A Portland pregnancy care program in which patients experience team care led by midwives and doulas will be in the national spotlight next week at the 2015 Catholic Health Assembly in Washington, D.C.
Providence Health & Services' Pregnancy Care Package, first introduced in 2013 at the 22-year-old Maternal Care Clinic in Northeast Portland, is one of four finalists in an "innovation challenge" co-sponsored by the Catholic Health Association of the United States and the Global Lab at the UCLA Institute for Innovation in Health.
The Pregnancy Care Package will be cited in a speech by Dr. Molly Joel Coye, former chief innovation officer at UCLA Health System. Also, Kathy Criswell, executive for Women and Children's Services at Providence, will talk about the program during a Monday panel.
The program coordinates care by midwives, doulas, physicians, nurses, patient navigators and social workers. The most basic office visits are replaced by group sessions during which women still get quick medical checks but spend most of the time discussing their experiences, expectations and concerns. Spouses and partners are encouraged to attend and participate.
"The primary reason our project was selected was because of the very high patient experience scores," Criswell said Thursday. Patient satisfaction with prenatal care through the Pregnancy Care Package is at 98 percent and satisfaction with the hospital experience is over 90 percent, she said.
Criswell said the program benefited from careful market research. Providence employees worked with focus groups and interviewed women, asking what mattered to them.
"I think we don't do enough of that," she said, referring to health care providers in general. "We are a little self-absorbed in health care about what we think people want or need."
Providence is selective about Pregnancy Care Package staff, making sure everyone understands that they are part of a health community "that's focused on outcomes," Criswell said.
And the program is "very intentional about being consistent with the mission and core values of a faith-based health-care system," Criswell said.
"We reveal God's love through our compassionate service. That should roll off the tongue of anybody who works for us," she said. "Every action should reflect that."
Criswell said the recognition is a credit to the employees at the Maternal Care Clinic. Eight midwives and five doulas are the heart of the staff, which also includes a physician, two patient navigators, a social worker, two registered nurses, three medical assistants and several support staff.
"It's been such a team effort and such a labor of love by the people who work in that clinic," Criswell said. "They are all so invested in what the childbirth experience is like for our families. It's so great that they get this recognition."
"It's a wonderful honor on some groundbreaking work," said Laura Klink, a spokeswoman for Providence.
Two other local programs will also have representatives at the conference. Providence'sCompassion Strategic Initiatives will lead a session on sustaining compassion in health care. PeaceHealth Southwest Medical Center of Vancouver will lead a session on crisis communications.
Keynote speakers at the 2015 Catholic Health Assembly include President Barack Obama; Dr. Siddartha Mukherjee, whose book "The Emperor of All Maladies" won the Pulitzer Prize and inspired the recent PBS documentary "Cancer"; and Archbishop Blase J. Cupichof the Archdiocese of Chicago.
-- Amy Wang
The first thing they should do, they're told, is call the midwife.
Eleven expectant mothers and fathers are sitting in a circle inside the Providence Maternal Care Clinic along with four Providence employees: two doulas, a nurse-midwife and a patient navigator. Together, they're going over what the women and their partners should do when they suspect they've gone into labor.
"The first person you talk to is your midwife," says Jesse Remer, one of five doulas at the clinic. She tells the parents-to-be about the triage room where they'll go when they arrive atProvidence Portland Medical Center. She assures them that once labor is confirmed, the doulas will be notified and "we'll be there in a couple of minutes." She recites the clinic's phone number for anyone who might not have it: 503-215-6262.
Providence Maternal Care Clinic is not new - it opened as a nurse-midwife practice about 20 years ago - but the coordinated pregnancy care package it has provided as its sole prenatal care model since January 2013 is mapping a new path to parenthood for its patients. And there are fewer bumps along that path, according to Providence statistics on the program's first year that compare the outcomes of Maternal Care Clinic deliveries with the average outcomes of all deliveries at Providence Portland Medical Center:
- The rate of Caesarean sections has dropped to 20.6 percent from 32 percent.
- The use of epidurals in vaginal deliveries has dropped to 47.5 percent from 85 percent.
- Prenatal care costs have dropped by more than 15 percent.
- Elective deliveries between 39 and 41 weeks have dropped to less than 1 percent.
- Patient satisfaction with the coordinated care model is more than 98 percent.
A prenatal care glossary
Obstetrician:Specializes in pregnancy, childbirth and postpartum (after childbirth) care. Has a medical degree.
Gynecologist:Specializes in women's health. Has a medical degree.
Midwife:Specializes in women's health. In Oregon, a midwife may be licensed or unlicensed. A licensed midwife must have credentials from theNorth American Registry of Midwives; clinical experience including at least 25 deliveries and at least 100 prenatal care visits; drug education; a written plan for emergency transport; and certification in CPR. A certified nurse-midwife often holds a master's degree, is usually licensed as a registered nurse and can prescribe medications.
Doula: Provides mental, emotional and physical support to the mother and family; does not necessarily have medical training. In Oregon, doulas must be certified. The Oregon Doula Association is encouraging doulas to apply for state certification.
Patient navigator:A role originally developed to help patients navigate the complexities of cancer treatment, it's now expanding to other areas of health care.
Rather than individual visits with an obstetrician-gynecologist or a nurse, these women, and their partners, experience a continuum of team care led by a nurse-midwife and coordinated with an obstetrician, nurse, doula, pediatrician, social worker and patient navigator. The most basic office visits, those that would typically last 10 to 15 minutes, have been replaced by two-hour group sessions during which each woman still has her blood pressure and uterus measured and the fetal heartbeat checked but spends most of her time talking with other moms-to-be and the clinic staff about what she's experiencing, what to expect and what she's concerned about. Dads-to-be are not only welcomed but encouraged to attend and participate as well.
So far, according to Providence, about 675 women have used the pregnancy care package model for their entire pregnancy. An additional 260 experienced it for part of their pregnancy. The clinic, which is averaging about 40 deliveries a month, saw its delivery volume increase by 10 percent in 2014 over 2013, an increase that Kathy Criswell, executive director of Providence Women and Children's Services, attributes to the new team approach.
The pregnancy care package has been successful enough that Providence is now offering it as an option at its westside Columbia Women's Clinic, adjacent to Providence St. Vincent Medical Center. It may soon become available in Clackamas County as well, said Providence spokeswoman Jean Powell Marks.
The model is a win-win for Providence and its pregnant patients, Criswell said.
For the health system, "you can build a lot of capacity to take care of your population without having to add incrementally as much cost as the former model of obstetrical care requires," she said. As for the women: "It's a much richer experience for the patient."
Nearly all of the mothers-to-be gathered at the Providence Maternal Care Clinic on Wednesday afternoon are about 34 weeks pregnant - between eight and nine months along, with due dates in late March. Remer, who not only works for Providence but also is a co-founder of the year-old Oregon Doula Association, welcomes them and asks them to introduce themselves.
Three are about to become parents for the first time; two have toddlers at home; and two are veteran mothers, one with three daughters whom she calls "big girls" and the other with six children, ages 2 through 12. Mixed in with the women are four fathers-to-be: two first-timers, one hoping for "a little bit shorter" delivery with No. 2, and one who beams as he talks about how much he's looking forward to having a second baby girl.
The clinic staff introduce themselves, too. Remer, who will lead the group through an agenda that includes an explanation of a doula's role and a thorough discussion of labor, says, "My wish for you is that you feel like you have everything you need to feel completely supported through the process."
Anna Spann, a certified nurse-midwife, says, "My hope for you when you go through labor is that I can be present and supportive for you and there's not too much else going on ... and that it's not too fast and not too long." She then spends much of the session taking each woman or couple into a side room for a short private exam. Seven times, the reassuring whom-whom-whom of a strong, regular fetal heartbeat, as heard through a handheld Doppler monitor, comes through the closed door.
Kate Fricke says she's new to Providence but has been a private birth doula for six years. She's here to observe the group and learn how it's run.
Kisha Johnston gives her job title as patient navigator, available to help with matters such as finding a pediatrician - the clinic aims to match each patient with a pediatrician by her 36th week of pregnancy - and baby supplies.
From there, the group is off and talking.
Doulas, Remer explains, are essentially an extra set of hands ready to assist with all sorts of things: comfort measures, labor positions, support for dads, grandparents in the room. "We don't have to chart anything; we don't have to think about anything clinical," she says. And "we're already in-house. There's always a doula at the hospital. You don't have to do anything special to have us there."
Remer also tells the women that Providence Portland Medical Center reserves four labor rooms for Maternal Care Clinic patients that are equipped with multiple birthing aids, including "birth balls of every shape and size," tubs, a labor-friendly Jacuzzi and thick mats for women who want to be on the floor. She passes around a picture of what she calls "the magic birth chair" - Providence says it's the first of its kind in the U.S.
The patients and staff share tips on what to pack for the hospital: Slippers. A robe. Hair ties. Lip balm. Snacks for Dad. Nursing bras and a comfortable long-sleeved shirt that can be unbuttoned. One of the women who's already given birth recommends an abdominal binder, a wide strip of fitted elastic, for extra support after the delivery. Remer says there's no need to put up with a hospital gown for labor; she suggests bringing a sports bra and "a really stretchy miniskirt" that can be thrown away. "You can wear whatever you want - including nothing at all, and then we know you're really in labor," she says.
They discuss how they cope with challenging situations. One woman says she plans to write positive thoughts on sticky notes and post them around the house: "baby's head down," "cord is free." Two other women credit their partners with supporting them through difficult times.
Remer sums up the various coping strategies she's heard and then says, "Draw on all those resources, all of these supports around you. ... Don't be shy, also, about telling us what you need." Fricke adds, "We want to know what's not working."
The questions and comments continue:
Experienced moms, what did early labor look like for you?
The mother of three "big girls" describes what it was like when her water broke.
They review how to time contractions.
They talk about where to park at Providence Portland - "oh my God, not in the big parking lot," says a second-time mom, "that was a long walk."
Who's had an epidural? "I cried the whole entire process of getting it because I didn't want it," says the same mom, "but I had to sleep." "Oh," says another mom, "I couldn't have gone without my epidural." Spann, the nurse-midwife, jumps in: "It's a very common procedure," she says soothingly. "If you get stuck at a certain centimeter and you're not progressing and you're getting exhausted ... sometimes just getting a little rest and sleep can help labor progress."
Don't forget the baby's car seat, says Remer.
Someone brings up fentanyl, an opiate that can block pain for the mother but that can cross the placenta to enter the baby's bloodstream and potentially slow its heart rate. Spann says, "There is a medication that we can give babies that turns it around on a dime." Remer says, "We come generally from a low-intervention mindset for you ... it wouldn't be our first go-to."
If you feel like cursing, go for it, the staff tell the patients. "Whatever you say at the peak of the contraction is Mom's coping - nobody takes any of that personally," Demer says, adding, "We get excited about blood and water and nakedness and cursing. That's when we know things are happening." Spann adds that it's fine to scream, too: "People cope differently. Loud is OK."
"There's no right way," Remer says, "to give birth to a baby."
The idea of group care for pregnant women isn't entirely new. In 2001, Sharon Rising, a certified nurse-midwife in Connecticut, established a new organization she called the Centering Pregnancy and Parenting Association, which incorporated group visits into prenatal and postpartum care.
What is now known as the Centering Healthcare Institute in Boston has grown to more than 300 sites worldwide, including five sites in Oregon, according to its website. The March of Dimes' Greater Oregon chapter has supported Centering work by more than a half-dozen Oregon and southwest Washington organizations with grants that have totaled $172,500 since 2010.
When Legacy Health System started a Centering Pregnancy model at its midwifery group in 2012, it placed women with similar due dates in groups of up to a dozen that met about 10 times to hear presentations, participate in activities, discuss their goals and offer one another support.
Criswell, of Providence, said its model differs from Centering because Providence has customized its pregnancy care package for patients seeking midwifery care, while Centering can be done in an all-obstetric office. "The way we use navigators, the way we use doulas ... we really felt like we needed to build that component to really be consonant with the model of care that were giving our patients," she said.
The Providence model also identifies which visits during a pregnancy are primarily educational or have no significant medical component and replaces those with group visits to allow patients to learn from one another and build community, Criswell said. "It lessens that sense of isolation that modern women feel during pregnancy," she said.
That community-building component is also a key part of a similar model that Oregon Health & Science University has offered since 2009, the Group Prenatal Care Option. Originally based on the Centering curriculum, it has since "veered away" to accommodate regional differences, such as Portland-area residents' keen interest in nutrition, said Laura Jenson, one of the three certified nurse-midwives who administer the program.
Under the OHSU model, patients see a midwife exclusively until they're between 20 and 24 weeks, Jenson said. They then attend seven group sessions, which takes them to their 35th or 36th week, at which point they resume individual visits.
As with the Providence model, the group visits at OHSU last two hours, during which a midwife checks vital signs for both mother and baby and then facilitates a discussion about whatever the patients have on their mind. "We talk about everything from your basic danger signs to interventions that might come about," Jenson said. "We talk about diet and nutrition, exercise. We talk about the media's portrayal and the sociopolitical views on labor."
Jenson said about 120 to 150 patients a year are choosing the group care option, making up nearly 10 percent of all those who deliver at OHSU, and that published studies show a group care model results in a decreased rate of premature births, increased birth weights, higher rates of breastfeeding and overall higher patient satisfaction. It's not clear whether the group care option has resulted in a decrease in C-section rates, Jenson said.
The best testimony to the program's effectiveness comes from the patients, Jenson said. One father-to-be told her that he felt valued as a partner. An expectant mother said she found the group visits useful in determining which questions were the most important. Another woman felt that she had more trust in the process and herself as a result of the group visits.
"It's less clinical," a third woman told Jenson. "It's more casual and warm than sitting in a tiny exam room."
"We're building community so that we have good support," Jenson said.
"That is the very most beautiful thing."
-- Amy Wang
The Integrated Team Approach at Providence Maternal Care Clinic provides pioneering support to women in the childbearing year. The Team includes a midwife, nurse, doula, patient navigator and social worker on KGW TV News May 15, 2015