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A 32-year-old African American woman pregnant with her second child presents for prenatal care in the first trimester. She is introduced to and enrolled in a Centering Pregnancy group, which gathers women with similar due dates and members of their support system together for group prenatal care. Not only do they have their health care assessment done at that time, they establish ownership of their own health and there is discussion of questions and concerns that honors the wisdom of the group members. Medical staff are present but act as facilitators instead of teachers. At first the woman is hesitant to join a group with people she does not know and is unsure about sharing with others during such an intimate part of her life. However, over the course of her pregnancy, she builds relationships with the women in her group and shares that her first delivery, preterm at 32 weeks, was traumatic. She discloses that she did not feel heard and certainly did not feel that she was allowed to participate in the decision-making process. She continues that she is fearful of what her experience may be like this time. Her disclosure leads to a loving but realistic conversation about making this birth what she envisions it to be. Several months later when she comes back for the Centering Reunion, she shares that her labor and term birth were almost exactly what she'd hoped for. But then she goes on to say something else. She reveals that prior to receiving support from Centering, she was considering delivering at home without a trained clinician to avoid the distress she associated with her previous hospital experience. Because of trust established through the Centering model, her concerns were allayed, and she was able to give birth feeling in control. This is one story of many like it.
How do we gain trust in an age of such distrust? In my opinion, it's about rebuilding “the village” that women so need to bring a healthy child into the world and to allow mothers and families to thrive. If you think about it, haven't women always interacted as if they were part of Centering? Haven't we always sought out advice from others who look like us, are experiencing something similar, or have lived experience that offers wisdom?
The worried 32-year-old woman was also a candidate for the services of a community-based doula. Doulas are trained non-medical professionals who provide physical, emotional, and educational support during pregnancy, birth, and postpartum. According to the National Institute for Children's Health Quality, community-based doulas “are of and from the same community as their clients, [and because of that] they are able to understand language and cultural needs and create long-term links to support networks. Women [who use their services] have been shown to have higher breastfeeding rates, lower C-section rates, and more positive mother-infant interaction” [1]. Because this mother was able to establish trust with someone who truly understood her history, she felt safe going to the hospital for her birth. Moreover, she knew that her doula would hold space for her to advocate for herself in a place where before she felt unheard.
We tend to think about new models of care as needing to increase access, to be more efficient, and to improve outcomes (thereby saving health care dollars). These are important, but why not strive for all these while still preserving, and even elevating, the value of connection and community voice?
Centering Pregnancy and community-based doulas are just 2 examples of models that put the voice of the patient at the crux of the solution. They are structured to acknowledge power in women as informed decision-makers.
Centering Pregnancy
There is data that strongly suggests that the Centering model reduces preterm deliveries and low birth weight babies while increasing breastfeeding rates at discharge from the hospital [2, 3]. These outcomes seem to be even better with Black or African American mothers who participate in Centering.
North Carolina is one of the states with the greatest number of Centering Pregnancy sites in the nation. There is growing interest and leadership focused on continuing to maintain and lift these sites through an active consortium and the work of the Centering Healthcare Institute. Our neighbors in South Carolina are prime examples of what other states strive to be. The research findings from Picklesimer and colleagues [4] that underscore the aforementioned outcomes led the state of South Carolina to expand Centering Pregnancy as one leg of its Birth Outcomes Improvement Initiative [5]. That expansion project is now in its sixth year and provides funding to offset startup costs of Centering as well as an enhanced payment, from both Medicaid and the Managed Care Organizations, for every Centering patient visit. It also provides for an ongoing research component that continues to monitor, evaluate, and report on patient outcomes for Centering compared to patients in individual care. This ongoing longitudinal study continues to demonstrate significant improvements in birth outcomes and reductions in medical costs attributable to Centering Pregnancy [5].
Community-Based Doulas
North Carolina is seen as a pioneer in the Community Centered Health Home model through movements like Mothering Asheville in the Western part of the state. Through this collaborative, programs like SistasCaring4Sistas (SC4S) have been born. SC4S is one example of a community-based doula program partnering with a larger health care institution. They use evidence-based criteria to accept referrals for their services from those clients most at risk for a poor outcome (African American, history of preterm delivery, infant loss or low birth weight baby, living in public housing). Mothering Asheville and SC4S are looked to as leaders in addressing the inequity in infant mortality between Black and white babies. They believe that through shifting the clinical system, building community capacity, and advocating for policy change, these inequities will start to decrease. Currently, they are consulting on possible doula reimbursement through Medicaid transformation and creating an infrastructure that could be replicated in other parts of the state (or nation) where access to care and information is limited.
These are not entirely new concepts. What is difficult is figuring out how they fit into complex health care systems. Modernity seems to prefer technology over technique, revenue over relationship, correct coding over communication. I would challenge you to ask any woman what she either valued most or was missing in her health care experience. My guess would be that the answer to both would have something to do with connection. How can we encourage health care systems to change, adapt, and support women—especially women facing inequities?
Health care providers are skilled at educating, and we have to continue to do that; but until clinics and clinicians start listening more to the voices in our community and less to our own voices, we will not begin to see a decrease in these gaps in outcomes. Trust is the single biggest health care shortfall. Trust is the medication that cannot be prescribed. It must be earned. That means building and maintaining relationships. Centering Pregnancy and community-based doulas are 2 examples of how our system can do this.
Acknowledgments
Potential conflicts of interest. A.B.M. has no relevant conflicts of interest.
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