CLINICAL OBSTETRICS AND GYNECOLOGY Volume 58, Number 2, 380–391 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Group Prenatal Care: Has Its Time Come? AMY PICKLESIMER, MD, MSPH,* EMILY HEBERLEIN, PhD,w and SARAH COVINGTON-KOLB, MSW, MSPH* *Department of Obstetrics and Gynecology, Greenville Health System, Greenville, South Carolina; and w Department of Public Health Sciences, Clemson University, Clemson, South Carolina Abstract: Group prenatal care is an emerging trend in obstetrics, and for medically low-risk women has been shown to result in lower rates of preterm birth, higher rates of breastfeeding, and higher rates of participation in postpartum family planning. Significant cost savings to the health care system are seen when the lower rates of preterm birth and neonatal intensive care unit admissions are considered. More research is needed about patients’ health outcomes as well as the economic and workforce implications to outpatient obstetric practices before widely transitioning prenatal care into group settings. Key words: Centering Pregnancy, group prenatal care, preterm birth, health economics
experiences such as childbirth. Long, unpredictable hours, and pressures from malpractice costs and reimbursement rates affect the number of medical students choosing the specialty, and negatively affect the career satisfaction of practicing obstetricians and gynecologists (OB-GYN). In combination with the large proportion of OB-GYN physicians approaching retirement age1,2 and geographic disparities in the availability of the specialty, the United States is facing a potential shortage in the OB-GYN workforce.2,3 These workforce challenges provide the context for the current delivery of prenatal care (PNC) in the United States. PNC is recognized as an important primary care service, combining early and ongoing risk assessment and intervention with patient education related to both maternal health and infant care. In practice, the great majority of PNC visits are brief, and the need to triage medical issues contributes to inconsistent coverage of anticipatory guidance topics such as breastfeeding, gestational weight gain, and exercise.4–8 Many OB-GYNs feel that inadequate time with patients is a major
Background Many physicians choosing to enter the specialty of obstetrics and gynecology are motivated by the unique opportunity to care for women across their lifespan, to combine surgical and clinical care, and to build relationships with their patients during life-changing and intimate Correspondence: Amy Picklesimer, MD, MSPH, Suite 470, Greenville, SC. E-mail: [email protected] Supported by South Carolina Chapter of the March of Dimes. The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
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NUMBER 2
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JUNE 2015
Group Prenatal Care obstacle to providing high-quality care.2 Although the proportion of women initiating early PNC has steadily increased in the last several decades,5 the continued high incidence and racial disparities in the rates of preterm birth and low birth weight, as well as the recognition of the complex causes of adverse birth outcomes, have led to a call to reexamine the traditional model of individual PNC.9,10 These multiple imperatives— assuring women have access to reproductive health services, removing health care system barriers to physicians delivering or overseeing the provision of high-quality PNC, controlling the costs of care, physician job satisfaction, and improving outcomes for women and babies—necessitate the development and evaluation of alternative PNC models.
Models for Change: Group Medical Appointments Group models for patient education and disease management are a promising means to meet the triple aim of improving the United States health care system: improving the patient experience of care, improving the health of populations, and reducing the cost of health care.11 Research on group medical care models conducted over the last 3 decades has demonstrated increased patient and provider satisfaction, improved health outcomes, and reduced costs.12 Although models vary in session length, frequency, duration, content, and approach, and target a range of health conditions and populations, group visit models include an individual medical evaluation with a physician or nurse practitioner combined with a group educational session.12 Because group models offer additional time for patients to interact with their physician or nurse practitioner, learn illness self-management skills, and participate in group problem solving and social
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support,12 group models may be especially effective in chronic disease management and have demonstrated positive outcomes in the care of diabetes, HIV/ AIDS, arthritis, chronic pain, cancer, and geriatric care.13–16 For years, many OB-GYN practices have been referring patients to group childbirth education classes, or conducting group educational sessions without formalizing the curriculum or publishing outcomes data. Because of this familiarity with group education, a growing number of obstetric and midwifery practices have recently made the transition to group prenatal care (GPNC) as an alternative PNC delivery model. Most groups form early in pregnancy, typically between 12 and 16 weeks’ gestation, after an initial individual medical and psychosocial assessment. GPNC sessions typically follow the schedule of PNC visits and tests recommended by the American College of Obstetricians and Gynecologists, and include educational content covered in traditional childbirth education classes. The physical assessment of a traditional individual PNC (IPNC) visit is typically bundled with the group session allowing these visits to be billed using standard PNC billing codes.
Centering Pregnancy (CP): Better Understanding, Greater Engagement, and Improved Health Outcomes for Pregnant Women Of GPNC models, the CP model of GPNC is the best known, most widely practiced, and currently supported by the most evidence. Originally developed and tested in the 1990s by Sharon Schindler Rising, a certified nurse-midwife, the Centering Healthcare Institute (CHI, Boston, MA) now administers the model, including management of the curriculum, oversight of facilitator training, and site www.clinicalobgyn.com
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certification for all practices offering CP. The site certification process includes an initial visit to the practice from CHI faculty for a comprehensive evaluation of model fidelity, as well as complete yearly assessments to assure ongoing quality in delivering the CP model of care. In the last several years, the United States (US) Department of Health and Human Services and a number of private foundations including the March of Dimes, the Duke Endowment, and the Kellogg Foundation have provided funding for the expansion of CP. The Agency for Healthcare Research and Quality has identified CP as a service delivery innovation with strong evidence. Thirteen essential elements collectively define the CP model’s format, content, parameters for patient/provider and group interactions, and the physical structure of the group meeting space (Table 1). CP groups include 8 to 12 women to deliver in the same month, and groups meet for ten 2-hour group sessions over the second and third trimesters. Patients are also encouraged to bring a support person (eg, boyfriend, husband, family member) to group sessions. During the first 30 minutes of each CP session, patients are actively engaged in their own health care by checking their own weight and blood pressure, and the physician or nurse practitioner conducts a brief physical assessment with each individual in a semiprivate area of the group space. This individual patient assessment, including a physical examination, allows the visit to be billed using the routine procedure codes for PNC. CHI recommends limiting these encounters to 3 to 5 minutes, deferring the majority of patient questions, concerns, and education for the group discussion. While these brief assessments take place, patients have time to socialize or review the CP notebooks (provided to each woman) and complete self-assessment activities. Once all of the physical examinations are complete, the remaining www.clinicalobgyn.com
60 to 90 minutes of the session is spent in facilitated group discussion. The curriculum covers a range of topics, organized by relevancy to gestational age (Table 2). GPNC is aligned with the Institute of Medicine’s rules for health care system redesign, which require knowledge sharing, evidence-based decision making, transparency, patient control, individualized care based on continuous relationships, cooperation among clinicians, patient safety, and decreased waste.17,18 Currently, formal site approval from CHI is largely dependent on model fidelity, or the degree to which a practice adheres to the essential elements. Research investigating the relative importance of the 13 CP model elements is limited, although evidence from 1 randomized control trial and several qualitative studies indicate that the model tenets of facilitation and participation are important in achieving improved birth outcomes, reducing overutilization of PNC, and in meeting women’s preferences and needs. Groups with greater fidelity to the facilitation and participation elements of the model are associated with lower rates of preterm birth and higher patient attendance at PNC visits.19 Qualitative studies indicate that women value the additional time with their physician or nurse practitioner, as well as the opportunity to share their pregnancy experience and care with other women. Patients describe multiple benefits from CP: feeling supported by their providers and group participants, encouraged that they are not alone in their concerns or experiences, motivated to engage in healthy behaviors, and prepared for birth and postpartum.20–24
Evidence for Change: Comparative Effectiveness of CP Compared With IPNC The rate of CP adoption has outpaced comparative effectiveness research on CP.
Group Prenatal Care TABLE 1.
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The 13 Essential Elements of the Centering Pregnancy Model of Group Prenatal Care17: Clinical Practice Descriptions and Patient Perspectives
Essential Element
Description*
Health assessment occurs Obstetricians or nurse practitioners assess fundal within the group space height, fetal heart tones, and individual concerns in an area set aside within the group space. Women are encouraged to bring concerns other women might share to the group discussion (eg, back pain, headaches, heartburn). This increases efficiency in providing pregnancy and health education, and encourages information sharing and social support among the women. Because all patients and family members attending group sessions discuss and sign a confidentiality agreement, and because patients choose what to disclose during the group, the Health Insurance Portability and Accountability Act regulations protecting patient confidentiality are not compromised. Examinations or discussion requiring greater privacy or additional time can always be conducted separately in an individual setting. Because of the brevity of the individual examination in the group space, many practices limit participation in CP to otherwise medically low-risk women. Participants are involved During group time, patients learn how to measure and in self-care activities record their own blood pressure, weight, and weeks of pregnancy in their medical chart. The CP curriculum includes a patient workbook, which includes pregnancy and health information and selfassessment sheets to initiate self-care activities (eg, quitting smoking, managing stress, exercising, and dietary changes). Facilitators encourage patients to set pregnancy goals and to plan for health-related decisions such as choosing a pediatrician, infant care and feeding, and comfort measures during labor. This increases patient engagement in medical care as well as improves patient knowledge and understanding, and giving women a more active role in maintaining a healthy pregnancy. A facilitative style of Each CP group session is led by 2 facilitators, one of leadership is used which must be a physician or nurse practitioner. There is no stipulation for the background of cofacilitators, and practices successfully use nurses, nursing assistants, and social workers The CP curriculum is not taught didactically. Instead, facilitators introduce topics as part of a group discussion, which encourages patients to share their knowledge, concerns, experiences, and ideas. This helps promote a sense of self-efficacy and confidence for patients, as a parent and as a health care consumer. Many group facilitators find that they are energized by the opportunity to cover topics in depth with discussion and peer to peer learning, in contrast to repetitive and superficial coverage of health topics resulting from time constraints posed by brief, individual PNC appointments. The group is conducted Group space should be configured in an open circle of in a circle chairs, without desks or a table in the center of the room. This facilitates open discussion and encourages patients to share their knowledge and experiences with each other, and to help women feel more confident asking questions. Many practices find that identifying a space large enough to accommodate groups of 20 or more people is the most challenging element of CP implementation. Few practices have the budget to specifically renovate clinical space to meet the unique needs of CP care. Some practices have adapted waiting rooms for CP groups after hours, and others have
Patient Perspectivesw ‘‘What I liked about Centering was to hear the baby’s heartbeat, and the discussions.’’ ‘‘I loved it, not being alone for doctor’s appointments.’’ ‘‘What I like about Centering was getting to share and compare my symptoms/complaints with other women in my position.’’
‘‘What I liked about Centering was meeting with the group, meeting with the doctor, and getting to be able to do my own blood pressure, weight, etc.’’ ‘‘What I liked about Centering was to monitor my own weight and blood pressure. So I have the knowledge to know what was right for me.’’ ‘‘I don’t have to wait in the waiting area for a long time and I can do some of my own prenatal care.’’
‘‘Everyone interacts as a group and we discuss all our concerns and interests as a group and learn from others concerns.’’ ‘‘We get to express ourselves, and tell and learn about one another’s pregnancies.’’ ‘‘I’m a first time mother, and I’m learning many things, not only from the health care providers, but other mothers in the group as well.’’ ‘‘What I liked about Centering was that I’m able to voice questions and get multiple opinions and answers.’’ ‘‘What I liked about Centering is that we can all talk openly and ask questions. We all kind of bond over our common symptoms and problems. It’s kind of funny. We spend a lot of time laughing together.’’
‘‘We get to be in a group, discussing all things, and it makes me feel comfortable and I have learned a lot.’’ ‘‘We talk about everything in the circley’’ ‘‘I’m learning a lot about pregnancy and even new things I didn’t know before. I like the setting of the group and being around the people here.’’ ‘‘The most important part was when we would have the circle time. Well, to me, after we would go over what we were supposed to in a session, she’d open up for any questions or comments we wanted to make. I think, to me, that was really a great part of it, because we learned—like we may have questions
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TABLE 1. (Continued) Essential Element
Description* identified appropriate spaces in hospital conference rooms.
Each session has an overall plan
CHI provides structure for groups through a comprehensive curriculum for each session, addressing topics of importance at key points during prenatal care (Table 2). The CP patient notebook contains supplemental information relating to each topic, which can serve to replace educational brochures that many practices stock to provide to patients with specific diagnoses. Decreasing the need for these patient educational materials can partially offset the cost of the CP patient notebooks to the practice.
Attention is given to core Patient notebooks provide a structured curriculum, but if patients express interest or concern in a topic content, although that is not specifically scheduled for the session’s emphasis may vary agenda, facilitators are encouraged to give priority to patient questions and concerns. For example, if a group member delivers preterm, this could provide a very compelling opportunity to discuss signs and symptoms of preterm labor even though the planned topic for the session is breastfeeding. The facilitator can make note of the divergence, and can cover curriculum topics at a later session. There is stability of group The relationships that develop within the group are leadership important to the patients’ sense of trust and wellbeing, and create a group environment in which patients feel empowered to ask uncomfortable or potentially embarrassing questions and to share personal experiences. Therefore, the same 2 facilitators (one of which must be a physician or nurse practitioner) must commit to lead all 10 of a group’s sessions. Obviously, exceptions can be made in the case of vacations or unexpected absences, but practices must plan for continuity within groups. Most providers who lead groups enjoy the opportunity to develop relationships with their patients through the increased contact time.
Group conduct honors the contribution of each member
In group sessions, each patient should feel welcome to voice her opinions and thoughts without fear of judgment. It is up to the group facilitators to ensure that the dynamics within the group create a respectful environment. As practices begin to implement CP, training sessions teach skills for leading groups and facilitating discussion. Developing techniques for dealing with difficult group members or inappropriate behavior is one of the significant challenges in the implementation of group care.
The composition of the group is stable, not rigid
Once the group has formed, often by the third session, additional patients cannot join without the permission of the women in the group. This protects the relationships that are developing within the group, but still allows for exceptions in particular circumstances.
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Patient Perspectivesw that we didn’t want to say it, and because somebody else was bold enough to say it, we were able to get it answered.’’ ‘‘What I like about Centering is the way it is organized. I also like that you actually learn more than you actually would in a regular visit.’’ ‘‘I get to interact with other women due within the same month and we always do different activities that make the sessions interesting.’’ ‘‘The nurses here are well prepared and that gives me a sense of security, the way they develop the program is awesome.’’ ‘‘I really enjoy the group discussions, the games, and how we all share what we’re feeling with each other.’’ ‘‘I like that we can be open and talk about anything.’’ ‘‘We have fun and if there are any questions or concerns we can talk freely and not be embarrassed.’’ ‘‘Providers are willing to answer all questions no matter how big or small.’’ ‘‘It’s very open, the conversations are easy, flowing, and you learn in a laid-back way. It’s very comforting.’’
‘‘What I like about Centering is the sincerity of the staff here. I love Centering because of [the facilitators] and being able to share experiences.’’ ‘‘What I like best about my prenatal care is that our nurses make us feel so comfortable and we’re able to share anything where feeling.’’ ‘‘I like my doctor and nurses they all seem to be caring and they make you feel good about yourself.’’ ‘‘I don’t feel awkward and I get to see the same person every time.’’ ‘‘I think just having actual time with the group leaders and with the nurse practitioner, I think that was really helpful because I was able to ask questions if I had any questions or concerns. And knowing that I had that extra time was really helpful and then also being with the other women that had some more questions and were going through the same thing.’’ ‘‘What I like about Centering is that it’s fun, lots of support, friendly mothers, and nurses.’’ ‘‘What I like best about my prenatal care is that our nurses make us feel so comfortable and where able to share anything where feeling.’’ ‘‘Everyone is friendly and we can talk about anything.’’ ‘‘Providers are willing to answer all questions no matter how big or small.’’ ‘‘What I like best about Centering is listening and sharing with others. Feeling comfortable talking with the teachers. I feel welcome and taken care of.’’ ‘‘All my questions are thoroughly answered without embarrassment.’’ ‘‘What I like best about Centering is that they are concerned about me. Nobody says it’s unusual, they answer all my questions and concerns. Everybody is so understanding and polite.’’ ‘‘What I like best about Centering is the people in the group. Make you feel like a family and I’ve learned a lot.’’ ‘‘I knew the group of ladies and felt comfortable voicing my opinion and asking questions.’’
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TABLE 1. (Continued) Essential Element
Description*
Patient Perspectivesw
Group size is optimal to promote the process
Eight to 12 patients in a group gives the patients enough peers to provide information, perspective, and reassurance to each other. It also helps the groups to be a more efficient way to provide prenatal care by approximating the volume of patients that could be seen in individual prenatal care in a similar period of time. In recognition that a pregnancy involves the entire family, patients can choose to bring a support person to the group sessions. This should also be taken into consideration when identifying space for group sessions, as large groups that include supporting partners can include as many as 24 individuals. Women who do not have supporting partners can often benefit the most from the social support provided by group members, and should not be made to feel excluded from groups if they do not have someone who can attend groups with them consistently. During the first 30 min of each group, while individual physical assessments are being performed, women are encouraged to socialize with one another. Although there is time during group for more structured interactions, informal conversation serves to build relationships. Often, women in groups will share contact information and carpool to group sessions or arrange other social activities outside of group.
‘‘It’s welcoming and I feel like I know everyone.’’ ‘‘It is personal. I know the people here and I am not just another patient.’’ ‘‘What I like best about Centering is that it is a small group and everyone is comfortable around each other.’’
Involvement of support people is optional
Opportunity for socializing within the group is provided
There is ongoing evaluation of outcomes
‘‘Tuvimos la oportunidad de conocer a mas parejas que esta´n esperando bebes y fue muy bueno porque compartieron sus experiencias.’’ ‘‘We had the opportunity to meet other couples that are expecting babies and it was really good because they shared their experiences.’’ ‘‘The girls and partners in the class were fun to have around and made the whole Centering experience complete.’’ ‘‘It was nice to meet all the other moms and dads.’’
‘‘Meeting and getting to know girls going through the same thing as me was helpful to know I wasn’t alone.’’ ‘‘I really enjoyed being part of Centering and getting to know others. We connected more as family.’’ ‘‘What I like about Centering is sitting with other women and getting a chance to talk with them.’’ ‘‘It’s light-hearted. I think going to a doctor’s appointment is more serious, it’s more, ‘What if something’s wrong with the baby,’ and you get all the anxiety and it’s not good. But when you’re in a group and you’re having fun, it makes it a lot easier, it really does. Probably just like the friends I made when I was there. And about halfway through, the girls that were there halfway through were the ones who stayed till the end. So you really got to know them and all their different life experiences. And everybody is coming from a different way and it’s really cool.’’
CHI requires that all sites engage in continuous quality improvement as part of their requirement for ongoing site approval. They require that sites collect patient satisfaction and basic health outcomes data.
*The description of each element reflects the literature describing the Centering Pregnancy model,17 the first and third authors’ clinical practice experience is implementing and sustaining their Centering Pregnancy program at the Greenville Health System, and their experience providing technical assistance to other practices implementing Centering Pregnancy in South Carolina. w The patient experiences are drawn from patient satisfaction surveys and qualitative interviews with patients at the Greenville Health System Centering Pregnancy program. CHI indicates Centering Healthcare Institute; CP, Centering Pregnancy; PNC, prenatal care.
Since 2003,
Group Prenatal Care: Has Its Time Come? AMY PICKLESIMER, MD, MSPH,* EMILY HEBERLEIN, PhD,w and SARAH COVINGTON-KOLB, MSW, MSPH* *Department of Obstetrics and Gynecology, Greenville Health System, Greenville, South Carolina; and w Department of Public Health Sciences, Clemson University, Clemson, South Carolina Abstract: Group prenatal care is an emerging trend in obstetrics, and for medically low-risk women has been shown to result in lower rates of preterm birth, higher rates of breastfeeding, and higher rates of participation in postpartum family planning. Significant cost savings to the health care system are seen when the lower rates of preterm birth and neonatal intensive care unit admissions are considered. More research is needed about patients’ health outcomes as well as the economic and workforce implications to outpatient obstetric practices before widely transitioning prenatal care into group settings. Key words: Centering Pregnancy, group prenatal care, preterm birth, health economics
experiences such as childbirth. Long, unpredictable hours, and pressures from malpractice costs and reimbursement rates affect the number of medical students choosing the specialty, and negatively affect the career satisfaction of practicing obstetricians and gynecologists (OB-GYN). In combination with the large proportion of OB-GYN physicians approaching retirement age1,2 and geographic disparities in the availability of the specialty, the United States is facing a potential shortage in the OB-GYN workforce.2,3 These workforce challenges provide the context for the current delivery of prenatal care (PNC) in the United States. PNC is recognized as an important primary care service, combining early and ongoing risk assessment and intervention with patient education related to both maternal health and infant care. In practice, the great majority of PNC visits are brief, and the need to triage medical issues contributes to inconsistent coverage of anticipatory guidance topics such as breastfeeding, gestational weight gain, and exercise.4–8 Many OB-GYNs feel that inadequate time with patients is a major
Background Many physicians choosing to enter the specialty of obstetrics and gynecology are motivated by the unique opportunity to care for women across their lifespan, to combine surgical and clinical care, and to build relationships with their patients during life-changing and intimate Correspondence: Amy Picklesimer, MD, MSPH, Suite 470, Greenville, SC. E-mail: [email protected] Supported by South Carolina Chapter of the March of Dimes. The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
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Group Prenatal Care obstacle to providing high-quality care.2 Although the proportion of women initiating early PNC has steadily increased in the last several decades,5 the continued high incidence and racial disparities in the rates of preterm birth and low birth weight, as well as the recognition of the complex causes of adverse birth outcomes, have led to a call to reexamine the traditional model of individual PNC.9,10 These multiple imperatives— assuring women have access to reproductive health services, removing health care system barriers to physicians delivering or overseeing the provision of high-quality PNC, controlling the costs of care, physician job satisfaction, and improving outcomes for women and babies—necessitate the development and evaluation of alternative PNC models.
Models for Change: Group Medical Appointments Group models for patient education and disease management are a promising means to meet the triple aim of improving the United States health care system: improving the patient experience of care, improving the health of populations, and reducing the cost of health care.11 Research on group medical care models conducted over the last 3 decades has demonstrated increased patient and provider satisfaction, improved health outcomes, and reduced costs.12 Although models vary in session length, frequency, duration, content, and approach, and target a range of health conditions and populations, group visit models include an individual medical evaluation with a physician or nurse practitioner combined with a group educational session.12 Because group models offer additional time for patients to interact with their physician or nurse practitioner, learn illness self-management skills, and participate in group problem solving and social
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support,12 group models may be especially effective in chronic disease management and have demonstrated positive outcomes in the care of diabetes, HIV/ AIDS, arthritis, chronic pain, cancer, and geriatric care.13–16 For years, many OB-GYN practices have been referring patients to group childbirth education classes, or conducting group educational sessions without formalizing the curriculum or publishing outcomes data. Because of this familiarity with group education, a growing number of obstetric and midwifery practices have recently made the transition to group prenatal care (GPNC) as an alternative PNC delivery model. Most groups form early in pregnancy, typically between 12 and 16 weeks’ gestation, after an initial individual medical and psychosocial assessment. GPNC sessions typically follow the schedule of PNC visits and tests recommended by the American College of Obstetricians and Gynecologists, and include educational content covered in traditional childbirth education classes. The physical assessment of a traditional individual PNC (IPNC) visit is typically bundled with the group session allowing these visits to be billed using standard PNC billing codes.
Centering Pregnancy (CP): Better Understanding, Greater Engagement, and Improved Health Outcomes for Pregnant Women Of GPNC models, the CP model of GPNC is the best known, most widely practiced, and currently supported by the most evidence. Originally developed and tested in the 1990s by Sharon Schindler Rising, a certified nurse-midwife, the Centering Healthcare Institute (CHI, Boston, MA) now administers the model, including management of the curriculum, oversight of facilitator training, and site www.clinicalobgyn.com
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certification for all practices offering CP. The site certification process includes an initial visit to the practice from CHI faculty for a comprehensive evaluation of model fidelity, as well as complete yearly assessments to assure ongoing quality in delivering the CP model of care. In the last several years, the United States (US) Department of Health and Human Services and a number of private foundations including the March of Dimes, the Duke Endowment, and the Kellogg Foundation have provided funding for the expansion of CP. The Agency for Healthcare Research and Quality has identified CP as a service delivery innovation with strong evidence. Thirteen essential elements collectively define the CP model’s format, content, parameters for patient/provider and group interactions, and the physical structure of the group meeting space (Table 1). CP groups include 8 to 12 women to deliver in the same month, and groups meet for ten 2-hour group sessions over the second and third trimesters. Patients are also encouraged to bring a support person (eg, boyfriend, husband, family member) to group sessions. During the first 30 minutes of each CP session, patients are actively engaged in their own health care by checking their own weight and blood pressure, and the physician or nurse practitioner conducts a brief physical assessment with each individual in a semiprivate area of the group space. This individual patient assessment, including a physical examination, allows the visit to be billed using the routine procedure codes for PNC. CHI recommends limiting these encounters to 3 to 5 minutes, deferring the majority of patient questions, concerns, and education for the group discussion. While these brief assessments take place, patients have time to socialize or review the CP notebooks (provided to each woman) and complete self-assessment activities. Once all of the physical examinations are complete, the remaining www.clinicalobgyn.com
60 to 90 minutes of the session is spent in facilitated group discussion. The curriculum covers a range of topics, organized by relevancy to gestational age (Table 2). GPNC is aligned with the Institute of Medicine’s rules for health care system redesign, which require knowledge sharing, evidence-based decision making, transparency, patient control, individualized care based on continuous relationships, cooperation among clinicians, patient safety, and decreased waste.17,18 Currently, formal site approval from CHI is largely dependent on model fidelity, or the degree to which a practice adheres to the essential elements. Research investigating the relative importance of the 13 CP model elements is limited, although evidence from 1 randomized control trial and several qualitative studies indicate that the model tenets of facilitation and participation are important in achieving improved birth outcomes, reducing overutilization of PNC, and in meeting women’s preferences and needs. Groups with greater fidelity to the facilitation and participation elements of the model are associated with lower rates of preterm birth and higher patient attendance at PNC visits.19 Qualitative studies indicate that women value the additional time with their physician or nurse practitioner, as well as the opportunity to share their pregnancy experience and care with other women. Patients describe multiple benefits from CP: feeling supported by their providers and group participants, encouraged that they are not alone in their concerns or experiences, motivated to engage in healthy behaviors, and prepared for birth and postpartum.20–24
Evidence for Change: Comparative Effectiveness of CP Compared With IPNC The rate of CP adoption has outpaced comparative effectiveness research on CP.
Group Prenatal Care TABLE 1.
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The 13 Essential Elements of the Centering Pregnancy Model of Group Prenatal Care17: Clinical Practice Descriptions and Patient Perspectives
Essential Element
Description*
Health assessment occurs Obstetricians or nurse practitioners assess fundal within the group space height, fetal heart tones, and individual concerns in an area set aside within the group space. Women are encouraged to bring concerns other women might share to the group discussion (eg, back pain, headaches, heartburn). This increases efficiency in providing pregnancy and health education, and encourages information sharing and social support among the women. Because all patients and family members attending group sessions discuss and sign a confidentiality agreement, and because patients choose what to disclose during the group, the Health Insurance Portability and Accountability Act regulations protecting patient confidentiality are not compromised. Examinations or discussion requiring greater privacy or additional time can always be conducted separately in an individual setting. Because of the brevity of the individual examination in the group space, many practices limit participation in CP to otherwise medically low-risk women. Participants are involved During group time, patients learn how to measure and in self-care activities record their own blood pressure, weight, and weeks of pregnancy in their medical chart. The CP curriculum includes a patient workbook, which includes pregnancy and health information and selfassessment sheets to initiate self-care activities (eg, quitting smoking, managing stress, exercising, and dietary changes). Facilitators encourage patients to set pregnancy goals and to plan for health-related decisions such as choosing a pediatrician, infant care and feeding, and comfort measures during labor. This increases patient engagement in medical care as well as improves patient knowledge and understanding, and giving women a more active role in maintaining a healthy pregnancy. A facilitative style of Each CP group session is led by 2 facilitators, one of leadership is used which must be a physician or nurse practitioner. There is no stipulation for the background of cofacilitators, and practices successfully use nurses, nursing assistants, and social workers The CP curriculum is not taught didactically. Instead, facilitators introduce topics as part of a group discussion, which encourages patients to share their knowledge, concerns, experiences, and ideas. This helps promote a sense of self-efficacy and confidence for patients, as a parent and as a health care consumer. Many group facilitators find that they are energized by the opportunity to cover topics in depth with discussion and peer to peer learning, in contrast to repetitive and superficial coverage of health topics resulting from time constraints posed by brief, individual PNC appointments. The group is conducted Group space should be configured in an open circle of in a circle chairs, without desks or a table in the center of the room. This facilitates open discussion and encourages patients to share their knowledge and experiences with each other, and to help women feel more confident asking questions. Many practices find that identifying a space large enough to accommodate groups of 20 or more people is the most challenging element of CP implementation. Few practices have the budget to specifically renovate clinical space to meet the unique needs of CP care. Some practices have adapted waiting rooms for CP groups after hours, and others have
Patient Perspectivesw ‘‘What I liked about Centering was to hear the baby’s heartbeat, and the discussions.’’ ‘‘I loved it, not being alone for doctor’s appointments.’’ ‘‘What I like about Centering was getting to share and compare my symptoms/complaints with other women in my position.’’
‘‘What I liked about Centering was meeting with the group, meeting with the doctor, and getting to be able to do my own blood pressure, weight, etc.’’ ‘‘What I liked about Centering was to monitor my own weight and blood pressure. So I have the knowledge to know what was right for me.’’ ‘‘I don’t have to wait in the waiting area for a long time and I can do some of my own prenatal care.’’
‘‘Everyone interacts as a group and we discuss all our concerns and interests as a group and learn from others concerns.’’ ‘‘We get to express ourselves, and tell and learn about one another’s pregnancies.’’ ‘‘I’m a first time mother, and I’m learning many things, not only from the health care providers, but other mothers in the group as well.’’ ‘‘What I liked about Centering was that I’m able to voice questions and get multiple opinions and answers.’’ ‘‘What I liked about Centering is that we can all talk openly and ask questions. We all kind of bond over our common symptoms and problems. It’s kind of funny. We spend a lot of time laughing together.’’
‘‘We get to be in a group, discussing all things, and it makes me feel comfortable and I have learned a lot.’’ ‘‘We talk about everything in the circley’’ ‘‘I’m learning a lot about pregnancy and even new things I didn’t know before. I like the setting of the group and being around the people here.’’ ‘‘The most important part was when we would have the circle time. Well, to me, after we would go over what we were supposed to in a session, she’d open up for any questions or comments we wanted to make. I think, to me, that was really a great part of it, because we learned—like we may have questions
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TABLE 1. (Continued) Essential Element
Description* identified appropriate spaces in hospital conference rooms.
Each session has an overall plan
CHI provides structure for groups through a comprehensive curriculum for each session, addressing topics of importance at key points during prenatal care (Table 2). The CP patient notebook contains supplemental information relating to each topic, which can serve to replace educational brochures that many practices stock to provide to patients with specific diagnoses. Decreasing the need for these patient educational materials can partially offset the cost of the CP patient notebooks to the practice.
Attention is given to core Patient notebooks provide a structured curriculum, but if patients express interest or concern in a topic content, although that is not specifically scheduled for the session’s emphasis may vary agenda, facilitators are encouraged to give priority to patient questions and concerns. For example, if a group member delivers preterm, this could provide a very compelling opportunity to discuss signs and symptoms of preterm labor even though the planned topic for the session is breastfeeding. The facilitator can make note of the divergence, and can cover curriculum topics at a later session. There is stability of group The relationships that develop within the group are leadership important to the patients’ sense of trust and wellbeing, and create a group environment in which patients feel empowered to ask uncomfortable or potentially embarrassing questions and to share personal experiences. Therefore, the same 2 facilitators (one of which must be a physician or nurse practitioner) must commit to lead all 10 of a group’s sessions. Obviously, exceptions can be made in the case of vacations or unexpected absences, but practices must plan for continuity within groups. Most providers who lead groups enjoy the opportunity to develop relationships with their patients through the increased contact time.
Group conduct honors the contribution of each member
In group sessions, each patient should feel welcome to voice her opinions and thoughts without fear of judgment. It is up to the group facilitators to ensure that the dynamics within the group create a respectful environment. As practices begin to implement CP, training sessions teach skills for leading groups and facilitating discussion. Developing techniques for dealing with difficult group members or inappropriate behavior is one of the significant challenges in the implementation of group care.
The composition of the group is stable, not rigid
Once the group has formed, often by the third session, additional patients cannot join without the permission of the women in the group. This protects the relationships that are developing within the group, but still allows for exceptions in particular circumstances.
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Patient Perspectivesw that we didn’t want to say it, and because somebody else was bold enough to say it, we were able to get it answered.’’ ‘‘What I like about Centering is the way it is organized. I also like that you actually learn more than you actually would in a regular visit.’’ ‘‘I get to interact with other women due within the same month and we always do different activities that make the sessions interesting.’’ ‘‘The nurses here are well prepared and that gives me a sense of security, the way they develop the program is awesome.’’ ‘‘I really enjoy the group discussions, the games, and how we all share what we’re feeling with each other.’’ ‘‘I like that we can be open and talk about anything.’’ ‘‘We have fun and if there are any questions or concerns we can talk freely and not be embarrassed.’’ ‘‘Providers are willing to answer all questions no matter how big or small.’’ ‘‘It’s very open, the conversations are easy, flowing, and you learn in a laid-back way. It’s very comforting.’’
‘‘What I like about Centering is the sincerity of the staff here. I love Centering because of [the facilitators] and being able to share experiences.’’ ‘‘What I like best about my prenatal care is that our nurses make us feel so comfortable and we’re able to share anything where feeling.’’ ‘‘I like my doctor and nurses they all seem to be caring and they make you feel good about yourself.’’ ‘‘I don’t feel awkward and I get to see the same person every time.’’ ‘‘I think just having actual time with the group leaders and with the nurse practitioner, I think that was really helpful because I was able to ask questions if I had any questions or concerns. And knowing that I had that extra time was really helpful and then also being with the other women that had some more questions and were going through the same thing.’’ ‘‘What I like about Centering is that it’s fun, lots of support, friendly mothers, and nurses.’’ ‘‘What I like best about my prenatal care is that our nurses make us feel so comfortable and where able to share anything where feeling.’’ ‘‘Everyone is friendly and we can talk about anything.’’ ‘‘Providers are willing to answer all questions no matter how big or small.’’ ‘‘What I like best about Centering is listening and sharing with others. Feeling comfortable talking with the teachers. I feel welcome and taken care of.’’ ‘‘All my questions are thoroughly answered without embarrassment.’’ ‘‘What I like best about Centering is that they are concerned about me. Nobody says it’s unusual, they answer all my questions and concerns. Everybody is so understanding and polite.’’ ‘‘What I like best about Centering is the people in the group. Make you feel like a family and I’ve learned a lot.’’ ‘‘I knew the group of ladies and felt comfortable voicing my opinion and asking questions.’’
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TABLE 1. (Continued) Essential Element
Description*
Patient Perspectivesw
Group size is optimal to promote the process
Eight to 12 patients in a group gives the patients enough peers to provide information, perspective, and reassurance to each other. It also helps the groups to be a more efficient way to provide prenatal care by approximating the volume of patients that could be seen in individual prenatal care in a similar period of time. In recognition that a pregnancy involves the entire family, patients can choose to bring a support person to the group sessions. This should also be taken into consideration when identifying space for group sessions, as large groups that include supporting partners can include as many as 24 individuals. Women who do not have supporting partners can often benefit the most from the social support provided by group members, and should not be made to feel excluded from groups if they do not have someone who can attend groups with them consistently. During the first 30 min of each group, while individual physical assessments are being performed, women are encouraged to socialize with one another. Although there is time during group for more structured interactions, informal conversation serves to build relationships. Often, women in groups will share contact information and carpool to group sessions or arrange other social activities outside of group.
‘‘It’s welcoming and I feel like I know everyone.’’ ‘‘It is personal. I know the people here and I am not just another patient.’’ ‘‘What I like best about Centering is that it is a small group and everyone is comfortable around each other.’’
Involvement of support people is optional
Opportunity for socializing within the group is provided
There is ongoing evaluation of outcomes
‘‘Tuvimos la oportunidad de conocer a mas parejas que esta´n esperando bebes y fue muy bueno porque compartieron sus experiencias.’’ ‘‘We had the opportunity to meet other couples that are expecting babies and it was really good because they shared their experiences.’’ ‘‘The girls and partners in the class were fun to have around and made the whole Centering experience complete.’’ ‘‘It was nice to meet all the other moms and dads.’’
‘‘Meeting and getting to know girls going through the same thing as me was helpful to know I wasn’t alone.’’ ‘‘I really enjoyed being part of Centering and getting to know others. We connected more as family.’’ ‘‘What I like about Centering is sitting with other women and getting a chance to talk with them.’’ ‘‘It’s light-hearted. I think going to a doctor’s appointment is more serious, it’s more, ‘What if something’s wrong with the baby,’ and you get all the anxiety and it’s not good. But when you’re in a group and you’re having fun, it makes it a lot easier, it really does. Probably just like the friends I made when I was there. And about halfway through, the girls that were there halfway through were the ones who stayed till the end. So you really got to know them and all their different life experiences. And everybody is coming from a different way and it’s really cool.’’
CHI requires that all sites engage in continuous quality improvement as part of their requirement for ongoing site approval. They require that sites collect patient satisfaction and basic health outcomes data.
*The description of each element reflects the literature describing the Centering Pregnancy model,17 the first and third authors’ clinical practice experience is implementing and sustaining their Centering Pregnancy program at the Greenville Health System, and their experience providing technical assistance to other practices implementing Centering Pregnancy in South Carolina. w The patient experiences are drawn from patient satisfaction surveys and qualitative interviews with patients at the Greenville Health System Centering Pregnancy program. CHI indicates Centering Healthcare Institute; CP, Centering Pregnancy; PNC, prenatal care.
Since 2003,
