- Email: [email protected]
Which Pregnant Adolescents Would be Interested in Group-Based Care, and Why?
Original Study Which Pregnant Adolescents Would be Interested in Group-Based Care, and Why? Kim D. Weber Yorga RN, MSN 1,*, Jeanelle L. Sheeder MSPH, PhD 1,2 1 2
Prevention Research Center for Family and Child Health, University of Colorado School of Medicine, Aurora, Colorado Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
a b s t r a c t Study Objective: To determine if pregnant adolescents interested in group-based prenatal care have different demographic and psychosocial characteristics than those interested in individual prenatal care. Factors that influence the preferred model of prenatal care patients were assessed. Design, Setting, and Participants: Prospective comparison of demographic and psychosocial characteristics of 153 pregnant adolescents enrolled in an adolescent-oriented prenatal and pediatric program at Children's Hospital Colorado. Interventions: None. Main Outcome Measures: Pregnant study participants were queried and their preferred mode of prenatal care and reasons for that preference were examined. Results: Younger (16 years and younger) and primiparous adolescents were more likely to be interested in group care. Those not interested in group-based care were more likely to smoke and wanted to be pregnant. Most participants were interested in group-based prenatal care to belong to a peer group, receive additional education and support, and to have fun. Reasons participants were not interested in groupbased care included concerns about belonging to a group, preferring individual care, and experiencing logistical concerns such as scheduling conflicts, limited transportation, and childcare resources. Conclusions: Identifying which patients are interested in group prenatal care influences development of the program model and recruiting procedures, maximizing the effectiveness of the program by offering services based on patient needs. Identifying factors that influence patients' prenatal care choices enables providers to offer support to reduce barriers to participation and structure care that is best suited to patients willing to commit to and engage in the program. Key Words: Pregnancy, Group-based care, Prenatal care, Adolescents, Patient choice
Introduction
Adolescence is a time of developmental and emotional transitions requiring adolescents to navigate many challenges and difficulties.1,2 These dramatic shifts become more complex when an adolescent is pregnant.3 While the number of births to adolescent mothers has declined in the United States, rates remain the highest among industrialized nations.4 There are health, social, and economic consequences of adolescent pregnancy and birth that affect the adolescents, their children, and society. Health consequences for pregnant adolescents include gestational hypertension, anemia, obstructed and prolonged labor, and infections, while birth complications include premature delivery and low birth weight infants.5 Adolescent pregnancy and birth have been associated with poor educational achievement, poverty, and social deprivation.5 Prenatal care services are provided with the goal to minimize preventable complications and optimize maternal and fetal health.6,7 Traditionally, the primary focus within The authors indicate no conflicts of interest. * Address correspondence to: Kim D. Weber Yorga, RN, MSN, Department of Pediatrics, Prevention Research Center for Family and Child Health, University of Colorado, Mail Stop 8410, 13121 E. 17th Avenue, Aurora, CO 80045; Phone: (303) 724-3893; fax: (303) 724-2901 E-mail address: [email protected] (K.D. Weber Yorga).
prenatal care systems is physical health monitoring,6 although ideally, comprehensive models of prenatal care would also include education and psychosocial support.8e10 This is especially critical for pregnant adolescents to address the dramatic transitions and challenges they experience.11,12 However, education and psychosocial support services are often considered ancillary and offered in limited capacity due to time and resource constraints.13 Within the past 15 years, models of group-based prenatal care (GPNC) have been developed to integrate health assessment, education, and support components. In the most common model of GPNC, these components are typically delivered in 10 sessions with groups of 10 to 12 women with similar gestational ages beginning in the second trimester of pregnancy.14 Several studies of GPNC have been completed, although only 1 assessed outcomes specifically for pregnant adolescents enrolled in GPNC.12 The majority of the studies have not examined characteristics of patients choosing group versus individual care, and there has been limited research describing factors that influence a patient's decisions to choose GPNC.1517 The Colorado Adolescent Maternity Program (CAMP) at the University of Colorado, School of Medicine and Children's Hospital Colorado is a multidisciplinary, adolescent-oriented prenatal, postpartum, and pediatric care program. The CAMP's model of individual care serves
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pregnant adolescents aged 14 to 21 years and provides medical care and case management services. These services continue to be offered to the mother and infant in joint visits after delivery. During the study period, a model of GPNC was being developed but was not yet available to patients. The CAMP patients were asked to share their thoughts and opinions about the new GPNC program. This new GPNC model consists of groups of 10 to 12 young women who have estimated due dates within a 6-week range. Each group meets every 2 weeks, beginning when participants are at 12 to 18 weeks' gestation, and continues through the infants' first birthday. The CAMP group care model was developed to address some of the limitations of GPNC and to specifically address the needs of pregnant and parenting adolescents. This study had 2 main objectives. The first objective was to determine if pregnant adolescents interested in GPNC have different demographic and psychosocial characteristics than those preferring individual prenatal care. Understanding the characteristics of pregnant adolescents who are interested in GPNC rather than individual prenatal care is useful because recruitment methods for group care models may be improved in order to make such programs more appealing to certain groups of pregnant adolescents. Also, understanding these characteristics allows the group care model to be tailored to best meet the needs of patients choosing to participate in group. The second objective of this study was to explore factors that influence the model of prenatal care patients would prefer. These factors may highlight perceived benefits and barriers for each care option and allow for improvements in how care options are presented and discussed with patients. Understanding these factors allows the program to be effectively marketed to the target population and can enhance recruitment for GPNC programs. Materials and Methods Participants
The study participants were a convenience sample of pregnant adolescents, aged 21 years and younger, who were receiving prenatal care at CAMP, who were English speaking, and who were willing to participate in the study. Participants were excluded when they did not meet all 4 inclusion criteria. All patients who enroll in CAMP are offered participation in ongoing institutional review boardeapproved research, approved by the Colorado Multiple Institutional Review Board. This study falls under the CAMP general research informed consent.
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GPNC program was presented by using a script. After hearing about the program, study participants were asked to complete a 5-item survey, developed by the researchers, to determine impressions about the newly developed group-based option of care to be offered at CAMP (Appendix). This project was completed as part of the development process of GPNC, before group care was an actual option for prenatal care in CAMP. Participant opinions about the group care program were collected while patients were receiving individual prenatal care before their participation in GPNC. The first survey item used a continuous rating scale that asked study participants how likely they would be to participate in group care on a scale of 1 to 10 (1 5 not at all likely and 10 5 extremely likely). Participants were dichotomized as “Interested” (I) when they provided a rating of 6 to 10 as they were more likely than not to want to participate in the group care program or “Not Interested” (NI) when they provided a rating of 1 to 5 as they preferred individual care. The second item asked participants to provide open-ended responses explaining their rationale for their selection, listing the reasons why they would or would not be interested in group care. The next 2 items asked what participants liked and did not like about the program. The final question asked participants if there was anything else they would like to share regarding the idea of receiving care in a group setting. The program overview and survey completion took approximately 5 minutes to complete. Data were entered directly by patients on an iPadâ into the Research Electronic Data Capture (REDCap) system,18 a secure, web-based application hosted by the University of Colorado. For patients who were not comfortable entering data on the iPadâ, a hard-copy version of the survey was provided. For patients with literacy issues, the research assistants read the survey questions, recording the patients' verbal responses. Data were deidentified and stored in REDCap on a secure server. Demographic and psychosocial variables, reproductive characteristics, and reasons for pregnancy were extracted from the CAMP database, the Electronic Report on Adolescent Pregnancy (ERAP).19 The ERAP compiles responses to the self-administered questionnaires that are used to collect information about program participants: (1) medical, psychological, sexual, and reproductive histories; (2) social context of their pregnancies; (3) clinical and research evaluations conducted by the CAMP staff; and (4) supplemental data abstracted from maternal and child medical records. Variables
Procedures
Data were obtained prospectively from patients attending prenatal appointments at CAMP for 2 periods (September 2009 to January 2010 and May to October 2013) as the GPNC program was being developed and again before implementation of the pilot. Three research assistants approached patients, explaining the purpose of the study and risks and benefits of participation. An overview of the
Demographic variables include age, race/ethnicity, education, and body mass index (BMI; kg/m2). Age at conception was calculated using the estimated first day of the last menstrual period and date of birth. Age was dichotomized as 16 years or younger as studies consistently demonstrate that adolescents who conceive when they are 16 years or younger are at a risk for adverse pregnancy, parenting, and personal outcomes.20e24 Race/ethnicity was
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self-reported by participants and categorized as black, Hispanic, white, or other. The BMI was computed using self-reported prepregnancy weight25 or, if not available, weight at the first prenatal appointment along with height. The BMI was categorized by using the Institute of Medicine categories: underweight less than 18.5, normal weight 18.5 to 24.9, and overweight/obese 25.0 or greater.26 Reproductive characteristics including gravidity and parity were evaluated and dichotomized as primigravid and nulliparous, respectively. Psychosocial variables include social support, depression, stress, and substance use and were assessed at CAMP prenatal intake appointments. Social support is determined using the Family APGAR, a measure of 5 parameters of family functioning: Adaptability, Partnership, Growth, Affection, and Resolve.27 Individuals' day-to-day functioning is compromised by poor family (social) support, indicated by a score of 6 or less. The Center for Epidemiologic StudieseDepression Scale (CES-D) is a measure used to quantify depressive symptoms during pregnancy.28 A score of 24 or greater is indicative of depressive symptomatology. Stress levels were determined using the Stress Scale, a 17-item checklist of negative life events used to quantify chronic exposure to personally stressful events. The Stress Scale was adapted from Newton's 24-item version of the Cochrane and Robertson Life Events Scale.29 Individuals who have perceived stress scores of 9 or greater are classified as “stressed.” Current use of alcohol and cigarettes was based on self-report at prenatal appointments. Use of illicit substances was determined by positive self-report or a positive urine toxicology screen. The reason for pregnancy was measured using the Hierarchal Algorithm for Classifying Reasons for Not Using Contraceptives.30 This algorithm classifies reasons for not using contraception into 7 categories: not wanting to prevent pregnancy, experienced contraceptive failure, did not believe that she could become pregnant, believed contraception to be unsafe or was concerned about side effects, not planning to have sexual intercourse, pregnancy prevention not a priority, or encountered logistical barriers. The reason for pregnancy, a proxy for pregnancy intention, is an important predictor of pregnancy outcomes including repeat pregnancy.31e34 Analyses
Descriptive statistics including mean and standard deviations or percentage were used to summarize sample characteristics and responses to survey items, and c2 tests (dichotomous variables) and t tests were used to compare the 2 study groups (I and NI). The reasons participants would be interested in GPNC or individual care were manually coded by 2 investigators. The investigators met to reach consensus on commonly reported categories. Results
Findings reveal difference in some of the sample characteristics based on interest in group-based or individual
prenatal care, and many reasons for the participants' choices are outlined next. Sample Characteristics
A total of 162 women were eligible to be included in the study; 1 could not be contacted to complete the questionnaire, 1 participant's medical record could not be accessed due to child protection concerns, and 7 participants did not complete the questionnaire. The study sample consisted of a multiracial group (49.4% Hispanic, 24.1% black, 17.9% white, and 8.6% other) of 153 pregnant 15- to 21-year-olds. The gestational age of the study participants was 4 to 33 weeks (mean gestational age 21.6 10.7 weeks). The majority of the study sample qualified for Medicaid insurance (91.9%). The majority (80.8%) of the women in the study had graduated from high school or were currently in school, and 79.7% of the sample completed a grade level considered to be appropriate for their age. Demographic and reproductive characteristics are listed in Table 1. Around one-quarter of the sample (22.9%) had poor social support. Depressive symptomology was present in Table 1 Characteristics of the Population Variable
Mean SD or % N 5 153
Age (y) Age #16 y Gravidity Primigravid Parity Nulliparous Race Black White Hispanic Other Body mass index (kg/m2) Underweight (!18.5) Average weight (18.5e24.9) Overweight/obese (O24.9) Psychosocial measures In school or graduated Grade completed appropriate for age* In a relationship with father of child Living with parent(s) Family Adaptability, Partnership, Growth, Affection, and Resolve (Family APGAR) Scale Family APGAR #6 (poor support) Center for Epidemiologic StudieseDepression Scale (CES-D) CES-D $24 (depressed) Stress score Stress score $9y Using illicit drugs Using alcohol Smoking Reasons for pregnancy Not wanting to prevent pregnancy Experienced contraceptive failure Did not believe that she could become pregnant Believed contraception to be unsafe or was concerned about side effects Not planning to have sexual intercourse Pregnancy prevention not a priority Encountered logistical barriers to obtaining contraception
18.4 1.6 18.5% 1.4 0.7 72.2% 0.2 0.5 86.4% 24.1% 17.9% 49.4% 8.6% 25.1 6.4 9.6% 49.0% 41.4% 80.8% 79.7% 86.3% 56.2% 8.1 2.6 22.9% 16.0 9.1 22.6% 4.4 5.1 20.3% 23.5% 27.2% 21.0% 29.7% 22.1% 6.9% 10.3% 9.7% 18.6% 2.8%
* Positive if age minus highest grade completed !7 for participants aged !20 years or 12th grade or high school graduation equivalence for participants aged $20 years. y Individuals who have perceived stress scores $9 are classified as “stressed”.
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22.6%, and 20.3% reported high levels of stress. One-quarter of the sample were not preventing pregnancy (29.7%), and the most prevalent reasons for being pregnant included contraceptive failure (22.1%), pregnancy prevention was not a priority (18.6%), believed contraception to be unsafe or was concerned about the side effects (10.3%), and not planning to have sexual intercourse (9.7%). Reasons for Choosing Group-based or Individual Prenatal Care
Overall, 94 young women (61.4%) were interested in group care (I) and 59 (38.6%) were not interested in group care (NI). The majority who were interested (77) provided reasons describing what they liked about the prenatal group care program (Table 2). Three participants who were interested did not provide any reason, and 14 indicated that they were unsure why they provided the rating they did. Multiple responses were permissible, and a total of 95 responses were provided. All responses provided were reviewed and placed into 3 categories: belonging to a group, perceived need/benefit of group care, and preference for group prenatal care. Of the patients who would be interested in group-based care, 43% provided responses fitting within the belonging to a group category. These participants reported that they liked that group care provided the opportunity to spend time with peers and that they could talk and share with others. Almost half (43%) of patients who were interested in group-based care provided reasons describing the perceived need/benefit of group care, sharing that group care provided additional education and information, was a forum to ask questions, that the program would be helpful, and liked that support people could attend sessions with them. Some patients (14%) indicated a preference for group prenatal care, sharing that groups sounded like fun and liked that group care provided the opportunity for frequent prenatal health monitoring. A total of 56 study participants provided rationale describing why they were not interested in GPNC (Table 3). Nine participants who were not interested did not provide any reason. Multiple responses were permissible and a total of 80 responses were provided. All responses provided were reviewed and placed into 5 categories: concerns about Table 2 Reasons Patients Were Interested in Group-Based Prenatal Care Reason
Percent of Total Responses*
Belonging to a group Spend time with peers Talk and share with others Perceived need/benefit of group care Receive education/information Able to ask questions It would be helpful Involves a support person Preference for group prenatal care Likes the idea of groups Sounds fun Frequent opportunity for prenatal assessment and to spend time with doctor
43%
* 95 total responses; 77 respondents.
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Table 3 Reasons Patients Were Not Interested in Group-Based Prenatal Care Reason
Percent of Total Responses*
Concerns about belonging to a group Does not want to be in a group Would not feel comfortable to be in a group Feels too shy “It is just not right for me” Does not like to talk to others Privacy concerns Does not sound like fun Preference for individual prenatal care Group appointments are too long There are too many group appointments Prefers individual care Barriers limiting attendance School/work conflict Limited transportation resources Too busy Limited childcare resources Perceived lack of need/benefit of group care Knows a lot about pregnancy Has a lot of experience caring for children Has a lot of help Pregnancy ambivalence Does not want to be pregnant Does not like to be pregnant
51%
26%
21%
1%
1%
* 80 total responses; 56 respondents.
belonging to a group, preference for individual prenatal care, barriers limiting regular attendance, perceived lack of need/benefit of group care, and pregnancy ambivalence. The most commonly reported reason patients did not choose group care related to concerns about belonging to a group (51%). These patients did not want to be part of a group, feel uncomfortable or shy in a group, did not want to talk with others, thought it would not be fun, and had concerns of privacy. A quarter of patients (26%) indicated a preference for individual care, sharing they wanted one-onone time with the doctor, that there were too many group appointments, or they were concerned that the group appointments were too long. Some of the participants provided reasons that were barriers limiting regular attendance to group appointments (21%) including school and/or work conflicts, limited transportation resources, limited childcare resources, and that they were too busy to attend regular group appointments. One participant responded that she had a lot of experience caring for child and perceived a lack of need/benefit of group care. One participant responded that she was not interested in GPNC because she did not like being pregnant. Sample Characteristics Based on Interest in Group-based or Individual Prenatal Care
43%
14%
The younger participants (16 years or younger) were more likely to be interested in group care (25.5% versus 6.8% NI; odds ratio [OR] 4.7, 95% confidence interval [CI] 1.6 to 14.4). Participants who were pregnant for the first time were more likely to be interested in GPNC than were adolescents who had been pregnant 2 or more times (81.9% versus 59.3%; OR 3.1, 95% CI 1.5 to 6.5). Similarly, participants who had never given birth to a child were
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Table 4 Comparison of Patients Who Were Interested or Not Interested in Prenatal Group Care Variable
Age (y) Age #16 y Gravida Primigravid Parity Nulliparous Race Hispanic Black White Other Body mass index (kg/m2) Underweight Average weight Overweight/obese Psychosocial measures In school or graduatedz Grade completed appropriate for age In a relationship with father of child Living with parent(s) Family Adaptability, Partnership, Growth, Affection, and Resolve (APGAR) Scale Family APGAR #6 (poor support) Center for Epidemiologic Studies Depression Scale (CES-D) CES-D $24 (depressed) Stress score Stress score $ 9x Using illicit drugs Using alcohol Smoking Reasons for pregnancy Wanted to be pregnant Pregnancy the result of birth control failure Thought they were sterile Worried about side effects of contraception Not planning to have sex Contraception not a priority Had barriers to obtaining or using contraception
Interested (I) n 5 94
Not Interested (NI) n 5 59
Mean (SD) or %
Mean (SD) or %
18.1 (1.6) 25.5% 1.2 (0.5) 81.9% 0.1 (0.4) 93.6%
18.7 (1.4) 6.8% 1.6 (0.8) 59.3% 0.3 (0.6) 76.3%
50.0% 24.5% 18.1% 7.4% 24.9 (6.9) 11.1% 51.1% 37.8%
47.5% 23.7% 20.3% 8.5% 25.5 (5.8) 8.6% 46.6% 44.8%
75.5% 78.2% 88.2% 58.5% 8.0 (2.6) 22.6% 16.3 (8.8) 21.3% 4.1 (4.8) 17.2% 19.1% 26.6% 12.8%
69.5% 83.0% 83.1% 50.8% 8.4 (2.5) 21.4% 14.7 (8.8) 21.1% 4.5 (4.8) 24.6% 28.8% 28.8% 33.9%
19.8% 26.7% 10.5% 10.5% 10.5% 18.6% 3.5%
47.1% 15.7% 0% 7.8% 7.8% 21.6% 0%
P Value*
OR; 95% CIy
.02 4.7; 1.6e14.4 .002 3.1; 1.5e6.5 .03 4.6; 1.6e12.7 ref 1.0; 0.4e2.2 0.8; 0.4e2.0 0.8; 0.2e2.9 .60 1.3; 0.4e4.0 ref 0.8; 0.4e1.5 1.4; 0.7; 1.5; 1.4;
0.7e2.8 0.3e1.8 0.6e3.8 0.7e2.6
.44 1.1; 0.5e2.4 .30 1.0; 0.5e2.3 .65 0.6; 0.6; 0.9; 0.3;
0.3e1.4 0.3e1.3 0.4e1.9 0.1e0.6
0.3; 0.1e0.6 2.0; 0.8e4.8 d 1.4; 0.4e4.7 1.4; 0.4e4.7 0.8; 0.4e2.0 d
* P values from t tests of continuous variables. y Odds ratio and 95% confidence interval for dichotomous or categorical variables. z Positive if age minus highest grade completed !7 for participants aged !20 years or 12th grade or high school graduation equivalence for participants aged $20 years. x Individuals who have perceived stress scores $9 are classified as “stressed.”
more likely to be interested in GPNC than were adolescents who had 1 or more child (93.6% versus 76.3%; OR 4.6, 95% CI 1.6 to 12.7). Participants who were not interested in group were more likely to smoke than participants who were interested in group (33.9% versus 12.8%; OR 0.3, 95% CI 0.1 to 0.6). Participants in the NI group were more likely to have wanted to be pregnant than were participants who were interested in group (47.1% versus 19.8%; OR 0.3, 95% CI 0.1 to 0.6). Race, BMI, and the other psychosocial measures were not significantly different between the 2 groups. For more information about these findings, refer to Table 4. Discussion
The rate of patients interested in participating in group care in this study (approximately two-thirds) is lower than what is cited by Schindler Rising for another model of GPNC, reporting “96% of women preferred receiving their prenatal care in groups.”35 Teate et al36 and Bloom37 report levels of interest as GPNC participation rates of 20% and 16%, respectively. These results may be lower because they
include actual participation in GPNC; more patients may indicate interest than actually participate in the group. A higher level of interest indicates patient perceived need and benefit. Level of interest influences patient uptake of GPNC, impacting the feasibility of offering this model of care. GPNC programs require a commitment from the patients, and outcomes of GPNC are enhanced when clients regularly attend group sessions.14 Determining the feasibility of GPNC also includes understanding patients' perceived benefits and what patients like and do not like about the program. Patients who were interested in the program liked that the program provided the opportunity to be part of a group, have fun, and share with other young mothers. GPNC provides opportunity for women who are experiencing the same life transition at the same time to come together for support and connect with each other. This aligns with findings indicating that adolescents found groups fun and reported decreased feelings of loneliness and isolation as they shared with other pregnant teens.12,38 Groups create an environment of positive peer support and encourage sharing, which is valued by participants and supports some of the challenges experienced by pregnant adolescents.2
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Almost half of adolescents reported they were interested in GPNC because of a perceived need and/or benefit such as groups would be helpful, they would receive extra information, they could ask questions, and they could bring someone with them. This supports that patients value education, and findings from other research demonstrate increased knowledge gains for patients participating in GPNC.12,14,15,38,39 Increased knowledge is important to facilitate understanding, support decision making, and enhance behaviors that are supportive of optimal physical and psychosocial health and well-being. Adolescent patients recognize that additional education offers support for having a healthy pregnancy and becoming a parent. Some patients did have concerns about belonging to a group, expressing that they were shy, would not feel comfortable sharing in the group, had concerns of privacy, and do not see the personal value of peer support. These reasons for not be interested in GPNC align with others cited in the literature including lack of privacy, feeling uncomfortable or anxious in groups, having concerns about or not liking groups, and wanting individual time with the medical provider.40,41 They demonstrate patient preference for the status quo and reluctance for something different and may be based on lack of knowledge about available care options.40 One-quarter of patients who were not interested in GPNC were concerned that group sessions were too long and that there were too many appointments (sessions). The group program requires commitment from patients to support the provision of regular medical care and to allow relationships and group process to be strengthened over time with consistent group membership. The expectation for commitment and participation may be overwhelming to patients who are not feeling well, are ambivalent about the pregnancy, have busy schedules, feel they already have adequate knowledge or support, do not want to be part of a group, or do not feel extra education and support are necessary. Some patients who were not interested in GPNC shared barriers to participating, including time constraints related to work, school, and other schedules, as well as limited transportation and childcare resources. These are external reasons for not being able to attend group sessions on a regular basis, although they can also be a proxy for feeling ambivalent about not wanting to participate in the program without directly having to tell the recruiter they do not want to participate. Results from this study indicated there are varying demographic characteristics between patients interested in GPNC and those preferring individual prenatal care. Younger adolescents (16 years or younger) and primiparous patients were more likely to be interested in a group. Primiparous adolescents may be vulnerable, experiencing the challenge of being pregnant and preparing to be a firsttime parent. These patients may be more receptive to interventions that provide education and support during this major life change.42 By participating in GPNC, they have the opportunity to learn about having a healthy pregnancy and preparing for a baby. Participants who were not interested in a group were more likely to smoke than were participants who were interested in a group. The length of the sessions may be a
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concern for individuals who smoke as participation in group requires that patients go at least 2 hours without smoking, which may be difficult for some. It may also be that individuals who smoked are concerned they would be frequently reminded or pressured to quit smoking during their pregnancy, although none of the participants reported that as a reason. Providers may want to be aware that these well-intentioned messages can create feelings of guilt and have a negative effect on promoting healthy behavior change. Participants who were not interested in a group were more likely to have wanted to be pregnant than were participants who were interested in a group. While planning for their pregnancies, these patients may have engaged in activities to help them prepare, such as talking with others and reading pregnancy-related materials. They may have felt that GPNC could not offer much more benefit beyond what they already had, therefore having a preference for individual care. Conversely, participants with an unplanned pregnancy recognize the need for information and support after they learn they were pregnant, and GPNC provides this. All of these factors are important consideration for program development and implementation. The level of interest in GPNC suggests that many patients were interested in this model of care although many also preferred individual care, thereby validating the potential demand for developing and offering a new model of care in the clinic. This assisted planning for the allocation of clinic resources to ensure staff and scheduling could accommodate new group care offerings to meet patient demand while continuing to offer individual care for the rest of clinic population. The reasons why patients were interested in participating in GPNC informed the program model as it was being developed. The program model included bring together women of similar gestational ages, creating opportunities for sharing and discussion while respecting privacy, having individual time with the group facilitators and medical provider, and offering fun and interactive activities to facilitate learning. When talking to patients about new care options such as GPNC, it is important to ensure they make informed decisions about the type of care they select. Findings from this project informed recruitment strategies when group sessions were being initiated to ensure maximum uptake of GPNC. Being aware of the patient characteristics that influence the model of care choice allows the GPNC program to be offered in a manner that appeals to and meets the needs of a wide segment of the clinic population, rather than only to patients who initially find it acceptable. We developed a process to share information about GPNC and then find out what the patients knew about the program along with their perceived benefits and barriers to participating. We anticipated benefits and highlighted these when sharing information about the program. We also anticipated barriers to participation and gathered resources to address these such as bus tokens, taxi vouchers, and on-site child care. Recruiters talked to multiparous women about the program, focusing not just on what they could learn but also on how they could support other women in the group by sharing their previous knowledge and experience about pregnancy and parenting. Recruiters were trained to identify patient ambivalence and to offer strategies to support this,
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including highlighting benefits, reducing barriers, trying out the first group session, or, in some cases, validating that individual care may be the best option for them. Limitations
This study had a few limitations. First, we were unable to find any validated instrument to evaluate patient interest in a group care model. Thus, the survey we developed was novel and not yet validated. The survey was useful in gathering unrestrained responses about the relationship between participants' interest levels and reasons for their selection because the survey largely consisted of openended questions. However, the use of a nonvalidated tool potentially limits the validity and reliability of the findings. The survey was self-report, useful for gaining patient perspective explaining their care choices. However, selfreport potentially creates information bias and possibly also limits the validity of the findings. Another limitation is that all of the study participants were adolescents, which limits the generalizability of these findings to a larger segment of the prenatal population. There is a need in the future to assess factors influencing patients' selection of prenatal care options with adult women. Factors influencing patient care option choices were examined, although this study indicates a need to further explore the factors impacting the patient's actual participation in GPNC. Conclusions
Exploring why patients are interested in group or individual models of care is important for a few reasons. A variety of prenatal care options can meet patient demand and their diverse needs. Identifying the factors influencing patient choice helps providers understand patient needs and perceived benefits, highlighting what is important to patients. It also highlights barriers to participation, some of which can be reduced with additional resources and scheduling considerations. Factors that affect actual participation in care options also warrant further investigation as interest does not directly translate into attendance or participation. Understanding factors influencing patient choice of model of care provides insight into the type of information that patients require, supporting development of the program model and enhancing recruitment and marketing approaches to use when presenting care options to patients that appeal to them in a positive way. It is also important to note that even when patient characteristics are identified and participation barriers are reduced, not all patients would choose, enjoy, and benefit from a group. More research is needed to understand factors that influence patients' choice for prenatal care options with other populations and to improve patient participation in prenatal care programs. Acknowledgments
We thank Marci Peralto MD, Dawn Foster-Jeffries MPH, Rebecca Seale BA, and the staff at the Colorado Adolescent Maternity Program for their assistance with this project. Funding for the REDCap system is provided by NIH/NCRR Colorado CTSI grant UL1 TR001082.
References 1. Brindis CD, Park MJ, Valderrama LT, et al: Improving the Health of Adolescents & Young Adults: A Guide for States and Communities. Atlanta, GA, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Adolescent and School Health; Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Adolescent Health, National Adolescent Health Information Center, University of California, San Francisco, 2004 2. Cypher RL: Collaborative approaches to prenatal care: strategies of successful adolescent programs. J Perinat Neonatal Nurs 2013; 27:134 3. Cardone I, Gilkerson L, Wechsler N: Teenagers and Their Babies: A Perinatal Home Visitor's Guide. Washington, DC, Zero to Three, 2008 4. Department of Economic and Social Affairs, United Nations: 2009e2010 Demographic Yearbook. New York, United Nations, Department of Economic and Social Affairs, 2011 5. World Health Organization: Adolescent PregnancyeUnmet Needs and Undone Deeds. A Review of the Literature and Programmes. Geneva, Switzerland, World Health Organization, 2007 6. Dragonas T, Christodoulou GN: Prenatal care. Clin Psychol Rev 1998; 18:127 7. Manant A, Dodgson JE: CenteringPregnancy: an integrative literature review. J Midwifery Womens Health 2011; 56:94 8. American Academy of Pediatrics and American College of Obstetrics and Gynecologists: Guidelines for perinatal care, (6th ed.). 2007. Elk Grove, Ill and Washington, DC: ACOG. 9. Moos MK: Prenatal care: limitations and opportunities. J Obstet Gynecol Neonatal Nurs 2006; 35:278 10. Lathrop B: A systematic review comparing group prenatal care to traditional prenatal care. Nurs Womens Health 2013; 17:118 11. Thielen K: Exploring the group prenatal care model: a critical review of the literature. J Perinat Educ 2012; 21:209 12. Grady MA, Bloom KC: Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program. J Midwifery Womens Health 2004; 49:412 13. Alexander GR, Kotelchuck M: Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research. Public Health Rep 2001; 116:306 14. Ickovics JR, Kershaw TS, Westdahl C, et al: Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol 2007; 110:330 15. Sheeder J, Weber Yorga K, Kabir-Greher K: A review of prenatal group care literature: the need for a structured theoretical framework and systematic evaluation. Matern Child Health J 2012; 16:177 16. Tilden EL, Hersh SR, Emeis CL, et al: Group prenatal care: review of outcomes and recommendations for model implementation. Obstet Gynecol Surv 2014; 69:46 17. Robertson B, Aycock DM, Darnell LA: Comparison of centering pregnancy to traditional care in Hispanic mothers. Matern Child Health J 2009; 13:407 18. Harris PA, Taylor R, Thielke R, et al: Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42:377 19. Sheeder J, Scott S, Stevens-Simon C: The Electronic Report on Adolescent Pregnancy (ERAP). J Pediatr Adolesc Gynecol 2004; 17:341 20. Eure CR, Lindsay MK, Graves WL: Risk of adverse pregnancy outcomes in young adolescent parturients in an inner-city hospital. Am J Obstet Gynecol 2002; 186:918 21. Flanagan PJ, McGrath MM, Meyer EC, et al: Adolescent development and transitions to motherhood. Pediatrics 1995; 96:273 22. Phipps MG, Sowers M: Defining early adolescent childbearing. Am J Public Health 2002; 92:125 23. Scholl TO, Hediger ML: Weight gain, nutrition, and pregnancy outcome: findings from the Camden Study of Teenage and Minority Gravidas. Semin Perinatol 1995; 19:171 24. Stevens-Simon C, Roberta K, Beach RK, et al: Does incomplete growth and development predispose teenagers to preterm delivery? A template for research. Am J Perinatol 2002; 22:315 25. Stevens-Simon C, Roghmann KJ, McAnarney ER: Bias in self-reported prepregnant weight: relationship to body habitus and age. J Am Diet Assoc 1992; 92:85 26. Institute of Medicine: Weight gain during pregnancy: reexamining the guidelines. Washington, DC, National Academies Press, 2009 27. Smilkstein G: The family APGAR: a proposal for a family function test and its use by physicians. J Fam Pract 1978; 6:1231 28. Radloff L: The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1:385 29. Newton RW, Webster PA, Binu PS, et al: Psychosocial stress in pregnancy and its relation to the onset of premature labour. Br Med J 1979; 2:411 30. Sheeder J, Tocce K, Stevens-Simon C: Reasons for ineffective contraceptive use antedating adolescent pregnancies, part 1: an indicator of gaps in family planning services. Matern Child Health J 2009; 13:295 31. Sheeder J, Tocce K, Stevens-Simon C: Reasons for ineffective contraceptive use antedating adolescent pregnancies, part 2: a proxy for childbearing intentions. Matern Child Health J 2009; 13:306 32. Stevens-Simon C, Beach RK, Klerman LV: To be rather than not to be: that is the problem with the questions we ask adolescents about their childbearing intentions. Arch Pediatr Adolesc Med 2001; 155:1298 33. Stevens-Simon C, Kelly L, Singer D, et al: Why pregnant adolescents say they did not use contraceptives prior to conception. J Adolesc Health 1996; 19:48. discussion 4.
K.D. Weber Yorga, J.L. Sheeder / J Pediatr Adolesc Gynecol 28 (2015) 508e515 34. Stevens-Simon C, Kelly L, Singer D, et al: Reasons for first teen pregnancies predict the rate of subsequent teen conceptions. Pediatrics 1998; 101:E8 35. Rising SS: Centering pregnancy. An interdisciplinary model of empowerment. J Nurse Midwifery 1998; 43:46 36. Teate A, Leap N, Rising SS, et al: Women's experiences of group antenatal care in Australia: the CenteringPregnancy Pilot Study. Midwifery 2011; 27: 138 37. Bloom KC: Use of the CenteringPregnancy program in a school-based clinic: a pilot study. Clin Excel Nurse Pract 2005; 9:213 38. McNeil DA, Vekved M, Dolan SM, et al: Getting more than they realized they needed: a qualitative study of women's experience of group prenatal care. BMC Pregnancy Childbirth 2012; 12:17 39. Ruiz-Mirazo E, Lopez-Yarto M, McDonald SD: Group prenatal care versus individual prenatal care: a systematic review and meta-analyses. J Obstet Gynaecol Can 2012; 34:223 40. Phillippi JC, Myers CR: Reasons women in Appalachia decline CenteringPregnancy care. J Midwifery Womens Health 2013; 58:516 41. Vonderheid SC, Carrie SK, Norr KF, et al: Using focus groups and social marketing to strengthen promotion of group prenatal care. ANS Adv Nursing Sci 2013; 36:320 42. Olds DL: The nurse-family partnership: an evidence-based preventive intervention. Infant Ment Health J 2006; 27:5
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Appendix. Group Prenatal Care Survey
1. We are still creating the program and currently not offering groups right now. However, if we were offering the group care program, how likely would you be to participate? 1 Not at all likely
2. 3. 4. 5.
2
3
4
5
6
7
8
9
10 Extremely likely
Why did you provide the response you did? What do you like about the group care program? What do you not like about the group care program? What else would you like to share regarding the idea of receiving care in a group setting?
Prevention Research Center for Family and Child Health, University of Colorado School of Medicine, Aurora, Colorado Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
a b s t r a c t Study Objective: To determine if pregnant adolescents interested in group-based prenatal care have different demographic and psychosocial characteristics than those interested in individual prenatal care. Factors that influence the preferred model of prenatal care patients were assessed. Design, Setting, and Participants: Prospective comparison of demographic and psychosocial characteristics of 153 pregnant adolescents enrolled in an adolescent-oriented prenatal and pediatric program at Children's Hospital Colorado. Interventions: None. Main Outcome Measures: Pregnant study participants were queried and their preferred mode of prenatal care and reasons for that preference were examined. Results: Younger (16 years and younger) and primiparous adolescents were more likely to be interested in group care. Those not interested in group-based care were more likely to smoke and wanted to be pregnant. Most participants were interested in group-based prenatal care to belong to a peer group, receive additional education and support, and to have fun. Reasons participants were not interested in groupbased care included concerns about belonging to a group, preferring individual care, and experiencing logistical concerns such as scheduling conflicts, limited transportation, and childcare resources. Conclusions: Identifying which patients are interested in group prenatal care influences development of the program model and recruiting procedures, maximizing the effectiveness of the program by offering services based on patient needs. Identifying factors that influence patients' prenatal care choices enables providers to offer support to reduce barriers to participation and structure care that is best suited to patients willing to commit to and engage in the program. Key Words: Pregnancy, Group-based care, Prenatal care, Adolescents, Patient choice
Introduction
Adolescence is a time of developmental and emotional transitions requiring adolescents to navigate many challenges and difficulties.1,2 These dramatic shifts become more complex when an adolescent is pregnant.3 While the number of births to adolescent mothers has declined in the United States, rates remain the highest among industrialized nations.4 There are health, social, and economic consequences of adolescent pregnancy and birth that affect the adolescents, their children, and society. Health consequences for pregnant adolescents include gestational hypertension, anemia, obstructed and prolonged labor, and infections, while birth complications include premature delivery and low birth weight infants.5 Adolescent pregnancy and birth have been associated with poor educational achievement, poverty, and social deprivation.5 Prenatal care services are provided with the goal to minimize preventable complications and optimize maternal and fetal health.6,7 Traditionally, the primary focus within The authors indicate no conflicts of interest. * Address correspondence to: Kim D. Weber Yorga, RN, MSN, Department of Pediatrics, Prevention Research Center for Family and Child Health, University of Colorado, Mail Stop 8410, 13121 E. 17th Avenue, Aurora, CO 80045; Phone: (303) 724-3893; fax: (303) 724-2901 E-mail address: [email protected] (K.D. Weber Yorga).
prenatal care systems is physical health monitoring,6 although ideally, comprehensive models of prenatal care would also include education and psychosocial support.8e10 This is especially critical for pregnant adolescents to address the dramatic transitions and challenges they experience.11,12 However, education and psychosocial support services are often considered ancillary and offered in limited capacity due to time and resource constraints.13 Within the past 15 years, models of group-based prenatal care (GPNC) have been developed to integrate health assessment, education, and support components. In the most common model of GPNC, these components are typically delivered in 10 sessions with groups of 10 to 12 women with similar gestational ages beginning in the second trimester of pregnancy.14 Several studies of GPNC have been completed, although only 1 assessed outcomes specifically for pregnant adolescents enrolled in GPNC.12 The majority of the studies have not examined characteristics of patients choosing group versus individual care, and there has been limited research describing factors that influence a patient's decisions to choose GPNC.1517 The Colorado Adolescent Maternity Program (CAMP) at the University of Colorado, School of Medicine and Children's Hospital Colorado is a multidisciplinary, adolescent-oriented prenatal, postpartum, and pediatric care program. The CAMP's model of individual care serves
1083-3188/$ - see front matter Ó 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2015.03.006
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pregnant adolescents aged 14 to 21 years and provides medical care and case management services. These services continue to be offered to the mother and infant in joint visits after delivery. During the study period, a model of GPNC was being developed but was not yet available to patients. The CAMP patients were asked to share their thoughts and opinions about the new GPNC program. This new GPNC model consists of groups of 10 to 12 young women who have estimated due dates within a 6-week range. Each group meets every 2 weeks, beginning when participants are at 12 to 18 weeks' gestation, and continues through the infants' first birthday. The CAMP group care model was developed to address some of the limitations of GPNC and to specifically address the needs of pregnant and parenting adolescents. This study had 2 main objectives. The first objective was to determine if pregnant adolescents interested in GPNC have different demographic and psychosocial characteristics than those preferring individual prenatal care. Understanding the characteristics of pregnant adolescents who are interested in GPNC rather than individual prenatal care is useful because recruitment methods for group care models may be improved in order to make such programs more appealing to certain groups of pregnant adolescents. Also, understanding these characteristics allows the group care model to be tailored to best meet the needs of patients choosing to participate in group. The second objective of this study was to explore factors that influence the model of prenatal care patients would prefer. These factors may highlight perceived benefits and barriers for each care option and allow for improvements in how care options are presented and discussed with patients. Understanding these factors allows the program to be effectively marketed to the target population and can enhance recruitment for GPNC programs. Materials and Methods Participants
The study participants were a convenience sample of pregnant adolescents, aged 21 years and younger, who were receiving prenatal care at CAMP, who were English speaking, and who were willing to participate in the study. Participants were excluded when they did not meet all 4 inclusion criteria. All patients who enroll in CAMP are offered participation in ongoing institutional review boardeapproved research, approved by the Colorado Multiple Institutional Review Board. This study falls under the CAMP general research informed consent.
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GPNC program was presented by using a script. After hearing about the program, study participants were asked to complete a 5-item survey, developed by the researchers, to determine impressions about the newly developed group-based option of care to be offered at CAMP (Appendix). This project was completed as part of the development process of GPNC, before group care was an actual option for prenatal care in CAMP. Participant opinions about the group care program were collected while patients were receiving individual prenatal care before their participation in GPNC. The first survey item used a continuous rating scale that asked study participants how likely they would be to participate in group care on a scale of 1 to 10 (1 5 not at all likely and 10 5 extremely likely). Participants were dichotomized as “Interested” (I) when they provided a rating of 6 to 10 as they were more likely than not to want to participate in the group care program or “Not Interested” (NI) when they provided a rating of 1 to 5 as they preferred individual care. The second item asked participants to provide open-ended responses explaining their rationale for their selection, listing the reasons why they would or would not be interested in group care. The next 2 items asked what participants liked and did not like about the program. The final question asked participants if there was anything else they would like to share regarding the idea of receiving care in a group setting. The program overview and survey completion took approximately 5 minutes to complete. Data were entered directly by patients on an iPadâ into the Research Electronic Data Capture (REDCap) system,18 a secure, web-based application hosted by the University of Colorado. For patients who were not comfortable entering data on the iPadâ, a hard-copy version of the survey was provided. For patients with literacy issues, the research assistants read the survey questions, recording the patients' verbal responses. Data were deidentified and stored in REDCap on a secure server. Demographic and psychosocial variables, reproductive characteristics, and reasons for pregnancy were extracted from the CAMP database, the Electronic Report on Adolescent Pregnancy (ERAP).19 The ERAP compiles responses to the self-administered questionnaires that are used to collect information about program participants: (1) medical, psychological, sexual, and reproductive histories; (2) social context of their pregnancies; (3) clinical and research evaluations conducted by the CAMP staff; and (4) supplemental data abstracted from maternal and child medical records. Variables
Procedures
Data were obtained prospectively from patients attending prenatal appointments at CAMP for 2 periods (September 2009 to January 2010 and May to October 2013) as the GPNC program was being developed and again before implementation of the pilot. Three research assistants approached patients, explaining the purpose of the study and risks and benefits of participation. An overview of the
Demographic variables include age, race/ethnicity, education, and body mass index (BMI; kg/m2). Age at conception was calculated using the estimated first day of the last menstrual period and date of birth. Age was dichotomized as 16 years or younger as studies consistently demonstrate that adolescents who conceive when they are 16 years or younger are at a risk for adverse pregnancy, parenting, and personal outcomes.20e24 Race/ethnicity was
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self-reported by participants and categorized as black, Hispanic, white, or other. The BMI was computed using self-reported prepregnancy weight25 or, if not available, weight at the first prenatal appointment along with height. The BMI was categorized by using the Institute of Medicine categories: underweight less than 18.5, normal weight 18.5 to 24.9, and overweight/obese 25.0 or greater.26 Reproductive characteristics including gravidity and parity were evaluated and dichotomized as primigravid and nulliparous, respectively. Psychosocial variables include social support, depression, stress, and substance use and were assessed at CAMP prenatal intake appointments. Social support is determined using the Family APGAR, a measure of 5 parameters of family functioning: Adaptability, Partnership, Growth, Affection, and Resolve.27 Individuals' day-to-day functioning is compromised by poor family (social) support, indicated by a score of 6 or less. The Center for Epidemiologic StudieseDepression Scale (CES-D) is a measure used to quantify depressive symptoms during pregnancy.28 A score of 24 or greater is indicative of depressive symptomatology. Stress levels were determined using the Stress Scale, a 17-item checklist of negative life events used to quantify chronic exposure to personally stressful events. The Stress Scale was adapted from Newton's 24-item version of the Cochrane and Robertson Life Events Scale.29 Individuals who have perceived stress scores of 9 or greater are classified as “stressed.” Current use of alcohol and cigarettes was based on self-report at prenatal appointments. Use of illicit substances was determined by positive self-report or a positive urine toxicology screen. The reason for pregnancy was measured using the Hierarchal Algorithm for Classifying Reasons for Not Using Contraceptives.30 This algorithm classifies reasons for not using contraception into 7 categories: not wanting to prevent pregnancy, experienced contraceptive failure, did not believe that she could become pregnant, believed contraception to be unsafe or was concerned about side effects, not planning to have sexual intercourse, pregnancy prevention not a priority, or encountered logistical barriers. The reason for pregnancy, a proxy for pregnancy intention, is an important predictor of pregnancy outcomes including repeat pregnancy.31e34 Analyses
Descriptive statistics including mean and standard deviations or percentage were used to summarize sample characteristics and responses to survey items, and c2 tests (dichotomous variables) and t tests were used to compare the 2 study groups (I and NI). The reasons participants would be interested in GPNC or individual care were manually coded by 2 investigators. The investigators met to reach consensus on commonly reported categories. Results
Findings reveal difference in some of the sample characteristics based on interest in group-based or individual
prenatal care, and many reasons for the participants' choices are outlined next. Sample Characteristics
A total of 162 women were eligible to be included in the study; 1 could not be contacted to complete the questionnaire, 1 participant's medical record could not be accessed due to child protection concerns, and 7 participants did not complete the questionnaire. The study sample consisted of a multiracial group (49.4% Hispanic, 24.1% black, 17.9% white, and 8.6% other) of 153 pregnant 15- to 21-year-olds. The gestational age of the study participants was 4 to 33 weeks (mean gestational age 21.6 10.7 weeks). The majority of the study sample qualified for Medicaid insurance (91.9%). The majority (80.8%) of the women in the study had graduated from high school or were currently in school, and 79.7% of the sample completed a grade level considered to be appropriate for their age. Demographic and reproductive characteristics are listed in Table 1. Around one-quarter of the sample (22.9%) had poor social support. Depressive symptomology was present in Table 1 Characteristics of the Population Variable
Mean SD or % N 5 153
Age (y) Age #16 y Gravidity Primigravid Parity Nulliparous Race Black White Hispanic Other Body mass index (kg/m2) Underweight (!18.5) Average weight (18.5e24.9) Overweight/obese (O24.9) Psychosocial measures In school or graduated Grade completed appropriate for age* In a relationship with father of child Living with parent(s) Family Adaptability, Partnership, Growth, Affection, and Resolve (Family APGAR) Scale Family APGAR #6 (poor support) Center for Epidemiologic StudieseDepression Scale (CES-D) CES-D $24 (depressed) Stress score Stress score $9y Using illicit drugs Using alcohol Smoking Reasons for pregnancy Not wanting to prevent pregnancy Experienced contraceptive failure Did not believe that she could become pregnant Believed contraception to be unsafe or was concerned about side effects Not planning to have sexual intercourse Pregnancy prevention not a priority Encountered logistical barriers to obtaining contraception
18.4 1.6 18.5% 1.4 0.7 72.2% 0.2 0.5 86.4% 24.1% 17.9% 49.4% 8.6% 25.1 6.4 9.6% 49.0% 41.4% 80.8% 79.7% 86.3% 56.2% 8.1 2.6 22.9% 16.0 9.1 22.6% 4.4 5.1 20.3% 23.5% 27.2% 21.0% 29.7% 22.1% 6.9% 10.3% 9.7% 18.6% 2.8%
* Positive if age minus highest grade completed !7 for participants aged !20 years or 12th grade or high school graduation equivalence for participants aged $20 years. y Individuals who have perceived stress scores $9 are classified as “stressed”.
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22.6%, and 20.3% reported high levels of stress. One-quarter of the sample were not preventing pregnancy (29.7%), and the most prevalent reasons for being pregnant included contraceptive failure (22.1%), pregnancy prevention was not a priority (18.6%), believed contraception to be unsafe or was concerned about the side effects (10.3%), and not planning to have sexual intercourse (9.7%). Reasons for Choosing Group-based or Individual Prenatal Care
Overall, 94 young women (61.4%) were interested in group care (I) and 59 (38.6%) were not interested in group care (NI). The majority who were interested (77) provided reasons describing what they liked about the prenatal group care program (Table 2). Three participants who were interested did not provide any reason, and 14 indicated that they were unsure why they provided the rating they did. Multiple responses were permissible, and a total of 95 responses were provided. All responses provided were reviewed and placed into 3 categories: belonging to a group, perceived need/benefit of group care, and preference for group prenatal care. Of the patients who would be interested in group-based care, 43% provided responses fitting within the belonging to a group category. These participants reported that they liked that group care provided the opportunity to spend time with peers and that they could talk and share with others. Almost half (43%) of patients who were interested in group-based care provided reasons describing the perceived need/benefit of group care, sharing that group care provided additional education and information, was a forum to ask questions, that the program would be helpful, and liked that support people could attend sessions with them. Some patients (14%) indicated a preference for group prenatal care, sharing that groups sounded like fun and liked that group care provided the opportunity for frequent prenatal health monitoring. A total of 56 study participants provided rationale describing why they were not interested in GPNC (Table 3). Nine participants who were not interested did not provide any reason. Multiple responses were permissible and a total of 80 responses were provided. All responses provided were reviewed and placed into 5 categories: concerns about Table 2 Reasons Patients Were Interested in Group-Based Prenatal Care Reason
Percent of Total Responses*
Belonging to a group Spend time with peers Talk and share with others Perceived need/benefit of group care Receive education/information Able to ask questions It would be helpful Involves a support person Preference for group prenatal care Likes the idea of groups Sounds fun Frequent opportunity for prenatal assessment and to spend time with doctor
43%
* 95 total responses; 77 respondents.
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Table 3 Reasons Patients Were Not Interested in Group-Based Prenatal Care Reason
Percent of Total Responses*
Concerns about belonging to a group Does not want to be in a group Would not feel comfortable to be in a group Feels too shy “It is just not right for me” Does not like to talk to others Privacy concerns Does not sound like fun Preference for individual prenatal care Group appointments are too long There are too many group appointments Prefers individual care Barriers limiting attendance School/work conflict Limited transportation resources Too busy Limited childcare resources Perceived lack of need/benefit of group care Knows a lot about pregnancy Has a lot of experience caring for children Has a lot of help Pregnancy ambivalence Does not want to be pregnant Does not like to be pregnant
51%
26%
21%
1%
1%
* 80 total responses; 56 respondents.
belonging to a group, preference for individual prenatal care, barriers limiting regular attendance, perceived lack of need/benefit of group care, and pregnancy ambivalence. The most commonly reported reason patients did not choose group care related to concerns about belonging to a group (51%). These patients did not want to be part of a group, feel uncomfortable or shy in a group, did not want to talk with others, thought it would not be fun, and had concerns of privacy. A quarter of patients (26%) indicated a preference for individual care, sharing they wanted one-onone time with the doctor, that there were too many group appointments, or they were concerned that the group appointments were too long. Some of the participants provided reasons that were barriers limiting regular attendance to group appointments (21%) including school and/or work conflicts, limited transportation resources, limited childcare resources, and that they were too busy to attend regular group appointments. One participant responded that she had a lot of experience caring for child and perceived a lack of need/benefit of group care. One participant responded that she was not interested in GPNC because she did not like being pregnant. Sample Characteristics Based on Interest in Group-based or Individual Prenatal Care
43%
14%
The younger participants (16 years or younger) were more likely to be interested in group care (25.5% versus 6.8% NI; odds ratio [OR] 4.7, 95% confidence interval [CI] 1.6 to 14.4). Participants who were pregnant for the first time were more likely to be interested in GPNC than were adolescents who had been pregnant 2 or more times (81.9% versus 59.3%; OR 3.1, 95% CI 1.5 to 6.5). Similarly, participants who had never given birth to a child were
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Table 4 Comparison of Patients Who Were Interested or Not Interested in Prenatal Group Care Variable
Age (y) Age #16 y Gravida Primigravid Parity Nulliparous Race Hispanic Black White Other Body mass index (kg/m2) Underweight Average weight Overweight/obese Psychosocial measures In school or graduatedz Grade completed appropriate for age In a relationship with father of child Living with parent(s) Family Adaptability, Partnership, Growth, Affection, and Resolve (APGAR) Scale Family APGAR #6 (poor support) Center for Epidemiologic Studies Depression Scale (CES-D) CES-D $24 (depressed) Stress score Stress score $ 9x Using illicit drugs Using alcohol Smoking Reasons for pregnancy Wanted to be pregnant Pregnancy the result of birth control failure Thought they were sterile Worried about side effects of contraception Not planning to have sex Contraception not a priority Had barriers to obtaining or using contraception
Interested (I) n 5 94
Not Interested (NI) n 5 59
Mean (SD) or %
Mean (SD) or %
18.1 (1.6) 25.5% 1.2 (0.5) 81.9% 0.1 (0.4) 93.6%
18.7 (1.4) 6.8% 1.6 (0.8) 59.3% 0.3 (0.6) 76.3%
50.0% 24.5% 18.1% 7.4% 24.9 (6.9) 11.1% 51.1% 37.8%
47.5% 23.7% 20.3% 8.5% 25.5 (5.8) 8.6% 46.6% 44.8%
75.5% 78.2% 88.2% 58.5% 8.0 (2.6) 22.6% 16.3 (8.8) 21.3% 4.1 (4.8) 17.2% 19.1% 26.6% 12.8%
69.5% 83.0% 83.1% 50.8% 8.4 (2.5) 21.4% 14.7 (8.8) 21.1% 4.5 (4.8) 24.6% 28.8% 28.8% 33.9%
19.8% 26.7% 10.5% 10.5% 10.5% 18.6% 3.5%
47.1% 15.7% 0% 7.8% 7.8% 21.6% 0%
P Value*
OR; 95% CIy
.02 4.7; 1.6e14.4 .002 3.1; 1.5e6.5 .03 4.6; 1.6e12.7 ref 1.0; 0.4e2.2 0.8; 0.4e2.0 0.8; 0.2e2.9 .60 1.3; 0.4e4.0 ref 0.8; 0.4e1.5 1.4; 0.7; 1.5; 1.4;
0.7e2.8 0.3e1.8 0.6e3.8 0.7e2.6
.44 1.1; 0.5e2.4 .30 1.0; 0.5e2.3 .65 0.6; 0.6; 0.9; 0.3;
0.3e1.4 0.3e1.3 0.4e1.9 0.1e0.6
0.3; 0.1e0.6 2.0; 0.8e4.8 d 1.4; 0.4e4.7 1.4; 0.4e4.7 0.8; 0.4e2.0 d
* P values from t tests of continuous variables. y Odds ratio and 95% confidence interval for dichotomous or categorical variables. z Positive if age minus highest grade completed !7 for participants aged !20 years or 12th grade or high school graduation equivalence for participants aged $20 years. x Individuals who have perceived stress scores $9 are classified as “stressed.”
more likely to be interested in GPNC than were adolescents who had 1 or more child (93.6% versus 76.3%; OR 4.6, 95% CI 1.6 to 12.7). Participants who were not interested in group were more likely to smoke than participants who were interested in group (33.9% versus 12.8%; OR 0.3, 95% CI 0.1 to 0.6). Participants in the NI group were more likely to have wanted to be pregnant than were participants who were interested in group (47.1% versus 19.8%; OR 0.3, 95% CI 0.1 to 0.6). Race, BMI, and the other psychosocial measures were not significantly different between the 2 groups. For more information about these findings, refer to Table 4. Discussion
The rate of patients interested in participating in group care in this study (approximately two-thirds) is lower than what is cited by Schindler Rising for another model of GPNC, reporting “96% of women preferred receiving their prenatal care in groups.”35 Teate et al36 and Bloom37 report levels of interest as GPNC participation rates of 20% and 16%, respectively. These results may be lower because they
include actual participation in GPNC; more patients may indicate interest than actually participate in the group. A higher level of interest indicates patient perceived need and benefit. Level of interest influences patient uptake of GPNC, impacting the feasibility of offering this model of care. GPNC programs require a commitment from the patients, and outcomes of GPNC are enhanced when clients regularly attend group sessions.14 Determining the feasibility of GPNC also includes understanding patients' perceived benefits and what patients like and do not like about the program. Patients who were interested in the program liked that the program provided the opportunity to be part of a group, have fun, and share with other young mothers. GPNC provides opportunity for women who are experiencing the same life transition at the same time to come together for support and connect with each other. This aligns with findings indicating that adolescents found groups fun and reported decreased feelings of loneliness and isolation as they shared with other pregnant teens.12,38 Groups create an environment of positive peer support and encourage sharing, which is valued by participants and supports some of the challenges experienced by pregnant adolescents.2
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Almost half of adolescents reported they were interested in GPNC because of a perceived need and/or benefit such as groups would be helpful, they would receive extra information, they could ask questions, and they could bring someone with them. This supports that patients value education, and findings from other research demonstrate increased knowledge gains for patients participating in GPNC.12,14,15,38,39 Increased knowledge is important to facilitate understanding, support decision making, and enhance behaviors that are supportive of optimal physical and psychosocial health and well-being. Adolescent patients recognize that additional education offers support for having a healthy pregnancy and becoming a parent. Some patients did have concerns about belonging to a group, expressing that they were shy, would not feel comfortable sharing in the group, had concerns of privacy, and do not see the personal value of peer support. These reasons for not be interested in GPNC align with others cited in the literature including lack of privacy, feeling uncomfortable or anxious in groups, having concerns about or not liking groups, and wanting individual time with the medical provider.40,41 They demonstrate patient preference for the status quo and reluctance for something different and may be based on lack of knowledge about available care options.40 One-quarter of patients who were not interested in GPNC were concerned that group sessions were too long and that there were too many appointments (sessions). The group program requires commitment from patients to support the provision of regular medical care and to allow relationships and group process to be strengthened over time with consistent group membership. The expectation for commitment and participation may be overwhelming to patients who are not feeling well, are ambivalent about the pregnancy, have busy schedules, feel they already have adequate knowledge or support, do not want to be part of a group, or do not feel extra education and support are necessary. Some patients who were not interested in GPNC shared barriers to participating, including time constraints related to work, school, and other schedules, as well as limited transportation and childcare resources. These are external reasons for not being able to attend group sessions on a regular basis, although they can also be a proxy for feeling ambivalent about not wanting to participate in the program without directly having to tell the recruiter they do not want to participate. Results from this study indicated there are varying demographic characteristics between patients interested in GPNC and those preferring individual prenatal care. Younger adolescents (16 years or younger) and primiparous patients were more likely to be interested in a group. Primiparous adolescents may be vulnerable, experiencing the challenge of being pregnant and preparing to be a firsttime parent. These patients may be more receptive to interventions that provide education and support during this major life change.42 By participating in GPNC, they have the opportunity to learn about having a healthy pregnancy and preparing for a baby. Participants who were not interested in a group were more likely to smoke than were participants who were interested in a group. The length of the sessions may be a
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concern for individuals who smoke as participation in group requires that patients go at least 2 hours without smoking, which may be difficult for some. It may also be that individuals who smoked are concerned they would be frequently reminded or pressured to quit smoking during their pregnancy, although none of the participants reported that as a reason. Providers may want to be aware that these well-intentioned messages can create feelings of guilt and have a negative effect on promoting healthy behavior change. Participants who were not interested in a group were more likely to have wanted to be pregnant than were participants who were interested in a group. While planning for their pregnancies, these patients may have engaged in activities to help them prepare, such as talking with others and reading pregnancy-related materials. They may have felt that GPNC could not offer much more benefit beyond what they already had, therefore having a preference for individual care. Conversely, participants with an unplanned pregnancy recognize the need for information and support after they learn they were pregnant, and GPNC provides this. All of these factors are important consideration for program development and implementation. The level of interest in GPNC suggests that many patients were interested in this model of care although many also preferred individual care, thereby validating the potential demand for developing and offering a new model of care in the clinic. This assisted planning for the allocation of clinic resources to ensure staff and scheduling could accommodate new group care offerings to meet patient demand while continuing to offer individual care for the rest of clinic population. The reasons why patients were interested in participating in GPNC informed the program model as it was being developed. The program model included bring together women of similar gestational ages, creating opportunities for sharing and discussion while respecting privacy, having individual time with the group facilitators and medical provider, and offering fun and interactive activities to facilitate learning. When talking to patients about new care options such as GPNC, it is important to ensure they make informed decisions about the type of care they select. Findings from this project informed recruitment strategies when group sessions were being initiated to ensure maximum uptake of GPNC. Being aware of the patient characteristics that influence the model of care choice allows the GPNC program to be offered in a manner that appeals to and meets the needs of a wide segment of the clinic population, rather than only to patients who initially find it acceptable. We developed a process to share information about GPNC and then find out what the patients knew about the program along with their perceived benefits and barriers to participating. We anticipated benefits and highlighted these when sharing information about the program. We also anticipated barriers to participation and gathered resources to address these such as bus tokens, taxi vouchers, and on-site child care. Recruiters talked to multiparous women about the program, focusing not just on what they could learn but also on how they could support other women in the group by sharing their previous knowledge and experience about pregnancy and parenting. Recruiters were trained to identify patient ambivalence and to offer strategies to support this,
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including highlighting benefits, reducing barriers, trying out the first group session, or, in some cases, validating that individual care may be the best option for them. Limitations
This study had a few limitations. First, we were unable to find any validated instrument to evaluate patient interest in a group care model. Thus, the survey we developed was novel and not yet validated. The survey was useful in gathering unrestrained responses about the relationship between participants' interest levels and reasons for their selection because the survey largely consisted of openended questions. However, the use of a nonvalidated tool potentially limits the validity and reliability of the findings. The survey was self-report, useful for gaining patient perspective explaining their care choices. However, selfreport potentially creates information bias and possibly also limits the validity of the findings. Another limitation is that all of the study participants were adolescents, which limits the generalizability of these findings to a larger segment of the prenatal population. There is a need in the future to assess factors influencing patients' selection of prenatal care options with adult women. Factors influencing patient care option choices were examined, although this study indicates a need to further explore the factors impacting the patient's actual participation in GPNC. Conclusions
Exploring why patients are interested in group or individual models of care is important for a few reasons. A variety of prenatal care options can meet patient demand and their diverse needs. Identifying the factors influencing patient choice helps providers understand patient needs and perceived benefits, highlighting what is important to patients. It also highlights barriers to participation, some of which can be reduced with additional resources and scheduling considerations. Factors that affect actual participation in care options also warrant further investigation as interest does not directly translate into attendance or participation. Understanding factors influencing patient choice of model of care provides insight into the type of information that patients require, supporting development of the program model and enhancing recruitment and marketing approaches to use when presenting care options to patients that appeal to them in a positive way. It is also important to note that even when patient characteristics are identified and participation barriers are reduced, not all patients would choose, enjoy, and benefit from a group. More research is needed to understand factors that influence patients' choice for prenatal care options with other populations and to improve patient participation in prenatal care programs. Acknowledgments
We thank Marci Peralto MD, Dawn Foster-Jeffries MPH, Rebecca Seale BA, and the staff at the Colorado Adolescent Maternity Program for their assistance with this project. Funding for the REDCap system is provided by NIH/NCRR Colorado CTSI grant UL1 TR001082.
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Appendix. Group Prenatal Care Survey
1. We are still creating the program and currently not offering groups right now. However, if we were offering the group care program, how likely would you be to participate? 1 Not at all likely
2. 3. 4. 5.
2
3
4
5
6
7
8
9
10 Extremely likely
Why did you provide the response you did? What do you like about the group care program? What do you not like about the group care program? What else would you like to share regarding the idea of receiving care in a group setting?