By Ahizechukwu C. Eke, MD, PhD, MPH
Associate Professor in Maternal Fetal Medicine, Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore
SYNOPSIS: This study demonstrated that, when compared to women receiving conventional prenatal care, CenteringPregnancy care was associated with a substantial decrease in interpregnancy intervals at ≤ 6 and ≤ 12 months and a remarkable increase in postpartum long-acting reversible contraception uptake.
SOURCE: Keller JM, Norton JA, Zhang F, et al. The impact of group prenatal care on interpregnancy interval. Am J Perinatol 2021; Dec 10. doi: 10.1055/s-0041-1739413. [Online ahead of print].
Group prenatal care is an innovative approach to prenatal care that is facilitated by skilled healthcare professionals and provided in a group setting while incorporating peer support, routine health assessments, information-gathering, and skills development.1 Pregnant women in group prenatal care receive 15-20 hours of prenatal care throughout their pregnancies, as opposed to two to four hours of prenatal care per visit in standard individual care.2 In addition to routine prenatal care history taking and physical exams, group prenatal care provides possibilities for social support and enhancement of patient education.3
Several group prenatal care models currently are being practiced in the United States, but the group prenatal care paradigm that is most well-known and has undergone the most in-depth study is CenteringPregnancy.4 CenteringPregnancy units typically consist of approximately 10 pregnant women of similar gestational ages who take their blood pressure and weigh themselves prior to a brief appointment with a qualified healthcare professional. Following that, the healthcare practitioner and group facilitators provide a conversation and instructional exercises to address common health issues.4 As such, CenteringPregnancy has been hypothesized to have many advantages, including being cost-effective, providing a solution to the current shortage of healthcare providers (fewer providers typically are involved in CenteringPregnancy), solving the issues of dissatisfaction and lengthy wait times associated with traditional individual prenatal care, and improving overall maternal and infant well-being. In this study, Keller and colleagues evaluated whether being a part of a CenteringPregnancy group prenatal care reduces the risk of short interpregnancy intervals (IPI).5
This was a retrospective cohort analysis of mothers who had been enrolled in Medicaid in Missouri between 2007 and 2014. Women 11 years of age or older with viable singleton delivery during the study period, domiciled in the city or county of St. Louis, with two or more prior prenatal visits met criteria for inclusion. Patients with multiple gestations and those judged at high risk for group prenatal care by an obstetrician were excluded and directed to a physician-led practice for standard prenatal care. Midwives or nurse practitioners led 10 two-hour CenteringPregnancy sessions with six to 10 women of similar gestational ages. Childbirth preparation, breastfeeding, and contraception were discussed.5
Participation in CenteringPregnancy group prenatal care was the exposure, while IPI six months or less was the primary endpoint. According to birth certificate records, IPI is the number of months between the end of one pregnancy and the beginning of a subsequent pregnancy. Secondary outcomes included IPI ≤ 12 months, IPI ≤ 18 months, and postpartum long-acting reversible contraception (LARC) uptake. Using descriptive statistics, demographics were analyzed. Student’s t-test, Wilcoxon’s rank-sum test, and chi-square test were used to compare the differences between CenteringPregnancy and traditional care for pregnant women. Multivariable logistic regression was used to calculate adjusted odds ratios (aORs). Maternal age, race, obesity, nulliparity, marital status, diabetes, hypertension, previous preterm births, and maternal education were potential confounders that were accounted for in the logistic regression analysis. P values were statistically significant at < 0.05.
A total of 54,968 pregnancies met study criteria: 1,550 (3%) received CenteringPregnancy prenatal care and 53,418 (97%) received standard prenatal care. CenteringPregnancy participants were more likely to be nulliparous, non-Hispanic Black or Hispanic, and have a normal body mass index. CenteringPregnancy participants were less likely to have an IPI ≤ 6 months (aOR, 0.61; 95% confidence interval [CI], 0.47-0.79) and ≤ 12 months (aOR, 0.74; 95% CI, 0.62-0.87) than those in the standard prenatal care group. There was no difference in IPI at ≤ 18 months (aOR, 0.89; 95% CI, 0.77-1.03). CenteringPregnancy women were more likely to select a LARC method than women in the traditional care model (aOR, 1.37; 95% CI, 1.20-1.57).
COMMENTARY
This study by Keller et al demonstrated for the first time that CenteringPregnancy reduces IPIs ≤ 6 and ≤ 12 months and increases postpartum LARC uptake compared to standard prenatal care.5 Data from previous studies demonstrate that the CenteringPregnancy paradigm enhances outcomes for pregnant women, as well as fetal outcomes. For example, preterm birth rates, low birth weight, and postpartum depression have been demonstrated to decline among women engaged in CenteringPregnancy compared to those engaged in traditional prenatal care.6-8 Additionally, CenteringPregnancy programs save time for both providers and patients, promote active problem-solving, and benefit patients with access to better knowledge, contentment with care, and compliance, as well as successful breastfeeding efforts.9
Although CenteringPregnancy has been demonstrated to prevent adverse pregnancy outcomes, it has its disadvantages. At present, the data support CenteringPregnancy for women with low-risk pregnancies, since patients with high-risk conditions usually are excluded from participating in CenteringPregnancy. As such, it is not known if the advantages of CenteringPregnancy are directly applicable to high-risk pregnancies. Patients’ privacy is not guaranteed during group physical exams in CenteringPregnancy models. Because eight to 10 women are evaluated at the same time, the history taking and physical examination evaluation sessions in CenteringPregnancy models often are rushed, increasing the potential for errors. Also, limiting CenteringPregnancy to eight to 10 women per group throughout pregnancy can limit relationships pregnant women form with other pregnant individuals and healthcare providers.10 CenteringPregnancy presents challenges for healthcare providers in terms of implementation, including difficulties with scheduling all participants at once, recruitment, and access to medical records.11 It also presents difficulties for healthcare providers in terms of developing group facilitation skills and sacrificing the benefits of one-on-one time with clients.12
Overall, the CenteringPregnancy care paradigm allows healthcare providers to give pregnancy and birth-related knowledge in a group environment, affording women a sense of ownership and involvement in their care, as well as access to community support that is not always available when working one-on-one with a healthcare practitioner. CenteringPregnancy also decreases IPI and optimizes pregnancy outcomes in low-risk pregnancies. Thus, the American College of Obstetricians and Gynecologists (ACOG) advises that women with low-risk pregnancies be given the option to choose between group prenatal care and traditional prenatal care models because group prenatal care is a promising model with comparable pregnancy outcomes to the individual standard prenatal care model.4 However, ACOG cautions that group prenatal care models can be difficult to initiate and maintain.4
REFERENCES
- Catling CJ, Medley N, Foureur M, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev 2015;2015:CD007622.
- Ickovics JR, Kershaw TS, Westdahl C, et al. Group prenatal care and perinatal outcomes: A randomized controlled trial. Obstet Gynecol 2007;110:330-339.
- Massey Z, Schindler Rising S, Ickovics J. CenteringPregnancy group prenatal care: Promoting relationship-centered care. J Obstet Gynecol Neonatal Nurs 2006;35:286-294.
- [No authors listed]. ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol 2018;131:616-618.
- Keller JM, Norton JA, Zhang F, et al. The impact of group prenatal care on interpregnancy interval. Am J Perinatol 2021; Dec 10. doi: 10.1055/s-0041-1739413. [Online ahead of print].
- Abshire C, McDowell M, Crockett AH, Fleischer NL. The impact of CenteringPregnancy group prenatal care on birth outcomes in Medicaid eligible women. J Womens Health (Larchmt) 2019;28:919-928.
- Tubay AT, Mansalis KA, Simpson MJ, et al. The effects of group prenatal care on infant birthweight and maternal well-being: A randomized controlled trial. Mil Med 2019;184:e440-e446.
- Heberlein EC, Picklesimer AH, Billings DL, et al. The comparative effects of group prenatal care on psychosocial outcomes. Arch Womens Ment Health 2016;19:259-269.
- Chae SY, Chae MH, Kandula S, Winter RO. Promoting improved social support and quality of life with the CenteringPregnancy® group model of prenatal care. Arch Womens Ment Health 2017;20:209-220.
- Phillippi JC, Myers CR. Reasons women in Appalachia decline CenteringPregnancy care. J Midwifery Womens Health 2013;58:516-522.
- Novick G, Womack JA, Lewis J, et al. Perceptions of barriers and facilitators during implementation of a complex model of group prenatal care in six urban sites. Res Nurs Health 2015;38:462-474.
- Novick G, Sadler LS, Knafl KA, et al. In a hard spot: Providing group prenatal care in two urban clinics. Midwifery 2013;29:690-697.
This study demonstrated that, when compared to women receiving conventional prenatal care, CenteringPregnancy care was associated with a substantial decrease in interpregnancy intervals at ≤ 6 and ≤ 12 months and a remarkable increase in postpartum long-acting reversible contraception uptake.
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