Children's Hospitals Today - Spring 2018 - 21

FETAL CARE / FEATURE

ore than 35 years ago, Michael Harrison, M.D., a pediatric surgeon at the University of California, San
Francisco, proposed operating on babies in utero to treat conditions that would likely be lethal during
pregnancy, such as bladder outlet obstruction. Since then, the pool of candidates for open fetal surgery has expanded to include those who would likely benefit from prenatal surgery for non-lethal conditions,
including, most commonly, myelomeningocele, a neural tube defect that is a severe form of spina bifida.
Today, in addition to surgical procedures, fetal care centers at children's hospitals provide diagnostic testing,
access to maternal-fetal medicine doctors, family-centered care and advanced-level NICUs. While there are some
operational challenges, these centers can play a role in children's hospitals' growth strategies for the future. Here's
a look at three children's hospitals that are moving upstream with the creation of comprehensive fetal care programs. As a result, they have increased volume, strengthened their market positions and advanced their missions.

Diagnosing and treating complex fetal conditions
In the fall of 2009, leaders from St. Louis Children's Hospital
(SLCH), which serves as the pediatric hub for a 15-hospital
system, joined colleagues from Barnes-Jewish Hospital
(BJH) and Washington University School of Medicine to
discuss forming a partnership to grow fetal care services.
Initially, the program only offered education, prenatal diagnostics, assessment and counseling. The organizations agreed
At St. Louis Children's
that SLCH and BJH would run
Hospital, fetal
the fetal care program jointly, and
evaluations
are up
over the next five years, the program grew at a slow pace.
After 24 months, the center hit
its growth projections for evaluations. It was 5 percent over
projections for NICU admissions but was down 32 percent
on deliveries. The fetal care center offered a limited range
of procedures, and most volume was in laser twin-to-twin
interventions. Following the departure of its maternalfetal medicine interventionalist, the program went into a
12-month holding pattern.
In 2013, SLCH and BJH examined the fetal care center with
renewed focus. Leadership realized success would be elusive
until a culture of collaboration and a willingness to make a
major financial commitment was in place. The group made
improvements to family support programs and increased genetics and genomic diagnostic services, advanced minimally
invasive procedures and fetal/placental imaging.
Then, spurred by the successful management of a myelomeningocele trial, hospital leadership decided to offer
these capabilities, which accelerated the development of a

comprehensive open fetal surgery program. This also meant
making a significant financial investment in the highly specialized equipment necessary to perform fetal interventions
and recruiting a fetal surgeon who could provide a broad
range of interventions. A year after the surgeon started, new
patient evaluations were up 70 percent, deliveries were up 12
percent and NICU admissions were up 12 percent.

Keep eyeing the future

Even for established children's hospitals that are part of major
academic medical centers, successfully providing fetal care
services requires hard work and a little bit of good fortune.
One key to success is planning for the future. As SLCH's fetal
medicine efforts move into the next few years, the organization will continue expanding in vitro fertilization services;
recruit a partner for the maternal-fetal interventionalist;
advance clinical care by better understanding primary developmental mechanisms early in pregnancy; integrate molecular biology, genetics and molecular imaging; and develop
advanced non-surgical pharmacologic fetal interventions.
Before establishing fetal care centers, evaluate the local, regional and national needs. Assess the organization's culture-
collaboration is important, and everyone must buy in and be
willing to work with obstetrics and maternal-fetal medicine
partners. Also, assess the organization's willingness to make
a substantial commitment and realize fetal medicine is more
than an operating room and a surgeon-it requires new infrastructure, such as nurse coordinators, social workers, genetic counselors, marketing, social media, outreach education,
follow-up services, research support and outcome evaluation.

CHILDREN'S HOSPITAL S TODAY Spring 2018

Table of Contents for the Digital Edition of Children's Hospitals Today - Spring 2018