available but a biopsy would provide a more definitive diagnosis.

Which form of hepatitis is most severe?

Broadly speaking, hepatitis can be acute or chronic. Acute hepatitis can be very severe and lead to significant liver injury and even liver failure requiring liver transplantation. This can occur with viral hepatitis or autoimmune hepatitis, but fortunately is rare. Chronic hepatitis, which can be caused by hepatitis B and hepatitis C, autoimmune hepatitis, or NASH can lead to long-term liver damage which can lead to cirrhosis (or end stage liver disease) over time, which can also lead to liver failure requiring liver transplantation.

What are the symptoms of hepatitis?

Hepatitis is often completely asymptomatic. That is why it is important to have screening recommendations in place. For example, recently the  U.S. Centers for Disease Control and Prevention and the US Preventive Services Task Force (USPSTF) have recommended screening of all adults age 18 to 79 for hepatitis C. Similarly, patients with risk factors and/or pregnant patients are recommended to be screened for hepatitis B. Hepatitis can also present with symptoms, and the common ones are jaundice (yellowing of the skin and eyes) and generalized symptoms like fatigue/malaise or not feeling well in general. If hepatitis has progressed to liver failure or cirrhosis, you can see symptoms like confusion, swelling of the abdomen and legs, and/or bleeding, including blood in the stool and vomiting of blood.

How does one get hepatitis? What are some risk factors?

Different types of hepatitis have different risk factors. For example, hepatitis B and hepatitis C are bloodborne infections, and therefore one acquires them through contact with an infected person’s blood. This can occur with injection drug use, obtaining tattoos with contaminated needles, blood transfusion prior to 1992 (when blood started being screened for hepatitis C), dialysis, and health care exposure. There is also a risk of sexual transmission as well as mother-to-child transmission. In contrast, hepatitis A and hepatitis E are transmitted through contaminated food, water, or human waste. Thus, it can be acquired by consuming contaminated raw meat or water, particularly in developing countries. Other forms of hepatitis, such as alcohol hepatitis, are caused by excessive alcohol use. Autoimmune hepatitis occurs sporadically, especially in persons with a prior history of autoimmune disease in general.

Are there groups more at risk of developing hepatitis?

Yes. Hepatitis C, for example, is most common among persons who inject drugs, as well as people born from the years 1945-1965, the Baby Boomers. High rates of hepatitis C occurred during this time due to lifestyle choices and drug use, as well as health care practices during that time period such as reuse of glass and metal syringes in medical practice. Hepatitis B is much more common in people from regions in Asia and Africa, where it is endemic.

How is hepatitis and the specific form of it diagnosed?

Generally hepatitis can be diagnosed with blood tests, which can distinguish between the different types of viral hepatitis, as well as evaluate for autoimmune hepatitis. Rarely, a liver biopsy can be helpful in particular for diagnosing autoimmune hepatitis.

What are the treatments for hepatitis?

Different types of hepatitis have different types of treatments. For example, for hepatitis B, we have antiviral medications that suppress virus replication, and therefore improve disease outcomes, such as decreasing the risk of developing cirrhosis and liver cancer. Although, there is currently no cure for hepatitis B, there are multiple ongoing clinical trials, including at Mount Sinai, which are evaluating new medications that can cure hepatitis B in the future.  For hepatitis C, we have a number of medication regimens available, called directly acting antiviral agents, which cure hepatitis C. This is an exciting recent development in our field, as prior to 2013 these medications had not been available. Now, we can cure virtually everyone with hepatitis C, even with advanced liver disease. For autoimmune hepatitis, we treat with immunosuppressive therapy such as steroids and other steroid-sparing medications. For alcohol hepatitis, the main recommendation is alcohol cessation. In specific instances, we can also treat with steroids if the alcohol hepatitis is very severe. For NASH, or fatty liver disease, lifestyle modification with the goal of weight loss and improved diabetes control, is critical, and we also have multiple ongoing clinical trials for the treatment and prevention of progression of NASH.

How does hepatitis affect pregnancy and childbirth?

Hepatitis is very important to consider in pregnant women. For example, hepatitis B and hepatitis C can be transmitted from the mother to the baby in pregnancy and childbirth. Therefore, we need to screen women for these viruses at the beginning of pregnancy to make sure we take all measures to prevent transmission which can lead to liver problems, and other problems, in the baby. For hepatitis B, we make sure that the baby gets the hepatitis B vaccine, as well as hepatitis B immunoglobulin (another agent that decreases risk of transmission) within 12 hours of birth to decrease risk of transmission. In addition, we recommend treatment with antiviral medication of the mother if she meets criteria. For hepatitis C, we currently do not treat mothers during pregnancy, but this is currently under evaluation. There are obstetrics management measures during the pregnancy that are also important to take in order to decrease the risk of transmission to the baby, such as minimizing invasive fetal monitoring.

Hepatitis can also impact the pregnancy. For example, hepatitis C increases the risk of cholestasis of pregnancy, a pregnancy-specific condition that can have a negative impact on the baby. There have also been studies which suggest an increased risk of preterm birth and gestational diabetes in women who have hepatitis during pregnancy.

Finally, hepatitis can also become more active in the setting of pregnancy. Hepatitis B can “flare” or become more active during pregnancy and in the postpartum period. Hepatitis E, although rare, can be especially severe during pregnancy.

What disparities exist between groups in regard to hepatitis prevalence or treatment?

There are disparities that exist in terms of testing and access to treatment in certain patient groups. For example, due to provider beliefs and insurance restrictions, it has been difficult for people who use drugs, and who are most affected by hepatitis C, to access hepatitis C medications, and therefore obtain a cure for hepatitis C. For example, a recent publication demonstrated significant disparities in outcomes from liver cancer in patients with hepatitis C between African Americans (mostly men) and Caucasian individuals with hepatitis C since the introduction of hepatitis C medications, suggesting that access to medications was inferior in the African American community.

There have also been disparities in testing and monitoring of hepatitis B, which affects a predominantly immigrant patient population. For example, immigrant patient populations, especially those without health insurance, often do not get the appropriate follow up for liver cancer screening as well as access to antiviral therapy, which leads to progression of the disease in these patient groups.

How do we work on reducing these disparities?

Education of health care providers, as well as of patients, is critical in order to reduce these disparities. For example, over the past few years there has been a significant emphasis on educating providers, and creating care models, in order to be able to provide people who use drugs with hepatitis C treatment. Furthermore, over time there has been a gradual reduction in cost of hepatitis C medications, as well as legislation changes, in order to lift insurance coverage restrictions that were targeting people who use drugs.

Providing education to patients about the importance of hepatitis B follow up, and the development of programs through the New York State Department of Health and the New York City Department of Health, dedicated to make sure that patients with hepatitis B are able to access care, are appropriately linked to care, and are not lost to follow up.

What can we do every day to prevent the spread of hepatitis?

It is important to know the current testing recommendations for hepatitis so that everyone gets tested, even if asymptomatic. Measures to decrease transmission, such as practicing safe sex, taking measures to decrease risk associated with drug use, and minimizing health care exposure (i.e. using sterilized techniques, not re-using needles – which is still currently in issue in certain countries abroad) are critical. For patients diagnosed with hepatitis, it is important to engage in care and be treated, in order to decrease community transmission.

Is there anything else you would like to share about hepatitis?

Adults age 18-79 should be tested for hepatitis C. If you test positive, there are excellent treatments available that can cure you. May 19, 2020 is Hepatitis Testing Day. Use this opportunity to get tested or check on the status if you have been exposed or diagnosed with hepatitis. Hepatitis is a leading cause of death worldwide. It is important to seek care if concerned if you develop symptoms such as jaundice. There are treatments available to halt progression of hepatitis such as hepatitis B and autoimmune hepatitis. If you have hepatitis B, come see us in Mount Sinai Institute for Liver Medicine to participate in clinical trials for the cure of hepatitis B. If you are interested in inquiring about additional hepatitis C trainings, visit ceitraining.org.

Map 1: Any health condition: Percent of deliveries in New York City to women with at least one risk factor for severe infection from COVID-19 (cardiovascular condition, lung disease, class 3 obesity (BMI≥40), diabetes, cancer, immune condition), by zipcode

Obstetric providers across the United States are adapting how they deliver prenatal and childbirth care in light of the COVID-19 pandemic.

Pregnant women do not appear to be at higher risk for severe COVID-19 illness. But maternal health issues such as obesity and chronic comorbidities are critical considerations for gauging disease burden among pregnant women in the United States.

Risk factors for serious illness include chronic lung disease and asthma, serious heart conditions, cancer, immunodeficiency, severe obesity (BMI≥40), and underlying health conditions such as diabetes.  Pregnancies complicated by one or more of these risk factors may require additional monitoring and preventive measures to minimize serious maternal-fetal complications of COVID-19 infection.

At the Blavatnik Family Women’s Health Research Institute, we have developed a series of maps to describe the geographic distribution of deliveries in New York City according to risk factors for COVID-19 severity.

We mapped quintiles of risk factors by zip code for women delivering in New York using 2014 linked birth certificate-hospital discharge data. Maps show risk factors individually as well as the total percentage of women with at least one risk factor.

For example, Map 1 displays areas of the city where pregnant populations are at high risk of severe illness, and Map 2 suggests areas with a potentially heavy burden in terms of number of serious infections.

Map 2: Any condition (count): Number of deliveries in New York City to women with at least one risk factor for severe infection from COVID-19, by zipcode

Resources should be directed toward supporting obstetric teams in hospitals in these areas, as well as providing as much assistance as possible to underserved communities with limited access to health care and financial and social protections during this crisis.

Kimberly Glazer, PhD, Natalia Egorova, PhD, and Teresa Janevic, PhD are epidemiologists and members of the Blavatnik Family Women’s Health Research Institute. Special thanks to Ben Janevic for helping create the maps.

Hover over or click on each map below for detailed information.

Disclaimer: The raw Statewide Planning and Research Cooperative System (SPARCS) data used to produce this publication was purchased from or provided by the New York State Department of Health (NYSDOH). However, the calculations, metrics, conclusions derived, and views expressed herein are those of the author(s) and do not reflect the work, conclusions, or views of NYSDOH. NYSDOH, its employees, officers, and agents make no representation, warranty or guarantee as to the accuracy, completeness, currency, or suitability of the information provided here.

Footnotes for maps Maps were developed using administrative databases, which may underestimate risk factors such as tobacco use and other health behaviors. Source: 2014 linked natality-Statewide Planning Research and Cooperative System (SPARCS) data. Estimates are based on data from all live births in New York City in 2014 (birth certificates linked to hospital discharge data).

Left to right: Mikhalya Brown; Ashaki Smith; Heather Reis, MBA; Amy Balbierz, MPH; and Naissa Piverger, MPH; taken at the The Blavatnik Family Women’s Health Research Institute’s Summer Networking Event in August 2019. 

Since I was five years old, I have been interested in women’s health. This passion comes in part from my background, being raised by a single mother and witnessing the births of all three of my siblings. I was in awe of the trust that my mother, and many other women, had in their gynecologists and obstetricians, as well as the support and attentiveness that OB/GYNs give every woman. I knew from then on that I wanted to become a provider like the ones my mother had.

Both in high school and on campus at Columbia University, finding research and internships in the field of women’s health proved a challenge in itself. Due to experience requirements and age restrictions, I could not take advantage of many opportunities. However, the Blavatnik Family Women’s Health Research Institute (BFWHRI) Summer Undergraduate fellowship afforded me the opportunity to work with skilled researchers in my desired field and get my own feet wet in a vast pool of information.

One focus of BFWHRI, and that of my summer fellowship, is research highlighting health disparities that gravely affect minority women. My initial research therefore focused on endometrial cancer. The most common gynecological cancer and fourth most common cancer in women, endometrial cancer is increasing in incidence among all women.  Among black women, however, the incidence is higher for more aggressive subtypes of the condition compared to both Hispanic and non-Hispanic white women.  Research is needed to identify and better understand risk factors that may increase the development of aggressive histologic subtypes in black women. In the summer of 2019, while under the supervision of cancer epidemiologist and BFWHRI faculty member Tracy Layne, PhD, MPH, I learned about the role of obesity as a risk factor for endometrial cancer in this context.

Obesity rates are increasing globally, but past research indicates that black women have the highest prevalence of class 3 obesity (defined as morbidly obese – body mass index ≥ 40 kg/m²). Socioeconomic factors, such as education level and income level, do not account for the higher obesity prevalence among black women. The physiological impact of obesity promotes an estrogenic environment that can create the perfect conditions for a tumor to grow in these estrogen-sensitive organs.  However, the obesity-estrogen-endometrial cancer association is strongest for non-aggressive endometrial cancer for which black women have a lower risk compared to non-Hispanic white women.  In addition, despite obesity rates similar to black women, Hispanic women do not face the same burden of aggressive endometrial cancer. Taken together, this suggests that other factor(s) beyond obesity may be relevant to risk of aggressive disease subtypes in black women.

During my fellowship, I also worked with Dr. Layne on her research exploring the relationship between vitamin D and endometrial cancer given its potential anticancer activity and the higher risk of suboptimal vitamin D status in black populations.

Along with this research, I learned that I love being in a predominantly female and racially and ethnically diverse work environment. I am thankful for the opportunity that BFWHRI has provided me this summer and for reinforcing my passion for women’s health. I look forward to the impactful research that all members of this team are doing and my continued work with the Institute.

The LEAP team joining the NYC community on the sunny steps of City Hall on May 15, 2019, as part of Hepatitis Awareness Month.

Hepatitis C virus (HCV) is affecting more women now than in previous decades. Many of these women are of child-bearing age. HCV largely affects men in the “baby-boomer” population, or adults born between 1945 and 1965. However, a new wave of HCV infections has started to affect younger men and women due to intravenous drug use.

A recent report from the Centers for Disease Control and Prevention noted that HCV infection has been increasing in women of child-bearing age, particularly in the rural area of Appalachia. The report found that between 2011-2014, increased HCV detection among women of child-bearing age and testing of children under two were observed both nationally and in Kentucky (by 22 percent detection in women and 14 percent testing in children under two nationally; for Kentucky the corresponding increase was 200 percent for detection and 151 percent for testing HCV among these populations). Further, the proportion of babies born to HCV-infected mothers increased by 68 percent nationally and 124 percent in Kentucky.

HCV was called the “mystery virus” when patients were first diagnosed in the 1970s. Before the virus was identified in the early 1990s, the medical community called it “non-A, non-B hepatitis.” Researchers pursued this unknown virus that was largely asymptomatic, though complications from HCV include decompensated cirrhosis, which presents with a buildup of toxins resulting in yellowing of skin, tar-ish stool, and psychological confusion. Risk factors for acquiring the virus were found to be largely blood-borne, including sharing contaminated drug items and tattoo or piercing needles. Other factors now include medical transmission through a pre-1992 blood transfusion or organ transplant, sexual transmission, and prenatal transmission.

HCV is easier to cure now than ever before. New treatments introduced after 2011 are highly effective, boasting more than a 90 percent cure rate and few side effects. These drugs, called Direct Acting Antivirals (DAAs), are taken once a day for 8-12 weeks for most patients diagnosed with HCV. However, patients with HCV may face many barriers in getting these medications. As health care advocates, we must challenge the health system to put patients first, and extend additional efforts to cure an infected population facing complex comorbidities and psychosocial barriers to care.

HCV presents unique challenges to pregnancy and reproductive health. In 2015, the New York State Department of Health noted that in New York State, “57% of female cases of HCV were of child-bearing age.” A recent weekly update from the Centers for Disease Control and Prevention reported that approximately 68 percent of pregnant women with HCV infection also have opioid use disorder. The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America now recommend HCV screening for all pregnant women. Increased screening during prenatal care can lead to an expanded sphere of testing that includes partners and children. Currently, children are still rarely screened for HCV.

Tatyana Kushner, MD, a hepatologist with a joint appointment in OB/GYN at The Mount Sinai Hospital, says that women are particularly affected by the spike in intravenous drug use. Women, she notes, may engage in particularly high-risk behaviors specific to intravenous drug use. She states that “women who inject drugs appear to have a higher risk of incident HCV, possibly due to higher risk-injecting behaviors compared to men. Women are more likely to be injected by others, more frequently to be injected by sex partners, and more likely to engage in high-risk sexual behaviors for drugs than their male counterparts.”

Dr. Kushner also highlights the challenge of linking HCV infected patients to care, citing research indicating that out of the approximately 3.5 million people estimated to be living with chronic HCV infection, 50 percent are aware of their diagnosis, just 16 percent have been prescribed treatment, and only 9 percent have achieved sustained virologic response. The steep drop in participation at each point of contact for HCV patients reflects the challenges of medical intervention in this at-risk population, and suggests that pregnancy can be used as an opportunity to diagnose new HCV infection among women who may otherwise not present to health care.

HCV treatment during pregnancy remains a controversial topic, since more data is needed to accurately represent current HCV treatment safety in pregnancy. The Food and Drug Administration has warned that the earlier HCV treatments interferon and ribavirin are teratogens, which may cause abnormalities in fetal development. Direct Acting Antivirals, however, are not classified as teratogens. Some hepatologists, including Dr. Kushner, advocate treating pregnant women with DAAs during pregnancy to reduce the risk of passing the virus on to children, which is uncommon but is thought to occur at or around the time of delivery. Many HCV DAAs are not associated with toxicity in animals, but human data is limited. According to Dr. Kushner, DAAs used in the third trimester after embryonic organogenesis is already complete can significantly decrease a high viral load in a matter of weeks and is likely to reduce mother to child transmission.

Linking patients with HCV to care, including the younger female cohort, can improve future health outcomes by positively reinforcing each point of contact between the patient and the health care system with care coordination initiatives.

What resources do we have to help connect vulnerable patient populations, including pregnant women, to care? The Liver Education and Action Program (LEAP) works to improve engagement in persons living with HCV infection as part of the Institute for Liver Medicine at Mount Sinai Health System. Led by Medical Director Ponni Perumalswami, MD and Behavioral Director Jeffrey Weiss, PhD, the LEAP program advocates for a system-wide approach to HCV screening and linkage to care that includes patients seen in the inpatient, outpatient, and emergency department units.

Our patient navigators help link persons who screen positive for HCV to follow-up care, while our care coordinators and peer navigators guide linked patients through the HCV treatment process. Patient navigators provide education and counseling, assist with scheduling appointments, and offer to accompany patients to appointments with peer navigators.

Since 2018, LEAP has partnered with the Mount Sinai Beth Israel Emergency Department in a comprehensive effort to screen patients in New York presenting at the Emergency Department for HCV. The program then uses its unique care coordination resources to effectively link infected patients to HCV care.

As a patient navigator with LEAP, it is my job to empower patients to feel like they are at the helm of their health journey. My role is part customer service and part advocacy. After speaking with the patient on the phone, I want them to know that they are in control of when and why they go to the doctor. I want to provide them with as smooth an entry into care as possible by helping them interact with insurance, medical record acquisition, and referrals.

A patient navigator is an important advocate for patients who need support when embarking on an HCV treatment regimen. Patients can call a patient navigator if they are billed incorrectly by the clinic, if they aren’t treated well by the front desk, or if they are having a hard time scheduling an appointment or transportation. The role is flexible, and provides patients with as much or as little support as they need. Efforts to provide patients with testing options, transportation, referrals to Mount Sinai’s social work office for financial support, reminder calls, appointment scheduling, and emotional support have contributed to positive changes in the health and lives of patients.

Drs. Perumalswami and Weiss also created HepCure, an innovative electronic web-based application that enhances patient engagement by providing resources directly to patients and offering a secure communication tool between patients and their providers. HepCure also sponsors weekly webinars that update the medical community on a range of HCV-related topics, including the evolving epidemiology of the virus and new trends in diagnostics, testing, and treatment.

The increased incidence of HCV among reproductive-age women presents significant public health challenges. These challenges are matched, however, by an enormous opportunity to support patients when they need it most. Care coordination programs utilizing patient navigators can provide substantial opportunities to increase the quality of life for some of NYC’s most at-risk patients by linking them to the health care system—for good.

Colleen Stapleton is a patient navigator with the Liver Education and Action Program (LEAP) at The Mount Sinai Hospital, where she works to improve care for patients living with hepatitis C.

Omara Afzal, DO, MPH, training community health workers in South Africa.

I have spent much of my career involved in global health care. I am an obstetrician/gynecologist, and the massive scale of maternal morbidity and mortality globally has humbled me. I have traveled to villages in South Sudan, refugee camps in Jordan, rural areas of South Africa, and a post-war post-Ebola Liberia among others, to train, educate, and increase health care capacity of areas in need. And yet, when I return home to New York, I see a country with advanced medicine and resources–and also the highest rate of maternal deaths among developed countries. I have come to the startling understanding that women at home in New York and the United States are also suffering in and around pregnancy at alarming rates, and something needs to change.

Sixty percent of maternal deaths in the United States may be preventable with better access to prenatal and postpartum care and self-management of chronic diseases. The United States has an overall system of care that focuses intently on a healthy baby and perhaps not as much on the mother, particularly in the postpartum period. Mothers are taught to take their prenatal vitamins, avoid unpasteurized products, and count belly kicks, but are often unarmed in knowing when and how to seek care for their own illnesses. Women also often do not receive the health maintenance and disease management that they need in the postpartum period. For example, very few women with gestational diabetes return for the recommended postpartum glucose testing to make sure blood sugar has returned to normal, and many others do not seek care for blood pressure checks, depression screenings, and other support that can help women get their health on track after childbirth.

At the Obstetrics and Gynecology (OB/GYN) Ambulatory Practice at The Mount Sinai Hospital, we have worked hard to provide comprehensive and evidence-based medicine while also offering a network of support services. However, the current care model depends on clinic-based counseling, requiring the patient to come to us. This really does not hit where the most impact may be made–in the patient’s home. Chronic diseases and evolving medical conditions require a holistic approach to manage and address issues, and office visits alone in a medical setting are just not enough.

A common health approach used globally, but especially in areas of low resources, is using community health workers (CHW). These are non-medical people who live and work in the same communities as the patients. They connect with the patients in a way that medical professionals may not be able to. This model, though used widely outside our borders, is now catching on within the United States and right here in New York City. Community health workers, or “health coaches,” bring much needed support into the home, through education and care coordination. Health care providers will often work closely with CHWs to connect patients who may need additional management and liaison with the medical system. These workers are trained to help women gain the skills to successfully self-manage their health and navigate medical and social services through one-on-one coaching and ongoing check-ins.

As a Fellow in the Clinical Scholars Program of the Robert Wood Johnson Foundation, I found an opportunity to engage in research around community health worker programming for maternal health. Collaborating with organizations that work with the model of CHWs, our team aims to train coaches in the prenatal and postpartum period, to increase health literacy, and improve outcomes for especially high-risk patients with diabetes or hypertension during their pregnancy. The health coaches will also continue to support patients postpartum with goal-directed health promotion and disease self-management counseling. Health care providers will be in close contact with CHWs to ensure that patients are on track in-between visits and after their deliveries. We are hoping a program such as this will improve rates of preventable maternal morbidity and mortality by empowering women for self-care and management of high-risk diseases. Through ongoing research and program development, we have the ability to change the statistics and improve a woman’s outcome during pregnancy and beyond.

Omara Afzal, DO, MPH, is a member of The Blavatnik Family Women’s Health Research Institute, the Medical Director of The Mount Sinai Hospital OB/GYN Ambulatory Practice, and an Assistant Professor in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai.