How Alabama Lowered Its Infant Mortality Rate

Milbank State Leadership Network
Focus Area:
State Health Policy Leadership
Delivery System Reform Maternity Care

By Roxanne Bangalan

Alabama has persistently had one of the highest infant mortality rates in the United States—one on par with those in developing nations. The rate has been particularly high in regions with large African-American populations. But in 2017, Alabama saw a nearly 20% drop in its infant mortality rate. By 2018, the infant mortality rate dropped for the second consecutive year, reaching a record low of 7.0 deaths per 1,000 live births, thanks in part to the state’s revitalized perinatal regionalization program.

Perinatal regionalization is an approach to lowering maternal and infant mortality that facilitates care coordination across health facilities, helping to ensure babies are born in or transferred to hospitals that can provide the appropriate level of care for them. Under Alabama’s revised guidelines, hospitals are categorized as level I (well newborn nursery) through IV (regional neonatal intensive care unit, or NICU).

State officials believe that the 2012 effort to update its 40-year-old perinatal regionalization system to incorporate strategies supported by the American Academy of Pediatrics and the Health Resources and Services Administration–funded Collaborative Innovation Improvement Network (CoIIN) to Reduce Infant Mortality played a role in the statistically significant drop in the infant mortality rate. This perinatal regionalization system, in combination with preventative techniques, such as safe sleep education for parents, attempts to minimize the need for specialized neonatal care, while targeting the most prominent causes of infant mortality. In 2017, the four leading causes were congenital anomalies (birth defects), preterm and low birth weight, bacterial sepsis of newborn, and Sudden Infant Death Syndrome (SIDS).

“By working with the CoIIN, we were able to look at other states…and see if we could borrow some of those ideas and implement them here,” says Janice Smiley, MSN, RN, director of the perinatal health division in the Alabama Department of Public Health. CoIIN’s infant mortality initiative, a public-private partnership, was launched in 13 southern states in 2012.

Implementation Challenges

Alabama is currently working toward getting all of its hospitals to adopt the guidelines and self-declare their perinatal level of care. But implementation is challenging given that adoption is not required by the Medicaid agency, for example, which funds more than half of the births in the state.

In addition, while state regulatory agencies engage in regular conversations with each hospital to ensure they understand what each level of care entails, a more rigorous verification system that ensures hospitals are meeting declared standards has yet to be implemented.

Moreover, hospitals and doctors may be disincentivized to comply with the referral system. “We try not to accuse people of bad motives, but there are very real financial disincentives to sending out your well-paying OB patients,” says Scott Harris, MD, the Alabama State Health Officer. “So, you just have to be aware of that, even though we don’t think people deliberately make a decision that way.”

Pushback to referrals can stem from patients as well. Often, patients have long-standing trust and rapport built with their regular physicians, making it difficult to persuade them see providers in other facilities.

“One of those expectations is, ‘I want this person who knows me to take care of me and my child,’ and they don’t expect [their regular physician] to say, ‘We need you to go to a hospital three hours away, to a place you don’t know,’ Harris says.

Other challenges include the costs of transportation to risk-appropriate care facilities, a significant barrier to accessing proper care, particularly in more rural areas. While funding for transport is not available, every facility in Alabama has telehealth capabilities, allowing physicians to hold virtual prenatal appointments to improve care quality. “Our level IV hospital is working with some rural communities, so their high-risk women are being provided the services in their own counties through telehealth,” Smiley says.

Even with these challenges, the process of regionalization—starting with guidelines adoption and self- declaration—and COIN-supported preventative strategies have had positive effects in Alabama.

Looking ahead, Ms. Smiley says, “Our long-term goal would be all our hospitals are appropriately declaring the level of care and are practicing within those guidelines. And we know this will take us a little while to get there, but we know it’s possible.”

Racial Disparities

Although the implementation of perinatal regionalization has helped to shrink the gap in racial disparities in Alabama, the state is still working to address health inequity as marked disparities remain. In 2018, Black infants died at a rate of 11.0 per 1,000 live births, while white infants died at a rate of 5.1 per 1,000 live births.

“We are in the midst of completing the next five-year plan of action to address the needs of the [Maternal and Child Health] population,” Smiley says. “The plan will outline strategies that we will engage in to address social determinants of health that impact maternal and infant health.”

Lessons Learned and Long-Term Goals

For other state leaders looking to establish similar systems, Harris and Smiley highlight two salient lessons:

  • “Don’t fail to recognize early the political implications of perinatal regionalization,” says Harris, referring to the fact some hospitals may lose status by stating that they are not NICUs, and that some doctors will lose money by referring patients. In addition, some patients will want to stay with their local physicians and not travel to the recommended facility for care.
  • “Make sure key players are there,” Smiley says. Though state agencies may have limited influence in convincing hospital systems to comply with perinatal regionalization, engaging with prominent leaders in these settings has proven to be an effective strategy. Well-respected physicians and health care providers can successfully lead the charge within their facilities to persuade their colleagues of the importance of perinatal regionalization and its impact on infant mortality rates.

Adds Harris, “It’s such a complicated issue, and it’s so tied into social determinants that we have a hard time influencing quickly. So connecting the dots is really difficult. We’ve had two straight years of statistically significant decline in infant mortality. We’re ecstatic about that. Our rate is still worse than the US average infant mortality rate, though. We have a lot of room to improve.”