New Pregnancy Program Improves Prenatal Care
Public Health Feature - October 2010
Tex Med. 2010;106(10):45-50.
By Crystal Conde
New models of delivering health care to groups of pregnant women are catching on at hospitals and clinics throughout Texas, replacing the one-on-one prenatal care physicians traditionally have provided expectant mothers.
The March of Dimes has assumed the lead in helping physicians and health care facilities implement evidence-based group modes of prenatal care. The organization promotes a program called Centering Pregnancy®, developed by the Centering Healthcare Institute, to bring together pregnant women at risk of preterm birth.
In this collective approach to prenatal care, expectant mothers with roughly the same due dates attend appointments together. An obstetrician, nurse practitioner, or certified nurse-midwife facilitates the visit in conjunction with a registered nurse, social worker, nursing assistant, or licensed vocational nurse. Facilitators lead discussions on the women's pregnancy and parenting concerns.
The March of Dimes Texas Chapter launched the initiative in 2006 to improve birth outcomes, increase social support and prenatal care, and improve the quality of prenatal education for pregnant women in Texas. To date, it has funded 15 Centering Pregnancy projects throughout Texas. (See "Centering Pregnancy Texas Project Sites.")
The Centering Pregnancy curriculum, developed by the Centering Healthcare Institute, encourages pregnant women to adopt healthy behaviors during pregnancy in a nurturing group environment. Group sessions cover topics such as nutrition, hygiene, contraception, postpartum care, breathing and relaxation techniques, child care, and the benefits of breastfeeding. Mothers can share their pregnancy experiences, have their abdomens measured, learn exercise techniques that relieve discomfort, and listen to the baby's heartbeat.
The initiative has produced some promising results. The March of Dimes conducted a three-year evaluation of all Centering Pregnancy sites. Data from the Texas chapter show only 6.5 percent of babies born to women in the initiative were preterm, compared with the Texas preterm birth rate of 13.7 percent. Preliminary data also show that, based on the number of premature births prevented, the Texas initiative achieved a potential medical cost savings of $1.2 million.
Methodist Health System in Dallas implemented the Life Shines Bright preterm birth prevention program with Centering Pregnancy at the core of the initiative in 2008. According to Stephen K. Patrick, MD, residency program director for the Department of Obstetrics and Gynecology at Methodist, the hospital system uses the group care model to address the high preterm birth rate in Dallas County.
The Dallas area's average preterm birth rate is about 13 percent. Dr. Patrick says some Dallas ZIP codes have preterm birth rates in the 20-percent range.
Dr. Patrick is a spokesperson for the March of Dimes Texas Chapter and promotes Centering Pregnancy throughout the state.
"I want obstetricians in Dallas and across the state to realize that it's possible to prevent preterm birth if you change how you provide prenatal care. Group prenatal care allows practitioners to spend more time with patients, and patients report increased satisfaction with prenatal care," he said.
Group Care Reduces Preterm Births
When it comes to its preterm birth rate, Texas doesn't fare well nationally. The March of Dimes slapped the state with an F on the organization's 2009 premature birth report card.
Based on data from 2007, the 2009 report card indicates Texas' preterm birth rate was 13.6 percent. The state's 2006 rate was 13.7 percent. The state scored an F in 2008, too. The nation got a D for its rate of preterm births, 12.7 percent.
Dr. Patrick points to a study led by Yale University as proof that group prenatal care methods can have a positive impact on preterm birth rates. The study, "Group Prenatal Care and Perinatal Outcomes: A Randomized Controlled Trial," [PDF] published in the August 2007 edition of Obstetrics & Gynecology , reported a 33-percent reduction in preterm births among Centering Pregnancy participants.
Of 1,047 women randomly assigned to either group prenatal visits or standard care, 9.8 percent of those in group visits had premature births, compared with 13.8 percent of those who received standard care. In the study, each two-hour group prenatal care session included physical assessment, education and skills building, and support through facilitated discussion.
One of the challenges to widespread adoption of Centering Pregnancy, Dr. Patrick says, is changing the way health care professionals provide prenatal care.
"Doctors in Texas have been trained to provide one-on-one care to pregnant women. Centering Pregnancy addresses groups of women and is a better fit for nurse midwives and nurse practitioners at this time since physicians haven't been trained in group prenatal care. I think it will take time for Texas to see a change in how health care professionals conduct prenatal care," he said.
A nurse practitioner runs each of the 10 group sessions Life Shines Bright participants attend. Most groups consist of 12 women who receive prenatal care and instruction from the nurse practitioner. Dr. Patrick is the sponsoring physician and screens each patient's chart.
Cynthia Wade, APRN, is a certified nurse-midwife conducting Centering Pregnancy at the Casa de Amigos Community Health Program in the Harris County Hospital District and also is a Centering Healthcare Institute faculty member. She says nurse practitioners and certified nurse-midwives always consult with and refer to medical doctors as they comanage high-risk pregnant patients.
"Consultation with a physician occurs in a similar way to traditional care, based on defined protocols. All practitioners, physicians, midwives, and nurse practitioners work together as a team to provide care to women in this evidence-based model," Ms. Wade said.
She says the level of involvement among medical doctors varies by Centering Pregnancy program.
"Medical doctors certainly have to approve of us [certified nurse-midwives] providing Centering Pregnancy, but they may or may not be very involved in the day-to-day running of the program," Ms. Wade said.
Marcel Thompson, DO,a member of TMA's Committee on Maternal and Perinatal Health and TMA's Select Committee on Medicaid, CHIP, and the Uninsured, is an obstetrician-gynecologist in Round Rock and regional program chair for the March of Dimes. He says Centering Pregnancy potentially can give women prenatal care at an earlier gestational period and is an efficient model because one or two practitioners can see a large group of mothers at once.
"Centering Pregnancy offers physicians and health care institutions a good way to utilize their midlevel practitioners to accommodate patient volume," Dr. Thompson said.
Instead of sitting in a medical office waiting room for hours to be seen by a doctor for five minutes, Dr. Thompson says, mothers participating in Centering Pregnancy get the benefit of a two-hour appointment consisting of prenatal care and education. The model is also efficient for practitioners, he says, because they're providing the same information to a large group of women at once, rather than relaying the same details several times to women individually.
Lower Costs, More Pay
Dr. Thompson says expanding Centering Pregnancy at clinics, medical practices, and health institutions throughout Texas, along with decreasing the number of elective inductions and cesarean sections, will help the state save money on Medicaid birth-related costs associated with prematurity.
According to the Texas Health & Human Services Commission (HHSC), Medicaid is the primary public coverage program providing prenatal and perinatal care in Texas. The state currently spends in excess of $2.2 billion per year in birth- and delivery-related services. Additionally, Medicaid pays for more than 55 percent of all births in Texas.
HHSC reports that costs related to infant care are growing almost 10 percent each year. Neonatal intensive care unit (NICU) utilization is increasing faster than expected. More than 50 percent of birth-related Medicaid costs can be attributed to extremely premature infants, who account for about 2 percent of births in the program.
Preterm infants can suffer from respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, and other complications of being born too early.
According to Dr. Patrick, Life Shines Bright participants range in age from 15-year-old teens to women in their 40s, and a majority are on Medicaid. He says widespread adoption of Centering Pregnancy and other evidence-based group models of care can save the state money up front and in the long term because disabilities due to preterm birth can be prevented.
"Centering Pregnancy has improved outcomes among participants and has the potential to reduce Medicaid costs. If using the Yale study as an example, the state of Texas could lower Medicaid birth-related costs by 30 percent. That means the number of babies admitted to NICU will go down by 30 percent, too," Dr. Patrick said.
He says reimbursement is another benefit of Centering Pregnancy.
"Because we see patients more often in the Centering Pregnancy program, we're billing for 20 hours of care instead of two and are reaping greater reimbursement," Dr. Patrick said.
Honey Child Helps African-American Mothers
In addition to Centering Pregnancy, March of Dimes has another group care model that takes a faith-based approach to preventing preterm births and infant mortality among African-American women. The Honey Child Prenatal Education Program helps women aged 18 to 40 at risk for preterm birth have the healthiest possible pregnancies and birth outcomes.
Charleta Guillory, MD, associate professor of pediatrics at Texas Children's Hospital Newborn Center and a member of TMA's Committee on Maternal and Perinatal Health, says eliminating disparities in birth outcomes, especially among African-American women, has been a persistent challenge in improving maternal and child health in Texas.
"In order to decrease the high prematurity rate in Texas, we must first focus on closing the gap of high prematurity rates and infant mortality rates in the African-American community," she said.
Participants in Honey Child attend six sessions with March of Dimes-trained facilitators in which they learn about nutrition, relaxation and exercise, prenatal care, self-esteem, preterm birth, and labor and delivery. A mentor provides weekly social support and reinforces the positive health behaviors discussed in the group.
In Texas, according to the National Center for Health Statistics, 18.7 percent of live births to African-American women are preterm, compared with 12.7 percent for white women and 13.3 percent for Hispanic women. The infant mortality rate also is higher among babies of African-American women at 12.4 percent, compared with 6 percent for white infants and 5.6 percent for Hispanic infants.
Dr. Guillory says the Honey Child program focuses on the specific needs and concerns of African-American women and creates a "support group" atmosphere among the participants. It allows participants to take an active role in the group by sharing their needs and experiences in a church setting.
"Learning becomes more effective when participants are empowered with culturally appropriate information and are in a relationship-building environment with mentors," she said.
Texas is home to the following Honey Child program sites:
- Cornerstone Baptist Church, Arlington,
- Greater Love Missionary Baptist, San Antonio,
- Greater Mount Tabor Christian Center, Fort Worth,
- Greenspoint Baptist Church, Houston,
- Wheeler Avenue Baptist Church, Houston,
- David Chapel Missionary Baptist Church, Austin, and
- Christian Stronghold Church, Dallas.
Texas Children's Hospital volunteers consult with and serve on the Greenspoint Baptist Church Honey Child consortium.
Texas Children's and the University of Texas Women, Infants and Children program lactation consultants conduct breastfeeding workshops, nutritionists support facilitators and teach participants to prepare healthy meals, and physicians lead discussions about stress reduction. Dr. Guillory contributes to the Greenspoint Baptist Church Honey Child consortium by following up with participants to ensure they're receiving prenatal care.
She says preliminary March of Dimes data on the effectiveness of the program show that for 176 participants, the preterm birth rate was 9 percent, compared with the overall preterm birth rate of 18.7 percent among African-American women in Texas. Ninety percent of births among participants have been full-term births. In addition, participants gave the Honey Child program an average score of 9.5 on a 10-point scale on meeting their needs and expectations.
For more information about Honey Child, contact Wanda Ford Wesson, MS, with the March of Dimes Texas Chapter, at (254) 598-8421.
Women Want Centering Pregnancy
While Centering Pregnancy programs follow a curriculum, Dr. Patrick adds that practitioners do have some flexibility with activities for the groups. For instance, the Life Shines Bright program has a partnership with the local Junior League, which provides a life skills class. Expectant mothers learn how to develop a financial budget, balance a checkbook, write a résumé, and prepare for a baby's first year of life.
The Centering Pregnancy program at Methodist also incorporates sewing classes to teach participants to make baby clothes. And Life Shines Bright collaborates with the Methodist Women's Group, whose members make blankets for the newborn babies.
"We've found that partnering with our local community groups adds a lot of value to our Centering Pregnancy program," Dr. Patrick said.
Life Shines Bright participants have been telling other pregnant women about the benefits of group prenatal care. Currently, the Golden Cross Academic Clinic is the site of Methodist's Centering Pregnancy groups. But Dr. Patrick says space is restricting Methodist's ability to meet increasing demand among prospective participants. The clinic is undergoing remodeling, which should be complete by January.
He encourages physicians and other health professionals to consider implementing a Centering Pregnancy prenatal care program. (See "Starting a Centering Pregnancy Program.")
"It's the care part of prenatal care that's most important," Dr. Patrick said. "Women are spreading the word about Centering Pregnancy, and we're getting lots of calls from people who want to partake in our program."
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Centering Pregnancy Texas Project Sites
- Texas Tech University Health Sciences Center Department of Obstetrics and Gynecology - Lubbock, Amarillo, and El Paso
- William Beaumont Army Medical Center - El Paso
- Longview Wellness Center - Longview
- CommUnityCare Rosewood Zaragosa Clinic - Austin
- Wilford Hall Medical Center Lackland Air Force Base - San Antonio
- The University of Texas Medical Branch - Beaumont
- Methodist Health System Golden Cross Academic Clinic - Dallas
- City of Houston Department of Health and Human Services - Houston
- Baylor College of Medicine Good Neighbor/Casa de Amigos clinics - Houston
- The University of Texas Health Science Center at Houston Aldine and Acres clinics - Houston
- People's Community Clinic - Austin
- Carl R. Darnall Army Medical Center - Fort Hood
Source: March of Dimes Texas Chapter.
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Starting a Centering Pregnancy Program
Implementing a Centering Pregnancy program requires medical staff to undergo training developed by the Centering Healthcare Institute. Stephen K. Patrick, MD, Methodist Health System residency program director for the Department of Obstetrics and Gynecology, says some may view the upfront cost of training as a barrier to starting a program. The March of Dimes can help offset the cost.
March of Dimes in Texas has provided more than $800,000 in start-up and ongoing funding for Centering Pregnancy programs. Check the Texas Chapter website for upcoming grant opportunities. For more information about Centering Pregnancy program opportunities in Texas, call (972) 232-1349 to speak to Karen Littlejohn, MMHS, state director of program services for the March of Dimes Texas Chapter.
To learn more about starting a Centering Pregnancy program, including the cost of training, call the Centering Healthcare Institute at (203) 271-3632. Information is available on the institute's website.
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