Group prenatal care

INTRODUCTION — Prenatal care has traditionally consisted of one-on-one visits with a clinical provider(s) that occurred at specific time intervals throughout the pregnancy. However, other models may offer patients and providers acceptable care alternatives. Group prenatal care, in which a small cohort of pregnant patients with similar due dates participate in a structured prenatal care program facilitated by a clinician, is one such alternative model of prenatal care delivery. It was developed on the premise that some types of health care are more effectively and efficiently provided in this way. The most publicized model is CenteringPregnancy, which replaces traditional prenatal care with all group visits and incorporates education, social support, and self-care [1]. Other less-studied models consist of blended models of group and traditional care, group educational and social support as an adjunct to traditional care, and group prenatal care augmented by social media [2-4].

This topic will focus on the structure, outcomes, and patient selection for group prenatal care. Specific components of prenatal care are discussed separately.

●(See "Prenatal care: Initial assessment".)

●(See "Prenatal care: Second and third trimesters".)

●(See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs".)

DESCRIPTION

Key elements — As defined by the CenteringPregnancy program, group prenatal care contains three components: health care, interactive learning, and community building, all of which occur within a single space. The model is defined by 13 essential elements that provide its structure [1]:

●Health assessment occurs within the group space

●Patient involvement in self-care activities

●Facilitative leadership style is used

●Each session has an overall plan

●Attention is given to the core content, but emphasis can vary

●Stability of group leadership

●Group conduct honors the contribution of each member

●Group is conducted in a circle

●Group composition is stable, but not rigid

●Group size is optimal to promote the process

●Involvement of support people is optional

●Opportunity for socializing within the group is provided

●There is ongoing evaluation of outcomes

Two important factors in the success of this approach for reducing preterm birth and intensive utilization of care are maintaining both process fidelity (the strategies and skill, particularly facilitative leadership, for delivering the intervention) and content fidelity (provision of all 13 elements of the intervention) [5].

Candidates — Group prenatal care was initially designed to meet the needs of nulliparous and multiparous patients with low-risk pregnancies who successfully completed the first trimester. As experience with the initial model accrued, it was successfully offered to wider patient populations, including patients with human immunodeficiency virus, gestational diabetes, substance use, and past preterm deliveries [6,7]. Groups have also been conducted for teens [8,9], incarcerated individuals [6], and individuals in resource-limited settings [10,11]. The model has demonstrated success both inside and outside of the United States [10,12-14] and in non-English speakers [10,15].

The optimal characteristics of candidates for group prenatal care have not been clearly defined [16]. The model appears to be ideal for pregnant patients who are seeking more active participation, enhanced information, and more social connection during pregnancy [9]. It may be particularly beneficial for patients in high-stress or low-support environments. However, to benefit from group care, the individual needs to have the developmental and communication skills to participate in discussion-based care. For some individuals (eg, patients with behavioral or psychiatric disorders), the loose group structure can be difficult for productive participation.

The American College of Obstetricians and Gynecologists considers group prenatal care a reasonable alternative to traditional prenatal care, but patients should be allowed to choose between these approaches [17]. The most commonly cited reasons for not electing group care are scheduling conflicts [18], childcare issues, lack of transportation, and a strong personal relationship with a specific nonparticipating provider.

Procedure

Routine prenatal visits — While specific group prenatal care models exist, no data are available regarding the optimal set-up for providing group care. The group prenatal care model traditionally brings together 8 to 12 patients with low-risk pregnancies at similar gestational ages for prenatal care and facilitated discussion and learning sessions. The facilitators and clinicians are generally the same for all of the sessions. After each patient has had an initial, individual prenatal visit, the cohort moves through prenatal care and milestones together as they meet over 8 to 10 visits, each visit lasting approximately 90 to 120 minutes [19].

The first part of each session typically includes the standard maternal and fetal assessments. The group prenatal care model encourages patients to be involved in their own care; in some programs, the patients measure and record their blood pressure and weight and calculate their gestational age. Data collection can be done with the assistance or supervision of a nurse or medical assistant. Routine physical assessments, such as fundal height and fetal heart rate, are often performed in a semiprivate area of the group space by one of the clinicians. This semiprivate portion of the visit also allows the provider and patient to discuss any concerns that should be addressed outside of the group context.

Before or after the standard maternal and fetal assessments, multiple patients can meet with nutritionists, counselors, and other such providers, as appropriate.

In the second portion of each session, group prenatal care clinicians and facilitators address routine prenatal care issues appropriate for the gestational age of the participants in a group format and provide facilitative leadership during a question and discussion period. The facilitator emphasizes the critical role that inclusive and engaged discussion plays in improving clinical outcomes [5]. Partners or support members can be included in the group, if desired by the participants. (See "Prenatal care: Initial assessment" and "Prenatal care: Second and third trimesters" and "Prenatal care: Patient education, health promotion, and safety of commonly used drugs".)

Additional questions or needs of any patient, such as laboratory evaluations, can be addressed once the group has finished its discussion. At the end of each session the check-out process is simplified because all of the group meetings can be scheduled in advance, typically at the first session.

Patients who develop complications — If a patient develops a pregnancy complication, she goes through the same triage process as patients in traditional care models. Patients are referred to specialists, such as a Maternal-Fetal Medicine provider, as needed. When possible, the patient is given the option of continuing routine care with her group and adding specialist visits as needed.

Postpartum and pediatric care — Group sessions can extend into the postpartum period and beyond, where they also incorporate well-child care and parenting [20]. Pediatric providers are included in the team [21]. Ideally, the patients continue their postnatal care with their original prenatal cohort and expand on the interactive learning and community building that occurred during pregnancy [22]. Key focus areas are follow-up of prenatal medical issues, setting and achievement of weight goals, depression screening and treatment, contraception, breastfeeding support, safe sleep, and screening for violence [22].

ADVANTAGES OF THE GROUP MODEL — Group prenatal care offers several advantages compared with traditional care models [23,24]. These advantages contribute to the increased satisfaction reported by patients receiving group care. (See 'Outcomes compared with traditional prenatal care' below.)

●For patients:

•All participants get the benefit of hearing answers to questions they did not think to ask.

•Group support can help individuals achieve goals that would be unattainable or more difficult to obtain by the individual alone (eg, smoking cessation).

•Participants meet each other, create a community, and share learning and skill development.

•Communication can be improved by hosting the sessions in the same language that is natively spoken by the participants.

•Being in a circle of other participants provides support for the sharing of issues, such as domestic violence, that are difficult to discuss in a relatively short one-to-one visit.

●For care providers:

•Answering questions in a group format is more efficient than repeatedly discussing the same information individually.

•Clinicians have an opportunity to hear patients' suggestions for strategies for dealing with common problems in culturally appropriate ways.

●For the practice:

•The group model creates efficiencies by concentrating resources within the group space: Fewer examination rooms are needed for prenatal care, and personnel (eg, translators, nutritionists, genetic counselors, nurses) can serve multiple patients at one time.

•The model can be used to provide prenatal care in resource-limited settings [10,25].

•The model allows flexibility in design that adjusts to the specific needs of different populations.

While the group model can decrease patient wait times and increase efficiency across the practice, cost savings depend on the specific setting [26,27]. One study that evaluated a financial model of group prenatal care for an urban underserved practice reported cost neutrality and potential cost savings; the outcome varied with the number of clinicians staffing a session [25]. Because billing practices for group care vary among states and insurers, this model may not be universally applicable.

DISADVANTAGES OF THE GROUP MODEL — Potential disadvantages include a lack of flexibility in scheduling visits. Group prenatal care visits are generally prescheduled at consistent times. If a visit is missed, the patient can schedule an appointment with an individual provider, if necessary; however, there is no way to review all the material covered in the missed group discussion. Also, because of the length of group visits (90 to 120 minutes), it is impractical and potentially disruptive for patients to bring along their young children, which is a disadvantage for patients with childcare issues.

Other potential disadvantages are some loss of privacy, the loss of a strong personal relationship with a particular provider, the need to feel comfortable listening and speaking in a group setting, and loss of cost-effectiveness if individual visits also need to be scheduled to address more acute issues.

OUTCOMES COMPARED WITH TRADITIONAL PRENATAL CARE — Compared with traditional prenatal care, group prenatal care seems to provide a richer, more satisfying experience for the participants [12,13,15,19,26,28,29], while evidence of improved obstetric outcomes is more modest [19,30-34].

In a 2015 systematic review of four trials including a total of 1800 patients, those receiving group versus traditional prenatal care had similar rates of preterm birth (relative risk [RR] 0.75, 95% CI 0.57-1.00), low birth weight infants (RR 0.92, 95% CI 0.68-1.23), small for gestational age infants (RR 0.92, 95% CI 0.68-1.24), and perinatal mortality (RR 0.63, 95% CI 0.3-1.25) [19]. As only three trials met inclusion criteria for the meta-analysis of preterm birth and low birth weight, it is possible that improved obstetric outcomes may be seen for some outcomes, such as preterm birth, or in specific subgroups of patients who receive group prenatal care, with larger randomized trials. In addition, because group prenatal care does not have a single, unified definition, it is possible that outcomes vary by the type of group care model being studied.

Group prenatal care has been associated with stress reduction [35,36] and increases in achieving appropriate gestational weight gain and loss [8,37,38], attendance at prenatal and postpartum care appointments [26,39], breastfeeding initiation [8,26,28,40], postpartum contraception initiation [8,39,41], and postpartum diabetes screening [42].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General prenatal care".)

SUMMARY AND RECOMMENDATIONS

●Group prenatal care, in which a small cohort of individuals with similar due dates participate in a structured prenatal care program facilitated by a clinician, is an alternative model of prenatal care delivery. It is built on the premise that some types of health care are more effectively and efficiently provided in groups that are facilitated rather than taught. (See 'Introduction' above.)

●The group care model appears ideal for patients who are seeking more active participation, enhanced information, and more social connection during pregnancy. They need to have the developmental and communication skills to participate in discussion-based care; thus, it is not the best care model for all patients. The American College of Obstetricians and Gynecologists considers group prenatal care a reasonable alternative to traditional prenatal care, but patients should be allowed to choose between these approaches. (See 'Candidates' above.)

●The group prenatal care model traditionally brings together 8 to 12 low-risk pregnant patients with pregnancies at similar gestational ages for prenatal care. After each patient has had an initial individual prenatal visit, the cohort moves through prenatal care together as they meet over 8 to 10 visits, each visit lasting approximately 90 to 120 minutes and consisting of both standard maternal and fetal assessments and facilitated discussion and learning sessions. (See 'Procedure' above.)

●If a patient develops a pregnancy complication, she goes through the same triage process as patients in traditional care models. Patients are referred to specialists, such as a Maternal-Fetal Medicine provider, as needed. When possible, the patient is given the option of continuing routine care with her group and adding specialist visits as needed. (See 'Procedure' above.)

●Advantages of group prenatal care include hearing answers to questions they did not think to ask, developing relationships among participants who have a common experience, sharing learning and skill development, developing the support of a community, and possibly motivating other participants to change behavior. (See 'Advantages of the group model' above.)

●The prenatal group and their infants can continue the group after delivery and add pediatric providers. (See 'Procedure' above.)

●Compared with traditional prenatal care, group prenatal care seems to provide a richer, more satisfying experience for the participants, while evidence of improved obstetric outcomes is more modest. In a systematic review of four trials including a total of 1800 patients, those receiving group versus traditional prenatal care had similar rates of preterm birth, low birth weight infants, small for gestational age infants, and perinatal mortality as those receiving traditional care. (See 'Outcomes compared with traditional prenatal care' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Sharon Schindler Rising, MSN, CNM, FACNM, who contributed to an earlier version of this topic review.