Why is the Preterm Birth Rate so high in Mississippi?

Pebbles of Hope “Bridging the Gap” Podcast

Pebbles of Hope speaks with Dr. Mobolaji Famuyide, Medical Director of the NICU at the University of Mississippi Medical Center, in today’s episode of the Bridging the Gap podcast

Pebbles of Hope releases today the third episode of its podcast series, Bridging the Gap, in which we explore the health disparities that affect NICU families. In this episode, Cheryl Chotrani, Executive Director of Pebbles of Hope, speaks with Dr. Mobolaji Famuyide to discuss the unique issues that affect NICU families in Mississippi and why the state has experienced poorer outcomes related to prematurity compared to other parts of the country. A condensed version of our conversation is below.

Please share with us your background, your career as a neonatologist and the path you took to become the Medical Director of the NICU at UMMC.

Dr. Famuyide: I am native to Nigeria in West Africa and come from a family of academics. Both of my parents are clinical psychologists so it was second nature for me to pursue a career in a field that is so beneficial to humanity. I went to medical school in Nigeria then moved to the United States for further training after one year of residency in Nigeria. I trained at the Bronx Lebanon Hospital in New York and at the University of Maryland for my fellowship. When I completed my training, I then came over to the University of Mississippi to start my academic career. I’ve been at UMMC now for almost 10 years and I know I made the right choice coming to Mississippi.

Every year, the March of Dimes publishes a report card that assigns a grade to each state based on their preterm birth rate in relation to the national average. Why does Mississippi consistently rank as the lowest performing state in the country and what are some of the underlying factors?

Dr. Famuyide: We have a huge burden of premature births and admissions to our NICU. Being the only level IV NICU in the state, we unfortunately get to see the sickest babies and sickest moms across the state. As you know, the reasons for prematurity are very multi-factorial. I like to think if as a combination of genes and environment. Genes are inherent in us, and that is something we can not change. In some studies that have been conducted amongst people of color, there seems to be, for some reason, a higher incidence of prematurity in that sub-group. The environment, however, is something that is modifiable. When we talk about the environment in relation to the African-American population, we have to talk about the long-term impact of racism and stress on the individual as they navigate their daily lives. In talking about the environment, we also have to consider modifiable factors such as access to healthcare, which is related to the geographic location in which the individual lives. Mississippi is a predominantly rural state, so all of these factors are critically important to health outcomes in the state. For rural populations, many are served by local access hospitals that are not always able to provide the necessary services that a high-risk pregnant woman needs.

Another thing that also impacts prematurity in general is maternal health. A mom that is perfectly healthy with a normal reproductive tract is most likely not going to have a premature baby if there is no genetic basis for it and if they are not exposed to added stress factors imposed by the environment. But a mom with pre-existing illness, such as diabetes or chronic hypertension, would be at a much higher risk of experiencing a negative birth outcome, including preterm birth. Mississippi has some of the highest rates of diabetes and hypertension and we believe that significantly impacts the rate of prematurity in the state.

Infant mortality is another indicator that Mississippi has challenges with, and the current rate in the state is comparable to some countries in the developing world. Are infant mortality comparisons between countries and/or states appropriate and how concerning are the current rates in Mississippi?

Dr. Famuyide: When we talk about anything that involves data, it’s always best to compare apples to apples. When we don’t, it becomes very difficult to interpret or make appropriate decisions based on those numbers. It is true that the infant mortality rate in the United States is higher than one would expect for a developed country, however, many of the things that we do here and the way we extract data is completely different than what is done in other parts of the world. I’ll give you an example. When we compare ourselves with our counterparts in Europe, in the US we tend to accept and perform interventions for babies at lower levels of viability. Therefore, when you compare resuscitation and mortality rates, you have invariably included a large sum of babies that in many European countries would not have been considered viable. When we calculate infant mortality in the US, we include all of those babies. I believe that explains in large part why our infant mortality rates appear significantly higher than other comparable countries.

That being said, there are several factors within the US that will impact infant mortality that other developed countries do not have to contend with. In Canada and the UK, for example, every legal resident has access to some healthcare. When that happens, individuals are more likely to seek out care when they need it. In the US, although a pregnant woman may be covered by Medicaid due to her pregnancy, she will likely not access healthcare if she is unable to afford it. For conditions such as Diabetes, it is not only what happens during pregnancy that affects the birth outcome, but pre-conception health also plays a major role as well. I think that is one of the primary reasons why our infant mortality rate is high in Mississippi.

Should we be concerned about the infant mortality rate then, particularly as it seems to be rising in Mississippi?

Dr. Famuyide: Well, I think we should be concerned. We’ve done a lot of work with regard to birth defects that are preventable. Folic acid is the classic example. It’s in many of the foods we eat now. That’s a good example of something that we have been able to modify to reduce morbidity and, in some cases, mortality as well. However, for something like Sudden Infant Death Syndrome (SIDS), we have seen many different campaigns to address this issue, but Mississippi still has many problems with this. Last year, we had a crop of cases across the state that forced us to rethink how we message sleep safety to parents. Going back to the fact that we live in a rural state with a substantial low-income population, if the message is not getting out to the people who need to hear it, there is no way for these parents to know the right way to practice. A mother with multiple children living in a single-bedroom house is most likely going to put her baby in the bed with her and the possibility of a roll-over happening is high. But, if mom is able to understand that it’s ok to put the baby on a simple surface, even if it’s just a small box next to the bed, she gets the message and we prevent that death. So, there is still more work that we can do to reduce the infant mortality rate.

With UMMC being the only level IV NICU in the state, how does that affect your provide optimal care to all of the babies that you receive?

Dr. Famuyide: There are many types of advanced levels of care that level IV NICUs can provide that lower level NICUs are unable to offer. When one thinks about the concept of regionalization, it makes sense to have one central regional level IV nursery that is able to provide the highest level of care, but what we currently lack in Mississippi is a good network of feeder level III and level II nurseries that can take care of babies that don’t need the highest level of care, or until they can be transported, if necessary. That way, more babies can be cared for closer to their parents’ home, which will help with bonding as well as make it easier and more cost effective for parents to visit their babies in the NICU. I believe that would be the best way to optimize care for these babies.

In an ideal world, what would you like to see change in your hospital or across the state of Mississippi to improve the care and outcomes for babies in your state?

Dr. Famuyide: Single bed, private NICU rooms. We still have the open bay system in our NICU with little pods containing 4-6 babies each. All of these babies are fully exposed to the noise and activity going on in the NICU. In an ideal world, I would like to have a single, private room NICU for several reasons. Parents are more likely to be able to visit and stay with their baby if they have a separate space. They will likely spend more time at the hospital, and breastfeeding rates would probably improve if mom has a private space to pump while watching her baby.

My second wish would be to have expertise across the state with level II and level III NICUs in strategic locations across the state. If we have more well-equipped lower level NICUs, babies can be cared for closer to the home and closer to the pediatricians that will ultimately be taking care of them after discharge.

The full audio copy of this episode as well as all other episodes of the Bridging the Gap podcast is available on iTunes, Google Play or wherever you get your podcasts.

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