Our goal was to increase access to quality prenatal care, empower women, and build relationships with other pregnant women and healthcare providers. This style of prenatal care also intends to teach women self-assessment skills, and gain affirmation about the development of her pregnancy and knowledge about pregnancy, birth, and parenting.
Our objective was to increase prenatal visit compliance, reduce premature birth disparities, and improve infant mortality. To date there have been 42 groups and 320 women enrolled. The average low birth weight infants in the group care model was 10 percent compared to 14 percent for the state of Florida and 15 percent for Orange County. An incidental finding of 80 percent initiation of breastfeeding is very encouraging. Prenatal visit compliance is elevated compared to traditional prenatal clients. Client and medical practitioner satisfaction rates exceed 90 percent.
Centering Pregnancy/Group CARE addresses the public health issue of providing quality prenatal care to decrease preterm/low birth weight infants, infant mortality, and health disparities. From 2003–2005, the premature birth rate for Florida was 13.7 percent. The premature birth rate for Orange County was 15.2 percent. Blacks, including African Americans and Non-Hispanic Caribbean women who resided in Orange County, had a premature birth rate of 19.1 percent compared to 13.8 percent for their White counterparts. There was an approximate 5 percent disparity. Hispanics in Orange County have a premature birth rate of 14.3 percent. Regarding infant mortality, approximately one African American infant dies in Orange County every six days. Despite these statistics, there was a national increase in overall prenatal visits; thus quality needed to be addressed. Statistics were obtained from the Healthy Start Coalition using local maternal and infant healthy start screens. Local Orange County Health Department Women’s Health Services numbers were also scrutinized.
The Florida Department of Health and the March of Dimes statistics were also used to determine relevancy to the community. Centering Pregnancy/Group CARE addresses the issue of quality prenatal care. Despite the fact that the number of prenatal visits have increased, poor birth outcomes have also increased. Group prenatal care allows the pregnant client to be a partner in her healthcare. Relationships are fostered with other pregnant women and with health care providers. Self-assessment tasks allow clients to discuss problems and recognize potential abnormalities. Education and group support intend to empower women to make better health and lifestyle choices. Approximately 90 percent of clients were Black or of Hispanic origin, races that statistically have higher preterm birth and infant mortality rates. Although organic factors may not be changed, behavior modifications in the presence of education and support intend to ultimately decrease poor birth outcomes and disparities. Group care has been used in outpatient settings for many years. Groups have been successfully convening for mental health, addictions, and other public health related issues. Group prenatal care was a concept that was introduced in 1995 as a way to provide quality service and efficiency, (S. Rising Journal of Nurse –Midwifery). Group prenatal care in Orange County was implemented to directly affect the large health disparity of preterm birth and infant mortality. Group prenatal care has the potential to directly affect the high premature birth rate and infant mortality present among minorities, especially among Black/African-Americans.
In the literature review of “Group Prenatal Care and Perinatal Outcomes” (Ickovicset. al, 2007), the researchers deduced that clients receiving group care were less likely to have a preterm birth. The Centering/Group CARE practice is a combination of two programs suited to our clients. The concept of using group care to deliver quality prenatal care was pioneered by Sharon Rising. She coined the term “centering pregnancy.” The concept of relationship building and empowerment is the foundation of the Centering Pregnancy/Group CARE Project.There are some parts of the Centering Pregnancy program that are not used for our clients. For example, Centering Pregnancy involves a firm didactic curriculum. There is homework, creative writing, and written pre- and post-tests. It also calls for the physical prenatal assessment to be done on a mat on the floor. Many of our clients felt that the didactic format was too rigid and it made them feel like they were in school. We also found that the writing in the books/curriculum was at a higher literacy rate than the clients we served. Clients and practitioners did not feel comfortable on the floor. In lieu of the Centering book, we found that the state sponsored Group CARE book was better suited to our clients. In the Group CARE proj
Agency Community RolesOrange County Health Department has added Centering Pregnancy/Group CARE as part of their commitment to provide quality comprehensive prenatal care. The Orange County Health Department contiunes to partner with the Healthy Start Coalition and the March of Dimes to decrease premature birth and health disparities through group prenatal care. Community partnering with the Black Infant Health Practice Initiative, a community board organized from State of Florida House Bill 1269, attempts to decrease the health disparity regarding infant mortality. Collaboration and recruitment for the program is supported by fluid communication with Healthy Start. Attendance to community board meetings and women’s health fairs also foster collaboration within the community.
Costs and ExpendituresFunding for this project commenced in November 2004. Funds up to $334,159 included $6,500 for snacks, incentives, and supplies; $50,500 for Centering Pregnancy Nurse Manager; $5,000 for related translation services; and $34,000 per month for unfunded care for eight months.
ImplementationRecognizing the need for quality prenatal care within Orange County was paramount to implementing Centering Pregnancy/Group CARE. A task force involving the Healthy Start Coalition and the Orange County Health Department was established in 2004. After the concept was considered feasible, funds were appropriated and a registered nurse program manager was hired and an advanced registered nurse practitioner was assigned. Formal staff training in the Centering Pregnancy Model, pioneered by Sharon Rising, was completed. Appropriate materials/curriculum were purchased and a usable space was designated. Pregnant women from targeted zip codes were recruited into the program based on Orange County clinic location and noted minority communities at risk for health disparities. Clients were also recruited based on similarities of due dates. Clients were taught to perform and keep log of their weights and blood pressures. One-on-one time was designated with the nurse practitioner and then the clients convened in a group. The clients sat in a circle and the program manager conducted the group in a facilitative style.
Using the curriculum, subjects related to pregnancy, birth, and parenting were introduced. Clients were allowed to speak freely, while the facilitator guided the group to avoid unrelated tangents or falsehoods. Clients were encouraged to bring a family member, a close friend, or a support person with them to their group appointments. The State of Florida Department of Health also recognized the concept of group prenatal care and established their own task force, which led to the development of the Group CARE Prenatal Project. This program was similar in concept to Centering Pregnancy, however the materials were different. Orange County was selected as a pilot site for Group CARE in 2006. Additional staff training using the Group CARE curriculum was also performed.
Performance measures included chart audits, anonymous client surveys, staff surveys, and demographic reporting data were recorded. Questions included satisfaction, necessary changes to program, birth weight, number of visits, initiation of breastfeeding, trimester of entry, weeks of gestation at delivery and fetal/infant mortality. The contract between the Orange County Healthy Start Coalition and the Orange County Health Department commenced on November 1, 2004. The Group CARE Project started in 2004 and lasted for four years. Those four years included workgroup formation and implementation of groups. Centering/Group CARE groups started on April 18,2005, to present.
More aggressive recruitment strategies need to be implemented and creative incentives to foster client visit compliance. There was a period in which the Nursing Program Specialist was on extended medical leave and renovations to the group meeting room made sessions inconvenient.
The Healthy Start Coalition is very supportive of this program. They have also provided some resources to assist in the formation of a Nurse-Midwifery Hospital Delivery Program. A local hospital also supports this effort. The addition of the Nurse-Midwifery Delivery Program supports Centering/Group Prenatal Care. The midwives in the program also are the practitioners for the groups.
This continuity of care will potentially lead to better birth outcomes. The program has been sustained by the local health department, Orange County Health Department. Grants and donations are sought and accepted to supplement the program for incentives, educational materials, craft materials, and shower gifts.