Nursing Center - Journal Issue

Keywords: Group care, Prenatal care, Pregnancy.

Abstract

Objectives: CenteringPregnancy, a model of group prenatal care, provides healthcare assessment, education, and support to women. The current study was designed to determine women's perceptions of the CenteringPregnancy program.

Methods: Twenty-one women participating in CenteringPregnancy, as part of a larger study, shared their thoughts related to the strengths and weaknesses of their healthcare, thoughts on improvement, and how the care impacted their health and health behaviors. A thematic and iterative analysis process, assisted by Ethnograph 6.0, allowed for the emersion of important themes that were validated in a member check process.

Results: The focus group participants provided rich insights into their prenatal experiences in CenteringPregnancy. Four substantive themes emerged from the data: It's about respect, Knowledge is Power, I'm a better mother, and Supporting each other.

Conclusions: CenteringPregnancy was well-received by urban, low-income women during their pregnancy and may have value with select populations. Themes, exemplar quotes, and participant observations may assist others interested in implementing the CenteringPregnancy model of care.

The prenatal period, with its inherent physical, social, and emotional dimensions, may be a very stressful period for mothers and their support persons. The needs of women during the prenatal period span physical, social, and emotional parameters. One model of care, CenteringPregnancy, has received acclaim for providing these elements in the form of group prenatal care. This research explores women's perceptions of the CenteringPregnancy experience by addressing their thoughts on the program, the people they encountered, their healthcare, changes in health behaviors, and their thoughts of program improvement.

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Review of the Literature

The CenteringPregnancy Model

The CenteringPregnancy model of care has a strong evidence foundation based on three cornerstones of treatment: assessment, knowledge, and support. In the form of group prenatal care, CenteringPregnancy encourages women to take care of their own health, attend to risk behaviors, self-monitor, participate in personal health assessments, participate in group discussions, receive comprehensive support, and become empowered to guide their own birth experience (Klima, 2009). CenteringPregnancy is a relationship-based model that provides a mechanism for mothers to support each other, espouses continuity of healthcare providers and effective group leadership, personalizes care, embraces and supports the family, and enhances control during pregnancy (Kennedy et al., 2009; Massey, Rising, & Ickovics, 2006). Educational strategies and health promotion activities that meet the needs of individual women are key components of the CenteringPregnancy model, not only for the positive outcome of the pregnancy, but also to lay down behaviors that reinforce health throughout the life span (Vonderheid, Norr, & Handler, 2007; Wallace et al., 2009). Other benefits of CenteringPregnancy include no waiting for appointments; meeting other women; having more time for questions, information, and concerns than brief office visits; receiving support from other mothers; and personalized care (Kennedy et al., 2009). Negative factors reported by prenatal clients in CenteringPregnancy include the lack of individualized time and attention, lack of comfort of partners with group format, and need for more food during the program (Kennedy et al., 2009; Novick et al., 2011). It is important to note that group prenatal care models are similar in cost to traditional prenatal care, dependent on the volume of births at the agency (Ickovics et al., 2007; Mooney, Russell, Prairie, Savage, & Weeks, 2008).

The impact of CenteringPregnancy

CenteringPregnancy has demonstrated effectiveness in increasing knowledge of pregnancy and perceived social support, increasing personal locus of control, decreasing anxiety, enhancing emotional care, fostering mothering skills, and improving self-image (Baldwin, 2006). This model is effective in increasing rates of attendance and patient satisfaction, promoting healthy weight gain during pregnancy, decreasing rates of preterm and low-birthweight infants, increasing rates of breastfeeding, and enhancing reproductive health behaviors (birth spacing, the prevention of STDs, enhanced health, and adherence to healthy behaviors) (Grady & Bloom, 2004; Ickovics et al., 2003, 2007; Kennedy et al., 2009; Klima, Norr, Venderheid, & Handler, 2009; Massey et al., 2006; Novick et al., 2011; Walker & Worrell, 2008).

In contrast, Shakespear, Waite, and Gast (2010) found no significant improvements in health behaviors when comparing CenteringPregnancy clients with those in traditional prenatal care. Research by Robertson, Aycock, and Darnell (2009) noted that Hispanic women revealed a high level of satisfaction with this model but did not demonstrate appreciable differences in other evaluation data, including healthy behaviors, self-esteem, depression, and infant outcomes, when compared with those in traditional care models. CenteringPregnancy may be most effective in providing specialized prenatal services for selected marginalized groups known to have racial, economic, or other perinatal disparities (Ickovics et al., 2003).

Methods

This qualitative, focus group study was designed to explore CenteringPregnancy participants' perceptions of the strengths and weaknesses of this model and their thoughts on potential improvements. The interview guide asked about the major concepts concerning the program, people, information, support, healthcare, and health behaviors; the positive and negative aspects of the program; and suggestions for improvement. Probing questions explored individual interpretations, specific events, and personal responses to CenteringPregnancy experiences.

Following agency Institutional Review Board approval, focus group participants were solicited by program staff. Women were informed of the 90-minute time commitment, the audiotaping of the focus groups, their role as a focus group participant, and their incentive of a $50 gift card for their participation.

Each group opened with an introduction including the purpose and methods of the focus group interview, reminders about confidentiality, and a discussion meant to put the participants at ease. Members were asked to be honest and constructive and not to divulge any information discussed during the interviews to others.

Five focus groups were conducted over a 3-week period and ranged from 55 to 90 minutes in length. A total of 33 women participated in these groups; one woman was interviewed via phone while on bed rest (Total n = 34; Centering Pregnancy n = 21). Focus groups had between four and nine women ages 18 to 35 years. The ethnic/racial breakdown included 23 Black non-Hispanic women, seven White non-Hispanic women, and four Hispanic women.

Data Analysis

The audiorecordings were transcribed and loaded into Ethnograph 6.0 software, which reformatted the document into codable segments and allowed coded phrases to be clustered under a search and filter mechanism. Observational notes including nonverbal activity and major areas of emphasis arising from the interviews were taken by the focus group leader and entered as additional files. Iterative, thematic analysis used the major ideas from the data to create a template for organizing findings (Miles & Huberman, 1994). The major emerging themes were identified and described; these were e-mailed to selected group participants to implement a member check process. Phrases from the data were categorized according to major code book concepts and were delineated as positive or negative evidence of each of the concepts. These methods of qualitative data analysis were conducted to increase the trustworthiness and rigor of the data interpretation.

Results

The template analysis categorized the findings as those related to the program, people, information, support, health behaviors, and suggestions for improvement. Each of these six concepts will be discussed.

Program

Participants made many positive comments and very few negative ones about the CenteringPregnancy model, one woman stating, "I looked forward to the classes and visits." The program components identified by focus group participants and exemplar quotes are found in Table 1. Multiparous women frequently commented that this type of prenatal care was far superior to their previous experiences. There was some discussion that some mothers may not like the group nature of CenteringPregnancy, that partners may be uncomfortable with being around other pregnant women, or there may be a lack of privacy.

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Table 1 Program Components

People

The people involved in CenteringPregnancy were definitely the key elements of program success. Even when asked about other program facets, women were quick to gravitate to a discussion about the importance of the people in their experiences and the key role people played in their ability to deal with other stressors. Women stated, "They helped me a lot," "If you have problems, you can call them any time," "They were always there when we needed them,""I can't say enough good things about the staff," and "The team is good at what they do." The major characteristics of the people involved with CenteringPregnancy cited by the participants appear in Table 2. The only negative characteristics about people were with personnel not involved with CenteringPregnancy, participants saying that when staff were not nice they didn't "mesh with the surroundings."

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Table 2 People Characteristics

Information

Information, teaching, and knowledge were considered vital in the participants' navigation of their pregnancy. CenteringPregnancy provided information about breastfeeding, nutrition, personal goal setting, anticipatory guidance, personal safety, contraception, dealing with stress, coping with postpartum depression, problems of pregnancy, the importance of prenatal care, and what to expect (during pregnancy, birthing, postpartum, and in parenting). One mother noted "people have told me what to do in the past...these people tell me why to do it so I understand it." A mother said that with her first pregnancy she didn't attend prenatal care: "I didn't know...I was scared." Another woman reflected "no one ever told me how important prenatal care was, I always just felt it was useless...rush in, rush out...pee in a cup...and you're gone. Now I know how important it is."

Teaching was recognized as both formal classes and informal discussions when questions were answered and information was shared between individuals. Participants discussed the games, fun activities, journaling, handouts, brochures, and other strategies used to teach content. Mothers discussed their CenteringPregnancy binders as ways to record events ("I learned to write down fundal heights and dates"), as sources of information ("I referred to my book if I had a question)," and feelings ("I wrote my goals and how I was feeling)." Others stated "the classes opened my eyes to a lot of stuff," "I learned a whole lot each two hour class," and "if you're having problems you want to know what is going on...what you're going to expect."

Most noteworthy were the sample's reactions to the classes on contraception. Participants discussed the ability to "make a choice from the many different methods...they explained each one...based on my lifestyle" and "They asked how I want to deal with contraception, rather than telling me what I should use." They discussed being unaware of the number of methods available; women indicating that, in the past, they were "offered one type of contraception and expected to use it." The use of contraception as a choice when spacing children was discussed, mothers identifying that "it is important for our bodies to give it a break" and "it's important to space your births."

Mothers summed up the information received as "I will be a better mother because of the information I learned in CenteringPregnancy,""you didn't walk out wondering, you knew," and "knowing all this will make things different." The information gleaned during CenteringPregnancy sessions was perceived to be effective in dispelling myths and superstitions, providing a valid source of information to participants. One mother expressed that "people listen to you differently when you are educated about matters...knowledge is power."

Support

The mothers discussed the support received by the CenteringPregnancy clients during their pregnancy from both the fellow program participants and program staff. A key concept of support was related to the cohesiveness among the women. One participant added, "We all got along...it wasn't like I don't know her...we all wanted to know how everyone was. I don't mingle with people so this group was important for me." One group member stated, "Everyone becomes special friends." The women discussed the importance of being with women who were in the middle of similar experiences, of similar backgrounds, and ready to share with each other as well as reap the benefits of programs. "It is good to be with someone who is at the same point, right at this moment" claimed one mother.

Mothers who brought partners and/or the baby's fathers with them expressed gratefulness for the respect shown to the men in the groups. Equally, the women were supportive of those mothers from unhealthy relationships or those without partners. They discussed accessing supports based on each individual woman's needs. They were also supportive of each others' mothering, providing encouragement and holding each others' babies to "give them a break." The participants had a "common bond of mothering" and stated "we were encouraged to help each other, and that helped us."

Another key component of support was that provided by the staff. The groups relayed ongoing appreciation, respect, and positivity about the level of support provided during their childbearing experience. Mothers stated, "It is so hard if you are by yourself," "I am shy and I don't ask for things...they taught me to ask for my baby," and "if you are feeling scared, they are willing to help." Others relayed, "They seemed to know when I needed them and would call me when I was frazzled or at the end of my rope" and "the baby was crying and they said find someone to watch her for a while."

The mothers discussed the support that was received was often more emotional than physical; that they felt they could "openly express their needs and wants"; and "during pregnancy, it's hard to handle things you could before you were pregnant...you need some extra help." One mother added "Just to sit and talk about your body...it's a huge change...physically, emotionally, hormonally, everything!" The staff was perceived as exceptionally accessible, mothers relaying that "she gave me her phone number and she called me right back," "I had emergency numbers, I knew I was only a phone call away," and "I was so surprised when she showed up at my delivery, it was great." Several mothers discussed the support they received in order to cope with abusive or bad relationships. Mothers stated, "they were genuinely concerned for my safety. They said, if someone abuses you, that's not someone you need in your life" and each possessed "deservingness of better...I am worth more."

Mothers shared that they were often asked if they had support at home and were frequently reevaluated for needed resources. One mother said "I was not treated like a statistic, they asked me about my home and wanted me to have the things I needed." Mothers were adept at determining that some situations required more external support than others. A mother shared, "some people don't have family-based homes...when they find themselves pregnant they think they are all alone."

Health Behaviors

The information and support received from CenteringPregnancy were perceived as effective in assisting women adopt healthy behaviors. By recognizing the importance of positive change, realizing the impact of behaviors on the baby, and receiving support and encouragement to make positive behavior changes, women expressed personal motivation and rewards for improving their own health. Incentives, such as baby supplies, coupons, and small gifts, were considered important motivators for behavior change. In addition, women stated "They told me my baby is more important," "everything that goes in me, goes to my baby," "baby gets it first," "I didn't realize how much risk I placed on the baby," and to "focus on your baby and do better things."

Women were noted to positively change behaviors through improved nutrition, decreases in risk behaviors, positive lifestyle changes, working toward educational and career goals, and dealing with stress. Mothers stated: "they taught me to take a deep breath...when I feel like strangling someone," "my first baby...I wanted to smack him...I was stressed out," "I didn't do anything bad...but attitude-wise, I turned a 360...now I think before I speak," and "I was a fighter...I had to learn to change that and deal with my temper." The philosophy of lifestyle change was embraced by one woman who stated "you have to take care of your body for the rest of your life."

Improvements

Although the CenteringPregnancy Program was largely deemed as positive, a few suggestions for improvement emerged. Specific suggestions and exemplar quotes are noted in Table 3.

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Table 3 Participant Suggestions for Improvements

Themes and Discussion

When the focus group findings were reviewed as an aggregate, four basic themes emerged from the data. These themes substantiated findings noted in the literature. The four themes, with validations from research, were:

It's about respect. This theme reflected the high-priority group members placed on the human interaction and mutual respect that contributed to highly effective relationships, trust, and positive communication. This communication allowed for free expression of personal needs and beliefs, for learning without bias, and for interaction in some of the most private experiences humans encounter. The respect, trust, and human connection associated with CenteringPregnancy enhanced adherence to health recommendations, reinforced positive behaviors, built perceptions of personal value, and supported social networks for program participants. Authors have noted that an important element in fostering positive working relationships, especially with low-income or disenfranchised women, is the cultivation of trust (Baldwin, 2006; Massey et al., 2006; Sheppard, Zambrana, & O'Malley, 2004). This theme was validated in previous studies determining that the relationship basis of the CenteringPregnancy model is key to program success (Ickovics et al., 2007; Kennedy et al., 2009; Massey et al., 2006; Rising, Kennedy, & Klima, 2004).

Women in this study discussed the motivation inspired by participating in their own care, such as blood pressures and weights. Researchers validated that women's participation in their care offers them control over their own prenatal course, further solidifying the respect inherent of CenteringPregnancy relationships (Kennedy et al., 2009; Sheppard et al., 2004).

Knowledge is power. Coined from a phrase from one of the group members, women discussed the wealth of information they learned about their pregnancy, parenting, and personal health. Several multiparous women reflected that they did not receive this depth of information with previous pregnancies and appreciated the value that education had on their health and the health of their babies. Women in this and other studies reflected that they learned more in CenteringPregnancy than previous pregnancies with traditional prenatal care (Baldwin, 2006; Kennedy et al., 2009). Mothers discussed feeling more confident, less fearful, and more empowered by the information shared with them about pregnancy, labor and delivery, and parenting. High levels of information and support reinforced motivation for behavior change, corroborating with the findings of previous researchers (Ickovics et al., 2007; Grady & Bloom, 2004). Mothers in this study noted that learning was enhanced by the lack of wait times, the increased time with providers, and the positive rapport with providers, confirming results of previous studies (Baldwin, 2006; Ickovics et al., 2003, 2007; Kennedy et al., 2009).

One of the assets of CenteringPregnancy is the ability for mothers to receive information, ask questions, assess personal learning needs, and receive formal and informal instruction in a group setting while also having the opportunity for personal consultation as needed (Ickovics et al., 2003, 2007; Massey et al., 2006). The facilitative leadership style meets adult learners' needs by focusing on learner readiness and internal motivation (Ickovics et al., 2003).

I'm a better mother. This theme represents the positive effects of personal self-worth, self-esteem, and confidence in mothering, which emerged from the data. The women shared that the support, information, and personal relationships established through CenteringPregnancy contributed to their nurturing skills and ability to cope with the inherent stressors of mothering.

CenteringPregnancy programs reinforce mothers' self-reflection about their capacity for mothering and their perceived self-image. Women in this study discussed enhanced independence, thoughts of self, and capacity for mothering, which was discussed by other researchers (Klima et al., 2009; Novick, 2004). According to one author, "the prenatal period is when serious doubts can surface about one's ability to deal with labor and develop a healthy relationship with the baby" (Massey et al., 2006, p. 288). The mothers' use of knowledge, resources, and supports provided a foundation for competent and confident mothering despite other stressors in their lives. As in previous research, mothers in this study reported more positive health behaviors, motivation to practice spacing of births, breastfeeding, and stress management to support positive mothering (Baldwin, 2006; Grady & Bloom, 2004; Ickovics et al., 2011; Sheppard et al., 2004).

Supporting each other. The final theme is reflective of the relationships formed between participants, their readiness to provide information and support to each other, and their encouragement of each other in the face of stressful lives and vulnerable families. These supportive relationships, modeled after the positive relationships between healthcare providers and participants in CenteringPregnancy, created a level of mutual support that promoted health for mothers, infants, and their families. Authors reinforced the value of meeting other women and this support as one of the greatest assets of CenteringPregnancy (Kennedy et al., 2009). Kennedy et al. (2009) substantiated that women valued contact with women having similar prenatal experiences, the support of other women, and the friendship established during CenteringPregnancy experiences.

Prior work by the developers of CenteringPregnancy found that women in this group care setting receive higher levels of support from healthcare professionals, each other, and family members than women in traditional prenatal care and that these levels of support have been correlated with positive birth outcomes (Baldwin, 2006; Massey et al., 2006). Successful CenteringPregnancy groups are established according to community and cultural norms and should support group values, traditions, and languages (Rising et al., 2004). Ickovics et al. (2003) proposed that CenteringPregnancy, through the support of connections and encouragement of healthy behaviors, fosters an ongoing positive influence on the entire community.

In contrast, Baldwin (2006) noted that social support was not found to be significantly greater in CenteringPregnancy programs when compared with traditional prenatal care, indicating a need for further research.

Limitations

The sample members self-selected into the CenteringPregnancy program and participation in the focus groups, and there was no randomization or random assignment. Not all focus group members were from CenteringPregnancy, potentially limiting the accuracy of findings. In addition, focus group concur inherent limitations associated with group process. It is not known if each participant was able to be candid in her response, whether some participants' thoughts were not heard, or if some focus group members' statements were influenced by the responses of others.

Implications and Conclusions

Many of the women interviewed in this study self-identified as having complex lives, high levels of stress, and few resources. CenteringPregnancy appeared to a play critical role in their health and that of their children (Table 4). Klima (2009) identified the key barriers to prenatal care include the brevity of office visits, long wait times, lack of continuity of healthcare providers, and lack of individual-based care. Low-income and minority women may experience even more pronounced obstacles when confronting financial, cultural, or discriminatory barriers (Klima, 2009; Phillippi, 2009). CenteringPregnancy may eliminate or reduce these barriers. Group prenatal care may provide important personalization of care and group support especially vital for marginalized women and families. Not only does CenteringPregnancy provide for the support, education, and referral by professionals, but it also fosters caring and advocacy skills among group members that may have current and long-term health implications. In light of these very positive findings, and those demonstrated in the literature, CenteringPregnancy may be a worthwhile program for selected populations of women during their pregnancy. Ongoing research is warranted to determine the effectiveness, cost-efficiency, and cultural appropriateness of CenteringPregnancy to meet the needs of women and families who are most at risk for being disenfranchised from traditional prenatal care models.