Improving Access to Risk-Appropriate Care Through a Partnership Between Obstetrics and Gynecology and Pediatrics

Some answers have been edited for clarity.

What is risk appropriate care and how does it relate to maternal and infant mortality?

CHRISTOPHER ZAHN:
Risk appropriate care actually has several definitions. One is a strategy to improve perinatal health by organizing the personnel and services capable of meeting the needs. There is another definition that describes a coordinated tiered system designed to ensure that obstetric and neonatal patients are provided care facilities with the most appropriate equipment and staff.

Again, there's other variations; but essentially, it's basically care at the right place at the right time. It involves having the right people and the right equipment and materials to meet the patient's needs and escalating needs of complexity. But it also involves anticipation of needing—you need to be aware and then have the recognition such that, when escalated care is indicated, that the patient is recognized and gets the care at the right place, at the right time, at the most appropriate facility.

In regards to the relation to maternal morbidity and mortality, delivering the care at the right place in the right time is absolutely critical. Again, with that awareness, anticipation, and utilization of the appropriate personnel and equipment to reduce morbidity and mortality because the facility would have the resources necessary to take care of those very potentially, very complex patients. I think a great example of this is placenta accreta syndrome, where clearly there is a significant demand on personnel, the availability of blood and well-stocked blood bank, etc., again to take care of these very complex patients.

As far as levels of care, this is a tiered system of care that matches patient needs with the equipment and personnel as described. This concept was originally developed in 1976 and actually started to develop at that time for neonatal care. And neonatal care levels were well established, but it never really gained ground related to maternal care until really the past few years.

But levels of care does define a minimum set of facility capabilities, including personnel and services to meet that need. It is an escalating system, so there's a greater degree of specialists and subspecialists, as well as available equipment and resources to meet the greater degree of complexity as you increase the levels.

It is really, I think, important to acknowledge that prior to levels of care, particularly levels of maternal care—again, because that's more recent—there was really no system by which a facility could assess what they could do and, maybe even more importantly, what they shouldn't do in order to provide care, particularly for more complex patients. So it really provided that framework to give facilities with the ability to determine, again, what's appropriate for them to take care of. And again, more importantly, what's appropriate for another facility with a greater degree of resources to be able to care for.

WANDA BARFIELD:
There are several definitions, but that it really is a tiered system of care that provides the right care at the right time, the right place with the right team. And I think it's so important for us to think about how pediatricians and obstetrician-gynecologists work together in this system of care.

And I think also, as you alluded to, for quite some time neonatal levels of care had been relatively well-defined, mostly because of a maybe more objective measure of birth weight and gestational age. But the challenge that we've seen is, one, the importance of noting that mothers and babies are couplets, and that their care is often intermingled, and the consequences may also be impacted as such as well, and how do we think about systems where we're providing the best care for both? And I think that's a really important idea that we're seeing now with both maternal and neonatal levels of care. Granted, they each may have their own distinct complications and needs, but it is also very important for us to work together to coordinate the care so that there are the best outcomes possible for both.

And as you alluded to, neonatal levels of care go from a more baseline level in terms of those with relatively healthy outcomes to higher levels, which includes subspecialty care and resources to care for the most complex infants.

But I think another thing that we also need to take into consideration, which is an important issue for ASTHO, is how do public health organizations play a role in terms of helping to support systems of risk appropriate care. CDC has a tool called the Levels of Care Tool, or LOCATe, and this is a way that helps to identify appropriate resources and capabilities in alignment with both maternal and neonatal levels of care to better assess facilities, needs, and capabilities.

And I think one of the other important pieces is how do we plan in advance in order to anticipate the needs, whether it's within a system or a region, and how do obstetrician- gynecologists and pediatricians not only communicate within facilities but across facilities to provide a system of care that supports moms and babies.

What are some best practices when it comes to maternal and neonatal transport while supporting the best equitable health outcomes for mother and baby?

BARFIELD:
So the best opportunities, in terms of thinking about maternal and neonatal transport—a transport that involves transporting with mom and baby together is the most ideal in terms of opportunities, not only for making sure that stability can occur while baby is still in utero but also the opportunity to make sure that moms and babies are together.

In a study that we did, which was a systematic review of the evidence on risk appropriate care, we found that there was a 60% increase odds for infants who were born outside of a level three or higher facility. So delivery and transport doesn't necessarily transfer into ideal outcomes for the baby. There's an important need for stabilization and support for critically ill newborns that really relate to rapid time and resources available. And being able to ideally transport a baby in utero is the best.

ZAHN:
So I think related to transport, I think the first most important step is to know your capabilities. You have to sort of follow a song, when to hold them and when to fold them. You've got to know what you have available to you to be able to determine who you need to transport.

Related to that is the awareness and recognition of escalating complexity. The best time to do it is to think proactively and not reacting when a patient is already too serious to be able to transport.

And third, it's really important to have a system in place. There's nothing more discomforting than recognizing the need to transfer a patient, picking up the phone, and then you have no idea who to call. Or you get through, but the phone gets passed around or you're put on hold. So this requires setting up a regionalized system proactively, which then requires outreach and communication between higher- and lower-level facilities to foster that communication and a process for that. And actually, in the levels of maternal care, it's a requirement that level three and four facilities actually provide outreach to create these systems to lower-level facilities.

The best practice is to have an established protocol so it's clearly written down or clearly known who to call, when to call, so that someone will be there. And so that there's a process in place for reporting and transfer documentation with all the appropriate and applicable information to go with the patient.

I think it's also critical that a review is required from a quality improvement perspective where transports are reviewed to make sure they're appropriately, efficiently, and effectively done, but also to review adverse outcomes internally to determine if transport would have been indicated and could have been applied.

I think another key feature is back transport and reporting. It's really important to keep families together to improve bonding, to allow the support system that the patient has to be implemented. It's a far more efficient use of resources. It costs less money. So that back transport thing often really doesn't get a whole lot of attention, but it's a really important aspect. And it's also important that that information gets included in the patient's record for their own health. For example, knowing that patients with pre-eclampsia are at higher risk of chronic hypertension, that the patient's primary provider understands that and can follow that. But it's also important to recognize in the records for future pregnancies, because if there are risk factors for adverse outcomes in that future pregnancy that that's identified and recognized before that pregnancy ever occurs.

State policies are also helpful to support transport. There was a study by Dr. Carla DeSisto from the CDC and colleagues published last year. It's a really good resource that talks about transport policies and state support of those. When you're talking about equitable access, clearly funding is an important aspect. Funding is definitely recognized as a barrier to transport, so that's key. Regulation, although oftentimes we look at regulation as being a negative influence, but it can help reinforce implementation. But it's also important that it's not an unfunded mandate, that it really does tie in the funding.

Getting back to the process, it's really important that there's adequate time and support for personnel to administer and oversee the system. It can't be an add on to someone who already has a full plate, but there really needs to be dedicated time necessary to develop an administrative program. Some systems have dedicated transport managers, so it's a single point of contact to allow it to occur.

It's really, really important to support a system being developed and also to remove barriers that are in place. So, some of the economic considerations about levels of care and transport are really critical. It makes no sense to transport a patient to a level four hospital 300 miles away because they're in the same health system when there is a level four in a different system, but it's only 25 miles away. We've got to overcome the economic barriers as well as punitive and restrictive policies. Tor example, with substance use disorder, we cannot have policies in place that limit recognition or indicated interventions that may require transport. So, a number of things to work through when considering appropriate transport policies.

How can OBGYNs and Pediatrics ensure equitable access to risk appropriate care for pregnant, postpartum, and parenting individuals, as well as their babies?

ZAHN:
Punitive policies—whether they're economic, whether they’re things such as restricting interventions for substance use disorder, or other policies—all of those provide barriers to effective use of levels of care, as well as transport, so it's really critical that we overcome some of those barriers.

As Dr. Barfield mentioned, that coordination and collaboration between OBGYNs and Pediatrics is critical because it is a dyad that we take care of. And it's very important that that occurs both at the society level but also at the level of the individual clinicians caring for these patients. And again, coordinating the care as appropriate for the dyad.

With that, I think we have to recognize that, although you have to look at the dyad and coordinate, you really need to consider each part of the dyad independently to some degree. Because you have to look at the maternal conditions and risks, but you also have to look at the neonate and the potential fetal indications and the risk. And I think the best way to frame this is to use an example.

So you could have a “normal” mom—totally normal pregnancy, no issues, no complexity—but the fetus might have a significant cardiac anomaly. The mother may only require a level one facility for her care, but the neonate would likely require delivery at a high level, making it either a level three or four, because of immediate post-delivery care that may be necessary.

On the flip side, you could have a mother with a corrected but significant congenital heart abnormality, but a normally developed and growing fetus. That neonate may not require any NICU care at all, but the mother would likely require at least level three and possible level four for maternal care due to her underlying cardiac disease.

So again, you have to look at each component in that dyad to make sure that that care is meeting the needs of whatever is needed for the most complicated patient.

BARFIELD:
Yes, Dr. Zahn, I think you bring up some really important points. And it is important for us to understand that we cannot stigmatize families based on substance use disorders or certain diseases as we try to provide the best care possible for mothers and babies. And it's also important for us to think about facilities that might also offer better opportunities in terms of nonpharmacologic care and interventions. For example, the appropriate use of rooming-in or Eat, Sleep, Console as an approach as babies may transition through neonatal opiate withdrawal syndrome, and giving the opportunity for mothers to spend time with their babies as well.

I think also in terms of thinking about how we continue to educate at these different levels of care is also very important. Level three and four facilities also play an important role in educating communities around the care that's being provided so that they are better prepared in the future and so that they also learn to identify certain scenarios which may need additional support.

We also have an opportunity in this coordination to also think about broader models because levels of care and risk appropriate care can also apply not only when individual patients have certain needs, but when we think about populations—for example, in the context of disaster and emergency preparedness. So these systems also work incredibly well in terms of making sure we have a system of communication and we know what the respective capabilities are within a geographic region.

How does the partnership between OBGYNs and Pediatrics promote equitable and respectful maternal and infant care and treatment?

BARFIELD:
We do know that, both for moms and babies, care is not always equitable and we really need to think about ways to provide care equitably for both mom and babies. And risk appropriate care does provide that opportunity when we really think about ways to provide the best care, the right care at the right place for moms and babies in need.

But we really have to think about things systematically. And again, thinking about maybe even our biases that may impact the way that patients are being cared for, can also impact their health in terms of whether their care is risk appropriate. So it's important for us to really identify where we may see differences in terms of transportation and support so that we're making sure that we're providing care most equitably. And risk appropriate care, again, focuses on clinical conditions in circumstances in which further support is needed. So it's really important for us to think about ways that we can address that more appropriately.

ZAHN:
Thank you, Dr. Barfield. I really don't have much to add to that. I do think one of the things—particularly around transport and levels of care that relates specifically to equitable access and health equity—is we recognize that some populations have greater risk of adverse outcomes, such as preterm delivery and hypertensive disease, certainly for adverse potential adverse outcomes for maternal care. So recognizing and transporting these patients is indicated—providing, again, optimizing the care at the appropriate place at the appropriate time with well-developed transport systems could really help address some of the health equity issues and disparities in outcomes by ensuring that these patients can access appropriate facilities and receive optimized risk appropriate care.

Again, I can't emphasize enough the importance of awareness and recognition so the patient can be transported in a timely fashion to the facility that can provide the best care. But again, that is an absolutely critical part, and I think that that does improve with the coordination and the collaboration between obstetric-clinicians as well as the pediatric operations.

How can state health organizations and agencies support these partnerships to improve equitable access to risk appropriate care?

ZAHN:
Well, I think the first aspect is helping to make the connections that help to foster the regionalization aspect or consideration, fostering the communication and collaboration between OBGYNs and the pediatricians and as well as the community health resources that might be available. It also helps to foster the collaboration and communication between the higher- and lower-level facilities, and support that necessary outreach that's so critical to connect the facilities together and to support a regionalized network.

Advocating for funding is clearly an important aspect. As I mentioned before, funding is recognized as a barrier, particularly when it comes to transport. So any advocacy that can be done to support funding is important.

I think the states and the systems can assist in a perinatal quality collaborative process—which can also help drive regionalization and implementation of levels of care, as well as advocacy to the regions, the systems, the states, the people within those systems—to help emphasize the importance of levels of care and why it is beneficial in addressing the health needs of patients, as well as assisting in education of local facilities’ personnel about the importance of regionalization. You don't know what you don't know; so for the people that haven't heard anything about it or don't understand what the potential benefits are, it's really important to get that education and information.

I think it's also important that the states and the systems can assist in patient or family support, particularly for long distance transports and extended time of family separation. I think state systems and community-based resources can really help in that area.

But with all of that, I want to acknowledge and we greatly appreciate all the support ASTHO and everyone affiliated with ASTHO has provided and the continued advocacy and support for implementation of levels of care. We very much appreciate that. We know this is relatively new, certainly in the maternal space, and we really appreciate all the support that you've given us. Thank you.

BARFIELD:
Yes, I would like to just second Dr. Zahn’s thanks for the work that ASTHO does in terms of the work in risk appropriate care. I think we all understand that these are systems of care that really do need support so that we can provide the best care for moms and babies, and it does include supporting our smaller, lower-level facilities.

We know that these facilities are really key to providing care in many rural communities, and we want to make sure that we're also prepared in the context of emergencies. And state official health officials play such a critical role not only in trying to help support the whole system of care, but also thinking about the data that may inform where outcomes may be disparate. And so, in collaboration with state health officials, there really has been the opportunity to improve our understanding of risk appropriate care as jurisdictions look at their landscape of care to make sure that babies and moms are getting the best care that's possible.

So we need to think about these solutions. And they may, of course, vary by jurisdiction, and that's where state health officials play such an important role in understanding the landscape of care that may be available in particular areas. So it's really important for us to think about risk appropriate care as not just an individual practitioner, individual facility, but really a system of care that involves many members—whether they're clinical, public health, and broader, as well as community. So again, thanks, ASTHO, for the work that you're continuing to do to improve care to moms and babies.