1. STFM Pre Conference on Teaching Maternity Care Addressing Health Disparities Using Community Health Workers and Group Prenatal Care Lucy M. Candib, MD Navid Roder, MD Sara G. Shields, MD, MS

2. Disclosures We all work at a federally-funded community health center

3. Founded 1970 (Model Cities) Worcester: Central Massachusetts 1974: Training site for UMass Family Medicine Residency Over 140 family physicians trained Maternity care always a part of care—about 500 prenatal patients, 300 births annually Medicaid 58% in 2013 Uninsured 24% in 2013

4. Birth Outcomes at FHCW 2014 321 deliveries 26 preterm <37 weeks (=8%) 23 LBW (7.2%) of these, 8 were term (>=37wks) (SGA) 75% started prenatal care in 1 st trimester Approx 5% privately insured at 1 st visit

5. Our Perinatal Program CNM Manager FM provider (“associate medical director for perinatal services”) FM provider with advanced c/s training OB nurse OB medical assistant 4 bilingual/bicultural advocates

6. “Community Health Workers: An Important Method for Addressing the Social Determinants of Health” Contribution of medical care on health is estimated to be 10%–15%. What are social determinants of health (SDH): Do people have a place to live? Sufficient and nourishing food? Jobs that provide them with an adequate income? Educational opportunities? Transportation to school, work, and shopping? Adequate warmth in the winter? Access to treatment for mental health and substance abuse problems? Are their neighborhoods safe? Do they suffer from discrimination in access to jobs, education, health care, or social services because of their race or ethnicity, gender, language, or income? Do they have cultural values that may make access more difficult or not be consonant with recommended treatment? Freeman J. Community Health Workers: An Important Method for Addressing the Social Determinants of Health. Fam Med 2016;48(4):257-259.

7. Our Advocates’ Stories: Sussanna Came to US from Kumasi in Oct 2001with husband and two kids then 15 and 7 yrs. Had been RN and midwife in Ghana First did VNA work in nursing homes and assisted living, 2 jobs; husband had been engineer and had to go to work at Home Depot She finally got job as FHCW advocate Why do it: “It’s my passion. I love pregnant women and babies. That’s my job. It’s me. It’s my work. I remember one where I delivered a woman’s daughter and then delivered the daughter’s son: the grandson!”

8. Our Advocates’ Stories: Fatima From Brazil Worked in domestic violence in first job in US Trilingual Portuguese/Spanish/Eng lish “I love to be at the labor, to be with the women”

9. Our Advocates’ Stories: Ha Vietnamese medical school for 3 years had wanted to be obstetrician, had also worked with midwives and seen births Philippines refugee camp 1989 To Worcester 1990, studied biology while working nights at Digital Catholic Charities helped her find job at FHCW, interviewed by Dr Candib, created job for education Now has done 3 generations “I love my job, I know the people, I like to help when they don’t speak English, when they don’t know the medical, they don’t know how to access care so I can help them” Late nights—”that’s my favorite!” “The money is not much, but I work with my heart, I try to help the people from the poor country coming to this country, how to raise kids here with different ways” “This is part of my life—I’m sharing, I’m helping, helping people go from scary to being happy, to see the kids and the families growing”

10. Our Advocates’ Stories: Luz Bilingual Spanish Sister of previous advocate

11. The Advocates: Key to Perinatal Services “ The advocates are incredible! They fulfill multiple roles, including doula, interpreter, educator, counselor and friend. I can’t imagine trying to take care of pregnant women without such a strong team.“ -2 nd year Family Medicine Resident “I think interpreting for a prenatal group could be totally overwhelming, but Ha knows all our topics well and also serves as a cultural interpreter, bringing up certain Vietnamese traditions that we may not have been aware of. I've learned so much from this group and from working with her!” -2 nd year Family medicine Resident

12. The Advocates: Key to Perinatal Services “Whether it is a food insecurity issue or postpartum depression, I can count on the advocates to help me address these issues holistically and efficiently” -2 nd Year Family Medicine Resident “The OB Advocates are wonderful and they are such an integral part to our prenatal team. They are willing to do home visits on-the-fly and to track them down to coordinate proper care.” -3 rd year Family Medicine Resident

13. FHCW Advocates Participate In… Perinatal case management Former Healthy Start Initiative site 1998-2012 Doula training (not certified) Labor support (hospital funding) PTSD screening/intervention training grant funded 2013-14 BabyCafe PPD MotherWoman Groups Interconception Care (IMPLICIT model) Case management thru 2 years of life

14. MBCP Based on MBSR (Mindfulness Based Stress Reduction Four intentions: 1)To teach mindfulness life skills for decreasing stress during pregnancy and beyond 2)Mindfulness training for working with pain and fear in childbirth 3)Mindfulness for parenting with wisdom and compassion from the moments of birth 4)Mindfulness skills for interrupting intergenerational patterns of suffering. https://www.youtube.com/watch?v=OukZauC UfoY

15. Centering Pregnancy FHCW: Oldest and longest accredited Centering program in Massachusetts (since 2007) 9 groups in 2014, including 3 Vietnamese language groups, 2 Spanish language groups, and 4 English groups 12 groups in 2015 Labor and delivery staff can tell who is in Centering! Family medicine residents and NP residents participate in Centering groups

16. Centering Outcomes 2014 49 women participated in at least 2 sessions of a group (15% of eligible women) English, Spanish, Vietnamese groups 73% nulliparous vs 37% nulliparous in non group 7.5% preterm birth rate (vs 8% non group) Birthweight no difference; LBW 5% group, 6% non group Postpartum visit attendance higher for group women (83% vs 65% non group) Breastfeeding at discharge (at least some) 85% group vs 81% non group

17. Residents and Advocates Orientation to prenatal care Experiential learning through patient care Working with advocates in group care Stories

18. Future Directions Is experiential learning enough? What “structure” could we add? Goals for learning about CHW collaboration as part of teaching underserved care Evaluation of resident-advocate work This needs to be bidirectional Evaluation of resident work in Centering Curriculum/competencies (underserved care) Team-based care review Huddles, other?

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