Prenatal Care Without the Stress: Group Care Using The Centering Pregnancy Model

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Prenatal Care Without the Stress Group Care
Using The Centering Pregnancy Model

• Anne-Marie Blanchard, RPAC

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Why prenatal care?

• 1902 Dr. Ballantyne Scottish physician noted that
  much was being done for mothers and babies during
  labor and birth, but this did nothing to reduce
  morbidity and mortality of congenital anomalies,
  fetal disease or contributing maternal disease
  like syphilis, TB, and teratogen exposure like
  alcohol, nicotine and lead
• Moos, Merry K, Prenatal care Limitations and
  Opportunites. JOGNN, 2006 278-285.

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What purpose does prenatal care serve?

• Williams Obstetrics, 1907
• Recognizes that pregnancy is a normal process but
  that the provider should keep alert for untoward
  symptoms
• Do outside exercise
• Eat an abundant and nutritious diet
• Loosen clothing (include dispensing with her
  corset)
• Be given guidance on sexual intercourse, breast
  care and bowel health

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Are we so different now?
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More history.

• By mid 1980s Medicaid coverage extended to
  otherwise uninsured pregnant women due to the
  fact that women without prenatal care had worse
  outcomes
• Adequate care reduced risks of low birth weight
  babies and PTL births and neonatal deaths
• (Adequate care is judged on timing of onset of
  care and number of visits not content of care)

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What impacts quality of care?

• Quality is defined by six factors
• Amount of insurance
• Delay in telling others about the pregnancy
• Attitudes toward health professionals
• Month of gestation in which pregnancy was
  diagnosed
• Perception of importance of prenatal care
• Initial feelings of acceptance of pregnancy
• Poland, et al. Quality of prenatal care,
  selected social, behavioral, and biomedical
  factors. Obstet Gynecol 1990 75607-612

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So where are we at today?

• US ranks 29th among industrialized nations in
  infant mortality with infant mortality rate 6.86
  infant deaths per 1000 live births
• Hong Kong, Sweden and Japan have half the infant
  mortality rates we do

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• Our number of prenatal care visits exceeds that
  of most countries
• We spend more for it
• Provide more of it
• Have intensified it with high tech modalities
• Still our infant mortality rate lags behind
• Rates reflect differences in health status of
  women before and during pregnancy and quality and
  accessibility of prenatal care
• Strong, (2000) Expecting Trouble What Expectant
  Parents should Know about Prenatal Care in
  America 188

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Whats happening here?

• NY, 2005
• Infant mortality rate was 5.81 deaths per 1000
  live births
• Whites 5.3 deaths per 1000 live births (combined
  white and Hispanic)
• African Americans 9.33 deaths per 1000 live
  births

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• Monroe County, 2006-2008 infant mortality rate
  7.5 infant deaths per 1000 live births
• Whites 4.2 infant deaths per 1000 live births
• African Americans 16 infant deaths per 1000 live
  births
• Hispanics 10.7 infant deaths per 1000 live births
• Rochester City Crescent, 2006-2008 infant
  mortality rate 13.1 infant deaths per 1000 live
  births
• Whites 7.3 infant deaths per 1000 live births
• African Americans 16.9 infant deaths per 1000
  live births
• Hispanics 11.6 infant deaths per 1000 live births

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from Caring for Our Future the Content of
Prenatal Care, USPHS, 1989
Objectives for prenatal and well baby care
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US PHS Expert Panel on the Content of Prenatal
Care

• Met in 1989 to issue recommendations
• Prenatal care should promote health and
  well-being of the pregnant woman, fetus, infant
  and family up to one year after the birth
• Prenatal care must be accessible and readily used
  to be effective
• A new psychosocial emphasis should be placed on
  the care, adding to the traditional medical
  concerns

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• The feeling that prenatal care should not be
  abandoned, but instead enriched with, greater
  attention to the psychosocial aspects of
  childbearing and adaptation to parenthood.
• Each womens care should be individualized based
  on an ongoing risk assessment and that movement
  away from the standardized current approach would
  benefit women, providers and outcomes

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• Recognizing that being pregnant can be a strong
  motivator to change or modify behavior choices
• And that prenatal visits give a frequency of
  follow up visits that allow re-enforcement of
  attempted changes

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Group Care

• What is the role of Group Care ?

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Group Care

• Provider moves from the authoritarian presence to
  a facilitator role that helps women find their
  own voices, connect and learn from others
  experiencing the same stresses in life and learn
  healthier adaptive ways through good example of
  other women with whom they can relate

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Do Our Patients Have Stress?
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What are stresses in pregnancy?Physical
symptomsbodily changesRelationship
strainsanxiety about labor and deliveryconcerns
about the babys healthparenting concerns
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How do you deal with stress?

• Cope-
• (Adopt a coping strategy that helps get through
  the stress)
• Get more rest
• Exercise
• Stress reduction methods-relax, vacation, seek
  out social supports

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How do you deal with stress?

• Cope
• (harmful with adverse health outcomes)
• Stop eating/ poor diet
• Vegetate
• Smoke cigarettes/ Drink alcohol /Use drugs
• Draw away from social contacts/ isolate

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What is stress doing to the baby?

• A neuroendocrine response is initiated and causes
  an increase in maternal blood levels of CRH, ACTH
  and cortisol (especially with stress early in
  pregnancy and for a chronic time period)
• Fasting or skipping meals will also cause
  increase in CRH
• In turn causing accelerated fetal maturation,
  preterm birth and low birth weight

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So what do we do to help our patients?

• Assess their stress
• At least once per trimester
• Are you depressed?
• Anxious?
• Chronically Stressed?

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How To Assess

• Questionnaire Available
• Prenatal Distress Questionnaire Items
• Edinburgh Postnatal Depression scale

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Revised Prenatal Distress Questionnaire Items

• (0) not at all, (1) somewhat, or (2) very much
• Are you feeling bothered, upset, or worried at
  this point in your pregnancy (asked at each
  trimester)
• .about the effect of ongoing health problems
  such as high blood pressure or diabetes on your
  pregnancy?
• .about feeling tired and having low energy
  during your pregnancy?

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• ..about paying for your medical care during your
  pregnancy?
• .about changes in your weight and body shape
  during pregnancy?
• .about whether you might have an unhealthy baby?
• .about physical symptoms of your pregnancy such
  as vomiting, swollen feet, or back ache?

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• .about the quality of your medical care during
  pregnancy?
• ..about working or caring for your family during
  your pregnancy?
• .about whether your baby might be affected by
  any alcohol, drugs, or cigarettes that you have
  been using?

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• Added at second and third trimester
• .about whether the baby might come too early?
• about changes in your relationships with other
  people due to having a baby?
• .about paying for the babys clothes, food or
  medical care?

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• Added at third trimester
• .about taking care of a newborn?
• .about pain during labor and delivery?
• .about what will happen during labor and
  delivery?
• about working at a job after the baby comes?
• .about getting day care, babysitters, or other
  help to watch the baby after it comes?

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So what do we do to help our patients?

• Assess their stress
• Encourage moms to adopt healthier life styles
• Reduce their stress levels
• Pursue better prenatal care

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And how do we reduce their stress?

• Stress relieving techniques can help including
• Psychosocial services
• Yoga
• Group care
• Social support services (not shown to improve
  preterm labor or LBW)

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• Reducing stress levels during pregnancy as a
  means to reducing PTB is supported by the March
  of Dimes

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Is there a way to reduce stress and enhance
prenatal care?

• How about group care?

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CENTERING a model for group health care
Centering Healthcare Institute, Inc
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You are a mom to-be imagine
No waiting Time for sharing and
learning Enjoying an afternoon at the doctors
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You are a provider imagine

• Needing to say things only once
• Working with really motivated patients
• Finding work fun and energizing

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You are an administrator imagine ...

• Better access for your patients
• Great marketing program
• Better birth outcomes
• Predictable clinic time schedules
• .and it doesnt cost extra

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Advantages

• Improved learning and skill development
• Attitude change and motivation
• Social support
• Enhanced insight through sharing of common life
  experiences
• Increased contact time
• Improved patient-provider contact

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Opportunity to discuss behavioral changes for a
healthy pregnancy

• Exposure to sensitive issues like interpersonal
  violence and STI risks
• Increased contact time
• Improved knowledge of essential skills
• Nurturing of support among group participants

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With luck, advantages may extend beyond the four
walls

• Maybe a group can even hasten the development of
  new community norms for health enhancing
  behaviors brought forth by members of the group

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How can a group reduce stress?

• More time together to promote a better
  understanding of physiology of pregnancy to
  increase health promoting behavior and decrease
  health damaging behaviors
• Promote changes in social norms to reduce high
  risk behaviors (such as smoking cessation)
• better prepare patients for labor and delivery

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What happens in group?

• Three essential components
• Assessment
• Education and Skills Building
• Support

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CenteringPregnancy Getting Started

• What do you need?
• Room
• Facilitator, probably two
• Curriculum

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CenteringPregnancy Getting Started

• Initial intake to system
• as usual
• History
• Physical exam
• Laboratory assessment

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Ultrasound confirmation of EDC

• Establish viability
• Invite 8-12 women with
• similar due dates into
• the group

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Design Two-Hour Session

• 30-40 minutes
• Check-in and individual assessments with the
  provider
• 60-75 minutes
• Formal circle-up or facilitated discussion time
  
• Informal time for socializing
• Closing and follow-up as needed

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Design Schedule
Additional visits as needed to address issues
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Assessment Self-Care
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Assessment Check-up

• Individual physical
• assessment

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Education Process

• Interactive discussion with input from health
  care providers and patients

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What are we talking about?

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Support

• Time for interaction
• Refreshments
• Group stability
• Share contact information
• Bonding as a group

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• In truth, I continue to be awed by the power of
  the group. We are having such a good time and
  have such laughs.
• Group care allows the power of peer pressure
  and persuasion to influence a good outcome.

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What Do Patients Like?
Evaluation is an important part of the process
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• The best part of care here was.
• The love they (staff) have for me and how much
  the group cares about me
• When I am in the group I feel like I am with
  people just like me

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• That they (staff ) treat me as important as
  everyone else in the group
• That it was a place to come and have fun

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• That here I know my baby and me are safe
• The group makes me feel happy about my
  pregnancy

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• They were just another group of friends

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Thirteen Essential Elements define the
Centering model of care
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Health assessment occurs within the group space
Privacy is protected
Care is normalized
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Participants are involved in self-care activities
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A facilitative leadership style is used

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Each session has an overall plan
Birth preparation
Stress reduction
Nutrition and infant feeding
Stress management
Comfort and safety
Infant development
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Attention is given to the general content
outline emphasis may vary

• Im learning that it doesnt matter what we
  dont talk about because were talking about what
  matters to the group

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There is stability of group leadership
Trust
Continuity of care
Group history
Relationship building
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Group conduct honors the contribution of each
member
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The group is conducted in a circle
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Opportunity for socializing is provided
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The composition of the group is stable but not
rigid
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Group size is optimal to promote the process
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Involvement of family support people is optional
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There is ongoing evaluation of outcomes

• Anything we want to see improved.benchmarking
• Patient experience (session 6 and 10)
• Attendance for prenatal care visits
• Breastfeeding rates
• Birth outcomes gestational age and
  birth weight

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Overall Evaluation

• 96-97 of all women polled stated they prefer
  receiving their prenatal care in group
• We came at the same time and left at the same
  time and something happened the whole time we
  were there.

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Effects of Group Prenatal Care on Perinatal
Outcomes Results from a Two-Site Matched
Cohort Study

• Data from Womens Center, New Haven and Grady
  Clinics, Atlanta
• Ickovics, Kershaw, Westdahl, Rising, Klima,
  Reynolds, Magriples
• Obstetrics Gynecology,Nov. 2003, 102(5) 1051-7.

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Matched Cohort Sample

• 458 patients
• 208 Yale 104 CPP 104 traditional
  PNC (Control)
• 250 Emory 125 CPP 125 traditional PNC
  (Control)
• Centering groups from 2000-2002
• Matched patients on
• Age
• Race
• Parity
• Closest day of delivery
• Ickovics, Kershaw, Westdahl, Rising, Klima,
  Reynolds, Magriples
• Obstetrics Gynecology, Nov. 2003, 102(5)
  1051-7.

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Matched Cohort Sample

• Race

Ickovics, Kershaw, Westdahl, Rising, Klima,
Reynolds, Magriples Obstetrics Gynecology,Nov.
2003, 102(5) 1051-7.
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Research Outcomes 2003 Matched Cohort Study

• Preterm infants of CenteringPregnancy patients
  were significantly larger than those in
  individual care
• 2397.8 vs 1989.9 Gms (F5.74, plt.01)
• Group patients maintained their preterm
  pregnancies two weeks longer than individual care
  patients
• 34.8 wks vs 32.6 wks (plt.001)
• Ickovics et al, Obstetrics Gynecology, Nov.
  2003, 102(5) 1051-7.

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Effects of Group Prenatal Care Randomized
Control Trial

• National Institute of Mental Health MH 61175,
  2001-2006
• Ickovics, et al. (2007)Obstetrics Gynecology.
  110(2)3230-9.

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METHODS

• CONDITIONS - RANDOMIZED
• Standard individual prenatal care (Control)
• Centering Pregnancy (CP)
• Enhanced Centering Pregnancy (CP)
• bundled HIV/STI prevention
• DATA COLLECTION (A-CASI)
• Trimester 2 (16-20 wks GA) 3 (34-38 wks GA),
• 6 12 months post-partum
• STUDY SAMPLE (N1,047)
• 14-25 years, HIV-, English/Spanish, public
  clinics
• in New Haven and Atlanta

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RANDOMIZED STUDY SAMPLE
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Preterm Delivery, Stratified by Study Condition
Research Outcomes 2006 Randomized Control Trial
Per 1000 women in group, 40 preterm deliveries
averted 60 per 1000 for African American women
OR.67, (.44-.99) OR.59 (.31-.92)
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Note All analyses controlled for study site,
factors that were different by study condition
despite randomization (race, prior preterm
delivery prenatal distress) and clinical risk
factors assoc with birth outcomes (smoking, prior
miscarriage/stillbirth). Ickovics, et al.
(2007)Obstetrics Gynecology. 110(2) 3230-39.
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Study Outcomes Group Care vs. Individual

• Rates of Breastfeeding were improved from 54 to
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• May be some protective factor against preterm
  birth 9.8 for group care versus 13.8 for
  individual prenatal visits, about 40 patients in
  1000 versus 60 per 1000 AA
• No influence on apgar scores at 5 minutes,
  infants admitted to NICU, or SGA, prenatal care
  costs or delivery care costs
• Ickovics et al, Group Prenatal Care and Perinatal
  Outcome.
• Obstet Gynecol 2007

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What did you like best about your prenatal care??
N777
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Measurable differences from traditional care
Research Outcomes 2006 Randomized Control Trial

• 78 average attendance rate for group
  participants
• Significantly higher prenatal knowledge and
  readiness for labor delivery (each plt.001)
• Higher readiness for baby care (p.0560)
• Significantly greater satisfaction with care
  (F27.2, plt.001)
• No difference antenatal or delivery costs
  (pgt0.69)

Planned contrast CP/CP vs control measured
post-intervention Ickovics, et al. (2007)
Obstetrics Gynecology. 110(2) 3230-39.
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Centering developments

• CenteringPregnancy Diabetes, CenteringDiabetes,
  CenteringMenopause and womens health through the
  childbearing years
• Developing initiative in the military - sites in
  the US and Germany.
• Resident training programs

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Our Centering Developments

• Partnership with Comienzo Sano program to
  transition from prenatal care to social support
  at the same visit
• Centering Pregnancy group for our refugee
  patients
• Movement from CenteringPregnancy to
  CenteringParenting
• Prenatal yoga as part of our group care

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With a happy ending for all..
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CHI 558 Maple Avenue Cheshire, CT
06410 203-271-3632 info_at_centeringhealthcare.org ww
w.centeringhealthcare.org
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