RISKAPPROPRIATEMATERNALANDNEONATALCARE:

Evidencebasedstrategytoreduceinfantmortality

M.KathrynMenardMDMPH

•  ViceChairforObstetricsDirectorofMaternalFetalMedicine,UNCSchoolofMedicine

•  MedicalDirector,NCPregnancyMedicalHomeProgram

•  PastPresident,SocietyforMaternalFetalMedicine

•  President,NCObstetricsandGynecologicSocietyMarch6,2018

STUDYLEVELSOFMATERNALANDNEONATALRISKAPPROPRIATECARE:HB741ANDSB311

  Supportastudybilltoassesstimelyandequitableaccesstohighqualityrisk-appropriatematernalandneonatalcare;studytoresultinactionablerecommendations.

  CFTFtoadministrativelysupportedstudy(additionalfundswouldneedtobemadeavailable)

  PassedHouselastyear;requestcontinuedsupport

NORTHCAROLINA,2014

66%ofchildhooddeathswereinfants

860infantdeaths

593deathswithinthefirst28daysoflife 187duetoprematurityandLBW 125duetomaternalfactors/complications

   Theseleadingcausesofneonataldeathdisproportionatelyaffectminorities

   Earlyandriskappropriateprenatalcarecanmakeadifference

3.IMPROVETHEQUALITYOFPRENATALCARE

3C.Improveaccesstoandutilizationoffirsttrimesterprenatalcare3E.Ensurethatallpregnantwomenandhigh-riskinfantshaveaccesstotheappropriatelevelofcarethroughawell-establishedregionalperinatalsystem

1.Decreasethe%ofVLBWandhigh-riskbabieswhoarebornatLevel1andLevel2hospitals

2.Define,identifyandpromotecentersofexcellenceforVBAC(vaginalbirthaftercesarean)

3.AssessthelevelsofneonatalandmaternitycareservicesforhospitalsusingtheconsensusrecommendationsoftheAmericanAcademyofPediatrics(AAP),theAmericanCollegeofObstetriciansandGynecologists(ACOG),andtheSocietyforMaternal-FetalMedicine(SMFM)

RISKAPPROPRIATEMATERNALANDNEONATALCARE

  Earlyonsetprenatalcare  Riskassessmentandinterventionformodifiableriskfactors  Tobaccocessation  Optimalmanagementofmedicalcomplicationsofpregnancy  Aspirintopreventpre-eclampsia  17hydroxyprogesteronetopreventrecurrentpretermbirth  Caremanagementforthosewhowillbenefitmost

PMHPROVIDERNETWORK:PARTICIPATION

Providerparticipation:380practicesparticipateinthePMHprogram,representing>1,700providersandmorethan90%ofmaternitycareprovidedtoMedicaidpatients.95of100NCcountieshaveaPMH.

EARLYANDRISKAPPROPRIATEPRENATALCARE

  Whoisavailabletoprovideprenatalcare?  Whataretheypreparedtomanage?  Whatistheircapacitytoseewomeninatimelymanner?  Whatifmoreadvancedcareisneeded?Whatisthesystemforreferral?Dowomenacceptreferral?

  Whydoonly65%ofMedicaidrecipientsreceiveprenatalcareinthefirsttrimester?

  Ruralcounties:69%  Metropolitan:65%

  Wherearetheservicegaps?Howcantheybefilled?

RISKAPPROPRIATEMATERNALANDNEONATALCARE

  Whenpretermdeliveryisinevitable  Antenatalsteroids  Maternaltransfertohospitalwithappropriateresourcesforneonatalcare

  VLBWnewbornsare1.8Xmorelikelytodieifbornoutsideofaregionalcenter

Lasswell, Barfield, Rochat, Blackmon. JAMA 2010

2012AAPLEVELSOFNEONATALCARE

LevelI(Basic)

>35wkswhoarestable

Stabilizeandtransfer<35weeks

LevelII(SpecialtyCare)

≥32 wks or ≥1500 gms who have physiological immaturity

Provideconvalescent care after intensive care; Assisted ventilation for ≤24 hours or CPAP

LevelIII(SubspecialtyCare)

Continuouslifesupport;Care<32wksand<1500gms

Advancedimagingw/interpretationonanurgentbasis(CT,MRI,echocardiography):Promptaccesstofullrangeofpediatricmedicalandsurgicalsubspecialistsonsiteorbypre-arrangedconsultativeagreements

LevelIV SeeLevelIII

Capabilitytoprovidesurgicalrepairofcomplexcongenitalorpostnatalconditions;Immediateat-siteaccesstopediatricsubspecialists,pediatricsurgeonsandpediatricanesthesiologists

AreNorthCarolina’highestriskinfantsborninfacilitieswithresourcestoprovidethebestcare?

DeliveriesatNorthCarolinaFacilitiesbyVolume

NCVLBWBIRTHBYHOSPITALTOTALBIRTHVOLUME,2014

1853VLBWbirths

1487(80%)borninhospitalswithbirthvolume>3,000

228bornw/1000–2,999birth

138(5%)bornw/<1000births

RISKAPPROPRIATEINTRAPARTUMCARE

  Arethehighestriskbabiesborninfacilitieswithresourcesandpersonneltoprovideappropriatecare?  Whatarethecapabilities/LevelofneonatalcareforNCmaternityhospitals?  HowisLevelofcaredesignated?  Whatsystemsareinplaceformaternaltransport,whenindicated?  Whatsystemsareinplaceforoutreacheducationandsupportforqualitymonitoringandimprovement?

  Whyare20%ofbabies<1500gramsborninhospitalswithlowdeliveryvolume?Arethematernalandneonatalresourcesappropriate?  Wherearetheservicegaps?Howcantheybefilled?

WHATABOUTTHEMOM?

DEFININGLEVELSOFMATERNALCARE

  Tointroduceuniformdesignations,withstandardizeddefinitionsforlevelsofmaternalcarethatarecomplementarybutdistinctfromlevelsofneonatalcare

  Toprovideconsistentguidelinesaccordingtolevelofmaternalcareforuseinqualityimprovementandhealthpromotion

  Tofosterthedevelopmentandequitablegeographicdistributionoffull-servicematernalcarefacilitiesandsystemsthatpromoteproactiveintegrationofrisk-appropriateantepartum,intrapartum,andpostpartumservices

Providenationallyapplicableuniformdefinitionsdescribingcapabilityoffacilitiestoprovideincreasingcomplexityofcaretopregnantwomen

LEVELS OF MATERNAL CARE

Jointly published by ACOG and SMFM

Endorsementandsupportfrom•  AmericanAssociationofBirthCenters•  AmericanCollegeofNurseMidwives•  AssociationofWomen’sHealthObstetricand

NeonatalNurses•  CommissionfortheAccreditationofBirth

Centers•  AmericanAcademyofPediatrics•  AmericanSocietyofAnesthesiologists»  SocietyofObstetricAnesthesiaand

Perinatalogy

LEVELSOFMATERNALCARE(LOMC)

  NOTaboutclosingsmallorruralmaternitycarecenters

  ISaboutroleofLevelIII/IV(Regional)Centerstosupporteducationandqualityimprovementamongtheirreferringfacilities

  ISaboutbuildingacultureofcollaboration

LOMC:DEFINITIONS/EXAMPLESBirthCenter

Low-riskw/uncomplicatedsingletontermpregnancies,vertexpresentation;Expectedtohaveuncomplicatedbirth

Term,singleton,vertex

LevelI

Uncomplicatedpregnancies;Detect,stabilize,andinitiatemanagementofunanticipatedproblemsthatoccurduringantepartum,intrapartum,orpostpartumuntiltransfer

TermtwinsUncomplicatedcesareanPreeclampsiaw/oseverefeatures

LevelII LevelIfacilitypluscareofappropriatehigh-riskconditions,bothdirectlyadmittedandtransferredfromanotherfacility.

Severepre-eclampsiaPlacentapreviaw/noprioruterinesurgery

LevelIII LevelIIfacilitypluscareofmorecomplexmaternalmedicalconditions,obstetriccomplications,andfetalconditions

Placentaaccreta/percreta;ARDS;Expectantmanagementseverepreeclampsia<34wks

LevelIV LevelIIIfacilityplusonsitemedicalandsurgicalcareofthemostcomplexmaternalconditionsandcriticallyillwomenandfetuses

SeverecardiacconditionsorpulmonaryhtnRequiresneurosurgery

3.IMPROVETHEQUALITYOFPRENATALCARE

3C.Improveaccesstoandutilizationoffirsttrimesterprenatalcare3E.Ensurethatallpregnantwomenandhigh-riskinfantshaveaccesstotheappropriatelevelofcarethroughawell-establishedregionalperinatalsystem

1.Decreasethe%ofVLBWandhigh-riskbabieswhoarebornatLevel1andLevel2hospitals

2.Define,identifyandpromotecentersofexcellenceforVBAC(vaginalbirthaftercesarean)

3.AssessthelevelsofneonatalandmaternitycareservicesforhospitalsusingtheconsensusrecommendationsoftheAmericanAcademyofPediatrics(AAP),theAmericanCollegeofObstetriciansandGynecologists(ACOG),andtheSocietyforMaternal-FetalMedicine(SMFM)

RECOMMENDATION:INFORMEDACTIONPLAN

CommissionabroadlyrepresentativetaskforcetostudydegreetowhichNCwomenreceiveriskappropriatematernalandneonatalcareWhoisavailabletoprovideprenatalcare?Where?

Whydoonly65%ofMedicaidrecipientsreceiveprenatalcareinthefirsttrimester?

Arethehighestriskbabiesborninfacilitieswithresourcesandpersonneltoprovideappropriatecare?Whyare20%ofbabies<1500gramsborninhospitalswithlowdeliveryvolume?

Arematernityhospitalsequippedforsafematernalcare?Dothehighestriskmothershaveaccesstonecessaryresourcesforhighqualitycare/

Wherearetheservicegaps?Howcantheybefilled?