Personal chaos

We’ve been doing a lot of work lately to figure out why patients don’t come to Centering groups and how we can fix it.

As you may know, I work with a practice that serves a high percentage of low-income and uninsured women – around 75% of our deliveries are covered by Medicaid. About 20-25% of those are just Emergency Medicaid for the deliveries, which means (in South Carolina) that they don’t have any insurance to cover their prenatal care costs. And many of the deliveries with private insurance have Medicaid as a secondary insurer because their income is still low enough to be eligible for it.

As you also probably know, Centering requires a certain commitment and consistency.

  • Patients have to come to the same group every time, so that they all get to know each other well and create trust within the group. That means they have to be available at the date and time of each of their session (Friday mornings, for example). What I mean by this is they can’t come to a Friday morning group one session and then come to a Wednesday afternoon group next time, or just come to the group session that is meeting at whatever time they come in this week. It requires advance planning.
  • Patients also must physically come in to the clinic every 4 weeks during their 2nd trimester and every 2 weeks during their 3rd; if they miss a certain number of groups then they are not invited back because the group has gone on to form bonds without them.
  • Patients must be willing to try a new way of providing care that still seems wacky and weird to most people.

(While I realize that some of these barriers are true of all prenatal care, if patients have individual prenatal care appointments there is a greater degree of flexibility. They can make appointments for the next day, later on that day, or a different day each week. Not true with Centering.)

As we’ve been talking with patients that don’t come to Centering groups for their prenatal care, we’ve found out a lot. The biggest takeaway is that there is no one thing we can fix to make more patients able to attend Centering. It’s more about what I’m calling “personal chaos” in which many of our patients live their lives.

Look, I’ve never lived through poverty. While my family wasn’t rich, we were comfortably middle class and I have all the socio-economic factors in my favor: I went to high-quality public schools, am Caucasian, have stable emotional relationships, enjoy pretty good health, carry relatively little debt, and have a white-collar job. In this unequal society, I am in the good place.

I have never appreciated that stability as much as I do when I talk with patients about coming to Centering groups. What I find is that there is a constellation of barriers in their lives that keep them from being able to plan to attend fixed-time Centering group sessions – their personal chaos. It’s not necessarily one thing that we can easily address. For example –

  • They don’t have a car. Our county has a big geographic area (some urban core, lots of suburban sprawl, even more rural areas) – without a car you are just not getting anywhere. And we just have one clinic location. Oh but public transit? Ours is totally useless, no exaggeration. What about the Medicaid van? Most patients don’t like it, because it can have long wait times and long rides as it traverses our huge county.
  • If they are counting on rides from friends or family members, they may not be able to require that that ride be provided at the time and place that works for her Centering group. She may just need to catch the ride whenever she can. Beggars can’t be choosers, right?
  • Or, she does have a car but it’s old and not in great shape because it’s what she can afford, and she doesn’t have the spare money for regular tune-ups, so it breaks down more often and leaves her stranded while her Centering group goes on without her. This happens a lot.
  • Their job is not accommodating. There are lots of reasons for this – it’s not always that employers aren’t supportive of patients getting their prenatal care. Sometimes patients have just gotten a job and don’t have the seniority to ask off for appointments in advance. Sometimes the schedules are only done a week beforehand. Also, most of our patients don’t have paid time off for medical appointments. If they are really hurting for money, they will choose to work instead of coming in for care.
  • Sometimes they have work and school (and sometimes other kids too). How am I going to tell someone that is struggling to stay in school to finish their degree in addition to a full-time workload to take 2 hours out of their schedule to come to Centering? I can’t even comprehend how anyone does that – I can’t handle my one job half the time!

And everything else. So many things. Here are some things that patients have told me recently when I tried to get them into Centering:

  • My mother is in critical care with diabetes and pneumonia right now
  • I have a court case going on in my family and that’s my focus right now
  • We’re living in my mother-in-law’s garage until we can find our own place, so I went to live with my sister for a while
  • My husband died in a car crash last month
  • My house burned down

Bottom line is, I’ve found many of our patients have not one barrier but several going on – not enough money to get by, staying with someone else until they can get their own place, unreliable baby daddies, irregular work hours, and family and friends they can’t always rely on. I get overwhelmed just listening to them. Even though I’ve never lived through it myself, I can feel how hard it is to think about one more thing when they have such personal chaos. It must be exhausting.

One of my providers today reminded me that I have the luxury of thinking six months ahead of time – where will I be and what will I be doing. I may even have some goals to accomplish by then. Heck, I even have a retirement account for 25 years from now! But, when you are going through personal chaos, you may be focused on getting through the day or the week. You may not have the energy or will to think about what your prenatal care appointment will be six months’ down the line.

And, when you’re thinking and planning just day-to-day, you don’t necessarily make the best long-term decisions. You may not think today about long-term contraception and end up pregnant again. You may choose to spend your money on a luxury to help you get through the day, instead of saving for next month. You may decide today’s not the day to quit smoking- that can wait until things calm down. You may give up on the idea of coming to group prenatal care.

Ideally, Centering can help provide some support for women with this kind of personal chaos. But the structure of the model puts up some barriers to women who really need it. I wish there were a way I could make it work for more women. And I’m humbled to have gotten some insight into why it doesn’t.

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