CENTERING PREGNANCY IN GESTATIONAL DIABETIC WOMEN Presented by Dolores Aguilar, NP-C, CDE, MSN, DNP-C At the end of the presentation, the participants will be able to: Understand Centering Pregnancy as a model of group prenatal care. Identify leadership characteristics that contribute to success in leading Centering Pregnancy groups. Understand the benefits of Centering group care to gestational diabetic women in empowering them to breastfeed their babies and make life style changes. o Problem GDM in Latinas Obesity & risk of Type II DM Breastfeeding o Prenatal Care Routine GDM care Group Care o o Project Purpose & Objectives Project Implementation (Literature review and description) o o Evaluation (findings/results) Limitations and Conclusion o o o o In the US , over 50 million or 16% of the US population, are Latinos (US Census, 2011). Latinas aged 15-44 have the highest birth rates at 9.3% compared to Whites 5.8%, Blacks 6.8%, Asians 6.8%, and American Indians/Alaskan Natives 6.2% (Sutton, Hamilton & Mathews, 2011). US adults (older than 20) 35% are obese, and 17% are children (CDC, 2011) 50% of Latinas are overweight (BMI 25-30) at conception (Vahratian, 2009). © 2008 Santa Clara Valley Health & Hospital System 4 Definition: Hyperglycemia (diabetes) that is diagnosed in pregnancy (ADA, 2011.) Stats: GDM incidence rate in U.S. 7-14% GDM incidence rate in Latinas 14% (Ferrara (2007). 5 © 2008 Santa Clara Valley Health & Hospital System 5 o o o © 2008 Santa Clara Valley Health & Hospital System Obese women are at 66% risk of developing diabetes during pregnancy Approx. 50% of women with GDM develop T2DM within 5 years of GDM diagnosis (Kim, 2002). Offspring of GDM women are at increased risk of obesity and T2DM (Franks, et al., 2010). 6 o o Breastfeeding (BF) lowers risk of obesity and T2DM o Mother o Offspring Healthy People 2020 BF Goals o Initiation rate at birth: 82% o At 6 months: 61% o At 12 months: 34% One of the largest public birthing Center in California with 4,200 births in 2011. Maternal Fetal Medicine (MFM): A multidisciplinary high-risk OB clinic. Maternal Fetal Medicine (MFM) Clinic • A multidisciplinary high-risk OB clinic. o o o o o o Problem with the system: Pregnant women were using ER as primary care. Piloted CP to provide comprehensive cultural and educational care (East coast hosp clinic) . Population sample (N = 111), LSE, ethnically diverse, adolescents to 30 years of age. Group care women were less likely to use ER in the 3rd trimester (26 % vs. 74%, P 0.001) Improved teen group attendance 92%, The women preferred receiving PNC in groups (96%). o o o Care 1:1 on risk assessment, intervention, education, & evaluation. Waiting period to be seen 10-20 minutes. Each patient is seen for 30 minutes by the nurse practitioner. o o o o Women learn skills, build friendship, and support. Empowers women to be active in their own care. Learn to be a better healthcare consumer. Improves the health of mother and baby. o o o Needing to say things only once. Working with motivated patients. Finding work fun and energizing. o o o o Ickovics, et al., (2007), conducted an RCT study. N=1047 randomized n=653 in CP and n=394 routine care. Mean age 20 and 80% were African American women. CP women had significantly lower odds of preterm birth( (9.8% vs. 13.8% P.045). Greater breastfeeding initiation rates (66.5% vs. 54.6% P .001), improved prenatal knowledge, readiness for labor & delivery, less likely to have inadequate care (26% vs. 33% P.01) and improved satisfaction with care when compared to routine care women. •Baldwin et al. (2006) Increased pregnancy knowledge and readiness for Labor & Delivery. •Cost-effective : Mooney et al. (2008) if >120 deliveries a year. THEORETICAL FRAMEWORK SOCIAL COGNITIVE THEORY (SCT) Albert Bandura o o Individuals learn behaviors through social observation of other individuals, media, social influences, and learned experiences. Used to guide practitioners on how to inform, enable, facilitate, and motivate patients to adopt healthy habits and behaviors to promote health and reduce illness (Bandura, 2002). o o o Soothing music was played to provide privacy during 1:1. Women were on average 28 weeks gestation at enrollment. Educational topics are facilitated and time is provided for women to talk and share their knowledge/experience. o Interested o Good listener o Focused o Organized but flexible o Willing to share expertise PROJECT EVALUATION Inclusion criteria Spanish speaking, gestational diabeticwomen,18-46 years old. Exclusion criteria T1DM and T2DM Recruitment Via flyers posted in MFM. By invitation during provider appointments Data collection Chart review Pt interviews o o o o o o o o Breastfeeding initiation at birth and continuation rates at 1-8 weeks postpartum Gestational age at 1st prenatal visit Number of prenatal visits (compliance) Maternal weight gain Infant weight at birth Gestational age of infant at birth Mode of delivery: vaginal versus C/S Patient testimonials o o o . One woman shared with the group how she experienced domestic violence with her exhusband and openly disclosed in detail how the frequency and severity of abuse made her decide to leave her abusive relationship. Coping with violence on a daily basis. Discussed community resources available to move on with her life. o o A multiparous participant openly disclosed to the group that her left nipple was defective (inverted) that formula was the only option for her. “I thought I was different, but I learned so much from the other women and I realized that they have the same problems and concerns that I do. They helped me feel better and taught me how to increase my milk supply and learn different breastfeeding techniques to be successful in breastfeeding.” o A first time mom recognized that newborn safety was one of the first challenges of parenthood: “I never had an experience like the educational guidance in the correct way to strap my baby in the car seat and I am thankful that the women were able to share their experience with me and I feel blessed to have the guidance and support right when I needed it.” o o o Self-selection bias, small sample size, and a homogeneous group limits the ability to generalize the information obtained. In the chart review: Incomplete documentation, missing data in the medical records, thus limiting the internal validity of the findings. Finally, due to the lack of statistical power and the observational nature of the project and lack of randomization, results do not indicate a causal relationship between group model attendance and maternal and infant outcomes. Centering The increase in breastfeeding rates demonstrated in this pilot project supports the benefits of the CenteringPregnancy prenatal care model for Latina women with GDM. Improved Breastfeeding I Centering Participant reports of knowledge gained during social interaction supports axioms of SCT and helps explain benefits of Centering prenatal care model for Latina women with GDM. Participant Satisfaction I o o o o o o J. Kitzmiller, MD and MFM Staff M. Nosek, PhD CNM, USF Assistant Professor (DNP Chair). J. Lambton, PhD, USF Professor Centering clients and families SCVHHS Administration and staff Sons (Samuel and Michael), family and friends American Diabetes Association. Accessed on May 13, 2011, on the Diabetes Care Web Site at http://care.diabetesjournals.org/content/,30 (Supplement_2): S2512.full. Bandura, A., Fernandez-Ballesteros, R., Diez-Nicolas, J., Caprara,G., & Barbaranelli, C. (2002). Determinants and structural relation of personal efficacy to collective efficacy. International Association for Applied Psychology, 51(1), 107-125. Centering Healthcare Institute (CHI) accessed on September 28, 2012 from http://www.centeringhealthcare.org Ferrara A. (2007). Increasing prevalence of gestational diabetes mellitus: A public health perspective. Diabetes Care, 30:S141-45. Franks, P., Hanson, R., Knowler, W., Sievers, M., Bennett, P., & Looker, H.(2010). Childhood obesity, other cardiovascular risk factors, and premature death. New England Journal of Medicine, 362(6), 485-493. Healthy People 2020: Breastfeeding objectives retrieved on October 1, 2012. http://www.usbreastfeeding.org/LegislationPolicy/FederalPolicies/ Healthy People Ickovics, J., Kershaw, T., Westdahl, C., et al. (2007). Group prenatal care and perinatal outcomes: A randomized controlled trial. Obstetric Gynecology, 110 (2), 330-9. Kim C., Newton K., & Knopp, R. (2002). Gestational diabetes and the incidence of type 2 diabetes: A systematic review. Diabetes Care, 25,1822-1868. Rising, S. (1998). CenteringPregnancy: An interdisciplinary model of empowerment. Journal of Nursing Midwifery, 43(1), 46-54. Sutton, P., Hamilton, B., & Mathews, T. (2011). Recent decline in births in the United States 2007-2009. Centers for Disease Control and Prevention’s National Center for Health Statistics Division of vital statistics; data brief report No 60. Accessed October 10, 2012 from http://www.cdc.gov/nchs/VitalStats.htm. U.S. Census. (2011). U.S. Department of Commerce Economics and Statistics Administration. The Hispanic population: 2010 Census Briefs. Accessed on October 12, 2012 from http://www.census.gov/prod/cen2010/briefs/c2010bc=04.pdf Vahratian, A. (2009). Prevalence of overweight and obesity among women of child bearing age. Journal of Maternal Child Health, 13(2), 268-273.