Saving Newborns by Changing the Delivery System

By Rachel Kremen

Charlene Collier
Charlene Collier, MD, MPH, MHS, from the Mississippi State Department of Health speaks at the Infant Mortality Summits in July 2014

Reducing infant mortality isn’t just a matter of treating a patient’s medical problems. Treating the medical system can have a significant impact, too. That’s why the Mississippi team from the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN) is working to create systemic change.

The Mississippi team is made up of social workers, nurses, vital statistics analysts and public health professionals from the state health department, as well as staff from the March of Dimes, the Mississippi Hospital Association and clinicians. The team set out to tackle two key challenges: establishing regulations regarding which hospitals should deliver high-risk, premature infants and promoting a program that helps hospitals establish policies that discourage early elective deliveries.

Providing the right care for high-risk babies
Charlene Collier, MD, MPH, MHS, perinatal health research and policy consultant at the Mississippi State Department of Health and director of Mississippi’s IM CoIIN team, says complications related to pre-term birth are a major factor in the state’s infant mortality rate and such high-risk babies should, ideally, be born in a hospital with a Level 3 Neonatal Intensive Care Unit (NICU), because such facilities have the required specialized staff and equipment. 

“It is important for us to make sure that we can provide the (Level 3) care that we know can increase survival, for those babies that need it,” says Collier.

Unfortunately, high-risk deliveries sometimes happen outside of Level 3 NICUs, and some infants are never transferred to an appropriate setting, Collier says. Even when it’s obvious well before delivery that a baby is likely to be born prematurely, some doctors do not advise patients to deliver at a Level 3 facility, because of the competitive nature of for-profit hospitals and a lack of regulation in Mississippi. Some hospitals without a Level 3 NICU still opt to deliver their high-risk patients, wrongly believing that they have the necessary skills and equipment, according to Collier.

It’s a tricky subject to discuss, Collier says, because while there is strong data to support the idea that high-risk infants do better at Level 3 facilities in general, there is no data to show whether this is true in Mississippi in particular. Moreover, laws enacted decades ago to assess whether a NICU should have Level 3 status did not affect those NICUs that were already established. Only new NICUs had to be assessed.

As part of the IM CoIIN, Collier brought the Mississippi team together to discuss the issue. Ultimately, the state health plan was updated to include the need to evaluate hospitals on an ongoing basis for perinatal levels of care, including both neonatal and maternal care. The team recommended that all hospitals participate in the Vermont Oxford Network (VON), which has the largest NICU reporting database in the country. “All of our hospitals that are likely Level 3 are now enrolled,” Collier says, so the next report from VON will provide a reasonable estimate of the state’s Level 3 capacity. That data will help her team find additional ways to reduce infant mortality, she says.

Discouraging early elective deliveries
The Mississippi team also implemented another systems change promoting the 39-Week State Pledge and Banner Program, which helps hospitals establish policies that discourage early elective deliveries.

“In essence, a (participating) provider cannot schedule a delivery before 39 weeks unless it goes through a review process,” explains Elaine Fitzgerald, project director for NICHQ’s IM CoIIN. “This creates a culture change in the institution, instilling the value that scheduled deliveries before 39 weeks are not encouraged without medical or obstetrical need.”

It also gives providers the support of their institution to emphasize the health benefits of delaying elective deliveries prior to 39 weeks when requested by their patients, Fitzgerald says. Doctors can point out that the system simply doesn’t allow for such a request. If the hospital is able to reduce the number of elective deliveries to 5 percent, it earns a banner from the March of Dimes, and the health department promotes the achievement as a part of the 39-Week program.

Not all Mississippi hospitals were ready to make such a substantial change. But at a minimum, Collier wanted hospitals to pledge to try to meet the target. Most of the hospitals have now taken the pledge, and at least 10 have submitted the data to prove they met the 5 percent goal. Collier says early elective deliveries are down from 18 to 11 percent for the state, from the beginning of 2012 to the second quarter of 2014. 

Collier is still participating in IM CoIIN and has learned a lot about implementing effective change. She says hearing from people in other areas dealing with similar challenges and how they are addressing them has been a highlight of the initiative. “Leaning on each other for resources, and just connecting people through virtual meetings has been a great experience.”