Centering Providers to Deliver Group Care: Implementing CenteringPregnancy and CenteringParenting at an Urban Federally Qualified Health Center

Background

Maternal and child health disparities are rampant across the city of Philadelphia. In certain communities and neighborhoods, federally qualified health centers (FQHCs) with fledgling prenatal care programs work to provide women with the support, resources, and health care they need. This paper describes the experiences of a FQHC in North Philadelphia in addressing and reducing maternal and child health disparities through expanding prenatal care services and implementing a group-based care model.

Although our small prenatal care team was constantly trying to guide our predominantly African American patients, living in the low-income neighborhood of North Philadelphia, through the multiple stressors of pregnancy, we were struggling to overcome the racial inequities in maternal health that our patients faced. Patients continually had higher low birth weight rates compared to city and national averages, and were facing alarming pregnancy complications. One patient was diagnosed with preterm premature rupture of membranes at 26 weeks. She experienced intimate partner violence throughout her pregnancy, and delivered via C-section at 27 weeks for breech complicated by chorioamnionitis. Her daughter stayed in the neonatal intensive care unit for 2 months. Another patient had to be transferred to an academic center for third trimester care, but came back to our FQHC at 32 weeks pregnant with gonorrhea – having never made it to her specialist prenatal appointments downtown because of financial and transportation obstacles.

These patients’ experiences solidified our resolve to offer full-spectrum prenatal care. After persuading administration, we started to work more closely with our integrated behavioral health team. We devised a system that enabled behavioral health providers to meet with the patient at the start of every visit to discuss her psychosocial needs. Patient visits started lasting, at times, longer than 2 hours. We also started to make home visits for babies with low birth weight who continued to fail to thrive. Although there was no increase in birth weight trends in response to this added care, our efforts highlighted the need for continued and expansive integrative maternal and child health care at our center.

CenteringPregnancy

These efforts led us to revisit a model of group care for maternal and child health, called CenteringPregnancy. ¹ CenteringPregnancy is an evidence-based model of group care for cohorts of pregnant women who are all due at the same time. ¹ Each cohort attends group prenatal-care sessions, during which each woman receives her scheduled prenatal care and participates in group discussions on topics related to stress management, labor and delivery, breastfeeding, and infant care. ¹ Through CenteringPregnancy, expectant mothers get to know their providers more, and connect with other women sharing a common pregnancy experience. ¹

When the idea of implementing CenteringPregnancy was approached, staff were interested but also hesitant – so we started planning, and spent more than a year preparing. We asked ourselves if this program would even succeed here. Were there enough patients? What if patients did not show up? Was there a staff infrastructure to maintain the program? During preparations, we shadowed groups at other institutions, taking notes on their challenges and recommendations, and attended a 2-day CenteringPregnancy training. Slowly, after extensive conversations with FQHC staff about the benefits of CenteringPregnancy for patients and the feasibility of implementing the program at our site, we started to get buy-in from leadership. We were getting somewhere.

Unforeseen Events: CenteringParenting

These well-laid plans took a detour in the fall of 2018, when the continuity resident physicians at the site approached us about starting a CenteringParenting ² group – the complementary program that follows CenteringPregnancy. We had always thought we would start CenteringPregnancy first and let it grow into CenteringParenting, but the residents were energetic and willing, and brought some additional funding for the endeavor. Meanwhile, our health system was failing our mothers, who were still delivering babies with low birth weight and struggling with a multitude of psychosocial needs. Therefore, we decided to jump into CenteringParenting right away, even before CenteringPregnancy. Shortly after onboarding a new group care coordinator, our first CenteringParenting group was established (December 2018). CenteringParenting is similar to CenteringPregnancy, but instead focuses on pediatric care versus prenatal care. Each CenteringParenting session brings parents or support people of same-age infants together for an interactive well-child visit. During each session, an infant gets a well-child assessment and parents and support people are provided the opportunity to engage in activities and various discussions concerning wellness, nutrition, self-care, interconception health, and family dynamics. ² Ten parent–child dyads were recruited from our infant (<6 months old) patient population. During the first group session, only 1 mom and her 2-month-old son attended. She was talkative and unfazed that no other parents were there. She shared how very overwhelmed she felt, but left saying that she was so thankful for the 2 hours she spent with us and that she would be back for the next group. We were grateful for her enthusiasm; with high hopes, we started to prepare for the second group session - which 6 dyads attended. Today, the program is going strong.

Conclusion

Throughout this time we never abandoned the goal of starting CenteringPregnacy. Finally, in May 2019, we were able to start the first CenteringPregnancy cohort. Most of these moms have now delivered and have graduated into a CenteringParenting group. We are excited about continuing these cohorts but know that there is still a learning curve to overcome. Some sessions have full participation, while others have high no-show rates. On days when it feels like the efforts with group care are for naught, we think about the support they provide patients. We remind ourselves about the comradery and fellowship they foster. During one CenteringParenting group session, a mother discussed having to give her young infant cereal mixed with formula because she was running out before her next monthly Women, Infants, and Children supply. Another mother jumped in and asked what type of formula she was using. It turns out this mom had some left over, and quickly walked home after a group session to get a large container of formula for the other mom.

Moments like this one remind us why we need to keep the group model going. Patients need this kind of peer support, and that is something the health care system cannot offer on its own. Moreover, the path to group care is a reminder to our care team, and to you, that sometimes any action is better than planned perfection. Implementing a new program can feel daunting, but we have to center ourselves as providers and recognize that, at times, living outside of our comfort zone may be the way we best support our patients.