Larry Culpepper, MD:
Building a Better Baby

By Laurie Jones
4 May 1990
American Medical News; Page 7

Pawtucket, RI -- At first, Larry Culpepper, MD, hoped for a small article in the local paper, perhaps a mention on a morning radio broadcast. A segment on the local television news seemed too much to expect.

So the 41-year-old family physician was shocked when his office began receiving requests for interviews from CBS, NBC, USA Today, National Public Radio, and ABC's "Good Morning America."

Dr. Culpepper directs the department of family medicine at Memorial Hospital of Rhode Island, a 340-bed private, non-profit hospital in this city of about 72,000. The mostly working class community, with its large number of Latino and Portuguese immigrants, is best known as the headquarters of Hasbro Inc., toy company and the home of the Boston Red Sox farm team.

But the attraction that has lured the national media here since February is not business or sports. It's the Healthy Baby Lottery, an innovative program using cash prizes to encourage pregnant women to start prenatal care as early as possible. It is believed to be the first such program in the nation.

"We were pretty overwhelmed when the networks and everyone else started calling," said Dr. Culpepper, who also heads the family medicine program at Brown University School of Medicine. "It got to where there were camera crews coming through here and reporters calling almost every day."

The lottery offers women the chance to win cash if they begin prenatal care before the 12th week of pregnancy and go to all their prenatal medical appointments. The program is open to any pregnant woman living in Pawtucket or neighboring Central Falls and receiving care from a physician in either city.

Each month, six names are drawn to receive six prizes: two each of $25, $50, and $100. If a woman's name is chosen and she registered for the program before her 10th week of pregnancy, she receives a $50 bonus. Every six months, a prize of $500 is awarded.

The lottery is run by the Blackstone Valley Perinatal Network, part of the hospital's family medicine department. The network coordinates the efforts of the major providers of prenatal care in the Pawtucket/Central Falls area, from social workers to school nurses to physicians.

THE LOTTERY is funded through a two-year $30,000 MArch of Dimes grant and partly from a three-year, $567,000 grant from the Dept. of Health and Human Services.

When Dr. Culpepper and other officials held a news conference in January to announce the lottery's Feb. 1 start date, the program quickly became national news.

And although Dr. Culpepper was pleased to have the national spotlight zoom in on the program, the publicity has had its drawbacks. Like other physicians involved with innovative programs that draw public attention, Dr. Culpepper soon discovered the difficulty of explaining a complex health issue to reporters who want everything made quick and simple.

"A lot of the media just wanted glitz; they wanted a simple message," he said. "Unfortunately, the issue isn't that simple. The attention has provided us with a good opportunity to get the message out that early prenatal care is important. But we don't want people to look at the lottery as a quick-fix solution."

Perinatal network officials came up with the lottery idea in late 1988, shortly after release of an Institute of Medicine study on access to prenatal care. The study named several barriers that often prevent women from receiving prenatal care: lack of finances, insufficient supply of practitioners, and institutional obstacles, such as large, impersonal clinics and lack of transportation.

Several factors happen to combine to make the Pawtucket/Central Falls an ideal place to try a lottery incentive program, said Toni McGuire, RN, perinatal network coordinator.

Medicaid and RITE Start, a state program for low-income pregnant women, takes care of the financial hurdle, said McGuire. And the fact that many of the doctors in area clinics are family physicians rather than obstetricians makes it easier to keep the clinics staffed, said Dr. Culpepper.

"A family physician who treats pregnant women pays a much lower malpractice insurance premium than an ob-gyn," he said.

Also, because of Memorial Hospital's affiliation with Brown University's School of Medicine, family medicine residents help staff the clinics and many of the physicians who work at the clinics also teach classes at the medical school. The offer of a part-time medical school faculty position helps in recruiting and retaining doctors at the clinics, said Dr. Culpepper.

As for institutional-barriers, such as lack of transportation for low-income women, a separate March of Dimes grant allows the network to provide cab or bus fare to those who otherwise couldn't make their doctor's appointments.

But even with financing available for low-income women, plenty of physicians and easily accessible clinics with evening and weekend hours, many area women delayed prenatal care. More than 75% of the pregnant women seen at the Pawtucket and CEntral Falls clinics during the first six months of 1988 did not begin their prenatal care until after the 12th week of pregnancy, Dr. Culpepper said.

AN ESTIMATED 1,500 women give birth each year in Pawtucket and Central Falls. About half, most with little or no health insurance, receive care at one of the public clinics. The rest, most of them insured, see private practitioners.

"We needed an incentive to get women in earlier," said Dr. Culpepper. Once they are drawn in, MDs nurses, and other clinic workers can inform them of the services and financial help that is available.

Network officials settled on the lottery idea after rejecting several other possibilities.

"Some of the things that have been thought about in other [incentive] programs -- giving away car seats or baby clothes -- just didn't make sense to us," said the softspoken Dr. Culpepper. "Those things aren't going to click with a young teen or a woman who's living hand-to-mouth. Nine months is too far away.

"The only incentive that made sense to us was money."

Dr. Culpepper 's intense interest in prenatal care stems from his family medicine residency at Montefiore Medical Center in New York. While there in the early 1970s, he worked at a public health clinic in the South Bronx and made home visits in the area. Many of the pregnant women he treated, most of them minorities or recent immigrants, simply did not know that they should see a doctor as early as possible in their pregnancy.

Most people would like to think, Dr. Culpepper said, that no woman would need incentives to entice her to keep regular appointments from the start of pregnancy through her child's birth. But in reality, many women, particularly those with limited education and low incomes, don't realize the importance of prenatal care, especially in the first months of pregnancy.

"A lot of women who come to our clinics simply aren't aware that many of the baby's limbs and organs are formed very early in the pregnancy. And there are a lot of women who wait to come to the clinic until they're ready to give birth because they don't have the money to pay for appointments and they aren't aware of state programs that can help them pay."

According to the state health department, more than 40% of women in Pawtucket and nearly 60% in Central Falls are low income.

Lottery officials concede their focus is to reach those with more chance of high-risk pregnancies -- minorities, recent immigrants, teenagers, those with lower incomes and little education. But they decided to open the lottery to all area women, regardless of income and health insurance status.

"We really wanted to reach women throughout the economic spectrum," said Dr. Culpepper. "For low income women, we're trying to say that prenatal care is available and it is accessible to them and that there are providers who care. For the higher income women, we want to identify to them that early prenatal care is a priority."

One of those providers is Nabil Khory, MD, an obstetrician in a group practice who also works at one of the Pawtucket clinics.

"The lottery is a wonderful program," said Dr. Khory, who also directs the ob-gyn department at St. Joseph's Fatima Hospital in North Providence. "I've already noticed it's helping. More women are coming to the clinic who normally would skip an appointment.

"The minute they think they're pregnant, they come in now. Before, many used to wait four or five months before coming in. I think the word is out and it's catching on."

During the lottery's first month, network officials expected a half dozen women to sign up. Thirty-seven registered, said McGuire.

"We have posters and pamphlets all over the community," she said. "And of course the publicity has helped tremendously. People are talking about it."

Because an estimated 20% of the Pawtucket/Central Falls area population has difficulty communicating in English, network officials are relying on word-of-mouth to tell many area residents about the lottery.

"That's why we settled on six winners a month. Those, combined with the two $500 winners each year, will give us 74 women in the community a year who have won something from the lottery," said Dr. Culpepper. "Within a community this size, having 74 women talking to their family, their neighbors, their friends about this will give us word-of-moutn penetration into a community that otherwise wouldn't hear from us. That's what we're counting on."

Susan Theroux, a 25-year-old divorced mother of one, was among the lottery winners the first month. She won $25, plus the $50 bonus for having gone to her first appointment before her 10th week of pregnancy. Theroux, laid off from her job in December, is due in September. She is engaged to be married in May.

"I'm going to use the money to buy some baby things," said Theroux, a petite woman with long red hair. "I think the lottery's a great idea. I went for my appointment before I knew anything about the lottery. But I guess there are women who don't know they're supposed to go right away, so maybe it'll help bring them in."

Network officials say it's too soon to determine if the lottery is reaching those women who wouldn't have gone for early prenatal care. They are conducting surveys of the women who go to the clinics after their 12th week of pregnancy, which should help them discover why these women delay their care, said McGuire.

Since the lottery was thrust into the national spotlight, several dozen hospitals and health departments have contacted the network asking how they could develop a similar program.

The main advice network officials offer, said Dr. Culpepper, is to eliminate the major barriers to prenatal care before attempting a lottery.

"You've got to establish the support system first," he said. "Otherwise what you're going to do is, you're going to put into place a healthy baby lottery and just raise everybody's sense of frustration and hopelessness.

"If a woman can't pay for care and there's not a program to help her pay and doctors aren't available anyway and you're giving out money if she comes in early, and she can't come in early because of these barriers, well -- everyone's just going to end up frustrated."

Culpepper Ancestry. Larry is the brother of theologian, Dr. R. Alan Culpepper and the son of theologian and missionary Dr. Hugo H. Culpepper, son of John Hurlston Culpepper, son of John Francis Culpepper, son of John Malcolm Culpepper, son of William Henry Culpepper, son of John and Nancy Gillespie Culpepper.