Group vs traditional prenatal care for improving racial equity in preterm birth and low birthweight: the Centering and Racial Disparities randomized clinical trial study

Women's experiences with Centering-Based Group Care in Zhejiang China: A pilot study

BACKGROUND

The group prenatal care model, which caters to women with low medical needs but high support needs, has become a highly prevalent and innovative approach implemented globally. For Centering-Based Group Care (CBGC) to remain effective, women's evaluations of the quality of care and perspectives about the model are crucial.

AIM

This study aimed to describe women's appraisal of CBGC quality and explore the experiences of women in the mixed-methods pilot study conducted in Zhejiang, China.

METHODS

From August 2021 to December 2022, 20 women provided complete quantitative data using the Quality of Prenatal Care Questionnaire before hospital discharge. Semi-structured interviews were conducted at 6 months postpartum. Qualitative data were analysed using Colaizzi's method.

FINDINGS

The mean (standard deviation) total score (of the 5) of the questionnaire was 4.43 (0.1) with a good quality of CBGC. Qualitative research identified five themes: motivations and concerns for participation, the appeal of interactive learning, the development of community ties and social support, healing from psychological trauma with CBGC, and suggestions for CBGC enhancement.

DISCUSSION

Women rated CBGC quality as good and benefited significantly from it in the study. As a new alternative option, the women's accounts suggested that CBGC performed excellently in enhancing knowledge, strengthening social bonds, and providing psychological support.

CONCLUSION

CBGC quality cannot be determined based on limited the sample size. This pilot study provides evidence regarding the beneficial effects of knowledge, socialization, and psychological healing on CBGC. Further research is suggested to measure CBGC effectiveness and quality.

Group Multimodal Prenatal Care and Postpartum Outcomes

Importance

An increasing body of evidence suggests equivalent if not improved postpartum outcomes of in-person group prenatal care compared with individual prenatal care. However, research is needed to evaluate outcomes of group multimodal prenatal care (GMPC), with groups delivered virtually in combination with individual in-person office appointments to collect vital signs and conduct other tests compared with individual multimodal prenatal care (IMPC) delivered through a combination of remotely delivered and in-person visits.

Objective

To compare postpartum outcomes between GMPC and IMPC.

Design, Setting, and Participants

A frequency-matched longitudinal cohort study was conducted at Kaiser Permanente Northern California, an integrated health care delivery system. Participants included 424 individuals who were pregnant (212 GMPC and 212 frequency-matched IMPC controls (matched on gestational age, race and ethnicity, insurance status, and maternal age) receiving prenatal care between August 17, 2020, and April 1, 2021. Participants completed a baseline survey before 14 weeks' gestation and a follow-up survey between 4 and 8 weeks post partum. Data analysis was performed from January 3, 2022, to March 4, 2024.

Exposure

GMPC vs IMPC.

Main Outcome Measures

Validated instruments were used to ascertain postpartum psychosocial outcomes (stress, depression, anxiety) and perceived quality of prenatal care. Self-reported outcomes included behavioral outcomes (breastfeeding initiation, use of long-acting reversible contraception), satisfaction with prenatal care, and preparation for self and baby care after delivery. Primary analyses included all study participants in the final cohort. Three secondary dose-stratified analyses included individuals who attended at least 1 visit, 5 visits, and 70% of visits. Log-binomial regression and linear regression analyses were conducted.

Results

The final analytic cohort of 390 participants (95.6% follow-up rate of 408 singleton live births) was racially and ethnically diverse: 98 (25.1%) Asian/Pacific Islander, 88 (22.6%) Hispanic, 17 (4.4%) non-Hispanic Black, 161 (41.3%) non-Hispanic White, and 26 (6.7%) multiracial participants; median age was 32 (IQR, 30-35) years. In the primary analysis, after adjustment, GMPC was associated with a 21% decreased risk of perceived stress (adjusted risk ratio [ARR], 0.79; 95% CI, 0.67-0.94) compared with IMPC. Findings were consistent in the dose-stratified analyses. There were no significant differences between GMPC and IMPC for other psychosocial outcomes. While in the primary analyses there was no significant group differences in perceived quality of prenatal care (mean difference [MD], 0.01; 95% CI, -0.12 to 0.15) and feeling prepared to take care of baby at home (ARR, 1.09; 95% CI, 0.96-1.23), the dose-stratified analyses documented higher perceived quality of prenatal care (MD, 0.16; 95% CI, 0.01-0.31) and preparation for taking care of baby at home (ARR, 1.27; 95% CI, 1.13-1.43) for GMPC among those attending 70% of visits. No significant differences were noted in patient overall satisfaction with prenatal care and feeling prepared for taking care of themselves after delivery.

Conclusions

In this cohort study, equivalent and, in some cases, better outcomes were observed for GMPC compared with IMPC. Health care systems implementing multimodal models of care may consider incorporating virtual group prenatal care as a prenatal care option for patients.

Obstetric violence is a misnomer

The term "obstetric violence" has been used in the legislative language of several countries to protect mothers from abuse during pregnancy. Subsequently, it has been expanded to include a spectrum of obstetric procedures, such as induction of labor, episiotomy, and cesarean delivery, and has surfaced in the peer-reviewed literature. The term "obstetric violence" can be seen as quite strong and emotionally charged, which may lead to misunderstandings or misconceptions. It might be interpreted as implying a deliberate act of violence by healthcare providers when mistreatment can sometimes result from systemic issues, lack of training, or misunderstandings rather than intentional violence. "Obstetric mistreatment" is a more comprehensive term that can encompass a broader range of behaviors and actions. "Violence" generally refers to the intentional use of physical force to cause harm, injury, or damage to another person (eg, physical assault, domestic violence, street fights, or acts of terrorism), whereas "mistreatment" is a more general term and refers to the abuse, harm, or control exerted over another person (such as nonconsensual medical procedures, verbal abuse, disrespect, discrimination and stigmatization, or neglect, to name a few examples). There may be cases where unprofessional personnel may commit mistreatment and violence against pregnant patients, but as obstetrics is dedicated to the health and well-being of pregnant and fetal patients, mistreatment of obstetric patients should never be an intended component of professional obstetric care. It is necessary to move beyond the term "obstetric violence" in discourse and acknowledge and address the structural dimensions of abusive reproductive practices. Similarly, we do not use the term "psychiatric violence" for appropriately used professional procedures in psychiatry, such as electroshock therapy, or use the term "neurosurgical violence" when drilling a burr hole. There is an ongoing need to raise awareness about the potential mistreatment of obstetric patients within the context of abuse against women in general. Using the term "mistreatment in healthcare" instead of the more limited term "obstetric violence" is more appropriate and applies to all specialties when there is unprofessional abuse and mistreatment, such as biased care, neglect, emotional abuse (verbal), or physical abuse, including performing procedures that are unnecessary, unindicated, or without informed patient consent. Healthcare providers must promote unbiased, respectful, and patient-centered professional care; provide an ethical framework for all healthcare personnel; and work toward systemic change to prevent any mistreatment or abuse in our specialty.

Elevating Voices, Addressing Depression, Toxic Stress, and Equity Through Group Prenatal Care: A Pilot Study

Introduction

Elevating Voices, Addressing Depression, Toxic Stress and Equity (EleVATE) is a group prenatal care (GC) model designed to improve pregnancy outcomes and promote health equity for Black birthing people. This article outlines the foundational community-engaged process to develop EleVATE GC and pilot study results.

Methods

We used community-based participatory research principles and the Ferguson Commission Report to guide creation of EleVATE GC. The intervention, designed by and for Black birthing people, centers trauma-informed care, antiracism, and integrates behavioral health strategies into group prenatal care to address unmet mental health needs. Using a convenience sample of patients seeking care at one of three safety-net health care sites, we compared preterm birth, small for gestational age, depression scores, and other pregnancy outcomes between patients in individual care (IC), CenteringPregnancy™ (CP), and EleVATE GC.

Results

Forty-eight patients enrolled in the study (n=11 IC; n=14 CP; n=23 EleVATE GC) and 86% self-identified as Black. Patients participating in group prenatal care (EleVATE GC or CP) were significantly less likely to experience a preterm birth <34 weeks. Rates of small for gestational age, preterm birth <37 weeks, depression scores, and other pregnancy outcomes were similar across groups. Participants in CP and EleVATE GC were more likely to attend their postpartum visit and breastfeed at hospital discharge than those in IC.

Discussion

Our findings model a systematic approach to design a feasible, patient-centered, community-based, trauma-informed, antiracist intervention. Further study is needed to determine whether EleVATE GC improves perinatal outcomes and promotes health equity.

Inflammatory markers in serum and placenta in a randomized controlled trial of group prenatal care

BACKGROUND

Racial and socioeconomic disparities in preterm birth and small for gestational age births are growing in the United States, increasing the burden of morbidity and mortality particularly among Black women and birthing persons and their infants. Group prenatal care is one of the only interventions to show potential to reduce the disparity, but the mechanism is unclear.

OBJECTIVE

The goal of this project was to identify if group prenatal care, when compared with individual prenatal care, was associated with a reduction in systemic inflammation during pregnancy and a lower prevalence of inflammatory lesions in the placenta at delivery.

STUDY DESIGN

The Psychosocial Intervention and Inflammation in Centering Study was a prospective cohort study that exclusively enrolled participants from a large randomized controlled trial of group prenatal care (the Cradle study, R01HD082311, ClinicalTrials.gov: NCT02640638) that was performed at a single site in Greenville, South Carolina, from 2016 to 2020. In the Cradle study, patients were randomized to either group prenatal care or individual prenatal care, and survey data were collected during the second and third trimesters. The Psychosocial Intervention and Inflammation in Centering Study cohort additionally provided serum samples at these 2 survey time points and permitted collection of placental biopsies for inflammatory and histologic analysis, respectively. We examined associations between group prenatal care treatment and a composite of z scored serum inflammatory biomarkers (C-reactive protein, interleukin-6, interleukin-1 receptor antagonist, interleukin-10, and tumor necrosis factor α) in both the second and third trimesters and the association with the prevalence of acute and chronic maternal placental inflammatory lesions. Analyses were conducted using the intent to treat principle, and the results were also examined by attendance of visits in the assigned treatment group (modified intent to treat and median or more number of visits) and were stratified by race and ethnicity.

RESULTS

A total of 1256 of 1375 (92%) Cradle participants who were approached enrolled in the Psychosocial Intervention and Inflammation in Centering Study, which included 54% of all the Cradle participants. The Psychosocial Intervention and Inflammation in Centering Study cohort did not differ from the Cradle cohort by demographic or clinical characteristics. Among the 1256 Psychosocial Intervention and Inflammation in Centering Study participants, 1133 (89.6%) had placental data available for analysis. Among those, 549 were assigned to group prenatal care and 584 of 1133 were assigned to individual prenatal care. In the intent to treat and modified intent to treat cohorts, participation in group prenatal care was associated with a higher serum inflammatory score, but it was not associated with an increased prevalence of placental inflammatory lesions. In the stratified analyses, group prenatal care was associated with a higher second trimester inflammatory biomarker composite (modified intent to treat: B=1.17; P=.02; and median or more visits: B=1.24; P=.05) among Hispanic or Latine participants.

CONCLUSION

Unexpectedly, group prenatal care was associated with higher maternal serum inflammation during pregnancy, especially among Hispanic or Latine participants.

Diabetes Group Prenatal Care: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate the effect of diabetes group prenatal care on rates of preterm birth and large for gestational age (LGA) among patients with diabetes in pregnancy compared with individual diabetes prenatal care.

DATA SOURCES

We searched Ovid Medline (1946-), Embase.com (1947-), Scopus (1823-), Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov.

METHODS OF STUDY SELECTION

We searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing diabetes group prenatal care with individual care among patients with type 2 diabetes mellitus or gestational diabetes mellitus (GDM). The primary outcomes were preterm birth before 37 weeks of gestation and LGA (birth weight at or above the 90th percentile). Secondary outcomes were small for gestational age, cesarean delivery, neonatal hypoglycemia, neonatal intensive care unit admission, breastfeeding at hospital discharge, long-acting reversible contraception (LARC) uptake, and 6-week postpartum visit attendance. Secondary outcomes, limited to the subgroup of patients with GDM, included rates of GDM requiring diabetes medication (A2GDM) and completion of postpartum oral glucose tolerance testing (OGTT). Heterogeneity was assessed with the Cochran Q test and I2 statistic. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean differences.

TABULATION, INTEGRATION, AND RESULTS

Eight studies met study criteria and were included in the final analysis: three RCTs and five observational studies. A total of 1,701 patients were included in the pooled studies: 770 (45.3%) in diabetes group prenatal care and 931 (54.7%) in individual care. Patients in diabetes group prenatal care had similar rates of preterm birth compared with patients in individual care (seven studies: pooled rates 9.5% diabetes group prenatal care vs 11.5% individual care, pooled RR 0.77, 95% CI, 0.59-1.01), which held for RCTs and observational studies. There was no difference between diabetes group prenatal care and individual care in rates of LGA overall (four studies: pooled rate 16.7% diabetes group prenatal care vs 20.2% individual care, pooled RR 0.93, 95% CI, 0.59-1.45) or by study type. Rates of other secondary outcomes were similar between diabetes group prenatal care and individual care, except patients in diabetes group prenatal care were more likely to receive postpartum LARC (three studies: pooled rates 46.1% diabetes group prenatal care vs 34.1% individual care, pooled RR 1.44, 95% CI, 1.09-1.91). When analysis was limited to patients with GDM, there were no differences in rates of A2GDM or postpartum visit attendance, but patients in diabetes group prenatal care were significantly more likely to complete postpartum OGTT (five studies: pooled rate 74.0% diabetes group prenatal care vs 49.4% individual care, pooled RR 1.58, 95% CI, 1.19-2.09).

CONCLUSION

Patients with type 2 diabetes and GDM who participate in diabetes group prenatal care have similar rates of preterm birth, LGA, and other pregnancy outcomes compared with those who participate in individual care; however, they are significantly more likely to receive postpartum LARC, and those with GDM are more likely to return for postpartum OGTT.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021279233.

Discrimination and Adverse Perinatal Health Outcomes: A Latent Class Analysis

INTRODUCTION

An intersectionality framework recognizes individuals as simultaneously inhabiting multiple intersecting social identities embedded within systems of disadvantage and privilege. Previous research links perceived discrimination with worsened health outcomes yet is limited by a focus on racial discrimination in isolation. We applied an intersectional approach to the study of discrimination to examine the association with adverse perinatal health outcomes.

METHODS

We analyzed data from a cohort of 2,286 pregnant participants (Black, n = 933; Hispanic, n = 471; White, n = 853; and Other, n = 29) from the Centering and Racial Disparities trial. Perceived discrimination was assessed via the Everyday Discrimination Scale (EDS) and perinatal health outcomes collected via electronic medical record review. Latent class analysis was used to identify subgroups of discrimination based on EDS item response and the rate of adverse perinatal health outcomes compared between subgroups using a Bolck, Croon and Hagenaars 3-step approach.

RESULTS

Four discrimination subgroups were identified: no discrimination, general discrimination, discrimination attributed to one or several social identities, and discrimination attributed to most or all social identities. Experiencing general discrimination was associated with postpartum depression symptoms when compared with experiencing no discrimination among Black (9% vs 5%, P = .04) and White participants (18% vs 9%, P = .01). White participants experiencing general discrimination gave birth to low birthweight infants at a higher rate than those experiencing no discrimination (11% vs 6%, P = .04). No significant subgroup differences were observed among Hispanic participants.

CONCLUSION

Perceived discrimination may play an influential role in shaping perinatal health. More research applying an intersectional lens to the study of discrimination and perinatal health outcomes is needed.

Randomized Controlled Trial on the Effect of Group Versus Individual Prenatal Care on Psychosocial Outcomes

OBJECTIVE

To assess the effect of group prenatal care (GPNC) compared with individual prenatal care (IPNC) on psychosocial outcomes in late pregnancy, including potential differences in outcomes by subgroups.

DESIGN

Randomized controlled trial.

SETTING

An academic medical center in the southeastern United States.

PARTICIPANTS

A total of 2,348 women with low-risk pregnancies who entered prenatal care before 20 6/7 weeks gestation were randomized to GPNC (n = 1,175) or IPNC (n = 1,173) and stratified by self-reported race and ethnicity.

METHODS

We surveyed participants during enrollment (M = 12.21 weeks gestation) and in late pregnancy (M = 32.51 weeks gestation). We used standard measures related to stress, anxiety, coping strategies, empowerment, depression symptoms, and stress management practices in an intent-to-treat regression analysis. To account for nonadherence to GPNC treatment, we used an instrumental variable approach.

RESULTS

The response rates were high, with 78.69% of participants in the GPNC group and 83.89% of participants in the IPNC group completing the surveys. We found similar patterns for both groups, including decrease in distress and increase in anxiety between surveys and comparable levels of pregnancy empowerment and stress management at the second survey. We identified greater use of coping strategies for participants in the GPNC group, particularly those who identified as Black or had low levels of partner support.

CONCLUSION

Group prenatal care did not affect stress and anxiety in late pregnancy; however, the increased use of coping strategies may suggest a benefit of GPNC for some participants.

Group vs Individual Prenatal Care and Gestational Diabetes Outcomes: A Secondary Analysis of a Randomized Clinical Trial

Importance

The impact of group-based prenatal care (GPNC) model in the US on the risk of gestational diabetes (GD) and related adverse obstetric outcomes is unknown.

Objective

To determine the effects of the GPNC model on risk of GD, its progression, and related adverse obstetric outcomes.

Design, Setting, and Participants

This is a single-site, parallel-group, randomized clinical trial conducted between February 2016 and March 2020 at a large health care system in Greenville, South Carolina. Participants were individuals aged 14 to 45 years with pregnancies earlier than 21 weeks' gestational age; follow-up continued to 8 weeks post partum. This study used an intention-to-treat analysis, and data were analyzed from March 2021 to July 2022.

Interventions

Eligible participants were randomized to receive either CenteringPregnancy, a widely used GPNC model, with 10 group-based sessions or traditional individual prenatal care (IPNC).

Main Outcomes and Measures

The primary outcome was the incidence of GD diagnosed between 24 and 30 weeks of gestation. The secondary outcomes included progression to A2 GD (ie, GD treated with medications) and GD-related adverse obstetric outcomes (ie, preeclampsia, cesarean delivery, and large for gestational age). Log binomial models were performed to estimate risk differences (RDs), 95% CIs, and P values between GPNC and IPNC groups, adjusting for all baseline covariates.

Results

Of all 2348 participants (mean [SD] age, 25.1 [5.4] years; 952 Black participants [40.5%]; 502 Hispanic participants [21.4%]; 863 White participants [36.8%]), 1176 participants were randomized to the GPNC group and 1174 were randomized to the IPNC group. Among all participants, 2144 (91.3%) completed a GD screening (1072 participants [91.3%] in GPNC vs 1071 [91.2%] in IPNC). Overall, 157 participants (6.7%) developed GD, and there was no difference in GD incidence between the GPNC (83 participants [7.1%]) and IPNC (74 participants [6.3%]) groups, with an adjusted RD of 0.7% (95% CI, -1.2% to 2.7%). Among participants with GD, GPNC did not reduce the risk of progression to A2 GD (adjusted RD, -6.1%; 95% CI, -21.3% to 9.1%), preeclampsia (adjusted RD, -7.9%; 95% CI, -17.8% to 1.9%), cesarean delivery (adjusted RD, -8.2%; 95% CI, -12.2% to 13.9%), and large for gestational age (adjusted RD, -1.2%; 95% CI, -6.1% to 3.8%) compared with IPNC.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial among medically low-risk pregnant individuals, the risk of GD was similar between participants who received GPNC intervention and traditional IPNC, indicating that GPNC may be a feasible treatment option for some patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT02640638.