Lauren Pellegrino

lauren.pellegrino@yale.edu
10/02/2011
N717a-Context of Care
Assignment #1

Dear Dr. Nieva,

I am writing to you to comment on the value of an innovation that I found through the AHRQ Health Care Innovations Exchange, an innovation titled “Nursing Students Provide Free Doula Care to Underserved Women, Leading to Fewer Preterm Deliveries, Low Birthweight Babies, and Cesarean Sections” and developed by the Johns Hopkins University School of Nursing as a program called Birth Companions.

It was first implemented in 1997 and received an evidence rating “suggestive” on its exchange profile. (AHRQ Health Care Innovations Exchange, 2011) I am a final year graduate APRN student at Yale University School of Nursing, specializing in both women's and adult health (WHNP/ANP) and looking forward to my graduation this upcoming May. My professional interests are reproductive health and underserved populations, especially young or adolescent women and LGBTQ individuals.

What drew my interest to this innovation is from seeing the great need for it from both an individual and policy level. My life experience is the most emotionally immediate place to start. The gap year between graduating Wesleyan in 2008 and beginning my nursing education was what brought me to these clinical interests. Living in New York City, where I was born, I worked for Yale School of Public Health as a field research assistant on a study exploring implementation of a new form of group prenatal care called Centering Pregnancy for young (14-21 year old) pregnant women in the poorest areas of New York City—public hospitals and community health clinics in the Bronx, far out in Queens, and upper Manhattan. The women enrolled in the program attended the same amount of prenatal care visits, but in groups matched up by due date, allowing the providers to spend 2 hours doing not just what was “clinically necessary” but time for there to be guidance in nutrition and exercise, breastfeeding, even instruction in prenatal yoga. These “extras” would have been all but impossible to cover in a standard 15 minute prenatal appointment, especially in a high-volume public hospital or community health clinic like the research sites—staff rolled their eyes and commented, “maybe in private medicine, with people who had insurance, but never here.” What I was most touched by was how extremely basic—and universal—the needs of the women were: a surprising amount of the visits were just needing a single person (here, the provider) to validate their fears and support their choices. The things they needed were so simple, and they were not able to get them with a broken healthcare system.

Simultaneously with my work with Centering Pregnancy, I was attending workshops to become a certified doula, a “para-clinical” provider trained to support women prenatally, during labor, and post-partum. Again, I saw a near-universal congruence between my a field research work and becoming a doula: women wanted the same simple guidance, validation and support as I saw in Centering Pregnancy groups. But again, like the 15 minute visit precluding education during Centering Pregnancy, only those women with the ability to pay for doula services would be able to have these services—doulas work mostly independently and are often priced at $700-$1,000 or more. Throughout this work with underserved young women about to become mothers, I saw the great need for guidance and the lack of resources by which to give it. I was witness to both the need and the solution, but an access problem between the two.

I took my training and my work with Centering Pregnancy with me to nursing school. There, my classes, especially my maternal-newborn rotation, expanded and grounded my individual experience with hard public health statistics. As a report Birth Companions innovation profile details, “Preterm births and the delivery of low birthweight babies are significant, growing problems that can lead to serious health problems, particularly among babies born to underserved women.” (AHRQ Health Care Innovations Exchange, 2011) To relate a telling statistical marker, Connecticut, where I am located, had a premature birth rate of 10.4% overall, but 12.8% for uninsured women—a number that increased 0.6% from 2007 to 2008 despite a drop in pre-term labor overall. (March of Dimes Foundation, 2010b) Although Maryland, where the innovation takes place, has a 17.4% pre-term labor rate for uninsured women, both are well over the national objective of 7.8%. (March of Dimes Foundation, 2010a) The program cites a rate of preterm birth 9.1% below and a rate of cesarean section 10.2% below the state-wide levels (13.3% and 32.2%, respectively)—just by adding this single support person. (AHRQ Health Care Innovations Exchange, 2011)

This need that I observed—on both an individual and population level—is one that the Birth Companions innovation addresses directly. “Hard” clinical outcomes for both mother and baby were also apparent. A later 2005 study of the cohort showed an inverse relationship between student doula interventions and epidural use. (Van Zandt, Edwards, & Jordan, 2005) Additionally, the student doulas showed very positive outcomes in more subjective measures: “Mothers found the presence of a student doula to be overwhelmingly positive, with 87% stating that the student doula was a “big help” to her physically, 80% believing that she was a “big help” to her emotionally, and 71% believing that the doula was a “big help” to the mother's other support person (spouse, mother, sister).” (Jordan, Van Zandt, & Wright, 2008) Similarly to the Centering Pregnancy study that I conducted field research for, the fundamental thrust behind Birth Companions is bringing holistic maternal-newborn support care—and the improved outcomes for both mother and baby—to underserved women that would otherwise not be able to access it.

This solution to a thought-intractable problem is the first element I liked about this innovation, and it is fundamental to the inception of Birth Companions. The additional positive difference about the Birth Companions program is that it uses a novel resource for providing this support: nursing students. I would have loved an opportunity to interact with patients as a new nursing student, especially in a way that was clinical enough to engage in a patient-provider relationship but not one in which I had to make decisions or feel my responsibility extended beyond my limited clinical skills. The doula model is one of support—halfway in-between the “civilian” world and the “practitioner” world, the exact world that beginning nursing students exist in. How do we turn our empathy into professional empathy and our development as people into development as nurses? In a 2008 article in the Journal of Professional Nursing on the Birth Companions program, Jordan, Van Zandt, and Wright write that “Service-learning experiences have been shown to augment traditional educational methods. Birth companions, or nursing students who become doulas while being educated as nurses, gain new skills, real practice experience, and strong professional standards and identity. Through the experiences of learning and applying doula skills to their professional nursing practice, new graduates will be better prepared to enter the real world of nursing practice.” (Jordan, Van Zandt, and Wright, 2008) In a related “lay” article for Johns Hopkins Nursing Magazine, Elizabeth Jordan, the faculty member who spearheaded this innovation, summarizes it elegantly and succinctly:

“Part of the mission of the program is to educate nursing students and to give them an opportunity to provide the emotional care that, as nurses, they might not always have the opportunity to do…Students really don't know how powerful it can be to hold a woman's hand, how powerful it is to be there with someone.” (Simpson, 2004)

My only reservation about this innovation was the surprisingly large price tag of $65,000 a year in running costs, despite no paid dedicated faculty or staff member. (AHRQ Health Care Innovations Exchange, 2011) However, as I investigated the itemization details, I think this figure could be substantially diminished with no depreciation in outcome or quality if this model was adapted. First, it seems appropriate to assume that much of this cost is start-up and curriculum development in origin—in adaptation, there would be no “reinventing the wheel” necessary, and that would save costs. Additionally, many of the running costs of the program could be streamlined with cheaper technology that has been developed since the program began in 1999—for instance, using web-based telephony programs such as Google Voice that are free and accessible from any location, instead of a more costly “physical” telephone system for the referral line. Paper brochures could be replaced exposure through social media, saving on printing costs. Lastly, since there was a fee for a doula trainer, getting a doula educator to “donate” his or her time should be explored. The cause could not be more altruistic in spirit. Unfortunately, there were no comments by experts cited in the profile of this innovation, so external However, I feel as if the proof of its practicality is immediately evident in the global outcomes it has on both mother and child.

Thank you for reading my letter. In summary, one of the most likable parts of this innovation was the fact that each group of stakeholders—the mothers, the babies, and the nursing students—obtains a tangible benefit from the program not only in covering a previous deficits but in receiving something positive in exchange. I would like to summarize three of my top points. First, there is a major issue with maternal-newborn outcomes for underserved women that continue to worsen even as overall outcomes improve. Second, there are well documented services, such as doula care, that can improve these outcomes but often have financial and cultural boundaries to access. Finally—and most importantly—far from being an intractable problem, there are solutions to this issue, like Birth Companions, that re-distribute human and clinical resources in novel ways to ameliorate these access problems and create abundance where there was previously only scarcity.

Thank you for your time.

Lola Pellegrino


References

AHRQ Health Care Innovations Exchange. (2011). Innovation profile: Nursing students provide free doula care to underserved women, leading to fewer preterm deliveries, low birthweight babies, and cesarean sections. Retrieved 10/06, 2011, from http://innovations.ahrq.gov/node/5536.

Byrne, W. (2002, Updated 2010). US nurse practitioner prescribing law: A state-by-state summary. Message posted to http://www.medscape.com/viewarticle/440315.

New York State Education Department Office of the Professions. (2010). NYS nursing. Retrieved 10/06, 2011, from http://www.op.nysed.gov/prof/nurse/.

Jordan, E. T., Van Zandt, S. E., & Wright, E. (2008). Doula care: Nursing students gain additional skills to define their professional practice. Journal of Professional Nursing, 24(2), 118-121. doi:10.1016/j.profnurs.2007.06.018

March of Dimes Foundation. (2010a). 2010 premature birth report card: Connecticut. March of Dimes. Retrieved from http://www.marchofdimes.com/peristats/pdflib/998/CT.pdf

March of Dimes Foundation. (2010b). 2010 premature birth report card: Maryland. March of Dimes. Retrieved from http://www.marchofdimes.com/peristats/pdflib/998/MD.pdf

New York State Education Department Office of the Professions. (2009). Nurse practitioner application packet. Albany, New York:

New York State Education Department Office of the Professions. (2011). NYS nursing license requirements: Nurse practitioner. Retrieved 10/06, 2011, from http://www.op.nysed.gov/prof/nurse/np.htm

New York State Education Department Office of the Professions. (2011). NYS nursing license requirements: Nurse practitioner. Retrieved 10/06, 2011, from http://www.op.nysed.gov/prof/nurse/np.htm

Simpson, J. C. (2004, The new labor movement. Johns Hopkins Nursing Magazine, (Fall 2004) Retrieved from http://magazine.nursing.jhu.edu/2011/08/the-new-labor-movement

Van Zandt, S. E., Edwards, L., & Jordan, E. T. (2005). Lower epidural anesthesia use associated with labor support by student nurse doulas: Implications for intrapartal nursing practice. Complementary Therapies in Clinical Practice, 11(3), 153-160. doi:10.1016/j.ctcp.2005.02.003

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