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Improving Pregnancy Outcomes for African American Teens Through Use of the CenteringPregnancy Model

Nicole Christian

Posted April 2010

Abstract
Abstract

Adolescence is a period of identity development and peer influence, and is typically defined as the years between thirteen and nineteen years of age. Physiologically, adolescence occurs with the start of puberty and terminates at the onset of adulthood, marked by an individual's physiologic maturity. The pregnant adolescent must meet the developmental needs of herself and her fetus, as well as the demands of physical growth during adolescence, while facing the life-altering challenge of pregnancy and motherhood (Klima, 2003). African American adolescents have a higher incidence of poor pregnancy outcomes than other teens, such as low birth weight, preterm birth, infant mortality, and maternal mortality (Johns Hopkins School of Public Health, 2003). Racial disparities persist across socioeconomic categories, but within the perinatal period, such disparities are thought to be mediated by inadequate prenatal care access and utilization (Agency for Healthcare Research and Quality Innovations Exchange, 2009). Likewise, the chronic stressors of racism may play a role in the high rates of mortality and morbidity among African Americans (Williams, Neighbors, & Jackson, 2003). The Centering Pregnancy model, a multidisciplinary, group approach to prenatal care, is an alternative to traditional prenatal care that combines health assessment, education, and support (Centering Health Institute, 2009). The social support intrinsic in this model of prenatal care is postulated to positively influence pregnancy outcomes, such as preterm birth and low birth weight among African American pregnant adolescents. The literature review revealed that interventions, such as group prenatal care, provide social networking, emotional support, peer education and tangible assistance to adolescent group members. In addition, the literature review showed that increased access and utilization to prenatal care are necessary components to improving perinatal outcomes. However, the literature has not directly demonstrated that the Centering Pregnancy model can affect change in pregnancy outcomes in African American teens. This inquiry will explore the effects of Centering Pregnancy on selected pregnancy outcomes (low birth weight, preterm birth, infant mortality) among African American teens. The planning and initiation of a teen clinic which uses the Centering model is described, including a detailed start up budget. A grant proposal to the Will and Jada Smith Family Foundation is presented to solicit start up funding for this worthy project.

Text

Chapter One: Statement and Significance of the Problem

Introduction
Adolescence is defined as the years between thirteen and nineteen years of age. Adolescence occurs with the start of puberty and ends at the onset of adulthood, which is evidenced by one's physiologic maturity. Adolescent women face increased risk in pregnancy, such as low-birth weight babies and infant deaths. These outcomes are thought to result from factors such as biologic immaturity, or sociodemographic factors related to adolescent pregnancy (Chacko, 2009). African American pregnant teens are affected disproportionately by poor pregnancy outcomes. They were found to have a higher incidence of poor pregnancy outcomes such as low-birth weight, preterm birth, and fetal death when compared to normative data in the United States (Johns Hopkins School of Public Health [JHSPH], 2003). Typical indices for monitoring pregnancy outcomes include: (1) the Institute of Medicine index (IOM), which considers the month in which care is initiated, the number of prenatal care visits, and the type of obstetric services and describes care as adequate, intermediate, and inadequate; (2) the revised, graduated index (R-GINDEX), which expands on the three IOM descriptors by adding on no care, missing, and intensive; and (3) the Adequacy of Prenatal Care Usage (APNCU), which proposes separate assessments of adequacy based a ratio between observed-to-expected visit ratio and the timing of the first prenatal care visit (Alexander & Kotelchuck, 1996).

Racial disparities exist and persist within healthcare for reasons that are unknown and poorly understood. According to the National Healthcare Disparities Report, there is inequality in the delivery of quality care among populations, and it is theorized that differential access may lead to these disparities in quality health care (Agency for Healthcare Research and Quality [AHRQ], 2004). Access to health care is a prerequisite to quality health care and barriers to accessible quality care can result in adverse health outcomes. These barriers include the lack of health insurance, the lack of use of evidence-based preventive services, and the lack of a primary health source (AHRQ, 2004). A study of access and utilization of prenatal care among African American and white women showed that racial disparities decreased with adequate use and early initiation of prenatal care. Still, with adequate access and usage of traditional prenatal care systems, racial disparities among high-risk groups such as pregnant adolescents did not improve (Rosenberg, 2003). Other theories as to why racial disparities exist and persist describe how the chronic stressors of racism and discrimination play a role in the high rates of mortality and morbidity among African Americans. The subjective experience of racial bias may be an ignored of health and a contributor to racial disparities in health care (Williams, Neighbors, & Jackson, 2003).

The Centering model of group prenatal care is an alternative to traditional prenatal care that combines health assessment, education, and support (Centering Health Institute, 2009). Women of similar gestational age are grouped together and meet for ten sessions throughout pregnancy and postpartum. This model strives to empower women with health-promoting behaviors, encouraging women to assume ownership of their health, while sharing the responsibility with the provider and the group. Facilitation of the group is focused on the self-defined needs of the group participants (Centering Health Institute, 2009). Centering has the potential to address sociocultural issues specific the African American adolescents that may help to decrease racial disparities.

Scope of the Problem

Birth rate data shows that adolescent births have declined significantly since 1991 among all races (Table 1). However, birth rates among African American teens remains higher when compared to the birth rate among all races (Hamilton, Martin, & Ventura, 2009). Pregnant adolescents are less likely to receive adequate prenatal care, and are more likely to experience poor pregnancy outcomes compared to older pregnant women (Baltimore City Health Department, 2008). Furthermore, African American teens are twice as likely to deliver babies of low-birth weight and 1.5 times more likely to deliver a preterm baby than white mothers (Chang, O'brien, Nathanson, Mancini, & Witter, 2003).

Table 1: Birth Rates of Teenagers in 1991 and 2007, according to the National Vital Statistics Reports Preliminary Birth Data for 2007

Age and Race 2007 1991
Ages 10-14
All races 0.6 per 1000 1.4 per 1000
Non-Hispanic Blacks 1.5 per 1000 4.9 per 1000
Ages 15-19
All races 42.5 per 1000 61.8 per 1000
Non-Hispanic Blacks 64.3 per 1000 118.2 per 1000
*Birth rates per 1000 women



Significance to Women's Health

Women's health is based on encouraging and empowering women to reach an optimal level of physical, mental, and spiritual health. The unique needs of the adolescent include the need for identity development and peer support. Adolescent mothers face such challenges as completing their schooling, securing prospects for their future income, and attaining sufficient parenting skills. They must also meet the physiologic, psychologic, and spiritual needs of their own growing bodies and psyches, while meeting the needs of their growing babies. The pregnant adolescent can meet these needs through use of the Centering Pregnancy for prenatal care, based on the premises of the model. The African American pregnant teen can benefit from the centering model of health care delivery, an approach to care that is being well-researched as to its effectiveness, and may be effective in improving pregnancy outcomes among African American teens (Klima, 2003).


Significance to Midwifery

Midwives serve women of all ages, races, religions, sexual orientations, and beliefs. It is important for midwives to help assure that pregnancy outcomes are optimal for all women, especially those who are at greatest risk for poor outcomes. The American College of Nurse-Midwives (ACNM) acknowledges the issue of health disparity, particularly in reproductive health. "For African American women, the lifetime and generational exposure to institutional and interpersonal racism have been shown to affect pregnancy outcomes such as birth weight, and other health conditions" (ACNM, 2007). The ACNM is committed to reducing these health disparities. The ACNM is particularly concerned with the great disparity gap in infant mortality, maternal mortality, preterm birth, and low birth weight, with African Americans suffering far worse than other races (ACNM, 2007). In addition, one of the four overarching goals of Healthy People 2020 is to "achieve health equity and eliminate health disparities" (U.S. Department of Health and Human Services, 2008). This inquiry will explore the effects of Centering Pregnancy on selected pregnancy outcomes among African American teens.


Chapter Two: Conceptual Framework and Literature Review

Restatement of the Problem

African American teens have a higher incidence of poor pregnancy outcomes such as low-birth weight and preterm birth, and finding mechanisms to improve pregnancy outcomes among this group is paramount. African American pregnant teens are affected disproportionately by poor pregnancy outcomes. These teens are twice as likely to deliver low birth weight infants and are one and a half times more likely to have premature infants than white mothers (Johns Hopkins School of Public Health, 2003). This problem effects all African American pregnant teens, their infants, and the health care members that care for them. This problem is significant to women's health, as it highlights chronicity of the racial disparities that plague specific populations of women and the need for change.

Conceptual Framework

The framework of a study is the theoretical rationale and the foundation on which the study's concepts are based. If the study is theory-based, then the conceptual underpinning is a theoretical framework. If the study is based on a specific conceptual model, then the conceptual underpinning is a conceptual framework. The terms conceptual framework and theoretical framework tend to be used interchangeably (Polit & Beck, 2008). Conceptual/theoretical frameworks guide critical inquiry into a topic of research and can serve as a basis for formulating hypotheses. Additionally, the conceptual/theoretical framework of a study may result in the birth of theories, based on the research findings.

Centering Pregnancy model is supported by several theoretical perspectives, including Feminism, the Midwifery Model of Care, the Social Support Theory, and the Self-Efficacy Theory. Feminism is based on theoretical and philosophical beliefs about women and their role in the world. The feminist foundation for health care seeks to create equality in the patient-provider relationship, which involves removal of: disrespect, social and physical barriers to care, and obstacles to accessing one's own medical information. Woman who use Centering Pregnancy are given full access and explanation of their medical records. They learn to be advocates for themselves and their families and communities. This model of care nurtures the needs of the participants, rather than the needs of the medical establishment (Schindler-Rising, Powell-Kennedy, & Klima, 2004).

The framework of the Midwifery Model of Care (MMOC) is based on creating an environment in which the needs of the woman are supported, and both the midwife and the woman bring knowledge and power to the patient-provider relationship. This dynamic results in a far reaching experience for both parties, that extends beyond the standard in prenatal care delivery (Schindler-Rising, Powell-Kennedy, & Klima, 2004). Furthermore, the MMOC is a model that can be used by all health care providers who care for women. Facilitators of the Centering groups are given ample time to get to know each women during their pregnancy journey. This affords the provider a sense of professional and personal satisfaction in their ability to listen and offer guidance in a non-hurried environment. The women of the group are afforded the opportunity to speak, listen, learn, and grow in a non-judgemental, non-hurried environment (Schindler-Rising et al., 2004).

The Social Support Theory encompasses the notion that a sense of community is vital to one's sense of well-being, and is associated with better pregnancy outcomes. Groups provide social support and this support grows as its members build an inclusive network of belonging. Lack of social support seems to be related to poor pregnancy and postpartum outcomes. Inversely, the presence of social support can positively effect pregnancy and postpartum outcomes. Centering Pregnancy groups share the common experience of pregnancy, and validation that each woman owns different experiences and challenges. Also, the resources and information offered and exchanged as a routine part of the Centering model may help to allay some of the mental and physical stressors of pregnancy. The group may be integral in helping one another to effectively cope with their experiences and challenges (Schindler-Rising, Powell-Kennedy, & Klima, 2004).

The premise of the Self-Efficacy Theory is based on the notion that one's perception of their own coping abilities affects the attainment of certain outcomes. People who have a strong sense of self-efficacy are likely to have a high level of assurance in their own capabilities, and therefore, will approach challenges and difficult tasks head-on, rather than avoid such challenges and tasks. Likewise, those with a strong sense of self-efficacy will recover quickly and find a renewed strength in the face of failure. Conversely, those with a poor sense of self-efficacy will likely avoid difficult situations but when faced with unavoidable challenges, they put forth little or no effort to tackle the task. For these individuals, it is difficult to recover their sense of self-efficacy once they believe themselves to have failed (Bandura, 1994). The group dynamic intrinsic in the Centering model can be integral in effective coping and can help the individual to apply the group strengths to the context of her own life. This has the potential to enhance that individual's self-efficacy (Schindler-Rising, Powell-Kennedy, & Klima, 2004).

This inquiry is guided by these theoretical frameworks, as it seeks to examine the principles and practices of the Centering Pregnancy model. The theoretical premises inherent in this model are likely to meet the unique needs of the vulnerable population of African American pregnant adolescents. The theoretical premises discussed are likely to affect positive physical, mental, emotional, and spiritual change in these women, which may result in more positive perinatal outcomes.

Conceptual Map




Literature Review

Article Search and Retrieval

For this inquiry, articles for literature review were obtained in various ways. Initially, the Google Scholar search engine was used. Many abstracts and article summaries were located, but finding full text articles was at times arduous. Often, paid membership to organizations was required in order to retrieve full text articles. A search of the databases on Medscape yielded several full text journal articles related to this inquiry. Medscape is a comprehensive resource website that includes a wealth of information for professionals and patients, and registration and access is free of charge. Search terms included Centering Pregnancy, adolescent pregnancy outcomes, African American adolescent pregnancy outcomes, and racial disparities in prenatal care. This article search was performed from September to October 2009 and included articles from 2003 to the present.

Review of Literature

State Infant Mortality: An Ecologic Study to Determine Modifiable Risks and Adjusted Infant Mortality Rates

Infant mortality rates (IMR) are disproportionate among races and geographic locations. The IMR for African Americans is twice that of Caucasian infants and southern states have a higher IMR than northeastern states. A goal of the Healthy People 2010 initiative is to decrease the IMR from 6.8 per 1000 live births to 4.5 per 1000 live births. States differ in their risk for infant mortality, making it difficult to compare state to state data. The purpose of this study was to determine the factors that influence the IMR and to develop an adjusted IMR in the United States (U. S.) for 2001 and 2002 based on those factors determined to influence infant mortality (Paul, Mackley, Locke, Stefano, & Kroelinger, 2009). An ecologic study seeks to discover the how the environment influences human behavior (Polit & Beck, 2008). Factors that potentially contribute to state IMR were investigated and include: racial demographics, ethnicity, population, median income, education, teen birth rate, proportion of obesity, smoking during pregnancy, diabetes, hypertension, cesarean delivery, prenatal care, health insurance, mental illness, and the number of in-vitro procedures. These data were extrapolated birth certificate information. State IMR rates were adjusted and compared with national IMR adjusted rates (Paul et al., 2009).

Linear Regression Models of State Infant Mortality Rates for 2001 and 2002 Using National Center for Health Statistics Data
Model 2001 r 2 = 0.69, P < 0.01Model 2002 r 2 = 0.81, P < 0.01
Variables in model
r 2
Variables in model
r 2
Percentage non-Hispanic African-American race
0.52
0.56
Percentage non-Hispanic African-American race
0.64
0.65
Smoking rate/pregnancy
0.11
0.08
Smoking rate/pregnancy
0.22
0.09
Teen birth rate
0.33
0.02
Teen birth rate
0.33
0.04
Percentage Hispanic ethnicity
-0.24
0.02
Percentage Hispanic ethnicity
-0.24
0.03
BMI (% women normal)
-0.12
0.01
Cesarean section rate
-0.13
0.01

Using a multiple regression analysis, the data showed that the percentage of African Americans in a state's population was directly related to the state's IMR in 2001 and 2002. Similarly, smoking during pregnancy and teen birth rates were associated with increasing IMR in 2001 and 2002. The percentage of Hispanics in a state's population was inversely associated with the state's IMR. Likewise, the percentage of women with normal BMI was inversely associated with the state's IMR in 2001, and in 2002, the cesarean section rate was inversely related to the state's IMR. Multiple regression analysis examines the effects of two or more independent variables (predictors) on a dependent variable. The Pearson's r statistic in this study is the correlation index between the independent variables. This index is squared and indicates the proportion of variance in the dependent variable, accounted for by the cumulative influence of the independent variables. In this study, the (1-) was calculated, which attests to the power of the statistical test. Beta (), as shown in the table above, is the probability of detecting a true relationship or group difference. The smaller the number, the smaller the risk of committing a Type II, or false negative error (Polit & Beck, 2008).

This study's strengths are the use of a large sample size, the use of multiple regression analysis to analyze complex relationships, and the calculation of the beta, which correlates to the power of the statistical test. A weakness of this study that it used summary data, which can lead to inappropriate associations between independent variables. Another weakness of this study is that it sought to determine that ecologic or environmental factors have an effect on IMR, but the study does not take into account such factors as racism, discrimination, chronic stress, substance abuse, birth defects, or hereditary disorders that can effect IMR. Other factors examined were apparently insignificant in association with IMR (Paul et al., 2009). These data are consistent with the known IMR disparity among African Americans and adolescents. The results also demonstrate the need to create initiatives that would help to eliminate disparities in infant mortality, particularly among African Americans and teens.

Characteristics and Risk Factors for Adverse Birth Outcomes in Pregnant Black Adolescents

The objective of this study was to characterize the impact of maternal age on birth outcomes within a group of minority adolescent teens. Chang, O'brien, Nathanson, Mancini, & Witter (2003) performed a ten-year retrospective chart review of 1120 pregnant African American adolescents who were seventeen years old or younger, and receiving prenatal care in a inner-city maternity clinic in Baltimore, Maryland. The results showed that younger adolescents (<15 years old) were more likely to inadequately utilize prenatal care (p<0.01). Older adolescents (15-17 years old) had a higher incidence of gonorrheal infection(p=0.046), self-reported substance abuse (p=0.063), and a higher history of cigarette smoking (p<0.01). Low prepregnancy body mass index (BMI), low weight gain during pregnancy, and inadequate prenatal care utilization were significant predictors of preterm birth (p<0.05). Similarly, low prepregnancy BMI, inadequate pregnancy weight gain, female infant, and cigarette smoking were significant predictors of decreased infant birth weight (p<0.05). Overall, the results indicate that pregnant African American adolescents have a higher incidence of low birth weight infants, preterm births, and fetal deaths, when compared to data on pregnant white women in the United States (Chang et al., 2003).

This type of correlational research uses the retrospective design through examination of case-control studies. Case-control studies make a comparison a case (like a person with a condition under scrutiny), with a matched control (like a similar person without the condition) [Polit & Beck, 2008]. Researchers attempted to examine the relationship between selected independent variables and outcomes (pregnant African American adolescents and adverse birth outcomes). Elucidation of a cause and effect relationship is difficult with this type of research, because of the researchers' lack of control over the independent variables, which have already occurred. However, through the use of the retrospective design and the extrapolation of data from case-control studies, wherein the cases and controls are comparable, researchers are able to cautiously infer a cause-effect relationship between variables (Polit & Beck, 2008). In this study, the "case" refers to both the younger and older groups of African American adolescents, while the "control" refers to national data on pregnant white women in the United States and pregnant African American women over the age of 17 in Maryland. The authors of this study concluded that pregnant African American adolescents have an increased risk of adverse pregnancy outcomes and that this population should be studied further to develop age-appropriate, population-specific interventions in order to improve birth outcomes (Chang et al., 2003). The authors' proposition that there is a need for further study of this population in order to develop interventions that would improve birth outcomes is in accord with this inquiry. Centering has great promise in this area.

Effects of Prenatal Care Intervention on the Self-Concept and Self-Efficacy of Adolescent Mothers

The purpose of this quantitative study was to examine the effects of prenatal care on the self-concept and self-efficacy of adolescent mothers (up to age 20), who were involved in a behavioral intervention. A sample of 282 urban pregnant adolescents from five clinics in a large urban setting, was comprised of 94% African Americans, 4% whites, and 2% listed as other. The subjects ranged from age thirteen to twenty, with the mean age of 17.6 years. Ford et al. (2001) measured self-concept, which is similar to self-esteem, through the use of the Tennessee Self-Concept Scale (TCSC). In this study, the TCSC uses 100 self-descriptive statements, and is a multidimensional approach to measuring self-concept. Likewise, a Likert scale was developed and evaluated to measure the self-efficacy of the adolescent mother during the childbearing year (Ford et al., 2001). A Likert scale is a composite measure of respondents attitudes regarding the degree to which they agree or disagree with a statement or set of items (Polit & Beck, 2008). In this study, the possible scores ranged from 5 to 60, with the lower end of the scale correlating to lower self-efficacy. In the analysis of the reliability of the Likert scale, the alpha value was calculated. Alpha provides an estimate of the proportion of variance in scale scores that can be attributed to the true score. The alpha values of the self-efficacy scale in this study confirmed the reliability of the three subscales (self-efficacy during pregnancy, labor and delivery, and postpartum/infant care). The 282 adolescents were randomly assigned to either the experimental (intervention) group or control (nonintervention) group, and to groups of six to eight participants. In the experimental group, the intervention was a peer-centered, mastery model intervention (PCMMI). The PCMMI was designed by researchers to "increase self-efficacy, improve self-concept, and affect short- and long-term perinatal outcomes" (Ford et al., 2001, p. 16). Adolescents in the PCMMI group provided prenatal care to each other, in a group setting, supervised by a nurse-midwife, nurse practitioner, or obstetrician. Those in this group were paired with another pregnant teens, and were shown how to perform routine elements of prenatal care like blood pressures, fetal heart tones, weights, and urine dipsticks. Adolescents in the control group had traditional, individual care delivered by health professionals. All teens were given the same boxed education material with information on the three trimesters of pregnancy (Ford et al., 2001).

Intake and Postpartum Measures of Self-Efficacy
Item
Experimental (N = 136)
Control (N = 94)
F Statistic
Mean IntakeMean PostpartumtMean IntakeMean PostpartumtTime * Condition
Total self-efficacy4.704.75−1.7 (p = 0.09)4.704.74−1.12 (p = 0.26)1.71 (p = 0.59)
Pregnancy4.674.71−0.7 (p = 0.45)4.664.72−0.9 (p = 0.33)0.22 (p = 0.64)
Labor/Delivery4.344.62−4.0 (p = 0.00)4.354.62−3.6 (p = 0.00)0.02 (p = 0.89)
Postpartum/
Infant
4.934.803.93 (p = 0.00)4.924.782.98 (p = 0.00)0.07 (p = 0.80)

Intake and Postpartum Measures of Tennessee Self-Concept
Experimental (N = 136)
Control (N = 94)
F Test
Tennessee Self-ConceptMean IntakeMean PostpartumtMean IntakeMean PostpartumtTime * Condition
Total Score340.9347.8−2.83 (p = 0.00)345.60347.10−0.52 (p = 0.60)1.95 (p = 0.16)
Self-criticism32.4632.99−1.26 (p = 0.26)32.0932.88−1.26 (p = 0.21)————
Identity125.43127.59−2.43 (p = 0.02)127.75128.27−0.54 (p = 0.60)3.06 (p = 0.08)
Self-satisfaction108.48110.74−1.97 (p = 0.05)109.22109.110.09 (p = 0.93)2.01 (p = 0.16)
Behavior106.97109.48−2.44 (p = 0.02)108.53109.83−1.01 (p = 0.31)0.42 (p = 0.52)
Physical self73.1073.86−1.20 (p = 0.23)73.7472.961.08 (p = 0.28)1.95 (p = 0.16)
Moral/Ethical self68.7069.72−1.45 (p = 0.15)69.2669.51−0.34 (p = 0.73)0.76 (p = 0.38)
Personal self68.8770.20−1.91 (p = 0.05)70.8970.160.85 (p = 0.40)3.04 (p = 0.08)
Family self66.8469.40−3.72 (p = 0.00)66.7968.25−1.65 (p = 0.10)1.29 (p = 0.26)
Social self63.3764.62−2.01 (p = 0.05)64.7866.22−1.69 (p = 0.09)0.08 (p = 0.77)

The results of the TSCS data showed that self-concept increased significantly for adolescents in the experimental group, but did not change significantly for teens in the control group. Between the intake for prenatal care and the postpartum period, self-efficacy changed significantly among both the experimental and control groups. These results show an increase in self-efficacy among adolescents in both the experimental and control groups. The experimental group showed significant increases in overall self-concept, but none of the measures of self-concept showed significant increase in the control group. The authors concluded that self-concept among this group of mostly African American adolescents was positively influenced by peer support and small group care. Likewise, self-efficacy among these teens was improved in association with professional and peer interactions (Ford et al., 2001). These results highlight to need to further study this population. The conclusions of this study support the basic premise of this critical inquiry: interventions that provide social support and prenatal care access and utilization can affect the psychological process, which could potentially affect physical outcomes.

Decreased Preterm Births in an Inner-City Public Hospital

The objective of this study was to examine preterm births among African American and Hispanic women who gave birth in an inner-city public hospital. Rates of preterm births (less than thirty-seven weeks gestation) of singleton neonates weighing more than 500 grams delivered to women receiving prenatal care at Parkland Memorial Hospital (PMH) in Dallas, Texas between 1988 and 2006 were compared with similar births in the United States between 1995 and 2002. Preterm birth rates were also compared among African Americans, white, and Hispanic women (Leveno, McIntire, Bloom, Sibley, & Anderson, 2009). The sample was a cohort of 260,197 women, 70% of whom were Hispanic, 20% African American, and 8% white. Selected obstetrical outcomes, as well as neonatal outcomes, were stored in a computerized database. Data on preterm birth, the outcome of interest, were extracted from this database. Data on neonatal outcomes were extracted from the discharge database. The national cohort for comparison was comprised of 29,366,816 women. Subgroups of the PMH data were chosen to corresponding data groups in the national database. These researchers used correlation through a prospective cohort design to study the rates of preterm births at one inner-city hospital, compared to the national rates of preterm births between the years 1995 to 2002 for the PMH cohort and 1988 to 2006 for the U.S. cohort. As is common with some prospective studies, researchers examine presumed causes and then go forward in time to observe presumed effects. This type of study is stronger than retrospective studies in providing quality evidence (Polit & Beck, 2008).

Demographic Comparisons
Characteristic United States Parkland Hospital

Total women 29,366,816 (100%) 260,197 (100)

Race/ethnicity
White 17,896,354 (61) 21,579 (8)
African American 4,251,665 (14) 50,813 (20)
Hispanic 5,622,376 (19) —
Mexican 3,978,824 (14) 181,176 (70)
Other 1,643,552 (6) —
Other 1,596,421 (5) 6,629 (2)

Maternal age (y)
14 or younger 67,294 (0.2) 1,724 (0.7)
15–19 3,503,394 (12) 52,917 (20)
20–34 22,058,067 (75) 190,234 (73)
35 or older 3,738,061 (13) 15,322 (6)

FIGURE 1:

Percentage of women with preterm births before 37 weeks in the U.S. (1995-2002) compared with Parkland Hospital (1988-2006)

A. Overall

B. White women

C. African American women

D. Hispanic women



These data show that the preterm birth rate at Parkland decreased since 1994 (see Figure 1). Additionally, the disparity in preterm birth rates between minorities and white women was decreased in the Parkland cohort, compared to the U. S. cohort (Leveno et al., 2009). Many explanations for these trends have been proposed, but refuted by the authors. According to Leveno et al. (2009), since the early 1990s, in an effort to improve access to and utilization of prenatal care, prenatal clinics were placed strategically throughout the county. These clinics were co-located with pediatric clinics and comprehensive medical clinics, all operated by the Parkland Memorial Hospital medical system. Also, each clinic site included a high-risk pregnancy clinic which operates daily. The medical staff adheres to agreed-upon practice guidelines, using evidence-based outcomes approach. This community-based, public health system is being attributed to the decline in preterm birth rates at this facility. A weakness of this study is that the data from the U.S. cohort and the PMH cohort were not evaluated based on the same years or time period. This threatens the internal validity of the study. The strengths of this study are prospective cohort design and the extremely large sample sizes of the cohort lend to the study's external validity. The authors' inference that preterm births declined as a result of improved access and utilization of prenatal care supports the foundation of this critical inquiry.

Racial Differences in Prenatal Care Use in the United States: Are Disparities Decreasing?

The Healthy People 2010 initiative set a goal of 90% of U. S. women initiating prenatal care in the first trimester, which to date, has not been reached. Adequate use of prenatal care, which is measured by the month that care began and the number of visits attended, has increased. The proportion of white mothers with adequate use of prenatal care increased from 33.6% to 50.2%, and the proportion of African American mothers with adequate use of prenatal care increased from 26.9% to 44%. These data are representative of years 1981 through 1998. The objectives of this quantitative study included: (1) examining trends in early, adequate, and intensive use of prenatal care by African American and white women in the U. S., (2) determining if existing racial disparities in early and adequate use of prenatal care have changed, and (3) determining if intensive use of prenatal care has been racially disproportionate (Alexander, Kogan, & Nabukera, 2002). Again, data were obtained from the National Center for Health Statistics natality files for the years 1981-1998. Singleton births to U. S. resident mothers who were either white or African American were examined. Through the use of the Revised Graduated Index of Prenatal Care Utilization (R-GINDEX) and the Adequacy of Prenatal Care Utilization Index (APNCU), the authors performed historical research in order categorize use of care.

The White-African American ratio for adequate use, R-GINDEX intensive use, and APNCU intensive use indicate less disparity between the years of 1981-1998.Data reveal that this trend toward less racial disparity in prenatal care is not occuring in all sociodemographic subgroups. Racial disparities in adequate use apparently are increasing among adolescent mothers. Alexander et al. acknowledged that African Americans are known to have higher risks of adverse pregnancy outcomes, which might explain their higher proportion of intensive prenatal care use (2002). This is indicative of the persistent nature of racial disparity in health care. Study limitations include the potential inaccuracy and incompleteness of reported gestational age and prenatal care indicators that may have changed over the study period. This is a threat to internal validity. Also, this study did not assess the quality and content of care, which may influence utilization. The authors opine that interventions such as universal health care for all pregnant women, continuing education of providers with respect to delivery of culturally competent care, and institution of comprehensive women's health programs should be explored in an effort to reach the national prenatal care goal (Alexander et al., 2002). These interventions noted by the authors are common components of the Centering Pregnancy model and stress the need to improve disparities in prenatal care.

The Design, Implementation and Acceptability of an Integrated Intervention to Address Multiple Behavioral and Psychosocial Risk Factors Among Pregnant African American Women

While infant mortality rates in the U. S. have decreased in the past decade, disparities persist for African-Americans. In Washington, DC, which has a predominately African American population, the infant mortality rate decreased from 18.6 per 1000 live births in 1992 to 11.6 per 1000 live births in 2003 (Katz et al., 2008). Still, the African American infant death rate in DC continued to be nearly three times that of white infants in Washington, DC, and two and a half times that of the national infant death rate. In an effort to reduce infant mortality, the National Institutes of Health (NIH), in collaboration with four academic research institutions in DC focused on reducing behavioral and psychosocial risks for adverse infant health outcomes among pregnant minority women. This study describes the conceptual design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for pregnant, low income African American women, with respect to multiple risk factor interventions (Katz et al., 2008).

The DC initiative, Healthy Outcomes of Pregnancy (DC-HOPE) targeted the following risk factors: cigarette smoking, tobacco exposure, depression, and intimate partner violence. In this randomized intervention study, a ten-session behavioral intervention was implemented in conjunction with prenatal and postpartum visits. A sample of 1044 pregnant women attending six urban prenatal clinics in the Washington, DC area were screened for eligibility and risks. Women who were identified through the use of an Audio Computer Assisted Self Interview (A-CASI) as having smoking, depressive symptoms, or intimate partner violence risks were asked to participate in the study. Additionally, if the respondents self-identified themselves as African American or Latina, a resident of the District of Columbia, 18 years old or older, English speaking, receiving prenatal care at one of the six clinics, and enrolled before 28 weeks gestation, they were included in the study. They were then randomized to the intervention care group or usual care group (control group). As a result of randomization, no differences were detected with respect to maternal characteristics or risk factors between the intervention and control group. The average age of participants was twenty-five years old and the average gestational age was nineteen weeks at the time of the baseline interview for screening into the study (Katz et al., 2008).


Conceptual Framework for DC-HOPE

The majority of women in the study (61%) reported a single risk factor, while 39% had multiple risk factors. Ninety-three percent of women in the intervention group had a positive view of their relationship with their counselor and over eighty percent found the session content and quality of services helpful. Each session that targeted at least one risk factor lasted, on average, 30 minutes. Sessions that incorporated more than one risk factor lasted on average, 45-55 minutes. All sessions included general and reproductive behavioral health risk content. Researchers found challenges in implementation when addressing multiple risk behaviors. Because the clinic staff was not informed of a patient's study arm assignment, they often wanted to refer patients to the intervention group and they often assumed that each of the participants in the study was receiving additional services. For some of the intervention sessions (32%), distractions such as women having to return to finish a clinic procedure, and interruptions such as participants bringing a child who is disruptive, presented a barrier to intervention delivery (Katz et al., 2008).

Intervention group participants perceived the active smoking, tobacco exposure, and reproductive health behavioral components more helpful than the depression and intimate partner violence (IPV) psychosocial components. Significant differences were found in the perceived helpfulness of the reproductive health and the depression or IPV content (p< or = 0.01 for both comparisons), between the tobacco exposure and the depression content (p< or = 0.01), between the tobacco exposure and IPV content (p< or = 0.05), and between the active smoking and the depression content (p< or = 0.01). The generalizability of the study results are limited to low income, urban, African American pregnant women over the age of eighteen years old, seeking prenatal care. The strengths of this study include its reproducibility, its identification of implementation obstacles, and its strategies to overcome challenges faced in multiple risk factor intervention in similar study settings (Katz et al., 2008). The behavioral and psychosocial components of this study are congruent with the Centering model's dynamic to motivate learning and support individual change.

Group Prenatal Care and Preterm Birth Weight: Results From a Matched Cohort Study at Public Clinics

The adequacy of prenatal care consists of the timing of initiation, the number of visits, and the quality and content of care. Ickovics et al. (2003) acknowledge that based on previous studies "enhanced prenatal care that includes patient education, behavioral interventions, and/or psychosocial support has resulted in reductions in low birth weight" (p. 1051). The Centering Pregnancy Program, a group prenatal care model, is designed to provide optimal, quality prenatal care, while improving perinatal outcomes. Group care allows for more time to develop the provider-patient relationship and to discuss the content of care, compared to individual care (two hours per session versus fifteen minutes per session, respectively). Women enrolled in group care share support from other group members and receive knowledge and skills related to pregnancy, labor, birth, and parenting (Ickovics et al., 2003). The objective of this matched cohort study was to compare group prenatal care to individual care, and its impact on the birth weight and gestational age of infants born to economically disadvantaged minority women at high risk for adverse perinatal outcomes.

The study included 458 pregnant women entering prenatal care at twenty-four weeks gestation or less. The women were matched by clinic, age, race, parity, and estimated date of delivery. Participants of the study were predominantly African American or Hispanic and of low socioeconomic status, who are Medicaid recipients. They received prenatal care in three public clinics in Atlanta, Georgia or New Haven, Connecticut. Half of these women received group prenatal care with women of the same gestational age. A computer program designed to select the first available patient with the closest delivery date meeting all matching criteria was used to randomly select the comparison group patients. Subsequently, 229 patients were self-selected to the group prenatal care cohort and 229 patients were randomly assigned to the individual prenatal care cohort. Low birth weight and preterm birth perinatal outcomes were the focus of the study because of their close association with neonatal morbidity and mortality (Ickovics et al., 2003).









The results revealed that birth weight was greater for infants born to patients in the group prenatal care cohort, compared to those in individual care. With approximately nine percent of women in both treatment groups having a preterm delivery, there was no significant difference in preterm delivery rates (p= 0.83). This could be an effect of the low sample size of the preterm subgroup. However, preterm infants of group prenatal care patients weighed more that preterm infants of individual prenatal care patients, with a difference of 407 grams (p< 0.05). Also of note, there were three neonatal deaths within the individual prenatal care cohort , and no neonatal deaths in the group prenatal care cohort. In summary, the results indicated that group prenatal care was associated with better weight gain for preterm infants and lengthened gestation. Because of the high rates of complications and associated costs of intensive medical care for preterm infants, these study results indicate that group prenatal care may be advantageous. The limitations of this study include the lack of randomization with respect to those who voluntarily selected group prenatal care, which could have resulted in self-selection bias in these women choosing group care versus individual prenatal care. However, the authors note that by matching participants based on indicators such as age, race, and parity, this bias is likely reduced significantly (Ickovics et al., 2003). Strengths of the study included: the large sample size from two different cities, the increased risk of adverse perinatal outcomes among the population of participants, and the prospective, longitudinal design which usually yields more quality evidence than retrospective studies (Polit & Beck, 2008). This study underscores the need to study the impact of group prenatal care in perinatal outcomes among African American adolescents.

Group Prenatal Care and Perinatal Outcomes

As previously stated, low birth weight and preterm birth rates disparities persist among African American women. Preterm birth results in many adverse outcomes, including neonatal and infant morbidity, prolonged hospitalization, increased costs, and potential lifelong developmental and medical sequelae. There has been limited success in preventing preterm births among all women, with respect to pharmacological, clinical, and psychosocial interventions (Ickovics et al., 2007). Preterm labor is caused by various known and unknown determinants, and therefore multiple interventions are required and there is no one intervention appropriate for all. However, an intervention like Centering embodies various aspects of prevention, and is theoretically a powerful prevention measure. The purpose of this study was to conduct a randomized controlled trial to determine whether group prenatal care leads to improved reproductive health outcomes such as lower rates of preterm births and low birth weight infants, improved psychosocial outcomes and patient satisfaction, and potential differences in health care costs (Ickovics et al., 2007). Recruitment of participants from large obstetrics clinics in two different university-based hospitals in New Haven, Connecticut and Atlanta, Georgia, yielded 1,047 pregnant women. The mean age of the participants was 20.4 years (ranging 14-25 years old) and 80% were African American. These 1,047 were randomly assigned to either standard prenatal care or group prenatal care and were followed one-year postpartum. There was no significant difference in terms of age, parity, education, or median income between study groups. Researchers used intent-to-treat analysis, a strategy for analyzing study data that assumes all participants received the treatment to which each was assigned (Polit & Beck, 2008). This type of analysis yields less bias in determining positive treatment effects. Groups of eight women, on average, were formed based on estimated delivery month. The Centering Pregnancy model curriculum was followed.

Group prenatal care participants were more likely to have adequate prenatal care, scored by the Kotelchuck Index. Adequacy of prenatal care in this study is based on both quantity and quality, as evidenced by thirty-three percent in the group prenatal sect and twenty-six percent among the standard care sect (p= 0.01). Women assigned to group prenatal care received about 20 hours, total, of care and women assigned to individual prenatal care received about 2 hours, total, of prenatal care. Women assigned to group prenatal care were less likely to have preterm births than those assigned to standard care (9.8% versus 13.8%). This is a risk reduction of thirty-three percent, or 40 per 1,000 births, with a confidence interval (CI) of ninety-five percent (p=0.045). Among the African American participants enrolled in group care, preterm labor birth rates was 10% compared to African Americans enrolled in standard care, which was 15.8% (p=0.02, CI=95%). There was no difference in Apgar score at five minutes, nor was there a difference in neonatal intensive care unit admission. Breastfeeding initiation rates were significantly improved among the women enrolled in group prenatal care compared to those enrolled in standard care: 66.5% versus 54.6% (p< 0.001). Billing data was only available from the New Haven site (n=503). The results showed no significant difference in raw costs or delivery of care costs. The group prenatal care enrollees had clinical and psychosocial advantages, compared to the standard care enrollees. For example, birth weight was not significantly different among the groups using the intent-to-treat analysis, likely due to a dose-response effect (i.e. the greater the exposure to the intervention, the longer the gestation and the higher birth weight) [Ickovics et al., 2007].

This study was limited by the fact that the favorable results from the interventions lacked uniformity. The intervention group data resulted in some documented benefits and some insignificant differences using the intent-to-treat analyses. Additionally, the sample represented a select group of young, minority women of low socioeconomic status and as such, they were at high risk for adverse perinatal outcomes. By virtue of this increased risk, there was an inherently greater need for clinical interventions to reduce risk. Reproducibility of this study in diverse populations and in diverse clinical settings is necessary to increase reliability, generalizability, and effectiveness. Ickovics et al. (2007) recommend that future research include an examination of the biological, behavioral, and social underpinnings that may enhance the effects of group prenatal care. This correlates with the need to examine biological, behavioral, and social aspects of the pregnant African American adolescent.

Comparison of Selected Outcomes of Centering Pregnancy Versus Traditional Prenatal Care

The objective of this study was to assess the effects of group prenatal care (Centering Pregnancy) versus traditional prenatal care on maternal knowledge of pregnancy, social support, the perception of the locus of control, and satisfaction. This study was conducted at three sites, in three different regions of the United States (Northeast, Midwest, and South). All sites offered both Centering Pregnancy programs and traditional prenatal care, and midwives who agreed to participate in the study. The study used a nonequivalent control group and the pretest/posttest design. The four instruments used for data collection were: Rising's Pregnancy Review Sheet; Labs and Wurtele's Fetal Health Locus of Control tool; Curry, Campbell, and Christian's Prenatal Psychosocial Profile; and Littlefield and Adams' Participation and Satisfaction tool.

Each of these tools has been evaluated for reliability and deemed to be reliable. The Rising's Pregnancy Review Sheet is a 35-item questionnaire using the true-false format (Baldwin, 2006) . A Kuder-Richardson 20 reliability analysis, which uses the alpha coefficient was performed on this questionnaire. This analysis assesses the adequacy of the content sampling and the heterogeneity of the items being sampled (ChangingMinds.org, 2010). Labs and Wurtele's Fetal Health Locus of Control tool is a six-point Likert scale that measures a pregnant woman's perceived control of the health of her unborn child in this study (Baldwin, 2006). The Cronbach alpha coefficient was used to analyze the reliability of the combined traditional and Centering groups. On a scale of 0 to 1.00 the Cronbach alpha evaluates internal consistency and higher values reflect a higher internal consistency (Polit & Beck, 2008). The Curry, Campbell, and Christian's Prenatal Psychosocial Profile is an 11-item questionnaire using a six-point Likert scale, and measures stress, social support, and self-esteem in pregnancy. Again, the Cronbach alpha coefficient was used to evaluate the internal consistency of this tool (Baldwin, 2006). The Littlefield and Adam's Participation and Satisfaction tool is a 23-item questionnaire using a five-point Likert scale, and measures satisfaction with the health care provider and the patient's perception of their participation in prenatal care. The Cronbach alpha coefficient was used to evaluate the internal consistency of this tool (Baldwin, 2006).
At the initial prenatal visit, patients were given a choice as to which type of care they preferred. Participants in each study arm had to be pregnant women without medical or obstetric complications, between eighteen and forty-two years old, and English-speaking. Financial compensation was given to the participants as an incentive for data collection. A total of 124 participants between eighteen and thirty-two years old were recruited and ninety-eight were retained (i.e. answered the posttest questionnaire). The traditional (control) group contained forty-eight women, while the Centering Pregnancy (experimental) group contained fifty participants. The traditional care group was composed of 79.2% white women and 20.8% nonwhite women, while the Centering Pregnancy group was composed of 78.0% white women and 22.0% nonwhite women (Baldwin, 2006).

Women in the experimental group scored higher than women in the control group on the posttest regarding knowledge about pregnancy. The experimental (Centering) group averaged 10.4 at the pretest and 11.38 at the posttest, and the traditional prenatal care group averaged 10.48 at the pretest and 10.88 at the posttest (p=0.03). There was a statistically insignificant difference between the experimental and control groups with respect to perceived social support from the midwife, one's significant other, or other pregnant women (p=0.07). Likewise, there was an insignificant difference between the experimental and control groups with respect to the perceived locus of control. In addition, results were almost identical between the experimental and control groups in the participants' participation and satisfaction with the care they received (Baldwin, 2006). Limitations of this study were numerous, and likely influenced the outcomes. The small sample size, non-randomization to the experimental and control groups, and the fact that posttest data were not collected at a similar gestational age for both groups served as limitations to this study. In addition, the ceiling effect of high pretest scores for social support and locus of control left limited room for improvement on the posttest. Baldwin (2006) asserts that the use of midwives in both the experimental and control groups might account for participants being equally satisfied with their care, and that future studies might include a qualitative approach to obtain pregnant women's perception of their care. Despite its limitations, this study demonstrates that Centering Pregnancy is valuable in increasing a pregnant woman's knowledge concerning pregnancy, which is empowering. Empowerment through knowledge can be an integral part of the pregnant adolescent journey to self-identity. This supports the foundation of an inquiry into the effects of Centering Pregnancy on the pregnant adolescent.

Pregnancy Outcomes of Adolescents Enrolled in a Centering Pregnancy Program

The purpose of this study was to evaluate the effects of the CenteringPregnancy model on pregnancy outcomes of adolescents enrolled in program. Information was collected on health visit attendance and perinatal outcomes on all clients in Centering groups from March 2001-April 2003 who gave birth at Barnes Jewish Hospital in St. Louis, Missouri. Adolescents who participated in Centering groups completed two evaluations of the program to assess teen satisfaction with CenteringPregnancy. The first evaluation was completed at session 7, and the second evaluation was completed during session 10 (the postpartum session). A total of 159 adolescents were enrolled in CenteringPregnancy prenatal care, but 35 transferred out due to insurance reasons, transfer to high-risk clinic, preference for traditional care, loss to follow-up after the first visit, or other issues associated with coming to clinic sessions. Adolescents who completed the program (N=124) were included in the data collection and analysis (9 of whom were co-managed by the Teen Pregnancy Center and the high-risk obstetric clinic). The age range of the Centering participants was 11 to 17 years old, with a mean age of 15.85 (standard deviation [SD]=1.24). For the 2001 comparison group, the age range was 17 years old or younger, with a mean age of 16.5 (SD=0.9). For the 1998 comparison group, the age range was 17 years old or younger, with a mean age of 16.3 (SD=1.2).

One portion of this study evaluated attendance rates for adolescents in the CenteringPregnancy groups, the level of satisfaction for teens in Centering groups, and the perinatal outcomes for adolescents in CenteringPregnancy groups. The outcomes of interest were the incidence of LBW infants, preterm delivery rate, cesarean birth rate, breastfeeding rate, and identification of pediatric provider at the time of delivery. Client satisfaction was evaluated through use of two surveys. Evaluation I asked the participants to rate the Centering program on a scale of 1 to 10 (with 1 being the worst and 10 being the best). Evaluation I also asked a series of questions, requesting that the participants to choose: agree, disagree, or uncertain. Evaluation II evaluated the participants' perception of the topics covered. They were to judge whether the Centering topics were well-covered, covered, or more coverage was needed. Evaluation II also evaluated the participants' perceptions and opinions of the group prenatal care model.

The other portion of this study was a comparison of two groups of pregnant adolescents. The first group (2001 group) consisted of teens 17 years old and younger who gave birth at Barnes Jewish Hospital in 2001 and participated in Centering groups through the Teen Pregnancy Center (N=144). The second group (1998 group) consisted of all teens, 17 years old and younger, who gave birth at Barnes Jewish Hospital in 1998 and were not participants in the Centering program (N=233). These data were collected from a maternal database of patients who delivered in 1998 at Barnes Jewish Hospital, including those with no prenatal care. Chi-square analysis, a statistical test used to assess differences in proportions, was used to analyze the differences between the Centering group and each comparison group (Polit & Beck, 2008).


Results: Pregnancy Outcomes

The Centering group had:
Preterm delivery rate = 10.5%
Incidence of LBW infants = 8.9%
Cesarean section rate = 13.7%

The 2001 comparison group had:
Preterm delivery rate = 37%
Incidence of LBW infants = 33%
Cesarean section rate = 21%

The 1998 comparison group had:
Preterm delivery rate =54%
Incidence of LBW infants = 42%
Cesarean section rate = 37%


Results: Client Satisfaction
The response rate for Evaluation I was 69% and among the respondents, the mean satisfaction rate was 9.2 on the 1 to 10 scale.
Responses to Evaluation I
Agree
n (%)
Disagree
n (%)
Uncertain
n (%)
I like the organization of my prenatal care this way (group sessions).
65 (94)
0
4 (6)
I feel that I have learned a lot about prenatal care during the sessions.
69 (100)
0
0
I am enjoying being with other pregnant women in this group.
64 (93)
0
5 (7)
I feel as if I am being prepared well for the labor/delivery process.
65 (94)
1 (1.5)
3 (4.5)
I feel as if I am being prepared well for caring for a new baby.
68 (98.5)
0
1 (1.5)


The response rate for Evaluation II was 77.9% (88 out of 113 participants).
Responses to Evaluation II: Topics Covered
Topic
Well Covered
n (%)
Covered
n (%)
Needed More
n (%)
Pregnancy issues
69 (78)
18 (21)
1 (1)
Nutrition
62 (71)
25 (28)
1 (1)
Exercise/relaxation
43 (49)
36 (41)
8 (9)
Childbirth preparation
55 (63)
32 (36)
1 (1)
Pregnancy problems
61 (69)
22 (25)
5 (6)
Infant care/feeding
52 (59)
35 (40)
1 (1)
Postpartum issues
40 (45)
34 (39)
14 (16)
Contraception
53 (60)
31 (35)
4 (5)
Communication/self-esteem
46 (52)
35 (40)
7 (8)
Abuse issues
45 (51)
32 (36)
11 (13)
Parenting
66 (75)
21 (24)
1 (1)

Responses to Evaluation II: Group Care
Question
Yes
n (%)
No
n (%)
Don't Know
n (%)
Did you get to know other women in the group?
86 (98)
2 (2)
Were you comfortable having your physical assessments in the group setting?
84 (96)
3 (3)
Would you rather have had your physical assessment in an exam room?
19 (22)
65 (74)
3 (3)
Did you feel satisfied that the assessment was adequate?
87 (99)
1 (1)
Was it OK with you to have men in the group?
84 (95.5)
4 (4.5)
Was it OK to have men present in the room during the physical assessment?
75 (85)
13 (13)
Do you think it is important to get the group together once or twice after you deliver?
85 (97)
3 (3)
Are you planning to keep in contact with any of the other group members?
50 (57)
37 (42)
1 (1)


Results: Comparison Groups
The Centering group had a lower incidence of preterm birth and LBW infants, which was a significant improvement in this outcome measure when compared to the 2001 group (p< .02) and the 1998 group (p < .05). There were no significant differences in rate of C-sections among the groups. Chi-square analysis shows a statistically significant difference in breastfeeding rates and identification of pediatric provider among teens in the Centering group and teens in the 1998 comparison group (p < .02). This is not represented in the table below. Adolescents in the Centering group had a self-reported breastfeeding rate of 46% at the time of discharge, which is significantly higher than the breastfeeding rate of the 1998 group (28%). Among those in the Centering group, 79% identified a pediatric provider at hospital discharge, compared to 52% of the 1998 group.


Demographic Characteristics and Outcomes of the Centering and Two Comparison Groups
Centering
n = 124
2001 Comparison Group
n = 144
1998 Comparison Group
n = 233
Age [mean (SD)]
15.85 (1.2)
16.5 (0.9)*
16.3 (1.2)*
African American (%)
116 (93.6)
130 (90.3)
198 (85.0)*
Caucasian (%)
6 (6.3)
13 (9.0)
35 (15.0)*
Other (%)
1 (1.0)
1 (0.7)
0 (0.0)
Preterm deliveries <37 wk (%)
13 (10.5)
^37 (25.7)
54 (23.2)*
Low birth weight <2500 g (%)
11 (8.87)
^33 (22.9)
42 (18.3)*
Cesarean births (%)
17 (13.7)
21 (14.6)
37 (15.9)

* P<.05 compared to Centering group.
^P<.02 compared to Centering group.

The authors avoid calling this work a research study, but rather, a demonstration project. Demonstrations are based on evaluations that are undertaken to answer questions about a complex program (Polit & Beck, 2008). One of the limitations of this project is that the quasi-experimental design makes it difficult to establish causal connections between interventions and outcomes. In lieu of randomizing and control-group use, this project made use of a historical comparison group. From this type of group, comparison data are gathered about a group of subjects before the implementation of the intervention (Polit & Beck, 2008). Another limitation is the self-selection of adolescents into either the Centering model or traditional prenatal care. Those choosing the Centering model may be a more motivated group of teens, which may have an influence on prenatal visit attendance and birth outcomes.

One strength of this project is the statistical significance of the comparison data with respect to the percentage of preterm deliveries and the percentage of infants born with low birth weight (as evidenced by the p value). Another strength is that the evaluations gave the participants an opportunity to report their perception of CenteringPregnancy. Likewise, these evaluation responses can be used to alter and/or improve the delivery of care within the Centering model for future clients. The limitations of this project include the self-selection of the participants to the Centering or traditional prenatal care groups, which potentiates bias. Another limitation is that the 2001 comparison group did not receive care at the Teen Pregnancy Center, which is a threat to the external validity of the study. We can learn from the strengths and limitations of this particular research, in order to construct a more reliable and valid study of this subject matter. The results of this project highlight the need for more studies to further evaluate the effect of the Centering model on improving pregnancy and birth outcomes among teens. This project can be helpful in moving forward with an inquiry that seeks to determine if the Centering model improves pregnancy outcomes among African-American teens.

Summary

This literature review supports the fact that racial disparities exist, particularly with respect to African American adolescents being more likely to have higher infant mortality rates, low birth weight infants, and preterm births. The literature review also shows that improved access to and utilization of prenatal care has the potential to improve adverse perinatal outcomes. Furthermore, the literature supports the positive effects of the Centering Pregnancy model on improving preterm birth rates, increasing birth weights, increasing knowledge about pregnancy, increasing levels of satisfaction with care, the improving the measured adequacy of prenatal care, and ameliorating self-concept and self-efficacy among those enrolled. Some of the studies failed to show generalizability, which in turn makes it difficult to confer the results to populations not included in the studies. A prospective study of a large, randomized sample to determine the validity, reliability, and generalizability of the effects of Centering Pregnancy on pregnancy outcomes is necessary. In the interest of eliminating the racial disparities among African American pregnant teens, further studies need to be done to understand the biological, psychosocial, and behavioral causes of adverse outcomes in this vulnerable population. Likewise, a comprehensive review of the research and theory emphasizes the need for an inquiry into the effects of Centering Pregnancy on the pregnant African American adolescent.


Chapter 3: Methods

Grant Application

Identify and describe the funding agency to which you will submit your proposal
The Will and Jada Smith Family Foundation (WJSFF) is a philanthropic organization whose funding focus is urban youth, education, and inner-city family welfare and support. The WJSFF focuses on supporting underprivileged children and families, educational projects for kids, and urban community development. This foundation has funded projects such as: the Lupus Foundation's research efforts for lupus treatments and cure, a library and computers in homeless shelters for families, and initiatives for disabled children at the Kennedy Krieger Institute (K. Evans, personal communication, March 4, 2010).

WJSFF is directed by Karen Evans, B.A., who reports that the organization typically distributes funds twice a year, but has no deadline for application submission. In the past, this foundation has donated as little as three thousand dollars to a cause, and as much as one million dollars to a cause. Though WJSFF has no required format or procedure for proposal submission, as a member of the Association of Baltimore Area Grantmakers (ABAG), WJSFF recommends that both for-profit and nonprofit programs use the ABAG application. However, Karen Evans disclosed that most grant-seekers can extrapolate the main points from the ABAG application. These main points include: the purpose of the fund request, a description of the need or issue, the amount of the fund request, an explanation of how the grantseeker's proposal fits the foundation's goals and grantmaking interests, the anticipated results, and a budget which includes expenses and pending sources of support if applicable (K. Evans, personal communication, February 27, 2010).

Description of the unique contributions offered by this program

As a division of the Community Hospital OB/GYN Clinic, Bright Beginnings Teen Clinic will be a midwife-run clinic seeking to serve the underserved. Bright Beginnings will provide prenatal care, birthing classes, and parenting classes based on the Centering Pregnancy model. The Centering Pregnancy model, a multidisciplinary, group approach to prenatal care, is an alternative to traditional prenatal care that combines health assessment, education, and support. Utilization of this model will provide social networking, emotional support, peer education and tangible assistance to adolescent group members. Bright Beginnings Teen Clinic will be devoted to (1) improving pregnancy outcomes in Baltimore teens, (2) providing assessment, support, and education to this unique population, (3) helping these young women to become empowered as parents and members of their community. The clientele will receive intrapartum care at the Community Hospital from the midwives, provided their pregnancies remain low-risk. If a client's pregnancy no longer fits the scope of practice for the midwives, then she will be referred to and/or co-managed by the consultant physician. For the postpartum period, a mother-baby parenting class will be offered in the group model within the first two weeks postpartum. Postpartum visits will take place between weeks six through eight, in the traditional manner. The services provided to the clientele by the midwife are billable. The Bright Beginnings Teen Clinic will utilize a large, unused conference room, an adjacent exam room, and furniture for the group sessions and private exams, which will be provided by Community Hospital for a monthly rental fee under a one year lease. Community Hospital will also allow Bright Beginnings to use hospital-based scheduling, charting, and billing systems for a fee. Salaries, benefits, and liability insurance will initially require funding until revenue is acquired from the billable services. Bright Beginnings is seeking a grant to fund the start-up capital and overhead for the first year of business.
The teen birth rate in Baltimore is calculated based on the number of teens aged 15-19 who give birth per 1,000 teens. In 2006, the teen birth rate was 66.9 per 1,000 teens for all races. Baltimore's teen birth rate was two times greater than Maryland's rate (33.6 per 1,000 teens) and 1.6 times greater than the national rate (41.9 per 1,000 teens) in 2006. In that same year, the birth rate for African American teens in Baltimore was 78.2 per 1,000 teens, and the birth rate for Latino teens was 166.3 per 1,000 teens (Baltimore City Health Department, 2008). According to the Baltimore City Health Department, pregnant teens are less likely to receive proper prenatal care and more likely to experience poor birth outcomes than older mothers (Baltimore City Health Department, 2008). The inception of the Bright Beginnings Teen Clinic will increase access and utilization of prenatal care among teens in Baltimore. Teens attending Bright Beginnings Teen Clinic will find social support within the group setting. They will develop skills and knowledge regarding pregnancy, birth and child care, and exhibit confidence in their new role of motherhood. They will become partners in their health and the health of their babies, as they acquire new knowledge and skills, and build upon current knowledge and skills.
As a part of the initial steps of program planning and implementation of this program, Bright Beginnings will apply for a tax identification number through the Internal Revenue Service. Bright Beginnings will then obtain the necessary credentials which would allow us to participate in both private and public insurance plans. Bright Beginnings, LLC will acquire a lease for its office space. The organization of staffing needs would include a renewable one-year employment contract with two midwives and a part-time office assistant. Both midwives will attend a Centering model start-up workshop. Bright Beginnings will become a Centering-approved practice through the purchase of a practice membership. Centering supplies will be ordered. Office and medical supplies will be ordered. The midwives and the office assistant will attend training sessions at the facility for the scheduling, charting, and billing computer systems. In addition, the midwives will develop a practice agreement with the Community Hospital OB/GYN Associates. Publicity and marketing plans will be initiated, particularly making use of free advertising in the City Paper and online social media. The midwives will start a flyer, pamphlet, and poster campaign which will be handed out at community health fairs and high schools. After the first year, staff expansion plans will be based on the first year growth and projections for the second year services. Likewise, a project director with experience in grantwriting will be hired as the program grows.
The American College of Nurse-Midwives (ACNM) Data Sets will be used as a data collection tool (ACNM, 1999). In addition, these data will be collected and evaluated quarterly, by the Bright Beginnings team (see Appendix D). Satisfaction surveys will be developed and handed out to the client at the final prenatal session, and at the postnatal mother/baby session. These data will be evaluated for refinements to the program. Ongoing budget planning and evaluation must take place quarterly to assess the program's financial sustainability. In the first year, financial accountability statements will be sent to the grantmaker at the sixth-month point and the twelve-month point.
Midwives serve women of all ages, races, religions, sexual orientations, and beliefs. It is important for midwives to help assure that pregnancy outcomes are optimal for all women. This program affords midwives the opportunity to utilize a healthcare model that will (1) provide social support for teens, and (2) increase access and utilization of prenatal care among teens. These are necessary components to improving pregnancy outcomes among this vulnerable group of young women.
-Centering start-up supplies, staff salaries, overhead expenses for 1st year: $256,200.00
*see Appendix C for details




Appendix A: Cover Letter

Bright Beginnings of Baltimore, LLC
1234 Bright Way
Baltimore, MD 12345
(410) 123-4567 (voice)
(410) 765-4321 (fax)
February 27, 2010

Mrs. Karen Evans
Executive Director- Will and Jada Smith Family Foundation
6614 Cross Country Boulevard
Baltimore, MD 21215

Dear Mrs. Evans,

This cover letter will serve as your introduction to Bright Beginnings of Baltimore, LLC, a collective of health care providers who seek to improve the lives of Baltimore’s pregnant teens. It is with our mutual concern for the health and well-being of African American young women that I write to you on behalf of our organization. As the Executive Director, I submit our grant proposal for your review. We are going to initiate a teen pregnancy clinic that will utilize the Centering Pregnancy group prenatal care model, in Northwest Baltimore. The midwives and staff of Bright Beginnings are members of the health care team of Community Hospital and will continue this partnership in the teen clinic.

Pregnant adolescents face tremendous challenges in their journey to motherhood and responsible adulthood. The African American pregnant adolescent (the highest constituency of pregnant adolescents in Baltimore) suffer added challenges. African American adolescents have a higher incidence of poor pregnancy outcomes, such as low birth weight, preterm birth, infant mortality, and maternal mortality (Johns Hopkins School of Public Health, 2003). This problem effects all African American pregnant teens, their infants, and the health care members that care for them. This problem is significant to women's health, as it highlights chronicity of the racial disparities that plague specific populations of women and the need for change. In addition, these teens must conquer such social challenges as finishing school, finding work, securing a safe place to live, and finding adequate childcare.

The Centering Pregnancy mode of prenatal care is a multidisciplinary approach that is an alternative to traditional prenatal care that provide assessment, education, and support. Women of similar gestational age are grouped together and meet for ten sessions throughout pregnancy and postpartum. This model empowers women with health-promoting behaviors, encouraging women to assume ownership of their health, while sharing the responsibility with the provider and the group. Facilitation of the group is focused on the self-defined needs of the group participants (Centering Health Institute, 2009). The utilization of the Centering model has been shown to positively influence pregnancy outcomes in adolescents (Klima, 2003). Centering has the potential to address the sociocultural issues specific to adolescents and may help to decrease racial disparities among African American pregnant adolescents. Similar to your organization's mission to help urban youth and to offer family support, our organization hopes to improve pregnancy outcomes through access and utilization of this model.

We are seeking start up funds for expenses related to the Centering model start up, salary and benefits for our modest staff for the first year, office space rental and overhead expenses for the first year, and office and medical supplies necessary for start up. Our services are billable services, and we project that we will become a financially sustainable entity within the first three years of business. Your investment in Bright Beginnings of Baltimore, LLC will surely make the difference in our ability to institute a teen pregnancy clinic under the group prenatal care model within Northwest Baltimore.

Thank you for your consideration.

Sincerely,


Nikki Christian, Executive Director
ENCLOSURE


Appendix B: Curriculum Vitae

Nicole S. Christian
209 Pittston Circle
Owings Mills, MD 21117
443-856-5419
nursenikki330@yahoo.com

EDUCATION ADDITIONAL COURSEWORK
Introduction to Administration in Clinical Setting 2009
*Designed a birthing center/clinical practice

AWARDS AND HONORS



WORK EXPERIENCE
CLINICAL EXPERIENCE PUBLICATIONS AND PAPERS LICENSES AND CERTIFICATIONS
Registered Nurse Board Examination (NCLEX) 2001
Maryland and Compact States Licensure--Registered Nurse current-2011
Advanced Cardiac Life Support current-2012
Basic Life Support current-2011
Neonatal Resuscitation Provider Certification current-2011

LEADERSHIP/MEMBERSHIPS
Perinatal Bereavement Committee Chairperson 2005-2007
(Sinai Hospital of Baltimore)

American College of Nurse-Midwives 2008-present
(student member)




Appendix C: Budget for grant proposal

*Start up needs through the first year*

ExpenseAmount for 1st yearDescription
Centering membership for Bright Beginnings, workshop (attendance for 2 midwives), Centering Model Start Up supplies$5420*1 year membership
*Centering handbook
*recruitment kit, patient brochures (100 count) *Centering posters (3 count)
*Mom's kit with notebook/tote/illustrated growth pamphlet (200 count)
*Facilitator's guide to Mom's notebook (2-pack) *Leader's kit (2 count)
*Centering pens (100 count)
*shipping/handling costs
Medical equipment and supplies$3500*automatic blood pressure monitor (2 count)
*electronic scale
*Doppler (2 count)
*2 air mattresses for routine fetal assessment (fundal height, Leopold's, fetal heart rate, etc)
*prenatal yoga DVD
*Belly casting supplies for 1st year
Healthy snacks for group (packaged nuts, bottled water, granola bars, cheese sticks, fresh fruits and veggies, etc)$3600$300 per month for 1st year, from wholesale club
Salaries/benefits/liability insurance (1 FTE x 2 midwives)$200,000*Salary
*medical/dental insurance
*Social Security and FICA
*Liability insurance
Salary/benefits (office assistant- 0.5 FTE -no benefits)$10,400$10/hour 20 hours per week
Overhead expensesOffice space rental and utilities $24,000

Billing Service $2880

Office Supplies $1800

Computer and software rental/service $4000





















OVERHEAD TOTAL: $32,680
OFFICE SPACE RENTAL ($2000/month):
*conference room
--conference table
--16 chairs
*exam room with lab essentials and exam supplies
--desk
--clinician chair on rollers
--patient chair x2
--PAP supplies
--culture supplies
--blood draw supplies
--speculum
--gloves
--exam table and table paper
--exam light
--trash disposal
--housekeeping service

UTILITIES:
*electricity, water, gas (heat/AC), telephone
--included in rent

MISCELLANEOUS:
*Office supplies (start up and 1st year- $150/month)
--fax/copier/scanner with supplies
--post-its, pens, paper, binders, appt cards
*Billing Service ($240/month)
*Computer (with charting software and scheduling software)
Initiating publicity and marketing$600*use of social media for advertisement (free)
*printing pamphlets and posters for high schools and health fairs


Appendix D: ACNM Data Set-Antepartum Care

DATASET ANTEPARTUM CARE.pdf

Appendix E: ABAG Common Grant Application

ABAG2003CommonFormatFinalForWebsite.doc

Appendix F: Will and Jada Smith Family Foundation


Contact information:
Karen Evans, B.A.
6614 Cross Country Boulevard
Baltimore, MD 21215
410-358-1380



References
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