Shifting the Paradigm of Prenatal Care: Prenatal Care in Groups

Dr. Gina Novick is a certified nurse-midwife (CNM) from the United States. Gina shares her experience both as a clinician and researcher on using different models of pregnancy care to build meaningful relationships between women and pregnancy care providers.

Read Gina’s blog here…

When I entered midwifery, I was introduced to the midwifery philosophy of care. I learned that pregnancy and birth were not pathologic conditions but rather were normal, physiologic processes, and that midwifery care incorporated a holistic approach that went beyond biomedical issues to address the psychological and social concerns of women and families. As a new midwife, I embraced out-of-hospital birth centers as a model of care that embodied this philosophy. I was inspired by the increasing availability of birth center care, as well as the growing impact of birth centers on U.S hospitals, which were adopting more family-centered approaches to maternity care.

But in my enthusiasm as a new midwife, it never occurred to me that there was no distinctive model of prenatal care that served to embody the midwifery philosophy for pregnancy in the way birth centers did for birth. Although many individual practitioners employ a holistic family-centered approach when conducting traditional prenatal visits, the prevailing prenatal care model is a biomedical approach—one that has remained essentially unchanged for over 100 years. We provide prenatal care one-on-one, in an exam room. We review history, lab results, and current concerns; conduct an abdominal exam; order more lab tests; and provide anticipatory guidance. In some busy settings, we conduct these visits in 15 minutes or less, which can prove frustrating to women, who may experience long waits for what may feel to them like rushed visits. Clinicians seeking to develop meaningful relationships and address complex psychosocial issues in pregnancy may also find this approach unsatisfying, and they may tire of repeating the same information visit after visit.

The Group Prenatal care Model
Group prenatal care shatters this paradigm. In this innovative midwife-designed model, prenatal care is provided to a group of 8-12 women and their significant others in a group setting. Sessions last 2 hours, resulting in approximately 20 hours of contact time with providers and other women over the course of pregnancy (compared with 2-3 hours total time in traditional care). When women arrive for group sessions, they enter the group space without waiting, engage in self-care (measuring their own weight and blood pressure) and receive a prenatal abdominal examination with a clinician. While waiting for their examinations, women snack and chat informally, seated in comfortable chairs in a circular seating arrangement, which promotes interaction. After everyone has been examined, a clinician and another health professional, both trained in facilitative leadership, lead group discussion for 60-90 minutes. This interactive conversation, in which women are encouraged to participate actively, covers a wide range of health education topics, including (but not limited to):
• Nutrition
• Common discomforts
• Sexuality in pregnancy
• Relaxation and stress management
• Preparation for labor and birth
• Infant nutrition and care
• Contraception

Group prenatal care, which has been increasingly widely disseminated in the U.S. and abroad, has been demonstrated in numerous studies to provide outcomes equal to or better than individual care, including reductions in rates of preterm birth, low birth weight, sexually transmitted infections, stress, and depression, and improved rates of breastfeeding, adequacy of care and satisfaction with care. Women also said they had fun in groups, looked forward to the next session, enjoyed sharing experiences with other women, and felt groups reduced isolation. One participant in my research described her overall reaction to receiving care in the group: “I love coming here. I love staying from 1:00 to 3:00. It’s just a different experience, so that’s probably why I have so much positive things, only because it helps.”1 Participating in group prenatal care also had a powerful impact on clinicians and staff. Practitioners in a busy urban clinic reported that groups brought “a lot of happiness” to challenging work sites, comparing the experience with that of having private patients.2

Implementation Challenges:
However, despite the appeal and mounting evidence of efficacy of group prenatal care, the jury is still out on whether this model will have a significant impact on the landscape of prenatal care. Group prenatal care can be challenging to implement and sustain in clinical settings designed to provide individual care—which is, after all, how most clinical settings are structured. For example, it can be difficult to find and furnish a group space that is welcoming and adequate for group activities. Resources are needed to purchase educational materials and food, work-flow patterns must be adjusted to staff group sessions, and a designated group prenatal care coordinator is needed to address ongoing administrative needs. It might seem surprising that the success of shifting the paradigm of care can hinge on these seemingly small logistical issues, but the importance of developing recruitment strategies and appointment templates that allow for groups of 8-12 women to be scheduled for one clinician over two hours cannot be overstated: if patients are not recruited, scheduled properly, or retained for group sessions, a group prenatal care program will likely fail; if reception staff is not properly trained in the alternative appointment templates, women will not be scheduled for group sessions.

In addition to the logistical demands group prenatal care places on health systems, for some clinicians group care is simply unappealing. For others, transition from providing individual care can be challenging. Although training in group facilitation allows clinicians to develop these skills, clinicians and staff also must embrace a new power dynamic, relinquishing the role of authority figure, and ceding power to group participants.

What Helps Group Prenatal Care Thrive in Real-life Clinical Settings?
How, then, can clinical settings succeed in implementing and sustaining this innovative model? My own research suggests that this model thrives in settings with:
• A program champion, who advocates for the group prenatal approach, problem solves, and is intimately involved in providing care.
• A steering committee assuring that ongoing logistical challenges are anticipated, understood, and addressed.
• Buy-in on all levels and across the board. This includes having an administrative champion, and making an investment in educating administrators and staff who might not be directly involved in providing care.
• Collaborative cultures that support innovation. In these settings, there is a kind of resilience: rather than being thrown by problems, staff work together to craft solutions to the many logistical challenges, seeing them as “glitches” or “hurdles,” rather than as insurmountable problems.
On the other hand, incremental approaches, in which the program is implemented by putting one “toe in the water” at a time, rather than really investing in establishing a strong program from the start, may be a recipe for failure.

So, It’s Challenging to Implement, Now What?
It’s relatively easy to wax enthusiastic about an appealing, efficacious, patient-centered innovation. But as anyone who has tried to implement a complex health care innovation understands, one has to move from inspiration to face the day-to-day realities of changing care delivery in demanding real-life clinical settings. This may require planning and investment. It also needs a less siloed approach: we need to see the benefits that accrue to mothers and babies after birth as being worth the cost of investing in this model during pregnancy. In the current health care environment, this might seem daunting. But if group prenatal care not only improves outcomes but also helps forge more meaningful bonds among women and between women and clinicians, this model may serve as an antidote to some of the very frustrations experienced by women and clinicians in these demanding settings, while improving maternal and child health at the same time.

Selected Readings
1. Novick, G., et al. (2011). “Women’s experience of group prenatal care.” Qual Health Res 21(1): 97-116.
2. Novick, G., et al. (2015). “Perceptions of Barriers and Facilitators During Implementation of a Complex Model of Group Prenatal Care in Six Urban Sites.” Research in Nursing & Health 38(6): 462-474.
3. Ickovics, J. R., et al. (2007). “Group prenatal care and perinatal outcomes: A randomized controlled trial.” Obstet Gynecol 110(No. 2, Part 1): 330-339.
4. Heberlein, E., et al. (2015). “The comparative effects of group prenatal care on psychosocial outcomes.” Archives of Women’s Mental Health: 1-11.
5. Rising, S. S., et al. (2004). “Redesigning prenatal care through CenteringPregnancy.” J Midwifery Wom Heal 49(5): 398-404.

Gina Novick RN, CNM, PhD
Assistant Professor
Yale University School of Nursing

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