Proper prenatal care is crucial for expectant women who want to do all they can to ensure a successful pregnancy and a healthy baby. A key step in this process is for women to attend prenatal classes to learn about different stages of pregnancy, what happens to your body, what to eat, recognizing signs of labor, etc. Annie's Song, a unique and innovative prenatal education program at Memorial Hospital‘s Family Practice Clinic, was created to attract a ‘lost' population of young and unmarried women who weren't attending these critical classes.

Patient Histories
Educating expectant women about pregnancy and childbirth can be a challenge even under the best of circumstances. But this task can be especially challenging when dealing with Memorial Hospital 's Clinic patients who are often in unique and difficult situations. A typical patient may be a pregnant teenager with no high school education or a single pregnant woman with three children under the age of seven who has recently moved to the community with no support system. They tend to be young, unmarried, and on the lower end of the socioeconomic and educational scale. Many have complicating medical or social issues such as substance abuse, homelessness, hypertension and little family support.

The Background
In 1998 Memorial's OB nurses were noting that few patients at the Family Practice Clinic, affiliated with the Memorial Hospital Family Practice Residency Program, were attending prenatal classes at the hospital. Determined to give these woman and their babies the best chance at a healthy future, Andrea ‘Annie' Schaffer, then working in the Family Practice Residency program as secretary to the Program Director and Dr. Madeline Lewis, decided to get to the root of the problem. They began by talking to Clinic patients themselves to pinpoint the reasons they weren't attending classes.

"We knew our patients at the Clinic didn‘t fit in at the hospital‘s prenatal classes," says Lewis. “The classes were geared towards those with a higher education. We found that even if they went once (which was rare) most would not go back." After digging deeper they learned more about the barriers keeping patient participation low. Although the content of traditional prenatal classes was excellent, they were geared toward couples. Clinic patients reported that they often felt intimidated by having to go without a spouse or support person. The cost of the classes was another concern (although if they had asked, the fee could have been lowered or waived but many didn‘t know to even ask). Childcare was an issue for those with young children and some admitted that going to, and maneuvering around, a large hospital was a challenge. Traveling by bus alone at night, when classes were offered, was both impractical and unsafe for a pregnant woman, especially in inclement weather. The architects of the new prenatal classes recognized that these, and other, issues would need to be addressed in order for their program to be a success.

Familiar Face: Familiar Place
Annie Schaffer and Dr. Lewis agreed on one thing early on in the process; they would do whatever it takes to make women feel comfortable and welcome in their new program. "We came up with the phrase ‘Familiar face, Familiar place,‘" says Lewis. "We wanted it to be taught by our own people at the Clinic to help our patients feel as secure and relaxed as possible." Although the class is offered to anyone in the community, the majority of the patients come from the Clinic. Having classes taught by the nurses they saw on a regular basis helped the program coordinator tackle several hurdles which had kept women from attending class in the past.

First Steps
After identifying the problem, Schaffer and Lewis knew that for their idea to flourish, they would need the help of many people, both at the hospital and in the community. One of the first steps was to survey resident physicians at the Clinic about their patients. In surveys, they asked the doctors how many classes they thought their ‘typical' patient would attend, what topics suited them, what types of incentives should be offered to encourage attendance and the top areas of prenatal education and infant/child care they felt needed to be included in the curriculum.

Agencies who offered similar programs in the area were contacted for advice on what worked for them. These agencies included substance abuse services, social services, nutritional services and junior and senior high school educational programs. Several agencies have since become actively involved in the classes by providing speakers, brochures and by acting as referral sources.

After communicating with residents, nursing staff members and others, Schaffer and Lewis made the following decisions:
* Classes would be offered to any pregnant woman in the community at no charge.
* Classes would meet at the Clinic in the afternoon - days would vary by month.
* Classes would be two hours in length.
* A one-time Early Prenatal class would be offered on a monthly basis to women less than 20 weeks pregnant.
* A three-part Childbirth Series would be offered monthly for women later in pregnancy.

The Course
Class developers researched prenatal program education materials for course content, cost and frequency of classes. The book they chose for their curriculum was "Pregnancy, Birth and You" by Trudy Keller, ICCE and Ron Keller, M.D. The class curriculum includes topics and activities typically found in traditional prenatal classes such as discussions on the labor process, viewing a birth film, taking a tour of the hospital, practicing breathing and relaxation exercises and discussing postpartum and infant care. The difference is that this program is taught at a fifth grade level so that all of the material can be understood and processed by all of the mothers. Handouts are designed at a fifth grade level, lectures are kept to a minimum and replaced with a game or activity whenever possible. Visual aids and props are in constant use and speakers from area agencies regularly spend time with the class. A healthy snack is also provided at every class. Nurse educators frequently have to deal with issues that are normally not addressed in traditional prenatal classes; issues such as substance abuse and the effects of smoking and alcohol on both mother and fetus. The nurses pack a lot of information into each class because some patients may only attend once.

As an incentive to attend classes, young women are given coupons to shop at a B.A.B.E. (Beds and Britches, Etc.) store. Parents earn coupons by keeping prenatal appointments, attending prenatal classes, getting their children immunized and other activities to improve family health and child development. Physicians, clinics and other social service vendors distribute the coupons to clients who can redeem them at B.A.B.E. stores for merchandise ranging from diapers (one coupon) to cribs (12 coupons). (See B.A.B.E. Learning History.)

Prenatal Class Description
Prenatal classes are held twice during pregnancy. Once early on in pregnancy for women less than 20 weeks pregnant, and once for women in their seventh, eighth, or ninth month.

Early Prenatal Class : (meets once for two hours)

Topics include:
* What to expect at doctors appointments
* Diet and exercise guidelines
* Common concerns like morning sickness, heartburn and stretch marks
* Preterm labor, gestational diabetes and pre-eclampsia
* When to call the doctor

Childbirth Series : (meets four times for two hours each)

Topics include:
* The labor and delivery process
* Breathing and relaxation techniques
* Comfort measures during labor
* When to call the doctor
* What to expect at the hospital
* What to take to the hospital
* A tour of the childbirth unit
* Newborn care: bathing, feeding, taking baby's temperature
* Immunization schedule for baby

The Staff
Knowing that patients would be more apt to attend prenatal classes if they were taught by nurses they already knew, Dr. Lewis talked to the Clinic nurses and decided that, if possible, they should be the ones to teach the classes. Many nurses were enthusiastic about teaching but this presented more hurdles. Funding was needed to pay the nurses and many were not certified in nursing education. "Nurses who wanted to be educators had to enroll in a childbirth education program," says Lewis.

Beth McNurney (sp?), a nurse who works in the Clinic and is also now a nurse educator for the prenatal classes, was nervous about teaching at first but finds it very rewarding. "I like teaching. It was nerve wracking at first, but it's fun now." She also finds it rewarding to help women with issues outside the class as well. "We had a woman who came up to me after class in tears. She was having problems with her husband, her phone was cut off, she didn't know how to deal with Medicaid, so I got her in touch with a social worker." Another issue that comes up is a patient who will come up to a nurse with questions for her doctor who she won't be seeing for three weeks. "In that case," says McNurney (sp?) "we'll take her downstairs right away to see her doctor, or page him or leave a message."

The fact that many of the nurse educators work in the Clinic is a definite plus to the success of the program. "I work in this building as one of the nurses who greets patients when they come to the Clinic to see their OBs," says McNurney (sp?). "I also teach prenatal classes. I would recommend that. Any chance to connect with them again is helpful. They're much more likely to come to me with a problem because I know the system here."

Funding
Although grants from the Memorial Health Foundation funded the program for start-up costs, the part-time coordinator and money for classes, the Health System, paid the educators. The Family Practice Residency program has allowed the program the use of their office space as a classroom. Area merchants and representatives from pharmaceutical companies have also donated items and coupons for class participants. But funding remains an issue. "Every year we've struggled," says Lewis. Many funding goals are in the works including having the program budget changed from grant money to an operational budget.

What Works
A large reason for the success of the program is Prenatal Services Coordinator Annie Schaffer‘s persistence in getting potential patients to attend classes. All involved agree that this is critical to the program's success. She calls patients before class to ensure their attendance and follows up in between sessions. The following is the text of the letter she sends to prospective prenatal class attendees:

Dear (patient) ,
Thank you for expressing interest in our prenatal education classes. I have not been able to reach you by phone so I thought a letter would be the next best thing!

We offer two different types of classes. A flier describing the classes is enclosed. Take a moment to look it over and please call me at xxx-xxxx. Our classes are offered on a monthly basis at the Family Practice Center and are free of charge.

I look forward to hearing from you.

She often follows up with a phone call or two, a letter confirming sign-up and then another call a week before the class. These efforts go a long way to increase attendance. "We need that because it's not unusual for these women to miss a doctor's appointment. Getting them to come to class is a real accomplishment and Annie is great with phone calls and letters to get them here," says McNurney (sp?).

Persistence and Flexibility
Two words that are frequently mentioned as the keys to the success of this program are persistency and flexibility. Because these patients are typically not likely to register on their own for prenatal classes, repeated reminder letters and phone calls can be invaluable. This process helps nurses keep track of what is typically a transient population and impress upon them the importance of attending classes. The patient's due date, address and phone number are verified at each meeting to help ensure that patients consider attendance of prenatal classes a normal and necessary part of their pregnancies.

Flexibility comes in when a patient calls and says she's due in less than six weeks and needs to get into class ASAP. Fitting this patient into an existing series of classes and allowing her to ‘make up' missed classes during the next month gives her an opportunity to receive some, if not all, of the benefits of classes, and all agree that some prenatal education is always better than none. Patients are also encouraged to repeat classes if they want as classes are often a source of support for many women.

Flexibility also means that nurse educators will often need to deviate, sometimes dramatically, from the set curriculum. If class participants are eager to discuss a topic that is ordinarily covered at a later date, the educators are sure to cover that topic at that moment as attendance of future classes is never a certainty. In one session, most of the attendees happened to be dog owners and they were particularly interested in knowing about dogs and babies. The nurse educator spent a lot of time talking about pets and, coincidently, Annie herself is a dog trainer, so she was very helpful in the discussion. The flexibility to schedule classes on different days of the week is beneficial to both patients and educators. Many patients have appointments or other classes during the week and by varying the days classes are offered, patients can often be accommodated. Nurse educators also like the flexibility of teaching on different days so they can choose what days and how often they want to teach.

Measuring Success
Success is measured in baby steps with this program. One way to measure success is to look at the patients who register for the classes again during subsequent pregnancies. Other subtle victories include seeing patients take on more responsibility. Patients will tend to call if they can't make a scheduled class. After delivering many still feel part of the program and will often drop by the office with their new babies. Pictures of class "graduates" hang proudly from the office door.

Another accomplishment came when a local agency that assists pregnant women asked to duplicate the program. Although they don't have enough staff to operate the entire program, they have structured it to fit their resources. The program coordinators have also worked with the medical staff at the county jail and county juvenile detention centers to modify the program for their use. “And remember, as in most endeavors, it's a group effort,” says Schaffer. "There isn't any way that one person could do this alone. It takes the whole Clinic to make it work."

The program's developers knew all along that success wouldn't, and couldn't, be measured in dollars and cents. "Our goal," says Dr. Lewis, "was to increase attendance. Not a lofty goal. We felt if they were going to attend even one class that was better than nothing." And finally, after all is said and done, it's the expectant mothers themselves who make the program work. Says one nurse educator, "Most of the girls who come here don't have the money or opportunities we do but they're really trying, they're really excited about doing their best and putting their best foot forward." And that means victory for all involved.