Group Prenatal Care
By Rebecca H. Allen, MD, MPH
Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI
Dr. Allen reports she is a Nexplanon trainer for Merck, and has served as a consultant for Bayer and Pharmanest.
Group prenatal care is a different model for the delivery of prenatal care that typically consists of groups of eight to 12 women of similar gestational age who have each visit together. This contrasts with the one-on-one patient/provider prenatal care visits that are the traditional model. Women are enrolled in group prenatal care after they have had an individual initial prenatal visit and health risk assessment, and have completed the first trimester. Most programs enroll low-risk women who are able to attend the scheduled visits (eight to 10 visits lasting 90 to 120 minutes) and have childcare. The groups are run by an obstetric provider (nurse practitioner, nurse midwife, OB/GYN, or family medicine physician) and a co-facilitator (nurse, nutritionist, social worker, psychologist, health educator, or medical assistant). The visits consist of the standard maternal and fetal assessments followed by a group discussion regarding the prenatal education topic at hand. Women are encouraged to participate in the physical exam components, such as measuring their own blood pressure and weight. Most groups have the option of performing fundal height and fetal heart tone measurements in a semi-private area. There also can be individual consultations and exams as needed. Although there are different variations to group prenatal care, the first model that was established in the 1990s, CenteringPregnancy, is the most recognized and studied.1 (See Table 1.) CenteringPregnancy (https://www.centeringhealthcare.org) provides a framework and assistance in starting a group prenatal care program for roughly $20,000 over the first two years; there is a $500 annual membership fee.2 In addition, “Moms Notebooks” must be purchased for each participant for $22.
Table 1: 13 Essential Components of CenteringPregnancy |
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Adapted from: Rising SS, Kennedy HP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health 2004;49:398-404. |
The advantages of group prenatal care include the promotion of a community of women who can support each other throughout the pregnancy and postpartum. Women also spend more time with a prenatal care educator than in a traditional model.3 Group prenatal care also is associated with decreased wait times for appointments and high satisfaction levels for patients.4 Group prenatal care has been implemented successfully for multiple different populations, including in adolescents, non-English speakers, incarcerated women, and women with HIV or gestational diabetes. For the practice, providers and educators can find efficiencies in meeting with a group to dispense routine prenatal information and answer questions.
The disadvantages of group prenatal care include the logistics in organizing the visits, enrollment and retention of participants, the need to find a large enough physical space for the meetings, and training facilitators. Some women face barriers to group prenatal care, such as transportation and childcare issues.3 The implementation of a group prenatal care program requires significant administrative support and provider buy-in. The group size needs to be maintained at a certain level to make the visit cost-effective, and this also depends on the provider types utilized. Group prenatal care is billed and reimbursed similarly to individual prenatal care.
What about the medical advantages of group prenatal care? Group prenatal care programs have become very popular and are supported by the March of Dimes, the Centers for Medicaid and Medicare Services, and multiple states. The main reason is the claim that group prenatal care reduces the rate of preterm birth. This also brings in the cost-saving argument for the healthcare system as a whole. There have been two meta-analyses examining group prenatal care compared with traditional prenatal care. The Cochrane Collaboration evaluated four randomized, controlled trials (RCTs) of 2,350 women.4 One trial contributed 42% of the participants. Although satisfaction with care was high, there was no significant difference between the two groups in preterm birth, low birth weight infants, or perinatal mortality. A second systematic review and meta-analysis included four RCTs and 10 observational studies.5 This study found that, overall, the rate of preterm birth was no different (7.9% group vs. 9.3% traditional; pooled relative risk [RR], 0.87; 95% confidence interval [CI], 0.70-1.09). Group care was associated with a decreased low birth weight rate among observational studies (7.5% group vs. 9.5% traditional; pooled RR, 0.81; 95% CI, 0.69-0.96), but not among RCTs (7.9% group vs. 8.7% traditional; pooled RR, 0.92; CI, 0.73-1.16). There were no significant differences between the groups in NICU admission or breastfeeding rates. Nevertheless, among African-American women, a subanalysis of two high-quality studies (one RCT, one observational) showed lower rates of preterm delivery with group prenatal care (8% group vs. 11.1% traditional; pooled RR, 0.55; 95% CI, 0.34-0.88). There was no difference among Latinas. The authors speculated that the effect seen among black women, who have preterm birth rates twice as high as white women, may be due to the social support and stress reduction obtained through group prenatal care. In my opinion, this finding has led to the wide implementation of group prenatal care as a panacea for reducing preterm birth rates. Other medical outcomes of group prenatal care, such as beneficial effects on breastfeeding, depression, stress, and positive health behaviors, have been shown inconsistently.3 There is some evidence for a positive effect on postpartum family planning and increased birth spacing. Some of the difficulty with evaluation clearly is linked to the different ways group prenatal care can be implemented and the quality of the groups.6
Although more RCTs are needed, there is no evidence that group prenatal care causes harm. It is a satisfying model to women who self-select into it and attend the visits. Therefore, it is certainly an alternative model of delivering prenatal care that should be studied and supported. However, there is evidence it can be difficult to recruit and retain women in the groups. It is certainly a challenge to change the entire paradigm of care delivery. In one study of 547 adolescents receiving group prenatal care in New York City, attendance at the groups averaged 60% and group visits were supplemented with individual visits.7 Another study evaluating barriers to group prenatal care implementation cited several issues related to successful and unsuccessful sites.8 In this study, only three of six sites randomized to start group prenatal care as part of a clinical trial were able to keep the program going after the trial ended. Successful sites were notable for an organizational culture that supported innovation and champions who were able to overcome obstacles. Unsuccessful sites were notable for lack of buy-in and financial support, as well as staff who were overwhelmed by logistical challenges such as lack of space, training facilitators, and scheduling patients into new templates. Clearly, group prenatal care programs should not be undertaken without adequate support on all levels, and such programs may not be appropriate for certain practices. In sum, group prenatal care is at least equivalent to individual prenatal care and is associated with high patient satisfaction. However, the evidence that it will solve the problem of preterm birth in the United States is not quite there.
REFERENCES
- Rising SS, Kennedy HP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health 2004;49:398-404.
- Rowley RA, Phillips LE, O’Dell L, et al. Group prenatal care: A financial perspective. Matern Child Health J 2016;20:1-10.
- Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol 2017; Feb 9. doi: 10.1016/j.ajog.2017.02.006 [Epub ahead of print].
- Catling CJ, Medley N, Foureur M, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev 2015;(2):CD007622.
- Carter EB, Temming LA, Akin J, et al. Group prenatal care compared with traditional prenatal care: A systematic review and meta-analysis. Obstet Gynecol 2016;128:551-561.
- Sheeder J, Weber Yorga K, Kabir-Greher K. A review of prenatal group care literature: The need for a structured theoretical framework and systematic evaluation. Matern Child Health J 2012;16:177-187.
- Cunningham SD, Grilo S, Lewis JB, et al. Group prenatal care attendance: Determinants and relationship with care satisfaction. Matern Child Health J 2016; Aug 2 [Epub ahead of print].
- 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.
Group prenatal care is a different model for the delivery of prenatal care that typically consists of groups of eight to 12 women of similar gestational age who have each visit together. This contrasts with the one-on-one patient/provider prenatal care visits that are the traditional model. Women are enrolled in group prenatal care after they have had an individual initial prenatal visit and health risk assessment, and have completed the first trimester.
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