A Nurse Midwife Ministers to Pregnant — and Often Troubled — Girls

At 6 a.m. the alarm goes off at Loral Patchen’s home

in the northwest quadrant of this city, but the first one out of bed is her husband, César Torres, who soon will bring his wife a fresh cup of coffee.

“I get to drink coffee until I become responsive, and then I get in the shower,” says Ms. Patchen. “César and I have the morning drill down to a fine art.”

That fine art translates into her husband, a family-practice physician, getting their 3-year-old daughter, Solana, up and fed. “Then I take over getting her dressed and doing her pigtails, before César takes her to pre-K,” says Ms. Patchen.

For the rest of the day, Ms. Patchen, a licensed nurse midwife, will take care of other people’s daughters.

On this particular morning, she arrives by 8 at the Upper Cardozo Health Center, where she will see 31 teenage girls who are part of the Teen Alliance for Prepared Parenting, a program that she developed to help young mothers prevent subsequent pregnancies for at least two years.

Under her nearly eight-year tenure as executive director of the Teen Alliance, the group has grown from one site to three and increased its budget from $200,000 to more than $665,000 annually.

About 500 girls participate in the Teen Alliance program, and of those, only about 6 percent have another child within two years of their previous one, compared with 21 percent of all teenage mothers in Washington. And many of the girls in the program do not get pregnant again for several years.

One of the reasons for Teen Alliance’s success is that when a girl joins the program, she submits to an interview with Ms. Patchen and a social worker, to determine whether the teenager is in school and how she is faring there, and whether she is living with her parents or elsewhere.

Helping the teenagers is not merely a matter of getting them prenatal checkups. Ms. Patchen and other members of her staff are also dealing with children coming to be tested, and frequently treated, for sexually transmitted diseases, as well as to arrange for birth control.

‘I Was Hooked’

Ms. Patchen’s current work stems from interests that began when she was a student at Brown University, from which she graduated with a degree in Portuguese and Brazilian studies.

“When I was at Brown I became very interested in community health work and very interested in women’s studies and African studies, as well,” says Ms. Patchen. “By majoring in Portuguese I could study in South America, Europe, and Africa. My major allowed me to learn about the world, and in that context I was always looking at women’s health care and maternal health.”

Upon graduation, Ms. Patchen was invited to assist one of her professors, who was working on a National Institutes of Health project in Samoa that studied chronic disease and the effects of modernization on health care. After a year in Samoa, Ms. Patchen joined the Peace Corps.

“I went to Honduras as a hillside agriculture volunteer, which was in some ways very familiar to me as I had grown up on a farm in Illinois,” she notes.

After Honduras, Ms. Patchen earned a master’s degree in economics from the Johns Hopkins University’s School of Advanced International Studies. She then went to work for the World Bank, but says she missed providing direct services.

“So I volunteered to do a cost-effectiveness analysis for Mary’s Center for Maternal and Child Care, a community health clinic in D.C., and as part of this pro bono work I got to meet the staff and discovered that all of their OB-GYN services were provided by midwives,” she says. “I was hooked.”

She decided to enroll at Yale University to study to become a nurse and midwife, earning a master’s degree there. Under the terms of a federal scholarship she received, she was required to work for three years in a health center that serves large numbers of Medicare and Medicaid patients, and wound up at the Washington Hospital Center’s department of women’s services.

The ‘Whole Child’

When Ms. Patchen reaches Cardozo, the waiting room is packed.

“We know that science says it is best if any mother waits two years before having another child,” she says. “TAPP works at how best to prevent multiple pregnancies in teens.”

The Teen Alliance for Prepared Parenting program started in 2000 with $150,000 from the Summit Fund of Washington and another local grant maker, the Alexander and Margaret Stewart Trust.

“We have supported the program because it works with some of the most challenging young women in the District,” says Linda Howard, executive director of the Summit Fund. “The TAPP program attempts to really treat the whole child, as well as encouraging the delay of a second pregnancy.”

The group’s leadership, says Ms. Howard, has been instrumental in its successes: “Loral really cares about these girls, is enormously competent, and has a real commitment to not only empowering these young women to create self-sufficient lives, but also to support them in being good parents in very difficult circumstances.”

The emphasis on the “whole child,” says Ms. Patchen, is the core of her group’s mission. “One of our goals is to get everything in place before a baby is born — that includes parenting programs, establishing goals with the client, and putting in place any necessary social services before birth.” She sees her patients every two weeks, she says, rather than once a month, to establish as much of a rapport with them as possible.

Before seeing her first patient, she fields a call from a teenage patient.

“Yes, you can come today as a walk-in, but you must be certain that you are not going to act out or get into fights as happened last week,” Ms. Patchen tells the girl.

After hanging up, she recounts the girl’s story:”She was sexually molested when she was 8 years old, is herself just 18, and her first child is three weeks old.” The girl, Ms. Patchen says, “is a ward of the city, her child is in foster care, and she is already having sex. The large scar on her forehead was the result of a family member stabbing her.” While pregnant, the girl spent time in the juvenile-justice system, says Ms. Patchen, for assaulting her guardian with a brick.

The teenagers that Ms. Patchen sees today are primarily Hispanic — such girls in the local area are more likely than their peers to rely on community-based services, rather than resources through their schools. Before the morning is over, Ms. Patchen will have seen patients who are anemic, given sonograms and shots of the contraceptive drug Depo-Provera, taken an implanted birth-control device out of a patient’s arm, sung the praises of breastfeeding, handed out the number of a domestic-violence hotline, urged one girl to get rid of her “toxic” boyfriend and move back in with her mother, sent one teenager for a ringworm test, and emphasized to everyone the importance of using condoms.

To more than one of her clients who acknowledges that she uses condoms sporadically, Ms. Patchen says, “Two weeks ago I had to tell one of my patients that she was HIV-positive. I do not want to have to give you the same diagnosis — use them all the time.”

She learns that gym is one pregnant client’s least favorite class in school. Speaking in Spanish, the girl acknowledges that she feels embarrassed changing into her gym suit and isn’t able to keep up with sports. Ms. Patchen writes a note to her gym teacher, requesting that the girl be allowed to wear her regular clothing — and, instead of playing sports, use the time to walk around the track.

“Small things like being embarrassed or teased about your body can lead to a child dropping out of school,” says Ms. Patchen. “We know that if we can keep these girls in school as long as possible, the percentage of those who return after giving birth is far higher than those who drop out early.”

Part of the success of the Teen Alliance program is, quite simply, Ms. Patchen herself, according to her young clients.

“Loral is the best,” says a 19-year-old mother who has come in complaining of the side effects of Depo-Provera, accompanied by her 6-year-old daughter. “After all these years, she is still great, and she’s a wonderful listener.”

For a year now, the young mother has been a full-time college student; she also works full time at a local supermarket. “In just six more months,” she says, “I’ll be eligible for health insurance and tuition reimbursement.”

Coming Up for Air

Finally, at 1 p.m., Ms. Patchen and two Cardozo physicians, Marsha Solomon and Dana Figueroa (who is pregnant and expecting a girl), can come up for air: returning phone calls, collecting their wits, and breaking for lunch.

Dr. Solomon volunteers to pick up lunch for everyone. While waiting for her return, Aviva Zyskind, a physician who works with Cardozo’s well-baby program, arrives and joins a discussion about how medical students specializing in obstetrics and gynecology have changed.

Fifty years ago, such physicians were overwhelmingly male. And, while there are still more men than women practicing the speciality in the United States, the numbers in medical school are changing. The American College of Obstetricians and Gynecologists currently says that 74.2 percent of all residents in that speciality are female.

All the women professionals eating lunch at Cardoza agree that the men are better at connecting with female patients.

“Women tend to be short and brusque with their patients, but the men really take the time to listen,” says Dr. Figueroa, before the conversation turns to what Ms. Patchen finds frustrating about her work.

“I recognize the controversy over what I do, which is to provide adolescent-sexual-health care,” Ms. Patchen says. “People have very strong opinions, but many do not understand the importance of comprehensive services that are developmentally appropriate and friendly to adolescents. I was helping a 13-year-old who was in labor, and the delivery nurse said something to the effect of, ‘Well, I guess she’s learning a hard lesson here.’ Or I’m accused of ‘coddling’ these girls.”

The rest of that 13-year-old’s story, notes Ms. Patchen, was that she had been molested at age 11 by her mother’s boyfriend: “She got herself a teenage boyfriend so she could go to his house and be safe. That is how she got pregnant. People talk about how all these children want is sex, but what that girl wanted much more was to find a safe place to live, rather than to have sex.

“What I really hate is when I have to make a call to child protective services because a girl who is not at home and not in school is breaking the law. I know exactly what will happen. She’ll be sent back to her mother and the abusive boyfriend.”

Ms. Patchen frequently talks about the controversy surrounding her charity’s mission. Schoolteachers and social workers, she says, can be “well-intentioned but misguided. People who think, for example, that keeping a pregnant girl in school will be a bad example for other children,” she says. “I tell them that while I understand that they are responsible parents, they have to understand that this population often has parents who are absent from the home or who are simply not involved with their child.”

Teen Alliance for Prepared Parenting receives about 80 percent of its budget from grant makers, according to Ms. Patchen, who serves as her group’s primary fund raiser, with the rest coming from individuals. The Washington Hospital Center pays the alliance’s clinicians.

She spends about three days a week raising money, she says, a task made challenging not only by the controversial nature of her work but also by a lack of understanding of the need for it. (Unicef figures place the United States highest among developed nations for births to teen mothers, at a rate four times that of the average of European Union countries.)

And support for preventing first pregnancies is much easier to find than for programs aimed at preventing subsequent pregnancies, Ms. Patchen says.

There are reasons for that, she acknowledges: “People think it is better to prevent pregnancy in the first place, but people don’t put much thought into what comes later. These girls are perceived as going from being a youth to being a mother, and people begin to confer adult standards on these children. Therefore, these girls begin to fall out of the system because they really don’t fit well anywhere.”

But, she adds, a group like hers can help those girls make the transition to full-fledged adulthood successfully. “The answer is long-term support that is different for every individual. When you look at our program, you’ll see that we are talking about parenting skills, finishing school — which is a very different conversation than simply saying, ‘Don’t have sex.’”

Violence Victims

Lunch ends at 2 p.m., and it’s back to seeing patients.

One girl says she has come in for birth-control pills, but Ms. Patchen believes she really wants to talk about something else. The girl responds to Ms. Patchen’s inquiries about whether her boyfriend has been hitting her with an answer just short of a yes. But she won’t take her clothes off to be examined for bruises. She is not the only Teen Alliance client who is being beaten: Another appointment this afternoon is with a girl who has had her jaw broken by a boyfriend.

“Another of my patients was pushed out of a third-floor kitchen window by her boyfriend,” says Ms. Patchen. “She survived, but is paralyzed from the waist down.”

Soon it becomes apparent that Ms. Patchen is not going have time to see all her patients and also make the 4 p.m. support- group meeting for Teen Alliance clients. The weekly meeting, she says, may feature guest speakers from the juvenile-justice system, who offer the girls advice on personal safety, or other experts who talk about domestic violence and how to negotiate relationships.

“And sometimes,” she notes, “the kids just play board games.”

After seeing the troubled girl who called to make an appointment at the start of the day, Ms. Patchen heads back to the Washington Hospital Center — where all the Teen Alliance babies are delivered — for her regular Thursday shift.

By 5:45 p.m., she and the attending physician and chief residents examine their patients. Ms. Patchen’s role is to do triage, evaluating pregnant patients for treatment and delivery. If a woman is experiencing normal labor — the medical niche of the midwife — Ms. Patchen may find herself delivering the baby solo.

At about 9 p.m., she leaves for home — with a sense of mission. Says Ms. Patchen, “My daughter won’t go to bed until I’ve kissed her goodnight.”