maternal morbidity

Pregnancy Medical Home Program for Mamas on Bedrest?…

August 17th, 2011

Not yet, but they would surely be a welcome addition to high risk pregnancy care.

The Pregnancy Medical Home Program is a program initiated in North Carolina that links payment incentives to prenatal care services-specifically those services and treatments shown to lower the incidence of premature birth and that lower maternal and infant morbidity and mortality.  The program currently targets providers who care for women who are eligible for Medicaid.

The maternal mortality rate in the United States is abysmal and is far higher than most European Countries.  According to statistics presented in a recent blog by Lee Partridge, Senior Health Policy advisor for the National Partnership for Women and Families,

In 1990 in the United States, 343 women died in childbirth; by 2007 that number had increased to 548.  A report released July 6 by the National Institute of Child Health and Human Development documents some progress on reducing the incidence of preterm birth, down from 12.8 percent in 2006 to 12.2 percent in 2009.  But that rate is still woefully behind the U.S. Healthy People 2010 target of 7.6 percent of all live births.

To date, little has been done that has had a significant impact on these statistics. With the Pregnancy Medical Home Program North Carolina hopes to reverse these turn statistics and turn the tide on maternal and infant mortality.

As previously stated, the Pregnancy Medical Home Program is an incentive program. Providers who wish to become Pregnancy Medical Home Centers agree to provide specific services and treatment during the perinatal period and in exchange, they will receive additional reimbursement, incentives, from Medicaid. The requirements and incentives are briefly outlined in the brochure put out by Community Care of North Carolina, the network of organizations that developed the program.  But the aforementioned blog from the National Partnership for Women and Families gives a very good 4 point summary of the program:

Maternity care providers – obstetricians, family practitioners, nurse midwives, community clinics – can apply to be designated as a Pregnancy Medical Home.  They must agree to do four things:

  1. At the first obstetric visit, administer a standardized pregnancy risk tool that provides not only clinical health history but other information about the woman and her situation that could indicate she is at risk of a poor outcome.  The questions include poor nutrition, smoking status, use of alcohol or possible physical violence.   If a women looks like a high risk, the provider must contact his or her CCNC network and arrange for care management services for that patient throughout her pregnancy.  The provider and patient also develop a plan for managing her care.
  2. Ensure that none of the providers in the Pregnancy Medical Home perform “elective” deliveries – deliveries for which there is no medical reason to induce labor — prior to 39 weeks of gestation.  Early deliveries increase the likelihood of infant death, admission to a Neonatal Intensive Care Unit, or life-long health problems for the child.
  3. Provide the drug 17 alpha hydroxyprogesterone caproate (commonly called 17P) to patients at risk of preterm delivery.
  4. Aim for a caesarean-section rate for low-risk, singleton births below 20 percent.  C-sections expose both mother and child to surgical risk and possible infection, and can create complications for future pregnancies.

The program offers providers an additional $200/patient over and above the normal maternity fees to participate in the program. They receive the first $50 once they complete the initial pregnancy risk tool. The final $150 is paid after a woman has her final post partum visit which must include screening for depression, reproductive health and family planning and any referrals for ongoing care if necessary. 

This is an amazing program! While I can appreciate the strategy of attacking the problem of maternal and infant morbidity and mortality in those who are often most vulnerable, women of low income and limited means/resources, I really wish that there had been at least a small portion of the program allotted to high risk pregnancy. I don’t really think that it would necessarily have to change the reimbursement incentives, but to include some provisions/requirements for care for women who do become high risk and require bed rest would have been nice. How about making sure that they have adequate resources for childcare of their existing children? How about at least asking if they are in danger of losing their jobs and assisting them to find resources to make ends meet? How about stress reduction? Maintaining physical strength and endurance while on bed rest? Okay, I am going a little bit off on a tangent, but once again I feel that high risk pregnancy and mamas on bed rest have been overlooked.

But there is a silver lining to this perceived dark cloud. This is the first program of its kind in this country. Other states are following. (See Washington State’s program here.) As a model, its not bad. Hopefully, as other states adopt and tweek the program for their citizens, they will remember the mamas on bed rest, at home (or in the hospital) silently waiting for help and assistance.

What would you add to the Pregnancy Home Program if you were to adapt it for Mamas on Bedrest? Share your comments below.

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Mamas on Bedrest: Follow Up on Gestational Diabetes

February 9th, 2011

This podcast discusses recent findings published in the January 30, 2011 Wall Street Journal. Columnist Lauran Neergaard reported on a study supported by Quest Diagnostics which found that women diagnosed with gestational diabetes mellitus are at increased risk for developing Type II diabetes later in life. However, these very women very often don’t have adequate follow up blood sugar screenings in the immediate post partum or throughout their lives. The implications of this oversight is discussed and follow up screening for women who had gestational diabetes mellitus is encouraged.