The COVID-19 pandemic has impacted the way antenatal care is being delivered in the United States, such as having fewer visits and replacing some in-clinic visits with virtual visits over telemedicine platforms. There has been some discussion of continuing some of these changes in care for low-risk pregnancies even after the pandemic ends – the pandemic is prompting a re-evaluation of routine antenatal care and how it should be delivered. Research has found that these changes align with the way that prenatal care is often provided in other countries; peer countries generally recommend fewer visits, longer intervals between visits, and less reliance on obstetric providers for routine and low-risk prenatal care (1).
Furthermore, there has been attention to increased isolation during the pandemic, and perinatal women may be particularly impacted due to the lack of typical social support (e.g., in-person new moms’ groups, visits from family and friends). The importance of social support for mental health is well documented, and it has been identified as a protective factor for postpartum depression and has other health benefits for both mom and baby (2-4). Thus, healthcare delivery models that also improve social support may be of great benefit for perinatal women.
Antenatal care is typically delivered individually in the United States, yet group models are becoming increasingly of interest given some promising findings with regards to improving birth outcomes. Such models of group prenatal care typically consist of three key components – clinical assessment, education and psychosocial support. Group perinatal care can thus provide social support while also making antenatal healthcare and education delivery more efficient and available. While comparison of group care with standard pregnancy care has been reviewed for outcomes such as preterm birth (5), less is known about the impact of group antenatal care on mental health.
A recent systematic review from Buultjens and colleagues(6) examined published studies that reported on the effect of group pregnancy care on mental health and wellbeing outcomes (i.e., stress, depression and/or anxiety) in childbearing women. Nine studies met inclusion criteria and were included in the review. All of the reviewed studies reported the primary outcome of postpartum depression, with three reporting on stress and three reporting on anxiety.
The CenteringPregnancy (CP) group philosophy was utilized across eight of the nine studies. In brief, women who participate in a CP program receive prenatal visits, acquire knowledge and skills pertaining to pregnancy and childbirth, and develop relationships with other women. Each group session lasts approximately two hours, starting with individual medical assessments and then followed by a group discussion. The curriculum focuses on topics such as nutrition, exercise, relaxation techniques, understanding pregnancy problems, infant care and feeding, contraception, communication and self-esteem, comfort measures in pregnancy, sexuality and childbearing, abuse issues, and preparation for childbirth and parenting.
The authors of this systematic review evaluated pre- versus post-test studies examining group pregnancy care and the cumulative impact on psychological health compared with outcomes of women experiencing standard (i.e., individual) pregnancy care. A comprehensive meta-analysis was not performed due to the diversity of group care content and lack of outcome measures universally reported. While varied, select results showed group prenatal care was associated with some improvement across subgroups. Specifically, women in group care at greater psychosocial risk experienced decrease in depressive symptoms compared to women in individual care. While there was no significant difference in the rates of postpartum depression in the group care model compared with standard care in five studies, results from four studies showed some positive effects of group care on depression symptoms.
There were mixed findings with the studies reporting on stress and anxiety, with some identifying significant decrease in anxiety and stress associated with group care and other studies finding no significant differences between individual care and group care participants. The authors highlight that even small effects can be meaningful, particularly in the context of preventative interventions that are relatively inexpensive.
The authors highlight some methodological considerations which made it difficult to draw generalizable conclusions across the nine studies. While outcomes related to mental health (i.e., depression, stress, anxiety) were measured, the primary purpose and target sample of each study varied widely (e.g., young women, military settings, pregnancies complicated by diabetes). The variance in time frame of group care and data collection points (e.g., from 6 weeks to 12 months postpartum) also created a challenge in terms of comparing findings across studies. Furthermore, the authors note other limitations with the included studies, such as being underpowered, having varying levels of complete data, and a lack of knowledge regarding whether or not study participants received other mental health treatments or other support (e.g., antidepressant treatment, psychotherapy).
Overall, the findings from the systematic review suggest that there may be promise for group antenatal care to benefit women’s psychological health, particularly for young pregnant women. However, more research is needed. Groups may provide additional social support, as well as standardization of antenatal care. The authors note future directions and considerations for group antenatal care. Of note, all studies included in this systematic review focused on group programs in pregnancy. It may be of interest and beneficial to expand these group models to cover postpartum care for continued support in the transition to the postpartum.
Furthermore, leveraging telehealth group programs may help to reduce barriers to prenatal care, such as transportation, long wait times, geographic constraints. The pandemic has highlighted the value of telehealth services to provide continued care; group programs offered virtually may help to decrease isolation and increase social support in addition to increasing access to healthcare services.
Rachel Vanderkruik, PhD, MSc
1. Friedman Peahl A, Heisler M, Essenmacher LK, Dalton VK, Chopra V, Admon LK, Moniz MH. A comparison of international prenatal care guidelines for low-risk women to inform high-value care. Am J Obstet Gynecol. 2020 May;222(5): 505-507.
2. K.M. Reid, M.G. Taylor. Social support, stress, and maternal postpartum depression: a comparison of supportive relationships, Soc. Sci. Res. 54 (2015) 246–262.
3. C. Pao, J. Guintivano, H. Santos, S. Meltzer-Brody, Postpartum depression and social support in a racially and ethnically diverse population of women, Arch. Womens Ment. Health 22 (1) (2019) 105–114
4. N. Jacques, C.L. de Mola, G. Joseph, M.A. Mesenburg, M.F. da Silveira, Prenatal and postnatal maternal depression and infant hospitalization and mortality in the first year of life: a systematic review and meta-analysis, J. Affect. Disord. 243 (2019) 201–208.
5. S.D. Cunningham, J.B. Lewis, F.M. Shebl, et al., Group prenatal care reduces risk of preterm birth and low birth weight: a matched cohort study, J. Womens Health 28 (1) (2019) 17–22
6. Buultjens M, Farouque A, Karimi L, Whitby L, Milgrom J, Erbas B. The contribution of group prenatal care to maternal psychological health outcomes: A systematic review. Women Birth. 2020 Dec 24:S1871-5192(20)30382-6.
This story is brought to you by Womens Mental Health.