Photo: Dr. Jeff Livingston, medical director for the ECU High-Risk Pregnancy Center examines patient Lashonda Bowers of Williamston.
Photo: Dr. Jeff Livingston, medical director for the ECU High-Risk Pregnancy Center (and Director of Maternal Fetal Medicine at ECU's Brody School of Medicine in Greenville), examines patient Lashonda Bowers of Williamston.

Doctors at a clinic at East Carolina University’s Brody School of Medicine have spent two decades trying to bring down the rate of preterm birth in the eastern part of the state, where infant mortality is higher than the state average.

This “classic” story was originally published June 12, 2012. It has been updated to reflect changes in funding.

By Amy Ellis

Nothing in the small, windowless waiting room of the East Carolina University High-Risk Pregnancy Center gives a clue of the state-of-the-art medical expertise found inside.

The threadbare wooden furniture in the dimly lit waiting room seems as if it hasn’t updated since the Greenville-based clinic was established more than two decades ago. But the facility boasts the only four obstetricians in Eastern North Carolina who specialize in maternal-fetal medicine, a sometimes high-tech subspecialty that requires years of extra training beyond traditional obstetrics.

Photo: Dr. Jeff Livingston, medical director for the ECU High-Risk Pregnancy Center (and Director of Maternal Fetal Medicine at ECU’s Brody School of Medicine in Greenville), examines patient Lashonda Bowers of Williamston. Photo by Amy Ellis.

Since its creation in 1988, when North Carolina ranked dead last in the nation for infant mortality, the center has provided frontline care and high-level access for women with high-risk pregnancies in the region. And it’s done so with the aid of state funding until 2011, when the legislature failed to renew its annual grant of $325,000.

Clinic leaders were forced to lay off staff and cut services.

During the past two budget years, the state’s Child Fatality Task Force urged lawmakers to restore support for the clinic. And Task Force support was crucial in having $375,000 allocated in last year’s and this year’s budgets, enough to restore staff and services.

That money is about the same amount one preterm birth costs the state’s Medicaid program.

“We support a package of key programs that work together to help babies to be born healthy and make it to their first birthday,” said Elizabeth Hudgins, executive director of the CFTF, a legislative study commission that promotes equity in birth outcomes. “Our focus with the ECU High Risk Pregnancy Center is to preserve services in Eastern North Carolina, where infant mortality rates are far higher than the state average.”

“With the loss of funding for the clinic [in 2011], wait times to see a doctor increased, outreach clinics were closed, and copays for procedures such as ultrasounds often imposed barriers to pregnant women getting the services they needed,” Hudgins said.

Poor region, poor outcomes

Infant mortality rates in Eastern North Carolina have always been the worst in the state; they’re currently three times higher than the state average of 7 deaths per 1,000 live births.

The ECU clinic backs up all private obstetrical offices in the 29 counties east of I-95.

Infant mortality rates in NC have declined steadily since 1980. Graph courtesy the March of Dimes

In most of those counties, the majority of babies are born to women on Medicaid, the state and federal program that provides care for disabled, aged, and some low-income people. However, changes in reimbursement in recent years have left fewer private providers willing to accept Medicaid, which pays for prenatal care and births to low-income women who otherwise might not be eligible for the program.

So many pregnant women in eastern North Carolina get their care from local health departments, who then refer complicated patients to the ECU clinic, where Medicaid is the biggest payer.

The region has a large population of childbearing-aged women, as well as high concentrations of multiple risk factors for complicated pregnancies. Experts attribute the high rates of infant mortality to many issues, including the poor overall health in that region. It’s an area plagued by obesity, diabetes and smoking. Poverty and poor education, are prevalent. And the region’s rural nature – long distances to health care providers, lack of transportation, and poverty – often translates into limited or delayed access to care for many residents.

Perhaps even more striking are the tremendous inequities based on racial differences within the region. African Americans in eastern North Carolina are 2.3 times more likely to be born early or die in the first year of life, a statistic unchanged since the 1940s explained Dr. Jeff Livingston, Director of Maternal Fetal Medicine at ECU’s Brody School of Medicine.

Livingston said socioeconomic differences, shorter times between pregnancies, and lack of breastfeeding among African Americans all affect outcomes. But long-standing attitudes of racism, and social barriers in Eastern North Carolina can’t be ignored if change is to happen. Even still, Livingston said there are some differences in outcomes that can’t be explained by income, education, or insurance coverage.

“This isn’t something people can educate themselves out of,” he said. “Black college graduates have poorer rates than white college graduates. Ethnicity plays a bigger role than education. We don’t know why.”

He notes Hispanic birth outcomes in North Carolina are the same as Caucasian outcomes, despite Latino tendencies toward more teen pregnancies and less insurance coverage.

US births, developing world statistics

The robin’s-egg-blue hallway of the ECU clinic hints at the impending new life that’s passed through it, including more than 7,300 patient encounters just this year. Some of these patients suffered from heart or kidney disease, diabetes, high blood pressure, cancer, HIV. Some were experiencing preeclampsia (dangerously high blood pressure that can kill a pregnant woman) or preterm labor. Others were expecting multiples, or babies with birth defects.

Lashonda Bowers of Williamston, 27 weeks pregnant, has been through three preterm deliveries under ECU’s care. Her last four children, including a set of twins, were born between 29 and 31 weeks of gestation. All are healthy.

Babies born early often need extensive care in high-tech neonatal intensive care units. Photo courtesy Matt&Janet, Flickr Creative Commons

“I thank God for this clinic,” she said. “Without them, I’d have nowhere to go, because my clinic couldn’t do anything more for me. I hope the state doesn’t give up on them, because we sure need them. They’ve saved so many lives.”

So far, funding hasn’t permitted ECU to track clinic-specific outcomes, but proponents of the clinic cite the overall decline in statewide infant mortality rates – roughly 40 percent since 1988 – as proof that existing measures are working. They worry continued funding cuts will undermine the progress that’s been made.

A continued lack of state funding will force the clinic to drastically reduce its capacity, said Livingston. “More expectant mothers with high risks for birth complications would have nowhere to go, or we’d see them later in their pregnancies. The result: more women getting the wrong care, from the wrong providers, at the wrong times, in the wrong places.”

Preterm birth is defined as being born before 37 weeks of gestatiion. Doctors at the High Risk Maternity Clinic attempt to keep women carrying their pregnancies to term. Graph courtesy the March of Dimes.

That’s a grim outlook for an underserved region where infant mortality rates still rival those of some developing countries.

“In a state where we have so much medical expertise, it’s a shame that one part of the state, and specifically one portion of that population, experiences such disparity in birth outcomes,” said Rob Thompson, executive director of the Covenant with North Carolina’s Children, a coalition of child advocacy groups. “There are some deep-seated issues that need to be addressed. The important thing to remember is that infant mortality is the best indicator of women’s health in general. We have to take a broader look at what our state is doing to promote women’s health overall.”

Thompson stressed the importance of timing in prenatal care.

“Two or three weeks can be an eternity when you’re trying to prevent a preterm birth,” Thompson said.

He noted the state will be caring for any preterm babies born with Medicaid as their only insurance, so regardless of moral reasons for funding the clinic, it makes financial sense to do so.

“If they can prevent just one preterm birth, it’s worth it,” Thompson said. “It’s much less expensive to prevent preterm births than to provide the treatment necessary for babies born early.”

Thompson described North Carolina’s infant mortality history as “abysmal.” He said the ECU clinic is a “critical piece for preventing our rates from worsening, and for possibly making them a little better.”

“It’s serving the most at-risk patients in Eastern North Carolina that local health departments aren’t equipped to handle,” Thompson said.

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