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Trudnak, Tara E.
A comparison of latina women in centeringpregnancy and individual prenatal care
h [electronic resource] /
by Tara E Trudnak.
[Tampa, Fla] :
b University of South Florida,
Title from PDF of title page.
Document formatted into pages; contains 242 pages.
(Ph.D.)--University of South Florida, 2011.
Includes bibliographical references.
Text (Electronic dissertation) in PDF format.
ABSTRACT: CenteringPregnancy is a model of group prenatal care that replaces routine, individual prenatal care. The program brings women together into small groups to receive their care and prenatal education, and is based on three components: risk assessment, education, and support. The model is client-centered, designed to empower pregnant women and support persons, and involves the woman in small group discussions of 8-10 other women of similar gestational age. The group discussions provide support, help women educate each other, and invoke self-monitoring. Currently, there have been few publications that closely examined maternal weight and obesity and associated outcomes in women involved in CenteringPregnancy; and there are a limited number of studies that examined Spanish-speaking CP groups with Latinas. Therefore, the primary purpose of this retrospective cohort study was to compare pregnancy outcomes of Latina women who completed CenteringPregnancy in a public health clinic to women who completed individual care in the same clinic during the same time. The secondary purpose of this study was to understand perceptions of care among multiparous women who recently completed CenteringPregnancy and completed individual prenatal care in the past. Both quantitative and qualitative methods were employed to examine differences in pregnancy outcomes and maternal factors in both prenatal care groups, and to understand women's perceptions and experience in both CenteringPregnancy and individual prenatal care. A total of 487 patient charts were obtained for data collection (Intervention n= 247, Comparison n=240) and 10 women who recently completed CenteringPregnancy at the health department and completed individual prenatal care in the past completed in person in-depth interviews. The results indicated that there were no differences in infant birthweight or gestational age at delivery between the groups. Compared to women in individual care, women in CenteringPregnancy had increased odds of: having a vaginal birth as opposed to a primary cesarean section, aOR =2.57, (95% CI: 1.23-5.36), attending prenatal care visits, aOR=11.03, (95% CI: 4.53, 26.83), attending postpartum care visits, aOR=2.21 (95% CI: 1.20, 4.05) and formula-only feeding their infants, aOR=6.07 (95% CI: 2.57-14.31). Compared to women in individual care, women in CenteringPregnancy had decreased odds of gaining below the recommended amount of gestational weight, aOR=0.41, (95% CI: 0.22, 0.78). Qualitative findings indicated that women who complete CenteringPregnancy were more satisfied with their care, received more education and support and were more empowered to make decisions about their pregnancy and childbirth. The program provides a system of social support that encapsulates all types of social support to provide relief of stress, encourage positive relationships and empower women to help facilitate healthy pregnancies. CenteringPregnancy at the Pinellas County Health Department increased health care utilization and informed and empowered women through social support.
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Perrin, Karen .
Group Prenatal Care
Maternal Weight Gain
x Public Health
t USF Electronic Theses and Dissertations.
A Comparison of Latina Women in CenteringPregnancy and Individual Prenatal Care b y Tara E. Trudnak A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Community and Family Health College of Public Health University of South Florida Major Professor: Karen Perrin, Ph.D. Elizabeth Gulitz, Ph.D. Cecilia M. Jevitt, Ph.D. Russell Kirby, Ph.D. Charles Mahan, M.D. Date of Approval : March 31, 2011 Keywords: birth outcomes, group prenatal care, pregnancy Hispanic, maternal weight gain Copyright 2011 Tara Trudnak
DEDICATION I dedicate this dissertation to my parents Selma and Robert Trudnak who have supported me in so many ways throughout the years. Your selfless dedication to all of your children and continued encouragement has helped us all become the people we are today To my father, you taught me hard work determination and to take every moment for what it is and enjo y the ride. To my mother, your endless love, laughter and excitement has always helped me continue on my journey All that am and ever hope to be, I owe to my parents. I would like to thank my parents and family, especially my three older brothers, Bob, Mark and Mike, for always reminding me of my roots and always being there for me no matter what. I would like to thank Alex Savon for being my rock, supporting me through the good and the bad and for always making me laugh. I could no t have done this been with me from day one through it all together. Mary, Lianne, Heather, Erica, Claudia, Donna and Abraham you are all amazing and y our continued support was how I made it through. To my special God daughters, Christina Peters and Madeline Trudnak, m ay you fulfill all of your dreams in life as you journey to becoming the wonderful women I know you will be.
ACKNOWLEDGEMENTS Firs Department and the Pinellas County Healthy Start Coalition. Their commitment to their clients and desire to improve health outcomes is undeniable. I would especially like to thank Dr. Elizabeth Arboleda and Malfis Cuevas for all of their dedication to this research and the CenteringPregnancy program I would also like to acknowledge and thank the individuals who have supported me throughout my academic career: Dr. Kay Perrin, I c ould not have asked for a better major professor. I always left your office smiling and confident that I could complete my work. Your positive energy and constant support and encouragement guided me through my doctoral program. I am truly grateful for all Dr. Elizabeth Gulitz, y ou helped inspire me to conduct my research on CenteringPregnancy and yo to help me complete my research. Even in your retirement, you exerted extra effort to always give me feedback and ch allenge me to take my researc h to the next level Dr. Cecil Jevitt, y our knowledge of midwifery helped me immensely through my dissertation process. You were always there for great insight to help me understand the midwifery perspective. I appreciate all that you have done for me.
Dr. Russell Kirby, and analyses. You always devote so muc h time to you r students and it is so greatly wonderful mentor. Dr. Charles Mahan, you are one of the great leaders in Maternal and Child Health and I am truly honored that you s erved on my doctoral committee. I thank you for all of your time and effort in helping me complete this dissertation and for always providing me with so much knowledge and history of maternity care. Dr. Wayne Westhoff, I cannot thank you enough for all t hat you have done for me at my time at USF. You dedicate so much of your time to your students and to the community. I am so grateful that I was able to work with you during my masters program together. Thank you for being the chairperson on my dissertation committee. Dr. Jaime Corvin, you have been such an amazing mentor for me over the past several years. Your commitment to your work, family and friends is truly inspir ing. professional career and for that I am thankful. Thank you for being the chairperson on my dissertation proposal defense. Your warm smile helped me get through it. Dr. Chris topher Kovats Bernat, thank you for your mentorship and support during my time at Muhlenberg College. Your constant encouragement guided me through my undergraduate studies and helped me have the confidence to continue my academic career.
i TABLE OF CONTENTS LIST OF TA BLE S ................................ ................................ ................................ ..... iii LIST OF FIGURES ................................ ................................ ................................ ......... v ABSTRACT ................................ ................................ ................................ .................. vii CHAPTER ONE: INTRODUCTION ................................ ................................ .............. 1 Statement of the Problem/Need ................................ ................................ ............ 7 Research Plan ................................ ................................ ................................ ...... 8 Study Purpose ................................ ................................ ........................... 8 Research Questions ................................ ................................ .................. 8 Phase I ................................ ................................ .......................... 8 Phase II ................................ ................................ ......................... 9 Definition o f Terms ................................ ................................ ................................ ....... 10 CHAPTER TWO: REVIEW OF THE LITERATURE ................................ ................... 23 Introduct ion ................................ ................................ ................................ ....... 13 History of Pren atal Care ................................ ................................ ..................... 14 CenteringPr egnancy ................................ ................................ .......................... 15 Comparison of CenteringPregnancy and individual prenatal care ............ 16 CenteringPreg nancy Research ................................ ................................ 17 Latin as ................................ ................................ ................................ ............... 24 Latinas and Adverse Pregnancy Outcomes ................................ ............. 24 Latinas and P renatal Care ................................ ................................ ....... 25 Maternal Weight ................................ ................................ ................................ 26 Maternal Weight and Adv erse Pregnancy Outcomes ............................... 26 Complications Associated with Maternal Obesity ................................ ... 28 Measuring Mate rnal Obesity ................................ ................................ ... 30 Prenatal Care Att endance ................................ ................................ ................... 30 Postpartum Care Attendance ................................ ................................ .............. 31 Theor y ................................ ................................ ................................ .............. 33 Social Sup port Th eory ................................ ................................ ........... 33 Social Su pport Measures ................................ ............................. 35 Types of Social Support ................................ .............................. 38 Social Support and Mate rnal and Child Health ................................ ........ 38 Social Support and CenteringPregnancy ................................ ................. 39
ii CHAPTER THREE: METHODS ................................ ................................ .................. 41 Preliminary Data Collection ................................ ................................ ............... 42 Individual Care at the Pinellas County Health Department ................................ 42 CenteringPregnancy at the Pinella s County Health Department .......................... 43 Study Pop ulation ................................ ................................ ................................ 44 Community Characteristics ................................ ................................ ..... 44 Overweight and Obesity ................................ ................................ ......... 44 Birth Cha racteristics ................................ ................................ ............... 45 Key Research Person nel and Training ................................ ................................ 50 Translator/Int erpreter ................................ ................................ ......................... 50 Research D esign ................................ ................................ ................................ 50 Phase I: Quantitative (Obj ectives 1 2) ................................ ................................ 51 Subjects an d Setting ................................ ................................ ............... 51 Centeri ngPregnancy ................................ ................................ .... 51 Individual Prenatal Care ................................ .............................. 52 Chart Review and Data Extraction ................................ .......................... 53 Confiden tiality ................................ ................................ ........................ 53 Var iables ................................ ................................ ................................ 53 Data A nalysis ................................ ................................ ......................... 57 Logistic Regression (Resea rch Questions 1 6) ................................ ........ 57 Ass umptions ................................ ................................ ............... 61 General Linear Model: ANCO VA (Research Questions 1,2) .................. 61 A ssumptions ................................ ................................ ............... 62 Phase II: Qualitative (Objective 3) ................................ ................................ ..... 64 Study population and re cruitment ................................ ........................... 64 Data collecti on procedures ................................ ................................ ...... 65 R affle ................................ ................................ ................................ ..... 66 Confiden tiality ................................ ................................ ........................ 66 Pilo t Test ................................ ................................ ................................ 66 Data analy sis methods ................................ ................................ ............ 67 Quality and Trustwo rthiness of Data ................................ ....................... 68 Instrum entation ................................ ................................ ...................... 69 Traini ng ................................ ................................ ................................ ............. 70 Inves tigator ................................ ................................ ............................ 70 Translator/ interviewer ................................ ................................ ............ 70 Data analyst /Second coder ................................ ................................ ...... 71 Timeli ne ................................ ................................ ................................ ............. 71 Data Sha ring ................................ ................................ ................................ ...... 73 Human Subjects Protection ................................ ................................ ................ 73 CHAPTER FOUR: R ESULTS ................................ ................................ ...................... 74 Research Ques tions ................................ ................................ ............................ 74 Phase I: Quantitative (Research Questions 1 6 ) ................................ .................. 75 Sample Chara cteristics ................................ ................................ ............ 75 Intervention CenteringPregnancy ................................ ............... 75 Comparison Indivi dual Prenatal Care ................................ .................... 76
iii Differences B etween Groups ................................ ................................ .. 77 Preliminary Observations abo ut Sample Characteristics .......................... 82 Age ................................ ................................ ............................. 82 Educ ation Level ................................ ................................ .......... 82 Mar ital Status ................................ ................................ .............. 82 Statu s in the U.S ................................ ................................ ......... 83 Parity ................................ ................................ .......................... 83 Pre pregnancy BMI ................................ ................................ ..... 84 Frequencies and Unadju sted Difference tests ................................ .......... 8 3 Gestational Age at Delivery ................................ ........................ 84 Infan t Birthweight ................................ ................................ ....... 84 Metho d of Deliver ................................ ................................ ....... 8 4 Birth Hospital ................................ ................................ ............. 84 Maternal Weight ................................ ................................ ......... 8 5 Attendance and Adequacy of Care ................................ .............. 85 Infant Feedi ng ................................ ................................ ............. 86 Binary and Multinomial Logistic Regression ................................ .......... 92 Research Questi ons 1: Preterm Birth ................................ ........... 9 2 Research Question 2: Low Birthweight ................................ ....... 92 Research Question 3: Method of Birth ................................ ........ 93 Research Question 4 : Gestational Weight Gain ........................... 9 5 Research Question 5: Attendance in Care ................................ .... 97 Research Question 6: Infant Feeding Method .............................. 99 Univariate General Linear Mode l (Research Questions 1 2) ................. 106 Descripti ve Statistics ................................ ................................ 106 A ssumptions ................................ ................................ ............. 1 06 Research Question 1: Ge stational Age at Delivery .................... 109 Research Qu estion 2: Birthweight ................................ ............. 112 Phase II: Qualitative (Research Question 7) ................................ ..................... 115 Study P opulation ................................ ................................ .................. 115 Families, Cod es and Themes ................................ ................................ 115 Themes ................................ ................................ ................................ 117 Perceptions o f CenteringPregnancy ................................ ........... 1 21 Informationa l Support ................................ ............................... 125 Emoti onal Support ................................ ................................ .... 1 30 Compani onship Support ................................ ............................ 134 Instrum ental Support ................................ ................................ 137 Appraisal/V alidation Support ................................ .................... 139 Recommendations of CenteringPregnancy ................................ 142 Summary ................................ ................................ .................. 143 CHAPTER FIVE: DISCUSSION, CO NCLUSIONS AND RECOMMENDATIONS ................................ ................................ .................... 146 Summary of Resear ch Protoco l ................................ ................................ ........ 146 Findin gs ................................ ................................ ................................ ........... 1 47 Gestational age at de livery (preterm) ................................ .................... 1 47
iv Infant birthweight ( low birthweight) ................................ ..................... 1 49 Method of Birth ................................ ................................ .................... 150 Maternal W eight Gain ................................ ................................ .......... 1 52 Utilization of Care ................................ ................................ ................ 155 Infant Feedi ng Method ................................ ................................ ......... 158 e ................................ ............................... 161 Summary of Per ceptions of Care ................................ .......................... 167 Social Suppo rt Theory ................................ ................................ ...................... 167 Conclus ion s ................................ ................................ ................................ ..... 169 Study Stren gths ................................ ................................ ................................ 171 Study Limitations ................................ ................................ ............................. 171 Future Res earch ................................ ................................ ............................... 1 73 Implications for Practice ................................ ................................ .................. 175 Recommendations ................................ ................................ ............................ 176 Take Home Message ................................ ................................ ........................ 1 79 LIST OF REFERENCES ................................ ................................ ............................. 180 APPENDICES ................................ ................................ ................................ ............. 192 Appendix A : C omponents of Routine Prenatal Care Based on the ACOG Prenatal Care Guidelines ................................ ................................ .................. 193 Appendix B : Prenatal High Risk Patient Criteria ................................ .............. 195 Appendix C : Pinellas County Health Department Prenatal Care Protocols ........ 198 Appendix D : Informed Consent Forms ................................ ............................. 2 17 Appendix E : Interview Guide ................................ ................................ ........... 223 ABOUT THE AUTHOR ................................ ................................ .................... E nd Page
v LIST OF TABLES Table 1.1: Estimated Time Frame of Individual Prenatal Care Appointments a nd C omplimentary CenteringPregnancy Session ................................ ............ 4 Table 1 .2: CenteringPregnancy Sessions ................................ ................................ .......... 5 Table 1.3: Phase I Research Questions ................................ ................................ ............. 9 Table 1.4: Phase II Research Questions ................................ ................................ ........... 9 Table 2.1: Literature review of research on CenteringPregnancy programs .................... 21 Table 2.2. IOM Maternal Weight Gain G uidelines. Body Mass Index (BMI) A ccording to the 19 90 IOM R eport ................................ ............................... 26 Table 2.3: IOM Maternal Weight Gain G uidelines. Body Mass Index (BMI) According to the 2009 IOM R eport ................................ ............................... 27 Table 3.1: Florida Charts Statistics for Pinellas Count y, FL and the state of Florida ................................ ................................ .............................. 47 Table 3.2 Florida Charts Birth Statistics for Pinellas County, FL by race/ethnicity from 2007 2009 ................................ ................................ ........ 48 Table 3.3: Description of Inde pendent and Dependent Variables ................................ ... 54 Table 3.4: Outcomes variables assessed in intervention and comparison group .............. 56 Table 3.5: Covariate outcomes assessed in intervention and comparison group .............. 56 Table 3.6: List of Research Questions 1 6 and Description of Variables and Type of Data Analysis ................................ ................................ ................................ 63 Table 3.7: Project Timeline ................................ ................................ ............................ 72 Table 4.1: Sample statistics for CenteringPregnancy and individual prenatal care clients ................................ ................................ ................................ ... 79
vi Table 4.2a: Outcomes for CenteringPregnancy and individual prenatal care clients: Frequenci es and unadjusted univariate test for differences ............... 88 Table 4.2b. Reasons for Cesarean section delivery in both groups ................................ .. 9 1 Table 4.3: Unadjusted Logistic Regression for type of prenatal care ............................ 101 Table 4.4: Adjusted Binary Logistic Regression for type of p renatal care ..................... 102 Table 4.5: Adjusted Multinomial Logistic Regression ................................ .................. 1 07 Table 4.6: Summary of statistically significant covariate relationships to outcomes ................................ ................................ ................................ ...... 105 Table 4.7: CenteringPregnancy Descriptive Statistics ................................ .................. 108 Table 4.8: Individual Prenatal Care Descriptive Statistics ................................ ............ 108 Table 4.9: Main Effects t est for between subjects effects for dependent variable, gestational age at birth ................................ ................................ ................. 110 Table 4.10: Tests of between subjects effects for dependent variable, gestational age at birth w ith covariates ................................ .......................... 110 Table 4.11: Follow up test for dependent variable gestational age at birth .................... 1 11 Table 4.1 2 : Main effects test of between subjects effects for dependent variable, B irthweight ................................ ................................ ............................... 1 13 Table 4.1 3 : Follow up t test for dependent variable, birthweight ................................ 1 13 Table 4.1 4 : Main effects test of between subjects effects for dependent variable, birthweight wit h covariates ................................ ................................ ........ 114 Table 4.1 5 : Descriptive statistics of women who were interviewed .............................. 115 Table 4.1 6 : Families and Codes ................................ ................................ ................... 116 Table 4.1 7 : Summary of results based on each research question ................................ 145
vii LIST OF FIGURES Figur e 2.1: Social Support Pathways. ................................ ................................ ............. 34 Figure 2.2: Supportive Actions Approac h and the Appraisal Perspective ....................... 37 Figure 2.3: The Social Cognitive Perspective and the Symbolic Interactionist Perspective ................................ ............................. 37 Figure 2.4: Relationship perspective (example) ................................ .............................. 37 Figure 4.1: Social Support Pathway that is depicted in CenteringPregnancy ................. 119 Figure 4.2: Illustration of the recipient of support, denoted by (R) receives care from multiple providers, denoted by (P) ................................ ..................... 119 Figure 4.3: Types of Social Support in Social Support Theory provided to the women re ceiving CenteringPregnancy ................................ ........................ 120
viii A BSTRACT CenteringPregnancy is a model of group prenatal care that replaces routine, individual prenatal care. The program brings women together into small groups to receive their care and prenatal education, and is based on three components: risk assessment, education and support The model is client centered, designed to empower pregnant women and support persons, and involves the woman in small group discussions of 8 10 other women of similar gestational age The group discussions provi de support, help women educate each other and invoke s elf monitoring. Currently, there have been few publications that closely examined maternal weight and obesity and associated outcomes in women involved in CenteringPregnancy; and there are a lim ited number of studies that examined Spanish speaking CP group s with Latinas. Therefore, the primary purpose of th is retrospective cohort study was to compare pregnancy outcomes of Latina women who completed CenteringPregnancy in a public health clinic to women who completed individual care in the same clinic during the same time. The se condary purpose of this study was to understand perceptions of care among multiparous women who recently completed CenteringPregnancy and compl eted individual prenatal care in the past. Both quantitative and qualitative methods were employed to examine differences in pregnancy perceptions and experience in both CenteringPregnancy and individual prenatal care. A total of 487 patient charts were obtained for data collection (Intervention n= 247,
ix Comparison n=240) and 10 women who recently completed CenteringPregnancy at the health department and completed individua l prenatal care in the past completed in person in depth interviews. The results indicated that there were no differences in infant birthweight or gestational age at delivery between the groups. Compared to women in individual care, women in CenteringPregn ancy had increased odds of: having a vaginal birth as opposed to a primary cesarean section, aOR =2.57, (95% CI: 1.23 5.36), attending prenatal care visits, a OR=11.03, (95% CI: 4.53, 26.83), attending postpartum care visits, aOR=2.21 (95% CI: 1.20, 4.05) a nd formula only feeding their infants, aOR=6.07 (95% CI: 2.57 14.31). Compared to women in individual care, women in CenteringPregnancy had decreased odds of gaining below the recommended amount of gestational weight, aOR=0.41, (95% CI: 0.22, 0.78). Qualit ative findings indicated that women who complete C enteringPregnancy were more satisfied with their care, received more education and support and were more empowered to make decisions about their pregnancy and childbirth. T he program provides a system of so cial support that encapsulates all types of social support to provide relief of stress, encourage positive relationships and empower women to help facilitate healthy pregnancies. CenteringPregnancy at the Pinellas County Health Department increased health care utilization and informed and empowered women through social support.
1 CHAPTER ONE : INTRODUCTION Support groups have been used in health care settings often with people trying to manage a disorder or treatment. Recently, these types of support groups have been implemented in prenatal care so that pregnant women could gather together in a positive environment, learn from and provide support for each other, take control of their own pregnancies, gain fr iends, become better educated about maternal he alth and labor and birth have prolonged contact w ith health care providers and have fun. In 1998, Sharon Rising, a nurse midwife, first introduced a new model for prenatal care (Rising, 1998) This model c alled CenteringPregnancy was formed in response to the newly revised recommendations of prenatal care at the time and satisfies Medicaid components of routine prenatal care. CenteringPregnancy is a model of group prenatal care that replaces routine, indiv idual prenatal care by incorporating assessment of the pregnancy along with extensive education and group support The program brings women together into small groups to receive their care and prenatal education, and is based on three components: risk asse ssment, education and support ( Ickovics Kershaw, Westdahl, Magriples, Massey et al., 2007 ; Klima, Norr, Vonderheid, & Handler, 2009 ; Rising, 1998 ) The CenteringPregnancy model is client centered, designed to empower pregnant women a nd support persons, and involve the woman in small group discussions that invokes
2 education and self monito ring ( Reid, 20 07 ) In each group, 8 10 women of similar gestational age gather together for ten 2 hour prenatal visits and two postpartum visits ( Rising, 1998 ) The time and number of settings is often altered in individual clinics to best meet the needs of the clients and the clinic. The CenteringPregnancy program along with a CenteirngParenting program are manages through the Centering Health Care Institute ( "Centering Health Care Institute," 2010 ) Women begin their first class at about 12 1 6 weeks gestation after they have an initial individual prenatal care visit. During the group visits, women spend individual time with a health care provider ( usually a midwife but it may also be an obstetrician ) for screenings and risk assessment to assess overall maternal and fetal well being U ltr asound monitoring is done to listen for fetal heart tones fetal position and size are assessed fundal height is measured and vaginal exams are conducted Each woman learns to do her own self assessment along with the rest of the women in the group. The s elf assessment includes measuring weight, and blood p ressure, calculating the estimated gestational age and completing self assessment tools. This is often done with assistance by health care providers during the first few visits As the group continues w omen help each other with these assessments. The risk assessment portion of the class is followed by group discussion and education that is moderated by a midwife, nurse or health educator. During the education portion several topics are addressed includ ing, comfort and relaxation during pregnancy, exercise and physical activity, nutrition, childbirth preparation, sexuality, communication and self esteem, issues of abuse or domestic violence, care for the baby, infant feeding (which an emphasis on breastf eeding), parenting and contraception. Time is also given
3 for women to share thoughts, ideas, and ask questions to the health care providers and each other ( Rising 1998 ) The class is structured as a support group. Chairs are set up in a circle and all of the women and the health care providers sit in the circle. Refreshments are served and one of the health care providers is the consistent leader of the group. There is als o a sense of stability in the group since all of the health care providers that are involved should attend all of the classes and women are highly encouraged to attend every class. There is a formal and informal sharing of information and women and their s upport partners are free to ask questions and state their opinions. Discussions among the participants are encouraged. There is an exchange of names and phones numbers and women are encouraged to contact each other outside of the group if they need additio nal support. The struct ure of the class is based on social support theory CenteringPregnancy is implemented and monitored through the Centering Healthcare Institute led by Sharon Rising. When a clinic or hospital decides to use CenteringPregnancy they must be trained by CenteringPregnancy staff and must purchase the program which includes trainings manuals and patient guides. The CenteringPregnancy program is an alternative to individual care and follow s the same guidelines for assessment, laboratory t esting and education set forth by the American College of Obstetrics and Gynecology (ACOG) (ACOG, 20 10) Table 1.1 shows the time frame based on estimated gestational age of CenteringPregnancy sessions compared to individual prenatal care visits. The topic s covered in the CenteringPregnancy manua l are listed Table 1 .2 See Appendix A for a table of assessments, routine laboratory/diagnostic procedures and education based on the ACOG routine prenatal care guidelines for CenteringPregnancy and individual pren atal care (ACOG, 2010 ).
4 Table 1.1: Estimated Time F rame of Individual Prenatal Care Appointments and complimentary CenteringPregnancy S essions ( Reid, 2007 ) Individual Care a ppointments based on gestational weeks CenteringPregnancy s essions based on gestational weeks 12 weeks (initial visits) 12 weeks initial visit 16 weeks 16 weeks: Session 1 20 weeks 20 weeks: Session 2 24 weeks 24 weeks: Session 3 28 weeks 28 weeks: Session 4 30 weeks 30 weeks: Session 5 32 weeks 32 weeks: Session 6 34 weeks 34 weeks: Session 7 36 weeks 36 weeks: Session 8 37 weeks 38 weeks: Session 9 38 weeks 40 weeks: Session 10 39 weeks 40 weeks If CenteringPregnancy program ends before a woman gives birth she may come in for individual visits until she gives birth
5 Table 1 2 : CenteringPregnancy Sessions ( Reid, 2007 ) Sessions Topics Initial visit Prenatal c are visits Introduction Introduction to CenteringPregnancy Session 1 My prenatal care P erson al goals for a healthy pregnancy N utrition during pregnancy My weekly food pyramid Session 2 Common discomforts Exercises Oral Health Session 3 Relaxation measures (controlling stress) Thinking about Breastfeeding: Family and Parenting issues Session 4 Family planning and c ontraception Keeping myself safe and health y Family and parenting issues Session 5 Personal goals update of session 1 Childbirth Session 6 Comfort measures for labor and delivery Postpartum care Session 7 Decisi ons of pregnancy Care of the baby P reparation for siblings Session 8 Personal Assessment (birth, feelings and concerns, postpartum emotional adjustment, support systems) Session 9 Pregnancy review Birth Care of the baby Session 10 All about my baby Social gathering Social gathering where women bring their babies. Conducted 1 week after last baby of the group is born. Postpartum visit Postpartum Postpartum visit (depending on the site may be several postpartum visits)
6 CenteringPregnancy was established to provide higher quality prenatal care for women and to reduce adverse birth outcomes and improve maternal health. CenteringPregnancy groups have been established throughout the U.S. and internationally such as in Germany and Australia. Groups are formed with women of all races, ethnicity, ages, and income levels. The number of Spanish speaking CenteringPregnancy groups is growing in the U.S. and many group leaders work with CenteringPregnancy to provide a culturally appropriate and linguistically sensitive program In the U.S., about half of women of reproductive age are either obese or overweigh t (Stotland, 2008), and it is estim ated that one third of pregnant women are obese ( Mills, Troendle, Conley, Carter, & Druschel, 2009 ) Obesity and other related pregnancy complications such as gestation al diabetes and hypertensive disorders disproportionately affects Latinas in the U.S. ( Yeo, Wells, Kieffer & Nolan, 2007; Thorpe, Berger, Ellis, Bettegowda, Brown, Matte et al., 2005) These complications can lead to adverse pregnancy outcomes such as pree clampsia high birth weight and la rge for gestational age infants. In Pinellas County, Florida, Spanish speaking CenteringPregnancy groups provide comprehensive prenatal education and focus on important issues for Latinas, such as nutrition, e xercise and healthy weight gain. C ontinued research is needed on the effectiveness of CenteringPregnancy groups. Specifically, research is needed to assess maternal obesity indicators in Latina women in CenteringPregnancy groups The Pinellas County Health Departme nt Clearwater clinic serves a prenatal clientele that is about 90 % Spanish speaking mainly Mexican Americans The health
7 department began CenteringPregnancy groups in late 2006 and all of the women enrolled in the groups are Spanish speaking In addition, a ll of the presentations and materials are presented in Spanish. The Centering Health Care Institute requests that women complete evaluation forms in each CenteringPregnancy group. However, t o date, there has been no formal evaluation of the CenteringPregna ncy program comparing findings to women in traditional individual care at the health department. The health department is in need of an evaluation of the CenteringPregnancy program to ensure quality prenatal care is provided for patients in the program and to in vestigate whether there are fewer adverse pregnancy conditions and outcomes due to the intervention than in traditional individual prenatal care. Statemen t of the Problem/Need An alternative form of prenatal care called, CenteringPregnancy, has been implemented to address and prevent adverse pregnancy outcomes through a client centered, group care approach. There are currently a limited number of studies that have assessed birth outcomes of women who attended CenteringPregnancy compared to individual prenatal care. To continue to fill gaps in the literature it is important to assess these programs and determine if there are improved outcomes associated with this type of care ( "Centering Health Care Institute," 2010 ) The number of Spanish speaking CenteringPregnancy groups is growing in the U.S. and group leaders are focusing on important issues such as nutrition, exercise and h ealthy weight gain for Latina women However, there are limited studies that have specifically assessed Latinas in CenteringPregnancy or closely examined maternal weight and obesity In addition, there is limited research that focuses on theory and how the types of social support are
8 provided to women in the group. Therefore, there is a need for research, specifically aimed at assessing birth outcomes and maternal factors of Latinas in CenteringPregnancy co mpared to Latinas in individual prenatal care. Research Plan Study p urpose The primary purpose of this retrospective cohort study is to compare pregnancy outcomes of Latina women who completed CenteringPregnancy in a public health clinic to women who completed individual care in the same clinic during the same time. The secondary purpose of this study is to understand perceptions of care among multip arous women who recently completed CenteringPregnancy and comple ted individual prenatal care in the past. This research will address a current gap in the literature on adverse birth outcomes and maternal factors related to CenteringPregnancy programs for Spanish speaking women. This pr oject complete s three main objecti ves when comparing CenteringPregnancy and individual prenatal care: 1) c ompare birth outcomes including gestational age at delivery, birth weight of infants and method of birth of women who completed CenteringPregnancy compared to individual care, 2) compa re maternal c onditions including maternal weight gain, adequacy of prenatal and attendance in postpartum visit of women who completed CenteringPregnancy com pared to individual care, and 3) their p ast experience with individual prenatal care The first two objectives were addressed in Phase I of the study while the third objective was addressed in Phase II. Research q uestions Phase I Specifically, the following r esearch questions about Latina women who initiated and completed prenatal care (CenteringPregnancy and individual care) in the Pinellas County Health Department Clearwater clinic over four
9 years. For pregnant women to be included in this study, they must have entered prenatal care by No vember 2006 and at least completed care by June 2010. Table 1.3: Phase I Research Questions Objective Research Q uestions 1 1. Is there a difference in gestational age at delivery based on type of prenatal care? 1 2. Is there a difference in infant birth weight based on type of prenatal care? 1 3. Is there a difference in the method of birth based on type of prenatal care? 2 4. Is there a difference in maternal weight gain based on type of prenatal care? 2 2 5. Is there a difference in prenatal care and postpartum care attendance rates based on type of prenatal care? 6. Is there a difference in infant feeding method based on type of prenatal care? Phase II The last research question pertains to Latina women who completed CenteringPregnancy at the Pi nellas County Health Department Clearwater clinic between and January 2010 and June 2010 and completed individual prenatal care in the past. Table 1. 4 : Phase II Research Questions Objective Research Questions 3 7. CenteringPregnancy prenatal care compared to their past experience with individual prenatal care?
10 Definition of Terms Birthweight: W eight of an infant in grams at the time of birth. CenteringPregnancy or (CP): A copyrighted b rand name of a group prenatal model of care in which women of simil ar gestational age receive prenatal care in a group setting. Gestational age at birth: The number of weeks a woman was pre gnant before she gave birth Gestational d iabetes : H igh blood sugar levels (di ag nosed as diabetes) that start or are f irst diagnosed during pregnancy. Group prenatal care : P renatal care given to women along with other women of similar gestational age given in a group setting. In addition to clinical care women receive education and s upport from the group facilitator and other women in the group. Healthy or normal maternal (gestational) weight: A ppropriate weight gain based on pre pregnancy BMI as define d by the Institute of Medicine ( IOM, 1990 ; IOM, 2009) High maternal weigh t gain: W hen a pregnant woman gains more weight than recommended based on her pre pregnancy BMI ( IOM, 1990 ; IOM, 2009). Individual prenatal care : T raditional prenatal care given to women in an individual clinical setting Large for gestational age: A n infant weighting above the 90 th percentile for their gestational age. Low birthweight: An infant weighing < 2,500 grams at birth.
11 Low maternal weight gain: W hen a pregnant woman gains less weight than recommended based on her pre pregnancy BMI ( IOM, 1990 ; IOM, 2009) Macrosomia (high birthweight) : An infant weighi Maternal (gestational) weight gain: The amount of weight that a pregnant woman gained from conception to birth Maternal weight gain can be categorized into low weight gain, normal weight gain or high weight gain. Multipara: A woman who has had 2 or more pregnancies resulting in potentially viable offspring. Multiparous: Describing a woman who has had 2 or more pregnancies resulting in potentially viable offspring. Preeclampsia: A condition of hypertension occurring in pre gnancy accompanied by edema (swelling) and proteinuria (presence of protein in urine). Prenatal c are: C linical care for a woman during pregnancy with a goal to monitor the progress of a pregnancy and to identify and manage potential problems and risk factors. Pre pregnancy body mass index ( BMI ) : B ody mass index (weight in grams/height in meters 2 ) of a woman before pregnancy. Preterm birth: A birth of an infant born < 37 weeks completed gestation. Primaparous: Describing a woman who has had one pregnancies resulting in potentially viable offspring. Primary Cesarean section /delivery : Live births delivered by Cesarean section to mothers with no previous history of a Cesarean section. Post term birth: A birth of an infant born after 40 completed weeks gestation
12 Small for gestational age: A n infant weighting below the 90 th percentile for their gestational age. Term birth: A birth > 37 weeks completed gestation and < 40 weeks completed gestation Unhealthy maternal (gestational) weight: maternal weight gain either below or above the recommended amount of maternal weight gain based on her pre pregnancy BMI ( IOM, 1990 ; IOM, 2009).
13 CHAPTER TWO : REVIEW OF THE LITERA TURE Introduction Prenatal care in the U.S. was implemented as a health care servic e to monitor the progress of a identify potential problems before they become serious concerns (Kiely & Kogan, 1994) Group prenatal care is an alternative to traditional individual prenatal care that is being used more often in prenatal care clinics in the U.S. CenteringPregnancy is a common and well known brand name of group prenatal care that was established to provide better care for patients and to improve pregnancy and birth outcomes while still maintaining the evidenced based prenatal care procedures and requirements (ACOG, 2002) CenteringPregnancy was firs t implemented as a response to newly revised recommendations to prenatal care to improve maternal well being and improve pregnancy outcomes (Rising, 1998) CenteringPregnancy groups are often formed for specific populations of women, and many Spanish speak ing groups for Latinas have emerged. Although maternal obesity is a problem for all groups of women in the U.S., Latina women tend to have a higher pre pregnancy BMI than White non Latina women ( Fortner, Pekow, Solomon, Markenson, & Chasan Taber, 2009 ) thus addressing maternal weight gain in research among Latinas is needed. Little research has been done with Spanish speaking CenteringPregnancy groups.
14 History of Prenatal Care P renatal care was first introduced in the early 20 th Century by J.W. Bal lantyne (Ballantyne, 1901, 1921 ). Although the original focus and concern of prenatal care was to prevent eclampsia, over time concerns about infant mortality, preterm birth and low birthweight were also addressed ( Moos, 2006 ) Throughout the century, pregnancy several times during each trimester of pregnancy. To reduce high rates of preterm birth, low birthweight and infant m ortality in the U.S., the 1985 Institute of Medicine report, Prenatal Care: Reaching Mothers, Reaching Infants suggested a short term, clinical approach through increasing access to early and consistent prenatal care visits ( Brown, 1988 ) In response, national and local programs were implemented to increase access to prena tal care services ( McCormick & Siegel, 1999 ) However, the persistence of adverse birth outcomes in the U.S. led many to question this strategy. Several researchers began to question the usefulness of prenatal care and found that in its current form, prenatal care may actually have a limited role in preventing adverse birth outcomes such as low birth weight ( Alexander & Korenbrot, 1995 ; Lu, Tache, Alexa nder, Kotelchuck, & Halfon, 2003 ) They suggested the need for system level approaches to impact access to care and the appropriateness of services that provide social services beyond what is encompassed in traditional pr enatal care ( Alexander & Korenbrot, 1995 ). In 1998, The U.S. Public Health Service convened an expert panel with the task of establishing good practices in prenatal care and making recommendations for improvements ( Baldwin, 2006 ) The final report emphasized not only access to care but a revamping of care. It indicated that prenatal care should include early and continuing risk assessment, education and health
15 promotion, medical and psychosoci al intervention, support and follow up ( Culpepper, 1989 ) In addition, the report recommended that the number of prenatal care visits for low risk women should be decreased, but each visit should be enriched with early pregnancy health promotion and discussions on psychosocial aspects of childbearing and parenting ( Moos, 2006 ) The reduction of prenatal visits was a controversial topic at the time; however, more recent research has indicated that a reduced frequency of prenatal care visits for low risk women is appro priate, effective, and safe ( Berglund & Lindmark, 1998 ; Binstock & Wolde Tsadik, 1995 ; McDuffie, Beck, Bischoff, Cross, & Orleans, 1996 ; Walker, McCully, & Vest, 2001 ) CenteringPregnancy An alternative form of prenatal care, CenteringPregnancy was piloted in the early midwife named Sharon Rising as a response to the new thinking of prenatal care ( Rising, 1998 ) The CenteringPregnancy model not only decreased the number of prenatal care visits from 13 total visits to 10 total visits but also added depth to the educational component of care and provided a group setting conducive to interaction among women and with health care providers to enable social support. The idea o f group care conducted in a support environment with increased education was an innovative framework to address the current issues with prenatal care services and in turn improve pregnancy outcomes. Although Ms. Rising had the idea of group prenatal care i n the (S S Rising, persona l communication, April 15, 2010 ). Now there are over 80 CenteringPregnancy cites in North America and continuing scientific research being conducting to providing findings of outcomes.
16 Compar ison of CenteringPregnancy and i ndividual prenatal c are Although there are some shared basic qualities, CenteringPregnancy differs from individual prenatal care in several ways. First, CenteringPregnancy prenatal care is done in 10 prenatal care visits with several other pregnant women as opposed to 13 visits in individual care ( Reid, 2007 ) The prenatal care visits after 36 weeks are the visit s that are decreased, however individual office visits may augment t he last few gro up sessions if additional exam s are needed ( Reid, 2007 ) or if women completed CenteringPregnancy but did not yet give birth Second, each CenteringPregnancy visit is 90 120 minutes long, sometimes longer depending on the clinic, as opposed to 15 20 minutes visits in individual prenatal care ( Rising, Kennedy, & Klima, 2004 ) One of the main strengths of the model especially when it is incorporated into health departments is tha t there is no wait time before CenteringPregnancy visits. Instead of women occupying waiting rooms for several hours, they spend that t ime participating in the group session learning about their pregnancy. Third, CenteringPregnancy has several education components that are mentioned in individual care, but due to time, are not covered in the same detail. Although there is a set curriculu m for education, the groups can be flexible and discuss specific topics with greater depth depending on the request of the group and the recommendation by the facilitator. For example, a CenteringPregnancy group in Orang e County, FL, primarily includes low income African American women. This particular group has low breastfeeding rates, thus the facilitator spends extra time discussing the importance of breastfeeding. The CenteringPregnancy group in Pinellas County, FL, provides services only low income Sp anish speaking women. As indicated by the physicians at the health
17 department and by the weight status data, this particular group of women often has more problems with overweight and obesity, and thus the facilitators emphasize the education on nutrition and physical activity during pregnancy and healthy weight gain. Lastly, the CenteringPregnancy groups function on the idea of group support. The formulation of a group of women coming together for care works under the assumption that social support can inf important, as women with a good support system tend to have more resources to help ( Rising, 1998, p. 49 ) In a CenteringPregnancy group, a supportive environment develops among the group facilitator, staff and women as they all share their thoughts, ideas and concerns throughout their pregnancy ( Rising, 1998 ) In the group, women are not seen as isolated patients but rather they are gathered together with a support network of other women and their health care providers. Many women in the program develop strong relationships with each other and begin to assist each other with different forms of support such as, teaching each other valuable information and providing each other with transportation and childcare ( Rising, 1998 ) Klima et al. ( 2009 ) reported that women in the group were bonding with each other and were able to become empowered through the group care ( Klima, et al., 2009 ) Such a strong bond was formed that Centering Parenting also run through the Ce ntering Health Care Institute, was formulated. Women and their partners wanted to continue the groups after their babies were born. The Centering Parenting groups provide support and education for new parents with a similar approach to CenteringPregnancy ( "Centering Parenting," 2009 ) CenteringPregnancy r esearch Since the model was developed, a number of studies have assessed the effectiveness of group prenatal care and CenteringPregnancy
18 programs compared to individual prenatal care ( Table 2. 1 ) Ickovic Kershaw, Westdahl, Rising, Klima et al. ( 2003 ) conducted a matched cohort study of women in Atlanta, Georgia and in New Haven, Connecticut of 485 women and found that birthweight was greater for infants of women in group care versus individual prenatal care (p< .01), and preterm infants of the group care patients were significantly larger than preterm infants of individual care p atients. One limitation to this study was that authors did not specify if any of the infants were high birthweight or large for gestational age. In a randomized control trial of 1,047 women aged 14 25 years old, Ickovic et al. ( 2007 ) found that when compared to individual prenata l care, group prenatal care resulted in equal or improved perinatal outcomes with no additional cost to the health cent ers. The authors found a 33 % ( adjusted odds ratio) a OR=0.67; 95% CI: 0.44, 0.99) odds reduction of preterm birth for those women randomi zed to group prenatal care ( Ickovics, et al., 2007 ) Ickovic et al. ( 2007 ) also found that women in group care had significantly better psychosocial outcomes compared to those in individual care. Women in the CenteringPregnancy groups had more prenatal car e knowledge, felt more pr epared for labor and birth (p<.001), and had significantly higher satisfaction with their prenatal care (p<.001) ( Ickovics, et al., 2007 ) Grady & Bloom ( 2004 ) conducted a cohor t study with a comparison group and found that adolescents in CenteringPregnancy groups who were at risk for low birthweight and preterm infants had a 50 % lower rate of low birthweight and preterm birth (p< 0.02) than the comparison group. This study had a limited s ample size of 124 adolescent women. Klima et al. ( 2009 ) examined women in a CenteringPr egnancy group and in individual prenatal care at a public health clinic predominately serving low income African American women. The authors did not find a
19 significant difference in birth outcomes, but reported increased attendance to prenatal care visits, increased breastfeeding rates, and higher levels of satisfaction of care in the CenteringPregnancy group ( Klima, et al., 2009 ) They also found a statistically significant difference in weight gain during pregnancy from the CenteringPregnancy groups (average weight gain, 32.2 lbs) compared to the individual care (a verage weight gain 28.5 lbs) ( Klima, et al., 2009 ) T here are a limited number of studies that have examined the knowledge that women gain during CenteringPregnancy groups versus traditional prenatal care. Baldwin ( 2006 ) sampled 1 24 pregnant women and found that between CenteringPregnancy groups and individual care groups, there was a statistically significant difference in posttest knowledge related to pregnancy compared to pretests (p=0.03). On the other hand, Shakespear Waite & Gast ( 2009 ) conducted a cross sectional study surveying 125 pregnant women and found that CenteringPregnancy had significantly lower health behavior index scores compared with women in individual prenatal care. It was not clear exactly what constructs w ere used in the index. However, the authors note d that the differences in the health behavior scores may have been due in part by a lack of one on one time for clients to ask questions to the provider (Shakespear et al., 2009) Conflicting studies such as these indicate that it is important to continue to examine health behaviors along with clinical and biological indicators when assessing pregnancy outcomes. Although there are increasing numbers of Spanish speaking CenteringPr egnancy groups, there are a limited number of studies that focus on Latinas in a group care setting. The only study that specifically examined Latinas in Centerin gPregnancy groups was done by Robertson, Aycock & Darnell ( 2008), who conducted a quasi experimental
20 prospective comparis on study of 49 Hispanic mothers (24 cases, 25 comparison) and found no differences in infant outcomes, maternal knowledge deficits and health behaviors between the groups ( Robertson, Aycock, & Darnell, 2009 ) However, the authors also indic ated that the CenteringPregnancy group had a high satisfaction rate with their care and the majority reported that they would choose CenteringPregnancy again ( Robertson, et al., 2009 ) A major limitation to this study is small sample size. St udies aimed at understanding outcomes of CenteringPregnancy group with Latinas with specific focus on the major pregnancy related issues with Latinas including maternal weigh are essential. Because of the limited number of studies, low sampl e size of many studies and inconsistency of results, there is a gap in research assessing CenteringPregnancy. In addition, there is limited research on CenteringPregnancy groups working specific ally with Latinas. Findings based on other racial and ethnic g roups may not be generalizable to Latina women.
21 Table 2 1: Literature Review of R esearch on CenteringPregnancy P rograms Author Year and Location Study Design Sample Size Population Birth Outcomes Prenatal care/Maternal Outcome Satisfaction of care/behaviors/ Knowledge outcomes Qualitative Limitations Rising (1998) New Haven, CT Pilot Non random N=62 Women in CP were less likely to have third trimester emergency room visits (p=0.001) Lack of randomization Low sample size Ickovic et al. (2003) Atlanta, Ga New Haven, C T Matched cohort prospective N=458 Individual (n=229) C P (n=229) Minority women of low socioeconom ic status from three public clinics Age: 1 4 41 yrs Birthweight was higher for infants in CP vs. individual (p< 0.01) birthweight was higher for CP vs individual (p<0.05) Lack of randomization Grady and Bloom (2004) St. Louis, MO Cohort N=268 Individual 1998 (n=144) Individual 2001 (n=233) CP (n=124) Adolescents Age: 11 17 yrs Women in CP were less likely to have a PTB (p<0.02) and LBW infant (P< 0.02) compared to both comparis on groups (50% lower rate of LBW) N o significant difference in the number of C sections between groups. Breastfeeding at hospital discharge was higher among women in C P than individual care (0<0.02) 87% of women in CP came for postpartum visit. No data for women in individual care Self selection of adolescents into CP or individual care Lack of information on adequacy of prenatal care in comparison groups
22 Baldwin (2006) Midwest, South and Northeast Pre/post test N =98 Individual care (n= 48) CP (n=50) 3 sites Age: 18 32 yrs Perinatal knowledge scores were higher among women in CP than in individual care (p =0.03) N o difference in sco res for perception of support (no p value) No difference with satisfaction of care or fetal health locus of control ( no p value) Low sample size Lack of randomization High education of women may lead to ceiling effect of pretest Post test data collected at d ifferent gestational age in CP than in individual care Ickovic et al. (2007) Atlanta, Ga New Haven, Co Randomized control trial N=1,047 Individual (n=394) CP (n=653) Low SES 80% African American women Mean Age: 20.4 yrs There was a 33% odds reduction in preterm birth (p=0.045). Women in CP were less likely to have suboptimal prenatal care (p<0.01) and had higher breastfeeding initiation than women in individual care (P<0.001) There were no differences in cost associated with prenatal care or deliver y Women in CP scored higher on pre natal knowledge test (p<0.001), felt more ready for labor and delivery (p<0.001) and had greater satisfaction with care (P<0.001) Only generalizable to restricted group of low income with at high risk for adv erse perinatal outcomes.
23 Robertson et al. (2008) Georgia Quasi experimental prospective Pre/post N= 49 Individual care (n=25) C P (n=24) Latina women Individual mean age: 26.5 yrs CP m ean age: 24.6 y rs No significant differences in birth outcomes No significant differences in knowledge or health behaviors but lower levels of postpartum self esteem among individual care women (p=0.037) Small homogenous sample size Self selection of care No data on country of origin among Latina women Klima et al. (2009) Midwest Cohort and qualitative study N=458 Individual (n=61) C P (n=207) Predominant ly African American Age: 14 38 yrs No significant difference between group s mean gestational age at birth and mean birthweight. (P>0.05) CP women had significantly more prenatal care visits, increased weight gain, increased breast feeding rates (all p values <0.05) CP women had significantly higher overall satisfaction (p<0.05) Participants in CP 1) e njoyed sharing their pregnancy experience 2) report ed they were well prepared for labor and birth and 3) felt CP enhanced relationships with their providers and other pregnant women No prepregnancy BMI only weight gain Only used # of prenatal visits no calculation or index Lack of r andomized control group Shakespear (2009) Utah Cross sectional survey N=125 Individual (n=75) C P (n=50) Primarily white low income women Participants from CP scored lower on a health behavior index than those in individual care. Self reports Cross sectional Non random Note. CP=Centering Pregnancy; PTB= Preterm birth, LBW= low birthweight, n=sample size
24 Latinas Latinas and adverse pregnancy outcomes In maternal ( Brown, Chireau, Jallah, & Howard, 2007 ) also known as the Latinos groups living in the U.S., especially Mexican Americans, despite high rates of low income status, low education and lack of access to services. In gener al, low income and years of education are thought to increase the likelihood of adverse outcomes however research has shown that some Hispanic groups, specifically Mexican Americans have similar adverse birth outcomes to those of non Hispanic whites ( Hummer, Powers, Pullum, Grossman, & Frisbe, 2007 ) Research suggests this paradox may be attributed to cultural differences such as healthier eating habits and increased family support with women who are less assimilated ( Franzini, Ribble, & Keddie, 2001 ; Hummer, et al., 2007 ) Becau se of the outcomes are often framed in a way that indicates Latinas have fewer adverse maternal and infant outcomes in general than other ethnic or racial groups. However, in reality, there are several pregnancy related issues that have been increasing among Latinas in the U.S., including maternal obesity and related metabolic syndr ome, gestational hypertension (including preeclampsia), gestational diabetes, preterm birth, large for gestatio nal age infants and macrosomia (Rosenberg, Garbers, Lipkind & Chiasson, 2005) In addition, Buekins, Notzon, Kotelchuck and Wilcox ( 2000 ) found that although Mexican Ame rican women had fewer low birth weight infants than non Hispani c white mothers, the mean birth weight of Mexican American babies was lower than tha t of non
25 Hispanic White babies. This shows the importance of examining birthweight both as a categorical and a continuous variable to better understand the true outcomes The idea of programming is directed away from Latinas who are the fastest growing ethnic group in the U.S. with the highest rates of fertility (National Vital Statistics Report, 2008). Latin as and prenatal care Prenatal care is a preventive service t hat is used to provide risk assessment and monitoring to pregnant women throughout gestation. Prenatal care services aim to prevent adverse pregnancy conditions and outcomes (Alexander & Korenbrot, 1995). Although there are several indices that measure adequacy of prenatal care, they focus more on timing of care and number of visits rather than the quality of the care. Tandon et al. ( 2005 ) conducted a mixed methods study on Latinas perceptions of patient centeredness during prenatal care. They found that Hispanic mothers were less likely to pe rceive that doctors and nurses treated them with respect during the ir prenatal care appointments (a OR, 0.29; 95% CI, 0.10, 0.86) than non Hispanic mothers ( Tandon, et al., 2005 ) Hispanic mothers were also less likely to feel that office staff treated them with respect during the ir prenatal care appointments (a OR, 0.29; 95% CI, 0.12, 0.73) and that they were more likely to experience language or communication problems than non Hispanic mothers ( a OR, 3.30; 95% CI, 1.40, 7.76) ( Tandon, et al., 2005 ) Through qualitative analyses the authors found that Hispanic questions during their visits and their desire for subseq uent care were hindered by a lack of patient centered care ( Tandon, et al., 2005 ) The authors concluded that Hispanic women could benefit from more culturally and linguistically appropriate prenatal care as
26 prenatal care as a forum for Latinas to re ceive this care. Group prenatal care can also address more specific pregnancy issues related to Latinas such as those mentioned in this proposal (maternal weight gain, gestational diabetes, gestational hypertension, preterm birth and other adverse pregnanc y outcomes). Maternal Weight Maternal weight and adverse pregnancy outcomes In the U.S., about half of women of reproductive age are either obese or overweight (Stotland et al., 2008), and an estim ated that one third of pregnant women are obese ( Mills, et al., 2009 ) Obes ity during pr egnancy is defined by pre pregnancy body mass index (BMI) and maternal weight gain (also known as, pregnancy weight gain). The Institute of Medicine ( IOM ) published standards on both of these measures in a 1990 IOM report and recently updated these standards in 2009 ( IOM, 2009; Rasmussen & Yaktine, 2009 ) ( See Table 2. 2 and Table 2 3 ) The new guidelines have a pre pregnancy BMI category that is consistent with the World Health O rganization categories and have slightly altered weight gain categories specifically for obese women. In general, i t is recommended that women with lower p re pregnancy BMI gain more weight during pregnancy than women with higher pre pregnancy BMI. Table 2.2. IOM Maternal Weight Gain G ui delines. Body Mass Index (BMI) A ccording to the 1990 IOM R eport ( IOM 1990 ) Pre pregnancy Weight BMI Total Weight Gain (lb) Underweight <19.8 28 40 Normal Weight 19.8 26.0 25 35 Overweight 26.1 29.0 15 25 Obese >29.0 15
27 Table 2 3 : IOM Maternal Weight Gain G ui delines. Body Mass Index (BMI) A ccording to the 2009 IOM R eport (2009) Pre pregnancy Weight BMI Total Weight Gain (lb) Mean weight gain range in lbs/week Underweight <18.5 28 40 1 1.3 Normal Weight 18.5 24.9 25 35 1 Overweight >25.0 29.9 15 25 0.6 Obese >30 11 20 0.5 Obesity rates in Latino populations in the U.S. are increasing and becoming an even greater health concern. Rates of obesity in Mexican American women are especially concerning. In 2002, the age adjusted prevalence of obesity among adult women age 20 or more was 26 % for Mexican Americans, which is 5 % higher than non Hispanic whites (Health and Human Services, 2003). Along with ot her ethnic and racial groups, the trend of obesity among Latinas of reproductive age in the U.S. has been also been increasing. A report from the National Health and Nutrition Examination Survey (NHANES) found that the prevalence of overweight among Hispan ic U.S. women aged 20 49 years in 2005 2006 was 29.4 % and the prevalence of obesity was 40.7 % (Sharma, Cogswell, Li, 2008). Maintaining healthy weight can be an important factor in preventing various adverse pregnancy outcomes. Women who are overweight or obese prior to conception, or gain more than ideal weight during pregnancy, are also at increased risk of gestational hype rtension including preeclampsia ( Asbee, Jenkin s, Butler, White, Elliot et al. 2 009) gestational diabetes, preterm birth, high birt hweight, large for gestational age infants, macrosomia, prolonged labor, caesarean birth, congenital malformations, spontaneous abortions, stillbirths and subfertility (Stotland et al., 2009; Villamour and Cnattinguis, 2006). Several studies have found sig nificant relationships between obesity and adverse
28 birth outcomes. After adjusting for many other risk factors including maternal age, parity, smoking and ed ucation, Cnattingius Bergstrm, Lipworth & Kramer (1998) found that obese women were 1.6 times mor e likely to deliver an infant preterm at <32 weeks gestation when compared to n on obese women. Kristensen Vestergaard, Wisborg, Kesmodel & Secher (2005) conducted a study in Denmark on 24,505 singleton pregnancies and found that maternal obesity, m ore t han doubles the risk of stillbirths or neonatal death compared to women of ideal body weight. A longitudinal study by Ehrenberg LeRoy, Milluzzi,& Merceer (2004) investigating the influence of obes ity on ternal obesity and pregestational diabetes were independently associated with increased risk of large for gestational age infants. Even with all the knowledge that is known about maternal weight and its profound influence on pregnancy complications and outcomes, many obstetric providers rarely discuss pregnancy related weight problems thoroughly with their patients. In a cohort study, Stoland et al. (2005) found that overweight women were often given the same guidelines on weight gain as women of normal weight. They determined that providers did not take extra time educate women about weight gain or problems associated with high weight during pregnancy. When coupled with problems in communication and translation with Spanish speaking wome n, the result can lead to increase weight problems and pregnancy complications for Latinas. Complication s associated with maternal o besity Maternal o besity has been found to be a causal factor for gestational diabetes and gestational hypertension. In the U.S. about 3 5% of all pregnant women have gestational diabetes (Gabbe & Graves,
29 2003). Latinas and obese women are at higher risk for developing ges tational diabetes (Berkowitz, Lapinski, Wein et al., 1992; Cheng & Caughey, 2008). Gestational diabetes among Latinas has been increasing in the U.S. (Garber et al., 2008) and is associated with other maternal complications such as preeclampsia, infection and postnatal type 2 diabetes ( Gonzalez Quintero, Istwan, Rhea, Rodriguez, Cotter, Carter et al. 2007 ). Infant risks related to gestational diabetes include preterm birth, high birthweight, macrosomia (Mendelson, Smith, Koniak Griffin et al., 2008), childh ood metabolic syndrome and diabetes later in life ( Vohr & Boney, 2008 ). Hypertension disorders during pregnancy can lead to maternal and infant mortality and morbidities including chronic hypertension and cardiovascular problems for mothers and preterm birth and low birthweight infants ( Thorsdottir, Torfadottir, Brigisdottir & Geirsson 2002; Fortner Pekow Solomon Mar kenson & Chasan Taber 2009). Preeclampsia affects about 5 8% of all pregnancies in the U.S. (Preeclampsia Foundation, 2008), but research has shown higher rates among Latinas (Wolf Shah, Jimenez Kimble, Sauk, Ecker, & Thadhani 2004). In 2007, t he rate of cesarean delivery in the U.S. was 31.8%, a record high which marked the 11th consecutive year of increase ( Hamilton, Martin, & Ventura, March 18, 2009 ) Obese pregnant women have an increased risk of cesarean section and lower success rates for vaginal births after cesarean section ( Davis et al., 2010 ) It is estimated that the risk of cesarean delivery is about two time s higher for obese women, and three times higher for morbidly obese women. A bout 16,000 cesarean deliveries annually in the U.S. are due to obesity ( Chu, Kim Schimd, Dietz, Callag han, Lau, et al. 2007 )
30 Measuring maternal o besity Pre pregnancy BMI and maternal weight gain are often studied as separate indicators for maternal obesity; however, these two variables are linked. Studies have found that women who are overweight before conception are likely to gain more weight than recommended during pregnancy and are at greater risk for adverse pregnancy outcomes. A cohort study by Kiel et al. (2007) found that 46% of women in their study who were already obese gained more than 25 pounds during pregnancy, exceeding the IOM recommendations for obese women. Chu et al. (2009) found that obese women gained less weight during pregnancy than normal or overweight women; however, about a quarter of the women still gained at least 35 pounds. To fully assess maternal obesity and its complications, the relationships between pre pregnancy BMI and maternal weight gain should be studied in addition to the relationship between these two f actors and adverse pregnancy outcomes. Prenatal Care A ttendance In 1994, Kotelchuck developed the Adequacy of Prenatal Care Utilization (APNCU) index to describe the utilization of prenatal care based on two dimensions, 1) adequacy of initiation into pren atal care and 2) adequacy of actual received prenatal care visits ( Kotelchuck, 1994 ) The APNCU index was developed as an improvement of the Kessner/I.O.M index which unlike APNCU did not calculate the adequacy of received visits based on initiation of care. The APNCU index is calculated by taking the number of American College of Obstetricians and Gynecol ogists ( ACOG ) recommended visits for a given gestational age and adjusting that number based on the data of prenatal care initiation ( Kotelchuck, 1994 ) ACOG ( 2002 ) recommends women to att end 14 prenatal care visits in a 40 week pregnancy. Thus, using the APNCU index, Kotelchuck ( 1994 )
31 describes an e xample of a woman wh o began prenatal care in month four of her pregnancy and thus missed three visits. She would only be expected to attend 11 visits throughout the rest of her pregnancy (14 3 =11 visits). A proportion is then derived using the number of e xpected and observed visits (observed visits/expected visits) multiplied by 100. This would be altered for CenteringPregnancy which only requires 10 visits. The two components of the index results are combined and scaled as described below. Inadequate: ca re began after the 4 th month or expected visits = 0 49% Intermediate: care began by the 4 th month and expected visits = 50 79% Adequate: care began by the 4 th month and expected visits = 80 109% Adequate plus: care began by 4 th Postpartum Care A ttendance According to the World Health Organization, the postpartum period, also known as the postnatal period or puerperium, begins about 1 hour after the placenta is delivered and continues for the following six weeks (WHO, 1998). There are many physical, psychological and interpersonal changes that occur during this period with distinctive numerous physical changes to return to their non pregnanc y state, and women often experience many different emotions as they make many adjustments in their family, social and professional lives. Postpartum care can aid in the prevention, early detection and treatment of complications and disease such as postpart um depression, urinary tract infections and postpartum hemorrhage (Albers, 20 00). It also serves to educate and assist women with breastfeeding, birth spacing, immunization and maternal nutrition and exercise (WHO, 1998).
32 Studies have suggested that earl y postpartum weeks are a critical period for the establishment of exclusive breastfeeding and suggest the need for postpartum strategies that could be a part of postpartum care (Semenic, Loiselle & Gottlieb, 2008). As public health research suggests, exclu sive breastfeeding is associated with many maternal and infant benefit s (Ip Chung, Raman, Chew, Magula, DeVine, et al., 2007; Semenic et al. 2008). E xclusive breastfeeding for the first 6 months is recommended for optimal outcomes ( Kramer & Kakuma, 2002 ) Postpartum visits are also critical opportunities to screen for and identify postpartum depression (Paulden Palmer, Hewitt & Gilbody 2009). Family planning, such as e ducating women on baby spacing and the use of contraception is an integral part of postpartum care Short birth intervals can lead to adverse pregnancy and birth outcomes ( Yeakey, Muntifering, Ramachandran, Myint Creanga & Tsui, 2009). National objectives have been set to increase birth spacing ( h and Healthy People ) and the World Health Organization (2005) recommend that women wait 2 3 years between pregnancies to reduce subsequent health problems. The provision of contraception is part of the standard of care for postpartum visits in the U.S. (Lopez, Hiller & Grimes, 2010) and is used to help increase birth intervals. Educating and providing contraception in the pos tpartum period provides an opportunity for women who do not routinely access health care, to obtain contraceptives (Tr ussell Schwarz, Guthrie, 2009). This is the case for many Latina immigrant women in the U.S. (Rodriguez et al., 2010). Studies have indicated that postpartum contraceptive education increases contraceptive use and decreases unplanned pregnancies (Lopez, H iller & Grimes, 2010 ). Improving attendance rates in postpartum care can help women better
33 receive the services and education needed during this time period. Many CenteringPregnancy groups report higher attendance rates among women for both prenatal care a nd postnatal care visits ( Teate, Leap, Rising, & Homer, 2009 ) Theory Social Support Theory The social support theory is an interpersonal theory that is often used in health research and programming. The constructs of the social support theory were ( 1974 ) John Cassel ( 1976 ) and Sidney Cobb ( 1976 ) All three authors laid the foundation for research being ( Vaux, 1988 ) Social support theory is complex and multifaceted and many different variations of the t identify the conditions in which social support can influence health outcome the main effects model and the stress buffering model ( Cohen, Gottlieb, & Underwood, 2000 ) The main effect model proposes that social support and social relationships can affect mental and physical health, while the stress buffering model propos es that support is related to well being only for people who are under stress. Both models are used in health research, however much of the maternal and child health literature identifies stress as the common factor that is mediated by social support. Social support theory is complex, and different theorists describe different variations and constructs within the theory. Hupcey (1998) described that characteristics and perceptions of the person giving support (the provider), denoted a P in Figure 1, an d the person receiving support (the recipient) denoted as R, influence the support. Hupcey ( 1998 ) also provides diagrams depicting the reciprocal relationship between the recipient
34 p ort, these relationships may also cause stress or negative and harmful effects that detract from the perceived notion of providing support. These pathways help in identifying social support and how it aff ects the recipient. See Figure 2.1 Figure 2. 1: Social Support Pathways ( H upcey, 1998 ) The pathways that Hupcey ( 1998 ) provides may be used to symbolize prenatal care. Figure 2. 1 (a) depicts one individual recipient and one individual provider of support. In prenatal care, this may represent the patient and the health care provider. This is often the pathway of support that is given individual prenatal care, one to one. Figure 2 .1 (b) depicts two providers of support for one recipient. In prenatal care, the second provider of support may be either another health care provide r, a family member who attends prenatal visit and is involved in the pregnancy, a patient advocate or Healthy Start worker for example. This may also be seen in in dividual prenatal care. Figure 2.1 (c) depicts one recipient with several providers of suppor t. This would likely be an example of support given to a pregnant woman in a CenteringPregnancy group. However, double arrows would be added to illustrate the reciprocal support provided in the group. The
35 providers and recipients of support would be one or more health care providers, the health educator and all of the other women involved in the group. Social support m easures Researchers use one of three main theoretical perspectives of social support described by Cohen ( 2000 ) 1) The Stress and Coping Perspective a. Supportive Actions b. Appraisal 2) The Social Constructivist Perspective a. Social Cognition b. Symbolic Interactionism 3) The Relationship Perspective A common use of social support theory in health related research operates under the assumption that social support mediat es stress that can affects health. This either happens through supportive actions of others which can enhance coping, or through the perceptions of available support which can lead to appraising situations as less stressful ( Cohen, 2000 ) See Figure 2 .2 In CenteringPregnancy the supp ort from the group can help alleviate stress which may in turn improve pregnancy outcomes. The social constructivist perspective to social support is rooted in social cognition and symbolic interactionism, and links self perspective and self reflection to perceiving support ( Cohen, 2000 ) The social cognitive perspective predicts that perceived social support can esteem and in turn affect health outcomes ( Cohen, 2000 ) See Figure 2.3 The symbolic interactionist perspective predicts which in turn affects health
36 outcomes ( Cohen, 2000 ) See Figure 2. 3. In CenteringPregnancy the support from the esteem and even empower h er to take control of her pregnancy which may help her to feel stronger and more comfortable with her pregnancy. Lastly, the relationship perspective conceptualizes support as part of a larger interrelated relationship ( Cohen, 2000 ) This perspective pr edicts that constructs such as companionship, low conflict and intimacy received from relationships effect social support and health ( See Figure 2. 4 ) In CenteringPregnancy the support from the group might increase companionship and intimacy through the building of low conflict friendships with other women.
37 Figure 2 .2 : Supportive Actions Approach and the Appraisal Perspective ( Cohen, 2000 ) Figure 2.3 : The Social Cognitive Perspective and the Symbolic Interactionist Perspective ( Cohen, 2000 ) F igure 2. 4: Relationship P erspective (example) ( Cohen, 2000 )
38 Types of social s upport There are several different types of social support that have been described by House ( 1981 ) emotional support such as empathy, love and trust; instrumental support such as tangible services; informational support such as educational informati on and advice and; appraisal support (also known as validation support) such as constructive feedback and affirmation. In Social Support Measurement and Intervention, Wills ( 1985 ) also included companionship support as another form of support. These types of support are often used in research to measure support. Social s upport and maternal and child h ealth The importance of the social environment, social relations h ips and social interactions has been used in various aspects of health and medicine. Many studies have used social support theory to test the effects of social support on birth outcomes and on maternal emotions and behaviors ( Pierce, Sarason, & Sarason, 1996 ) of investigation b ecause pregnancy and birth are ( Pierce, et al., 1996 ) Specifically in maternal and child health, the stress and coping perspective of the social support theory has been used often in research and programming. Stress, depression, anxiety and other psychosocial factors have been the focus of many studies on p regnancy and birth outcomes. Research has supported that stress is associated with the diagnosis of many high risk pregnancies ( Black, 2007 ) and is frequently linked to preterm birth, miscarriages, pregnancy complications and impaired fetal development ( Elsenbruch Benson Rucke, Rose, Dudenhausen, Pincus Knackstedt et a. 2007 ) Stress and poor maternal psychosocial support can also be associated with severe pregnancy related nausea and vomiting and increased morbidity during pregnancy ( Chou, Avant, Kuo, & Fetzer, 2008 ) Various studies have linked social support with better physical and
39 mental health during pregnancy ( Balaji et al., 2007 ; Berkman & Syme, 1979 ) In particular, social relationships have been found to affect mental health in pregnant women through influencing s tress levels, anxiety, depression and psychological well being ( Balaji, et al., 2007 ) Social support has been found to act as a mediator between stress and its symptoms ( Gupton, Heaman, & Ashcroft, 1997 ) and has been further investigated as a mediator between stress and high risk pregnancies ( Black, 2007 ) Chou et al. ( 2008 ) investigated the relationships between nausea and vomiting, perceived s tress and social support for pregnant mothers and found that pregnancy related vomiting associated with high perceived stress levels may be mediated by social support. Perceived social support has been shown in various studies to have a positive effect on pregnancy outcomes ( Feldman, Dunkel Schetter, Sandman, & Wadhwa, 2000 ; Collins, Dunkel Schetter, Lobel, & Scrimshaw, 1993 ; Oakley, Rajan, & Grant, 1990 ) Social support has been related to higher utilization of prenatal care, less difficult labors, higher birthweight, and reduced rates of postpartum depression ( Logsdon & Davis, 2003 ) Social s upport and CenteringPregnancy The presence of support has been linked to positive health outcomes and it can be used as a useful tool in health interventions ( Hogan, Linden, & Najarian, 2002 ) Due to the large component of social support, Westdahl, Milan, Ma griples, Kersha w, Rising et al. ( 2007 ) suggested group prenatal care may be a useful tool for addressing psychological issues, such as prenatal depression. In a CenteringPregnancy group, a supportive environment develops among the group facilitator, staff and women as they all share their thoughts, idea s and concerns throughout their pregnancy ( Rising, 1998 ) Many women in the program develop strong relationships with each other (companionship support) and begin to assist each other with
40 different forms of support such as, teaching each other valuable information (informational support) and providing each oth er with transportation and childcare (instrumental support) ( Rising, 1998 ) Klima et al. ( 2009 ) reported that women in the group were bonding with each other and having camaraderie (emotional support) and women were able to discover their voice and are empowered through the group care (appraisal/validation support) ( Klima, 2003 ) The dimensions of support (function, the quality, the quantity and the source of support) and the characteristics of the recipient (context, age, ethnicity, stress level, socioeconomic st atus, educat ion etc) can influence how social support effects health outcomes ( Pierce, et al., 1996 ) Creating a supportive environment in the clinical setting is especially important for women who lack social supp ort in other areas of their lives For example, women who do not have supportive families or partners and low income women who may have few supportive resources in the ir neighborhoods or communities may be in greater need of social sup port from their prenatal care. Many of the CenteringPregnancy groups are held with women who tend to have high level s of stress especially during pregnancy, including low income women, women with low education levels, racial and ethnic minorities and teenagers (Baldwin, 2006; Grady & Bloom, 2004; Rising, Kennedy & Klima, 2004; Klima, 2003).
41 CHAPTER THREE : METHODS Research Site: Pinellas County Health Department The Pinellas County Health Department Clearwater clinic was the main research site for data collection. This health department clinic is a low risk clinic, thus only low risk obstetric patients are seen by the health care providers. If a woman is considered high risk at the start of her pregnancy or becomes high r isk at any point in her pregnancy she is referred to Bayfront Medical Center, which as a high risk obstetric clinic. Some conditions that categorize a woman as high risk are severe hypertension and gestational diabetes. A list of high risk criteria that i s used at the health department is provided in Appendix B The investigator worked with the CenteringPregnancy program coordinator and clinic staff to conduct the research. The Pinellas County Health Department Clearwater clinic began offering CenteringPre gnancy to all Spanish speak ing obstetric patients in December of 2006. Thus, women who completed their initial prenatal care visit as early as November 2006 had a choice to participate in CenteringPregnancy. Because approximately 85% of the obstetrical cli ents are Spanish speaking, CenteringPregnancy is only offered in Spanish.
42 Preliminary Data Collection Prior to the start of the dissertation research, the investigator conducted preliminary qualitative observations with women in the CenteringPregnancy program at the Pinellas County Health Department Clearwater clinic. She conducted participant observation of a CenteringPregnancy group from start to finish. There were a total of ten group sessions in which the researcher attended eight. Each session last ed approximately three hours. Although not involved in the clinical assessment portion of the session, the researcher became a part of the group, sat with the participants in the group circle, listened to the education being given and participated in group activities. This preliminary research allowed the researcher to 1) better understand how the CenteringPregnancy groups functions, 2) understand the group dynamics and interactions 3) establish relationships with the group facilitators, nurses and staff an d, 4) obtain preliminary qualitative data to develop the interview guide to answer research question 7. Individual care at the Pinellas County Health Department Individual prenatal care at the clinic comprises an initial prenatal care visit 13 subsequen t v isits, and one postpartum visit. The prenatal care protocol follows three main components including assessing health risks of the mother and the baby, educating the mother about components of a healthy pregnancy and birth and providing proper interventi on or services based on the mother risks and health status. The intended outcome of prenatal care at the health department is to improve pregnancy outcomes re sulting in a full term, healthy infant and a healthy mother See Appendix C for prenatal care pr otocols followed at the health department. Since 2006 there have been only three consistent obstetricians caring for obstetric patients at the clinic (with the exception of
43 doctors who may have filled in for vacation and sick time ). Two of these obstetrici ans also care for the CenteringPregnancy patients and participate in the group sessions. CenteringPregnancy at the Pinellas County Health Department After a few pilot groups, the first official CenteringPregnancy group began in December 2006. A health edu cator who works for Pinellas County Healthy Start Coalition, has served as the group facilitator for all of the CenteringPregnancy groups. The group facilitator along with the physician, provides education to the women, conducts group activities, and lea ds discussions. Two of the three obstetricians who consistently care for maternity patients at the clinic also care for the CenteringPregnancy patients and participate in the group sessions. Each physician participated in about half of session, she/he conducts the physical e xam including ultrasound and discusses the in the group discussion and activiti es. Both physicians and the health educator have conducted the groups since the start of the program and no other physicians or health educators have been involved. A nurse is also usually present in the group to assist with taking body weight and blood pr essure and to provide paperwork to women who need laboratory testing. The nurse introduces herself and participates in the group in the first session but does not consistently participate in the group education or activities. All groups are facilitated in Spanish and all material given to women is in Spanish. In addition, all personnel who work with the CenteringPregnancy groups are fluent Spanish speakers.
44 There are on average 10 women in each CenteringPregnancy group. The 10 prenatal care groups sessio ns follow the guidelines set by the Centering Health Care Institute ( "Centering Health Care Institute," 2010 ) which is the organizat ion that established and evaluates CenteringPregnancy programs. CenteringPregnancy at the health department clinic also follow the same protocols which based on Medicaid elements of prenatal care, as individual care in terms of risk assessment and educati on. See Appendix C for protocols In addition to the 10 prenatal care sessions, there is an individual initial prenatal care visit, a reunion social (approximately one week after the last woman delivers her baby) and a postpartum visit (scheduled six weeks after birth ). The postpartum visit is the same for women who attend individual prenatal care. Study Population Community c haracteristics Th e participants in this study were sampled from a larger population of Latina women who reside in Pinellas County FL. Data listed in Table 3.1 was derived from the Florida Charts ( "Florida Charts County & State Profile," 2009 ) The total population of Pinellas County, FL was 932, 909 ( "Florida Charts County & State Profile," 2009 ) and the population of Florida was 18,5 37,969. According to these data, almost 17% of the people in the county are females of reproductive age (15 44 years). Overweight and o besity Over 55% of the total female population in Pinellas County was overweight or obese, a slightly higher proportion than females in Florida (52.3%) ( "Florida Charts County & State Profile, 2009 ) Specific statistics for Hispanic women in Pinellas County are not available ; however the proportion of Hispanic women in Florida who are either overweight or obese is 54.3%. Obesity is a great concern for the
45 St ate of Florida. The Trust for Ame Health issued a report in July 200 9 and identified Flo %, and ranked Florida 39 out of 50 stat es for highest rates of obesity ( ). In 2009, over 50% of wo men in Florida were obese or overweight ( BRFSS, 2009 ) In March 2004, Florida began to include maternal he ight and pre pregnancy weight on Florida birth certificates to increase surveillance on maternal obesity. Pre pregnancy BMI and maternal obesity along with maternal behaviors and birth outcomes are more often being reported in national surveys (Pregnancy Nutrition Surveillance System (PN SS), 2009) and examined at the state and local level. Birth c haracteristics The following statistics reflect the 2009 data from Florida Charts ( "Florida Charts County & State Profile," 2009 ) and are listed in Table 3.1 In Pinellas County, 72.5% of births were to women who had adequate prenatal care based on the Adequacy of Prenatal Care Utilization (APNCU) index while 69.4% of births were to women who had adequate prenatal care in Florida. The rate of Hispanic births in the county was 19.3 per 1,000 Hispanic popu lation. Bir th spacing is an important indicator for healthy pregnancies. In Pinellas County, 22.4% of births had an inter pregnancy interval <18 months compared to 21.3% in Florida. Several pr egnancy and birth statistics were examined over 2007 2009 and a nalyzed by ethnicity. The following statistics reflect the 2009 data from Florida Charts ( "Florida Charts County & State Profile," 2009 ) and are listed in Table 3.2 Pre pregnancy weight is an important indicator of healthy pregnancies. In the county, 19.3% of births were to obese women while 23.3% were to overweight women compared to 19.5% and 23.2% respectively. About 9.5% of women in the county smoked cigarettes during pregnancy
46 compared to 14% in Florida; however only 3% of Hispanic women smoked during pregnancy. Almost 77% of women in the county initiated prenatal care in the firs t trimester co mpared to almost 79% in Florida. A bout 73% of Hispanic women initiated prenatal care in the first trimester. Slightly more than 4% of women in the county initiated care in the 3 rd trimester or had no prenatal care compared to 5% in Florida. A l most 4% of Hispanic women initiated care in the 3 rd trimester or had no prenatal care. Low birthweight and preterm birth are adverse birth outcomes that prenatal care attempts to prevent. The proportion low birthweight infants in the county was 8% c ompared to 8.7% in Florida; while 6.4% of Hispanic women had low birthweight infants. About 13% of births in the county were preterm compared to 14% in Florida; while 13% of Hispanic women had preterm births. The infant mortality rate in the county was 8.3 /100,000 births compared to almost 7/100,000 births in Florida; while the rate was 9.8/100,000 births among Hispanics in the county which was higher than the rate among Hispanics in Florida, 5.5/100,000 births. The fetal mortality rate in the county was 7. 4/1,000 births compared to 7/1,000 births in Flo rida. T he rate was 7.1 /1,000 births among Hispanics. The proportio n of cesarean section births in 2007 was 34.4% in the county compared to 38.1% in Florida; the proportion among Hispanics in the county was lo wer at 31.1% of births.
47 Table 3 1 : Florida Charts Statistics for Pinellas County, FL and the state of Florida ( "Florida Charts County & State Profile," 2009 ) Female Community Characteristic Pinellas County (%) Florida (%) Total female population 51.6 50.8 Hispanic female population 7.2 21.4 Total females in the population ages 15 44 yrs (%) 16.8 19.3 Total females ages 15 44 yrs among total females (%) 32.5 Hispanic female population ages 15 44 yrs (%) 1.63 4.83 Female Weight Status a Characteristics Pinellas County (%) Florida (%) 25.5 23.0 Overweight: BMI 25 30 30 30.2 Overweight or Obese BMI >25 All females 55.5 53.2 White 54.3 50 Black 72.1 Hispanic 54.3 Birth Characteristics Pinellas County (%) Florida (%) Hispanic births (per 1,000 Hispanic population) 19.3 17.8 Births with adequate prenatal care (%) (APNCU index) 72.5 69.4 Breastfeeding b New moms who ever breastfeed New moms who breastfed at two months postpartum 80.9 76.6 54.9 53
48 Table 3 2 : Florida Charts Birth Statistics for Pinellas County, FL by race/ethnicity from 2007 2009 Florida Charts. ( "Florida Charts County & State Profile," 2009 ) 2007 2008 2009 Weight categories of mothers who gave birth a (%) Births to obese women Pinellas 18.4 18.3 19.3 Florida 18.8 19 19.5 Births to overweight moms Pinellas 22.4 23.7 23.3 Florida 22.7 23.2 23.2 Live births to women who smoke during pregnancy (%) Pinellas 10.9 9.3 9.6 White 12.3 10.6 10.8 Black 7.7 7.2 6.8 Hispanic 2.8 1.9 3 Florida 14.1 14.2 14 Birth to mothers with first trimester prenatal care (%) Pinellas 74.5 76.1 76.7 White 76.9 79.0 80.3 Black 65.2 63.7 63.4 Hispanic 63.5 72.9 72.8 Florida 75.9 76.9 78.3 Birth to mothers 3rd trimester or no prenatal care (%) Pinellas 5.7 5.2 4.3 White 4.5 4.4 3.3 Black 10.5 8.2 7.7 Hispanic 5.7 4.4 3.8 Florida 6 5.8 5 Low birthweight (%) Pinellas 8.4 8.9 8 White 6.9 7.1 6.6 Black 14.9 15.6 13.9 Hispanic 6.2 6.6 6.4 Florida 8.7 8.8 8.7 White 7.2 Black 13.4 Hispanic 7.1
49 Preterm birth (%) Pinellas 12.6 12.9 13.1 White 11.1 11.3 11.5 Black 19.2 19.6 19.4 Hispanic 12.3 11.9 13.1 Florida 14.1 14.2 14 Infant Mortality Rate (per 100,000 live births) Pinellas 7.3 9.3 8.3 White 5.5 6.5 5.4 Black 15.8 18.9 20.8 Hispanic 8 8.2 9.8 Florida 7.1 7.2 6.9 Pinellas 7.3 9.3 8.3 White 5.5 6.5 5.4 Black 15.8 18.9 20.8 Hispanic 8 8.2 9.8 Florida 7.1 7.2 6.9 White 4.9 Black 13.2 Hispanic 5.5 Fetal Mortality (stillbirths) rate (per 1,000 live births) Pinellas 6.8 7 7.4 White 6 6.4 6.7 Black 11.4 10.5 11.5 Hispanic 4.8 7.4 7.1 Florida 7.6 7.2 7 White 5.6 Black 11.6 Hispanic 6.2 C section (%) Pinellas 33.7 33.5 34.4 White 33.6 33.2 34.3 Black 34.4 34.5 36.5 Hispanic 32.9 33.2 31.1 Florida 37.2 37.6 38.1 Note: BMI= Body Mass Index; APNCU= Adequacy of Prenatal Care Utilization a. Data from 2007 Behavioral Risk Factors Surveillance; 544 adults were surveyed in Pinellas county b. Data from 2004 2005 Florida Pregnancy Risk Assessment Monitoring System County Report ( "Florida Pregnancy Risk Assessment Monitoring System (PRAMS)," 2008 ) All other data derived from Florida Charts ( "Florida Charts County & State Profile," 2009 )
50 Key Research Personnel and Training The investigator trained as a volunteer at the Pinellas County Health Department, completed all research requirements including HIPPA compliance documents and completed a full training on the Health Management System (HMS) computer system A ll research was approved first by the University Of South Florida Institutional Review Board and then by the Pinellas County Health Department Education and Training Department. Translator/Interpreter The investigator collaborated with a non profit health organization called, Fundacin Famil i a Sana to contract with a fluent Spanish speaking promotora (health educator) to assist in translation of documents and in conducting the in depth interviews in the qualitative portion of the research. The organization has conducted research and programs with the Florida Health Department and the Hillsborough County Health Department. The promotora who was contracted in this research project is a medical doctor certi fied in Venezuela and has been trained on translating health related materials and conducting interviews for various projects. Her tasks on this project were to translate the interview guide and informed consents and to conduct the interviews in Spanish al ong with the investigator. All of the translated documents were back translated to ensure accuracy and reviewed by various Spanish speaking staff from both Fundacin Familia Sana and the Pinellas County Health Department. Research Design This study employ ed both quantitative and qualitative methods to answer the research questions. T he investigator conducted a retrospective cohort study to obtain
51 quantitative chart and vital statistics data to address obj ectives 1 and 2. To address objective 3, qualitative in depth interviews were conducted to assess the perceptions of care of multiparous women who completed CenteringPregnancy and individual prenatal care in the past. In this section, the CenteringPregna n cy may be interchanged with intervention group and t he individual prenatal care group may be interchange d with the comparison group. Phase I : (Objectives 1 2) Subjects and s etting To address objectives 1 and 2 and answer research questions 1 6 (See Table 3. 3 for list of research questions) the investigator conducted a retrospective cohort study using chart review of women who completed prenatal care in the Pinellas County Health Department Clearwater clinic. The study eligibility criteria were as follows: the woman must have self identifie d as Spanish speaking and Hispanic, entered into prenatal care at the clinic for an initial visit between November 2006 and November 2009 and completed prenatal care by June 2010. Women were excluded if they did not complete prenatal care. This was indicat ed in the chart as a transfer out of the clinic or stopped care due to a miscarriage or any other reason. In addition, women who did not complete at least 50% of their expected number of visits were considered to not have completed prenatal care and were e xcluded. The investigators sampled a total of 487 women who were enrolled in prenatal care (2 47 CenteringPregnancy and 240 individual prenatal care). CenteringPregnancy. There were 255 women who completed CenteringPregnancy at the clinic. Eight charts were unobtainable at the clinic and thus,
52 247 charts were assessed. The month and year that each CenteringPregnancy patient entered prenatal care was noted and summarized. Individual care A group match based on ethnicity, primary language an d the month and year the patient entered into prenatal care at the clinic was done to include eligible women in the comparison group. This was done to reduce bias based on ethnicity and the time in which women received care. The following steps were taken to match the comparison group to the intervention group and extract data from charts. 1) To match the women in CenteringPregnancy entered into prenatal care a list of women who entered into individual prenatal care within the inclusion criteria time fram e was compiled and categorized by the month and year the women entered into prenatal care. 2) All women who did not indicate Spanish as their primary language and did not self identify as Hispanic were excluded from the list 3) The list of women in t he comparison group in each month/year category was then randomized using a random number generator. The number of charts pulled from the comparison group was matched to the n umber of charts that were pulled for the same month and year from the intervention g roup. For example, if 10 women in the intervention group entered into care in July 2007, then 10 women were randomly selected from the comparison group who also entered into care in July 2007. 4) The intervention and comparison group charts were pulled fo r data extraction. All charts were further examined to exclude any chart of a woman who did not complete the prenatal care or did not fit the inclusion and exclusion criteria.
53 Chart review and data extraction The investigator worked with the medical rec ords department at the PCHD Clearwater clinic to obtain charts for all women who completed prenatal care and fit the eligibility criteria. The investigator reviewed all of the charts in the clinic over a four month period and extracted the necessary inform ation for data collection from each chart and entered the data into to a Microso ft Access database. If there were any missing data about birth outcomes (gestational age at birth, birthweight), method of birth or the birth hospital, the investigator worked with the health department staff to obtain vital records data to fill in the missing data. Some women obtained prenatal care more than once at the clinic however only the information from the date in which she entered care that was randomly selected was u sed for the analysis. After the investigator entered all of the data into the Microsoft Access database, 10% of the total number of records (25 from CenteringPregnancy and 25 from individual care) were checked for accuracy. Less than 10% of the data were discrepant and thus the data did not need to be reentered. Confidentiality To ensure confidentiality, charts were reviewed in the health department clinic and all data were kept in an electronic password secured file. Before analysis the data were de id entified (names and medical record numbers removed). Variables Variables based on maternal factors and birth outcomes were examined in the quantitative phase of the study: birth outcomes, gestational age at birth, birthweight, type of birth infant feeding method and maternal factors, maternal weight gain, attendance in prenatal visits and attendance in postpartum visit ( See Table 3.3) Several demographic variables and covariate outcom es were assessed for each group ( See Table 3. 4 and Table 3.5 ).
54 Table 3. 3 : Definition of Variables Outcome Variable Variable Type Definition and Categories Gestational age at birth Continuous The number of weeks a woman was pregnant before she delivered her baby. This variable was obtained in the hospital record that was in the patient chart or from vital records if it was not available in the chart. The weeks and days gestation was rounded down to complete weeks. For example, 39 weeks and 2 days was round to 39 w eeks. Preterm Binary This variable derived from the variable, gestational age at birth. Preterm: A n infant born < 37 weeks gestation Term: Infant birthweight Continuous The w eight in grams of an infant at the time of birth. This variable was obtained in the hospital record that was in the patient chart or from vital records if it was not available in the chart. Low birthweight Binary This variable was derived from the v ariable, infant birthweight. Low birthweight: An infant born < 2,500 grams. Normal birthweight: Method of birth Binary This variable was obtained in the hospital record that was in the patient chart or from vital records if it was not available in the chart. Vaginal birth woman delivered her infant by a normal vaginal birth to a woman with no previous history of a cesarean section Cesarean section woman delivered her infant by a primary cesarean sectio n with no previous history of cesarean section Gestational Weight Gain Category nominal Nominal The amount of weight that a preg nant woman gained from her pre pregnancy weight to her last Using the 1990 IOM recommendations for maternal weight gain using both weight gain and pre pregnancy BMI, each woman was grouped into one of three weight gain categories. Low maternal weight gain: Gained less than recommended weight Normal maternal weigh t gain: Gained within the recommended range High maternal weigh gain: Gained more than recommended weight
55 Outcome Variable Variable Type Definition and Categories Gestational Weight Gain binary Binary This variable was derived from Gestational Weight Gain Category nominal to assess whether women gained a healthy weight compared to an unhealthy weight Healthy weight gain: Gained within the normal weight gain range Unhealthy weight gain: gained either above or below the recommended weight gain ran ge. Adequacy of prenatal care Binary A modified APNCU index was used to calculate adequacy of prenatal care. See Chapter 3. Women who did not initiate prenatal care prior to the 4 th month of pregnancy were excluded in the study because they did not complete prenatal care. Adequate care: Women who initiated prenatal care before the 4 th month of pregnancy and attended at least 80% of their expected visits. Not adequate care: Women wh o initiated prenatal care before the 4 th month of pregnancy and attended less than 80% of their expected visits. Attendance in postpartum visit Binary The postpartum visit was scheduled 6 weeks postpartum to follow the health of the infant. Whether or not a woman attended the postpartum visit was noted in the patient chart. Not all women attended the visit at exactly 6 wee ks postpartum. Only if the physician noted the visit as a postpartum visit was it counted as attended. Attended postpartum visit: The woman attended to a postpartum visit at the clinic Did not attend postpartum visit : The woman did not attend a postpartu m visit at the clinic. Infant feeding type Nominal The type of infant feeding the mother indicated she was using at the time of her 6 week postpartum visit. This information was noted in the patient chart. Exclusive breastfeeding: mother indicated she was only breastfeeding her infant either through direct breastfeeding or pumping Formula only : mother indicated she was only formula feeding her infant Breastfeeding supplemented with formula: mother indicated she was breastfeeding a nd formula feeding her infant
56 Table 3 4 : Outcome Variables A ssessed in Intervention and C omparison G roup Demographic variables Maternal age Race Country of origin Status in U.S. Marital status Educational attainment Employment status Pregnancy intention Tobacco use Previous preterm Parity Pre pregnancy BMI Table 3 5 : Covariate Outcomes A ssessed in Intervention and C omparison G roup Covariates Initiation of prenatal care Prenatal care adequacy (APNCU index) Postpartum attendance Healthy maternal weight gain Postpartum BMI Method of birth Birth hospital Infant birthweight Gestational age at delivery Infant feeding method Parity
57 Data a nalysis Data analyses for each research question is listed in Table 3. 6 Descriptive statistics for each variable including frequencies and chi square and t test were performed to compare means and describe statistically significant relationships. Using a generalized linear model (GLM) in PAWS Statistics 18 and IBM SPSS 19, the investigator conducted a one way analysis of variance (ANOVA) and one way analysis of covariance (ANCOVA) for continuous dependent variables and binary and multinomial logist ic regression for categorical dependent variables. In the logistic regression analysis, odds ratios and confidence intervals were computed to determine the odds of an outcome based on the type of prenatal care. In the ANOVA and ANCOVA, an R 2 illustrates th e overall variability in the model and an omnibus F statistic show ed the statistical significance of the independent variable. An ANCOVA also includes other covariates that may contribute to the variability in the dependent variable. In all of the analyses a listwise deletion of m issing data was conducted which delete d the e ntire observation of any data was missing. This was done because the overall percentage of missing data was low and thus, other missing data methods such as inputting averages did not ne ed to be completed. Logistic regression (research q uestions 1 6) Logistic regression was used to predict a nominal dependent variable with a nominal independent variable. A binary logistic regression was used when the dependent variable was dichotomous and a multinomial logistic regression was used when the dependent variable was a nominal variabl e with more than two categories ( Szklo & Ni eto, 2007 ) The logistic regression was used to predict the odds of an outcome based on the independent variable.
58 Research question 1 addresses differences in gestational age at delivery based on the type of prenatal care. Gestational age at delivery wa s assessed as a continuous variable in the ANCOVA analysis and as a binary categorical variable in a binary logistic regression analysis. It is important to also conduct this test to be able to report on increased or decreased odds in preterm birth and be able to compare results with other epidemiology studies that have used these categories. In this analysis gestational age at delivery is categorized as preterm or full term See Table 3. 3 for definition of variables. Research question 2 addresses differe nces in infant birthweight based on the type of prenatal care. This variable was assessed as a continuous variable in the ANCOVA analysis and as a binary variable in a binary logistic regression analysis. It is important to conduct this test to be able to report on increased or decreased odds in low birthweight and be able to compare results with other epidemiology studies that have used these categories. In this analysis birthweight was categorized as low birthweight and normal birthweight which included h igh birthweight infants. Normal birthweight and high birthweight were combined in this analysis because of the low sample size in the high bir thweight category. See Table 3.3 for definition of variables. Research question 3 addresses the method of birth of the infant based on the type of prenatal care. This variable will be assessed in a binary logistic regression as a binary variable with two categories, vaginal or cesarean section See Table 3. 3 for definition of variables. Research question 4 address es maternal weight gain based on the type of prenatal care. Maternal weight gain is a variable that was calculated based on the 1990 IOM weight gain recommendations ( IOM 1990 ) Although new recomme ndations were
59 published in 2009 ( IOM, 2009 ) these new recommendations were not in place at the time the women in the study received their prenatal care. The IOM weight gain recommendation categories are based on pre pregnancy BMI and define weight gain as, high maternal weight gain, normal maternal weight gain, and low maternal weight gain. The variable was assessed in a multinomial logistic regression using each of these categories and in a binary logistic regression using healthy weight gain and combining low weight gain and high weight gain to form an unhealthy weight gain category. See Table 3. 3 for definition of variables. Research question 5 addresses attendance in care. Attendance for prenatal care was calculated using a modified APNCU index ( Kotelchuck, 1994 ) The four possible categories of the index are Inad equate, Intermediate, Adeq uate, and Adequate plus, however, in this research adequate was combined with adequate plus and intermediate was combine d with inadequate, to form a binary variable with two categories adequate and not adequate. Thus, the data will be assessed in a binary logistic regression. Data on entry into prenatal care and attendance in visits was used to calculate the modified APNCU index. This index is modified because there is a difference in the recommended number of visits for each group. Women in individual pren atal care are recommended to attend 14 total visits including the initial visits and women in CenteringPregnancy are recommended to attend 11 total visits including the initial visit. Due to this difference, the modified index uses a different denominator in each type of care. Data for the individual prenatal care is calculated using 14 as the expected number of prenatal care visits while data for the CenteringPregnancy prenatal care will be calculated using 11 as the expected numbe r of prenatal care visits See T able 3.3 for definition of variables.
60 There are two components that are used to calculate the APNCU index, initiation of prenatal care and % of visits. To be considered as adequate prenatal care a woman must initiate prenatal care before the 4 th mo nth of pregnancy. The % of visits is calculated as follows: Observed number of visits/Expected number of visits x 100 = % of visits. The two components of the index results are combined and scaled as described below. Inadequate: care began after the 4 th m onth or expected visits = 0 49% Intermediate: care began by the 4 th month and expected visits = 50 79% Adequate: care began by the 4 th month and expected visits = 80 109% Adequate plus: care began by 4 th In this analysis the adequate and adequate plus were combined to form one variable, adequate prenatal care. Women who had inadequate were excluded from the study because completion of prenatal care was part of the inclusion criteria. The interme diate category was formed into a new category, not adequate prenatal care. Not adequate: care began by the 4 th Adequate: care began by the 4 th The following is an example of the modified APNCU index: A woman began ind ividual prenatal care in month three of her pregnancy and thus according to the Am erican College of Gynecologists guidelines ( Guidelines for Perinatal Care 6th edition 2007 ) she missed two visits. She would only be expected to attend 11 visits throughout the rest of her pregnancy (14 3 =11 visits). She attended 10 prenatal care visits. Thus, her % of visits is 91% (10/11). Since she attended care before the 4 th month of pregnancy and she attended 91% of her visits she would fall into the category of adequate care.
61 Attendance in the six week postpartum care visit is assessed in a binary logistic regression with the binary attendance variable, attend and did not attend. Although the postpartum visit was scheduled for 6 weeks postpartum a few women attended the postpartum visit after 6 weeks. As long as the physician categorized the visit as postpartum is was included as attended in this analysis. See Table 3. 3 for definition of variables. Research question 6 addresses infant feeding at 6 weeks postpartum based on the type of prenatal care. The type of infant feeding exclusive breastfeeding, formula only or breastfeeding supplemented with formula was assessed in a multinomial logistic regression analysis. See Table 3. 3 for definition of variables. Assumptions Unlike linear regression, no assumptions are made about the distribution in logistic regression. However, larger sample sizes are needed and it should be assumed that explanatory variables should not be highly correlated with one another ( Bewick, Cheek, & Ball, 2005 ) General Linear Model : ANOVA/ANCOVA (r esearch questions 1, 2) Much of the research done on preterm birth and low birthweight categorizes these variables as discrete. This may be important as these variables are often described in the literature in such a way. However, both variables are continuous by nature. When con tinuous variables are transformed into discrete variables and placed into categories, important information may be lost. Thus, the associations between type of prenatal care and the dependent variables, gestational age at delivery and infant birthweight wi ll be analyzed using a statistical test that account for continuous dependent variables.
62 ANOVA and ANCOVA are analyses that are conducted when there is one continuous dependent variable with a discrete independent variable ( Tabachnick & Fidell, 2007 ) The analyses test whether mean differences on a single variable between women in the prenatal care groups are likely to have occurred. An ANOVA was used first to assess these differences on one single independent variable (type of prenatal care) and one single dependent variable. An ANCOVA was then used to assess the independent variable along with other covariates that may contribute to the differences in the dependent variable. The ANCOVA produces an overall model fit test to determine if the model i s significant and an F statistic (omnibus test) that allows the researcher to test the null hypothesis through a main effects test. If the main effect for the independent variable of interest was significant, the researcher conduct s follow up t test tests to identify the direction in which the variable was statistically significant ( O'Rourke, Hatcher, & Stepanski, 2005 ) Assumptions There are three main assumptions to consider when conducting an ANOVA or ANCOVA. First, the data should have a normal distribut ion. Thus, a test for normality such as Shapiro Wilk and an assessment of central tendency through skewness and kurtosis should first be conducted to assure normality. Normality is less critical as sample size increases ( Tabachnick & Fidell, 2007 ) and thus with larger sample sizes the test is robust to normality. Second, it is important th at the two groups being assessed are independent of each other. Third, the error variance across ea test of equality of variance can be used to test the null hypothesis that the variances are equal.
63 Table 3. 6: List of Research Q uestions 1 6 and Description of Variables and Type of Data A nalysis. Research Question Data Collection Method Dependent Variable Dependent Variable Type Type of Analysis 1) Is there a difference in gestational age at delivery based on type of prenatal care? Patient Charts and vital records Gestational age at delivery Continuous ANCOVA Preterm Categorical Logistic regression 2) Is there a difference in infant birth weight based on type of prenatal care? Patient Charts and vital records Birthweight Continuous A N C OVA Low birthweight Categorical Logistic regression 3) Is there a difference in the method of birth based on type of prenatal care? Patient Charts and vital records Method of birth Categorical Logistic regression 4) Is there a difference in maternal weight gain based on type of prenatal care? Patient Charts Maternal weight gain categories Categorical Logistic regression 5) Is there a difference in prenatal care and postpartum care attendance rates based on type of prenatal care? Patient Charts Adequacy of prenatal care Categorical Logistic regression Postpartum care attendance Categorical Logistic regression 6) Is there a difference in infant feeding type based on type of prenatal care? Patient Charts Infant feeding method Categorical Logistic regression
64 Phase II : Qualitative (Objective 3) Using a convenience sample of multiparous women who completed their CenteringPregnancy prenatal care between November 2009 and May 2010 to conduct postpartum interviews were conducted with women about their experiences and perceptions of CenteringPregnancy compared to their past experience with individual prenatal care. Study population and r ecruitment The investigator worked with staff at the health department to recruit 8 10 Latina women who completed CenteringPregnancy in the past 6 months and who have completed individual prenatal care sometime in the past. A list of twenty five women who fit these inclusion criteria from the more recent eight CenteringPregnancy groups was formulat ed. The investigator assigned numbers to each woman and used a random number generator to choose the order in which the women would be contacted to recruit for the interview. The health educator who coordinates CenteringPregnancy at the health department c ontacted each woman starting from the beginning of the randomized list until she scheduled ten women to come to the health department to complete the interview. The women were all given several dates and times to choose from. During the initial phone call, in Spanish, the health educator briefly explained the research and told the women about the incentive to participate. Five women who were originally called declined the offer to participate and a total of ten women were scheduled. On the day they were sup posed to arrive, three of the women did not come for the interview. The next three subsequent women on the randomized list were called and they all agreed to participate. A total of ten women completed the interviews within a two
65 week period. The women wer e from six different CenteringPregnancy groups that were held over the previous six months. Data collection p rocedures All of the interviews were conducted at the health department clinic in a conference room separate from the obstetrics clinic and the CenteringPregnancy program room. The investigator, the translator/interviewer and the participants, along with their child(ren) in some cases, were in the room during the interview. Snacks and water were provided for all participants and children. When the participant came to the room she was welcomed, offered refreshments and then asked to sit down to listen to the explanation of the research, what the interview would entail and the informed consent process. Since the investigator was not fluent in Spanish the translator spoke directly to the women in Spanish. The translator explained the main objectives of the research, introduced the investigator, and then told the participant that the interview would be about 25 minutes long and that she could stop at a ny time. She then read through the main points of the informed consent documents and assured the participant that the information they spoke about would be completely confidential and would not in any way affect the care she received at the health departme nt. See Appendix D for informed consent documents. The translator also asked permission to allow the interview to be recorded for transcription and analysis purposes. After the participant indicated she understood and agreed to take part in the interview, she signed the informed consent form and the interview proceeded. None of the interviews lasted more than 30 minutes. At the end of the interview the participant was given a small baby gift and was told that she would be called in the next fe w weeks if she won the raffle for a $100.00 Walmart gift card.
66 Raffle As an incentive to participate in the study, the women were told they would be entered into a drawing to win a $100.00 Walmart gift card. After the final randomly drawn. The CenteringPregnancy coordinator contacted the woman who won and asked to schedule a time with the investigator to receive the gift card. Confidentiality included in transcripts or any part of data analysis. There was no identifying information such as names or medical record numbers included in the transcription or anal ysis. Pilot Test A pilot test was conducted with 10 % percent of the expected sample size to reflect any poorly designed questions or problems with data collection and analysis ( Larossi, 2006 ) One woman completed CenteringPregnancy (10% of the sample) was asked to be interviewed and comment on the questions appropriateness. The women wh o participated in the pilot interview were compensated with a small baby gift. Prior to the pilot test, three women participated in practice interviews during the interviewer training. After each interview, the investigator and interviewer talked with the woman who was interviewed about her perception of the interview questions and asked for suggestions on improvements. The suggestions were taken into consideration for possible changes to the interview guide. The comments were assessed and the necessary imp rovements were made to the protocol. Two examples of such modifications are as follows. First, some of the Spanish language in the interviews was modified to accommodate a broader range of Spanish speakers. Because the majority of the women being interview ed were of Mexican origin some language was changed to fit a Mexican dialect. In addition, some questions were modified to be clearer and better address the
67 objective of the question. One question that was modified was about physical activity and exercise. attention that there was confusion about the difference between physical activity and exercise to do during pregnancy to stay healthy versus exercises to do to prepare for labor and birth or manage pain during pregnancy or labor. The question was changed to be more specific about the type of exercise it was referring to. To complete the full pilot test, the pilot interview was transcribed, translated and analyzed as if it were t he actual data. This allowed the investigator to work through any issues with this process before the actual data collect ion and analysis began. Data analysis m ethods All ten interviews were audio recorded and the electronic recording was sent to Avalon Transcription Services for transcription and translation. The transcription company transcribed the interviews in Spanish and translated the interviews into English. Back translation from English to Spanish was done to ensure accuracy. The transcriptions were c oded using a prior and emerging codes in Atlas Ti v6 a qualitative data analytical software program. The investigator combined an a priori code book based on the types of interview questions and the five types of social support (emotional, instrumen tal, informational, companionship and appraisal/validation) with emerging codes. The codes were merged into family groupings and the investigator summarized the data into themes for interpretation. Another data analyst coded all of the interviewers using t he same a priori code book as the investigator and his own emerging codes. The second coder, coded the interviews separately from the investigator. The two sets of codes were merged to formulate the final summary of codes and themes.
68 Quality and trustwor thiness of d ata The credibility of the data is trustworthiness and the accurate representation of the context of the study ( Ulin, Robinson, & Tolley, 2005 ) To ensure credibility, the investigator examined the findings to first, assess if the results had a logical and consistent relationship to each other. The data were logical and the information obtained from the women was consistent across each interview. S econd, the data were assessed to test whether they were sufficiently supported by the findings. The investigator completed in depth interviews and continued until saturation of data was reached in each area of analysis. Third, the investigator assessed if the findings accurately depicted the opinions of the study population by reviewing the information at the end of each interview. Either during the interview or at the end of the interview, the interviewer summarized the information obtained and asked the p articipant if the summary was accurate. If it was not accurate, the interviewer asked the participant to summarize the information in her own words. Similar to reliability in quantitative data, dependability tests whether the research process and method ology is consistent and replicable ( Ulin, et al., 2005 ) To ensure dependability, the investigator made a clear and logical research question that was linked to the third objective of the study. There was only one interviewer and thus inter rater reliability was not a concern. The interv iewer was trained and followed a strict protocol for each interview. Confirmability is the process in which objec tivity is utilized and minimizes the influence of the investigator s personal values on the research ( Ulin, et al., 2005 ) Confirmability was ensured in two ways. First, t he investigator was reflexive in disclosing her roles in the research process and when necessary indicated when personal
69 reactions influenced data interpretation. Second, a data collector who was not involved in CenteringPregnancy or the health department in any way interviewed the women. In addition to the investigator, a second data analyst coded the interviews and codes were combined for data summary and analysis of themes. Dual coding was done to decrease bias and ensure more accurate results. It is i mportant to be able to generalize findings to the study population. Transferability is the concept of transferring the findings to other contex ts beyond this particular study ( Ulin, et al., 2005 ) This was addressed in the study by randomizing the women who were eligible to be contacted to participate in the interview. Randomizing helped with making certain that the women were well represented in the study and that the findings transfer to other contexts. Instrumentation A semi structured interview guide was developed to address objective 3 and answer research question 5. The interview guide consist ed of questions that ask ed women about their overall experience and satisfaction with CenteringPregnancy (likes, dislikes good experiences, bad experiences ), what they learned in the program, what they learned specifically about nutrition and exercise, if they felt their questions and concerns were addressed, if they felt the program prepared them well for labor and birth and about any friendships and relationships they may have formed. They were also asked to compare the CenteringPregnancy program to their past experience with individual prenatal care. Specifically they were asked to compare the program overall, what they learned differently in general and specific ally about nutrition and exercise, how comfortable they felt and which program they would recommend to others and for themselves to do over again. The interview qu estions were formulated to
70 address the five types of social support, emotional, instrumental, informational, companionship and appraisal/validation. See Appendix E for the interview guide of questions. The interview was administered in Spanish by a bilingual interviewer along with the investigator Training Investigator. The investigator completed the Human Subjects Training offered through the University of South Florida and ensured the research met ethical standards. The investigator also completed HIPPA training, a complete background check and computer training on the Health Management System and new employee training with the Pinellas County Health Department. Translator/Interviewer. The translator/i nterviewer held a position as a health educator and assisted in research at Fundacin Familia Sana. She had previous tr aining on qualitative research data collection and conducting interviews but was also trained by the investigator. The investigator trained the translator/interviewer on how to conduct the entire interview process including explain ing the study objectives, obtaining informed consent from the participant and ask ing the interview questions and probes. During the training, the translator/interview er was provided with the study objectives, interview guide, and the qualitative data collection protocol. She was a lso briefed on the CenteringPregnancy program and the process in which clients obtain prenatal care at the health department. The tr anslator/interviewer conducted three practice interviews with Spanish speaking women who were not affiliated the health depa rtment. She also conducted one pilot interview with a woman who obtained prenatal care at the health department. The investigator reviewed strengths and weaknesses of the overall interview
71 process, conversation style and probing techniques with the transla tor/interviewer and suggested improvements. Data analyst/Second coder. The second coder was previously trained in qualitative data collection and analysis and had experience with using the Atlas Ti software. However, he was also trained by the investigator. During the training, the second coder was provided with the study objectives, interview guide, and the qualitative data collection protocol and data analysis method and was also give n the list of a priori codes. He was also briefed on the Cen teringPregnancy program and the process in which clients obtain prenatal care at the health department. Timeline A project timeline is illustrated in Table 3.4. Preliminary work included conducting qualitative obs ervations of women in the Cente r i ngPregna ncy group, competing all trainings and requirements of the health department and completing the requirements of the University of South Florida Institutional Review Board. All dissertation research was conducted between May 2010 and March 2011.
72 Table 3. 4 : Project Timeline Preliminary Work Time Frame Complete d Health Department HIPPA requirements and become volunteer Fall 2009 Conducted observations in CenteringPregnancy groups Fall 2009 Spring 2010 Met with health department administration to access data Spring 2010 Complete d PCHD computer training Spring 2010 Complete d IRB Spring 2010 Data Collection and Analysis Time Frame Phase 1: Developed Microsoft Access database to store data May 2010 Phase 1: Review ed CenteringPregnancy electronic and patient charts and enter ed data into database June 2010 July 2010 Phase 1: Based on ethnicity, language and month/year entered into prenatal care, a list of individual prenatal care participants who were matched to CenteringPregnancy participants was obtained. The list in each date category was randomized and medical records numbers of each random match participant was obtained. July 2010 Phase 1: The individual participants charts were reviewed and data was enter ed i nto the database July 2010 September 2010 Phase 2: Submitted IRB modification to conduct interviews August 2010 Phase 1: A list of participants from both groups in which birth outcomes were missing in the chart was compiled. The investigator worked with the health department staff to obtain the missing information and it was entered into the database. September 201 0 Phase 2: Conducted training for interviewer/translator and conducted 3 practice interviews September 2010 Phase 2: Worked with health department staff to complete a list of potential interviewees. The list was randomized and each woman was contacted t o participate in the interview. September 2010 Phase 1: Began to analyze quantitative data October 2010 Phase 2: Pilot tested one interview, made small revisions of interview guide October 2010 Phase 2: Interviewed CenteringPregnancy participants at the health department October 2010 Phase 2: Sen t all interviews to be transcribed and translated to Avalon Transcription Services November 2010 Phase 2: Coded and analyzed interviews November 2010 December 2010 Phase 1 and 2: Complet e d data analysis and summarize d all data December 2010 February 2011 Phase 1 and 2: Complete dissertation January 2011 March 2011
73 Data S haring Findings from this study will provide much needed data on pregnancy outcomes that are associated with maternal obesity and related complications among Latinas, and on the effectiveness of CenteringPregnancy programs for Latina populations. All data collect ed for this study will be de identified and stored in a password protected Microsoft Access and Microsoft Word file. The investigator will use data for the purposes of the dissertation and will prepare a report for the Pinellas County Health department. In addition, findings will be shared with academic peers in scholarly journals and conference presentations. Human Subjects P rotection There are no known serious threats to subjects in this study. This research was submitted and approved by the University of South Florida institution al review board (IRB) and by the review board of the Pinellas County Health Department In phase I: there was n o interaction with participants and thus informed consent was not need However, in Phase II informed consent was obt ained from each woman who participated in the interview. A ll participants were asked to read and sign an informed consent which was provided in both English and Spanish. The investigator and translator read through t he consent with the participant before a sking them to sign. The participants were assured tha t all of the data collected would be kept confidential and stored under electronic passwords. For bo th phases of the study, data were kept in an electronic password protected file and was de identified for use in analysis and reporting. any other identifying information was not used in the study.
74 CHAPTER FOUR: RESULTS This study examined pregnancy outcomes of women in CenteringPregnancy (CP) compared to women in s of CenteringPregnancy compared to their past experience s with individual care. The results are presented in this chapter, in the order of the research questions. Research Questions 1. Is there a difference in gestational age at delivery based on type of prenatal care? 2. Is there a difference in infant birthweight based on type of prenatal care? 3. Is there a difference in the method of birth based on type of prenatal care? 4. I s there a difference in maternal weight gain based on type of prenatal care? 5. Is there a difference in prenatal care and postpartum care attendance rates based on type of prenatal care? 6. Is there a difference in infant feeding method based on type o f prenatal care? to their past experience s with individual prenatal care?
75 Phase I: (Research Questions 1 6) Sample Characteristics Intervention CenteringPregnancy Data were collected from a total of 247 charts of women who complete d CP. The remaining 8 charts were not included because they were not available at the clinic. The mean age of women in CenteringPregnancy ( the intervention group ) was 24.63 years with a range o f 14 40 years. All of the women identified themselves as Hispanic, however 42.1% identified as White Hispanic and 49% identified as other Hispanic, 8.9% did not indicate a specific race while none of the women identified as Black Hispanic. The majority of the women indicated that their country of origin was Mexico (84.6%) while others were from El Salvador, Costa Rica and other Latin American and Caribbean countries. Most of the women in the intervention group also identified themselves as migrant (72.1%) w hen asked about their status in the U.S, while 8.5% said they were either permanent or temporary residents. It was surprising that most of the women stated that they were single (83.0%). However 40.1% of those women indicated they lived with their partners This may have been due to issues with legal status and fear of documenting spouses. Few women said they were married (12.6%) and even fewer were separated (1.6%) or divorced (0.8%). The majority of the women graduated from high school or obtained an equi valent degree (58.3%). About 30% of women did not complete high school (about 19% of those women were < 18 years old and may have still been in high school), 3.6% had some college education and 4.5% graduated from college. It was not specified whether the degrees were obtained in the U.S. or abroad. The majority (53.8%) of women were primiparous, while 28.3% had one child, 12.1% had 2 children and 5.7% had 3 or more children. About 36% of
76 women either worked full time or half time when they began prenatal c are. Most of the women said t hat they planned their pregnancies (61.9%) and only two women reported that they smoked cigarettes or cigars (0.81%) at the time of their initial prenatal care visit. Almost all of the women who received prenatal care at the he alth department also had their pregnancy test s completed at the health department. At that time, they were weighed for their pre pregnancy weight. Pre height and her pre pregnancy weight and was included in Based on pre pregnancy BMI, the overall proportion of births to obese and overweight women in both groups was greater than normal weight women, 14% and 33.1% respectively. The average BMI for women in CenteringPregnancy was 25.05 with a standard deviation of 4.62. Slightly more than half (55.5%) of the women in the CenteringPregnancy group were within a normal BMI range, 26.7% were in the overweight, 13.4% were obese, 2.5% w ere underweight and only 2 (0.81%) were morbidly obese. See Table 4.1. Comparison Individual prenatal care Data from a total of 240 charts of women who completed individual prenatal care were included in the study. The mean age of women in individual c are ( the comparison group ) was 25.95 years with a range of 15 44 years. All of the women identified as Hispanic but half (50%) identified as White Hispanic, 43.8% identified as other Hispanic, 6.3% did not indicate a specific race while none of the women i dentified as Black Hispanic. Like the women in CenteringPregnancy, the majority of the women indicated that their country of origin was Mexico (91.7%). Most women in individual care also identified themselves as migrant (80%) when asked about their status in the U.S. and 3.3% identified as either a permanent or temporary residents (3.3%). Like in CenteringPregnancy, most women said they were
77 single (72.9%) yet 46.3% of those women were living with their partner. However, slightly fewer women in individual c are said they were married (17.9%) and slightly more were separated (4.6%). Only one woman in individual care (0.4%) said she was divorced. Unlike the CenteringPregnancy, the majority (48.8%) of women in individual care said they did not complete high scho ol (about 11% of those women were < 18 years old and may have still been in high school), while 40.8% completed high school or an equivalent degree. Almost 7% graduated from college and one woman (0.4%) completed some college. Compared to CenteringPregnan cy fewer women in individual care were primiparous (33.4%), 28.8% had one child, 26.7% had two children and 11.3% had three or more children. Fewer women in the comparison group indicated that they worked at least part time (27.9%). Most of the women s aid they planned their pregnancies (65.8%) and only one woman reported that she smoked cigarettes or cigars (0.4%) at the time of her initial prenatal care visit. The average BMI for women in individual care was 25.96 with a standard deviation of 4.32. Fewer women in the comparison group had a BMI within the normal range (43.4%) while more women had a BMI in the overweight category (39.6%). Almost 13% of women were obese, while 1.3% of women were underweight and 1.3% of women were underweight. A little bit mo re than half (55.5%) of the women in the intervention group were within a normal BMI range, 26.7% were in the overweight range, 13.4% were in the obese range, 2.5% were underweight and only 2 (0.81%) were morbidly obese. See Table 4.1. Differences betwee n groups Women in the CenteringPregnancy were younger than women group in individual care, t= 2.67, p=0.01. There were differences in 2 = 25.68, p=0.00. Compared to
78 women in individual care, more women i n CenteringPregnancy graduated from high 2 = 15.7, p<0.00, fewer women did not 2 = 18.21, p< 0.00) and more women attended 2 = 6.33, p=0.012). The re were also differences in parity between the groups. In general women in the CenteringPregnancy had lower parity than women in individual care, t= 5.14, p=0.00. Lastly, women in CenteringPregnancy tended to have a lower mean pre pregnancy BMI than women in individual prenatal care (25.05 compa red to 25.96), t= 2.44, p=0.02 ( See Table 4.1 )
79 Table 4. 1: Sample S tatist ics for CenteringPregnancy and Individual Prenatal Care C lients Variable CP n (%) Individual n (%) t statistic or 2 df p value N 247 (100) 240 (100) Age t = 2.67 485 0.01* <20 yrs 42 (17.2) 31 (12.9) 20 24 yrs 89 (36.0) 75 (31.3) 25 29 yrs 69 (27.9) 76 (31.7) 30 34 yrs 35 (14.2) 41 (17.1) > 34 yrs 12 (4.9) 17 (7.1) Race 2 = 2.14 1 0.14 White Hispanic 104 (42.1) 120 (50) Other Hispanic 121 (49.0) 105 (43.8) Missing 22 (8.9) 15 (6.3) Country of o rigin Mexico 209 (84.6) 220 (91.7) El Salvador 9 (3.6) 2 (0.8) Costa Rica 5 (2.0) 0 (0) Peru 3 (1.2) 0 (0) Argentina 2 (0.8) 1 (0.4) Guatemala 2 (0.8) 2 (0.8) Honduras 2 (0.8) 3 (1.3) Chile 1 (0.4) 0 (0) Colombia 1 (0.4) 4 (1.7) Cuba 1 (0.4) 1 (0.4) Ecuador 1 (0.4) 0 (0) Venezuela 0 (0) 1 (0.4) Missing 11 (4.5) 6 (2.5)
80 Country of origin c ombined 2 = 3.71 1 0.05 Mexico Other Missing 209 (84.6) 27 (10.9) 11 (4.5) 220 (91.7) 14 (5.8) 6 (2.5) Status in U.S. 2 = 13.07 1 0.00* Migrant 178 (72.1) 192 (80.0) Permanent/temporary resident 21 (8.5) 8 (3.3) Missing 48 (19.4) 40 (16.7) Marital status 2 = 5.43 2 0.07 Married 31 (12.6) 43 (17.9) Separated 4 (1.6) 11 (4.6) Divorced 2 (0.8) 1 (0.4) Single 205 (83.0) 175 (72.9) Living with Partner 99 (40.1) 111 (46.3) 2 = 1.89 a 1 0.17 Missing 5 (2.0) 10 (4.2) Educational attainment 2 = 25.68 3 0.00* College 11 (4.5) 16 (6.7) 2 = 1.12 1 0.29 Some college 9 (3.6) 1 (0.4) 2 = 6.33 1 0.01* Graduated high school or equivalent 144 (58.3) 98 (40.8) 2 = 15.69 1 0.00* < high school 74 (30.0) 117 (48.8) 2 = 18.213 1 0.00* Missing 9 (3.6) 8 (3.4) Employment s tatus 2 = 3.33 1 0.68 Employed (full or part time) 90 (36.4) 67 (27.9) Missing 10 (4.0) 16 (6.7) Pregnancy i ntention 2 = 0.424 1 0.52 Planned 153 (61.9) 158 (65.8) Unplanned 73 (29.6) 67 (27.9) Missing 21 (8.5) 16 (6.7)
81 Tobacco Use 2 = 1.96 1 0.16 Smokes cigarettes or cigars 2 (0.81) 1 (0.4) Does not smoke Unknown 241 (97.6) 4 (1.6) 233 (97.1) 6 (2.5) Previous preterm t = 0.047 485 0.96 0 241 (97.6) 231 (96.3) 1 4 (1.6) 6 (2.5) 2 1 (0.4) 0 (0) Parity t = 5.14 484 0.00* 0 133 (53.8) 80 (33.4) 1 70 (28.3) 69 (28.8) 2 30 (12.1) 64 (26.7) 14 (5.7) 27 (11.3) Prepregnancy BMI t = 2.44 478 0.02* <19 kg/m 2 underweight 6 (2.5) 3 (1.3) 19 24 kg/m 2 normal weight 137 (55.5) 104 (43.4) 25 29 kg/m 2 overweight 66 (26.7) 95 (39.6) 30 39 kg/m 2 obese 33 (13.4) 31 (12.9) 2 morbidly obese 2 (0.81) 3 (1.3) Missing 3 (1.2) 4 (1.7) Note. CP= CenteringPregnancy; individual = individual prenatal care; n = sample size df = degrees of freedom; t = test statistic to compare means; 2 = chi square statistic to compare means. a. Follow up chi square are listed for each multinomial variable. The follow up chi square compare means differences between the groups in one category of the variable. Overall chi square for each outcome are bolded. *p value < 0.05.
82 Preliminary o bservations about s ample c haracteristics Age. Women in the intervention group tended to be younger than women in the comparison group. Differences in age and parity may be related since women who have fewer children tend to be younger. Younger women may also have been open to participating in an alternative prenatal care program. Education level There was a statistically significant difference in education level between the two groups. Women in the intervention group tended to have more education than women in the comparison group. This may indicate that women with higher education chose the CenteringPregnancy prenatal care over individual prenatal care. Their higher education may also have been due to the fact that they tended to be younger and primiparious and thu s had more opportunities to complete high school. Since women had the option to choose CenteringPregnancy, i t may indicate that women who were higher educated were more open to alternative prenatal care with an education component. Marital status Given the age range and ethnicity of the women in both groups, it was surprising that most of the women reported their marital status as single. Further anecdotal analysis from discussions with health department staff indicated that many of the women may have been married in their country of origin but reported they were single for either the purposes of financial assistance or immigration issues. Several women who said they were single reported that they live d with their partner who may either be a marital pa rtner or may provide similar support as a marital partner. Further qualitative data is needed to better understand these findings.
83 Status in the U.S Compared to the comparison group, fewer women in the more women reported they were permanent residents. This may be correlated to educational level and age. In general, most of the women in both groups were from Mexico and indicated they were of uestions about whether women are documented and legal in the country and thus this information is not obtainable There are very few people in Pinellas County who are actual migrant workers because of the low agriculture in the county. Based on chart infor mation, the majority of women indicated they worked in retail, restaurants or housekeeping Parit y. More women who had lower parity were in the intervention group compared to the comparison group. This may be because women who already had children chose individual care with the assumption that they did not need alternative prenatal care. Pre pregnancy BM I. Women in the intervention group tended to have a lower BMI than women in the comparison group. A higher percentage of women in the intervention gro up had a BMI in the normal range and fewer in the overweight range compared to the comparison groups. However the percentage of obese women in the intervention group was slightly higher compared to the comparison group. It may be that women with lower BMI tended to choose CenteringPregnancy rather than individual care.
84 Frequencies and unadjusted difference tests Gestational age at delivery. The majority of women in both CenteringPregnancy (93.9%) and in individual care (95.8%) delivered their babies full term. Very few (5.7% ) in CenteringPregnancy and 2.1% in individual prenatal care) delivered preterm. There were no statistically significant difference between the groups, t= 0.87, p=0.39. ( See Table 4.2a ) Infant b irthweight. There was a statistically significant difference in mean birthweight between the two groups, t = 2.06, p=0.04. There were slightly more women in CenteringPregnancy who had normal birthweight infants (87%) compared to women in individual care (81.7%), but also more women in CenteringPregnancy who had low birthweight infants (6.1%) compared to women in individual care (4.7%). Slightly fewer women in CenteringPregnancy had infants that were high birthweight (6.1%) compared to women in individual care (9.2%). See Table 4.2a. Meth od of birth More women in CenteringPregnancy (83.4%) had vaginal births as opposed to cesarean section deliveries (10.1%) compared to women in individual care 2 =5.4, p=0.02 ( See Table 4.2a ) When info rmation was provided, reasons for cesarean sections were noted for women in both groups. Although most of the reasons were unknown, breech and failure to progress were among the most common. ( See Table 4.2b ) Birth hospital. The majority of the women in both groups gave birth at Morton Plant Hospital (78.1% in CenteringPregnancy and 77.1% in individual care). Fewer women gave birth a t Bayfront Medical Center (4.1% in CenteringPregnancy and 6.3% in individual care) and only one woman who was in the CenteringPregnancy group gave
85 birth at Helen Ellis Hospital. There was no statistically significant difference in the birth 2 =2.13, p=0.25. See Table 4.2a. Maternal Weight. More women in CenteringPregnancy gained more than the recommended amount of gestational weight (41.3%) compared to women in individual 2 = 7.12, p=0.01; while less women in CenteringPregnancy gained lower than the recommended amount of gesta tional weight (15.4%) compared to women in 2 = 21.62, p=0.00. Although slightly more women in CenteringPregna n cy gained within the healthy weight gain range (35.6%) compared to women in individual care (31.3%), it was not a statis 2 = 0.98, p=0.32. ( See Table 4.2a ) There was a statistically significant difference in postpartum BMI between the group s, t = 2.72, p=0.01, reflecting that the mean BMI of women in CenteringPregnancy (mean=26.33) was lower than the mean BMI for women in individual care (mean=27.60). This was consistent with the difference in the mean pre pregnancy mean BMI between the groups. ( See Table 4.2a). Attendance and adequacy of care The overall proportion of women in both groups who initiated care before the 4 th month of pregnancy was 81.3%. More women in CenteringPregnancy initiated prenatal care before the 4 th month of pregnancy (90.7%) 2 = 39.1, p=0.00. Howeve r, all of the women in CenteringPregnancy who initiated prenatal care after the 4 th month had a pregnancy test completed at the health department clinic prior to 4 months gestation. The pregnancy test is not a prenatal care visit, however, blood pressure, weight and family and medical history are completed at this visit. Thus, the women sought health care and
86 were placed into the health system before the 4 th month of pregnancy. Depending on the weeks gestation they came in for their pregnancy test, either t he wome n were not scheduled for their first prenatal care visit until after their 4 th month or they did not make an appointment until after the 4 th month. More than half (58.2%) of the women in individual care who initiated prenatal care after the 4 th mont h also completed a pregnancy test at the health department clinic prior to 4 months gestation. ( See Table 4.2a ) To determine adequacy of prenatal care, the women were first grouped in one of four categories based on the APNCU index which is derived using the initiation of prenatal care and the number of prenatal care visits. Since the sample size of women in the intermediate and adequate categories was low the four categories were combined to form two categories. Adequate plus and adequate were combined t o form the new adequate, and intermediate and inadequate were combined to form the not adequate category. More women in CenteringPregnancy had adequate prenatal care (91.9%) compared to women in individual care (63.8%) indicating they attended over 79% of 2 = 55.13, p=0.00 ( See Table 4.2a ) There was also a statistically significant difference in attendance in the 2 = 11.22, p=0.00. More women in CenteringPregnancy attended the ir postpartum visit (86.7%) compared to women in indivi dual prenatal care (74.6%) ( Table 4.2a ) Infant feeding More women in CenteringPregnancy (28.7%) indicated at their postpartum visit that they formula only fed their babies compared to women in individual 2 = 31.51, p=0.00. In addition, fewer women in CenteringPregnancy indicated they were exclusively breastfeeding their infant (15.4%) compared to women in
87 2 = 12.05, p=0.00. However, the majority of women i n both groups indicated they were supplementing breastfeeding with formula (38.5% in CenteringPregnancy and 40.4% in individual care) and there was no statistically 2 =2.99, p=0.09 ( See Table 4.2a ) When combinin g the breastfeeding only category with the breastfeeding and formula feeding category the percentage of women who non exclusively breastfed their infants at 6 weeks postpartum was 53.9% for women in CenteringPregnancy and 65.4 % for women in individual care
88 Table 4. 2 a : Outco mes for CenteringPregnancy and Individual Prenatal Care Clients: Frequencies and Unadjusted Univariate Test for D ifferences Variable CP n (%) Individual care n (% ) 2 or t statistic df p value Total Sample Size ( N ) 247 (100) 240 (100) Initiation of Prenatal care 2 = 39.1 1 0.00* Before 4 th month 224 (90.7) 172 (71.7) After 4 th month 10 (4.0) 55 (22.9) Missing 13 (5.6) 13 (5.4) Prenatal Care Adequacy ( Modified APNCU Index) 2 = 211.5 3 0.00* Adequate Plus 212 (85.8) 49 (20.4) 2 = 210.8 a 1 0.00* Adequate 15 (6.1) 104 (43.3) 2 = 96.8 1 0.00* Intermediate 1 (0.4) 15 (6.3) 2 = 16.1 1 0.00* Inadequate 10 (4.0) 55 (22.9) 2 = 39.0 1 0.00* Missing 9 (3.6) 17 (7.1) Prenatal Care Adequacy ( Modified APNCU index Binary ) 2 = 55.13 1 0.00* Adequate 227 (91.9) 153 (63.8) Not adequate 11 (4.5) 70 (29.2) Missing 9 (3.6) 17 (7.1) Postpartum Attendance 2 = 11.22 1 0.00* Attended Did not Attend Missing 214 (86.7) 33 (13.3) 0 (0) 179 (74.6) 61 (25.4) 0 (0) Healthy Weight Gain 2 = 21.53 2 0.00* Above Healthy Weight Gain 102 (41.3) 71 (29.6) 2 = 7.12 1 0.01* Below Healthy Weight Gain 38 (15.4) 80 (33.4) 2 = 21.62 1 0.00* Healthy Weight Gain 88 (35.6) 75 (31.3) 2 =0.98 1 0.32 Preterm (no statistics) 14 (5.7) 5 (2.1) Missing 5 (2.0) 9 (3.8)
89 Postpartum BMI t = 2.72 384 0.01* <19 kg/m 2 underweight 2 (0.80) 2 (0.8) 19 24 kg/m 2 normal weight 81 (32.8) 48 (20) 25 29 kg/m 2 overweight 86 (34.8) 78 (32.5) 30 39 kg/m 2 obese 39 (15.8) 42 (17.5) 2 morbidly obese 3 (1.2) 5 (2.1) Missing 36 (14.6) 65 (27.1) Method of Birth 2 = 5.41 1 0.02* Vaginal 206 (83.4) 185 (77.1) Cesarean section 25 (10.1) 42 (17.5) Missing 16 (6.5) 13 (5.4) Hospital 2 = 2.13 2 0.25 Morton Plant 193 (78.1) 185 (77.1) Bayfront 10 (4.1) 15 (6.3) Helen Ellis 1 (0.4) 0 (0) Missing 43 (17.4) 40 (16.7) Birthweight (grams) t = 2.25 479 0.03* >4000 g 2500 g 4000 g 15 (6.1) 219 (87.0) 22 (9.2) 205 (81.7) <2500 g 11 (5.3) 9 (3.4) <1500 g 2 (0.8) 3 (1.3) Missing 2 (0.8) 4 (4.6) Gestational age at delivery t = 0.87 479 0.39 <37 weeks 232 (93.9) 14 (5.7) 230 (95.8) 5 (2.1) <35 weeks 6 (2.4) 2 (0.8) <32 weeks Missing 0 (0) 1 (0.4) 2 (0.8) 12 (5.0)
90 Infant feeding 2 = 41.86 2 0.00* Breast only 38 (15.4) 60 (25) 2 = 12.05 1 0.00* Formula only 71 (28.7) 18 (7.5) 2 = 31.51 1 0.00* Both breast and formula 95 (38.5) 97 (40.4) 2 = 2.99 1 0.09 Missing 43 (17.4) 65 (27.1) Note. CP= CenteringPregnancy; individual = individual prenatal care; n = sample size df = degrees of freedom; t = test statistic to compare means (continuous); 2 = chi square statistic to compare means (categorical) a. Follow up chi square are listed for each multinomial variable. The follow up chi square compare means differences between the groups in one category of the variable. Overall chi square for each outcome are bolded. *p value < 0.05.
91 Table 4.2b. Reasons for Cesarea n Section Delivery in Both Intervention and Comparison Groups Reason for Cesarean Section CenteringPregnancy n (%) Individual care n (%) Unknown (not indicated on hospital chart or no hospital chart data available) 15 (60%) 13 (31%) Breech 5 (20%) 7 (17%) Failure to progress 3 (12%) 8 (19%) Fetal intolerance to labor 0 (0%) 1 (2%) Induction then arrest of descent 1 (4%) 3 (7%) Intrauterine pregnancy 0 (0%) 2 (5%) Macrosomia 0 (0%) 1 (2%) Pregnancy induced hypertension 1 (4%) 4 (10%) Premature rupture of membranes 0 (0%) 2 (5%) Scheduled non emergency 0 (0%) 1 (2%) Total Cesarean section count 25 42
92 Bin ary and Multinomial Logistic Regression Research question 1: preterm b irth A binary logistic regression describing the relationship between the type of prenatal care and gestational age at birth was performed. The outcome variable of interest is a binary variable that takes on the value of one if a woman had a term birth and two if a woman had a preterm birth. The women who had term births are treated as the reference group. In an unadjusted model, there were no differences in the groups, OR= 0.39 (95% CI: 0.14, 1.11) ( See T able 4.3 ) To control for other variable relationships wi th the outcome, a binary logistic regression adjusting for several covariates including, age, employment status, educational attainment, marital statu s, parity and pre pregnancy BMI In this analysis, the probability of the model chi square is statisticall 2 = 23.3, p<0.05. The null hypothesis that there was no difference between the model without independent variables and the model with independent variables was rejected. However, the existence of a relationship between the type of prenatal c are and gestational age at birth was not supported. The likelihood ratio test established that there was no statistically significant relationship 2 = 0.63, p=0.46 ( See Table 4.4 ) Employment status was statistically significant in the model indicating a relationship with method of b irth 2 = 6.23, p=0.13. There is an increased odds of preterm birth among w omen who worked either part time or full time compared to women who did not wo rk a OR=3.97 (95% CI: 1.32, 11.96) ( See Table 4.4 ) Research question 2: l ow birthweight A binary logistic regression describing the relationship between the type of prenatal care and infant birthweight was performed. The
93 outcome variable of interest is a binary variable that takes on the value of one if an infant was normal birthweight or high birthweight and two if the infant was low birthweight. In this case, normal birthweight and high birthweight were combined to form binary variable because there were too few high birthweight infant s to form a multinomial variable. The combined normal birthweight and high birthweight category are treated as the reference group. In an unadjusted model, there were no differences in the groups OR=0.84 (95% CI: 0.34, 2.10) ( See Table 4.3 ) To control for other variable relationships with the outcome, a binary logistic regression adjusting for several covariates including, employment status, marital status, and parity was performed. In this analysis, the probability of the model chi square is not 2 = 14.99, p<.05. The null hypothesis that there was no difference between the model without independent variables and the model with independent variables was not rejected. The likelihood ratio test established that there was no statistically significant relationship between the type of prenatal care and infant 2 = 0.38, p=0.54 ( See Table 4.4 ) The likelihood ratio for employment status as an independent variable was statistically signific 2 = 8.58, p=0.01 in the model. Women who worked part time or full time were 4.39 times more likely to have a low birthweight infant than women who did not work, aOR=4.21 (95% CI, 1.54, 11.52) ( See Table 4.4 ). Research question 3: method of birth A binary logistic regression describing the relationship between the type of prenatal care and method of birth was performed. The outcome variable of interest is a binary variable that takes on the value of one if a woman had a vaginal birth and two if a w oman had a primary cesarean section. The women who
94 had a vaginal birth are treated as the reference group. In an unadjusted model, there is an increased odds of vaginal birth as opposed to primary cesarean section among women in CenteringPregnancy compared to women in individual care OR=1.87 (95% CI: 1.10, 3.19) ( See Table 4.3 ) To control for other variable relationships with the outcome, a binary logistic regression adjusting for several covariates including, age, educational attainment, parity, status i n country, pre pregnancy BMI, employment status and birth hospital was performed. In this analysis, the probability of the model chi square is statistically 2 = 50.98, p<.05. The null hypothesis that there was no difference between the model w ithout independent variables and the model with independent variables was rejected. The existence of a relationship between the type of prenatal care and attendance in the method of birth was supported. The likelihood ratio test established that there was a statistically significant relationship between the type of prenatal care and type of birth 2 = 6.60, p=0.01. Women in CenteringPregnancy were more l ikely to have a vaginal birth compared to women who completed individual prenatal care. T here is an in creased odds of vaginal birth as opposed to primary cesarean section among women in CenteringPregnancy compared to women in individual care, aOR=2.57 (95% CI: 1.23, 5.36) ( See Table 4.4 ) Parity was statistically significant in the model indicating a relat ionship with type of birth Women who were primiparous were almost 8 times more likely to have a primary cesarean section compared to women who were multiparous, aOR=7.95 (95% CI: 3.45, 18.29). In addition, women who gave birth at Morton Plant hospital com pared
95 to Bayfront hospital were less likely to have a cesarean delivery, aOR=0.20, (95% CI: 0.06, 0.65) ( See Table 4.4 ) Research question 4: gestational weight g ain A multinomial logistic regression describing the relationship between the type of prenatal care and gestational weight gain was performed. The outcome variable of interest is a nominal variable that takes on the value of one if a woman gained above the rec ommended weight during pregnancy, two if a woman gained within the recommended weight and three if a woman gained below the recommended weight, as defined previously from the 2009 IOM weight gain guidelines. The women who gained within the recommended amount of weight are treated as the reference group. In an unadjusted model, there were no differe nces in low weight gain between the groups, OR=1.22 (95% CI: 0.80, 1.89). However, there were differences between the groups in the unadjusted model for high weight gain, OR=0.41 (95% CI: 0.25, 0.66). Women in CenteringPregnancy were less likely to gain mo re than the recommended amount of weigh t than women in individual care ( See Table 4.3 ) However, this did not hold true after covariates were controlled for. To control for other variable relationships with the outcome, a multinomial logistic regression a djusting for several covariates including, age, educational attainment, employment, marital status, parity, pre pregnancy BMI and status in the country. In this 2 = 111.74, p<. 05. The null hypothesis that there was no difference between the model without independent variables and the model with independent variables was rejected. The existence of a relationship between the type of prenatal care and maternal weight gain was suppo rted. The likelihood ratio test established that there was a statistically
96 2 = 15.63, p=0.00. Women in CenteringPregnancy were less likely to gain below than the recommend ed amount of weight gain compared to women who completed individual prenatal care, aOR=0.41 (95% CI: 0.22, 0.78) but there was no statistically significant difference with women who gained more than the recommended amount of weight, aOR=1.45 (95% CI: 0.79, 2.62). Classification accuracy is assessed to determine the utility of the multinomial logistic regression model. This measure compares the predicted group memberships based on the logistic model to the actual group membership (value of dependent variabl es) ( Rudner, 2005 ) The benchmark that is used to characterize the model as can be achieved by chance alone ( Rudner, 2001 ) The proportion by chance accuracy criteria is computed by summing the squared percentage of cases in each group of the dependent variable. The overall percentage accuracy rate produced in the SPSS computation is compar ed to 25% more than the proportional by chance accuracy. In this case, the classification accuracy rate (54.2%) is greater than the computed proportional by chance accuracy criteria (43.1%) indicating that the criteria for classification criteria is satisf ied. Pre pregnancy BMI showed a statistically significant relationship with gestational weight gain. Women who were obese before pregnancy had higher odds of gaining above the healthy weight recommendations than women who were normal weight, aOR= 57.40 ( 95% CI: 15.7, 210.20) and gaining below the recommended amount of weight aOR=6.61 (95% CI, 1.64, 26.6). Women who were overweight before pregnancy also had
97 a higher odds of gaining below the healthy weight recommendations than women who were normal weight, aOR= 3.08 (95% CI: 1.67, 5.66) ( See Table 4.4 ) ly significant differences between the two groups. The likelihood ratio test established that there was no t statistically significant relationship between the type of prenatal care and maternal weight 2 = 0.61, p=0.44. However, there was an increased odds of gaini ng a healthy gestational weight among obese women and overweight women in both groups combined, aOR=25.98 (95% CI: 7.46, 90.41) and, aOR 2.17 (95% CI: 1.29, 3.65) respectively ( See Table 4.4 ) Research question 5: attendance in c are Adequacy of prenatal care A binary logistic regression describing the relationship between the type of prenatal care and the adequacy of prenatal care was performed. The outcome variable of interest is a binary variable that takes on t he value of one if a woman received adequate care and two if a woman received inadequate care, as defined previously using a modified APNCU index. The women who received adequate care are treated as the reference group. In an unadjusted model, there was an increased odds of receiving adequate prenatal care among women CenteringPregnancy compared to women in i ndividual care, OR=9.44 (95% CI: 4.84, 18.41) ( See Table 4.3 ) To control for other variable relationships with the outcome, a binary logistic regressi on adjusting for several covariates including, age, educational attainment, employment, marital status, parity, pre pregnancy BMI, and status in the U.S. In this
98 2 = 58.10, p< .05. The null hypothesis that there was no difference between the model without independent variables and the model with independent variables was rejected. The existence of a relationship between the type of prenatal care and adequacy of prenatal care was supported. The likelihood ratio test established that there was a statistically significant relationship between the type of prenatal care and adequacy of prenatal care 2 = 38.2, p=0.00. Women in CenteringPregnancy were more likely to have received adequ ate prenatal care rather than inadequate prenatal care compared to women who completed individual prenatal care. There was an increased odds of receiving adequate prenatal care among women CenteringPregnancy compared to women in i ndividual care, a OR=11.03, (95% CI: 4.53 26.83) ( See Table 4.4 ) Pre pregnancy BMI was statistically significant in the model indicating a relationship with type of birth 2 = 9.03, p=0.04. Women who were obese were less likely to have adequate prenatal care than women who were of normal weight, aOR=0.25 (95% CI: 0.08, 0.73) ( See Table 4.4 ) Attendance in postpartum visit A binary logistic regression describing the relationship between the type of prenatal care and attendance in the postpartum visit was performed. The outcome variable of interest is a binary variable that takes on the value of one if a woman attended the po stpartum visit and two if a woman did not attend the postpartum visit. The women who attended the postpartum visit are treated as the reference group. In an unadjusted model, there was an increased odds of attending the postpartum visit among women Center ingPregnancy compared to women in i ndividual care, OR=2.2 (95% CI: 1.38, 3.51) ( See Table 4.3 )
99 To control for other variable relationships with the outcome, a binary logistic regression, adjusting for several covariates including, age, employment, marita l status, parity, pre pregnancy BMI and status in the U.S was performed. In this analysis, the 2 = 22.28, p<.05. The null hypothesis that there was no difference between the model without in dependent variables and the model with independent variables was rejected. The existence of a relationship between the type of prenatal care and attendance in the postpartum visit was supported. The likelihood ratio test established that there was a stati stically significant relationship 2 = 6.71, p=0.01. Women in CenteringPregnancy were more likely to attend their postpartum visit compared to women who completed individual prenatal c are. There was an increased odds of attending the postpartum visit among women CenteringPregnancy compared to women in i ndividual care aOR=2.21 (95% CI: 1.20, 4.05) ( See Table 4.4 ) No other covariates in model were statistically significant indicated any relationship with birthweight. Research question 6: i nfant feeding method A multinomial logistic regression describing the relationship between the type of prenatal care and the type of infant feeding was performed. The outcome variable of interest is a multinomial variable that takes on the value of one if the mother was supple menting breastfeeding with formula, two if the mother was using formula only to feed, and three if the mother was exclusively breastfeeding. Mothers who supplemented breastfeeding with formula are treated as the reference group. In an unadjusted model, th ere was an increased odds of formula only feeding infants among women in CenteringPregnancy compared to women in i ndividual
100 care OR=4.03 (95% CI: 2.23, 7.26). There were no differences between the groups with women who exclusively breastfeed their babies OR=0.65 (95% CI: 0.39, 1.06) ( See Table 4.3 ) To control for other variable relationships with the outcome, a multinomial logistic regression adjusting for several covariates including, age, birth hospital, employment, educational attainment, parity and p re pregnancy BMI. In this analysis, the 2 = 59.72, p<.05. The null hypothesis that there was no difference between the model without independent variables and the model with independent vari ables was rejected. The existence of a relationship between the type of prenatal care and infant feeding was supported. The likelihood ratio test established that there was a statistically significant relationship between the type of prenatal care and inf 2 = 32. 63, p=0.00. There was an increased odds of formula only feeding infants among women in CenteringPregnancy compared to women in i ndividual care aOR=6.07 (95% CI: 2.57, 14.31) ( See Table 4.5 ) Employment status was statistically si gnificant in the model indicating a relationship with feeding method. Women who worked either part time or full time were less likely to exclusively bre astfeed, aOR=0.44 (95% CI: 0.21, 0.94), or formula only feed their infants aOR=0.42 (95% CI: 0.21, 0.88) ( See Table 4.5 )
101 Table 4.3: Una djusted Logistic Regression for Type of Prenatal C are Outcome Variable Unadjusted OR 95% CI Preterm 0.39 [0.14, 1.11] Low birthweight 0.84 [0.34, 2.10] Method of birth 1.87* [1.10, 3.19] Gestational Weight Gain binary 1.25 [0.85, 1.84] Gestational Weight Gain nominal (reference: healthy weight gain) 1.22 (low weight gain) 0.41*(high weight gain) [0.80, 1.89] [0.25, 0.66] Adequacy of prenatal care 9.44* [4.84, 18.41] Attendance in postpartum visit 2.20* [1.38, 3.51] Infant feeding method (reference: both breast and formula) 4.03* (formula only) 0.65 (breast only) [2.23, 7.26] [0.39, 1.06] Note. df = degrees of freedom; OR = odds ratio; CI = confidence interval *p < 0.05.
102 Table 4.4: Adjusted Binary Logistic Regression for Type of Prenatal C are Outcome Variable Adjusted OR 95% CI Wald Statistic P value Likelihood ratio test 2 (df) Preterm 23.30* (13) Type of prenatal care 0.61 [0.18, 2.10] 0.61 0.44 0.63 Age 3.27 Education 1.07 Employment 3.97* [1.32, 11.96] 5.71* 0.02 6.23 Marital status 0.01 Parity 0.33 Pre pregnancy BMI 0.26 Low birthweight 14.99* (5) Type of prenatal care 1.35 [0.52, 3.51] 0.38 0.53 0.38 Employment status 4.21 [1.54, 11.52] 7.89* 0.01 8.58* Marital status 0.07 Parity 5.09 Method of birth 50.98* (13) Type of prenatal care 2.57* [1.23, 5.36] 6.35* 0.01 6.60* Age 6.48 Birth Hospital 0.20* [0.06, 0.65] 7.12* 0.01 6.84* Education 4.24 Employment 0.28 Marital status 0.58 Parity 7.95* [3.45, 18.92] 23.76* 0.00 27.63* Pre pregnancy BMI 1.25 Gestational weight gain 64.4* (14) Type of prenatal care 1.23 [0.73, 2.07] 0.61 0.44 0.61 Age 9.04 Education 1.75
103 Employment 1.51 Marital status 3.84 Parity 0.04 Pre pregnancy BMI Obese Overweight 25.98* 2.17* [7.46, 90.41] [1.29, 3.65] 26.20* 8.55* 0.00 0.00 51.23* Status U.S 3.10 Adequacy of prenatal care 58.10* (14) Type of prenatal care 11.03* [4.53, 26.83] 27.99* 0.00 38.2* Age 0.89 Education 0.36 Employment 0.66 Marital status 2.21 Parity 5.66 Pre pregnancy BMI Obese 0.25* [0.08, 0.73] 6.41* 0.01 9.03* Status U.S 1.88 Postpartum visit 22.28 (14) Type of prenatal care 2.20* [1.20, 4.05] 6.49* 0.01 6.71* Age 6.07 Employment 2.29 Marital status 2.51 Parity 1.84 Pre pregnancy BMI 1.85 Status in the U.S. 1.35 Note. df = degrees of freedom; OR = odds ratio; CI = confidence interval *p < 0.05.
104 Table 4.5: Adjusted Multinomial Logistic Regression Outcome Variable Adjusted OR 95% CI for OR Wald P value Likelihood ratio test 2 (df) Gestational Weight Gain a 111.74* (28) Type of prenatal care 1.45 (high weight gain) 0.41* (low weight gain) [0.79, 2.62] [0.22, 0.78] 1.42 7.39 0.23 0.01 15.63* Age 12.34 Education 2.45 Employment 2.02 Marital status 3.59 Parity 2.78 Pre pregnancy BMI Obese Overweight 57.39* (high weight gain) 6.61* (low weight gain) 3.08* (high weight gain) [15.67, 210.18] [1.64, 26.60] [1.67, 5.66] 37.39* 7.06* 13.04* 0.00 0.01 0.00 78.29* Status on U.S. 3.62 Infant feeding method b 59.72* (28) Type of prenatal care 6.07* (formula only) 0.16 (breast only) [2.57, 14.31] [0.33 1.19 ] 16.93 0.00 32.63* Age 7.82 Birth Hospital 1.09 Employment 0.44* (formula only) [0.21, 0.94] 4.52* 0.03 8.26* 0.42* (breast only) [0.21,0.88] 5.24* 0.02 Education 2.54 Parity 1.01 Pre pregnancy BMI 2.27 Note. df = degrees of freedom ; Wald = Wald test statistic; OR = odds ratio; CI = confidence interval *p < 0.05. a. Reference: healthy weight gain b. Reference: breast supplemented with formula
105 Table 4.6: Summary of Statistically Significant Covariate Relationships to O utcomes Outcome Variable Independent Variable Adjusted OR 95% CI Wald P value Preterm Worked 3.97* [1.32, 11.96] 6.0* 0.01 Low birthweight Worked a 4.39* [1.62, 11.87] 8.48* 0.00 Vaginal birth Primiparous 7.95* [3.45, 18.29] 23.76* 0.00 Vaginal birth Bay Front Hospital 0.20* [0.06, 0.65] 7.12* 0.01 Low gestational weight gain Overweight pre pregnancy BMI 6.61* [1.64, 26.60] 7.06* 0.02 Low gestational weight gain Obese pre pregnancy BMI 18.65* [5.21, 66.73] 20.23* 0.00 High gestational weight gain Overweight pre pregnancy BMI 57.40* [15.7, 210.20] 37.4* 0.00 High gestational weight gain Obese pre pregnancy BMI 3.08* [1.67, 5.67] 13.04* 0.00 Formula only feeding Worked 0.43* [0.22, 0.85] 5.88* 0.02 Exclusive breastfeeding Worked 0.47* [0.24, 0.89] 5.38* 0.02 Note. Wald = Wald test statistic; OR = odds ratio; CI = confidence interval *p < 0.05. a. Adjusted covariates to obtain model fit 15.104. Included only parity and treatment as covariates.
106 Univariate General Linear Model ( Research Questions 1 2 ) Descriptive s tatistics Descriptive statistics for the continuous outcome variables are displayed in Table 4.7 and Table 4.7. For the CenteringPregnancy group, the mean age of the women was 24.6, the mean infant birthweight was 3 333.6 grams (SD= 487.34) and the mean gestational age at birth was 39.1 weeks (SD = 1.51) ( See Table 4.6 ) For the individual prenatal care group, the mean age of the women was 25.9, the mean infant birthweight was 3427.5 grams (SD= 497.71) and the mean gestational age at birth was 39.1 weeks (SD= 1.6) ( See Table 4.8 ) Assumptions There are three assumptions to be met to conduct a one way ANOVA or ANCOVA using a general linear model, normality, independent groups and equal variance across groups. All three of these assumptions have been met for the two dependent variables, birthweight and gestational age at birth. The birthweight variable for infants of women in CenteringPregnancy has a kurtosis value that is >|1| which indicates non normality. However, since the within group degrees of freedom is >40 the ANO VA is robust to this assumption ( Tabachnick & Fidell, 2007 ) The birthweight variable for women in individual care, the skewness and kurtosis values are >|1| which indicates non normality. However, again since the within group degrees of freedom is >40 the ANOVA is robust to this assumption The two groups are assumed to be independent of each other since different women were sampled in each group who received their prenatal care at the same time ich test the null hypothesis that the error variance of the dependent variables is equal across groups. For the dependent variable gestational age at delivery the test was not significant, F=0.869,
107 p=0.352 indicating that there is equal variance across the groups. For the dependent variable infant birthweight the test was also not significant, F=0.425, p=0.515 indicating that there is equal variance across the groups.
108 Table 4.7: CenteringPregnancy Descriptive Statistics Outcome Variable N Min Max Mean Std. Deviation Skewness Kurtosis Statistic Std. Error Statistic Std. Error Statistic Std. Error Gestational age at birth (weeks) 239 33 42 39.13 0.10 1.51 1.71 0.16 4.47 0.314 Birthweight (grams) 238 1361 4508 3333.63 31.59 487.34 0.91 0.16 2.46 0.314 Note. N= sample size; Min= minimum; max= maximum, std.= standard Table 4.8: Individual Prenatal Care Descriptive Statistics Outcome Variable N Min Max Mean Std. Deviation Skewness Kurtosis Statistic Std. Error Statistic Std. Error Statistic Std. Error Gestational age at birth (weeks) 242 28 42 39.36 0.10 1.60 2.81 0.16 16.31 0.31 Birthweight (grams) 243 907 4763 3427.35 31.93 497.71 1.12 0.16 4.12 0.31 Note. N= sample size; Min= minimum; max= maximum, std.= standard
109 Research question 1: g estational age at delivery An unadjusted one way ANOVA statistical test performed in a univariate general linear model with no covariates indicated that the main effect for type of treatment showed no statistically significant relationship between the type of prenatal care and gestational age at birth, F=2.95, p=0.086, indicating there is no observed difference in average gestational age a t birth between the two groups ( See Table 4.9 ). When employment status, maternal age and parity are added to the model as covariates the ANCOVA model was statistically significant, F=1.80, p=0.045. The adjusted R 2 was 0.02 indicating 2% of the variance in gestational age at birth was accountable by the set of predictors. However, the main effect for type of treatment still showed no statistically significant relationship between the type of prenatal care and infant bir thweight, F=0.778, p=0.38. On the other hand, the main effect for employment status showed a statistically significant relationship with gestational age at delivery, F= 7.18, p=0.01, indicating there was an observed difference in average gestational age at delivery between women who worked comp ared to women who did not work ( See Table 4.10 ) A follow up t test indicated that there was a difference in the average birthweight of women who worked comp a red to women who did not work, t= 1.97, p=0.049, however, t he p value was only s lightly below 0.05 ( See Table 4.11 )
110 Table 4.9: Main Effects Test for Between Subjects Effects for Dependent Variable, Gestational Age at B irth Variable Type III Sum of Squares df Mean Square F P value Partial Eta 2 Adjusted R 2 Type of prenatal care 7.16 1 7.16 2.95 0.09 .01 0.00 Note. df = degrees of freedom ; F= Omnibus test for overall mean difference: Partial eta 2 = proportion of variance accounted for by the main effect or interaction; adjusted R 2 =the proportion of the variation in the dependent variable accounted for by the independent variables. *p < 0.05. Table 4.10: Tests of Between Subjects E ffects for Dependent Variable, Gestational Age at B irth with C ovariates Variable Type III Sum of Squares df Mean Square F P value Partial Eta 2 Adjusted R 2 Corrected Model 50.67 12 4.22 1.81 0.05 0.05 0.02 Type of prenatal care 1.82 1 1.82 0.78 0.38 0.00 Age 0.29 1 0.29 0.12 0.73 0.00 Parity 6.96 2 3.48 1.49 0.23 0.01 Employment status 16.80 1 16.80 7.18 0.01 0.02 Type of prenatal care with Employment status 1.96 1 1.96 0.84 0.36 0.00 Parity with Employment status 10.58 2 5.29 2.26 0.11 0.01 Note. df = degrees of freedom ; F= Omnibus test for overall mean difference; Partial eta 2 = proportion of variance accounted for by the main effect or interaction; adjusted R 2 =the proportion of the variation in the dependent variable accounted for by the independent variables. *p < 0.05.
111 Table 4.11: Follow up Test for Dependent Variable Gestational Age at B irth Parameter t test P value 95% CI Partial Eta 2 Women who worked 1.97 0.049* 1.47, 0.00 0.01 Note. df = degrees of freedom ; t = test statistic to compare means ; CI = confidence interval; Partial eta 2 = proportion of variance accounted for by the main effect or interaction *p < 0.05.
112 Research q uestion 2: b irthweight An unadjusted one way ANOVA statistical test run in a univariate general linear model indicates that the main eff ect for type of treatment showed a statistically significant relationship between the type of prenatal care and infant birthweight, F=0.26, p=0.04, indicating that there is an observed difference in average birthweight between the two groups. The obtained R 2 was 0.01 indicating only 1% of the variance in birthweight was accountable by the set of predictors. See Table 4.1 2 A follow up t test shows women in CenteringPregnancy had on average lower birthweight infants than women in individual prenatal care, t= 2.06, p=0.04. See Table 4.1 3 However, when other covariates are added to the model in an ANCOVA this relationship does not hold true. When employment status, maternal age and parity are added to the model as covariates the main effect for type of treatme nt showed no statistically significant relationship between the type of prenatal care and infant birthweight, F=3.74, p=0.054. The obtained R 2 was 0.06 indicating 6% of the variance in birthweight was accountable by the set of predictors. In addition, the main effect for employment status, age and parity wer e not statistically significant ( See Table 4.1 4 )
113 Table 4.1 2 : Main Effects Test of Between Subjects E ffects for Dependent Variable, B irthweight Variable Type III Sum of Squares df Mean Square F P value Partial Eta Squared Adjusted R 2 Type of prenatal care 1033570.20 1 1033570.20 4.26 0.04 0.01 0.01 Note. df = degrees of freedom ; F= Omnibus test for overall mean difference: Partial eta 2 = proportion of variance accounted for by the main effect or interaction; adjusted R 2 =the proportion of the variation in the dependent variable accounted for by the independent variables. *p < 0.05. Table 4.1 3 : Follow Up t test for Dependent Variable, B irthweight Parameter T P value 95% CI Partial Eta Squared CenteringPregnancy 2.06 0.04 181.02, 4.43 0.01 Note. df = degrees of freedom ; t = test statistic to compare means ; CI = confidence interval; Partial eta 2 = proportion of variance accounted for by the main effect or interaction *p < 0.05.
114 Table 4.1 4 : Main Effects Test of Between Subjects E ffects for Dependent Variable, B irthweigh t with C ovariates Variable Type III Sum of Squares df Mean Square F P value Partial Eta Squared Adjusted R 2 Corrected Model 18240715.42 52 350782.90 1.51 0.02 0.16 0.06 Type of prenatal care 870089.41 1 870089.41 3.74 0.05 0.01 Employment status 579029.88 1 579029.88 2.49 0.12 0.01 Age 307094.90 4 76773.72 0.33 0.86 0.00 Parity 819937.38 2 409968.69 1.76 0.17 0.01 Note. df = degrees of freedom ; F= Omnibus test for overall mean difference: Partial eta 2 = proportion of variance accounted for by the main effect or interaction; adjusted R 2 =the proportion of the variation in the dependent variable accounted for by the independent variables. *p < 0 .05.
115 Phase II : (Research Question 7) Study p opulation A total of ten women participated in in person, in depth interviews. All of the women completed Cente ring Pregnancy at the health department clinic and thus were all Latina and Spanish speaking All of the women were from Mexico and were multiparous. Their mean age was 27.9 years old. Most of the women indicated they were single but many were living with their partners, and m ost of t he women did not work All of the women who gave birth at Morton Plant Hospital and had full term normal birthweight infants t hrough a normal vaginal birth ( See Table 4.1 5 ) Table 4.1 5 : Descriptive statistics of women who were interviewed Variable Results for all 10 women Marital Status 7 single (5 living with partner), 3 married Mexican Origin All 10 Maternal Age Range: 22 33 Mean: 27.9 Employment Status 7 di d not work, 3 work ed Type of Birth All 10 vaginal Birthweight All normal birthweight Gestational age at birth All term Birth Hospital All Morton Plant Families, codes and t hemes The social support theory was used as a theoretical base when developing the research protocol. The interview guide was developed based on the social support theory to address specific issues related to CenteringPregnancy (CP), and to answer research question 7 ( See Appendix E ) The 5 types of social support (emotional, instrumental, informational, appraisal, companionship) were used as a priori codes to identify how the CP provides social support to the women. Additional codes were used to identify other topics or subtopics of t he types of social support. Often, sections of the interview were double coded to identify a type of support and a specific topic area. Six families of codes were identified and the list of a priori codes was
116 combined with emerging codes that were formed w hile analyzing the data. The families and codes are listed in Table 4.1 6 Table 4.1 6 : Families and Codes for Qualitative Analysis Families List of Codes (A priori and emerging) Social Support Theory a Informational support Emotional support Companionship support Instrumental support Appraisal support Overall experience Positive experiences Negative experiences New things learned in CP Education compared to past Questions and concerns addressed Differences between CP and individual care Recommendations of CP Nutrition Nutrition education Information compared to past Exercise Exercise education Information compared to past Preparedness of labor and birth Well prepared Poorly prepared Comfort Comfort level compared to past Support F rom physician From other women From health educator or staff Friendships Note. a. Social support theory codes overlapped with other codes
117 Based on the social support theory several themes and subthemes emerged that are included in the following descriptions. Themes Perceptions of C are including positive and negative experiences and overall perceptions Informational Support including any new information learned, nutrition education, exercise education and education on labor and birth Emotional Support including the development of trusting relationships, addressing concerns and questions during CP, how comfortable women felt in the group, how well they felt they were prepared for labor and birth and differences in CP compared to indiv idual care. Companionship Support including support from relationships with other women in the group, with the doctor and with the health educator/facilitator as well as the structure and style of the group. Instrumental Support including tangible serv ices provided by the health department and by the CP program and differences in CP compared to individual care. Appraisal/Validation Support: including constructive feedb ack, appraisal of progress, a forum for questions and concerns to be addressed and emp owerment of women by knowledge and support to make decisions about their pregnancy and labor and birth Recommendations of CP including which type of care women would want in the future and which type of care they would recommend to others.
118 The Social Support Theory identifies at least three pathways in w hich support is received and provided ( Hupcey, 1998 ) These pathways are depicted in Chapter 2. The CP model of prenatal care most closely resembles the pathway in which the recipient of support received support for several providers as denoted in Figure 4 .1 The maternity client is the recipient of care and the health department staff physician nurse and the health educator and all of the other women in the group are the providers of care. However, in addition to receiving support from multiple providers, the maternity patient also provides support to other women in the group. This relationship is reciprocal, as other women also r eceive support. In addition, the health care providers not only provide support to wom e n but they receive support back as well. Because the groups are discussion based, all participants are engaged and are both recipients and providers of support. Thus, the CenteringPregnancy model does not fit directly into the current social support models. Rather, a model depicting the reciprocal support of all participants in the group (denoted by double arrows in the figure) more closely identifies the way in which support is provided and received (See Figure 4.2). The social support theor y also describes five types of social support ( House, 1981 ; Wills, 1985 ) that were used in the analysis. Each type of social support was identified as a theme along with several subthemes. An illustration of how a woman in CP receives each type of social s upport is provided in Figure 4. 3.
119 Figure 4.1 : Social Support Pathway that is depicted in CenteringPregnancy ( Hupcey, 1998 ) R denotes the recipient of care Figure 4.2 : Illustration of the recipient s of support, denoted by (R) re ceiving care from multiple providers, denoted by (P). (R) (P) Woman receiving CP prenatal care (P) (R) Other women in the group (P) Health Educator (P) Doctor (P) Nurse (P) Other staff and services
120 Figure 4.3 : Types of Social Support in Social Support Theory provided to the women receiving CenteringPregnancy. Emotional Support: T rusting relation ships Questions and concerns answered C omfort Preparedness for labor and birth Informational Support: New information Questions and concerns a ddressed Nutrition information Exercise information Labor and birth information Companionship Support: Friendships Relationships with women and staff Structure of group Style of group Instrumental Support: Health educator Physician Risk assessment Health department services CP tools (guide book/journal) Games and demonstrations Appraisal/Validation Support : Feedback from group Appraisal from group Questions and concerns answered Woman receiving CP prenatal care
121 P erceptions of Centering Pregnancy All of the women discussed very positive experiences they had with the CP program at the health department. They talked about several aspects of the program in particular that made their experience positive. The women appreciated the support they received from the staff at the health department and from other women in the group and the friendships they made. They also enjoyed the games they played to learn the information, especially those that involved preparing for labor and birth and caring for their bab y. They were grateful that they did not have to spend much time in the waiting room, especially when they compared it to how long they normally wait for an appointment at the same clinic. They also valued the extent of and the quality of the interaction th ey had with the physician, nurses, health educator and other women in the group. Positive e xperiences The women were all asked to talk about their overall experience of CP, both positive experiences and negative experiences. However, women discussed many more positive experiences than negatives ones. A woman who volunteered her overall opinion of the program said, years a go when I had my first daughter? Another woman said the following: run the group make you feel at home and support you and you meet friends. Any questions or doubts that you have, they answer it for you. They teach you how to nourish yourself and how to go through your pregnancy as best as possible. It was so nice to be able to count on people who support me and become my friend. I am very grateful to them. That is Several women mentioned that even though they already had children they stil l learned a great amount from CP and appreciated the information and support. Some
122 women said they did not realize how much they still had to learn about pregnancy and/or caring for the baby. One woman said, childr th they still had doubts and we all helped them get Another woman said, The women als o enjoyed several other aspects of CP. Many women stated that they were glad they did not have to be in the waiting room and could go right into the CP room. All of the time spent at the health department for the women involved learning and interacting wi th other women and the staff. Even while they waited for each woman to have her individual exam, they were learning by playing games or completing their weight and blood pressure assessment. A few women said they enjoyed hearing the ultrasound monitor on t women said they appreciated that the entire program was in Spanish and tailored toward Latina women. Some of them seemed surprised that such a program was offered. Almost all of the women said th at they felt freer to talk about any problems they had and had more time to discuss issues or concerns. In addition to enjoying talking about their pregnancies, some of the women said they liked socializing in general with other women. They talked about ot her normal life issues and joys and were happy to make friends in the program. This may have been extremely helpful to women who had a weak social network outside of the clinic and were eager to interact with other women. Those women with weaker social net works may have been more recent immigrants, many of whom were from Mexico. Some women indicated that they appreciated that the doctor and
123 health educator would allow them to talk about their ideas on a certain topic first and talk to each other before the professional opinion was introduced. In general, women were happy that the opportunity to participate in CP. They discussed some very positive experiences and showed their appreciation for the program. About their overall experience women made the follow ing comments: women and the first day everyone kept to themselves but after that we all became friends and of the other moms and we talked about everything from our pregna ncy, Negative e xperiences When asked specifically about negative experiences with the program, most women said that they did not have any and enjoyed every aspect of the program. However, som e women discussed some things they disliked or made them feel uncomfortable. One woman indicated that she felt uncomfortable with fathers/ male partners in the group, especially when the women had to do exercises. She said that this was the only problem s he had but did show some concern with it. In general, fathers and partners are welcome to participate in the CP program with the pregnant woman. In many of the groups, the fathers/ male partners participated in the first few classes but then as time went o n they did not come as often or at all. However, in some classes, they stayed in the group over the entire course of the pregnancy. Only one of the women interviewed said it sometimes bothered her that males were in the group, but it was not asked
124 specific ally to each woman how she felt. Future qualitative research is needed to A problem another woman remarked on was that she felt uncomfortable with all of the women in the group discussed her issues with the doctor doing the individual examinations in the back of the room behind a screen. She did not say that she was completely unsatisfied with the approach but she menti oned a specific instance that bothered her. She said that one day health. She indicated that it was very sad to hear this and she did not think that it was appropriate for the doctor to discuss this in the same room as the other women. She said that once everyone in the room heard, all of the women were upset. It is not known whether the woman who was told wanted to be told in the group or discuss it in the group or if she preferred to discuss it in private. In conversations with other women and the staff, in general if women want to talk about something in private they are welcome to do so. One person said that although she enjoyed the classes they were slightly too long. She had other children to attend to and it was too long to be there without her children being allowed to come with her. The woman was asked by the interviewer if there would still be a concern if there were free childcare at the health department during CP. The Another woman said that she did not like when they sent her out of the CP room to get laboratory work completed because she fe lt like she would miss something. While
125 some women were sent for laboratory work, the health educator continued to do activities with the women who were still in the group. This was something some women actually liked so that when others were sent out of t he room they still had something to do. However, as indicated it caused some concern for one woman. Informational Support Informational support is support that involves gathering and sharing information and advice. The women were all asked about specific information they learned in CP that was either new to them or something that was particularly helpful to them. Most of the women said they were glad they learned how to take their blood pressure and calculate their g estational age, which were skills they appreciated learning more about. It was an empowering experience for women to be able to understand these health assessments better. One woman even indicated that she still took her own blood pressure even after she w as done with CP, Healthy weight gain was something several of the women mentioned as well. They said the doctor talked t understand that the amount of weight to gain during pregnancy depends on pre pregnancy BMI. The women all charted their weight in a grid that shows healthy weight gain each time they went to the CP class and one woman mentioned this grid during the interview. The women also said they learned about nutrition and exercise during pregnancy and the importance of eating healthy for the mother and the baby.
126 All of the women said they learned about caring for the baby and most of them named activities about this topic as their favorite. They stated that they learned how to have patience with the baby, bathe the baby, feed and nur se and learn the meaning of the each cry means was what most of them said was their favorite activity. They enjoyed this activity because many of them said they did not rea lize the baby had different cries and it was good to learn different sounds may mean the baby has different wants and needs. Another topic most women discussed and elaborated on was being prepared for labor and birth The women mentioned a video they enjoyed watching, spoke about exercises to quicken the labor and said they learned pain management and relaxation d shown what to do on the arrival day She said, day so that you are not struggling while the pain is strong. They showed us how to get there and what were going to do when we got This facility tour was done for every CP group. Women were asked to meet the health educator at Morton Plant hospital and then continue with their CP session after the tour. Two other women mentioned a video they were shown of what will happen when a laboring mother arrives at the hospital to deliver the baby. The women said the video was very helpful for them to see even though they already had children. Other topics women mentioned were, the babies growth and change s during pregnancy, signs and symptoms of pregnancy complications, a video on breastfeeding, discussion about sexual intercourse during pregnancy and postpartum depression and
127 mood changes during and after pregnancy. Some other comments by women are as fo llows: Nutrition information The doctor, health educator and a nutritionist facilitated discussion with the women to eat healthy during their p regnancy and to sustain healthy eating habits postpartum. The women discussed several nutrition topics they went over in CP such as, the food pyramid, portion sizes, food to avoid during pregnancy and nutrients and minerals that are especially important. I n addition to the doctor, the nutritionist also discussed weight gain during pregnancy and talked about the importance of gaining a healthy weight. The women said they learned it is important to eat healthy not just for the baby but for the mother as well They talked about the importance of maintaining healthy eating habits and staying healthy after the baby is born. More specifically, the women said they learned they should eat plenty of green vegetables and fruit, choose low fat milk and dairy products drink plenty of water and exercise daily. They also discussed what they learned about sugar and not eating too many sweets. Most of the women said they learned about portion control, which was something that seemed new to many of them. About portion con trol one woman said, In one CP class, they
128 played games to learn portion sizes and had to guess what size they thought was the correct portion. The women seemed to enjoy the games they played to learn information. A few women indicated that the games also helped them to remember the information better. The women liked that there was a separate nutrition ist who came into the group to talk to them. Some of the women indicated that the nutritionist talked about what is healthy to eat but also talked about many myths of consuming certain food during pregnancy. It seemed very helpful to the women to talk to t he nutritionist. Some old us. Before we used to drink the y nice and Exercise/physical a ctivity information The women discussed various physical activity exercises they were taught and encouraged to do during their pregnancy, but walking was one that all of the women mentioned. They said the doctor told them to stay active by walking if it did not put too much s train on them. They were also encouraged to stretch their muscles often. One woman said, The women were also given several exercises to do if they had certain pains either in their stomach or back. They were shown different positions,
129 stretches and exercises to get more comfortable during their pregnancy. Another woman said, nd afternoon. It helped me with a healthy weight Some of the women indicated that they continue to get exercise by walking every day even after they had their babies. Many of them walk their ch ildren to school or walk to work. One woman said that she walks longer now that she is not pregnant and that exercise feels good and helps her to increase her energy. She said, now because I realized that you feel more energy to do more things when you finish Other women said that they knew they should still walk and get more exercise but they did not do it as much as they should. This indicates that it may be beneficial to im plement a feature or program to help encourage women postpartum to continue to exercise and stay healthy. Information about labor and birth The women discussed the information they learned about labor and birth All of them said that they were given advice about pain management and relaxation techniques to try during labor contractions and pains. Many of them said that the doctor encouraged them to walk around as much as possible during early stages of labor to help the progression. They also spoke about exercises they learned to help progression and pain management. They practiced many of the exercises in the group and were very grateful that they were able to do this. The following are quotes from three differ ent women about the techniques they learned to help with labor and birth : relax myself would help so much with the delivery. It was easier to delivery when I relaxed and practices the e
130 what was going to happen because we went through it and I did the exercises. It we nt by faster more relaxing, more normal without any About pain management the women said they learned to focus on certain things, to breathe and concentrate on breaths and not to be ashamed for making noise and screaming if they needed to do that to manage pain. About her labor and birth experiences, one wo man said, Emotional Support Emotional support involves empathizing and listening as well physical comforts such as hand holding or hugging. There are many aspec ts of CP that encourage and provide emotional support to women. The group is structured for emotional support in that women are encouraged to listen to each other, discuss problems or concerns and joys, and develop relationships with each other. At the end of each group, everyone in the group circle holds hands for the final words of the session to promote an idea of connectedness and unity. Women talked about several concepts and experiences in the group that depicted how emotional support was provided. Th ese topics include, addressing concerns, comfort in the group and preparedness for labor and birth A few women mentioned that there was good support from other women in the group who all talked about their own experiences, either past or current. Women ta lked about pain management techniques and what they were planning to do in their labor, what they do to stay comfortable, what eat, how they deal with stress among other topics. One It was so nice to be able to count on people who support me a nd become
131 The same woman also said, other women go through it to...you know The relationships women formed with other women and the health care providers is also part of emotional support. Addressing c oncerns The women were asked if they felt that all of their questions and concerned were answered during their time in the CP program. All of the women indicated that they always received answers and had their concerns addressed either from other women in the grou p or the doctor/staff. This seemed to make the women feel more at ease with their pregnancy. A woman said, group mates would ask something and we would respond amongst ourselves or the doctor would sometimes answer Several women mentioned their questions were always answered and often times their myths were dispelled. They said that some of them would bring up different things they heard from friends, neighbors and relatives about the pregnanc y, birth or childcare and would ask the group about what they heard to make sure they knew the truth. The doctor and health educator encouraged Being able to ask questions and having the time to get answers not just from a doctor but from other women who were also pregnant was something that many women cherished. Comfort All of the women said they felt more co mfortable in CP than in individual care. The primary reason was because of the comfort they felt with other women in the group. They enjoyed the fact that they made friends and they were in the
132 program together. Many said they felt more comfortable becaus e they were able to talk and think more. They did not often leave the group with many concerns or problems. They felt the concerns they may have been worried about or thinking about were addressed. Three of the women said the following: and more comfortable. It was much easier to talk about what you wanted I would get there and know th at I was going to be with other mothers and be with the friendly people there. That was a day I had to myself, it was my time and the babies when we because of my back hurt, or my legs hurt, they showed us li However, this level of comfort was not always felt over the whole CP program. Some women said that at first they were hesitant to be in a group with other women and not all of the women bonded in the beginning. One woman said, embarrassing for me to be with all of the other pregnant women and the first day Another woman said, Preparedness for labor and birth The women were asked to speak specifically ab out how well they were prepared for labor and birth All of the women said they felt prepared and many said they were more prepared than they were in the past because of
133 information they learned in CP. About her birth one woman said, re A few of the women said that they were glad they learned that they could speak out about the type of labor and birth t hey wanted to have at the hospital. They said they were taught to take control of their pregnancy and to discuss with the labor team what they wanted and did not want and to do what was comfortable for them. One woman said, at the hospital, Another said, Comments such as these show how CP can serve to empower women especially in terms of taking control and making their own decisions about their labor and birth Differences between CP and individual care The emotional support of other women was identified as a main difference between CP and individual care. The women really enjoy ed and appreciated the support they received in CP and how it made them feel. They also liked that they could ask questions to other women as well as the health care providers. Another woman said, The women also said that compared to individual care, the CP program was more fun, more enc ouragement and the people involved provided more support to get through the pregnancy. A woman said, pregnant and now what? You have other people to go through it with you. Seeing your
134 group member you get Another woman said, group The women indicated that they enjoyed being in the group and enjoyed the CP program more than their previous experience with individual care. Several of the women indicated that they did not feel the same nervousness during their pregnancy as they had with past pregnancies because it was so comfortable for them. They did n ot have as many doubts because they always had questions answered and learned so much more than they have in the past. Companionship Support Companionship support involves relationships that provide comfort, stability, friendship and having camaraderie. Many relationships are formed in CP that help provide this support. One of the main concepts of CP is to provide a forum for women to develop f riendships with other pregnant women and establish positive relationship with the clinicians and staff. The structure and style of the CP program helped women to develop relationships and gain companionship support. In the group, women had to work with ea ch other in teams during activities and games, they sat in a circle for the entire class to encourage unity and they were encouraged to help each other during the self assessments (taking weight and blood pressure). In each group, the health educator also asked women to exchange phone numbers so that they can call each other outside of CP if they needed additional support. The relationships with other women, the doctor and the health educator were all discussed. Women All of the women talked about the fri endships they developed in CP. Some of them still keep in communication with the women they met in their group. One
135 said that she developed a very close relationship with one of her group mates and is living with her now as they continue to support each ot her. She said, the group. In fact, I live with one of them now. Her husband left her so now we are In this particular circumstance, the women who met in the group became great supporters for each ot her beyond the CP program. Many of the women who already had children would help the new mothers with their questions and concerns. The women with children enjoyed helping the other women and dissipating their fears. All of the women mentioned the friends they made and indicated that being able to develop relationships with other pregnant women was one of the greatest benefits of CP. Women made contact with each other postpartum as well to get support and help from the other members of the group. Some of t hem called each other after they had their babies to tell them about their experience and to talk about any concerns they had. A woman said, r his checkup. I talked to A few of the women indicated that they still keep in touch with other women in their group and get together occasionally. There may be more primiparous women who get together more or talk since they are learning how to take care of their child for the first time. In fact, one woman said that she was friendly with everyone but some of the first timers were closer to each other. She said, friends but I think the new moms in our group would This was not something that was explored further in the interviews because all of the women interviewed already had children.
136 Doctor The doctors and other staff were very supportive and helpful to the women. Most of the wom en said they talked about many issues amongst themselves and when the doctor had to intervene he/she did. The doctor talked to women separately about any specific health concern or problem they had. One woman said that she needed to watch her weight and s he talked to the doctor about it on her own in addition to discussing it in the group. She said she felt comfortable talking about it in the group but liked that she was able to talk to the doctor on her own as well. Several women said that the doctor was always there the whole time in the group and was always willing to answer questions or talk about things they wanted to talk about. One woman said, of us in but she They appreciated and were surprised that the doctor was with them the full 2 3 hours of the session. Another woman said was t Health educator The health educator who facilitated the group was an integral part of the group dynamic as she set the tone for each session. The women enjoyed the health educator and talked about the demonstrations she would do and the activities and games she would coordinate. The said that the health educator would show them exercises they had to do and different positions to lay in to get more comfortable later in pregnancy. The women appreciated that they were shown what t o do rather than just told. individual care. The women also seemed to appreciate the general encouragement they received from the health educator. About the general staff, women said:
137 difficult for me to eat. They would say to me at Centering me. They would search for a solution for me to find things I could eat that Instrumental S upport Instrumental support involves tangible goods and services that may provide needed assistance. The CP program in itself is a service that is provided to women and serves as instrumental support. In addition, components of the program such as the staff (doct or, health educator and other staff), clinical risk assessment services, other referral health services (such as The Healthy Start Coalition or Women Infant & Children ( WIC ) ), the tools used in the sessions (guide book and gestational calculator) and games activities and demonstrations all serve as instrumental support. When asked about their favorite activities, the women mentioned playing games, especially those they involved preparing for labor and birth and caring for their baby. Several women talked about a meant. One woman said, Sometimes is a diaper cha Women also talked about demonstrations that were done when the health educator was showing the women different positions that are more comfortable. They appreciated that the information was shown to t hem in creative ways that helped them retain the information better. All of the women were given a guide book to follow during each session. The women had to bring the book to every class. This served as a tool to help women follow along with the topics of that session and to complete self assessments. The
138 self assessments were used as data for the CP program but they were also used for the women to reflect on what they have learned, concerns they had any factors they were either positively or negatively ef fecting their pregnancy. Although all of the activities were not mentioned in the interviews, the women participate d in either an activity or a game for whichever topic was being discussed in every CP session. Differences between CP and individual care The women discussed many differences between their experience with CP and individual prenatal care. One of the main differences women talked about was that they learned so much more in CP. They said that in individual care they were given many brochures an d pamphlets about keeping a healthy pregnancy but in CP they were able to talk and discuss the information they were given, and were able to practice some of it as a group. It may not have been that the content of the information was very different but it was the way in which the information was presenting that made a difference in how the women learned. One woman said, Another women said, The techniques of the education and care are what women identified as what made them learn more in CP. One woman said CenteirngPregnancy over the regular appointment. It was a wonderful experience in the Another difference women talked about was the time it took for the appointment. In general, they discussed that they only had a limit ed time in individual care (for example 5 10 minutes). They appreciated the 2 3 hours they had in CP to discuss the
139 information and get questions and concerns answered. They also enjoyed that they did not have to wait to be seen as they did in individual care. They appreciated that the whole time they were in the clinic they were involved in some kind of activity for their prenatal care. Even when they were waiting to be seen by the doctor individually behind the screen in the room, they were taking their blood pressure, weight, talking with other women or doing an activity with the health educator. Some of the women said even though they were in the group for 2 3 hours, the time would pass quickly, unlike when they had to wait hours in the waiting room. On e woman said, of the time. We learned so much about nutrition, exercise, how to care for your baby, how to labor. We took better advantage of the time in C entering A few women talked about bringing what t hey learned back home to their partner and family. One woman talked about how every time she went back home after CP she would tell her husband what she learned and show him her CP manual so that he could learn too. A few women mentioned the manual and lik ed that they were able to look ahead on what they were going to cover in the next class and bring home their notes to their family. Another woman said that she liked that she could read ahead and come to the class with questions. Having the manual was a be nefit to the women because they were able to keep track of everything they learned and use it to disseminate information to their family. Appraisal/Validation Support Appraisal/validation support involves receiving constructive feedback and affirmation. This is done in every CP session when women are given the opportunity to talk to each one another about specific problems or topics and provide feedback. Many times women will ask a question or pose a topic to talk about
140 and the other women in the group w ill share their own similar experiences to help provide either an answer to a question or simply affirm that the problem exists for them as well. pregnancies, feelings, concerns, questions and opinions. They revealed that they really pregnancies, compare experiences, understand what was normal and empathize with others. Many women also enjoyed helping each othe r with different symptoms or discomforts. They talked to each other about what worked and made them feel better to know that they were not alone in their concerns. One woman said, another. Whenever anyone had a problem, between all of us we were able to help. Sometimes they would have a lot of fear but after talking to all of us they felt much better, Since the participants who were interviewed all already had children, they spoke about how they liked helping the women who were f irst time mothers. One woman said, would happily answer the first Another woman said, those of us who were moms and um I enjoyed participating a lot and explaining what a The experience of mentoring each other seemed to be empowering to the women who had children already and it made their experience more enjoyable. In fact, the health educator and doctor would sometimes ask or defer questions to the women with children and sometimes the new mothers would directly ask questio
141 I liked In the individual session, the doctor provided feedback for wome n on how well their pregnancies were progressing on a more individual level. The doctor along with the health educator also answered questions in the groups that helped women feel more at ease with their concerns. As previously discussed, women felt as tho ugh their questioned and concerned were answered of not by other women in the group, then by the doctor or health educator. Empowerment One of the overall themes that emerged that was not specifically linked to codes was empowerment. The CP program provi ded needed prenatal care for women by assessing risks and providing education and support but it also empowered women to take control of their health and their pregnancies. Women were very happy with their care and mentioned several things that showed they were given control. Women would take their own blood pressure, weight and calculate their gestational age. They would help each other take these measurements and had assistance from the nurse, especially in the beginning of the program. Women talked about this experience in a very positive manner and were very happy to learn how to do these measurements themselves. They were grateful that they learned how to do them on their own and seemed as though they felt more in control of their prenatal care by doing so. They were not only taught how to do these measurements but they learned what they mean and how they affected the status of their pregnancy. Another important point was their experience in the group and at the time of their labor and birth they seemed
142 confident and had power in the situation. They had the knowledge to be able to make their own decisions. The women interviewed who previously had children also talked abo ut their mentorship in the program. The doctor and other women in the group would specifically direct questions to the multiparous women so they could discuss their previous experiences. They were also respected as mothers who had experience with labor a nd birth and caring for infants. The women appreciated this respect and were happy to be able to share their knowledge. Recommendati ons of CenteringPregnancy All of the women said that they would recommend CP to other pregnant women and many of them said that they already nd I think she is in law who is trying to get pregnant One woman said she would recommend CP to other women but she questioned the fact that they discouraged children from attending the group. She said because sometimes She seemed as through this was the only problem with recommending CP because if women already have children it may be difficult for them to arrange child care.
143 Two of the women mentioned that they would recommend CP to everyone but especially single mothers who did not have a partner. They felt as though the support in CP would be very essential to women who may not have much support at home from a partner. One woman said: etimes with single moms you can be very sad and depressed and at CP at least you have women there who ask you how your pregnancy is going and they talk to you about depression there. They give you a number to call a help center if anyone feels depressed an d needs Summary Women talked very positively about their experiences with CP. They were very happy with their care, appreciated the staff and doctor giving them time to talk and express themselves, being able to ask questions to the staff and other women and the friendshi ps they made and support they received from other pregnant mothers. They all had a very positive attitude toward CP and felt they were more in control with CP than they were in their past experience with individual care. There were a few negative aspects o f the group the women mentioned including lack of childcare, lack of privacy at times and the presence of male partners in the group. However, these did not overshadow the o verall they had more positive perceptions than negative ones. Although all types of social support were identified when women spoke about the program, informational support and companionship support were the most prominent. Women talked extensively about how much information they were provided in CenteringPregnancy and how much more they learned in the program compared to their past experience with individual care. Throughout the interviews they also spoke about the friendships they made and the relationsh ips they had with the health care providers. They
144 really appreciated the comradeship that was developed and the support they obtained from other women in the group. The women identified this type of companionship support as biggest difference between the C enteringPregnancy program and their past experience with individual prenatal care, and that it was the most appreciated aspect of the program. A summary of all of the results listed by each research question can be found in Table 4.1 7
145 Table 4.1 7 : Summary of results based on each research question Research Question Summary Findings Research question 1: Is there a difference in gestational age at delivery based on type of prenatal care? There were no differences in gestational age at delivery based on the type of prenatal care Research question 2: Is there a difference in infant birthweight based on type of prenatal care? There were no differences in infant birthweight based on the type of prenatal care Research question 3: Is there a difference in the method of birth based on type of prenatal care? Women in CenteringPregnancy were less likely to have cesarean section deliveries compared to women in individual prenatal care Research question 4: Is there a difference in mater nal weight gain based on type of prenatal care? Women in CenteringPregnancy were less likely to gain below the recommended amount of weight (based on 1990 IOM guidelines) compared to women in individual prenatal care. Research question 5: Is there a diffe rence in prenatal care and postpartum care attendance rates based on type of prenatal care? Women in CenteringPregnancy were more likely to have adequate prenatal care and were more likely to attend their postpartum visit compared to women in individual pr enatal care. Research question 6: Is there a difference in infant feeding method based on type of prenatal care? Women in CenteringPregnancy were more likely to formula only feed their infants compared to women in individual prenatal care. Research que stion 7: perceptions of CenteringPregnancy prenatal care compared to their past experience with individual prenatal care? Women had many positive experiences with CenteringPregnancy and identified many aspects of the program that provided them each of the 5 main types of social support. Women enjoyed the c ompanionship they had with other women in the group and felt they learned more about their pregnancy and childbirth in CenteringPregnancy than they did in past individual prenatal care.
146 CHAPTER FIVE: DISCUSSION, CONCLUSIONS AND RECO MMENDATIONS Summary of Research P rotocol CenteringPregnancy is a model of group prenatal care that can be used in place of individual prenatal care. The program brings about 8 10 women of similar gestational age together into small groups to receive their care and education, and is based on risk assessment, education, and support. The model is client centered and designed to e mpower pregnant women and support persons. The literature on the effectiveness of the program show mixed results in terms of birth outcomes, but illustrate positive outcomes in terms of breastfeeding initiation, attendance in care and satisfaction of care. A CenteringPregnancy program was implemented at the Pinellas County Health Department Clearwater clinic for Latina women in late 2006. No form al assessment of the program had been conducted to compare pregnancy outcomes with women in CenteringPregnancy co mpared to women in individual care. In addition, few studies h ave assessed Latina women in CenteringPregnancy and thoroughly examined maternal weight gain In addition, more studies are needed that better understand the relationship of CenteringPregnancy w ith improved birth outcomes. T h e purpose of this research was to fill the gaps in the literature and compare pregnancy outcomes of Latina women in CenteringPregnancy to women in individual prenatal care and explore their perception of
147 CenteringPregnancy compared to their past experience s with individual care. Both quantitative and qualitative methods were employed to specifically examine gestational age at delivery, infant birthweight, method of birth maternal weight gain, attendance in prenatal and post partum visits, infant feeding method and A total of 487 patient charts were extracted, 247 were from women who completed CenteringPregnancy and 240 were from women who completed individual care. In addition, 10 women who recent ly completed CenteringPregnancy and completed individual prenatal care in the past completed in person in depth interviews. Logistic regression, ANCOVA and qualitative analysis were conducted to answer seven research questions about pregnancy outcomes, mat ernal factors and perceptions of care. Findings Gestational age at delivery (preterm) There was no difference in gestational age at delivery based on t he type of prenatal care. A slightly higher percen tage of women in CenteringPregnancy delivered preterm ; however this difference was not significant when other covariates were examined in a logistic regression model. Th is finding is consistent with some of the literature including, Robertson et al. ( 2009 ) who also examined Latina women and Klima et al. ( 2009 ) but is inconsistent with others such as, Ickovic et al. ( 2003 ) Grady & Bloom ( 2004 ) and Ickovic et al. ( 2007 ) With the exception of Robertson et al. ( 2009 ) t here is little in the literature that explores CenteringPregnancy programs with Latina w omen Thus, is difficult to compare these findings However, based on literature of birth outcomes for Mexican American women in the U.S., this finding was expected. Mexican American women in general have lower rates of preterm birth than other minority po pulations in the U.S ( McDonald, 2008; Brown, 2007 ;
148 Hummer, et al., 2007 ) ) In addition, the women included in the study were all considered to be low risk maternity patients. The proportion of preterm birth for both the intervention and comparison group in this study was already low and thus it was unlikely that a difference between the two groups would be found However, a positive finding is that t he overall proportion of preterm births for all women in the study who received care at the health departmen t clinic was smaller (3.9%) than the proportion for Hispa nic women Pinellas County as a whole ( 13.1% ) ( "Florida Charts County & State Profile," 2009 ) Both the logistic regression model and the ANCOVA models showed that women who worked either part time or full time were more likely to have a preterm infant than women who did not work. This may have been due to additional stress from work. Most of the wo men who work ed had low paying jobs in various food industry positions, retail or housekeeping. These types of jobs may have added physical strain or additional stress on the women The l iterature on employment status and adverse birth outcomes shows mixed results about either being employed or unemployed and having an a dverse birth outcome ( Jansen, 2010; Rodrigues & Barros, 2008 ; Savitz, 1996 ) found that long work infants born to mothers in the Netherlands. Savitz et al. ( 1996 ) found elevated risk for preterm birth and still birth among certain groups of wo rkers, including women working in food service and janitorial positions On the other hand, Rodrigues et al. ( 2008 ) found that unemployed women had a significant increa se in the risk of preterm birth and the duration of weekly work had no effect on outcomes. Further research into the specific
149 types of jobs and weekly duration of work of the maternity patients at the clinic is needed to further explore this relationship. Infant birthweight (low birthweight). There was no difference in infant birthweight based on the type of prenatal care. Both unadjusted and adjusted logistic regression models showed no differences in low birthweight between the two groups When examining gestational weight gain as a continuous variable, a n ANOVA model without adjustments showed a stat istically significant relationship but an ANCOVA adjusting for covariates showed no statis tically significant relationship Similarly to preterm bir th outcomes, this finding is consistent with studies by Robertson et al. ( 2009 ) and Klima et al. ( 2009 ) but inconsistent with Ickovic et al. ( 2003 ) and Grady & Bloom ( 2004 ) B ased on literature of birth outcomes for Mexican American women in the U.S., this finding was also expected Like preterm bir th, Mexican American women in general have lower rates of low birthweight infants compared to other minority populations in the U.S ( Brown, et al., 2007 ; Hummer, et al., 2007 ) The proportion of low birthweight infants for both groups was low and thus it was unlikely that a difference between the two groups would be found A positive outcome is that t he ov erall proportion of low brithweight infants for all women in the study was smaller (4.1%) than the proportion for Hispanic women in the overall county (6.4%) ( "Florida Charts County & State Profile," 2009 ) Similarly to preterm birth, t he logistic regression model showed that women who worked either part time or full time were more likely to ha ve a low birthweight infant compared to women who did not work. However, the ANCOVA model examining birthweight as a continuous variable did not show a statistically significant relationship
150 between employment status and infant birthweight. Low bi rthweight is related to preterm birth and thus a similar relationship with employment status was expected. It may be that simi lar reasons of additional physical and emotional stress may be the cause of the relationship however; further research is needed to examine this finding. Method of birth There was a statistically significant difference between the method of birth and the type of prenatal care. Women in CenteringPregnancy were more likely to have a vaginal birth as opposed to a primary cesarean section compared to women in individual care. This relationship was found with an unadjusted logistic regression and when covar iates were controlled for in an adjusted mode l. These findings a re not c onsistent with the one study that reported method of birth among adolescent girls in CenteringPre gna ncy ( Grady & Bloom, 2004 ) One of the emerging themes in the qualitative analysis portion of this study was that of appraisal support and e mpowerment. Especially when talking about the labo r and birth process experience s in the hospital, women said they felt more in control after they completed Center i ngPregnancy and were more comfortable with speaking up and talking to the hospital staff ab out the kind of birth they wanted. Some women gave specific examples of their experience in the hospital and refusal for pain medication. CenteringPregnancy seemed to give women a voice and give them the power to make decisions for the pregnancy and birth. This may have contributed to the l ow number of cesarean sections. E mpowerment of women to make their own decisions about the method of birth they prefer is especially important among the group of women being studied in this investigation. Most of the wome n w ere born outside of the U. S. and were not fluent English speakers They already had a difficult time communicating wit h health
151 care professionals and lack the c onfidence to make their opinions about their care pregnancy and birth experience clear. The education and support they receive d through CenteringPregnancy may have contribute d to women making more dec isions to have a normal vaginal birth or to interfere with interventions that may have led to cesarean sections. More qualitative research is needed with a greater number of women who experienced both CenteringPregnancy and individual care to further investigate this finding. In addition, gathering more data on why cesarean sections were done at the hospital would h elp with further understanding this outcome. The overall proportion of births by cesarean section for women at the health department was 13.8%, which was lower than the overall rate for Hispan ic women in Pinellas County, 31.1% ( "Florida Charts County & State Profile," 2009 ) Because the women were also low risk at the clinic and never had a prior ces arean section delivery most likely contributed to the lower rate. In the logistic regression model, parity was found to have a statistically significant relationship with type of birth. Women who were primiparous were more li kely to have a primary cesarean section than women who were multiparous. Again, a ll of the women in the clinic were low risk and thus the multiparous women never had a cesarean section del ivery. Because they had vagin al birth s in the past they may have been more likely to have a subsequent nor mal vaginal birth W omen who gave birth at Morton Plant H ospital compared to Bayfront H ospital were less likely to have a cesarean section delivery. This may b e because most of the births that occur at Morton Plant hospital are with a midwife who, based on the midwifery model, may be less likely to defer to a cesarean section unless absolutely
152 needed. Unlike Morton Plant Hospital, it is primarily physicians who attended births at Bayfront Hospital. Maternal weight g ain There was a statistically significant relationship with maternal weight gain based on the 1990 IOM recommendations ( IOM 1990 ) and the type of prenatal care. Women in CenteringPregnancy wer e less likely to gain below the recommended amount of weight gain compared to women who completed individual prenatal care Although there were more women in Ce nteringPregnancy who gained more than the recommen ded amount of weight, there was no stati stically significant difference betwe en the groups After initial analysis, the weight gain categories were combined to form a binary variable (healthy vs. unhealthy). T he proportion of women in CenteringPregnancy who gained a healthy weight as opp osed to an unhealthy weight was higher than w omen in individual care, but this difference was not statistically significant. However, the findings did indicate that in both groups combined, younger women had higher odds of gaining a healthy weight compared to older women. Only one study examined weight gain in women who completed CenteringPregnancy ( Klima, et al., 2009 ) Klima (2003 ) found that women in CenteringPregnancy had significantly higher weight gain (mean=32.2 lbs) than women in individual care (mean=28.5 lbs). Although both weights are within normal range for a woman of normal pre pregnancy BMI, it does not appear as though the authors used pre pregnancy weight or any guidelines to distinguish healthy weight gain. Thus, it is difficult to compare the findings to this research. Due to the emphasis on prenat al nutrition and exercise in CenteringPregnancy it was expected that women in the CenteringPregnancy group would be more likely to gain
153 a healthy weight compared to women in individual care. Although this difference in not significant, the qualitative findings help to better understand any differences. Women indicated that they learned more about nutrition and exercise in CenteringPregnancy compared to individual care and in the interviews they discussed many healthy habits and behaviors they learned in the group. They talked specifically about gaining healthy weight in pregnancy and gave some examples of what they learned from the guest nutritionist and health educator The women seemed to understand the information on nutrition and exercise and indicated they followed some of the recommen dations that were made to them. Women said they ate plenty of fruits and vegetables and said they Yet, there was still no difference between women in CenteringPregnancy and wom en in individual care in terms of healthy weight gain. Only about 1/3 of women in both groups were gaining healthy weight. It may be that what is needed for pregnant women is not to learn the information for the first time after they are already pregnant a nd in the middle of prenatal care but to learn the information before pregnancy. Preconception care and education may be a more useful tool to encourage women to eat healthy, exercise, maintain a healthy weight and try to gain a healthy weight during preg nancy ( Korenbrot, Steinberg, Bender, & Newberry, 2002 ; Jack & Culpepper, 1990 ) Another finding about maternal weight gain was that w omen who were obese or ove rweight before pregnancy were more likely to gain either higher than the recommended amount or lower than the recommended of gestational weight. This does not necessarily mean that more women with higher pre pregnancy BMI are gaining more weight during pre gnancy. Rather, it means that more women with higher pre pregnancy
154 BMI are not gaining weight within their recommended categories. This may have been because the recommendations for women with higher pre pregnancy BMI (overweight or obese categories) were to gain less gestational weight than normal weight women. Obese women in this study either gained too much or too little. The women who gained too much were not able to keep their weight gain to the limited amount of weight ; for obese women this was 15 pou nds and for overweight women it was 15 25 lbs. The women who gained to o little either were not able to gain a healthy amount of weight throughout their whole pregnancy or they may have lost a significant amount of weight in the first few weeks of pregnancy and then began to gain more weight but still did not gain up to the recommendations eight charts indicated that some women (in all weight categories) lo st between 5 15 lbs in the first few weeks of pregnancy. This may have been due to a sudden change in their diet to a healthier lifestyle, or to being sick during the first few weeks and not being able to eat or keep food down. The weight gain data only ta bulated the total weight gain from the pre pregnancy BMI through the last prenatal care visit and thus it did not capture initial weight loss For example an obese woman may have lost an initial 15 lbs during the first trimester and then gained the 15 lbs back plus 14 additional lbs throughout her pregnancy She gained 29 lbs total but from the baseline weight she only gained 14lbs which was less than the r ecommended amount Based on pre pregnancy BMI, the overall proportion of births to overweight wom en in this study (both groups) was greater (33.1%) than that of all women in Pinellas County (23.3%), while the proportion of obese women was lower among women in this study (14.2%) compared to all women in the county (19.3%) ( "Florida Charts County &
155 State Profile," 2009 ) A breakdown of ethnicity was not available for the county and thus there is no comparison of Hispanic only women Utilization of c are Attendance in prenatal care visits According to the modified APNCU index, about 86% of women in CenteringPregnancy initiated care before the 4 th month of pregnancy and attended over 110% of their expected number of visits. Women in CenteringPregnancy may have attended more than the 11 expected visits for various reasons. First, a woman may have had additional individual care visits due to a specific problem with her pregnancy which caused her to need an additional appointment. Second and more likely, a woman may have had additional appointments because did not give birth by the time the CenteringPregnancy gro up ended. If she did not give birth by the end of the program she would attend weekly individual visits wi th the doctor until the birth It may also have been a combination of these two that contributed to the higher number of women who had adequate plus care. Due to the vagueness of what may constitute additional visits, the APNCU index was further modified further to form a binary variable and examine only adequate vs. non adequate care. There were statistically significan t differences between the two groups in prenatal care adequacy. A logistic regression analysis indicated that women in CenteringPregnancy were more likely to obtain adequate prenatal care as opposed to non adequate care compared to women in individual care This relationship was found both in the unadjusted and adjusted models.
156 This finding was expected and was consistent with findings from other studies ( Grady & Bloom, 2004 ; Ickovics, et al. 2007 ; Klima, et al., 2009 ) Using the same APNCU index Ickovicks et al. ( 2007 ) found that women in a randomized controlled study were less likely to have less than adequate care in CenteringPregnancy than in individual care. Klima et al. ( 2009b ) only examined the number of prenatal care visits and found that wom en in CenteringPregnancy attended significantly more visits than women in individual care (9.7 vs. 8.3). Grady & Bloom ( 2004 ) found that adolescent girls in CenteringPregnancy had fewer no show appointments (19%) compared to women in individual care (28%). This finding was further explained with what was found in the qualitative analysis First, women seemed to develop a sense of cohesiveness with the group and had companionship in the class. Women may have been more likely to attend their care because they were part of a larger group that they in which they belonged N ot attending would perhaps alter that cohesiveness since they women realized it took all of them to make up the group Second, the women said they enjoy ed attending the program and liked being in the group. T hey liked that there was social time, they played games, ate food and made friends at the group and truly looked forw ard to seeing each other. I n general the women viewed the classes as an enjoyable experience. Enjoying the time spent in the program may have contributed to high attendance since women looked forward to attending Third, the women did not want to miss out on any information by not attending. S ome women mentioned that even when they had to leave the group for laboratory work they f elt that they may be missing inform ation or an activity that they wanted to participate in They felt as though they were learning in the group and wanted
157 to be there to obtain the information and participate. From preliminary research observations, when a woman missed a session, other wome n in the group would ask where she was and if anything was wrong, and sometimes would call her to follow up. This companionship support may have encouraged women to attend. Attendance in postpartum visit There were statistically significant differences between the two groups in postpartum care attendance W omen in CenteringPregnancy were more likely to attend their postpartum care visit compared to wom en in individual care. This was true in both the unadjusted and adjusted logistic regression mod els. Similar to reasons why women attending prenatal care, this difference may also have occurred because of the relationships that were formed and the cohesive of the group. This finding is consistent with the only study that reported on postpartum rates among women in CenteringPregnancy ( Grady & Bloom, 2004 ) Grady and Bloom ( 2004 ) examined postpartum attendance with women in CenteringPregnancy. Although they did not compare attendance rates to w omen in individual care they found that 87% of the women in CenteringPregnancy attended their postpartum visit within 8 weeks which was consistent with the findings is this study (86.7%). Although the postpartum visit is an individual visit women may hav e been more likely to attend the visit because of the relationships they made with the doctor and nurses. Many women who came to their postpartum visit brought food in for the staff and thank you cards to show their appreciation The postpartum visit serve d as an additional time to follow up with the doctor and staff not only with maternity care but for the women this was also time to talk a bout their experience with the childbirth and to bring their baby in for the staff to see. The postpartum visit is ver y important to assess any
158 maternal morbidities or problems, test for postpartum depression, check postpartum weight and provide essential family planning which includes contraception and education on baby spacing. An increase in utilization of care both in terms of prenatal care and postpartum care is a positive outcome of CenteringPregnancy that may be an important Infant feeding m ethod There was a statistically significant difference in the infant feeding method and the type of prenatal care. Women in CenteringPregnancy were more likely to formula only feed their infants at six weeks postpartum. Although fewer women in CenteringPregnancy exclusively breastfed their infants at six weeks postp artum there were no statistically significant diff erences between the two groups either in the un adjusted or in the adjusted logistic regression model. This finding was surprising since breastfeeding is highly encouraged in CenteringPregnancy and infant fe eding is covered as an educational topic. However, the proportion of women who both breast and formula fed their infants was similar between the two groups and the majority of women in both groups reported using both feeding methods T he finding that women in CenteringPregnancy are more likely to formula only feed than women in individual care is not consistent with the literature on breastfeeding among women in CenteringPregnancy ( Klima, et al., 2009 ; Ickovics, 2007 ; Grady & Blo om, 2004 ) However, the data on breastfeeding from each study come from different time periods and thus they cannot be directly compared to data in this study. Gr ady & Bloom ( 2004 ) did not do a comparison but found that at hospital discharge, 46% of the adolescent girls who attended CenteringPregnancy were breastfeeding. Data on whether the y were exclusively breastfeeding or breastfeeding beyond hospital discharge was not
159 reported. This cannot be directly compared to finding in this study because infant feeding was assessed at six weeks postpartum and not at hospital discharge. Klima et al. ( 2009 ) also reporte d that breastfeeding at hospital discharge was higher among women who attended CenteringPregnancy than women who were in individual care, p<0.05. Ickovics et al. ( 2007 ) examined initi ation of breastfeeding from a six mon th postpartum interview with mothers and found more women in CenteringPregnancy initiated breastfeeding than women in individual care, p=0.001 The rates of breastfeeding are higher among Hispanic women especially Mexican American women than other et hnic groups in the U.S ( McDonald, Suellentrop & M orrow, 2008 ) In Pinellas County, the proportion of new mothers who reported ever breastfeeding was 80.9% and the proportion of new mothers who reported breastfeeding at two months postpartum was 54.9% ( "Florida Pregnancy Risk Assessment Monitoring System (PRAMS)," 2008 ) Data specifically for Hispanic women i n the county and data on exclusive breastfeeding vs. supplementing breast feeding was not available. The percentage of women in the current study who non exclusively breastfed (combination of two variables, exclusively breastfeeding and breastfeeding suppl emented with formula) their infants at six weeks postpartum was 53.9% for women in CenteringPregnancy and 65.4% for women in individual care which is still higher for women in individual care however both groups are comparable to the two month postpartum breastfeeding report for Pinellas County. The reason for the difference in women formula only feeding their infants is unknown. In most CenteringPregnanc y groups, breastfeeding is a high priority of the education, especially among groups of African American women. In this group, i t may
160 no t have been emphasized as much, assuming that Hispanic women will breastfeed anyway ; however, breastfeeding was covered as an important topic in the group A conversation with WIC lactation consultants at the health department provide d some anecdotal information to help explain the findings. The WIC lactation consultants indicated that they do not speak fluent Spanish and often have trouble with communicating with Spanish speaking women about breastfeeding. This may have contributed to fewer women in both groups (treatment and control) not exclusively breastfeeding or formula only feeding; however it does not explain the difference between the two groups. Additional qualitative interviews of women and of hea lth department staff including WIC staff, may contribute to better understanding reasons for infant feeding methods. Two other variables that were thought to influence infant feeding method was status in the U .S. and employment status. Some research has indicated that women who were recent immigrants were more likely to breastfeed their infants than those who were permanent resident or citizens ( Byrd, Balcazar, & Hummer, 2001 ) However, i n this analysis there was no difference in infant feeding meth ods based on status in the U.S. T here were very few women who were permanent or temporary residents and the length of time in the U.S. was unknown. Some research also indicates that women who are employed may be less likely to brea stfeed and more likely to formula feed due to convenience and restrictions at work ( Ryan, Wenjun, & Arensberg, 2006 ) In this analysis employment status was related to method of feeding; women who worked either part time or full time were more likely to supplement breastfeeding with formula than exclusively breastfeed. Most women who obtained care at the health department had jobs
161 in the food service industry or housekeeping positions and may not have had the financial privileges to take much time off of work after having their baby and may have had limited opportunities to pump breast milk while at work. This may have been due to either, limited time, a lack of privacy at work and a lack of refrigeration. A new provision from the U.S. Department of Labor requires employers with 50 or more employees to provide a reasonable amount of break time and a private area to pump milk other than a bathroom ( "Fact Sheet #73: Break time for nursi ng mothers under the FLSA," 2010 ) As this new provision begins to be implemented it will be interesting to reexamine infant feeding methods of women who work. are Overall p erceptions W omen had very positive experiences with CenteringPregnancy and would choose CenteringPregnancy over individual care. The women discussed many positive experiences but ma inly the y expressed their appreciation for the friend ships with other women in the group, the time that was devoted to them for care and the creative ways of learning new information such as the activities and games that were played. The women interviewed were all multigravida and spoke e specially about their ple asure in learning new things and helping to teach the primigravida women. Some of the women expressed that they did not think they were going to learn many new things since they already had children but they were surprised with what they learned in the pro gram. The idea that even multigravida women were learning more and that they enjoyed teaching other women is a positive outcome for CenteringPregnancy. The program engages all women and helps to increase knowledge among both new mothers
162 and mothers who alr eady have children. Overall, t he women were all very appreciative of the care they received and enjoyed the CenteringPregnancy program. There were a few women who expressed some negative experiences but nothing that indicated women did not enjoy the group overall. Lack of privacy at times was a concern for one woman. She spoke about one specific instance where should would have appreciated a matter be taken care of in private for another woman. None of the other women said privacy was a problem and thus more information is needed to determine if privacy was a larger issue. Childcare was a problem that another woman mentioned mainly because of the time that needed to be dedicated to the visit. She en joyed coming to the group but often h ad issues with leaving her other children and would have appreciated childcare at the health department. Although this was only mentioned in one other interview, it was discussed in more details during the preliminary o bservation research. Women with young children in particular had difficulties with obtaining childcare and would benefit from the health department proving a childcare service. Women in individual care are able to bring their children with them because the majority of time spent at the health department is in the waiting room. If childcare was provided at the health department for women in CenteringPregnancy, it may interest more women in attending CenteringPregnancy and may help alleviate barriers to women in CenteringPregnancy to atte nding the group Another woman discussed some discomfort with male partners being in the group. The woman said she especially felt uncomfortable doing exercises in the groups with males. None of the other women mentioned this as a problem. In addition, qualitative
163 data from preliminary observations indicated that many women did not mind male partners and felt more comfortable with them as the group cont inued Additional qualitative research specifically addressing comfort leve ls of women with male partners in the group is needed to better assess this concern. Informational support All of the women indicated they learned more in CenteringPregnancy than in individual care. The women discussed many topics in the group and learned about nutrition, exercise, pain management, labor and birth and care for the baby among others. They especially liked learning about pain management and discussed specific a ctivities such as talking about their own experiences and listening to others, watching videos and going to the hospital to see what the process would be on their delivery day. Even though all of the women who were interviewed had children already, they s aid they still learned things in the group that either they did not know before or had to be reminded of. They appreciated the discussions with other women few education topi cs that CenteringPregnancy provides that were not mentioned during the interviews including, contraception and family planning, depression and family violence. The women may not have discussed these topics because they were not specifically asked about in one of the interview questions. Along with companionship support, aspects of informational support were the most commonly talked about in the interviews. Women felt as though they were receiving more information about their pregnancies and childbirth in Ce nteringPregnancy than what they received in previous prenatal care. In addition, they felt as though the information that was given to them in CenteringPregnancy was better taught in more creative teaching strategies that helped
164 them learn. Since one of th e most important aspects of prenatal care is education, it is positive outcome that women indicated they learned more in CenteringPregnancy and were given more information and taught in innovative learning styles. Emotional support Aspects of emotional s upport were frequently discussed in the interviews. The women talked about how much they appreciated the relationships they had with the doctor, the health educator and the other women in the group. They were able to talk about their emotions, feelings and concerns I n general the women indicated they felt very comfortable in the grou p and had their concerns addressed which made them feel less stressed an d less nervous. These findings were inconsistent with the study by Shakespear et al. (2009) who indicat were lower possibility due to a lack of questions and concerns being addressed. The women in the current study also indicated they felt prepared for their labor and birth and empowered to make their ow n decisions about the process. Being able to share and listen especially in terms of pain management seemed to help put women at ease and made them feel more comfortable about their own upcoming childbirth experie nce. Overall aspects of emotional support that women discussed were that they deve loped better relationships in CenteringPregnancy had more encouragement and enjoyed being in the presence of other women and the health care providers. The emotional support that was provided to the women seemed to be key component in what mediated any stress or concernment that may have affected the Instrumental support The CenteringPregnancy program in its inception is based on provi ding a service to women to give them support during t heir prenatal care. Thus,
165 one of the main objectives of the program is to provide this support for women. The services the doctor and the health educator provided, the additional services at the health d epartment and the tools and activities that were used in the CenteringPregnancy program all served as instrumental support for the women. In particular, women enjoyed the activities and games t hat were played and indicated they were helpful learning tools. One of the main differences they spoke about when comparing CenteringPregnancy to individual care w as that in CenteringPregnancy the information was taught to them in unique ways to help them learn rather than just inform ation in a brochure or other handout Another difference in the service was that women di d not have any wait time with CenteringPregnancy like they did with individual care. Women appreciated that the time they spent at the health department was well used and they were able to participate in the program for the whole duration of their visit. This may also be a key component as to why attendance rates were higher for women in CenteringPregnancy. If they thought the quality of their whole experience at the he alth department was high they may have been more likely to attend. Appraisal support/validation support Feedback and appraisal was something that the women also talked about as a positive aspect of CenteringPregnancy They were able to talk about thing s in the 2 3 hour sessions that they normally may not have time to discuss in an individual appointment. They received feedback not only from the doctor but also from the health educator and other women in the group. In fact, often it was the other women i n the group who provided much of the feedback and encouragement. The women really appreciated that this kind of support came from other pregnant women.
166 Although specific questions were not asked in the interview, empowerment emerged as a subtheme of appra isal support. Many women indicated that they felt more comfortable in th e class, gained more knowledge, were more in control and thus were able to make more decisions about their own pregnancy and childbirth. Women learned to take their own blood pressure chart their weight and estimate their gestational age. A few women also said that felt more in control at the hospital during their birth to tell staff what decisions they made about their birth plan. This may have played a role in the outcomes that women in CenteringPregnancy were less likely to have cesarean sections compared to women in individual prenatal care. Empowerment of women is a goal of CenteringPregnancy and it was clear that the women int erviewed felt empowered through the program. Companionship support Along with informational support, companionship support was one of the most common types of support discussed with the women. All of the women talked about the friendships they made and the appreciation they had for the companionship of other women in the group. According to the women this was an integral part of why they both enjoyed the group and why they had such great support. Some wo men discussed the closeness of the friendships and co ntact they had even after the CenteringPregnancy program was complete. Women also discussed the relationships they developed with the doctor and health educator and voiced that it was unlike the interactions they had with health care providers in past p renatal care or in other types of The women were not used to other women being a part of their car e or having the doctor so much a part of the education and support. This was a different experience for women but also a much appreciated and welcoming aspect of care. The
167 relationships formed were an integral part of women receiving companionship support. As previously discussed, companionship support may have played a role in why women in CenteringPregnancy attended care more often and felt v ery satisfied with their care. Recommendations of CenteringPregnancy All of the women said they would both complete CenteringPregnancy again with future pregnancies and they would recommend CenteringPregnancy to others. A few women said they already have recommended it to others. One woman said that the only issue she would have recommending it to other women who have children is that there is no childcare provided. An inclusion of childcare at the health department for women in CenteringPregnancy wou ld most likely eliminate a major barrier o f choosing CenteringPregnancy for women with children. Summary of perceptions of care. All of the women interviewed spoke very positively about CenteringPregnancy, would participate in the program again and would recommend it to others. They appreciated the information they learned and the educational techniques used to teach the information. They enjoyed making new friends and the relationships they developed and the support they received from other women in the g roup and from the health care providers. Social S upport Theory The women identified aspects of all five types of social support that they received through the CenteringPregnancy program and identified several providers of social support. The support may have been received in several ways. The support may have acted as a mediator to stress by way of helping wo men cope better with stress or through the perceptions of available support which can lead to appraising situations as less stressful ( See Figure 2 2 ) Women stated they felt more comfortable in
168 CenteringPregnancy They felt more at ease because their questions and concerns were always answered. Although t his did not improve birth outcomes it may have contributed to higher utilization of care which can lead to increased utilization of care for future visits to the health care provider Through influencing self esteem, the social cognitive perspective predicts that perceived social support can affect health outcomes, and the symbolic interactionist affects health outcomes ( Cohen, 2000 ) ( See Figure 2 3 ) A theme that emerged from speaking to women ab out their experience s with Cente r i ngPregnancy was empowerment. Women felt more in charge of their health and more in control of their decision making. An increase in self esteem and a greater sense of self thro ugh the support may have health. The women indicated that they felt more comfortable and felt as though they had the knowledge to make decisions and have a healthy pregnancy. number of cesarean sections for women in CenteringPregnancy. Although it is not completely clear as to why the cesarean section rate is low er for women in social support from t he group may have influenced this outcome. The relationship perspective which conceptualizes support as part of a larger interrelated relationship ( Cohen, 2000 ) also playe d a role in how support was delivered through CenteringPregnancy. Healthy relationships with others can provide companionship and intimacy and a low conflict environment. Many women spoke about the friendships they made in the group and the pleasure of spe nding time with oth er
169 pregnant women who understood what they might be going through. In CenteringPregnancy the friendships that were made between the women was one of the most important avenues of social support that may have improved outcomes. Specifi cal ly, prenatal care attendance rates were higher among women in CenteringPregnancy than in individual care. Many women spoke about not wanting to miss class and wanting to spend time with the friends they made in the group. In addition, women had positive re lationships with the health department staff including the health educator and the doctor. The women talked about their appreciation for the staff and close relationships they develop ed The support from the relationships may have contributed to an increas e in prenatal and postpartum care attendance. Women wanted to come back for care so they could socialize and spend time with the people they developed relationships with. Conclusions In general, the women at the health department had good birth outco mes compared to the overall county. Since all of the women were low risk obstetric clients, it was expected that they would have overall good birth outcomes and that differences between the groups would be difficult to find. However, there were differences in utilization of care and in the type of birth In addition, women had very positive perc eptions of their care and were generally more satisfied with CenteringPregnancy than with their past experience with individual prenatal care. For over a century, prenatal care has been evolving and has been recognized as an essential component of health care for pregnant women ( Kiely & Kogan, 1994 ) Several studies have shown positive effects of the utilization of prenatal care on birth outcomes and maternal health ( Kiely & Kogan, 1994 ; Koonin, Atrash, Lawson, & Smith, 1991
170 Greenberg, 1984;) but high racial disparities with adverse infant outcomes are still seen (Rosenthal, 2011; MMWR, 2005 ; Guyer, 1999 ) Preventing adverse outcomes require s a re conceptualization of prenatal care and the role it plays along with health promotion and educa tion throughout the life course ( Lu, et al., 2003 ) Traditional prenatal care focuses on the important task of assessing ri sks for both the mother and baby and providing education to the mother to help her maintain a healthy pregnancy. However, innovative group prenatal care programs such as CenteringPregnancy show that p renatal care can be used for more than just risk asses sment and basic education. CenteringPregnancy provides essential risk assessment but also educates women with interactive approaches to teaching such as with games, activities and group discussion that help women learn more and better understand their health In addition, the program provides a system of social support that encapsulates all types of social support to provide relief of stress, encourage positive relationships and empower women to he lp facilitate healthy pregnancies. This holistic ap proach to prenatal care has shown in this study to increase utilizati on of care, empower women and connect mothers to each to facilitate additional support and resources. This group care approach along wi th preconception and interconception care fits into the life course model of helping women stay healthy throughout their reproductive age. However, i mprovements in preconception care are needed. Several studies (Coonrod, Bruce, Malcolm, Crachman & Frey, 20 09; Delgado, 2008; Frey & Files, 2006) found that women are not receiving messages about preconception care from their obstetrician/gynecologist or primary care providers. Specifically examining knowledge and attitudes of preconception care of Mexican Ame rican women Coonrod (2009) also found that although most women did not receive
171 messages, they were interested in preconception education and agreed that preconception health leads to improves pregnancy health (Coonrod, Bruce, Malcolm, Crachman & Frey, 2009 ). Thus, a greater effort to incorporate preconception care along with CenteirngPregnancy among Latina women to help improve outcomes may be an appropriate should be made Study s trengths There are several strengths to this research. First, compared to other studies assessing CenteringPregnancy, the sample size is larger and includes both an intervention and comparison group from the same clinic over the same time frame. Second, there are s everal outcomes studied in this research including both birth outcomes and maternal factors that are not often a ssessed in a single population. It is important to examine a variety of the possible outcomes of the program including maternal weight gain whic h is not often studied with CenteringPregnancy participants. Third this study employed both quantitative and qualitative methods to fully understan d differences in prenatal care. This helped to answer all of the research questions and helped triangulate d ata to better understand outcomes. Fifth, this study included a population of Latina Spanish speaking women which addresses a gap in the current literature on CenteringPregnancy outcomes. To date, only one other study has been published on Latina women in the program, yet many Spanish speaking groups are being implemented Study l imitations There are several limitations to this study. First, since this was a retrospective study, women were not randomized to the intervention or comparison group. At their time of their first initial appointment at the clinic both types of care were explained to all of the women and they were able to choose their type of care. The
172 reasons women chose CenteringPregnancy or individual care were not accounted for but may have contributed to differences in outcomes There are several reasons why women may not have chosen CenteringPregnancy. On paper, the program had a longer time commitment since the CenteringPregnancy appointments were 2.5 hours Although with wait times, indiv idual appointments sometimes last just as long. However, this was not accounted for in the appointment time. CenteringPregnancy did not provide child care (although some women did bring their children) which may have also deterred some women from choosing the program. In addition, some women who already had children may have felt as though they did not need to attend a program for their prenatal care since they have already gone through the process before Nonetheless, the population from which the sample of women from both groups was drawn was the same and with the exception of age and parity there were no major demographic differences between the groups and most of the variables that may have contributed to differences were controlled for in the analysis model. Second, the study was done on a single population of women at a health department clinic and thus the study findings can only speak to this population of women in Pinellas County, FL. The women were main ly of Mexican descent and most were born in M exico The research findings are distinct to this particular population of women. This is a limitation in that the findings are not generalizable to a larger population but the strength is that these findings fill in a gap in the literature about this spec ific population. Third, the women in prenatal care at the health department were all low risk obstetric patients, and thus were less likely to have adverse birth outcomes. If a woman became high risk at some point in her pregnancy, she was transferred to a high risk clinic.
173 These women were not included in the study since they did not complete their prenatal care at the clinic. Thus, the findings are limited to low risk obstetric patients Fo u rth in the qualitative phase, women were asked to compare the ir experiences with past individual prenatal care. This required women to think back to their last pregnancy and thus there may have been some recall bias In addition, the only requirement on where the individual care occurred was that it was in the U.S. and thus there may have been large variation in the comparison of the care. However, t his was only a small portion of the overall study and the comparison of care was only one section of the complete interview. Future r esearch CenteringPregnancy and group prenatal care is becomin g a more popular way to deliver prenatal care especially at public health clinics. Future studies particularly randomized controlled trials with large sample sizes are needed to assess pregnancy outcomes of women in Ce nteringPregnancy to determine the effectiveness of care M ore qualitative research is needed to assess and health as well as to provide evidence to support quantitative research findings S pecific issues such as maternal weight gain, prenatal and postpartum depression, violence during pregnancy, gestational diabetes, gestational hypertension and stress during pregnancy is all lacking and should be addressed to determine if these outcomes are influenced by Centeri ngPregnancy A cost analysis comparing the overall cost to the health department for CenteringPregnancy and individual care should be computed. This will provide evidence to show whether or not the program is cost effective even if pregnancy outcomes are not different b etween the groups. Ickovic et al. ( 2007 ) was the only study on
174 CenteringPregnancy that reported costs associated with care. The authors determined that there was no significant difference in cost associated with prenatal care or birth and conclude d that CenteringPregnancy was an efficient program. In the current research, some outcomes need to be further examined. First, a difference between the groups was found in the method of birth indicating fewer women in CenteringPregnancy had cesarean sect ions, controlling for age, educational attainment, parity, status in country, pre pregnancy BMI, employment status and birth hospital. Further information about the birth is needed to un derstand this outcome including which interventions were done if any, and more complete data on the reason for the cesarean section Some research indicates that the use of medication to artificially induce or augment a labor can lead to cesarean sections ( Wilson, Effken, & Butler, 20 09 ) and thus this information is important to assess. In addition some research has indicated that ( Scott, Hankins, Strickland, & Gilstrap, 1989 ) height and type of birth may also help explain d ifferences in type of birth. Second an ou tcome that was not expected was that women in CenteringPregnancy were more likely to formula only feed their infants compared to women in individual prenatal care. Further qualitative research is needed to understand this outcome better and determine why women would be more likely to formula only feed The qualitative analysis may include interviews and focus groups with women who completed CenteringPregnancy and with health care providers. In addition, an assessment of the utilization and extent of use of WIC f or women in each group may help indicate
175 whether support through WIC had an effect of infant feeding method. All women at the health department were referred to WIC but the extent of use is not currently known. Third, th e findings indicated that there was no relationship between the type of prenatal care and preterm birth or low birthweight. However, f urther research should also explore additional birth outcomes such as the combined variable preterm low birthweight, small for gestational age infants, and l arge for gestational age infants. These outcomes are all important to assess in determining the health of the infant in addition to the ones assessed in this research. Another area to investigate is assessing consumption of food and health behaviors before during and after pregnancy for women who completed CenteringPregnancy and women who completed individual care. This assessment would help in understanding differences in food consumption that may contribute to differences in weight gain and perhaps refle ct the education women received in either type of care. Implications for Practice This research has implications for practice in that it adds to the evidence of research on CenteringPregnancy programs. The research findings help with the evaluation of the CenteringPregnancy program at the Pinellas County Health Department and provide evidence of outcomes to show positive effects as well as areas to improve. The findings also provide evidence for other public health clinics as they decide to develop Cent eringPregnancy programs or maintain current programs Although this investigation showed t he CenteringPregnancy program was not associated with any improve d birth outcomes it was associated with higher utilization of care in terms of attendance in prena tal care and postpartum care and with less cesarean section deliveries In addition, women had better experiences and had more social support
176 in CenteringPregnancy compared to their past experience with individual care. These are very important outcome s especially for immigrant non English speaking Latina women who in general have low access to health care and low social networks However, based on this research, two areas that may need more attention are promoting healthy weight gain and breastfeeding Partnering with The Healthy Start Coalition and WIC to further promote healthy eating/exercise and exclusive breastfeeding may be a way to improve weight gain and infant feeding outcomes. Proving additional counseling in Spanish on breastfeeding along wi th ways to overcome barriers of breastfeeding and pumping milk (financial, environmental, time) may be beneficial. Recommendations Qualitative findings indicated that many women became friends in the CenteringPregnancy group and stayed friends beyond the program. The lasting friendships and support that existed beyond the program may have implications for future programming for parenting support. Programs such as CenteringParenting which is also part of the Centering Health Care Institute may benefi t women who want to continue being part of a system of support in their health care center This can be especially beneficial for a population similar to the one in this study who are not native to the county and may have lim ited social networks, problems with communication and navigating the health care system and have a limited ability to speak English Nutrition and exercise was an integral part of the CenteringPregnancy program at the health department, and women discussed the various topics they were t aught and indicated that some behavior changes wer e made. However, there were a high proportion of women gaining above the recommended amount of gestational weight. Trying to encourage women to gain a healthy weight during pregnancy and eat well and exerci se is
1 77 an important part of prenatal care. However, it may be more beneficial to couple this with preconception care and interconception care pr ogramming to help women obtain and maintain a healthy weight and develop good eating habits and exercise behavior s. These suggestions align with the Healthy People 2020 goals for maternal and child health ( "Healthy People 2020: Maternal, Infant and Child Health," 2011 ) Culturally and linguistically appropriate programming that promotes healthy lifestyles to encourage healthy pregnancies before and in between pregnancy is needed. A negative finding was that women in CenteringPregnancy were more likely to formula only feed their infants than women in individual care. There was no significant difference in women who exclusively breastfed t heir infants or in women who supplemented breastfeeding with formula but this outcomes is still troubling. A recommendation to the health department based on this research finding is to first further assess this finding and then reevaluate how infant feedi ng is discussed in the CenteringPregnancy group to encourage exclusive breastfeeding. Based on this research, there are two recommendations for the Centering Health Care Institute as they reevaluate their program and plan the future of CenteringPregnancy. The first is to link theory to practice. In the current investigation, the Social Supp perceptions of care. CenteringPregnancy uses the Social Support Theory, along with feminism theories as a framework to their model (Rising, 1998). However, it may be beneficial to further dissect the CenteringPregnancy model as a whole to show how the key components align with theoretical frameworks such as the Social Support Theory In this research, it was clear that the CenteringPregnancy program provided the five types of
178 s ocial support as are noted in the results chapter A model was also developed to illustrate how the support is provid ed and received in the program. P erhaps an important step for the Centering Health Care Institute is to use more theory based research to strengthen research f indings and link theory to practice. Another possible step for the Centering Health Care Institute is to begin to increase the use of technology in the CenteringPregnancy program. The internet and S martphones with text message s, video messaging, and phone application are used often in the U.S. and proving to be powerful tools in promoting health even among low income populations ( Santosh, Boren, Balas, 2009; Patrick, William, Griswold, Raab, Intille, 2008; Buhi, Oberne, Trudnak, Martina sek, Furhman and McD ermott, ND). I t may be a time for the C enteringPregnancy model to move in the direction of including some of these technologies into their program. An example is developing a CenteringPregnancy phone application or internet site for women to utilize and keep track of their blood pressure, weight, gestational age etc. and send questions and comments to other women in their group. This type of communication is currently done during the group session but using technology can allow the w omen to access the information and talk to each other at any time. Since teenagers and young adults are more likely to have and use such technologies (Lenhart Purcell, Smith & Zickuhr, 2010) a pilot intervention with adolescent CenteringPregnancy groups m ay be beneficial to see if/ how the use of technology increase s support. Depending on the age, income status and geographic location of women, there will be variation in who has access to cell phones and the internet and thus this will need to be taken into consideration when implementing an
179 intervention. Some health related programs provide phones to participants for the duration of an intervention (Patick et al., 2008). Take home message Although there were no differences in infant birthweight or gestational age at delivery, women in CenteringPregnancy were more likely to receive adequate prenatal care, more likely to attend their postpartum visit less likely to have cesarean deliveries less likely to gain below the recommended amount of weight and more likely to use for mula only to feed their infants compared to wo men in individual prenatal care Qualitative findings indicated that women who completed CenteringPregnancy were more satisfi ed with their care, received more education and support, felt more comfortable with their care, felt more prepared for labor and birth and felt more empowered to make decisions about t heir pregnancy and childbirth. These outcomes are especially important for the women in this study population who are all low income, Spanish speaking, non U.S. born and often have low social networks. Among this population of women, CenteringPregnancy at the Pinellas County Health Department increased health care utilization and informed and empowered women through social support.
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193 APPENDIX A: COMPONEN TS OF ROUTINE PRENAT AL CARE BASED ON THE AC OG PRENATAL CARE GUIDELINES CenteringPregnancy Session Individual Care ( Gestational Age ) Assessments Routine Laboratory/Diagnostic procedures Routine Prenatal Education Initial visit Up to 12 Weeks Screen for Preterm labor (PTL) risk factors transmitted disease gain goals for pregnancy mellitus (GDM) risk factors and screen if high risk for dental care if needed HCT/HGB ype sc reen based on family history Premature labor signs and symptoms BMI diseases Sessions 1 3 12 28 Weeks PTL multiple gestations dates screen for substance abuse alphafetoprotein glucose un sensitized Rh neg itive (28 wks) diabetes identifying and managing signs and symptoms e counsel, provide interventions and/or referrals for tobacco, alcohol or illicit drug use
194 Sessions 4 6 (nutrition is covered in session 1) 28 36 Weeks controlled GDM and inadequate fetal growth treat if indicated for reproductive tract infections (pregnancy induced hypertension) of Rho (D) immunoglobulin (28 wks) gluc ose at each visit Nutrition W eight gain assessments as a means of antepartum fetal surveillance elective deliveries before 39 weeks gestation Session 10 (Education on labor and readiness for baby discussed in sessions 6 10) After 36 Weeks Continued risk assessment Urinalysis for albumin an d glucose at each visit Review onset of labor, bleeding, membrane rupture analgesic/anesthetic options choice not be performed before 39 weeks gestation to minimize prematurity related prenatal C omplications Individual visit After 41 Weeks assessment testing, evaluation of amniotic fluid volume, biophysical profile ( BPP ) Fetal movement counts reviewed
195 APPENDIX B : PRENATAL HIGH RISK PATIENT CRITERIA BAYFRONT MEDICAL CENTER REGIONAL PERINATAL INTENSIVE CARE CENTER PRENATAL CRITERIA HIGH RISK Two (2) previous losses 2 D+C OR 2 EAB with D+E Chronic hypertension Mean arterial pressure > 95 second trimester or > 105 for third trimester or requiring medication Premature rupture of membranes Preterm labor or delivery < 34 weeks Multiple gestation Transplants Abnormal amniotic fluid AFP Cardiac disease including rhythm abnormalities Class 1, 2, 3, 4 Mitral stenosis, mitral insufficiency, aortic stenosis, aortic insufficiency, pulmonary hypertension All insulin dependent diabetics Gestational diabetes Screen with hour glucose test If greater than 135 do 3 GTT If value is 182 no 3 GTT, treat as gestational diabetes Values of 3 GTT If 2 abnormal values hi risk FBS less than 105 (if FBS greater than 105 repeat fastin g, if still high consider diabetic) 1 less than 190 2 less than 165 3 less than 145 Placenta previa > 24 weeks or complete previa Isoimmunization Severe pre eclampsia, mild pregnancy induced hypertension Hemoglobinopathies Sickle cell disease Recur rent intrauterine growth retardation by history Malignancy Autoimmune disease Thromboembolic disease previous or current Full anticoagulation or prophylactic use of heparin Incompetent cervix, history of cervical conization, > Two elective abortions with D+E (not methotrexate) Proven DES exposure Previous cerebral vascular accident Thyrotoxicosis, hypothyroidism, hyperthyroidism Asthma with history of intubation Cystic fibrosis disease
196 Mother with neurologic pathology Gastro i ntestinal bypass surgery Aplastic anemia Myasthenia gravis Guillain Barre Antiphospholipid syndrome Previous placental abruption Chronic renal disease Proteinuria > 0.5 gm/2r hours Di alysis Anuria Renal calculi HIV Psychiatric diagnosis requiring medication Depression, severe requiring medication Genetic evaluation Abnormal ultrasounds, oligohydramnios, polyhydramnios Fetal anomaly, molar pregnancy partial or total Intrauterine growth retardation (IUGR) < 10% Abnormal Quad Screen Ultrasound abnormality Amniocentesis, CVS, PUBS Cytogenetics Polyhydramnios >20 AFI Oligohydramnios < 5 AFI Fetal anomalies Fibroid uterus Advanced maternal age Substance abuse or daily use of controlled drugs Methadone use INTRAPARTUM CRITERIA HIGH RISK TRANSPORTS Pre term labor <34 weeks Placenta previa (persistent of bleeding) Abruption Fetal scalp sampling Malpresentation Severe pre eclampsia/eclampsia Disseminated intravascular coagulati on clinical, lab Oligohydramnios Fetal anomalies Hemoglobinopathies
197 Chorioamnionitis and/or fever of undetermined origin Shock Multiple gestation Cesarean section Anticoagulation Pulmonary edema and /or embolism Active varicella or V. pneumonia Maternal cardiac disease Maternal trauma Unexplained jaundice Hemophilia POSTPARTUM HIGH RISK CRITERIA ICU care required Pulmonary embolism Aspiration pneumonia Postapartum hemorrhage with transfusion and/or s hock Eclampsia Severe pre eclampsia
198 APPENDIX C : PINELLAS COUNTY HE ALTH DEPARTMENT PREN ATAL CARE PROTOCOLS Initial Prenatal Visit I. TITLE : Protocol for the management of the initial prenatal visit for pregnant clients II. TYPE OF STANDARD : Service III. OUTCOME : Improve pregnancy outcome resulting in a full term, healthy infant, and a healthy mother IV. PERSONNEL : M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., L.P.N., R.D., L.D., and Aides/Techs, Health Educator within the constrai nts of their individual practice acts and protocols A. Subjective and objective data gathering: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., R.D., L.D., L.P.N., Aide/Tech. B. Assess and evaluate: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., R.D., L.D. C. Plan ning/ Education/ Counseling: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., L.P.N., R.D., L.D, Health Educator D. Intervention: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., L.P.N., R.D., L.D. E. Evaluation: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., R.D., L.D. F Emergency: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N. G. Documentation: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., L.P.N., R.D., L.D. Aide/Tech, Health Educator V. COMPETENCIES: Health care providers must demonstrate knowledge of the responsibilities rela ted to pregnancy according to the constraints of their individual practice acts and protocols. Professional personnel records should document training as appropriate for their individual practice acts. This should include didactic, practicum, and clinical training that covers pharmacology, clinical studies, patient selection, counseling, client management, complications, and side effects. The practitioner may practice independently in each skill area once proficiency is obtained in that skill area. VI. ARE AS OF RESPONSIBILITY: For County Health Departments Who Provide The Initial Prenatal Visit Only And Refer Client To Another Provider For Ongoing Prenatal Care: The following components must be completed in order to classify this visit as an initial prenat al visit: A. History B. Explanation of Healthy Start screening. C. Weight, blood pressure and fetal heart tones. D. Education appropriate for gestational age. E. Blood tests appropriate for gestational age and TB testing, if indicated. F. Provide HIV pretest counseling and offer HIV testing. G. Referral to WIC. FOR COUNTY HEALTH DEPARTMENTS WHO PROVIDE THE INITIAL PRENATAL VISIT AND ONGOING PRENATAL CARE: TA MATERNAL 2 p.1 TECHNICAL ASSISTANCE: MATERNAL 2 July 1, 2003
199 VII. AREAS OF RESPONSIBILITY: For County Health Departments Who Provide The Initial Prenatal Visit And Ongoing Prenatal Care: A. Assessment 1. The subjective factors are: a. Obtain a medical and obstetrical history. This history should include, at a minimum the information on the Prenatal Record Form, DH 3142, pages 1 2. b. Healthy Start Prenatal Risk Screening (1) Complete the Healthy Start Screening Form, DH 3134. (2) Assess the screening score or documentation of refusal. (3) Assess the client's n eed for follow up according to the Healthy Start Standards and Guidelines. c. Complete a nutritional assessment. d. Assess the client's risk for underlying tuberculosis infection. Risk factors: (1) Client has recent contact to persons with infectious TB disease. (2) HIV positive individual or those at high risk for HIV infection (IV drug user or high risk sexual behavior). (3) Organ transplant recipient and other immunosuppressed person (e.g., receiving > or = 15 mg/d of prednisone for a month or longer. (4) Recent immigrant (within the last 5 years) from a high TB prevalence country, (e.g., Asia, Africa, Latin America, Eastern Europe, Russia). (5) Client with one or more of the following clin ical conditions: (a) Silicosis (b) Diabetes mellitus
200 (c) Chronic renal failure (6) Client with some hematological disorders, (e.g., leukemia and lymphomas). (7) Client with other specific malignancies (e.g., carcinoma of the head, neck or lung). (8) Client with weight loss of equal or greater than 10% of ideal body weight. (9) Client with gastrectomy or jejunoileal bypass. (10) Residents or employees of high risk congregate settings (e.g., nursing homes, jails, hospitals). (11) Fibrotic changes on chest x ray consistent with prior TB disease. e. Assess for high risk factors for gestational diabetes. Risk factors: (1) Overweight > or =120% overweight or BMI > or = 26 (2) Personal history of gestational diabetes (3) Previous adverse pregnancy ou tcome (4) Strong family history of diabetes (5) Glycosuria f. Assess for history of a previous infant with invasive Group B streptococcus (GBS) disease. A positive finding must be clearly documented in the ing to the standards of care for prevention of perinatal GBS is provided to the client. g. Assess for substance abuse. Risk Factors: (1) Drank alcohol in past and smoked more than three cigarettes in the month before pregnancy. OR (2) Drank alcohol in the month before pregnancy. h. Assess for signs of depression. The following two brief
201 screening questions have been found to be highly predictive of depression. The screening test is considered positive if one or both depression sym ptoms are present. i. Assess for signs of domest ic violence: female clients the following client screening questions: (1) Are you in a relationship in which you are being hurt or threatened? (2) Do you feel unsafe in your home? If t he client answers yes to either question, assess client further to fully evaluate abuse and clients safety. Refer to TA General 15, Domestic Violence Screening, Identification and Referral. 2. The objective factors are: Complete a physical assessment. Th is assessment should include, at a minimum, the information on the Prena tal Record Form, DH 3142, pages 3 4. B. Planning/Education/Counseling 1. Develop all education and counseling to be culturally, educationally, and linguistically appropriate, client centered, and non judgmental. 2. Provide education and counseling on pregnancy and childbirth at the appropriate gestational period. This info rmation should include, at a minimum, the information on the Prenatal Record Form DH 3142, page 5. 3. Provide HIV pre test counseling to all prenatal clients. This counseling is outlined in TA HIV/AIDS 9: Provision of HIV Counseling and Testing Services. 4. Educate and counsel the client on identified high risk medical conditions.
202 5. Educate and counsel the client on good oral hygiene. 6. Educate and counsel the client on all diagnostic tests and procedures. 7. Educate and counsel on signs and sy mptoms that require urgent medical follow up. C. Intervention 1. Develop and implement an individualized plan of treatment for the client to include, but not be limited to; services, treatment, additional diagnostic testing and/or procedures and referra ls appropriate for gestation. Additionally, the treatment plan is to include special client needs such as substance abuse, tobacco use, oral hygiene/dental care, domestic violence and depression. 2. Develop and implement an individualized and appropriate plan of treatment for the high risk client, as determined in your assessment, which should include, but not be limited to; extra services and testing, home visits, more frequent prenatal visits, and/or referral to a Regional Perinatal Intensive Care Cente r (RPICC) or other high risk providers. 3. Healthy Start a. Inform and explain to the client her Healthy Start screening score. b. Place a copy of the Healthy Start Prenatal Risk Screening Form in the client's medical record and give a copy to the client. 4. Provide client a written referral to WIC for nutritional services. 5. Provide or arrange for vitamins and iron an d folic acid supplementation as medically indicated. If folic acid is not inclu ded in the vitamins, provide or arrange for folic acid supplementation. 6. For the client who has had an infant with a neural tube defect, provide or arrange for appropriate folic acid supplementation. Refer to I nternal Operating Policy, Maternal 1, Folic Acid Supplementati on for At Risk Women to Prevent Neural Tube Defects. 7. Glucose Tolerance Testing a. Clients determined at minimal risk of having gestational diabetes do not requi re glucose testing at the initial prenatal visit. This minimal risk category only applies to those clients who meet all of the following characteristics :
203 (1) Age < 25 years (2) Weight normal before pregnancy (3) Member of ethnic group (generally white non Hispanic) with a low prevalence of gestational diabetes (4) No known diabetes in first degree relative (5) No history of abnormal glucose tolerance, and (6) No history of poor obstetrical outcome b. Test any client for glucose tolerance IF client is at 24 28 weeks or greater gestation at the initial prenatal visit. c. Test any client for glucose tolerance at this initial visit IF client is HIGH RISK for gestational diabetes AND less than 24 weeks gestati on. If negative results, retest between 24 28 weeks gestation. This high risk category applies to those women that meet any one of the following criteria : (1) Overweight. > or = 120% overweight or BMI > or = 26 (2) Personal history of gestational diabet es (3) Previous adverse pregnancy outcome (4) Strong family history of diabetes (5) Glycosuria d. Refer to TA Guideline Chronic 9: Gestational Diabetes Mellitus. 8. At the initial visit, each client should receive the following laboratory tests: a. Blood group, Rh type determination and antibody screen. b. Hemoglobin/hematocrit. c. Rubella antibody titer measurement if there is no documentation of immunity by previous screening or vaccination. d. Syphilis (RPR, both quantitative and qualitative).
204 e. Hepatitis B surface antigen (HBsAg). f. Encourage and offer HIV testing. Complete DH3161, Statement of Objection to HIV testing, if client refuses HIV testing. g. Administer Mantoux Tuberculin Skin Test (TST) to clients at risk for underlying tuberculosis infection listed under Assessment 1 d. h. Urinalysis with microscopic exam for bacteriuria. i. Culture and sensitivity (C&S), if indicated. Urine specimens from prenatal clients s pregnancy status. Document any findings of group B streptococcus standards of care for prevention of perinatal GBS is provided to the client. j. Pap smear. k. Sensitive test for Neisseria gonorrhea (GC), e.g., amplified test technology. l. Sensitive test for Chlamydia trachomatis, e.g., amplified test technology. m. Wet mount and KOH or other test with improved sensitivity and specificity a s indicated to differentiate vaginal infections, including bacterial vaginosis. n. Screening for abnormal hemoglobin (Sickle cell) using Hemoglobin Electrophoresis for client of African, Southeast Asian, or Mediterranean descent, unless the record contain s documentation of previous testing. o. Tay Sachs for client of Jewish descent. p. Offer Multiple Marker Screening testing if client is between 15 20 weeks gestation on initial prenatal visit. q. Urine dipstick for glucose, protein, ketones, leukocyte e sterase and nitrites r. If at this initial visit the client is at 35 streptococcus (GBS) current recommendations include vaginal and rectal GBS screening cultures at 35 pregnant women. If the patien t has a history of positive GBS in this pregnancy (i.e. GBS bacteruria)
205 or a previous infant with invasive GBS disease, screening cultures at 35 not necessary. In these cases, clearly mark the chart for GBS prophylaxis in labor. 9. Provide additional diagnostic testing as indicated. 10. Refer clients for genetic counseling if indicated. 11. If ALL these factors are present with client, give antenatal Rho (D) immune globulin. a. RH negative blood type b. Rh titers are negative c. The initial visit is at 28 weeks gestation with negative antibody screen 12. Provide intervention and referrals as indicated for substance and tobacco use and abuse. 13. Refer to mental health professional for psychosocial assessment if screening test is positive for depression or other mental health need. immediate safety is at risk. If client is unwilling, strongly encourage client to talk to an advocate in person or by telephone during the visit if this can be accomplished without jeopardizing safety. 15. Schedule follow up visits based on individual needs, risk factors and weeks gestation. A client with an uncomplicated pregnancy should generally be seen every f our weeks for the first 28 weeks of pregnancy, every two to three weeks until 36 weeks of gestation, and weekly thereafter. 16. TB: a. Interpretation of a positive Tuberculin Skin Test (TST). Refer to TA TB 5: Tuberculin Skin Testing (TST), pages 5 7. b. For treatment of a positive TST refer to TA TB 3: Targeted Testing and Treatment of Latent TB Infection (LTBI) c. Refer client to TB clinic for follow up 17. Provide a written referral to a dentist for cleaning, oral hygiene instruction, early chil dhood caries prevention education, and possible
206 treatment of disease during the second trimester. Assist in locating affordable dental care, as needed. 18. Follow up or facilitate follow up with client who does not keep her appointment. D. Evaluation 1. Evaluate and assure that the client assessment, education and counseling, interventions and plan of treatment have been completed. 2. Schedule follow up visits based on individual needs, risk factors and weeks gestation. E Emergency 1. Call 911 for life threatening situation. 2. In all cases, contact M.D. or D.O. and follow orders. F. Documentation 1. Document all client information on Prenatal Record 3142, page 1 5. If a similar DOH approved form is used, the information must include, at a min imum, the information identified on this form. 2. Document client needs on the Problem List, DH 3115. Documentation should include, but be not limited to these categories; physical, psychosocial, and environmental. 3. Document NO SHOW and follow up for client who has not kept her appointment. 4. Document and plot weight on Prenatal Weight Gain Grid, DH 3086D. 5. Document the client's risk for underlying tuberculosis infection. 6. DOH Approved Forms: a. Prenatal Record, DH 3142, pages 1 5 b. Florida's Healthy Start Prenatal Screening Instrument, DH 3134 c. Tell Us About Yourself, DH 3131 d. Adult and Adolescent Nutrition Assessment, DH 3086E e. Prenatal Weight Gain Grid, DH 3086D
207 f. Statement of Objection to HIV Testing, DH 3161 g. Problem List, DH 3115 h. Medication Profile, DH 3116 i. Progress Notes, DH 3056 j. Referral Form, DH 5065 k. Domestic Violence Documentation Form, DH 3202 l. Other DOH approved forms as indicated VIII. SUPPORTIVE DATA: A. 2001 Compendium of Selected Publications, American College of Obstetrics and Gynecology ACOG) B. Physician Coverage and Limitations Handbook, Florida Agency for Health Care Administration (AHCA). C. Understanding the Health Culture of Recent Immigrant s to the United States: A Cross Cultural Maternal Health Information Catalog. American Public Health Association publication, 11/2000. D. Best Practice Guidelines from specific program areas in DOH. E. Florida Statute 384.31. F. Revised CDC Guidelines (MMWR), Prevention of Perinatal Group B Streptococcal Disease, 08/16/02.
208 Subsequent Prenatal Visits I. TITLE : Protocol for the management of the subsequent prenatal visits for pregnant clients II. TYPE OF STANDARD : Service III. OUTCOME : Improve pregnancy outcome resulting in a full term, healthy, infant and a healthy mother IV. PERSONNEL : M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., L.P.N., R.D., L.D., and Aides/Techs, Health Educator within the constraints of their individual pra ctice acts and protocols A. Subjective and objective data gathering: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., R.D., L.D., L.P.N., Aide/Tech. B. Assess and evaluate: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., R.D., L.D. C. Planning/ Education/ Counseling : M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., L.P.N., R.D., L.D, Health Educator D. Intervention: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., L.P.N., R.D., L.D. E. Evaluation: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., R.D., L.D. F. Emergency: M.D., D.O., C. N.M., A.R.N.P., P.A., R.N. G. Documentation: M.D., D.O., C.N.M., A.R.N.P., P.A., R.N., L.P.N., R.D., L.D. Aide/Tech, Health Educator V. COMPETENCIES: Health care providers must demonstrate knowledge of the responsibilities related to pregnancy accordin g to the constraints of their individual practice acts and protocols. Professional personnel records should document training as appropriate for their individual practice acts. This should include didactic, practicum, and clinical training that covers phar macology, clinical studies, patient selection, counseling, client management, complications, and side effects. The practitioner may practice independently in each skill area once proficiency is obtained in that skill area. VI. AREAS OF RESPONSIBILITY: A. Schedule client follow up visits based on individual needs, risk factors and week of gestation. A client with an uncomplicated pregnancy should generally be seen every four weeks for the first 28 weeks of pregnancy, every two to three weeks until 36 wee ks of gestation, and weekly thereafter. B. Schedule client follow up visits for a high risk client as indicated to meet individual health care needs.
209 C Assessment 1. The subjective factors are: b. Assess client for any changes in the nutritional assessment, including WIC status. c. Assess client for any changes in risk factors for underlying tuberculosis infection. Refer to TA TB 5: T uberculin Skin Testing (TST), page 5. d. Assess client for any changes in risk factors for Gestational Diabetes. Refer to listing of risk factors in TA: Maternal: Guidelines 2: Initial Prenatal Visit, page 3 4. e. Assess client for previous history of birth of infant with invasive GBS disease. f. Assess status of alcohol, tobacco, and other drug use. g. Assess for signs of depression. The following two brief screening questions have been found to be highly predictive of depression. The screening test is considered positive if one or both depression symptoms are present. e you often been bothered h. Assess for signs of domestic violence by asking the following client screenin g questions only when complete privacy of the patient is assured. female clients the following client screening questions: (1) Are you in a relationship in which you are being hurt or th reatened? (2) Do you feel unsafe in your home? If the client answers yes to either question, assess client further to fully evaluate abuse and clients safety. Refer to TA
210 General 15, Domestic Violence Screening, Identification and Referral. i. Assess c lient for any changes in risk factors for exposure to STDs. 2. The objective factors are: a. Update prenatal assessment. This assessment should include, at a minimum, the information on the Prenatal Record Form, DH 3142 page 4. b. Review laboratory and diagnostic test results. D Planning/Education/Counseling 1. Develop all education and counseling to be culturally, educationally, and linguistically appropriate. 2. Provide education and counseling on pregnancy and childbirth at the appropriate gestational period. This information should include, at a minimum, the information on the Prenatal Record Form, DH 3142, page 5. 3. Provide HIV post test counseling to all prenatal clients that received HIV testing. This counseling is outlined in TA HIV/AIDS 9: Provision of HIV Counseling and Testing Services. 4. Educate and counsel the client on identified high risk medical conditions. 5. Educate and counsel the client on good oral hygiene. 6. Educate and counsel the client on a ll diagnostic tests and procedures. 7. Educate and counsel the client on signs and symptoms of conditions that require urgent follow up, e.g., preterm labor, decreased fetal movement, etc. E. Intervention 1. Update and implement an individualized plan of treatment for the client to include, but not be limited to; services, treatment, additional diagnostic testing and/or procedures, and referrals appropriate for gestation. Additionally, the treatment plan is to include special client needs such as subst ance abuse, tobacco use, oral hygiene/dental care, domestic violence, and depression. 2. Update and implement an individualized and appropriate plan of
211 treatment for high risk clients which should include, but not be limited to; extra services and testing, home visits, more frequent prenatal visits, and/or referral to a Regional Perinatal Intensive Care Center (RPICC) or other high risk providers. 3. Re fer client to Healthy Start as indicated. 4. Follow up on WIC referral. 5. Address nutritional needs as indicated. 6. Glucose Tolerance Testing a. Test all prenatal clients at 24 28 weeks gestation unless previously tested positive for gestational d iabetes at initial visit. b. Retest prenatal clients at high risk for gestational diabetes at 24 28 weeks gestation if initial testing was negative. c. Refer to TA Guideline Chronic 9 Gestational Diabetes Mellitus. 7. Each client should receive the following laboratory tests. a. Routine : (1) Urine dipstick for glucose, protein, ketones, leukocyte esterase, and nitrites at each visit. (2) Hemoglobin/Hematocrit at 32 36 weeks (3) Syphilis (RPR, both quantitative an d qualitative) at 28 32 weeks. Clients who have a reactive (positive) RPR must receive a treponemal test such as EIA IGG or MHA TP. Clients with a positive test should be tested monthly. (4) Repeat Hepatitis B Surface Antigen (HbsAg) at 28 32 weeks for pa tients who initially tested negative at the first visit but are considered high risk for Hepatitis B. (5) If previous HIV test during this pregnancy was negative, another HIV test should be encouraged and offered at 28 32 weeks. (6) Sensitive test for Ne isseria gonorrhea (GC), e.g., amplified test technology at 28 32 weeks. (7) Sensitive test for Chlamydia trachomatis, e.g., amplified test technology at 28 32 weeks.
212 (8) Wet mount and KOH or other test with improved sensitivity and specificity as indic ated to differentiate vaginal infections, including bacterial vaginosis at 26 32 weeks. (9) Group Beta Strep (GBS): Current recommendations include vaginal and rectal GBS screening cultures at 35 pregnant women. If the patient has a history of positive GBS in this pregnancy (i.e. GBS bacteruria) or a previous infant with invasive GBS disease, screening cultures at 35 not necessary. In these cases, clearly mark the chart for GBS prophylaxis in labor. Colle recommended to improve the sensitivity and specificity of detection of women who remain colonized at delivery. Cultures before 35 weeks gestation may have a less predictive value for carrier status at delivery. Swabbing both lower vagina (not cervix) and rectum (i.e. through the anal sphincter) increases the yield substantially as compared with sampling the cervix or sampling the vagina without also swabbing the rectum. Because the lower vaginal area a s opposed to cervical cultures are recommended, cultures should not be collected by speculum examination. b. As indicated : (1) Hemoglobin/Hematocrit at 24 28 weeks (2) Genetic Studies (a) Chorionic Villus Sampling (CVS) at 10 13 weeks (b) Amniocentesi s at 15 20 weeks (3) Offer Multiple Marker Screening testing if client is between 15 20 weeks gestation on initial prenatal visit. (4) Rh Factor (a) Antibody screen and titers at 28 weeks if client is Rh negative. (b) Antibody screen and titers at 36 weeks if client is Rh negative and did not receive Rhogam at 28 weeks.
213 (5) Ultrasound (6) UA for C&S if client has history or symptoms of UTI. (7) Wet mount and KOH or other test with improved sensitivity and specif icity, as indicated to differentiate vaginal infections, including bacterial vaginosis. 8. Provide additional diagnostic testing as indicated. 9. Refer clients for genetic counseling if indicated. 10. For Rh negative clients, if Rh titers remain negativ e at 28 weeks gestation, give antenatal Rho (D) immune globulin. 11. Provide intervention and referrals as indicated for substance and tobacco use and abuse. 12. Refer to mental health professional for psychosocial assessment if screening test is positi ve for depression or other mental health concerns. 13. Domestic Violence: Refer to Domestic Violence shelter or 800# if encourage client to talk to an advocate in person or by telephon e during the visit if this can be accomplished without jeopardizing safety. 14. TB a. Interpretation of a positive Tuber culin Skin Test (TST). Refer to TA TB 5: Tuberculin Skin Testing (TST), pages 5 7. b. For treatment of a positive TST refer to TA TB 6: Treatment of Tuberculosis (TB) Disease, page 4. c. Refer client to TB clinic for follow up. 15. Reinforce the need for ongoing good oral hygiene practices. Assist client in locating affordable dental care during the second trimester, as needed. 16. STD a. Monthly RPR and titers as indicated for clients found to be infected at initial screen. b. Follow up sexual risk assessment. c. Treatment as appropriate with penicillin desensitization, if indicated.
214 17. Immunizations: The Ad visory Comm ittee on Immunization Practices (ACIP) General Recommendations on Immunizations (February 8, 2002/Vol. 51/No. RR 2, page 20) it states "The benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease ex posure is high, when the infection would pose a special risk to the mother or fetus, and when the vaccine is unlikely to cause harm." Follow the latest recommendations of the ACIP, which currently includes the following vaccination recommendations for preg nant women: a. Td toxoid is indicated routinely for pregnant women. Previously vaccinated pregnant women who have not received a Td vaccination within the last 10 years should receive a booster dose. Pregnant women who are not immunized or only partially immunized against tetanus should complete the primary series. Although no evidence exists that tetanus and diphtheria toxoids are teratogenic, waiting until second trimester of pregnancy to administer Td is a reasonable precaution for minimizing any concer n about the theoretical possibility of such reactions. b. Women in the second and third trimester of pregnancy have demonstrated to be at increased risk for hospitalization from influenza. Therefore, routine influenza vaccination is recommended for healthy women who will be beyond the first trimester of pregna ncy (i.e., > 14 weeks of gestation) during influenza season (usually December March in the United States). c. Hepatitis B vaccine may be considered for susceptible pregnant women who are at risk hepatitis B infection. 18. Follow up or facilitate follow u p with clients who do not keep their appointment. F. Evaluation 1. Evaluate and assure that the client assessment, education and counseling, interventions and plan of treatment have been completed. 2. Schedule follow up visits based on individual needs, risk factors and weeks gestation. G. Emergency 1. Call 911 for life threatening situation. 2. In all cases, contact M.D. or D.O. and follow orders
215 H. Documentation 1. Document all client information on Prenatal record 3142, pages 1 5. If a similar DOH approved form is used, it must include, at a minimum, the information identified on these forms. 2. Document client needs on the Problem List, DH 3115. Documentation should include, but be not limited to these categories; physical, psychosocial, and environmental. 3. Document NO SHOW and follow up for client who has not kept her appointment. 4. Document and plot weight on the Prenatal Weight Gain Grid, DH 3086D. 5. DOH Approved Forms: a. Prenatal Record, DH 3142, pages 1 5 b. Florida's Healthy Start Prenatal Screening Instrument, DH 3134 c. Tell Us About Yourself, DH 3131 d. Adult and Adolescent Nutrition Assessment, DH 3086E e. Prenatal Weight Gain Grid, DH 3086D f. Statement of Objection to HIV Testing, DH 3161 g. Problem List, DH 3115 h. Medication Profile, DH 3116 i. Progress Notes, DH 3056 j. Referral Form, DH 5065 k. Domestic Violence Documentation Form, DH 32 02 l. Other DOH approved forms as indicated
216 VIII. SUPPORTIVE DATA: A. 2001 Compendium of Selected Publications, American College of Obstetrics and Gynecology (ACOG). B. Physician Coverage and Limitations Handbook, Florida Agency for Healthcare Administration (AHCA). C. Understanding the Health Culture of Recent Immigrants to the United States: A Cross Cultural Maternal Health Information Catalog. American Public Healt h Association publication, 11/2000. D. Best Practice Guidelines from specific program areas in DOH. E. Guidelines for Vaccinating Pregnant Women, Advisory Committee on Immunization Practices (ACIP), 10/1998. F. The Advisory Committee on Immunization Pra ctices (ACIP), General Recommendations on Immunizations, 02/2002. G. Revised CDC Guidelines (MMWR), Prevention of Perinatal Group B Streptococcal Disease, 08/16/02.
217 APPENDIX D : INFORMED CONSENT FOR MS English Informed Con s ents
219 English Informed Con s ents
223 APPENDIX E : INTERVIEW GUIDE Interview Questions English The following guide was used qualitative phase (objective 3). These questions were formulated using the theory of social support constructs (emotional support, instrumental support, informational support, companionship support, appraisal/validation support ). CenteringPregnancy Assessment Interview Guide Introduction questions about your experience with CenteringPregnancy compared to your experience with individual prenatal c that you do not have to complete this interview and this is strictly volunteer. This will not affect the care that you receive at the health department. If it is okay with you I am going to r ecord our conversation. Our conversation will be kept confidential and your identity will not be disclosed in this research. I appreciate your honest answers. Questions about experience with CenteringPregnancy 1) Tell me about your experience with prenatal care here at the health department. Probe: How did you like receiving your care through the CenteringPregnancy group? 2) Tell me about your favorite part of CenteringPregnancy. Probe: What were some things in your group sessions you liked best? 3) Tell me about your least favorite part about CenteringPregnancy. Probe: care? 4) What were one of the most important things you learned in the CenteringPregnancy s essions? 5) Do you think that CenteringPregnancy prepared you for your labor and delivery? (instrumental support, validation support) Probe: How so? Or Why not? What do you wish you would have known or understood? 6) Did you become friends with other women in the group? Did these friendships help you get through your pregnancy? (companionship support, emotional support) Probe: Do you still talk to other women in your group? 7) Do you feel your concerns and questions were addressed in the group by other women or by the health educator or doctor? (validation support)
224 Nutrition during pregnancy 8) What were some things that your health care provider talked with you about regarding nutrition and eating healthy during pregnancy? Probe: Was this information helpful to you? What made it helpful or not helpful? Probe: Did you use this information and make any changes in your diet? Probe: Did you learn about nutrition and things that are good and bad to eat during pregnancy? What this important for you to learn? Prob e: Were the food examples and tips given to you appropriate for the types of foods you normally eat? Physical activity during your pregnancy 9) What were some things that your health care provider talked with you about regarding physical activity or exercise during pregnancy? Probe: Was this information helpful to you? What made it helpful or not helpful? Probe: Did you use this information and make any changes in your daily activity? Questions about your past experience with individual prenatal care (not C enteringPregnancy ). 10) Tell me about your overall experience with prenatal care with individual prenatal care that you received in the past when you were pregnant before. Probe: How did you like receiving your care individually compared to the CenteringPregnancy group? 11) What were some of the main differences between CenteringPregnancy and your experience with regular individual care? Probe: What were some things in your ind ividual care you liked and dislikes compared to CenteringPregnancy ? 12) Did you learn more or less about your pregnancy and childbirth in individual care compared to CenteringPregnancy ? 13) Did you feel more or less comfortable in individual prenatal care compared to CenteringPregnancy ? Probe: What were some things that made you feel more comfortable in either? 14) How did CenteringPregnancy prepare you for your labor and childbirth that may hve been different from what you learned or how you were prepared in your past experience with individual prenatal care? 15) Think about the information you received on nutrition during your pregnancy. Did you learn more, the same or less abo ut nutrition in individual care compared to CenteringPregnancy ?
225 Probe: What are some things you learned about nutrition in the Centering 16) Think about the information you received on exercis e during your pregnancy. Did you learn more, the same or less about exercise in individual care compared to CenteringPregnancy ? Probe: What are some things you learned about exercising in the versa? 17) Would you recommend CenteringPregnancy or individual prenatal care to a friend? Probe: Why did you pick that choice? What are some reasons you would recommend that choice? 18) If you have another baby would you chose CenteringPregnancy or individual prenatal care? Probe: Why did you pick that choice? What are some reasons you would recommend that choice.
226 Interview Questions Spanish Evaluacin de CenteringPregnancy en Equipo Gua para Entrevista Introduccin : Gracias por tomarte este tiempo para hablar conmigo hoy. Voy a hacerte unas pocas preguntas acerca de tu Experiencia con el CenteringPregnancy en equipo en comparacin con tu experiencia en atencin prenatal individual vivida en el pasado. Tambin quiero r ecordarte que no tienes que completar esta entrevista si no quieres y que la misma es estrictamente voluntaria. Tu decisin no afectar los cuidados que recibes en el Departamento de Salud. Si te parece bien voy a grabar nuestra conversacin. Nuestra con versacin ser mantenida confidencial y tu identidad no ser mostrada en esta investigacin. Yo agradezco tus respuestas honestas. Preguntas acerca de la experiencia con CenteringPregnancy de forma Grupal 1) Hblame acerca de tu experiencia de cuidados prenatales en el departamento de salud. Probe: Que te gust de recibir tus cuidados a travs del grupo de Centering Pregnancy en equipo? 2) Hblame acerca de tu actividad favor ita en Centering Pregnancy en equipo. P robe: Cuales fueron las actividades de tus sesiones de grupo que ms te gustaron? 3) Hblame acerca de la actividad/es que menos te gust en CenteringPregnancy en equipo. Probe: Cual fue la actividad/es que no te gust en tu reciente cuidado prenatal? 4) Dime qu fue lo ms importante que aprendiste en las sesiones de CenteringPregnancy en equipo? 5) Piensas que CenteringPregnancy en equipo te prepar para tu trabajo de parto y parto? Probe: Cmo fue eso? O por qu crees que no sucedi? Qu cosas desearas haber conocido o entendido durante las sesiones? 6) Hiciste amigas entre las compaeras del grupo? Te ayudaron esas nuevas relaciones de amistad a superar tu embarazo? Probe: Todava mantienes relacin con alguna de las mujeres de tu grupo? 7) Sientes que tus in quietudes o preguntas fueron dirigidas adecuadamente por las otras compaeras de grupo o por tu educador de salud o doctor?
227 Nutricion durante el embarazo 8) Menciona algunas de las cosas, de las que tu proveedor de salud te habl, respecto a nutricin y comer saludable durante tu embarazo? Probe: Fue esta informaci n de ayuda para ti? Que la hizo til o no? Probe: Usaste esa informacin e hiciste algn cambio en tu alimentacin? Probe: Aprendiste acerca de nutricin y cosas que son buenas y malas de comer durante el embarazo? Por que fue importante para ti aprender eso? Probe: Fueron los ejemplos de comidas y pequeos consejos dados apropiados para ti y el tipo de comida que normalmen te comes? Actividad Fisica durante tu embarazo 9) Menciona algunas de las cosas que tu proveedor de cuidados de salud hablo contigo respecto a la actividad fsica o ejercicio durante el embarazo? Probe: Fue esa informacin til para ti? Que la hizo til o no? Probe: Usaste esa informacin e hiciste algunos cambios en tu actividad diaria? Preguntas acerca de tu experiencia anterior con cuidados prenatales individuales y CenteringPregnancy 10) Hblame acerca de tu experiencia en cuidado prenatal, respecto a la atencin prenatal individuales que recibiste cuando estuviste embarazada previamente. Probe: Que te gust de los cuidados prenatales individuales recibidos en comparacin con el Cen teringPregnancy en equipo? 11) Cuales fueron algunas de las principales diferencias entre el CenteringPregnancy en equipo y tu experiencia con los cuidados prenatales individuales? Probe: Que cosas te gustaron o que cosas no te gustaron en tu atencin prenatal individual comparada con el CenteringPregnancy en equipo? 12) Aprendiste ms o menos acerca de tu embarazo y el nacimiento del bebe en la atencin prenatal individual en comparaci n con el CenteringPregnancy en equipo? 13) Te sentiste ms o menos cmoda en la atencin prenatal individual en comparacin con el CenteringPregnancy en equipo? Probe: Menciona algunas de las cosas que te hicieron sentir ms cmoda en cualquier de lo s dos? 14) Que cosas aprendiste acerca del trabajo de parto y el parto en el grupo de CenteringPregnancy comparado con tu anterior experiencia en trabajo de parto y parto? 15) Piensa en la informacin nutricional que recibiste durante tus embarazos. A prendiste mas, lo mismo o menos acerca de nutricin en atencin individual comparada con el CenteringPregnancy en equipo?
228 Probe: Menciona algunas cosas que aprendiste de nutricin en tu CenteringPregnancy en equipo que no aprendiste en la atencin individual y viceversa? 16) Piensa en la informacin que recibiste de actividad fsica y ejercicio durante tus embarazos. Aprendiste mas, lo mismo o menos en cuanto al ejercicio en la atencin individual en com paracin con el CenteringPregnancy en equipo? Probe: Menciona que cosas aprendiste acerca del ejercicio en el CenteringPregnancy en equipo que no aprendiste durante la atencin individual y viceversa? 17) Recomendaras el CenteringPregnancy en equipo o la atencin prenatal individual a una amiga? Probe: Por qu hiciste esa eleccin? Dime algunas de las razones por las que recomendaras esa opcin? 18) Si tuvieras otro embarazo, escogeras CenteringPregnancy en equipo o atencin prenatal individual? Probe: Por qu escogiste esa opcin? Menciona alguna de las razones por las que escogeras esa opcin?
ABOUT THE AUTHOR T ara E. Trudnak grew up in Clarks Summit, Pennsylvania and earned a B.A. degree in Anthrop o logy from Muhlenberg College in Allentown, Pennsylvania She moved to Florida in 2005 and earn ed her M.P.H in Global Health from the University of South Florida during which time she completed her field experience and research in the Dominican Republic. S he continued on to her doctoral program in the Department of Community and Family Health in the College of Public Health at the University of South Florida She currently works for a non profit health foundation and hopes to continue her career in the fi el d of maternal and child health