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An innovative model for prenatal care: CenteringPregnancy

Access to obstetrical care (the full continuum of obstetrical care from prenatal care through post-partum care) has been dramatically reduced for all women across diverse geographical settings ranging from large urban areas to rural areas. Reasons contributing to reduced access include workforce shortages, inadequate reimbursement from insurers to cover cost of care, rising costs of professional liability insurance, and increasing cultural diversity including undocumented pregnant women accessing health care at the time of delivery.

Quotation from "CenteringPregnancy®--A Group Model of Prenatal Care Holds Promise for Improving Access to and the Quality of Prenatal Care" by Vonderheid, Klima, and Norr (2008) on the CRN website.


You might think this describes Japan's recent access issues. In fact, this describes maternity health care in the U.S. Unfortunately, problems in availability and accessibility of maternity health care affect the lives of women and their families around the globe. Sharing innovative ideas as well as lessons learned across countries can help us make informed decisions when determining changes aimed at improving our future health care system.

In Japan, many hospitals and clinics are closing, and an increasing number of maternity health care providers, particularly obstetricians, are leaving their jobs. A new term "osan-nanmin (childbirth refugees)" has emerged in Japanese society in recent years and refers to women who cannot access necessary maternity health care. There is an urgent need to restructure the distribution of health care resources to ensure adequate access to high quality care. If some drastic remedial actions or reforms are not taken urgently, it is so clear that Japan will not continue having world's lowest level maternity and infant mortality rates and providing the superior health care Japanese had taken granted until recently. Though effective measures have not been found yet, some new strategies began to be implemented. For example, some hospitals opened nurse-midwifery clinics inside the hospitals in which nurse-midwives take more initiative in providing maternity health care for women.

In the U.S., to address national shortages of health care providers and to meet the increasingly complex health needs of many populations, nursing education has evolved over the last century (Hawkins, 2000; Lancaster, Lancaster, & Onega, 1994). While basic nursing education remains important, there has been increasing attention to nursing programs that prepare advanced practice nurses such as nurse practitioners and certified nurse-midwives. Advanced practice nurses provide independent nursing care in their specialty areas and often serve populations that would otherwise have no or limited access to care. Not only are patient outcomes of advanced practice nursing care equal to or better than traditional medical care, advanced practice nursing care is more cost-effective. Recently, more nursing programs have begun offering a doctorate in nursing practice to prepare additional advanced practice nurses.

Besides the effort to prepare the nursing workforce to best address the evolving health needs of the population, health care delivery models are also being restructured. For example, gaining in popularity and implemented in about 300 sites in the U.S. and abroad with ethnically, socioeconomically diverse populations since 1995, CenteringPregnancy® (CP) is a multifaceted model of group prenatal care (Rising, 1998). CP fundamentally alters the format of prenatal care for women. CP draws on the holistic nurse-midwifery philosophy (Rising, Kennedy, & Klima, 2004; Rising, 1998).

CP draws on the benefits of traditional individual visit prenatal care (e.g., assessment, education, support), and participatory childbirth education class (e.g., active patient participation, peer group interaction/community building, interactive health education, efficient use of provider and patient time) as well as the holistic nurse-midwifery philosophy (Rising, Kennedy, & Klima, 2004; Rising, 1998). In CP, after an individual first visit (a pregnancy risk assessment) that is the same as that for women in traditional individualized visit, a group of 8-12 women at similar gestational ages attend 10 two-hour visits together. Group visits are initiated between 12 and 16 weeks gestation through 40-42 weeks gestation. The two-hour session consists of self-assessment by the women, brief individual assessment with a provider (e.g., nurse-midwife,obstetrician) and group health education focused on interactive games and other activities including time for in-depth discussions as needed.


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Two trained facilitators (a prenatal provider, typically a nurse-midwife or obstetrician, and a co-facilitator) take leadership throughout the 10 sessions. The content of CP sessions is consistent with professional standards for prenatal care and is enhanced based on the CP model. However, the model allows for flexibility. Each session has an overall plan with "core" health promotion content relevant to the stage of pregnancy of each visit, but any concerns women express are also discussed. The degree of emphasis varies and additional content is discussed depending on the concerns of women in the group.

Studies showed that CP improves pregnancy and health related outcomes for women and their infants compared to the traditional model of individual care. Compared to traditional individual prenatal care, women in CP have lower prematurity and low birth weight rates, become more aware of their health, gain knowledge and skills for health promotion, build closer and longer-term relationships with peers and professionals (Baldwin, 2006; Grady & Bloom, 2004; Ickovics, et al., 2003 Ickovics et al., 2007; Klima, Norr and Vonderheid, in press). The benefits of CP are likely greater for those in greatest need, such as socially disadvantaged women (i.e., low-income African American women in the U.S) (Ickovics et al., 2007).

Providers also indicated that they enjoyed providing group care (Klima, Norr and Vonderheid, in press). They liked "discussing" health promotion content with a group of women and learned information about their patients that might not otherwise have been expressed during a traditional prenatal visit. Additionally, providers found group visits more efficient and professionally satisfying than repeating similar information to each woman individually. Providers who are more satisfied with their work are likely more willing to remain in the workforce compared to a provider that is not satisfied. In addition a study of the productivity and cost of CP found that it was more productive (could serve twice as many women) and reduce cost in the setting studied (Cox, 2006).

In Japan, due to the burden of client payment and limited accessibility, increasing number of women skip their prenatal care. CP holds promise as an exciting strategy to increase access to prenatal care, help pregnant women build peer support system, establish stronger relationship between women and professionals, and promote women's active participation in their own health. CP represents a major restructuring of prenatal care that could improve the efficiency of service delivery, and improve satisfaction with care by providers and patients.

For more information about CP, please read the research paper and visit the CP website.


Reference

Baldwin, K.A. (2006). Comparison of selected outcomes of Centering Pregnancy versus traditional prenatal care. Journal of Midwifery & Womens Health, 51(4):266-72.

Cox, J.R., Obichere, T., Knoll, F., & Baruwa, E.M. (2006). A study to compare the productivity and cost of the CenteringPregnancy model of prenatal care with a traditional prenatal care model. Final report to March of Dimes.

Grady, M.A., & Bloom, K.C. (2004). Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program. Journal of Midwifery & Women's Health, 49(5):412-20.

Hawkins, J.W. (2000). The evolution of advanced practice nursing in the United States: caring for women and newborns. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29(1), 83-89.

Ickovics, J.R., Kershaw, T.S., Westdahl, C., Magriples, U., Massey, Z., Reynolds, H., & Rising, S.S. (2007). Group prenatal care and perinatal outcomes - A randomized controlled trial. Obstetrics and Gynecology, 110(2):330-9.

Ickovics, J.R., Kershaw, T.S., Westdahl, C., Rising, S.S., Klima, C., Reynolds, H., & Magriples, U. (2003). Group prenatal care and preterm birth weight: Results from a matched cohort study at public clinics. Obstetrics and Gynecology, 102(5 Pt 1):1051-7.

Klima, C., Norr, K.F., Vonderheid, S.C., & Handler, A.S. (in press). Introduction of CenteringPregnancy® in a Public Health Clinic Journal of Midwifery and Women's Health.

Lancaster, J., Lancaster, W., & Onega, L.L. (1994). Reform of primary health care: effective use of advanced practice nurses. Journal of ambulatory care marketing, 5(2), 101-114.

Rising, S.S. (1998). Centering pregnancy. An interdisciplinary model of empowerment. Journal of Nurse-Midwifery, 43(1):46-54.
Rising, S., Kennedy, H., & Klima, C. (2004). Redesigning prenatal care through Centering Pregnancy. Journal of Midwifery and Womens Health, 49:398-404.
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