Haitian Doctors Study Latest Practices in Group Care at Yale

The partnership began when Associate Professor of Obstetrics, Gynecology, and Reproductive Services Jessica Illuzzi, M.D., M.S., sought to do some work in international medicine. Through the American Association of Birth Centers, where Illuzzi is a board member, she reached out to the Hopital Universitaire Mirebalais (University Hospital) in the Central Plateau of Haiti, and asked staff there if she could assist them in their work to improve maternal health in the region.

Mirebalais is a 300-bed tertiary care academic health center built by Partners in Health in 2011, after the earthquake that struck Haiti the previous year. Illuzzi spoke with Meredith Jean-Baptiste, CNM, the coordinator for women’s health at University Hospital. Jean-Baptiste told her that while the hospital had made some progress in decreasing the high rates of maternal and fetal death in the region, there was a long way to go. Many women from the surrounding communities came to the hospital too late to address serious problems during pregnancy, such as preeclampsia, or too far into postpartum complications such as hemorrhage. More antenatal education was severely needed.

“We deliver 400 babies a month,” said Christophe Millien, M.D., director of the Obstetrics and Gynecology service and deputy medical director at University Hospital. “Our prenatal clinic provides care to between 60 and 75 infants each day. But there are some limitations to providing optimal care to patients, and one of those is the education level of the community.”

The team from Haiti, which included both obstetricians and pediatricians, thought that learning about group prenatal and pediatric care might be a good focus for cooperation. “They said, if only we could talk to the women while they were pregnant and educate them about the signs and symptoms of preeclampsia or placental abruption, when to come in, or even how to rehydrate babies who have diarrhea” said Illuzzi. “They began to notice all these women showing up in the waiting room of clinics, not for regular visits, but with problems and they realized if they wanted to provide this education, they could go stand out in the waiting room, and try to educate them in the waiting room. Someone there said, that’s kind of like group prenatal care.”

In the group prenatal care model, groups of patients in the same stage of pregnancy hold regular visits together, rather than meet one-on-one with their provider. Eight women, for example, might meet for two hours, rather than for the fifteen minutes traditionally allotted for individual visits. During a group visit, women are measured and their vitals checked together, and are pulled aside for more sensitive matters. Once assessed, the women discuss a variety of topics, such as breastfeeding, nutrition, or signs of preeclampsia.

Not only would this model allow the team to provide more education to patients in Mirebalais, it would help them, as has been shown in other practices that have adopted the model, see more patients, and better manage their time. “We are focused on the patients, but for the numbers of patients we have to see, we don’t have enough time,” said pediatrician Lydia Lauretty Lominy, M.D. “In one day, a physician can see 30 or more patients, but we try to do our best.” In group pediatric care, babies in the first year of life and their caregivers come in for shared visits with other babies of the same age.

During their weeklong visit, the team from Haiti observed a group prenatal care session at Fair Haven Community Health Center, and a pediatric group at the Yale Primary Care Center. Illuzzi also conducted a full day of training on the nuts and bolts of establishing a group prenatal care program.

Conducted by School of Public Health researcher Samuel and Liselotte Professor of Social and Behavioral Sciences Jeannette Ickovics, PhD, the first significant research on group prenatal care occurred at Yale. During their visit, the team from Haiti met with Jessica Lewis, MFT, who directs Ickovics’ pregnancy research. “The results of group prenatal care in [Ickovics’s] randomized trial showed decreased rates of preterm birth, especially among minority populations,” said Illuzzi, “as well as better pregnancy spacing, increased breastfeeding rates, and lower rates of sexually transmitted infections. In Haiti, if the team is able to implement this type of care, not only would they aim to achieve these results, they may also be able to impact the maternal and neonatal mortality rates. That’s their hope.”

The team’s visit to New Haven extended beyond the ins and outs of establishing group care. They also observed a breastfeeding support group, and the “SimMom” birthing simulator used to train medical students and residents on labor and delivery. They also met with School of Medicine leadership to discuss collaborations in teaching medical and midwifery students, and residents at both institutions.

Since their visit, the team from Mirebalais have begun to delve into what it would take to begin the program at their hospital. “We are partners now,” said Illuzzi. They hold a conference call with Illuzzi every Monday to catch her up on their progress, and to discuss the questions and concerns they are facing along the way. Once they are ready, Illuzzi and an eager group of Yale physicians, nurse-midwives, and residents will travel to Mirebalais to help the team bring their plan to fruition.