About 75% of the pregnant patients at Neighborhood Health Center qualify as high risk patients. High risk could mean a number of things, depending on each patient. It could be related to a previous complication during pregnancy, comorbidities such as hypertension and diabetes, and preeclampsia. High risk can also mean having two or more social drivers of health (SDOH) barriers to care. (read more here)

SDOH barriers contribute greatly to a baby being born at a low birth weight. This could be anything from lack of access to food or proper nutrition, lack of a stable living situation, or lack of transportation to important appointments. Low birth weight can also occur due to other comorbidities that are outside of a patient’s control. Low birth weights are tracked and reviewed weekly and monthly to make sure no patient slips through the cracks. 

“In 2022 we had almost 50 babies delivered underweight and in 2023 we had 20, which is a big feat for Neighborhood and our OBGYN team, especially Chan and Donna,” said Casey MacLeod, quality manager at Neighborhood.

Chan Myae Thu and Donna Marien are OB-GYN care coordinators at Neighborhood. Chan and Donna have been in these roles with the organization for 9 and 7 years, respectively. To Chan, working with this patient population is what she always wanted to do. Originally from Myanmar (Burma), Chan worked in an STD clinic taking care of pregnant patients and helping with prenatal care. 

“I have always been in this field, that is my love,” said Chan. “When I came [to Buffalo] I knew this is what I wanted to keep doing.”

Before Neighborhood, Donna worked as a medical liaison for children in a group home. Neighborhood is her first time in a primary care setting, but she has always been interested in fields that focus on people and connecting with them. 

“This is not a job you can do if you are not loving and enjoying caring for the patients,” said Donna. 

In their roles at Neighborhood, Chan and Donna work to fill in any gaps to patient care including encouraging patients staying engaged in their care during pregnancy, assisting patients with transportation to appointments, scheduling of any clinical and specialist appointments, connecting patients to resources and necessary supplies, and more. 

“Assisting our patients with navigating patient care and connecting them with social supports ultimately ends up in better health outcomes for the patient, and higher birth weights of the babies delivered under care at Neighborhood,” said Casey.

Whether it is taking a call after hours from a patient with a concern, or delivering a car seat to a patient at the hospital giving birth, or following up with patients to get them seen by their provider, Chan and Donna are there with the patient every step of the way. This includes after patients go through labor and delivery. 

“We are lucky that we have pediatrics in office as well,” said Chan. “Once the baby is delivered and we know that the baby is low birth weight and will need extra care, we have the team and resources here for the baby to be taken care of right away.”

This also means that the patient and their baby can continue care with Neighborhood and not have to navigate an entirely new system or medical office following labor. Since pregnancy is a long and at times stressful process, Chan and Donna have the opportunity to create lasting connections with patients, as a stable source of support in their lives.

Chan recalls a patient that she helped who was from China. The patient’s husband was in the U.S. for school, and she was here with him on a visa. Though the patient’s pregnancy was planned and she went to preconception counseling, she was above 35 years old which automatically put her in the high risk patient category. With the support of Chan and the OB-GYN team, the patient was able to get connected with insurance assistance, immigration assistance, and was able to have a healthy pregnancy and birth. When her baby was three months old, they returned to their home and family in China. Some time later, Chan received a call from that patient in China, and that patient’s mother in law.

“They just said how thankful they were for the care that she received here,” said Chan. “That they were made to feel safe at Neighborhood even though they were so far away from home.”

To Chan, being able to assist pregnant women and care for those two (or more) lives at the same time makes her happy. Dr. Anne Marie Davis, associate director of Neighborhood’s OB-GYN department appreciates Donna’s determination in keeping in touch with her patients, and making sure they have everything they need ahead of their delivery date.

“I have high risk patients that have Donna’s extension so they can call her and get the things they need,” said Dr. Davis. “They never feel like they can’t call her for something.”

Donna explained that the lengths they go to keep patients engaged in their care is unique to Neighborhood. Just recently, she had a pregnant patient that was dealing with unstable housing, while also caring for 3 other children under the age of 6. Close to her delivery date, the patient ended up needing emergency dental care, which Donna was able to support her in setting up. Donna was also able to get this patient a car seat and other supplies that she would need when the baby was born. 

“Had she gone somewhere else for care, it is less likely she would have been connected with all this assistance,” said Donna. 

Donna connected the work that she and Chan do to Neighborhood’s mission. In their role, they care for the whole person and that person's child(ren). They help patients following pregnancy by getting them connected with lactation experts, nutrition needs, supplies and more. 

“We are promoting growth and health in our community,” said Donna. “Our care doesn’t stop at the end of pregnancy.”