Group Prenatal Care Boosts Pregnancy Outcomes

New results are forcing health care providers to reconsider the best ways for preventing preterm births.

Pregnant women pray during a holy ecumenical mass at the second day of the 2nd ecumenical Kirchentag on May 13, 2010 in Munich, Germany.
National Journal
March 12, 2014, 10:58 a.m.

NE­WARK, N.J. — At first glance, little about the Lud­low Street Ne­wark Com­munity Health Cen­ter seems dif­fer­ent from any oth­er fed­er­ally fun­ded clin­ic.

Re­quis­ite posters re­mind vis­it­ors to “cov­er their cough.” Bro­chures en­cour­age HIV screen­ing, healthy eat­ing, flu shots, and fre­quent hand wash­ing in both Span­ish and Eng­lish. But it’s what’s hap­pen­ing in a meet­ing space just down the hall that’s drawn the at­ten­tion some of the na­tion’s lead­ing ex­perts and ad­voc­ates work­ing to re­duce the num­ber of Amer­ic­an chil­dren born too soon.

Be­hind a closed door, a group of wo­men mill around the room. In a far corner, mid­wife Edith Eze runs a hand­held Dop­pler — a ma­chine slightly lar­ger than a smart­phone with a flat-topped mi­cro­phone-shaped wand at­tached — over a smil­ing wo­man’s lower ab­do­men. With­in seconds Eze loc­ates a baby’s heart­beat. A rhythmic whoosh­ing sound fills the room.

“Oh­hh,” the wo­man sput­ters. The baby is her second but the first she will de­liv­er in the United States. “Wow. There it is.”

Oth­er wo­men stand near a white­board chat­ting with a so­cial work­er, trans­lat­or, doc­tor, and nurse prac­ti­tion­er about the myri­ad but­tons that con­trol a free-stand­ing di­git­al blood-pres­sure mon­it­or and the white doc­tor’s-of­fice scale parked in the front of the room. The wo­men, all of them preg­nant, will need to get com­fort­able with both.

The group has gathered for its first ses­sion of a pren­at­al care pro­gram known as Cen­ter­ing Preg­nancy. As part of the pro­gram, which began five years ago, par­ti­cipants see a mid­wife as of­ten as oth­er preg­nant wo­men or as their health re­quires. But over the course of 10 ses­sions, they will re­cord and re­port their own vi­tal stat­ist­ics, and they’ll share their ex­per­i­ences, con­cerns, and fears about preg­nancy in fa­cil­it­ated group dis­cus­sions.

If the res­ults for the Lud­low Street clin­ic’s pro­gram hold, few if any of the six preg­nant wo­men slated to par­ti­cip­ate in the group will de­liv­er their ba­bies pre­term. All of the wo­men are healthy but they are con­sidered at par­tic­u­lar risk of pre­term birth be­cause they live at, near, or be­low the poverty line. In the last two years, none of the more than 200 wo­men in the clin­ic’s Cen­ter­ing Preg­nancy pro­gram have de­livered their ba­bies be­fore 37 weeks gest­a­tion. (In Oc­to­ber, the Amer­ic­an Col­lege of Ob­stet­ri­cians and Gyneco­lo­gists and the So­ci­ety for Ma­ter­nal-Fetal Medi­cine moved the goal­post for healthy, full-term preg­nan­cies to a min­im­um of 39 weeks gest­a­tion.)

And in 2013, there were not only no pre­term births among Cen­ter­ing Preg­nancy pa­tients, but al­most all of the nearly 800 wo­men who re­ceived pren­at­al care of some sort at a Ne­wark Com­munity Health Cen­ter de­livered ba­bies that were a healthy weight. Only 34 chil­dren ar­rived weigh­ing less than 5.5 pounds.

“What we do here,” says Eze, a Ni­geri­an im­mig­rant and long­time mid­wife, “is a lot like what we wo­men do at home. We gath­er. We talk. We share what we know. We share our con­cerns. Here we do it with a bit more tech­no­logy but something in­cred­ible, something beau­ti­ful still hap­pens.”

While pre­term births are by no means lim­ited to the poor or un­in­sured, they are most com­mon among wo­men who lack ac­cess to reg­u­lar health care, enter their preg­nan­cies with per­il­ous habits such as smoking or eat­ing an un­bal­anced but of­ten low-cost diet, or struggle with a bio­lo­gic­ally de­tect­able de­gree of chron­ic stress cre­ated by eco­nom­ic strain, so­cial isol­a­tion, and per­ceived dis­crim­in­a­tion.

In the United States, home of the world’s largest eco­nomy and some of its most ad­vanced med­ic­al tools, just over 12 per­cent of the 4.3 mil­lion chil­dren born alive in 2010 ar­rived at less than 37 weeks gest­a­tion, ac­cord­ing to the most re­cent glob­al meas­ure of pre­term birth em­ployed by the World Health Or­gan­iz­a­tion. Those fig­ures put the United States in league with coun­tries such as Ir­an, Tur­key, Ni­ger, and An­gola. Wo­men and chil­dren in only a hand­ful of coun­tries — in­clud­ing Zi­m­b­ab­we, Pakistan, and In­done­sia — fared worse.

Amer­ic­an pre­term births hap­pen at such dis­pro­por­tion­ate rates among black, Lat­ina, and Nat­ive Amer­ic­an wo­men that some re­search­ers have come to sus­pect something about their med­ic­al and so­cial ex­per­i­ences in the United States may be driv­ing the prob­lem. In 2012, the most re­cent year for which na­tion­al data are avail­able, a full 16.8 per­cent of black chil­dren, 13.6 per­cent of Nat­ive Amer­ic­an in­fants, and 11.7 per­cent of Latino ba­bies ar­rived be­fore their moth­er’s 37th week of preg­nancy. That’s com­pared to just 10.5 per­cent of white chil­dren and 10.3 per­cent of Asi­an in­fants.

The fig­ures rep­res­ent some im­prove­ment, after climb­ing for three dec­ades and peak­ing in 2006. In fact, in 2013, the black pre­term birthrate hit a 20-year low. But the na­tion’s young­est res­id­ents re­main in sig­ni­fic­ant per­il.

Chil­dren born too soon are sig­ni­fic­antly more likely to ex­per­i­ence prob­lems with breath­ing and feed­ing, and of­ten face fu­ture learn­ing dif­fi­culties. They are also more likely to suf­fer from cereb­ral palsy and to die with­in their first year of life. Amer­ic­an chil­dren born dur­ing their moth­er’s 37th and 38th week of preg­nancy are 50 per­cent more likely to die be­fore the age of 1 than chil­dren born later. And, for chil­dren born at 34 to 36 weeks gest­a­tion, their first-year mor­tal­ity rate sits 3.5 times high­er than that of full-term in­fants.

“Med­ic­ally, we are good,” says Dr. Ed­ward Mc­Cabe, the March of Dimes’ chief med­ic­al of­ficer. “We have a lot of ad­vanced tech­no­logy and tools that can help an in­fant as young as 23 weeks sur­vive. But I don’t think we are as good as every­one thinks we are at sav­ing ba­bies born too soon.”

In the early 1990s, Shar­on Schind­ler Rising, founder of Cen­ter­ing Preg­nancy and now CEO of a Bo­ston-based non­profit bear­ing the same name, was an ex­per­i­enced nurse prac­ti­tion­er and mid­wife work­ing with some of New Haven, Conn.’s poorest moth­ers at a Yale Uni­versity-af­fil­i­ated clin­ic. Schind­ler Rising star­ted bring­ing to­geth­er small groups of wo­men due around the same time for reg­u­lar dis­cus­sions and health checks. It was a dif­fer­ent ap­proach to provid­ing pren­at­al care, one that fo­cused on wo­men and their ex­per­i­ences with preg­nancy.

Soon oth­er mid­wives began to clam­or for train­ing. Then, phys­i­cians as­so­ci­ated with Yale. Be­fore long, one Yale re­search­er ap­proached Schind­ler Rising with an of­fer to study 200 wo­men in the New Haven pro­gram and in­de­pend­ently ana­lyze its res­ults.

The re­search­er’s find­ings at­trac­ted Na­tion­al In­sti­tutes of Health fund­ing for a 1,000 wo­man study in New Haven and At­lanta. The lar­ger study found that Cen­ter­ing Preg­nancy par­ti­cip­a­tion seemed to re­duce pre­term de­liv­er­ies by 33 per­cent. And among Afric­an-Amer­ic­an wo­men the res­ults were even more stark. Eighty per­cent of the study’s par­ti­cipants were black. These wo­men saw a 41 per­cent re­duc­tion in pre­term de­liv­er­ies (when com­pared with sim­il­ar wo­men).

The study also found that health care sys­tems de­liv­er­ing pren­at­al care us­ing the Cen­ter­ing Preg­nancy mod­el re­duced the cost of pren­at­al care provided to each pa­tient by about $2,000. And each pre­term birth pre­ven­ted saved about $53,000 in med­ic­al ex­penses.

“Those find­ings were rep­lic­ated. They were pulled apart and ex­amined every which way,” says Schind­ler Rising. “But it still took us years to get the thing pub­lished. People just had a hard time be­liev­ing that after dec­ades of de­liv­er­ing pren­at­al care one way, teach­ing wo­men to mon­it­or their own health and bring­ing wo­men to­geth­er to talk about their ex­per­i­ences could make such a dif­fer­ence. It wasn’t some big, new fancy drug.”

In 2003, the Journ­al of Ob­stet­rics and Gyneco­logy pub­lished the res­ults, spread­ing the word about Cen­ter­ing Preg­nancy across the coun­try. In the years since, the March of Dimes, the na­tion’s lead­ing private re­search fund­ing and health ad­vocacy or­gan­iz­a­tion work­ing to re­duce pre­term births, has fun­ded Cen­ter­ing Preg­nancy pro­grams in com­munit­ies with el­ev­ated pre­term birth rates, in­clud­ing Ne­wark. The Cen­ter for Medi­care and Medi­caid Ser­vices has also ini­ti­ated a large-scale study of pren­at­al care that in­cludes Cen­ter­ing Preg­nancy pro­grams.

Today, more than 300 private prac­tices, clin­ics, and hos­pit­als op­er­ate Cen­ter­ing Preg­nancy pro­grams. Cen­ter­ing Preg­nancy is the sort of pa­tient-driv­en care that has swept medi­cine, says March of Dimes’ Mc­Cabe.

When Mc­Cabe was train­ing to be­come a doc­tor, he can re­mem­ber a chief res­id­ent balk­ing at a pa­tient-con­trolled blood-sug­ar mon­it­or­ing demon­stra­tion. The chief res­id­ent saw the prac­tice as un­wise since it would put pa­tients in con­trol, Mc­Cabe says. “Today, of course, at-home pa­tient blood-sug­ar mon­it­or­ing is a corner­stone, an ab­so­lutely stand­ard part of dia­betes care.”

Back in Ne­wark, the Lud­low Clin­ic’s res­ults have been so im­press­ive that the March of Dimes de­cided to fund sim­il­ar pro­grams at a num­ber of hos­pit­als and health-care agen­cies around the city. At the time the ef­fort was an­nounced in late 2012, nearly 20 per­cent of black chil­dren born in that city ar­rived early. Lud­low Street Ne­wark Com­munity Health Cen­ter staff have offered ad­vice and in­sight to these or­gan­iz­a­tions, and they are mak­ing plans to in­crease the num­ber of wo­men en­rolled at Ne­wark Com­munity Health Cen­ters.

The Cen­ter­ing Preg­nancy pro­gram has had such a pro­found im­pact that Dr. Neveen Elk­holy, the Ne­wark Com­munity Health Cen­ter’s chief med­ic­al of­ficer and a self-de­scribed one-time Cen­ter­ing Preg­nancy cyn­ic, has be­gun in­vest­ig­at­ing oth­er pa­tient-centered group mod­els of care.

“We’re really look­ing closely at pro­grams that bring to­geth­er groups of people liv­ing with dia­betes, high blood pres­sure, obesity, and all sorts of chron­ic con­di­tions,” Elk­holy said. “I guess you could say Cen­ter­ing Preg­nancy has really shown us what’s pos­sible.”

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