C ENTERING P REGNANCY  Changing the Prenatal Care Paradigm

1. CENTERINGPREGNANCYChanging the Prenatal Care Paradigm

2. CENTERINGPREGNANCY FROM EXAM ROOMS TO GROUP SPACE FOR PRENATAL CARE

3. “Nobody should be in this room….if you believe health care is fine. The reality we have is a reality of defective care….a gap between where we are and where we could be. And the first step has to be a kind of owning of the problem.” D. Berwick, IHI

4. Six Aims for Improvement of the Health Care System • Safe: avoiding injuries to those we are intending to help • Effective: providing services based on scientific knowledge to all those likely to benefit..refraining from providing services to those not likely to benefit

5. Six Aims … • Patient-centered: care that is respectful and responsive to individual preferences, needs, and values..letting these values guide all clinical decisions • Timely: care that reduces waits and harmful delays both for providers and recipients

6. Six Aims …. • Efficient: care that avoids waste of supplies, equipment, ideas, and energy • Equitable: care that does not vary in quality because of personal characterists such as gender,ethnicity, geography, socioeconomic status • Crossing the Quality Chasm: A New Health System for the 21st Century. IOM, March 2001

7. Caring for Our Future: The Content of Prenatal CareA Report of the Public Health Service Expert Panel on the Content of Prenatal CareUSPHS, 1989

8. Objectives for Prenatal Care • For the pregnant woman • For the fetus and infant • For the family

9. The Pregnant Woman • Increased well-being • Improved self-image • Decreased maternal mortality and morbidity • Self care skills • Development of parenting skills

10. The Fetus and Infant • Reduce preterm birth, IUGR, congenital anomalies, failure to thrive • Appropriate care • Ongoing health promotion • immunizations • developmental assessment • regular health supervision

11. The Family • Promote healthy family development • Reduce family violence • Reduce unintended pregnancies • Promote use of community resources

12. CENTERINGPREGNANCYCombines Group: • Assessment • Education • Support

13. TRADITIONAL Accepted model Exam room space Repetitive, individual teaching Random Education Little social contact Provider centered Narrow approach to prenatal care (i.e. - assessment) . . . GROUP CARE New model Group space Group teaching Comprehensive education Lots of social contact Consumer centered Broad approach to prenatal care (all 3 components) CENTERINGPREGNANCYTRADITIONAL VS. GROUP CARE

14. TRADITIONAL Physician / midwife care Medical outcome focus Efficient if limited / focused May be disappointing to consumers Routine / boring to providers GROUP CARE Practitioner / self-care Health empowerment focus Efficient if 8 - 12 in group Empowering to consumers Fun, energizing to providers TRADITIONAL VS. GROUP CARE (cont.)

15. Why Groups? Groups ... • …honor women’s needs for affiliation • ...provide an efficient conduit for information • …encourage active participation • …enable participants to learn from each other

16. Groups ... • …build community • …provide a vehicle for social change • …are efficient for the health care system • …are fun and interesting

17. “In truth, I continue to be awed by the power of the group. We are having such a good time and have such laughs. I am learning that it doesn’t matter what we don’t talk about, because we are talking about what matters to the group.” - Claire Westdahl, CNM

19. CENTERINGPREGNANCY PROGRAMEssential Elements • Health assessment occurs within the group space • Women are involved in self-care activities • A facilitative leadership style is used • Each session has an overall plan

20. Essential Elements…. • Attention is given to the core content; emphasis may vary • There is stability of group leadership • Group conduct honors the contribution of each member • The group is conducted in a circle

21. Essential Elements…. • The composition of the group is stable, but not rigid • Group size is optimal to promote the process • Opportunity for socialization within the group is provided • There is on-going evaluation of outcomes

22. Program Design • Initial intake to system before entry into a group • Nursing/medical history obtained • Physical assessment/lab work completed • Woman invited to receive care within a group

23. The Design... • Groups of 8 - 12 women, same month EDD • Begin between 12- 16 weeks gestational age • Individual physical assessment done within group space by a provider • Women do self-monitoring of weight & B/P

24. The Design. . . • 10 two-hour sessions facilitated by group leader, usually the health care provider • Sessions focus on issues of pregnancy and parenting • Self assessment sheets help guide the discussion

25. The Design . . . • Four sessions every 4 weeks: 16, 20, 24, 28 • Six sessions every 2 weeks: 30, 32, 34, 36, 38, 40/PP • additional visits as needed for problems • weekly visits during the last month, if desired

26. CENTERINGPREGNANCY • ASSESSMENT • EDUCATION • SUPPORT

27. ASSESSMENT Self Physical Psychosocial

28. SELF ASSESSMENT • Blood Pressure • Weight • Urine Dipstick, prn • Gestational Age • Chart review • Self Assessment Sheets (SAS)

30. SELFASSESSMENT SHEETS (SAS) ... • Nutrition • Common Pregnancy Problems • Family Issues • Parenting Styles • Relaxation Measures • Comfort Measures for Labor

31. Self Assessment Sheets... • Personal Adjustment/Feelings • Personal Goals • Thinking about Breastfeeding • Keeping Safe and Healthy • Decisions of Pregnancy • Self-Inventory • Contraceptive Use

32. PHYSICAL ASSESSMENT • Fundal Height • Fetal Heart Tones • Fetal Position • Maternal / Fetal Well Being • Appropriate Testing

34. Responses . . . Physical Assessment • It was no big deal. • It gets easier; everyone has the same marks on their bellies. • We watched each other grow; everybody loved it. ‘Oh, you’re a lot bigger this week’ • Once you have a baby you have no modesty anyway!

35. Responses…Listening to Heartbeats • ‘Oh, his heart’s good’; then it was fun for me. • You could hear other heartbeats. • I couldn’t wait to go to my visit so I could hear the heartbeat. • I think it was as much of a reassurance for us as it was for each individual mother. • Ok. Well Becky’s baby is Ok, and Sue’s and everybody’s.

36. PSYCHO-SOCIAL ASSESSMENT • Support System • Basic Necessities • Safe Environment • Adjustment to Pregnancy

38. EDUCATION • Comfort issues • Exercise / relaxation • Nutrition • Childbirth preparation • Sexuality . . .

39. EDUCATION (cont’d) • Communication / self esteem • Issues of abuse • Baby care • Infant feeding • Parenting • Contraception

42. Responses . . . Education/Learning • I learned more than I could ever tell. I read a lot of books. I learned more than I could learn in a book by coming to group. • You learn what to expect and everything. It makes it easier for you. • If someone wouldn’t ask a question, someone else would. • I felt prepared to care for the baby--that was the strongest part.

43. SUPPORT • Refreshments • Formal and informal sharing • Stability of group • Exchange of names, telephone no. • Consistency of leadership

45. Responses . . .Support • You knew you were going to be with people that you knew, who were all going through the same thing. They were just another group of friends. • Or somebody shared the same problem you had, and you thought you were the only one and you’d come to group and say, ‘Oh, we have the same problem’. • It was nice because you knew that there were people who were really concerned.

46. CENTERING PREGNANCY THE PILOT PROGRAM 1993-94

47. The Setting • NE industrial city of 100,000 • Hospital prenatal clinic • 30 deliveries / month • OB residents, nurse midwife, nurse practitioner, RN staff • Usual clinic resources

48. Goals of the Project • System • Cost effective, attract patients • Outcome evaluation • Staff • Promotes growth • Nursing staff assume increasing leadership • Patient • Active involvement in prenatal care • Safe outcomes for mom and baby

49. Outcome objectives • Client satisfaction • Professional satisfaction • Attendance • Emergency room use • Learning • Group support • Safe birth outcomes

50. How did it go? • Length of time - 15 months • No. of groups - 10 regular, 3 teen • Ave. no / group - 8.75 • Attendance 85.9% (Range 71.9-100%) • Regular - 83% • Teen - 91.7%