BY JEN MILLER

The state of Missouri is ranked 44th in the United States for maternal mortality, according to America’s Health Rankings 2019. Missouri’s maternal mortality rate for black women is nearly three times higher than that for white women. And, according to the Missouri Foundation for Health, approximately 600 infants die every year in Missouri; 33% of those deaths occur in St. Louis and in the Bootheel, in the southeasternmost part of the state.

According to the Institute for Public Health at Washington University, “This represents an increase of 42.8%—from 28.5 to 40.7 deaths per 100,000 live births—since 2016.” Maternal mortality, and especially the racial disparity related to maternal mortality, is at the center of an urgent national conversation, says Roxane Rampersad, MD, maternal-fetal medicine specialist at the Women & Infants Center, a collaboration by Barnes-Jewish Hospital, Washington University Physicians and St. Louis Children’s Hospital. “We all know there are opportunities to try to tackle our morality rates.”

Rampersad and colleagues are addressing this complex problem with a variety of strategies, from implementing national initiatives to providing hands-on training in rural communities, where obstetric specialists are scarce and hospitals are closing.

Assessing the risk

Lack of obstetric care is the leading contributor to rising mortality rates, a fact that is especially true in Missouri’s more rural counties. In fact, rural hospitals are closing at alarming rates. The National Rural Health Association reports that, between 2010 and 2018, 100 rural U.S. hospitals shut down; another 700 are financially vulnerable and at risk for closure. Missouri and many southern Illinois counties have not been spared. For example: In 2018, the Twin Rivers Regional Medical Center, a 116-bed facility in Kennett, Missouri, Dunklin County, closed. Before this closing, Dunklin already had one of the highest neonatal mortality rates in Missouri, as well as the second-highest rate of infant deaths (occurring prior to the first birthday). In a story published in the online newspaper The Guardian, a local pediatrician noted that obstetric care in the area was so scarce that pregnant women often arrived at the hospital so far into labor that they delivered immediately after arrival or before, sometimes in the facility’s parking lot.

PREGNANCY DOESN’T END AFTER THE DELIVERY OF THE BABY. THE ‘FOURTH TRIMESTER’ COMES WITH SIGNIFICANT RISK. EXPANDING MEDICARE COVERAGE, WHICH WOULD AFFECT MEDICAID COVERAGE FOR PREGNANT WOMEN, COULD HELP SAVE LIVES.

Those scenarios aren’t uncommon, even when a rural hospital manages to keep its doors open to patients, says Janet Chandarlis, perinatal outreach coordinator at the Women & Infants Center, because many of those hospitals no longer have obstetric specialists or labor and delivery facilities. In communities and counties experiencing a strained health care system, she adds, obstetric and pediatric specialties are often the first to go. This kind of pressure can be caused by a number of factors, from limits in Medicaid reimbursement to low profit margins for hospitals and practicing physicians. Implementing new initiatives

Implementing new initiatives

To help address the problem, Missouri created the Pregnancy-Associated Mortality Review Board (PAMR), which reviews patient care and outcomes. Today, pregnant women insured through Medicaid receive reimbursed care for 60 days after delivery. Unfortunately, Rampersad notes, complications arising from labor and delivery can occur well past that 60-day limit, especially when new mothers have additional health issues such as hypertension or gestational diabetes. In fact, maternal mortality is defined as a pregnancy-related death that occurs during pregnancy and up to one year after delivery. “Pregnancy doesn’t end after the delivery of the baby,” Rampersad says. “The ‘fourth trimester’ comes with significant risk. Expanding Medicare coverage, which would affect Medicaid coverage for pregnant women, could help save lives.”

On another front, physicians and other health care professionals from Washington University School of Medicine and Barnes-Jewish Hospital are working to support existing rural hospitals, including those that no longer have a labor and delivery unit. Part of that effortincludes training onsite staff to manage common scenarios that can put mom and baby at risk: preterm birth, infection and genetic abnormalities for infants; hypertension and hemorrhage for women. But sometimes the best care means transferring a pregnant woman to a well-equipped hospital, where specialists are waiting. To that end, the Women & Infants Center offers emergency maternal-fetal and newborn transport services via ambulance, helicopter and fixed-wing aircraft. And the team provides telephone and telemedicine intervention to staff in outlying community hospitals. “We do receive a number of transfers from hospitals that don’t offer obstetrics care or don’t have providers who are prepared to manage and treat significant obstetrics complications,” says Rampersad.

Samuel Julian, MD, adds: “For those mothers and their babies to have the best outcomes, they need to be stabilized and transferred as soon as possible.” For this reason, Washington University School of Medicine, St. Louis Children’s Hospital and Barnes-Jewish Hospital offer training and educational sessions to hospitals throughout most of Missouri and Southern Illinois. Julian, a Washington University neonatologist, is director of outreach for St. Louis Children’s Hospital’s newborn intensive care unit.

The Women & Infants Center also has joined forces with community hospitals and the U.S. Centers for Disease Control and Prevention to implement the Alliance for Innovation on Maternal Health (AIM) program. Funded by the U.S. Department of Health and Human Services, AIM is a voluntary program that provides educational materials on a variety of relevant topics, from maternal mental health to obstetric hemorrhage, as well as tool kits that outline protocols for managing patient care and safety. AIM was launched in 2014; Missouri was accepted into the program in 2019. The first AIM initiative in the state will focus on pregnancy and hypertension.

To help address racial disparity in maternal mortality rates, the Women & Infants Center sponsors birthing classes for pregnant women, held in community hospitals and clinics, and it offers training to emergency-room physicians who treat pregnant women whose only resource for prenatal care may be a visit to the E.R. “The education we provide is designed to help make sure those patients aren’t forgotten,” Chandarlis says.

Simulation training

The Women & Infants Center also provides hands-on training for physicians working in community hospitals without labor and delivery specialists on staff. Many of the doctors and nurses in these hospitals “aren’t trained to deliver babies,” says Chandarlis. “They’re not trained to note signs of hemorrhage or to resuscitate a premature infant.” And emergency-room physicians often aren’t trained to perform an emergency cesarean birth, a situation that might render transfer to another hospital too late.

A robotic mannequin named Victoria facilitates the training. She is quite lifelike, programmed to open her eyes and track conversations. She can show symptoms of hypertension; she can exhibit signs of labor and delivery. She will register vital signs on a fetal monitor, and she can be used to practice C section techniques. And she can talk back. “Sometimes she gets sassy,” Chandarlis says.

While practice on a simulator—even one like Victoria— isn’t the same as the real thing, “it gives physicians and caregivers the opportunity to practice skills and processes,” Julian says. After a simulation session, the training team debriefs, discussing what went well and what could be improved. And this kind of simulation training isn’t one-and-done. The team returns for additional sessions, making each one a little more complex. If Victoria exhibits symptoms of hypertension in an initial session, she may experience eclampsia in the next and then progress to a seizure. The goal is to offer a range of experiences designed to help caregivers provide the best and most timely care.

The training team also visits community hospitals that do have labor and delivery units but they may, in such instances, work with E.R. staff who are frequently at the frontline of care. “A hospital might have an obstetrician on staff, but that specialist could be 30 minutes away,” Chanderlis notes. “Nurses in the emergency room may take care of those patients for the first 30 minutes. And those minutes can make all the difference in outcome.”

THE WOMEN & INFANTS CENTER OFFERS EMERGENCY MATERNAL-FETAL AND NEWBORN TRANSPORT SERVICES VIA AMBULANCE, HELICOPTER AND FIXED-WING AIRCRAFT.