Dr. Nathana Lurvey was on duty at a Los Angeles-area hospital when a pregnant woman walked in. She hadn’t been receiving prenatal care, and her hemoglobin levels were half what they should have been, indicating that she had anemia.
“The baby looked terrible on the monitor,” Dr. Lurvey recalled. The mother had so few red blood cells that it was impairing the ability of those cells to reach the fetus. Dr. Lurvey transfused the patient, and she and her baby improved.
But Dr. Lurvey has seen plenty of anemia among the mothers she treats, both at the hospital and at Eisner Health, a federally qualified health center that serves many low-income, primarily Latina, mothers-to-be. About 10-15% of the pregnant women Eisner Health’s providers see already have anemia when they deliver their babies.
“For many, many, many years, folks have recognized that folks in certain socioeconomic groups are more likely to show up anemic,” Dr. Lurvey said. “Between food deserts and cultural perspectives…many of [the women Eisner Health serves] don’t have an ideal diet.”
Despite the risks to mother and baby, which include premature birth, low birth weight, and a slower recovery, Dr. Lurvey said anemia during pregnancy hasn’t received much attention: “It’s not sexy, it’s not a big picture thing, and people don’t hold marches.”
The local level
Instead, anemia – and other micronutrient deficiencies, such as folate, Vitamin D, and iodine – during pregnancy are often addressed on the local level by organizations caring for medically underserved pregnant women. Dr. Lurvey wanted to implement a program to address the anemia she frequently saw among Eisner Health’s patients and find a way to do it without pulling away from the vital care that her health center provided to patients every day.
Through funding from the life sciences company Bayer, as part of The Nutrient Gap Initiative, Direct Relief identified four California health centers working to address micronutrient deficiencies in pregnant patients. Each of these received a $50,000 grant through dedicated Community Health Awards. The awards are intended to help fund or expand programs that work to improve pregnancy outcomes in medically underserved communities by educating patients or providing nutritional interventions.
Eisner Health was one of them, adding a new perinatal nutrition case manager to its Women’s Health Center, with the goal of reducing anemia among pregnant patients by half. (“Perinatal” refers to the time before and after birth.)
“I need someone to follow [the patients] for the free weeks between when they identify the anemia and when they deliver the baby,” Lurvey sad. “The problem with big systemic changes is that they’re really hard to pull off. This is a targeted intervention in a time-sensitive population.”
“Struggling to keep anything in their stomach”
At Camarena Health in Madera, Claudia Arrellano, an educator in the Comprehensive Perinatal Services Program, noticed that a number of pregnant patients weren’t taking their prenatal vitamins. “In the first trimester, mostly, we see a lot of moms who are struggling to keep anything in their stomach, and one thing they often stop is their prenatals,” she said.
The health center’s staff members were particularly concerned about patients missing out on folate, iron, and Vitamin D. But Arrellano and her colleagues empathized with patients, and wanted to teach them how to maximize their micronutrient intake.
Camarena Health staff are developing an interactive program to teach pregnant patients about these vital nutrients. Emily Valdez, a registered dietician, explained that some of the health center’s patients are unable to read, and many have low health literacy. For that reason, she and her colleagues didn’t want to simply give out information sheets about the importance of micronutrients.
“We’re not just handing people a handout….but having an interactive education while they’re there in the office with our educators,” she said. Patients can learn about different micronutrients through sound features, and tap on foods containing high levels of a nutrient like folate. “I sometimes think with our patients less is more – giving them one or two things to take away,” Valdez said.
Arrellano said that the pregnant women she works with are very receptive to learning about nutrition, in part because they feel responsible for the health of their babies. “They enjoy learning about it, that [prenatal multivitamins] aren’t the only way they can get these nutrients,” she said. “There’s a lot of vague information that they have, and I do see the ‘Aha’ moment when they see what foods are recommended for pregnancy.”
Overcoming “linguistic and cultural isolation”
At Asian Health Services in Oakland, the focus is on providing information that’s culturally and linguistically appropriate for their primarily Asian and Pacific Islander perinatal patients. In particular, explained Dr. Emily Guh, a family medicine specialist, the federally qualified health center is emphasizing participation in its Mommies 2 Be program, which provides education, support, and a community to pregnant patients.
“A lot of our patients are facing linguistic and cultural isolation, so pregnancy can be a really challenging time,” she said.
Asian Health Services is partnering with a local chapter of WIC – the government’s supplemental nutrition program for women, infants, and children – to add a culturally appropriate nutrition component to group Mommies 2 Be meetings.
“It’s not lecture-based, but really discussion,” Guh said, explaining that a typical conversation might involve asking women in the discussion what foods they think of as nutritious or bringing in examples of familiar foods. Before a group facilitator answers a question, she may open the forum up to other participants to share their own answers, and pregnant women may discuss together how they’ll incorporate healthy foods into their diets.
“A lot of the routine counseling…can be done in the group setting,” Guh said
The health center works to enhance community by grouping pregnant women with similar due dates together, with the hope that they’ll also graduate together to a new group intended for the mothers of new infants. They also work with volunteer students from nearby U.C. Berkeley, who act as labor coaches and translators for women in delivery. Part of the students’ responsibility is to help pregnant patients develop a birth plan, so that they can think in advance about some of the major decisions they’ll have to make during the delivery process.
“Another life depends on them”
According to Ivan Flores, associate director of Prenatal Support Services at Family Health Centers of San Diego, deficiencies of iron, folic acid, and vitamin B12 are frequent among the roughly 3,500 pregnant patients his health center treats each year. Many patients eat few fruits and vegetables. And many are overweight.
In response, Family Health Centers is ensuring that patients have access to healthy food through a local WIC program, helping eligible patients navigate the complex sign-up process “to make sure they actually receive the benefits,” Flores said. He estimated that 80-90% of the pregnant women Family Health Services works with are eligible for WIC, although some decline the option because they’re concerned about their immigration status.
They’re combining the access to nutrition with high levels of monitoring and education, seeing some patients as often as weekly, working to secure needed supplies – such as glucose monitoring equipment for patients with gestational diabetes – and teaching patients to get the most out of their nutrition, such as by combining high-acid foods like orange juice with meat.
Part of their process is being realistic about patients’ needs, said, Gina Parra, manager of the health center’s prenatal support program, who oversees its nutritionists and dieticians.
“As much as we want them to eat five meals a day, or eat your fruits, or eat your vegetables…tell that to a homeless mom,” she said.
Still, she said, it can be particularly rewarding to work with pregnant women, precisely because their nutrition and health are so important to them.
“These are patients who, for the most part, listen to you because another life depends on them,” she said.