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Wednesday Sep 24, 2014

Group Visits: A Patient-Centered Approach to Improving Pregnancy Outcomes

One of the things I love most about being a family physician is caring for families. Although this may seem obvious, I think it bears stating because some family physicians focus on specific areas within the field, and as such, not all of us care for patients at all stages of their lives. But for me, offering prenatal care, postpartum care and pediatric care for women and their families is one of my favorite perks of being a family doc.

CenteringPregnancy is a group visits model of prenatal care that brings together eight to 10 women whose babies are roughly the same gestational age for a checkup, interactive learning and social support.

Despite the variety inherent in practicing family medicine, we often find ourselves repeating the same recommendations over and over again, particularly when it comes to common chronic conditions such as diabetes, hypertension and obesity. Prenatal care can fall into this same pattern. Although each patient is unique, a good deal of each visit includes a standard repertoire of instructions and advice about nutrition and diet, common concerns and discomforts, what testing is offered and when, how to manage labor pains, and the importance of breastfeeding. Group visits are a great way to disseminate this information to patients in an efficient manner.

The community health clinic I work in is part of a larger family medicine organization that has chosen to provide prenatal care through a group visits model called CenteringPregnancy(centeringhealthcare.org). Although the overall concept of providing group visits for various conditions has been gaining traction for many years, CenteringPregnancy is a specific model that was developed in the 1970s by nurse-midwife Sharon Rising, who began teaching the model in the 1990s.

Rising said in an interview with The New York Times(opinionator.blogs.nytimes.com) that she developed the model because she feared that answering the same questions and providing the same advice day after day might lead to burnout.

The model has three key components: the checkup, interactive learning and social support. The basic structure is a two-hour group visit that, ideally, takes place in a large exam or conference room and involves eight to 10 women whose babies are roughly the same gestational age.

The visit begins with each patient taking her own weight and blood pressure as the first step in actively participating in her prenatal care. After a brief one-on-one visit with the clinician in one area of the room to measure fetal heart tones, review any private questions, etc., the women sit in a circle. Often, their partners or support people are with them, and healthy snacks are available.

There is a standard curriculum for each monthly visit (and, later, biweekly visits) that covers all that would be addressed in a typical prenatal visit and more. The idea is to allow the patients to direct the discussion. Clinical staff members are there only to confirm the medical accuracy of clinical issues raised, if needed. By running the show themselves, these women, many of whom are from low-income backgrounds with significant socioeconomic hardships, build a support network that often continues beyond their pregnancy.

I was first introduced to CenteringPregnancy during residency. In my program, a second-year resident was paired with a third-year resident, and the two physicians would follow a group of continuity patients who were all due within a six-week period. For a second-year resident without much experience, these groups were a valuable way to learn not only about the medical aspects of prenatal care (such as what is considered appropriate weight gain and when to check for group B Streptococcus disease), but also the normal range of signs and symptoms that accompany pregnancy and the techniques and remedies that are available to manage them. As a resident, it can be particularly anxiety-inducing to care for a woman and her developing baby, but in the CenteringPregnancy environment, I was able to learn a great deal from the anecdotal experiences of my patients without feeling pressure to reassure them that I "knew enough" to deliver their babies.

Although this approach was helpful during my training and continues to be a great way to provide prenatal care, the truly inspiring and fascinating aspect of CenteringPregnancy is how these patient-centered visits improve health outcomes. At a time when the United States is seeing rising rates of maternal morbidity and mortality, the evidence to support CenteringPregnancy is heartening: decreased rates of premature deliveries(www.ncbi.nlm.nih.gov) and Cesarean sections and increased rates of breastfeeding. Perhaps the "icing on the cake" is the increased patient and clinician satisfaction that accompanies these visits.

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.

Posted at 03:22PM Sep 24, 2014 by Margaux Lazarin, D.O., M.P.H.

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