Birth trauma rates are one of the measures of hospital quality used by the Joint Commission. Recent Mayo Clinic-led research, published in the Maternal and Child Health Journal, shows that babies born at rural hospitals are more likely to experience a birth-related injury than those born in urban hospitals.

This disparity is of concern to researchers and clinicians.

To address gaps and disparities in care, the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery works with the medical practice to investigate factors that contribute to high quality, high value care.

"In order to provide care that meets the needs of patients and the overall population, there is a need to understand current outcomes, in the context of current care settings and processes," says Aaron Spaulding, Ph.D., a health services researcher at Mayo Clinic in Jacksonville, Florida, and the study's senior author.

This is not Dr. Spaulding's first study into the disparities of care and outcomes that are multi-faceted and not easily assessed. Within the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, he has led several multiinstitutional collaborations investigating differences in hospital quality outcomes between geographical settings, including the current study.

"Our work in this area seeks to understand better how communities in which hospitals reside influence hospital outcomes and vice versa," he says. "We are led by the belief that many policies attempt to use a one-size-fits-all mentality which may be inappropriate and may punish or reward hospitals based on aspects they have little control over."

Dr. Spaulding and his team hope that as they gain a better understanding of the association between communities and their hospitals, they will find better opportunities for policy or practice interventions that can make a difference. 

Babies in distress

In the current study, Dr. Spaulding, along with Hanadi Hamadi, Ph.D.; Jing Xu, Ph.D.; and Farouk Smith all of the University of North Florida, Jacksonville; and Aurora Tafili, University of Alabama at Birmingham; used Florida hospitals' inpatient data from 2013 to 2018. Originally collected by the Florida Agency for Health Care Administration, the study data included information from 125 inpatient hospitals across the state. It included information for 1,192,336 singleton births and noted up to 31 diagnoses present on admission, as well as up to 31 injury-related diagnoses for the births.

"The most notable finding of the study is that no matter your race, a rural location was associated with an increased odds of birth trauma compared to an urban location," says Dr. Spaulding.

His team is especially concerned about people of Hispanic ethnicity receiving care at a rural location, he continues, since the greatest birth trauma risk was among rural Hispanic or Latino babies.

The dataset they used only included Florida, however many states make this type of data available, which could be used for a similar analysis. It would not be unreasonable to assume that many states would show disparities between urban and rural outcomes much like those the researchers found in Florida, he says.

A possible solution to rural health care disparities at birth

Telemedicine has taken hold as a viable means by which people can access care not available in their geographic area. Mayo Clinic has been steadily implementing and evaluating a wide range of solutions to connect with patients wherever they are, and whenever they need that connection.

For babies born in rural settings or even urban hospitals with no access to neonatologists — pediatricians specializing in medical care for newborns (neonates) — Mayo's Teleneonatology Program may bridge an essential gap, leading to better outcomes following birth-related traumas like those noted in Dr. Spaulding's study.

"With this technology, we can be at the bedside of any newborn in need of critical care," says Jennifer Fang, M.D., medical director of Mayo Clinic's Teleneonatology Program.

In another recent publication, Dr. Fang describes how she and her colleagues are able to use telemedicine to remotely respond to newborn emergencies. In the paper, she notes the significant improvements in outcomes since teleneonatology consultations were integrated into the family birth centers and emergency departments of nineteen participating community hospitals. These include advancements in quality, safety and provider experience.

During a teleneonatology consult, a neonatologist at Mayo Clinic in Rochester, Minnesota, connects with the local care team in real time, via a telemedicine platform incorporating high resolution, secure audio and video capabilities.

"We are able to see and assess the infant, and guide the local doctors and nurses through resuscitation, including positive pressure ventilation, advanced airway placement and umbilical catheter placement, when needed" says Dr. Fang.

"As one of the acute care telemedicine services developed at Mayo Clinic, we were looking for a way to help more babies – even before they arrive to the neonatal ICU," she says.

"Before our teleneonatology program we would try to help via a phone call with the care team during a particularly complex delivery. But nothing compares to being able to visualize the baby, to see what the local team is seeing, and how the newborn responds in the minutes after birth and following interventions." Says Dr. Fang.

Other research has shown that approximately 10% of newborns require breathing assistance after delivery, and one in 1,000 require extensive resuscitation. These babies are much more likely to die in when delivered in hospitals with lower levels of neonatal care. Mayo's Teleneonatology Program aims to reduce that risk.

In Dr. Fang's paper, she reviews some of Mayo's program results, including:

• Substantially higher quality resuscitation for infants whose care team used the service.
• Safer care — as demonstrated by significant reduction in birth injury cases.
• Willingness to use the capability is good. In fact, 99% of providers would use teleneonatology support again — and recommend it to their colleagues.

Mayo's various telemedicine capabilities are enabled by Mayo Clinic's Center for Digital Health. Much of the research validating and evaluating new telemedicine and remote care capabilities is done in collaboration with the Mayo Clinic Kern Center for the Science of Health Care Delivery.

Next steps for researchers

Dr. Spaulding's team continues to work on topics assessing disparities, geographic location and care outcomes. Also in an effort to understand factors that contribute to healthier infants, they are assessing the value of designation under the Baby-Friendly Hospital Initiative. They hope to determine which hospital and community characteristics are associated with hospital attainment of the designation.

On a broader scope, he and his colleagues seek to better understand the effect of community characteristics and health care outcomes. For example, his team is evaluating the presence of Magnet-designated hospitals and differences in associated health care outcomes between Magnet and non-Magnet-designated hospitals. (Read a related publication, "The influence of community health on hospitals attainment of Magnet designation: Implications for policy and practice.")

"We hope to develop further our understandings of how community characteristics influence health outcomes and how hospital characteristics affect community health," says Dr. Spaulding. 

Dr. Fang agrees that more research will be helpful for her program in particular.

"If we could get this program into every rural setting, I am confident we would see positive health outcomes for babies," she says. "Research can help us determine costs and savings (a cost analysis of teleneonatology performed by the Division of Neonatal Medicine and the Kern Center is currently under review for publication), as well as quantifiable public health outcomes that can help shift perceptions among the people and agencies who oversee policies, payment, and care offerings at local, regional, state and national levels."

In general Drs. Fang and Spaulding both agree that it is high time the health care community pays attention to diversity and inclusion research and the associated attempts to improve care for all. This research sheds light on the importance of the community in which one lives, which impacts health from the cradle to the grave.

"We hope that our research can help further clarify areas of needed policy and practice intervention," concludes Dr. Spaulding. "Improved measurement of disparities and comparisons between communities and geographic locations will provide us with better tools to fight unequal access to quality care."

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