Hospital District Trustee Allen Jones, a retired senior Merrill Lynch executive, is by his own admission obsessed with numbers. Babies? Not particularly, beyond his three grandchildren. But when he took a look at high infant mortality figures in Indian River County, he went into data overdrive, compiling an in-depth report within months of joining the Hospital District Board.
The program he pegged to solve the problem wasn’t a new one; Partners in Women’s Health, a practice begun to treat pregnant women of very limited means, was formed in the mid-1990s, just as the mom-focused Healthy Start initiatives were getting underway here and across the country.
What Jones saw as the solution to high infant mortality was not just the Partners clinic, but a network of prenatal and post-partum services.
Today, the Partners in Women’s Health Collaborative Committee, which Jones co-chairs with IRMC board member Kathy Hendrix, aims to save the lives of newborns. A half-dozen community health agencies, all receiving Hospital District support for indigent care, are involved in services ranging from help in quitting smoking and getting off drugs to breast-feeding advice and tips for finding a safe spot for a baby to sleep.
“No other county in the state is doing this,” said Jones proudly.
Last month, as the District Board listened to Jones present his bi-annual report – stepping down from his usual seat at the dias to take a turn at the podium – Jones challenged his Partners team to beat the numbers he has crunched so diligently. As a reward, he convinced the board to approve an incentive bonus to invest in much-needed equipment.
Jones wants the county to beat the state’s neonatal mortality rate, preventing deaths of babies one-month old or younger, a challenge the pre-collaboration District program, the Partners in Women’s Health clinic, had not been able to consistently conquer.
In 2016, Indian River County’s infant mortality rate, which measures deaths in the first year after birth, was 25 percent higher than the state as a whole. That year, of the 1,245 babies born here, 10 died before their first birthday. Of those, 7 were newborns, hence the Collaborative’s new focus.
Along with reducing infant deaths, the Partners Collaborative is initiating a healthcare relationship with economically challenged families.
“If the family trusts you, and you form that relationship, there’s going to be more growth and development,” says Andrea Berry, executive director of the Indian River County Healthy Start Coalition, which of the Partners Collaborative.
Leaders of the various agencies meet quarterly with the Partners obstetricians to discuss their successes and their challenges. Along with Berry, Hendrix and Jones, the group includes Dr. Felix Bigay and Dr. George Fyffe from the Partners in Women Health medical practice; Vicki Soulé of Treasure Coast Community Health; and Miranda Hawker of the Indian River County Health Department.
“We talk about the health issues we’re seeing and how we can do things better,” said Berry. “I always say I wish that everyone knew how much we’re looking out for this community.”
That community includes Gifford, a majority black neighborhood that borders U.S. 1 just a mile or so west of the hospital. Yet that population, as well as neighborhoods in the southern end of the county, are particularly vulnerable to the tragedy of infant death.
Despite Partners’ best efforts over two decades, the trend line has barely budged: Black babies under a year old are dying in this county at rates far higher than the state average for black babies.
Of the 202 black babies born in Indian River County in 2016, five died in their first year. That translates to a shocking rate of 25 deaths per thousand births that year.
The statewide rate among black babies is 11.6 per thousand – still shameful, considering the white infant mortality rate is 4.3 per thousand statewide, and 6 per thousand here.
In January, at the suggestion of the Health Department’s Hawker, the Partners Collaborative began offering prenatal visits one day a week with a nurse practitioner at the Gifford Health Center, with hopes of adding a mobile ultrasound unit.
The best news in all the numbers came from the county’s Hispanic community: Zero babies died in 2016. That compared to five per thousand in the Hispanic community statewide.
While that positive news warrants a closer look to see what practices other populations might emulate, Berry and Jones agree the trend lines among whites and blacks are not conclusive; with just over 1,200 births a year in the county, any death makes for a major change in the rate.
Then again, any death is one too many for health advocates. As a result, Healthy Start tries to screen every newly pregnant woman. If they are deemed at high risk, counselors immediately try to develop a bond with the moms-to-be, to inform them of conditions that affect the growing fetus, like obesity, diabetes, smoking, substance abuse and even stress.
That counseling, which includes home visits and classes, complements the clinical care provided to indigents through the District’s program. “It’s really the collaboration that makes it work,” says Berry.
“In our county, the main causes (of neonatal death) are preterm labor and low birth weight babies,” says Berry. Prenatal care, starting with the moment a woman learns she is pregnant, “is our only line of defense. If she’s stressed or can’t afford prenatal care, that is delaying care and encouraging a big cause of infant mortality.”
Pregnancy complications in either the mother or the fetus are another cause of infant death. So are sudden infant death syndrome and injuries to the baby, including suffocation, according to the CDC. To help reduce those risks, post-partum guidance has long been offered through Healthy Start.
Now a pilot program is underway for more intensive home contact; currently, Healthy Start is recruiting 25 moms-to-be to be part of a study that involves home visits from the moment mother and baby are released from the hospital.
Post-partum care is also being offered now at the Partners in Women’s Health Clinic. “So we’re now tracking that,” Jones said.
When District trustees first focused on infant mortality rates in 1995, “They were dramatically higher than other counties in the state,” says Jones. “The hospital was giving anecdotal reports of people showing up ready to deliver without having had any prenatal care. Nobody was ready for this. It was kind of a disaster situation.”
While the Health Department did have obstetrical services, Jones said, for some reason, it wasn’t being utilized by the county’s poorest women, even though the District was funding it.
“We took it upon ourselves and set up our own program to take care of indigent mothers,” recalls McCrystal. “We set up that program very fast. We hired the obstetricians and we set up an office.”
The hospital was selected to run the District’s program. “IRMC would provide prenatal and obstetrical care to indigent woman and collect Medicaid from those who qualified, and in exchange, the District would offset the losses,” explained Jones.
When the Partners program began in 1996, there were eight obstetricians practicing in the county, but few if any accepted Medicaid, according to Jones.
As the cost of malpractice insurance for OBs skyrocketed, one by one, doctors stopped delivering babies. Today, only one obstetrician is still in private practice and he does not accept Medicaid.
Now, Jones says, of the annual 1250 or so births in the county, the Partners in Women’s Health medical practice sees more than 800 mothers. Some 600 of those are indigent women, and another 200 women have private insurance.
“I look at this program as a real badge of success of what the District does,” said Jones of the private-public patient mix. “It has funded a prenatal program that’s providing substantially equal care for the indigent as well for privately insured patients, in a really nice facility.”
Over time, though, the Partners program costs rose from an initial $600,000 to more than $2 million. The budget appeared bloated, Jones says, and there was talk of doing away with it altogether.
“That’s why I got involved, because there was a movement to unfund this,” said Jones. He had already begun intensive study of the Partners program, including touring relevant agencies, even before he assumed his place on the District Board in December 2014. The District had already cut the hospital’s reimbursement for indigent care, with $1 million of that coming out of the Partners program. And there was talk of cutting it further, he recalls.
Then Jones discovered the county’s high infant mortality rates. “And I thought as I got into this, wow, this is key to community health. I thought I could get the trustees to understand what this program was all about because it pre-dated all of us: This is a District program, not a hospital program – the hospital is just running it for the District,” Jones pointed out.
As Jones wrapped up his presentation, fellow Trustees made it clear the program could be a shining example of where the District is headed, if and when taxpayer funds are no longer needed for indigent support at the hospital under new ownership.
“I believe this is what the District should be doing, and what we’re all about,” said Cunningham. “Finding where those gaps are in health for our citizens and working together with the appropriate agencies to fund and make them better. And that’s exactly what you’re doing.”