Centering contraception: postpartum contraceptive choices of women enrolled in Centering group prenatal care versus traditional prenatal care

Group prenatal care successes, challenges, and frameworks for scaling up: a case study in adopting health care innovations

BACKGROUND

Group prenatal care enhances quality of care, improves outcomes, and lowers costs. However, this healthcare innovation is not widely available. Using a case-study approach, our objectives were to (1) examine organizational characteristics that support implementation of Expect With Me group prenatal care and (2) identify key factors influencing adoption and sustainability.

METHODS

We studied five clinical sites implementing group prenatal care, collecting qualitative data including focus group discussions with clinicians (n = 4 focus groups, 41 clinicians), key informant interviews (n = 9), and administrative data. We utilized a comparative qualitative case-study approach to characterize clinical sites and explain organizational traits that fostered implementation success. We characterized adopting and non-adopting (unable to sustain group prenatal care) sites in terms of fit for five criteria specified in the Framework for Transformational Change: (1) impetus to transform, (2) leadership commitment to quality, (3) improvement initiatives that engage staff, (4) alignment to achieve organization-wide goals, and (5) integration.

RESULTS

Two sites were classified as adopters and three as non-adopters based on duration, frequency, and consistency of group prenatal care implementation. Adopters had better fit with the five criteria for transformational change. Adopting organizations were more successful implementing group prenatal care due to alignment between organizational goals and resources, dedicated healthcare providers coordinating group care, space for group prenatal care sessions, and strong commitment from organization leadership.

CONCLUSIONS

Adopting sites were more likely to integrate group prenatal care when stakeholders achieved alignment across staff on organizational change goals, leadership buy-in, and committed institutional support and dedicated resources to sustain it.

TRIAL REGISTRATION

The Expect With Me intervention's design and hypotheses were preregistered: https://clinicaltrials.gov/study/NCT02169024 . Date: June 19, 2014.

The Impact of Group Prenatal Care on Interpregnancy Interval

OBJECTIVE

To evaluate whether participation in CenteringPregnancy group prenatal care is associated with decreased risk of an interpregnancy interval (IPI) ≤6 months.

STUDY DESIGN

We conducted a retrospective cohort study of women enrolled in Missouri Medicaid from 2007 to 2014 using maternal Medicaid data linked to infant birth certificate records. Inclusion criteria were women ≥11 years old, ≥1 viable singleton delivery during the study period, residency in St. Louis city or county, and ≥2 prenatal visits. The primary outcome was an IPI ≤6 months. Secondary outcomes included IPI ≤12 months, IPI ≤18 months, postpartum long-acting reversible contraception (LARC) uptake, and postpartum LARC or depot medroxyprogesterone acetate (DMPA) uptake. Data were analyzed using descriptive statistics and logistic regression. Backward stepwise logistic regression was used to adjust for potential confounders including maternal age, race, obesity, nulliparity, marital status, diabetes, hypertension, prior preterm birth, and maternal education.

RESULTS

Of the 54,968 pregnancies meeting inclusion criteria, 1,550 (3%) participated in CenteringPregnancy. CenteringPregnancy participants were less likely to have an IPI ≤6 months (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.47-0.79) and an IPI ≤12 months (aOR: 0.74; 95% CI: 0.62-0.87). However, there was no difference for an IPI ≤18 months (aOR: 0.89; 95% CI: 0.77-1.13). Women in CenteringPregnancy were more likely to use LARC for postpartum contraception (aOR: 1.37; 95% CI: 1.20-1.57).

CONCLUSION

Participation in CenteringPregnancy is associated with a significant decrease in an IPI ≤6 and ≤12 months and a significant increase in postpartum LARC uptake among women enrolled in Missouri Medicaid compared with women in traditional prenatal care.

KEY POINTS

· CenteringPregnancy is associated with a significant decrease in interpregnancy intervals ≤6 and ≤12 months.. · LARC uptake is significantly higher among patients participating in CenteringPregnancy.. · CenteringPregnancy participation enhances self-efficacy in making contraception decisions and promotes healthy pregnancy spacing..

Impact of Group Prenatal Care on Contraceptive Use at Twelve Weeks Postpartum

OBJECTIVES

To compare the prevalence of highly effective contraceptive use by 12 weeks postpartum among participants of Centering Pregnancy®, a model of group prenatal care (GPC), and traditional prenatal care (TPC), and to investigate differences in contraceptive method choice by type of prenatal care.

METHODS

We performed a retrospective review of all eligible patients who participated in GPC (n = 143) and a random sample of patients participating in TPC (n = 290) who followed up at our institution within 12 weeks of delivery. Our primary outcome was the proportion of participants using a highly effective contraceptive method within 12 weeks postpartum. Contraceptives were classified in tiers (Tier 1, long-acting reversible and permanent contraception; Tier 2, oral contraceptive pills, transdermal patch, vaginal ring, or injection; Tier 3, barrier and fertility awareness methods, withdrawal, spermicide; and no method). Tier 1 and Tier 2 methods were considered highly effective.

RESULTS

The prevalence of highly effective contraceptive use by 12 weeks postpartum was 63.6% (91 of 143) and 63.1% (183 of 290) among participants in GPC and TPC, respectively (p = 0.99). We found no difference in Tier 1 versus other method use (adjusted odds ratio (aOR) 1.05, 95% CI 0.95-1.15, p = 0.34) or Tier 2 versus other method use between groups (aOR 0.98, 95% CI 0.89-1.08, p = 0.69), in a multivariable model controlling for demographic and clinical factors.

CONCLUSIONS FOR PRACTICE

The prevalence of highly effective contraceptive use at 12 weeks postpartum was not different between GPC and TPC participants in this study. GPC was not associated with increased use of Tier 1 or Tier 2 contraceptive methods.

Group prenatal care and improved birth outcomes: Results from a type 1 hybrid effectiveness-implementation study

To compare birth outcomes for patients receiving Expect With Me (EWM) group prenatal care or individual care only, we conducted a type 1 hybrid effectiveness-implementation trial (Detroit and Nashville, 2014-2016). Participants entered care <24 weeks gestation, had singleton pregnancy, and no prior preterm birth (N = 2402). Mean participant age was 27.1 (SD = 5.77); 49.5% were Black; 15.3% were Latina; 59.7% publicly insured. Average treatment effect of EWM compared to individual care only was estimated using augmented inverse probability weighting (AIPW). This doubly-robust analytic method produces estimates of causal association between treatment and outcome in the absence of randomization. AIPW was effective at creating equivalent groups for potential confounders. Compared to those receiving individual care only, EWM patients did significantly better on three of four primary outcomes: lower risk of infants born preterm (<37 weeks gestation; 6.4% vs. 15.1%, risk ratio (RR) 0.42, 95% Confidence Interval (CI) 0.29, 0.54), low birthweight (<2500 g; 4.3% vs. 11.6%, RR 0.37, 95% CI 0.24, 0.49), and admission to NICU (9.4% vs. 14.6%, RR 0.64, 95% CI 0.49, 0.78). There was no difference in small for gestational age (<10% percentile of weight for gestational age). EWM patients attended a mean of 5.9 group visits (SD = 2.7); 70% attended ≥5 group visits. Post-hoc analyses indicated EWM patients utilizing the integrated information technology platform had lower risk for low birthweight infants (RR 0.47, 95% CI 0.24, 0.86) than non-users. Future research is needed to understand mechanisms by which group prenatal care improves outcomes, best practices for implementation, and health systems savings. Trial registration: ClinicalTrials.govNCT02169024.

Postpartum Contraceptive Use and Other Reproductive Health Outcomes Among CenteringPregnancy Group Prenatal Care Participants

Background: CenteringPregnancy^® is a model of group prenatal care (PNC) that reduces preterm birth and increases patient satisfaction. Less is known about postpartum outcomes. Methods: This study aimed to evaluate whether CenteringPregnancy participants have more favorable postpartum reproductive health outcomes compared with traditional PNC participants. Our primary outcome was utilization of long-acting reversible contraception (LARC). As secondary outcomes, we examined breastfeeding at the postpartum visit, follow-up at the postpartum visit, and rapid repeat pregnancy. We conducted a retrospective cohort study of 422 women who received PNC and delivered at tertiary care hospital in Atlanta, Georgia between 2011 and 2015. Participants were eligible to participate if they were enrolled in Medicaid and received at least three PNC visits with a Certified Nurse Midwife in either CenteringPregnancy (n = 248) or traditional PNC (n = 174). Demographic and clinical data were abstracted from the electronic medical record. Multivariable log binomial regression was used to compare CenteringPregnancy participants and women who received traditional PNC. Results: One quarter of women (26%) chose LARC for postpartum contraception. There was no difference in overall contraceptive uptake between CenteringPregnancy and traditional PNC groups. CenteringPregnancy participants were 70% more likely to use LARC postpartum compared with women receiving traditional PNC (adjusted relative risk [aRR] 1.76; p < 0.01). CenteringPregnancy participants were significantly more likely to initiate breastfeeding before hospital discharge (aRR 1.14, p = 0.01) and to report exclusive breastfeeding at the postpartum visit (relative risk [RR] 2.54; p < 0.01). Women in the CenteringPregnancy group were marginally more likely to report any breastfeeding at the postpartum visit and to attend the postpartum visit (RR 1.31, p = 0.05 and RR 1.17, p = 0.05 respectively), but were no less likely to have a rapid repeat pregnancy (RR 0.90, p = 0.57). Conclusion: Women in CenteringPregnancy groups had increased uptake of LARC compared with a similar cohort of women in traditional PNC. Other potential benefits of CenteringPregnancy, including breastfeeding and attendance at the postpartum visit require further study.

Increasing the Signal-to-Noise Ratio: COVID-19 Clinical Synopsis for Outpatient Providers

The novel coronavirus (SARS-CoV-2), which is the cause of coronavirus disease (COVID-19 formally 2019-nCoV), has received widespread attention from the medical community. Despite the rapid publication of research on the virus and the disease it causes, there is a lack of concise and relevant material to help busy medical providers navigate recognition and management of the disease in the ambulatory setting. This review article aims to bridge this gap by briefly reviewing the key points of the evaluation and treatment of patients with COVID-19 in the ambulatory clinic environment.