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Decreasing the Preterm Birth Rate Through Telehealth

Expecting Better: Improving South Carolina's Scorecard for High-Risk Pregnancies Through Telemedicine

South Carolina has the fourth highest preterm birth rate in the nation (14.5%, even higher for African American infants at 19.3%), earning it a grade of D from the March of Dimes, which has set a goal of decreasing preterm deliveries to 9.6% by 2020.1 And South Carolina’s rate has been going in the wrong direction: preterm deliveries increased by more than 4% between 1999 and 2009.2 In an average week in South Carolina, 169 babies are born preterm, 30 of whom are very preterm, and 116 babies are born at low birth weight, 21 of whom are at very low birth weight.1 Preterm birth, defined as birth before 37 weeks  gestation,  is  the  leading cause of newborn death and often places babies at an  increased lifetime risk of breathing problems, neurological disorders, cerebral palsy, and other disorders because many important organs are not completely developed until late in gestation. In 2005, preterm birth is estimated to have cost the United States at least $26.2 billion.3 Excess hospitalization due to low-weight birth removes $163 million from South Carolina’s coffers annually.4

Pregnant women with comorbid conditions such as hypertension, diabetes and obesity are at increased risk of preterm delivery and a host of other complications. South Carolina has among the highest rates of hypertension and diabetes in the country, with minority populations being especially hard hit. Further complicating this situation is the shortage of maternal fetal medicine specialists in South Carolina (five or six more are currently needed in the state) who could help regulate blood glucose levels and blood pressures in women at high risk, thereby improving outcomes. Maternal fetal medicine specialists pursue three years of additional training for high-risk pregnancies after completion of four years of obstetrics-gynecology residency.

A Vision for Improving Women’s Care in South Carolina

Donna Johnson, M.D., Chair of Obstetrics and Gynecology at MUSC and a maternal fetal medicine specialist herself, thinks that South Carolina women should be able to expect better.

Her desire to “improve women’s health in South Carolina” led her to develop a maternal fetal telemedicine program in 2008 that could provide more convenient and reliable access to specialty care for women with high-risk pregnancies.

She realized that women in many poorer or rural areas of the state did not have access to a local specialist in maternal fetal medicine.  She realized as well that traveling to Charleston or to some other urban center for specialty care would be a challenge to these women. According to Dr. Johnson, these   women “are often the working poor—they have a job and must rely on Medicaid because they cannot afford insurance. Medicaid pays for transportation but picks up early in the morning and takes them home when everyone on the van is finished with their medical appointment. They don’t know if they will be home when their children come home from school.” Many of these women, who live paycheck to paycheck, must ask for time off work, face the consequences of the missed salary for the weekly bills, arrange for child care and incur additional transportation expenses such as gas and parking. All in all, it is an expensive day for women with limited income, and one which many mothers-to-be forego, never showing up to their referral appointments.

If the service could be provided conveniently at a local hospital or a local physician’s office, Donna Johnson speculated, then these women would be more likely to take advantage of specialty care that could improve their chances of a healthy pregnancy.

By improving the outcomes of high-risk pregnancies, she knew that she would also reduce the economic burden of such pregnancies for South Carolina. Each premature birth carries a price tag of one to two million dollars; if those pregnancies could be carried to 32 weeks, that cost could be reduced to half a million.

Dr. Johnson began what turned out to be a long but successful quest to provide better pregnancy care to underserved women. She found easy-to-use, inexpensive technology that would not pose a barrier to participation (essentially a high-definition webcam and user- friendly software for establishing secure video conferences), lobbied for reimbursement for telemedicine by the Department of Health and Human Services, established relationships with hospitals in areas with a critical shortage of maternal fetal specialists, ensured that all telecommunications would be HIPAA-compliant and developed a business plan whereby the telemedicine program could sustain itself through insurance reimbursements alone. In doing so, she blazed a trail that many other physicians in other specialties at MUSC are now beginning to explore.

Improving Outcomes by Expanding Access to Specialty Care

Through telemedicine, MUSC maternal fetal specialists perform as many as 50 to 60 consultations per week. They provide gap coverage to areas with critical shortages in these specialists, including Columbia and Florence, extending maternal fetal medicine services to three of five perinatal regions in the state (the Lowcountry, PeeDee and Midlands).

The MUSC maternal fetal telemedicine team offers their partner sites an impressive breadth and depth of coverage. It is on call 24 hours a day, 7 days a week–something no single specialist could manage. Team members offer expertise in a variety of issues associated with high- risk pregnancy. They consult with each other constantly without the need for formal requests for second opinions, meaning that patients can expect coordinated care informed by the expertise of multiple specialists.

According to Dr. Johnson, “the goal of all of this is to be sure the baby is delivered at the right place.” She emphasizes that such services fill a critical shortage for specialists and do not compete with services offered by local providers: “We complement care; we don’t compete for care.” Preliminary data suggest that expanded access to specialty care has dramatically improved outcomes for high-risk pregnancies.

Reception by Patients and Local Providers

Patients have embraced the program, which surprised and pleased Ann Adams, a nurse at McLeod Regional Medical Center in Florence, SC, who initially had reservations about how well her large Medicaid patient base would accept telemedicine-delivered care. “Being an older person I forget how young people are much more technology oriented than I am,” admits Adams, “They have just loved the telemedicine program and are more receptive to treatment—they feel like they are on the cutting edge of medicine, something out of this world. They think that this is something out of Star Wars.”

Because patients can be seen by specialists via telemedicine at a location that is convenient for them, they are more likely to keep their appointments and to bring family members for support, something Medicaid transport, limited to the patient alone, would not have allowed.

They can also rely on the support of a genetics counselor when deciding whether to have prenatal genetic testing or when interpreting and assimilating the results of such tests.

For example, MaterniT21TM (Sequenom CMM, San Diego, CA), a new test recently approved for reimbursement by Medicaid that can identify extra fetal chromosomes by analyzing a drop of the mother’s blood, screens for major genetic disorders such as Down Syndrome as early as 10 weeks into pregnancy with almost 100% accuracy. Unlike amniocentesis, the previously used method for screening that involved insertion of a needle into the amniotic sac to withdraw a small amount of amniotic fluid for analysis, MaterniT21 carries no threat of miscarriage. However, the information it provides can pose ethical dilemmas for women and so it is important that they have the support of a genetics counselor. With telemedicine, Adams notes, women can spend as long as 45 minutes with a genetics counselor and see the same genetics counselor at each visit.

Medicaid that can identify extra fetal chromosomes by analyzing a drop of the mother’s blood, screens for major genetic disorders such as Down Syndrome as early as 10 weeks into pregnancy with almost 100% accuracy. Unlike amniocentesis, the previously used method for screening that involved insertion of a needle into the amniotic sac to withdraw a small amount of amniotic fluid for analysis, MaterniT21 carries no threat of miscarriage. However, the information it provides can pose ethical dilemmas for women and so it is important that they have the support of a genetics counselor. With telemedicine, Adams notes, women can spend as long as 45 minutes with a genetics counselor and see the same genetics counselor at each visit.

Just Getting Started

Although MUSC’s maternal fetal telemedicine program has already improved high-risk pregnancy outcomes, removed barriers to specialty care for women in rural areas of the state and strengthened relationships with partner hospitals, it is just getting started. Dr. Johnson looks forward to a day when every physician’s office in a perinatal region will have the capacity for telemedicine so that specialty care can be made as patient friendly, convenient and available as possible. She envisions a better future for South Carolina’s women, made possible by telemedicine: “Telemedicine will be a significant advancement in medicine. In South Carolina, it has been made possible by computer technology…and forward-thinking individuals who have used technology to dramatically improve health care. We have the technology, the innovation and the thinking to really put it to use.”

References

1  March of Dimes. Peristats. Available at http ://www.marchofdimes.com/peristats/Peristats.aspx Accessed Aug ust 31, 2012.

2 National Center for Health Statistics, final natality data.

3 Institute of Medicine. 2007. Preterm Birth: Causes, Consequences, and Prevention. National Academy Press, Washington, D.C.

4 South Carolina Budget and Control Board. South Carolina Kids Count. The Right Start 2005. Available at http ://www.sckidscount.org/casey/rightstart05.php. Accessed September 6, 2012.

This article originally appeared in the January 2013 issue of Progressnotes.

KEY POINTS

  • South Carolina has the fourth highest preterm birth rate in the nation (14.5%), earning it a grade of D from the March of Dimes.
  • A major factor contributing to such high-risk pregnancies is the presence of comorbid conditions such as diabetes, hypertension and obesity, which are rampant in South Carolina, particularly among minority women who have an even higher rate of preterm births (19.3%) than their white counterparts.
  • South Carolina is experiencing a critical shortage of maternal fetal medicine specialists, who have received additional training in the comorbid diseases (ie, high blood pressure, diabetes) that can increase the risk of a bad outcome for a pregnancy. The shortages are especially dire in remote rural regions where many women with high-risk pregnancies live.
  • A trail-blazing telemedicine program developed by MUSC’s Department of Obstetrics and Gynecology is bringing specialty care in maternal fetal medicine to women in traditionally underserved areas or in areas where there is a shortage of such specialists, thereby overcoming geographic and economic obstacles to the highest-level prenatal care for at-risk populations.