CommitteeOpinion2017
Number 731, March 2018


Committee on Obstetric Practice
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice in collaboration with committee members Brigid K. McCue, MD, PhD; and Ann E. Borders, MD, MSc, MPH; and the American Academy of Family Physicians’ liaison member Beth Choby, MD.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.


PDF Format

Group Prenatal Care

ABSTRACT: Individual prenatal care is intended to prevent poor perinatal outcomes and provide education to women throughout pregnancy, childbirth, and the postpartum period through a series of one-on-one encounters between a woman and her obstetrician or other obstetric care provider. Concerns regarding increasing health care costs, health care provider availability, dissatisfaction with wait times, and the minimal opportunity for education and support associated with the individual care model have given rise to interest in alternative models of prenatal care. One alternative model, group prenatal care, may be beneficial or preferred for some practice settings and patient populations, although individual prenatal care remains standard practice. Group prenatal care models are designed to improve patient education and include opportunities for social support while maintaining the risk screening and physical assessment of individual prenatal care. Bringing patients with similar needs together for health care encounters increases the time available for the educational component of the encounter, improves efficiency, and reduces repetition. Evidence suggests patients have better prenatal knowledge, feel more ready for labor and delivery, are more satisfied with care in prenatal care groups, and initiate breastfeeding more often. There is no evidence that suggests that group prenatal care causes harm. Individual and group care models
warrant additional study with a goal of demonstrating differences in outcomes and identifying populations that benefit most from specific care models.


Recommendations and Conclusions

The American College of Obstetricians and Gynecologists makes the following recommendations:

  • Group prenatal care models are designed to improve patient education and include opportunities for social support while maintaining the risk screening and physical assessment of individual prenatal care.
  • Studies appear to demonstrate high levels of patient satisfaction, obstetric outcomes equally efficacious as individual prenatal care, and improved outcomes for some populations.
  • Specific group prenatal care models can be challenging to initiate and maintain. The cost of initiating a group prenatal care model in current obstetric practices may be a barrier to implementation.
  • When participation in group prenatal care is offered, it should be provided as an alternative option to traditional prenatal care and not mandated. Individual and group care models warrant additional study with a goal of demonstrating differences in outcomes and identifying populations that benefit most from specific care models.

Introduction

Individual prenatal care is intended to prevent poor perinatal outcomes and provide education to women throughout pregnancy, childbirth, and the postpartum period through a series of one-on-one encounters between a woman and her obstetrician or other obstetric care provider. The American College of Obstetricians and Gynecologists recommends routine regularly scheduled visits that consist of objective assessments, testing, maternal support, and education (1, 2). Concerns regarding increasing health care costs, health care provider availability, dissatisfaction with wait times, and the minimal opportunity for education and support associated with the individual care model have given rise to interest in alternative models of prenatal care. One alternative model, group prenatal care, may be beneficial or preferred for some practice settings and patient populations, although individual prenatal care remains standard practice.

Group prenatal care models are designed to improve patient education and include opportunities for social support while maintaining the risk screening and physical assessment of individual prenatal care. Bringing patients with similar needs together for health care encounters increases the time available for the educational component of the encounter, improves efficiency, and reduces repetition. Evidence suggests patients who participate in group prenatal care have better prenatal knowledge, feel more ready for labor and delivery, are more satisfied with overall care, and initiate breastfeeding more often (3). Group care has been used successfully in a variety of medical settings for management of chronic medical conditions such as chronic pain, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), cancer, diabetes, and congestive heart failure (4–9). Pediatric group care models also are emerging (9, 10).

Models of Group Prenatal Care

Several group care models have been described, such as Expect with Me (11), Pregnancy and Parenting Partners (www.pregnancyandparentingpartners.org), and Expecting and Connecting in Queensland, Australia (12). These models often are adaptations of the CenteringPregnancy program, which is in use internationally and is the most widely studied model. First piloted in 1993, the CenteringPregnancy program is characterized by essential standardized elements that guide the structure and content of the group sessions, and emphasize health-promoting behaviors (13). Assembled at the start of the second trimester, groups are composed of approximately 8–10 women of similar gestational age, their support partners, an obstetrician or other obstetric care provider, and co-facilitator and meet every 2–4 weeks. A series of 10 visits, each lasting 90–120 minutes, are scheduled over a 6-month period, concluding in the last month of pregnancy. Each session begins with socializing opportunities, self-data collection, and a brief one-on-one interaction with the obstetrician–gynecologist or other obstetric care provider for individual assessment and solicitation of patient concerns. Most of the visit is then spent in facilitated discussion of topics suggested by the curriculum but prioritized by the group. Obstetricians and other obstetric care providers are trained to enhance adult learning by avoiding didactic lectures and facilitating peer-to-peer learning through robust participation of women and their support partners. Discussion topics include childbirth preparation, nutrition and exercise, health self-awareness, stress management, breastfeeding, and contraception (13). Pregnancy complications are managed through supplemental individual visits and as-needed specialist referrals, although routine prenatal care and health assessments usually continue within the group.

In theory, the expanded visit time and opportunity for in-depth peer-to-peer personal discussion facilitates learning opportunities and social support. Prenatal educational information is reliably communicated to the patients in a manner that avoids repetition for patients and obstetricians and other obstetric care providers. Some patients appreciate the ease of long-term scheduling, avoidance of wait times, and the unique and long-term social bonds that develop within the group, sustaining patients through unforeseen outcomes and into the postpartum period.

Outcomes Research

The existing body of literature evaluating group prenatal care, although growing, is relatively small and includes mostly observational studies yielding a mix of positive and negative results. These have demonstrated reductions in preterm birth and neonatal intensive care unit (NICU) admissions; increased birth weight for term and preterm infants; increased rates of breastfeeding initiation and continuation; decreased emergency department visits in the third trimester; improved pregnancy-related weight management; an increase in patients presenting in active labor and at greater cervical dilatation; increased patient and obstetrician and other obstetric care provider satisfaction; and improved knowledge of childbirth, family planning, postpartum depression, and early child rearing (3, 14–21). A 2017 retrospective cohort study of 207 group care patients matched with 414 traditional prenatal care patients showed similar baseline characteristics between the two groups, but group care was associated with significant reduction in low-birth-weight infants compared with individual care (11.1% versus 19.6%; relative risk [RR], 0.57; 95% CI, 0.37–0.87). Patients in group care were significantly less likely than controls to require cesarean delivery, have low 5-minute Apgar scores, and need higher level neonatal care (1.5% versus 6.5%;RR, 0.22; 95% CI, 0.07–0.72) (16).

Although initial observational trials and a large randomized controlled trial (RCT) of group prenatal care that included 1,047 women found significant improvement in perinatal outcomes, including preterm birth risk reduction of 33% (OR, 0.67; CI, 0.44–0.99, P=.45),with the largest reduction in preterm birth for low-income black women (OR, 0.59; CI, 0.38–0.92, P=.02) (3), a Cochrane review of group prenatal care that included four RCTs (n=2,350 women) reported no statistically significant differences for the primary outcomes of preterm birth (RR, 0.75; 95% CI, 0.57–1.00), low birth weight (less than 2,500 g) (RR, 0.92; 95% CI, 0.68–1.23), small for gestational age (RR, 0.92; 95% CI, 0.68–1.24), perinatal mortality (RR, 0.63; 95% CI, 0.32–1.25), or initiation of breastfeeding (RR, 1.08; 95% CI, 0.96–1.2) (22). A meta-analysis of 10 observational studies and four RCTs similarly found no statistically significant difference in the primary outcomes of preterm birth (RR, 0.87; 95% CI, 0.70–1.09), low birth weight (limited to three high-quality RCTs: RR, 0.92; 95% CI, 0.64–1.32), breastfeeding initiation (RR, 1.08; 95% CI, 0.99–1.17), or NICU admission (RR, 0.91; 95% CI, 0.68–1.23) (23).

Special Populations

Racial and ethnic disparities persist in the prevalence of preterm birth and infant mortality, and group prenatal care may be particularly useful in addressing disparities in perinatal outcomes such as preterm birth among black women. Differences in perinatal outcomes by race or ethnicity and socio-economic status, and patient satisfaction outcomes were not evaluated in the Cochrane Review (22) or reported as a main outcome in the meta-analysis (23). Analysis of trials of group prenatal care in specific at-risk populations shows promise in addressing these disparities. Although the meta-analysis (23) reported similar rates of preterm birth, overall, in the individual and group prenatal care arms, outcomes in low-income black women suggest reduced risk of preterm birth with group care (RR, 0.55; 95% CI, 0.34–0.88) (23). The largest RCT also found that black women as a group had the greatest reduction in preterm birth, with a rate of 10.0% in group care compared with 15.8% among those who received traditional prenatal care (OR, 0.59; 95% CI, 0.38−0.92; P=.02) (3). Preterm birth among Latina women who participated in group prenatal care was not significantly different (5.5% versus 5.9%, RR, 1.05; 95% CI, 0.37–2.99) (23). Because race was not included in the data collection, neither the meta-analyses nor the comprehensive review was able to assess racial differences in low birth weight, NICU admission, or breastfeeding initiation. Because of heterogeneity in the primary studies, neither the meta-analyses nor the comprehensive review assessed patient and obstetrician or obstetric care provider satisfaction and improved knowledge of childbirth, family planning, postpartum depression, or early child rearing. Both analyses are limited by the preponderance of observational and smaller trials.

The emphasis placed on education and social support in group prenatal care is hypothesized to be advantageous to the adolescent population. Several trials of this population suggest that adolescent group prenatal care is associated with higher patient satisfaction, increased self-esteem, decreased social conflict, increased visit attendance, improved weight management, increased breastfeeding, increased rates of postpartum contraception, and decreased incidence of repeat pregnancy within 12 months (3, 24–27). However, most study designs excluded adolescents who did not attend most of the scheduled visits, which resulted in additional selection bias.

Group prenatal care also has been hypothesized to address the stressors borne by women in the military. An RCT of group prenatal care in the military setting found an increase in visit attendance (OR, 5.92; 95% CI, 3.21–10.91), patient satisfaction (P<.001), and women less likely to report “feelings of guilt and shame” (P=.04). However, no differences were seen in rates of preterm birth, breastfeeding, perinatal and infant health, and depression (28).

Nonpregnant women with diabetes show improved disease management using group care models. Pregnant women with diabetes are another group thought to benefit from the added education and social support offered by group prenatal care. To date, no such randomized trials have been performed in this population. Observational studies show that women with diabetes in group prenatal care improved their hemoglobin A1c levels, less often progressed to needing insulin or other medications, and were more likely to breastfeed and to adhere to postpartum glucose tolerance screening. However, no improvement in fasting blood glucose or number of visits attended was seen, and there was no difference in neonatal outcomes (29–31).

In summary, obstetric outcomes for women participating in group prenatal care are at least equivalent to traditional prenatal care. There is no evidence that suggests that group prenatal care causes harm. Larger, randomized trials are needed to identify subpopulations that might benefit from different models of prenatal care.

Challenges to Implementation

Specific group prenatal care models, such as CenteringPregnancy, can be challenging to initiate and maintain. Training for obstetricians, obstetric care providers, and facilitators; site certification; and ongoing data collection are encouraged to ensure model fidelity. Dedicated meeting space is optimal but not easily available in all locations, which might, for instance, necessitate the use of the waiting area after hours. Child care is usually not available. Although confidentiality and Health Insurance Portability and Accountability Act (HIPAA) compliance are addressed within group prenatal care, the potential loss of privacy is unattractive to some patients. Because group prenatal care is not a good fit for every patient, when participation in group prenatal care is offered, it should be provided as an alternative option to traditional prenatal care and not mandated.

The cost of initiating a group prenatal care model in current obstetric practices may be a barrier to implementation. Centering Healthcare Institute instructor training and site approval incur start-up costs, although the Centering Healthcare Institute offers preliminary readiness assessment for practices interested in implementation, and grants are available. Ongoing costs (eg, patient notebooks and snacks, supplies for group activities, program coordination, meeting space set up and breakdown) can be cost prohibitive without a sustainable funding source or the availability of enhanced reimbursement above the standard set for prenatal visits. Although a few commercial insurance companies and several states reimburse at higher levels for Medicaid patients who participate in validated group care models, enhanced reimbursement is not widely available. One cost analysis of group prenatal care that used actual claims paid data for women enrolled in Medicaid in South Carolina found it to be cost effective through improved pregnancy outcomes. Although a $2.3-million-dollar savings was reported after initial investment (32), these data may not be generalizable to other states and populations with a different racial mix or lower rates of prematurity and low-birth-weight infants. One study developed mathematical cost–benefit models to forecast the cost of group prenatal care with various payer mixes and facilitators and predicted financial sustainability and possibly income generated for the outpatient clinic (33).

Opportunity for Future Research

Group prenatal care offers a promising alternative for patients, their partners, and obstetricians and other obstetric care providers. Although evidence to support group prenatal care models still is emerging, studies appear to demonstrate high levels of patient satisfaction, obstetric outcomes equally efficacious as individual prenatal care, and improved outcomes for some populations. Further studies are needed to clarify the effect that group prenatal care may have on patients at higher risk of preterm delivery, including black women, adolescents, and others. The effect on partners of women who participate in group prenatal care offers additional promising areas of investigation (34). Additional technological adaptations that incorporate elements of telemedicine and supportive social media into the group care model, such as the “high touch–high tech” modifications of Expect With Me, have the potential to lower cost and increase the reach of group prenatal care and also deserve careful study (11). Long-term assessment of the effect of the group prenatal care model is warranted.

Conclusion

Experts suggest that “group prenatal care is an innovative and promising model with comparable pregnancy outcomes to individual prenatal care in the general population and improved outcome in some demographic groups” (35). Individual and group care models warrant additional study with a goal of demonstrating differences in outcomes and identifying populations that benefit most from specific care models.

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/GroupPrenatalCare.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.

References

  1. American Academy of Pediatrics, American College of Obstetricians and Gynecologist. Guidelines for perinatal care. 8th ed. Elk Grove Village (IL): AAP; Washington, DC: American College of Obstetricians and Gynecologists; 2017.
  2. Rosen MG, Merkatz IR, Hill JG. Caring for our future: a report by the expert panel on the content of prenatal care. Obstet Gynecol 1991;77:782–7.
  3. Ickovics JR, Kershaw TS, Westdahl C, Magriples U, Massey Z, Reynolds H, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial [published erratum appears in Obstet Gynecol 2007;110:937]. Obstet Gynecol 2007;110:330–39.
  4. Webel AR. Testing a peer-based symptom management intervention for women living with HIV/AIDS. AIDS Care 2010;22:1029–40.
  5. McCorkle R, Ercolano E, Lazenby M, Schulman-Green D, Schilling LS, Lorig K, et al. Self-management: enabling and empowering patients living with cancer as a chronic illness. CA Cancer J Clin 2011;61:50–62.
  6. Lorig K, Ritter PL, Villa FJ, Armas J. Community-based peer-led diabetes self-management: a randomized trial. Diabetes Educ 2009;35:641–51.
  7. Housden LM, Wong ST. Using group medical visits with those who have diabetes: examining the evidence. Curr Diab Rep 2016;16:134.
  8. Quinones AR, Richardson J, Freeman M, Fu R, O’Neil ME, Motu’apuaka M, et al. Educational group visits for the management of chronic health conditions: a systematic review. Patient Educ Couns 2014;95:3–29.
  9. Bialostozky A, McFadden SE, Barkin S. A novel approach to well-child visits for Latino children under two years of age. J Health Care Poor Underserved 2016;27:1647–55.
  10. Saysana M, Downs SM. Piloting group well child visits in pediatric resident continuity clinic. Clin Pediatr (Phila) 2012;51:134–9.
  11. Cunningham SD, Lewis JB, Thomas JL, Grilo SA, Ickovics JR. Expect With Me: development and evaluation design for an innovative model of group prenatal care to improve perinatal outcomes. BMC Pregnancy Childbirth 2017;17:147.
  12. Craswell A, Kearney L, Reed R. ‘Expecting and Connecting’ group pregnancy care: evaluation of a collaborative clinic. Women Birth 2016;29:416–22.
  13. Rising SS. Centering pregnancy. An interdisciplinary model of empowerment. J Nurse Midwifery 1998;43:46–54.
  14. Picklesimer AH, Billings D, Hale N, Blackhurst D, Covington-Kolb S. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obstet Gynecol 2012;206:415.e1–7.
  15. Carter EB, Barbier K, Sarabia R, Macones GA, Cahill AG, Tuuli MG. Group versus traditional prenatal care in low-risk women delivering at term: a retrospective cohort study. J Perinatol 2017;37:769–71.
  16. Tanner-Smith EE, Steinka-Fry KT, Lipsey MW. The effects of CenteringPregnancy group prenatal care on gestational age, birth weight, and fetal demise. Matern Child Health J 2014;18:801–9.
  17. Magriples U, Boynton MH, Kershaw TS, Lewis J, Rising SS, Tobin JN, et al. The impact of group prenatal care on pregnancy and postpartum weight trajectories. Am J Obstet Gynecol 2015;213:688.e1–9.
  18. Hale N, Picklesimer AH, Billings DL, Covington-Kolb S. The impact of Centering Pregnancy Group Prenatal Care on postpartum family planning. Am J Obstet Gynecol 2014;210:50.e1–7.
  19. Tilden EL, Emeis CL, Caughey AB, Weinstein SR, Futernick SB, Lee CS. The influence of group versus individual prenatal care on phase of labor at hospital admission. J Midwifery Womens Health 2016;61:427–34.
  20. Novick G, Sadler LS, Kennedy HP, Cohen SS, Groce NE, Knafl KA. Women’s experience of group prenatal care. Qual Health Res 2011;21:97–116.
  21. Felder JN, Epel E, Lewis JB, Cunningham SD, Tobin JN, Rising SS, et al. Depressive symptoms and gestational length among pregnant adolescents: cluster randomized control trial of CenteringPregnancy® plus group prenatal care. J Consult Clin Psychol 2017;85:574–84.
  22. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, et al. Group versus conventional antenatal care for women. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD007622. DOI: 10.1002/14651858.CD007622.pub3.
  23. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group prenatal care compared with traditional prenatal care: a systemic review and meta-analysis. Obstet Gynecol 2016;128:551–61.
  24. Ickovics JR, Reed E, Magriples U, Westdahl C, Schindler Rising S, Kershaw TS. Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled trial. Psychol Health 2011;26:235–50.
  25. Ickovics JR, Earnshaw V, Lewis JB, Kershaw TS, Magriples U, Stasko E, et al. Cluster randomized controlled trial of group prenatal care: perinatal outcomes among adolescents in New York City health centers. Am J Public Health 2016;106:359–65.
  26. Trotman G, Chhatre G, Darolia R, Tefera E, Damle L, Gomez-Lobo V. The effect of Centering Pregnancy versus traditional prenatal care models on improved adolescent health behaviors in the perinatal period. J Pediatr Adolesc Gynecol 2015;28:395–401.
  27. Grady MA, Bloom KC. Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program. J Midwifery Womens Health 2004;49:412–20.
  28. Kennedy HP, Farrell T, Paden R, Hill S, Jolivet RR, Cooper BA, et al. A randomized clinical trial of group prenatal care in two military settings. Mil Med 2011;176:1169–77.
  29. Mazzoni SE, Hill PK, Webster KW, Heinrichs GA, Hoffman MC. Group prenatal care for women with gestational diabetes. J Matern Fetal Neonatal Med 2016;29:2852–6.
  30. Schellinger MM, Abernathy MP, Amerman B, May C, Foxlow LA, Carter AL, et al. Improved outcomes for Hispanic women with gestational diabetes using the Centering Pregnancy(c) group prenatal care model. Matern Child Health J 2017;21:297–305.
  31. Parikh LI, Jelin AC, Iqbal SN, Belna SL, Fries MH, Patel M, et al. Glycemic control, compliance, and satisfaction for diabetic gravidas in centering group care. J Matern Fetal Neonatal Med 2017;30:1221–6.
  32. Gareau S, Lopez-DeFede A, Loudermilk BL, Cummings TH, Hardin JW, Picklesimer A, et al. Group prenatal care results in Medicaid savings with better outcomes: a propensity score analysis of CenteringPregnancy participation in South Carolina. Matern Child Health J 2016;20:1384–93.
  33. Rowley RA, Phillips LE, O’Dell L, Husseini RE, Carpino S, Hartman S. Group prenatal care: a financial perspective. Matern Child Health J 2016;20:1–10.
  34. Andersson E, Small R. Fathers’ satisfaction with two different models of antenatal care in Sweden—Findings from a quasi-experimental study. Midwifery 2017;50:201–7.
  35. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol 2017;216:552–6.

Copyright March 2018 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Requests for authorization to make photocopies should be directed to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400.

The American College of Obstetricians and Gynecologists
409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920

Group prenatal care. ACOG Committee Opinion No. 731. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e104–8.

American College of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188 | Mailing Address: PO Box 70620, Washington, DC 20024-9998