Sometime in 2007, labor and delivery nurses at Sanford Bemidji Medical Center began seeing a disturbing shift in their patient population. The opioid-addiction crisis had taken hold in the region, and its impact was being felt among its youngest and most vulnerable residents.
More and more mothers with opioid use disorder (OUD) were giving birth at the hospital to babies suffering from neonatal abstinence syndrome (NAS). Unlike care providers at large, urban hospitals, Sanford Bemidji physicians and staff lacked experience in how to care for babies struggling with NAS’ painful withdrawal symptoms and weren’t well versed in helping expectant mothers safely reduce their drug use.
It was a stressful time at the hospital, said Lisa Johnson RN, Sanford Bemidji director of women’s and children’s services.
“When I first started here it was pretty unheard of to see a mom that was suspected of using,” she said. “Then it became the norm.”
“We were experiencing pretty high turnover in our labor and delivery staff,” she recalled. “People didn’t know how to respond to these moms and babies.”
Babies born with NAS at Sanford Bemidji were placed on child protective hold, separated from their mothers and put into foster care. Many members of the nursing staff didn’t fully understand the addiction process, and so they blamed the mothers for not just quitting opioids and losing custody of their children.
This heartbreaking family separation made working in labor and delivery — once a coveted job in the hospital — feel horrible.
“Before they quit,” Johnson said, “a lot of our nurses would tell us, ‘I went into labor and delivery because I wanted to be part of something happy, but it doesn’t feel happy here anymore.’ It got to the point where these [child protective] holds were happening so frequently that it was upsetting for everyone.”
Looking back on the numbers, it is clear why Sanford Bemidji’s labor and delivery staff was in crisis: In 2014, 6.3 percent of all babies born at the hospital were placed on child protective hold due to illicit substance use. Things only got worse in 2015, when 7.9 percent of births at the hospital ended in protective-hold separations.
“This hit us pretty quickly,” Johnson said. “We didn’t have an opportunity to help our staff plan for how to respond to caring for this type of patient. It unfolded so rapidly.”
Around the same time, other hospitals in Greater Minnesota were experiencing similar increases in NAS births, said Rahul Koranne M.D., Minnesota Hospital Association chief medical officer.
“By 2016 there were many hospitals in the state that were feeling the impact directly,” Koranne said. Because Greater Minnesota residents have the highest rates of opioid addiction in the state, he added, “Care teams at the front lines in the OB units in many rural hospitals were seeing moms and babies that were significantly affected. One of the most joyous moments in a family’s life can turn tragic when NAS comes into play.”
Analyzing the numbers
Katy Kozhimannil, associate professor in the University of Minnesota School of Public Health and director of the University of Minnesota Rural Health Research Center, likes to keep a razor-sharp focus on the lives of people — particularly women and children — living in the state’s more sparsely populated regions.
When she collaborated on a national study of opioid-affected births, Kozhimannil noticed some numbers that stood out.
“We saw that while opioid use disorder was increasing all over the place, the rate of increase is faster among rural residents than urban residents,” she said.
This data in hand, Kozhimannil gathered a team of colleagues to conduct an in-depth study of the characteristics of opioid-affected births to rural Minnesota moms. They examined maternal and infant records for childbirths of rural residents that occurred from 2007 to 2104, some 942,798 rural mothers and 981,090 rural infants. The research, which was published in the Journal of Rural Health, analyzed the impact of these opioid-affected births on medical systems in rural and urban settings.
“We looked at rural moms,” Kozhimannil said. “We looked at how many are being diagnosed with opioid use disorder. Where are they giving birth? In their own communities? At urban teaching hospitals that have more supports for opioid affected births?”
Pregnant women with OUD present distinct challenges in their pregnancies. Opioid use raises the risk of miscarriage and preterm birth, and children born with NAS need special care as they struggle with withdrawal symptoms during their first days of life. Many rural hospitals are not well equipped to handle complicated births. This means that many mothers with OUD are transferred to urban hospitals where they can receive higher levels of care. Still, Kozhimannil and her colleagues found that as much as 60 percent of rural Minnesota mothers with OUD during the study period gave birth in smaller, local hospitals like Sanford Bemidji.
This presents problems for hospital staff, Kozhimannil said. “These mothers are more likely to have preterm birth, higher needs, and social and clinical risk factors that may affect their pregnancies.”
The seven years covered by Kozhimannil’s research may have represented the peak of the state’s NAS crisis, Koranne said. Hospitals saw the numbers of mothers and babies affected by opioid use rise steadily during that period, and many, like Sanford Bemidji, responded with new programs designed to confront the problem.
“We are seeing some signs that our efforts are working,” Koranne said. “For example the number and rate of cases of NAS in Minnesota went up from 2012 to 2015, but the latest numbers from the Minnesota Department of Human Services show that since 2016 they have decreased. That gives me a tiny ray of hope. Obviously more needs to be done, but now it seems to be heading in the right direction.”
Johnson believes that the University of Minnesota research, while pointing out important gaps in rural maternal care, may already be a bit behind reality, in her hospital at least.
“If you look at our records from 2007 to 2014, you’ll see that same increasing trend,” she said. But the numbers in Bemidji have changed in the last four years: In 2017, out of 970 deliveries at Sanford Bemidji, the number of placed on child-protective hold was down to 4.3 percent.
Community response to crisis
How was Sanford Bemidji able to reverse this trend?
Johnson allows that at first, hospital staff members were caught off guard by the rapid increase in mothers with OUD. When the trend began to intensify, hospital leaders decided that they needed to do something to stem the tide of traumatic births and family separations.
Sanford Health, Beltrami County and Red Lake Family and Children’s Services applied for and was awarded a $1.67 million community health reinvestment grant from PrimeWest Health to develop a comprehensive program aimed at reducing the number of NAS births. The program, named First Steps to Healthy Babies, took a holistic approach to helping expectant mothers with OUD have a safe a healthy pregnancy through prenatal outreach and support, advocacy for substance-use treatment and in-home postnatal care for mothers and babies.
But the program didn’t stop with mothers and babies. Hospital staff were trained in the addiction process with a goal of building understanding of the struggles that mothers with OUD face and the hurdles they must overcome in order to achieve lasting sobriety.
“We realized that many of our staff didn’t really understand what addiction was or how it worked,” Johnson said. “A lot of people, even health care workers, feel that addiction is a choice, but it is an illness of the brain. Once we worked with our staff to get them to understand what addiction is, that helped them figure out how best to work with these moms.”
Ali Bruning, RN, First Steps to Healthy Babies program coordinator, added that the program also owes some of its success to its inclusive approach to education. Workers in all parts of the hospital were required to attend the training workshops to deepen their understanding of addiction. “I saw a lot of those good changes our workshops,” she said. “We did one for all of the staff that interacted with the patients. That included nurses and our staff that sits at the front desk and registration as well as hospital and clinic staff. That improved understanding and enhanced the way our patients were cared for.”
Each mother in the First Steps program is assigned a case manager who works closely with her to address barriers she faces to achieving a healthy pregnancy and birth. Case managers meet with the mothers each week in locations that are convenient to them. This could be at home, in the clinic, at work, a shelter or a library.
Kami Kelm is a case manager with Beltrami County Department of Health and Human Services and the First Steps to Healthy Babies program. She said it’s her job to interact with expectant mothers with OUD as early as possible in their pregnancies. Those early interactions are key in keeping families intact.
“The whole purpose of me trying to reach out to mothers while they are pregnant is to prevent child-protection intervention later on,” she said. “If we can meet with a woman while she’s still pregnant and address those issues, hopefully she can avoid that child protection intervention.”
Though the addiction crisis is still significant in the community, Kelm said that the First Steps program seems to have been effective at keeping mothers and their babies together.
“Child protective holds for Beltrami County used to be a pretty regular occurrence at our hospital,” she said. “We are now seeing a significant decline in this population, and that’s positive. There are just not as many babies being placed in foster care directly from the hospital.”
Spread the word
Sanford Bemidji staff was so pleased with the First Steps results that they worked to make the program available to other rural hospitals. They wanted as many people as possible to be helped by their efforts, Johnson said. That was their goal from the start.
“We wanted to develop program that’s easily replicable in other systems. We wanted to build something that other small community hospitals with limited resources can take and use for themselves.” It seems the team’s impulse was on target. When news got out about its success in reducing numbers of NAS births in the community, the calls started coming in, Johnson said: “We’ve had numerous systems reach out to us and say, ‘We want to use this program in our systems.’”
In 2016, in cooperation with the Minnesota Hospital Association, staff from Sanford Bemidji served on a committee that developed a NAS toolkit outlining best practices for health care systems. “That particular NAS toolkit got some national attention,” Koranne said. “It was one of the more comprehensive kits in the country.”
Encouraged by the success of the toolkit, the next logical step is to make the outline even more comprehensive. In the next few weeks, Koranne said the Minnesota Hospital Association will publish a formal roadmap outlining steps toward developing a comprehensive response to NAS. The roadmap will be available in the public domain so that hospitals around the country can replicate successes like those seen in Bemidji.
“That’s something we felt was important to do, not just for members of our association,” Koranne said, “but also for the entire healthcare system nationwide.”
For Johnson and the rest of the Sanford Bemidji staff, accolades like this are welcome, but their focus is on getting as many rural hospitals as possible to understand the steps they can take to safely reduce the number of NAS births.
“We know our program is effective,” Johnson said. “Had we not intervened, these statistics would continue to be on the rise. We really want other small hospitals to see this same kind of success.”