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

Implementing group care in Dutch and Surinamese maternity and child care services: the vital importance of addressing outer context barriers

BACKGROUND

By addressing physical and psychosocial needs, group care (GC) improves health-related behaviours, peer support, parent-provider interactions and may improve birth outcomes. Hence, global implementation of GC is encouraged. Context analyses prior to implementation are vital to elucidate which local factors may support or hinder implementation.

METHODS

Contextual analyses conducted in the Netherlands and Suriname were compared to identify the factors relevant to the implementability of GC as perceived by healthcare professionals (HCPs). 32 semi-structured interviews were conducted with Dutch and Surinamese healthcare professionals. Audio recordings were transcribed verbatim and coded using the Framework approach. The Consolidated Framework for Implementation Research guided the development of the interview guide and of the coding tree.

RESULTS

Outer setting: Concerns regarding funding surfaced in both countries. Due to limited health insurance coverage, additional fees would limit accessibility in Suriname. In the Netherlands, midwives dreaded lower revenue due to reimbursement policies that favour one-on-one care. Inner setting: Appropriate space for GC was absent in one Dutch and three Surinamese facilities. Role division regarding GC implementation was clearer in the Netherlands than in Suriname.

INNOVATION

HCPs from both countries expected increased social support, health knowledge among women, and continuity of care(r). Individuals/innovation deliverers: Self-efficacy and motivation emerged as intertwined determinants to GC implementation in both countries. Individuals/innovation recipients: Competing demands can potentially lower acceptability of GC in both countries. While Dutch HCPs prioritised an open dialogue with mothers, Surinamese HCPs encouraged the inclusion of partners.

PROCESS

Campaigns to raise awareness of GC were proposed. Language barriers were a concern for Dutch but not for Surinamese HCPs.

CONCLUSIONS

While the most striking differences between both countries were found in the outer setting, they trickle down and affect all layers of context. Ultimately, at a later stage, the process evaluation will show if those outer setting barriers we identified prior to implementation actually hindered GC implementation. Changes to the health care systems would ensure sustained implementation in both countries, and this conclusion feeds into a more general discussion: how to proceed when contextual analyses reveal barriers that cannot be addressed with the time and resources available.

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.

Promoting informed decision making about maternal pertussis vaccination: the systematic development of an online tailored decision aid and a centering-based group antenatal care intervention

Introduction

Maintaining and enhancing vaccine confidence continues to be a challenge. Making an informed decision not only helps to avoid potential future regret but also reduces susceptibility to misinformation. There is an urgent need for interventions that facilitate informed decision-making about vaccines. This paper describes the systematic development of two interventions designed to promote informed decision making and indirectly, acceptance of maternal pertussis vaccination (MPV) in the Netherlands.

Materials and methods

The 6-step Intervention Mapping (IM) protocol was used for the development of an online tailored decision aid and Centering Pregnancy-based Group Antenatal Care (CP) intervention. A needs assessment was done using empirical literature and conducting a survey and focus groups (1), intervention objectives were formulated at the behavior and determinants levels (2), theoretical methods of behavior change were selected and translated into practical applications (3), which were further developed into the two interventions using user-centered design (4). Finally, plans were developed for implementation (5), and evaluation (6) of the interventions.

Results

The needs assessment showed that pregnant women often based their decision about MPV on information sourced online and conversations with their partners, obstetric care providers, and peers. Responding to these findings, we systematically developed two interactive, theory-based interventions. We created an online tailored decision aid, subjecting it to four iterations of testing among pregnant women, including those with low literacy levels. Participants evaluated prototypes of the intervention positively on relevance and usability. In addition, a CP intervention was developed with midwives.

Conclusion

Using IM resulted in the creation of an online decision aid and CP intervention to promote informed decision making regarding MPV. This description of the systematic development of the interventions not only serves to illustrate design rationales, it will also aid the interpretation of the evaluation of the interventions, the development of future interventions promoting informed decision and acceptance of vaccines, and comparisons with other interventions.

Promoting informed decision-making about maternal pertussis vaccination in Centering Pregnancy group-antenatal care: A feasibility study

PROBLEM

Effective interventions are needed to promote informed decision making about vaccination.

BACKGROUND

We developed a group-antenatal care (CP; Centering Pregnancy) intervention, i.e., a session about MPV within existing group-care settings, to promote informed decision making about Maternal Pertussis Vaccination in the Netherlands.

AIM

This study aimed to assess (1) to what extent the intervention was implemented as intended, (2) to what extent the intervention met the needs and wishes of pregnant individuals and midwives facilitating CP.

METHODS

We conducted exploratory interviews with 6 CP facilitators and 10 CP participants to assess the implementation of the intervention, and how the intervention and its different components were perceived. Interviews were analysed using thematic analysis. In addition, we conducted a pre- and post-intervention survey amongst 35 participants, measuring knowledge about MPV, and MPV attitude and intention.

RESULTS

The CP intervention was implemented as intended in 6 out of 7 groups. Participants were positive about the interactive CP-methods used to discuss MPV. Participants and facilitators evaluated the intervention as positive and relevant, although the intervention was time-consuming, and some participants had already made the de decision about MPV. Those who had not yet decided indicated that the session was helpful for their decision.

DISCUSSION AND CONCLUSION

Discussing MPV in CP care settings is a feasible strategy to support decision making about MPV during pregnancy. The intervention could be improved by discussing the MPV sooner than 16-18 weeks of pregnancy. A larger-scale study is needed to assess effects on MPV uptake and informed decision making.

Long-term cost savings with Centering-based group antenatal care

INTRODUCTION

Group antenatal care (gANC) is a group-based care-model combining routine antenatal care, with health assessment, education, and community building. GANC has shown positive results on perinatal outcomes. However, midwives in Dutch primary care have reported higher costs when providing gANC. The purpose of this study was to assess the effect of replacing individual prenatal care (IC) by gANC on (expected future) health care costs and health outcomes.

METHODS

We performed an exploratory cost-benefit analysis comparing costs and consequences of gANC with those of IC, using a hypothetical cohort of 12,894 women in gANC. Primary input data were derived from a stepped wedge cluster randomized controlled trial carried out in the Netherlands, assessing both health and psychosocial effects of gANC comparing them with IC. Other data was retrieved from available literature and an online questionnaire among midwifery practices. The main outcome measure was differential cost of gANC and lifetime direct healthcare costs related to the effects of gANC compared to IC (price level 2019).

RESULTS

Results showed that gANC comes at a differential cost of €45 extra per person when compared to IC. However, projected healthcare cost-savings related to increased breastfeeding rates, reduced prevalence of pregnancy induced hypertension and less postpartum smoking, lead to an average net cost-savings of €67 per gANC participant.

DISCUSSION

Although gANC shows better health- and psychosocial outcomes when compared to IC, it is more costly to provide. However, findings indicate that the differential costs of gANC are off-set by long-term healthcare cost-savings.

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.

CenteringPregnancy: A Review of Implementation and Outcomes

Importance

CenteringPregnancy (CP) is a model for group prenatal care associated with improved perinatal outcomes for preterm birth and low birthweight, increased rates of breastfeeding, and higher rates of patient and clinician satisfaction.

Objective

The study aims to review the literature related to perinatal outcomes associated with CP, benefits and barriers to implementation, and utility of the model.

Evidence

An electronic-based search was performed in PubMed using the search terms "CenteringPregnancy" OR "Centering Pregnancy," revealing 221 articles.

Results

The CP model improves patient centeredness, efficiency, and equality in prenatal care. Challenges include administrative buy-in, limited resources, and financial support. Multisite retrospective studies of CP demonstrate improved maternal, neonatal, postpartum, and well-being outcomes, especially for participants from minority backgrounds; however, prospective studies had mixed results. CenteringPregnancy is feasibly implemented with high tenet fidelity in several low- and middle-income settings with improved perinatal outcomes compared with traditional care.

Conclusions

CenteringPregnancy is feasible to implement, largely accepted by communities, and shows positive qualitative and quantitative health outcomes. This body of literature supports CP as a potential tool for decreasing racial inequalities in prenatal access, quality of care, and maternal mortality. Further investigation is necessary to inform obstetric clinicians about the potential outcome differences that exist between group and traditional prenatal care.

Self-management support by health care providers in prenatal Shared Medical Appointments (CenteringPregnancy©) and prenatal individual appointments

OBJECTIVE

This cross-sectional questionnaire study investigates if there a difference in the extent to which health care providers in prenatal Shared Medical Appointments (CenteringPregnancy©) and in prenatal individual appointments support self-management in patient education. It also investigates if there is a difference in the extent to which health care providers in CenteringPregnancy@ and in individual appointments pay attention to the factors of the Integrated Model for Behavioral Change (I-Change) in supporting self-management.

METHODS

Dutch health care providers in prenatal care were invited to fill out a questionnaire. Respondents who provided care in CenteringPregnancy© formed the CenteringPregnancy© group, the others were categorized in the individual appointments' group. After a definition of self-management and an introduction of the I-Change model, respondents were asked if they supported self-management and if they paid attention to the I-Change model for each of 17 themes of prenatal patient education. Pearson's chi-squared tests and Fisher's Exact tests were performed to compare both groups.

RESULTS

We included 133 respondents. Health care providers in the CenteringPregnancy@ group supported self-management to a higher extent compared to the individual appointments group. This difference was statistically significant for eight themes (body position and exercises, oral health, domestic violence, birth mechanism and premature birth, postnatal period, transition from pregnancy to parenthood, taking care of the baby and newborn's safety). In both groups, health care providers paid most attention to information or to awareness factors instead of motivation factors.

CONCLUSION

We found a first prove that health care providers in CenteringPregnancy@ support self-management to a higher extent than health care providers in individual appointments. This could be explained by factors as time, feelings of safety and bonding, continuity of care and emphasis on future health behaviour changes. For effective self-management support, attention to motivation factors is important. However, we found that health care providers in both groups paid more attention to information or to awareness factors than to motivation.

PRACTICE IMPLICATIONS

Health care providers in prenatal individual appointments should be aware of the fact that they possibly support self-management less than health care providers in CenteringPregnancy@ . Health care providers in both types of prenatal care should be aware of the fact that they pay little attention to motivation factors. They might need some skills to change their role from teaching professional to supportive leader.

CenteringPregnancy in the Netherlands: Who engages, who doesn't, and why

BACKGROUND

CenteringPregnancy (CP), a model of group antenatal care, was implemented in 2012 in the Netherlands to improve perinatal health; CP is associated with improved pregnancy outcomes. However, motivating women to participate in CP can be difficult. As such, we explored the characteristics associated with CP uptake and attendance and then investigated whether participation differs between health care facilities. In addition, we examined the reasons why women may decline participation and the reasons for higher or lower attendance rates.

METHODS

Data from a stepped-wedge cluster randomized controlled trial were used. Univariate and multivariate logistic regression models were used to determine associations among women's health behavior, sociodemographic and psychosocial characteristics, health care facilities, and participation and attendance in CP.

RESULTS

A total of 2562 women were included in the study, and the average participation rate was 31.6% per health care facility (range of 10%-53%). Nulliparous women, women <26 years old or >30 years old, and women reporting average or high levels of stress were more likely to participate in CP. Participation was less likely for women who had stopped smoking before prenatal intake, or who scored below average on lifestyle/pregnancy knowledge. For those participating in CP, 87% attended seven or more out of the 10 sessions, and no significant differences were found in women's characteristics when compared for higher or lower attendance rates. After the initial uptake, group attendance rates remained high.

CONCLUSION

A more comprehensive understanding of the variation in participation rate between health care facilities is required, in order to develop effective strategies to improve the recruitment of women, especially those with less knowledge and understanding of health issues and smoking habits.