What’s broken in maternal healthcare, from a frontline nurse leader | Rose Horton

[00:00:00] Kristin Tully: Welcome to the Advancing Maternity Care podcast. I'm Kristin Tully, founder and chief scientist at Couplet Care. In this podcast, we invite maternal, infant and family health thought leaders to share their perspectives and their work.

[00:00:14] Kristin Tully: Okay. Connecting around research and experiences is key for implementing more meaningful support for families and those who care for them. It's a joy to welcome Rose Horton. Rose Horton is a leader and advocate for maternal health equity. She has served as director of Women and infant Services at Emory Decatur Hospital and was the 2025 president of the Association of Women's Health Obstetric.

[00:00:44] Kristin Tully: And neonatal nurses. Rose has dedicated her career to transforming clinical practices and health policy. In 2022, she earned an induction as a fellow of the American Academy of Nursing. She is founder of the Not On My Watch Movement to reduce maternal mortality. Through her consulting, she equips healthcare professionals to practice respectful maternity care for every birthing person.

[00:01:14] Kristin Tully: We have shared interests too around promoting and protecting families through the fourth trimester Rose, welcome.

[00:01:22] Rose Horton: Thanks so much. I'm so excited to be here. Kristin, and thank you for all the work that you do as well.

[00:01:28] Kristin Tully: Thank you. Will you share more about your current work and in what drives you with that?

[00:01:35] Rose Horton: I would love to, I, in 2017. I coined a hashtag not on my watch. and I coined that hashtag after doing some research for a presentation, was doing the research for the hospital that I was working as an interim leader, because I hadn't been working in the OB space for about four years. And so in preparation for the presentation, I really wanted to. Just be really well prepared and know what's happening in the space. So as I'm Googling, I am seeing things that horrified me. I first learned about the death of Kira Johnson, in California. that was completely preventable. I learned of the death of Lauren Bloomstein in New Jersey that was preventable as well.

[00:02:26] Rose Horton: And the death of Shalon Irving in Atlanta, Georgia. And know how it is when you're Googling and researching, you know, the And

[00:02:36] Rose Horton: up in the ProPublica Lost Mothers page, and by that time I was like crying hysterically. and just so concerned. And I was like, the, what the heck?

[00:02:49] Rose Horton: What's been happening in the past couple of years? And I was wondering, what can I do? How can I be part of the solution and not on my watch? was what popped in my head, and I was like, yes. Within my locus of control, I will ensure we mitigate morbidity and mortality for, mothers birthing people, and for infant. I remember when I did the presentation at, Emory Decatur Hospital, I said to the leaders, there were probably about 250 people in the space. said, y'all, this hashtag is gonna go viral. And everybody started chuckling, myself included, I said, even if it means that it's viral around Emory Decatur Hospital. so I felt like 2017 was really, was really a, a tipping point for me that I really wanted to part of the solution. And that really drove everything that I did as the executive leader at, Emory Decatur Hospital for the women in infant service line. Looking back retrospectively, I can say that we were on the journey towards equity. We didn't say there wasn't a banner that's saying effective today, we're on the journey, but. From that experience, from coining the hashtag and sharing it with the leadership team and getting the buy-in and the support, that was really, really lovely. I felt like we were well positioned Really make some of these substantive changes that would have an impact. And yeah, that's how it started. And I'm so incredibly proud of the work that we were able to accomplish, the outcomes that we were able to accomplish for the birthing community. And that really led me in February of 2024. it led me to. Be courageous and take the leap into being self-employed as a consultant because I wanted the opportunity to help other healthcare organizations achieve the same kind of results that we achieve because I felt like it was with intentionality that it was absolutely replicable. so that's what I'm doing now. I'm doing some consulting and lots of public speaking around many topics. but at the core of it, which now I've embraced as my life's work, is mitigating maternal and infant morbidity and mortality holding space for how do you create a culture that recognizes the sacredness of pregnancy, labor, and

[00:05:45] Rose Horton: so that's what I've been up to.

[00:05:47] Kristin Tully: It's amazing. And I love the hashtag because it's about responsibility and individual responsibility and collective and it, that's so powerful. Could you share more about, shifting culture for, you know, meaningful support?

[00:06:06] Rose Horton: Yes. Yes, I'd be happy to do that. I remember in, 2019, so this was 2017, so. 2018, I, I made the decision to accept the position, and to move from interim to a full-time position. we started the work then and we started with, a journal article, review the leaders, and looking and hearing some stories and looking at outcomes. and that really led to us asking some questions of ourselves. You know, how are we doing with things like that? Because in 20 18, 20 19, I'll be completely honest, we were not looking at our outcomes stratifying our

[00:06:51] Rose Horton: based on race or ethnicity or language. So we're like, okay, we need to do this.

[00:06:58] Rose Horton: We need to start looking. So the first metric we used was based on race, and we started with looking at our breastfeeding rates. and we, Decatur Hospital, about 60% of our patients. as black or African American, and 18% white, about 12% Latina, and maybe six, 7%, Asian. And we have a small percentage of of other, which was multi-racial and some, you know, other demographic. when we looked at our overall breastfeeding rate. was great. Well, maybe not great. It was trending in the right direction year over year. You know, we made the decision to become, a birth friendly, breastfeeding friendly. Sorry. I'm having, you know what I

[00:07:52] Kristin Tully: Yeah, well there and there are so many designations and that, that's another interesting thing. You know, baby friendly, birthing friendly, mama certified, there's, there's a lot.

[00:08:02] Rose Horton: Yes. So it was a, the baby friendly

[00:08:05] Rose Horton: around, you know, the 10,

[00:08:08] Rose Horton: 10, tenets, I'll call them tenets for now. So we made that decision, and as a result, our breastfeeding rate was trending in the right direction. But in 2019, when we decided to look at our data stratified, white

[00:08:24] Rose Horton: an exclusive breastfeeding rate of in the 80 percentile, which was fantastic. black patients, the majority of our patients, had a rate, in the 40th, 50th percentile. know, which begged the question why, you know, so we started with the, the five why's and asking some questions and looking at our processes. And one thing just led to another. We were very curious and we were very committed to solutions and to, finding equitable outcomes.

[00:08:54] Rose Horton: So as a result, we did a lot of investigation. We looked at the data in many different ways, and, Subsequently, we had education. We created a course called Respectful Equitable

[00:09:05] Rose Horton: that was mandatory for everyone to attend. and everyone, it just, you know, not just, the nurses, but we wanted the techs, we wanted the unit secretaries.

[00:09:15] Rose Horton: and it was for the entire service line. So it wasn't just for labor and delivery, it wasn't just for triage. It wasn't just for mother baby. You know, NICU, lactation, everybody who touched the patient needed to understand what respectful equitable care looked like. and through our process every year we had another focus, three and a half hour mandatory, everybody had to attend. so we started with providing education, we set an expectation, and then we audited,

[00:09:45] Rose Horton: and then we both in

[00:09:48] Rose Horton: So it was a full circle. It wasn't just. You know, this is the flavor of the month. It was like, no, this is what we're gonna do from now

[00:09:56] Rose Horton: and we're gonna be looking and we're gonna have some difficult conversations. And you know, we had some attrition along the

[00:10:03] Rose Horton: there were some people who felt like they didn't want that level of accountability and that level of responsibility, that level of shared responsibility. Which was absolutely fine, where we wanted people who wanted to be part of the change, who wanted to, ensure that we had equitable outcomes. but it was through a very intentional process that we were able to see equitable changes. There's a slide that I use when I talk about, breastfeeding disparities that showed our data, you know, and, I said. The first data looks like, like vtech, you know, because it looked just like that. But the second one, it was very, very, equitable. And I love that because that's what happens with intentionality. So, yeah, I'm a big fan. I'm a big fan of setting an expectation, providing education, and, Really sharing responsibility and weaving in accountability. I feel like if there's any initiative that's really important to you that you wanna be successful in, you need to have those clear steps, so that you can be successful and it can be hardwired and it becomes part of the And, yeah, I can go on and on when I'm gonna stop there.

[00:11:18] Kristin Tully: so visibility, like, I, I just wanna repeat back some of the, so understanding what's working well and where the gaps are, gaps to go, so that that can be known in a timely manner and actively addressed.

[00:11:37] Kristin Tully: And as part of an ongoing cycle.

[00:11:39] Rose Horton: that we were sharing, we were sharing that on a weekly

[00:11:44] Kristin Tully: weekly.

[00:11:45] Rose Horton: That's how, how intense it was for a time. And we would have conversations. I, I know in our rounding I did, lead a rounding our nurses and also with our patients, but with our nurses, you know, on mother, baby and postpartum, I would ask the question, Hey, who's exclusively breastfeeding? and my expectation is that you'll know of all the couplets that you know who is. breastfeeding and I would ask, you know, any, any concerns, any barriers that we can remove for them. You know, how are things going? so that, you, you mentioned visibility, it was definitely leadership visibility as well, the whole leadership team, that was our commitment that we would all round on every unit, you know, so it was a, A and

[00:12:35] Rose Horton: so that we can ask these questions and ensure that we were helping our patients ensuring that we were providing equitable outcomes.

[00:12:45] Kristin Tully: That's really exciting. You know, I've written about that, our values show, and so, and I think breastfeeding is such a, Sacred and special and complex relationship that that's a really good sort of indicator of how supportive and enabling the, the journey. I was gonna say, you know, the, the team, but like every aspect of it is so that people can achieve their goals.

[00:13:17] Rose Horton: Right. Right. And that was really important to us because when we first started and we looked at our data and we were horrified, I remember had, some at least three times a year, I would have mandatory meetings with all 320 people who reported to me at all times of the day. So I can meet them at times that work best for them.

[00:13:40] Rose Horton: But when we first started the process and I shared the data, you know, the disparate data, I, and I would ask, why, why do you think the data's that bad? And there was a lot of victim blaming. There was like, oh, black people don't wanna breastfeed. Oh, it's, it's, the, the patient's mother, the grandmothers, you know, they're really hard. Oh, the providers are not giving them adequate information in the clinic about breastfeeding. There was a lot of that. and it was really curious because in my heart of hearts, I knew it was more than that. I knew that we. And the hospital space were contributing in some way. But it was interesting how the conversation started.

[00:14:18] Rose Horton: So I remember our, our nurse scientist on our team. She's like, let's change the denominator. change a denominator to everyone that we ask on admission. What is your feeding? what's your feeding plan?

[00:14:34] Rose Horton: And they say breastfeeding. I said, that will be

[00:14:38] Rose Horton: because it was

[00:14:39] Rose Horton: at first.

[00:14:39] Rose Horton: And so there was, it is education. It's stem. It's stem. It's stem. So when we change a denominator to the patient on admission, they wanna exclusively breastfeed. And we looked at our data again and our data was basically the same. We had to go back and ask another question. It's like, okay, y'all. So these are people who already did the education.

[00:15:02] Rose Horton: They see the value, they've made the commitment and an admission they want to, and I'm discharged or not. What, what do you think the problem is? And those were the harder conversations. and I wanted the team to come up to say, yikes, I think it might be us. I think we may be contributing to that. and some groups. Came to it quicker. and others, I had to say, we are the problems. It's us. us. You know, how are we showing up for patients? what stereotypical thinking do we

[00:15:35] Rose Horton: certain patient populations and how they value, breastfeeding and, you know, other things. So, it wasn't, it was interesting.

[00:15:43] Rose Horton: It wasn't easy. Not at all. it was hard conversations. I think oftentimes perceive that it's easy for leaders to, to have these hard conversations. It is not easy, it is not desirable. I have, you know, I don't, I don't wanna do that, but let me tell you, it's important enough that I will do it. You know, that's why I am called to be a leader, to have the really great, wonderful conversations and also to have the ones that challenge us. because at the end of the day, we're better a result when you have somebody who will ask you those difficult, conversa questions really encourage self-reflection, which we did a lot

[00:16:28] Rose Horton: know, let's look at, let's look inside, do you think this is coming from? You know, what are some thoughts you have about this? So that was, yeah, was good. Necessary.

[00:16:41] Kristin Tully: Yeah.

[00:16:41] Rose Horton: easy.

[00:16:42] Kristin Tully: Yeah. That's why in, in my mind of research, it's been so helpful. To, we film in, various settings, in partnership with people, sometimes in their homes, sometimes in a laboratory, and also on the postpartum unit. And then we can see what people experience. So when clinicians, for example, when they come in, do they offer a welcome?

[00:17:11] Kristin Tully: You know, do they introduce themselves a welcome? Do they share the purpose? Of their presence to do a certain assessment or to check or to ask how you're doing. And one of the key things too is are we offering encouragement? Not just, not just not being discriminatory and making negative assumptions about people and bringing in, for example, formula to breastfeeding family, which we see.

[00:17:36] Rose Horton: Right,

[00:17:37] Kristin Tully: You know, or making hand gestures for people who speak a language other than English, like, about how to, how to wash their hair, when to call, or, it's just really stunning, some of the workarounds because it's hard to get interpretation services, you know, like, it, it's such a, a, a systems issue, but then it is felt and experienced in these interpersonal.

[00:18:01] Kristin Tully: Dynamics, and that's where we've seen too, right? If you can't see or reach your infant, you know, with the,

[00:18:09] Rose Horton: Right.

[00:18:09] Kristin Tully: then, you know, it's been really exciting to, well, I mean to live it myself too, but, you know, before that and through it to, to see what people navigate

[00:18:21] Rose Horton: Right.

[00:18:21] Kristin Tully: you know, we wanna address as you've shared.

[00:18:24] Kristin Tully: what do people need to know?

[00:18:26] Kristin Tully: do we need to feel, you know, respected and cared for, valued, and like, there are a lot of things that help with that. And then we also need access, to, of course, technical support, but also to be able to pick up and, set down your baby however you want and need. And that's a, that's a well lifetime thing, but you know, that's a, something that needs active support.

[00:18:52] Rose Horton: No, I think you raise a really good point. with the encouragement. I remember having conversations, with the team, especially during the mandatory all teams As you know, black people do wanna breastfeed and for some. black people, just like with some white people. It's difficult, you know, and it's really important.

[00:19:17] Rose Horton: We talk about the energy. I talk about the energy a lot. The energy that you bring into a space. I said it's really important to bring in the energy of, I wanna encourage, I wanna motivate, I inspire. I remember some, questions that felt a little bit like pushback from some of our, lactation consultants. Around, well, we don't wanna coerce anyone. And I'm like, oh, absolutely not. I, I think, think coercion, I, I think there's a specific intentionality around coercion. They said coercion or perceived coercion. I said, I completely understand that. I said, but encouraging and supporting and using words like I can imagine, this must be difficult for you. What can I make this easier for you? I, I said there's words that we can use to really get to that and there's lots of barriers, that we can remove. And we talked about those barriers as well. And one of the barriers, as you mentioned, we recognize, and this is so important, I just wanna share a really quick story. One of our. Patient care techs. she was newly hired. I think it's, she was probably three or four months in. She went to a leader and she said, know, I've discovered something. She said, as I'm going to patient's room, what these patients have in common is that they all want to exclusively, exclusively breastfeed, she said, but in some patient's room, I see formula. And in some patients' room I see milk, and as a leader is having more of a conversation and asking some more questions. you know, the tech said, and I, I also feel like the black patients are more likely to have formula, and the white patients have donor milk. And I was so appreciative of, of that conversation, her observation, and that we've created a culture where

[00:21:23] Kristin Tully: Okay.

[00:21:24] Rose Horton: can speak up. then we recognized that we didn't have a standardized process on how have the conversation about

[00:21:34] Rose Horton: So it was an opportunity and it's like, okay, well here is a standard process and we did education. We have a form. And it's like everybody who says that their, that their intent is. exclusive breast, milk feeding, human milk feeding, they will have donor milk. We will not offer them formula. Not that there's anything wrong with formula. I just wanna say that my granddaughter a fed formula and she's totally, totally fine. but we wanted to ensure that in our

[00:22:08] Rose Horton: to help and support, our patients. we know that breastfeeding can be difficult and, and challenging in our effort to support them, that we were not providing an additional barrier or a reason stop. so was really important to us. And as you talk about access to the baby,

[00:22:31] Kristin Tully: Okay.

[00:22:32] Rose Horton: quite simply we know that our NCSV rates are rising, right?

[00:22:35] Rose Horton: There's more, c-section, and a lot of these C-sections. Are occurring after many days of labor our patients are exhausted. They're exhausted when they go to the postpartum unit. So, no, that's why I love, I love Couplet Care. I'm gonna say something about it. but I love it because it's important that the patient has the ability to have access to their baby and have the freedom to do that and, and can do it naturally. It's all about being vigilant and looking around and saying, gee, with her laying in this position, it's like impossible for her to get the baby out of this bassinet. You know, it's important for us to do that and I think nurses do that beautifully. not for self-promotion, but I just wanna tell you that, we're having a conference, this is our third, our third year having a not on my watch conference. year we've decided to make it a two day conference. First day is conference as usual. The second day is a hackathon. and the whole goal, because in my experience and my travels around the country and having worked in seven different states, nurses are incredibly innovative and creative. We, we do so many, so many workarounds, right? wanted to hold. Space for that innovation. and Kristin, I have to tell you that I am a huge fan of couplet care. The ease of moving that bassinet and raising it and lowering it, and I just think it's beautiful. So that's the whole, that's like the whole reason I'm having a hackathon because I feel like nurses have solutions and sometimes they don't have a platform to say. I have this really great idea. so I'm really excited. and along with that, I was telling you about, Anna and her, her, birthing bed, which is a beautiful, beautiful innovation because the birthing bed has movement, you know, figure eight movements and other gentle movements that really help aid what they're finding is that it really, activates labor, stronger contractions and, and dilation. And we know that many of our patients, based on the region where you work, many of our patients have continuous fetal monitoring and they have to be on the bed or they want an epidural and they can't move around. love the innovation. So, I think holding space renovation

[00:25:02] Kristin Tully: Anything.

[00:25:04] Rose Horton: because. And our healthcare system. You know, there's, there's many things that are working and lots of things that are not working, and I do think the people closest to the

[00:25:14] Kristin Tully: Yeah.

[00:25:15] Rose Horton: are almost always the best ones with the solutions. So I just wanna do a shout out for.

[00:25:22] Rose Horton: Not just nurses, but all clinicians who are innovative and creative and have a solution.

[00:25:28] Rose Horton: I wanna say I see you. I appreciate you and please continue to drive your, your innovation or your recommendations forward because there's a space for it. there's absolutely a space for it. But enough of that, I just wanted to, to talk about that for a second.

[00:25:44] Kristin Tully: That's so exciting. Yeah. I mean, and that's what we all like, what do. Humans need. And then we have people who, you know, what, what gets in the way then becomes the way, like, how can we, establish a process or, you know, communication or a thing, you know, whatever it is. And then, Share that and help them institutionalize it, so then, then we can improve something else.

[00:26:09] Kristin Tully: You know, there there's, there's so many things and so I think that this partnership of human-centered design for, you know, what would be helpful and then working, you know, to improve that in collaboration instead of, you know, we don't need buy-in when we're doing it together. Yeah, it's really exciting.

[00:26:28] Rose Horton: Yeah. I love that. What gets in the way becomes a way that's, I'm gonna use that. that's really true though. You know? Then we become socialized and, and this is the way we've done it for 30 years. Words that make me crazy, like, well, However, it's a new day.

[00:26:45] Kristin Tully: Yeah,

[00:26:45] Rose Horton: Let's see if we can do something

[00:26:47] Kristin Tully: we, we've talked and we published about renovating. Right. Let's keep, let's keep what's, strong and appropriate and a, a good fit, and then let's restructure the rest. And like when people create it, we can undo it and then, and then recreate. And so that's what I hope, you know, that you, in addition to being a useful thing, I, I really hope that the Couplet Care bassinet is just an example of how we can listen.

[00:27:16] Kristin Tully: To each other and then have the commitment as you described, to follow through on that. and that, that's a lot of work, but it's, you know, people do it every day, you know, improve, improve quality of care. So we just wanna help, facilitate that.

[00:27:32] Rose Horton: Absolutely.

[00:27:34] Kristin Tully: Great. Well, is there anything else that you'd like to share? I, I think, that's really exciting about your conference and we can put a link, or if you wanna share a little bit more, right now about when that is and how people can learn more. That would be great.

[00:27:47] Rose Horton: Oh, thank you. I would love to. So our conference is gonna be October 21st and 22nd in the beautiful city of Atlanta, Georgia. And, we have some amazing speakers. last year's theme was, glimmers of Hope because. You know, last year was trash and people needed a little bit,

[00:28:09] Kristin Tully: Yeah.

[00:28:09] Rose Horton: bit of hope, you know, clinicians needed. So this year, our theme is hope in Action. need hope, but

[00:28:18] Kristin Tully: Yeah.

[00:28:18] Rose Horton: now we need. Action. We need to be part of the solution, which is why we thought it'd be great to have a, a hackathon or innovation hub, whatever term, really resonates with people. So it's gonna be a two day, event and I'm really excited.

[00:28:32] Rose Horton: so we have speakers. we have a couple of speakers that are CEOs in the FemTech space because I feel like, you know, the healthcare space and the FemTech space are

[00:28:46] Rose Horton: and it doesn't make any sense because. The FemTech is created for the patients

[00:28:52] Rose Horton: So I'm excited about that. And we have somebody from, Maven Clinic. 'cause

[00:28:57] Rose Horton: about re-imagining healthcare and being

[00:29:01] Kristin Tully: Yeah.

[00:29:02] Rose Horton: I was really excited that we could have that. We have, Charles Johnson that's gonna be speaking for us, and his. he's an amazing advocate for, the loss of his wife, Kira Johnson, but also he has started, fatherhood initiative because fathers are forgotten in this space, especially, black dads.

[00:29:23] Rose Horton: So I wanna talk about his inspiration to, you know, to focus on, fathers and how fathers could be part of the solution. So. It's very much, leaning towards innovation, but also talking about the power of the clinician and the nurse. Our keynote speaker is, the one and only Dr. Monica McLemore, and she's fantastic.

[00:29:49] Rose Horton: So it's gonna be. Pretty awesome, and I'm very, very excited about that. so I'll be happy to share,

[00:29:58] Kristin Tully: Okay.

[00:29:58] Rose Horton: a link. but I'd love to, if we have just a few minutes, I'd love to share a call to

[00:30:07] Rose Horton: because I think that all of us need to be part of the change. there are five tenets that, are part of the, not, not on my watch movement. And I am encouraging everyone who's listening to this podcast to really partner with me, with Kristin and I, and these five tenets. 'cause I believe that if we do these five things, we will significantly mitigate morbidity and mortality. And the first is that we treat everybody with dignity and respect. That's tenet number one. Number two is that we listen to and we believe women. Number three, that we provide evidence-based care. So our care is not arbitrary. It's not my opinion. It's not I do this today and I do something tomorrow. What is the data reveal? So that means we have to look at the data, we have to do our research, right? evidence-based care, and then shared decision making. It's really important that we dismantle the hierarchy that we've created in healthcare, that decisions are made at the top by the physician. Who's the most important person? No, I think we need to. Look at it in a circle, right? And the patient's in the center of our care. Shared decision making. What's important to you during your birth? What's important to you as your babies in the nicu? What's important to you? Shared decision making. And last but not least, advocacy. We need to advocate for all women and birthing people and infants. Those are the five tenets. It's not super expensive. there's really no innovation needed it. it's very foundational, it's, it's, it doesn't exist at a level that it should exist. So that's my call to action to everyone who's listening. partner with me. Let's, let's make this all different.

[00:32:00] Kristin Tully: Okay. That's wonderful. Thank you, rose. Thank you so much.

[00:32:03] Rose Horton: you. Thank you Kristin. Thank you for the opportunity and the conversation

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