Centering Pregnancy

1. Centering Pregnancy ….. an innovative antenatal program Caroline Homer Professor of Midwifery Centre for Midwifery, Child and Family Health 28 May 2009

2. Today • Antenatal care • Models of antenatal care • One to one care • CenteringPregnancy care • Australian Pilot Study UTS: NURSING, MIDWIFERY & HEALTH

3. What is antenatal care? • Formal antenatal care has been provided for about 100 years • one of the most common health care activities today • developed from the British system of assessment, screening and monitoring of pregnant women • Little has changed in a century

4. Aims of antenatal care • Promote the health of the mother and that of her unborn child and to detect and treat any problems • Includes physical, social, emotional aspects of health • ‘Physical’ has had more emphasis until recent times

5. Common antenatal care patterns • In healthy (normal risk) women • In Australia • 8-12 visits during pregnancy • In the UK • 10 visits for women having their first baby • 7 visits for women having a subsequent baby • More visits for women with risk factors (physical, social or emotional)

6. Evidence about patterns ... • Cochrane Review on Patterns of Routine Antenatal Care included 60,000 women • 7 countries and ten RCTs • a reduction in visits could be implemented without an increase in any of the negative maternal and perinatal outcomes measured • women had less satisfaction with the reduced number of visits, felt greater worry and that their expectations with care were not met (Villar et al., 2007)

7. How is antenatal care organised? • Little has changed in how care is arranged • Traditionally one-to-one visits with doctor or midwife • Characterised in many places by: • long waiting times • lack of continuity of caregiver • social isolation

8. Efforts to improve care • Community-based care • Care based on risk factors • Midwives clinics • Obstetric clinics (higher risk care) • Collaborative clinics • Shared care with GPs • Exclusive care with GPs • Continuity of care models • Midwives • Midwives and doctors • Doctors

9. What do women want? • Women want • information and support • unhurried care • clinician continuity (someone who remembers them) • a provider who individualises care and puts them at ease • access to nonmedical services • a setting in which their partner and other children are welcomed

10. What do women expect? • Reassurance, education and information from antenatal care • They prefer: • reasonable waits, unhurried visits, continuity, flexibility, comprehensive care, meeting with other pregnant women in groups, developing meaningful relationships with professionals, and becoming more active participants in care

11. What makes women dissatisfied? • inappropriate amount of time allocated to health check-ups • lack of information provision • An inability of care providers to give support, and pay attention to partners’ needs.

12. What do women need? • They need us to: • monitor the health of their baby and themselves • provide information that allows them to make health care decisions • provide access to services that can help improve health in ways that will have long-lasting effects • provide social support • have systems that ensure continuity of information and caregiver

13. One way to look at continuity • Informational continuity • Longitudinalcontinuity • Relational continuity

14. Informational continuity • information about each woman is readily available to all care providers and can be accessed and communicated among those involved • might be the most important aspect of continuity in preventing errors and ensuring safety, but by itself informational continuity might not improve access to, or experience of, care.

15. Longitudinal continuity • creates a familiar setting in which care can occur and should make it easier for women to access care when needed • each woman or family has a ‘place’ where she receives most care and a team who assumes responsibility for coordinating the quality of care, including preventive services.

16. Relational continuity • the development of personal trust between an individual care provider and a recipient of care • an ongoing relationship exists between each woman and a care provider • the woman or family knows the provider by name and has come to trust them

17. Think about your antenatal services • Informational continuity • Longitudinal continuity • Relational continuity • Access to records • Women-held notes • Consistent protocols • Team models • Local settings – community-based • Named care providers • Caseload models

18. Mostly these still mean a one-to-one model

19. Ways of providing antenatal care Individual care Group care

20. What is CenteringPregnancy? Antenatal Care in a Group Individual consultation → Group facilitation

21. Assessment Education Facilitated Group Antenatal Care + Support =

22. How does it work? • Group Antenatal Care • Facilitated model • Structured schedule • Core content - Education/Information • Emphasis on the women • Creating support networks with their peers • Development of community • Strengths based

23. How did it evolve?

24. How is it different? • Incorporates social support • ↑ Time - Women • Share / Discuss • Peer support • Network / Community • ↓ Time - Midwives • Incorporates 8-12 visits → 1 group • Less repetition • Energising • Focus of knowledge on the women

25. The group: • Conducted in a circle • Honours the contribution of each member • Composition is stable, but not rigid • Size optimal to promote the process

26. What are the benefits of group care?

27. The evidence so far • ↑ Gestation with preterm (34.8wks vs. 32.6wks) →↑ Birth weight (2397gms vs.1989gms) • ↓33% preterm birth rate (African American 41%) • ↓ additional visits (26% vs. 74%) • ↑ Satisfaction • Teenage women • →↓LBW, • ↓ preterm • ↑BF (discharge) • ↑ Knowledge uptake ↑ antenatal knowledge • ↑ Readiness for labour • ↑ Perception of support Ickovics, J. et al. (2007), Baldwin, K. (2006), Grady, M. A., & Bloom, K. C. (2004), Hodnett, E. and S. Fredericks (2003), Ickovics, J. et al. (2003), Petrou, S., T. Sach, et al. (2001), Rising, S. S. (1998), Oakley, A., Hickey, D., & Rajan, L. (1996).

28. Group care in general ... • Group care has been found to be an effective approach in the management of health conditions, including • obesity, smoking, diabetes • Compared with traditional one-on-one visits, group care has the advantage of providing in-depth health education, skill development, and peer support

29. CenteringPregnancy in Australia

30. Australian Pilot Study Telstra Foundation

31. The first Australian model • Replaces individual antenatal care with group care • 8 X 2 hour sessions facilitated by a midwife • 8 - 12 women, due in same month • Begin at 16-20 weeks gestation • Individual check-up done in group by the Midwife • Sessions focus on issues of pregnancy and parenting • Discussion guided by group activities & unique group dynamics • Individual booking visit • Individual appointments with doctors and others when required

32. What have we found out Organisation level • Challenging and rewarding • Centering group sessions easily incorporated into current ANC system • Time • Involvement of all • Support and Education

33. Midwives - before No time! How to sell it? Did they learn anything today? Worried about facilitating!

34. Challenges of working in this way Before • Developing Confidence • New • Nervous • Time • Recruitment • Motivation After • Developing Confidence • Learning to facilitate • Adapting • Fear • Being prepared • Time • Increased workload

35. Highlights of working in this way Before • New • Excitement • Pioneer • Opportunity • New antenatal care • Fun • Learning • New skills • Collaboration After • Developed relationships • Watching women and group develop • Watching colleagues develop • Working collaboratively • Confidence • Exciting • Being a part of something new • Experiencing benefits of CP

36. Midwives - after ‘ ‘Feeling really confident to sit back’ ‘Women are feeling safe in the group to talk through things themselves’ When you finish the groups you feel really buzzy’.

37. I thought my role would change greatly – but the group were very welcoming of the presence of the midwife – although I was not the ‘expert’ – I was their facilitator and in the end a ‘good friend. … it changed the way you look at your practice and I mean I guess we try to say was practice in a women centred thing [way] any way. But certainly it gives them that opportunity to discuss things that are of interest to them … I think understanding, it was understanding group dynamics … Coz you end up being more didactic and drier, the less they speak the more didactic you end up being. And you are trying not to be, and yet you’re having to be sometimes.

38. Women in the Pilot Study • 33 women – gave birth 37-42 weeks

39. Women rated group care highly ... Gained information • Story telling • Sharing information Support networks were developed

40. Women – what did they want? Making friends Sharing ideas Connecting early Learn more

41. Women – what they said! Hear questions you hadn’t thought of yourself It makes you feel normal Share opinions with others Hearing that you are not alone ‘I feel at ease about what I am going through and what is to come’

42. The way forward in Australia Become an Australian CenteringPregnancy site through the Centre for Midwifery, Child and Family Health - http://www.nmh.uts.edu.au/cmcfh/research/centering_pregnancy.html

43. Questions …

44. References • Baldwin, K. (2006). Comparison of Selected Outcomes of CenteringPregnancy Versus Traditional Prenatal Care. Journal of Midwfiery & Women's Health, 51(4), 256-272. • Bergsjo, P., & Villar, J. (1997). Scientific basis for the content of routine antenatal care. II. Power to eliminate or alleviate adverse newborn outcomes; some special conditions and examinations. ActaObstetricia et Gynecologica Scandinavia, 76(1), 15-25. • Brydon- Miller, M. (2003). Why action research? Action Research, 1(1), 9-28. • Carroli, Rooney, & Villar. (2001a). How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatric and Perintatal Epidemiology, 15 ((Supp1)), 1-42. • Carroli, G., Villar, J., Piaggio, G., Khan-Neelofur, D., Gulmezoglu, M., Mugford, M., et al. (2001). WHO systematic review of randomised controlled trials of routine antenatal care. Lancet 357(9268), 1565-1570. • Clement, S., Sikorski, J., Wilson, J., Das, S., & Smeeton, N. (1996). Women's satisfaction with traditional and reduced antenatal visit schedules. Midwifery 12(3), 120-128. • Elliot J (1991). Action Reseach for Educational Change. Milton Keynes. Open University Press • Grady, M. A., & Bloom, K. C. (2004). Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program. Journal of Midwifery & Women's Health, 49(5), 412-420 • Handler, A., Raube, K., Kelley, M., & Giachello, A. (1996). Women's Satisfaction with Prenatal Care Settings: A Focus Group Study. Birth, 23(1), 31-37. • Holter, IM, Schwarz-Barcott, D.(1993), Action research: what is it and how has in been used in nursing. Journal of Advanced Nursing18, 298-304 • Hildingsson, I., Waldenstrom, U., & Radestad, I. (2002). Women's expectations on antenatal care as assessed in early pregnancy: number of visits, continuity of caregiver and general content • ActaObstetGynecol Scand, 81(2), 118-125. • Ickovics, J. R., Kershaw, T. S., Westdahl, C., Magriples, U., Massey, Z., Reynolds, H., et al. (2007). Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstetrics & Gynecology, 110(2), 330-339. • Ickovics, J. R., Kershaw, T. S., Westdahl, C., Rising, S. S., Klima, C., Reynolds, H., et al. (2003). Group prenatal care and preterm birth weight: results from a matched cohort study at public clinics. Obstetrics and Gynecology 102(5), 1051-1057. • Klima, C. S. (2001). Women's health care: a new paradigm for the 21st century. Journal of Midwifery & Women's Health 2001 Sep-Oct; 46(5): 285-91 (47 ref), 46[5], 285-291. • Massey, Z., Rising, S. S., & Ickovics, J. (2006). CenteringPregnancy group prenatal care: promoting relationship-centered care. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing 2006 Mar-Apr; 35(2): 286-94 (25 ref), 35(2), 286-294. • Mathole, T., Lindmark, G., Majoko, F., & Ahlberg, B. M. (2004). A qualitative study of women's perspectives of antenatal care in a rural area of Zimbabwe. Midwifery 20(2), 122-132. • Oakley, A., Hickey, D., & Rajan, L. (1996). Social support in pregnancy: does it have long-term effects? Journal of Reproductive and Infant Psychology, 14, 7-22. • Petrou, S., Sach, T., & Davidson, L. (2001). The long-term costs of preterm birth and low birth weight: results of a systematic review. Child: Care, Health and Development, 27(2), 97-115. • Reason & Bradbury (2001). Handbook of Action Research. London. Sage. • Rising, S. S. (1998). Centering pregnancy: an interdisciplinary model of empowerment. Journal of Nurse-Midwifery, 43(1), 46-54. • Rising, S. S., Kennedy, H. P., & Klima, C. S. (2004). Redesigning prenatal care through CenteringPregnancy. Journal of Midwifery & Women's Health 49(5), 398-404. • Scott, J. C., Conner, D. A., Venohr, I., Gade, G., McKenzie, M., Kramer, A. M., et al. (2004). Effectiveness of a Group Outpatient Visit Model for Chronically Ill Older Health Maintenance Organization Members: A 2-Year Randomized Trial of the Cooperative Health Clinic. Journal of the American Geriatrics Society, 52(9), 1463-1470. • Sikorski, J., Wilson, J., Clement, S., Das, S., & Smeeton, N. (1996). A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project BMJ, 312(7030), 546-553. • Tucker, J. S., Hall, M. H., Reid, M. E., Florey, C. D., & McIlwaine, G. M. (1996). Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians. BMJ, 312(7030), 554-559. • Turnbull, D., Holmes, A., Shields, N., Cheyne, H., Twaddle, S., Gilmour, W. H., et al. (1996). Randomised, controlled trial of efficacy of midwife-managed care. Lancet, 348(9022), 213-218. • Villar, J., Ba'aqeel, H., Piaggio, G., Lumbiganon, P., Belizan, J. M., Farnot, U., et al. (2001a). WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet, 357(9268), 1551-1564.