A systematic overview of the literature regarding group prenatal care for high-risk pregnant women

Adolescents' experiences with group antenatal care: Insights from a mixed-methods study in Senegal

OBJECTIVES

Group antenatal care (G-ANC) is an innovative model in which antenatal care is delivered to a group of 8-12 women of similar gestational age. Evidence from high-income countries suggests G-ANC is particularly effective for women from marginalised populations, including adolescents. The objective of this study was to examine the experiences of Senegalese adolescents engaged in group antenatal care.

METHODS

This convergent parallel mixed-methods study is derived from a larger effectiveness-implementation hybrid pilot study conducted in Kaolack district, Senegal. Quantitative data for adolescent participants were collected through baseline and postnatal surveys and descriptively analysed. One-on-one interviews and focus-group discussions were conducted with adolescent participants, and qualitative data were analysed using qualitative descriptive analysis.

RESULTS

Forty-five adolescents aged 15-19 participated in G-ANC, with a median age of 18 years. The majority (93.3%) were married, and 64.4% were nulliparous. Findings indicated similar levels of G-ANC participation for adolescent and adult women. The majority (93.1%) of participants who had previously attended individual ANC indicated they would prefer G-ANC to individual care for a future pregnancy. Qualitative findings indicated key facets of consideration relevant to G-ANC for adolescents include social connectedness, the influence of social norms and the opportunity for engagement in healthcare.

CONCLUSIONS

This study suggests that G-ANC has the potential to be an adolescent-responsive and culturally appropriate method of delivering antenatal care in Senegal.

A systematic review of providers' experiences of facilitating group antenatal care

Background

Group antenatal care is a rapidly expanding alternative antenatal care delivery model. Research has shown it to be a safe and effective care model for women, but less is known about the perspectives of the providers leading this care. This systematic review examined published literature that considered health care professionals’ experiences of facilitating group antenatal care.

Methods

Systematic searches were conducted in seven databases (Cinahl, Medline, Psychinfo, Embase, Ovid Emcare, Global Health and MIDRS) in April 2020. Qualitative or mixed methods studies with a significant qualitative component were eligible for inclusion if they included a focus on the experiences of health care providers who had facilitated group antenatal care. Prisma screening guidelines were followed and study quality was critically appraised by three independent reviewers. The findings were synthesised thematically.

Results

Nineteen papers from nine countries were included. Three main themes emerged within provider experiences of group antenatal care. The first theme, ‘Giving women the care providers feel they want and need’, addresses richer use of time, more personal care, more support, and continuity of care. The second theme, ‘Building skills and relationships’, highlights autonomy, role development and hierarchy dissolution. The final theme, ‘Value proposition of group antenatal care’, discusses provider investment and workload.

Conclusions

Health care providers’ experience of delivering group antenatal care was positive overall. Opportunities to deliver high-quality care that benefits women and allows providers to develop their professional role were appreciated. Questions about the providers’ perspectives on workload, task shifting, and the structural changes needed to support the sustainability of group antenatal care warrant further exploration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01200-0.

Receiving antenatal care in a group setting has been found to be safe and satisfying for women and is supported by international public health guidelines. However, questions remain about the experience of health care professionals tasked with providing this model, such as whether they like working in this model and whether they support its expansion. To answer these questions, the team searched for studies about the experiences of health care providers with group antenatal care, and only included those studies where providers themselves spoke about their own experiences of providing this kind of care. Our review demonstrated that midwives, doctors, nurses and community health workers mostly enjoyed facilitating group antenatal care. They particularly appreciated the ability to give women the kind of care they felt women want and need. Health care providers also experienced some changes in their professional roles, in relation to both the women they serve and their colleagues and organizations. In order to determine if group antenatal care models are a satisfying and sustainable option for health care professionals in the long term, more research is needed.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes

In 2017-2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

Group Pregnancy Care for refugee background women: a codesigned, multimethod evaluation protocol applying a community engagement framework and an interrupted time series design

INTRODUCTION

Pregnancy and early parenthood are key opportunities for interaction with health services and connecting to other families at the same life stage. Public antenatal care should be accessible to all, however barriers persist for families from refugee communities to access, navigate and optimise healthcare during pregnancy. Group Pregnancy Care is an innovative model of care codesigned with a community from a refugee background and other key stakeholders in Melbourne, Australia. Group Pregnancy Care aims to provide a culturally safe and supportive environment for women to participate in antenatal care in a language they understand, to improve health literacy and promote social connections and inclusion. This paper outlines Froup Pregnancy Care and provides details of the evaluation framework.

METHODS AND ANALYSIS

The evaluation uses community-based participatory research methods to engage stakeholders in codesign of evaluation methods. The study is being conducted across multiple sites and involves multiple phases, use of quantitative and qualitative methods, and an interrupted time series design. Process and cost-effectiveness measures will be incorporated into quality improvement cycles. Evaluation measures will be developed using codesign and participatory principles informed by community and stakeholder engagement and will be piloted prior to implementation.

ETHICS AND DISSEMINATION

Ethics approvals have been provided by all six relevant authorities. Study findings will be shared with communities and stakeholders via agreed pathways including community forums, partnership meetings, conferences, policy and practice briefs and journal articles. Dissemination activities will be developed using codesign and participatory principles.

Effect of comprehensive care on the negative emotions and life quality in parturients with postpartum depression and gestational hypertension

OBJECTIVE

To investigate the efficacy of comprehensive care during the nursing process of parturients with gestational hypertension and postpartum depression.

METHODS

This prospective study recruited 70 patients with gestational hypertension concurrent with postpartum depression, and the patients were randomly divided into a control group (35 patients received routine care) and an observation group (35 patients, treated by comprehensive care). Indicators including psychological condition, life quality, thyroid function, the incidence of eclampsia, and nursing satisfaction were recorded and compared before intervention (at the diagnosis of postpartum depression) and after intervention (three months after delivery) in the two groups.

RESULTS

The Hamilton Anxiety (HAMA) Scale and Hamilton Depression (HAMD) Scale scores were decreased in both groups after care intervention. Scores of Quality of Life Comprehensive Assessment Questionnaire (GQOLI-74) in all dimensions were higher after intervention than those of before intervention, and improvement was greater in the observation group (P<0.05). The levels of thyroid-stimulating hormone, free triiodothyronine and free thyroxine after the intervention were higher than those before the intervention in the two groups, and the increase in the observation group was greater significant than that in the control group (P<0.05). The incidence of postpartum eclampsia in the observation group was lower than that of the control group, and the nursing satisfaction of patients in the observation group was higher than that of the control group (both P<0.05).

CONCLUSION

Comprehensive care effectively relieved the abnormal psychological condition, promoted thyroid function, reduced the risk of postpartum eclampsia and improved the quality of life in patients with gestational hypertension and postpartum depression.

The Influence of Four Constructs of Social Support on Pregnancy Experiences in Group Prenatal Care

Objective: This study aimed to identify the influence of the four constructs of social support on positive pregnancy experiences in CenteringPregnancy, a group prenatal care (GPNC) model. Methods: Using a qualitative descriptive design, semi-structured interviews were conducted with 11 women who had participated in at least 6 of 10 GPNC sessions at a family practice medicine residency. Participants were asked to describe their experiences in GPNC. Results: Using a standard content analysis, four constructs of social support (emotional, informational, instrumental, and appraisal) were identified through three major themes: (1) informational support, offered by peers in GPNC settings, promotes learning and prepares women for motherhood; (2) emotional and appraisal support, offered by peers in GPNC, improves emotional well-being and helps women build lasting, supportive connections with peers, and (3) emotional, informational, instrumental, and appraisal support work in tandem to create positive relationships between women and health care providers. Conclusion: Social support provided a means to a positive prenatal health care experience that facilitated the attainment of new knowledge and the formation of positive relationships with health care providers and peers. The findings of this study can provide health care providers with a framework to examine and enhance their practice and care of women in the perinatal period.

Effectiveness of the CenteringPregnancy program on maternal and birth outcomes: A systematic review and meta-analysis

BACKGROUND

The World Health Organization has emphasized the critical role of prenatal care in achieving the Millennium Development Goals to reduce child and maternal mortality. The CenteringPregnancy program is a widely recognized model of prenatal care. Several countries have attempted to implement the program in prenatal care practice; however, its effectiveness on maternal and birth outcomes has not been systematically evaluated and analyzed.

OBJECTIVES

To determine the effect of the CenteringPregnancy program on improving maternal and birth outcomes, including low birth weight, preterm birth, and postpartum depression.

DESIGN

This study evaluated and analyzed randomized controlled trials by comparing the CenteringPregnancy program with o0bstetric led prenatal care. Maternal and birth outcomes of interest included low birthweight, preterm birth, and postpartum depressive symptoms.

DATA SOURCES

Embase, PubMed, CINAHL, Web of Science, and The Cochrane Library were utilized in this systematic review. Additionally, a supplemental Google Scholar search was performed to capture all relevant articles.

METHODS

All data were extracted independently by two trained researchers, who evaluated the quality of the study by examining the risk of bias. The biases of selection, allocation, measurement, reporting, and loss of follow-up were assessed using the Cochrane risk of bias for these included randomized controlled trials. A meta-analysis of eligible randomized controlled trials was conducted using Review Manager. Heterogeneity of studies was assessed using the I² statistic.

RESULTS

Out of 591 articles reviewed, seven randomized controlled trials were included in this study. Findings showed that the CenteringPregnancy program was not associated with lower rates of preterm birth (0.88 [0.71-1.07], p = 0.20, I² = 0%), low birth weight (0.87 [0.68-1.12], p =0.29, I² = 0%), or 12-month postpartum depressive symptoms (0.07 [-0.12-0.26], p =0.46, I² = 69%). However, the CenteringPregnancy program was associated with reduced rates of 6-month postpartum depressive symptoms (0.49 [0.40-0.59], p < 0.01, I² = 40%).

CONCLUSIONS

Existing evidence suggests that the CenteringPregnancy program and obstetric led care have similar effects on reducing the rates of preterm birth and low birth weight but different effects on postpartum depressive symptoms. More studies are needed to examine the effect of the CenteringPregnancy program on the improvement of postpartum depressive symptoms. PROSPERO Registration number: CRD42020171831. Tweetable abstract: We conducted a systematic review and meta-analysis of randomized controlled trials to determine the effects of the CenteringPregnancy program on improving maternal and birth outcomes, including low birth weight, preterm birth, and postpartum depressive symptoms. Seven randomized controlled trials were included in this study. The findings suggested that the CenteringPregnancy program and obstetric led care had similar effects in reducing the rates of preterm birth and low birth weight. More studies are needed to examine the effect of the CenteringPregnancy program on the improvement of postpartum depressive symptoms.

Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action

BACKGROUND

Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care.

METHODS

We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility.

FINDINGS

Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences.

CONCLUSIONS

The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

Risks of Adverse Neonatal Outcomes in Early Adolescent Pregnancy Using Group Prenatal Care as a Strategy for Public Health Policies: A Retrospective Cohort Study in Brazil

Background: Adolescent pregnancy is a public health concern and many studies have evaluated neonatal outcomes, but few have compared younger adolescents with older using adequate prenatal care. Objective: To compare the risks of adverse neonatal outcomes in younger pregnant adolescents who are properly followed through group prenatal care (GPC) delivered by specialized public services. Methods: This retrospective cohort study followed pregnant adolescents (aged 10-17 years) who received GPC from specialized public services in Brazil from 2009 to 2014. Data were obtained from medical records and through interviews with a multidisciplinary team that treated the patients. The neonatal outcomes (low birth weight, prematurity, Apgar scores with 1 and 5 min, and neonatal death) of newborns of adolescents aged 10-13 years were compared to those of adolescents aged 14-15 years and 16-17 years. Incidence was calculated with 95% confidence intervals (CIs) and compared over time using a chi-squared test to observe trends. Poisson Multivariate logistic regression was used to adjust for confounding variables. The results are presented as adjusted relative risks or adjusted mean differences. Results: Of the 1,112 adolescents who were monitored, 758 were included in this study. The overall incidence of adverse neonatal outcomes (low birth weight and prematurity) was measured as 10.2% (95% CI: 9.7-11.5). Apgar scores collected at 1 and 5 min were found to be normal, and no instance of fetal death occurred. The incidence of low birth weight was 16.1% for the 10-13 age group, 8.7% for the 14-15 age group and 12.1% for the 16-17 age group. The incidence of preterm was measured at 12, 8.5, and 12.6% for adolescents who were 10-13, 14-15, and 16-17 years of age, respectively. Neither low birth weight nor prematurity levels significantly differed among the groups (p > 0.05). The infants born to mothers aged 10-13 years presented significantly (p < 0.05) lower Apgar scores than other age groups, but the scores were within the normal range. Conclusions: Our findings showed lower incidence of neonatal adverse outcomes and no risk difference of neonatal outcomes in younger pregnancy adolescents. It potentially suggests that GPC model to care pregnant adolescents is more important than the age of pregnant adolescent, however further research is needed.

The evolution of prenatal care delivery guidelines in the United States

The coronavirus disease 2019 pandemic led to some of the most drastic changes in clinical care delivery ever seen in the United States. Almost overnight, providers of prenatal care adopted virtual visits and reduced visit schedules. These changes stood in stark contrast to the 12 to 14 in-person prenatal visit schedule that had been previously recommended for almost a century. As maternity care providers consider what prenatal care delivery changes we should maintain following the acute pandemic, we may gain insight from understanding the evolution of prenatal care delivery guidelines. In this paper, we start by sketching out the relatively unstructured beginnings of prenatal care in the 19th century. Most medical care fell within the domain of laypeople, and childbirth was a central feature of female domestic culture. We explore how early discoveries about "toxemia" created the groundwork for future prenatal care interventions, including screening of urine and blood pressure-which in turn created a need for routine prenatal care visits. We then discuss the organization of the medical profession, including the field of obstetrics and gynecology. In the early 20th century, new data increasingly revealed high rates of both infant and maternal mortalities, leading to a greater emphasis on prenatal care. These discoveries culminated in the first codification of a prenatal visit schedule in 1930 by the Children's Bureau. Surprisingly, this schedule remained essentially unchanged for almost a century. Through the founding of the American College of Obstetricians and Gynecologists, significant technological advancements in laboratory testing and ultrasonography, and calls of the National Institutes of Health Task Force for changes in prenatal care delivery in 1989, prenatal care recommendations continued to be the same as they had been in 1930-monthly visits until 28 weeks' gestation, bimonthly visits until 36 weeks' gestation, and weekly visits until delivery. However, coronavirus disease 2019 forced us to change, to reconsider both the need for in-person visits and frequency of visits. Currently, as we transition from the acute pandemic, we should consider how to use what we have learned in this unprecedented time to shape future prenatal care. Lessons from a century of prenatal care provide valuable insights to inform the next generation of prenatal care delivery.

Group Prenatal Care as a Strategy to Address Diabesity

Group prenatal care is a health care delivery model that utilizes shared medical appointments to place greater focus on patient education, mutual support, and increased time with the clinician to promote a healthy pregnancy. Several studies suggest that medically low-risk women participating in group prenatal care have improved pregnancy outcomes, but the same tenants can likely be used to help women with diabetes and obesity achieve healthy outcomes during pregnancy and throughout their life course. This chapter will review the background, care model, and evidence regarding group medical visits for pregnant women with diabetes and obesity.

Fertility and Reproductive Health in Women Physicians

Background: Our aim was to evaluate trends of childbearing during medical training, evaluate issues of infertility, and measure institutionalized barriers to childbearing among women physicians. Materials and Methods: Attendees of a national women physician's leadership conference (Brave Enough Women Physicians Continuing Medical Education Conference) were surveyed during the conference using Qualtrics^© (2019 Qualtrics, Provo, UT), in September 2019. Survey data included demographics, training level, and medical specialty. Data related to reproductive health factors, pregnancy status and history, current number of children, medical history related to pregnancy, breastfeeding history, institutional family planning support, and use of previous fertility treatments were collected. Descriptive analyses were done using IBM SPSS v26.0. Results: Three hundred seventy-seven survey participants were included in the study. 10.6% of respondents reported at least one pregnancy during medical school, versus 78.8% as a practicing physician. Of the participants, 25.8% reported having taken off 1 month or less of clinical duties after giving birth, 39.4% reported that their job prevented breastfeeding for the desired length of time, and 52.2% reported significant workplace limitations to breastfeeding. Of them, 25.5% reported having had fertility issues in the past. Fertility drugs (72.9%) was the most common fertility treatment method used, followed by fertility tracking (54.2%). Demands of training (72.9%) and long work hours (61.5%) were the most cited factors in delaying having children as reported by women physicians. Conclusions: This study reported several barriers related to fertility, family planning, and reproductive health among women physicians. Our results highlight the need for a paradigm shift in fertility awareness and institutional support for childbearing during medical training, postgraduate training programs, and in practice for women in medicine.

Group antenatal care (Pregnancy Circles) for diverse and disadvantaged women: study protocol for a randomised controlled trial with integral process and economic evaluations

Background

Group antenatal care has been successfully implemented around the world with suggestions of improved outcomes, including for disadvantaged groups, but it has not been formally tested in the UK in the context of the NHS. To address this the REACH Pregnancy Circles intervention was developed and a randomised controlled trial (RCT), based on a pilot study, is in progress.

Methods

The RCT is a pragmatic, two-arm, individually randomised, parallel group RCT designed to test clinical and cost-effectiveness of REACH Pregnancy Circles compared with standard care. Recruitment will be through NHS services. The sample size is 1732 (866 randomised to the intervention and 866 to standard care). The primary outcome measure is a ‘healthy baby’ composite measured at 1 month postnatal using routine maternity data. Secondary outcome measures will be assessed using participant questionnaires completed at recruitment (baseline), 35 weeks gestation (follow-up 1) and 3 months postnatal (follow-up 2). An integrated process evaluation, to include exploration of fidelity, will be conducted using mixed methods. Analyses will be on an intention to treat as allocated basis. The primary analysis will compare the number of babies born “healthy” in the control and intervention arms and provide an odds ratio. A cost-effectiveness analysis will compare the incremental cost per Quality Adjusted Life Years and per additional ‘healthy and positive birth’ of the intervention with standard care. Qualitative data will be analysed thematically.

Discussion

This multi-site randomised trial in England is planned to be the largest trial of group antenatal care in the world to date; as well as the first rigorous test within the NHS of this maternity service change. It has a recruitment focus on ethnically, culturally and linguistically diverse and disadvantaged participants, including non-English speakers.

Trial registration

Trial registration; ISRCTN, ISRCTN91977441. Registered 11 February 2019 - retrospectively registered. The current protocol is Version 4; 28/01/2020.

Assessing antenatal depression in primary care with the PHQ-2 and PHQ-9: Can It Be carried Out by auxiliary nurse midwife (ANM)?

Antenatal Depression (AD) is prevalent in India but remains unidentified and untreated in primary care settings. The Auxiliary Nursing Midwife (ANM), a non-specialist health care worker at antenatal care (ANC) clinic or at a primary care centre can improve the detection of women with AD. In this study, we aimed to estimate the inter-rater reliability of the Patient Health Questionnaire (PHQ-9) and PHQ-2, administered by ANMs, with mental health professionals, that is, Clinical Psychologists(CP). The prospective, blind, observational study was conducted in an antenatal clinic of tertiary care rural hospital of India. PHQ-2 and PHQ-9(Marathi) valid and translated versions were administered to consecutive antenatal women (n = 108) aged 18-45 years by two raters (CP, ANM) independently. Raters and data analyst were blinded to each other's scores. Kappa Coefficient, weighted kappa, Intra-class correlation coefficients (ICC) were used to assess Inter-rater reliability. The mean age of the study participants was 25.91 ± 4.39 years. Inter-rater reliability for PHQ-2 (Screen -Positive or Negative for depression) and PHQ-9 (Severity of depression) was (k = 0.675) and (k_w = 0.732) respectively, which suggested the 'substantial' agreement between ANMs and CP. Among raters, the ICC (95 % confidence interval) was 0.90 (0.85, 0.93) for the PHQ-9 score and for the PHQ-2 was 0.873 (0.819-0.911), which was suggestive of excellent and good reliability respectively. The 'substantial' agreement and 'good to excellent' inter-rater reliability among ANM and CP suggest that these two scales can be used to screen and assess the severity of AD by either qualified or minimally trained, community health workers.

Associated factors of labor satisfaction and predictor of postnatal satisfaction in the north-east of Peninsular Malaysia

INTRODUCTION

Identifying the factors contributing to maternal satisfaction is a proxy measure to improve the quality of care. It evaluates the health service provision by understanding maternal perceptions and expectations and promoting adherence to health services. This study aimed to identify the sociodemographic, obstetric, and medical factors contributing to labor satisfaction among postpartum women and examine the association between labor and postnatal satisfaction.

METHODOLOGY

A cross-sectional study using systematic random sampling in a ratio of 1:5 based on the delivery list in a labor room in a tertiary hospital was applied. Information was obtained from medical records for sociodemographic characteristics and obstetric and medical histories. Face-to-face interviews were performed to obtain responses for Malay versions of the Women's Views of Birth Labour Satisfaction Questionnaire and the Women's Views of Birth Postnatal Satisfaction Questionnaire. Simple and general linear regression analyses were performed.

RESULTS

A total of 110 participants responded, accounting for a response rate of 100%. High-risk color codes, the period of gestation, household income, and were significantly associated with maternal satisfaction during labor. The association between labor and postnatal satisfaction was significant.

CONCLUSION

Identifying these associated factors and differences may lead to understanding and contributing to specific and targeted strategies for tackling issues related to maternal satisfaction.

A crack in the wall: Chronic pain management in integrative group medical visits

Amidst a national crisis of opioid overdose, substantial uncertainty remains over how to safely and effectively address chronic pain. In response to this crisis, safety-net primary care clinics are instituting integrative group medical visits (IGMVs) for chronic pain management. Through two qualitative studies of IGMVs, we found that these groups acted as workarounds implemented by clinicians seeking to innovate upon standard pain management protocols. While clinical uncertainty is often framed as a problem to be managed, in this instance, overlapping uncertainties provided an opportunity through which enterprising clinicians could generate reform at the local level. However, these clinician-led changes were incremental, situational, and partial, and occurred outside of broader systemic reform. In the following article, we draw on 46 interviews with clinicians and staff associated with IGMVs and observations of 34 sessions of 22 distinct IGMVs. We begin by describing the structure of the IGMVs we observed. We analyze the multiple uncertainties surrounding chronic pain and its treatment at the time of our data collection, just before the opioid crisis was declared a national public health emergency. We then demonstrate how clinicians tinkered with existing pain management protocols via their involvement with IGMVs. Lastly, we discuss the conditions of possibility that allowed for the existence of IGMVs at our study sites, as well as the conditions of limitation that restricted the expansion of these groups. Our research points to the potential of IGMVs for treating chronic pain, while showing that IGMVs continue as an innovation by individual clinicians, not as a result of broader reforms.

Gestational Weight Gain: Achieving a Healthier Weight Between Pregnancies

Rates of obesity continue to be a cause of morbidity and mortality, requiring intervention. Excessive gestational weight gain is related to postpartum weight retention and subsequent development of obesity, which translates into higher risk of adverse maternal and neonatal outcomes in future pregnancies and long-term excess cardiovascular disease and cancer for the mothers. Limiting gestational weight gain to within recommended limits prevents postpartum weight retention. This article provides an overview of methods and practices aimed at helping women achieve a healthy weight between pregnancies by improving gestational weight gain. These interventions include lifestyle behavioral changes, diet and exercise, and motivational interviewing.

Family-Centered Primary Care for Teen Parents and Their Children

Although the teen birth rate in the United States continues to decline, births remain disproportionately high among disadvantaged teens and teens of color. The vulnerabilities and resilience of teen parents are described from a historical context, with recommendations for advancing primary care of these families. We endorse comprehensive primary care and clinical practices that capitalize on the strengths and resilience of these families while recognizing the social inequities that compromise their health and development. To strengthen the bonds among young mothers, fathers, and children, we recommend family-centered primary care services that are of a youth- and father-friendly, nonstigmatizing, strength-based, and trauma-informed nature.

Pregnancy in adolescence and adverse neonatal outcomes in Ecuadorian mestizo newborns

BACKGROUND

To establish the association between pregnancy in early and middle adolescence and adverse neonatal outcomes in Ecuadorian mestizo newborns.

METHODS

Study design: epidemiological, observational/descriptive, and cross-sectional.

SETTINGS

Gynecological and Obstetric Hospital Isidro Ayora at Quito, Ecuador, from July to October of 2018.

PARTICIPANTS

this study included 303 newborns and their mothers, 101 children of adolescent mothers between 14 and 16 years old, 101 adolescents between the ages of 17 and 19, and 101 infants born to adult mothers between 20 and 34 years of age.

RESULTS

There is no statistically significant association between maternal age, gestation time, neonatal morbidity and APGAR at 5 min. Neonatal morbidity is higher in adolescent mothers residing in rural areas and in these who had fewer than five prenatal check-ups. In the case of mothers with a pathological history, regardless of the area in which they resided, the highest percentages were recorded in the case of mothers of 24-30 years with five or more prenatal appointments, and in adolescent mothers from 14 to 19 years of age with fewer than five prenatal appointments. Indeed, the greater the number of prenatal evaluations the higher the percentage of pathological findings. There is a close relationship between the age of the mother and the number of prenatal check-ups performed during pregnancy.

CONCLUSION

Teenage mothers have a higher percentage of neonatal morbidity in deliveries with gestational age equal to or greater than 37 weeks of gestation and AGPAR 8 and 9 at 5 min. In addition, there were a higher percentage of cases of respiratory failure and sepsis in newborns, especially when fewer than five prenatal examinations were performed. The highest percentage of identified prenatal pathological antecedents occurred in the group of mothers from 20 to 34 years old who attended more than five prenatal controls. Young pregnant women go less frequently to prenatal appointments, particularly in rural areas, and their newborns have a higher percentage of respiratory failure and sepsis.

Early life antecedents of positive child health among 10-year-old children born extremely preterm

BACKGROUND

To identify modifiable antecedents during pre-pregnancy and pregnancy windows associated with a positive child health at 10 years of age.

METHODS

Data on 889 children enrolled in the Extremely Low Gestational Age Newborn (ELGAN) study in 2002-2004 were analyzed for associations between potentially modifiable maternal antecedents during pre-pregnancy and pregnancy time windows and a previously described positive child health index (PCHI) score at 10 years of age. Stratification by race was also investigated for associations with investigated antecedents.

RESULTS

Factors associated with higher PCHI (more positive health) included greater gestational age, birth weight, multiple gestation, and medical interventions, including assisted reproduction and cervical cerclage. Factors associated with lower PCHI included correlates of lower socioeconomic status, pre-pregnancy chronic medical disorders in the mother such as pre-pregnancy body mass index (BMI), and maternal asthma. When stratified by race, variation in significant results was observed.

CONCLUSIONS

Among children born extremely preterm, medical interventions and higher socioeconomic status were associated with improved PCHI, while chronic illness and high BMI in the mother is associated with lower PCHI at 10 years of age. Knowledge of such antecedent factors could inform efforts to develop interventions that promote positive child health outcomes in future pregnancies.

Key Considerations for Implementing Group Prenatal Care: Lessons from 60 Practices

INTRODUCTION

Group prenatal care combines clinical care with peer support and education. Research has indicated neutral or positive results for group care when compared with traditional individual prenatal visits. A national initiative, Strong Start II, was implemented to determine if specific prenatal care interventions such as group prenatal care can reduce the rate of preterm birth, improve health outcomes, and lower costs. This study explored barriers to implementation and sustainability and strategies for overcoming barriers and sustaining the model.

METHODS

Results from prenatal care provider-level qualitative case studies for the independent evaluation of Strong Start were examined. Case studies for sites implementing group prenatal care were based on a total of 313 interviews with 441 Strong Start key informants (eg, prenatal care providers, project staff, and health administrators involved in group care) and 53 focus groups with 428 Strong Start participants from 2013 to 2016. Supplemental interviews with 25 additional stakeholders were also conducted. Case study data were queried using content analysis followed by a grounded theory-based analysis of these findings.

RESULTS

Barriers to implementation existed at patient, provider, administrator, system, and funding levels and included inflexible appointment times, lack of childcare, lack of appropriate meeting space, new scheduling and training needs, meeting requirements of graduate medical education programs, prenatal care provider and administrator reluctance to adopt new practices, and Medicaid payment policies. Sites newly implementing group prenatal care had varying degrees of success sustaining their programs. Both new and established sites identified provider champions and opt-out enrollment approaches as critical for maintaining buy-in.

DISCUSSION

Successful implementation of group prenatal care depends on systematic strategies at the practice, payer, provider, patient, and policy levels to implement, reimburse for, and sustain the model. Strategies for overcoming barriers can assist practices in offering this transformative approach, including practices with graduate medical education programs or those serving women with clinical, demographic, or psychosocial risk factors for preterm birth.

Group prenatal care: effectiveness and challenges to implementation

Group prenatal care is an alternative model of care during pregnancy, replacing standard individual prenatal care. The model has shown maternal benefits and has been implemented in different contexts. We conducted a narrative review of the literature in relation to its effectiveness, using databases such as PubMed, EBSCO, Science Direct, Wiley Online and Springer for the period 2002 to 2018. In addition, we discussed the challenges and solutions of its implementation based on our experience in Mexico. Group prenatal care may improve prenatal knowledge and use of family planning services in the postpartum period. The model has been implemented in more than 22 countries and there are challenges to its implementation related to both supply and demand. Supply-side challenges include staff, material resources and organizational issues; demand-side challenges include recruitment and retention of participants, adaptation of material, and perceived privacy. We highlight specific solutions that can be applied in diverse health systems.

Women-centered care: Implementation of CenteringPregnancy® in The Netherlands

INTRODUCTION

In response to a relatively high perinatal mortality rate in The Netherlands, the Dutch Health Ministry recommended changes to maternity care, opening a pathway toward more integrated woman-centered services. Because of its potential to positively influence risk factors for adverse pregnancy outcomes, CenteringPregnancy (CP) group prenatal care was implemented.

METHODS

We performed a retrospective cohort study (n = 2318) and survey on women's experiences (n = 222) in eight primary care midwifery practices to investigate outcome differences between CP and traditional individual prenatal care. Data from the period 2011-2013 were analyzed.

RESULTS

Primiparous and multiparous CP women attended more prenatal care visits compared with women who received individual care (adjusted odds ratio [aOR] 1.23 [95% confidence interval [CI] 1.18-1.29] and 1.29 [1.21-1.36]). Fewer primiparous CP women used pain relief during labor (0.56 [0.43-0.73]), and they initiated breastfeeding more often (1.74 [1.15-2.62]). Women participating in CP were more likely to feel that their wishes with respect to medication use (69.1% vs 54.4%, P = 0.039), physical activities (72.8% vs 52.5%, P = 0.008), and relaxation exercises (67.9% vs 35.6%, P ≤ 0.001) were listened to by care providers. They also felt more supported to actively participate in their care (89.6% vs 68.5%, P = 0.001) and felt more able to voice opinions about care (92.7% vs 73.9%, P = 0.002).

CONCLUSIONS

The CP model is a good approach aligning with Dutch policy calling for women-centered care and responding to the needs of pregnant women. This study supports CP scale-up in The Netherlands and adds to the pool of international knowledge about CP implementation.

National Analysis of Risk Assessment Content in Prenatal Records Across Canada

Each Canadian province/territory has a distinct prenatal record form to guide maternity health care. Because there is no national oversight of these forms, little is known about how they compare regarding content on risk assessment for adverse perinatal outcomes. We cataloged and compared the risk factors that are captured on prenatal record forms across Canada. Nine out of 12 records included risk sections, with an average of 35 risk items. We identified 100 prenatal risk factors and categorized them as medical (73%), lifestyle (11%), psychosocial (11%), or personal (5%). Where present, clinical definitions for risk factors often varied. The substantial differences in risk assessment content in the prenatal record forms may contribute to differences in health care quality among provinces. The development of standardized national guidelines for prenatal risk assessment may be a valuable goal.

Before and after implementation of group antenatal care in Rwanda: a qualitative study of women's experiences

Background

The Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women’s experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements.

Methods

We completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation.

Results

Before implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout.

Discussion

These results are consistent with other published reports of women’s perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women’s experiences of care.

Conclusion

Group antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model.

Trial registration

This trial is registered at clinicaltrials.gov as NCT03154177.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0750-5) contains supplementary material, which is available to authorized users.

Transcultural Modifications of a Japanese Language Group Prenatal Care Program for Transcultural Adaptation

INTRODUCTION

The CenteringPregnancy model has been demonstrated to improve birth outcomes for certain cultural and ethnic groups, but the literature lacks examples on how to modify their guidelines for socioculturally isolated women. Our aim is to examine the modifications we made to the CenteringPregnancy group prenatal care for Japanese women and to examine the implications for transcultural modification.

METHODS

Using a descriptive case study design, we examined the cultural fit and modifications of our Japanese prenatal group approach. We report the aspects that do not require modifications and the transcultural modifications that are needed. Based on this descriptive case, we discuss the lessons learned for making transcultural modifications that may apply to other cultural groups.

RESULTS

Many aspects of the CenteringPregnancy were readily adopted. We made 10 substantive transcultural modifications and articulate considerations for transcultural modifications.

DISCUSSION/CONCLUSION

This research illustrates transcultural considerations for modifying the CenteringPregnancy model and provides implications for use in other isolated populations of pregnant women.