She's pregnant, but Corinne is still smoking.
Dr. Kirsten Johnsen talks to a patient during a prenatal exam at Southeast Lancaster Health Services.
"I just want to stop," Corinne says, "but it's not that easy."
The three other women in the room agree: Kicking the smoking habit is one of the biggest challenges they face in waiting for their babies to be born.
The expectant mothers are taking part in an innovative program at SouthEast Lancaster Health Services called CenteringPregnancy, a support group of sorts allowing women to talk about concerns and challenges with each other and with nurses.
For SouthEast, CenteringPregnancy is just another sign of the way things have changed at the clinic.
Five years ago, 50 to 75 pregnant women a year got prenatal care at SouthEast, a federally qualified community health center. Now the caseload is 335 and growing.
SouthEast's executive director, Jim Kelly, says a number of factors have contributed to the increase: uninsured people, a larger immigrant population and overall population growth.
But the chief factor, one also affecting Lancaster General Hospital, is the ripple effect from Lancaster Regional Medical Center's decision in 2003 to drop its obstetrics program.
SouthEast's obstetrics caseload more than doubled since then. LGH has seen a similar boom in its Healthy Beginnings Plus, which provides prenatal care for women eligible for Medical Assistance, or Medicaid.
"The combination of all those factors has just exploded into the demand we're seeing today," Kelly says.
In response, SouthEast has added more doctors and nurses, expanded prenatal services and begun CenteringPregnancy, making it one of two obstetrics programs in the county to join a national trend. The clinic's staff also has begun doing deliveries.
"We think," says Dr. Kirsten Johnsen, one of SouthEast's physicians, "we're doing a pretty good job."
'The right place'Johnsen is measuring a patient's belly with a tape. She laughs.
"I just got kicked!" she says.
The patient, who's 22, is 35 weeks pregnant. She's having trouble catching her breath and worries that didn't happen in two previous pregnancies.
Johnsen reassures her that breathlessness is common in the last weeks of gestation.
Both women are speaking Spanish. Johnsen, like all obstetrics providers at SouthEast, is fluent in Spanish.
It's a Wednesday morning, one of two days when Johnsen sees prenatal patients.
The first, Patricia, who's 32 weeks pregnant, is having what might be Braxton-Hicks contractions. Johnsen applies a monitor to Patricia's belly; the baby's heartbeat is loud and clear.
Another woman arrives with her husband and two daughters. She has just been at Lancaster General Women & Babies Hospital for a recurring vaginal infection. Johnsen explains that infections can put a mother at greater risk for preterm labor.
Another patient, 32 weeks pregnant, shows Johnsen a photo album of sonogram pictures. She asks for help in pronouncing some English names she picked out of a baby name book.
"Our patients are the poorest of the poor and underserved in Lancaster County," Johnsen says. "Many of them come to us without any insurance at all."
SouthEast's doctors see 100 to 130 prenatal patients every week. Kelly says the growth in prenatal care is "pretty consistent with what we're seeing as an overall facility."
Five years ago the clinic had 24,000 patient visits annually. Now it's closer to 40,000 a year.
But because of the need for prenatal care, SouthEast has focused on hiring doctors and nurses trained in obstetrics as well as in other kinds of care.
"In the last year, we added four physicians, all family practitioners with dually trained capabilities in obstetrics," Kelly says. Medical director Dr. William Fife also is dually trained. Nurse practitioners Linda Gort-Walton, the director of maternal and child health, and Cherilyn Reynolds are trained in women's health and obstetrics.
Five doctors and two nurse practitioners provide prenatal care. A sixth is joining the staff in October.
Johnsen, who worked with migrant farm laborers before medical school, came to SouthEast a year ago from LGH's family residency program. She and a colleague, Dr. Rachel Eash-Scott, are fulfilling scholarship commitments of three years of service with a federally qualified health care center.
Changes in the obstretrics market are driving numbers at SouthEast.
Before Health Management Associates, a for-profit chain, bought Community Hospital in 1998 and the former St. Joseph Hospital in 2000, both Community and St. Joe's offered Healthy Beginnings Plus.
But Community stopped delivering babies in 2002; its Healthy Beginnings program shifted to Lancaster Regional. In 2003, Lancaster Regional closed its obstretrics program.
Alice Yoder, who oversees Healthy Beginnings at LGH, says the closure contributed to a doubling of LGH's caseload, from 550 to 1,000-plus. Ephrata Community Hospital also has Healthy Beginnings patients.
LGH spokesman John Lines says Women & Babies delivered 3,200 babies in 2000, its first year, and 5,200 now.
Heart of Lancaster Regional Medical Center, which replaced Community, has opened a maternity unit at the Warwick Township hospital. SouthEast officials doubt that will have much effect on their caseload, considering transportation difficulties that women have in getting to Heart.
Johnsen notes that before 2004, SouthEast providers cared for pregnant women until their 28th week and then had to transfer them, usually to LGH's residency program clinic. The numbers began growing after Gort-Walton, director of women's and children's services at St. Joseph, joined SouthEast.
A year ago, SouthEast began delivering the babies of its own prenatal patients, Johnsen says; that year there were about 190 deliveries.
"Currently we have enrolled 332 prenatal patients in 2008," she says. "We have had 121-plus deliveries" through the end of June.
"We've made it a focus to do more OB care," Kelly says.
All prenatal patients are assigned to a primary OB doctor and nurse. SouthEast offers support groups, prenatal and mother-baby yoga and pregnancy education. SouthEast also has begun sending maternity patients to its dental clinic, since a pregnant woman's oral health is connected to her child's health.
Johnsen says SouthEast's outcomes are better than national averages for most areas. Caesarean sections, for instance, are 27 percent of the total deliveries, and 16 percent for first-time births, below national rates.
"Our low-birth and pre-term birth rates are also quite good at 8.3 percent per year, which is impressive, particularly because of the population with whom we're working," she says.
Patients, who pay on a sliding scale based on income, face more challenges than other pregnant women, Johnsen notes: poverty, homelessness, transportation, low literacy, difficult family situations, domestic violence, language barriers, substance abuse, mental health concerns and teen pregnancies.
"So far this year, 24 percent of our patients have been considered high-risk depression patients," she says.
But, she adds, "Those of us who work at SELHS are there for a reason, and we share a common mission.
"… When a patient brings you fresh-baked flan at Christmastime as a way of saying thank you, or invites you to their daughter's
quinceañera or baptism, you know you're in the right place."
Getting centeredWomen in CenteringPregnancy feel they're in the right place, too.
As the group, which formed in June, gathers for its July meeting, Marlisa Bontrager-Yoder, a nurse from LGH's Healthy Beginnings Plus, and Gort-Walton set up paper cups labeled with the kinds of triggers that lead to someone picking up a cigarette.
The three mothers and one expectant father drop beads into the cups to indicate triggers that represent their strongest temptations to smoke. The most common: finishing a meal.
Jen, in her second pregnancy, started smoking at age 9. Brittany and Corinne started at 14. Kicking the habit, even though they know it's bad for babies, hasn't been easy.
Licensed practical nurse Jill Markham and Gort-Walton point out that they were once smokers.
"Pick a quit day and say, 'This is the date I'm going to quit,' " Markham advises. "It's really, really, really, really hard, but you can do it."
CenteringPregnancy, originated by a nurse-midwife in 1993, now has programs in almost every state. Women delivering around the same time meet monthly at first, then biweekly, to share concerns and questions.
SouthEast and May-Grant Obstetrics & Gynecology are the first local groups to offer CenteringPregnancy.
"It just makes so much sense," Gort-Walton says. New data indicate that women who attend centering groups have fewer low-birth-weight and preterm babies, she says.
The next class begins in September.
At the July session, first-time mothers ask Jen, the only veteran among them, what a contraction feels like. Jen shudders.
The leaders ask Corinne's boyfriend Chris if he has noticed any emotional changes. She's moody, he admits.
"That's hormones," Gort-Walton explains.
The session pauses so mothers can get a snack and have their blood pressures recorded and charts reviewed. They talk about "kick counts."
Corinne, 19 weeks pregnant, asks the other mothers if they're feeling movement yet. Brittany, at 17 weeks, is starting to feel flutters.
"I think it's a girl," she says.
"I think it's a girl, too," Corinne agrees. "I always have dreams of a little girl.
"He swears it's a boy, though."
Helen Colwell Adams is a Sunday News staff writer. E-mail her at hcolwell@lnpnews.com .
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