By Curtis Lowery, MD

Prior to 2003, women’s access to specialty obstetrical care was available only in Arkansas’ large urban centers. Women living in rural areas did not have easy access to care, contributing to Arkansas’ high rates of infant mortality, and maternal morbidity and mortality.

Forty-four percent of Arkansans live in rural areas compared with the U.S. rate of 19 percent.1 Seventy-three of the state’s 75 counties are designated as medically underserved areas.2 Arkansas has one of the highest rates of poverty in the nation, is one of the worst states for women’s health, and has higher-than-average rates of infant mortality and low birthweight deliveries.1,3 With the highest rate of maternal mortality in the developed world,4 the U.S. rate is 17.3 per 100,000 live births per year in 2013.5 Severe maternal morbidity has steadily increased nationwide to a rate of 144 per 10,000.6 

Lacking access to specialty expertise and fearing possible liabilities of treating high-risk pregnancies, Arkansas’ rural family practitioners and obstetricians often referred high-risk patients to urban centers. This resulted in a numerical decline in rural doctors’ patients and high-risk women had to travel for needed care. Too often, these women could not or did not seek the specialty care they needed.

Arkansas Medicaid lacked the clinical resources to meet increased demand for high-risk pregnancy care. In 2003, leaders at UAMS, Arkansas Medicaid and the Arkansas Medical Society crafted a successful solution for the state: the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS), a high-risk obstetrical telemedicine program. With funding from Arkansas Medicaid, ANGELS has extended expertise to Medicaid beneficiaries experiencing high-risk pregnancies and made possible the local co-management of high-risk pregnancies.

The ANGELS team, including maternal-fetal medicine specialists, genetic counselors, radiologists, sonographers, neonatologists, pediatric subspecialists, dietitians, social workers and nurses, is available to women, providers, hospitals and clinics statewide through telemedicine.

ANGELS provides a 24-hour call center staffed by registered nurses offering appointment assistance, evidence-based guidance for patients and providers, and emergency transport arrangements for women needing immediate care.

Other ANGELS initiatives include:

  • Collaborating with Arkansas’ physicians to develop and publish evidence-based obstetrical and neonatal guidelines
  • Neonatal Resuscitation Program – evidence-based, newborn resuscitation education for professionals
  • Fetal monitoring courses using the Association of Women’s Health, Obstetric and Neonatal Nurses’ curriculum
  • STABLE (sugar/safe care, temperature, airway, blood pressure, lab and emotional support) training for neonatal critical-care nurses to establish continuity of care while stabilizing distressed newborns
  • Following Baby Back Home – care-management and home visiting for families of high-risk infants, following neonatal intensive care unit (NICU) discharge
  • Obstetrical simulation program drills teach rural delivering hospitals how to use a high-fidelity mannequin programmed to simulate obstetrical emergencies
  • Newborn screening that provides physician consultations, education and secondary testing support for expanded newborn genetic testing
  • Statewide infant safe-sleep education and outreach program for families
  • Expansion of the telemedicine model to labor and delivery units statewide
  • Arkansas’ Perinatal Outcomes Workgroup using Education and Research (POWER) implements evidence-based practices in Arkansas’ delivering hospitals to improve quality of care and reduce maternal morbidity and mortality

POWER is currently focused on implementing maternal safety bundles for hypertensive emergencies and postpartum hemorrhage. More than half of Arkansas’ 40 delivering hospitals have implemented safety bundles. At the request of Arkansas Medicaid, AFMC is partnering with POWER to educate health care professionals about best-care practices for post-birth warning signs in new mothers. As of June 2018, AFMC has extended this education to nine Arkansas hospitals and received enthusiastic reviews.

The ANGELS evaluation and research team has recognized a general continuation in improved birth outcomes for Arkansas’ Medicaid beneficiaries since ANGELS’ implementation. Improvements include:

  • Decreases in both neonatal and post-neonatal deaths
  • Increased percentage of deliveries in NICU hospitals
  • Significant decrease in the rate of postpartum complications in Medicaid deliveries in the two years following implementation;5 maintaining the lower rate for six years before increasing in 2014

In 2015, ANGELS diverted emergency visits that would have cost $1.2 million. ANGELS has improved clinical outcomes and provided a means to promote and manage perinatal regionalization to ensure that complicated deliveries are routed to the best-equipped hospital.

The Agency for Healthcare Research and Quality designated ANGELS as one of five Medicaid programs in the nation that should serve as a model of patient care and outreach. ANGELS’ unique collaboration will continue to be a model for institutions that want to implement telemedicine and women’s health disparity solutions. For more information, call 501-526-7425 or 866-273-3835. s

Dr. Lowery is chair, UAMS Department of Obstetrics and Gynecology and director, ANGELS and Center for Distance Health.

Excerpted from the Journal of the Arkansas Medical Society, Jan. 2019.

References

1. U. of A. Division of Agriculture. Rural Profile of Arkansas 2015.
2. U.S. Dept. of Health and Human Serv. MUA Find. HRSA Data Warehouse – Shortage Areas. Accessed 6-22-18. https://datawarehouse.hrsa.gov/tools/analyzers/MuaFind.aspx.
3. Associated Press. Poverty Rate in Arkansas Shrinks. U.S. News & World Report. https://www.usnews.com/news/best-states/arkansas/articles/2017-09-18/poverty-rate-in-arkansas-shrinks.
Pub 9-18-17. Accessed 6-22-18.
4. Robeznieks A. U.S. has highest maternal death rate among developed countries. Modern Healthcare. Pub 5-6-15. Accessed 6-22-18. http://www.modernhealthcare.com/article/20150506/NEWS/150509941.
5. Centers for Disease Control and Prevention (CDC). Reproductive Health. 
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html. Pub 11-9-17. Accessed 6-25-18.
6. CDC. Reproductive Health. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html. Pub. 11-27-17. Accessed 6-25-18.