Health service use and health system costs associated with diabetes during pregnancy in Australia.

BACKGROUND AND AIMS: In the context of the rising rate of diabetes in pregnancy in Australia, this study aims to examine the health service and resource use associated with diabetes during pregnancy. METHODS AND RESULTS: This project utilised a linked administrative dataset containing health and cost data for all mothers who gave birth in Queensland, Australia between 2012 and 2015 (n = 186,789, plus their babies, n = 189,909). The association between maternal characteristics and diabetes status were compared with chi-square analyses. Multiple logistic regression produced the odds ratio of having different outcomes for women who had diabetes compared to women who did not. A two-sample t-test compared the mean number of health services accessed. Generalised linear regression produced the mean costs associated with health service use. Mothers who had diabetes during pregnancy were more likely to have their labour induced at <38 weeks gestation (OR:1.39, 95% CI:1.29-1.50); have a cesarean section (OR: 1.26, 95% CI:1.22-1.31); have a preterm birth (OR:1.24, 95%: 1.18-1.32); have their baby admitted to a Special Care Nursery (OR: 2.34, 95% CI:2.26-2.43) and a Neonatal Intensive Care Unit (OR:1.25, 95%CI: 1.14-1.37). On average, mothers with diabetes access health services on more occasions during pregnancy (54.4) compared to mothers without (50.5). Total government expenditure on mothers with diabetes over the first 1000 days of the perinatal journey was significantly higher than in mothers without diabetes ($12,757 and $11,332). CONCLUSION: Overall, mothers that have diabetes in pregnancy require greater health care and resource use than mothers without diabetes in pregnancy.

Redesigned Care Delivery for Insulin-Requiring Diabetes in Pregnancy Improves Perinatal Glycemic Control While Reducing Neonatal Intensive Care Admissions, Length of Stay, and Costs.

Objective: We sought to improve perinatal glycemic control and downstream neonatal outcomes through redesigned ambulatory management for women with insulin-requiring diabetes in pregnancy. Methods: To address gaps in perinatal glycemic management of women with insulin-requiring diabetes in pregnancy, redesigned care delivery (RCD) utilized integrated practice unit and minimally disruptive medicine concepts with incorporation of cellular-enabled glucose monitoring. Primary outcomes of RCD (N = 129) included hemoglobin A1c ([HbA1c], within RCD cohort), and gestational age (GA) at delivery, neonatal intensive care (NICU) admission, and NICU length of stay (LOS) compared with a preredesign care cohort (Pre-RCD; N = 122). Secondary outcomes included facility, payer reimbursement, and program costs. Generalized linear models assessed continuous variables while logistic regression methods assessed categorical outcomes. Results: Utilizing RCD, 92% of women with an initial HbA1c <6.5% maintained glycemic control until delivery, and 67.2% with an initial HbA1c ≥6.5% achieved delivery levels <6.5%. NICU admissions and GA-adjusted LOS decreased significantly [Pre-RCD vs. RCD: NICU admissions, 41.0% vs. 27.3%, p < 0.024; NICU LOS (95% confidence interval [CI]), 21.9 (17.1-26.6) vs. 14.6 (9.1-20.1), p = 0.045]. Every 10 days of redesigned management decreased mean NICU LOS by 1 day. Mean payer neonatal reimbursements decreased over $18,000 per delivery (p = 0.08) compared with implementation costs of $1,942 per delivery. Conclusion: Redesigned perinatal diabetes care with remote glucose monitoring demonstrated improved outcomes and value through downstream neonatal outcomes and lower payer costs. Therefore, subsequent dissemination and sustainability of similar programs' improved outcomes will likely require payer support.

Costs of Neonatal Intensive Care for Canadian Infants with Preterm Birth.

OBJECTIVE: To develop and validate an itemized costing algorithm for in-patient neonatal intensive care unit (NICU) costs for infants born prematurely that can be used for quality improvement and health economic analyses. STUDY DESIGN: We sourced patient resource use data from the Canadian Neonatal Network database, with records from infants admitted to 30 tertiary NICUs in Canada. We sourced unit cost inputs from Ontario hospitals, schedules of benefits, and administrative sources. Costing estimates were generated by matching patient resource use data to the appropriate unit costs. All cost estimates were in 2017 Canadian dollars and assigned from the perspective of a provincial public payer. Results were validated using previous estimates of inpatient NICU costs and hospital case-cost estimates. RESULTS: We assigned costs to 27 742 infants born prematurely admitted from 2015 to 2017. Mean (SD) gestational age and birth weight of the cohort were 31.8 (3.5) weeks and 1843 (739) g, respectively. The median (IQR) cost of hospitalization before NICU discharge was estimated as $20 184 ($9739-51 314) for all infants; $11 810 ($6410-19 800) for infants born at gestational age of 33-36 weeks; $30 572 ($16 597-$51 857) at gestational age of 29-32 weeks; and $100 440 ($56 858-$159 3867) at gestational age of <29 weeks. Cost estimates correlated with length of stay (r = 0.97) and gestational age (r = -0.65). The estimates were consistent with provincial resource estimates and previous estimates from Canada. CONCLUSIONS: NICU costs for infants with preterm birth increase as gestation decreases and length of stay increases. Our cost estimates are easily accessible, transparent, and congruent with previous cost estimates.

Cost-effectiveness evidence for strategies to promote or support breastfeeding: a systematic search and narrative literature review.

BACKGROUND: Global health policy recommends exclusive breastfeeding until infants are 6 months. Little is known about the cost-effectiveness of breastfeeding promotion strategies. This paper presents a systematic search and narrative review of economic evaluations of strategies to support or promote breastfeeding. The aim of the review is to bring together current knowledge to guide researchers and commissioners towards potentially cost-effective strategies to promote or support breastfeeding. METHODS: Searches were conducted of electronic databases, including MEDLINE and Scopus, for economic evaluations relevant to breastfeeding, published up to August 2019. Records were screened against pre-specified inclusion/exclusion criteria and quality was assessed using a published checklist. Costs reported in included studies underwent currency conversion and inflation to a single year and currency so that they could be compared. The review protocol was registered on the PROSPERO register of literature reviews (ID, CRD42019141721). RESULTS: There were 212 non-duplicate citations. Four were included in the review, which generally indicated that interventions were cost-effective. Two studies reported that breastfeeding promotion for low-birth weight babies in critical care is associated with lower costs and greater health benefits than usual care and so is likely to be cost-effective. Peer-support for breastfeeding was associated with longer duration of exclusivity with costs ranging from £19-£107 per additional month (two studies). CONCLUSIONS: There is limited published evidence on the cost-effectiveness of strategies to promote breastfeeding, although the quality of the current evidence is reasonably high. Future studies should integrate evaluations of the effectiveness of strategies with economic analyses.

The cost of Hypertensive Disorders of Pregnancy to the Australian healthcare system.

In Australia, Hypertensive Disorders of Pregnancy are one of the leading causes of maternal death. Additionally, mothers and babies can experience significant morbidity associated with Hypertensive Disorders of Pregnancy. Currently, there is little understanding about the resources spent on this pregnancy complication in Australia. Therefore, using a linked administrative dataset from the Queensland population in Australia, this study aims to determine the difference in government expenditure between mothers that have Hypertensive Disorders of Pregnancy and mothers who do not. The total government expenditure on mothers that had HDP was significantly higher than in mothers who did not have HDP ($14,388 and $11,395 respectively). Most notably, the greatest difference in costs were experienced during the time of birth ($8696 and $6509).

Team-Based Implementation of an Exclusive Human Milk Diet.

BACKGROUND: The University of Virginia neonatal intensive care unit is a 51-bed unit with approximately 600 to 700 admissions per year. Despite evidenced-based clinical care, necrotizing enterocolitis (NEC) and feeding intolerance remained problematic. PURPOSE: In September 2016, the neonatal intensive care unit implemented an exclusive human milk diet (EHMD) for infants born 1250 g or less with the goal of reducing NEC, feeding intolerance, parenteral nutrition use, and late-onset sepsis. Length of stay, bronchopulmonary dysplasia (BPD), and retinopathy of prematurity were also evaluated. METHODS: A work group developed systems for charging and documenting products used in an EHMD. Outcomes were compared with a control group of similar infants born prior to the availability of the EHMD. RESULTS: Infants who received an EHMD had significantly fewer late-onset sepsis evaluations (P = .0027) and less BPD (P = .018). While not statistically significant, less surgical NEC was also demonstrated (4 cases vs 1 case, which was 57% of total NEC cases vs 14.3%) while maintaining desirable weight gain and meeting financial goals. IMPLICATIONS FOR PRACTICE: A multidisciplinary team that implements financial and documentation systems can provide a sustainable clinical practice that improves patient outcomes. Ongoing evaluations of clinical and financial data provide valuable information to guide future clinical practices related to the EHMD. IMPLICATIONS FOR RESEARCH: Future research on the anti-inflammatory effect of an EHMD is needed to provide direction regarding a potential dose-dependent response for reduced BPD rates and severity. The role of human milk and prevention or mitigation of sepsis is not fully understood, but the reduction of the number of late-onset sepsis evaluations may support the relationship between an EHMD and infection protection. Exploring clinical and financial outcomes for implementing the EHMD in infants born more than 1250 g remains a key area for research.

Optimising neonatal service provision for preterm babies born between 27 and 31 weeks gestation in England (OPTI-PREM), using national data, qualitative research and economic analysis: a study protocol.

INTRODUCTION: In England, for babies born at 23-26 weeks gestation, care in a neonatal intensive care unit (NICU) as opposed to a local neonatal unit (LNU) improves survival to discharge. This evidence is shaping neonatal health services. In contrast, there is no evidence to guide location of care for the next most vulnerable group (born at 27-31 weeks gestation) whose care is currently spread between 45 NICU and 84 LNU in England. This group represents 12% of preterm births in England and over onr-third of all neonatal unit care days. Compared with those born at 23-26 weeks gestation, they account for four times more admissions and twice as many National Health Service bed days/year. METHODS: In this mixed-methods study, our primary objective is to assess, for babies born at 27-31 weeks gestation and admitted to a neonatal unit in England, whether care in an NICU vs an LNU impacts on survival and key morbidities (up to age 1 year), at each gestational age in weeks. Routinely recorded data extracted from real-time, point-of-care patient management systems held in the National Neonatal Research Database, Hospital Episode Statistics and Office for National Statistics, for January 2014 to December 2018, will be analysed. Secondary objectives are to assess (1) whether differences in care provided, rather than a focus on LNU/NICU designation, drives gestation-specific outcomes, (2) where care is most cost-effective and (3) what parents' and clinicians' perspectives are on place of care, and how these could guide clinical decision-making. Our findings will be used to develop recommendations, in collaboration with national bodies, to inform clinical practice, commissioning and policy-making. The project is supported by a parent advisory panel and a study steering committee. ETHICS AND DISSEMINATION: Research ethics approval has been obtained (IRAS 212304). Dissemination will be through publication of findings and development of recommendations for care. TRIAL REGISTRATION NUMBER: NCT02994849 and ISRCTN74230187.

Making a Genetic Diagnosis in a Level IV Neonatal Intensive Care Unit Population: Who, When, How, and at What Cost?

OBJECTIVE: To investigate the prevalence of genetic disease and its economic impact in a level IV neonatal intensive care unit (NICU) by identifying and describing diseases diagnosed, genetic testing methodologies used, timing of diagnosis, length of NICU stay, and charges for NICU care. STUDY DESIGN: A retrospective chart review of patients admitted to a level IV NICU from 2013 to 2014 (n = 1327) was undertaken and data collected up to 2 years of age from the electronic medical record. RESULTS: In total, 117 patients (9%) received 120 genetic diagnoses using a variety of methodologies. A significant minority of diagnoses, 36%, were made after NICU discharge and 41% were made after 28 days of age. Patients receiving a genetic diagnosis had significantly longer mean lengths of stay (46 days vs 29.1 days; P < .01) and costlier mean charges ($598 712 vs $352 102; P < .01) for their NICU care. The NICU stay charge difference to care for a newborn with a genetic condition was on average $246 610 in excess of that for a patient without a genetic diagnosis, resulting in more than $28 000 000 in excess charges to care for all patients with genetic conditions in a single NICU over a 2-year period. CONCLUSIONS: Given the high prevalence of genetic disease in this population and the documented higher cost of care, shortening the time to diagnosis and targeting therapeutic interventions for this population could make a significant impact on neonatal care in level IV NICUs.

Modelling potential cost savings from use of real-time continuous glucose monitoring in pregnant women with Type 1 diabetes.

AIM: To investigate potential cost savings associated with the use of real-time continuous glucose monitoring (RT-CGM) throughout pregnancy in women with Type 1 diabetes. METHODS: A budget impact model was developed to estimate, from the perspective of National Health Service England, the total costs of managing pregnancy and delivery in women with Type 1 diabetes using self-monitoring of blood glucose (SMBG) with and without RT-CGM. It was assumed that the entire modelled cohort (n = 1441) would use RT-CGM from 10 to 38 weeks' gestation (7 months). Data on pregnancy and neonatal complication rates and related costs were derived from published literature, national tariffs, and device manufacturers. RESULTS: The cost of glucose monitoring was £588 with SMBG alone and £1820 with RT-CGM. The total annual costs of managing pregnancy and delivery in women with Type 1 diabetes were £23 725 648 with SMBG alone, and £14 165 187 with SMBG and RT-CGM; indicating potential cost savings of approximately £9 560 461 from using RT-CGM. The principal drivers of cost savings were the daily cost of neonatal intensive care unit (NICU) admissions (£3743) and the shorter duration of NICU stay (mean 6.6 vs. 9.1 days respectively). Sensitivity analyses showed that RT-CGM remained cost saving, albeit to lesser extents, across a range of NICU costs and durations of hospital stay, and with varying numbers of daily SMBG measurements. CONCLUSIONS: Routine use of RT-CGM by pregnant women with Type 1 diabetes, would result in substantial cost savings, mainly through reductions in NICU admissions and shorter duration of NICU care.

The disproportionate cost of operation and congenital anomalies in infancy.

BACKGROUND: Congenital anomalies are the leading cause of infant death and pediatric hospitalization, but existing estimates of the associated costs of health care are either cross-sectional surveys or economic projections. We sought to determine the percent of total hospital health care expenditures attributable to major anomalies requiring surgery within the first year of life. METHODS: Utilizing comprehensive California statewide data from 2008 to 2012, cohorts of infants undergoing major surgery, with birth defects and with surgical anomalies, were constructed alongside a referent group of newborns with no anomalies or operations. Cost-to-charge and physician fee ratios were used to estimate hospital and professional costs, respectively. For each cohort, costs were broken down according to admission, birth episode, and first year of life, with additional stratifications by birth weight, gestational age, and organ system. RESULTS: In total, 68,126 of 2,205,070 infants (3.1%) underwent major surgery (n = 32,614) or had a diagnosis of a severe congenital anomaly (n = 57,793). These accounted for $7.7 billion of the $18.9 billion (40.7%) of the total health care costs/expenditures of the first-year-of-life hospitalizations, $7.0 billion (48.6%) of the costs for infants with comparatively long birth episodes, and $5.2 billion (54.7%) of the total neonatal intensive care unit admission costs. Infants with surgical anomalies (n = 21,264) totaled $4.1 billion (21.7%) at $80,872 per infant. Cardiovascular and gastrointestinal diseases accounted for most admission costs secondary to major surgery or congenital anomalies. CONCLUSION: In a population-based cohort of infant births compared with other critically ill neonates, surgical congenital anomalies are disproportionately costly within the United States health care system. The care of these infants, half of whom are covered by Medi-Cal or Medicaid, stands as a particular focus in an age of reform of health care payments.

Cost Effectiveness of Neonatal Resuscitation at 22 Weeks of Gestation.

OBJECTIVE: To evaluate the cost effectiveness of three different approaches to the care of neonates born at 22 weeks of gestation: universal resuscitation, selective resuscitation, or no resuscitation. METHODS: We constructed a decision-analytic model using TreeAge to compare the outcomes of death and survival with and without neurodevelopmental impairment in a theoretical cohort of 5,176 neonates (an estimate of the annual number of deliveries that occur in the 22nd week of gestation in the United States). We took a societal perspective using a lifetime horizon, and all costs were expressed in 2017 U.S. dollars. Effectiveness was based on combined maternal and neonatal quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio was determined (cost/QALY) for each additional survivor. The willingness to pay threshold was set at $100,000/QALY. All model inputs were derived from the literature. Deterministic and probabilistic sensitivity analyses were performed to interrogate model assumptions. RESULTS: Universal resuscitation would result in 373 survivors, 123 of whom would have severe disability. Selective resuscitation would produce 78 survivors with 26 affected by severe impairments. No resuscitation would result in only eight survivors and three neonates with severe sequelae. Selective resuscitation was eliminated by extended dominance because this strategy had a higher incremental cost-effectiveness ratio than universal resuscitation, which was a more effective intervention. The incremental cost-effectiveness ratio of universal resuscitation compared with no resuscitation was not cost effective at $106,691/QALY. Monte Carlo simulations demonstrated that universal resuscitation is more effective but also more expensive compared with no resuscitation, with only 35% of simulations below the willingness to pay threshold. CONCLUSION: In our model, neither selective nor universal resuscitation of 22-week neonates is a cost-effective strategy compared with no resuscitation.

Human Milk and Clinical Outcomes in Preterm Infants.

The LOVE MOM cohort (Longitudinal Outcomes of VLBW Infants Exposed to Mothers' Own Milk; NIH: R010009; Meier PI) enrolled 430 infants with very low birth weight (VLBW) between 2008 and 2012 to study the impact of the dose and exposure period of MOM during hospitalization in the neonatal intensive care unit (NICU) on potentially preventable complications of prematurity and their associated costs. In this prospective study, MOM and formula feedings were calculated daily (mL), medical diagnoses for NICU morbidities (necrotizing enterocolitis [NEC], late-onset sepsis [sepsis], and bronchopulmonary dysplasia [BPD]) were confirmed independently by 2 neonatologists, and propensity scoring was used to analyze covariates. Neurodevelopmental outcome was measured for a subset of 251 LOVE MOM infants at 20 months of age, corrected for prematurity (CA). Data revealed a dose-response relationship between higher amounts of MOM received during critical NICU exposure periods and a reduction in the risk of NEC, sepsis, BPD, and their costs, as well as higher cognitive index scores at 20 months CA. MOM appears to function via different mechanisms during NICU exposure periods to reduce the risk of potentially preventable complications and their costs in VLBW infants. Institutions should prioritize the economic investments needed to acquire, store, and feed high-dose MOM in this population.

Phototherapy for Neonatal Unconjugated Hyperbilirubinemia: Examining Outcomes by Level of Care.

OBJECTIVES: Newborns hospitalized with unconjugated hyperbilirubinemia without critical comorbidities may receive intensive phototherapy (IP) in non-ICU levels of care, such as a mother-newborn unit, or ICU levels of care. Our aim was to compare outcomes between each level. METHODS: Using hospital discharge data from 2005 to 2011 in New York's State Inpatient Database, we performed multivariate analyses to compare outcomes that included total cost of hospitalization, length of stay, 30-day readmission rate after IP, and the number of cases of death, exchange transfusion, and γ globulin infusion. We included term newborns treated with IP in their first 30 days of life and without diagnosis codes for other critical illnesses. Explanatory variables included level of care, sex, race, insurance type, presence or absence of hemolysis, hospital, volume of IP performed at each hospital, and year of hospitalization. RESULTS: Ninety-nine percent of IP was delivered in non-ICU levels of care. Incidence of major complications was rare (≤0.1%). After adjusting for confounders, ICU level of care was not associated with difference in length of stay (relative risk: 1.2; 95% confidence interval [CI]: 0.91 to 1.15) or 30-day readmission rate (odds ratio: 0.74; 95% CI: 0.50 to 1.09) but was associated with 1.51 (95% CI: 1.47 to 1.56) times higher costs. CONCLUSIONS: For otherwise healthy term newborns with jaundice requiring IP, most received treatment in a non-ICU level of care, and those in intensive care had no difference in outcomes but incurred higher costs. IP guideline authors may want to be more prescriptive about IP level of care to improve value.

Rapid Challenges: Ethics and Genomic Neonatal Intensive Care.

NICUs are a priority implementation area for genomic medicine. Rapid genomic testing in the NICU is expected to be genomic medicine's "critical application," providing such clear benefits that it drives the adoption of genomics more broadly. Studies from multiple centers worldwide have now demonstrated the clinical utility and cost-effectiveness of rapid genomic sequencing in this setting, paving the way for widespread implementation. However, the introduction of this potentially powerful tool for predicting future impairment in the NICU also raises profound ethical challenges. Developing models of good practice that incorporate the identification, exploration, and analysis of ethical issues will be critical for successful implementation. In this article, we analyze 3 such issues: (1) the value and meaning of gaining consent to a complex test in a stressful, emotionally charged environment; (2) the effect of rapid diagnosis on parent-child bonding and its implications for medical and family decisions, particularly in relation to treatment limitation; and (3) distributive justice (ie, whether the substantial cost and diversion of resources to deliver rapid genomic testing in the NICU can be justified).

Cost Analysis of Treating Neonatal Hypoglycemia with Dextrose Gel.

OBJECTIVE: To evaluate the costs of using dextrose gel as a primary treatment for neonatal hypoglycemia in the first 48 hours after birth compared with standard care. STUDY DESIGN: We used a decision tree to model overall costs, including those specific to hypoglycemia monitoring and treatment and those related to the infant's length of stay in the postnatal ward or neonatal intensive care unit, comparing the use of dextrose gel for treatment of neonatal hypoglycemia with placebo, using data from the Sugar Babies randomized trial. Sensitivity analyses assessed the impact of dextrose gel cost, neonatal intensive care cost, cesarean delivery rate, and costs of glucose monitoring. RESULTS: In the primary analysis, treating neonatal hypoglycemia using dextrose gel had an overall cost of NZ$6863.81 and standard care (placebo) cost NZ$8178.25; a saving of NZ$1314.44 per infant treated. Sensitivity analyses showed that dextrose gel remained cost saving with wide variations in dextrose gel costs, neonatal intensive care unit costs, cesarean delivery rates, and costs of monitoring. CONCLUSIONS: Use of buccal dextrose gel reduces hospital costs for management of neonatal hypoglycemia. Because it is also noninvasive, well tolerated, safe, and associated with improved breastfeeding, buccal dextrose gel should be routinely used for initial treatment of neonatal hypoglycemia. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12608000623392.

Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery.

OBJECTIVE: Neonates undergoing congenital heart surgery require highly specialized, resource-intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi-institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. METHODS: We retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 children's hospitals). Multivariate generalized estimating equations adjusted for center- and patient-specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. RESULTS: Of 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a $20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a $23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. CONCLUSIONS: Admission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery.

Survival and negotiation: narratives of severe (near-miss) neonatal complications of Syrian women in Lebanon.

The World Health Organization has elaborated a maternal and neonatal near-miss reporting, audit and feedback system designed to improve the quality of care during and after childbirth. As part of a four-hospital comparative study in the Middle East, this article discusses the experiences of mothers whose newborns suffered from severe complications at birth in the Rafik Hariri University Hospital, the only public hospital in Beirut. Based on in-depth home interviews several weeks after childbirth, it aims to explore the experience of neonatal near-miss events through the mothers' birth narratives. The central concerns of these vulnerable and marginalised women regarded access to neonatal care, and how to negotiate hospital bureaucracy and debt. It argues that financial and bureaucratic aspects of the near-miss event should be part of the audit system and policy-making, alongside medical issues, in the quest for equitable access to and management of quality perinatal care.