Intention to Participate in Group Prenatal Care: Moving Beyond Yes or No

Group prenatal care successes, challenges, and frameworks for scaling up: a case study in adopting health care innovations

BACKGROUND

Group prenatal care enhances quality of care, improves outcomes, and lowers costs. However, this healthcare innovation is not widely available. Using a case-study approach, our objectives were to (1) examine organizational characteristics that support implementation of Expect With Me group prenatal care and (2) identify key factors influencing adoption and sustainability.

METHODS

We studied five clinical sites implementing group prenatal care, collecting qualitative data including focus group discussions with clinicians (n = 4 focus groups, 41 clinicians), key informant interviews (n = 9), and administrative data. We utilized a comparative qualitative case-study approach to characterize clinical sites and explain organizational traits that fostered implementation success. We characterized adopting and non-adopting (unable to sustain group prenatal care) sites in terms of fit for five criteria specified in the Framework for Transformational Change: (1) impetus to transform, (2) leadership commitment to quality, (3) improvement initiatives that engage staff, (4) alignment to achieve organization-wide goals, and (5) integration.

RESULTS

Two sites were classified as adopters and three as non-adopters based on duration, frequency, and consistency of group prenatal care implementation. Adopters had better fit with the five criteria for transformational change. Adopting organizations were more successful implementing group prenatal care due to alignment between organizational goals and resources, dedicated healthcare providers coordinating group care, space for group prenatal care sessions, and strong commitment from organization leadership.

CONCLUSIONS

Adopting sites were more likely to integrate group prenatal care when stakeholders achieved alignment across staff on organizational change goals, leadership buy-in, and committed institutional support and dedicated resources to sustain it.

TRIAL REGISTRATION

The Expect With Me intervention's design and hypotheses were preregistered: https://clinicaltrials.gov/study/NCT02169024 . Date: June 19, 2014.

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.

Anticipated benefits and challenges of implementing group care in Suriname's maternity and child care sector: a contextual analysis

BACKGROUND

Suriname is a uppermiddle-income country with a relatively high prevalence of preventable pregnancy complications. Access to and usage of high-quality maternity care services are lacking. The implementation of group care (GC) may yield maternal and child health improvements. However, before introducing a complex intervention it is pivotal to develop an understanding of the local context to inform the implementation process.

METHODS

A context analysis was conducted to identify local needs toward maternity and postnatal care services, and to assess contextual factor relevant to implementability of GC. During a Rapid Qualitative Inquiry, 63 online and face-to-face semi-structured interviews were held with parents, community members, on-and off-site healthcare professionals, policy makers, and one focus group with parents was conducted. Audio recordings were transcribed in verbatim and analysed using thematic analysis and Framework Method. The Consolidated Framework for Implementation Research served as a base for the coding tree, which was complemented with inductively derived codes.

RESULTS

Ten themes related to implementability, one theme related to sustainability, and seven themes related to reaching and participation of the target population in GC were identified. Factors related to health care professionals (e.g., workload, compatibility, ownership, role clarity), to GC, to recipients and to planning impact the implementability of GC, while sustainability is in particular hampered by sparse financial and human resources. Reach affects both implementability and sustainability. Yet, outer setting and attitudinal barriers of health professionals will likely affect reach.

CONCLUSIONS

Multi-layered contextual factors impact not only implementability and sustainability of GC, but also reach of parents. We advise future researchers and implementors of GC to investigate not only determinants for implementability and sustainability, but also those factors that may hamper, or facilitate up-take. Practical, attitudinal and cultural barriers to GC participation need to be examined. Themes identified in this study will inspire the development of adaptations and implementation strategies at a later stage.

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.

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.

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.