Impact of two scheduling systems on early enrollment in a group prenatal care program

It takes two to tango: the recruiter's role in accepting or refusing to participate in group antenatal care among pregnant women-an exploration through in-depth interviews

OBJECTIVE

The purpose of this study was to explore how women are recruited for group antenatal care (GANC) in primary care organisations (PCOs), what elements influence the behaviour of the recruiter, and what strategies recruiters use to encourage women to participate.

METHOD

Using a qualitative research design, we conducted 10 in-depth interviews with GANC facilitators working in PCOs. Selected constructs of the domains of the Consolidated Framework for Implementation Research and the Theoretical Domains Framework helped to develop interview questions and raise awareness of important elements during interviews and thematic analyses. GANC facilitators working in multidisciplinary PCOs located in Brussels and Flanders (Belgium) were invited to participate in an interview. We purposively selected participants because of their role as GANC facilitators and recruiters. We recruited GANC facilitators up until data saturation and no new elements emerged.

RESULT

We identified that the recruitment process consists of four phases or actions: identification of needs and potential obstacles for participation; selection of potential participants; recruitment for GANC and reaction to response. Depending on the phase, determinants at the level of the woman, recruiter, organisation or environment have an influence on the recruitment behaviour.

CONCLUSION

Our study concludes that it takes two to tango for successful recruitment for GANC. Potential participants' needs and wishes are of importance, but the care providers' behaviour should not be underestimated. Therefore, successful recruitment may be improved when introducing a multidisciplinary recruitment plan consisting of specific strategies, as we suggest.

How to Support the Referral Towards Group Antenatal Care in Belgian Primary Healthcare Organizations: A Qualitative Study

Introduction

Group Antenatal Care (GANC) is an alternative for traditional antenatal care. Despite the model is well accepted among participants and is associated with positive effects on pregnancy outcomes, recruitment of participants can be an ongoing challenge, depending on the structure and financing of the wider health system. This is especially the case for primary care organizations offering GANC, which depend on other health care providers to refer potential participants. The main objective of this study is to understand what determinants are at play for health care providers to refer to GANC facilitators in primary care organizations. Accordingly, we make recommendations for strategies in order to increase the influx of women in GANC.

Methods

Qualitative findings were obtained from 31 interviews with healthcare providers responsible for the referral of women to the GANC facilitators working in primary care organizations, GANC facilitators and stakeholders indirectly involved in the referral. The domains of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF) helped to develop interview questions and raise awareness of important elements during interviews and thematic analyses.

Results

The findings show that before health care providers decide to refer women, they undergo a complex process that is influenced by characteristics of the potential referrer, GANC facilitator, woman, professional relationship between the potential referrer and the GANC facilitator, organization and broader context.

Discussion

Based on these findings and current literature, we recommend that the GANC team implements strategies that anticipate relevant determinants: identify and select potential referrers based on their likelihood to refer, select champions, invest in communication, concretise the collaboration, provide practical tools, involve in policymaking.

Beyond Implementation: Sustaining Group Prenatal Care and Group Well-Child Care

INTRODUCTION

Group prenatal care and group well-child care (collectively called group care) provide health care in groups. Group care is being introduced in many settings, and the model's benefits are increasingly recognized. Yet, little attention has been paid to understanding model sustainability. This study examined barriers to sustainability and offers suggestions for sustaining group care programs.

METHODS

This qualitative research was guided by interpretive description. Semistructured interviews with 17 professionals were conducted in 4 sites in one community to explore barriers to sustaining group care and key ingredients for sustainability. Sites were 2 clinics that had provided group prenatal care, a clinic currently providing group prenatal care, and a clinic currently providing group well-child care. Two clinics have continued providing group care and 2 have discontinued it. Participants included midwives, physicians, nurses, and nurse practitioners. Interviews were audio recorded, transcribed, and entered in ATLAS.ti. A priori and inductive coding schemes were developed; code content was compared across individuals, participant types, and settings.

RESULTS

Five themes were identified: administrative buy-in, robust recruitment, clinician and staff buy-in, owning it, and sustainability mindset. Group care needs to be sold to many different constituencies: administrators, staff and clinicians, and patients. Furthermore, sustainability requires having a conscious awareness of the importance of sustainability from the outset, taking ownership by adapting group care to needs of settings, creating venues for expressing divergent viewpoints and problem-solving, and recognizing that these processes are ongoing with change occurring incrementally. It also includes addressing the need for long-term financing.

DISCUSSION

Those implementing group care must be prepared to go beyond managing the logistics of introducing a complex new program; they must also be prepared to develop sustainability mindsets, sell the model to everyone on all levels within their institutions, and advocate for enhanced reimbursement for group care and value-driven payment systems.

A Model of Group Prenatal Care for Patients with Prenatally Diagnosed Fetal Anomalies

The model of group prenatal care was initially developed to include peer support and to improve education and health-promoting behaviors during pregnancy. This model has since been adapted for populations with unique educational needs. Mama Care is an adaptation of the CenteringPregnancy Model of prenatal care. Mama Care is situated within a national and international referral center for families with prenatally diagnosed fetal anomalies. In December 2013, the Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia began offering a model of group prenatal care to women whose pregnancies are affected by a prenatal diagnosis of a fetal anomaly. The model incorporates significant adaptations of CenteringPregnancy in order to accommodate these women, who typically transition their care from community-based settings to the Center for Fetal Diagnosis and Treatment in the late second or early third trimester. Unique challenges associated with caring for families within a referral center include a condensed visit schedule, complex social needs such as housing and psychosocial support, as well as an increased need for antenatal surveillance and frequent preterm birth. Outcomes of the program are favorable and suggest group prenatal care models can be developed to support the needs of patients with prenatally diagnosed fetal anomalies.

A Qualitative Study of Women's Recall of Content and Skills Developed in Group Prenatal and Well-Baby Care 2 Years Later

INTRODUCTION

Group prenatal and well-baby care is a system of health care visits that occur in a group setting. Each individual session lasts approximately 2 hours, allowing more time for education and support than can occur in an individual visit. Compared with individual care, research suggests that group care is associated with similar or better short-term outcomes, but no studies have yet examined potential long-term benefits beyond one year postpartum. The purpose of this qualitative descriptive study was to elicit women's recall about content covered in group prenatal and well-baby care and whether they were or were not continuing to use skills discussed during group prenatal and well-baby care 2 or more years after their group ended.

METHODS

Eligible women participated in group prenatal and/or well-baby care between 2008 and 2012, were aged at least 18 years, and were English-speaking. Of the 127 eligible women, 32 were reached and 17 agreed to participate. Women were interviewed on average 3 years after group prenatal or well-baby care ended using a semistructured interview guide. Transcripts were reviewed and coded by each team member. Final codes and themes were identified using an iterative review process among the research team.

RESULTS

Three themes were identified: sustained change, transferable skills, and group as a safe haven. All women were still using strategies discussed during group and had made sustained improvements in nutrition, stress management, and/or in the quality of their interactions with their children, partner, or families. The group environment was described as a safe haven: a respectful, nonjudgmental space that allowed women to share and support each other while learning new skills.

DISCUSSION

This is the first study to document that group prenatal and well-baby care is associated with long-term benefits in areas not yet reported in the literature: nutrition, family communication, and parenting.

Promoting improved social support and quality of life with the CenteringPregnancy® group model of prenatal care

This prospective cohort study compared women participating in CenteringPregnancy® group prenatal care (N = 120) with those in standard individual care (N = 221) to determine if participation in Centering was associated with improvements in perceived social support and quality of life, with concomitant decreases in screens of postpartum depression and improvements in breastfeeding rates. Participants completed surveys at the onset of prenatal care, in the late third trimester and in the postpartum period. Centering participants had higher scores of perceived social support from friends after participating in group care (p < 0.05) with associated improvements in quality of life in the psychological and relational domains (p < 0.05) compared to standard care participants who showed higher scores of perceived support from family (p < 0.05) but did not show concomitant improvements in quality of life. This did not translate to any significant difference in scores on postpartum depression screens but was associated with improvements in breastfeeding continuation rates among Centering participants in the postpartum period. This study indicates that Centering care is associated with improved perceptions of peer social support with associated improvements in quality of life and higher rates of continued breastfeeding.

Perceptions of Barriers and Facilitators During Implementation of a Complex Model of Group Prenatal Care in Six Urban Sites

Group prenatal care improves perinatal outcomes, but implementing this complex model places substantial demands on settings designed for individual care. To describe perceived barriers and facilitators to implementing and sustaining CenteringPregnancy Plus (CP+) group prenatal care, 24 in-depth interviews were conducted with 22 clinicians, staff, administrators, and study personnel in six of the 14 sites of a randomized trial of the model. All sites served low-income, minority women. Sites for the present evaluation were selected for variation in location, study arm, and initial implementation response. Implementing CP+ was challenging in all sites, requiring substantial adaptations of clinical systems. All sites had barriers to meeting the model's demands, but how sites responded to these barriers affected whether implementation thrived or struggled. Thriving sites had organizational cultures that supported innovation, champions who advocated for CP+, and staff who viewed logistical demands as manageable hurdles. Struggling sites had bureaucratic organizational structures and lacked buy-in and financial resources, and staff were overwhelmed by the model's challenges. Findings suggested that implementing and sustaining health care innovation requires new practices and different ways of thinking, and health systems may not fully recognize the magnitude of change required. Consequently, evidence-based practices are modified or discontinued, and outcomes may differ from those in the original controlled studies. Before implementing new models of care, clinical settings should anticipate model demands and assess capacity for adapting to the disruptions of innovation.

Collaborative approaches to prenatal care: strategies of successful adolescent programs

Adolescent pregnancy is not a new phenomenon in the United States. The 31.3% adolescent birth rate in the US remains one of the highest among industrialized nations. Healthy People 2020 targeted a specific goal of a 10% reduction in pregnancy rates among adolescent females. This objective is important to healthcare providers working in the maternal-child arena, as the consequences of pregnancy and birth can be relatively detrimental to the adolescent, the offspring, and society as a whole. Programs purposely designed for the adolescent population are essential to promoting and achieving optimal results. The intent of this article was to highlight 3 successful prenatal programs that use a collaborative and interprofessional approach to caring for pregnant adolescents: group prenatal care, school-based programs, and age-specific clinics.

In a hard spot: providing group prenatal care in two urban clinics

OBJECTIVES

CenteringPregnancy (Centering) group prenatal care has been demonstrated to improve perinatal outcomes and provide a positive experience of care for women, but it can be difficult to implement and sustain in some clinical settings. The purpose of this study was to examine the challenges encountered when Centering group prenatal care was provided, and the responses of Centering group leaders to these challenges.

DESIGN

this was a longitudinal, qualitative study using interpretive description. Data collection included participant-observation and interviews with group leaders and women receiving group prenatal care.

SETTING

two urban clinics providing care to low income women in the northeastern United States.

PARTICIPANTS

interview participants were 23 pregnant women (primarily African-American and Hispanic) receiving group prenatal care; other participants were 24 significant others and support staff participating in groups, and two nurse-midwife group leaders.

FINDINGS

the clinics did not always provide full resources for implementing Centering as designed, creating numerous challenges for the group leaders, who were committed to providing group prenatal care. In an attempt to sustain the model in the face of these limitations, the group leaders made a number of compromises and modifications to the Centering model.

KEY CONCLUSIONS

the limited clinic resources and resulting modifications of the model had a number of downstream effects, some of which affected relationships within groups, participation, and group cohesion.

IMPLICATIONS

modifications of the Centering model should be undertaken with caution. Strategies are needed to enhance the success and sustainability of Centering in varied clinical settings so that the benefits of the model, which have been demonstrated under more controlled circumstances, can be conferred to women receiving routine care during pregnancy.

CenteringPregnancy: an integrative literature review

INTRODUCTION

A critical analysis of the CenteringPregnancy model of care research has not been conducted across studies. The aims of this project were to describe 1) the conceptual components of the CenteringPregnancy practice model, 2) the characteristics of the CenteringPregnancy literature, and 3) the research methods and outcomes across the CenteringPregnancy research literature.

METHODS

An integrative literature review methodology was used to assess the CenteringPregnancy literature published between 1994 and 2009.

RESULTS

The sample consisted of 26 articles (14 narrative descriptions, 10 quantitative studies, 1 mixed methods study, and 1 qualitative study) published predominantly in nursing and midwifery journals. The majority of quantitative studies were exploratory or quasi-experimental and longitudinal designs with the exception of 1 large, federally funded, randomized, controlled trial. Variables were individual and community level outcomes, which were not uniformly operationally defined or measured consistently across studies. Significant results for prenatal care attendance rates, adequate prenatal care, and breastfeeding rates were reported in a number of studies. Other results were often mixed or nonsignificant.

DISCUSSION

Positive outcomes for the CenteringPregnancy model have been suggested by research findings to date but require more systematic approaches to developing knowledge about the factors inherent in this model that promote participant behavior changes, which lead to better perinatal outcomes as well as circumstances that maximize the effectiveness of this model. Areas for improving the strength of the evidence are discussed. Building consistently demonstrated relationships across studies is essential for creating the evidence base on which practice decisions can be made. Further research is required for developing clarity and understanding about this model's effectiveness.

Women's experience of group prenatal care

Group prenatal care (GPNC) is an innovative alternative to individual prenatal care. In this longitudinal study we used ethnographic methods to explore African American and Hispanic women's experiences of receiving GPNC in two urban clinics. Methods included individual, in-depth, semistructured interviews of women and group leaders in GPNC, participant observation of GPNC sessions, and medical record review. GPNC offered positive experiences and met many of women's expressed preferences regarding prenatal care. Six themes were identified, which represented separate aspects of women's experiences: investment, collaborative venture, a social gathering, relationships with boundaries, learning in the group, and changing self. Taken together, the themes conveyed the overall experience of GPNC. Women were especially enthusiastic about learning in groups, about their relationships with group leaders, and about having their pregnancy-related changes and fears normalized; however, there were also important boundaries on relationships between participants, and some women wished for greater privacy during physical examinations.

Innovative Strategies to Reduce Disparities in the Quality of Prenatal Care in Underresourced Settings

This study examined what innovative strategies, including the use of health information technology (health IT), have been or can be used to reduce disparities in prenatal care quality in underresourced settings. Based on literature review and key informant interviews, the authors identified 17 strategies that have been or can be used to (a) increase access to timely prenatal care, (b) improve the content of prenatal care, and (c) enhance the organization and delivery of prenatal care. Health IT can be used to (a) increase consumer awareness about the importance of preconception and early prenatal care, facilitate spatial mapping of access gaps, and improve continuity of patient records; (b) support collaborative quality improvement, facilitate performance measurement, enhance health promotion, assist with care coordination, reduce clinical errors, improve delivery of preventive health services, provide decision support, and encourage completeness of documentation; and (c) support data integration and engineer collaborative innovation.