Am Fam Physician. 2008 Apr 15;77(8):1165-1166.
Background: Preterm birth and low birth weight show marked racial disparities, with twofold higher rates in black mothers. Several programs that are based on augmented prenatal care have attempted to reduce preterm birth and related adverse perinatal outcomes, but the results have been inconsistent. Among innovative approaches, group visits incorporating family and peer support have shown encouraging results, especially in minority, teenage, and other high-risk mothers. Ickovics and colleagues conducted a randomized controlled trial of perinatal care based on group visits.
The Study: Pregnant women who were 14 to 25 years of age and attended publicly funded clinics in two urban areas before 24 weeks' gestation were randomly assigned to individual standard prenatal care or group care. Mothers with complications requiring individualized therapy (e.g., multiple pregnancies, diabetes, human immunodeficiency virus infection) were excluded. All participants completed baseline interviews and underwent second-trimester ultrasonography to confirm gestational dates and exclude anatomic abnormalities. In the group-care model, groups of about eight mothers with the same estimated delivery date met with an obstetrician or a midwife for 10 sessions of approximately two hours each, which took place from 16 to 40 weeks' gestation. The group process stressed education, self-care, and peer support. Self-empowerment activities included keeping one's own health records, active participation in collecting data (e.g., blood pressure, fetal heart rate), and in-depth discussions within the group about participant concerns. Each group provided continuity of care from a single provider and a “one-stop shop” for all services required by its members. The control group received standard prenatal care in scheduled 10- to 15-minute clinic visits.
Study participants were followed for one year postpartum. Primary outcomes were gestational age at birth (less or more than 37 weeks) and rates of low birth weight (less than 2,500 g [5 lb, 8 oz]). Other measured outcomes included perceived adequacy of prenatal care; Apgar scores at five minutes; rates of breastfeeding; pregnancy knowledge; prenatal maternal distress; and preparation for labor, delivery, and infant care.
Results: The average age of mothers included in the study was 20.4 years, but nearly one half were 14 to 19 years of age. Only 38 percent had completed high school, and 36 percent were still high school students. Eighty percent were black. The 623 women randomized to group care were more likely to be black and to have high levels of prenatal distress, but were less likely to have a history of preterm birth, than the 370 women randomized to individual prenatal care. The study results controlled for these variables in all analyses.
Mothers assigned to group care were significantly less likely to have preterm births (9.8 compared with 13.8 percent). This risk reduction remained significant after adjustment for a history of preterm birth. Differences between the groups in preterm deliveries became apparent by 26 weeks' gestation and peaked at 35 to 37 weeks' gestation. The outcomes for gestational age and low birth weight were strongly correlated with the number of visits attended. The advantages of group care were even greater when only black mothers were considered (10.0 compared with 15.8 percent preterm births for group and individual care, respectively).
On intention-to-treat analysis, group patients were significantly less likely to receive inadequate care (26.6 compared with 33.0 percent). They were also significantly more likely to initiate breastfeeding (66.5 compared with 54.6 percent), feel better prepared for labor and delivery, and report higher satisfaction with prenatal care. No significant differences were recorded in Apgar scores or in rates of admissions to neonatal intensive care units. Costs calculated at one center indicated no significant differences in prenatal or delivery costs.
Conclusion: The authors conclude that group prenatal care was associated with improved pregnancy outcomes at no increased cost. They advocate innovative approaches to impact the complex and multifaceted problem of preterm births. The group-care approach may be particularly effective for young, disadvantaged black mothers who have disproportionately high rates of poor pregnancy outcomes.
Ickovics JR, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol. August 2007;110(2):330–339.
Copyright © 2008 by the American Academy of Family Physicians.
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