On a rainy Tuesday morning in May, social worker Meghan Bragers drove up to Ferguson, Mo. to visit a 23-year-old expectant mother named Marie Anderson.
Anderson, who was 33 weeks pregnant at the time, was having a particularly difficult pregnancy.
“She’s been in a car accident, her car has been totaled, she’s having back issues, she’s having increased depressive symptoms,” Bragers said en route to the visit. “Things have gotten pretty difficult.”
Difficult, or as Anderson herself called it, “a tornado.”
Not only has she had one crisis after another, but nearly everything about her life—her income, her race, even her zipcode— puts her at higher risk for giving birth too early.
Bragers is here to see if she can relieve some of the pressure Anderson is under. She’s helping connect her to health resources and other support to increase her chances of a full-term delivery.
This is typical work for a social worker; what’s unusual about her role is who’s paying her. Bragers is working out of the obstetrics practices of Signature Medical Group—a physician-owned medical group with offices across Missouri—as part of an experiment in maternal health care funded by the federal government.
Testing New Models of Prenatal Care
Close to 400,000 children are born prematurely—before 37 weeks—in the US every year, roughly one out of every 10 births. Preterm birth can lead to long term health and development problems, and is one of the main reasons for children dying in infancy.
The traditional approach to preventing this problem is for obstetricians to monitor fetal health with tools like ultrasounds, urine sampling and amniocentesis. But for patients like Anderson, sometimes that’s not enough.
Maribeth Hollinshead, an obstetrics nurse for 30 years, says she’d see some of those cases throughout her career and ask, “What are we missing with this patient? We’ve done everything medically but yet we’re still getting a preterm delivery.”
Hollinshead is not alone. Health care providers everywhere have started asking what can be done about known risk factors for preterm birth like chronic unemployment, a stressful home life or depression that aren’t so easily observed in the doctor’s office.
And the federal government has started to fund new models of care to address these issues through a grant program called Strong Start. The program is run by the Centers for Medicare and Medicaid, the Health Resources and Services Administration, and the Administration on Children and Families and has given out $41 million to support the work.
Innovations around the country vary but they all have the goal of providing increased psychosocial support for low-income expectant moms.
For the past two years, Hollinshead has directed one of these new initiatives at Signature Medical Group. Their approach was to add Masters-level social workers like Meghan Bragers to its obstetrics team.
Crying Spells and Early Contractions
After her car accident, Marie Anderson started having back pain, and even had to use a walker for several weeks. The baby, a girl she’s already named Dallace, is positioned awkwardly in her womb, putting pressure on Anderson’s sciatic nerve.
This was just one of several crises Anderson’s been dealing with. A few months ago she lost a close family member, her sister’s fiancé, who died suddenly in a car crash. She gets crying spells out of the blue when she thinks about it.
“It’s only been five months,” Anderson told Bragers. “I can be laying in my bed, or see something we did [together] or something we said, and it just makes me cry.”
She also told Bragers she’s had to have early contractions stopped twice since they last met, which was stressful for her whole family, including her three-year-old son Aiden who didn’t understand why he couldn’t go to the hospital with his mother.
“He got nervous,” Anderson said while Aiden leaned his arms against her legs.
“I was mad,” Aiden corrected.
Aiden himself was delivered by emergency cesarean section, one of several factors making Anderson’s current pregnancy high-risk. Other factors include her depression, her low income, and the fact that she’s African-American (the preterm birth rate for black women is about 60 percent higher than for white women).
Even the place she lives makes her statistically less likely to carry the baby to term. More premature births happen in this zip code where Anderson lives than anywhere else in the St. Louis region, which itself accounts for a full quarter of all premature births in the entire state.
If case management is going to prevent premature births, it’s needs to happen with women like Marie Anderson.
Throughout her pregnancy, Bragers has helped Anderson with many of her problems: she got her enrolled in Medicaid, so her prenatal care would be covered. She helped her get set up with a mental health counselor and with home visits from a nurse who checks on her health and gives her training in parenting skills.
She’s also made sure she has all the supplies she needs when the baby comes, bringing her a delivery of free diapers, bottles and even a baby bed.
“People always say, ‘it’s not the things that make you happy,’” Bragers says, “but when you don’t have very basic items, things really matter, they really make a difference.”
Bringing Babies to Term
The Strong Start program at Signature Medical Group has provided case management like this to over 2,000 women in two years. In that time, the overall preterm birth rate for all of Signature’s patients has dropped from 10.4 percent to 8 percent, which is lower than the rates in Missouri (11.3 percent), St. Louis County (12.1 percent), and St. Louis City (14.9 percent).
“We’re talking about over a thousand deliveries and being consistently eight percent or less. This is very consistent,” Maribeth Hollinshead says. “I really truly believe that it’s working.”
Nationally, Strong Start programs so far appear promising, though results are still very preliminary.
But the challenge now for people like Hollinshead who run these programs is figuring out how to fund them when the federal grant money goes away. The last pregnancy covered by the grant here in Missouri is due in August.
The solution, says Hollinshead, is to convince private insurers as well as the state’s Medicaid agency that this model of care is worth covering, and make the kind of work her team of social workers do reimbursable.
“There needs to be a way to bill for case management and enhanced prenatal care,” Hollinshead says. “The psychosocial, enhanced prenatal care model is going to take a little bit of fine tuning to get to happen, but I feel very hopeful.”
For Marie Anderson, that enhanced support is making a tangible difference—at least to her state of mind.
When Bragers first arrived for her May visit, Anderson told her she thought she could only manage to hold out until 34 weeks before the baby would come, the sciatic pain was wearing on her. But by the end of their visit after a long conversation with Bragers, Anderson was feeling optimistic she could make it to at least 36 weeks, which is still early but much closer to the 37 week threshold. And every week matters.
“It’s a mind thing, it really is,” Anderson said, “I think I can do it.”
This story was produced by Side Effects Public Media, a reporting collaborative focused on public health.