What a Difference a Week Makes: Kentucky Pioneers Healthy Baby Efforts

Sep 24, 2012, 1:52 PM

Ruth Ann Shepherd, MD, division director for maternal and child health in the Kentucky Department for Public Health, was an early pioneer in recognizing the critical public health problem of preterm births in Kentucky, and that the troubling trend was common to most states in the country. Dr. Shepherd’s research revealed that babies born at 37 or 38 weeks had far worse health outcomes than babies born at 39 or 40 weeks. With support from the leadership at the Kentucky Department of Health, and many other organizations who have since taken up the cause of helping to create conditions for healthier babies, many states are beginning to make strides in preventing early births. Last week, Dr. David Lakey acknowledged her leadership in preventing preterm birth and infant mortality by awarding her the Association of State and Territorial Health Officials (ASTHO) Presidential Meritorious Service Award.

Charles Kendell, MPA, chief of staff at the Kentucky Health Department, accepted the award on behalf of Dr. Shepherd, who was unable to attend the ASTHO meeting. NewPublicHealth caught up with Kendall to get his take on Kentucky’s role in catalyzing a national movement around healthier babies.

NewPublicHealth: Tell us about the award Dr. Shepherd received and what it was for.

Kendell: The award today was given by David Lakey as President of ASTHO for the last year. The Presidential Meritorious Service Award is given at the ASTHO president’s discretion for those he feels have contributed the most to the President’s Challenge that he or she has championed for the year. This year, he awarded it Dr. Ruth Shepherd, who was one of the early advocates for doing something about the prematurity birth rates in the country.

Dr. Shepherd has long championed that concern, and it was through her efforts that much of the initial data and advocacy and publicity about the issue became apparent to a lot of people. Through the connection of Dr. Shepherd to David Lakey, he was able to put a voice and a voice to the issue through his presidency. It’s really taken off from there, and connected with an awful lot of people.

NPH: What did the data Dr. Shepherd uncovered show?

Kendell: Dr. Shepherd presented to us that she was showing the prematurity rate for infants in Kentucky was exceptionally high. The average number of weeks at birth was about 36 weeks. There was a corresponding infant death rate that was far exceeding the national average. When she looked at the data, it occurred to her that many of those deaths could have been prevented. Much of the prematurity rate had nothing to do with medical issues. The data were telling her that women who smoke are much more likely to deliver early and to have smaller babies. The size of the baby was really the predictor for the infant death rate. But she also understood that many premature births at 36 or 37 weeks were actually planned early for convenience. That was one of the more startling pieces of information from the data. In many cases it was not a medical issue but a lack of education or convenience.

She also brought the science from her work that showed that the fetal brain is still in critical stages of development in those early weeks, and that it’s not at its full capacity until 39 or 40 weeks. That was very compelling. She also said this is not just a Kentucky issue. This is going on everywhere. The ongoing cost to care for these infants is very high because they develop so many other health issues when they are born too early. Those of us in public health have understood infant death rates for a long time, but this was very dramatic because those images showed that those early births were really doing the children a disservice. Some expectant mothers and even some physicians may have thought, “what difference does a week make?” It does make a difference, and that was her message. This was convincing evidence that when it comes to a baby at 36 or 37 weeks—we’re not done here. We need to have the baby stay as long as it can in the mother’s womb so it can fully develop. Once that happens, we begin to see a reduction in all these other problems that we have come to accept are just going to occur—and they don’t have to.

NPH: One of the solutions is clearly education. What else can states and other public health officials do to help stem the tide of climbing preterm birth rates?

Kendell: Dr. Shepherd and Dr. William Hacker, who was our commissioner at the time, caught the attention of the March of Dimes. They came to Kentucky and looked at her data and her evidence and said, “This is the project we want to put our efforts behind.” They gave us some money to develop a pilot project in hospitals. The experimental group focused an awful lot on education of both the provider and the expectant mother, as well as programs to reduce smoking rates among expectant mothers. There are some medical interventions to help prevent preterm births as well.

As a result of the study, other states began to get interested and started looking at different pieces that they could work with. HRSA [Health Resources and Services Administration] got involved and convened a meeting last year, and they had states bring a team of people—realizing that this is not just a maternal and child health bureau issue. It’s not just a physician issue. It’s all of these things, as well as payment and insurance provider issue, and it touches on many other sectors as well. That was when the issue really began to develop into a movement. A lot of those recommendations were transformed into state action plans, and Dr. Shepherd is leading that effort in Kentucky.

NPH: Did you all realize from the start that Kentucky would be the catalyst for this healthier babies movement?

Kendell: We didn’t sit down and Kentucky and say, “we’re going to solve a national issue.” But we knew Dr. Shepherd was on to something. Dr. Hacker came to an ASTHO meeting and started talking to Paul Jarris and David Lakey. He also sent Dr. Shepherd to a number of other states to talk about the issue. Everybody that heard the story and began to look at their own data realized what an important issue it was. From there it began to take on a life of its own.

We started to realize this was a problem we all had across different states, and what we needed were some solutions. And the solutions existed. The size of the problem was such that it was going to take all of us to work on it. We were amazed at the number of federal, state and other organizations that have picked up this challenge and run with it.

Dr. Hacker did what I think state health officers need to do. He listened to this very committed person on his staff, and then empowered her to move ahead into what she thought were the right plans of action. At the same time, he took the cause up and connected through his connections such as ASTHO. The next thing we knew there was a meeting of people who were interested. You just never know where these opportunities are going to come from.

NPH: What else is happening in public health in Kentucky?

Kendell: We are struggling in Kentucky like all health departments across the country in how to have better health outcomes with a whole lot less money. It is a challenge, and we can learn a lot from one another. We know the ACA will change how we work and how we are perceived in many different ways. I think it will make the relationships we have even more important. We’re working with our health departments to provide them some more flexibility—to not be as concerned with clinical services, and to let other partners in the community do that. Let us worry about population health, because that’s what we can do very, very well. We’re struggling with outbreaks of many kinds—pertussis, West Nile, tuberculosis—all of the traditional public health issues. But we’re very much encouraged by the structure and connections ASTHO can give us.

This commentary originally appeared on the RWJF New Public Health blog.