Fearless 11.27.23

Good morning, Fearless readers:

I hope you had a peaceful and enjoyable Thanksgiving.

Did you see that the two turkeys pardoned by Iowa Gov. Kim Reynolds were raised by a 15-year-old girl from Manson, Iowa? Ava Moline of Golden Prairie Turkeys told Iowa Public Radio that she plans to use money from her turkey business to help pay for her college tuition. Moline started with 300 turkeys and has been running her own business for six years.

In this week’s Fearless e-newsletter, you will find:

A story about the “Bridging the Gap: Improving Maternal and Rural Health Symposium,” which was held in Ankeny. Access to maternal health care services is becoming an increasing concern in Iowa, as the number of counties in the state operating without an obstetric unit has increased by 157.14% since 1999.
A profile of Ashley Miles Greig, who left corporate America to become Iowa State’s head gymnastics coach.
Fearless book recommendations: What are your reading goals for the holidays or the new year? Here are some recommendations from the Fearless staff.
A break from the news: Learn about Dr. Jessie Smith, one of the first “lady doctors” who happened to deliver a 13-pound baby named Marion Robert Morrison in 1907 in Winterset. That baby eventually changed his name to John Wayne.
Lots more!

– Nicole Grundmeier, Business Record staff writer

Access to maternal health care services is becoming an increasing concern in Iowa, as the number of counties in the state operating without an obstetric unit has increased by 157.14% since 1999.

In addition to the rising number of obstetric unit closures – 42 shut down between 2000 and 2021 – Iowa ranks 52nd out of 52 states and territories for OB-GYN physicians per capita, according to data from the American College of Obstetrics and Gynecology.

Coinciding with increasing obstetric unit shutdowns and widening workforce gaps, Iowa’s maternal mortality rate more than doubled between 1999 and 2019, a July 2023 JAMA study says. A maternal death is defined by the World Health Organization as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”

Nationally, the maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births, up from rates of 23.8 in 2020 and 20.1 in 2019, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics.

The closures and lack of OB-GYN physicians in the state have created a “crisis of access,” Stephen Hunter, professor of obstetrics and gynecology at the University of Iowa Hospitals and Clinics, said, driving an “immense expansion of obstetric deserts in our state.”

Hunter was one of more than a dozen health care professionals who shared current data and trends, as well as proposed solutions for addressing some of the greatest challenges related to maternal health in Iowa, during the Bridging the Gap: Improving Maternal and Rural Health Symposium on Oct. 30 in Ankeny.

Hosted by Healthy Birth Day Inc., the daylong event covered the landscape of Iowa birthing centers; innovative clinical approaches; health equity, access and improvement; access to maternity care and evidence-based supports for maternal and infant health in rural areas; maternal morbidity and mortality in Iowa; prevalence, causes and policy solutions for maternal morbidity and mortality in rural areas; and community-based solutions.

Hunter presented what he believes are the top five Iowa maternal health care issues: workforce, education and quality of care, data, communication and coordination, and access to care.

At a conference in Des Moines shortly before COVID-19 became a major public health issue, Hunter said he held an event for all of the CEOs of hospitals to talk about maternal health. In a survey he conducted, one question he asked was, “Do you have concerns regarding the continued viability of your labor delivery units?”

“[These were] CEOs of hospitals that had labor delivery units,” he said. “And 34 of the 55 said yes. Well over 50% said they were concerned about the viability.”

Preliminary data for 2023 released by the Association of American Medical Colleges showed that the average number of applications per obstetrics and gynecology residency program fell from 663 in 2022 to 650 in 2023.

OB-GYN workforce shortages and a rising number of obstetric unit closures have coincided with countrywide increases in cesarean delivery rate, preterm birth rate and low birth weight rate, all of which can increase other health risks and require specialized care, according to a National Vital Statistics Report from January.

The study found that the cesarean delivery rate increased to 32.1% in 2021 from 31.8% in 2020, marking the second increase in a row after the rate had declined in 2018 and 2019. The preterm birth rate (percentage of all births delivered at less than 37 completed weeks of gestation) rose from 10.09% in 2020 to 10.49% in 2021, the highest level reported since at least 2007. The percentage of infants born with a low birth weight – less than 5 pounds, 8 ounces – rose from 8.24% in 2020 to 8.52% in 2021.

In addition to an association between labor and delivery unit closures and poor outcomes, there is also an association between poor outcomes and higher costs.

Hunter said for businesses, that could mean employees needing to spend additional time in the hospital and out of work.

“Good perinatal outcomes should be important to businesses because bad outcomes cost money,” Hunter said.

“If [mothers are] sick and they’re in the hospital, they’re not working. They’re in the hospital. If they have a bad outcome, and their baby is in the [neonatal intensive care unit], they’re not at work; they’re in the hospital,” he said. “Bad outcomes always cost more money, and they cost not just Medicaid, they cost the entire society more money. And that’s why businesses should care.”

Not only does the quality of care affect businesses, and society as a whole, but the lack of labor and delivery services in a county could be a determining factor for a family deciding where to live, Hunter added.

“If they’re a young family and they’re starting out having kids, and they can’t get labor and delivery services there, they may choose not to live there,” he said. “And that might be the first step of that town’s demise. On the flip side, it could be a sign of the deterioration of the town – they no longer have enough young people having babies just to maintain and support labor and delivery. I don’t know the answer to that question, but it’s an interesting question.”

Current efforts
With the rise of labor and delivery unit closures, as well as worker shortages, have come new efforts to improve maternal health care in Iowa. One of those is the University of Iowa Hospitals and Clinics’ nurse midwifery education program and clinical practice.

A Health Resources and Services Administration Maternal Health Innovation grant in 2019 kick-started the development of the program, with the initial round of funding used to hire a consulting group to help complete a feasibility study and needs assessment for the program. Pre-accreditation status was granted in 2022 and the first class started this year.

An Iowa certified nurse midwife must have a bachelor’s degree in nursing or another field. They must also have a master’s degree or doctorate degree, which can be in any field.

In addition to the education requirements, a certified nurse midwife has to be a registered nurse, which requires passing the National Council Licensure Examination.

“I would say that midwives in general kind of have convoluted paths to becoming a nurse midwife,” Lastascia Coleman, certified nurse midwife and clinical associate professor in the Carver College of Medicine at the University of Iowa, said. “For state licensure, Iowa certified nurse midwives are licensed as advanced registered nurse practitioners. And we have full prescriptive authority. We also, prior to becoming licensed, have to take the national certification exam, and we recertify every five years.”

The roles of nurse midwives expand beyond pregnancy, birth and postpartum care.

“We can also do a lot of other things,” Coleman said. “So I have a lot of patients who I’m their primary care provider for. We can do gynecologic care, we can do contraception management, we can also take care of newborns up to 28 days.”

According to the United Nations Population Fund, “Midwives can meet about 90% of the need for essential sexual, reproductive, maternal, newborn and adolescent health interventions.”

One way that technology has played a role in improving maternal health care is through an app called Count the Kicks, which helps pregnant people during the third trimester record how long it takes for their baby to reach 10 movements, tracks changes over time and reminds them to count every day.

“We have developed the Count the Kicks app to meet the needs of parents who want to monitor their baby’s movement,” Christine Tucker, health equity coordinator for Count the Kicks, said. “What really sets us apart from other pregnancy apps is that our app is free. It’s got no pop-ups, no ads, it’s available in 16 languages, and more to come as well.

“Parents get this visual feedback after their counting sessions, so they know if their graph is staying level, that’s a good sign. But if we see a spike in the amount of time it’s taking to get to 10 movements, then they need to speak up to their doctor or midwife.”

Count the Kicks also provides downloadable paper charts and web-based counters on its website to expand accessibility.

“There are a lot of ways we approach this work,” Tucker said. “We have the paper charts and movement monitoring bracelets for rural areas with less access to Wi-Fi and data that we primarily distribute through home visiting programs.”

Count the Kicks advises pregnant people to start counting between 26 to 28 weeks, when there’s a consistent movement pattern, and spend time once a day with their baby checking in to see how long it takes them to get to 10 movements.

Proposed solutions
If given the opportunity to start from scratch with available resources to tackle the greatest concerns with maternal health care in Iowa, a solution that Hunter proposed was placing hospitals that would include everything for a high-quality labor delivery unit in strategic locations throughout the state.

“24/7, physicians, well-trained nurses, anesthesia, blood bank, imaging, it’d all be there,” Hunter said. “And then, in the outlying communities, and we’ve heard hints of this today, we’d have prenatal care.”

Any effort to improve maternal health care, though, is going to require money, Hunter said.

“Just know that everything I’m talking about takes money,” he said. “Everything talked about today, and there were some great programs out there, takes money. And everybody has to have some skin in the game, including the patients. I was glad to see some of the programs gave gift certificates after completion of certain requirements. That’s skin in the game.

“Everybody has to have some skin in the game: patients, patient families, health care providers, health care organizations, state and federal government, everybody. And it’s got to be a team effort, or it’s going to fail. Guaranteed.”

Ashley Miles Greig just went through an extraordinary career change. Miles Greig, 38, spent most of her career in auto finance – working at dealerships, and then beginning in 2013 with JPMorgan Chase & Co. She and her husband, Orestes Greig, wanted to start a family. They underwent treatments for infertility, which Miles Greig has talked about publicly. The treatments did not result in a successful pregnancy. She ultimately decided to expand her family by accepting the head coaching position for ISU women’s gymnastics in 2023. She had never coached gymnastics. But she had a long and wildly successful career as an elite gymnast and then as a collegiate gymnast at the University of Alabama. Miles Greig grew up in San Antonio, Texas. She was considered a tall gymnast, around 5 feet, 7 inches, as a senior elite. In 2001, Miles Greig competed at the World Artistic Gymnastics Championships in Ghent, Belgium. She was essential in securing a bronze medal for Team USA during a stretch of time when the U.S. did not medal consistently in international competitions. Miles Greig also made the vault final – she was one of the top eight women vaulters in the world in 2001. She and her husband live in Ames.

The following story has been formatted to be entirely in her words, and has been edited and condensed for clarity.

I was 6 years old [when I started gymnastics], which is actually a little bit older than you hear from a lot of athletes. They’re like, “I started when I was 2 and did the mommy-and-me classes.” But for me, I saw a rerun of the 1984 Olympics. Mary Lou Retton, right? Where she scores the perfect 10? I started jumping, running, flipping off things, probably scaring the crap out of my mom. When we moved to Texas, I begged for them to put me in gymnastics. I finally got my way, and the rest is kind of history. Showed up, never looked back.

From the day I showed up at the gym when my mom took me – the owner of the gym, he was eventually my first coach, all my foundational skills came from him – Michael Harris at HUGS, Harris Unlimited Gymnastics School. He approached my mom and said, “Your daughter looks like she has a natural talent for this. Would you be interested in signing her up for team? Not just recreational. She’d come X amount of days a week.” And then of course, it got to the financial part of that, and the answer was, “Absolutely not. No, we’re not doing that.”

The next time I went, my dad took me, and we came home – “Oh, she’s going to be on team, and she’s going to do this and that.” So Mike got his way.

Seeing the other team girls that were of competition level doing all the fun skills on all the different events … I wanted to do it all. I want to be over there with them. And it didn’t take me long to get there. I was fearless.

You look at gymnastics and you see the equipment, the skills. I think one of the favorite sayings of some coaches growing up, especially for the balance beam: I love the beam, because if you don’t do what you’re supposed to do, I don’t have to do a thing: the equipment’s gonna punish you. You’re gonna fail, you’re gonna split the beam, you’re gonna fall off. It helps you be more intentional about the decisions that you’re making. That actually is the word of the week for the first week of official practice for gymnastics here, is “intentional.”

I saw those big girls doing the big skills and trying new things, and I wanted to be them. I wanted to be in that group. I would do just about anything to get there. I remember as I progressed through my training, I was homeschooled, I practiced two times a day. There was a group of us, maybe six or seven, altogether that we homeschooled. It’s all we did. We did gym, we went to school, we did gym again, we conditioned, we did ballet. It was a competitive environment to develop and grow up in, which I think helped all of us kind of elevate. Everything was a competition.

Starting off, I was the same as everybody else. I was this little teeny-tiny thing. And then puberty hits, and I just shot up.

I got used to, in my lifetime, being “the only.” That’s a thing you just learn as a young kid, how to operate as being the only Black girl just about everywhere you go. Gymnastics, historically, is a very white sport. It’s subjective, too. So throw that into the mix and, wow, that’s breeding grounds for potentially lots of insecurities.

I always say that my foundation, my family, was so positive and so reinforcing: “You’re beautiful. You are who you are. Be comfortable and confident in who you are. You’ve got to work hard.”

That’s a real thing for Black kids growing up: You’ve got to be twice as good as everybody else. I felt that. I did. I had to fight extra hard to get everything I got because I wasn’t the typical. I’m not going to say names, but teeny-tiny athletes that you think of when you think gymnasts: It’s not me.

Even now, I think with my height, it could be recruits, or, even when I got here, the assistant coach Haylee Young, she just looks at me one day and she goes, “Was this your competition height?” Because they’re just floored, and I’m like, “Yeah, this is how tall I was when I was competing. Yeah, this was me.”

When I look at the elite gymnastics world now, I see the diversity. I mean, we could potentially have a United States Olympic team that’s all Black. Legitimately. They all deserve to be there. They are good. They are representing the sport. So we’ve come such a long way, I think, in that space.

——————

I ended up, oddly enough, in the car business right out of college, when I graduated from Alabama. It was my first really important insight into the business world and how it works through connection. Everything is all about who you know. I got my job through a connection at Alabama, the head coach there, Sarah Patterson.

The owner of the dealership where I worked was a big sponsor for the University of Alabama gymnastics program. They did demos for a lot of the head coaches. They supported the annual “pink meet” every single year.

He literally was just asking Sarah, “Hey, what’s Ashley Miles doing now that she’s graduated?” He was like, “She looking for a job?” And he was like, “Send her over to me. I might have something in mind for her.”

I didn’t have a resume, didn’t have anything together. Just went to have a conversation, and I left with a job. I think that’s one of the benefits of being a student-athlete. I think corporate America and businesses see the value and the experience – even though they might not have that work experience, they have the goal-setting, the communication, the pursuing something in spades. So they can pretty much be guided and taught to do anything, and generally, they’re going to be pretty successful at it.

Initially, I was supposed to be a manager of a brand within Toyota. It was the Scion brand. I was going to go through training, learn how to sell cars, but also do the front and the back. I would be doing the selling, also the financing part, for that brand. As it grew, the plan was to add more and more and more. Well, somehow along that line, when I was going through that training process, somebody in the finance department quit.

Then it was another, “Hey, Ashley, why don’t you just go sit in there with the finance director and see what you can pick up, see what you can learn?” I just took it in. Probably 90 days later, I’m a full-fledged finance manager, not realizing that at the time, 21, 22 years old, that that’s not normal, to go into a dealership and you’re a finance manager, telling people that have been doing this for 15, 20 years to “Go get your stuff and your deal, get everything together.” “I need you to do your job so I can do my job.” I was totally oblivious to the fact that they’re probably looking at me like, “Who does this little girl think she is?”

But again, I’m process-oriented. If you teach me how to do something, I will follow instructions. I’m very much a rule-follower, just in life, and I think most gymnasts are. I took it in and evolved and learned the craft, really got trained very well in selling. That’s a big part of what I’m doing here as a head coach.

There are a couple of additional foundational items that you have to have to be successful, because, really, what I’m doing every day is selling my program. Selling Iowa State to recruits, getting the buy-in from these athletes to get on the same page. Everything is kind of connected, and it transfers.

Once I left being in a dealership, I took about a year and a half off. I did some independent contracting where I would fill in at dealerships if they had a finance manager that’s out on vacation. I would go into the dealership and work so they had coverage but also do an overview of things that I saw and ways that they can improve training.

I did that for a bit and then ended up getting hired on at JPMorgan Chase as a dealership relationship manager, so I had a territory of retailers throughout the Southeast that I was responsible for.

Every single job that I’ve had in my life is one that I technically wasn’t qualified for. Like, “We normally don’t hire people that don’t have outside sales experience, but we see something in you, so, we’re going to give you an opportunity.” I just thrive in those types of situations.

——————

(Reporter’s note: Miles Greig has been a gymnastics commentator, working as an analyst for the ESPN family of networks. She served as a member of the ESPN/ABC broadcast crew for the 2023 NCAA Women’s Gymnastics Championships. She has also worked as a choreographer.)

With broadcasting, of course, I know gymnastics. I’ve been around it. I’ve competed in it. I’ve had a college career. I was an elite. Never coached, but to me – I can make corrections, right? I can look at a skill and communicate what I see that needs to be done. That’s not where I’m strong, but that’s definitely a role I can grow into.

But I think it’s all of the other pieces where I can thrive here at Iowa State, and I think that’s what they saw. They needed a change in leadership and new energy, a CEO of the program.

I didn’t get here on my own, either – don’t get it twisted, I did have help. I had some very heavy hitters and big names helping me along and talking me up and making that recommendation: “Why don’t you talk to Ashley Miles Grieg?” Sarah Patterson, obviously, very supportive. Miss Val, Valorie Kondos Field, she is my superstar. She’s my hero. Love that woman.

Things that happened in my personal life catapulted me to making this big leap of faith, or this big transition, and giving up a very solid, financially sound career where I have flexibility, I can kind of do what I want.

The big thing was, my husband, Orestes, and I wanted to have kids and grow our family. We got married in 2014, and shortly after that decided that this is what we want to do. We were back and forth between whether we wanted to do that or not. We decided yes, full steam ahead.

Needless to say, five years later, however many years later, it just didn’t happen. I went through IVF, went through all the things, had the transfers, three different cycles of it, and it just never resulted in a successful pregnancy.

But my life foundation at that time was set up to be conducive to grow our family and be a mom to raise my kids, as well as have flexibility, a good-paying job. So, was I passionate about what I was doing? Not really. I wasn’t passionate about the car business but I am passionate about people. I love the connections I made, the relationships I built in that business, with the clients that I had.

I finally had that moment where I realized, “OK, this might not happen for us. What am I doing? Am I going to continue down this path of having this job that I really don’t care for too much? Or do I need to figure out, if I’m not going to have kids and that’s not going to be my contribution to this world, having little mini-me(s) running around” – Who knows what will happen? You never know, right? It’s in God’s hands, at this point – I said, “What am I passionate about?”

It’s always gymnastics. It’s always been there – choreography, the commentating, staying close to the sport, knowing what’s going on. That’s when I decided, “Hey, I’m going to pursue this, I’m going to put it out there that I want to do this and see what happens.”

It took a few years for this opportunity to come up, but when it did, I was ready and it was a good fit. My initial thoughts about coming to Iowa was what I think a lot of people would think: “What the hell is in Iowa? Central Iowa, what do I know? Corn, right?” But then you get here, and you’re pleasantly surprised. Especially Ames, it’s a college town, it’s great people. I was floored.

I know what a good college environment, a good college town, looks like and feels like – I mean, I went to school in Alabama. Tuscaloosa, hello. They’ve got that and more here. Same type of energy. There’s no professional teams around, so lots of support for the Cyclones. Cyclone Nation is strong. It’s been a wonderful onboarding process and transition to being here.

I’m so blessed to just be doing this, to have this opportunity to influence young women, to grow young women, and to teach them what I know. We had a recruit here on campus this past weekend, and she asked me, “Do you have kids?” And I said, “No, but yeah, kind of, I have 21.” So I would never say this to them, because that’s too much pressure to put on kids, but they’re my babies. That’s how I look at them. That’s my contribution.

——————

We had our family weekend here recently over Labor Day, the first football game where we invite our families to come spend time with the coaching staff, with their children, their daughters and go to a football game. We do a dinner, and it’s really fun.

One of the moms of one of the athletes, maybe she heard the same conversation I had [with Jessica O’Beirne, where she mentioned infertility] and she just was like, “Look, if you ever need to talk about it, same situation. They told me I would never have kids, and I have four.” One of them is here and she’s on the team. She was a preemie; she just told me her whole story.

For me, it’s helpful to talk about it. I’d rather not be a part of keeping that stigma alive. Because when you do say something, there’s not very many degrees of separation between people that have experienced this, or know someone that has, and I think it’s just helpful. We should just normalize: It’s not easy to get pregnant for everybody. And it sucks. And it’s OK to talk about it. It’s OK to be sad. You can be mad that somebody else is having that joy and elated for them at the same time.

——————

The top priority for me is that young student-athletes and prospects have a passion for the sport of gymnastics still. They could be the best, most talented athlete, but as a coach and as somebody that’s been through it, I know that once you get here, it doesn’t get easier. Because you have all those other components that go with it. So, transitioning to making your own decisions, academics. What you want to do, what type of work, all the things that come along with it, that you have to focus on.

What does it mean to be fearless?
Being fearless is being rooted and comfortable with who you are. Being able to articulate what you believe in and who you are and stand behind it. I think that’s what being fearless is: being yourself.

“Three Girls from Bronzeville” by Dawn Turner
I read this book for my graduate school program this semester and couldn’t put it down. In this memoir, Turner talks about growing up in Bronzeville, a historic district renowned as an African-American business and cultural hub. She tells the story through three lenses: her own lens, her childhood friend’s and her younger sister’s. She illustrates how the three girls started from the same humble beginnings but ended up going down drastically different paths. The memoir addresses complex topics, like poverty, racism, addiction, child loss and the justice system; but it also includes themes of love, forgiveness, childhood joy and family. (I don’t want to spoil anything, but I will say that I finished Turner’s book right before reading reporting on the Beacon’s jail diversion program in Des Moines from Fearless Staff Writer Nicole Grundmeier. I noticed many correlations. Check out that story as well if you haven’t already.)

“Wisdom of Wildly Creative Women” by Angela LoMenzo
This book was recommended by staff at the Des Moines Public Library as part of an ongoing partnership with the Business Record. The 2023 book combines beautiful photography with powerful interviews with a diverse group of accomplished, creative women. Their stories – artists, authors, entrepreneurs and more – share their experiences, both good and bad, to empower readers. The book is filled with words of wisdom, and helps illustrate the possibility that you can live the life you desire.

Sex workers have been shunned by banks, even when their work is legal (New York Times). Which cities welcome women in finance? Des Moines among the standouts (Des Moines Register). How women leaders are navigating heightened visibility amid rising antisemitism and Islamophobia (the 19th). Rosalynn Carter hired a wrongfully convicted murderer to serve as White House nanny. They remained lifelong friends. (Time magazine). Muslim runner says she was cut from Lululemon campaign over religious identity (New York Times). A Black physician takes on racism in medicine (Scientific American).

A couple of weeks ago I took my mom to visit John Wayne’s birthplace in Winterset for her birthday. My parents and grandparents were big fans of the “Duke.” The exhibits on his life were very interesting, but I was most intrigued by a small photo of a woman on display in the house where he was born and lived as a baby.

I learned that Dr. Jessie Smith delivered the renowned actor, born Marion Robert Morrison, on May 26, 1907. He was a big star from the beginning – weighing in at 13 pounds. I thought it must have been unusual for a woman to be a physician at that time (more than a century later, women still only account for just over a third of physicians).

Smith graduated from medical school in 1892, in her mid-20s, while caring for three stepchildren and an infant. Her office was on the second floor of a building adjacent to the Iowa Theater in Winterset.

She died in 1916 from a disease that doctors in Iowa, Baltimore and the Mayo Clinic couldn’t diagnose.

In researching Smith, I found reporting from Iowa PBS about female physicians at that time. In 1870, there were eight female doctors, compared to 1,857 male doctors in the state. By 1900, there were 260 female physicians compared to the 3,749 male doctors in Iowa.

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