CenteringPregnancy and the Current State of Prenatal Care Gina Novick, CNM, MSN Prenatal care is often credited with improving pregnancy outcomes. Yet rates of low birthweight (LBW) and prematurity have risen in recent decades, calling into question the efficacy of traditional prenatal routines. Proposals have included broadening the objectives of prenatal care beyond prevention of LBW and enriching care to provide education and support for pregnant women. CenteringPregnancy, an innovative model of prenatal care that integrates extensive health education and group support with the standard prenatal exam, incorporates many of these elements. Impediments to wider implementation of CenteringPregnancy are explored, as well as proposals for addressing these challenges. J Midwifery Womens Health 2004;49: 405– 411 © 2004 by the American College of Nurse-Midwives. keywords: consumer participation, health education, infant, low birth weight, infant, premature, patientcentered care, pregnancy, pregnancy outcomes, prenatal care, support groups, midwifery

INTRODUCTION Expressions of despair and anger over inadequacies in our health care system can be heard everywhere in the last decade, from consumers of care and providers alike. A recent report from the Institute of Medicine, Crossing the Quality Chasm, succinctly summarizes this state of affairs: The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive. . . . The frustration levels of both patients and clinicians have probably never been higher. Yet the problems remain (p. 1).1 Despite the widespread sense of the shortcomings of care, there has been little progress in restructuring outmoded health care systems. Prenatal care, one of the most widely used preventive health services in the United States,2 is beleaguered by problems of fragmentation, lack of evidence of effectiveness, and barriers to innovation. The prevailing approach to care of women during pregnancy is based largely on a century of tradition.2– 4 Questions regarding the efficacy and purpose of prenatal care have been raised and debated in the literature for decades. Although important investigations examining the content and practice of care have been published, few of their recommendations for change have been implemented.5 CenteringPregnancy (Centering) is an innovative group prenatal care model that seeks to address the concerns of consumers and professionals about the shortcomings of traditional prenatal care. This approach has recently been implemented in a number of settings throughout the United States6,7 but is not yet widely disseminated or used. This article reviews the existing recommendations for redesigning prenatal care and proposes Centering as one model that meets the recommenda-

Address correspondence to Gina Novick, CNM, MSN, 65 Wright Lane, Hamden, CT 06517. E-mail: [email protected]

Journal of Midwifery & Women’s Health • www.jmwh.org © 2004 by the American College of Nurse-Midwives Issued by Elsevier Inc.

tions of a body of research on the effectiveness of prenatal care as well as the Institute of Medicine report. Impediments to the use of Centering and some strategies for advancing this model are also reviewed. BACKGROUND: PRENATAL CARE IN THE UNITED STATES The traditional model of prenatal care was designed a century ago with the primary objective of preventing complications of preeclampsia.2,5 This program consists of an initial visit with complete history and examination, followed by approximately 13 brief, one-on-one office visits that typically last 10 to 15 minutes. During return visits, clinicians update history, conduct physical assessments, evaluate risk status, and, if time permits, answer questions or provide counseling regarding health behaviors.6 This routine has changed little over the last century. Although new technologies, tests, and interventions have been added, this has often occurred in the absence of evidence for their efficacy.8 As concerns developed about the high rate of infant mortality in the United States (ranked 28th internationally),9 the objective of prenatal care has increasingly shifted to the prevention of low birth weight (LBW), one of the major causes of infant mortality.5,10 This shift evolved over many decades, after several studies noted an association between decreased rates of LBW and increased numbers of prenatal care visits or early onset of care, particularly in medically and socioeconomically highrisk women.2,11 These studies ultimately precipitated several federal initiatives to increase access to prenatal care for low-income women.2,12 More recent reviews of the effectiveness of care have challenged the validity of earlier studies that concluded prenatal care reduces LBW.2,3,8,12,14 Overall infant mortality has declined from 10.9 to 6.8 per 1000 live births between 1983 and 2001,15 and birth weight-specific mortality has declined in the last several decades; however, rates of infants born with LBW have actually risen from 405 1526-9523/04/$30.00 • doi:10.1016/j.jmwh.2004.06.001

6.8% to 7.8%, and prematurity has risen from 9.4% to 12.1% between 1981 and 2002.16 This finding suggests that declines in infant mortality may be attributable to advances in neonatal care rather than more effective prenatal care.2,12 Several reviews of the effectiveness of prenatal care conclude that prenatal routines are based on custom or ritual,4,8 rather than on evidence of efficacy.2,5,13,14,17 Strong asserts that the lack of evidence for the effect of prenatal care on LBW is so egregious, that if prenatal care were a drug, “the Food and Drug Administration would likely not approve it due to lack of effectiveness” (p. 188).4 Beyond the question of success in reducing rates of LBW, however, we must also ask if this particular outcome should in fact be the foremost objective of contemporary prenatal care. Although current research focuses heavily on the challenge of reducing prematurity and its unfavorable consequences,10,12,17 investigations of other concerns in maternal-child health, such as preventing potentially devastating congenital anomalies, or adverse maternal outcomes, have been relatively scarce.13,17 There is also a “striking” lack of evidence that prenatal interventions are in fact responsible for those improvements in maternal morbidity and mortality that have occurred (p. 27).13 Several studies suggest that improving perinatal outcomes requires a broader view of pregnancy, as an opportunity to reach a large population of women at a receptive moment.13,14,17 Historically, approaches that emphasize family health promotion, preventive care, and family planning have been overlooked in favor of a “physician-directed system of prenatal visits in institutions, often outside a woman’s own culture and community” (p. 27).18 Recent proposals, however, suggest the development of a less medicalized model— one that addresses unhealthy behaviors and provides education and support for pregnant women and their families.3,5,10,12,13,17 These proposals also recommend that programs with the goal of modifying health behaviors that can adversely affect pregnancy should begin prior to conception.4,5,10,13,17 Although it is obviously too late to provide preconception care for a current pregnancy, prenatal care can serve as an opening to offer information and support on medical and social issues that may affect future pregnancies. Although data are limited and sometimes conflicting, health education and support have been hypothesized to lead to a sense of empowerment; and they may improve self-esteem and coping, as well as maternal and infant outcomes.3,19 –23 Psychosocial support may also decrease maternal stress and increase healthy behaviors.24 For example, educational interventions in pregnancy have been demonstrated to reduce smoking, thus reducing LBW14,25,26 and enhancing long-term maternal and family health.

Gina Novick, CNM, MSN, has been in clinical practice in a variety of settings since 1983. She is currently a doctoral student at the Yale University School of Nursing.

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In some sense, women have long ago revised the content of prenatal care to include education and support, by turning to separately run childbirth preparation classes and, more recently, to online chatrooms. However, although childbirth education programs often contain pregnancyrelated educational content, they historically have had the primary purpose of preparation for birth and thus are not designed to address comprehensive educational and support needs throughout pregnancy. In addition, although childbirth education programs may indeed be beneficial and satisfying to many women, many low-income families are unable to attend these programs due to logistical barriers. Thus, childbirth education programs may be too little, too late, for too few women. Although questions of effectiveness and objectives proliferate, there is little research on the experience or satisfaction of consumers with the current approach to prenatal care, partly because most research has examined outcomes or settings rather than processes or approaches to care.27 It might also be noted that although clinician satisfaction with prenatal care is not well studied, some anecdotal evidence suggests that obstetric providers are experiencing burnout and, as the Institute of Medicine report observes, many clinicians are dissatisfied with systems of care.1 In summary, studies have drawn conflicting conclusions about the success of prenatal care in improving perinatal outcomes. However, they agree on the need for additional research on effectiveness as well as the need to modify the content and practice of prenatal care. Proposals for research have included the examination of other outcomes besides LBW, such as maternal complications, the impact of prenatal care on health-related behaviors and health care use, and outcome disparities among different socioeconomic, demographic, and cultural groups.2,5,13,17 Proposals for modification of practice have included augmenting prenatal care with education and social support and to address broader social determinants of health.3,5,10,12,13,14,17 The redesign of care to address this wide range of factors is a radical idea, because the notion that prenatal care should be “directed solely toward improving the outcomes of pregnancy” is “hard to dislodge” (p. 634).10 However, if the objectives of prenatal care were expanded beyond improving specific biomedical outcomes, prenatal care might eventually take full advantage of its unique role as a “vital gateway into ongoing health care for women” (p. 476).14 In view of the many deficiencies of traditional prenatal care, increased access to our current system of care is not what is needed. The Institute of Medicine formulated 10 guidelines for creating a health system that better meets patients’ needs.1 These include: designing care that is customized to patient choices and preferences, shared decision making, and the free flow of information between patient and provider (Table 1). These guidelines imply that redesigning prenatal care requires going beyond simply Volume 49, No. 5, September/October 2004

Table 1. Institute of Medicine Recommendations for Redesigning Prenatal Care Care based on continuous healing relationships Customization based on patient needs and values The patient as source of control Shared knowledge and the free flow of information Evidence-based decision making Safety as a system property Transparency Anticipation of needs Continuous decrease in waste Cooperation among clinicians Source: Institute of Medicine.1

incorporating education and support into the existing model of care—it requires an entirely new paradigm of care. AN ENRICHED MODEL OF PRENATAL CARE—CENTERINGPREGNANCY One new model of prenatal care, CenteringPregnancy, has been in use since 1994, when it was developed and piloted by a certified nurse-midwife, Sharon Schindler Rising. Rising developed this model after experience with successful family-centered approaches to prenatal care and in recognition of the repetitiousness of one-on-one prenatal care for providers. Centering provides prenatal care to groups of 8 to 12 women of similar gestational age in an ongoing group. The group stays together for the duration of pregnancy.6 After an initial visit in which history, physical examination, and laboratory testing are done on a one-onone basis, subsequent visits consist of group sessions lasting 90 to 120 minutes, that women in the group attend according to a standard prenatal visit schedule. Many women bring their partners or another support person to Centering groups. When they arrive for a session, women first perform self-assessment and recording of weight, blood pressure, and urine, with assistance from medical staff if needed. The prenatal examination is then provided by a clinician (nursemidwife, nurse-practitioner, or physician) in the group setting. At this time, the clinician reviews the client’s history and orders appropriate laboratory testing or ultrasounds. The woman has the opportunity to ask questions of the provider, and if she has concerns that might be of general interest, she is encouraged to share them during group discussion time. Arrangements can also be made for follow-up for medical or personal issues requiring more time or privacy.6 Women and families who are not being examined chat informally over refreshments, review their charts, and fill out worksheets that facilitate the discussion that follows.6 This eliminates unproductive patient waiting time and allows families to become better acquainted. After physical assessments are completed, the remainder of the session consists of group discussion. Content includes, but Journal of Midwifery & Women’s Health • www.jmwh.org

is not limited to, nutrition, early pregnancy concerns and self-care, substance abuse, preparation for childbirth, adaptation to the postpartum period, infant feeding, contraception, and parenting. Handouts and written information supplement the discussion. In addition to physical assessment and education, Centering also includes a third, and possibly most important element: group interaction. The format, facilitated group discussion, encourages a broad scope of topics, with concerns raised by the women themselves and responses and support often provided by the group members. Among the many factors that enable patients to change as a result of facilitated group interaction are the instillation of hope, confirmation that their problems are not unique, receipt and offering of support and advice, and interpersonal learning.28 Centering is currently paid for by insurance carriers as prenatal care at standard rates. In some places, additional payment is made for preparation for childbirth services at the standard rates reimbursed for attendance at childbirth education classes (Rising, personal communication, July 23, 2003). Thus, Centering is an innovative, patient-centered model of prenatal care that offers the possibility of replacing an outmoded system of care with one that meets the recommendations of several research reports on prenatal care effectiveness. It also meets almost all of the Institute of Medicine’s recommended rules for the redesign of health care processes (Table 1). Yet, despite its apparent advantages, Centering is not well known and faces many barriers to wider use. OBSTACLES TO CHANGE The Institute of Medicine notes that many dedicated providers already strive to give quality care that is consistent with their guidelines, but they are thwarted by poorly designed systems that are resistant to change.1 In addition to systemic impediments to innovation, there are several other barriers to wider implementation of Centering. First, conventional prenatal care has assumed an “aura of indispensability” among medical providers and policy makers (p. 38).4 This is due in part to the popularity of the notion that traditional prenatal care is a cost-effective public health intervention that succeeds in preventing LBW.14 But as noted above, this notion may be flawed (apart from the paucity of evidence that prenatal care does reduce LBW). The original studies that concluded prenatal care was cost-effective had a variety of methodological faults that may have underestimated costs and overestimated benefits of care.29 Furthermore, as Alexander and Kotelchuck point out, the characterization of prenatal care as a preventative public health intervention, derived largely from prenatal care’s link with auxiliary programs such as nutrition and social services, may be incorrect, given that the centerpiece of prenatal care is actually a medical obstetric visit.2 As a result of these perceptions, however, a 407

perinatal advocacy network has evolved, consisting of numerous overlapping medical and social service programs with the principal goal of preventing LBW; a central strategy for achieving this goal has been to develop programs that aim to improve access to conventional prenatal care. Another barrier to wider use of Centering may be the attitudes and beliefs of some consumers and professionals. Although groups actually offer patients more contact time with clinicians and increased customization of care, many people assume that a system of one-on-one visits enhances intimacy and individualization. In addition, many women and clinicians are comfortable with a familiar approach and may be hesitant to consider a new model. According to Yalom, although interactive group processes are quite successful in bringing about interpersonal change, the effectiveness of groups is often underestimated in a health care system that sometimes mistakes the “appearance of efficiency for true effectiveness” (p. xiv).28 Thus, care in groups may be seen by some as intrinsically inferior to one-on-one care. Furthermore, learning to facilitate groups can be a challenge,6,28 and even skilled practitioners require training. This, in turn, requires institutional investment in clinician education. Finally, current payment policies lack incentives for correcting quality problems. According to the Institute of Medicine, efforts to improve quality may require financial risk in the form of initial expenditures not paid for by insurers. Thus, an institution may lose revenues and additional resources may not be available to sustain such projects. The most common payment methods, therefore, could create obstacles to innovation.1 In summary, obstacles to change are comprised of several factors: the common perception of consumers, clinicians, and policy makers that prenatal care is a costeffective public health intervention; provider and consumer familiarity with individual care compared to group processes; and financial impediments to institutional innovation. FROM PROTOTYPE TO PRACTICE AND POLICY: A RECIPE FOR CHANGE These obstacles are by no means trivial. However, given recent calls for the overall redesign of health care and prenatal care in particular, the time may be right for an alternative model. In addition, current emphasis on the increasing incidence of LBW and prematurity provides an opportunity to redefine the problem and to advocate for the expansion of the content as well as the objectives of prenatal care. For example, the growing public attention being given to the issue of LBW by researchers, media,30 and organizations such as the March of Dimes,31 may present a “policy window” (p. 166)32—an opportunity to reframe the goals of prenatal care and present Centering as a model to meet those new goals. 408

To take advantage of this policy window, however, Centering’s effectiveness in improving outcomes must first be demonstrated. Furthermore, professionals, the public, and policy makers must be educated about the potential benefits of the model; and avenues for financing research and delivery of care need to be fully explored. Thus, a three-pronged program, which consists of 1) research, 2) education/dissemination, and 3) securing funding and reimbursement, is needed. Research Research to Date The paucity of funded and published research on Centering is one of the great impediments to demonstrating its value, as well as to disseminating the model. Despite the lack of evidence that traditional, one-on-one prenatal care is effective, as a challenger to the status quo, a burden of demonstrating effectiveness rests on Centering’s shoulders. Other innovative approaches to care have faced this challenge too, such as freestanding birth centers compared to hospital birth.3 Although birth centers have not become the predominant model, research has nevertheless been instrumental in educating the public and professionals regarding its safety,3 allowing this approach to gain wider acceptance. To date, published data on Centering consists of three reports. One is a pilot study of 111 women who received Centering care, which suggests that there may be a decrease in emergency room visits for women who are enrolled in Centering (compared to a convenience sample), and high patient satisfaction.6 Limitations of the study include lack of randomization and small sample size. More recently, a demonstration project evaluated outcomes in 159 pregnant adolescents who received Centering care.33 Outcomes of Centering participants were compared with outcomes of two different convenience sample groups that delivered at the same institution. There was a statistically significant decrease in LBW and prematurity in infants born to adolescents in the Centering groups compared with the two cohorts (P ⬍ .02 and P ⬍ .05, respectively). Breastfeeding rates at discharge were also significantly higher in the Centering subjects than in the one comparison group for which these data were available (P ⬍ .02). The primary limitations of this evaluation include lack of randomization, convenience sample cohorts, incomplete data for comparison groups, and statistically significant differences in age and ethnicity between Centering and comparison subjects. A larger, matched cohort study compared outcomes of care for 458 women, half of whom enrolled in Centering, and half of whom enrolled in traditional care at these same settings.34 Centering subjects had longer gestations (P ⬍ .001), and the infants of women in the Centering cohort had heavier birth weights (F ⫽ 7.68; P ⬍ .01). There was a statistically and clinically significant increase in the birth weights in preterm infants born to mothers in the Centering groups compared with the birth weights of preterm infants Volume 49, No. 5, September/October 2004

in the control group: (2397.8 versus 1989.9 g; F ⫽ 5.66; P ⬍ .05). The principal limitation of this study is lack of randomization; however, the matched design reduces the likelihood of selection bias. Currently, Yale University School of Epidemiology and Public Health is conducting a 5-year, randomized, controlled trial of Centering funded by the National Institute for Mental Health. Women entering care in public health clinics in two cities will be randomly assigned to one of three groups: Centering, traditional care, and an enhanced version of Centering that includes HIV/STD skills development. The principal outcomes will be maternal outcomes such as STD incidence, repeat pregnancy, and behavioral changes that reduce health risk such as unprotected intercourse; perinatal outcomes such as LBW, gestational age, and pregnancy complications; and health care use (CPPA, 2002, HRSA Grant Application; J. R. Ickovicks, personal communication, July 24, 2003).

Future Research Needs Future research on Centering needs to address a wide range of issues, which include the following: Safety and effectiveness, including standard outcome measures such as length of labor, cesarean birth rate, prematurity, and LBW Impact on health behaviors such as smoking, prenatal diet, and breastfeeding Impact on broader determinants of health such as infant care, family violence, contraception, repeat pregnancy, social support, and empowerment Health care system use, including onset of care, attendance, wait times, postpartum follow-up, and emergency room visits Experience of the process of group care by participants and satisfaction with the model Success in varying patient populations Cost-effectiveness, including costs of implementing a new program, and indirect long-term benefits Coverage by third-party payers Staffing issues (e.g., support staff and training time) Barriers to implementation Success of basic and advanced training programs and adaptation of training programs to meet the needs of different types of practitioners (e.g., midwives, physicians, and nurse-practitioners) Impact on clinicians, including the experience of group facilitation and satisfaction with the model Model integrity as Centering is adapted to the needs of different settings, socioeconomic groups, and cultures Journal of Midwifery & Women’s Health • www.jmwh.org

Education/Dissemination Clinician Education As noted by the Institute of Medicine, to prepare the clinical workforce for redesigned systems of care, clinical education programs need extensive restructuring. Among the proposed changes are teaching “new skills in communication and support for patient self-management” and collaborative management between providers and patients (p. 211).1 One approach for meeting these educational goals in the area of prenatal care is to include modules on group prenatal care and to offer clinical rotations for nursing, midwifery, and medical students through academic sites that provide Centering. In addition to changes in the curricula of basic training programs, retooling is necessary for practicing clinicians, non-clinical personnel, and management.1 Although approaches to continuing education vary in their effect on health professional performance, improvement can result from workshops and outreach visits.35 Basic training and advanced training for leading Centering groups are already provided through workshops, and a system for ongoing guidance and support of Centering providers is currently being formed. However, funding is needed to further develop such programs and to support institutions that seek to implement the model. Influence of Professional Organizations The support of perinatal advocacy organizations can be important in influencing the opinions of consumer and policy makers in government. Such support helps in obtaining funding from foundations that might further the research, education, or dissemination of new ideas or projects. For example, if professional organizations, such as the American College of Nurse-Midwives (ACNM), the American College of Obstetricians and Gynecologists (ACOG), or the American Public Health Association (APHA), were to write position statements that advocate making Centering more widely available as an option for consumers seeking prenatal care, this might encourage the interest of policy makers and funding organizations in the model. ACNM could also promote incorporation of Centering training in midwifery education programs by including knowledge of Centering in ACNM “Core Competencies.” In addition, influential groups that are seeking to improve care for women and children, such as the March of Dimes, can be enlisted to support the model. Securing Funding and Financing Care Although research, education, and diffusion of the model are top priorities, these will only be possible if adequate funding is procured for these activities, and if Centering care is fully covered by third-party payers. 409

Funding for Research Funding for research on Centering could come from public agencies such as The National Institutes for Health, and the Agency for Healthcare Research and Quality, or the Maternal and Child Health Bureau of the Department of Health and Human Services. The Institute of Medicine suggests that the Department of Health and Human Services establish “state-of-the-art-processes” for priority medical conditions and provide the resources to address important research questions.1 Centering would be a suitable candidate for such funding. Institutional Funding Organizations, such as the not-for-profit CenteringPregnancy and Parenting Association, that are developing and disseminating education about Centering need operational funding from private and public sources. This is essential to develop organizational infrastructures, conduct workshops, train workshop leaders, develop site accreditation, further develop materials used by Centering sites, and provide consultation services. Financing Delivery of Care

The author thanks Salley S. Cohen, RN, PhD, FAAN, for her detailed and helpful comments on this article.

REFERENCES 1. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington (DC): National Academy Press, 2001. 2. Alexander GR, Kotelchuck M. Assessing the role and effectiveness of prenatal care: History, challenges, and directions for future research. Public Health Rep 2001;116:306 –6. 3. Rooks JP. Midwifery and childbirth in America. Philadelphia (PA): Temple, 1997. 4. Strong TH Jr. Expecting trouble: What expectant parents should know about prenatal care in America. New York: New York University Press, 2000. 5. U.S. Department of Health and Human Services, U.S. Public Health Service. Caring for our future: The content of prenatal care. Washington (DC): U.S. Public Health Service, 1989. 6. Rising SS. Centering pregnancy: An interdisciplinary model of empowerment. J Nurse Midwifery 1998;43:46 –54. 7. Rising SS, Kennedy HP, Klima CS. Redesigning care through CenteringPregnancy. J Midwifery Womens Health 2004;49:398 – 404.

For Centering to be sustainable, institutions need full payment from insurers for educational as well as medical aspects of care. Payment from public and private insurers will ensure access to Centering care for women of all income levels. Health care delivery sites also need funding to cover the startup costs of implementing a new program. The Institute of Medicine addressed this issue, advocating that the Center for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality study ways for payment methods to support programs aimed at quality improvement. They also recommend that resources be provided to fund innovative projects that deliver health care services.1

8. Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gu¨ lmezoglu M. Patterns of routine antenatal care for low-risk pregnancy (Cochrane Review). In The Cochrane Library, Issue 4. Chichester (UK): John Wiley & Sons, Ltd., 2003.

SUMMARY

12. McCormick MC. Prenatal care: Necessary but not sufficient. Health Serv Res 2001;36:399 –403.

Compelling reports of government and private agencies as well as the body of research on the effectiveness of prenatal care point to the profound inadequacies of our health care system in general, and prenatal care in particular. These documents offer a road map for change, and their publication opens a window of opportunity for action. CenteringPregnancy is a new paradigm of prenatal care that addresses many of the concerns articulated in these reports, but it remains largely unknown to providers, consumers, and policy makers. Although Centering has the potential to revolutionize prenatal care in America, many impediments to widespread implementation remain. With further research as well as intensive activity in the policy arena, Centering may be recognized as a viable alternative to the current flawed system of prenatal care. 410

9. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Health United States [Internet] 2002. [cited January 16, 2004]. Available from: http://www.cdc.gov/nchs/data/hus/tables/2003/03hus025.pdf. 10. Klerman L. A public health perspective on “caring for our future.” In Merkatz IR, Thompson JE, editors. New perspectives on prenatal care. New York: Elsevier, 1990:33–42. 11. Institute of Medicine. Preventing low birthweight: Committee to study the prevention of low birthweight. Washington (DC): National Academy Press, 1985.

13. Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatr Perinat Epidemiol 2001;15(Suppl 1):1–42. 14. Fiscella K. Does prenatal care improve birth outcomes? A critical review. Obstet Gynecol 1995;85:468 –79. 15. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2003, Trend Tables [Internet]. [updated January 5, 2004; cited April 22, 2004]. Available from: http://www.cdc. gov/nchs/data/hus/tables/2003/03hus019.pdf. 16. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. National vital statistics reports, Volume 52, No. 10 [Internet]. [updated February 17, 2004; cited April 22, 2004]. Available from: http:// www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_10.pdf.

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17. McCormick MC, Siegel JE. Recent evidence on the effectiveness of care. Ambul Pediatr 2001;1:321–5. 18. Thompson JE. The history of prenatal care. In Merkatz IR, Thompson JE, editors. New perspectives on prenatal care. New York: Elsevier, 1990:3–29. 19. Smith S, Carey B. Prenatal education: Quality materials empower patients to improve outcomes. Inside Case Management 1999; 6:1–6.

26. Malchodi CS, Oncken C, Dornelas EA, Caramanica L, Gregonis E, Curry SL. The effects of peer counseling on smoking cessation and reduction. Obstet Gynecol 2003;101:504 –10. 27. Handler A, Rosenberg D, Raube K, Kelley M. Health care characteristics associated with women’s satisfaction with prenatal care. Med Care 1998;36:679 –94. 28. Yalom ID. The theory and practice of group psychotherapy. 4th ed. New York: Basic Books, 1995.

20. Klima CS. Women’s health care: A new paradigm for the 21st century. J Midwifery Womens Health 2003;46:285–91.

29. Huntington J, Connell FA. For every dollar spent—The costsavings argument for prenatal care. N Engl J Med 1994;331:1303–7.

21. Hodnett ED, Fredericks S. Support during pregnancy for women at increased risk of low birthweight babies (Cochrane Review). The Cochrane Library, Issue 4. Chichester (UK): John Wiley & Sons, Ltd., 2003.

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22. Norbeck JS, DeJoseph JF, Smith RT. A randomized trial of an empirically-derived social support intervention to prevent low birthweight among African American women. Soc Sci Med 1996;43:947– 54. 23. Klerman LV, Ramey SL, Goldenberg RL, Marbury S, Hou J, Cliver SP. A randomized trial of augmented prenatal care for multiple-risk, Medicaid-eligible African-American women. Am J Public Health 2001;91:105–11.

31. March of Dimes. What is the prematurity campaign? [Internet] 2003. [cited July 23, 2003]. Available from: http://www.marchofdimes. com/prematurity/5408_5409.asp. 32. Kingdon JW. Agendas, alternatives and public policies. New York: Addison, Wesley, Longman, 1995. 33. Grady MA, Bloom KC. Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy Program. J Midwifery Womens Health 2004;49:412–20.

24. Thompson JE. Maternal stress, anxiety and social support. In Merkatz IR, Thompson JE, editors. New perspectives on prenatal care. New York: Elsevier, 1990:319 –35.

34. Ickovicks JR, Kershaw TS, Westdahl C, Rising SS, Klima C, Reynolds H, et al. Group prenatal care and preterm birth weight: Results from a matched cohort study at public clinics. Obstet Gynecol 2003;102:1061–7.

25. Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy. (Cochrane Review). The Cochrane Library, Issue 4. Chichester (UK): John Wiley & Sons, Ltd.

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50TH AMERICAN COLLEGE OF NURSE-MIDWIVES ANNUAL MEETING Be a part of the American College of Nurse-Midwives Golden Anniversary Celebration! June 10 –16, 2005 Marriott–Wardman Park, Washington, DC For more information: http://www.midwife.org/meetings/50

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