Cause for Hope in North Carolina

| Jul 12, 2011

Infant mortality rates are widely used in this country and internationally as a barometer of the quality of a community’s, or a nation’s, health care system – and with good reason. Despite our sophisticated and expensive health resources, the infant mortality rate in the United States is significantly higher than that of many other countries. In 2005, for example, our infant mortality rate of 6.9 per thousand births put us above that of most European countries, Canada, Australia, New Zealand, Hong Kong, Singapore, Japan and Israel.[1]

Our maternal mortality rate – the measure of women dying in childbirth – is also shockingly high compared to that of European countries. What’s worse, it is rising. In 1990 in the United States, 343 women died in childbirth; by 2007 that number had increased to 548.[3] A report[4] released July 6 by the National Institute of Child Health and Human Development documents some progress on reducing the incidence of preterm birth, down from 12.8 percent in 2006 to 12.2 percent in 2009. But that rate is still woefully behind the U.S. Healthy People 2010 target of 7.6 percent of all live births.

Taken together, these statistics should be a cause of major concern and inspire action to reverse that trend.

One state, North Carolina, has set out to address these problems. In March, North Carolina opened a Pregnancy Medical Home program for women eligible for Medicaid. – Working with their medical community, local health departments, and a network of community support organizations called Community Care of North Carolina (CCNC), state health leaders combined payment incentives and specific care requirements into a package they believe will improve pregnancy outcomes throughout the state.

Here’s how the new program works.

Maternity care providers – obstetricians, family practitioners, nurse midwives, community clinics – can apply to be designated as a Pregnancy Medical Home. They must agree to do four things:

  1. At the first obstetric visit, administer a standardized pregnancy risk tool that provides not only clinical health history but other information about the woman and her situation that could indicate she is at risk of a poor outcome. The questions include poor nutrition, smoking status, use of alcohol or possible physical violence. – If a women looks like a high risk, the provider must contact his or her CCNC network and arrange for care management services for that patient throughout her pregnancy. The provider and patient also develop a plan for managing her care.
  2. Ensure that none of the providers in the Pregnancy Medical Home perform “elective” deliveries – deliveries for which there is no medical reason to induce labor — prior to 39 weeks of gestation. Early deliveries increase the likelihood of infant death, admission to a Neonatal Intensive Care Unit, or life-long health problems for the child.
  3. Provide the drug 17 alpha hydroxyprogesterone caproate (commonly called 17P) to patients at risk of preterm delivery.
  4. Aim for a caesarean-section rate for low-risk, singleton births below 20 percent. C-sections expose both mother and child to surgical risk and possible infection, and can create complications for future pregnancies.

To encourage providers to enroll in the Pregnancy Medical Home program, the state Medicaid agency will pay Pregnancy Medical Home practices $200 more per patient over the state’s usual maternity fee. $50 of this money is paid upon completion of the pregnancy risk tool, and the remaining $150 for managing the care is paid once the women has had her post-partum visit. The post-partum visit must include screening for depression, reproductive life planning, and referral for ongoing care if necessary. The state expects to offset the cost of the additional reimbursement through savings in hospital costs.

North Carolina is not the only place trying to improve maternity outcomes; projects are underway, for example, in California, Ohio and Washington state. But to my knowledge, North Carolina is the first to employ the patient-centered medical home model in that effort. – This is a promising program, and we will all likely learn a lot from the state’s experience.

[1] NCHS Data Brief, #23, November 2009;

[2] NCHS Health US 2010, Table 36;

[3] Child Health USA 2010, Health Resources and Services Administration, U.S.DHHS;

[4] America’s Children: Key National Indicators of Well-Being 2011;