AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
JANE PEACOCK: Well, it's a real pleasure to be able to be here today, and we're going to see if this slide show gets really exciting, because the person that sent me this slide show actually built it in with these car brakes on every single entry of the slide. So I think we fixed it. I'm happy to be here. I'm representing two people from New Mexico who pioneered centering pregnancy, Ms. Van (inaudible) and Ms. Robert a Moore. Unfortunately they couldn't come, but I'm going to endeavor to share their work with you, and I will defer any questions you may have to these two very knowledgeable ladies.
I'm the family health bureau chief. I'm a nutritionist, so I'll do my best. I don't claim to be an expert.
Well, why would we want to change the way prenatal care is delivered in New Mexico ? I want to give you an idea of our situation in New Mexico . How many have been there before? Wow. People are really getting around now. When I went to school at Penn State , I was moving out to New Mexico , and I was standing next to a very knowledgeable grad student at the bus stop. They said: You know, how is the peso holding out there, when they heard I was moving to New Mexico . So I just wanted to check to see if you knew where we were.
In an average week in New Mexico we have 64 babies born preterm, nine babies born very preterm. 42 born low birth weight. Six babies born very low birth weight. These are very small numbers, but you have to realize we're the fifth largest state in the country and we have a WIC caseload, at least I know, the same size at Maine. So it's a challenge to deliver services there.
As far as preterms go, you can see that we're holding at around 10% compared to the U.S. average, which is about 12. Low birth weight rates. We see a slow creeping up to 8%, and so we definitely have our work cut out for us.
The traditional prenatal care strategy, which has really been focusing on reducing infant mortality rates, primarily through reduction of low birth weight infants has focused on the physical progress and detection of what might go wrong, with a major emphasis on risk assessment. And if we look at the current cost of things, the present prenatal care system is not necessarily probably the most cost‑effective, any of us sitting in a group like Chan was saying it's going to be less expensive in New Mexico . We're very interested in what might be less expensive but we've been working in facilitated groups for about ten years. So we are interested in our clients.
For each dollar spent on prenatal care, the expected medical cost savings have been estimated to range from about $2.57 to $3.38. The comprehensive prenatal care has long‑term effects on improving health behaviors and increasing the use of preventive healthcare. What we'd like to emphasize, it impacts the entire family. A lot of times we're focusing on the woman herself. But this kind of approach really does impact the entire family and how they relate to healthcare. In 2000, the charges for hospital stays for infants with any diagnosis of prematurity was estimated at $13.6 billion.
And in New Mexico we have a lot of late or no prenatal care, and the percent of mothers with late or no prenatal care was 30.4% in 2000, 29.3% in 2001 and 2002. We tend to have a lot of young mothers who get late or no prenatal care, and the Native American population, 36.3% got late or no prenatal care.
It happens with folks with less than a high school education more often. Those that are not married, those who have had previous live births, and so that kind of says something about my second round with my second birth, on whether I needed prenatal care or not. You do get an attitude the first time. Being a nutritionist with my first prenatal care, first thing I was handed was a nice big package of formula. So I thought I really didn't need this. So I wasn't very impressed.
But why would we have reasons for no prenatal care or later than desired? One of the number one leading causes in New Mexico is the lack of money or insurance to pay for a visit. We have a lot that don't know that they're pregnant. They're unable to get appointments. They lack Medicaid cards, and they have too many other things going on. Some lack transportation. But getting child care wasn't the number one reason. Since 1984, New Mexico has been 50th or 51st among the states in DC for prenatal care utilization. We're the frontier. We're the state that has probably the worst prenatal care in the country. That's why we're very excited that centering has come along, because with us, you know, there are reasons why people are not getting prenatal care, and some of it is culturally associated.
Elaine Germano, how many of you know Elaine? She usually comes to these. I haven't seen her this year. In 2000 she analyzed our PRAMS data, found the three factors that were highly significant were awareness of pregnancy, intendedness of pregnancy and ethnicity. And I need to catch up on my slides a little bit here. As far as the ethnicity goes, the Native Americans, 48% of Native American women received adequate levels of prenatal care versus 57% Mexican‑Hispanic, 55% other Hispanic and white, and 58% other non‑Hispanic.
But going back to what our PRAMS data now indicates is that among the 24% of women who got late or no prenatal care, almost 60% get prenatal care, quote, as early as they wanted. And this shows us that the women that get the low levels don't recognize the importance of the prenatal care. And among the 40% of women that didn't get the prenatal care as early as they wanted, 34% could not pay for a doctor's appointment.
I do have to say as a state, and as Texas and California and Arizona are, we are experiencing a huge influx of undocumented immigrants that we're dealing with and all of our high risk prenatal care goes for that in our state.
And that has not, I don't think, been recognized yet as a real need by our federal government.
New Mexico uses the following things to increase prenatal care. We have done Navajo focus groups and we came up with a public awareness campaign that we put in theaters and billboards after doing the focus group based on our research that encouraged native Americans to have culturally appropriate prenatal care through those messages. We also have a prenatal care task force where we encourage women to get tested for pregnancy as soon as they suspect. We explore all clinical payment options, because in New Mexico , this is a very big deal. And healthcare institutions, we encourage them to provide culturally appropriate prenatal care, and that was another reason why we were interested in centering.
In New Mexico , our women on Medicaid and their infants fare much better than women with no prenatal care payer. As you can see from this slide, both with birth weight, premature birth incidents, admission to intensive newborn care, newborn hospitalization, timely prenatal care, all the way down, the uninsured mothers are suffering worse than the Medicaid moms.
So the potential for behavior change is really great during pregnancy, isn't it? I mean it's a time when people are very interested in making change. And as a dietitian, I can tell you that I've worked with a lot of people all different ages and the pregnant women are the most motivated for making any changes, because they're basing that on the health of their baby. And so this is when they really are open to examining and altering their unhealthy behaviors.
The basic assumptions that we base our work on is the majority of teaching or learning experiences for child bearing women need to take place during the prenatal period, because professionals have very limited contact during the actual delivery.
And the parent who starts out with faith in themselves and confidence in their own coping skills is going to handle the practices of parenting much better and differently than an uncertain and fearful person.
Our group prenatal model philosophy is that the emphasis is on the woman who is pregnant, not just the pregnancy. The expectation is that her pregnancy is progressing well and this is continually reinforced throughout. And as a result each woman can recognize she has control over some things in her pregnancy.
This is one of my favorite quotes by Ron Labonte from the University of Toronto : "The most important act of power is relating one's experience and having that experience recognized by others." This is a very powerful approach to any kind of teaching you may be doing.
And we based a lot of education in New Mexico over the last ten years, especially with our WIC program, on this empowerment model, where we tried to move away from a medical model of power over where we focus on the reality of things and tolerance with our patients. And education to our terms. As a dietitian I can tell you: We start out like that in school. Over time we realize, as the glazed eyes kind of roll back in people's heads, that does not work and we move to a power with stance, where we look at the reality of people's experience and respect for where they are, dialog for shared meeting, and we look for finding common ground and trusting in the community wisdom. And really trusting in community wisdom is a big step for health professional. But it's one that's really required if you want to, you know, really communicate with your client.
So Healthy Babies is what we call the program in New Mexico . And it's a group prenatal care model, based on centering. And the care is taken out of the exam room like Rima said placed in a large conference room or meeting place where we can gather in a group, circle. The design of the group is very similar. So I'm going to kind of whisk through these to save time but they receive their basic prenatal assessment and share informally with other women and discuss content related to child bearing and parenting.
And the design of the model is not child birth education classes or any kind of information download. Because sometimes you can just back‑up and download all that important information and walk away and they're just left like, you know, amazed. But it doesn't make much difference.
And so we do the first assessment, which is conducted at conception or the first prenatal visit. And it's a physical assessment, psychosocial and self‑assessment. And we complete a medical and psychosocial history, and we use our Families First folks, our perinatal case management to do that. We do a complete physical exam and laboratory tests. And we invite women to participate in a group who are scheduled to deliver around the same time.
And we work in very rural areas. Like I mentioned, we're a very frontier state. So in rural areas we found that five to ten women are really best for a centering group and in an urban area you can deal with eight to 12 women. This is kind of hard. This is just a matter of getting everybody there at the same time.
We do have one county in New Mexico where we have eight WIC clients. So you know it's pretty sparse.
Women join after their initial medical assessment, and most groups organize at about 16 weeks gestation. Each group meets for 90 minutes. We have a total of ten sessions. And we recommend two postpartum sessions if not more.
Other considerations are that we do the four monthly sessions first, and then the last six sessions are held biweekly. And support persons including expectant fathers are welcome to come. But we don't really bring the kids, because you know it's a time to not get distracted.
Who facilitates? Well, in New Mexico the main provider, the nurse midwife, OB/GYN or primary care doctor leads the group. And interdisciplinary collaboration is encouraged and increases the provider's satisfaction.
And then we do the same thing that Rima was recommending. Women come in, get their chart, participate and record their weight and blood pressure and do a urine dip. And step two is fundal height, fetal heart tones, laboratory and various evaluative tests. Step two, the group assessments are organized to identify the women having problems. Preeclampsia and these other problems they can run into.
Continuing step two, we do the psychosocial assessment where we check to make sure their basic needs are being met. We also really look to try to identify domestic violence and substance abuse.
And step 3 is facilitated education, which is my absolute favorite part. And the group comes together for facilitated discussions. And core content areas are emphasized, and I really enjoyed hearing Rima really emphasize that we can't come up with what they should be discussing. And I really believe that what every woman is concerned about is right here in the front of her head. The minute she walks in she knows what will be meaningful for her. So when you only have a few minutes for education, then it's really important to get right down to what her issues are. And when given a chance the women share and it all comes to the forefront what their issues are.
This is Acterburg's Behavioral Change Model. Cheryl Acterburg is from Penn State . I don't know if you've heard of her. She's been focusing on behavioral change models for several years. And we feel like the centering and facilitated sessions really are, in this step‑by‑step approach to changing someone's behavior, they really appear in the working through area. And that's where you use experiences and choose alternatives and test consequences and talk about things through your experience and dialog. And if you're familiar with stages of change models, this sort of behavioral change model takes people wherever they are in stages of change and will move them basically to the next step toward making real changes in their lives. And during pregnancy they may be making short‑term changes, but it also may impact them long‑term.
And this is a facilitated ‑‑ have to put all the clients in ‑‑ facilitated model. This shows you what true facilitation is. And that's when the facilitator actually takes off their professional hat and becomes such a part of the group that the group kind of forgets them, and just starts talking to each other; and the true facilitator, when you do that, you're much more effective.
The conclusions from our New Mexico research on facilitation, and this was something we did several years ago in the State of California with Penn State, was we proved that facilitated groups are as effective as lectures on the client's self‑perceived skills, because we were up against folks who would say, well, but how do I know they'll know everything that I want them to know? And what we found they really do cover everything. And so we wanted to take that away as a concern for providers.
Facilitated groups are better than lectures in the terms of the positive impact on the client's self‑efficacy and more than 90% of clients are satisfied with the sessions. Facilitated groups are accepted by all ethnic groups that we tested.
And our sessions, we have videos that are complemented with the facilitated group discussion, or we do facilitated group discussions with providers or experts in the topic. And we just want to make sure that we change the discussion often enough to continue interest, but believe me once people get in those sessions sometimes you have to try to have them leave eventually. And some of our sessions, they will move out into the other room, because they get so intrigued with talking to each other. It's just everything Rima said about the personal relationships that form through these groups are just very valuable.
The support component, step four. The studies indicate that the women with high self‑esteem and social support really seek prenatal care earlier and follow through with more visits a and have greater satisfaction with care. So the support component of the program might be the most important as the women with a good support system tend to have fewer critical problems.
And we create support through providing an environment where women network with each other. We offer refreshments, and we do name tags and informal networking time. And that's really been nice, because the women have even come back for well child checks later. They'll bring back clothing for new moms. You can tell they appreciate and value the experience that they have. They also remember the midwives' names. They care. They really get involved with who they're working with.
At the first group, and throughout the group sessions, we encourage women to use local resources, including Duly and Promotas and as far as evaluation goes, step five, we use all of these methods to try to collect data, eliciting formal responses from clients, collecting outcome data, doing comparisons against other prenatal clients. And, let's see, just like Chan, we're just getting off, I won't go through this, this is just do we have a parking lot.
Okay. The New Mexico evaluations indicate that we have improved outcomes and that we've increased client satisfaction. You can see that here Healthy Babies compared to peristats, significant improvement in levels of prenatal care, reduced levels of preterms, decreased low birth rate, decreased DBAC and increased natural child birth. But this was in kind of a rural area of New Mexico where this was done, and I think the natural child birth is also just because it was where it was. You know New Mexico .
Qualitative data. The clients preferred group versus traditional methods. The women wanted to continue the group process after delivery. They participated, like I said, in the well child checks much better. And the providers expressed an interest in continuing the group model. What's very interesting is other medical providers are modeling their appointments on the group approach. We did have increased knowledge.
Here are some of the topics that we covered. You can see it's a wide variety and a lot of topics that new potential moms would be very interested in. And we also noted an increased self‑confidence among the women because we had an increased number delivering naturally, which takes nerve and increased breastfeeding initiation, and the providers indicate that there seems to be less chaos during delivery. Reduced logistical barriers to the access to quality prenatal care. I just wanted to say we didn't have any women with a lack of access to quality prenatal care through the healthcare coverage track, and this is unusual in New Mexico . So this was very exciting. Presumptive eligibility enabled them to get coverage quickly. And only one needed transportation in the group we were looking at. So that's it. I'd like to go ahead and open it up for your questions at this time.