Women’s Perceived Quality of Care and Self-Reported Empowerment With CenteringPregnancy Versus Individual Prenatal Care

CLINICAL EVALUATION & IMPROVEMENT childbearing

Women’s Perceived Quality of Care and Self-Reported Empowerment With CenteringPregnancy Versus Individual Prenatal Care Lisette Saleh

Objective: To compare perceived quality of prenatal care and pregnancy-related self-reported empowerment between women participating in CenteringPregnancy versus those receiving individual prenatal care provided by certified nurse-midwives in the same clinic. Design: Nonexperimental, longitudinal, descriptive feasibility study of two independent groups. Setting/Local Problem: A prenatal clinic in northern Texas where all care is provided by certified nurse-midwives. Participants: The study assessed 51 women receiving selfselected prenatal care in the form of individual prenatal care (n ¼ 37) or CenteringPregnancy (n ¼ 14). Intervention/Measurements: Outcomes analyzed included perceived quality of prenatal care and pregnancy-related selfreported empowerment.

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Results: The results showed no statistical significance between the individual prenatal care and CenteringPregnancy groups with regard to perceived quality of prenatal care or pregnancy-related self-reported empowerment. Conclusion: CenteringPregnancy has the capability to provide women with quality of care equal to that achieved through traditional prenatal care. Despite the lack of statistically significant findings, this study exposes several areas of interest and provides guidance for future studies evaluating prenatal care. doi: 10.1016/j.nwh.2019.03.008

Accepted March 2019

KEYWORDS: antepartum care, CenteringPregnancy, childbirth education, group prenatal care

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ABSTRACT

Saleh

CLINICAL IMPLICATIONS n CenteringPregnancy (CP) has been associated with improved

maternal outcomes, yet there is a dearth of research comparing it with traditional prenatal care to determine equivalency in personal experience and outcomes. n Measurement of quality of prenatal care was evaluated and

showed that CP has the capability to provide quality of care equal to that of traditional prenatal care. n Active engagement in CP includes women taking their own blood

pressure measurements, testing their urine, and weighing themselves, thereby fostering a greater depth of knowledge related to physiologic changes of pregnancy and their own current pregnancy health state. n Innovative prenatal care models, such as CP, have the potential

to improve perinatal outcomes and empower women through use of a comprehensive and holistic education plan and inclusion of women as active participants in their own health care. n Despite the static nature of prenatal care provision in the United

States, there has been a major shift in the health of our nation, requiring us to evaluate how prenatal care is provided, the quality of this care, and how we can improve maternal and neonatal outcomes.

Photo ª FatCamera / iStockphoto.com

P

renatal care is a doorway to women’s health through the prevention, detection, and treatment of maternal and fetal conditions. Despite the importance of prenatal care, most current prenatal care models are lacking in the following areas: adequate contact between women and health care providers, health education, patient satisfaction, and support for women (Hanson, VandeVusse, Roberts, & Forristal, 2009; Massey, Rising, & Ickovics, 2006; RuizMirazo, Lopez-Yarto, & McDonald, 2012). Although the health of our nation has continued to change, prenatal care has remained static. There is a need to examine prenatal care and determine how to reform care to minimize and finally eliminate poor maternal and fetal outcomes in the United States. Prenatal care is a focus of legislation, funding, and research to determine what is effective and where change is needed. Current legislation and national health agencies, including the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and Centers for Medicare and Medicaid, have recognized the need for evaluation and transformation of traditional prenatal care, hereafter referred to as individual prenatal care (IPC), to move toward an evidence-based model of care (Rotundo, 2011). Research indicates that when compared with women receiving IPC, women receiving group prenatal

Lisette Saleh, PhD, MSN, RNC-OB, is an assistant professor in the Harris College of Nursing & Health Sciences at Texas Christian University in Fort Worth, TX. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].

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The goal of prenatal care is to detect, treat, and prevent potential health problems, yet the current one-onone prenatal care model has been criticized for remaining unfocused, fragmented, and inefficient care are more likely to be satisfied (Bell, 2012; Rising & Quimby, 2017) and to experience continuity of care (DeCesare & Jackson, 2014). However, further research is needed to quantify the impact on maternal experience and pregnancy outcomes.

Background Current U.S. prenatal care models are based largely on a systems-based medical model that lacks focus on the woman (Thielen, 2012). For example, prenatal care historically has focused on prevention of eclampsia, low birth weight, and preterm birth (Alexander & Kotelchuck, 2001). The traditional prenatal approach is based on standards developed in the 1920s, with the exception of an increase in number of visits (Moos, 2006). The goal of prenatal care is to detect, treat, and prevent potential health problems, yet the current one-on-one prenatal care model has been criticized for remaining unfocused, fragmented, and inefficient (Rising & Quimby, 2017; Risisky, Asghar, Chaffee, & DeGennaro, 2013). There is a need to broaden the focus of prenatal care to include a woman and her family as part of the health care team through increased education and support, potentially creating a ripple effect to community health as a whole. Consequences of current models remaining stagnant and outdated include the continuation of health care disparities and poor neonatal outcomes in the United States, despite women seeking prenatal care earlier in their pregnancies (March of Dimes, 2014).

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CenteringPregnancy (CP) is an alternative approach to prenatal care developed in 1993 by Sharon Schindler Rising, a certified nurse-midwife (CNM), in response to women’s dissatisfaction with traditional care (Bell, 2012; Rising & Quimby, 2017). The CP model is women-centered group care, encouraging women to feel empowered through participation in self-care activities and information sharing (Rising & Quimby, 2017). With greater scientific understanding of this model, it has the potential to answer the call for evidencebased prenatal care. An integral component of good prenatal care is quality, although this is a metric that has proven difficult to identify and measure.

Quality of Care The study of quality of care is omnipresent, as organizations such as the National Academy of Medicine and Quality and Safety Education for Nurses focus on the degree to which quality improvement can increase positive health outcomes (Kohn, Corrigan, & Donaldson, 2000; Quality and Safety Education for Nurses, 2014). In qualitative studies, researchers seeking to define quality of care from the woman’s perspective have identified common themes, including access to care, active listening, spending appropriate time, respect, and education (Armstrong et al., 2006; Sword et al., 2012; Wheatley, Kelley, Peacock, & Delgado, 2008). Quantitative studies to examine the quality of care women experience during pregnancy often measure only certain facets of quality, such as service quality (SQ) or customer quality (CQ). Gholipour, Tabrizi, Asghari Jafarabadi, Iezadi, and Mardi (2018) measured SQ and CQ in a randomized control trial for Iranian women seeking care and randomly assigned to receive CP or IPC. Although their results showed that use of CP increased SQ and CQ, researchers across various health care fields lack continuity in defining quality. Because of the lack of quantifiable evidence of agreement on the definition of quality of prenatal care, exploration of a woman’s perceptions of quality prenatal care through measurable means needs some elucidation.

BOX 1 CENTERINGPREGNANCY CURRICULUM DISCUSSION TOPICS Prenatal testing Nutrition Healthy behaviors Common discomforts of pregnancy Dental health Breastfeeding Family planning Sex during pregnancy Domestic violence/abuse Preterm labor signs Labor Birth facility Pain management during labor and birth Newborn’s first days Pediatric care Circumcision Postpartum depression Newborn safety Growth and development Family unit changes Postpartum norms Source: Centering Healthcare Institute (2017).

weight. The results showed that of the 25 studies included, empowerment was consistently shown to correlate with a decrease in perinatal depression symptoms, preterm birth, and low birth weight. Despite the fact that none of the articles reviewed specifically measured empowerment in the perinatal period, it is important to note the positive nature of empowerment on maternal and neonatal outcomes.

Empowerment

About CP

The World Health Organization has identified facilitation of an individual’s empowerment as an important variable in quality of care by influencing decision-making and creating a supportive environment through an improved women–provider relationship (World Health Organization, 2006). Haines, Hildingsson, Pallant, and Rubertsson (2013) found that women who were fearful of pregnancy perceived their care to be lacking in emotional support, understanding, and respect. Empowerment counters the experiences of those with pregnancy-related stress or fear (Bell, 2012; Heberlein et al., 2016). Maternal empowerment, a focus of CP, can decrease negative experiences with pregnancy and birth and improve health behaviors (Bell, 2012; Gaudion et al., 2011; Rising & Quimby, 2017). Garcia and Yim (2017) conducted a systematic review of women’s empowerment in the perinatal period as it relates to maternal affect, preterm birth, and low birth

CP is a group-based antenatal care model created to provide education and care that helps women be empowered. The three main components of CP are assessment, education, and support. The major underpinnings for CP include feminism, social cognitive theory, midwifery, and learning theory (Rising, Kennedy, & Klima, 2004; Rising & Quimby, 2017). The CP model is currently being provided in approximately 500 sites in the United States and internationally in areas such as Sweden, Denmark, and the United Kingdom (Andersson, Christensson, & Hildingsson, 2012, 2013; Carlson & Lowe, 2006; Centering Healthcare Institute, 2018; Gaudion et al., 2011). Some of the major themes identified through analysis of studies on CP have included an increase in women’s sense of knowledge and readiness for birth and infant care, enhanced satisfaction among women and health care providers, increased breastfeeding rates, longer contact with a

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The purpose of this study was to compare quality of care and pregnancy-related self-reported empowerment of women participating in CP compared with those receiving IPC in the same clinic. The variables related to structure, process, and outcomes of prenatal care were evaluated through measurement of perceived quality of prenatal care and self-reported pregnancy-related empowerment. The main research questions were (a) Do women in CP and women in IPC groups differ with regard to perceived quality of care? and (b) Do women in CP and women in IPC groups differ with regard to pregnancyrelated self-reported empowerment?

Theoretical Framework

health care provider, and improved neonatal outcomes (Baldwin, 2006; Benedicktsson et al., 2013; Davis-Floyd, Barclay, Daviss, & Tritten, 2009; Herrman, Rogers, & Ehrenthal, 2012; Teate, Leap, Rising, & Homer, 2011). At the facility where this project was conducted, current IPC is provided during a series of appointments that last 10 to 15 minutes each, totaling approximately 2 hours of contact with a provider over the course of a pregnancy, often limiting time for education or relationship-building between a woman and provider. CP consists of groups of 8 to 10 women with similar estimated due dates meeting 10 times during pregnancy, for 90 to 120 minutes per session, or for approximately 20 hours (Rising et al., 2004). Through grouping of women with similar due dates, pregnancy is normalized, and women find social support. However, IPC does work well for some women; therefore, both models may be appropriate for different women.

The theoretical framework of Donabedian’s quality of care, developed in 1966, guided this study. Donabedian (1988) stated that for quality improvement to occur, there must be a known connection between structure, process, and outcome (see Figure 1). This framework was chosen for the study because it guided the development of one of the primary tools, the Quality of Prenatal Care Questionnaire (QPCQ; Sword, Heaman, & QPCQ Research Team, 2013). The structure of quality of care reflects the attributes of service delivery and of the provider, more specifically encompassing technical and interpersonal aspects of the care provided (Heaman et al., 2014). Structure was evaluated through collecting data on the health care system; for this particular study, the QPCQ was used to measure the structure and process arms of Donabedian’s quality of care framework (see Figure 1). Process reflects the actual clinical and technical care provided. Based on the development of the QPCQ, process was evaluated by measuring the interpersonal relationship between a woman and her provider (Sword et al., 2013). The outcomes include the effects of health care on a woman and her pregnancy, and in this project, these were measured by assessing pregnancy-related self-reported empowerment. Pregnancyrelated self-reported empowerment was measured with the Pregnancy-Related Empowerment Scale (PRES).

Methods

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The three main components of CP are assessment, education, and support Through use of the standardized CP curriculum (see Box 1), CP facilitators work to help women learn, make decisions, and ask questions about their own pregnancies (Centering Healthcare Institute, 2017). Women become empowered through engagement and understanding of the physiologic changes of pregnancy and the normalization of pregnancy and by actively participating in their own health care. For example, there is a self-monitoring component in which women are taught how to take their own blood pressure, test their urine with dipsticks, weigh themselves, and document all findings in a log. June 2019

Design Before beginning the study, approval was obtained from the institutional review boards of the University of Texas at Tyler, the University of North Texas Health Science Center, and Texas Christian University. The three institutional review boards were chosen as a result of the primary investigator studying at the University of Texas at Tyler and being employed at Texas Christian University at the time of the study. Additionally, the study site itself was part of University of North Texas Health Science Center. The study was a nonexperimental, longitudinal, descriptive feasibility study of two independent groups. The intervention for this study was the delivery model of prenatal care; the differences in experience and application of prenatal care influenced the measured dependent variables, perceived

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FIGURE 1 APPLICATION OF DONABEDIAN’S QUALITY OF CARE FRAMEWORK

Note. QPCQ ¼ Quality of Prenatal Care Questionnaire.

quality of prenatal care (QPCQ) and pregnancy-related selfreported empowerment (PRES). Additional data collected included overall self-assessed health perception and chronic health conditions, such as obesity, hypertension, or asthma, to ascertain the overall health of the participants.

Participants and Setting Convenience sampling was used to obtain study participants. Eligibility criteria included the ability to read and write in English, no previous prenatal care outside of pregnancy confirmation visit, age 18 years or older, no prior fetal demise, and carrying a singleton pregnancy. Women were excluded from the study and not included in the data analysis if they did not complete prenatal care at the same facility for their entire pregnancy. Recruitment ran from May through August 2016, with the final data collection completed by March 2017. Because of a short study time line, I was able to approach only 125 pregnant women. Of those, five women were not enrolled because of declination or not meeting eligibility

requirements (e.g., pregnant with multiples), and 120 met eligibility criteria and were enrolled (n ¼ 54 in the CP and n ¼ 66 in the IPC groups). The setting was a prenatal clinic in northern Texas with six CNMs providing CP and IPC to women from a variety of backgrounds and economic situations. Clinic staff cared for women with commercial insurance and Medicaid, and the clinic is associated with two large hospitals for births—one public and one private. The clinic’s office space has the appearance of that of a typical outpatient facility with smaller examination rooms for IPC visits with the addition of a conference room down the hall that has chairs and tables for CP visits.

Recruitment Women were recruited at the clinic as they attended their initial prenatal appointments with a CNM. Potential participants were approached to determine interest in the study and eligibility (Time [T] 1; see Figure 2). Participants were divided into two groups, those who self-selected IPC (n ¼ 66) and

FIGURE 2 FLOW OF PARTICIPANTS IN THE STUDY

Note. PRES ¼ Pregnancy-Related Empowerment Scale; QPCQ ¼ Quality of Prenatal Care Questionnaire; T1 ¼ Time 1; T2 ¼ Time 2.

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those who self-selected CP (n ¼ 54). Prenatal care was selfselected so that individual participant factors such as comfort, motivation, and timing did not influence perception of care. If a woman dropped out of CP before starting care, she was included in the IPC group. The same group of CNMs provided care for all participants regardless of model. Participants received verbal description of the study and signed a written consent form. At the time of consent, contact information, including e-mail address and phone number, and demographic and health history information, were collected from all participants (see Table 1). Participants were contacted for data collection two times—T1 and T2. T1 was at baseline at the time of consent during the initial prenatal visit, and T2 was at 36 weeks gestation or greater (e-mail QPCQ and post-PRES).

Instruments The QPCQ is a 46-item instrument developed to measure quality of prenatal care on a 5-point Likert-type scale (1 ¼ strongly disagree, 5 ¼ strongly agree). The QPCQ measures quality of prenatal care through six subscales: Information Sharing, Anticipatory Guidance, Sufficient Time, Approachability, Availability, and Support/Respect (Heaman et al., 2014). The scoring of the QPCQ is computed as a total score with ranges from 46 to 230, with higher values indicating higher quality of prenatal care. The instrument had previously been validated for construct validity and reliability with a Cronbach’s a ¼ .96 and a test–retest correlation coefficient of 0.88 (Heaman et al., 2014). For this study, the Cronbach’s a matched the previous at a ¼ .96. The Cronbach’s a for the subscales in this study ranged from .72 to .96. The PRES, developed and studied by Klima, Vonderheid, and Norr (2007), is a 21-item instrument for measuring pregnancy-related self-reported empowerment on a 4-point Likert-type scale (1 ¼ strongly disagree, 4 ¼ strongly agree). Items 1 through 16 are rated by all participants, and items 17 through 21 are rated only by women in the CP group. Scores range from 21 through 84 for those in CP and 16 through 64 for those in IPC, with higher scores indicating greater empowerment. It had a previously reported reliability of Cronbach’s a of 0.90. The instrument also showed interitem correlations and internal consistency reliability, as well as content validity as verified by a panel of experts. For this study, the pre- was .88, and the post-PRES a was 0.92. The four subscales included Provider Connectedness, Skillful Decision-Making, Peer Connectedness, and Gaining Voice.

Data Analysis All analyses were performed with the use of SPSS (Version 24). Demographic data, obstetric history, and health history were analyzed with descriptive statistics. Multivariate analysis of variance was run to determine if there was a significant difference in the quality of prenatal care for those women participating in CP versus IPC. One-way analysis of covariance

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was run to determine if there was a significant difference in pregnancy-related self-reported empowerment. The pre-PRES scores were used as a covariate to statistically control for individual differences, with the post-PRES scores as the dependent variable in the analysis of covariance tested across the two types of care. The total scores of the first 16 questions were used for comparison between groups. The five questions for CP only were excluded because of low sample size.

Results Of the 120 women who completed the T1 survey (n ¼ 54 for CP, n ¼ 66 for IPC), 72 (60%) completed the T2 survey (see Figure 2). Between recruitment and baseline data collection, one participant changed from IPC to CP and 12 from CP to IPC. No specifics related to why a participant chose to switch models were collected; however, timing of appointments and lack of child care were anecdotally noted for most participants. Because of the inadequate sample size, statistics were not reliable. Demographic statistics for the participants by group indicated few differences between those in the IPC and CP groups. Exceptions to the differences included significant differences in race (p ¼ .007) and education level (p ¼ .044). Compared with the IPC group, participants in the CP group had a larger proportion of women identifying as Hispanic, and the IPC group had more participants with a minimum of some college education. This demographic phenomenon will require further evaluation in future studies. The participants in both groups were predominately White and married, and most had a minimum of some college education and good or excellent overall health. One participant in each group did not complete the income question on the survey. The past pregnancy histories of the groups were statistically similar before the study began (see Table 2). Results of the QPCQ analysis indicate there were no significant differences found between types of care for any of the six subscales or total QPCQ score. Thus, it appears that the two prenatal care models were not different with regard to perceived quality of prenatal care. The mean post-PRES score for those participating in IPC was 60.22, with a standard deviation of 4.308. This was slightly higher than that for the CP group, which had a mean post-PRES score of 57.64 and a standard deviation of 6.16. After controlling for the pre-PRES covariate, the IPC group had a mean score of 60.263, and the CP group had a mean score of 57.519. Results indicated that there was no significant difference found between the two types of prenatal care with respect to pregnancy-related selfreported empowerment.

Discussion The study showed that there were no statistically significant differences between the two groups. Those women who attended CP had comparable outcomes to those who received IPC. Because of the small sample size, this feasibility study

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TABLE 1 DEMOGRAPHIC STATISTICS COMPARISON BETWEEN GROUPS USING FISHER EXACT TEST Categoric Variable Racea

Hispanic

b

Marital statusa

a

Education

IPC Group, % (n) (n [ 37)

CP Group, % (n) (n [ 14)

Black: 5.4 (2)

Black: 7.1 (1)

White: 86.4 (32)

White: 50 (7)

Other: 8.1 (3)

Other: 42.8 (6)

No: 86.5 (32)

No: 57.1 (8)

Yes: 13.5 (5)

Yes: 42.9 (6)

Married: 89.2 (33)

Married: 71.4 (10)

Separated/divorced: 0 (0)

Separated/divorced: 7.1 (1)

Never married: 10.8 (4)

Never married: 21.4 (3)

High school diploma: 10.8 (4)

High school diploma: 35.7 (5)

Some college: 35.1 (13)

Some college: 14.3 (2)

College degree: 24.3 (9)

College degree: 42.9 (6)

Any postgrad: 29.7 (11)

Any postgrad: 7.1 (1)

75% had annual income of $40,000 or more

69% had annual income of $40,000 or more

Average: 8.1 (3)

Average: 35.7 (5)

Good: 40.5 (15)

Good: 35.7 (5)

Excellent: 48.6 (18)

Excellent: 28.6 (4)

No: 91.9 (34)

No: 100 (14)

Yes: 8.1 (3)

Yes: 0 (0)

No: 100 (37)

No: 100 (14)

Yes: 0 (0)

Yes: 0 (0)

Renal disease

No: 100 (37)

No: 100 (14)

Yes: 0 (0)

Yes: 0 (0)

Self-assessed obesitya

No: 97.3 (36)

No: 92.9 (13)

Yes: 2.7 (1)

Yes: 7.1 (1)

No: 91.9 (34)

No: 92.9 (13)

Yes: 8.1 (3)

Yes: 7.1 (1)

Alcohol

No: 100 (37)

No: 100 (14)

Yes: 0 (0)

Yes: 0 (0)

Drugs

No: 100 (37)

No: 100 (14)

Yes: 0 (0)

Yes: 0 (0)

a

Income

Self-assessed healtha

Hypertensiona Heart disease

Asthma

a

Note. CP ¼ Centering Pregnancy; IPC ¼ individual prenatal care; postgrad ¼ postgraduate study. a Fisher exact test. bChi-square test.

should be replicated with a larger sample to increase the effect size and power of the statistics. There have been several studies to evaluate a variety of psychological outcomes associated with CP care. Risisky, Asghar, Chaffee, and DeGennaro (2013) studied feelings of empowerment from a qualitative aspect; however, no researchers have looked specifically at pregnancy-related selfreported empowerment in the United States as measured

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by the PRES survey, which supports direct measurement of self-reported empowerment of the woman who is pregnant, thereby quantifying this variable. Authors of one previous study did use the PRES and compared group care to IPC; however, the study was conducted in Malawi and Tanzania, and women received only four prenatal visits based on the CP model. The results were mixed, showing that women in group care in Malawi had a higher PRES score than those

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TABLE 2 COMPARISON OF PREGNANCY RELATED METRICS IPC (n [ 37)

Variable

M ¼ 28

Age in years Number of births,a % (n) a

Number of term births, % (n) a

Number of preterm births, % (n) Number of late-term births,a % (n) a

Number of cesareans, % (n)

CP (n [ 14) M ¼ 27.57

SD ¼ 4.466

SD ¼ 4.620

0–2: 95 (35)

0–2: 79 (11)

3þ: 5 (2)

3þ: 21 (3)

0–2: 97 (36)

0–2: 93 (13)

3þ: 3 (1)

3þ: 7 (1)

0: 78 (36)

0: 93 (13)

1–2: 22 (1)

1–2: 7 (1)

0: 97 (29)

0: 93 (13)

1–2: 3 (8)

1–2: 7 (1)

0: 84 (31)

0: 93 (13)

1–2: 16 (6)

1–2: 7 (1)

Note. CP ¼ Centering Pregnancy; IPC ¼ individual prenatal care; M ¼ mean; SD ¼ standard deviation. a Fisher exact test.

receiving individual care; however, the women in Tanzania had similar results for the PRES between both groups (Patil et al., 2017). The results of the current study show that although there was not statistical significance between CP or IPC related to quality of prenatal care and pregnancy-related self-reported empowerment, there were intriguing findings that merit further investigation. In this study, self-selection by the participants influenced potential differences found when comparing the groups. Of interest was the finding that more Hispanic women participated in CP and more women with higher education selected IPC. Authors of a future study should seek to determine if demographic characteristics such as race or education influence self-selection to participate in CP due to perceived barriers. More than 20% of the CP participants changed method of care compared with fewer than 2% of the ICP participants; this may have contributed to the nonsignificant findings, and further investigation is necessary. Participants were asked what form of prenatal care they had continued to participate in throughout their pregnancy at the data collection point T2 at 36 weeks gestation or greater. Anecdotally, the care providers and women noted that most switch prenatal care models before or after the first appointment due to barriers such as scheduling or child care. A multitude of variables could influence the higher rate of attrition in the CP group, including access to e-mail/phone, lack of understanding of expectations, potential influence of the specific CNM providing care, relocation of domicile, or desire to seek care elsewhere that may or may not offer CP. Suggestions for future research include barriers and facilitators to participating in these different models.

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Women experienced no significant differences in the two variables identified, but other aspects of CP that may influence outcomes should be determined. Without further information on health behaviors such as diet, exercise, pregnancy weight gain, and smoking, it is difficult to identify clear associations with different models of prenatal care. Women who receive care from CNMs may be actively seeking a provider who practices low-intervention holistic care and does not medicalize pregnancy. Women who participated in the study did have the option to see a physician for their entirety of their prenatal care but instead opted for care with a CNM. Local physicians had offices within steps of the CNMs’ offices, took the same insurance, and had privileges at the same facilities as the CNMs. The lack of significant findings in the study is likely due to small sample size and lack of adequate effect size. The sample size was not as large as originally desired because of a short study time line and attrition from disconnected phones, incorrect e-mail addresses, or nonresponses to e-mailed surveys. Another potential explanation for lack of significant findings is the providers themselves. The CNMs provided care for women in both groups, and this was viewed as an advantage for the study because it took into account the variable of provider influence on quality of prenatal care. However, a future study is proposed that would look to compare physicians, CNMs in IPC settings, and CNMs in CP settings to determine if provider, length of visit, or content are variables of interest.

Strengths and Limitations The strengths of this study include the use of two reliable instruments, the QPCQ and the PRES. Use of the QPCQ

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participants’ demographics (predominately White, married, educated, and with higher household income), the ability to generalize to the greater population is limited. Future research should focus on seeking a larger, more diverse sample, including individuals with less education and varied socioeconomic status.

CP facilitators work to help women learn, make decisions, and ask questions about their own pregnancies allowed for verification of its reliability with a specific population of women. Because of the defined gap in the research on perceived quality of prenatal care and self-reported pregnancy-related empowerment, the study results will add to the current literature and, more specifically, help support future research related to evidence-based prenatal care. Other strengths of the study include the limited risk to the participants and use of participants from one identified prenatal health care system with a single type of provider. This study was limited by the small sample size and short data collection time period. Over the 10-month recruitment and data collection period, some women dropped care from the clinic, disconnected their phones, or changed e-mail addresses, limiting the final sample that completed all three data collection points. The small sample size allowed for analysis of trends but limited the ability to obtain statistical significance. The QPCQ has a limitation of a Flesch-Kincaid grade level of 8.7, according to the authors (Heaman et al., 2014). Incongruence between the group size, demographic characteristics, small sample size, and non-randomization of groups should be controlled for in future studies. Participants were able to self-select to receive CP or IPC, and this may be influenced by their individual empowerment levels before receiving care. Because of the nature of the sample

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The care we provide women during pregnancy has a lasting effect on all family members. Group care has been shown to have improved outcomes in a variety of populations, including women who are pregnant, women with diabetes, and caregivers. The idea that a woman who is pregnant is not alone in her experiences and the normalization of pregnancy through group interaction can allow for a greater sense of engagement and empowerment. As we focus on improving quality of care and womancentered care, we should not follow prenatal care models blindly, but rather seek models based on evidence. To take full advantage of our potential to influence maternal/neonatal outcomes, we, as health care providers, must work to ensure that women receive high-quality care. Clinicians and researchers are seeking ways to improve quality, but with this study I found clear gaps in our understanding of how this highly population-specific and influential prenatal care affects women. Previous research has shown that CP has been associated with improved outcomes, yet there is a lack of appraisal of the aspects of CP that influence change. Further research is needed to understand how prenatal care can be optimized and to compare various models proposed. As we seek to understand prenatal care and its empowerment of women, we must continue to study and seek to find answers to these many questions. CP remains a woman-centered model that facilitates empowerment and should continue to be chosen by women seeking a group experience. A greater understanding of prenatal care and its influence on women and newborns will help health care providers understand the importance of this relatively short time they have with women during pregnancy. Women will seek care that fits their needs and desires and that results in good health for them and their offspring. Understanding the relationship between prenatal care models and their influence on outcomes is crucial to improving the care provided.

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Photo ª Courtney Hale / iStockphoto.com

Implications for Practice

Saleh

Conclusion Although these study findings did not duplicate findings seen in previous studies, they did identify clinical similarities and differences between CP and IPC. To appreciate the differences between the two groups receiving care, it would be helpful to understand why some women choose CP and others do not. These personal choices or barriers could influence care and should be appraised to allow modification of CP delivery, so that all women have access to this type of care. CP was developed to facilitate empowerment of women, and yet, to my knowledge, this is the first study to seek to measure women’s self-reported empowerment after receiving prenatal care. Ultimately, in this study, women reported equivalent levels of perceived quality of care for both models, with no significant differences in self-reported empowerment. NWH

Acknowledgment The author acknowledges financial support from the Beta Alpha chapter of Sigma Theta Tau in Fort Worth, TX.

References Alexander, G. R., & Kotelchuck, M. (2001). Assessing the role and effectiveness of prenatal care: History, challenges, and directions for future research. Public Health Reports, 116, 306–316. https:// doi.org/10.1016/S0033-3549(04)50052-3 Andersson, E., Christensson, K., & Hildingsson, I. (2012). Parents’ experiences and perceptions of group-based antenatal care in four clinics in Sweden. Midwifery, 28, 442–428. https://doi.org/ 2048/ 10.1016/j.midw.2011.07.006. Andersson, E., Christensson, K., & Hildingsson, I. (2013). Mothers’ satisfaction with group antenatal care versus individual antenatal care—A clinical trial. Sexual & Reproductive Healthcare, 4, 113–120. https://doi.org/10.1016/j.srhc.2013.08.002 Armstrong, P., Grant, K. R., Boscoe, M., Clow, B., Guberman, N., Jackson, B. E., . . . Willson, K. (2006, August). It’s about time: Woman defined quality care. Paper presented at the annual meeting of the American Sociological Association, Montreal, Canada. Retrieved from https://convention2 .allacademic.com/one/asa/asa/index.php?click_key=2#search_top Baldwin, K. A. (2006). Comparison of selected outcomes of CenteringPregnancy versus traditional prenatal care. Journal of Midwifery and Women’s Health, 51, 266–272. https://doi.org/ 10.1016/j.jmwh.2005.11.011 Bell, K. M. (2012). Centering Pregnancy: Changing the system, empowering women and strengthening families. International Journal of Childbirth Education, 27, 70–76. Benediktsson, I., McDonald, S. W., Vekved, M., McNeil, D. A., Dolan, S. M., & Tough, S. C. (2013). Comparing CenteringPregnancy to standard prenatal care plus prenatal education. BMC Pregnancy and Childbirth, 13, S5. https://doi.org/10.1186/1471-2393-13-S1-S5 Carlson, N. S., & Lowe, N. K. (2006). CenteringPregnancy: A new approach in prenatal care. MCN American Journal of Maternal/Child Nursing, 31, 218–223. https://doi.org/10.1097/00005721-200607000-00004 Centering Healthcare Institute. (2017). CenteringPregnancy facilitator’s guide. Boston, MA: Author. Centering Healthcare Institute. (2018). CenteringPregnancy. Retrieved from https://www.centeringhealthcare.org/what-we-do/centering-pregnancy

June 2019

Davis-Floyd, R., Barclay, L., Daviss, B., & Tritten, J. (Eds.). (2009). Birth models that work. Berkeley, CA: University of California Press. Retrieved from http://www.jstor.org/stable/10.1525/j.ctt1ppszz DeCesare, J. Z., & Jackson, J. R. (2014). Centering Pregnancy: Practical tips for your practice. Archives of Gynecology and Obstetrics, 291, 499–507. https://doi.org/10.1007/s00404-014-3467-2 Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260, 1743–1748. Garcia, E. R., & Yim, I. S. (2017). A systematic review of concepts related to women’s empowerment in the perinatal period and their associates with perinatal depressive symptoms and premature birth. BMC Pregnancy and Childbirth, 17(Suppl. 2), 347. https://doi.org/ 10.1186/s12884-017-1495-1 Gaudion, A., Menka, Y., Demilew, J., Walton, C., Yiannouzis, K., Robbins, J., … Bick, D. (2011). Findings from a UK feasibility study of the CenteringPregnancy model. British Journal of Midwifery, 19, 796–802. https://doi.org/10.12968/bjom.2011.19.12.796 Gholipour, K., Tabrizi, J. S., Asghari Jafarabadi, M., Iezadi, S., & Mardi, A. (2018). Effects of customer self-audit on the quality of maternity care in Tabriz: A cluster-randomized controlled trial. PLoS One, 13(10), e0203255. https://doi.org/10.1371/journal.pone.0203255 Haines, H. M., Hildingsson, I., Pallant, J. F., & Rubertsson, C. (2013). The role of women’s attitudinal profiles in satisfaction with the quality of their antenatal and intrapartum care. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42, 428–441. https://doi.org/10.1111/15526909.12221 Hanson, L., VandeVusse, L., Roberts, J., & Forristal, A. (2009). A critical appraisal of guidelines for antenatal care: Components of care and priorities in prenatal education. Journal of Midwifery and Women’s Health, 54, 458–468. https://doi.org/10.1016/j.jmwh.2009.08.002 Heaman, M. I., Sword, W. A., Akhtar-Danesh, N., Bradford, A., Tough, S., Janssen, P. A., … Helewa, M. E. (2014). Quality of prenatal care questionnaire: Instrument development and testing. BMC Pregnancy and Childbirth, 14, 188. https://doi.org/10.1186/1471-2393-14-188 Heberlein, E. C., Picklesimer, A. H., Billings, D. L., Covington-Kolb, S., Farber, N., & Frongillo, E. A. (2016). Qualitative comparison of women’s perspectives on the functions and benefits of group and individual prenatal care. Journal of Midwifery and Women’s Health, 61, 224–234. https://doi.org/10.1111/jmwh.12379 Herrman, J. W., Rogers, S., & Ehrenthal, D. B. (2012). Women’s perceptions of Centering Pregnancy: A focus group study. MCN American Journal of Maternal/Child Nursing, 37, 19–26. https:// doi.org/10.1097/NMC.0b013e3182385204 Klima, C., Vonderheid, S., & Norr, K. (2007, May). Measuring empowerment in pregnancy: The pregnancy-related empowerment scale. Poster presented at the American College of Nurse-Midwives 52nd Annual Meeting, Chicago, IL. doi:10.1016/j.jmwh.2007.05. 003 Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. March of Dimes. (2014). Premature babies cost employers $12.7 billion annually. Retrieved from www.marchofdimes.org/news/prematurebabies-cost-employers-127-billion-annually.aspx Massey, Z., Rising, S. S., & Ickovics, J. (2006). CenteringPregnancy group prenatal care: Promoting relationship-centered care. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35, 286–294. https:// doi.org/10.1111/J.1552.6909.2006.00040.x Moos, M. (2006). Prenatal care: Limitations and opportunities. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35, 278–285. https:// doi.org/10.1111/J.1552-6909.2006.00039.x Patil, C. L., Klima, C. S., Leshabari, S. C., Steffen, A. D., Pauls, H., McGown, M., & Norr, K. F. (2017). Randomized controlled pilot of a group antenatal care model and the sociodemographic factors

Nursing for Women’s Health

243

Care and Empowerment With CenteringPregnancy associated with pregnancy-related empowerment in sub-Saharan Africa. BMC Pregnancy and Childbirth, 17(Suppl. 2), 336. https:// doi.org/10.1186/s12884-017-1493-3 Quality and Safety Education for Nurses. (2014). QSEN competencies: Quality improvement. Retrieved from http://qsen.org/competencies/ pre-licensure-ksas/#quality_improvement Rising, S. S., Kennedy, H. P., & Klima, C. S. (2004). Redesigning prenatal care through CenteringPregnancy. Journal of Midwifery and Women’s Health, 49, 398–404. https://doi.org/10.1016/ j.jmwh.2004.04.018

Sword, W., Heaman, M. I., Brooks, S., Tough, S., Janssen, P. A., Young, D., … Hutton, E. (2012). Women’s and care providers’ perspectives of quality prenatal care: A qualitative descriptive study. BMC Pregnancy and Childbirth, 12, 29. https://doi.org/10.1186/1471-2393-12-29 Sword, W., Heaman, M., & QPCQ Research Team. (2013). Quality of Prenatal Care Questionnaire. Hamilton, Canada: McMaster University. Retrieved from milo.mcmaster.ca/questionnaires/request-for-aquality-of-prenatal-care-questionnaire-qpcq.

Rising, S. S., & Quimby, C. H. (2017). The CenteringPregnancy model. New York, NY: Springer.

Teate, A., Leap, N., Rising, S. S., & Homer, C. S. E. (2011). Women’s experiences of group prenatal care in Australia—The CenteringPregnancy pilot study. Midwifery, 27, 138–145. https:// doi.org/10.1016/j.midw.2009.03.001

Risisky, D., Asghar, S. M., Chaffee, M., & DeGennaro, N. (2013). Women’s perceptions using the CenteringPregnancy model of group prenatal care. Journal of Perinatal Education, 22, 136–144. https:// doi.org/10.1891/1058-1243.22.3.136

Thielen, K. (2012). Exploring the group prenatal care model: A critical review of the literature. Journal of Perinatal Education, 21, 209–218. https://doi.org/10.1891/10581243.21.4.209

Rotundo, G. (2011). Centering Pregnancy: The benefits of group prenatal care. Nursing for Women’s Health, 15, 510–518. https://doi.org/ 10.1111/j.1751-486X.2011.01678.x

Wheatley, R. R., Kelley, M. A., Peacock, N., & Delgado, J. (2008). Women’s narratives on quality of prenatal care: A multicultural perspective. Quality Health Research, 18, 1586–1598. https:// doi.org/10.1177/1049732308324986

Ruiz-Mirazo, E., Lopez-Yarto, M., & McDonald, S. D. (2012). Group prenatal care versus individual prenatal care: A systematic review and meta-analyses. Journal of Obstetrics and Gynaecology Canada, 34, 223–229. https://doi.org/10.1016/S1701-2163(16)35182-9

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World Health Organization. (2006). What is the evidence on effectiveness of empowerment to improve health?. Retrieved from http://www.euro .who.int/__data/assets/pdf_file/0010/74656/E88086.pdf

doi: 10.1016/j.nwh.2019.03.008