In Preterm Birth Research, Local Efforts Have Global Benefit

By Andy Evangelista

A study in Rwanda of the effectiveness of group prenatal care in reducing preterm birth is also relevant to women in Fresno, CA.
Photo by Ibe Ikuzwe.

When it comes to global health research, borders are taboo. These days, data, care models and evidence from successful demonstration projects are shared quickly, across continents. And scientists, policymakers, health ministries and advocacy organizations all over the world welcome new knowledge to help ease the burden of disease and achieve better health.

It’s not just a one-way road for research dissemination. Low income countries, for example, show ways to provide public health with fewer dollars and how to mobilize communities of caregivers.

UCSF’s Preterm Birth Initiative (PTBi), with projects in California and East Africa, demonstrates the idea that global is local and local is global.

Improving birth outcomes

Preterm birth is the leading cause of newborn deaths around the world. One in 10 babies is born prematurely each year, according to the World Health Organization, and almost 1 million of these infants die within the first months of life. Others face lifelong struggles with health deficits and disabilities.

Researchers with PTBi-East Africa are finding ways to buck the deadly trend. Working with the Rwanda Ministry of Health and researchers at the Rwanda Biomedical Center and University of Rwanda, they are conducting the largest cluster randomized controlled trial of group prenatal and postnatal care in the world.

As of May, more than 16,000 women in 36 health centers in five Rwandan districts were enrolled in the trial, which offers education and support along with clinical care. In this model of care, developed in the U.S.in the 1990s, pregnant women with similar due dates are assigned to a group of about 10 by their midwife or healthcare provider.

After an initial one-on-one visit, the women return to the clinic together. They check their own blood pressure and weights, which are then reviewed by the midwife, who also examines each woman’s pregnancy and monitors them for complications. Afterward, the women gather for an hour-long meeting on pregnancy-related topics, such as nutrition and self-care. The midwife guides the discussion, but ideally group members learn from and support each other.

The group holds three subsequent visits and one postnatal visit about six weeks after delivery.

“Group care helps women feel more confident and comfortable expressing themselves,” said Yvonne Delphine Nsaba Uwera, a Rwandan midwife with UCSF’s PTBi-East Africa. “It empowers women to speak up and talk about their problems and seek help. The group is like a village of women that empowers them during a very vulnerable time, both mentally and physically.”

Researchers suggest that this model has potential to improve perinatal outcomes in other parts of the world, including in the U.S. where the rate of pre-term birth (before 37 weeks) among African American women and Latinas is 50 percent higher than the rate for white women.

A Glow in Fresno

Some 10,000 miles from Rwanda, the UCSF PTBi-California researchers collaborate with Fresno State’s Central Valley Health Policy Institute and First 5 Fresno County, an effort to ensure that children are born healthy.

They created a demonstration project, named “Glow!,” which, like its sister program in Rwanda, employs group care to reduce preterm births. Fresno County has one of California’s highest rates of babies born prematurely – approximately 1 out of 9 births.

Glow! participants at their postnatal meeting.

“Pregnancy is supposed to be a time of celebration and excitement,” said Lauren Lessard, principal investigator of Glow! “For women in Fresno, many of them are on Medi-Cal and that poses some challenges -- access to child care, transportation, two- to three-hour wait times in the offices and feeling lonely and separated from other women experiencing the same thing.”

“So, what do we do?  We disrupt that system,” she said. “We bring in group prenatal care. And good prenatal care means that these women will come together as a community throughout their pregnancy. And at the end of the day, we hope to have improved birth outcomes.”

Similar to the Rwanda program, Glow! offers groups of 12-15 women with similar due dates prenatal and medical care, risk assessments and peer support. It builds on the “centering pregnancy” model of providing medical services in a group setting, while offering a centralized location and an increased focus on stress reduction, mindfulness, importance of sleep, safe relationships, healthy eating, physical activity and other topics.

In addition to group prenatal care, the women receive other benefits such as transportation to sessions, childcare, healthy groceries, behavioral and social services and more.

In its first seven months, Glow! has enrolled some 70 women, who are on MediCal, into the project. Attendance to sessions has averaged a remarkable 90 percent, said Lessard.

“You have to consider that for these women, many of whom are already mothers, fighting poverty – and all that goes with it -- is a full-time job,” she said. “They’ve had little time, energy and resources to care for their own health.”

What Lessard has found surprising and rewarding is that women who complete the group sessions often want to stay engaged with their groups or the program. “Many, after they’ve had healthy pregnancies and babies, have asked to stay engaged with the program as mentors to pregnant women. Some have even asked how they can become a doula or birth coach.”

Both the Rwanda and Fresno PTBi programs continue to grow and learn, often from each other.  “Programs like Glow! give us an opportunity to see the results from different models and understand what some of the most important components might be,” said Elizabeth Butrick, senior program manager for the UCSF PTBi-East Africa.

In the Rwanda study, mental health in pregnancy has emerged as an issue. Rwanda researchers are thus interested in Fresno findings from its offerings on stress reduction and psychosocial care.

 “I think Glow! has done a lovely job as well, responding to women’s needs for transport and childcare and working with provider groups to make the system work for everyone,” said Butrick.

Lessard acknowledged that Glow! learned from Rwanda the importance of stakeholder involvement -- from designing the program and through implementation.

“Stakeholder and community collaboration are critical,” said Butrick.  “We have partnered throughout with the government agency responsible for health care delivery nationwide in Rwanda. We also did focus groups with women about their needs and conducted pilot group sessions to get their input on content, format and how it worked. Our program was given its Rwandan name by the women in those sessions.”

The program is called “Ibaruke Neza Mubyeyi in Kinyarwanda,” which loosely translated means, “May all pregnant women have a healthy pregnancy, birth and baby.”

This article is excerpted from an article originally published at UC Global Health Institute.