FYC Action Team 4:  Findings and Recommendations

On September 3, 2020 Community Action Council meeting, Rita Horwitz, President and CEO, Better Health Partnership, and Dr. Brian Mercer, Department Chair of Obstetrics & Gynecology, MetroHealth, provided an update on the work of First Year Cleveland (FYC) Action Team 4 during Better Health Partnership's 2020 Virtual Annual Report to the Community.

View the webinar slide deck here

View the Zoom webinar recording

FYC Action Team 4 was formed in May 2018 with the overarching goal of reducing extreme premature births and racial disparities. Four Cuyahoga County healthcare systems (Cleveland Clinic, University Hospitals, MetroHealth and Southwest General) were brought together to establish goals for the Action Team. The goals were informed by the Cuyahoga County Board of Health 2017 data on premature births, which indicated that 90 percent of infant deaths resulted from births before 26 weeks gestation, including a significant number of deaths occurring before 20 weeks gestation.

The goals of FYC Action Team 4 include:

• Prevent or delay premature births before 26 weeks gestation
• Reduce racial disparities in premature births
• Optimize outcomes of periviable births (babies delivered at 20-25 weeks)
• Collect data and launch monthly learning circles with local birth hospitals and researchers/experts to share knowledge
• Launch quality improvement interventions, monitor progress
• Identify and spread best practices across all healthcare systems 

Early data review and findings
Early in the process, baseline data were gathered from all county healthcare systems for the period 2013-2017 and reviewed by FYC Action Team 4. Findings were discussed in learning circles where data elements meriting further review were defined. 

Overall, the data indicated that about 1 in 100 deliveries occurred before 26 weeks gestation, and these extreme premature births were responsible for nearly 75 percent of infant deaths throughout Cuyahoga County. It was determined that focusing on this one percent of the population could significantly impact infant mortality overall.

While prevention of premature births is certainly important, the data revealed that delaying inevitable preterm births dramatically increased infants’ potential for survival. The vast majority of infants born between 30–37 weeks gestation survived. The data demonstrated that each week an inevitable preterm birth was delayed was critically important. Even a brief delay impacted infant mortality significantly.  

Based on these findings, the Team prioritized the following areas for additional data collection and evaluation in 2018:  

• Access to early care, risk identification and follow-up
• Access to timely consultation and intervention
• Coordinated counseling and care planning at admission
• Appropriate access to critical newborn interventions and comfort care

2018-2019 Key Data
In 2018, data were collected, using 150 questions, on every birth that occurred at 26 weeks gestation or less. The cohort was comprised of 170 mothers across all four healthcare systems.  

Forty-eight percent of mothers in the cohort were African American, higher than any other race or ethnicity. Maternal characteristics including age, previous births, high school graduation rate, living with partners, tobacco/alcohol/illicit drug use, frequent address changes, homelessness, weight, history of multiple gestations, prior surgeries, and history of infertility, were analyzed and determined to be insignificant. The data did not support the assumption that mothers failed to do something or did something to cause premature births. No single characteristic stood out that could lead to a focused intervention.

The data analysis included a review of the participants’ history of premature births – the most common risk factor associated with premature births. Twenty-seven percent of the sample had a history of prior premature births, the majority of which were the result of spontaneous preterm births due to the onset of labor, fluid leakage, and the presence of a weak cervix.

Not finding significance in the analysis of these characteristics and risk factors, the Team went further to look at other prenatal care events present in this cohort of preterm births before 26 weeks gestation. They found that one in three mothers presented to an emergency department prior to the onset of prenatal care. The emergency department was the access point of care.

The data also revealed that the time between an emergency room visit and the onset of prenatal care was anywhere between an immediate referral to prenatal care up to 11 weeks before prenatal care was accessed. This delay in accessing prenatal care after an emergency department visit is a dramatic finding, representing lost opportunities to provide care, coordinate care, and identify risks. 

Of the 170 women in the cohort,

• 11 percent had first trimester care, but no first trimester ultrasound to identify factors possibly leading to preterm birth
• Nine percent had a first trimester ultrasound or emergency department visit, but no first trimester prenatal care with missed opportunities to identify risks
• Three percent had received an ultrasound or had an emergency department visit prior to 22 weeks gestation, but no documented prenatal care

Additionally, measuring cervical length with an ultrasound can identify women who are likely to deliver early because they have shorter cervical lengths. It is accepted practice that pregnant women have a cervical length measurement between 18-20 weeks gestation. The data in the cohort revealed:

• 53 mothers had first trimester care but no cervical length measurement; this was a missed opportunity to schedule testing at the appropriate time
• 11 mothers had an ultrasound prior to 23 weeks gestation with no prenatal care visit or cervical length measurement
• Of those mothers presenting prior to 23 weeks gestation, one half did not have a documented cervical length measurement; the information was not available for care

Another clinical intervention for women with a history of prior spontaneous preterm birth is the use of weekly Progesterone injections. About one-third of women who could have potentially benefited from this intervention did not receive it. It is not clear whether the intervention was not offered, or was offered and declined. This result was similar for all races.

A weak cervix or cervical insufficiency can be treated by placing a stitch in addition to other measures. This condition was disproportionately represented in the cohort among those women who had a prior preterm birth. More than half of the women who ultimately had a diagnosis of cervical insufficiency, and who might have benefitted from a stitch, were either not diagnosed, not diagnosed in time to place a stitch, or declined the intervention.

Another treatment for a woman with no prior preterm births, but with a very short cervix, is a daily vaginal progesterone treatment. Approximately one-third of women who were potentially eligible for this treatment did not receive it.

Women with twins and multiples are a high-risk population. While consultation is not mandated for these women, they are at high risk for early delivery, hypertension, and diabetes during pregnancy. About one-third of the women with multiple gestations did not receive a high-risk consultation.

The Team also focused on what happened once pregnant women entered the hospital. The vast majority of women who delivered before 26 weeks gestation presented with spontaneous preterm birth. The time from their admission to delivery was very short.

• One in eight delivered within one hour of coming to the hospital
• Nearly one-third delivered within 12 hours of coming to the hospital
• Over half of the patients delivered within 24 hours of coming to the hospital

If there was an intention to intervene after consultation with the patient, and if there was more than one hour within which to intervene, clinical interventions were offered and received. But for some, there was not enough time to intervene once the pregnant woman entered the hospital. 

Of women who came to the hospital before 26 weeks gestation, and who had a discussion with an obstetrician, about 60 percent were considered candidates for intervention and the intention to intervene was documented. After discussion with patients, neonatologists were willing to intervene 70-75 percent of the time, recognizing that when neonatologists see patients some were already in the hospital for a while and were at a more advanced gestational age. The overall survival rate of newborns at discharge was about 50 percent. This hospital data tells us that interventions need to be focused much earlier in pregnancy. 

The data analysis also identified the zip codes for each patient that delivered and looked at social determinants of health. Early preterm births occurred in 43 out of 52 zip codes in Cuyahoga County. The experience of preterm births was widespread and no one zip code stood out for intervention. The targeted OEI zip codes did not have significantly higher rates than other zip codes.

Characteristics based on birth certificate data and other available data were also analyzed, comparing zip codes with the highest rates of preterm birth to those with low rates and to those with no incidence of preterm births. The most significant differences were present when comparing the high rate zip codes to zip codes with no preterm births. There was less difference between high rate zip codes and low rate zip codes. Within the high and low rate zip codes, mothers were more likely to have Medicaid, inadequate prenatal care, were more likely to be African American, had a higher deprivation index, higher maltreatment rate, lower median income, more single parent households, and less availability of broadband and smart phones. No single characteristic was more significant than others.

2020 QI Interventions
As a result of these findings, three quality improvement interventions were identified:

• Early access to prenatal care for pregnant women presenting to an emergency department for evaluation
• Early establishment of gestational age, pregnancy viability, and determination of pregnancy risk
• Consistent cervical length screening in all pregnancies receiving prenatal care before 20 weeks gestation

FYC Action Team 4's work to date in 2020 has included the following:

• Chart review findings have been disseminated
• Health systems are sharing current processes related to the three QI interventions in learning circles
• Key driver diagrams have been developed for each QI intervention
• Journey mapping and fishbone diagrams of current processes and pain points are underway

The approaches within each health care system are unique, but all address the prioritized QI interventions. Moving forward, the Team will continue to identify and implement QI interventions and examine with OEI the analysis of emergency department visits and accessibility. A critical component will integrate journey mapping of system processes with journey mapping of patient experiences which were conducted by FYC Action Team 1. The patient experience will provide insight into structural racism, implicit bias and other obstacles that may be affecting premature birth outcomes and help us achieve better outcomes and reduce disparities.

COVID-19 March 2020 to present
Prenatal care was rapidly converted to telehealth care, due to concerns about access to care and the number of expected sick patients. In fact, the use of telehealth has been an opportunity to engage pregnant women in care. Appointment no-show rates have dramatically decreased with the use of telehealth. The next surge of rapid change is coming as health systems prepare to open up in-person care. The Team will continue to evaluate the effects of COVID-19 on care and birth outcomes.