| Abstract: | Objectives. We compared an evidence-based model of group prenatal care to traditional individual prenatal care on birth, neonatal, and reproductive health outcomes.Methods. We performed a multisite cluster randomized controlled trial in 14 health centers in New York City (2008–2012). We analyzed 1148 pregnant women aged 14 to 21 years, at less than 24 weeks of gestation, and not at high obstetrical risk. We assessed outcomes via medical records and surveys.Results. In intention-to-treat analyses, women at intervention sites were significantly less likely to have infants small for gestational age (< 10th percentile; 11.0% vs 15.8%; odds ratio = 0.66; 95% confidence interval = 0.44, 0.99). In as-treated analyses, women with more group visits had better outcomes, including small for gestational age, gestational age, birth weight, days in neonatal intensive care unit, rapid repeat pregnancy, condom use, and unprotected sex (P = .030 to < .001). There were no associated risks.Conclusions. CenteringPregnancy Plus group prenatal care resulted in more favorable birth, neonatal, and reproductive outcomes. Successful translation of clinical innovations to enhance care, improve outcomes, and reduce cost requires strategies that facilitate patient adherence and support organizational change.Bundling health care services—integrating prevention and treatment—is a strategy to meet “triple aim” goals: enhanced health care quality, improved health outcomes, and lower cost.1,2 The institutional benefits of bundling health care include reduced infrastructure and cost, the opportunity to provide additional services, and collaborative partnerships. Patient benefits include integrated services and reduced barriers to care.Pregnancy is an important window of opportunity, with frequent health care contact. Nonetheless, adverse birth outcomes remain leading causes of US infant morbidity and mortality3 and are concentrated among disadvantaged groups.4 Pregnant adolescents also have higher rates of sexually transmitted infection (STI) than do their nonpregnant counterparts and those who are nulliparous.5 Taken together, adolescent women from socially disadvantaged groups face adverse reproductive and sexual health disparities.Yet, bundled preventive interventions are not as common as are those that address individual risk factors.6 Regarding pregnancy, interventions among pregnant adolescents target either reproductive or sexual health, both with limited effectiveness. Clinical interventions such as progesterone administration and cervical cerclage prevent preterm birth in singleton gestations with previous preterm birth or short cervix.7 However, one half of women who deliver preterm have no known risks.8 An independent review of prenatal care models found only 1 randomized controlled trial (RCT) that demonstrated improved health outcomes.9 This study, from our research team, compared CenteringPregnancy group prenatal care to standard individual prenatal care. Our previous research documented that women randomized to group prenatal care had a 33% lower rate of preterm delivery.10 We also documented improved outcomes among women randomized to group prenatal care that bundled reproductive health promotion (CenteringPregnancy Plus): greater than 50% reduction in rapid repeat pregnancy among all women and incident STI among adolescents.11Translating evidence to routine health care practice is a National Institutes of Health priority.12 It is important to determine whether clinical interventions with demonstrated efficacy can be implemented to produce clinical benefits comparable to those observed during efficacy studies. First developed in 1968 to improve well-child care, group care consists of the same components of individual care visits coupled with education and skills building and takes place in a group of patients.13 Previous research across a range of health conditions suggests many clinical and psychosocial benefits, including improved patient self-management, adherence, satisfaction, and clinical outcomes.14 More time between patients and health care providers results in more patient-centered care.We conducted a multisite cluster RCT to assess the clinical effectiveness of group prenatal care bundled with reproductive health promotion compared with the clinical effectiveness of standard individual prenatal care. Cluster randomized trials can evaluate changes in service provision under conditions of actual use and are characterized by their multilevel nature15: in this case, pregnant women clustered into prenatal care settings. We hypothesized that women at clinical sites randomly assigned to deliver group prenatal care would have better reproductive and sexual health outcomes than those of women at sites randomized to individual care and that greater exposure to group prenatal care would be associated with better outcomes. Specifically, a priori outcomes included gestational age at delivery, infant birth weight, and small for gestational age as well as incident STI, rapid repeat pregnancy, and behavioral risk factors (e.g., condom use). We also included admission to and days in the neonatal intensive care unit (NICU). |
