Peter S. Bernstein, MD, MPH

Disclosures

October 03, 2003

Prenatal care in the United States has hit a dead end. It is a large part of routine healthcare, but has become unfocused in its goals. Most generally, it is intended to ensure that pregnancies end with a healthy mother and baby and that the foundation is laid for the newly expanded family to thrive. A variety of other goals fall under the umbrella of this general goal, such as prevention or management of birth defects, prevention of preterm delivery and low birth weight, prevention of pregnancy loss and intrauterine fetal death, reduction of traumatic birth injuries, and reduction of maternal, fetal, and neonatal infections. Modern prenatal care has focused on many of these goals, with some great successes and some notable failures, especially in light of rising rates of preterm birth.

Still, these are only some of the goals that fall under the more general objective of prenatal care. Others include family planning, reducing the incidence of unintended birth, promoting breastfeeding, promoting good nutrition and healthy behaviors for women and their families, preparing for labor and delivery and for bringing a new baby into the home, screening for and treating postpartum depression, and screening for domestic violence. With greater pressures on providers to see more patients, many of these goals are becoming more difficult to achieve -- and yet they can be of major importance for the development of a healthy family. The Institute of Medicine in its 1989 report Caring for Our Future: The Content of Prenatal Care, highlighted many of these goals (see Table ).

Given the constraints of modern healthcare (falling reimbursements, rising medical malpractice costs, increasing amounts of paperwork for providers, and more impersonal care), innovative approaches are needed to reinvigorate the specialty and better achieve the goals of prenatal care.

One such model is promoted by the Centering Pregnancy and Parenting Association This organization is promoting a model of group prenatal care that incorporates all the elements of traditional prenatal care and offers much more, without reducing provider productivity.

Traditional prenatal care starts with a first prenatal visit that lasts approximately 30 minutes and includes a complete history and physical examination. Subsequent visits are typically scheduled for 15 minutes (and with increasing pressures on providers to see more patients are frequently much shorter) and include little more than a blood pressure check, a measurement of fundal height, and listening for fetal heart tones. Along the way, the provider orders various screening tests. This model makes it difficult to achieve many of the important other goals of prenatal care that are included in the Institute of Medicine report -- and has even led some authors to question the usefulness of prenatal care in general.[1]

In the model advocated by the Centering Pregnancy and Parenting Association, patients have their routine first prenatal visit as in the traditional care model, but after that, all revisits are held in a group setting. Each group consists of approximately 10 women of similar gestational ages, and each session lasts for 90-120 minutes. All the elements of traditional care are included. Seeing women as a group allows the provider to maintain productivity in terms of number of patients seen while achieving an economy of time that gives the provider the opportunity to do more with the patients. All the blood pressures, maternal weights, fundal heights, etc, can be done in the first 30 minutes of the session (especially if the women help by doing some of it themselves -- which can be an empowering experience), and that leaves the provider a large block of time to sit and talk with the group.

In the 90 minutes left in each session, the provider leads a discussion on issues important to pregnant women. Topics covered in the suggested curriculum put together by the Centering Pregnancy and Parenting Association are tailored to the particular gestations of the women in the group. They include nutrition, common pregnancy complaints, preparation for labor, relaxation measures, smoking cessation, sexuality, contraception and family planning, breastfeeding, domestic violence, postpartum adjustment, and newborn care. Partners are invited to participate as well. The women in the group often develop a support network for themselves.

The sessions do not simply consist of providers lecturing to the patients; rather, they are facilitated discussions -- the women are active participants who learn from each other and are able to raise concerns and issues that they might otherwise not have had the opportunity to bring up in a brief 10-minute encounter with a provider. The group dynamic can reinforce the message that the provider wants the patients to absorb, and having a provider lead the discussion adds authority to the message that would otherwise be lost if the patient were to get it from a handout or other source. Thus, a discussion about nutrition, smoking cessation, or breastfeeding, as examples, can become more culturally appropriate for the group and be more likely to change patient behavior than if the patient were simply to read about good nutrition in a pamphlet, for example. These are all key components of prenatal care that are frequently not well dealt with in traditional prenatal care.

Women who have participated in groups in our office have raved about it. Multiparas have commented that they never knew there was so much they could learn during prenatal care. Nulliparas have reported that they feel well prepared for labor and delivery. Our observation is that women are much more satisfied with their prenatal care when they have participated in group care. And because we get to know our patients better, we have been in a better position to support our patients through the significant stresses at home such as situations of domestic violence and postpartum depression. Our impression is that women who have participated in group care are more successful at breastfeeding and that we hope will translate into healthier mothers and babies.

By lowering levels of stress during pregnancy through support and education, group prenatal care may even have an impact on rates of low birth weight. With improved patient satisfaction and closer bonds with providers (in the traditional model of care, patients will spend approximately 2 hours with their providers in total over the course of their pregnancy as compared to 20 hours in the group model), patients may be even less likely to initiate frivolous lawsuits against their doctors. This model of care may not be for all patients, but given that it allows providers to accomplish more with their patients without sacrificing their productivity or any of the elements of traditional prenatal care, I believe the Centering Pregnancy model is clearly a superior model of prenatal care.

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