Troubled Births

Until recently, Louisiana was steadily falling behind in important national reports, rankings, studies and analyses of health status and health systems performance. The National Center for Health Statistics ranked our state 49th nationally in infant mortality, preterm birth and the percentage of low birth weight and very low birth weight.

On top of the state’s poor birth outcomes sits the fact that Medicaid publicly finances almost 70 percent of Louisiana’s birthing costs due to the state’s high poverty levels – the highest percentage of Medicaid-financed births in the nation. In many hospitals throughout Louisiana, unnecessary Caesarean sections and inductions occur before the 40-week gestation period is over. Although some of these procedures are unavoidable, the majority are not needed, and overwhelming evidence shows that unnecessary Caesarean sections and inductions are harmful to both mothers and babies.

In addition to the risks these procedures pose by themselves, inductions and Caesarean sections increase the number of babies who are admitted into the neonatal intensive care unit, or NICU. This leads to increased costs for hospitals, as NICU care is an enormous driver of Medicaid costs.
There are 4.1 percent more Caesarean sections performed in Louisiana than the national average. Louisiana annually spends $4,000 Medicaid dollars on full-term vaginal births, compared to the $33,000 the state spends on premature babies (primarily due to Caesarean sections, NICU care and unnecessary inductions).

With nearly 7,000 premature births covered by the Medicaid program each year, the excess costs to Louisiana surpass $200 million.

Rebekah Gee

The Department of Health and Hospitals was determined to address this long-standing public health problem, and thus they began planning for the Birth Outcome Initiative, or BOI, in early 2010. The initiative was formally launched on Nov. 17, 2010 – Prematurity Awareness Day – in conjunction with the release of the March of Dimes 2010 Premature Birth Report Card. The March of Dimes report gave Louisiana a failing grade based on the state’s high preterm birth rate of 15.4 percent of births. In an attempt to better the health of mothers and babies, Louisiana was the first state to accept the March of Dimes challenge to reduce preterm births to 8 percent or less by 2014.

The BOI, led by Dr. Rebekah Gee, is working to encourage awareness and kick off important changes to meet this challenge and lower infant mortality rates. In addition to working with the BOI, Gee is an assistant professor of public health and obstetrics and gynecology at Louisiana State University.

“In my practice at LSU, where I deliver babies at Touro Hospital, I see women with some of the greatest challenges I have ever encountered,” Gee says. “Even though I trained in major cities like Boston, New York and Philadelphia, the extent of the social problems – whether drug use, chronic disease or stress – could not match what I see in Louisiana. But this is why our work here is so compelling; there are lots of problems with our social fabric. If we can’t at least get it right so that babies are starting off life with the best chance, they are falling behind and trying to catch up, or may never catch up, [and] we will stay at 49th in the nation. I know we can do better than that!”

According to the BOI’s Web site, “The Birth Outcomes Initiative is a targeted cross-departmental and cross-sector initiative to improve the outcomes of Louisiana’s births and health of Louisiana’s moms and babies.” Through quality improvements in Louisiana’s birthing hospitals, the BOI team envisions a healthier generation of women and children in the state.

On top of improving the health of Louisiana’s mothers and babies, the BOI team hopes to reduce Medicaid costs by encouraging at least 39 weeks of gestation, creating a safer environment for women and their babies and improving the quality of the state’s birthing hospitals.

“I am currently pregnant with twin girls – my first pregnancy – and being pregnant has made me truly understand how important health is prior to pregnancy as well as how important it is to carry a pregnancy as long as possible to ensure that babies are born with the best chance at life,” Gee says. “I also understand that pregnancy can be uncomfortable! But what are a few more weeks of discomfort for Mom if she can get to the full 39 weeks and give that baby the best shot for the rest of its life?  It seems like a trade-off that just makes sense.”

The BOI’s Web site reads: “Healthy babies start with healthy mothers. The health of a woman is [composed] of more than her prenatal and delivery experience. Current evidence recognizes birth outcomes as the end product of not only the nine months of pregnancy but the entire life course of the mother before the pregnancy.”

According to the BOI, other states that have put in the effort to improve their birth outcomes have succeeded greatly. Wisconsin; Florida; and Washington, D.C., have all successfully implemented programs to improve the health and well-being of women in their child-bearing years and lower neonatal and infant mortality rates.

“Louisiana could be among the first states to have a statewide quality collaborative with the goal of implementing successful 39-week policies and reducing neonatal harm,” the BOI team says on its Web site. “This quality improvement initiative puts Louisiana in a national leadership position at a time when multiple other organizations including the American College of Obstetricians and Gynecologists, the March of Dimes and the American Academy of Pediatrics have all prioritized this issue. … NICU quality must be addressed. Systems are designed to produce the outcomes they achieve, and with Louisiana ranked 49th in the nation on neonatal quality metrics like infant mortality, the system must be changed if we are to expect better outcomes.”

As explained at the 2011 Family Impact Seminar, our state must take on many challenges headfirst to improve birth outcomes, which include “improved care coordination and preconception health, improvements in the measurement of birth outcomes, improvements in patient safety and quality, addressing the maternal and infant health disparities in birth outcomes and addressing the behavioral health needs of pregnant women.” DHH is now asking hospitals throughout Louisiana to avoid the delivery of any infant prior to 39 weeks gestation unless the hospital deems it to be medically necessary. This, in turn, will reduce NICU admissions and other early birth complications, thus improving birth outcomes and reducing Medicaid costs.

The BOI team holds the high goal of improving the quality and safety of Louisiana’s birthing hospitals while reducing Medicaid costs, but the team’s ambitions don’t stop there. They also hope to improve the state’s pre- and post-pregnancy resources for new mothers, particularly those who live in poverty.

Finding a Way

While prenatal care is a hugely important aspect of birthing healthy babies, it is often too little, too late to improve the actual birth outcomes. As explained at the 2011 Family Impact Seminar, some of the most vital events in the life of the developing embryo happen at three to four weeks post-conception. This poses an enormous problem because many women do not even recognize they are pregnant at this point.

As opposed to only caring for women once they know they are pregnant, the Birth Outcomes Initiative believes that finding a way to care for reproductive-age women is hugely important to Louisiana’s health care system. Preconception care is cost-effective, and initiatives are now in place in order to teach women, particularly those who live in poverty, to take care of themselves.

Dr. Michael C. Lu, who also holds a master’s of public health degree and is the associate director of the Child and Family Health Training Program at the University of California in Los Angeles, said at the Family Impact Seminar: “For decades we have searched for maternal risk factors during pregnancy rather than looking at the mothers’ cumulative life course experiences. The danger of focusing solely on risk factors during pregnancy is not only that it doesn’t adequately explain the disparities, but more importantly it can misguide public health programs and policies. For two decades we thought if we could get women universal access to good quality prenatal care, then we can do something about reducing infant mortality and racial disparities in this country.

Many of us recognize now that to expect prenatal care in less than nine months to reverse all the cumulative disadvantages and inequities over the life course of the woman may be expecting too much of prenatal care. If we are serious about improving birth outcomes and reducing disparities, we have to start taking care of women and families not only during pregnancy but before and between pregnancies and indeed, across their entire life course.”

Louisiana is now the only state in the nation with a statewide, all-encompassing Birth Outcomes Initiative. By 2014, Louisiana’s Medicaid population will have the largest proportional expansion in the nation and will set the bar much higher for Louisiana’s standard of care. Currently, women in Louisiana lose Medicaid coverage 60 days after their baby is born; however, in the next two years, these women will receive ongoing coverage. Women in the Greater New Orleans area are now eligible for an inter-pregnancy program, which includes screening for such health risks as smoking, alcohol and drug use as well as violence against women.

In addition to this, all 58 delivery hospitals in Louisiana have now promised to end the practice of elective deliveries before 39 weeks. This means that women will have the assurance that if a doctor recommends they deliver early, there will be a reason for it. By expanding the health care needs of women in their reproductive years, Louisiana’s BOI is assessing the needs of women and their babies to achieve better birth outcomes and give way to a healthier generation of Louisiana women.

Since the BOI’s launch, Gee says that hospitals in Louisiana have already seen 20 to 40 percent reductions in the number of babies admitted to NICUs in several hospitals in our state, “meaning that instead of spending the first weeks of life in a plastic box hooked up to tubes, babies are going home with Mom and Dad and in better health.”

“Nothing is more important to the future of Louisiana than a healthy next generation,” Gee says. “I am passionate about improving women’s health and children’s health. It is unacceptable that our state has rates that rival developing countries in terms of babies born too early, babies who die in the first year of life and moms that have severe health problems that go untreated. I think that a society should be measured partly by how we deal with these issues and care for those who are most vulnerable. Without fixing some of these problems, the future of our state is at risk. Data tell us that prematurity leads to a whole host of social problems, both physical disabilities and learning disabilities – and even increased crime. Prevention is always better than treating a problem, and even though we all face challenges, I want every Louisianian to start life the healthiest possible.”