When getting mom and baby to the right hospital is a matter of life or death

Editor's note: Giles Bruce was a 2016 Center for Health Journalism National Fellow whose Fellowship project, "What Killing Indiana's Infants?" explored the reasons for Indiana's high infant mortality rate.  It led to numerous efforts around the state to reduce the death toll and was chosen as the 2017 Indiana Story of the Year by the Hoosier Press Association.

The U.S. has some of the best perinatal care on earth, but kids die before the age of 1 here at a higher rate than the most of the developed world. 

A big part of the problem is that high-risk pregnant women and newborns aren't getting the right care during their time of need. 

That's a problem lawmakers across the country are increasingly trying to address. Indiana, for instance, recently passed a law establishing a system that rates hospitals on the complexity of neonatal and maternal care each can provide. At least 22 states have rating systems for neonatal care, while 17 have them for maternal care, according to the March of Dimes. 

State health officials say these measures help ensure expectant mothers and infants are cared for in the appropriate facilities. 

"The purpose of it really is to make sure that, if at all possible, we identify any risk factors a pregnant women has or a baby has ... and we make sure that the woman or child not only has the level of personnel but also the level of technology and the level of equipment that's required to address whatever those risk factors are,” said Indiana State Health Commissioner Dr. Kristina Box. 

Those risk factors might include a baby with congenital birth defects or a mom with a previous preterm birth, heart condition or bout of preeclampsia, Box said. 

Will these laws save the lives of infants? The data suggests that making sure babies are delivered at the right kind of hospital can be a matter of life and death. 

In 2010, researchers from the Centers for Disease Control and Prevention reviewed more than 30 years of mortality data on both babies with very low birth weights (less than 3.3 pounds) and who were also born very premature (less than 32 weeks). The scientists found that those infants were more likely to die if they weren't born at highly specialized (or “Level III”) hospitals. 

One of the earliest systems of this kind started in Arizona in 1975, with a grant from the Robert Wood Johnson Foundation. The state also funds medical transport for high-risk pregnant women and newborns to ensure they’re taken to a facility equipped to care for them.

But has this reduced infant mortality in the state? 

"We know it has," said Deb Christian, executive director of the Arizona Perinatal Trust. "We transport approximately 700-plus mothers and 700-plus babies a year. Previously a significant number of patients would have been delivered or taken care of at the wrong levels of care." 

Arizona’s infant mortality rate fall from 14.8 deaths per 1,000 live births in 1975 to 5.4 today, though that decline roughly mirrors that of the country overall. 

While the U.S. infant death rate has dropped, the preterm birth rate in America has risen in that time period, the result of women giving birth later in life and having more elective, early cesarean sections, among other factors. 

The model pioneered by Arizona certified hospitals both for neonatal and maternal care. “For so long, everyone was more concerned about the baby," Christian said. "We decided that mothers are the best incubators.”

The state with the most births, California, has had a system to distinguish infant levels of care since 1976, but no designated program for maternal care, according to its Department of Public Health. 

"We do this for trauma, we do this for stroke, we do this for other areas. As we know, when you follow an evidence-based care, standardized approach across the country, not only do the outcomes get better, but your ZIP code doesn't define whether you're going to live or die after something like labor and delivery."

 

                                                   — Dr. Rahul Gupta, chief medical and health officer, March of Dimes

That state has focused its infant mortality efforts on addressing the social determinants of health, through programs to specifically support black mothers (who are more than two times as likely than white women to lose a baby); provide nutrition, counseling and health education to pregnant women on Medicaid; provide case management to pregnant and parenting teens; and visit the homes of families in at-risk communities. 

"There's no one-size-fits-all factor that to going to reduce infant morbidity or infant mortality all by itself," said Dr. Christopher Zahn, vice president of practice activities for the American College of Obstetricians and Gynecologists, which released a classification of maternal levels of care in 2015. "But the best ICU for a baby is a healthy mom." 

Zahn said there’s been some concern these laws make it harder for smaller hospitals to stay open. But he noted that most births happen at Level I and II facilities anyway, and that Level III and IV hospitals are supposed to provide outreach and education to their less specialized counterparts. 

There can also be costs involved: Facilities may have to spend money to get their capabilities up to a certain level, and some states charge a fee for certification. 

Dr. Rahul Gupta, chief medical and health officer for March of Dimes (which published the first standards on perinatal levels of care in 1976), said the only pushback he’s heard about these programs is from people who oppose regulations in general and think hospitals should self-report rather than undergo certification. 

“We do this for trauma, we do this for stroke, we do this for other areas," said Gupta, a former state health commissioner in West Virginia. "As we know, when you follow an evidence-based care, standardized approach across the country, not only do the outcomes get better, but your ZIP code doesn't define whether you're going to live or die after something like labor and delivery.”

Elaine Johnson-Merkel is the director of the Women and Children’s Pavilion at Porter Regional Hospital in Valparaiso, Indiana. She has worked in the field for more than three decades. She said that, if nothing else, the spotlight being put on her life’s work from these laws is “long overdue.” 

“Women’s health issues need to have the focus on and same kind of dollars spent supporting as, say, cancer and strokes,” she said. “This has definitely brought attention to women’s health disparities.”