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?