The young woman who entered the clinic was typical of many of the patients Mary Ann Awadalla, RNC, MSN, case coordinator, sees at Women’s Ambulatory Clinic Services at Saint Peter’s University Hospital, New Brunswick, N.J. She was several weeks’ pregnant, Spanish-speaking, in her early 20s, unmarried, and uninsured. But in this case, the patient had diabetes and had recently lost her home to a fire, making her a particularly high-risk patient.
Awadalla, who specializes in high-risk patients, followed the woman through her entire pregnancy, paving the way for a healthy birth by providing her with prenatal education and arranging for replacement of testing supplies to keep the diabetes well managed throughout her pregnancy.
Located in the heart of the heavily multiethnic borough of New Brunswick, the personalized and comprehensive health services provided by Women’s Ambulatory Clinic Services is no secret to the local community. In 2007, clinic personnel saw 1,379 women. Despite the many challenges presented by a primarily multicultural, low-income population, the clinic reports a 4% low-weight birth rate, which is markedly below the state’s average of 12.5%.
A Poor Grade
Poor prenatal care is a growing issue in New Jersey and nationwide. The March of Dimes released a report card on prematurity in late 2008, ranking New Jersey 27th in the country and slapping it with a “D” — the same as the national average — for its rate of preterm births, late preterm births, and the number of uninsured women. Nationally, 12.7%, or one in every eight babies, is born prematurely each year, a toll that’s risen steadily for two decades. The federal government’s goal is to reduce that number to no more than 7.6% of babies born before completion of the 37th week of pregnancy.
In yet another study published in the National Women’s Law Center 2007 edition of Making the Grade on Women’s Health, New Jersey received a ranking of 40th in the country for women receiving first trimester prenatal care.
A Comprehensive Strategy
Determined to turn those numbers around, the Garden State is attacking the issue on several fronts. In October 2008, Saint Peter’s Women’s Clinic was the kick-off site for the Department of Health and Senior Services’ two-month educational campaign to raise awareness about the importance of early prenatal care and preconception health to achieve healthy birth outcomes.
In November 2008, the NJHA also announced the creation of a statewide quality collaborative to improve perinatal care for the state’s mothers and newborns. The effort will involve a coordinated approach between hospital leaders, physicians, nurses, midwives, and others to share problems, strategies, lessons learned, and best practices, to improve prenatal care for mothers and newborns. DHSS Commissioner Heather Howard is cochairing the initiative.
“The March of Dimes report card points out that there are many critical factors in caring for expectant mothers and their babies,” says Aline Holmes, RN, NJHA senior vice president of Clinical Affairs. “Our collaborative will examine the most pressing issues — from communication between caregivers to educating mothers-to-be about cesarean sections — and will zero in on the key factors where we can make a significant difference in improving care and patient outcomes.”
Early, Early, Early
It has been well documented that prenatal care is integral to help prevent poor birth outcomes such as preterm labor and birth, low birth weight, and infant mortality. Early prenatal care can help to identify risks for preterm labor and sometimes can lower them.
“Prenatal care offers the best opportunity for risk assessment, health education, and management of pregnancy-related complications,” says Howard, who has made the prenatal care awareness and educational campaign a top priority. “We know that there are many racial and ethnic disparities, and these women are much less likely to get prenatal care. We need to get to them in the family planning stage and begin talking to these women about topics like preconception care, quitting smoking, eating healthily, and taking vitamins.”
According to the commissioner’s Prenatal Care Task Force report, the rate of first trimester prenatal care for New Jersey mothers in 2004 was 78%, falling short of the Healthy People 2010 goal of 90%. The report lists the primary reasons for delaying the initiation of early prenatal care as unintended pregnancies, lack of awareness of a pregnancy, and no health insurance. Women without insurance had the lowest rate of first trimester prenatal care, at 73%. The percentage of pregnancies in New Jersey that are unintended, mistimed, or unwanted weighs in at 32%. Initiation of prenatal care for women with unintended pregnancies can fall below 60%, says Howard.
There is also the issue of late preterm births, which refers to babies born between 34 and 37 weeks. According to Holmes, many of these births are inductions and cesarean sections and are contributing to the rise in the nation’s prematurity rates. Babies born even a few weeks early can have learning or behavioral delays and other problems.
Nurses are a critical component in promoting prenatal health and halting the prematurity cycle. “Nurses are the hands-on caregivers who interact most closely with patients; that puts them in the most pivotal position to educate their patients,” says Holmes.
A Comprehensive Approach
Comprehensive education by nurses at Saint Peter’s clinic is a primary reason for its success, says Susan Cox, RN, MSN, WHNP-BC, manager of Women’s Ambulatory Clinic Services. “Our patients are actively case-managed by our nurses; that’s the reason that our patients do so well. Our nurses are very diligent about keeping track of patients and communicating vital information to their doctors and nurse practitioners,” says Cox.
An outreach worker dispenses prenatal education and awareness in the community by distributing pamphlets in high-risk neighborhoods and, sometimes, by visiting women door-to-door to encourage compliance with prenatal care. In addition, registration and scheduling staff work hard to get new patients in for their first visit within two weeks. In some parts of the state, women wait as long as 8 to 10 weeks to see a physician. The clinic also relies on a pool of nurses to fill in when the clinic is exceptionally busy, to ensure new patients are seen within that two-week time slot. The ED also has been notified to refer pregnant patients to the clinic for evaluation.
Once patients are in the clinic, they are offered comprehensive services to meet their individual needs, from help for substance and alcohol abuse, nutrition education, and diabetes counseling, to HIV screenings and care. Nurses work closely with social services to ensure that their patients’ social and economic needs are being met.
“We provide a holistic approach to care,” says Awadalla. “We do a lot of education on patients’ first and last visits, including general wellness, nutrition, natural family planning, and the importance of early prenatal care.” Awadalla says the clinic also educates its gynecologic care patients about the importance of early prenatal care, in the hope of reaching them sooner when they do become pregnant.
“Many women’s clinics are not nurse case management-focused,” says Barbara Ghigliotcy, RN, WHNP, a case coordinator with Women’s Ambulatory Clinic Services. “That’s what makes the difference. Our patients never leave the clinic without talking to a nurse.”
Holmes says the NJHA collaborative is in the process of developing goals and strategies and plans to launch a formal campaign by March. “This effort comes down to basics like good communication and standardization,” says Holmes. “We have everything we need in our arsenal; we just need to use it appropriately in an environment committed to sharing, communicating, and following through.”