The effects of CenteringPregnancy group prenatal care on postpartum visit attendance and contraception use

Abstract

Objective

We examined whether Medicaid-enrolled women in CenteringPregnancy group prenatal care had higher rates of (1) postpartum visit attendance and (2) postpartum uptake of contraceptives, compared to women in individual prenatal care.

Study design

We linked birth certificates and Medicaid claims for women receiving group prenatal care in 18 healthcare practices and applied preferential-within cluster propensity score methods to identify a comparison group, accounting for the nested data structure by practice. We examined five standardized, claims-based outcomes: postpartum visit attendance; contraception within 3 days; and any contraception, long-acting reversible contraception (LARC), and permanent contraception within eight weeks. We assessed outcomes using logistic regression for two treatment levels: (1) any group attendance compared to no group attendance and (2) attendance at five or more group sessions to at least five prenatal care visits, including crossovers attending fewer than five group sessions (minimum threshold analysis).

Results

Women attending at least five group sessions had higher rates of postpartum visit attendance (71.5% vs. 67.5%, p < .05). Women with any group attendance (N = 2834) were more likely than women with individual care only (N = 13,088) to receive contraception within 3 days (19.8% vs. 16.9%, p < .001) and to receive a LARC within eight weeks’ postpartum (18.0% vs. 15.2%, p < .001). At both treatment levels, group participants were less likely to elect permanent contraception (5.9% vs. 7.8%, p < 0.001). Women meeting the five-visit group threshold were not more likely to initiate contraception or LARCs within 8 weeks’ postpartum.

Conclusion

Participation in at least five group compared to five individual prenatal care visits is associated with greater rates of postpartum visit attendance. Additional engagement and education in group prenatal care may influence postpartum visit attendance.

Implications

Planning for postpartum care and contraception during prenatal care is an important strategy for connecting women to postpartum healthcare. Regardless of prenatal care model, women have low uptake of contraception in the postpartum period. Increased use of group prenatal care with its scheduled family planning discussion may help to increase postpartum contraceptive uptake. This benefit is dependent on availability of postpartum contraception options.

Introduction

Comprehensive postpartum care, including family planning, is a critical preventive health service that promotes optimal health for mother and infant [1]. Yet, as many as 40–50% of women do not attend a postpartum visit 4–6 weeks after birth despite current guidelines [2]. Low attendance rates are particularly common among women with limited resources, including those with Medicaid [3], [4], [5]. This lack of engagement with postpartum care risks delay in addressing peri- and postnatal health issues, missed opportunities for identifying problems with the physical and mental adjustments to motherhood, and planning for the healthy timing and spacing of future pregnancies [6], [7]. Acknowledging the historical context of fertility control and sterilization abuse, current best practice guidelines emphasize that each woman receive information on the full range of contraception options so she can make a well-informed, individualized choice [2], [8]. The importance of measuring patient engagement around these two metrics – postpartum visit attendance and contraceptive use – has been recognized by the National Committee for Quality Assurance (NCQA) and the Office of Population Affairs who have each developed clinical performance measures to support quality improvement efforts aimed at increasing utilization of these services [9], [10].

The CenteringPregnancy® model of group prenatal care addresses the topics of family planning and postpartum care explicitly and in greater detail compared with traditional, individual prenatal care [11]. Medical providers deliver educational content through facilitating group discussion, which fosters patient engagement and encourages women to ask questions. This model has overall demonstrated positive outcomes, including higher rates of prenatal care use and satisfaction, improvements in preterm birth rates, and higher rates of breastfeeding [12], [13], [14], [15]. One of the curriculum development goals was to optimize care and support for women in the postpartum period and address postpartum contraceptive methods [16]. Several smaller observational studies have noted that group participants have higher rates of postpartum visit attendance, are more likely to utilize contraceptive care visits, and are more likely to choose long-acting, reversible contraception (LARC) [17], [18], [19].

Larger studies with standardized measures and more rigorous approaches to addressing selection bias are needed to understand CenteringPregnancy’s impact on these metrics. We investigate this research gap through comparing these standardized quality of care measures using Medicaid claims in the context of an 18-site state-supported expansion of CenteringPregnancy group prenatal care.