Understanding the Value of Group Prenatal Care

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Whether it is someone’s first or fourth child, pregnancy is a journey with each and every time. Questions are aplenty, and often pregnant moms only get a short time to spend with their providers each visit. They may forget their questions, be embarrassed to address issues, or just be overwhelmed and fail to ask all they had hoped to. In addition, the prenatal world is full of books, websites, unsolicited advice, and misinformation that can lead our patients down the wrong path at times. In order to provide holistic and fulfilling prenatal care as well as a built-in support system, centering group prenatal visits have been slowly introduced into healthcare. In an effort to share their success and grow support, this article will describe their benefits. 

Introduction 

It’s 2 a.m.
Janey sits up in bed, choking on her own gastric acid. She rushes to the bathroom to get a glass of water; she is out of breath, and the burning sensation she is feeling in her throat is so painful, she wants to vomit. Her significant other sleeps through it all, and for a moment, it is hard to breathe as she chokes the liquid back down. 

Janey is four months pregnant with her first child. She is experiencing a common nighttime symptom related to gastric reflux as the baby grows bigger and takes up more room in her stomach. Acid reflux symptoms are very common in pregnancy and have very few complications (6). 30-50% of pregnant women experience these symptoms during their pregnancy (6). During the first pregnancy, however, it is hard to know and expect sometimes vicious symptoms. Often the ability to talk about these with other pregnant women can help prepare a newly pregnant woman with what to expect. But what if you are limited in support systems? What if you are the first pregnant female in your immediate peer group? Who do you turn to? The ideas surrounding centering prenatal care are to provide the support for these exact questions and conversations in a safe and mentored setting with other pregnant women and your care team. 

Current Prenatal Statistics 

Since 1989, the United States has worked to change the goals of prenatal care to beyond just biological reproduction and to include the holistic care of the pregnant woman (6). The goals expanded their reach to include looking at the entire pregnancy, fetal development as well as the care and wellbeing of the mom. Recent CDC data suggests 8.31 % of babies are born with low birth weight (LBW), and 10.23% are born prematurely (less than 36 weeks gestation) (8). Despite the approach to prenatal care as defined by the goals of the US Public Health Service Expert Panel on the Content of Prenatal Care updated in 1989, care has really not changed a huge amount since then (5, 6). 

The 1989 Goals

For the Pregnant Woman: 

1. To increase her wellbeing 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 wellbeing.
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 (6) 

These lofty goals are so appropriate for the health and wellbeing of our pregnant women and their children but are so hard to meet with all of the barriers in our current ways of practicing: quick visits, reimbursement for care models, and health disparities in reaching all pregnant women.  

Low birth weight (LBW) is defined as an initial post-birth weight at less than 2,500 grams per the WHO (World Health Organization (7). It is an important indicator of a healthy mom, healthy pregnancy, and healthy baby. LBW can be associated with long-term neurological issues, so prevention remains paramount to successful maternal health. Everything from infectious diseases to poor nutrition and can lead to a subsequent preterm birth (7). In a group prenatal care setting, physicians will be able to dive deeper into explanations of LBW risks or subsequent preterm labor that they may not have time for during regular practice. In fact, they will reach more mothers with these potential questions at once, rather than seeing them one by one.  

Sharon Schindler Rising, a certified Nurse-Midwife, developed the group prenatal care model, CenteringPregnancy TM, in 1998 (4). It has grown a lot over the years as offices become shorter on staff and time but have an increased need for productivity (1). According to an interview with the director of UR Medicine Midwifery group at the University of Rochester, group prenatal care has been shown to decrease the number of preterm births as well as decrease the rate of LBW babies (1, 3, 4).  

A promising study showed a 33% reduction in preterm birth among 1,000 women living in the inner-city aged 14-25 years of age when randomized to centering groups (5). Also helpful in this study was the decrease in secondary pregnancies less than six months later, increased condom use, and less unprotected sex overall among those in the centering groups (5). In addition, the CDC has reported that 40% of pregnant women were unmarried in 2019. This suggests a potential for a decrease in support systems and may be a continued reason to find other pregnant women to talk things through with. Dr. Burtner also relates centering to improve adolescent pregnancy health and improve compliance with postpartum health follow-up visits. 

Case Study 

You are the nurse in a busy, urban OB/GYN Clinic. You work alongside several physicians and a couple of midwives each shift. You provide care to a 16-year-old that has a positive pregnancy test, and she is in tears in the exam room when you re-enter to get vital signs. She is alone, and you sit down to offer comfort. As you talk with her, you learn that she is living with her grandparents because her parents passed away when she was 12. She has a boyfriend, but her grandparents don’t know about him. She is so scared to share the truth with them because her grandmother just thinks she is here for a routine visit. She wants to keep the baby but just doesn’t know where to begin…What do you do now? 

Centering in Detail 

The typical pregnant woman is seen about ten times by the physician or midwife team for about 15 minutes each throughout their pregnancy. With the rise of electronic medical records, questions can be answered online but often have a delay or a starkness to the responses via computer. Centering, which is offered in 45 states at over 470 certified Centering Pregnancy practices, offered care and services for about 1% of all pregnant women in 2015. During these sessions, patients are placed into groups of 8-10 people according to the stage of pregnancy they are in.  

At the start of the centering visit, the moms have an individual health assessment with a provider. The mom is taught and encouraged to take her own weight and blood pressure and monitor in a notebook (3). This empowers them to be an active part of their care and have direct knowledge of their status. They get private time with the provider or midwife prior to meeting in their group setting. The sessions are led by certified providers, and if someone expresses a concern that requires more of a need to address, the patient is set up with a 1:1 visit with a provider (2). 

The prenatal group visits last up to 90 minutes to two hours and allow for discussions on prenatal health, nutrition, common health concerns, stress management, labor techniques, breastfeeding, infant care, postpartum care, and complications. This is 10x the amount of time a patient will normally spend with a provider during their pregnancy! Essentially patients can spend 23 hours with providers over the course of their pregnancy as opposed to just under two hours (2, 3).  

Case Study 

Think back to Janey from the opening paragraph.  

Choking on your own acid reflux at 2 a.m. is quite scary. If she could have participated in a centering visit, she may have heard about these symptoms, been more prepared, or even started taking measures to avoid GERD during pregnancy to begin with. This is not a reach but rather an expected outcome of centering visits. A quote from a mom participating in group prenatal care was found online, “My doctor and nurse would lead the group on various topics, but it wasn’t like a class: it was a discussion, a group of pregnant women together on a journey with health care providers investing in our wellbeing, our health, the health of our babies, and most importantly giving us a safe environment to learn the facts that would get us to our goals.” This speaks so much to the journey that pregnancy is; the stress that goes along with trying to do all the right things while pregnant can diminish as one learns from others in a safe environment. 

Barriers to Centering 

As with any innovative practice in our complex healthcare environments, barriers exist. The time spent in group prenatal care centering sessions may be unattainable for women with demanding jobs, other children, and limited support systems (2). Billing and insurance have not been completely reviewed in relation to this type of practice. Space to hold sessions, especially now with social distancing and virtual visits common during the pandemic, may be difficult to find in some clinics. Also, adapting to any new and innovative practice with consistency and certainty may be hard for providers. In addition, pregnant moms may not want to participate in a group setting or be wary of this approach (3). These barriers can be overcome through the use of implementation methods if a team commits to this kind of care. 

Conclusion 

It is well known that it takes 17 years for evidence to go from “bench to bedside” formally. This downfall in adapting to innovative practices leads to delays in optimizing the best patient care. Centering and/or other elements of group prenatal care has been shown to be valuable to meet those 1989 public health goals in a variety of ways-none more important than basic patient satisfaction.  

Despite all of that, it is not a traditional way of practice, and there continue to be delays in the overall pursuit of this type of group prenatal care. The benefits, especially to the underserved and under-supported women who are pregnant, are endless, and it should continue to be offered as much as possible. In addition, as we try to address the many public health needs facing our nation today, let’s consider how innovative group practices could help build relationships and strengthen the care of all kinds of diagnoses and conditions. Learning from, with and about each other as well as how to manage illnesses and promote health may improve when working for 10x as long with providers in group settings focused on health and well being! 

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