AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
CHAN McDERMOTT: First of all, I'm Chan McDermott from Texas , and I'm very happy to be here. I'm happy that when the idea of a session on centering was suggested that AMCHP was interested. From my perspective, I'm not really even sure anymore how I first heard about centering or how I became, first became interested. Part of my job is to be looking at best practices and trying to find new and creative and innovative ways to improve perinatal outcomes, especially in a state with almost 370, well over 370,000 births a year. And with a very disparate population where our outcomes can range from pretty decent to not very good at all.
And so somewhere along the line I think somebody mentioned centering pregnancy to me. It's interesting, because their whole perspective was actually it's really great because all the prenatal care takes place at once and so it saves a lot of money. And you know it was a different perspective than what we were looking at. But that is there. That is something to consider as well, if you're looking at ways of serving more clients, having better outcomes and then maybe saving some money, centering might be a way to go.
I need to tell you though that in Texas we're very, very much at the beginning of looking at this. Basically what we did is we looked, we became a bit familiar with the model. We looked at what was happening in our state with the model, and we found one place that had implemented it, which is a small free‑standing birthing center in south Texas . And what we decided to do was to talk to them, see if they were interested in sharing their data with us and then just seeing what we could find out about how they had implemented centering in their program and if there were, what kind of results there were and what that could tell us about the model.
So let me tell you just a little bit about that birthing center. It's Holy Family Birth Services. It's in West Laco Texas . I'll show you real quick. It's 11 miles north of the border. So if you're not sure where Texas is, that little tiny inset map shows you Texas , and then the larger map of Texas shows you where West Laco is down in that blue area down at the bottom. And basically, it's actually on this map, but I don't know if you can see Harlan James, just a little bit to the left of Harlan James. So it's not as close as Jane was, but pretty darn close.
They have six birthing suites, a clinic, a classroom, a chapel, medical storage rooms, and then they rely quite a bit on volunteers, both coming through the Catholic church and coming from midwifery programs and that kind of thing and just people who are interested in, I guess, just in natural birth, and just kind of seeing what a truly ininterventive place is like. Plus Holy Family was started by Sister Angela Murdough, who has, if you're not familiar with her, has quite a reputation as a teacher and as kind of an organizer. So a lot of people I think go just to kind of bask in her knowledge. She's a tough task master.
They provide pregnancy testing. They have full prenatal care. They do all the lab work. They will refer out of course if needed. They do provide child birth classes. But they also offer some things that a lot of free‑standing birthing centers don't offer. In‑house Social Services. Nutrition consultants. They'll help people with housing. They'll help people find work. They'll help people with transportation. So they kind of do go above and beyond, and so it is a little hard sometimes to tease out what might be an effective centering and what might simply be an effect of being at Holy Family. They have postpartum care for the mother and the baby, and including, and this is a little bit unique, in that they do home visits at the mother's house at the third and tenth day postpartum.
Lots of breast feeding support. And also, because it is completely staffed by certified nurse midwives, they're also providing vaccinations. They do well baby exams all the way through the first year. They also have this special project for teens which is the Paloma Project. Paloma means dove, and they do water birth. When I went to visit Holy Family we talked about the different places that women give birth. The midwife who was taking me on tour said they birth everywhere, they birth in the bed and bathtub and the kitchen. If they want to go out and birth in the garden, they birth in the garden. They're not too hung up on where the births actually took place. So there just is a midwife with a client. I don't know if you can see the big birth ball, I know other people have different names for it, physio ball or whatever you want to call it. They said the least preferred place is in the bed. The Paloma Project started in 1998. Initially it was funded by a grant from the Catholic Health Initiative. Since then the March of Dimes has been funding it. And what happens then at Holy Family, the teens that start prenatal care there, they traditionally start with prenatal care. At 26 weeks of gestation they're separated out, based on their due dates, and they begin to meet every two weeks with a goal of eight meetings. So I think there are a lot of elements of the ten essential points that are hit, but you do see they get one less meeting, typically, or two less meetings.
And then just like you heard Rima say, the topics, they cover all those topics, diet, exercise, labor, breast feeding. They're facilitated by the certified nurse midwife, but they're extremely client‑led. Very informal. I've seen the room where they do it and it's really just kind of like being in a living room. Very, very comfortable. And then postpartum, when we were there we were actually there for a reunion. Food was definitely served and then actually after the reunion was over, Holy Family had managed to secure gift certificates to Target. So they loaded all the moms and babies up in vans and took them to Target to get to go buy things with their gift certificates. And then the teens do evaluate their experiences, and most of those evaluations are in Spanish, because most of the teens that are served by Holy Family are either bilingual or monolingual Spanish speaking.
Of the total, of all of Holy Family's clients, those who opt to be in Paloma, and Paloma is only offered to teens, 19 and under, we asked why, do you not think this would be a good model with your adults? They said yeah, it would be. The midwife that we talked with who was not the midwife who initially started Paloma at Holy Family, she really didn't know why it wasn't being offered for adults; but it traditionally was offered to their teens. Of all their participants in 2003, when this data is from, 13% of their clients were participating in Paloma.
And I need to get to the point where I can tell you how many people that actually was. I believe it was 43 people. Hold on one sec. Yeah, it was 43 people. Okay. So of their teenage clients, ages 13 to 19, 23% were in the Paloma ‑‑ I'm sorry, 77% were in the Paloma project. 23% opted out of it.
And then just to give you kind of some background on the births to Hispanic teens in Texas in the same year, and again this is ages 13 to 19, and this is 31,444 births that took place in that year. And so we just want to show you the breakdown, that 40% of those were 13 to 17‑year‑olds and 60% of those were 18 and 19‑year‑olds.
Because we'll be showing you the data, we'll be showing for those that participated in Paloma and those that didn't and wherever we can against that teen population.
So you'll see a lot of similarities. For example, this just basically shows you the breakdown in ages, how many were in that 13 to 17 category, in those three groups, and then how many were in the 18 to 19. And a lot of similarities. You had a slightly younger population that had opted into Paloma. Across the board, 100 percent Hispanic. So in Paloma, out of Paloma, and then we're only looking at the Hispanic teen data.
Education. A lot of similarities as well. In the folks that had opted for Paloma, they all had six to 12 years of education. Of the women that had not opted for Paloma, you also had about 10 percent had zero to five years education. In the state you had a small percentage that had 13 years. Again, this is teens. They didn't have that many years to get all this education in.
Marital status. There's a little bit of a difference in the data here, because Holy Family, in their history, they include the category of cohabitating, but as a state we don't when we're collecting that data. So you see a field with the Paloma and non‑Paloma folks. It's not for the whole state. You had about 44% of the teens in Paloma were married; 50% were not. And, I'm sorry, 50% that were not in Paloma were married and 30% for the teens in the state were married.
And a little, we weren't able ‑‑ we don't collect data for the teen group on employment. So what you have here, you've got unemployed. You've got homemaker, which was the other big category that was marked. And other could be anything. It could be migrant worker. It could be retail. It was anything at all. It's just that it was so many little categories that we just grouped them all as together.
Annual income. Again we only have it on the Holy Family clients, and you'll see basically ‑‑ those that opted into Paloma, those that opted out of Paloma, very similar. And again a lot of ‑‑ let's see, those that opted into Paloma, about 80% of them and also those that opted out 80% were in their first pregnancy. When we looked at the teens in general across the state about 92% in 2003 were in their first pregnancy.
Okay. Now looking just at Paloma. You see that at birth, the newborns did slightly better, the newborns that were born to the women in the Paloma Project did slightly better. About 85% were just fine at birth. About 15% maybe exhibited some respiratory distress, maconium aspiration, that type of thing. In your non‑Paloma group that was about 20%.
There was only one still birth of this whole group, and that occurred in the non‑Paloma group.
In prematurity, actually, you have to remember our sample size is very, very small, and also I remember too that we're talking about a group here that has generally pretty decent birth outcomes in Texas. So we only had, I believe, one premature baby among the teens in this year, and that occurred in the Paloma project. But then if you compare that to Texas in general, you see that we had 11.8 that were earlier than 37 weeks and probably almost 6% that were possibly even earlier than that.
And birth weight, basically I think the thing to look at here is really Holy Family versus the teens, the Hispanic teens in Texas . Generally whether you're in Paloma or not, you had better outcomes in terms of birth weight than the general population of Hispanic teens in Texas .
Now, the thing about this slide is when we're talking about the week prenatal care began, it began, as you look into the slide, if you opted into Paloma, you started prenatal care a little bit earlier, but the thing is if you entered into prenatal care in the third trimester, there's a good chance you didn't opt for Paloma. You could have. They wouldn't have disallowed it, but I think some of those moms probably just said I've only got a couple of weeks let me just do what I need to do and not get involved in something like that. So I'm not really sure what you can conclude from this slide.
And I have to be really honest with y'all about this slide. I've been studying it and studying it and I wish I had taken it out. Because I'm not ‑‑ I wish I had my data person here to explain to you, because it seems like this slide kind of conflicts with the earlier slide that we showed. So let's just pretend this slide isn't really here. If you really want to know e‑mail me and I'll get with her and I'll be able to answer.
This was disappointing to me as a breast feeding advocate. I don't have a good reason for why. I'd love to go back and talk to the folks at Holy Family about this, but there definitely seems to be great reliance on formula in the Paloma folks. The bottom, the green, was exclusive breast. And the purple in the middle was exclusive formula; and the part at the top was both. And you definitely saw more moms, fewer moms that were breastfeeding at three days postpartum Paloma and more that were using the combination exclusive formula. This held true as well at that 10‑day second postpartum visit. So now we were equal in terms of breasts, but still more reliance on formula.
Okay. So what does all this mean for us in Texas ? Well, it means that we're still kind of a starting point. It means that, you know, the folks at Holy Family, they feel really very good about centering; they feel like it's a very effective way of working with their teens. They feel like they have good birth outcomes, but I don't know if they would attribute it to centering. I think they'd just find that it's a good model that the teens feel good about.
I've read some of the evaluations and they're all positive, really. The teens convey that they're excited about meeting other pregnant teens; that they feel more connected to the midwives, and that they're generally thankful. They generally feel like they're well cared for. So I think for Holy Family they just see this as a good way of conveying information and building connections between these women and of helping them to be a little more empowered and more a part of their care. What does that mean for us in Title V? As I said, I think it is a starting point. I think what we'll do is spend more time looking at Holy Family, trying to see if we can go a little deeper with that evaluation. Maybe try to broaden out that sample size a bit. It also means we'll be talking more to the centering pregnancy folks like Rima and to Sharon and to some of the other states like Jane and some of the other states that are doing things at the same level with centering pregnancy.
I think there's the possibility that we may ultimately issue an RFP for our Title V contractors, and maybe in selected parts of the state that might want to try to implement Paloma, or implement centering and see where that goes.
I did want to point this out to you, though. This is from a draft. So we'll see what happens with it. Omnibus Medicaid Bill. We're in a legislative session right now. What it said was allow the creation of reimbursement rates for group and shared appointments with medical providers for patients in prenatal classes and certain diseases and other medical conditions. And obesity was also mentioned. So like Rima said, it's certainly being considered for prenatal care but also for other types of care as well.
If you're interested in learning more about how Paloma has been implemented or about Holy Family, there's a website or contact Sister Angela. They're mostly going to want to hear from you, though, if you want to give them money or if you want to work there. They need both.
Just one more scene from one of their births. If you have, would like to try to contact me about anything, you have contact information on me, and then I do want to thank some of the midwives at Holy Family that helped us get started on this, and the teens and babies we met at the reunion. And Vonna Draton at the Department of Public Health Services did this initial evaluation for us. Thank you.