Cynthia L. Line, Ph.D. Patricia Morris, MPH Katherine C. Maus, ACSW, LSW

1. Examining the Impact of Non-Resident Births on Systems Limitations in Philadelphia Obstetrical Care Cynthia L. Line, Ph.D. Patricia Morris, MPH Katherine C. Maus, ACSW, LSW Philadelphia Department of Public Health, Division of Maternal, Child and Family Health

2. Background

4. Public health system study Local healthcare system advocacy Gathering qualitative data from consumers Background By 2007 multiple processes were underway - each representing a different part of the obstetrical picture

5. Public Health system study Local healthcare system advocacy Gathering qualitative data from consumers Background There were various conclusions, including: • Women’s access to delivery options might be limited • Systems planning should occur to mitigate other worries • Hospitals are operating at/near capacity

6. Background Limitations of simultaneous multiple processes • Limited communication • Limited data sharing/analysis • Limited solutions

7. Background • The Division of Maternal, Child and Family Health (Philadelphia Health Department) proposed a different process: Upon completion of simultaneous multiple processes, unite under a common purpose to better understand OB capacity and subsequent impacts in Philadelphia

8. Improving Practice Mid- 2007 the Philadelphia Department of Public Health convened and hosted a meeting of key stakeholders and decision makers: Hospital CEO’s OB Department Chairs Representatives from the Philadelphia Health Centers (FQHC and city) Midwifery community Health insurers MCH advocates in the city

9. Improving Practice Philadelphia Health Department would share information from its analysis for systems planning, including the following findings: • Despite hospital closures, there do not appear to be significant changes in birth outcomes for Philadelphia residents • Including changes in the geographic distribution of existing hospitals • System changes have disproportionately impacted certain hospitals • Total available delivery beds in Philadelphia and nearby suburbs might become inadequate for the number of Philadelphia and suburban births

10. Improving Practice Three taskforces were convened and charged with work into 2008: • Sentinel Perinatal Health Events • OB Services for Uninsured and Undocumented Pregnant Women • OB Services Reimbursement Taskforce Each taskforce was co-chaired by a stakeholder and a Health Department staff member

11. Improving Practice Some Conclusions: • Sentinel Perinatal Health Events Collect sentinel events metrics Implement data sharing • OB Services for Uninsured and Undocumented Pregnant Women Develop partnerships and create a forum for planning, delivery, and monitoring of services Use ongoing studies of local need and capacity to inform planning • OB Services Reimbursement Taskforce Improve access to care, including sharing information, alternative models of care, research on barriers to care, etc. Advocate for reimbursement of OB care that is adequate to cover costs

12. Improving Practice Recommendations from the floor lead to the creation of three new work groups to continue this work through 2008: 1. Monitoring Sentinel Events • Comparison of Costs and Reimbursement • Medical Liability Costs and Coverage

13. Improving Practice MCFH recognized the ability to plan for OB services in Philadelphia should not be limited to understanding the births of Philadelphia residents only • Major city with some of the best hospitals • Major metropolitan area with a large suburban population

14. Improving Practice MCFH Evaluation Unit realized conversations by multiple partners were based on different realities: • Some partners were planning based only on Philadelphia city residents • Some partners were planning based on “all patients” served by systems

15. Improving Practice In order to inform planning moving forward, the MCFH Evaluation Unit analyzed city and non-city residents to determine what impact, if any, non-city residents had on the OB system in Philadelphia

16. Improving Practice • Birth record data for 2003-2007 were analyzed. • Data are received from the PA Dept of Health • Data reflect births in Philadelphia hospitals • Data were geocoded to indicate whether births were to Philadelphia residents or to non-residents • Data for all years were combined to minimize extreme sample size differences

17. Improving Practice Births to non-residents average 3,000-4,000/year while births to residents average 22,000-23,000/year

18. Improving Practice Chi-Square analysis compared residents and non-residents on several categorical measures.

19. Improving Practice Non-residents were more likely: • To have gestational diabetes &/or gestational hypertension • Vaginal bleeding and/or perineal lacerations • To have premature rupture of membranes • To have c-sections

20. Improving Practice Non-residents were also more likely : • To have babies who are low birth weight and/or of early gestational age • To have had infertility treatments • Have multiple births greater than twins • Be of advanced maternal age • Have babies requiring NICU admissions

21. Improving Practice Philadelphia residents were more likely • To have had a previous pre-term birth • To experience precipitous labor • To have prolonged labor • To be teens

22. Improving Practice Conclusions • Analysis indicates differing patient needs and issues for resident and non-resident women • Differing needs and complications have the potential to impact capacity of OB units differently • E.g. if non-residents have more multiple births requiring c-sections and NICU admits, the level of care and length of stay is much greater

23. Improving Practice Obstetrical planning in Philadelphia should include planning for different populations with different needs as opposed to planning based only on data for resident births

24. Contact Information Cynthia Line, Ph.D. Research/Data Manager Maternal, Child and Family Health Philadelphia Department of Public Health 215-685-5264 cynthia.line@phila.gov