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«Pregnancy Outcomes for Hispanic Women in Washington, DC A comparison of the Centering Pregnancy Curriculum and Prenatal Education Submitted by Joanna ...»

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Pregnancy Outcomes for Hispanic

Women in Washington, DC

A comparison of the Centering Pregnancy

Curriculum and Prenatal Education

Submitted by Joanna Bloomfield

Joanna80@gwmail.gwu.edu (650)207-1082

In partial fulfillment of the requirements of the Master of Public Health

Maternal and Child Health/Prevention and Community Health

The George Washington University


Joanna Bloomfield Culminating Experience Spring 2011 Table of Contents Acknowledgements




Literature Review

Benefits of early entry to prenatal care

A brief history of group medical care

The Hispanic Community

Centering Pregnancy as Group Prenatal Care

Public Health Significance

Specific Aims

Health and Behavioral Objectives

Theoretical Framework


Data analysis instruments

Results- Mary’s Center and Providence Hospital Birth Outcomes

Table 1: Birth Outcomes Among Participants in Mary’s Center Prenatal Education Program....... 24 Providence Hospital Birth Outcomes

Table 2: Birth Outcomes Among Participants in Providence Hospital Prenatal Care Program..... 25 Mary’s Center Satisfaction Outcomes

Prenatal education participant satisfaction

Staff Satisfaction

2 Joanna Bloomfield Culminating Experience Spring 2011 Providence Hospital Participant Satisfaction

Table 3: Satisfaction Outcomes among Providence Hospital

Prenatal Care Participants, from evaluation surveys


Statistical Tests

Birth Outcomes

Table 4: Percent of Birth Outcomes with specific characteristics

Table 5: Comparisons of Mary’s Center and Providence Hospital with United States

Low Birth Weight

Figure 1: Distribution of Birth weight Among Participants in Mary’s Center and Providence Hospital Prenatal Programs

Participant Retention

Providence Hospital and Mary’s Center Satisfaction

Delivery Types


Methodological Limitations



Appendix 1- Interview questions Mary’s Center Participants

Mary’s Center Staff Interviews:

Appendix 2 Common themes -Staff Interviews

Common themes Participant Interviews -Mary’s Center

Appendix 3- Socio-Ecological Model

3 Joanna Bloomfield Culminating Experience Spring 2011 Acknowledgements I would like to extend my appreciation to my academic advisor, Dr. Karen McDonnell, for her continued support and assistance through the duration of my studies and throughout the entire process of my culminating experience. I would also like to thank Alis Marachelian who guided my research at the Mary’s Center for Maternal and Child Care, and Debra Keith of the Providence Hospital Center for Life who directed my research of the Centering Pregnancy program at that site.

Thank you to my family, Laura, Richard, Aaron Bloomfield and Jameel Alsalam for their ongoing support and curiosity in my academic endeavors.

4 Joanna Bloomfield Culminating Experience Spring 2011 Abstract Objective To evaluate and compare two prenatal programs serving Hispanic women in Washington, DC. The two programs are a prenatal education program provided by a federally qualified health center (FQHC) Mary’s Center for Maternal and Child Care, Inc. (MC), and a group prenatal care program based on the Centering Pregnancy (Providence Hospital, 2011) curriculum provided by the Providence Hospital Center for Life (PH).

Methods Data collected from program administrative records from 2009 prenatal program participants (MC: N = 25;

PH: N = 186). Interviews with contributing staff members and former program participants at MC and direct observation of MC program.

Outcome measures included Programs were evaluated based on both birth outcomes and program satisfaction outcomes. Birth outcomes included: birth weight, occurrence of low birth weight (LBW), occurrence of cesarean delivery. Satisfaction outcomes included: attendance rates, participant opinions, staff opinions.

Results MC participants had lower recorded birth weights with 25% qualifying as LBW, as compared to 7% from the PH program. Independent sample t-test and Chi-squared tests were used to confirm the difference in birth weight was statistically significant. PH and MC program participants expressed satisfaction at high rates. Staff from MC identified opportunities for program improvement. Participant satisfaction as indicated by attendance was lower at MC (highly variable attendance) than at PH (94%) attendance. The MC program and PH program differ as MC offers education while PH offers both education and medical care. Both programs are conducted in a group setting in contrast to the traditional approach to individual based prenatal care. The education elements of both programs go beyond traditional childbirth education classes to include newborn care skills, breastfeeding and nutrition.

Conclusions Initial evidence indicates birth outcomes among participants in the Centering Pregnancy program at PH are more favorable than those among participants in the MC program. Birth outcomes from both programs are similar to national averages. The observations indicate advantages to combining prenatal care with prenatal education as is achieved in the Centering Pregnancy curriculum. However, data limitations and lack of experimental design to conclusively report one program as more effective than the other.

5 Joanna Bloomfield Culminating Experience Spring 2011 Definitions Several terms specific to maternal and child health are repeated throughout this paper. The short list below provides relevant definitions to ensure clarity of the content presented.

Prenatal Care –Prenatal care incorporates medical care, education and counseling from a clinical obstetric provider. Prenatal care covers various features of pregnancy, such as fitness, nutrition, labor and delivery, and infant care.

Group Prenatal Care- Prenatal care in the group setting includes check-ups, vital measurements, and psychosocial assessments followed by a support group meeting with a group of other women and their partners (when available) who are at similar gestational ages. Group is facilitated by clinical provider with obstetric expertise. Entry to care initiates in first trimester or early on in the second trimester.

Group Prenatal Education- Incorporates healthy lifestyle recommendations with information relevant to the lead up to labor and delivery experiences. These courses typically serve women and partners in the last trimester of the pregnancy. Unlike prenatal care and group prenatal care, prenatal education does not include a medical care component and no medical professional is present.

Low Birth Weight- infant born under 2500 grams (5 pounds, 8 ounces).

6 Joanna Bloomfield Culminating Experience Spring 2011 Background Providence Hospital in the Northeast quadrant of Washington, DC has offered the nationally recognized Centering Pregnancy (Centering Healthcare Institute, 2009) prenatal education, health and support curriculum for over three years. This particular site serves both Spanish speaking and English speaking populations, requiring the adaptation of culturally sound health promotion efforts.

The Centering Pregnancy model combines health assessment, support and education to create a comprehensive group care setting for expecting families. Each pregnancy cohort assembles for a total of ten sessions throughout pregnancy and early postpartum. During the sessions, the provider conducts standard physical health check-ups in the group environment. Each woman receives a three to five minute individual physical assessment on a mat in the group space from the designated provider. Following these check-ups, the women convene as a group and typically have a facilitated discussion focused on topics of pregnancy, childbirth, and parenting. The group setting offers the chance for these women to express the challenges they have confronted, ask questions about pregnancy as well as labor and delivery, and exchange information.

The Mary’s Center for Maternal and Child Care, Inc. site included in the study is a Federally Qualified Health Center (FQHC) serving a high volume Latino immigrant community, and particularly pregnant women throughout the duration of their pregnancy with wide-ranging services including regular checkups, assessments and screenings to examine the fetal growth and development and the mother’s progress and general health. Among the variety of innovative service approaches offered at Mary’s Center, for two years the group prenatal series has integrated family and peer supports demonstrating encouraging results, particularly in minority, teenage, and other high-risk mothers (Mary's Center for Maternal and Child Health, Inc, 2010). During these sessions, expectant mothers are guided through the stages of pregnancy and are supplied with information regarding nutrition, exercise, lactation, labor and delivery as well as other relevant psychosocial 7 Joanna Bloomfield Culminating Experience Spring 2011 topics. When available, partners are encouraged to attend group meetings together and to engage in their care as much as possible. This study aims to gather what the benefits of attending a group model are for to Hispanic women in Washington, DC from these two sites. The aim of Mary’s Center’s prenatal class is to provide a environment where women can come to learn about themes pertinent to perinatal health. Some class participants may be toward the end of their pregnancy while others are in the first or second trimesters. Staff contributes to the curriculum by donating time and expertise due to the lack of financial resources available to fund this series.

Literature Review Racial inequality in perinatal outcomes within the United States has been recorded since the early 1920s (National Center for Health Statistics., 1966). Although numerous enhancements have improved perinatal care among all races, outcomes are still disparate between Caucasian and nonCaucasian populations. Commonly cited justifications are racial discrepancies in socioeconomic status (SES), incidence of particular risk factors, and admission to prenatal care (Vital and Health Statistics, 1995).

In Washington, DC, the highest Infant Mortality Rate (IMR) is within the population of nonHispanic blacks in both D.C. and the U.S. The IMR for the United States was 6.86 infant deaths per 1,000 live births. In Washington, D.C., the IMR was nearly twice the national rate, at 11.42 infant deaths per 1,000 live births (Mathews & MacDorman, 2007). On a national scale, Hispanic women have a lower IMR than non-Hispanic Caucasian women, but in Washington, D.C., the rate of infant death in the Hispanic population is approximately twice that among non-Hispanic white women.

Infant mortality was also higher for single women, women giving birth to multiple infants, male infants (7.4 per 1,000 among male babies versus 6.1 among female babies), and mothers who were born in the US (Mathews & MacDorman, 2007).

8 Joanna Bloomfield Culminating Experience Spring 2011 PNC was developed as healthcare model in the United States in the early 1900s.

Researchers recognize the institutionalization of regular medical visits for pregnant women as one of the most critical progressions in obstetric care over the past 100 plus years. The effect of this development has been to lower fetal mortality significantly (Ryan, Sweeny, & Solola, 1980) (Foster, Guzick, & Pulliam, 1992) (Vintzileos, Ananth, Smulian, & Scorza, 2003) (Keeping, Chang, Morrison, & Esler, 1980).

Women in different demographic, economic, and racial groups’ access and utilitize PNC at different rates (Ryan, Sweeny, & Solola, 1980). The Federal Government has attempted to respond to the disparities in prenatal care consumption. Healthy People 2010 are a federal initiative introduced with the objective of bridging racial disparities in health. Included among its goals is to make early (first-trimester) entrance to PNC accessible to 90 percent of all pregnant women. What is the potential for early admission to PNC to curb racial inequalities in perinatal morbidities in our contemporary obstetric practices? The standard influential elements measuring adequacy of medical attention are comprised of the point of initiation, the sum of prenatal visits, and the gestational age of delivery (Alexander & Kotelchuck, Quantifying the Adequacy of Prenatal Care: A Comparison of Indices, 1996).

Benefits of early entry to prenatal care The benefits of early entry to PNC include better educational opportunities about pregnancy and infant health as well as easing the transition to newborn and infant medical care. PNC can improve a woman’s health during pregnancy, provide prevention or preparation for concerns such as pregnancy-induced hypertension, Eclampsia, maternal morbidity, placenta interruption, anemia, and maternal hospitalization. If care starts early, these challenges can be readily dealt with and possibly averted (Conway & Kutinova, 2006) (Jaime-Perez & Gomez-Almaguer, 2002). Women can 9 Joanna Bloomfield Culminating Experience Spring 2011 benefit from PNC because they incorporated into medical coordination efforts such as cancer screenings, and can receive appropriate referrals once they are recognized as members of at-risk populations. HIV-positive women are a critical at-risk population, and can especially benefit from early entrance to PNC (Wilson, Ickovics, & Royce, 2004) (Clark, Samsom, & Simpson, 2006). Testing for maternal health difficulties including substance use, mental health needs, as well as the presence of domestic violence is further indispensable and embedded within the realm of PNC.

These issues are known to impact maternal health and influence fetal development and infant health. Timely screening is additionally essential to identify anomalies and abnormalities in the infant’s genetic composition or development (Morris, Egan, & Fang, 2007).

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