In a hard spot: Providing group prenatal care in two urban clinics
Introduction
Group prenatal care (GPNC) is an innovative approach for providing prenatal care that integrates prenatal physical examinations, health education, and peer support. CenteringPregnancy (Centering), the predominant model of GPNC, has been implemented in over 300 sites in the United States since 1993 (S.S. Rising, CNM, written communication, 2009), and has been introduced in Canada, the UK, and Australia (Teate et al., 2009, Gaudion et al., 2011a, Gaudion et al., 2011b). Centering appears to produce pregnancy outcomes and experiences comparable or superior to individual care (Ickovics et al., 2007, Kennedy et al., 2009, Klima, 2009, Lu et al., 2010, Novick et al., 2011, Picklesimer et al., 2012). Centering provides substantially greater contact time with pregnant women than individual prenatal care, yet requires a minimal increase in provider time (Tanner-Smith et al., 2012). This multifaceted programme is attractive to clinicians seeking to provide prenatal care that addresses pregnant women's emotional, social, and behavioural concerns (Rising et al., 2004, Klima, 2009, Tanner-Smith et al., 2012) and may be particularly beneficial for women from low income and minority populations (Ickovics et al., 2007, Herrman et al., 2012, Novick et al., 2012, Picklesimer et al., 2012).
Implementing and providing this complex model, however, requires novel approaches and distinct resources. In clinical settings designed to provide individual care in examination rooms, these adaptations collectively represent a ‘paradigm shift’ in prenatal care (Rising et al., 2004). These institutional adaptations often can be quite challenging. Difficulties reported include problems with scheduling, staffing, training, timely entry into care (Klima, 2009), and recruiting women into prenatal groups (Hackley et al., 2009, Teate et al., 2009, Tanner-Smith et al., 2012). In a programme evaluation of five sites, four sites reported ‘implementation difficulties,’ including inadequate administrative buy-in and allocation of administrative time for managing Centering (Tanner-Smith et al., 2012). Furthermore, this paradigm shift may be unsettling for clinicians and staff who view traditional, individual prenatal care as indispensible, or who are unfamiliar with the advantages of group health care (Strong, 2000, Novick, 2004, Yalom and Leszcz, 2005, Herrman et al., 2012, Tanner-Smith et al., 2012). Consequently, clinicians providing GPNC may confront resistance from colleagues, or encounter logistical challenges in implementing the Centering model as designed because of institutional limitations.
To date, there have been no studies published that examine directly and in depth the challenges faced by clinicians when providing group prenatal care. This study investigated some of these challenges. While collecting data for a qualitative parent study of women's experience of GPNC in two clinics, we were struck by the obstacles Centering group leaders encountered and by the discrepancy between programme guidelines and programme delivery. Although Centering is designed to accommodate variation, the extent and nature of the discrepancies raised questions about implementation and fidelity when translating Centering into clinical settings—problems that warranted further investigation. Consequently, we modified the study design, consistent with emergent design in qualitative research (Patton, 2002), to more fully explore the way Centering1 was actually being provided and the challenges encountered when delivering it.
The analysis was guided by these questions: (1) What do group leaders and participants identify as challenges related to the delivery of Centering? (2) How is the Centering model adapted to address contextual challenges in clinical settings? The findings reported illustrate the complexity of providing this promising model in settings designed for individual care.
CenteringPregnancy provides prenatal care to groups of 8–12 women of similar gestational ages (Rising, 1998, Novick, 2004, Rising et al., 2004, Novick et al., 2011). After an initial individual prenatal visit for complete history and examination, women attend 8–10 2 hour group sessions during pregnancy. In a typical session, women enter the group space without waiting, measure their own blood pressure, weigh themselves, and record findings in their health record. While awaiting physical examinations, they usually sit in chairs arranged in a circle, chatting together and completing self-assessment sheets, which are used later in discussions. Snacks are provided. Women are examined individually in the group space, often on a mat on the floor outside the group circle. After examinations, facilitated discussions cover pregnancy-related health topics and provide an opportunity for peer support. Women's partners and significant others often attend, although children are typically discouraged. Centering is ideally facilitated by two people, at least one of whom is a prenatal provider. Sessions also can incorporate other perinatal professionals (e.g. social workers, nutritionists, paediatricians). A six-week postpartum reunion brings the group together to share birth experiences, to see one another's babies, and to establish continuing connections.
Centering has been demonstrated to improve important perinatal outcomes compared with individual prenatal care. In a randomized controlled trial (RCT) of 1,047 women, Ickovics et al. (2007) demonstrated 33% reduced risk of preterm birth, with a stronger effect in African-American women. Recently, a retrospective cohort study comparing 316 women who elected group prenatal care with women who elected individual care demonstrated a 47% reduction in preterm birth and reduced racial disparities in pregnancy outcomes for black women (Picklesimer et al., 2012). Women in the RCT also had higher rates of breast feeding, although this was not demonstrated in an RCT in military settings (Kennedy et al., 2011) or in the retrospective cohort study. Women randomized to Centering were also less likely to be pregnant again at six months postpartum (Kershaw, 2009), reported greater satisfaction with care, and were less likely to receive suboptimal care (Ickovics et al., 2007, Kennedy et al., 2011). Women who scored in the third tertile of stress on the Perceived Stress Scale who were randomized to Centering reported increased self-esteem, and decreased stress and social conflict (Ickovics et al., 2011). Qualitative studies report that women were enthusiastic about learning in groups, felt supported by other women and clinicians (Kennedy et al., 2009, Novick et al., 2011, Herrman et al., 2012, Novick et al., 2012), and found that talking with others normalized fears (Novick et al., 2011, Herrman et al., 2012).
The Centering Healthcare Institute (CHI) markets Centering resources and conducts model implementation and site approval processes. Site approval requires provision of 13 ‘Essential Elements of Centering’ (Table 1). Although over 300 sites have implemented Centering, there are only approximately 90 approved sites (Centering Healthcare Institute, 2011a, Centering Healthcare Institute, 2011b, Centering Healthcare Institute, 2011c).
Section snippets
Methods
This analysis was part of a longitudinal, qualitative study of Centering in two urban clinics using interpretive description (Thorne, 2008). Parent study methods, reported in detail elsewhere (Novick et al., 2011), were modified to investigate issues surrounding provision and receipt of Centering. Data were elicited regarding barriers or facilitators group leaders encountered when providing Centering, divergence between how Centering was provided and CHI recommendations, and group leaders'
Findings
The central finding of this research was that the clinics did not always provide full resources for implementing Centering as designed, resulting in multiple challenges for the group leaders. In response, the group leaders developed strategies for providing Centering within these limitations. Findings are presented in three sections: (1) Clinic Context describes the factors in the clinics surrounding and affecting providing Centering, (2) Group Leader Responses describes how group leaders
Discussion
CenteringPregnancy is being implemented increasingly widely across the U.S and internationally. Our analysis discovered that this innovative model – which requires a different institutional infrastructure and mindset for clinicians and administrators accustomed to individual care – can be difficult to provide and sustain. In the clinics studied, institutional constraints had profound effects on how Centering was implemented, and created multiple challenges for the CNMs facilitating groups.
References (35)
- et al.
Impact of two scheduling systems on early enrollment in a group prenatal care program
Journal of Midwifery & Women's Health
(2009) - et al.
“I wasn't alone”—a study of group prenatal care in the military
Journal of Midwifery & Women's Health
(2009) Introduction of CenteringPregnancy in a public health clinic
Journal of Midwifery and Women's Health
(2009)CenteringPregnancy and the current state of prenatal care
Journal of Midwifery & Women's Health
(2004)Centering Pregnancy: an interdisciplinary model of empowerment
Journal of Nurse-Midwifery
(1998)- et al.
Group antenatal care: new pedagogic method for antenatal care—a pilot study
Midwifery
(2010) - et al.
Parents' experiences and perceptions of group-based antenatal care in four clinics in Sweden
Midwifery
(2011) Disseminating innovations in health care
JAMA: The Journal of the American Medical Association
(2003)- Centering Healthcare Institute. Site Approval: Centering Healthcare site approval process. 2011a....
- Centering Healthcare Institute. Centering Care Start Up. Centering Healthcare Institute. 2011b....