Advisory Council Improvements Will Help Mothers, Newborns

TMA Testimony by Eugene Toy, MD

House Public Health Committee
Committee Substitute House Bill 3433

Tuesday, April 21, 2015

Good morning/afternoon Chairwoman Crownover and committee members. Thank you for the opportunity to testify. My name is Dr. Eugene Toy, and I am a practicing obstetrician/gynecologist in Houston, testifying for Committee Substitute House Bill 3433 on behalf of the Texas Medical Association, Texas Pediatric Society, Texas Academy of Family Physicians, Texas Association of Obstetricians and Gynecologists, American Congress of Obstetricians and Gynecologists-Texas District, and March of Dimes. Our organizations urge you to pass the bill, which proposes additional rural representation on the state’s Perinatal Advisory Council and extends the timeframe for establishing neonatal and maternal levels of care. 

As you may recall, the 2013 legislature adopted House Bill 15, championed by then-Rep. Lois Kolkhorst and Sen. Jane Nelson, as well as Reps. Garnet Coleman; John Zerwas, MD; and Elliott Naishtat, to establish a statewide perinatal system of care. The passage of HB 15 was an important step towards improving Texas’ perinatal system. Perinatal care includes both neonatal and maternity care. More than 30 states have adopted state-level hospital designation processes for perinatal care. Two broad trends — Texas’ high preterm delivery rates and alarming increase in maternal mortality — provided the impetus for HB 15. A coordinated perinatal system, which promotes collaboration among hospitals, physicians, nurses, patients, and the state, will help improve birth outcomes. 

Texas’ preterm delivery and maternal mortality rates are above the national average. Premature babies, particularly those at less than 3.3 pounds or 32 weeks gestation, have dramatically better survival and outcomes when they are born at a hospital with a level 3 or 4 neonatal intensive care unit (NICU), the highest levels. Very low birth-weight (VLBW) babies are at risk for severe complications, including neurological impairments, hearing and vision losses, anemia, and infection. Long-term, VLBW babies also are at higher risk of developmental delays, respiratory illnesses, and sensory challenges. When born at a level 3 or 4 NICU rather than in a “well nursery,” these babies have a 60-percent better chance of survival. This is because level 3 and 4 NICUs provide the onsite pediatric and maternal subspecialists needed to intervene to either minimize or prevent complications. It should be noted that VLBW babies make up more than one-third of all neonatal costs yet comprise less than two percent of all births. The percent of VLBW babies born at level 3 or 4 NICUs is a national quality measure, with the goal being 90 percent. In 2010, only 49 percent of Texas’ VLBW babies were born in a level 3 or 4 NICU, while the national average is 74 percent.  Texas ranks at the bottom of the nation in this statistic, above only Puerto Rico. 

Over the past 12 years, Texas’ maternal mortality has quadrupled but is highest among minority women, especially African-Americans. The most recent Texas statistics are astounding and demand dramatic intervention: African-American pregnant women account for one-third of Texas’ maternal deaths. Maternal mortality cannot be placed solely at the feet of hospitals and physicians. It is much more complicated. Inadequate or no prenatal care and/or interconception care are partly to blame. Domestic violence is another. There also may be genetic factors we do not fully understand yet. But we do know that establishing a statewide perinatal system is a vital step towards improving the lives of mothers and babies. And when we look at the demographics, it is not just large metropolitan areas with maternal deaths and severe morbidity, but all areas of the state, especially east Texas.  

But even within the best perinatal systems, not all babies will be born at the facility best suited to their medical needs. Not all high-risk mothers will travel to higher levels of care before they deliver. That is why we also need level 1 and 2 nurseries to be ready for the arrival of premature babies or very sick mothers and to have transfer agreements in place to facilitate higher level of care, recognizing that hospitals must establish their own referral patterns. So the rationale for Texas’ perinatal system is a coordinated statewide system approach because these infants are born throughout the state, not only in urban areas.

Developing a system of care takes time. Since early 2014, the Perinatal Advisory Council has met quarterly and recently provided its recommendations for neonatal levels of care to the Texas Department of State Health Services (DSHS). DSHS hopes to officially propose the rules in September 2015. The Perinatal Council’s recommendations parallel national neonatal standards but are designed for Texas. The proposal provides more flexibility to hospitals than the national guidelines to accommodate the unique challenges faced by rural hospitals. At each step of the drafting process, the council obtained lively, honest, and robust stakeholder input. As a result, numerous improvements were made to the draft rules to minimize the administrative, financial, and clinical burdens faced by rural facilities. The Texas Organization of Rural and Community Hospitals, among others, was especially helpful in conveying the unique challenges in these settings. Working collaboratively with our rural colleagues, the council revised the level 1 (basic) neonatal requirements to provide the flexibility needed in these regions to take care of newborns, yet also to safeguard patient safety and quality. 

The council also recommended a level 2 “rural extended” hospital to recognize rural hospitals that can provide more advanced care than a level 2 facility but do not meet the level 3 criteria. Additionally, the Perinatal Council realizes the timeframe specified to implement neonatal standards is a bit too tight. DSHS must designate some 250 hospitals by 2017. Some hospitals will need more time to recruit physicians; others will need to structure new contracts or collaboration, fill out the application, obtain site visits, address deficiencies, and respond to queries, all before 2017.  

For these reasons, our organizations strongly support CSHB 3433, which will add additional rural representation to the Perinatal Advisory Council and delay by one year each the timeframes for implementing the neonatal and maternal standards of care. 

Our organizations also thank Rep. J.D. Sheffield, DO, for his commitment to improving care for mothers and babies and working with us to address our initial concerns with the legislation.

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May 20, 2016

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