Program Evaluation: Learnings from ACES and a Multi-Year Group Prenatal Care Evaluation in NJ

Prenatal and perinatal health and medical care are critical predictors of maternal and child health postpartum. Healthy moms are more likely to have healthy babies. Some of these important drivers of health are included on the City Health Dashboard, including low birthweight and prenatal care. These indicators of health are important to understand at the local level, because there are known maternal morbidity and mortality disparities between races and ethnicities. Women of color, particularly non-Hispanic Black women, experience three to four times higher rates of maternal mortality than non-Hispanic White women. There are programs and policies available to help improve these outcomes and reduce disparities. One of these programs, CenteringPregnancy, is our focus today as we interview ACES, a public health consulting firm that completed a program evaluation of CenteringPregnancy as it was being implemented in southern New Jersey. We hope to describe more about the benefits of Centering Pregnancy as a program, and also how program evaluation can be useful for cities.

CHDB: What is public health program evaluation and why is it so important?

ACES: Public Health program evaluation is the systematic assessment of how well programs and policies make the intended positive impact on the target community. Public health programs aim to prevent complex issues, such as disease, injury, or death. The programs created to tackle these large public health challenges are complex themselves, and do not occur in a vacuum. That is to say, there is no “one size fits all” solution for these issues, so programs must be evaluated to measure success in achieving intended outcomes, and make changes along the way as needed.

CHDB: What is the CenteringPregnancy model, and what was the NJ program that you evaluated?

ACES: CenteringPregnancy is a multifaceted model of group maternity care that incorporates health assessment, education, and support. Eight to ten women with similar gestational ages meet to learn skills, participate in a facilitated discussion, and develop a support network with other group members. This approach to prenatal care has been proven to lower health care costs and improve birth outcomes.

The March of Dimes created and launched the Healthy Babies are Worth the Wait (HBWW), a community-based preterm birth prevention initiative.  As part of the initiative, CenteringPregnancy group sessions were offered at two locations in Southern New Jersey. ACES was hired to evaluate the program in these locations.

CHDB: Can you give an overview of the CenteringPregnancy program evaluation? What did that process look like?

ACES: The evaluation team used a summative qualitative content analysis approach. Between April 2015 to July 2017, 65 women participated in the CenteringPregnancy program, and general demographic and birth data was recorded for these patients. Five focus groups and 10 key informant interviews with health center staff were conducted. Facilitators used a semi-structured interview guide for each discussion, and questions focused on the women’s knowledge, attitudes, and beliefs on the program and their prenatal care experience at the clinic.  Primary questions included, “How soon did you come to see a doctor after you found out you were pregnant?” “Were there any services during pregnancy you wanted but couldn’t get for some reason?” “How do you define a Preterm Birth?  How many weeks does a baby need to develop to be considered a full-term delivery?” Participants completed an anonymous demographic form that included questions pertaining to race, marital status, employment, number of previous live births and birth outcomes.

CHDB: What did your results from the CenteringPregnancy evaluation tell you about this program and the potential benefits for the women involved?

ACES: The findings from the evaluation show that CenteringPregnancy was well received among all participants. Patients receiving care from CenteringPregnancy were satisfied with being involved in group-focused care that allowed them to receive health education and medical care all in one setting. The benefits of group-level prenatal care for participants can serve as a buffer for some of the stressors women face during pregnancy. Additionally, the benefits of CenteringPregnancy, such as information about breastfeeding and growth and development of the baby can serve as the only credible source of information for some women that participate in the program.

CHDB: What are the lessons learned from this evaluation? How can your findings guide further implementation of this program in other communities?

ACES:  Attendance for the program is something that needs to be improved in CenteringPregnancy implementations at the site. Participants attributed session attendance difficulties to lack of transportation, lack of childcare for additional children, and lack of family and social support in the home. Future research is warranted to determine the systemic barriers that prevent women of color from participating in CenteringPregnancy programs. CenteringPregnancy staff that participated in interviews identified the poor relationships that often exist between physicians, medical providers and their patients. To determine the most common relationships and bedside manner that are taking place in CenteringPregnancy, it is imperative to examine the patient-provider relationship that is formed through the CenteringPregnancy program. This effort could improve attendance rates, and overall satisfaction rates with the CenteringPregnancy program.

A multi-level and collaborative approach is needed to properly implement CenteringPregnancy group prenatal care to women from diverse backgrounds. Investing in the health of women during the pregnancy and post-partum period yields a great return on investment for everyone involved and provides an opportunity that aids in the reduction of health disparities and adverse birth outcomes.

CHDB: How do you see COVID impacting maternal child health outcomes and how prenatal care is provided to pregnant women in the short and long term?

ACES: As a result of COVID-19, we are seeing drastic policy changes at birthing hospitals across the U.S. In many states, doulas are deemed as “visitors” by hospital administration and banned from attending births or entering hospitals. Although states like New Jersey have recently deemed doulas as essential, they were not for the beginning of this pandemic, and are still not allowed in many other states. This is a problem for Black women, who are known to benefit from the presence of doulas. Banning doulas could negatively impact maternal and birth outcomes among Black women. In addition to the lack of doula support, some hospitals have denied access to anyone in the hospital room – including partners and spouses, leaving women with no support during labor and delivery.

In many cases, breastfeeding mothers are being separated from their babies immediately after birth, often without a medical reason, and have little to no support for breastfeeding. The World Health Organization (WHO) has announced any interruption of breastfeeding may actually increase the infant’s risk of becoming ill.

There are also concerns about women going into birth alone within a system that is known to mistreat women. A recent study by the Birthplace Lab found that one in six women, regardless of race or experience, have experienced mistreatment by healthcare providers during birth. It is well documented that mental well-being is imperative for mothers and infants; increased anxiety may impact pre-term birth rates, C-section rates and postpartum depression.

During this stressful and uncertain time, it is imperative to provide a safe space for birthing mothers to receive support during labor and postpartum, whether from their spouses, partners or extended families.

CHDB:  For policymakers working to enact and implement effective policies responding to COVID19’s health and economic impact, are there lessons from your work that they should keep in mind during this process?

ACES: What COVID-19 has done is shine a spotlight on our fragile public safety nets. Nonprofits alone are not equipped to fill the gap caused by lack of policies and government funding. Policymakers need to look at how they can strengthen our healthcare safety nets and provide long-lasting systemic change. Policies need to explicitly target aid to those most in need; whether due to the current COVID-19 crisis or as a result of economic crises down the road. We also must work towards equity to dismantle systemic racism, gender inequities, and other social determinates of health that perpetuate these health disparities.

Learn more at: www.amakaconsulting.com

Authors

Ndidiamaka N. Amutah-Onukagha, PhD, MPH, CHES

Founder and President, Amaka Consulting and Evaluation Services

Dr. Amutah-Onukagha received her PhD in Public Health with a focus on Maternal and Child Health at the University of Maryland, College Park School of Public Health in 2010. She received her Masters in Public Health from The George Washington University School of Public Health and Health Services in Maternal and Child Health in 2005. As an evaluator and project manager, Dr. Amutah-Onukagha has conducted evaluation work for organizations such as the March of Dimes, the Partnership for Maternal and Child Health of Northern New Jersey, and The State University of NJ. Dr. Amutah-Onukagha has deep expertise in health disparities, maternal and child health, and HIV/AIDS.

Jacqueline Gifuni-Koutsouris, MPH, CHES

Senior Research Associate, Amaka Consulting and Evaluation Services

Ms. Gifuni-Koutsouris worked directly in evaluations of Healthy Babies are Worth the Wait programs for both New Jersey and National March of Dimes, where evaluation outcomes for these projects include program performance assessment, patient outcomes, increased knowledge on prenatal care as a result of the program, and provider perception on the effectiveness of the group prenatal care program. Her current research interests include health equity and health disparities, reproductive health, and infant mortality.