Journal of Midwifery & Women’s Health
www.jmwh.org
Original Research
Facilitating Access to Prenatal Care Through an Interprofessional Student-Run Free Clinic
CEU
Kathleen Danhausen, CNM, MSN, MPH, Deepa Joshi, BA, Sarah Quirk, CNM, FNP, MSN, Robert Miller, MD, Michael Fowler, MD, Mavis N. Schorn, CNM, PhD
Introduction: Addressing the persistent challenge of inadequate prenatal care requires innovative solutions. Student-run free health centers are poised to rise to this challenge. The Shade Tree Clinic Early Pregnancy Program, jointly operated by university medical and nursing programs, functions as an ongoing access-to-care portal for pregnant women without health insurance. The clinic is run by medical students and nursemidwifery students and uses a service-based learning model that allows students to work and learn in supervised, interprofessional teams while providing evidence-based prenatal care. Methods: All data reported in this paper were obtained from a retrospective chart review of women served by the prenatal clinic. These data are descriptive in nature, and include the patient demographics and services provided by the clinic to 152 women between the years of 2010–2013. Results: During this time period, the clinic served a demographically diverse clientele. Approximately half lacked documentation of legal immigration status. The majority of women seeking care were in their first trimester of pregnancy and had previously given birth. Several women had medical or obstetric complications that required timely referral to specialist care; and many women received treatment for infection and other primary care concerns. Discussion: Shade Tree Clinic provides the basic components of prenatal care and assists women with other medical needs. Women also receive help when applying for and accessing public maternity insurance, and the clinic facilitates entry to any necessary specialist care while that insurance is processed. In many cases, necessary and time-sensitive care would be delayed if Shade Tree Clinic’s prenatal services were not available. In addition, the clinic presents a valuable opportunity for interprofessional socialization, increased respect, and improved collaboration between students in different but complementary professions, which is an important experience while we move to meet national goals for interprofessional care among health professionals. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health. c 2015 by the American College of Nurse-Midwives. J Midwifery Womens Health 2015;60:267–273 Keywords: antepartum care, midwifery education, medical education, vulnerable populations, access to health care, interprofessional relations
Address correspondence to Kathleen Danhausen, CNM, MSN, MPH. E-mail: [email protected]
The Shade Tree Clinic Early Pregnancy Program (STEPP), jointly operated by Vanderbilt University Schools of Medicine and Nursing, Nashville, Tennessee, functions as an access-to-care portal for pregnant women who are without health insurance. The clinic uses a service-based learning model that allows student volunteers to work and learn in supervised interprofessional teams to provide evidence-based prenatal care. The Core Competencies for Interprofessional Collaborative Practice note that the opportunity for students to work in interprofessional teams is critical to the development of a collaborative, practice-ready medical workforce.22 Although incorporating interprofessional learning experiences into clinical education can be challenging,23 evidence shows that it results in a better working culture, reduced clinical errors, and increased patient satisfaction.24 Moreover, students who engage in interprofessional learning and teamwork demonstrate increased knowledge of roles and scope of practice, improved attitudes related to mutual trust and willingness to collaborate, and increased behaviors identified as critical to successful team functioning.25 This article presents the model of a prenatal clinic offered by a student-run health center. We describe the patient population and services provided and review the interprofessional learning and professional socialization experienced by student volunteers.
1526-9523/09/$36.00 doi:10.1111/jmwh.12304
c 2015 by the American College of Nurse-Midwives
INTRODUCTION
Women often struggle to access prenatal care when they do not have medical insurance, especially during the first trimester of pregnancy. Approximately 25% of reproductiveaged women lack health insurance, which presents a major barrier to their timely initiation of care.1,2 First-trimester prenatal care is essential for accurate pregnancy dating, timesensitive genetic screening, identification of maternal infections that contribute to preterm birth, and the opportunity to provide early education and risk reduction interventions.3,4 Delayed or minimal prenatal care is associated with poor health outcomes, including premature birth, low birth weight, and neonatal and maternal morbidity.3,5–7 Moreover, multiple studies confirm that the most vulnerable women have lower initiation and use of prenatal care.8–17 Undocumented, lowincome immigrant women are most likely to be uninsured because many states do not offer maternity benefits to those who reside illegally in the United States.18,19 Much has been written about barriers to timely prenatal care; however, there are few program descriptions, and little program evidence exists to guide efforts to facilitate access to this care.8,20,21
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✦ Uninsured and vulnerable women have decreased access to prenatal care and lower rates of prenatal care utilization. ✦ Student-run free clinics can serve as an access-to-care portal for uninsured pregnant women. ✦ Interprofessional training facilitates professional socialization, increased respect, and improved collaboration between students in complementary professions.
SHADE TREE CLINIC EARLY PREGNANCY PROGRAM
Shade Tree Clinic, established in 2004 and operated by Vanderbilt University medical students, provides medical, social, and legal services to approximately 300 uninsured individuals. STEPP was developed in 2009, when students staffing the clinic observed that uninsured women, particularly immigrants, had difficulty accessing timely prenatal care. Students and Shade Tree Clinic faculty mentors determined that their clinic had the existing service structure to fill this gap. Establishing a free prenatal program was logistically feasible because the university’s institutional support for Shade Tree Clinic included free laboratory testing for patients, which was expanded to absorb the cost of ultrasound services for women served by the prenatal clinic. However, student clinicians with consistent knowledge of prenatal care were needed because medical students receive obstetric didactic content at variable times. In addition, the clinic needed credentialed maternity care providers who were willing to volunteer their time each month to staff the prenatal clinic. Thus, Shade Tree Clinic’s leaders turned to the university school of nursing for assistance. Midwifery faculty embraced the opportunity to meet a community need in a way that would expose students from both professions to each other and the midwifery model of care. In addition, the prenatal program could offer valuable clinical opportunities for student nurse-midwives (SNMs) and student nurse practitioners. With this in mind, the midwifery faculty committed to send a certified nurse-midwife (CNM) each month to instruct and supervise students. Interested medical and midwifery students were invited to volunteer, and the medical school obstetrics and gynecology department agreed to assign third-year students as part of their clerkship rotation. Thus, the framework for an interprofessional service-learning clinic was created. Program Description
Now in its fifth year of operation, the STEPP is codirected by medical and midwifery students. It is a thriving part of Shade Tree Clinic, which has in turn furnished the prenatal clinic with supplies, medications, and institutional buy-in. Medical students and SNMs work in collaborative teams to provide patient care, with advanced students teaching new learners. A typical team consists of 2 students who volunteer, without receiving academic credit, to conduct 2 prenatal visits at the monthly clinic. Each team is led by a medical student or SNM in the final years of schooling and includes another student
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from the opposite discipline who is at the beginning of their education program. Licensed clinicians, including a CNM and often an obstetrician, supervise 4 teams that provide a standard initial prenatal visit for 8 women. When a CNM and obstetrician are both present, the CNM supervises the teams led by the medical students, whereas the obstetrician works with the teams led by the SNMs. Each prenatal visit features an extended appointment time of approximately 90 to 120 minutes, allowing students to practice skills and gain a holistic view of patient needs. Key components of care include the elicitation of a thorough history; pregnancy dating, including a referral for an ultrasound if one is indicated; laboratory testing and screening for infection; genetic testing as appropriate; and individualized education and risk-reduction counseling. In addition to providing the basic components of prenatal care, the STEPP also assists women with other medical needs. For example, women are commonly treated for infections or other primary care concerns and receive follow-up testing for cervical cancer. Throughout the visit, students receive supervision and guidance from the attending CNM or physician. Providers are available to answer clinical questions and demonstrate patient care techniques, allowing students to learn from the perspective and expertise of a professional from another discipline. Furthermore, the pairing of students from different disciplines provides a rich practice in interprofessional learning and collaboration. In this context, students together navigate the social and economic aspects of health. For instance, students work with women to develop a nutritional plan within the context of their financial constraints, and they apply health-coaching skills to discuss a wide variety of topics (Table 1). Students learn with and from each other through the provision of patient care, whether that learning involves substance abuse screening or appropriate laboratory testing for uncommon diseases. Finally, the collaborative and collegial interaction between the CNM and physician providers serves as a positive role model of interprofessional communication for the student teams. Additional medical and nursing students care for the clinic in nonclinical roles, serving as Spanish interpreters and offering social support. Students providing social support services primarily assist women who are applying for public maternity insurance. All women seen by Shade Tree Clinic are eligible for public insurance because Tennessee offers maternity coverage regardless of immigration status. Women are also offered resources to respond to needs for food, housing, transportation, parenting groups, intimate partner violence shelters, mental health services, dental care, and legal aid.
Volume 60, No. 3, May/June 2015
Table 1. Common Topics for Individualized Education Provided by Student Clinicians at the Shade Tree Clinic Early Pregnancy Program
Anticipatory guidance for pregnancy Breastfeeding Cervical cancer screening Choices of maternity care provider Circumcision Contraception Coping with common discomforts of pregnancy Dental hygiene Exercise Housing safety and hygiene
METHODS
All data reported in this article were obtained from a retrospective chart review of women served by the prenatal clinic from 2010 to 2013. These data are descriptive in nature and include patient demographics and services provided by the clinic. Institutional review board exemption was received from Vanderbilt University prior to data collection. Deidentified data from the records of 152 women were reviewed and extracted from clinical encounter notes, social support records, and documentation of patient follow-up. This documentation was created by student clinicians under the supervision of credentialed providers. Although students received a checklist to guide their documentation in later clinic years, earlier clinical notes vary in their thoroughness. Missing data are noted in tables as applicable.
Hypertension and pregnancy Medications/recreational drugs and pregnancy
RESULTS
Monthly breast examinations
From 2010 to 2013, the prenatal clinic served a demographically diverse group of women. The largest proportion of them were Latina, and a broad range of nationalities were served, including women from Burma, Nepal, Egypt, Sudan, and Ethiopia. Approximately half of the women lacked documentation of legal immigration status. Most women had experienced prior pregnancies, and approximately two-thirds reported previously giving birth (Table 2). Shade Tree Clinic’s goal is to increase access to prenatal care for women early in their pregnancies, and the majority of women who attended the prenatal clinic were in their first trimester of pregnancy. However, more than 40% of women entered care during their second or third trimester. Several women in this sample presented with histories of gestational diabetes mellitus and gestational hypertension. Less frequently, women presented with more complicated conditions such as first trimester bleeding and spontaneous abortions, molar pregnancies, preexisting diabetes mellitus, and multiple sclerosis. Rarely, fetal anomalies such as anencephaly and cardiac defects were identified by ultrasound. Referrals for continuing care are presented in Table 3.
Nutrition and hydration Pregnancy options Prevention of gestational diabetes mellitus Postpartum depression Self care Sexual risk reduction Smoking cessation Warning signs for pregnancy Weight gain guidelines Vaccinations Vaginal birth after cesarean Vaginal health Vitamins and supplements
Follow-up care is administered by the program directors, who remain in contact with women following their visit to ensure that they are informed of laboratory results and return to the clinic for any follow-up testing or treatment, which is offered free of charge. Shade Tree Clinic faculty mentors supervise the interpretation of laboratory results and subsequent follow-up care. Ultimately, Shade Tree Clinic provides free, initial prenatal care for women and facilitates their access to insurance coverage and ongoing care. Based on their risk status, women are given an appointment with a university-associated nursemidwifery or obstetrics practice through which they receive care during the remainder of their pregnancy. Most women seen at the prenatal clinic are referred for midwifery care; however, women with both low- and high-risk pregnancies benefit from the network of specialists available to them when necessary. Shade Tree Clinic’s goal is for women to be insured by the time they have a subsequent prenatal visit, with laboratory and ultrasound results available to their provider and any necessary medical care or follow-up testing underway. When necessary, program directors assist women who experience difficulty with their follow-up care or delays in insurance benefits. Journal of Midwifery & Women’s Health r www.jmwh.org
DISCUSSION Benefits for Women
In general, under the auspices of this clinic, gestational ages were established; infections, illness, and other conditions requiring timely medical treatment were identified; and risk-reduction counseling and social supports were initiated earlier than they would have been otherwise. In many cases, necessary and time-sensitive care would have been delayed if Shade Tree Clinic’s prenatal services were not available. Prenatal care, with its emphasis on maternal screening and risk reduction, is strongly associated with a decreased risk of prematurity, stillbirth, and neonatal or infant death.3 For example, one study found that undocumented pregnant women experienced poorer perinatal health outcomes as compared to documented women receiving timely prenatal care, and these unfavorable outcomes were largely attributed to untreated maternal infections.2 It is not undocumented women alone who struggle to obtain prenatal care because of a lack of health insurance; county-level data from across the 269
Table 2. Obstetric Characteristics and Medical Care Provided to Women Served by the Shade Tree Clinic Early Pregnancy Program (N = 152)
Table 3. Shade Tree Clinic Early Pregnancy Program Referrals for Continuing Prenatal Care, by Practice Type (N = 152)
Characteristic
Midwifery practice
Women, n ()
Gravidity 38 (25.5)
Multigravida
111 (74.5) 3 (2)
Parity Nulliparous
41 (27)
2 prior births
22 (14.5)
ࣙ 3 prior births
30 (19.7) 3 (2)
Gestational age at visit ⬍14 weeks
79 (51.0)
14 weeks-27 6/7 weeks
51 (33.6)
⬎ 28 weeks
12 (7.9)
Unknown
10 (6.6)
Medical condition reported and treated Abdominal pain/cramping Abnormal Papanicolaou test
9 (5.9) 15 (9.9)
Asthma
4 (2.6)
Chlamydia
7 (4.6)
Dermatological condition
5 (3.3)
Fatigue
5 (3.3)
History of gestational diabetes mellitus
9 (5.9)
History of gestational hypertension
7 (4.6)
History of preterm birth
4 (2.6)
Missing/lost to follow-up
4 (2.6) 11 (7.2) 2 (1.3) 10 (6.6)
One of the greatest advantages of the Shade Tree prenatal clinic is its connection to university resources, coupled with ample time for the students and women who they care for during each prenatal encounter. This allows women to receive personalized care, including individualized education; risk reduction counseling; and much needed support, encouragement, and reassurance. The prenatal program is particularly well suited to serve immigrant women because the extended visit length accommodates ample time for translation; thus, social support services can help women navigate public resources. Similarly, although this model of care benefits all women served by the clinic, it is particularly important for those who are at higher risk for poor outcomes. For the 40% of women who presented in their second or third trimester of pregnancy, the clinic was able to provide expeditious care, facilitate insurance paperwork, and quickly schedule follow-up services. Similarly, women whose initial visit or ultrasound was concerning were immediately connected with appropriate resources and specialist care from university providers who agreed to care for women while their insurance was processed.
11 (7.2)
Heartburn
5 (3.3)
Benefits for Students
Hypertension
5 (3.3)
Approximately 200 medical and nursing students have benefitted from volunteering with the prenatal clinic as student clinicians, interpreters, and those providing social supports. The extended appointment times provide students with the opportunity to engage in meaningful clinical practice and hands-on interprofessional teamwork within a relaxed and supportive environment. The demographic and medical diversity of Shade Tree Clinic patients offers rich experiences, allowing students to learn and practice cultural competence in a clinical setting. Normally, medical and nursing students seldom have an opportunity to interact, and often they may not understand the other professions’ educational preparation. Thus, the clinic provides a valuable opportunity for interprofessional socialization, which results in students reporting a greater appreciation for the particular knowledge and skills of their teammates. For instance, SNMs are immersed in— and apply a holistic lens to—women’s health and prenatal care, whereas medical students have a deeper understanding of the pathophysiology and management of the medical comorbidities that affect STEPP patients. These complementary skills result in better patient care than students could provide individually.
Hyperemesis Mental illness/depression
29 (19.1) 2 (1.3) 10 (6.6)
Palpitations/shortness of breath
5 (3.3)
Thyroid disorder
6 (3.9)
Tobacco use
8 (5.3)
Urinary tract infection
20 (13.2)
Vaginitis
21 (13.8)
Range: 1-12 pregnancies.
United States demonstrate that the proportion of individuals without health insurance is significantly associated with the number of women receiving late or inadequate prenatal care.9 Shade Tree’s prenatal clinic is able to sidestep the barrier of health insurance by providing initial prenatal services while assisting women to access coverage and enter into ongoing care. Furthermore, the clinic connects women to social services and provides follow-up services to troubleshoot insurance delays and ensure that subsequent care is received. 270
With maternal-fetal medicine consult Maternal-fetal medicine practice
3 (2) 23 (15.1)
Headache
Nausea and vomiting
a
99 (65.1)
General obstetric practice
Outside practice 56 (36.8)
1 prior birth
Missing
Women Referred, n ()
With maternal-fetal medicine consult
Primigravid Missing
Practice Type
Volume 60, No. 3, May/June 2015
The Core Competencies for Interprofessional Collaborative Practice include working cooperatively with other disciplines, understanding the roles and responsibilities of members in complementary professions, and using these unique skill sets to optimize patient care.23 These competencies are addressed through the Shade Tree prenatal clinic model of exposure to the other profession’s training and philosophy. Although more than 130 medical schools have student-run free clinics, only a small proportion involve students from more than one health profession, and even fewer offer prenatal care.26 This clinic provides a valuable opportunity for improved collaboration and increased respect between students in different but interconnected professions, which is an important step toward meeting national goals for interprofessional care. In addition, 12 students have gained leadership experience through prenatal clinic directorships. Each year, midwifery and medical students apply and 3 are selected as student leaders. Under the guidance of Shade Tree Clinic faculty mentors, prenatal clinic directors learn the practicalities of clinic management, apply clinical knowledge in interpreting laboratory results and planning subsequent care, and acquire an understanding of the maternity care system and the particular needs of the uninsured. Moreover, as supported by research, interprofessional student leadership enhances overall collaboration and program sustainability.25 CHALLENGES AND LESSONS LEARNED
Using an existing, student-run free clinic as a vehicle for prenatal and access-to-care services has been crucial to the success of STEPP. For example, university resources such as a network of specialists willing to see women while their insurance status is in transition, as well as a provider commitment to medical education, have ensured quality of care and student success. However, this endeavor has not been without challenges. Although the prenatal clinic receives material and inkind resources through Shade Tree Clinic and Vanderbilt University, these resources are not endless, and the prenatal clinic has adapted its services accordingly: Ultrasound services are provided for pregnancy dating, and anatomy scans are free of charge as an essential component of prenatal care. Although early clinics used ultrasound services as a recruitment strategy and offered them to all women, this was later changed to ultrasounds only when indicated. Furthermore, while the standard of care asserts that genetic testing should be offered to all women, Shade Tree Clinic is only able to offer this service to women aged 35 years or older and those with a family history of congenital illness. This is primarily because of the expensive and time-sensitive nature of the testing. For instance, a woman presenting at 13 weeks’ gestation and desiring genetic testing would need an ultrasound within the next 6 days, and the ultrasound department is not able to routinely schedule in-kind urgent appointments. Likewise, the laboratory is not able to absorb the expensive genetic serum screen tests for all women. Although this is an unfortunate caveat to free prenatal care, women served by Shade Tree Clinic will have insurance in place by their next visit and can elect genetic testing at that point if they fall within the appropriate gestational window. Journal of Midwifery & Women’s Health r www.jmwh.org
Another challenge is the prenatal clinic’s steep learning curve for the students who volunteer each month. Most students are first-time volunteers and need orientation to the layout of the clinic, location of supplies and medications, and procedures for providing care. Moreover, there is a range of comfort and experience among students; some are approaching the end of their training and others are just beginning. To address this challenge, program directors have developed a detailed, clinical flow sheet to guide important components of the history and physical examination. Similar checklists are used to outline charting documentation and the provision of social support services. This approach, in addition to onsite midwifery and physician supervision, helps ensure that women seeking prenatal services are cared for consistently, correctly, and with a high quality of service. At the inception of the clinic, the prenatal program was challenged by resistance from university-affiliated midwifery and physician practices. Practice managers were wary of Shade Tree Clinic’s prenatal program and concerned that the clinic was duplicating services and diverting possible clientele. This necessitated substantial education and reassurance that the program’s function was to facilitate patient access to university practices, reduce the time that practice staff spent assisting women to access maternity insurance, and not bill for any services. Other ongoing challenges include the recruitment of patients and providers. Program directors have learned that ongoing community outreach is necessary to ensure that women are aware of Shade Tree Clinic’s prenatal services, which includes continually networking with community providers. The recruitment of CNMs and obstetricians willing to volunteer their time to supervise the prenatal clinic is aided if a senior or respected clinician in the practice agrees to assume responsibility for recruiting and scheduling volunteers. CONCLUSION
Although the Patient Protection and Affordable Care Act has increased the number of women with insurance coverage across the United States, innovative solutions are required to improve women’s access to prenatal care for those who are uninsured when they become pregnant.18 Student-run free health centers are poised to rise to this challenge. Shade Clinic’s prenatal clinic reduces delays in the initiation of prenatal care by providing care before a woman receives insurance benefits, assisting her in obtaining benefits, and facilitating her entry into ongoing prenatal care. In addition, this student-driven initiative has enhanced clinical training opportunities. The clinic model meets national standards for interprofessional competencies of collaborative practice23 : students who volunteer benefit from the long visit times, interprofessional supervision and guidance, and opportunity to care for a demographically and medically diverse group of women. Finally, the Shade Tree Clinic experience has shown that these services can be offered as part of an existing student-run free clinic, with a relatively low increase in cost. Student and faculty leaders of student-run free clinics are urged to consider offering interprofessional prenatal and access-to-care services. The benefits to the school, students, and community are significant. 271
AUTHORS
Kathleen Danhausen, CNM, MSN, MPH is a recent graduate of Vanderbilt University’s nurse-midwifery program and was a 2012–2013 Co-director of the Shade Tree Early Pregnancy Program. She is in clinical practice in Bowling Green, KY. Deepa Joshi, B.A. is in her final year of medical school at Vanderbilt University and was one of the 2012–2013 Co-Director’s of Vanderbilt’s Shade Tree Early Pregnancy Program. Sarah Quirk, CNM, FNP, MSN recently graduated from the dual degree nurse-midwifery/family nurse practitioner program at Vanderbilt University, where she was a 2012–2013 CoDirector of the Shade Tree Early Pregnancy Program. She is in clinical practice in Chicago, IL. Robert Miller, M.D., is an Associate Professor of Allergy, Pulmonary and Critical Care Medicine at Vanderbilt University, and the Co-Medical Director of Shade Tree Clinic. Michael Fowler, M.D. is an Assistant Professor of Diabetes and Endocrinology at Vanderbilt University, and the Co-Medical Director of Shade Tree Clinic. Mavis N. Schorn, CNM, PhD, FACNM is the Senior Associate Dean for Academics at Vanderbilt University School of Nursing and an advisory board member for Shade Tree Clinic. CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. ACKNOWLEDGEMENTS
Thank you to Heather Davidson, PhD. and Julia Phillippi CNM, PhD, FACNM for reviewing drafts of this manuscript. Thank you to the midwives and physicians who volunteer their Saturday mornings to make these services available to women. SUPPORTING INFORMATION
Additional Supporting Information may be found in the online version of this article at the publisher’s Web site: Appendix S1: Shade Tree Clinic Early Pregnancy Program History of Present Illness Form Appendix S2: Shade Tree Clinic Early Pregnancy Program Visit Checklist Appendix S3: Appendices Abbreviations REFERENCES 1.Kozhimannil KB, Abraham JM, Virnig BA. National trends in health insurance coverage of pregnant reproductive-age women, 2000 to 2009. Womens Health Issues. 2012;22(2):135-141. doi:10.1016/j.whi.2011.12.002. 2.Munro K, Jarvis C, Munoz M, D’Souza V, Graves L. Undocumented pregnant women: What does the literature tell us? J Immigr Minor Health. 2013;15:281-291. doi:10.1007/s10903-012-9587-5. 3.Partridge S, Balayla J, Holcroft CA, Abenhaim HA. Inadequate prenatal care utilization and risks of infant mortality and poor birth outcome: A retrospective analysis of 28,729,765 U.S. deliveries over 8 years. Am J Perinatol. 2012;29(10):787-794. doi: 10.1055/s-00321316439.
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4.Phelan ST. Components and timing of prenatal care. Obstet Gynecol Clin North Am. 2008;35(3):339-353. doi:10.1016/j.ogc.2008.06.002. 5.Debiec KE, Paul KJ, Mitchell CM, Hitti JE. Inadequate prenatal care and risk of preterm delivery among adolescents: a retrospective study over 10 years. Am J Obstet Gynecol. 2010;203(2):122-e1. doi:10.1016/j.ajog.2010.03.001. 6.Cox RG, Zhang L, Zotti ME, Graham J. Prenatal care utilization in Mississippi: Racial disparities and implications for unfavorable birth outcomes. Matern Child Health J. 2011;15(7): 931-942. doi: 10.1007/s10995-009-0542-6. 7.Ip M, Peyman E, Lohsoonthorn V, Williams MA. A case-control study of preterm delivery risk factors according to clinical subtypes and severity. J Obstet Gynaecol Res. 2010;36(1):34-44. doi: 10.1111/j.1447-0756.2009.01087. 8.Phillippi JC, Roman MW. The Motivation-facilitation theory of prenatal care access. J Midwifery Womens Health. 2013;58(5):509-515. doi:10.1111/jmwh.12041. 9.Shoff C, Yang TC, Matthews SA. What has geography got to do with it? Using GWR to explore place-specific associations with prenatal care utilization. GeoJournal. 2012;77(3):331-341. doi:10.1007/s10708010-9405-3. 10.El-Sayed AM, Galea S. Prenatal care and risk of preterm birth among foreign and US-born mothers in Michigan. J Immigr Minor Health. 2012;14(2):230-235. doi:10.1007/s10903-011-9458-5. 11.Korinek K, Smith KR. Prenatal care among immigrant and racialethnic minority women in a new immigrant destination: Exploring the impact of immigrant legal status. Soc Sci Med. 2011;72(10):1695-1703. doi:10.1016/j.socscimed.2011.02.046. 12.Weir S, Posner HE, Zhang J, Willis G, Baxter JD, Clark RE. Predictors of prenatal and postpartum care adequacy in a Medicaid managed care population. Womens Health Issues. 2011;21(4):277-285. doi:10.1016/j.whi.2011.03.00. 13.Bengiamin MI, Capitman JA, Ruwe MB. Disparities in initiation and adherence to prenatal care: Impact of insurance, raceethnicity and nativity. Matern Child Health J. 2010;14(4):618-624. doi:10.1007/s10995-009-0485-y. 14.Sunil TS, Spears WD, Hook L, Castillo J, Torres C. Initiation of and barriers to prenatal care us among low-income women in San Antonio, Texas. Matern Child Health J. 2010;14(1):133-140. doi:10.1007/s10995-008-0419-0. 15.Epstein B, Grant T, Schiff M, Kasehagen L. Does rural residence affect access to prenatal care in Oregon? J Rural Health. 2009;25(2):150-157. doi:10.1111/j.1748-0361.2009.00211.x. 16.Mar´ın HA, Ram´ırez R, Wise PH, Pe˜na M, S´anchez Y, Torrez, R. The effect of Medicaid managed care on prenatal care: The case of Puerto Rico. Matern Child Health J. 2009;13(2):187-197. doi:10.1007/s10995-008-0345-1. 17.Johnson AA, Hatcher BJ, El-Khorazaty MN. Determinants of inadequate prenatal care utilization by African American women. J Health Care Poor Underserved. 2007;18(3):620-636. doi: 10.1353/ hpu.2007.0059. 18.Heberlein M, Brooks T, Alker J, Artiga S, Stephens J. Getting into gear for 2014: Findings from a 50-State survey of eligibility, enrollment, renewal, and cost-sharing policies in Medicaid and CHIP, 2012-2013.” Henry J. Kaiser Family Foundation. 2013. http:// kaiserfamilyfoundation.files.wordpress.com/2013/05/8401.pdf. Accessed June 19, 2014. 19.Jarlenski MP, Bennett WL, Barry CL, Bleich SN. Insurance coverage and prenatal care among low-income pregnant women: As assessment of states’ adoption of the “unborn child” option in Medicaid and CHIP. Med Care. 2014;52(1):10-19. doi: 10.1097/MLR. 0000000000000020. 20.Phillippi JC. Women’s perceptions of access to prenatal care in the United States: a literature review. J Midwifery Womens Health. 2009;54(3):219-225. doi:10.1016/j.jmwh.2009.01.002. 21.O’Connell E, Zhang G, Leguen F, Prince J. Impact of a mobile van on prenatal care utilization and birth outcomes in Miami-Dade County. Matern Child Health J. 2010;14(4): 528-534. doi:10.1007/s10995-0090496-8. Volume 60, No. 3, May/June 2015
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implication for educators, researchers, and policymakers. Med Educ. 2008;42:654-661. doi:10.1111/j.1365-2923.2008.03042.x. 26.Society of Student-Run Free Clinics. Clinic profiles. http://www. studentrunfreeclinics.org/index.php?option=com˙comprofiler&task= usersList&listid=4 Accessed June 10, 2014.
Continuing education units (CEUs) for this article are offered as part of a CEU theme issue. To obtain CEUs online, please visit www.jmwhce.org. A CEU form that can be mailed or faxed is available in the print edition of the theme issue.
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Original Research
Facilitating Access to Prenatal Care Through an Interprofessional Student-Run Free Clinic
CEU
Kathleen Danhausen, CNM, MSN, MPH, Deepa Joshi, BA, Sarah Quirk, CNM, FNP, MSN, Robert Miller, MD, Michael Fowler, MD, Mavis N. Schorn, CNM, PhD
Introduction: Addressing the persistent challenge of inadequate prenatal care requires innovative solutions. Student-run free health centers are poised to rise to this challenge. The Shade Tree Clinic Early Pregnancy Program, jointly operated by university medical and nursing programs, functions as an ongoing access-to-care portal for pregnant women without health insurance. The clinic is run by medical students and nursemidwifery students and uses a service-based learning model that allows students to work and learn in supervised, interprofessional teams while providing evidence-based prenatal care. Methods: All data reported in this paper were obtained from a retrospective chart review of women served by the prenatal clinic. These data are descriptive in nature, and include the patient demographics and services provided by the clinic to 152 women between the years of 2010–2013. Results: During this time period, the clinic served a demographically diverse clientele. Approximately half lacked documentation of legal immigration status. The majority of women seeking care were in their first trimester of pregnancy and had previously given birth. Several women had medical or obstetric complications that required timely referral to specialist care; and many women received treatment for infection and other primary care concerns. Discussion: Shade Tree Clinic provides the basic components of prenatal care and assists women with other medical needs. Women also receive help when applying for and accessing public maternity insurance, and the clinic facilitates entry to any necessary specialist care while that insurance is processed. In many cases, necessary and time-sensitive care would be delayed if Shade Tree Clinic’s prenatal services were not available. In addition, the clinic presents a valuable opportunity for interprofessional socialization, increased respect, and improved collaboration between students in different but complementary professions, which is an important experience while we move to meet national goals for interprofessional care among health professionals. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health. c 2015 by the American College of Nurse-Midwives. J Midwifery Womens Health 2015;60:267–273 Keywords: antepartum care, midwifery education, medical education, vulnerable populations, access to health care, interprofessional relations
Address correspondence to Kathleen Danhausen, CNM, MSN, MPH. E-mail: [email protected]
The Shade Tree Clinic Early Pregnancy Program (STEPP), jointly operated by Vanderbilt University Schools of Medicine and Nursing, Nashville, Tennessee, functions as an access-to-care portal for pregnant women who are without health insurance. The clinic uses a service-based learning model that allows student volunteers to work and learn in supervised interprofessional teams to provide evidence-based prenatal care. The Core Competencies for Interprofessional Collaborative Practice note that the opportunity for students to work in interprofessional teams is critical to the development of a collaborative, practice-ready medical workforce.22 Although incorporating interprofessional learning experiences into clinical education can be challenging,23 evidence shows that it results in a better working culture, reduced clinical errors, and increased patient satisfaction.24 Moreover, students who engage in interprofessional learning and teamwork demonstrate increased knowledge of roles and scope of practice, improved attitudes related to mutual trust and willingness to collaborate, and increased behaviors identified as critical to successful team functioning.25 This article presents the model of a prenatal clinic offered by a student-run health center. We describe the patient population and services provided and review the interprofessional learning and professional socialization experienced by student volunteers.
1526-9523/09/$36.00 doi:10.1111/jmwh.12304
c 2015 by the American College of Nurse-Midwives
INTRODUCTION
Women often struggle to access prenatal care when they do not have medical insurance, especially during the first trimester of pregnancy. Approximately 25% of reproductiveaged women lack health insurance, which presents a major barrier to their timely initiation of care.1,2 First-trimester prenatal care is essential for accurate pregnancy dating, timesensitive genetic screening, identification of maternal infections that contribute to preterm birth, and the opportunity to provide early education and risk reduction interventions.3,4 Delayed or minimal prenatal care is associated with poor health outcomes, including premature birth, low birth weight, and neonatal and maternal morbidity.3,5–7 Moreover, multiple studies confirm that the most vulnerable women have lower initiation and use of prenatal care.8–17 Undocumented, lowincome immigrant women are most likely to be uninsured because many states do not offer maternity benefits to those who reside illegally in the United States.18,19 Much has been written about barriers to timely prenatal care; however, there are few program descriptions, and little program evidence exists to guide efforts to facilitate access to this care.8,20,21
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✦ Uninsured and vulnerable women have decreased access to prenatal care and lower rates of prenatal care utilization. ✦ Student-run free clinics can serve as an access-to-care portal for uninsured pregnant women. ✦ Interprofessional training facilitates professional socialization, increased respect, and improved collaboration between students in complementary professions.
SHADE TREE CLINIC EARLY PREGNANCY PROGRAM
Shade Tree Clinic, established in 2004 and operated by Vanderbilt University medical students, provides medical, social, and legal services to approximately 300 uninsured individuals. STEPP was developed in 2009, when students staffing the clinic observed that uninsured women, particularly immigrants, had difficulty accessing timely prenatal care. Students and Shade Tree Clinic faculty mentors determined that their clinic had the existing service structure to fill this gap. Establishing a free prenatal program was logistically feasible because the university’s institutional support for Shade Tree Clinic included free laboratory testing for patients, which was expanded to absorb the cost of ultrasound services for women served by the prenatal clinic. However, student clinicians with consistent knowledge of prenatal care were needed because medical students receive obstetric didactic content at variable times. In addition, the clinic needed credentialed maternity care providers who were willing to volunteer their time each month to staff the prenatal clinic. Thus, Shade Tree Clinic’s leaders turned to the university school of nursing for assistance. Midwifery faculty embraced the opportunity to meet a community need in a way that would expose students from both professions to each other and the midwifery model of care. In addition, the prenatal program could offer valuable clinical opportunities for student nurse-midwives (SNMs) and student nurse practitioners. With this in mind, the midwifery faculty committed to send a certified nurse-midwife (CNM) each month to instruct and supervise students. Interested medical and midwifery students were invited to volunteer, and the medical school obstetrics and gynecology department agreed to assign third-year students as part of their clerkship rotation. Thus, the framework for an interprofessional service-learning clinic was created. Program Description
Now in its fifth year of operation, the STEPP is codirected by medical and midwifery students. It is a thriving part of Shade Tree Clinic, which has in turn furnished the prenatal clinic with supplies, medications, and institutional buy-in. Medical students and SNMs work in collaborative teams to provide patient care, with advanced students teaching new learners. A typical team consists of 2 students who volunteer, without receiving academic credit, to conduct 2 prenatal visits at the monthly clinic. Each team is led by a medical student or SNM in the final years of schooling and includes another student
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from the opposite discipline who is at the beginning of their education program. Licensed clinicians, including a CNM and often an obstetrician, supervise 4 teams that provide a standard initial prenatal visit for 8 women. When a CNM and obstetrician are both present, the CNM supervises the teams led by the medical students, whereas the obstetrician works with the teams led by the SNMs. Each prenatal visit features an extended appointment time of approximately 90 to 120 minutes, allowing students to practice skills and gain a holistic view of patient needs. Key components of care include the elicitation of a thorough history; pregnancy dating, including a referral for an ultrasound if one is indicated; laboratory testing and screening for infection; genetic testing as appropriate; and individualized education and risk-reduction counseling. In addition to providing the basic components of prenatal care, the STEPP also assists women with other medical needs. For example, women are commonly treated for infections or other primary care concerns and receive follow-up testing for cervical cancer. Throughout the visit, students receive supervision and guidance from the attending CNM or physician. Providers are available to answer clinical questions and demonstrate patient care techniques, allowing students to learn from the perspective and expertise of a professional from another discipline. Furthermore, the pairing of students from different disciplines provides a rich practice in interprofessional learning and collaboration. In this context, students together navigate the social and economic aspects of health. For instance, students work with women to develop a nutritional plan within the context of their financial constraints, and they apply health-coaching skills to discuss a wide variety of topics (Table 1). Students learn with and from each other through the provision of patient care, whether that learning involves substance abuse screening or appropriate laboratory testing for uncommon diseases. Finally, the collaborative and collegial interaction between the CNM and physician providers serves as a positive role model of interprofessional communication for the student teams. Additional medical and nursing students care for the clinic in nonclinical roles, serving as Spanish interpreters and offering social support. Students providing social support services primarily assist women who are applying for public maternity insurance. All women seen by Shade Tree Clinic are eligible for public insurance because Tennessee offers maternity coverage regardless of immigration status. Women are also offered resources to respond to needs for food, housing, transportation, parenting groups, intimate partner violence shelters, mental health services, dental care, and legal aid.
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Table 1. Common Topics for Individualized Education Provided by Student Clinicians at the Shade Tree Clinic Early Pregnancy Program
Anticipatory guidance for pregnancy Breastfeeding Cervical cancer screening Choices of maternity care provider Circumcision Contraception Coping with common discomforts of pregnancy Dental hygiene Exercise Housing safety and hygiene
METHODS
All data reported in this article were obtained from a retrospective chart review of women served by the prenatal clinic from 2010 to 2013. These data are descriptive in nature and include patient demographics and services provided by the clinic. Institutional review board exemption was received from Vanderbilt University prior to data collection. Deidentified data from the records of 152 women were reviewed and extracted from clinical encounter notes, social support records, and documentation of patient follow-up. This documentation was created by student clinicians under the supervision of credentialed providers. Although students received a checklist to guide their documentation in later clinic years, earlier clinical notes vary in their thoroughness. Missing data are noted in tables as applicable.
Hypertension and pregnancy Medications/recreational drugs and pregnancy
RESULTS
Monthly breast examinations
From 2010 to 2013, the prenatal clinic served a demographically diverse group of women. The largest proportion of them were Latina, and a broad range of nationalities were served, including women from Burma, Nepal, Egypt, Sudan, and Ethiopia. Approximately half of the women lacked documentation of legal immigration status. Most women had experienced prior pregnancies, and approximately two-thirds reported previously giving birth (Table 2). Shade Tree Clinic’s goal is to increase access to prenatal care for women early in their pregnancies, and the majority of women who attended the prenatal clinic were in their first trimester of pregnancy. However, more than 40% of women entered care during their second or third trimester. Several women in this sample presented with histories of gestational diabetes mellitus and gestational hypertension. Less frequently, women presented with more complicated conditions such as first trimester bleeding and spontaneous abortions, molar pregnancies, preexisting diabetes mellitus, and multiple sclerosis. Rarely, fetal anomalies such as anencephaly and cardiac defects were identified by ultrasound. Referrals for continuing care are presented in Table 3.
Nutrition and hydration Pregnancy options Prevention of gestational diabetes mellitus Postpartum depression Self care Sexual risk reduction Smoking cessation Warning signs for pregnancy Weight gain guidelines Vaccinations Vaginal birth after cesarean Vaginal health Vitamins and supplements
Follow-up care is administered by the program directors, who remain in contact with women following their visit to ensure that they are informed of laboratory results and return to the clinic for any follow-up testing or treatment, which is offered free of charge. Shade Tree Clinic faculty mentors supervise the interpretation of laboratory results and subsequent follow-up care. Ultimately, Shade Tree Clinic provides free, initial prenatal care for women and facilitates their access to insurance coverage and ongoing care. Based on their risk status, women are given an appointment with a university-associated nursemidwifery or obstetrics practice through which they receive care during the remainder of their pregnancy. Most women seen at the prenatal clinic are referred for midwifery care; however, women with both low- and high-risk pregnancies benefit from the network of specialists available to them when necessary. Shade Tree Clinic’s goal is for women to be insured by the time they have a subsequent prenatal visit, with laboratory and ultrasound results available to their provider and any necessary medical care or follow-up testing underway. When necessary, program directors assist women who experience difficulty with their follow-up care or delays in insurance benefits. Journal of Midwifery & Women’s Health r www.jmwh.org
DISCUSSION Benefits for Women
In general, under the auspices of this clinic, gestational ages were established; infections, illness, and other conditions requiring timely medical treatment were identified; and risk-reduction counseling and social supports were initiated earlier than they would have been otherwise. In many cases, necessary and time-sensitive care would have been delayed if Shade Tree Clinic’s prenatal services were not available. Prenatal care, with its emphasis on maternal screening and risk reduction, is strongly associated with a decreased risk of prematurity, stillbirth, and neonatal or infant death.3 For example, one study found that undocumented pregnant women experienced poorer perinatal health outcomes as compared to documented women receiving timely prenatal care, and these unfavorable outcomes were largely attributed to untreated maternal infections.2 It is not undocumented women alone who struggle to obtain prenatal care because of a lack of health insurance; county-level data from across the 269
Table 2. Obstetric Characteristics and Medical Care Provided to Women Served by the Shade Tree Clinic Early Pregnancy Program (N = 152)
Table 3. Shade Tree Clinic Early Pregnancy Program Referrals for Continuing Prenatal Care, by Practice Type (N = 152)
Characteristic
Midwifery practice
Women, n ()
Gravidity 38 (25.5)
Multigravida
111 (74.5) 3 (2)
Parity Nulliparous
41 (27)
2 prior births
22 (14.5)
ࣙ 3 prior births
30 (19.7) 3 (2)
Gestational age at visit ⬍14 weeks
79 (51.0)
14 weeks-27 6/7 weeks
51 (33.6)
⬎ 28 weeks
12 (7.9)
Unknown
10 (6.6)
Medical condition reported and treated Abdominal pain/cramping Abnormal Papanicolaou test
9 (5.9) 15 (9.9)
Asthma
4 (2.6)
Chlamydia
7 (4.6)
Dermatological condition
5 (3.3)
Fatigue
5 (3.3)
History of gestational diabetes mellitus
9 (5.9)
History of gestational hypertension
7 (4.6)
History of preterm birth
4 (2.6)
Missing/lost to follow-up
4 (2.6) 11 (7.2) 2 (1.3) 10 (6.6)
One of the greatest advantages of the Shade Tree prenatal clinic is its connection to university resources, coupled with ample time for the students and women who they care for during each prenatal encounter. This allows women to receive personalized care, including individualized education; risk reduction counseling; and much needed support, encouragement, and reassurance. The prenatal program is particularly well suited to serve immigrant women because the extended visit length accommodates ample time for translation; thus, social support services can help women navigate public resources. Similarly, although this model of care benefits all women served by the clinic, it is particularly important for those who are at higher risk for poor outcomes. For the 40% of women who presented in their second or third trimester of pregnancy, the clinic was able to provide expeditious care, facilitate insurance paperwork, and quickly schedule follow-up services. Similarly, women whose initial visit or ultrasound was concerning were immediately connected with appropriate resources and specialist care from university providers who agreed to care for women while their insurance was processed.
11 (7.2)
Heartburn
5 (3.3)
Benefits for Students
Hypertension
5 (3.3)
Approximately 200 medical and nursing students have benefitted from volunteering with the prenatal clinic as student clinicians, interpreters, and those providing social supports. The extended appointment times provide students with the opportunity to engage in meaningful clinical practice and hands-on interprofessional teamwork within a relaxed and supportive environment. The demographic and medical diversity of Shade Tree Clinic patients offers rich experiences, allowing students to learn and practice cultural competence in a clinical setting. Normally, medical and nursing students seldom have an opportunity to interact, and often they may not understand the other professions’ educational preparation. Thus, the clinic provides a valuable opportunity for interprofessional socialization, which results in students reporting a greater appreciation for the particular knowledge and skills of their teammates. For instance, SNMs are immersed in— and apply a holistic lens to—women’s health and prenatal care, whereas medical students have a deeper understanding of the pathophysiology and management of the medical comorbidities that affect STEPP patients. These complementary skills result in better patient care than students could provide individually.
Hyperemesis Mental illness/depression
29 (19.1) 2 (1.3) 10 (6.6)
Palpitations/shortness of breath
5 (3.3)
Thyroid disorder
6 (3.9)
Tobacco use
8 (5.3)
Urinary tract infection
20 (13.2)
Vaginitis
21 (13.8)
Range: 1-12 pregnancies.
United States demonstrate that the proportion of individuals without health insurance is significantly associated with the number of women receiving late or inadequate prenatal care.9 Shade Tree’s prenatal clinic is able to sidestep the barrier of health insurance by providing initial prenatal services while assisting women to access coverage and enter into ongoing care. Furthermore, the clinic connects women to social services and provides follow-up services to troubleshoot insurance delays and ensure that subsequent care is received. 270
With maternal-fetal medicine consult Maternal-fetal medicine practice
3 (2) 23 (15.1)
Headache
Nausea and vomiting
a
99 (65.1)
General obstetric practice
Outside practice 56 (36.8)
1 prior birth
Missing
Women Referred, n ()
With maternal-fetal medicine consult
Primigravid Missing
Practice Type
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The Core Competencies for Interprofessional Collaborative Practice include working cooperatively with other disciplines, understanding the roles and responsibilities of members in complementary professions, and using these unique skill sets to optimize patient care.23 These competencies are addressed through the Shade Tree prenatal clinic model of exposure to the other profession’s training and philosophy. Although more than 130 medical schools have student-run free clinics, only a small proportion involve students from more than one health profession, and even fewer offer prenatal care.26 This clinic provides a valuable opportunity for improved collaboration and increased respect between students in different but interconnected professions, which is an important step toward meeting national goals for interprofessional care. In addition, 12 students have gained leadership experience through prenatal clinic directorships. Each year, midwifery and medical students apply and 3 are selected as student leaders. Under the guidance of Shade Tree Clinic faculty mentors, prenatal clinic directors learn the practicalities of clinic management, apply clinical knowledge in interpreting laboratory results and planning subsequent care, and acquire an understanding of the maternity care system and the particular needs of the uninsured. Moreover, as supported by research, interprofessional student leadership enhances overall collaboration and program sustainability.25 CHALLENGES AND LESSONS LEARNED
Using an existing, student-run free clinic as a vehicle for prenatal and access-to-care services has been crucial to the success of STEPP. For example, university resources such as a network of specialists willing to see women while their insurance status is in transition, as well as a provider commitment to medical education, have ensured quality of care and student success. However, this endeavor has not been without challenges. Although the prenatal clinic receives material and inkind resources through Shade Tree Clinic and Vanderbilt University, these resources are not endless, and the prenatal clinic has adapted its services accordingly: Ultrasound services are provided for pregnancy dating, and anatomy scans are free of charge as an essential component of prenatal care. Although early clinics used ultrasound services as a recruitment strategy and offered them to all women, this was later changed to ultrasounds only when indicated. Furthermore, while the standard of care asserts that genetic testing should be offered to all women, Shade Tree Clinic is only able to offer this service to women aged 35 years or older and those with a family history of congenital illness. This is primarily because of the expensive and time-sensitive nature of the testing. For instance, a woman presenting at 13 weeks’ gestation and desiring genetic testing would need an ultrasound within the next 6 days, and the ultrasound department is not able to routinely schedule in-kind urgent appointments. Likewise, the laboratory is not able to absorb the expensive genetic serum screen tests for all women. Although this is an unfortunate caveat to free prenatal care, women served by Shade Tree Clinic will have insurance in place by their next visit and can elect genetic testing at that point if they fall within the appropriate gestational window. Journal of Midwifery & Women’s Health r www.jmwh.org
Another challenge is the prenatal clinic’s steep learning curve for the students who volunteer each month. Most students are first-time volunteers and need orientation to the layout of the clinic, location of supplies and medications, and procedures for providing care. Moreover, there is a range of comfort and experience among students; some are approaching the end of their training and others are just beginning. To address this challenge, program directors have developed a detailed, clinical flow sheet to guide important components of the history and physical examination. Similar checklists are used to outline charting documentation and the provision of social support services. This approach, in addition to onsite midwifery and physician supervision, helps ensure that women seeking prenatal services are cared for consistently, correctly, and with a high quality of service. At the inception of the clinic, the prenatal program was challenged by resistance from university-affiliated midwifery and physician practices. Practice managers were wary of Shade Tree Clinic’s prenatal program and concerned that the clinic was duplicating services and diverting possible clientele. This necessitated substantial education and reassurance that the program’s function was to facilitate patient access to university practices, reduce the time that practice staff spent assisting women to access maternity insurance, and not bill for any services. Other ongoing challenges include the recruitment of patients and providers. Program directors have learned that ongoing community outreach is necessary to ensure that women are aware of Shade Tree Clinic’s prenatal services, which includes continually networking with community providers. The recruitment of CNMs and obstetricians willing to volunteer their time to supervise the prenatal clinic is aided if a senior or respected clinician in the practice agrees to assume responsibility for recruiting and scheduling volunteers. CONCLUSION
Although the Patient Protection and Affordable Care Act has increased the number of women with insurance coverage across the United States, innovative solutions are required to improve women’s access to prenatal care for those who are uninsured when they become pregnant.18 Student-run free health centers are poised to rise to this challenge. Shade Clinic’s prenatal clinic reduces delays in the initiation of prenatal care by providing care before a woman receives insurance benefits, assisting her in obtaining benefits, and facilitating her entry into ongoing prenatal care. In addition, this student-driven initiative has enhanced clinical training opportunities. The clinic model meets national standards for interprofessional competencies of collaborative practice23 : students who volunteer benefit from the long visit times, interprofessional supervision and guidance, and opportunity to care for a demographically and medically diverse group of women. Finally, the Shade Tree Clinic experience has shown that these services can be offered as part of an existing student-run free clinic, with a relatively low increase in cost. Student and faculty leaders of student-run free clinics are urged to consider offering interprofessional prenatal and access-to-care services. The benefits to the school, students, and community are significant. 271
AUTHORS
Kathleen Danhausen, CNM, MSN, MPH is a recent graduate of Vanderbilt University’s nurse-midwifery program and was a 2012–2013 Co-director of the Shade Tree Early Pregnancy Program. She is in clinical practice in Bowling Green, KY. Deepa Joshi, B.A. is in her final year of medical school at Vanderbilt University and was one of the 2012–2013 Co-Director’s of Vanderbilt’s Shade Tree Early Pregnancy Program. Sarah Quirk, CNM, FNP, MSN recently graduated from the dual degree nurse-midwifery/family nurse practitioner program at Vanderbilt University, where she was a 2012–2013 CoDirector of the Shade Tree Early Pregnancy Program. She is in clinical practice in Chicago, IL. Robert Miller, M.D., is an Associate Professor of Allergy, Pulmonary and Critical Care Medicine at Vanderbilt University, and the Co-Medical Director of Shade Tree Clinic. Michael Fowler, M.D. is an Assistant Professor of Diabetes and Endocrinology at Vanderbilt University, and the Co-Medical Director of Shade Tree Clinic. Mavis N. Schorn, CNM, PhD, FACNM is the Senior Associate Dean for Academics at Vanderbilt University School of Nursing and an advisory board member for Shade Tree Clinic. CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. ACKNOWLEDGEMENTS
Thank you to Heather Davidson, PhD. and Julia Phillippi CNM, PhD, FACNM for reviewing drafts of this manuscript. Thank you to the midwives and physicians who volunteer their Saturday mornings to make these services available to women. SUPPORTING INFORMATION
Additional Supporting Information may be found in the online version of this article at the publisher’s Web site: Appendix S1: Shade Tree Clinic Early Pregnancy Program History of Present Illness Form Appendix S2: Shade Tree Clinic Early Pregnancy Program Visit Checklist Appendix S3: Appendices Abbreviations REFERENCES 1.Kozhimannil KB, Abraham JM, Virnig BA. National trends in health insurance coverage of pregnant reproductive-age women, 2000 to 2009. Womens Health Issues. 2012;22(2):135-141. doi:10.1016/j.whi.2011.12.002. 2.Munro K, Jarvis C, Munoz M, D’Souza V, Graves L. Undocumented pregnant women: What does the literature tell us? J Immigr Minor Health. 2013;15:281-291. doi:10.1007/s10903-012-9587-5. 3.Partridge S, Balayla J, Holcroft CA, Abenhaim HA. Inadequate prenatal care utilization and risks of infant mortality and poor birth outcome: A retrospective analysis of 28,729,765 U.S. deliveries over 8 years. Am J Perinatol. 2012;29(10):787-794. doi: 10.1055/s-00321316439.
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Continuing education units (CEUs) for this article are offered as part of a CEU theme issue. To obtain CEUs online, please visit www.jmwhce.org. A CEU form that can be mailed or faxed is available in the print edition of the theme issue.
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