CenteringPregnancy : Incorporating a Prenatal Care Model for Improved Outcomes

1. CenteringPregnancy: Incorporating a Prenatal Care Model for Improved Outcomes Deborah Brandt Karsnitz, DNP, CNM, FACNM Associate Professor – Frontier Nursing University

2. CenteringPregnancy Model • Model of group prenatal care developed in 1993 • Sharon Rising saw a need • Designed to meet the mother’s physical and educational needs • CenteringPregnancy offers education, encourages self-care/empowerment, and facilitates a supportive network

3. CenteringPregnancy Model A Model of Group Prenatal Care • Includes 3 components of prenatal care in one setting: • Risk assessment • Education • Support

4. Group Model for Prenatal Care • Designed to meet the mother’s physical and educational needs through group care, while fostering individual responsibility for health care. • (Rising, 1998) • Decreased time with patients has become a reality in today’s healthcare system, leading to decreased prenatal education. Group care is an innovative answer to time constraints. • (Rising, 1998)

5. Health Care Recommendations • Institute of Medicine (IOM) 2001 – Crossing the Quality Chasm • Institute for Health Care Improvement (IHI) 2011, Across the Chasm: Six aims for changing the health care system • safe, effective, patient centered, timely, efficient and effective care • National Institute for Health & Clinical Excellence (NICE) - United Kingdom (2010) • Identify and offer recommendations for improved prenatal care

6. Quality Health Care - 2014 • CenteringPregnancy is a model of care that meets the needs outlined in Crossing the Quality Chasm (Schindler Rising et al., 2004) • American College of Nurse-Midwives position statement on Models of Group Prenatal Care encouraging midwives to “implement evidence based models of group prenatal care to improve women’s experiences and satisfaction with prenatal care and to improve pregnancy outcomes” (ACNM, 2010)

7. Social Support Theory Combines a sense of community or similarity Offers a sense of purpose and well-being Support Groups Offer this type of relationship Creates an environment with the sole purpose of sharing experience, value, and validation

8. Theoretical framework Social Support… (definitions vary) *positive relationships *provision of physical and psychological needs Family/Friends - can differ in support Advice Information Physical help Financial Aid Validation of feelings Social Support Theory

9. Evidence • (RCTs) High risk subgroup (AA, low socio-economic, older age) - better: psychosocial outcomes, self esteem, less social conflict, less depression= all extended to 1y. PTB 9.8% v 13.8% overall, 10% v 15.8% AA CI>95%, p<.05 J.Ickovics. 2003, 2007 & 2011 • Meta Analysis - 3 randomized controlled trials, 5 cohort studies, and over 80 texts revealed a decrease in preterm birth, an increase in breastfeeding initiation and duration, as well as increased knowledge and satisfaction with care with CP Ruiz-Mirazo, Lopez-Yarto & McDonald, 2012 • Beneficial effects CP: GA,PTB, LBW, VLBW for high risk women. Tandon-Smith, 2012 • (Integrative Review) mixed results – no worse outcomes for CP: conclusion: Results were the same or better • For GPC to be sustainable must have positive outcomes and satisfied participants (including providers) Lathrop. 2013 • Process (lower PTB + NICU admission) v. content fidelity in CP groups • Process better than content (fidelity) Novick., 2013.

10. Group care is a change from traditional prenatal care Prenatal cohorts based on similar gestational age 8-12 women 1 ½ - 2 hour sessions Education Socialization Self-Awareness/Empowerment CenteringPregnancy Model

11. Obstetrical Provider does initial assessment Next 10 visits in group format (begin around 12 - 16 weeks Women obtain and record own BP and Weight Socialize and Snack (healthy foods) Mat time occurs during this time (rotate) (time with provider – usual check-up) Self-Assessment Personal issues May be addressed in private following group time CenteringPregnancy Model

12. Socialization • Getting to know each other • Describing birth stories • Sharing personal goals • Games • Ice breakers • Educational games • Sharing Food • Snacks at each session • Potluck meals by participants • Sharing recipes

13. Informal Education • Group Lead Discussion Topics of Interest to Group Members (Just a Few) Postpartum concerns (mom) weight loss, sleeping Infant concerns sleeping, feeding, massage Relationship issues/concerns help at home, attention, sex Helping each other advice, ideas, support

14. Self-Assessment/Empowerment • Encourages the shift of responsibility to the woman, rather than the provider • (Moos, 2006) • Women are encouraged to seek information about healthy perinatal practices, and common concerns of pregnancy • (Moos) • Traditional prenatal - paternalistic concept - a provider often describes what the woman should do or should be feeling • (Moos) • As women take a larger role in their own self-care, they become empowered, confidence increases leading to decision making • (Massey et al., 2006).

15. Self-Assessment/Empowerment • The CenteringPregnancyModel builds partnerships between patient and provider. • Women regain self or improve self image as value is placed on sharing their own knowledge and personal experience within the group. • As women become more confident in their ability to take care of themselves at prenatal visits, decision making in all forms of healthcare becomes increased • (Rising, Kennedy, & Klima, 2004).

16. Framing a New Program - CP • Use of a Framework • examine organizations • assist in making systems changes • application of the evidence. • (Bolman & Deal, 2013)

17. Tread Carefully • Frames are charts or plots • Navigate the domain • Visualize surroundings • Choosing the right tools • Stay focused • (Bolman & Deal, 2013)

18. Know the Structure • Assess the Organization’s Structure • Vertical • Horizontal • Does CP align with Goals and Vision

19. Tasks, Technology & Environment • Identify • Goals • Roles • Relationships • Coordination • Tools

20. Tasks, Technology & Environment • Allotted Time • Budget • Realistic budget • Training Money • Technology • Staff

21. Human Resources • Know the internal and external stakeholders • Discussion Points • New projects/programs can increase productivity, revenue and quality of care • Stakeholder Buy-in • Fit is most important • Identify support • Balance needs of participants and the organization

22. Pregnant Women/families CNMs Health Care Administrators Health Care Staff Other Health Care Practices seeking to set up similar practice Key Stakeholders

23. Communication • Stakeholder meetings with OB personnel • Formal presentation • Informal discussion • Generation of ideas and buy-in • The project leader needs staff and staff needs the project

24. Communication • GANTT Chart • Key meetings between stakeholders • Project implementation, duration, completion • Milestones

25. STRENGTHS Facility site familiar to participants Education increases awareness Education can improve healthy behaviors Self-Funding opportunities OPPORTUNITIES Facilitate/sustain group support Facilitate social support outside sessions Increase knowledge Decrease cultural biases Obtain future funding Increase Quality of Prenatal/Postnatal Care and Outcomes WEAKNESSES New Group formation First time for implementation Cultural Biases Partial Funding THREATS Lack or withdrawal of stakeholder support Group members stop participating Funding withdrawn Space limitations SWOT Analysis

26. Politics • Organizations – coalitions • Variations • Difficult decisions • Conflict secondary to scarce resources and core differences • Goals & decisions > bargaining/negotiations • (Bolman & Deal, 2013)

27. Politics • Map political landscape • Network • Form coalitions • Be prepared for roadblocks

28. Politics • Project Leader – delivers agenda • What are the varying agendas • Will resources be allocated • Bargaining and negotiations

29. Preparation • Know organizational agenda/competing agendas • Present the evidence • Anticipation • Strategize

30. Panel Discussion/Questions?

31. References American College of Nurse Midwives. (2010). Position statement : Models of group prenatal care. Bolman L. G., & Deal, T. E. (2008). Reframing organizations: Artistry, choice, and leadership. (4th Ed.). San Francisco, CA: Jossey-Bass. Ickovics, J, Kershaw, T, Westdahl, C, Schindler Rising, S, Klima, C, Reynolds, H, & Magriples, U. (2003). Group prenatal care and preterm birth weight: Results from a matched cohort study at public clinics. The American College of Obstetricians and Gynecologists, 102(5), 1051-1057. doi:10.1016/S0029-7844(03)00765-8 Ickovics, J, Kershaw, T, Westdahl, C, Magriples, U, Massey, Z, Reynolds, H, & Schindler Rising, S. (2007). Group prenatal care and perinatal outcomes: A randomized controlled trial. Obstetrics and Gynecology, 110(2, part 1), 330-339. Ickovics, J., Reed, E., Magriples, U., Westdahl, C., Rising, S. S., & Kershaw, T. S. (2011). Effects of group prenatal care on psychosocial risk in pregnancy: Results from a randomized controlled trial. Psychology & Health, 26(2) Institute for Health Care Improvement. (2011). Across the chasm: Six aims for changing the health care system. ().Institute for Health Care Improvement. doi:www.ihi.org› Home › Knowledge Center › Improvement Stories‎ Institute of Medicine. (2001). Crossing the Quality chasm: A new Health system for the 21st Century  Retrieved March 6, 2014.www.iom.edu/.../Crossing-the-Quality-Chasm-A-New-Health-System-for. Lathrop, B. (2013). A systematic review comparing group prenatal care to traditional prenatal care. Nursing for Women's Health, 17(2), 118-130. doi:10.1111/1751-486X.12020 Institute of Medicine (2002). Crossing the Quality Chasm: A New Health System for the 21st Century. Bernard S. Bloom. JAMA. 287(5):646-647. Massey, Z., Rising, S. S., & Ickovics, J. (2006). CenteringPregnancy group prenatal care: Promoting relationship-centered care. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN / NAACOG, 35(2), 286-294. Moos, M. (2006). Prenatal care: Limitations and opportunities. JOGNN, 35(2), 278-285.

32. References National Institute for Health and Clinical Excellence. (June 2010). Antenatal care: NICE clinical guideline 62. ( No. 62). doi:guidance.nice.org.uk/cg62 Novick, G. (2004). CenteringPregnancy and the current state of prenatal care. Journal of Midwifery and Women’s Health, 49(5), 405-411. Novick, G., Reid, A. E., Lewis, J., Kershaw, T. S., Ickovics, J. R., & Rising, S. S. (2013). Group prenatal care: Model fidelity and outcomes. American Journal of Obstetrics and Gynecology. Schindler Rising, S. (1998). Centering Pregnancy: An interdisciplinary model of empowerment. Journal of Nurse-Midwifery, 43(1), 46-54. Schindler Rising, S., Powell Kennedy, H., & Klima, C. (2004). Redesigning prenatal care through CenteringPregnancy. Journal of Midwifery and Women's Health, 49(5), 398-404. Tanner-Smith, E., Steinka - Fry, K., & Lipsey, M. (2012). A multi - site evaluation of the CenteringPregnancy programs in Tennessee. (Peabody Report). Vanderbuilt University, Nashville, Tennessee: Peabody Research Institute. . (CenteringPregnancy)