July 2001 volume 17 number 07 Division of Public Health http://health.state.ga.us Kathleen E. Toomey, M.D., M.P.H. Director State Health Officer Epidemiology Branch http://health.state.ga.us/epi Paul A. Blake, M.D., M.P.H. Director State Epidemiologist Mel Ralston Public Health Advisor Georgia Epidemiology Report Editorial Board Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H. Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer Georgia Department of Human Resources Division of Public Health Epidemiology Branch Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-7517 Please send comments to: Gaepinfo@dhr.state.ga.us The Georgia Epidemiology Report is a publication of the Epidemiology Branch, Division of Public Health, Georgia Department of Human Resources Geographic Disparities in Access to Recommended Delivery Site for Very Low Birthweight Infants in Georgia, 1994-1996 Introduction In Georgia infants born weighing <1,500 grams, or about 3.3 pounds (very low birthweight, VLBW) account for 2% of births but nearly half of all infant deaths.1 Major reductions in infant mortality require decreasing the proportion of very low birthweight births2, but this proportion has remained steady over the past two decades. This is due to lack of knowledge about the underlying causes for and effective interventions against preterm delivery (the major reason for very low birthweight births).3 Therefore, it is important to assure that very low birth weight infants receive appropriate care to reduce associated morbidity and mortality. The Recommended Guidelines for Perinatal Care in Georgia4 state that when pregnant women meet criteria for being at high-risk for themselves or their infants, such as preterm labor before 34 weeks gestation or multiple gestation pregnancies, consultation with and transport to a subspecialty care hospital should be considered. A national Healthy People 2010 objective is to deliver 90% of very low birthweight infants (<1,500g) at hospitals offering subspecialty perinatal and newborn care.5 The transfer of women before delivery to hospitals with subspecialty care is preferred to transport of high-risk neonates after delivery because of improved survival and morbidity outcomes.6 Regional perinatal care systems reduce perinatal morbidity and mortality through improved access to appropriate levels of maternal and neonatal care.7-8 Georgia began a regional system of perinatal care in 1974. The regional system's primary goal has been to establish a network of perinatal services that can include consultation, referral, or transport of maternal and neonatal patients at high risk to subspecialty care centers. To determine if improvements in the Georgia Regional Perinatal Care system can further reduce infant morbidity and mortality by achieving 90% of very low birthweight deliveries at recommended perinatal care levels, we 1) examined the proportion of VLBW deliveries that occurred at each perinatal care level, and 2) identified characteristics of women who did not deliver at a recommended level. Methods We used Georgia birth and death certificates to examine 4,770 live births weighing 500-1499 g born to 4,310 Georgia resident mothers from 1994 through 1996. Hospitals were grouped according to perinatal care level. State perinatal care guidelines define three levels of care based on neonatal services: subspecialty, specialty and basic.4 Subspecialty care (level 3 or 4) hospitals provide the highest level of technological capability. These hospitals provide inpatient care for nearly all maternal and fetal complications, and have neonatal intensive care units equipped to treat critically ill neonates. Six hospitals were assigned by the state as regional perinatal subspecialty care centers and designated level 4. Level 3 hospitals have state-certified neonatal intensive care units (NICUs). Specialty care hospitals (level 2) manage certain high-risk pregnancies and moderately ill newborns. Given the Healthy People 2000 objective definition, specialty care hospitals were further separated into two levels based on the reported availability of a neonatalogist. Specialty care hospitals with a neonatalogist on staff were labeled expanded specialty care, or level 2+. Basic perinatal care, also called level 1, provides basic inpatient care for normal pregnancies and newborns. Proximity to a subspecialty hospital was assessed using the mother's county of residence, which was separated into three categories. These categories were 1) counties with a subspecialty hospital, 2) counties adjacent to those with such a hospital (i.e., adjacent), and 3) all others (i.e., nonadjacent) (Figure 1). Because mothers with multiple gestation pregnancies could have a higher chance of being identified as high-risk, this group of mothers was assessed separately from women with singleton births. Results Most (77.1%) very low birthweight infants were delivered at subspecialty care hospitals, 9.8% at expanded specialty care hospitals, and 13.1% at all other levels (Figure 2). The maternal characteristic most strongly associated with delivery of a very low birthweight infant outside a subspecialty care hospital was residence in a nonadjacent county, followed by residence in an adjacent county. Although 89% of mothers who resided in a county with a subspecialty hospital delivered at that level, 71% of mothers who resided in an adjacent county delivered at that level, and only 53% of mothers who resided in a nonadjacent county did so (Figure 2). The overall pattern of delivery by maternal residence was similar for the mothers who delivered singletons (n=3,845, 81% of VLBW births) or multiple gestation births (19% of VLBW births) with 76% and 79% respectively delivering in subspecialty care. However, among mothers who lived in adjacent counties, 71% of mothers with singleton births delivered at subspecialty care hospitals compared to 83% with multiple gestation births (p<0.05) (Figure 3). Among mothers who resided in non-adjacent counties, 53% of singleton births occurred at subspecialty care hospitals compared with 61% of multiple gestation births (p=NS). We assessed in more detail singleton births only. Mothers with less than adequate prenatal care (defined by number and timing of visits by gestational age) had an increased risk for delivery outside recommended levels regardless of place of residence. Among women who lived outside a county with a subspecialty care hospital, women less than 20 years of age and/or with less than a high school education were at an increased risk of delivering at a non-recommended level. Summary The proportion of VLBW infants delivered at the recom- mended subspecialty care hospitals in Georgia was similar to that in other states9, but did not meet the Healthy People 2010 objective of 90%. To achieve this objective, subpopulations at risk for delivering outside the recommended levels should be targeted. Women residing near subspecialty care hospitals (i.e., essentially urban populations) are better served to deliver at subspecialty care facilities, but more distant residents remain at higher risk for delivering at facilities without the recommended level of care despite a regionalized system of perinatal care. A greater proportion of women with multiple gestation births who resided adjacent or non-adjacent delivered at recommended levels as compared with singleton births, particularly among women who resided in adjacent counties. This suggests that identification of specific risk conditions during prenatal care improved the chance of appropriate delivery site, but significant barriers remained among nonadjacent residents, such as the longer distance or differences in prenatal risk assessment. Time and distance might be the immediate factors related to the residential proximity barrier. However other underlying reasons need to be examined, such as: the content of prenatal care (e.g., adequate risk assessment, education about signs and symptoms of labor, communication and transportation plans), delays in assessment of labor by women and providers, the adequacy of emergency transport for pregnant women, and the physician's or institution's willingness to transfer. Among singleton births several other factors contributed to site of delivery. Women with less than adequate prenatal care were less likely to deliver at subspecialty care hospitals. Women who were less than 20 years old or had less than a high school education and lived farther from counties with subspecialty care hospitals were at increased risk of delivery outside recommended levels. Perhaps this was due to lack of prenatal care knowledge or limited access to care. One limitation of this study is that patient and health-care provider preferences regarding obstetric and neonatal management could not be assessed but probably influenced choices regarding site of delivery.10-11 Second, adequacy of maternal transport in each county could not be assessed but may have affected decisions about delivery site. The skill level of Emergency Medical System transport staff for high-risk obstetric patients in each county could affect choices regarding maternal transport. Recommendations Strengthening the regional perinatal care system in Georgia has the potential to further reduce neonatal mortality and morbidity. Health-care staff in each perinatal region will need to identify specific problems in their regions but could consider the following assessments and interventions to decrease risks faced by distant residents: 1) assess gaps and improve the current maternal transport system including developing a clear transport policy (Georgia has a formal transport system with trained staff for neonatal transports only); 2) ensure that local providers are aware of the increased risk of delivery outside subspecialty care facilities among women who reside in more distant areas; 3) lower the threshold of risk for consult, referral and transfer of women who reside distantly; 4) improve outreach and case management for younger and less-educated women. Regardless of residence, 5) improve access to early and adequate prenatal care including risk assessment, and 6) assure that reimbursement policies do not affect the place of delivery. The 1999 expansion of Medicaid to enroll providers within a 50-mile radius of the border should provide some residents who live near a Georgia border with easier access to subspecialty care in other states. If after specific activities are implemented, a larger proportion of VLBW deliveries continues to occur outside subspecialty care, Georgia should reconsider whether the 90% objective is feasible and identify other interventions such as: 1) assess the appropriateness and impact of VLBW infant delivery at expanded specialty care hospitals. In rural areas, expanded specialty care hospitals may serve as the `next best option' to match the needs of distant high-risk women and infants to appropriate care. However, more than half of the expanded specialty care centers are located in counties with subspecialty care hospitals, primarily urban areas. Therefore, collaboration is needed to ensure that the full set of services provided by the regional perinatal care centers are supported and available to all high-risk women and infants during follow-up periods as well as pre- and perinatally; 2) develop cooperative working arrangements to refer/transport pregnant women to the most appropriate facility given the distance constraints, using knowledge about the specific perinatal care capabilities available at hospitals in the region; and 3) encourage appropriate transfer of VLBW neonates to recommended levels after birth, particularly from level two hospitals (77% of VLBW infants from level 1 were transported after delivery, 41% from level 2 and 15% from level 2+). Overall, these findings suggest that strong, collaborative regional and local perinatal care networks are required to ensure that the needs of high-risk women and infants are matched to optimal health care. Addendum: 1997 and 1998 data became available before this publication. The proportion of deliveries at each level remained constant, as did the findings related to the association of mother's proximity of residence to site of delivery. For more information on the Recommended Guidelines for Perinatal Care in Georgia, Second Edition, visit: www.ph.dhr.state.ga.us/ publications/perinatal/. This report was prepared by Julia Samuelson, B.S.N., M.P.H., James Buehler, M.D., Dianne Norris, R.N.C., B.S.N., Ramses Sadek Ph.D. with acknowledgments to Mohammed Qayad, M.D., M.P.H., William Kanto M.D., Roberta Smith M.D., and Andrew Pelletier, M.D., M.P.H. This article has been submitted for publication to Blackwell Science's Paediatric and Perinatal Epidemiology Journal. -2 - Figure 1: Counties by proximity to a level 3 or level 4a hospital, Georgia, 1994 - 1996 *Level three and four hospitals are perinatal care levels for subspecialty hospitals Figure 2: Distribution of In-State Births 500<1500g by Mother's Residential Proximity to Subspecialty Care and Care Level at Delivery Site, Georgia, 1994 - 1996 Figure 3: Proportion of Women with Singleton Versus Multiple Gestation Pregnancies by Site of Delivery and Residence, Georgia, 1994 - 1996 References 1. Hogue CJR, Buehler JW, Strauss LT, Smith JC. Overview of the national infant mortality surveillance (NIMS) project--design, methods, results. Public Health Reports 1987;102:126-30. 2. MacDorman MF, Rowley DL, Iyasu S, Kiely ML, Gardner PG, Davis MS. Infant mortality. In: From Data to Action. Editors: Wilcox LS, Marks JS. U.S. Dept Health Human Services, Public Health Service. Centers for Disease Control, NCHS, 1994. 3. In: Charting a course for the future of women's and perinatal health: Volume 1-Concepts, findings and recommendations. Editors: Grason HA, Hutchins JE, Silver GB. Baltimore, MD: Women's and Children's Health Policy Center, Johns Hopkins School of Public Health, 1999:24-26. 4. Council on Maternal and Infant Health, Recommended guidelines for perinatal care in Georgia, 2nd Edition, Draft, 1998. 5. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington D.C.: U.S. Department of Health and Human Services, Publication No. 91-50212, 1991. 6. Shlossman PA, Manley JS, Sciscione AC, Colmorgen GHC. An analysis of neonatal morbidity and mortality in maternal (in utero) and neonatal transports at 24-24 weeks' gestation. American Journal of Perinatology 1997;14(8):449-56. 7. Perkins BB. Rethinking perinatal policy: history and evaluation of minimum volume and level-of-care standards. Journal of Public Health Policy 1993;14(3):299-319. 8. Shenai JP, Major CW, Gaylord MS, Blake WW, Simmons A, Oliver S, et al. A successful decade of regionalized perinatal care in Tennessee: the neonatal experience. Journal of Perinatology 1991;11(2):137-143. 9. Guild PA, Schectman R, Johnson AJ, Owens IS. Consensus in Region IV: Women and infant health indicators for planning and assessment. Chapel Hill, NC: Cecil G. Sheps Center for Health Services Research, 1999. 10. Saigal S, Stoskopf BL, Feeny D, Furlong W, Burrows E, Rosenbaum PL, et al. Differences in preferences for neonatal outcomes among health care professionals, parents, and adolescents. The Journal of the American Medical Association 1999;281:1991-1997. 11. Reuss MS, Gordon HR. Obstetrical judgments of viability and perinatal survival of extremely low birthweight infants. American Journal of Public Health 1995;85(3):362-66 -3 - The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186 PRESORTED STANDARD U.S. POSTAGE PAID ATLANTA, GA PERMIT NO. 4528 July 2001 Volume 17 Number 07 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for April 2001 Selected Notifiable Diseases Total Reported for April 2001 2001 Previous 3 Months Total Ending in April 1999 2000 2001 Previous 12 Months Total Ending in April 1999 2000 2001 Campylobacteriosis 40 Chlamydia trachomatis 1887 Cryptosporidiosis 9 E. coli O157:H7 2 Giardiasis 70 Gonorrhea 997 Haemophilus influenzae (invasive) 16 Hepatitis A (acute) 88 Hepatitis B (acute) 26 Legionellosis 0 Lyme Disease 0 Meningococcal Disease (invasive) 7 Mumps 2 Pertussis 1 Rubella 0 Salmonellosis 84 Shigellosis 17 Syphilis - Primary 3 Syphilis - Secondary 22 Syphilis - Early Latent 42 Syphilis - Other** 27 Syphilis - Congenital 1 Tuberculosis 61 184 128 137 8934 7583 7147 60 42 26 2 3 4 247 272 210 5527 4330 3796 22 23 35 136 69 194 46 62 86 0 3 1 0 0 0 24 16 21 0 1 5 12 12 5 0 0 0 256 222 190 68 84 65 29 39 18 65 75 62 210 159 128 215 180 142 4 8 2 115 145 127 820 27259 192 86 1280 20596 73 785 173 8 1 79 1 44 0 1920 918 122 248 841 844 19 593 645 30863 148 44 1369 21172 87 376 255 9 0 70 6 61 0 1920 287 149 292 599 732 18 668 627 31467 173 43 1141 19724 98 542 399 9 0 56 7 36 0 1688 321 105 262 514 706 15 680 * The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. ** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. Report Period Latest 12 Months: 05/00 - 04/01 Five Years Ago: 05/95 - 04/96 Cumulative: 7/81 - 04/01 Total Cases Reported* Percent Female AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 1237 26.8 28.8 9.7 1.8 10.6 1.6 47.5 2382 18.5 48.4 18.9 5.0 17.4 1.2 8.9 23011 16.8 48.4 18.3 5.6 13.0 1.9 12.8 MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section - 4 - Race Distribution (%) White Black Other 19.2 76.8 4.0 36.6 60.4 3.0 35.7 62.2 2.2