ARDEN HANDLER: Good afternoon, everybody. For those of you -- can we hear sound? Can you hear? No? Can't hear. Hello? Is the mike working? Mike is working. Is it mic working? Okay. Good afternoon, everyone. I'm Arden Handler.
>> We can't hear you.
>> That is what I was wondering. They are coming, that's...
>> Go back to eating.
ARDEN HANDLER: Now try it? Okay. (Feedback). Okay. Good afternoon. I'm Arden Handler for those of you who did not come this morning. Hopefully, most of you were able to attend. Michael Patton was one of the best keynote speakers I've ever heard in terms of setting it all straight. (Applause). I want to welcome you, if you weren't here this morning, to our 17th annual making change happen MCH leadership conference. The theme of the conference is research to practice. We are focusing on evaluation. We have another great afternoon and tomorrow planned. This morning, I want to say I thanked everyone in the world, but I for got not purposely but because she wasn't in the room, Chris Gupta who you have all been talking to, or E-mailing over the last six months. She is in the back. We want to thank her for putting together a fabulous conference. (Applause). She is still not smiling. She will be smiling tomorrow when it's over. I want to remind you that we have a reception tonight. You are invited to attend at 5:30. Reception down here, Chris? Upstairs again? So after today, you will have, we have this session, then workshops upstairs, and the reception will be upstairs. Then tomorrow morning, we begin with workshops.
So again you will be upstairs. We will conclude here tomorrow for lunch.
If you are interested in this conference and would like to join the planning committee meeting tomorrow, feel free to check out at the registration desk and let somebody know. We will let you know which room we will be having the planning meeting in. It will be directly after the conference ends tomorrow. We have exciting lunchtime presentation. This is an area of interest, near and dear to my heart because it focuses on the prenatal period and pregnancy outcomes and what we can do to improve the quality of prenatal care and the entire experience for women, so we can get more women interested in coming in early. We can give them a high quality experience and better pregnancy outcomes. We will be speaking about a n innovative model for delivering prenatal care called centering pregnancy. We will be talking about the rule of Doula support during the prenatal period and interim period.
Our first speaker this afternoon is Dr. Cary Klima. She is a national trainer who he had indicates healthcare profession -- educates healthcare professionals and is a member of the Board of Directors of the centering pregnancy and parenting association. I have the privilege of working with Dr. Klima on the centering pregnancy project in a small role , but it is fun to work with her and her group. She will be our first speaker. William, Dr. Klima (applause). .
CARRIE KLIMA: Hi, welcome. Hope you are enjoying your lunch. Chris is going to find out why the -- can everyone hear me in the back? No? Okay. Maybe if I get a little closer, how is that? Better? Okay. Chris is going to find out what's happened to our slides. How many of you heard about centering pregnancy? Awesome. So there is people that know about it. It is nice to know there is friendly faces in the audience, when I come to talk about centering pregnancy. Sometimes I'll ask that question and nobody raises their hand. So I'm glad when that happens. We are almost there. Is Arden set?
I've been involved with centering pregnancy since about 1997. I am a nurse midwife. I've been providing prenatal care since 1986. In the last five years, I have felt that I've been able to deliver the best prenatal care of my life using centering pregnancy. I base that not only on my own experiences but the experiences of the women that I care for in prenatal care. So what I hope to do today is, I have a fairly short period of time. I want to make sure you had all the information on the slides. I don't know that we will have time to talk about each one of them. There we go. So many of you in this room have probably heard of IHI. I have people over there adjusting things. The Institute for Healthcare initiatives. Dr.Berwick is one of the founding members of the organization. I think he and his organization are looking to address some of the in adequacies of our healthcare system and our prenatal care system. Hopefully no one is in this room if we think healthcare is fine. Does anybody think healthcare is fine here? And we have to own the problem before we can start addressing its inadequacies.
The Institute of Medicine a few years ago created I think a landmark document, crossing the quality chasm. These are the six aims for improvement that they dent fide. -- identified. Some of them are troubling that we have to identify, that we need a safe healthcare system. To me that seems innate like we should already know that. We want it to be effective. We want it based on good quality evidence. We want to give service s to the people who are going to need them and to not give service s that we don't think they need. We want to be patient centered. I think that is the biggest challenge for all of us. Most of our healthcare systems now are not patient-centered. They are either health systems centered or provider centered. We want to be timely for providers and patients, efficient. We are in a n environment where cost is driving the quality of healthcare. We need to use our money wisely. We want it to be equitable. Wet it not to have in adequacies and disparate east that we see -- disparities that we see commonly in our country. I'm sure almost everyone in this room is familiar with caring for our future, the content of prenatal care. Unfortunately, I think that though this was an absolutely landmark document that came out in the early '90s, most of the recommendations of the content of prenatal care have never been implemented in our prenatal healthcare system.
Centering pregnancy was developed in 1993 by Sharon Rising, a nurse midwife. It was initially piloted in water bury, Connecticut. When she developed the model, she went to the document of caring for our future and looked at the recommendation of the document, what we had evidence for and what we needed to implement. As you know, the document created goals for both women, infants and families. These aren't rocket science. We want women to feel good about themselves. We want to decrease morbidity and mortality which we know is a rising problem and has not improved in this country. We need them to develop self-care skills. They are going to be taking care of a family shortly. We have a very short window of time to make sure they have the skills to do that and helping them to develop those skills should be a goal for women in pregnancy . Certainly for the fetus and the infant, we want to reduce those kinds of things that create morbidity and mortality in infants. We want them to get appropriate care so they are getting routine care and the kind of care they need in order to be healthy, developing children . And the family, I think that is one of the things that is not addressed very well in our current prenatal system, that is mostly based upon looking at those morbidity and mortality factors.
We want to try and look at the development of healthy families, trying to reduce the escalating family violence that is creating havoc within our cities and towns. Unintended pregnancies, we know intended pregnancy are better pregnancies and those children are healthier. We want to reduce those. Promote appropriate use of community resources. Lots of women and families don't know what the resources are . Getting them connected with services is a goal. What centering pregnancy does is combines the three aspects of prenatal care into one model. It includes both the the assessment, the education and support proponents into a comprehensive model of prenatal care. Why would we think about using groups for prenatal care? Women who are pregnant want to be with other women. If you have ever been in a room full of pregnant women, if you sat in a waiting room, you see that women start to talk to each other. They don't have to be getting healthcare to do that. We want it to look at being able to provide an efficient conduit for information.
As a prenatal care provider in a busy clinic, I might talk to ten women in one day about nutrition, about gene tic screening, about prevention of preterm labor and birth, about getting ready for labor. Instead of doing that 15 individual times, I can do it once to a group of ten women. I don't have to do it all. They get to share their experiences. They get to learn from each other and through learning from each other and building support, networks within each other; they are building a community of support for themselves. We believe that in centering pregnancy, that these are a vehicle for changing communities that women live in, because they are creating a support network for themselves. They are efficient. I work in; I have always seemed to have worked in fairly dysfunctional healthcare systems. Finding a way for it to be more efficient was pretty easy. Groups are a lot of fun. They are fun to do as a provider. They are fun for women to be and families to be involved with.
Centering pregnancy develops essential elements, that need to be in place in order for centering
pregnancy to be happening. We develop these for a number of reasons, so there is fidelity of the model. We know individual sites are going to have to adapt the model somewhat to their particular institutions or settings. But there have to be critical things present in order for centering to be taking place. One of them is the risk assessment needs to occur in the group space. In a few minutes, you will see a slide with what a centering group might look like. Risk assessment in the group's base makes it normal, means women are developing normally. They hear the baby's heart beats of everyone in the group. They see everyone's bellies are growing the same way. That takes away the mystique of putting it behind a closed door, making it secret. Women learn how to take their own blood pressure, do their own weight. They chart that information in their medical records. They figure out that mysterious gestational age wheel that seems to be a constant source of confusion for most women in prenatal care. They figure -- prenatal care. They figure it out themselves. We show them how to do it.
Each session has an overall plan. The content may vary based upon the needs of the group. There is stability of group leadership. So the same person who is usually a prenatal care provider, it could be a nurse midwife, a physician, family practice physician, nurse practitioner and a -- nurse practitioner, an LPN, a Doula, those people are going to bond with that group. That group will go through the pregnancy together. That stability needs to be in place. We conduct groups in a circle. We honor the contributions of each member. Already had that one. The design is that the groups are eight to 12 women. We think that ten is a great optimal size for groups. We know some are bigger and some smaller. They usually begin at approximately 16 weeks. After women have had a n initial, their initial prenatal exam. And had laboratory studies and is close to a confirmation of their due date.
There are ten two-hour sessions that follow the normal schedule of prenatal care. Each will have a time for self-care activities to take place, a short targeted provider assessment, a majority of the time spent with group discussion . You can see we use the same schedule, so four weeks until about 28 weeks. Then we go every two weeks. Then continue on until the pregnancy is over. The end of the pregnancy -- the end of group is usually a post partum visit. Many women had their babies already. They bring babies back to group. What a better way to talk about what labor was like, when you have your moms who just delivered and has her baby with her and can tell the story, tell what the first few days of parenting was like. It is coming from their peer s, not me as a provider. This is what a group might look like. You can see in the foreground -- I don't have a pointer. You can see the two women in the front. One is taking her blood pressure, the other one getting her weight. In the back in the corner is a blue mat on the floor underneath those posters. That is where the assessment takes place. You see the rest of the group is in the circle starting to do their self-assessment sheets and get ready for group to start.
There is always something happening in group. There is no downtime. There is always something to do in group. We use self-assessment sheets, things that women will fill out on their own depending on the group session, which are based on the period of pregnancy that they are in. You can see that they really cover the gamut of all of the kinds of things that need to happen in prenatal care, many of which don't happen in prenatal care in individual groups. This is what the mat assessment looks like. This is a targeted time with the provider on the mat. It is about three to five minutes , no more. That private time with the provider is whether we do our physical assessment, we assess for any problems and assess for patient safety. Then those issues that might come up on the mat are brought back to the group. Aches and pains of pregnancy, discomfort, contractions. Worries about labor and birth. Worries about delivery. You can see that it is a targeted time.
The education components that are present in centering pregnancy really go through all of the kinds of things that need to happen in prenatal care, that probably aren't happening, some of which because we don't have time. Some of which because we expect women to go to other place s for that like childbirth education, parenting classes, breast-feeding classes. Instead, why don't we say we will do all that for you. We know under you are getting. We will do it with your prenatal care. There is no need for women to sign up for four different classes to have the baby. How do we know it works? I could tell you that because I've been doing this for the last seven years and I have seen what it's meant for the women in my care, that I can tell you that it works. They are happy. Their pregnancies are healthier. Their babies are happier. Most people probably want to know a little bit more.
We are in the infancy stages of evaluating this model. The first group started in 1993. There are now about 60 sites throughout the United States and Canada that have implemented the model. We have only a few evaluations studies that know it works. Here is another reason why groups work. If someone complains about back pain during their pregnancy, in a n individual exam room, you would be hard -pressed to get down on a mat on the floor and show them positions that might help with that. In a group, you get people on the mat, in the floor. Everybody is practicing. Everyone goes away with that information a how to deal with discomfort s of pregnancy.
When Sharon Rising initiated the model, she did an evaluation study of the model at her clinic in water bury, Connecticut. It was a typical kind of hospital based clinic in a small city. They did 13 groups, about nine people in each group. You can see the attendance rates are actually quite high. One of their teen groups had 100 percent attendance. Those of you who deal with adolescents know what kind of a feat that is to get eight to nine adolescents to show up every single group time for their entire pregnancy. One of the things they were concerned about in their particular setting was the use of the emergency room. It was costing their healthcare system and hospitals a lot of money. So that was one of the things they wanted to look at. They compared women who were in group, which you can see in green, to women who were getting individual care in their clinic. They did show a significant difference in the use of the emergency room, by the third trimester of pregnancy for those women. That was a benefit to their health care system. How did the women like it? 96 percent preferred group. They rated it highly, very highly.
This is a quote from a provider who is doing groups in San Francisco with 100 percent Latino population. For me, the stories that come out of centering are so poignant and moving. But that women really feel like this is how they get to feel like they are part of a community. It really moves me when I listen to the comments and hear the comments of what women say about, women and providers who are doing groups, say about pregnancy. Mary Alice Grady is a nurse midwife who works in St. Louis at Barns Jewish hospital. They have a n adolescent care center. A few years ago in 2001, they adopted centering pregnancy as their model of care for their adolescent healthcare setting. They have a very comprehensive program that covers the needs of adolescence, adolescents in their community. They have a great incentive program called baby bucks, where teams earn bucks to buy things for their babies and for them. They have a father support group, breast-feeding support group. It is a great program. They made it even greater by implementing centering.
What Mary Alice did when she wanted to evaluate how things were going once groups started was that she did two comparison groups. She looked at all of the teens who had delivered at Barns during the same time of centering, but had not been enrolled in centering. Then she went back because they had good data collection, and looked at a 1998 group of teens before centering had been implemented. This is a retrospective review. You can see she has a young adolescent population, which is the majority of which are African-American. What she looked at first was pre maturity, instance of low birth weight and cesarean section. You can see the C sections are pretty much the same across groups. There were striking differences between pre maturity and low birth weight. Between centering groups and the two comparison groups. She refined it a little more closely when she took out those teens that didn't have any prenatal care. We didn't think that was very fair to include those in the data. So when she took them out, those differences persisted. She is actually, this data is going to be published in the journal of midwifery in the November/December issue this year. You will be able to get a complete idea of the data . This is a case controlled study.
I was on faculty at Yale and practiced at Yale before I came back to UIC. We implemented the model at Yale. In order to implement it, we decided to do a pilot study. These are the results of the pilot study that we did at Yale. There is currently a randomized control trial going on now. You can see that the groups were divided between Yale and Emory University in Atlanta. Yale had a little smaller. But we looked at women who were enrolled in centering. These were self-selected women. Centering groups were offered to all women. Some were unable to choose it because of the time s groups met or they weren't able to find child care or they had other problems. Or they didn't want to do group . We matched them for a control based on age, race, parity and the closest date of delivery. You can see that the population in terms of the cultural groups are a little different. Emory has 100 percent African-American population in this particular study. The ages were similar between the two groups as well as their parity. These were some of the words that women said when we did some qualitative analysis of their experiences with centering. I think for me the most poignant one, at first, I didn't know anybody. But by the time we finished, I felt like I had known them for a lifetime.
That is a woman who has created a support network for herself that will last way beyond her pregnancy . This was patient satisfaction with the groups . This is on Yale data. That we implemented at Yale. Patients were quite satisfied with the model and how this model was improving their prenatal care. This is their evaluation of group, how well they prepared or felt prepared for labor and how they felt prepared for caring for their new baby. This was probably the best part of the study. What they did was we looked at birth weight by gestational age and group. What we found were some really significant differences in birth weight and gestational age. You can see that in term infants, though the differences were statistic ally significant, they weren't Clee significant. There is -- weren't clinically significant. There isn't that much difference. But when we look at preterm infants and the rates of prematurity were about the same in both groups, we noticed that almost pound difference in between women who were enrolled in centering pregnancy versus those who were enrolled in individual care.
For preterm babies, a pound makes a big difference, in terms of cost, and in terms of the sequela. And here is the numbers. It was a difference of about 540 grams. So they seem to stay inside longer. Whether that was responsible for increased one pound, probably not a whole pound in two weeks, but they also maintain their pregnancies two weeks longer. Which in terms of gestational age, we know the longer babies stay inside for the most part, the better off they will be healthwise. We saw differences in attendance. We had some problems certainly at Yale and they had it at Emory at well. We were not getting women back for post partum visits. We know what happens when that happens. They don't get started or maintained on contraception, they start to fall through the cracks. They return within a year with an unintended pregnancy. We saw a statistically significant difference in attendance at prenatal care -- in postpartum visits as well.
I want to spend the last few minutes letting you know about the randomized control trial. We don't have any results of that yet. It was funded by IMIH. Some of you may know the public health researcher from the Yale school of public health. It was based upon an intervention to help reduce HIV and STD risk in teen pregnancies. We looked at three randomized groups. One is individual care. One is centering pregnancy. One is an enhanced model of centering pregnancy that has additional information and practice with safer sex negotiations skills, condom use, and prevention building skills. We have a young population, up to 25. You can see that the two studies sites remain Yale and new haven. They can be English or Spanish speaking. All materials are translated into English and Spanish.
These are the primary outcomes that we are looking at. Certainly the normal kinds of things, morbidity and mortality. STDs, and repeat pregnancies, since that was one of the purposes of the grant. We are looking at behavioral outcomes also. Secondary outcomes we are looking at, prenatal care knowledge and saves, psychological and sex related outcomes. I want you to have the information to contact people that are involved in the RCT. Sharon Rising's contact information, it is actually changed to a dot org now, our Website. So you can cross that off on your book. It is a dot org. So in case you have any questions, you can contact them.
What is next? What do we need to do? We need to do more evaluation of the model. That is something we are working on at UIC. We are interested in looking at the effect of the model on depression, especially post partum depression, if there are differences in long term health of children, how it affects providers. Provider satisfaction, there are a number of people interested in that . Cost analysis and effectiveness. We have no data about whether is it cost -effective. Centering parenting is our logical extension of centering pregnancy. It is mother and baby care for the first year of life. It allows these groups that has bonded and started during pregnancy to continue as new parents for the first year of life. We think we have about ten reimbursable visits between moms and their babies, in that first year between well child care, contraceptive management.
This is our Website, centering pregnancy and parenting association, a nonprofit organization that is dedicated to changing the paradigm with prenatal care. Because we think when people get to know everybody, they get to care about everybody. And that is what people need to be doing in prenatal care, which is not happening, by the way, in individual care. Here is another quote I would like to end with from Dr. Berwick. To create a future different from its past, healthcare leaders, and that is all of us in this room, I think, we need to understand this innovation. I think there is a lot of innovation talk going on at this conference. I think that that is one of our roles and that is one of my goals, is that we want to help to disseminate this innovation and prenatal care. I think we are going to save questions until the end of the three presentations. Thank you. (Applause).
ARDEN HANDLER: Thank you very much. I think those of you who haven't heard about centering are probably intrigued. I think this has the potential to be a fantastic model. The more data, the better off we will be. Thank you for letting us know about it. If you are interested, you can contact any of those Website s and also Cary as well at UIC. We will talk about the Doula model. We have two speakers to talk about it. The first speaker will talk about the empowerment piece of the model. The speaker is Rachel Abramson. She has provided leadership for the Chicago health connection since 1986. She was project director for four years of the Chicago health connection project fund ed by the Harris foundation and Johnson foundation. She has experience in breast-feeding promotion and management, community based health services research , and nonprofit administration. She accepted in 2003 the national healthy mothers, healthy babies state impact a ward for the Harris Doula institute at Chicago health connection. Also received a start early, learning begins at birth award in 2003. She was a warded a Harris a ward from the 0 to 3 press with a book contract for the manuscript development of the community based Doula
re-claiming birth and families. She is also my very good friend. Welcome Rachel Abramson. (Applause).
RACHEL ABRAMSON: Now I'm a short person. We may have technical moving around here. Can everyone hear? There is no screeching? Yet? I'm really honored to have the opportunity to talk with you about the community based Doula model which is another relationship based approach to perinatal support, that takes advantage of the powerful time around birth and also the strength and resources that exist within communities to nurture new families. Chicago health connection has continued to be, since 1986, impressed time after time with the power of woman to woman support to nurture health and growth and change. Since we began as the Chicago breast-feeding task force, we have engaged in this kind of community based support. It was our breast-feeding peer counselors who pushed us to see how critical birth is, the experience of birth. And the circumstances around birth have lasting impacts and lasting implications for families.
Childbirth is a moment of risk and opportunity. Particularly for families who are vulnerable, for women who face huge challenges in their lives. Women who have not necessarily had a lot of success in their lives. Birth is a critical developmental opportunity for growth and change. It is an opportunity that we can't afford to miss in our program. The pilot project that developed and tested this model was funded by the Irving Harris foundation and Robert Wood Johnson foundation and brought together a broad collaboration of agencies and communities. Ultimately, integrated this model into three parents too soon programs, those are programs serving parenting, pregnant and parenting teens, administered by the ounce of prevention found. And in three very different neighborhoods in Chicago . We were incredibly fortunate to have a full time evaluator who was based at the ounce of prevention fund.
The word Doula means a woman who serves. It is an experienced woman, who helps another woman around the time of childbirth. It is a Greek word. But it is an ancient role. For our agency, the community-based Doula model developed from the work of breast -feeding peer counselors, others have come to it from other directions. It's relationship-based which means it depends on that ongoing trusting relationship between the Doula and the mother. It develops the support relationships around the mother and her extended family. And ultimately focuses on the relationship between parent and child. It is collaborative, meaning it bridge s the often separate worlds between agencies and between, particularly healthcare and social support. It's community-based which means not only is it placed in agencies rooted in the communities, but the Doulas are recruited from and identify with the communities they serve. We have called this Doula model the extended Doula model. You hear a lot about Doula s these days. There are fee for service Doulas who are available to support families for a fee, around labor and delivery. There are postpartum Doulas who are like the old baby nurses, provide whatever kinds of support services, including breast-feeding support that are needed by the family. I've heard the term, Doula, used for end of life support. So this extended model begins early in pregnancy, intensifies around labor and delivery, and then extends into the postpartum model. It was developed as a piece of an ongoing program of long-term social support.
Our pilot project was nested in that parents too soon program which can last for years. Other projects have done it differently. But essential it is not a silver bullet. It is one piece. When we talk about collaborative work, those of you who are here this morning heard collaboration compared to teen pregnancy. It rarely does it come easy. But the Doula model brings something different to any project into which it is integrated . So agencies that haven't necessarily talked before have to talk. And have to build support for the development of the project from the beginning. I'm a program person. My first job out of nursing school was a research job. But it has been a long time since I've been in a community agency. So we don't have the data to support this claim. But as a program person, I know that the success of a program depends on how it is managed. So the successful Doula programs that we have seen have focused on recruitment of the right Doulas, good extended popular education based training, and supervision that is sacred, weekly, and ongoing support, and continuing education for the Doulas.
Doula training is the linchpin of the development of the Doula role and ours is based on empowerment education or popular education. We are training lay women to support families in a clinical area, by which I mean nursing or a medical area. So there is lots of clinical content. But the training itself is very personal, very interactive. Ultimately, seems to be transformational for the participants. What we know about the impact of the training comes from the words of the Doulas who have been trained. Erin at the University of Chicago did a study of the development of the African-American Doula which was published in 0 to 3. This quote is from a Doula in Atlanta. "I am my authentic self now. I had to go through the Doula class to get to where I am now. “So not only is it teaching content, but it develops inner resources for what is really quite a demanding complicated role. Prenatal work of the community based Doula involved prenatal education, both in home visits and in site based group, preparing for the labor but also supporting the pregnancy, developing the relationship between the mother and her growing baby.
During labor and delivery, the Doula provides continuous physical and emotional support. That means she is there the whole time. Where other providers may not be able to be. It seems, although our evaluation is still at the beginning stage, in its infancy, it seems as if that early labor support is critical to the outcome. In the postpartum period, Doula support continues, focusing on infant care, breast-feeding support, newborn capacities and facilitating the parenting role. The pilot project was evaluated by Susan Altf*eld at the Ounce of Prevention funds. You can reach them on their Website, ounce of prevention.org. The project was a service projects, not a research project. So our partners would never have agreed to randomize, not a longitudinal randomized control study but we got good data from birth certificate data and other comparison groups.
This was a teen project. The age was, mean age was 16.8 years. Mostly, African-American, and Latina young women. The outcomes in the project were similar to those noted in the original research by Marshal Klaus and John Kennel which had significantly lower C section rates, 8.1 percent compared to 14.5 percent C section rates for U.S. teens and teens tend to have low C section rates to begin with. Epidural rates. Breast-feeding initiation rates, 80 percent in this teen population. This represented a profound change in the communities that we were serving. Particularly at one site where there were no breast-feeding teens before the projects began. In the first year, the breast-feeding rate went up to 65 percent. It has stayed there, gone up and down a little bit. But pretty much two -thirds of the teens breast-feed their babies. You can see from this slide that this is really successful breast-feeding by six weeks , two-thirds of the population is still, of the sample was still breast-feeding. Those of you who support breast-feeding know if you get to six weeks, you can do it as long as you want . The outcomes of the pilot project were strong enough to move us into replication, perhaps faster than we wanted.
The Doula Institute is working with six replication sites around the country. We facilitate a national network of more than 20 communities based Doula programs, including Illinois programs that are being ad ministered by the ounce of prevention funds. We believe that the Doula piece adds a continuity to the intervention, that doesn't get broken around the time of birth, having been a prenatal support provider I remember how you lost family when it came time for them to go to the hospital, an then they wouldn't come back to the same house or they changed their phone or lose their cell phone. So this provides continuity. One of the Doulas said, from three years ago, receiver a women, -- ten women she started out with, seven of them are still in the program. The earlier they have come into the program, the longer they have stayed. As I said before, this is really an early stage in the exploration of the impact of the community-based Doula role. I feel like we are infants as well.
The pilot project provided what we call rich descriptive data. There is a randomized control led study going on at the University of Chicago which John can talk about up to a point. And we are trying to be patient until the data comes out from that. We are beginning to gather data from replication sites around the country, who have extremely, a n extreme variation in their capacity or their ability to both collect and share data and also are interested in a variety of different outcomes. We do have some descriptive research that's already completed and now in process. Let me go back to this. One of them is Ginger Breedlove who did her PhD dissertation. She is a mid wife at the University of Kansas in Missouri, did a description of social support and hope in pregnant and parenting teens, receiving care from a Doula. The Doulas she interviewed. Well, it is love when you can feel it. That is an interesting term. And one that requires more research. I've never heard someone talk about a service project in terms of love before.
Another ongoing research question is whether giving women the opportunity to experience a natural birth, a normal birth, makes a difference in outcomes. By that, I mean natural childbirth without unnecessary, non-medically indicated interventions. It seems to be an empowering experience for those young women who have chosen it. Just the pride that they talk about their power and their ability to do that is particularly striking. Being there, she helped me feel comfortable. They helped me. They told me; just breathe through all the pains. Every time it came, they was right next to me showing me how to breathe. So I didn't need medication. Another research question involves the importance of recruiting the Doulas from the communities being served. Some of the data that came out from Breedlove's study talked to the issue of Doulas having been through the same experience as the women they were serving. Many of them were teen mothers themselves. Lived in the community, and were seen as role models by the women they were serving. Got to brag about the healthy mothers, healthy babies. But mostly, I love the voice s of the women in the program.
Both qualitative and quantitative outcomes, including quotes like this, speak to the intense personal connections that are developed by the Doulas with their clients. But I would also maintain that it is the incorporation of re-claiming and focusing on birth that allows the program providers into the women's lives in such an intimate and impactful way. So this may be heretical, but though the work is based on science and continues to be evaluated, for me, there is a magic about it. I'd like to give you some of that story by switching projectors and showing a piece of videotape, a trailer to a documentary that will be hopefully airing in the fall. (Video played).
VIDEO TAPE: These Doulas partner with disadvantaged young mothers to be, through the first month of their baby's lives.
>> Nearly one out of ten births in this country is to a teenager. Many without education, resources and support. Their future is often uncertain. This future is a legacy of their children.
>> They are always there, nurturing them with wisdom and trust, working to radically change the way they see the world and how in turn they will love their children.
>> (undecipherable).
>> I've been looking for you. Where were you?
>> Picking my baby up.
>> I'll be back.
>> (Inaudible).
>> The part that the young ladies needing help and search so hard for is in the community now. I didn't know where to go to get help. I was about to attempt suicide because it was so hard. I thought no one was listening to me. It's okay.
>> I love you enough. When you go through this, everything else will stop. You will understand.
>> Each person is an individual. If she is afraid, she is afraid. You can't just say, everybody is afraid, that is normal, go home, get over it. You can't say that. That is why this gets done, A, B, C and D. That that into consideration. Is the nurse going to be there with you? When do you usually see a doctor?
>> When it's time to have the baby.
>> Anybody have a number to call? If it's like 2:00 in the morning, you call. (Applause).
ARDEN HANDLER: That was incredible. I cried twice instead of once. I'm sorry this is such a long session. But I think is it amazing. I'm glad we are having one more speaker. The doctor will present the evidence to date on Doula s in terms of what has been done and tell us about the randomized control trial that is going on through the University of Chicago. He is a n associate professor at the Eriksson Institute. He received his doctorate from a joint program between the department of clinical psychology and institute of child development at the University of Mississippi. His research in general deals with studying programs and practices and now comes a n early child intervention exploring how different families of young children engage in and get help from programs including early head start, Doula support programs, home visiting programs and toddler service s. Before coming to Erikson, he worked with David Olds who will be here later today. It is exciting. Welcome, Jon Korfmacher. Thank you (applause).
JON KORFMACHER: So, this is I think the third time I've had to follow Rachel and her video. And I hate it. So I love Rachel. But I hate following you. End of lunch. You are all like getting that lunch feeling coming over you. Or you have to go to the bathroom. So let's try to see what we can do. (Laughter). I'm going to talk briefly about the research base of Doulas' practice before discussing research. I'm involved in studying one particular model of community based Doulas, the model that Rachel just talked about. We are studying one particular site. Let's see if I can get this. There we go. Rachel has covered a lot of this territory. But just a basic definition of what Doulas do, and as Rachel noted there are different sorts of Doulas.
This talk is focused on those who provide support around the birth experience. Now, there is considerable research on the use of Doula s which I'm summarizing in the next couple slides. I have tables coming up which I think we don't have to spend a lot of time on. A number of randomized trials have demonstrated positive birth outcomes. When mothers had the assistance of a Doula, such as reduced cesarean delivery rates, reduced rates of more invasive medical procedures. And reduced need for epidural and other pain relief medication. Mothers seem to be more satisfied with the birth experience, seem to show more positive feelings towards their child immediately after birth. They show, there is some research that suggests there is a possible increase in breast-feeding.
There are lower rates of anxiety and depression in these mothers. Though studies are not all consistent in showing all these results, there have been a few meta analyses and a review that was done by the Cochran collaboration that supports these summary conclusion. If Doulas were a drug, they would be mandated in every hospital, Klaus said. He is a big proponent of Doulas. This table is, just shows we do have these studies and I can put them in a table and put them up here. (Laughter). What is important to recognize, most of the research that has been conducted on Doulas has been done with a low income population. In this country, most of the Doula work that is happening is mostly done with middle or upper income women to a large extent, because at this point, research does not reimburse the use of Doulas. You have to be lucky enough to be able to afford one. -- insurance does not reimburse the use of Doulas. You have to be lucky to be able to afford one. There are things we don't really now so far about research or about Doulas.
So there are still a lot of unanswered questions, even though there is considerable evidence to support their use. One is that we don't really know what the mechanism for positive birth outcomes are. There is three main hypothesize that seem to be floating around there. One is stress reduction. So Doulas reduce stress in mothers which through a, not all together clear physiological mechanism al ours her body to deal better with pain, to have more noncomplicated deliveries. The second hypo thesis is that having a person in the room basically acts as a monitor to the medical staff. So that either consciously or unconsciously, they become more attentive to the mother and more appropriate to the mother and less likely to advocate for the use of a more invasive procedure until it is absolutely necessary. This is a somewhat cynical
hypothesis. Because it suggests we don't trust our healthcare providers. But it has been tested in a few trials where they have simply put as a comparison condition, someone in the room to watch what the doctor is doing even though they don't directly intervene with the mother.
In general, the Doula’s condition shows more positive outcomes than that, just monitoring groups. The third hypo thesis is that we are trying to, that the use of a Doula empowers the mother to feel more in control of the birth and the feeling of mastery propels other positive birth experiences . There are other things we don't know. We don't know what the long term outcomes of Doula support is. Most of the research only goes to about six weeks postpartum. We don't know if there are long term effects in mother's self efficacy or if the immediate sense of connection to her child that you see from a Doula will translate into improved care giving or improved parent/child relationships .
The other thing we don't know is the Doulas themselves are a mystery. Given the flexibility inherent in the role, as you can see from the video, what exactly do Doulas do with these mothers? And with any intervention, there will be some mothers who make good use of the program. There will be others who won't tell their Doula when they go into labor. So trying to figure out with whom do the Doulas seem in particular most effective. For the past four years, I've been involved in a n evaluation of the Chicago Doula project implemented at one site at the University of Chicago. This iteration of the model is focused exclusively on young low income mothers. As Rachel noted, this is an expanded model of Doula support. We offer service s, they offer services prenatally, on average beginning during the second trimester and they work with the mothers until the child is three months old. The expectation is that they will have weekly contact, either in the home or at the outpatient clinic or during the mother's hospital visits before labor and delivery. The expectation is that they will be there for the entire time during labor and delivery.
The Doulas come from the same social backgrounds as the mothers. A number of teen mothers themselves. They come from families who lived in low income environments. They live on the south side of Chicago, mostly all are African-American. Most have not had formal training as Doulas are family support providers until they underwent the training through the Chicago health connection. In many ways, they fit the definition of para professional service providers. Yet at the same time, as part of project, they are University of Chicago hospital employees. This is a significant modification of what might be considered a typical, proto typical Doula who is often an outside of the hospital or medical system. In the Doula community, and research literature, there is debate about the cost and benefits of using Doulas, of having Doulas as hospital employees. All the Doulas in the program I'm connected with are not trained medical professionals. They are on paper at least considered part of the hospital team. The Doula’s ability to navigate between a friendly informal helper to the mother and being a professional employee by the hospital is a compelling narrative thread as we are coming to understand this program.
The principal investigator for this study is Sidney Hons at the University of Chicago. We have received funding from the Bureau of Maternal and Child Health and from the Harris foundation. We are conducting a randomized clinical trial of almost 2 50 mothers, 2 1 years of age or less. Half are being assigned to a Doula. The other half to a comparison group. Because of the nature of the population that served in the clinics that we are recruiting from that feed into the University of Chicago hospitals, all of the clients are African-Americans. We try to get them during the second trimester. They are almost exclusively low income moms. We conduct outcome assessments immediately following the birth, within one to two days. We go to the hospital right after the mother has given birth.
Following the entire intervention. And also long term up to two years. We use a combination of maternal interview, and videotaped observation of the mother and child together. We have a fairly extensive valuation -- evaluation of program implementation and content so we can examine in detail what is happening when Doulas spend time with the young mothers. Because we are collecting data on this sample still, I am not allowed to discuss results from the outcome evaluation at this point. But I can discuss some of the emerging lessons that are coming out of the implementation study and that is what I want to spend the rest of my time on today. First I'll tell you the outcomes we are collecting. The usual suspects of obstetric outcomes, looking at breast-feeding initiation and duration, mother psychological aspects, anxiety, depression, labor, efficacy, sense of self as a parent. We are collecting information on parent stress, both through maternal reports. We are collecting cortisols saliva samples and measuring cortisol in the saliva. We collect it at baseline, also two days and four days after delivery, and at four months.
Parenting, we have a parent attitudes and beliefs. We have videotaped observation of sensitive and responsive interaction. What my piece of the study, my major role in the evaluation and main focus of my research and career so far has been on examining program implementation and process . Most major reports of intervention evaluations especially those conducted in the context of randomized trials are focused on program outcomes. They want to know if participants, the curious participants, well, in essence, the intervention is a black box. You have a curious participant who goes in, something wonderful happens and they come out happier. What happens in the black box? Although randomized trials assume a uniform treatment variable applied across all the different participants, the reality is that participants have very different experiences within an intervention. Some fully commit. They will squeeze every last drop out of the Doula that they can, some will never return the Doula’s phone calls. Then you have everybody else in between those two extremes.
Studying the implementation of a program involves putting a window on the black box, peering inside to see what happens. Because interventions are dynamic, they change over time; we want to be able to put in multiple windows to see how the mother's experience changes over time. That is about as exciting as my Power Point presentation gets. (Laughter). Thank you. Took me an hour to do that. I see program implementation as involving both looking at a couple different dimensions, at both the sheer amount of contact the families have, what the medical community cause dosage, which is a term I don't like, so I prefer to say participation. Not just quantity of contact but also quality of contact. In the context of the Doula intervention, we are looking closely at what is the sort of relationship formed between the mother and Doula.
We want to know what actually happens. What is the Doula doing with the mother to promote breast-feeding? What are they doing during labor and delivery that might be helpful? Then who are the Doulas? What is the quality of the provider themselves? Three questions have become the focus of the implementation study, which I have listed on the left. How do Doulas understand and implement the program model, what is the nature of the relationship with the mother, how do Doula s negotiate their professional goal. We are collecting data across these domains, by using both quantitative and qualitative data. We have developed a recordkeeping forms for the Doulas to fill out after every contact that includes rating scales and checklists to document what happens during the visit, who might be at the visit besides the mother and what the mother's emotional engagement is like. We are with a subgroup more intensively interviewing both the mother and the Doula about the relationship they are forming with each other, twice, both soon after they become enrolled in the projects and gotten a sense of who the Doula is or mother is, and then towards the end of the time after the child is born.
This interview is semi structured, has ten to 12 questions and many follow-up probes to capture how each person conceptualizes the relationship, how other family members respond to the Doula, how issues of gender, culture, age and social identity impact the relationship. How this changes over time. Finally, we debated the best way to capture the nuances of what Doulas do. We came upon the brilliant realization they might be able to tell us what it is they do better than other people. So I and a colleague met with them once a month to do focus groups, though I'm being fast and loose with the term. We would sit down and ask them questions as a group, questions about what they do, how do they deal with challenging situations such as when Doulas and grandmothers don't agree with the advice they are giving. What techniques they find helpful to promote program outcomes.
I'll show you because of time limitations, a couple examples of major themes and ideas that have been emerging from the study of implementation. One is that Doulas are being strongly challenged in how to promote breast-feeding in this population of young African-American women. For the most part, these young mothers have no interest in breast-feeding and have few positive models of it within their families or friends. The Doulas work at a hospital that only recently hired a dedicated lactating consultant. You can see from this example how do you encourage breast-feeding. The Doula is talking about what the mother is saying. She said, I'm not going to do it. I said you haven't given it a try. Why should I try something I know I won't finish. I tried to go through the thing about the baby being healthy. The mother says I had a bottle. I'm healthy. I know other people who had a bottle and they are healthy. It is constant back and forth. The mother said, that is the only thing we disagreed about. I didn't do it. I didn't want to go through it. I was just like, Unh-unh Unh-unh. This girl made up her mind. This is one of the favorite parts is listening to these transcripts. I can't do justice to the kind of emotional intensity that they are sometimes. As you can probably guess. (Laughter). The Doula s had to be creative in trying to develop compelling arguments for breast-feeding and seeking out additional training and consultation, finding videos so they can have role models for these moms.
An interesting finding we stumbled on is they are not going into the mother's home immediately after the baby's birth to see how breast-feeding may be going. Some believe in terms of best practice that you have a limit ed window after the birth of the baby when you can get in there and do it. If you don't get in there in that time and if she is not breast-feeding in that time, it won't happen. The Doulas are encouraged to go into the mother's home as soon as possible. But collectively, they decided that this is a time for the mother to be with her family. It seemed to them intrusive to be able to come in so early, based upon what they knew about the family's culture and the community they are working in. So it really became a deliberate trade-off that they are trying to make and trying to be respectful of the family's beliefs and feelings and trying to do what they know the program model is asking them to do.
A lot of my findings are in terms of tensions. As an academic, I don't actually have to have answers, I just keep bringing up interesting tensions and questions. Another thing that developed, the Doulas and mothers often think about the relationship they form with each other on very personal terms. The Doula 's job is intimate. This quote is a n example. It is common in para professional service providers, and one way they separate themselves from other professional providers, this is another quote that uses love. It is something you don't normally hear nurse s and doctors and other types of providers talk about. They don't talk about love and yet this is something that the Doula s bring up a fair bit. At the same time they are using these terms, they are part of a professional team as hospital employees and their interest in being viewed by the medical staff as valuable contractors to the birth process and also interested in seen by mothers with information they can share with them. They are rigged to do things to promote that. They requested and received hospital staff coats they wear in the hospital to increase professional identity.
They are trying to walk a fine line between being able to conceptualize and think about their work with the moms in this way, but also being seen as professionals that have something valuable to contribute. This is another example. They conceptualize themselves in family. The mothers and Doula s think about themselves using family terms. One of the Doulas calls her self an Auntie Doula to most of the mothers. How do they keep this personal connection they use to help the mother while at the same time demonstrating professional levels of knowledge and expertise? This is something that is constantly being played out with this group. Is it not just personal professional negotiations but also the fact that Doulas are often seen as Jacks or Jills of all trades. Because the role is not precisely defined, they take on additional duties which they have varying levels of comfort about. This is a case where the mother didn't deliver at the University of Chicago hospital, but delivered at a smaller hospital that was close by.
The Doula without knowing any of this staff gained access to work with the mother. She says after the internal monitor was on, it was totally blanked out and the screen of the baby's heartbeat, and I was encouraging her to turn over. There was five minutes where no one checked. I had to go down the hall and tell them there is no heart sound. I was more invasive than I'm used to because my role is a comfort. Now I'm becoming a medical watch dog. There is no mother, father, grandfather. Everybody gave an hour or two of their Christmas but I was there. She was there for 24 hours on Christmas Day. She was the only one who stayed that entire time. This was a scary and difficult labor. It ended in an emergency C section. You can see in this quote, she had to shift roles quickly when the mother and grandfather came back. I never met them but that went well because during this, I had to explain everything. I was like a translator. Everything the doctor was saying, I would explain to them. When everything started going downhill, so to speak, they both started crying and reached for me to hug them. As they took the young mother back for the crash Cesarean, I stayed with them and consoled everybody. The ability to be flexible and all the degrees of uncertainty that comes from helping mothers give birth is an important quality of the Doula. At the same time it makes intervention harder to study. They are not rigidly designed interventions where everybody can do the same thing, where you can ask fidelity checklists, and know if they are doing the job.
The challenge has been trying to understand the Doula model of support. By helping Doulas articulate and define what they do. The Doula s appreciate being able to share insights with us. They have not appreciated the recordkeeping system. But it helps us understand better what it is they are supposed to be doing. We are supposed to be talking about translating research into practice. I'll end the presentation on this note. To understand a program, it is important to talk to the people implementing the program. Which is a simple point to make. And one that has been made by other people. But it is often overlooked as we go through data screen after data screen of numbers, means, logistic regressions, statistical
significance levels. The meaning behind these numbers only emerges through a true understanding of the trials and tribulations of providings these services. It is understanding, and this only comes when evaluators and researchers form relationships with the program and its providers. The tension for us, since I like to speak in tension, as evaluators is how to maintain a level of objectivity in interpreting results as we form relationships. It is the same tension that the Doula s experience with their clients in many ways. How do we be helpful while still getting the job done. So thanks. (Applause).
>> (Inaudible).
ARDEN HANDLER: I have a question from Penny Sellby. The question is how does the centering pregnancy process work with women who have significant mental health and/or substance abuse issues that impact their pregnancy?
JON KORFMACHER: That is a good question. We found that women with severely psychotic mental illness don't tend to do well in centering pregnancy groups. It speaks to a larger issue of what happens when women develop complications of pregnancy, depending on what they are and the skills and training of the people facilitating the group, women can very effectively be managed in a group setting. If you have a group of women with the same complications, such as substance abuse, gestational diabetes, heart disease, whatever, those women learn about that illness from each other and how that impacts their
pregnancy. I think it lends itself well to the group concept. In particular complex issues like substance abuse it might be helpful to have as a co-facilitator if you were doing a group of women with substance abuse, that you would have a co-facilitator who is trained in that. We have specialized groups actually happening throughout the country. One with women incarcerated in prison, HIV -positive teens. So these medical complications that a whole group would have actually lend itself well to the group.
ARDEN HANDLER: I have a comment to make. It would be interesting in terms of looking at outcomes of both these programs, Doula and centering pregnancy, are measuring aspects of social support. Those are very important. It might be interesting to get together and do comparisons sometime, and see what are the longer, in terms of longer term outcomes, implications of both, different models. Not to say one is better than the other, but to see what sort of outcomes you get and evaluating your long term effects of what you are doing in each individual program.
JON KORFMACHER: Since I work with physicians, I was wondering, you mentioned that in the centering pregnancy program, some of the groups facilitators are physicians. But for both programs, I'd like you to speak a little more about what has been happening as far as the relationship of physicians to the people providing the primary support.
ARDEN HANDLER: The relationship of the physicians with who?
JON KORFMACHER: In the one case, with the Doulas, and in the other case with the people leading the support group. When we initially started centering pregnancy, we felt like the only people that could do this were mid wives. We found out we were wrong. There are physicians who can be facilitative and they are a loving group and they are loving this relationship that they can have with patients that they were never allowed to have in individual care. I think it is more, not so much what your training is but what your skills are at being facilitative, being open to a new idea and doing things in a different way. We found that other kinds of groups who have been, that tend to want to do this are physicians and family practice docs and other kinds of professionals who want to change the way they have been interacting with their patients because it has not been professionally rewarding for them.
ARDEN HANDLER: You want to talk about Doulas and physicians?
JON KORFMACHER: That would take another couple hours. If any one saw that Wall Street Journal article that came out a couple months ago about...Well, the Wall Street Journal came out on the side of the medical establishment, which was kind of a shocking kind of position for it to take. (Laughter). I think with the Doula s, it is a fine line they have had to walk. In our project at least, there are some doctors who love the Doulas. There are some midwives, there was a nurse, a midwife clinic that loved the Doulas but that got shot down about six months ago. The Doula s deal with a lot of residents because it is a training hospital. The residents have a harder time with the Doulas. One of the quotes from one of the Doulas we have is, she said it took, one of the attending doctors, it took half a dozen times of meeting him at a labor and delivery before he realized she wasn't just a member of the family. Do you have anything to add? Anything positive to add?
>> First of all, you have to include nursing in terms of the relationship s with this new role. It is important to engage the nurse s as allies in the process. I approach it as sort of a community organizing activity. You really need to develop those relationships over time. Then by the time you have developed them, the whole staff of the hospital turns over. Has to start all over again.
>> Two more questions. Then we are going to have to...I'm getting my Master's degree in public health. In terms of the Doulas, I have to commend the University of Chicago and training them and making them part of hospital staff, because that is a huge issue. I think where nurse s tend to have a more poor of a relationship with the Doulas because they don't see them as being -- the patients can get misinformation sometimes, when they are not trained. I think that is phenomenal you have done that for that program. My question shave you seen, have you looked at all the relationships between nurse s and Doulas in their role? Do you think part of the positive outcome with the Doulas is because, as you were mention ing in this country it is mainly a higher income status, that uses them? Do you think it is more positive because they tend to care more about their health and take a more active role?
JON KORFMACHER: I would say, one of the issues with the research is that the couple of studies that have looked at middle or upper income populations that have gotten dull I s have not seen the impressive effects that when you provide Doulas to a low income population. I think that is partly because of the services that are already available to upper income or higher income families. So I don't know if the positive, I think most of the positive effects we have seen has been through research that's worked with lower income families. The other issue, one of the other questions brought up the idea of social support. A lot of studies have dealt with mothers who don't have many other supportive people. In some cases, those were the people who are getting Doula services. I think, also thinking about who are the other family members who are supporting the families is a n important aspect we have to look at as well.
>> One more question.
>> For low income head start families in Chicago, I'm wondering, this is a wonderful opportunity for some parents to participate and become trainers. To be qualified for the head start program, they have to be working or in school. I wonder which one of the three I should talk to about a potential partnership if we can get seed money from the Department of Human Services, the children services division.
ARDEN HANDLER: We will just say you probably should talk to everybody up there. I've been trying to get Rachel and Carrie together. I want to thank our incredible presentation for a great session. (Applause). We are a little bit late. We will still try to start on time for the next plenary. Everything will be a few minutes late. But thank you very much. We will see you upstairs.