Seven neonatal intensive care units serve the entire state of Oregon. One of those NICUs, a Salem Health facility, is the only one of its kind serving both Marion and Polk Counties, a region outside of the Portland metropolitan area where homelessness has swelled 15% since 2021. And while homelessness does not directly correlate with preterm birth rates, poverty does.
Recently, the NICU nurse manager at Salem Health told me that their 27-bed unit typically cares for 12-14 preterm infants or sick newborns at a time. One or two of those are typically “micro preemies,” premature infants born well before the third trimester weighing less than two pounds. These infants are born with incredibly complex medical needs – needs that require specialized clinical guidelines, advanced resources, and on-demand nursing staff to properly address. However, during a birth surge last summer, the unit saw 18 micro preemies admitted in a single week, straining the resources and providers.
Not for lack of trying, this unit is fighting a losing battle, but it’s far from the only NICU struggling to save lives against all odds. Just last month, UMass Memorial Hospital announced it will be closing maternity services at Leominster hospital in Massachusetts. Access to vital maternity services across the country continues to restrict as hospitals struggle to staff – and, in the worst cases, completely shutter – their prenatal and postpartum care units.
The United States healthcare system is in the midst of a debilitating maternal care crisis that shows no sign of slowing: preterm births continue to rise year after year, maternal mortality rates are skyrocketing, and as demand for maternal and infant care grows, access to the services pregnant women and new mothers need is shrinking.
This is also, beyond a shadow of a doubt, a health equity crisis. America’s maternal care deserts, where food insecurity and economic instability run rampant and access to care is sparse, have expanded to affect nearly seven million women and almost 500,000 births across the country as of 2022. They fester and grow in our most vulnerable, socioeconomically disadvantaged communities – in geographically distributed rural areas, in impoverished urban environments, in Tribal and frontier territories.
Healthcare’s approach to remedying this ongoing emergency has been the same approach it’s taken to every other dilemma: recruit more nurses, caretakers or support staff and hope for the best. But as Covid-19 demonstrated, the mental health of providers has been strained and turnover is still a system-wide problem.
The “throw more bodies at it” strategy doesn’t work anymore. It’s not working to curb the growth of our nation’s chronic disease burden, or to lower the burnout rates that are accelerating labor attrition within the industry. In the midst of an unprecedented workforce shortage – one that is not expected to get any better for the next decade – we no longer have the option of hiring our way out of a crisis, let alone one that is placing maternal and infant public health in peril.
The supply-demand paradigm that limits healthcare’s impact on patient outcomes is only growing worse with each passing day. We cannot afford to hold out hope for some X-factor that will miraculously solve all of our problems, be it generative AI, regulatory hail marys, or some other moonshot. The industry needs to tip the scales, to shift the economics of care delivery toward its own favor, and it needs to do it now. The only path forward for hospitals and health systems is to leverage technology and create more efficient resources to collectively address public health crises – starting with maternal care.
A collective, tech-enabled approach to maternity care
Approximately 30 percent of all community hospitals are operating in financial purgatory – borrowed time. Over 150 have closed since 2010, completely closing off access to care for the communities that depend on them. Funding is a persistent challenge for these facilities – they treat a greater volume of patients than academic health centers, the majority are privately insured or uninsured, and they do so with a staff composed largely of generalists.
In the context of providing quality maternal care, the contrast between academic medical centers and community hospitals is stark.
In scenario #1, A pregnant mother going into early labor and the baby she will birth prematurely are received by an academic medical center. The treatment she receives there is often excellent; despite high turnover among a staff that largely consists of fellows and residents, the understaffed obstetric care team and NICU staff will follow highly regulated, industry-standard guidelines. Additionally, the mother will have access to quality reproductive health services throughout her maternal health journey that significantly reduces the risks of adverse events or complications for her and her baby. The quality of care in the NICU is consistent, with a standard that creates predictable outcomes.
In scenario #2, a mother and child will receive different treatment in a rural community hospital. Although the facility is struggling with a similar shortage in staff, the reasons are altogether different. The care team to patient ratios are lower – fewer people to provide care, monitor the mother or infant’s progress – and the mother has often not had access to quality reproductive health services during her pregnancy, increasing her risk of complications. The hospital does not have the resources – human or knowledge-based – to provide consistent, high-quality care. Shift changes result in a drop in communication, and critical information around individual nutrition and feeding protocols can be lost. The deck is stacked against them.
Providing consistent, high-quality care in any healthcare facility requires three things: access to timely patient health data, standards for intervention and escalation, and clinical capacity to execute them. In the NICU, the ability to report on key milestones as they relate to feeding, nutrition, and growth to make timely interventions can significantly improve preterm infant outcomes and improve survival rates, or quality of life in the future. Most academic medical centers will have two of the three requirements; a rural community hospital is lucky to have one.
Digital tools like remote monitoring devices, virtual care, and clinical intelligence platforms – all of which can be leveraged to fill the gaps in these requirements – have an opportunity to bolster the industry. In the hands of a collective many, they can be deployed to level the playing field to increase bandwidth and improve adherence to quality guidelines.
Consider an arrangement where expertise and technology are shared across health systems: a well-known academic medical center may be able to share their clinical guidelines for NICU or pediatric care with community hospitals, low-income facilities, and rural hospitals in maternal care deserts, or have an expert on-call available for virtual consultations for complex prenatal cases. Imagine a healthcare system in which an underserved facility is able to leverage technology to collect and share vital data on their patient populations – data that can be aggregated and analyzed to improve best practices, detect infants at-risk of adverse events, and reduce health disparities.
It’s an ambitious vision, but not one that is beyond our abilities. But it must start with the patients to whom we owe our best efforts – infants and children. Preterm babies who do not receive the quality care they need are likely to age into adults with debilitating chronic diseases, further taxing system infrastructure. For them, good health is not a choice. A healthcare system where access to knowledge and tools is more evenly distributed, however, is one that may be able to give them one.
Photo: Kwangmoozaa, Getty Images
