For Mothers-to-Be, Finding Health Care in a Group
By Tina Rosenberg, New York Times Opinionator
Recently in a nondescript conference room near Union Square in Manhattan, eight very pregnant women, husbands, boyfriends and a sister sat in a circle around a small patchwork quilt for two hours and talked about managing the discomforts of pregnancy.
The remedies discussed ranged from the ultimate — epidural: yes or no? — to the prosaic, including that cliché of pregnancy: “I don’t get acid reflux if I have a pickle,” said a woman named Kimberly, to general laughter. “I have two pickles right before bed and it’s fine.”
They drank seltzer and ate strawberries, bananas, hummus and carrots and cereal bars. They watched videos about labor pain and interviewed doulas. The meeting looked like a social gathering or a support group.
It did not look like what it was: a doctor’s appointment.
The Institute for Family Health runs the group, using a model created by the Centering Healthcare Institute. Centering Pregnancy sites provide group medical visits for pregnant women; Centering Parenting sites gather new mothers and their babies for the first year of life.
When they arrived, one by one the patients rotated through stations to get their regular prenatal checkups. They took their own blood pressure, weighed themselves, stretched out on a cot behind a screen so Dr. Insung Min could listen to the baby’s heartbeat, and sat with Dr. Rachel Rosenberg (no relation) in another corner for the traditional chat with the doctor. The usual checkups, however, are only part of the health care the group provides. Being part of a community, the research shows, is also good medicine.
The idea behind Centering (the name refers to care that is centered on the patient) is to help mothers — especially low-income mothers — become more involved in their own care, to acquire the skills and confidence to take care of themselves and their babies, and to have a community.
Sharon Rising, a nurse-midwife, devised Centering in Waterbury, Conn., in the mid-1970s. “I was answering the same questions over and over as the day went along,” she said. “It was very clear to me that if I didn’t do something different I was going to burn out. So I spent some time thinking about care: what is it, and what do we want from it?”
Rising concluded that good care had three important pieces. One was the checkup. A second was interactive learning – the chance to talk to someone about your concerns. Third was social support, which was a two-way street; providing support to others was just as therapeutic as receiving it – perhaps more so.
All these things could be done in a group, she decided, and she began to experiment in her own practice. In 1998 she began conducting workshops to teach the model to others. Now about 300 sites around the country use Centering. A vast majority are in practices that generally work with low-income women.
Centering is part of a larger movement toward group doctor visits that began around the same time. Group visits are useful for any condition in which the patient’s participation matters.
That’s nearly every condition, but it’s especially important for chronic diseases such as diabetes. In a two-hour meeting, a doctor can see (and bill for) the same eight patients she would see individually. But instead of a rushed 15-minute consultation, patients get two hours to ask the doctor questions. And most important, they get the benefits of regular meetings with other patients going through the same thing.
There have been few studies of the effects of group medical appointments on chronic disease. The most important is a major randomized controlled trial of diabetes patients in 13 hospital- based clinics in Italy. It found that after four years, group patients had better health outcomes, control of their disease, quality of life, health behaviors and knowledge about diabetes than patients in traditional care.
Group visits for new mothers and babies – the Centering Parenting model – have not been widely studied. But Centering Pregnancy groups have been, and the results are dramatic. A randomized controlled trial of more than 1,000 mothers found that participants were 33 percent less likely to have a premature birth than women in traditional prenatal care. The effect was even greater for black women – a 41 percent drop. This is important as more than 17 percent of births to African-American mothers are pre-term — a rate 50 percent higher than that of white women. And African-American women are four times more likely than white women to delivery extremely prematurely — at 20 to 28 weeks. (Some of the reason is demographics, but much of it is a mystery; a married, college-educated black woman is more likely to have a preterm delivery than a white, unmarried high-school dropout, and no one knows why.) Women in the Centering program also had fewer C-sections and breast-fed more. They had more knowledge about their pregnancies, were more satisfied with their care and felt better prepared.
One in eight babies in America are born prematurely; it is the leading cause of neonatal death. The March of Dimes (which finances some Centering Pregnancy programs) estimates that a premature birth costs $60,000 more than a full-term birth (pdf) -- and that counts only medical care for baby and mother for the first year. It does not count the lifelong learning, development and health problems premature babies are more likely to have than their full-term counterparts.
Centering Pregnancy groups begin in the second trimester. The women meet every month at first, then every two weeks, then every week as delivery approaches – 10 meetings in all. The group I visited – one of 5 run by the Institute for Family Health in Manhattan, the Bronx and upstate – was in their sixth meeting; most of the women were about 32 weeks along. The women varied in age and race. Some were coming from work, dressed in crisp business clothes; others were in sweats.
Rosenberg led the group in talking about baby names. They watched some short videos about labor and pain management, and discussed when to go to the hospital and what to bring. They interviewed visiting doulas and talked about epidurals. But much of the discussion was about what they were going through now.
“My wife is having trouble finding a good sleeping position. She has stomach pains, said a man named Anthony. “Is that normal?”
“What are you guys experiencing?” Rosenberg asked the group. She almost always threw back the questions.
“Sleep doesn’t exist for me anymore,” said Gina. “I’m lucky if I get two hours without waking up.”
“What about pillows?” asked Rosenberg.
“Pillows don’t do anything except get in the way of trying to turn,” said Gina. “Then you wake the other person up. You have to be respectful, but you feel, ‘you know, I really don’t care about you.’” Everyone laughed.
Christina Shenko, the maternity coordinator of the institute’s Harlem Residency in Family Medicine, said that when she proposed something to try for pain or other issues, her advice was often ignored – but women would respond to the same advice coming from a fellow group member.
The credibility of the group, with subtle guidance from the doctors, encourages women to adopt healthier behaviors. Gina, whose fiance opposes vaccines, wasn’t planning to get a flu shot. Now she has decided to. “Majority rules,” she said. Kimberly said the group persuaded her to try breast-feeding. “I’m Puerto Rican, and in my culture we don’t really breast-feed,” she said. “It’s not something we even talk about. I didn’t know much about it till I started group.”
The research on Centering Pregnancy shows that it makes both patients and doctors happier with their care. But Rising said that it’s used in fewer than 100,000 births in the United States each year. Nor are group visits common in treating chronic disease. Edward Shahady, the medical director of the Diabetes Master Clinician program at the Florida Academy of Family Physicians, said that probably fewer than 1 percent of diabetes patients nationwide are in group care.
One reason is that the benefits of group visits accrue to society, not to the doctors who make decisions about care. Doctors have very little financial incentive to achieve better health outcomes; reimbursement is still largely based on quantity of care, not quality. And group visits can add (minor) costs for a medical practice. Centering usually costs a practice about $290 per patient once established – for training doctors, providing patients with notebooks, paying a coordinator and buying food.
One response is to pay a practice more for group visits. South Carolina is doing just this. After a study in Greenville found a 47 percent reduction in preterm births with Centering, the state this year began to pay $150 to the health care provider and $50 to the managed care organization for every Medicaid patient who attends five meetings of a Centering Pregnancy group.
A more difficult problem is that switching to group visits means shaking up business as usual. “As physicians we’re taught in a more autocratic style,” said Shahady. “Group visits require another skill – facilitation skills. This is not commonly taught in medical schools. You have a 45- year-old family physician who’s reached the pinnacle of his profession, and you want him to get in an arena where he’s a novice.”
Shahady is in Jacksonville and works largely with African-American patients. When he has a patient in individual care who isn’t getting better, he asks her to try the group visits. Half of them get better there, he said. “A patient says she has trouble with her eating. I’m a white guy and male, and I’m not stupid enough to tell them how to do it. I say, ‘How about you, Mrs.
Jones, what do you eat?’ And she tells us. And that’s powerful. Patient stories are so powerful.”
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Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.”
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