Perinatal Statistics: Small Lives Matter

03/01/2016

Healthy Living - March 1, 2016
William Sturrock, MD

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Lost in the past months news cycle with the distraction caused by the Zika virus and the presidential wrestling matches was a very important report from the CDC that the most recent infant mortality statistics now show favorable 2.3% decrease down to 582 deaths per 100,000 live births. Although this is the lowest recorded US infant mortality rate, an article in the February 2 Journal of the American Medical Association (JAMA) tried to put this into perspective -- we are still lagging way behind all other industrialized countries at 26th place.  Another way of looking at our rates is to examine the results that are perennially obtained by the leaders in this important measure of obstetric and pediatric outcomes: this year Finland had the best statistics with a rate of 180 deaths per 100,000 births…In brief, we have a long way to go!

The authors of the JAMA report provide an excellent analysis of our shortcomings in this area of medicine.  It does not come from spending less – we consistently are at the top of the pack for per capita health costs. Nor does it come from a lack of high tech equipment and intensive care specialists for our neonates. Again we lead the world in NICU beds and number of specialists to care for our most vulnerable patients. It also has nothing to do with Obamacare since our dismal performance in this arena long predates the minor changes made with the Affordable Care Act.  Instead, the authors believe the ‘uncomfortable’ truth lies in the very structure of our health care system that does not provide the seamless, coordinated care for our pregnant patients that is possible in other healthcare systems.

The largest driver of poor outcomes in this area is the very high percentage of US pregnancies that have the complication of premature labor and result in the delivery of an infant unprepared to live outside the womb. To compound matters, the highest percentage of pregnancies with this outcome occurs in our underserved, immigrant, and inner-city communities – politely described as our ‘communities of color’. Access to healthcare in these communities remains a very large problem, with many women of childbearing age having significant barriers both financial and geographic that impede them from receiving the prenatal care necessary to prevent these bad outcomes.

 In countries like Finland that are the leaders in this measurement of healthcare quality,  doctor’s offices and clinics are better distributed , and in closer proximity to the high risk populations.  Also, there is a higher degree of coordination of care between primary care providers and the high-risk pregnancy specialists that work in the medical centers. As an example on how these factors work to influence pregnancy outcomes, let’s examine how the treatment of urinary tract infections (UTI), which are a known reversible cause of preterm labor, differs in the US compared to most European countries. Unlike in the US, every primary care office in Finland welcomes pregnant patients, and someone with early signs of infection would not need to drive herself or get a ride to some distant hospital to get seen. Also, all clinics and hospitals use the same electronic medical record so that if there was a question about the best treatment for that woman with the UTI symptoms, the providers in the neighborhood clinic can get an immediate ‘consult’ with the obstetrician at the nearest  high-risk center. Finally the medication necessary to prevent the preterm labor would be either free or very affordable, and usually dispensed right at the clinic site to insure quick compliance with the needed treatment.

Obviously we are a long way from having such a ‘patient-friendly’ process in the US.  There are many obstacles to having such a system which include:  
1)    Liability costs which prevent local clinics from seeing pregnant women
2)     Lack of any system to ‘distribute’ medical resources, especially to communities at risk
3)    Lack of incentives to encourage providers to work  together for these patients, instead insurance will not pay for the services of the high-risk obstetrician unless the patient physically goes to that providers site
4)    An electronic medical record that is still in its infancy,  with multiple  proprietary systems that do not ‘talk’ to each other
5)    A checkerboard pharmaceutical system with differing co-pays and preferred medications for everyone depending on their  insurance category

It was not the intention of the authors of this report to make suggestions on real reforms that could address our challenges in the delivery of quality perinatal care. However, as we progress in an election cycle, it may be important to recognize that we do not have the ‘best medical system in the world’ particularly for our more vulnerable communities and small patients. With this admission, we are at least more prepared to have an honest and thoughtful conversation about how we can improve and do the right thing for all lives, the big and the small.