Editorials
www.AJOG.org
CenteringPregnancy: an innovative approach to prenatal care delivery Diana Garretto, MD; Peter S. Bernstein, MD, MPH
F
rom an initial narrow focus on preventing eclampsia, prenatal care has evolved to become a prime example of preventive care. It has been expanded from a temporal focus on occurrences during late pregnancy to encompass preconception preparation for pregnancy and to include goals for the mother and infant that stretch well beyond the peripartum period. The scope has broadened from an original emphasis on preventing maternal and neonatal mortality to include an in depth concern with short- and longer-term morbidities for the mother, child, and family. Similarly, the goals of prenatal care have grown beyond the purely biological to include the psychosocial influences on pregnancy outcome. In the United States, these goals were most recently outlined by the US Public Health Service Expert Panel on the Content of Prenatal Care in 1989 (Table).1 They are admirable goals, yet prenatal care as commonly practiced in the United States and elsewhere remains largely unchanged over the last century. Certainly new and improved tests and interventions have been added to the armamentarium of prenatal care providers, such as ultrasound, screening for chromosomal aneuploidies and genetic disorders, etc, that have improved pregnancy outcomes. Still, it is hard to imagine how the increasingly comprehensive goals for prenatal care can be achieved with the current model for prenatal care delivery. Recognition of the failure to achieve the goals for prenatal care as outlined by the Public Health Service Expert Panel was among the reasons that led the Centering Healthcare Institute to develop the CenteringPregnancy model of group prenatal care.2 It represents a major change in the delivery of prenatal care, allowing enough time for the provider to focus on antenatal education while integrating family members, peer support, and self reliance.
From the Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY. Received Sept. 27, 2013; accepted Oct. 1, 2013. The authors report no conflict of interest. P.S.B. did serve as an unpaid member of the Board of Directors of the Centering Pregnancy and Parenting Association from September 2003 through September 2006. Reprints: Peter S. Bernstein, MD, MPH, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine/Montefiore Medical Center, Jack D. Weiler Hospital, 1825 Eastchester Rd., Bronx, NY 10461. pbernste@montefiore.org. 0002-9378/free ª 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.10.002
See related article, page 50
14 American Journal of Obstetrics & Gynecology JANUARY 2014
CenteringPregnancy replaces individual care with a group model that starts after the initial prenatal visit for obstetrically low-risk women. Groups of 10-12 participants with similar gestational ages are brought together for the remainder of the pregnancy following the traditional schedule of prenatal visits. Each group visit lasts 90-120 minutes during which time pregnant women participate in discussions about a range of health education topics in addition to the usual physical assessments. This model of care allows for approximately 20 hours of prenatal care over the course of the pregnancy as compared with approximately 2 hours in total that is typical with the individual visit model. This is accomplished without affecting provider productivity and creates an economy of scale that allows more time for a wide range of pregnancy-related topics. Basic tenets of the group care model include health promotion, peer support, and self-management of care facilitated through discussions among participants during each session. Relationships are built among the participants and with the provider. There are educational objectives including topics such as health and nutrition, childbirth preparation, stress reduction, family planning, and parenting.3 Data are now starting to appear in the literature to support the benefits of the group model of care. These include improved compliance with prenatal care, higher rates of breastfeeding, and greater patient satisfaction and readiness for childbirth and parenting.4 Even more promising is the 33% reduction in preterm birth reported in a trial of more than 1000 inner-city women aged 14-25 years (9.8% vs 14.8%) among women randomized to Centering groups, compared with those who received traditional individual care.5 That same study found fewer repeat pregnancies within 6 months of delivery, increased use of condoms, and less unprotected sexual intercourse among Centering participants.5 This group later reported that patients who attended Centering groups that adhered to the model most faithfully accrued the most benefit.6 But can Centering accomplish these results outside academic studies? It is intuitive that this model of care can do a better job achieving the goals we have for prenatal care. We anticipate a more definitive answer from the Strong Start for Mothers and Newborns Initiative sponsored by the Centers for Medicare and Medicaid Services, the Health Resources and Services Administration, and the Administration on Children and Families.7 This recently funded initiative will compare outcomes in women receiving different models of prenatal care on a national scale and hopes to identify care models that achieve the best outcomes at the least expense to the system.
www.AJOG.org In this issue of the Journal, Hale and colleagues8 ask a simpler question: does the Centering model of prenatal care result in increased utilization of postpartum family planning services? In their retrospective study of more than 3500 pregnant women enrolled for Medicaid services in a 12 month period, they compared the 570 who participated in the CenteringPregnancy program with those who received traditional individual prenatal care. Using an interesting method to improve the rigor of the study design and to control for potential confounding variables, the authors found that use of family-planning services was significantly greater among women who attended group prenatal care at 3, 6, and 12 months postpartum. The magnitude of this benefit was even larger when the analysis was restricted to non-Hispanic black women compared with non-Hispanic white counterparts. The most disappointing finding in the study, however, was that the percentage of the subjects utilizing the familyplanning services in both groups was small. For example, at 12 months’ postpartum, 29.3% of the Centering participants had utilized family-planning services vs 20.4% among the women who received individual care. Thus, it appears that we still have a way to go. Although the analysis used in this study was rigorous, there are a number of limitations. For example, the data were abstracted from administrative billing records. Information could not be obtained about how family-planning needs were addressed at initial postpartum visits (which may not have been billed as family-planning visits), and no information on contraceptive method choices was captured (eg, how many women underwent immediate postpartum sterilization). Finally, there may be other confounding variables that the authors were unable to measure that may have influenced study outcomes. Despite these issues, this study is consistent with previous reports showing that the group model of care in general, and CenteringPregnancy in particular, provides benefits that individual care does not. Much of medical care involves educating patients about their condition and helping them to develop behaviors to improve their health outcomes. Effective strategies to accomplish this goal will likely involve more than simply providing them with education in a short lecture in the examination room or reading material. The unhurried environment, the facilitated discussion, and the peer group dynamics offered in a group care model may afford women the rationale for behavior change as well as the emotional support to encourage that change. The premise that care is more effective and efficient in the CenteringPregnancy model of prenatal care has been shown now in several studies, but significant challenges to implementing this model of care remain. It can be difficult to identify space, to develop and implement a program, and to ensure appropriate staffing support. Additionally, providers need appropriate training in the facilitative style of leadership required. For physicians, the traditional didactic method of interacting with patients is often deeply ingrained. Nevertheless, the benefits of the program have the potential to be
Editorials TABLE
Objectives of prenatal care For the pregnant woman: 1. To increase her well-being before, during, and after pregnancy and to improve her self-image and self-care. 2. To reduce maternal mortality and morbidity, fetal loss, and unnecessary pregnancy interventions. 3. To reduce the risks to her health prior to subsequent pregnancies and beyond child-bearing years. 4. To promote the development of parenting skills. For the fetus and infant: 1. To increase well-being. 2. To reduce preterm birth, intrauterine growth restriction, congenital anomalies, and failure to thrive. 3. To promote healthy growth and development, immunization, and health supervision. 4. To reduce neurological, developmental, and other morbidities. 5. To reduce child abuse and neglect, injuries, preventable acute and chronic illness, and the need for extended hospitalization after birth. For the family: 1. To promote family development and positive parent-infant interaction. 2. To reduce unintended pregnancies. 3. To identify for treatment behavior disorders leading to child neglect and family violence. Adapted, with permission, from United States Public Health Service Expert Panel on the Content of Prenatal Care.1
enormous. We believe it is time to start thinking of group prenatal care as the default model for prenatal care. REFERENCES 1. United States Public Health Service Expert Panel on the Content of Prenatal Care. Caring for Our Future: the content of prenatal care. Washington, DC: United States Department of Health and Human Services; 1989. 2. Rising SS, Kennedy HP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health 2004;49: 398-404. 3. Picklesimer AH, Billings D, Hale N, Blackhurst D, Covington-Kolb S. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obstet Gynecol 2012;206:415. e1-7. 4. Ickovics JR, Kershaw TS, Westdahl C, Magriples U, Massey Z, Reynolds H, Schindler Rising S. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol 2007;110(2 Pt 1): 330-9. 5. Kershaw TS, Magriples U, Westdahl C, Rising SS, Ickovics J. Pregnancy as a window of opportunity for HIV prevention: effects of an HIV intervention delivered within prenatal care. Am J Public Health 2009;99:2079-86. 6. Novick G, Reid AE, Lewis J, Kershaw TS, Rising SS, Ickovics JR. Group prenatal care: model fidelity and outcomes. Am J Obstet Gynecol 2013;209:112.e1-6. 7. Innovation.cms.gov. Baltimore, MD: Centers for Medicare and Medicaid Services. Available at: http://innovation.cms.gov/initiatives/ strong-start/. Accessed Sept. 21, 2013. 8. Hale N, Picklesimer AH, Billings DL, et al. The impact of Centering Pregnancy Group Prenatal Care on postpartumfamily planning. Am J Obstet Gynecol 2014;210:50.e1-7.
JANUARY 2014 American Journal of Obstetrics & Gynecology
15
www.AJOG.org
CenteringPregnancy: an innovative approach to prenatal care delivery Diana Garretto, MD; Peter S. Bernstein, MD, MPH
F
rom an initial narrow focus on preventing eclampsia, prenatal care has evolved to become a prime example of preventive care. It has been expanded from a temporal focus on occurrences during late pregnancy to encompass preconception preparation for pregnancy and to include goals for the mother and infant that stretch well beyond the peripartum period. The scope has broadened from an original emphasis on preventing maternal and neonatal mortality to include an in depth concern with short- and longer-term morbidities for the mother, child, and family. Similarly, the goals of prenatal care have grown beyond the purely biological to include the psychosocial influences on pregnancy outcome. In the United States, these goals were most recently outlined by the US Public Health Service Expert Panel on the Content of Prenatal Care in 1989 (Table).1 They are admirable goals, yet prenatal care as commonly practiced in the United States and elsewhere remains largely unchanged over the last century. Certainly new and improved tests and interventions have been added to the armamentarium of prenatal care providers, such as ultrasound, screening for chromosomal aneuploidies and genetic disorders, etc, that have improved pregnancy outcomes. Still, it is hard to imagine how the increasingly comprehensive goals for prenatal care can be achieved with the current model for prenatal care delivery. Recognition of the failure to achieve the goals for prenatal care as outlined by the Public Health Service Expert Panel was among the reasons that led the Centering Healthcare Institute to develop the CenteringPregnancy model of group prenatal care.2 It represents a major change in the delivery of prenatal care, allowing enough time for the provider to focus on antenatal education while integrating family members, peer support, and self reliance.
From the Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY. Received Sept. 27, 2013; accepted Oct. 1, 2013. The authors report no conflict of interest. P.S.B. did serve as an unpaid member of the Board of Directors of the Centering Pregnancy and Parenting Association from September 2003 through September 2006. Reprints: Peter S. Bernstein, MD, MPH, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine/Montefiore Medical Center, Jack D. Weiler Hospital, 1825 Eastchester Rd., Bronx, NY 10461. pbernste@montefiore.org. 0002-9378/free ª 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.10.002
See related article, page 50
14 American Journal of Obstetrics & Gynecology JANUARY 2014
CenteringPregnancy replaces individual care with a group model that starts after the initial prenatal visit for obstetrically low-risk women. Groups of 10-12 participants with similar gestational ages are brought together for the remainder of the pregnancy following the traditional schedule of prenatal visits. Each group visit lasts 90-120 minutes during which time pregnant women participate in discussions about a range of health education topics in addition to the usual physical assessments. This model of care allows for approximately 20 hours of prenatal care over the course of the pregnancy as compared with approximately 2 hours in total that is typical with the individual visit model. This is accomplished without affecting provider productivity and creates an economy of scale that allows more time for a wide range of pregnancy-related topics. Basic tenets of the group care model include health promotion, peer support, and self-management of care facilitated through discussions among participants during each session. Relationships are built among the participants and with the provider. There are educational objectives including topics such as health and nutrition, childbirth preparation, stress reduction, family planning, and parenting.3 Data are now starting to appear in the literature to support the benefits of the group model of care. These include improved compliance with prenatal care, higher rates of breastfeeding, and greater patient satisfaction and readiness for childbirth and parenting.4 Even more promising is the 33% reduction in preterm birth reported in a trial of more than 1000 inner-city women aged 14-25 years (9.8% vs 14.8%) among women randomized to Centering groups, compared with those who received traditional individual care.5 That same study found fewer repeat pregnancies within 6 months of delivery, increased use of condoms, and less unprotected sexual intercourse among Centering participants.5 This group later reported that patients who attended Centering groups that adhered to the model most faithfully accrued the most benefit.6 But can Centering accomplish these results outside academic studies? It is intuitive that this model of care can do a better job achieving the goals we have for prenatal care. We anticipate a more definitive answer from the Strong Start for Mothers and Newborns Initiative sponsored by the Centers for Medicare and Medicaid Services, the Health Resources and Services Administration, and the Administration on Children and Families.7 This recently funded initiative will compare outcomes in women receiving different models of prenatal care on a national scale and hopes to identify care models that achieve the best outcomes at the least expense to the system.
www.AJOG.org In this issue of the Journal, Hale and colleagues8 ask a simpler question: does the Centering model of prenatal care result in increased utilization of postpartum family planning services? In their retrospective study of more than 3500 pregnant women enrolled for Medicaid services in a 12 month period, they compared the 570 who participated in the CenteringPregnancy program with those who received traditional individual prenatal care. Using an interesting method to improve the rigor of the study design and to control for potential confounding variables, the authors found that use of family-planning services was significantly greater among women who attended group prenatal care at 3, 6, and 12 months postpartum. The magnitude of this benefit was even larger when the analysis was restricted to non-Hispanic black women compared with non-Hispanic white counterparts. The most disappointing finding in the study, however, was that the percentage of the subjects utilizing the familyplanning services in both groups was small. For example, at 12 months’ postpartum, 29.3% of the Centering participants had utilized family-planning services vs 20.4% among the women who received individual care. Thus, it appears that we still have a way to go. Although the analysis used in this study was rigorous, there are a number of limitations. For example, the data were abstracted from administrative billing records. Information could not be obtained about how family-planning needs were addressed at initial postpartum visits (which may not have been billed as family-planning visits), and no information on contraceptive method choices was captured (eg, how many women underwent immediate postpartum sterilization). Finally, there may be other confounding variables that the authors were unable to measure that may have influenced study outcomes. Despite these issues, this study is consistent with previous reports showing that the group model of care in general, and CenteringPregnancy in particular, provides benefits that individual care does not. Much of medical care involves educating patients about their condition and helping them to develop behaviors to improve their health outcomes. Effective strategies to accomplish this goal will likely involve more than simply providing them with education in a short lecture in the examination room or reading material. The unhurried environment, the facilitated discussion, and the peer group dynamics offered in a group care model may afford women the rationale for behavior change as well as the emotional support to encourage that change. The premise that care is more effective and efficient in the CenteringPregnancy model of prenatal care has been shown now in several studies, but significant challenges to implementing this model of care remain. It can be difficult to identify space, to develop and implement a program, and to ensure appropriate staffing support. Additionally, providers need appropriate training in the facilitative style of leadership required. For physicians, the traditional didactic method of interacting with patients is often deeply ingrained. Nevertheless, the benefits of the program have the potential to be
Editorials TABLE
Objectives of prenatal care For the pregnant woman: 1. To increase her well-being before, during, and after pregnancy and to improve her self-image and self-care. 2. To reduce maternal mortality and morbidity, fetal loss, and unnecessary pregnancy interventions. 3. To reduce the risks to her health prior to subsequent pregnancies and beyond child-bearing years. 4. To promote the development of parenting skills. For the fetus and infant: 1. To increase well-being. 2. To reduce preterm birth, intrauterine growth restriction, congenital anomalies, and failure to thrive. 3. To promote healthy growth and development, immunization, and health supervision. 4. To reduce neurological, developmental, and other morbidities. 5. To reduce child abuse and neglect, injuries, preventable acute and chronic illness, and the need for extended hospitalization after birth. For the family: 1. To promote family development and positive parent-infant interaction. 2. To reduce unintended pregnancies. 3. To identify for treatment behavior disorders leading to child neglect and family violence. Adapted, with permission, from United States Public Health Service Expert Panel on the Content of Prenatal Care.1
enormous. We believe it is time to start thinking of group prenatal care as the default model for prenatal care. REFERENCES 1. United States Public Health Service Expert Panel on the Content of Prenatal Care. Caring for Our Future: the content of prenatal care. Washington, DC: United States Department of Health and Human Services; 1989. 2. Rising SS, Kennedy HP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health 2004;49: 398-404. 3. Picklesimer AH, Billings D, Hale N, Blackhurst D, Covington-Kolb S. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obstet Gynecol 2012;206:415. e1-7. 4. Ickovics JR, Kershaw TS, Westdahl C, Magriples U, Massey Z, Reynolds H, Schindler Rising S. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol 2007;110(2 Pt 1): 330-9. 5. Kershaw TS, Magriples U, Westdahl C, Rising SS, Ickovics J. Pregnancy as a window of opportunity for HIV prevention: effects of an HIV intervention delivered within prenatal care. Am J Public Health 2009;99:2079-86. 6. Novick G, Reid AE, Lewis J, Kershaw TS, Rising SS, Ickovics JR. Group prenatal care: model fidelity and outcomes. Am J Obstet Gynecol 2013;209:112.e1-6. 7. Innovation.cms.gov. Baltimore, MD: Centers for Medicare and Medicaid Services. Available at: http://innovation.cms.gov/initiatives/ strong-start/. Accessed Sept. 21, 2013. 8. Hale N, Picklesimer AH, Billings DL, et al. The impact of Centering Pregnancy Group Prenatal Care on postpartumfamily planning. Am J Obstet Gynecol 2014;210:50.e1-7.
JANUARY 2014 American Journal of Obstetrics & Gynecology
15
