Better prenatal care cuts NICU costs dramatically
Community partnership pays off
An ounce of prevention can be worth better health care and millions of dollars in intensive care savings when applied correctly. That lesson has been proved year in, year out over the past decade by a Eugene, OR, program that drastically reduced admissions at the Sacred Heart General Hospital's NICU.
The program began in 1988, says Martha Teich, RN, nursing service director at Sacred Heart Prenatal Clinic. "There was a real crisis here in terms of the ability of women without health insurance having access to adequate prenatal care. As a result, we had increasing numbers of women coming in through our emergency department to our delivery area and delivering babies who often were premature and sick."
As a remedy, the hospital spearheaded a collaborative program with the Lane County Health Department and local obstetricians. Now, thanks to a comprehensive prenatal program that offers low-cost care to women without insurance, the number of premature births resulting from inadequate prenatal care is down, as are NICU admissions and the number of babies exposed to substance abuse by their mothers.
Though physicians initially showed little interest collaborating in the program, changes in health care management and increases in malpractice insurance premiums for obstetricians prompted a turnaround.
Named the Lane County Comprehensive Pregnancy Services Program, of which the prenatal clinic is a major part, the collaborative project involves the following elements:
r Certified nurse midwives provide prenatal care at off-site clinics.
Under sponsorship of physicians on Sacred Heart's medical staff, the nurse midwives care for the women throughout their pregnancies and deliver babies at the hospital.
r Physicians provide care for women with high-risk pregnancies.
Recognizing the crisis level of pregnant women receiving inadequate care, obstetrical/gynecological practices in town agreed to participate in the project. The clinic contracts with physician practices to rotate clinic staffing among the practices every six months.
r The Lane County Health Department serves as the clearinghouse for referring patients to the program.
Health department staff conduct the initial lab work and an orientation to the program. Following a birth, the health department provides follow-up home visits under the county's Well Baby program. In addition, the health department offers family planning services.
The program defines "inadequate" prenatal care as a pregnant mother who:
r seeks medical care fewer than five times during her pregnancy;
r waits until the third trimester to seek medical care;
r receives no medical care throughout her pregnancy.
The financial implications for the program became evident after a study of the program in 1991. It found during 1991, 147 mothers sought care from the prenatal program. Had that care not been available to them, it would have resulted in 38 NICU admissions. JoAnne Lutz, RN, nurse manager of the prenatal clinic who took part in that study, notes that since the average length of a NICU stay then was 16 days, those 38 avoided NICU admissions would have cost more than $1.2 million.
The study also found that:
r Babies born to mothers receiving prenatal care in clinics weighed an average of 2,933 g and had an average gestation time of 38 weeks (33 to 42).
r Babies born to mothers receiving inadequate prenatal care weighed an average of 2,442 g and had an average gestation time of 35 weeks (27 to 43).
r Babies born to mothers receiving private physician care weighed an average of 2,662 g and had an average gestation time of 36 weeks (26 to 43).
Program cuts NICU admissions
Since the study, the program has "held its gains," says Lutz. While the socioeconomic status of mothers in the prenatal care program has remained basically the same - today over 50% are Spanish-speaking - NICU admissions have experienced a dramatic reduction.
"When the program was established in 1988, 4.03% of all deliveries in Sacred Heart were NICU admissions," says Teich. "Recently, we have reduced the NICU admission rate to only 0.26%." She credits the combination of prenatal care, educational lectures, and postpartum follow-ups for this reduction.
One significant addition to the original program has been the introduction of the New Start program. This program offers support services to pregnant and postpartum women who are at risk for using alcohol and drugs during their pregnancies.
New Start, which is federally funded through the Center for Substance Abuse Prevention in Rockville, MD, is based in the prenatal clinic but open to all women in the community, says Teich.
A study was conducted of pregnancy outcomes of the New Start program, comparing pregnant women in three groups: New Start members, women on public assistance, and non-New Start substance users.
Among the findings were that the mean gestational age of the infants born to women in all three groups was almost identical at about 39 weeks.
Infants born to New Start members, however, were less likely to deliver before 38 weeks than substance users who were not in the program. New Start members also were more likely than women on public assistance to deliver early because of their higher risk due to substance abuse.
In addition, the study showed:
r New Start infants in the NICU made up 7.8% of the NICU population.
r Infants born to non-New Start substance users were 13.2% of the NICU population.
r Infants born to women on public assistance were 10.1% of the NICU population.
Partners for such wellness programs can also include private concerns, such as large employers. For instance, the North Colorado Medical Center in Greeley is involved in a prenatal preventative program with one of the largest employers in the region, ConAgra Red Meats. The program involves monitoring and education, with free dinners as an inducement.
"We have seen a noticeable cost reduction in hospitalization from complicated pregnancies," says Kent McDaniel, director of benefits and compensations at ConAgra. In fact, the ranking of claims for pregnancies and sick babies has undergone a startling change.
In 1993, pregnancy claims ranked first and those for sick babies fourth. In 1996, these have slipped to thirteenth and fourteenth, respectively.
"It is fair to say that we are seeing an investment return that may be up to $10 for every dollar spent on health care cost," says McDaniel.
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