Prenatal care: limitations and opportunities

Prenatal care is a venerable tradition in the U.S. health care system and one that deserves critical examination. Inordinate amounts of public and personal resources are expended on a tradition of care that has not proven itself equal to current perinatal prevention challenges. In this article, the evolution of prenatal care is reviewed, its efficacy is critiqued, and efforts at restructuring the content and processes of care are examined. Three promising alternatives to the dominant medical model are described: the comprehensive prenatal care approach illustrated by many publicly funded prenatal clinics, the prenatal empowerment model as exemplified by midwifery care, and the prenatal group model as illustrated by CenteringPregnancy. Nurses are called upon to champion prenatal options for women.     

Introduction of CenteringPregnancy in a Public Health Clinic

CenteringPregnancy is a promising group visit prenatal care innovation that provides substantial health promotion content. Elements unique to group care include peer support and self‐management training and activities. CenteringPregnancy was introduced at a large public health clinic serving predominantly low‐income African American pregnant women. All prenatal care at this clinic was provided by certified nurse‐midwives, and all providers were trained in the CenteringPregnancy model. One hundred and ten women received prenatal care in CenteringPregnancy groups. Focus groups of pregnant women, providers, and health center staff reported that the program benefited women despite implementation challenges such as scheduling changes. Compared to women in individual care, women in CenteringPregnancy had significantly more prenatal visits, increased weight gain, increased breast feeding rates, and higher overall satisfaction. This pilot project demonstrated that CenteringPregnancy can be implemented in a busy public health clinic serving predominantly low‐income pregnant women and is associated with positive health outcomes.     

CenteringPregnancy and the current state of prenatal care

Prenatal care is often credited with improving pregnancy outcomes. Yet rates of low birthweight (LBW) and prematurity have risen in recent decades, calling into question the efficacy of traditional prenatal routines. Proposals have included broadening the objectives of prenatal care beyond prevention of LBW and enriching care to provide education and support for pregnant women. CenteringPregnancy, an innovative model of prenatal care that integrates extensive health education and group support with the standard prenatal exam, incorporates many of these elements. Impediments to wider implementation of CenteringPregnancy are explored, as well as proposals for addressing these challenges.     

Comparison of selected outcomes of CenteringPregnancy versus traditional prenatal care

The purpose of this study was to assess the effect of traditional prenatal care versus a group model of care, CenteringPregnancy, on maternal knowledge of pregnancy, social support, health locus of control, and satisfaction. The CenteringPregnancy model of care gives patients extended time with the provider in a group setting. The study used a two-group, pretest/posttest design of pregnant women who elected either the traditional approach to prenatal care (n = 48) or the Centering approach (n = 50). The results of this study showed statistically significant differences between the groups on posttest in knowledge of pregnancy. For social support and health locus of control, the high scores at pretest contributed to a ceiling effect, which limited the potential for change. Additional research is needed to assess health status outcomes among women electing alternative approaches to prenatal care.     

A Model of Group Prenatal Care for Patients with Prenatally Diagnosed Fetal Anomalies

The model of group prenatal care was initially developed to include peer support and to improve education and health‐promoting behaviors during pregnancy. This model has since been adapted for populations with unique educational needs. Mama Care is an adaptation of the CenteringPregnancy Model of prenatal care. Mama Care is situated within a national and international referral center for families with prenatally diagnosed fetal anomalies. In December 2013, the Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia began offering a model of group prenatal care to women whose pregnancies are affected by a prenatal diagnosis of a fetal anomaly. The model incorporates significant adaptations of CenteringPregnancy in order to accommodate these women, who typically transition their care from community‐based settings to the Center for Fetal Diagnosis and Treatment in the late second or early third trimester. Unique challenges associated with caring for families within a referral center include a condensed visit schedule, complex social needs such as housing and psychosocial support, as well as an increased need for antenatal surveillance and frequent preterm birth. Outcomes of the program are favorable and suggest group prenatal care models can be developed to support the needs of patients with prenatally diagnosed fetal anomalies.     

Redesigning prenatal care through CenteringPregnancy

CenteringPregnancy is a model of group prenatal care that provides more than 20 hours of contact time between the childbearing care provider and a cohort of pregnant women with similar due dates. During this time, each woman has the opportunity to build community with other pregnant women, learn self-care skills, get assurance about the progression of her pregnancy, and gain knowledge about pregnancy, birth, and parenting. Ten essential elements have been defined, which contribute to the success of this model of prenatal care delivery. These elements correspond with the Institute of Medicine's 2001 challenge to improve the quality of health care in the United States. Foundational perspectives provide potential explanations for the model's growing influence and success. Implications for clinical practice and further research to link it with perinatal health outcomes are suggested.     

Birth Outcomes Associated with Receipt of Group Prenatal Care Among Low‐Income Hispanic Women

Introduction: Although Hispanic women in the United States have preterm birth and low‐birth‐weight rates comparable to non‐Hispanic white women, their rates fall short of 2010 Healthy People goals, with variability found across states. This study examined the effectiveness of the CenteringPregnancy group prenatal care model in reducing preterm birth and low‐birth‐weight rates for Hispanic women. Methods: Pregnant Hispanic women at less than or equal to 20 weeks, gestation initiating prenatal care between January 2008 to July 2009 at 2 Palm Beach County, Florida, public health clinics selected either group or traditional prenatal care. Data on neonatal birth weight and gestational age were obtained through abstraction of Palm Beach County Health Department medical records. Records were abstracted for 97% of CenteringPregnancy (n = 150) and 94% of traditional care (n = 66) participants. Results: A statistically significant difference was found in the percentage of women giving birth to preterm neonates (5% group prenatal care vs 13% traditional care; P= .04). There were no statistically significant differences in the percentage of women having a low‐birth‐weight neonate when group and traditional care participants were compared. Discussion: The CenteringPregnancy model holds promise for improving the birth outcomes of Hispanic women. Future research should be conducted with larger sample sizes to replicate study findings using experimental designs and incorporating formal cost‐effectiveness analyses.     

Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program

Adolescent pregnancy remains a significant social, economic, and health issue in the United States. The unique developmental needs of the pregnant adolescent require attention when designing prenatal care services. The CenteringPregnancy model of group prenatal care provides education and support for young women in an active and developmentally appropriate environment. Thirteen groups of adolescents (N = 124) have completed the Centering program at the Teen Pregnancy Center at Barnes Jewish Hospital in St. Louis, Missouri. Evaluation data suggest that the model has encouraged excellent health care compliance, satisfaction with prenatal care, and low rates of preterm birth and low birth weight infants.     

“I Wasn't Alone”—A Study of Group Prenatal Care in the Military

The military has recognized that health and quality of life for service members are closely tied to the resources for their families, including how they are cared for during pregnancy and childbirth. However, there has been little examination of women's experience with different models of prenatal care (PNC) in military settings. The purpose of this article is to describe the results of a qualitative study of women's experiences with the CenteringPregnancy model of group PNC compared to individual PNC in two military health care settings. This clinical trial enrolled 322 women who were randomized into group or individual PNC at two military treatment facilities. Qualitative interviews were completed with 234 women during the postpartum period. Interpretative narrative and thematic analysis was used to identify three themes: 1) “I wasn't alone”—the experience with group PNC; 2) “I liked it but…”—recommendations to improve group PNC; and 3) “They really need to listen”—general concerns across the sample about PNC. Greatest concerns of women in individual PNC included lack of continuity and time with the provider. Our military families must be assured that their health care system meets their needs through personal and family‐centered care. Group PNC offers the potential for continuity of provider while also offering community with other women. In the process, women gain knowledge and power as a health care consumer.     

CenteringParenting: An Innovative Dyad Model for Group Mother‐Infant Care

CenteringParenting is a group model that brings a cohort of 6 to 7 mothers and infants together for care during the first year of life. During 9 group sessions the clinician provides well‐baby care and also attends to the health, development, and safety issues of the mother. Ideally, CenteringParenting provides continuity of care for a cohort of women who have received care in CenteringPregnancy, group prenatal care that is 10 sessions throughout the entire pregnancy and that leads to community building, better health outcomes, and increased satisfaction with prenatal care. The postpartum year affects the entire family, but especially the mother, who is redefining herself and her own personal goals. Issues of weight/body image, breastfeeding, depression, contraception, and relationship issues all may surface. In traditional care, health resources for support and intervention are frequently lacking or unavailable. Women's health clinicians also note the loss of contact with women they have followed during the prenatal period, often not seeing a woman again until she returns for another pregnancy. CenteringParenting recognizes that the health of the mother is tied to the health of the infant and that assessment and interventions are more appropriate and efficient when done in a dyad context. Facilitative leadership, rather than didactic education, encourages women to fully engage in their care, to raise issues of importance to them, and to discuss concerns within an atmosphere that allows for the surfacing of culturally appropriate values and beliefs. Implementing the model calls for system changes that are often significant. It also requires the building of a substantial team relationship among care providers. This overview describes the CenteringParenting mother‐infant dyad care model with special focus on the mother and reviews the perspectives and experiences of staff from several practice sites.     

Women with primary antibody deficiencies requiring IgG replacement therapy: their perception of prenatal care during pregnancy

OBJECTIVE: To investigate how a group of women with primary antibody deficiencies (PAD) and receiving replacement therapy with IgG experienced the care they received in their prenatal clinics in relation to PAD and IgG therapy. DESIGN: An exploratory study using a written questionnaire. SETTING: The study originates from an immunodeficiency unit but evaluates care experienced at prenatal clinics. PARTICIPANTS: Nine women (25-43 years) attending an immunodeficiency unit and who fulfilled inclusion criteria for simultaneously having PAD, replacement IgG therapy, and full-term pregnancy (the latter within the past 5 years). MAIN OUTCOME: Women's perception of the response of midwives and physicians at their prenatal clinics to their PAD and IgG therapy during pregnancy. RESULTS: Women perceived that the obstetricians and the midwives had insufficient knowledge about PAD and IgG replacement therapy. Two women reported that their IgG therapy during pregnancy had been questioned. All nine women felt marginalized and unheard by staff regarding their PAD and need for IgG therapy. However, the women were satisfied with the checkups regarding the pregnancy as such. CONCLUSIONS: This study is the first attempt to investigate the prenatal experience of women with PAD (Search of PubMed, 1980 to present, including search terms primary immunodeficiency, pregnancy, and prenatal care). This study demonstrates that increased knowledge about PAD and IgG replacement therapy among midwives and physicians working in prenatal care clinics is needed. This can prevent misleading advice that puts the health of the mother and her fetus at risk. Sensitizing staff about this special group of women can create conditions in which women feel respected, heard, and satisfied with their prenatal care.     

A qualitative study of the experience of CenteringPregnancy group prenatal care for physicians

Background

This study sought to understand the central meaning of the experience of group prenatal care for physicians who were involved in providing CenteringPregnancy through a maternity clinic in Calgary, Canada.

Method

The study followed the phenomenological qualitative tradition. Three physicians involved in group prenatal care participated in a one-on-one interview between November and December 2009. Two physicians participated in verification sessions. Interviews followed an open ended general guide and were audio recorded and transcribed. The purpose of the analysis was to identify meaning themes and the core meaning experienced by the physicians.

Results

Six themes emerged: (1) having a greater exchange of information, (2) getting to knowing, (3) seeing women get to know and support each other, (4) sharing ownership of care, (5) having more time, and (6) experiencing enjoyment and satisfaction in providing care. These themes contributed to the core meaning for physicians of “providing richer care.”

Conclusions

Physicians perceived providing better care and a better professional experience through CenteringPregnancy compared to their experience of individual prenatal care. Thus, CenteringPregnancy could improve work place satisfaction, increase retention of providers in maternity care, and improve health care for women.

     

The Mexican Experience Adapting CenteringPregnancy: Lessons Learned in a Publicly Funded Health Care System Serving Vulnerable Women

Group antenatal care is an innovative model of health care in which all components of antenatal care—clinical, educational, and supportive—happen in a group context with health care professionals as facilitators. CenteringPregnancy is the most studied model of group antenatal care, now widely implemented in the United States. This model has been shown to be effective in improving health and behavioral outcomes in the United States, but there is less known about the experience adapting group antenatal care in settings outside the US health care system. This article describes the adaptation of the CenteringPregnancy model to a Mexican context. We describe the Mexican health care context and our adaptation process and highlight key factors to consider when adapting the content and modality of the CenteringPregnancy model for diverse populations and health systems. Our findings are relevant to others seeking to implement group antenatal care in settings outside the US health care system.     

Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome

Rates of maternal morbidity and mortality are rising in the United States. Non-Hispanic Black women are at highest risk for these outcomes compared to those of other race/ethnicities. Black women are also more likely to be late to prenatal care or be inadequate users of prenatal care. Prenatal care can engage those at risk and potentially influence perinatal outcomes but further research on the link between prenatal care and maternal outcomes is needed. The objective of this article is to review literature illuminating the relationship between prenatal care utilization, social determinants of health, and racial disparities in maternal outcome. We present a theoretical framework connecting the complex factors that may link race, social context, prenatal care utilization, and maternal morbidity/mortality. Prenatal care innovations showing potential to engage with the social determinants of maternal health and address disparities and priorities for future research are reviewed.     

Determinants of periodontal health in pregnant women and association with infants’ anthropometric status: a prospective cohort study from Eastern Uganda

Background

Pregnant women in Canada have traditionally received prenatal care individually from their physicians, with some women attending prenatal education classes. Group prenatal care is a departure from these practices providing a forum for women to experience medical care and child birth education simultaneously and in a group setting. Although other qualitative studies have described the experience of group prenatal care, this is the first which sought to understand the central meaning or core of the experience. The purpose of this study was to understand the central meaning of the experience of group prenatal care for women who participated in CenteringPregnancy through a maternity clinic in Calgary, Canada.

Methods

The study used a phenomenological approach. Twelve women participated postpartum in a one-on-one interview and/or a group validation session between June 2009 and July 2010.

Results

Six themes emerged: (1) "getting more in one place at one time"; (2) "feeling supported"; (3) "learning and gaining meaningful information"; (4) "not feeling alone in the experience"; (5) "connecting"; and (6) "actively participating and taking on ownership of care". These themes contributed to the core phenomenon of women "getting more than they realized they needed". The active sharing among those in the group allowed women to have both their known and subconscious needs met.

Conclusions

Women's experience of group prenatal care reflected strong elements of social support in that women had different types of needs met and felt supported. The findings also broadened the understanding of some aspects of social support beyond current theories. In a contemporary North American society, the results of this study indicate that women gain from group prenatal care in terms of empowerment, efficiency, social support and education in ways not routinely available through individual care. This model of care could play a key role in addressing women's needs and improving health outcomes.     

Maternal decision on obtaining prenatal care: a study in Brazil

Objective

to address the social aspects of pregnancy and the views of pregnant women regarding prenatal assistance in Brazil.

Design

this qualitative study was focused on describing the Social Representations of prenatal care held by pregnant women. The discourse of the collective subject (DCS) framework was used to analyse the data collected, within the theoretical background of social representations, as proposed and developed by Serge Moscovici.

Participants and setting

21 pregnant women who were users of the publicly funded Brazilian unified health-care system and resided in the area served by its family health programme in a low- to middle-income neighbourhood on the outskirts of Campo Grande, the capital of the state of Mato Grosso do Sul, in southwestern Brazil. Data were collected by conducting in-depth, face-to-face interviews from January to October 2006.

Findings

all participants were married. Formal education of the participants was less than five years in four cases, between five and eight years in six cases, and greater than 11 years in 10 cases. Nine participants had informal jobs and earned up to US$ 200 per month, four paricipants had administrative jobs and earned over US$ 500 per month, and eight participants did not work. No specific racial/ethnic background predominated. Lack of adherence to prenatal care allowed for the identification of two DCS themes: ‘organisation of prenatal care services’ and ‘lifestyle features’.

Key conclusions

the respondents were found to have negative feelings about pregnancy which manifest as many fears, including the fear of harming their children's health, of being punished during labour, and of being reprimanded by health-care professionals for overlooking their prenatal care, in addition to the insecurity felt towards the infant and self.

Implications for practice

the findings reveal that communication between pregnant women and health-care professionals has been ineffective and that prenatal care has not been effective for the group interviewed—features that are likely to be found among other low- to middle-income groups living elsewhere in Brazil.     

Exploring the associations between intimate partner violence victimization during pregnancy and delayed entry into prenatal care: Evidence from a population-based study in Bangladesh

ObjectiveIntimate partner violence (IPV) during pregnancy can have serious health consequences for mothers and newborns. The aim of the study is to explore: 1) the influence of experiencing IPV during pregnancy on delayed entry into prenatal care; and 2) whether women's decision-making autonomy and the support for traditional gender roles act to mediate or moderate the relationship between IPV and delayed entry into prenatal care.Designcross-sectional survey. Multivariate logistic regression models were estimated that control for various socio-demographic and pregnancy related factors to assess whether women who experienced IPV during pregnancy were more likely to delay entry into prenatal care compared with women who had not experienced IPV. The influence of traditional gender roles acceptance and decision-making autonomy were examined both as independent variables and in interaction with IPV, to assess their role as potential mediators or moderators.SettingChandpur district, Bangladesh.Participantsthe sample comprised of 426 Bangladeshi women, aged 15–49 years. Postpartum mothers who visited vaccinations centres to receive their children's vaccinations constitute the sampling frame.Resultsalmost 70% of the women surveyed reported patterns consistent with delayed entry into prenatal care. Accounting for the influence of other covariates, women who experienced physical IPV during pregnancy were 2.61 times more likely (95% CI [1.33, 5.09]) to have delayed entry into prenatal care than their counterparts who did not report physical IPV. Neither sexual nor psychological IPV victimization during pregnancy was linked with late entry into prenatal care. Both gender role attitudes and levels of autonomy mediate the effect of IPV on prenatal care.Key conclusionsthe results suggest that the high rates of IPV in Bangladesh have effects that can compromise women's health seeking behaviour during pregnancy, putting them and their developing fetus at risk. Specifically, Bangladeshi women who experience physical IPV during pregnancy are more likely to delay or forgo prenatal care, an effect that is further magnified by cultural ideals that emphasize women's traditional roles and limit their autonomy.Implications for practicethis study reinforces the need to detect and assist women suffering IPV, not only to offer them help and support but also to increase entry into prenatal care. Healthcare professionals involved in obstetrics and midwifery need to be aware of the risk factors of IPV during pregnancy and be able to identify women who are at risk for delayed entry into prenatal care.