Group prenatal care: effectiveness and challenges to implementation

Zafiro Andrade-Romo Ileana B. Heredia-Pi Evelyn Fuentes-Rivera Jacqueline Alcalde-Rabanal Lourdes Bravo Bolaños Cacho Laurie Jurkiewicz Blair G. Darney About the authors

ABSTRACT

Group prenatal care is an alternative model of care during pregnancy, replacing standard individual prenatal care. The model has shown maternal benefits and has been implemented in different contexts. We conducted a narrative review of the literature in relation to its effectiveness, using databases such as PubMed, EBSCO, Science Direct, Wiley Online and Springer for the period 2002 to 2018. In addition, we discussed the challenges and solutions of its implementation based on our experience in Mexico. Group prenatal care may improve prenatal knowledge and use of family planning services in the postpartum period. The model has been implemented in more than 22 countries and there are challenges to its implementation related to both supply and demand. Supply-side challenges include staff, material resources and organizational issues; demand-side challenges include recruitment and retention of participants, adaptation of material, and perceived privacy. We highlight specific solutions that can be applied in diverse health systems.

Atención Prenatal; Efectividad; Modelos Organizacionales; Servicios de Salud Materno-Infantil

RESUMEN

La atención prenatal en grupo es un modelo alternativo de atención durante el embarazo, que sustituye la atención prenatal individual estándar. El modelo ha mostrado beneficios maternos y se ha implementado en diferentes contextos. Llevamos a cabo una revisión narrativa de la literatura en relación a su efectividad, utilizando bases de datos como PubMed, EBSCO, Science Direct, Wiley Online y la editorial Springer, para el periodo 2002 a 2018. Adicionalmente, discutimos los retos y soluciones de su implementación desde nuestra experiencia en México. La atención prenatal en grupo puede mejorar el conocimiento prenatal y el uso de servicios de planificación familiar en el postparto. El modelo se ha implementado en más de 22 países y existen retos de su implementación desde la oferta y la demanda. Los retos desde la oferta incluyen al personal, recursos materiales y cuestiones organizacionales; desde la demanda, el reclutamiento y retención de participantes, adaptación del material y privacidad percibida. Resaltamos soluciones concretas que pueden aplicar a diversos sistemas de salud.

Atención Prenatal; Efectividad; Modelos Organizacionales; Servicios de Salud Materno-Infantil

INTRODUCTION

Prenatal care is recognized as standard of care during pregnancy. It is usually provided by individual consultations with a trained health care provider, offering a set of cost-effective interventions that improve maternal and child outcomes and reduce complications during pregnancy, childbirth and the postpartum period11. Banta D. What is the efficacy/effectiveness of antenatal care and the financial and organizational implications? Copenhagen (DNK): WHO Regional Office for Europe; 2003. , 22. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Luxembourg: WHO; 2016. .

Despite these benefits, the individual care model has been criticized in the literature for long waiting times, gaps in the continuity of care, and low user satisfaction with health care personnel33. Williamson S, Thomson AM. Women’s satisfaction with antenatal care in a changing maternity service. Midwifery. 1996;12(4):198-204. https://doi.org/10.1016/S0266-6138(96)80007-6
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, 44. Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS Med. 2013;10(1):e1001373. https://doi.org/10.1371/journal.pmed.1001373
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.

In recent years, experiences of the implementation of group care models have been reported55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
in high income countries such as the United States55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, Canada77. Benediktsson I, McDonald SW, Vekved M, McNeil DA, Dolan SM, Tough SC. Comparing CenteringPregnancy® to standard prenatal care plus prenatal education. BMC Pregnancy Childbirth. 2013;13 Suppl 1:S5. https://doi.org/10.1186/1471-2393-13-S1-S5
https://doi.org/10.1186/1471-2393-13-S1-...
, Australia88. Craswell A, Kearney L, Reed R. ‘Expecting and Connecting’ Group Pregnancy Care: evaluation of a collaborative clinic. Women Birth. 2016;29(5):416-22. https://doi.org/10.1016/j.wombi.2016.03.002
https://doi.org/10.1016/j.wombi.2016.03....
, 99. Hoope-Bender PT, Kearns A, Caglia J, Tunçalp Ö, Langer A. Group Care: alternative models of care delivery to increase women’s access, engagement, and satisfaction. Boston (USA): Harvard School of Public Health; 2014 [cited 2018 Jul 19]. Available from: https://cdn2.sph.harvard.edu/wp-content/uploads/sites/32/2014/09/HSPH-Group5.pdf
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, Sweden99. Hoope-Bender PT, Kearns A, Caglia J, Tunçalp Ö, Langer A. Group Care: alternative models of care delivery to increase women’s access, engagement, and satisfaction. Boston (USA): Harvard School of Public Health; 2014 [cited 2018 Jul 19]. Available from: https://cdn2.sph.harvard.edu/wp-content/uploads/sites/32/2014/09/HSPH-Group5.pdf
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, Netherlands99. Hoope-Bender PT, Kearns A, Caglia J, Tunçalp Ö, Langer A. Group Care: alternative models of care delivery to increase women’s access, engagement, and satisfaction. Boston (USA): Harvard School of Public Health; 2014 [cited 2018 Jul 19]. Available from: https://cdn2.sph.harvard.edu/wp-content/uploads/sites/32/2014/09/HSPH-Group5.pdf
https://cdn2.sph.harvard.edu/wp-content/...
, 1010. Zwicht BS, Crone MR, Lith JM, Rijnders ME. Group based prenatal care in a low-and high risk population in the Netherlands: a study protocol for a stepped wedge cluster randomized controlled trial. BMC Pregnancy Childbirth. 2016;16(1):354. https://doi.org/10.1186/s12884-016-1152-0
https://doi.org/10.1186/s12884-016-1152-...
, some middle and low income countries such as Bangladesh, India, Iran, Nepal, several countries in Africa, Suriname, Brazil1111. Sharma J, O’Connor M, Rima Jolivet R. Group antenatal care models in low- and middle-income countries: a systematic evidence synthesis. Reprod Health. 2018;15(1):38. https://doi.org/10.1186/s12978-018-0476-9
https://doi.org/10.1186/s12978-018-0476-...
, Haiti1212. Abrams JA, Forte J, Bettler C, Maxwell M. Considerations for implementing group-level prenatal health interventions in low-resource communities: lessons learned from Haiti. J Midwifery Womens Health. 2018;63(1):121-6. https://doi.org/10.1111/jmwh.12684
https://doi.org/10.1111/jmwh.12684...
, and Mexico1313. Heredia-Pi IB, Fuentes-Rivera E, Andrade-Romo Z, Bravo Bolaños Cacho MdL, Alcalde-Rabanal J, Jurkiewicz L, et al. The Mexican experience adapting CenteringPregnancy: lessons learned in a publicly funded health care system serving vulnerable women. J Midwifery Womens Health. 2018;63(5):602-10. https://doi.org/10.1111/jmwh.12891
https://doi.org/10.1111/jmwh.12891...
.

Group prenatal care replaces individual care. All prenatal visits are conducted with the same group of eight to 12 pregnant women, who receive a clinical evaluation in the same space by one or more health care providers, who do not vary during the follow-up of six to 10 sessions, every two to four weeks55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1414. Andersson E, Christensson K, Hildingsson I. Parents’ experiences and perceptions of group-based antenatal care in four clinics in Sweden. Midwifery. 2012;28(4):502-8. https://doi.org/10.1016/j.midw.2011.07.006
https://doi.org/10.1016/j.midw.2011.07.0...
. The model has three main components: clinical assessment, education, and support. Facilitators seek to establish a less hierarchical relationship with women by involving them more actively during the session1515. Rising SS. Centering pregnancy: an interdisciplinary model of empowerment. J Nurse Midwifery. 1998;43(1):46-54. https://doi.org/10.1016/S0091-2182(97)00117-1
https://doi.org/10.1016/S0091-2182(97)00...
. The model has a component focused on improving perinatal and postpartum education by experience-based learning and activities that require the active participation of women. These activities are guided by a curriculum, with health topics of interest during pregnancy, childbirth and postpartum. There is a key element of socialization and an element of self-evaluation of some health parameters55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
.

The CenteringPregnancy model has been the most studied and internationally used group prenatal care model55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1111. Sharma J, O’Connor M, Rima Jolivet R. Group antenatal care models in low- and middle-income countries: a systematic evidence synthesis. Reprod Health. 2018;15(1):38. https://doi.org/10.1186/s12978-018-0476-9
https://doi.org/10.1186/s12978-018-0476-...
, 1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
, 1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
. A midwife created it in the United States in the early 1990s1515. Rising SS. Centering pregnancy: an interdisciplinary model of empowerment. J Nurse Midwifery. 1998;43(1):46-54. https://doi.org/10.1016/S0091-2182(97)00117-1
https://doi.org/10.1016/S0091-2182(97)00...
. It is a flexible model, but with essential elements that must be met during all sessions ( Table 1 )1818. Rising SS, Kennedy HP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health. 2004;49(5):398-404. https://doi.org/10.1016/j.jmwh.2004.04.018
https://doi.org/10.1016/j.jmwh.2004.04.0...
. Other group care models have been described55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 88. Craswell A, Kearney L, Reed R. ‘Expecting and Connecting’ Group Pregnancy Care: evaluation of a collaborative clinic. Women Birth. 2016;29(5):416-22. https://doi.org/10.1016/j.wombi.2016.03.002
https://doi.org/10.1016/j.wombi.2016.03....
; however, most of the literature focuses on the adaptation, implementation, and evaluation of the CenteringPregnancy model.

Table 1
Essential elements of the CenteringPregnancy model and key points for its implementation.

Currently, there is a worldwide interest in the model. The American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization (WHO) have highlighted its potential benefits, leading to improvements in quality of care and outcomes in maternal and perinatal health in diverse populations. Both institutions have recommended the implementation of the model, encouraging research to generate reliable evidence about its effects in the short, medium, and long term22. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Luxembourg: WHO; 2016. , 55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
.

There is scarce scientific literature in Spanish that documents the benefits of this new model and the challenges that arise during its implementation. This limitation represents a barrier to Spanish-speaking countries to access information and make decisions regarding its implementation. The objectives of this article are: 1) present a narrative synthesis in Spanish of the most recent and relevant evidence on the maternal and perinatal health outcomes of the group prenatal care model, 2) identify and summarize the challenges of implementing the model in different contexts, as well as the solutions recommended in the literature, and 3) share our experience of implementing and adapting the model to the Mexican context.

NARRATIVE REVIEW OF THE LITERATURE ABOUT THE EFFECTIVENESS OF GROUP PRENATAL CARE

From January 23, 2018, to July 27, 2018, we conducted a narrative or classical review2020. Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26(2):91-108. https://doi.org/10.1111/j.1471-1842.2009.00848.x
https://doi.org/10.1111/j.1471-1842.2009...
of the most recent literature. The search period included 2002 to 2018. We used the following search terms in Spanish: atención prenatal en grupo, control prenatal en grupo, embarazo and atención en grupo. And in English: group antenatal care, group prenatal care, centering pregnancy, pregnancy, pregnant women, prenatal education, prenatal care, antenatal care, antenatal control, prenatal control, antenatal visit, pregnancy care and group visit or group care. We used databases (PubMed, EBSCO, Science Direct, Wiley Online, the publisher Springer) and registry pages of systematic reviews such as The Cochrane Library and Prospero. Because of our first objective, we gave priority to systematic reviews, meta-analyses and randomized clinical trials that have comparatively evaluated individual prenatal care and group models in different maternal and perinatal health outcomes66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
, 1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
, 2121. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2015(2):CD007622. https://doi.org/10.1002/14651858.CD007622.pub3
https://doi.org/10.1002/14651858.CD00762...
( Table 2 ).

Table 2
Neonatal and maternal outcomes of group prenatal care compared to individual prenatal care.

Evidence showed better maternal outcomes in terms of the knowledge that pregnant women acquire during group prenatal care, nutrition, breastfeeding, changes during pregnancy, family planning and substance abuse66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
; as well as increased use of family planning services in the postpartum period66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
and reduced use of medication in women with gestational diabetes2626. Byerley BM, Haas DM. A systematic overview of the literature regarding group prenatal care for high-risk pregnant women. BMC Pregnancy Childbirth. 2017;17(1):329. https://doi.org/10.1186/s12884-017-1522-2
https://doi.org/10.1186/s12884-017-1522-...
, compared to pregnant women in individual care ( Tables 2 and 3 ).

Table 3
Reviews and clinical trials: outcomes of interest of women in group prenatal care.

For other maternal outcomes, such as the initiation of breastfeeding66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
, 1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
, 2121. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2015(2):CD007622. https://doi.org/10.1002/14651858.CD007622.pub3
https://doi.org/10.1002/14651858.CD00762...
, the rate of cesarean section1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
or attendance to prenatal visits2323. 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(2):359-65. https://doi.org/10.2105/AJPH.2015.302960
https://doi.org/10.2105/AJPH.2015.302960...
, 2525. 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. Military Med. 2011;176(10):1169-77. https://doi.org/10.7205/MILMED-D-10-00394
https://doi.org/10.7205/MILMED-D-10-0039...
(among others), the available evidence was not always conclusive ( Table 2 ). The results varied, depending on the characteristics of the population55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 2626. Byerley BM, Haas DM. A systematic overview of the literature regarding group prenatal care for high-risk pregnant women. BMC Pregnancy Childbirth. 2017;17(1):329. https://doi.org/10.1186/s12884-017-1522-2
https://doi.org/10.1186/s12884-017-1522-...
( Table 3 ).

The most studied perinatal results are preterm childbirth66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
, 1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
, 2121. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2015(2):CD007622. https://doi.org/10.1002/14651858.CD007622.pub3
https://doi.org/10.1002/14651858.CD00762...
, low birth weight66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
, 1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
, 2121. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2015(2):CD007622. https://doi.org/10.1002/14651858.CD007622.pub3
https://doi.org/10.1002/14651858.CD00762...
, 2222. Ford K, Weglicki L, Kershaw T, Schram C, Hoyer PJ, Jacobson ML. Effects of a prenatal care intervention for adolescent mothers on birth weight, repeat pregnancy, and educational outcomes at one year postpartum. J Perinat Educ. 2002;11(1):35-8. https://doi.org/10.1624/105812402X88588
https://doi.org/10.1624/105812402X88588...
, Intensive Care Unit admission66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
, 2121. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2015(2):CD007622. https://doi.org/10.1002/14651858.CD007622.pub3
https://doi.org/10.1002/14651858.CD00762...
, size for gestational age2121. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2015(2):CD007622. https://doi.org/10.1002/14651858.CD007622.pub3
https://doi.org/10.1002/14651858.CD00762...
, 2323. 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(2):359-65. https://doi.org/10.2105/AJPH.2015.302960
https://doi.org/10.2105/AJPH.2015.302960...
and neonatal mortality2121. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2015(2):CD007622. https://doi.org/10.1002/14651858.CD007622.pub3
https://doi.org/10.1002/14651858.CD00762...
. Results were inconclusive ( Table 2 ), but no studies have reported that the model has harmful outcomes either for the mother or the newborn1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
.

The group model achieved greater effectiveness for particular outcomes (knowledge, family planning, and use of services). Because the model is women-focused, these are perhaps the outcomes most likely to be achieved. Others require more structural changes in the health system and social determinants, beyond just a change in the model of care. Future evaluations should strengthen evidence about the effects on satisfaction, self-efficacy, empowerment, and improvements in the experience during pregnancy. According to the principles of client-centered care models, these are more immediate results to be achieved2727. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Family Med. 2011;9(2):100-3. https://doi.org/10.1370/afm.1239
https://doi.org/10.1370/afm.1239...
.

EVIDENCE ABOUT IMPLEMENTATION OF GROUP PRENATAL CARE MODELS IN DIFFERENT CONTEXTS: CHALLENGES AND POTENTIAL SOLUTIONS

Implementation of the group prenatal care model involves challenges that can be analyzed from the user or the provider’s perspective.

From the provider’s perspective, challenges are those related to the personnel who will implement the model66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, material resources and physical inputs55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
and organizational challenges, specific to national institutions or regulations for the provision of health services1313. Heredia-Pi IB, Fuentes-Rivera E, Andrade-Romo Z, Bravo Bolaños Cacho MdL, Alcalde-Rabanal J, Jurkiewicz L, et al. The Mexican experience adapting CenteringPregnancy: lessons learned in a publicly funded health care system serving vulnerable women. J Midwifery Womens Health. 2018;63(5):602-10. https://doi.org/10.1111/jmwh.12891
https://doi.org/10.1111/jmwh.12891...
( Table 4 ). These challenges have a potential impact on acceptability of the model by health care providers66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
. From the provider’s perspective, the greatest challenges involve infrastructural issues of the health care services. Although physical spaces requirements are crucial for the implementation of the model, feasible alternatives are available1212. Abrams JA, Forte J, Bettler C, Maxwell M. Considerations for implementing group-level prenatal health interventions in low-resource communities: lessons learned from Haiti. J Midwifery Womens Health. 2018;63(1):121-6. https://doi.org/10.1111/jmwh.12684
https://doi.org/10.1111/jmwh.12684...
.

Table 4
Challenges, recommendations and potential solutions for implementing the group prenatal care model in different contexts.

Group prenatal care has been implemented in diverse populations in the United States: African-American women55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
, 2222. Ford K, Weglicki L, Kershaw T, Schram C, Hoyer PJ, Jacobson ML. Effects of a prenatal care intervention for adolescent mothers on birth weight, repeat pregnancy, and educational outcomes at one year postpartum. J Perinat Educ. 2002;11(1):35-8. https://doi.org/10.1624/105812402X88588
https://doi.org/10.1624/105812402X88588...
, military55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
, 1717. Tilden EL, Hersh SR, Emeis CL, Weinstein SR, Caughey AB. Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv. 2014;69(1):46-55. https://doi.org/10.1097/OGX.0000000000000025
https://doi.org/10.1097/OGX.000000000000...
, and some populations that may be relevant to countries in Latin America such as: adolescents55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 2626. Byerley BM, Haas DM. A systematic overview of the literature regarding group prenatal care for high-risk pregnant women. BMC Pregnancy Childbirth. 2017;17(1):329. https://doi.org/10.1186/s12884-017-1522-2
https://doi.org/10.1186/s12884-017-1522-...
, Latina or Hispanic55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
, women with diabetes55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 2626. Byerley BM, Haas DM. A systematic overview of the literature regarding group prenatal care for high-risk pregnant women. BMC Pregnancy Childbirth. 2017;17(1):329. https://doi.org/10.1186/s12884-017-1522-2
https://doi.org/10.1186/s12884-017-1522-...
, and low-income women55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
, 66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, 1111. Sharma J, O’Connor M, Rima Jolivet R. Group antenatal care models in low- and middle-income countries: a systematic evidence synthesis. Reprod Health. 2018;15(1):38. https://doi.org/10.1186/s12978-018-0476-9
https://doi.org/10.1186/s12978-018-0476-...
, 1616. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group Prenatal Care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(3):551-61. https://doi.org/10.1097/AOG.0000000000001560
https://doi.org/10.1097/AOG.000000000000...
, 2626. Byerley BM, Haas DM. A systematic overview of the literature regarding group prenatal care for high-risk pregnant women. BMC Pregnancy Childbirth. 2017;17(1):329. https://doi.org/10.1186/s12884-017-1522-2
https://doi.org/10.1186/s12884-017-1522-...
. From the users’ perspective, challenges to implementation are less common, but include: women’s willingness to participate in a new model of care, attendance at medical consultations66. Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216(6):552-6. https://doi.org/10.1016/j.ajog.2017.02.006
https://doi.org/10.1016/j.ajog.2017.02.0...
, patients’ language and education level, and patients’ adjusting their schedules in order to participate in the group (considering that the group sessions last longer than an individual consultation)1212. Abrams JA, Forte J, Bettler C, Maxwell M. Considerations for implementing group-level prenatal health interventions in low-resource communities: lessons learned from Haiti. J Midwifery Womens Health. 2018;63(1):121-6. https://doi.org/10.1111/jmwh.12684
https://doi.org/10.1111/jmwh.12684...
. Other reported challenges include women’s privacy concerns due to the group nature of care55. .ACOG Committee Opinion No. 731 Summary: Group Prenatal Care. Obstet Gynecol. 2018;131(3):616-8. https://doi.org/10.1097/AOG.0000000000002526
https://doi.org/10.1097/AOG.000000000000...
. The user-centered approach of the group care model may explain why so few challenges have been identified from a users’ perspective. This type of health care has also been linked to a positive perception of rights by the users, influencing the acceptability of the model2727. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Family Med. 2011;9(2):100-3. https://doi.org/10.1370/afm.1239
https://doi.org/10.1370/afm.1239...
.

Some of the challenges noted in the literature may depend on the context or culture, for which very specific solutions have been proposed ( Table 4 ). However, discussion and dissemination of challenges and solutions among stakeholders, both clinical and academic, and with decision-makers, may be useful for future efforts to implement the model in Latin America.

THE MEXICAN EXPERIENCE DURING THE ADAPTATION AND IMPLEMENTATION OF A GROUP PRENATAL CARE MODEL

During 2016-2018, researchers at the Instituto Nacional de Salud Pública de México (INSP - National Institute of Public Health of Mexico), adapted and implemented the CenteringPregnancy model in the public sector of the Mexican health system. As in many countries, this sector faces particular challenges, especially in infrastructure, financing, and organization.

We summarize our experience of adapting and implementing the model in Table 5 . A more detailed description of the adaptation process can be found in a previous article1313. Heredia-Pi IB, Fuentes-Rivera E, Andrade-Romo Z, Bravo Bolaños Cacho MdL, Alcalde-Rabanal J, Jurkiewicz L, et al. The Mexican experience adapting CenteringPregnancy: lessons learned in a publicly funded health care system serving vulnerable women. J Midwifery Womens Health. 2018;63(5):602-10. https://doi.org/10.1111/jmwh.12891
https://doi.org/10.1111/jmwh.12891...
. Two challenges and their respective solutions or recommendations are highlighted ( Tables 4 and 5 )2828. Secretaría de Salud (MEX). Manual de organización tipo jurisdicción sanitaria. 3 ed. Toluca (MEX): Instituto de Salud del Estado de México; 2010. .

Table 5
Experience of adaptation and implementation of a Group Prenatal Care model in Mexico, 2016-2018.

The first challenge was selecting health facilities (clinics) to participate in implementing the model, which requires specific criteria. These criteria include: 1) having an adequate physical space for group care, allowing a meeting of approximately 15 people; 2) having enough health care personnel at each location so there is more than one team of facilitators trained, both for group follow-up and for recruiting participants; and 3) having clinic management and administrative support, which is key due to the time that the health care personnel has to allocate to logistics and organization activities before, during and after the sessions.

The second main challenge we want to highlight is the change of mentality about how to deliver care during pregnancy, due to the prevailing hierarchical medical culture. The presence of a research team member during the sessions enabled reinforcement of this new facilitating style and immediate feedback once the session was over. We had a research team member present as part of our feasibility study; however, monitoring implementation may not always be possible. Strategies such as intermediate reinforcement trainings during the time between the “adaptation” and “adoption” stages could be established. The first stage allows adjusting the model to the local context; the second (more difficult) refers to health care personnel and users adopting it as a learned and internalized practice.

Preliminary evidence showed implementation feasibility in Mexico, as long as a process of staggered steps is followed which can promote the buy-in of the relevant health sector authorities, training, and on-going support to participating health care personnel.

FINAL CONSIDERATIONS

The quality and continuity of prenatal care remains a challenge in Spanish-speaking and Latin American countries2929. Heredia-Pi I, Serván-Mori E, Darney B, Reyes-Morales H, Lozano R. Measuring the adequacy of antenatal health care: a national cross-sectional study in Mexico. Bull World Health Organ. 2016;94(6):452-61. https://doi.org/10.2471/BLT.15.168302
https://doi.org/10.2471/BLT.15.168302...
, especially in vulnerable populations3030. Saavedra-Avendaño B, Darney BG, Reyes-Morales H, Serván-Mori E. ¿El aseguramiento público en salud mejora la atención en los servicios? El caso de la atención prenatal en adolescentes en México. Salud Publica Mex. 2016;58:561-8. https://doi.org/10.21149/spm.v58i5.8246
https://doi.org/10.21149/spm.v58i5.8246...
. Group prenatal care represents an opportunity to improve the quality of care and health outcomes for these populations: it is a user-centered model, it improves maternal health outcomes, achieves greater adherence to prenatal care, increases knowledge among pregnant women, and increases the use of postpartum family planning services.

The main approach of the model is that care is provided in a group setting with the women at the center, which motivates participation and interest of the patient. In addition, it favors a positive experience during pregnancy, with respectful care, based on a vision of rights, high level of participation and involvement of the pregnant woman during her health care encounter. Group prenatal care is an innovative and valuable approach as an alternative to the existing models.

Finally, it is necessary to develop studies with rigorous designs, and on a larger scale, both in the national context and in countries similar to ours. These studies can contribute to generate evidence to support recommendations on the implementation of this type of models and eventually evaluate not only feasibility but sustainability.

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  • 29
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    » https://doi.org/10.2471/BLT.15.168302
  • 30
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    » https://doi.org/10.21149/spm.v58i5.8246

  • Funding: Fundación John D. y Catherine T. MacArthur (Grant number: 15-108371-000-INP, año 2015).

Publication Dates

  • Publication in this collection
    30 Sept 2019
  • Date of issue
    2019

History

  • Received
    31 Oct 2018
  • Accepted
    7 Apr 2019
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E-mail: revsp@usp.br