GREENVILLE, South Carolina — When Amy Crockett was in high school, she shadowed an obstetrician for a day, and absolutely loved all the state-of-the-art technology she saw.
“I knew right away that was the coolest for me,” she says.
Crockett ended up deciding pretty early: She wanted to be a doctor who worked with pregnant women. She went through medical school and residency, and kept learning about other cool technologies. “A lot of things I was seeing in training were like, in utero surgery for spinal cord defects and lasers to treat Twin-Twin transfusion,” she remembers.
When Crockett first started her job running a women’s clinic here in the mid-2000s, South Carolina was one of the most dangerous places for a baby to be born. It had the 49th worst infant mortality rate in the United States in 2005, doing better than only Mississippi. Rural counties had infant mortality rates similar to Third World countries.
Crockett began running an experiment to try to fix this problem. But her solution wasn’t driven by a new technology or innovation. It was much simpler than that: She had women in her clinic do their prenatal care visits in big, group appointments. The visits last two hours, and look a lot more like a support group than a traditional doctor visit.
It’s a seemingly minor intervention — but it’s made a difference. Her research shows that these women have significantly better outcomes than those who receive traditional, one-on-one prenatal care. Their babies are less likely to be premature, which significantly lowers their risk of death.
South Carolina’s infant deaths have declined 28 percent since 2005. South Carolina has risen from 49th in state rankings up to 37th. While it’s hard to pinpoint one reason for that change, it’s all happened as the state has embraced public health experiments like Crockett’s.
“South Carolina has absolutely been at the forefront, from a state perspective,” says Jessica Lewis, a health researcher at Yale University whose research focuses on infant health. “I think they do serve as a model for what can be done nationwide.”
Crockett’s approach to improving health outcomes cuts against the American health care system’s obsession with the latest technology and expensive pills.
Her choice intervention — 12 pregnant women, sitting and talking in a circle of folding chairs — isn’t fancy at all. It isn’t expensive either. But there’s early evidence it could save babies’ lives.
Too many American babies are dying too early
Earlier this year, a team of researchers from Johns Hopkins University published a stunning paper in the journal Health Affairs.
They found that babies born in the United States are 76 percent more likely to die before their first birthday than babies born in our peer countries, like Canada, France, or Japan.
“I think a lot of people have this idea that children are probably healthy in the U.S.,” says, Ashish Thakrar, one of the study authors. “It turns out, that’s not true. The U.S. is one of the worst performers in terms of infant mortality.” Thakrar’s study finds that the leading cause of infant death in the United States is prematurity: babies born before 37 weeks of pregnancy.
“The rate at which US infants are dying from prematurity is three times the rate as in other countries,” he says.
Babies born early have worse outcomes than those who spend more time in utero. Their lungs are less likely to be fully developed, and their bodies less able to retain heat. Premature babies are more likely to get sick, and more likely to die.
America’s high preterm birth rate is, in part, driven by the fact American doctors will sometimes try to deliver extremely premature babies as early as 22 weeks of pregnancy because we have the technology that might keep these children alive. Other countries would consider such early births a miscarriage.
But this is not the entire story: Thakrar says that the data shows that these extremely early births account for only a small fraction (about 1 percent) of infant deaths. Something else is going on.
A growing body of research suggests it has to do with American women — especially low-income and minority women — experiencing greater stress during their pregnancy due to the lack of social supports.
The theory, essentially: A less-stressed out body might be one where a tiny, developing human wants to spend a little more time.
“Stress is known to trigger inflammation in a lot of other settings,” she says. “I think reducing psychosocial stress may help mute some of the pathways that lead to preterm birth. To me, that’s the biggest hypothesis of what is happening in here.”
America’s lack of a national health care system means women may go years without insurance coverage before they become pregnant. On top of that, having no paid maternity leave or child care subsidies can make planning for a baby’s birth an exceptionally stressful experience.
A new way to do doctor’s visits
When Crockett started working at the Greenville clinic, she used to do normal, one-on-one visits with her pregnant patients. They felt too fast. Crockett would take some vitals, ask her patients if they were okay ... and that was pretty much it.
“When the goal of the visit is to make sure you’re not sick, that takes a very short period of time,” she says. “But when you change the goal of the visit to prepare women to become mothers, that’s a totally different game plan.”
So, in 2008, she decided to start doing things differently. Crockett applied for a grant from the March of Dimes to start offering group prenatal care. The program she would implement was called CenteringPregnancy, which started in the mid-1990s in the Northeast.
Around the time Crockett applied for her grant, controlled trials of other studies were starting to show promising results. A 2007 Yale study found that the program reduced preterm births 29 percent (and an even steeper, 36 percent decline for African-American women). A study the next year, of women in New York City, found that group visit participants were significantly less likely to have babies that were low-weight or required NICU care.
Crockett knew that quick visits weren’t doing a great job. At the same time, she was pretty skeptical these group visits would do much better. She mostly thought these visits would be fun for her patients, and a decent way to clear out her overcrowded waiting room.
“The idea that having women sit together in a circle for their medical visits would somehow improve their birth outcomes, I didn’t understand how that could be a thing,” she says.
But Crockett was quickly surprised: The results in her own clinic started to match those from others. “Even from that first small cohort we started seeing that our outcomes matched exactly what they were reporting from the randomized controlled trials,” she says. “That was when we really ramped up the research side.”
At the time, about 19 percent of African-American babies were being born early in South Carolina. And when you include all races, the number sat at 12 percent.
But Crockett’s results? They showed that only 8 percent of the Centering patients were having their babies early. What’s more, the racial disparity completely disappeared.
The study wasn’t large enough to show a decline in infant mortality (which, even though South Carolina had a high rate, is still a relatively rare outcome affecting less than 0.1 percent of births).
Additional research in South Carolina found similar results to Crockett’s. A 2016 paper, for example, found that CenteringPregnancy reduced the risk of preterm birth by 36 percent. It also saved the state money by preventing costly admissions to the neonatal intensive care unit.
That research converted Crockett from Centering skeptic to full-blown evangelist. She kept running the program in her own clinic, and urging state officials to expand it across the state, too. Because of her work, South Carolina is now the only state in the country where Medicaid patients routinely have access to CenteringPregnancy.
Crockett is studying these patients, too. She has enrolled 4,000 pregnant women across the state into a study that will see whether CenteringPregnancy reduces infant mortality.
“It’s just being able to talk to people that actually would listen”
Last March, I sat in on one of the CenteringPregnancy sessions at Dr. Crockett’s clinic in Greenville.
This was one of the last sessions for this group of women, who were eight months pregnant with round bellies. They sat in a circle of white, folding chairs set up in a bright pink room.
Patients would trickle in, have a nurse listen to their babies’ heartbeat, grab some snacks (a must at 8 months pregnant) and sit down in the chairs.
There was lots of joking and laughing; it was clear the women felt very comfortable with each other at this point in their pregnancy.
“We have fun, we trip, joke around, talk about everything,” Tianna Blakley, 36, says, and then repeats with emphasis, “Everything. When you don’t get enough support from the actual main person that you think should be the one to give you support, it means a lot [to come to the group]. It is better and comforting.”
Blakely enrolled in CenteringPregnancy reluctantly. She already had two daughters, after all, so she knew what it was like to be pregnant.
“I thought it was going to be boring and a waste of time,” she says bluntly. Her views changed with each visit — as she actually got to know the other pregnant women in the program. “Coming in here, meeting everybody, it was better than I thought it was going to be. I fell in love with it.”
Blakely has a lot of instability in her life. She moves around a lot. Weeks before her due date, she wasn’t sure if her baby’s father would be involved in the child’s life. These sessions seemed to be a reliable place where people would listen. Where she could talk openly about the hard parts of expecting a child.
“It’s just being able to talk to people that actually would listen and not cut you off or not make assumptions or not judge you,” Blakeley says. “These were people that were going through some of the same things that I was.”
At the session, a nurse ran through a curriculum about recognizing the signs of postpartum depression. There were also tips about where to buy cheap baby bath tubs, and how to situate pillows for their growing body’s aches and pains.
The group also ended up on a lot of tangents, about new haircuts and Facebook videos they’d seen and what their babies’ astrological signs will mean. I was a bit surprised that the nurse let those run on for a while. Didn’t she want to get back to her curriculum?
She told me that the curriculum wasn’t actually the most important thing going on in the room. The main objective was creating a comforting environment for the pregnant women — a place where pregnancy feels a little less stressful.
Jennifer Bassatt, one of the patients I met, told me she doesn’t know a lot of pregnant people. Her baby’s father isn’t in the picture. The group makes her feel less lonely. “It’s good to meet other people who are doing the right thing, who want to have families,” she says.
Hanging out with other pregnant women probably won’t eliminate all stress for Tianna, or Jennifer, or for anybody. But if it can dial down stress levels enough to help moms deliver healthier babies, that means these two-hour meetings are a pretty powerful drug.
How South Carolina leads — and falls behind — on infant mortality
South Carolina is now home to two statewide, randomized-controlled trials to improve infant health outcomes. One is the study that Crockett helms, which is looking at whether the statewide implementation of CenteringPregnancy is indeed reducing infant deaths.
The other is run by the Nurse-Family Partnership, testing a similarly low-tech intervention: having nurses travel to low-income mothers’ homes for regular visits during their pregnancy, and then for the first two years of their new child’s life. That program exists elsewhere on a smaller scale, but South Carolina’s implementation is the biggest to-date.
The idea, like Crockett’s study, is to take a simple health care intervention that has seen early success in small studies, scale it up to the state level, and see if it works.
To evaluate that program, South Carolina has contracted with top health economists from M.I.T. and Harvard. Like in Crockett’s study, they will also be recruiting 4,000 South Carolina women for the trial and publish their results in about two years.
“We’ll find exciting results in some cases or we might find disappointing results,” says Mary Ann Bates, executive director of M.I.T’s Poverty Action Lab, one of the evaluators. “But the encouraging and rewarding thing is that governments are willing to ask hard questions about their investments. I think this is really where we need to be.”
South Carolina has become a fertile testing ground for new policies that can help babies have a better start to life. But there is one obvious policy that could likely do even more to save babies that the state isn’t thinking about: expanding Medicaid.
A recent study published in the American Journal of Public Health found that states participating in the Affordable Care Act’s expansion of Medicaid saw greater declines in infant deaths than those that do not.
South Carolina is still in the latter category, which means that about 92,000 low-income South Carolinians who would otherwise qualify for the public program are currently not covered.
Pregnant women do qualify for Medicaid while carrying their child, but typically lose their coverage a few months later if their income is higher than 67 percent of the poverty line (that works out to an $11,000 annual income for a family of two).
Bryan Amick, a state Medicaid official, demurred when asked about why the state does not participate in that program. “I think South Carolina has largely been consistent with that of the rest of the Southeast,” he says. “Those decisions happen above my pay grade. It’s my job to implement the Medicaid program that we have today.”
There’s no one reason that South Carolina’s infant mortality rate has declined in recent years. But these inexpensive interventions might be doing their part, which is exciting because these are solutions that are generally low-cost and scalable. It’s easier to bring a group of women into a clinic to talk for two hours than it is to bring a fancy piece of technology.
But for all its progress, South Carolina is still missing something it could do to tackle infant mortality. As Ashish Thakrar, the public health researcher puts it, “The easiest thing the state could do is expand Medicaid.”
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