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

Linking Adverse Experiences to Pregnancy and Birth Outcomes: A Life Course Analysis of Racial and Ethnic Disparities Among Low-Income Women

Racial and ethnic disparities in birth outcomes have persisted in the United States for decades, though the causes remain poorly understood. The life course perspective posits that poorer outcomes of Black birthing people stem from heightened exposure to stressors early in life and cumulative exposure to stressors over time. Despite its prominence, this perspective has seldom been investigated empirically. We analyzed longitudinal data gathered from 1319 women in low-income households in Wisconsin who received perinatal home visiting services. Variable- and person-centered analyses were performed to assess whether 15 adverse childhood experiences (ACEs) and 10 adverse adult experiences (AAEs) were associated, alone and in combination, with pregnancy loss, preterm birth, and low birth weight among Hispanic (i.e., Latinx) and non-Hispanic Black and White participants. As expected, there were disparities in preterm birth and low birth weight, and both ACEs and AAEs were linked to poorer pregnancy and birth outcomes. Unexpectedly, bivariate and multivariate analyses showed that the associated effects of ACEs and AAEs were most robust for non-Hispanic White women. A latent class analysis produced four patterns of life course adversity, and multigroup latent class analyses confirmed that, compared to White women, higher-adversity class assignments were associated with less robust effects for Hispanic women, and even less robust effects for Black women. We discuss interpretations of the paradoxical findings, including the possibility that alternative sources of stress such as interpersonal and structural racism may better account for the reproductive disparities that disproportionately affect Black birthing people.

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.

Integrating Mental Health In Perinatal Care: Perspectives Of Interprofessional Clinicians

Despite the prevalence of perinatal mental health issues in the United States, gaps in care persist. To address this, perinatal health care settings are asked to focus on patients' mental health by administering standardized screening and, increasingly, by integrating mental health teams in their clinics. Using in-depth interviews and ethnographic observations, I investigated these emerging practices, exploring the experiences of certified nurse-midwives, obstetricians, and mental health clinicians. I found that certified nurse-midwives and obstetricians lack time, resources, and expertise, restricting their ability to address patients' mental health. Integrated mental health clinicians are constrained by the stratified organization of health care and structural deprioritization of mental health. Redesigning perinatal health care and de-siloing mental health training are necessary to increase clinicians' effectiveness and to improve perinatal health outcomes.

The Effect of CenteringPregnancy Group Antenatal Care on Maternal, Birth, and Neonatal Outcomes Among Low-Risk Women in the Netherlands: A Stepped-Wedge Cluster Randomized Trial

INTRODUCTION

This study was carried out to assess the effects of participating in CenteringPregnancy (CP) on maternal, birth, and neonatal outcomes among low-risk pregnant women in the Netherlands.

METHODS

A total of 2124 pregnant women in primary care were included in the study. Data were derived from the Dutch national database, Perined, complemented with data from questionnaires completed by pregnant women. A stepwise-wedge design was employed; multilevel intention-to-treat analyses and propensity score matching were the main analytic approaches. Propensity score matching resulted in sample sizes of 305 nulliparous women in both the individual care (IC) and the matched control group (control-IC) and 267 in the CP and control-CP groups. For multiparous women, 354 matches were found for IC and control-IC groups and 152 for CP and control-CP groups. Main outcome measures were maternal, birth, and neonatal outcomes.

RESULTS

Compared with the control-CP group receiving standard antenatal care, nulliparous women participating in CP had a lower risk of maternal hypertensive disorders (odds ratio [OR], 0.53; 95% CI, 0.30-0.93) and for the composite adverse maternal outcome (OR, 0.52; 95% CI, 0.33-0.82). Breastfeeding initiation rates were higher amongst nulliparous (OR, 2.23; 95% CI, 134-3.69) and multiparous women (OR, 1.62; 95% CI, 1.00-2.62) participating in CP compared with women in the control-CP group.

CONCLUSION

Nulliparous women in CP were at lower risk of developing hypertensive disorders during pregnancy and, consequently, at lower risk of having adverse maternal outcomes. The results confirmed our hypothesis that both nulliparous and multiparous women who participated in CP would have higher breastfeeding rates compared with women receiving standard antenatal care.

National assessment of obstetrics and gynecology and family medicine residents' experiences with CenteringPregnancy group prenatal care

OBJECTIVE

To examine family medicine (FM) and obstetrician-gynecologist (OB/GYN) residents' experiences with CenteringPregnancy (CP) group prenatal care (GPNC) as a correlate to perceived likelihood of implementing CP in future practice, as well as knowledge, level of support, and perceived barriers to implementation.

METHODS

We conducted a repeated cross-sectional study annually from 2017 to 2019 with FM and OB/GYN residents from residency programs in the United States licensed to operate CP. We applied adjusted logistic regression models to identify predictors of intentions to engage with CP in future practice.

RESULTS

Of 212 FM and 176 OB/GYN residents included in analysis, 67.01% of respondents intended to participate as a facilitator in CP in future practice and 51.80% of respondents were willing to talk to decision makers about establishing CP. Both FM and OB/GYN residents who spent more than 15 h engaged with CP and who expressed support towards CP were more likely to participate as a facilitator. FM residents who received residency-based training on CP and who were more familiar with CP reported higher intention to participate as a facilitator, while OB/GYN residents who had higher levels of engagement with CP were more likely to report an intention to participate as a facilitator.

CONCLUSION

Engagement with and support towards CP during residency are key factors in residents' intention to practice CP in the future. To encourage future adoption of CP among residents, consider maximizing resident engagement with the model in hours of exposure and level of engagement, including hosting residency-based trainings on CP for FM residents.

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.

Contributions of CenteringPregnancy to women's health behaviours, health literacy, and health care use in the Netherlands

The objective of this study was to assess the effects of CenteringPregnancy (CP) in the Netherlands on different health outcomes. A stepped wedged cluster randomized trial was used, including 2132 women of approximately 12 weeks of gestation, from thirteen primary care midwifery centres in and around Leiden, Netherlands. Data collection was done through self-administered questionnaires. Multilevel intention-to-treat analysis and propensity score matching for the entire group and separately for nulliparous- and multiparous women were employed. The main outcomes were: health behaviour, health literacy, psychological outcomes, health care use, and satisfaction with care. Women's participation in CP is associated with lower alcohol consumption after birth (OR = 0.59, 95 %CI 0.42-0.84), greater consistency with norms for healthy eating and physical activity (β = 0.19, 95 %CI 0.02-0.37), and higher knowledge about pregnancy (β = 0.05, 95 %CI 0.01-0.08). Compared to the control group, nulliparous women who participating in CP reported better compliance to the norm for healthy eating and physical activity (β = 0.28, 95 %CI0.06-0.51)) and multiparous CP participants consumed less alcohol after giving birth (OR = 0.42, 95 %CI 0.23-0.78). Health care use and satisfaction rates were significantly higher among CP participants. A non-significant trend toward lower smoking rates was documented among CP participants. Overall, the results of this study reveal a positive (postpartum) impact on fostering healthy behaviours among participants.

Effects of the online and offline hybrid continuous group care on maternal and infant health: a randomized controlled trial

BACKGROUND

The group care is a well-established maternal care model that has been widely used in many developed countries, but in China, it is confined to prenatal care services. In addition, affected by traditional birth culture, Chinese women tend to focus more on their fetuses and newborns but lack attention to their own intrapartum and postpartum care. The aim of this study was to construct and implement a prenatal, intrapartum, and the postpartum continuous group care model that combines online and offline service in Hainan Province, China, and to evaluate the effect on maternal women and newborns.

METHODS

This study was a randomized controlled trial involving 144 pregnant women in a first-class tertiary general hospital in Hainan Province, China. Women were divided into an intervention group and a control group using the random number table, with 72 women in each group. The control group received routine maternal care services, and the intervention group received the continuous group care based on the routine maternal care services. Count data such as rate of cesarean section and incidence rate of fetal macrosomia were analyzed with the chi-square test or Fisher's exact test, and the General Self-efficacy Scale scores were analyzed by repeated measures ANOVA. P < 0.05 was considered statistically significant, with two-sided probability values.

RESULTS

Compared with the control group, the rate of excessive prenatal weight gain, cesarean section, and 42-day postpartum depression were significantly lower in the intervention group (P < 0.05), and higher General Self-efficacy Scale scores (in the expectant period and 42 days postpartum) and exclusive breastfeeding rate (42 days postpartum) (P < 0.05). The incidence of fetal macrosomia was significantly lower in the intervention group (P < 0.05). But there was no significant difference in birth weight, preterm birth, the incidence of low-birth-weight infants and 1-min Apgar score (P > 0.05).

CONCLUSION

The continuous group care with online and offline service can effectively control the gestational weight gain, reduce the rate of cesarean section, macrosomia, and postpartum depression. It can improve the self-efficacy of women and the rate of exclusive breastfeeding effectively.

TRIAL REGISTRATION

Chinese Clinical Trial Regestry (ChiCTR2200065765, 04/11/2022, Retrospectively registered).

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

BACKGROUND

The United States has persistently high rates of preterm birth and low birthweight and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, such as CenteringPregnancy, have been proposed as a potential approach to improve the rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes.

OBJECTIVE

This study aimed to test whether participation in group prenatal care would reduce the rates of preterm birth and low birthweight compared with individual prenatal care and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients.

STUDY DESIGN

This was a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth at <37 weeks of gestation and low birthweight of <2500 g. The primary analysis was performed according to the intent-to-treat principle. The secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per-compliance approaches. The analysis of effect modification by race and ethnicity was planned.

RESULTS

A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 Black (40.5%), 502 Hispanic (21.4%), 863 White (36.8%), and 31 "other races or ethnicity" (1.3%) participants. Group prenatal care did not reduce the rate of preterm birth (10.4% vs 8.7%; odds ratio, 1.22; 95% confidence interval, 0.92-1.63; P=.17) or low birthweight (9.6% vs 8.9%; odds ratio, 1.08; 95% confidence interval, 0.80-1.45; P=.62) compared with individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most noticeable for the rates of low birthweight for Black participants in group care: intent to treat (51/409 [12.5%]), modified intent to treat (36/313 [11.5%]), and per compliance (20/240 [8.3%]). Although the rates of low birthweight were significantly higher for Black participants than White participants seen in individual care (adjusted odds ratio, 2.00; 95% confidence interval, 1.14-3.50), the difference was not significant for Black participants in group care compared with their White counterparts (adjusted odds ratio, 1.58; 95% confidence interval, 0.74-3.34).

CONCLUSION

There was no difference in the overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, lower rates of preterm birth and low birthweight for Black participants were observed. The role of group care models in reducing racial disparities in these birth outcomes requires further study.

Group Care in the first 1000 days: implementation and process evaluation of contextually adapted antenatal and postnatal group care targeting diverse vulnerable populations in high-, middle- and low-resource settings

Background

Group care (GC) improves the quality of maternity care, stimulates women’s participation in their own care and facilitates growth of women’s social support networks. There is an urgent need to identify and disseminate the best mechanisms for implementing GC in ways that are feasible, context appropriate and sustainable. This protocol presents the aims and methods of an innovative implementation research project entitled Group Care in the first 1000 days (GC_1000), which addresses this need.

Aims

The aim of GC_1000 is to co-create and disseminate evidence-based implementation strategies and tools to support successful implementation and scale-up of GC in health systems throughout the world, with particular attention to the needs of ‘vulnerable’ populations.

Methods

By working through five inter-related work packages, each with specific tasks, objectives and deliverables, the global research team will systematically examine and document the implementation and scale-up processes of antenatal and postnatal GC in seven different countries. The GC_1000 project is grounded theoretically in the consolidated framework for implementation research (CFIR), while the process evaluation is guided by ‘Realistic Evaluation’ principles. Data are gathered across all research phases and analysis at each stage is synthesized to develop Context-Intervention-Mechanism-Outcome configurations.

Discussion

GC_1000 will generate evidence-based knowledge about the integration of complex interventions into diverse health care systems. The 4-year project also will pave the way for sustained implementation of GC, significantly benefitting populations with adverse pregnancy and birthing experiences as well as poor outcomes.

The Experience of Pregnant Women in the Health Management Model of Internet-Based Centering Pregnancy: A Qualitative Study

Background

CenteringPregnancy Care is a promising group prenatal care innovation that combines assessment, education, and peer support. In China, it is not clear how best to integrate the CenteringPregnancy Care into existing maternal health care models. This qualitative study aimed to explore Chinese pregnant women’s experience in the Internet-based CenteringPregnancy management model.

Methods

The Internet-based CenteringPregnancy was applied in a tertiary hospital between 2018 and 2019 in Wuhan, Hubei Province. Through purposive sampling, a total of 9 pregnant women who had experienced Internet-based CenteringPregnancy were recruited. A semi-structured interview was used to collect qualitative data, and Colaizzi’s 7-step method of phenomenological data analysis was used to analyze the collected data.

Results

Three themes were extracted from the participants’ interviews, including: 1) empowerment; 2) psychological and social support; 3) challenges of the Internet-based CenteringPregnancy. The Internet-based CenteringPregnancy management model retained advantages of CenteringPregnancy, emphasizing the pregnant woman as the subject of health care and promoting them to participate in health care. Participants believed that they could exchange pregnancy knowledge, help each other, and improve mood both timely and efficiently from the new model. However, it was found that there were challenges in seminar time arrangement, topic selection, and discussion management.

Conclusion

The Internet-based CenteringPregnancy management model positively affected pregnant women’s empowerment, psychological, and social support. It is recommended to improve the seminar’s design in future studies.

Current Resources for Evidence-Based Practice, November 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of autonomy and respect in maternity care and commentaries on reviews focused on whether to induce women who present with mild preeclampsia in the late preterm period and the extent to which urinary incontinence symptoms prevent women from participating in exercise. It also includes a brief update about the USPSTF guidelines on screening for gestational diabetes.