Group Prenatal Care: A Pilot Project Aimed to Reduce Health Disparities in an Urban Medical Residency Program Utilizing an

Interdisciplinary Care Model

Stephanie M. Trudeau, MS, LAMFT, PhD StudentJerica M. Berge, PhD, MPH, LMFT, CFLE

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session C4b: #5808347October 17, 2015

Faculty Disclosure

The presenters of this session

• have NOT had any relevant financial relationships during the past 12 months. OR

• currently have or have had the following relevant financial relationships (in any amount) during the past 12 months.

Learning Objectives

• Describe core components of evidence-based group prenatal care.

• Identify the clinical and research rationale for implementation of group prenatal care in underserved clinical populations.

• Discuss the theoretical and practice rationale for including a family systems approach to prenatal group care.

Preterm Birth RatesNationally

• Preterm Birth: Percentage of all live births less than 37 completed weeks gestation.

• National Data – 450,000 babies born premature (1 in 9)

• Giving the United States as a whole a grade of a “C” (11.5%) as compared to other high-income countries.

• Preterm birth rate greater than or equal to 11.3%, but less than 12.9%

Preterm Birth RatesMinnesota

• Minnesota Data - “B” (Preterm birth rate greater than 9.6%, but less than 11.3%)

• Hispanic 10.3% White 9.6% Black 13.0% Native American 15.8% Asian 10.5%

• Goal in the state of Minnesota is 9.6 - current rate is 9.8

Preterm Birth RatesHennepin County

• In 2013, 1,265 births, or 8.2 percent, of all single births in Hennepin County were babies born before 37 weeks of pregnancy, or preterm.

• The percentage of babies born preterm is higher for younger mothers (under age 20) compared to older mothers.

Targeting a Specific Demographic

• The 2013 preterm birth rate for black infants was 60% higher than the rate for non-Hispanic white infants and 44% higher than the rate for Hispanic infants.

• Even after accounting for known risk factors (e.g. obesity, smoking, hypertension), preterm birth rate disparities between white and black infants persist.

• The rate for black women (11.5 per 1000) was 2.2 times greater than that for white women (5.2), this racial gap has widened as infant mortality rates have declined from 1960 to 2011

Broadway Family Medicine

• Located in North Minneapolis

• Family Medicine Residency Clinic - University of Minnesota North Memorial

• 70% African-American patients

• 60% of patients live below poverty line

Intervention – Group Prenatal Care Centering Pregnancy – Evidence Based

• Health assessment occurs within the group space

• Participants are involved in self-care activities

• A facilitative leadership style is used

• The group is conducted in a circle

• Each session has an overall plan

• Attention is given to the core content, although emphasis may vary

• There is stability of group leadership

• Group conduct honors the contribution of each member

• The composition of the group is stable, but not rigid

• Group size is optimal to promote the process

• Involvement of support people is optional

• Opportunity for socialization within the group is provided

• There is ongoing evaluation of outcomes

Evidence Based

• Group Prenatal care such as Centering as shown to: •Reduce preterm birth rates• Increasing gestational age• Increase patient/provider satisfaction

Core Components

• Peer to peer healthcare 

• Participatory healthcare

• Empowerment through education

• Connection through peer support

• Connectedness has a dose response effect

Broadway’s Adaptations

• Residency clinic

• Interdisciplinary Healthcare Team• 1-2 residents• Nurse/lactation consultant• Behavioral health provider (LMFT)

• Structured behavioral health protocol to compliment the medical education curriculum

• Inclusion of partners (future)

Initial Outcomes Demographics (mean)

• Age – 25• Ethnicity – Black• Education – Some high school• Employment (self) – unemployed• Household income - < $20,000• Relationship status – single • Education (partner) – some high school • Employment (partner) – Part time or

unemployed

Additional Measure

• PHQ-9 Depression Screen• 5 - mild; 10 – mod; 15 – mod/severe; 20 – severe

• GAD-7 Anxiety Screen• 5 – mild; 10 – moderate; 15 – severe

• SF-8 Quality of Life

• Short term pain, physical function, mental function

• RDAS Relationship Satisfaction• Lower score = more distressed; 48 = distress

cutoff

Initial Outcomes

Pre Group• PHQ -9: Depression

• 12: moderate

• GAD -7: Anxiety• 13: mod/severe

• SF-8: QOL• Moderate pain

• Moderate physical fxn

• Moderate mental fxn

• RDAS: Relationship satisfaction• 47: distressed

Post Group• PHQ -9: Depression

• 12: moderate

• GAD -7: Anxiety• 11: moderate

• SF-8: QOL• High pain

• Low physical fxn

• Low mental fxn

• RDAS: Relationship satisfaction• 51: WLN

Results

• Participation:• A total of 9 monthly sessions were conducted• Average attendance of 6 participants per session

• Patient experience themes: • Benefit of peer to peer counseling, increased perceived

support, increased perceived ability to parent and increased understanding of pregnancy and labor.

• Improved self-efficacy:• Self-care in pregnancy, utilization of hospital care,

preparation for labor, stress management, family planning.

Structure of Group Prenatal

• First Hour• Patient arrival and check in, snacks served, vital

signs with RN, patient documents in her notebook, individual visits with physician, fundal height measurement, fetal heart tones, private concerns addressed, lab work collected as indicated

• Second Hour• Group discussion• Resident Lead Topics: nutrition, stages of pregnancy,

common complaints, breast feeding, labor, family planning

• Mental Health Lead Topics: stress, mindfulness, family roles, intimate relationships, post partum depression, parenting skills

Importance of Group Facilitation Skills!!

General Process:

• 1. Acknowledge Issue• “That’s a great question”

• 2. Reflective Listening (Motivational Interviewing Style)• “You are wondering…”, “It sounds like you are

concerned about…”

• 3. Respond• “What do other’s think about this?”

• 4. Review• “Did you get your question answered?”

Demonstration of Group Activity

Breastfeeding Continuum

• Based on how you fed other children in the past, or what you think you will do now

• Why did you put yourself here?

Post-it Note B & B’s

• Barriers to Breastfeeding

• Benefits of Breastfeeding

• Cluster Analysis/Themes

Barriers/ Lessons Learned

• Recruitment

• Clinic space

• Resident buy in

• Time of day

• Attrition

• Group facilitation skills

Question and Answer

References• Ickovics, J. R., Reed, E., Magriples, U., Westdahl, C., Schindler Rising,

S., & Kershaw, T. S. (2011). Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled trial. Psychology and Health, 26(2), 235-250.

• Kennedy HP, Farrell T, Paden R, et al. "I wasn't alone"--a study of group prenatal care in the military. J Midwifery Womens Health. May-Jun 2009;54(3):176-183.

• Love, C., David, R. J., Rankin, K. M., & Collins, J. W. (2010). Exploring weathering: effects of lifelong economic environment and maternal age on low birth weight, small for gestational age, and preterm birth in African-American and white women. American journal of epidemiology, kwq109.

• Rising SS, Senterfitt C. Repairing health care: building relationships through groups. Creat Nurs. 2009;15(4):178-182.

• Shakespear, K., Waite, P. J., & Gast, J. (2010). A comparison of health behaviors of women in centering pregnancy and traditional prenatal care. Maternal and child health journal, 14(2), 202-208.

Session Evaluation

Please complete and return theevaluation form to the classroom monitor before

leaving this session.

Thank you!