Prenatal Care in the YK Delta

1. Prenatal Care in the YK Delta Ellen Hodges, MD Chief of Staff

2. Importance of Prenatal Care • Provides for optimal outcomes for mother and baby • Best if started in the first trimester (the first 12 weeks of pregnancy) • Allows for screening of common complications of pregnancy

3. Importance of Prenatal Care • Allows education and preparation of the entire family for the new member • In our region allows for planning of the safest place of delivery, Bethel or Anchorage.

4. Common Complications in pregnancy • Preeclampsia – a collection of symptoms like high blood pressure and protein in the urine • Gestational Diabetes – a problem with regulation of blood sugar levels in pregnancy

5. Risk Factors in Pregnancy • Prior C-section • Prior post-partum hemorrhage (problems with bleeding after delivery) • Prior Large for Gestation Age baby – risk increases for diabetes in current pregnancy • History of Cholestasis of Pregnancy

6. Risk Factors in Pregnancy • Prior Pre-term delivery – any delivery before 37 completed weeks of gestation • Any problems with prior pregnancies • During the prenatal visits, our providers review all risk factors and prepare an individualized plan for each patient.

7. Complications in Labor and Delivery • Malpresentation of baby – breech, transverse, face, etc • Fetal distress • Post-partum hemorrhage • Shoulder dystocia

8. Place of Delivery • The safest place for a baby to be born in our region is a hospital. • We make a careful determination if that hospital should be in Bethel or Anchorage • We don’t always know what might go wrong before labor starts

9. Be in Bethel • After a series of complications many decades ago, the determination was made that all women come to Bethel to await delivery in the last month of their pregnancy • We call this the BIB or Be in Bethel date

10. Be in Bethel • Generally one calendar month before • Can be adjusted based on prior complications or current complications • Twins • Cholestasis of pregnancy • Gestational Diabetes • Problems with fetal growth • Preeclampsia

11. Village Delivery • Pre-term labor and delivery sometimes happens • Women who miss their BIB • Women we don’t know are pregnant because they didn’t get any prenatal care

12. YKHC Medevac in Pregnancy Policy • If there are no other risk factors present and the woman has remained in the village past her BIB date, YKHC will not medevac her unless a life-threatening condition develops in the mom or baby.

13. Village Delivery • Community Health Aides receive no detailed training in child birth and labor complications • Many complications that occur in labor and delivery require immediate and urgent attention or both the mom and baby could suffer serious consequences.

14. Village Deliveries • In 2010 we had 3 village deliveries • In 2011 we had 18 village deliveries

15. Solutions • A few years ago, we also had a marked increase in village deliveries • Most of these were women who hadn’t received timely prenatal care. • We started to pay for the travel of these women who needed to come into Bethel for visits who didn’t have another source of payment. • We also paid for cab vouchers and meal vouchers

16. Solutions • Most of the village deliveries that took place in 2011 were women who had received prenatal care and had missed their BIB dates. • In other words, our solution wasn’t matching the problem any more • So we decided on another solution!

17. Centering in Pregnancy • A novel way of delivering medical care • A nationwide program that has shown good success and patient satisfaction. • Groups are 8-12 people in size • Group focuses on 3 elements: • Health Assessment • Education • Support

18. Centering in Pregnancy • Nationwide: • 33% reduction in preterm birth rate • Higher prenatal knowledge and readiness for labor and delivery • Higher rates of initiation of breastfeeding and higher rates of breastfeeding at 6 months of age • When there is a preterm birth, the gestation age of the baby is significantly older and the baby weighs more and spends less time in the NICU

19. Centering in Pregnancy • Patients spend more time with their providers • Patients receive much more extensive education than traditional visits • Patients have a much higher rate of compliance with prenatal testing and self-care. • Patient satisfaction is higher than with traditional care.

20. Centering in Pregnancy • Groups meet about 9 times starting at about 16-18 weeks of gestation. • Members have similar due dates • Members learn to perform some of their own health assessments – like blood pressure and weight. • Helps educate patients on the importance of these measurements

21. Centering in Pregnancy • We have 10 groups currently – 106 patients • 4 Bethel • 6 village-based • New groups starting every month for village based patients and about every 6 weeks for Bethel-based patients

22. Centering in Pregnancy • The sessions all have an educational topic • Dental • Tobacco cessation • Domestic Violence • Depression • Care of the new infant • Labor and pain management techniques

23. Centering in Pregnancy • Members all have similar due dates • Share concerns that are common at each visit • Spend time together at prematernal home • Support each other in labor • Young moms can learn from more experienced moms.

24. Centering in Pregnancy • Preliminary evaluations from the groups have all been very positive.

25. What we need from Tribal Members • Encourage women to get early prenatal care • Encourage women to keep their BIB dates • Spread the word about Centering in Pregnancy • Support the Community Health Aides when they advise women to keep BIB dates

26. Questions?