Rural Maternal Health Series: Obstetric Readiness in Rural Facilities Without Birth Units

Featured Speakers

	Dr. Lisa Hollier, Senior Medical Advisor on the Maternal Mortality Prevention Team in the Division of Reproductive Health, Centers for Disease Control and Prevention (CDC)
	Christie Allen, Senior Director, Quality Improvement and Programs, American College of Obstetricians and Gynecologists (ACOG)
	CDR Tina Pattara-Lau, M.D., FACOG, Maternal and Child Health Consultant, Office of Clinical and Preventive Services (OCPS), Indian Health Service (IHS)
	Katherine Craemer, MPH, Senior Research Specialist, Center for Research on Women and Gender at the University of Illinois at Chicago

Rural facilities that no longer provide planned maternity care face challenges in providing safe, high-quality services to pregnant, birthing, and postpartum people who arrive needing care. Presenters will share innovative work that puts foundational skills, teamwork, and equipment in place to be ready and responsive to their patients' needs. This is the fourth in a webinar series on improving maternity care in rural healthcare settings.

From This Webinar

• PowerPoint Handout
• Listen to or download an audio version [MP3]

Transcript

Kristine Sande: I'm Kristine Sande, and I'm the program director of the Rural Health Information Hub. I'd like to welcome you to today's webinar, and this is the fourth in a series of webinars that we're hosting in collaboration with the Federal Office of Rural Health Policy on rural maternal health issues. In today's webinar, we'll focus on obstetric readiness in rural facilities without birth units. We have provided a copy, a PDF copy of the presentation on the RHIhub website, and that's accessible through the URL that's on your screen. And with that, I will turn it over to my co-host from the Federal Office of Rural Health Policy, Dr. Kristen Dillon. Dr. Dillon.

Kristen Dillon: Thank you. Thank you. Good morning, good afternoon. So thank you all so much for joining us today. We can tell from the over a thousand of you who've registered for one or more of these webinars that there's a strong commitment across our country to transform our rural healthcare system for safer, higher quality care, and better outcomes across pregnancy, birth, postpartum, and the newborn period. I want to thank today's speakers as well as my colleagues from within the US federal government's Department of Health and Human Services and also our partners at Rural Health Information Hub for contributing to this series. Here at the Federal Office of Rural Health Policy, we have a role in improving health and healthcare for the one in five Americans who live in rural areas. So many of us are watching with alarm as the landscape from maternity care in rural communities changes. Based on recent CDC data that you'll be seeing some of today the rates of maternal death have risen over the past 30 years, and death rates as of 2019 were highest in rural communities and small towns.

In rural communities, the risk of death was nearly double that of the lowest-risk group, which was residents of suburban communities. This happens in a context where many rural birth units are closing, impairing access to optimal care, and it's for this reason that this fourth installment in our series focuses on strategies for hospitals that do not have birth units, how they can define and train to a scope of care that will optimize outcomes for pregnant, birthing, and postpartum patients who arrive for care. Here in our office, we see the many struggles that rural hospitals and healthcare providers face: finances, workforce, technology, extreme weather events, changing demographics. We understand all of the factors that compete for your time and attention, and that's why we're so grateful that so many of you have chosen to join today to learn, and then we hope to improve and demonstrate your capacity to provide maternity care that's high quality, safe, and patient-centered.

It's my pleasure to introduce our speakers for today's webinar. Dr. Lisa Hollier is the senior medical advisor on the Maternal Mortality Prevention Team in the division of reproductive health at the Centers for Disease Control and Prevention. She received her doctorate in medicine and master of public health from Tulane University. She completed her residency in OB-GYN at Baylor University Medical Center and a fellowship in maternal-fetal medicine at University of Texas Southwestern, both in Dallas, Texas. Dr. Hollier is a past president of the American College of Obstetricians and Gynecologists. She remains clinically active outside the CDC, seeing patients at a large federally qualified health center.

Commander Tina Pattara-Lau is the maternal and child health consultant with the Indian Health Service (IHS) Office of Clinical and Preventive Services. In this role, she serves as subject matter expert for the IHS, develops national programs and policies, and collaborates with federal and community resources to optimize patient access to quality care. She began her IHS career in 2015 as an OB-GYN, providing comprehensive care to the American Indian/Alaska Native community at Phoenix Indian Medical Center, Parker and Peach Springs Indian Health Centers, and Valleywise Health Medical Center. During the COVID-19 pandemic, she developed modified guidelines for OB-GYN care, including delivery of telehealth prenatal care, vaccine education, and multidisciplinary simulation training for obstetrics readiness in emergency departments known as ObRED. Commander Pattara-Lau graduated from the University of California, Berkeley, with degrees in molecular and cell biology and psychology. She commissioned into the U.S. Public Health Service in 2007 and received her medical degree from the Uniformed Services University of the Health Sciences in 2011. She completed her OB-GYN residency at the Naval Medical Center in San Diego, is board-certified, and a fellow of the American College of Obstetricians and Gynecologists.

Christie Allen is the senior director of quality improvement and programs at the American College of Obstetricians and Gynecologists and provides clinical support to and supervision of national patient safety and quality improvement efforts for people who seek obstetric and gynecologic care. A nurse by background, Ms. Allen has worked in obstetrics, neonatology, and quality improvement for over 25 years and holds a degree in health policy. Ms. Allen has also served as the project director of AIM since 2019.

Katherine Craemer is a senior research specialist at the University of Illinois at Chicago Center for Research on Women and Gender. She's been working on research programs and evaluation for the past seven years in both Illinois and Wisconsin. Kate is the project manager and co-principal investigator for the development, pilot, and statewide implementation of the Maternal Health Emergency Department Toolkit that provides maternal health education to emergency departments and promotes engagement between hospital service lines.

So with that, I will turn it over to our first speaker, Dr. Lisa Hollier, take it away.

Lisa Hollier: Thank you so very much. It is a privilege to be here today to start this important discussion. I have no potential conflicts to disclose. The CDC Division of Reproductive Health has two surveillance programs for pregnancy-related mortality, the Pregnancy Mortality Surveillance System, or PMSS, and Maternal Mortality Review Committees, or MMRCs, as noted here. I'll present data from both of them today. A pregnancy-related death is defined as a death that occurs during pregnancy or within a year of the end of pregnancy from any cause related to or aggravated by the pregnancy. PMSS identifies and reviews deaths occurring during pregnancy and up to one year after using death records and linkages. PMSS provides national estimates for pregnancy-related mortality ratios. MMRCs seek to provide a deeper understanding of maternal mortality through understanding the contributors to death and developing and prioritizing recommendations that may reduce future deaths. MMRCs like PMSS use vital records, and they use medical records, social service records, mental health records, autopsy, and in some cases, informant interviews.

MMRCs are multidisciplinary committees including representation of diverse expertise to maximize the use of the broad array of data sources in MMRC decision-making. Because of the broad data sources and expertise, MMRCs can increase our understanding of both the medical and non-medical contributors to death and identify specific prevention opportunities.

First, I'll present data from PMSS. This graph shows trends in pregnancy-related mortality ratios between 2000 and 2019. We have not seen improvement over this time period. Some of the increases may be due to better ascertainment. Considerable racial ethnic disparities in pregnancy-related mortality exist in the United States. With the 2019 PMSS data, CDC released information for Native Hawaiian and other Pacific Islander persons as a separate race category to improve the documentation of the disparities that need to be addressed. During 2017 to 2019, the pregnancy-related mortality ratios were 62.8 deaths per 100,000 live births among non-Hispanic, Native Hawaiian, and other Pacific Islander persons. 39.9 deaths per 100,000 live births among non-Hispanic, black persons, and 32 per 100,000 live births among non-Hispanic, American Indian/Alaska Native persons. You can see the other pregnancy-related mortality ratios here. This graph shows the pregnancy-related mortality ratios by urban-rural classifications, metropolitan counties, large central, large fringe, medium, and small can be considered urban, and micropolitan, and non-core counties as rural. During 2017 to 2019, the pregnancy-related mortality ratios increased with increasing mortality. Next, I'll present data from MMRCs.

The next slides include data on 1,018 pregnancy-related deaths occurring from 2017 to 2019 among residents of 36 states shown here on this map. 53% of pregnancy-related deaths occurred one week to one year after the end of pregnancy, a time when most individuals would've left the hospital. These are the most frequent underlying causes among the pregnancy-related deaths. Only the 10 most frequent causes of pregnancy-related deaths are shown here on the slide. More than 80% of the pregnancy-related deaths were related to the following seven categories. Mental health conditions at 23%. This category includes deaths due to suicide, unintentional or unknown intent, overdose or poisoning, and other deaths determined by the MMRCs to be related to a mental health condition. Hemorrhage at 14%, cardiac and coronary conditions, which includes conditions like MI and aortic dissection at 13%, infection, thrombotic embolism, and cardiomyopathy at 9% each and hypertensive disorders of pregnancy at 7%.

MMRCs determined that with one or more reasonable changes to patient family provider facility system, and/or community factors, 84% of pregnancy-related deaths had at least some chance of being prevented. I have focused on pregnancy-related mortality data, and I wanted to add additional data from authors outside the CDC, more specifically addressing severe maternal morbidity and facility delivery volumes. This is a paper from Katy Kozhimannil and colleagues published last year. Their objective was to assess associations between obstetric volume and severe maternal morbidity in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients. This retrospective cross-sectional study used vital statistics and patient discharge data from four states, with dates ranging from 2004 to 2020. The authors' caveat that while this is not a nationally representative sample, these states make linked data available and reflect a diversity of geography, socio-demographic characteristics, and healthcare systems.

This results table focuses on hospitals located in rural counties, including both micropolitan and non-core counties. After adjusting for clinical and patient characteristics, the risk ratios for both low-risk and higher-risk patients were elevated at lower-volume facilities compared with rural hospitals with more than 460 births a year. Associations between birth volume and SMM were more pronounced for low-risk patients at rural hospitals. For these patients, the risk of severe maternal morbidity more than doubled for patients giving birth at the lowest-volume hospitals. These findings suggest a need for tailored quality improvement resources for rural hospitals, rural clinician training, and establishment of referral or transfer networks for rural hospitals to continue to improve obstetric patient safety. Now I'll transition to my colleagues. Thank you.

Christie Allen: Thank you, Dr. Hollier, and thank you everyone for having me today. I'm really excited to be back with you to talk about the Alliance for Innovation on Maternal Health or the AIM Technical Assistance Center's Obstetric Emergency Readiness Resource Kit. It's quite a mouthful, but I'm hoping to give you sort of the high-level overview of what that looks like and the context for it today. For those that aren't familiar or weren't on our last call where we discussed AIM's TA Center, it is a cooperative agreement we hold with HRSA, the federal government at ACOG, and we work to provide technical assistance, engagement opportunities, and data strategy for state teams to support hospital teams that are implementing inpatient safety bundles.

The inpatient safety bundles are structured ways of improving processes of care and patient outcomes. They are descriptive, not prescriptive, so they're not going to tell you how to treat a condition, but they prepare folks for giving the care that's needed with specific clinical conditions that Dr. Hollier touched on that we know contribute to maternal mortality and morbidity in the United States. They have collections of evidence-informed best practices, and they address, like I mentioned, those clinical conditions that are specific. For those that aren't familiar with the AIM Core patient safety bundles. These are the bundles. There are eight. They cover the conditions that were discussed as causes in the previous talk, including substance use disorder.

Primary cesarean is one we're seeking to reduce, severe hypertension in pregnancy, obstetric hemorrhage, perinatal mental health conditions, postpartum discharge transition, which we know is a vulnerable time for those who've given birth, cardiac conditions in obstetric care, as well as sepsis in obstetric care. So one frequent ask that I've had in my time with the AIM program and at ACOG has been for an emergency room bundle to address perinatal emergencies in settings that don't typically provide obstetric care.

The typical asks include things that you all are pretty familiar with, I would imagine, and we'll hear more about today. Trainings, resources, a basic grounding in obstetric care for non-obstetric clinicians, as well as training and readiness for obstetric emergencies.

So why don't we have an emergency room or emergency department bundle? There are limitations to patient safety bundles, which are a tool, and they have to be addressed to identify those needs. The needs in obstetric emergency are different because they extend past areas that typically would have obstetric quality improvement support. The bundles are best implemented by folks that do obstetrics and do quality improvement around that work. The bundles are typically limited to one clinical condition, which the needs in an emergency department that they may encounter are never at one condition for any patient. There's a wide variety. It is not homogenous. And then there's a need for development of infrastructure that outstrips the typical bundle because we don't have the structures in place to implement like we would with a patient safety bundle.

So that brings us to resource kits, and this is the differences that I'm going to touch on briefly so folks understand why it's not an AIM bundle per se. So resource kits are curated collections of best practices, resources, and planning materials. These are for folks to use across settings of care. They're constructed with multidisciplinary subject matter experts just like bundles are, and they're intended to support and augment bundle implementation. They're targeted efforts in response to needs we've heard about on the ground. They're for specific populations, so in this case, folks that may present with obstetric emergencies, and they're for settings that may not be fully addressed by other patient safety bundles. So this is just breaking down what I just talked about, the difference between a patient safety bundle and resource kit, and it's just putting sort of a finer point on it for someone who may be jumping through slides as opposed to listening to me talk.

So current AIM resource kits that exist, we have the Obstetric Emergency Readiness Resource Kit, which I'm going to jump into. We are shortly going to be publishing a community birth transfer resource kit. This is specific for births taking place at home or at a birthing center and those transitions to the hospital to allow for patient-centered and safe transitions, as well as the maternal early warning system implementation resource kit, which is applicable to pretty much all clinical care settings. It's settings of vital signs and how to implement those to catch conditions that may be progressing and/or are causing significant harm in a timely manner. So you can see the little icons here that may not make as much sense to you as they do to me, but all of the resource kits are intended to complement a variety of bundle implementation including community birth and maternal warning signs are for all of the bundles.

OB emergencies does not touch on reduction of safe primary cesarean because that is not typically a leading consideration in the areas that need the attention from this resource kit.

So the bundles revolve around a framework of five Rs. I'm going to just briefly discuss because the resource kit does too. So readiness, recognition and prevention, response, reporting, and systems learning, and then respectful, equitable, and supportive care, which is also interwoven in the other four R's.

So coming to the kit, I'm going to show you some examples from the kit and sort of how it's intended to be used. So the goals, as I mentioned, we're supporting planning and establishment of readiness for obstetric emergencies in non-obstetric settings. It is not, and I'm going to say this probably more than once, intended as a response manual. It is not a real-time response manual. Instead, it's intended to allow a framework to be prepared when emergencies do present, and it does follow that five R framework I had mentioned.

For anyone who's interested, it is free and widely available on saferbirth.org. It's also available if you want to use your phone to scan. That'll take you directly to, or device, it'll take you directly to the webpage, and it can be downloaded in its entirety, which it's substantial, or in sections, which I'm going to touch on in just a moment. So as you can see here, the table of contents, like I mentioned, is somewhat extensive, and there are appendices that also accompany each of those sections at the bottom that also have additional resources, which I will go over briefly. The picture, there is a screenshot from the website, so you can choose individual sections to review.

Within the resource kit, you'll see that we have these resources with a little icon. Those are curated tools that are immediate tools or items that can be used in implementation. You don't need to build something from it. It's readily available, typically free, easily accessible online, and can be used for implementing work either for staff education or for readiness. And there are some AIM-developed tools and non-AIM-developed as well.

There are also examples. Now, these are tools and samples that were actually already used in other places and were developed sort of as outlines, guidelines, or input on what you may need to develop to meet the needs in your community. You can see here this is comprehensive drills and simulations that was developed for the state of Vermont, which really runs the gamut from an academic center all the way to critical access hospitals. Again, the readiness kit also addresses these specific clinical conditions that I touched on in the beginning of the conversation, and there are sections that can be broken out. As you can see, readiness is one. This is a screenshot directly from our website, so it should look like this if you go there. If you click on that, it's going to take you to the specific section.

So this is an example of what it looks like in the resource kit. So this is information, policies, and different pieces that can help folks get ready to provide care in an obstetric emergency, and it's hyperlinked out to each of these, so there's no sort of the Google and hoping for the best. It provides a little more structure than that and some context as well. This is another example. As I mentioned, for specific clinical conditions, we broke out response by those because there are the general concepts of response to an emergency, and then there are specific ones that your facility may need to focus on based on acuity, based on need, or based even on the limitations within the community to address those needs.

These are the examples specific to perinatal mental health conditions. So it talks about screening tools. It gives some clinical takeaways at the top as well as background with some statistics. It defines what we mean by perinatal mental health conditions and then provides tools, resources, and examples that may be useful and meaningful in the implementation in non-obstetric settings.

There are also, as I mentioned, appendices and algorithms. These link out. There are things that are printable, like algorithms that have been developed by ACOG in collaboration with the CDC on cardiovascular disease and hypertension. These are more treatment-specific, and some others that we have developed as well. Checklists, flow sheets that can be used in a hemorrhage, suggestions for what should be in a hemorrhage cart in a facility that may not have access to that already, and those are all free and available for downloading and printing.

A couple just quick points to touch on that support that OB readiness kit because, as with the bundles, a kit is a tool, so we always need implementation supports. We did host last year a community of learning, so eight shared learning sessions that were reported. One was specific to OB emergency readiness. We had a wonderful attendance to that, largely led by emergency department nurse managers. So these are recorded. They're available on the AIM Vimeo channel, and they are a great way to get started in learning or in planning for OB readiness. We also have a drills and simulations manual that is currently available for hemorrhage and hypertension on the AIM website. We are in the process of, excuse me, developing emergency department OB readiness drills and simulation scenarios that are specific to non-obstetric settings. And those are being facilitated by an OB physician who is formerly a labor and delivery nurse and an expert in simulation. Those should be available within the next few months on the AIM website. We also offer technical assistance presentations monthly through the AIM program that anyone is welcome to join any hospital, any group, anyone who's interested, and they tend to do deep dives on subjects that are specific to patient safety bundles but also obstetric readiness. Those are also recorded and available on Vimeo.

And then we've recently launched patient safety bundle learning modules. These are free and available for CME/CE credit on the health stream learning platform. Also, on ACOG, if you don't happen to have access to HealthStream. ACOG's website has them as well linked out from our webpage. There's a bundle for each of those clinical conditions, and then a module for each of those bundles. They are closed caption and available for learning to better understand the clinical conditions and why we're addressing them, and how.

We also have some, you heard Dr. Hollier mentioned, pregnancy-related versus pregnancy-associated. We recognize that language is hard and complex. AIM developed a few three to four-minute videos that talk about specific definitions that are related to data and implementation on maternal health work. If that's not your background, these might be really useful for you. Introduction to Maternal Morbidity, Introduction to NTSV Cesarean Birth Rate, what the NT and the S and V stand for, as well as Introduction to Maternal Mortality Data, with the terminology I just mentioned.

Then we have a podcast, if you haven't gotten enough of my voice yet. We do have an AIM for Safer Birth podcast, and the first season's fully recorded and published. It touched on the integration of equity in maternal health into quality improvement, and we have a second season coming soon with a few episodes in there that are specific to rural maternity care. Finally, we have the urgent maternal warning signs. These are actually a patient-facing resource that are available on the AIM website. There are 39 plus languages, and these are downloadable and printable for use in facilities. Some folks have even loaded them into their EMRs or their medical records to give at discharge.

These allow patients to understand basic conditions and symptoms that they may want to report to a clinician and how to do that. They are also accessible through Badge Buddies. There's a download there that allows clinicians, nurses, physicians, and folks at the bedside to have patients scan it with their phone, and it will be a little icon on their phone so they can access this at any time, even if they lose their discharge handout.

So I just wanted to make you aware of some of the resources that support some of that obstetric readiness in real and tangible ways. You can see here our AIM website. And please feel free to reach out with any questions. We're always happy to support you in your work and appreciate what you're doing.

Tina Pattara-Lau: Thank you, Christie. And thank you all for the opportunity to share our IHS approach to care and maternity care deserts today. As mentioned, I'm an OB-GYN and provide care for indigenous communities in both urban and rural settings for the past eight years. We used to fly actually with the LARC and contraception in the backpacks to reach some of the reservation sites. I'll briefly review some background that informs IHS work and note that the data may refer to gender-specific pronouns, but IHS includes all birthing persons. As Dr. Hollier shared a CDC report from the state, MMRCs found that 93% American Indian/Alaska Native pregnancy-related deaths are preventable, about 64% are postpartum. Leading causes of death include mental health conditions, including death by suicide, or overdose, and hemorrhage. And so many American Indian/Alaska Native families reside in rural communities. About 13% deliver in maternity care deserts.

One in four women do not receive adequate prenatal care. About one in four babies are born in areas of limited or no access to maternity care. In August, the March of Dimes reported that more than one-third of U.S. counties are considered maternity care deserts, and birthing units continue to close. Also, while data do not always provide us with the full story, we must acknowledge that there are systemic gaps and barriers to care before, during, and after pregnancy that contribute to these inequities. And again, just to break down IHS, a federal agency that provides healthcare to 2.8 million American Indian/Alaska Natives from 574 federally recognized tribes in 37 states. We are divided into 12 geographic service areas, as shown on your screen, providing care in three types of health systems, first being federal, second being tribal, third being urban Indian clinics, which are about 60 to 70% of indigenous communities in urban centers.

And so the populations and places we serve are very unique. And I often, of course, ask why is it important? What does it matter? And so we see that indigenous and rural areas face challenges and changes in healthcare before the rest of the country. And as Christie mentioned, our approach is not one size fits all. So please take this opportunity to learn from our experience and use what works best for your communities.

This is a map of the United States from the March of Dimes, which will help illustrate the challenge that IHS faces with access to care. And the red counties represent maternity care deserts, i.e., no hospitals providing OB care, no birth centers, OB/GYN, and midwives. It's about 26% of American Indian/Alaska Native births occur nationally at one of the nine IHS facilities represented by the blue stars or one of the 11 tribal facilities represented by the green or gray stars, many of which border low-access for maternity care deserts.

And so that tells us about the three out of four American Indian/Alaska Native births occur outside IHS communities, which speaks again to the need to share a culturally sea of practices. I've been fortunate to travel to five of the seven states where IHS provides delivery care over the past year and a half. On the left, a picture of the interior of Alaska, the Tanana Chiefs Conference service area, which is about the geographic size of Texas. We visited Fairbanks with the American Academy of Pediatrics, knowing that they provide services to 37 villages, 12 of which are accessible by road. They maintain care through a spoken hub model, which utilizes community health aids and telehealth, with recent expansion of broadband where available. And on the right, this is a photo driving through rural South Dakota, about 600 miles round trip, but patients will actually drive between one to two hours, depending on weather conditions, just to obtain delivery services.

IHS has maintained OB care in these rural sites using a collaborative approach with midwives, family practice providers, and indigenous community programs.

This illustration is presented here with permission and credit to our neighbors in Canada at the First Nations Health Authority. And it is important that our initiatives lead with cultural safety and humility, which means the need to transform the system to be led by and for the people it serves. I acknowledge I speak to you today from the ancestral lands of the Tongva and Acjachemen communities, we must understand that the effects of historical trauma, including systemic racism, can last generations. And together with adverse childhood experiences and social determinants of health such as transportation or access to clean running water disproportionately affect indigenous birthing persons. And this can contribute to the high rate of comorbidities, including mental health conditions, substance use, or, as we see recently, congenital syphilis. And so we acknowledge this history contributes to mistrust and avoidance of seeking care within institutionalized systems. As a non-native provider, it's important to practice openness, curiosity, and humility to build trust in the community. And we're also intentional about lifting up indigenous voices in our work.

I'll briefly share three programs that address maternal care in indigenous and rural communities with you. First, in response to the closure of rural labor and delivery units and the decline in birth volume nationwide, we have developed the Obstetric Readiness in the Emergency Department, or ObRED Manual and Training. This is a collaborative, multidisciplinary team effort across areas. This program provides sites without OB services with checklists, quick reference protocols, and training curriculum for safe triage, stabilization, and transfer of pregnant, postpartum patients, and newborns. Over 25 IHS sites have contributed to or implemented ObRED, and 225 staff have been trained. The demand continues. Within IHS, we'll be, actually just found out today, working with Arizona, up in Minnesota, Montana, and New Mexico to expand this work. The manual is currently undergoing internal review, and we hope to share this resource with our partners.

Just examples from the manual for you on the left. Readiness checklists for your site, do you have the space, personnel, equipment, medications to provide safe care for pregnant postpartum patients? And then, on the right, a partial list of equipment needed to again provide safe care in your inner OB kits.

I really do like this slide. It was developed in collaboration and led by one of our emergency medicine physicians and nursing who asked for just quick reference protocols in this case, emergency treatment for postpartum hemorrhage. I'm sorry. So step one, placing the Foley catheter. Step two, addressing uterine atony, and so forth. And just something again that can be kept in a binder along with the OB hemorrhage cart.

We've been fortunate to lead training, as I mentioned, at five different sites. On the left, there's a picture of what was actually a nursing-led initiative at Phoenix Indian Medical Center. In the middle there, that's the helipad at Pine Ridge in South Dakota, which is about 40 minutes by helicopter and one and a half hours by ground Rapid City, which is their next level of care. And on the wall there, they actually have a system that connects them through Avera with a 24/7 consultation to emergency department physicians and nurses who can help them with emergencies such as trauma and, of course, obstetric emergencies.

And we've again been doing this training over the last several years, and we're able to survey over 100 staff in Phoenix, who, along the X-axis there, reported on their confidence levels with OB triage, delivery management and complications, newborn care, and the overall value of the simulation. And you can see in the blue bars before simulation and the orange bars after simulation, they did have a consistent increase in self-reported confidence, and again, which is why we've received numerous requests from sites to continue this work.

And then second, to promote maternal safety in rural communities. It's important to provide that trusted prenatal care close to home and shared decision-making model for a planned delivery site. So this is a visual presentation with patient's prenatal care pathway through the pandemic, which may be familiar to many of you who work in rural communities. And this pregnant person that we cared for visited seven groups of providers among four sites, including the emergency department and primary care clinics. And this model required them to take time off of work and coordinate transportation appointments across town. And although there's prenatal care close to home, then they must travel to deliver at a site with labor and delivery. And so we must ask, is this model working for patients and families? And if not, how can we begin to change the system?

And with inspiration from and credit to our colleagues in the VA, they do not provide maternity care services directly but often refer out. They've been able to support their pregnant and postpartum patients through a model of telehealth, which has resulted in increased patient satisfaction, improved outcomes, and importantly, about a 60 to 70% return rate postpartum back into the VA. And we know that that is a critical gap in maternity care.

So IHS is actually adapting the maternity care coordinator MCC program to increase access to culturally safe care during, again, pregnancy and postpartum. And so we'll utilize telehealth and home visitation to increase screening education intervention, as well as support for referrals and communication with tertiary care centers, especially around the time of delivery. We'll also pair this with referrals such as self-monitoring blood pressure, which, again, during the pandemic, was able to discharge a patient home and standard of care to return back for a blood pressure check in one week. If they had a cuff at home, they were able to actually take the values and trend themselves, and I could again touch base over the phone to follow up. Our patients really appreciated this extra flexibility.

This program will be led by, I apologize, trusted community leaders to extend care beyond the 15-minute appointment and also pair with our public health nursing and community health aid programs. We actually just closed this funding opportunity, and we'll be announcing our site selections next month.

Finally, it's important to us to get the national resources out to the bedside, especially when someone might be the only prenatal care provider in their community. So we're actually in partnership with Northwest Portland Area Indian Health Board started an Indian Country ECHO called Care and Access for Pregnant People, which provides on-demand continuing education but also consultation for topics such as congenital syphilis, substance use in pregnancy, and the importance of indigenous birthing practices, and use of a partnership with indigenous birth workers to provide culturally safe care. It's reached over 1,400 participants, and it's actually available to anyone interested in care for indigenous communities, you can see our upcoming curriculum there. And then that hyperlink will actually take you to the site for information.

And finally, as I mentioned, there are so many programs nationally that support indigenous communities and really acknowledging the work that's been done at the CDC with the HEAR HER Campaign, Northwest Portland Area Indian Health Board, again, with Paths (Re)Membered and Stop Syphilis, the Hope Committee has actually just released an update to their family care plans for substance use in pregnancy, HRSA's Maternal Mental Health Hotline, and the American Indian Cancer Foundation. We've also developed a twice-monthly newsletter that'll consolidate these resources and updates and send them to you, as well as links through our MCH website.

I want to again, thank our team across the areas as well as you all for your time and interest today. And please reach out, of course, if you have questions. Thank you.

Katherine Craemer: Hello, my name is Kate Craemer, and I am presenting about the Maternal Health Emergency Department Toolkit, which was funded by the Illinois Department of Public Health. All right, so it comes as no surprise you all that people who are pregnant and people who are postpartum are visiting the emergency department. And data from the Illinois Department of Public Health and the Maternal Mortality Review Committees, just as Dr. Hollier shared earlier, in Illinois specifically, our data has 88 people on average have died while pregnant with postpartum. And importantly, these people are visiting the emergency department. Two-thirds of them in general in Illinois are visiting the emergency department at some point during their pregnancy or postpartum. And this is much higher in rural areas, which means that there's an opportunity to provide support and education to emergency departments providing care for pregnant and postpartum individuals.

And so we looked at what kind of education are these people currently receiving. What do they have access to? And so we started in Illinois. We have 10 perinatal regional centers, and they provide support and education to the hospitals and emergency departments in their regions. And the education that they provide is primarily focused on the obstetric department. And birthing hospitals often receive more education than non-birthing hospitals. And we also looked at nationwide. So we looked at your wonderful AIM bundles, and we looked at the most recent ACOG programs, but we are also developing this now, almost two years ago. And overall, looking at the education that's available, it's primarily focused on physiological, emergent OB conditions, and it's missing some of the most key social determinants of health stuff for the emergency department, the substance use disorders and mental health condition, referrals and discharge, and care coordination. And these are some of the things that we really thought about when we were building the maternal health emergency department toolkit.

But I would be remiss to not mention the challenges about providing consistent education across hospital staff and providers. We've experienced a high turnover rate, which was made more difficult with COVID-19, and especially some of the first people to let go are those people who are directing the education and encouraging it, which makes it more difficult to have continual education. There's also hospital closures, especially birthing hospitals. And these are some of the things we continue to think about as we build a comprehensive option for maternal health education in emergency departments. And so we have the maternal health emergency department toolkit. It's rooted in our data findings from our maternal mortality review committees in Illinois and their recommendations. It was built by statewide experts. This included emergency medicine physicians and nurses, maternal health experts, policy experts, substance use disorders, mental health. And they were across the state because the ultimate goal, and now we're going to be rolling out statewide.

We built the content, it's three and a half hours of self-guided, narrated content, and it's broken up into chunks. So we have modules about the data, why is it important in Illinois to have maternal education for emergency departments? We had case studies for acuity assessment of some of those common obstetric emergent conditions. We also covered, importantly, screening mental health, and behavioral health, and substance disorders because that is the leading cause of maternal death in Illinois. We also had trauma resuscitation during pregnancy and best practices for discharge and care coordination. Further, for the past year, so starting in May of 2023. So we're ongoing and currently entering the end and evaluation phase. We've been piloting this toolkit at six hospitals in Illinois. Two of them are in rural areas, and two of them are non-birthing without obstetric units. And we've been evaluating with electronic medical record data polls, interviews with hospital champions and staff, and surveys to assess before and after.

Was there knowledge change? Was there self-reported behavioral change? And I'm excited to show you some of our results. And so the impact of the toolkit, these are preliminary findings, but overall, we've had 61% of the emergency department staff and providers have completed the toolkit. This is a little bit lower in our rural and non-birthing facilities, but we're still seeing a great impact there. And our electronic medical record data has been showing some really great documentation. And this is aggregate across all six hospitals. And we polled 10% of females of reproductive age across our time points. So we looked at before the toolkit was implemented, and now we're on our fourth poll after implementation. And I'm excited to share that we've had increases in documentation and asking, is this patient pregnant or are they postpartum? Further, we've also had increases in referral and transfers to higher levels of care.

And then, specifically, for patients who are identified as pregnant or postpartum, we've had increases in referrals and transfers to obstetricians. We've also had higher communication between hospital service lines that the toolkit has contributed to. The ED has been communicating with either the on-site or the on-call obstetric provider. Additionally, we have documentation about that actually person is not pregnant, which is another important finding. Further, we also looked at the patients who were stable upon entry, were they able to receive a mental health or substance use disorder screening? And we also saw increases in that. And lastly, we also asked hospitals to put up a sign in their emergency department so that way patients know to also alert the providers and staff members that I'm pregnant or I'm postpartum because it will change how they approach care.

But it would be silly to not talk about some of the challenges we encountered. This was a pilot, and we've been learning from it and we have challenges that we face across all hospitals. And then challenges that were more specific to our rural and non-birthing hospitals. I do want to note again that our sample was small, with six hospitals overall. So while these are likely common at other hospitals, they aren't necessarily generalizable. So overall, we had some challenges with getting leadership buy-in at the emergency departments. These are busy people. It was difficult to make connections with them, but once we were able to get those established relationships, it substantially improved the project. We were able to have greater recruitment, greater engagement, and they really did understand that this is an important area to address. But in rural and non-birthing hospitals, the smaller hospitals are less likely to be large triage centers. There's less resources, there's less time. So it makes it more difficult to have that engagement between leadership and staff members to be able to encourage and support. They're still excited. It is just more challenging.

Further, we also experienced staff turnover, both at the leadership level and the staff level. And so from our end, this looks like continuing checking in with the hospitals to see do you have new people added. All right, let's get them on board. Do you have new leaders that we need to know about? All right, let's make those connections. We also had challenges with educational methods. As I previously noted, this training was originally, it's a self-guided training that you complete online, but that's not a one-size-fits-all. And so we started offering webinar trainings that worked great at one hospital and especially embedding the content into the hospital's learning management system. And that's something we're really going to look at for our statewide rollout. We did assess learning management systems in Illinois. Where are they located? And they're not surprisingly located in our largest city of Chicago, and surrounding suburbs.

This is something that we are taking in consideration and planning for with statewide rollout. This training was also not required, which makes it more challenging for completion and especially for a number of hospitals that more often have contract workers that float between hospitals. They're not always there, so you can't always check in with them, or they're not completing things that are not within their contract. And there's also, overall the time of insufficient time to complete trainings, conflicting trainings. There just isn't enough time in the day to do everything that you want to do, no matter how much you value it. And this made it a little bit more challenging in our rural non-birthing hospitals for completion. However, we did have a wonderfully successful two simulations that were a surprise at the rural non-birthing hospital. And they did well with them despite lower completion rates. They were able to apply their knowledge, and it's really exciting to see.

And then lessons learned. What can you learn from our pilot for other states or for us going statewide? This is incentivizing the toolkit, especially for contract workers. This is establishing those relationships with emergency department leaderships and maintaining those throughout implementation. And this is also incorporating whenever possible into the learning management system as the hospital. This is what people are used to using for their trainings. So let's keep using it and overall requiring the education completion.

And so, looking statewide, what are we doing in Illinois? Well, we have 187 hospitals with emergency departments, and half of them are non-birthing. And so our next steps are including, we're establishing relationships with these emergency department leaders and with our perinatal centers. We're also working with our critical access hospital network. So these are federally funded hospitals that are most commonly in rural areas, most commonly non-birthing and getting them on board, which they are so excited. And we're also making and designing the content to be implemented in multiple formats, whether that's learning management system, webinar, or in person. And overall, I'm excited to get started working with these hospitals. And this is my thank you. You can reach me at this email address. And I also want to acknowledge my colleagues at the Center for Research on Women and Gender who have been instrumental in the success of this project. Thank you.

Kristine Sande: Thanks so much to all our speakers for their great presentations. So a question for Christie Allen, are the patient safety bundles in the OBERRK modified to be specific to non-birthing facilities?

Christie Allen: No, in a word. They're not modified bundles. They're more addressing the clinical conditions that are specific without being a full bundle. The bundles themselves are designed for implementation in hospitals that do have obstetric services. The other component that bundles have is an associated metric and measurement strategy, which you need for quality improvement. And what's tricky is the resource kits thus far do not. Although, stay tuned. I think that one of the components we really struggle with is that in order to implement a bundle that was designed specifically by obstetric providers with other folks also from EDs, from rural facilities, family medicine providers, et cetera, you do run into some limitations. And the limitation we have in this case is the bundles are not truly meant to be implemented in non-obstetric facilities.

Kristine Sande: Great, thank you. Another one for you, Christie. Are there additional kits for primary care clinics who provide prenatal care, or would that be the M-E-W-S-I-R-K? I could see the perinatal mental health portion being really helpful.

Christie Allen: Yeah, so we don't have bundles specifically designed for those settings, but what I would say is that I think the Obstetric Emergency Readiness resource kit, again, it's a mouthful. That's why we use acronyms, that has components that would be useful in a variety of settings, including potentially some outpatient settings if folks wanted to dig into them. Also, honestly, all of the AIM resources, if you're working on perinatal mental health conditions, we know those extend well past the delivery hospitalization. We know substance use treatment extends well past that as well. So there are a variety of resources that we've pulled in and have access to on the website, but we've developed and then links out to other folks. So I do encourage folks to dig through there and search by topic, and I think you may find some that are really useful to your work.

Kristine Sande: Next question is for Tina Pattara-Lau. It says, In North Dakota, we do have one IHS facility that provides birth, yet they're increasingly sending patients out to other facilities for prenatal care as well as labor and delivery. The facility has experienced a year-to-year decline in the number of births for most of the past decade. Since giving birth within the community is so important, is IHS taking steps to help improve maternity care and birthing facilities specifically so women can actually obtain care in their local facility?

Tina Pattara-Lau: Thank you, Andrew, for that question. And the short answer is yes. I am familiar with the facility and recognizing that there are challenges, especially at our more rural and remote sites, specifically with staffing. Many sites do utilize OB-GYNs that are board-certified where possible, but also work in collaboration with midwives and family practice providers. I'm also aware of their declining birth volumes as a result of oftentimes the challenges with staffing. I actually received an update today that that may be changing soon, so hopefully we'll have more information to announce shortly. But I am aware the MCH consultant for Great Plains has been working with that site specifically as the volume declines on obstetric readiness training and protocols. The second challenge, which I know many of you face and I certainly did even working in downtown Phoenix, was the ability for our facility to care for high-risk pregnant patients and/or neonatal conditions, specifically preterm deliveries.

And so oftentimes we were a level one facility, so even a patient that I had followed through pregnancy and delivery, we needed to make the call for transfer primarily out of safety, not only for the pregnant person but for the newborn. And so sometimes that is a challenge at the time of delivery, and always mindful when we made those consultations too, that we would optimally like to keep the dyad within our facility. But our MCH program does work again, not only on obstetric readiness, which was one of our priorities, but also to strengthen prenatal care support, which you see in our MCH funding opportunity and resource sharing. And we also have the maternal child safety work group that is also working on this issue as well. So thank you again for the question.

Kristine Sande: Another question for you, how can states PQCs best engage with IHS facilities in terms of data sharing and resource sharing?

Tina Pattara-Lau: I was actually starting to engage with Arizona's PQC during my time as well as through NICHQ's PQC Collaborative to provide, again, resource sharing and opportunities. So hopefully on deck to present for them and share again the resources we've developed. Some of our tribal sites have participated in their site surveys. And then, of course, with data, we always want to be respectful of tribal sovereignty, especially around mutual trust and, of course, permissions to share the data. But I think the first step is always, again, being able to connect and share resources with those on the ground. Thanks for the question.

Kristine Sande: And here's a question for everybody, I guess. The person asking says, My organization, CALS Program, provides this type of education. It is team-based, scenario simulation focuses courses for OB emergencies for rural and critical access hospitals. We have been doing this for some time. Online education access is great, but bringing simulation hands-on training is optimal but expensive to make this education accessible. In rural settings, short supply and staffing to travel for education is difficult. Bringing education to the area can be very helpful, yet too expensive. We find the real barriers is funding resources for hands-on simulation-type resources. Any thoughts on options available for funding for this kind of work?

Christie Allen: So simulation is very important, and it comes in a lot of different tiers. I've helped lead it in critical access hospitals and sort of across the country in different ways in different roles. I think tabletop scenarios are important. I think low-fidelity simulations also important, and a lot of the concepts you're drilling are less clinical care and more teamwork and communication strategy-based. So I think there's a large variety that you can do without it being as expensive as the gold slash platinum standard. I also think that we have actually funded through the previous AIM format, and I know that HRSA has funded work in AIM through implementation strategy.

That includes drills and simulations. There are mobile vans that go out and do it. I know that the IHS facilities do some work around simulation that's really meaningful. And I think it's getting buy-in and support, as Kate had mentioned in her talk, from perinatal regional centers that may be able to help and support that. There's some beautiful SIM sites that folks can work together with. So while I don't think everybody needs a simulation center built at their facility, I do think there are ways to access it in relatively low-cost ways that may not be specifically funded for simulation.

Kristine Sande: It looks like there are a couple of questions about frequency of simulation training needed, and I think one of the questions is for you, Kate, as far as how frequent that simulation actually happens. But any thoughts too about optimal frequency for training?

Katherine Craemer: I do want to clarify on our end. The toolkit training did not include simulations. However, the regional perinatal centers often host their own separate simulations. It was a collaborative effort, but the training itself did not, unfortunately. It was three and a half hours long, so adding more simulations was a lot to add. So I cannot also speak to the frequency of simulations.

Stacie Geller: So Kate, do you want to talk about how we're going to roll it up with one-hour sessions going forward?

Katherine Craemer: Yes, certainly. So while the Maternal Health Emergency Department toolkit does not include simulations, we are breaking down the content to be rolled out and slowly transfer to sustainable responsibility by our perinatal centers to host beyond the original implementation. And so that will be in an hour, a couple of modules that add up to an hour each quarter. So it's a much more feasible amount of training that would be completed instead of three and a half hours assigned in one go.

Kristine Sande: Thank you, everyone, for participating today, and I'll turn it over to Dr. Dillon for some last thoughts from the Federal Office of Rural Health Policy.

Kristen Dillon: Yeah, I just want to express our gratitude for all the work that you all have done, for the work that our presenters have done in supporting facilities, especially those where obstetric services is really an addition to their core service, helping those facilities do the best they can for the people who are going to present for care. Please keep an eye on our announcements in the Rural Health Information Hub site. We will be offering one additional webinar in this series, kind of a wrap-up, and also talking about some future directions in four weeks later, in May. So please join us for that. Keep up the good work and stay in touch. Thank you, everyone.

Kristine Sande: All right. Again, thank you so much for joining us today, and thank you, a huge thank you to all of our speakers for sharing with us today.