Being born at the right place
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Being Born at the Right Place. Mary Boyd, MD, FAAP, President, WV Chapter American Academy of Pediatrics. Risk Appropriate Perinatal Care. Healthy People 2020 Goals. Case Study. Story of a birth of twins. National Performance Measure #17. Percent of VLBW (<1500 gram) infants

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Being Born at the Right Place

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Being born at the right place

Being Born at the Right Place

Mary Boyd, MD, FAAP,

President, WV Chapter

American Academy of Pediatrics

Risk appropriate perinatal care

Risk Appropriate Perinatal Care

Healthy People 2020 Goals

Case study

Case Study

Story of a birth of twins

National performance measure 17

National Performance Measure #17

Percent of VLBW (<1500 gram) infants

delivered at

Level III Perinatal Facilities

(This has been measured for about 30 years)

Goal performance measure 17

GoalPerformance Measure #17:

90% of VLBW Babies Should be born at Level III Perinatal Facilities

Why 90

Why 90%??!!

Vlbw mortality is lower for infants born in a level iii centers

VLBW Mortality is Lower for Infants Born in a Level III Centers

Shown in multiple studies since 2004 including:

  • US

    • California, New York, Missouri, South Carolina, Missouri

  • Sweden – national registry

  • Finland – national registry

  • France - EPIPAGE

Being born at the right place

Preterm Delivery, Level of Care, and Infant Death in Sweden: A Population-Based Study

Stefan Johansson, MD*, ,Scott M. Montgomery, MD, PhD ,Anders Ekbom, MD, PhD ,Petra OtterbladOlausson, PhD||, Fredrik Granath, PhD ,Mikael Norman, MD, PhD*, Sven Cnattingius, MD, PhD

* Women and Child HealthMedical Epidemiology and BiostatisticsClinical Epidemiology Unit, KarolinskaInstitutet|| National Board of Health and Welfare, Stockholm, Sweden

Results. The rate of infant mortality increased from 5% amonginfants born at 31 weeks’ gestation to 56% among infantsborn at 24 weeks’ gestation. Compared with infants bornat university hospitals, the unadjusted odds ratio (OR) of infantdeath was 0.70 (95% confidence interval [CI]: 0.54–0.90)among infants delivered at general hospitals. However, afteradjustment, the OR of infant death shifted to 1.33 (95% CI:0.88–2.02) for preterm births at general hospitals. Thisshift was primarily due to different gestational age distributionsin regional and general hospitals. Among infants born at 24to 27 weeks’ gestation, infant mortality rates were 23%(87 deaths) in university hospitals and 32% (73 deaths) in generalhospitals.

Pediatrics, 2004

Being born at the right place

TABLE 4. Unadjusted Neonatal Outcomes by Location of Birth

Pediatrics, 2004

Study done in Cincinnati; SPC=Specialty Perinatal Center

Being born at the right place

Study done at George Washington University

Cdc research published 2010

CDC Research Published 2010

Perinatal regionalization for very low birth weight and very preterm infants a meta analysis

Perinatal Regionalization for Very Low-Birth-Weight and Very Preterm Infants—A Meta-analysis,

Lasswell SM, Barfield WD, Rochat RR, Blackmon LR. 

JAMA 2010; 304.9: 992-1000

Being born at the right place


VLBW and very preterm infants born outside of a level III hospital are at an increased likelihood of neonatal death or death prior to discharge from the hospital. 

Being born at the right place

The researchers identified 41 publications that met criteria to be included in the study. Analysis of the data of the VLBW studies (n = 37; 104,944 infants) indicated a 62 percent increase in odds of neonatal/predischarge death for infants born in non-level III hospitals compared with those born in level III hospitals (38 percent vs. 23 percent). When restricted to only higher-quality evidence (9 publications; 46,318 infants), a 60 percent increase in the odds of neonatal and/or predischarge mortality was estimated for VLBW infants born at non-level III hospitals (36 percent vs. 21 percent). Also, extremely low-birth-weight infants (1,000 grams [35 ounces] or less) born in non-level III hospitals had an estimated 80 percent increase in odds of neonatal and/or predischarge mortality compared with those born at level III hospitals (59 percent vs. 32 percent).

Wanda barfield md mph cdc drh director and neonatologist

“These recent scientific findings indicate that more work must be done to better understand the impact of risk-appropriate care on babies born too little or too soon.  Our regionalized systems must be systematically evaluated to determine effective care of neonates and prevent infant death”.

Wanda Barfield, MD, MPH

CDC/DRH Director and neonatologist

How measured

How Measured?

# <1500 gram infants born at Level III facilities

Total # <1500 gram infants born

Level iii perinatal centers in wv

Level III Perinatal Centers in WV

CAMC - Women & Children's

Cabell-Huntington Hospital

WVU Children’s Hospital

Being born at the right place

Locations of WV Birthing Facilities, 2010


Weirton General, Weirton,

Ohio Valley Medical Center

Wheeling Hospital



Monongalia General, Morgantown

Reynolds Memorial, Glen Dale

WVU Hospitals



Preston Memorial



Fairmont General




City Hospital, Martinsburg


Camden Clark

St. Joseph’s







Jefferson Memorial, Ranson







United Hospital Center, Clarksburg





Grant Memorial, Petersburg


Pleasant Valley Hospital





WomenCare Birth Center



Davis Memorial, Elkins


St. Mary's Hospital

St. Joseph's, Buckhannon

Cabell Huntington Hospital





Stonewall Jackson Memorial, Weston





CAMC Women’s and Children’s



Summersville General


Thomas Memorial Hospital



Logan General Hospital

Greenbrier Valley Medical Center



Williamson Memorial Hospital




Raleigh General Hospital



Princeton Community Hospital

Welch Community Hospital

Bluefield Regional Medical Center

Where should we go from here

Where should we go from here?

Where should we go from here1

Where should we go from here?

  • WV leaders need to examine statistics more closely

  • Obstacles to maternal transport need to be studied.

  • A cost/benefit analysis of statewide maternal transport should be considered.

  • Quality Improvement Initiative

Being born at the right place

Lawyers are like other people--fools on the average; but it is easier for an ass to succeed in that trade than any other.-quoted in Sam Clemens of Hannibal, Dixon Wecter

Lawsuit in iowa

Lawsuit in Iowa

Do we need a quality improvement initiative

Do we need a Quality Improvement Initiative?

Guidelines for perinatal care 2007 quality indicator

Guidelines for Perinatal Care 2007 Quality Indicator:

Delivery of an infant less than 32 weeks gestation in an institution without a NICU

1Guidelines for Perinatal Care, 6th Edition, co-published and endorsed by the American Academy of Pediatrics

and American College of Obstetricians and Gynecologists. 2007

Some questions to ask

Some questions to ask

  • How long was the mother at the non-tertiary hospital before she gave birth to a baby weighing less than 1500 grams?

  • Was there an attempt to transport the mother?

  • If so what factors prevented her transport?

This is the best incubator

THIS is the best incubator

Being born at the right place1

Being Born at the Right Place

Isn’t it worth the price because it’s the right thing to do?

Maternal transport log

Maternal Transport Log

Available on Perinatal Partnership Website

Being born at the right place

Maternal Transport Log for Community Hospitals

(Report multiple calls for same patient as separate entries)

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