Though efforts have been made to support women before, during, and after pregnancy, the number of OB-GYNs and obstetricians is steadily declining across the state. New research has revealed the most drastic increase in child and adolescent mortality rates in nearly half a century. Recent trends reveal an urgent need to address the underlying causes of these crises and a change in practice to enhance the health outcomes for mothers and their children.
According to the March of Dimes, a maternity care desert is “any county in the United States without a hospital or birth center offering obstetric care and without any obstetric providers.” In their recent report, the March of Dimes reported that 1,119 (36%) counties nationwide are defined as maternity care deserts. Areas with low or no access affect up to 6.9 million women and 500,000 births across the U.S.
Thirty-seven of Arkansas’ 75 counties are considered maternity care deserts. From 2018–2020, Arkansas had the highest mortality rate in the nation, with 40.4 deaths per 1,000 women, according to the Centers for Disease Control and Prevention. Additional CDC data from 2020 confirmed that Arkansas had the third-highest infant mortality rate at 7.38 deaths per 1,000 live births, an increase from 2019’s rate of 7.0 per 1,000 live births.
37 of Arkansas' 75 counties are considered maternity care deserts. That's just under 50% of the counties.
Most pregnancy-related deaths are preventable, but in rural areas, where women struggle to access care, preventing maternal and infant mortality can be challenging. Today, many Arkansas women lose Medicaid coverage just two months after giving birth. Women in rural counties experience a much harder time transitioning to other means of coverage, causing an even greater gap in care.
Health care organizations across the state have begun implementing measures to reduce maternal mortality. The University of Arkansas for Medical Sciences (UAMS) has been a statewide leader in promoting efforts to reduce maternal mortality. Their High-Risk Pregnancy Program uses telemedicine to offer consultations with board-certified experts and educational courses/simulations for nurses and doctors in the field. Tina Pennington, Clinical Services Manager at the UAMS Institute for Digital Health & Innovation, explains the initiatives UAMS has taken to address infant and maternal mortality statewide.
UAMS’s High-Risk Pregnancy Program is a conglomerate of several training programs for neonatologists, obstetricians, gynecologists and their patients. The Perinatal Outcomes Workgroup Education and Research (POWER) team was founded in 2016 to “get the 37 delivering hospitals in the state involved in inpatient emergency education,” Tina says. The POWER team meets once per month virtually and once per year in person to discuss current topics and provide one another with education and guidance. In their most recent in-person meeting on April 18 (the first since before the pandemic), there were 98 attendees representing 31 of Arkansas’ 37 delivering hospitals. “The in-person meetings allow us to get to know each other and let people know that they’re not alone in dealing with these high-stakes situations,” Tina says.
Online simulations of safety scenarios provide a more hands-on approach to neonatal education. Through the Obstetrics Emergency Drill Simulation, attendees take a didactic course online. Then the POWER team travels to one of the state’s 37 delivering hospitals to provide Obstetrics Emergency In Situ Simulation Drills. “Since the attendees have already finished the course online,” Tina says, “when we get there, it’s more hands-on. Participants can practice in their own hospital settings using their own equipment and processes.” Each participant has their own role in the simulation, just as they would in a real-life scenario. “We travel around with a life-sized mannequin who actually gives birth to a baby and yells and screams when she’s pushing,” she says. The mannequin can also mimic symptoms of a seizure or other critical health conditions that keep the participants on their toes.
Neonatal Resuscitation Program
Tina leads the Neonatal Resuscitation Program (NRP), a national program through the American Academy of Pediatrics where participants must use cognitive, technical, and teamwork skills to resuscitate and stabilize newborns. Participants again complete exercises online before Tina’s team comes to a facility to assist with the simulation portion, which usually involves simulating a distressed neonate immediately following birth. “Each delivering hospital must participate in the NRP. Many hospitals don’t have the experience to have an instructor, so I actually instruct the on-site program,” Tina says. “In FFY 2022 – 2023, I have instructed 156 participants in 26 classes across the state.”
The UAMS Institute for Digital Health and Innovation also offers S.T.A.B.L.E. classes to delivery facilities in Arkansas to promote standardization of care and improve outcomes for infants needing transport to a higher level of care. S.T.A.B.L.E. is a mnemonic for Sugar, Temperature, Airways, Blood Pressure, Lab, and Emotional Support, which are all post-resuscitation/pre-transport stabilization procedures to perform while waiting on the transport team. “You can get a head start on x-rays, interpreting labs, assessing blood sugar levels, temperature, blood pressure, and all of these things so that when the transport team arrives, they don’t have to go through these processes. You’ve already done them,” Tina says. “The S.T.A.B.L.E. class provides a standardized procedure for what to do while you wait for help to arrive.”
Through the S.T.A.B.L.E. classes, you can learn how to get a head start on x-rays, interpreting labs, assessing blood sugar levels, temperature, blood pressure, etc. so that the transport team will not have to do it when they arrive.
Fetal Monitoring Courses
The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) fetal heart monitoring courses administered by the UAMS Institute for Digital Health & Innovation are directed toward doctors and nurses in the delivering hospitals. “These courses teach you how to read the mother’s and baby’s heart monitors. By interpreting the data on the device, you can determine the intensity of a mother’s contractions and monitor her labor progression,” Tina says. “The fetal monitoring courses offer another tool to use in your toolbox so that, when the baby or mother is in distress, you can recognize the signs and respond appropriately.”
AIM Safety Bundles
Tina’s team also facilitates the implementation of Alliance for Innovation on Maternal Health (AIM) safety bundles. “These safety bundles provide multidisciplinary, clinical-condition-specific procedures that support best practices and make birth safer,” Tina says. “The procedures cover postpartum hemorrhage, hypertensive emergencies, and safe reduction of primary cesarean sections.” The bundles are standardized to guide doctors and nurses through an emergent event. “The standardization helps avoid multiple people doing it multiple different ways,” Tina adds. “You have one way to recall information, one way to respond, that is standard across the board.”
AIM safety bundles are standardized guides that guide doctors and nurses through an emergent event.
For a full list of programs, simulations, and consultations, including fetal monitoring, home visits, women’s health, and nutrition education, visit the Outreach Services page of the UAMS High-Risk Pregnancy Program website.
The UAMS High-Risk Pregnancy Program offers many more services to support mothers and ensure that neonatologists, OB-GYNs, and other health care professionals are fully trained and stay current on the latest technology, trends, and best practices of maternal and child care.
Know Where to Find Your Resources
To effectively address maternal mortality, Tina says health care professionals must be flexible and teachable. “Know how to stay updated on trends and new studies that are released,” Tina says. The American College of Obstetricians and Gynecologists (ACOG) and the AWHONN frequently post new practice bulletins for obstetricians and neonatologists to stay current on maternal health. “It’s very important to keep up with those to maintain best practices within your organization,” Tina adds. “Don’t dig yourself into the hole of ‘I learned this in med school 30 years ago, and that’s how I do it.’ You can’t function like that.”
It's important to stay current on best practices and strategies. Don't dig yourself into the hole of 'I learned this in med school 30 years ago, and that's how I do it.' You can't function like that.
In addition to keeping up with studies from ACOG and AWHONN, UAMS offers Obstetrical and Neonatal Angels Guidelines for providers. The mobile-friendly website provides 24/7 access to over 170 best practice guidelines at the point of care. Using these powerful tools and conducting independent research to gather resources from other maternal care leaders is essential to providing the best possible care for mothers and their children.
AFMC’s maternal mortality resource center provides downloadable media for professionals to review. These resources come from a variety of reputable organizations, including the Alliance for Innovation on Maternal Health, the Institute for Perinatal Quality Improvement, and the March of Dimes. The page even includes the story of a mother who experienced complications while delivering her baby at home. Mothers like Kamilah deserve professionals who know the warning signs and can act fast to save lives.
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