By Robert G. Locke, DO, MPH, FACOP
Professor of Pediatrics/Neonatology
Robert G. Locke, DO, MPH, FACOP
A paradox of neonatology and other subspecialty medicine is that we have more frequent opportunities to have substantive interactions with our patients and families than our primary care partners. Although our primary care partners form many meaningful physician-patient interactions, their challenges are greater. PCPs have external pressures for short visits and, for many patients/families, visits are infrequent. Visits can be scattered across a year, limited to short well-child or school physical visits. The young or adolescent patient does not have the opportunity to form a trusting and valued relationship. Parents interact far more frequently with the internet and often seek guidance from friends or online sources than their PCP. This is not the PCP’s fault. This is the economic structure of healthcare. Lack of funding for mandatory coverage for preventative services will further limit low and middle-income individuals access to PCPs.
In contrast, as a tertiary care neonatologist, I have many opportunities to have constructive meaningful interactions with parents. This is true for everyone in the NICU healthcare team (nurses, respiratory therapists, clerks, service attendants, etc). Many nurses in my NICU state that this is one of the primary reasons they prefer NICU versus the office setting, despite increased holiday and weekend obligations.
The difference is situational. In the NICU, we have patients who require in-hospital care for days, weeks or months. Similarly, we often have interactions with parents on daily basis for weeks or months. Everyone on the healthcare team – physicians, nurses, respiratory therapists, service attendants, clerks -- gets to talk to parents almost every day. While a PCP has 6-10 minutes for anticipatory guidance in the office, or the brief time nurses have for instructions to a new parent with a healthy child on the mother-baby unit, we have hours, weeks, months. This is an opportunity. Some of this opportunity is short-term practical. Creating small talk allows normalization of conversation and space for the parent to share, and broader foundation for conversations about the healthcare of their child whether going well, not well or in-between. We can also delve into issues, parenting, lifestyle, life-choices, and other big issues. Sometimes we use this time well. Sometimes this time is underutilized.
A significant number of parents in the NICU had no risk factors. However, a majority of mothers of NICU infants have identifiable risks. Although the public often mistakenly perceives this to be mothers with substance abuse issues, teenagers, etc, leading maternal risk factors across a large population (our NICU is the regional center, averages 1200 admissions/year with 50-70 critical infants/day) are reflective of our country’s general well-being: maternal weight-related disorders, diabetes, hypertension and other maternal health factors top the list alongside sociodeterminants of health.
Although, I take advantage of every opportunity to develop a bond, have meaningful interactions and sometimes positively change the life-course of the adolescent mother during the 50 days her infant is in the NICU, I don’t always take this opportunity with other parents. For every adolescent mother, there are forty mothers with weight-related health disorders, non-adherence with CDC-recommended interpregnancy intervals, and a dozen other potential modifiable risks. If we are going to make a difference in neonatology and critical neonatal outcomes, research and effort should be spent on more than studying intricacies of cardiopulmonary physiology, stem cells, ventilator management and nutritional adjustment. We also need to advocate for public health factors of prevention: prevention of infant requiring neonatal intensive care services and, if the infant does, maximizing long-term neurodevelopmental, economic and quality of life outcomes, by maximizing the home environment and family opportunities after the infant is discharged home.
Most neonatologists get this. This does not mean that scientific inquiry into basic science and translational bedside critical medicine is not important. (My own research of >50 peer review manuscripts and 900 citations has predominantly focused on these translational and basic science aspects.) At national and international neonatology meetings and in the leading publications, attention to public health and the social determinants of health now hold equal standing to detailed basic science and translational research. At the state and national level, neonatologists are often highly involved in areas of public health advocacy. At the core of this movement to think outside the walls of the NICU to change what is happening within the NICU are four consistent undisputable facts: (1) infant mortality is driven by prematurity; (2) the United States has third highest infant mortality rate among economically developed countries (only Turkey and Mexico have higher), yet; (3) the chance of survival for a premature infant is better in the US than almost any other country and (4) there is great racial/ethnic disparity wherein the infant mortality rate among non-Hispanic Blacks in the US is two-fold higher than non-Hispanic and Hispanic whites.
What is driving the higher infant mortality rate in the US is not the lack of high quality of neonatal intensive care for infants in the intensive care unit, but higher rates of prematurity and racial disparities. These are interactive processes. Fifty-five percent of the black-white racial disparity is secondary to higher rates of premature births among blacks. Higher preterm birth rates are associated with lower socioeconomic status, high-stress lives/challenging social environments, induced preterm birth secondary to maternal or fetal-health factors, multiple gestation, teen or advanced maternal age, maternal tobacco use and shorter interpregnancy intervals. Eighty-three percent of the variance in preterm birth among blacks is from socio-environmental differences. Genetic differences are mediated through socio-environmental impact on epigenetic and other gene-environmental interactions. Reducing racial differences is crucial in reducing preterm birth and infant mortality. Overall improvement in maternal health status and socioeconomic factors are crucial for all race/ethnicities.
Maternal socioeconomic status and structural public health supports are keys, if not the key drivers in the differential preterm birth rate in the US compared to other resource intact countries. The US white infant mortality rate is worse than 27 of 30 countries in the OECD (Organization of Economic Co-operation and Developed Countries). The US spends less on social expenditures than 24 of 30 countries in the OECD and, with Mexico, is the only other country to spend more on health delivery than social service and family-environmental support.
Are there other ways to reduce preterm birth? Yes, reducing maternal tobacco use, multiple gestation, and progesterone to name a few, but these influences are already highly utilized and impacting the current system. Further implementation would have only marginal difference on the overall rate. The primary modifiable factors at a society level to reduce the US’s high infant mortality rate remain outside the NICU and OB offices, but in the realm of socioeconomic opportunity and equality.
Outcomes other than mortality have significant impact on families and society. There are significant impacts of prematurity on long-term neurodevelopmental outcomes, especially in terms of school-aged performance, neurobehavioral function and adult economic productivity. These are consequential events for the individual, parent, family and have multi-generational and societal impact. Addressing racial inequality, racism and socioeconomic challenges for all individuals is essential if the US is going to reduce preterm birth and subsequent consequences on mortality and child and family well-being.
Neonatology has long been a haven for physician-scientists, pediatricians who enjoy procedures, and practitioners who enjoy the opportunity to talk to parents for more than a few minutes every several years. Neonatologists have been advocates for their patients and families within the hospital walls including highly robust quality improvement and inter-NICU comparative outcomes databasing. It is now common practice that neonatologists are involved and assuming leadership activities in addressing the socioeconomic and environmental challenges that drive the modifiable negative factors affecting the health outcomes of their newborn patients and the families that care for them after discharge.