In 2011, Rick Majzun, vice president of strategic operations and planning at St. Louis
Children’s Hospital, traveled to Kenya and Sweden as an Eisenhower Fellow to study infant
mortality and the role health care organizations can play in improving the overall health
of women and children. During his visits to 14 cities in both countries, Majzun met with 90
individuals representing 50 organizations. He was introduced to leaders from hospitals
of all sizes, geographies and prosperity levels, medical school faculty and administrators,
university researchers, government officials, physicians, nurses and other clinical
personnel. What he learned, he says, was enlightening, challenging and motivating.
Infant mortality is the leading indicator of
a country’s maternal and infant health, and
since 1960, the infant-mortality ranking in
the United States has steadily worsened
when compared to the rankings of other
developed countries. Although the gross
domestic product (GDP) in the United
States is second highest in the world (the
European Union GDP is first), it is ranked
number 48 for infant mortality, according
to the World Factbook, published by the
Central Intelligence Agency (CIA). On
average, there are six infant deaths per
1,000 live births in the United States. As
with many other trends in this country, the
infant mortality rate is significantly higher
among the most vulnerable populations:
under-insured and uninsured minority
citizens residing in central cities and
remote rural communities.
Maternal and infant health care outcomes
in St. Louis city and county illustrate
this disparity. If a person standing in the
urban setting surrounding Barnes-Jewish
Hospital and St. Louis Children’s Hospital
throws a baseball one ZIP code to the
north, it will hit health care outcomes
not altogether different from those in
sub-Saharan Africa. If the ball is thrown
to the west, it will hit outcome rates
more like those in Scandinavia. (See the
Health Outcomes table on page 6.) Only
a few of the reasons for these drastic
differences in maternal and infant health
outcomes have medical causes; most
are driven by a complex combination of
social and economic issues. Among the
major barriers to healthy outcomes are
poverty, health literacy, malnutrition,
access to health care and the
transportation needed to receive it.
Health Outcomes in
Sweden and Kenya
Swedes consider health care a basic civil
right, regardless of an individual’s
socioeconomic status. In Sweden, the infant
mortality rate is three per 1,000 infants, and
the country is ranked fifth in the world for
best infant mortality outcomes, according
to the
Factbook.
In Kenya, where infant mortality is
very high—44 per 1,000 live births—
the challenges to maternal-newborn
wellness are great. Due to the scarcity
of health care facilities and a lack of
transportation to those facilities that do
exist, more than 50 percent of Kenyan
women deliver at home, with or without
a trained birth attendant.
While Kenya does offer national health
care to all children younger than age 5,
transportation to that care is costprohibitive,
even for those living in cities.
Given the significant challenges faced in
Kenya, nearly 13 percent of all children
die before the age of 5.
Improving Outcomes
According to Sweden's Ministry of Public
Health, health care is available to all of
that country’s citizens from cradle to grave.
UNICEF data pertaining to Sweden reveal that:
• All Swedish women have access to
preconception health care. A total of
98.5 percent of women in the country
attend the recommended course of
prenatal visits.
• Advanced-practice nurses help reduce
the cost of health care while improving
the continuity of care for newborns. At
birth, every child is assigned to a nursemanaged
medical home. An assigned
nurse serves as a third parent, ensuring
the child receives excellent preventive care.
• Each health care provider is measured
using a scorecard that shows his or
her performance compared with other
providers in the same city, the county and
the country. All nurses and physicians are
facile with local and national rankings.
In Kenya, local groups, some supported by
international aid, are organizing to improve
maternal-newborn health care. For example,
the “Umama Salama,” or Safe Motherhood,
program is a partnership between Lwala
Community Hospital, in Lwala, Kenya, and
the area's traditional birth attendants. The
primary intent is to encourage women
to travel to the hospital to deliver. Since
the program began, infant mortality has
improved by an estimated 50 percent.
In the United States, the Affordable Care Act
(ACA), upheld in June by the Supreme Court,
is intended to increase the total number
of insured individuals from the current
84 percent of Americans to 94 percent
within 10 years. While all pregnant women
are already entitled to Medicaid coverage
from the time pregnancy is confirmed
through six weeks postpartum, the ACA will
ensure that more women have the option to
obtain care from preconception to beyond
the postpartum period.
The Local Perspective
In St. Louis, community health organizations
and providers, convened locally by the
Maternal, Child and Family Health Coalition
and the Integrated Health Network (IHN),
are partnering in a regional initiative to seek
funding through the Strong Start for Mothers
and Newborns grant from the Center for
Medicare and Medicaid Innovation (CMMI).
The grant itself stands as an example of the
national movement toward an emphasis on
public health and prevention. CMMI offers
more than $40 million in grant funding for
initiatives aimed at reducing preterm birth,
and the regional initiative seeking funding is
composed of representatives from multiple
organizations, including several that are
business competitors.
A regional group, led by the IHN, will
work to increase the number of providers
that offer group prenatal care in St.
Louis and enhance the care offered. The
Women's Health Clinic, with 11 years
of experience offering group prenatal
services, will receive funding to improve
the existing program and will act as a
resource site for new providers.
On the campus shared by Barnes-Jewish
Hospital, St. Louis Children’s Hospital and
Washington University School of Medicine,
efforts are increasing to reduce poor
perinatal outcomes. This work includes
improved communication between
providers and patients, ongoing research
and implementation of change using
evidence-based education, and development
of partnerships with community-based
organizations and initiatives that share the
goal of improving maternal-newborn health.
Outpatient Care
The Ob/Gyn Clinic at Barnes-Jewish Hospital,
working in close coordination with community
agencies and schools, provides women with
the preconception, prenatal and postnatal care
that too often can be insufficient for vulnerable
populations. Ongoing and new programs are
aimed at improving care continuity and health
literacy, as well as perinatal outcomes for
mothers and babies.
Centering Care
The Centering Pregnancy initiative runs on a
model of group-centered health care, whereby
pregnant women receive prenatal care,
education and support in a group setting.
The Teen Pregnancy Center Ob-Gyn Clinic
at Barnes-Jewish Hospital is one venue for
Centering Pregnancy. The center implemented
this care model in 2001 and expanded to
serve low-risk adult women in 2009.
The program annually serves 150 low-risk
pregnant teens and adult women. The
center has seen a significant decrease in
rates of preterm birth and low birth weight
among participants. By using Centering
Pregnancy, the center has increased patient
satisfaction scores as compared to those
from women who are treated using the
traditional prenatal-care model.
Health Literacy Initiative
The Health Literacy Initiative, begun in the
spring of 2011, is a five-year strategic plan
to improve clear communication between
patients and health care staff within the
Barnes-Jewish Ob-Gyn Clinic.
Outpatient and Inpatient Care
The Fetal Care Center at Washington
University Medical Center is designed to
serve pregnant women and their families
whose fetus is diagnosed with any kind
of anomaly. It provides evidence-based,
patient- and family-centered, coordinated,
multidisciplinary maternal, fetal and
pediatric care for all who need it.
Barnes-Jewish Hospital, St. Louis Children’s
Hospital and Washington University School
of Medicine provide and are continuously
working to improve world-class health
care for both low- and high-risk births
and newborn inpatient care. These
entities participate in ongoing training to
implement the patient- and family-centered
care model, improve cultural competency
and participate in training that emphasizes
the use of best evidence to inform practice.
Women and Infants Services at Barnes-
Jewish Hospital supports communityoutreach
programs, including health fairs
and educational events for both health
professionals and the broader community.
Additionally, health care professionals at
St. Louis Children’s Hospital continuously
work to improve existing programs and
implement new community-outreach
initiatives, including the successful asthma
and dental mobile outreach initiatives, as
well as a variety of safety-related programs.
Improving Care Through Research
The Women and Infants Health Specimen
Consortium (WIHSC) collects specimens and
patient medical data longitudinally throughout
gestation from the mother and, after delivery,
from the infant. These mother-infant sets of
data are recorded, stored and made available
to investigators. The consortium has formed
the central infrastructure critical for the
Washington University academic community
to actively engage in research focused on
many of the clinically important issues
in women's health. Those issues include:
pregnancy-specific reference intervals,
pre-eclampsia, recurrent pregnancy loss,
preterm delivery and other adverse pregnancy
outcomes, many of which are more common
in and lead to worse outcomes among the
underinsured and uninsured.
Resources
CIA Factbook:
https://www.cia.gov/library/publications/
the-world-factbook/index.html
Center for Medicare and Medicaid Innovation:
http://bjhne.ws/cw
Fetal Care Center:
fetalcare.org
St. Louis Maternal, Child and Family
Health Coalition:
http://bjhne.ws/cx
Umama Salama:
http://bjhne.ws/cv
Women and Infants Health Specimen Consortium:
wrhr.wustl.edu/wihsc