A signal moment in the history of this blog was the arrival in late summer of a new ally, the birthing movement, represented by Amy Romano, the blogger at Science and Sensibility, the Lamaze International blog.

Amy gets it: participatory medicine is not just about the internet – it’s about being empowered and engaged. Her first guest post, A lifetime of participatory medicine can start with maternity care, is one of my all-time favorites.

Here’s her next – a scientifically controlled study that demonstrates how being an engaged patient produces life-altering improvements that no physician intervention has achieved. The results span all demographic boundaries and didn’t involve a bit of technology. It’s exciting; please help scrutinize.

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Guest post by Amy Romano, Science and Sensibility

In the process of reposting on my blog the archives of research summaries I wrote for a Lamaze e-newsletter from 2004-2008, I came across this summary of one of my all-time favorite randomized controlled trials. (Yes, I’m a nerd and have favorite RCTs.) I thought there was no better place to repost it than here, on e-Patients.net.

Reading this summary almost 2 years after I wrote it, I am struck by how important it is to the emerging Participatory Medicine movement. As you read it, keep in mind:

• The “intervention” – a participatory model of group prenatal care known as CenteringPregnancy – is the only prenatal intervention known to reduce the risk of preterm birth in mixed-risk populations. Preterm birth is one of the costliest conditions in our entire healthcare system, is the largest contributor to our newborn death rate, and frequently results in long-term morbidity and disability. [Please stop and read that sentence again. These results matter. —Dave]
• Although Participatory Medicine is fueled by advances in health information technology, CenteringPregnancy is a decidedly low-tech participatory intervention.
• Accordingly, it has been implemented with many disadvantaged populations – teens, low-income women, women who do not speak English, women in prison, and the list goes on.
• The organization that developed the model of care is currently testing its use in other healthcare contexts, such as mother-baby care through the first year, and chronic disease care. Participatory Medicine enthusiasts interested in learning more about group care models may wish to attend the Centering Healthcare Institute’s Third National Conference on Group Healthcare February 7-9, 2010 in San Antonio, TX

I am contributing this post to next month’s Bloggers Unite in the Fight for Preemies event, sponsored by the March of Dimes, because, as one MoD representative told me recently, “We LOVE CenteringPregnancy!”

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Group Prenatal Care Reduces Preterm Birth by One-Third, Improves Breastfeeding Success
Ickovics, J. R., Kershaw, T. S., Westdahl, C., Magriples, U., Massey, Z., Reynolds, H., et al. (2007). Group prenatal care and perinatal outcomes: A randomized controlled trial. Obstetrics and Gynecology, 110(2), 330-339. [Abstract]

Summary: In this multi-center randomized, controlled trial, investigators evaluated the effect of the CenteringPregnancy model of group prenatal care on perinatal outcomes, including preterm birth, birth weight, psychosocial outcomes, breastfeeding success, women’s satisfaction, and health care costs. Eligible women were randomized to group prenatal care (intervention group, n=653) or traditional care (control group, n=394). All women attended their first prenatal visit in the traditional one-to-one setting. For their subsequent care, women in the intervention group attended 10 prenatal sessions with approximately 7 other pregnant women due in the same month. During the group prenatal visits each woman:

• had a brief a brief one-to-one encounter with the facilitating obstetrician or midwife, conducted in a semi-private area of the group space
• conducted self-care activities such as weight checks and blood pressure monitoring and recorded the results in their own charts
• completed self-assessment worksheets to evaluate aspects of their own wellbeing, such as nutritional status, readiness for parenting, or postpartum birth control preferences
• participated in facilitated discussion with the other expectant parents and one or more healthcare professionals. While a specific topic was suggested each week, women themselves determined what the group discussed, shared advice, and answered eachother’s questions.
• had access to educational materials developed by the Centering Healthcare Institute
• shared a healthy snack with the group

Women in the control group continued to attend prenatal visits at the clinic according to the traditional schedule. Women in both groups could access a care provider between scheduled visits for problems.

Consistent with previous observational studies of the program, findings strongly favored group care. Statistically significant results (controlling for confounders) included:

• A 33% reduction in preterm birth (10% versus 14%)
• A 41% reduction in preterm birth among African American participants, who represented 80% of all participants (10% vs. 16%)
• Greater likelihood of initiating breastfeeding (67% versus 55%)
• Increased pregnancy knowledge and self-reported readiness for labor and birth
• Higher satisfaction with their prenatal care
• No differences in costs, despite women in the group care model having ten-times the duration of interaction with care providers over the course of their pregnancies (20 hours versus 2 hours). However, the cost analysis did not factor in NICU charges, which were likely lower in the CenteringPregnancy group.

Significance: That CenteringPregnancy’s effect on preterm birth has not been matched by any medical or technological intervention reinforces an important lesson about what is good for mothers and babies. It is not surprising that care that builds women’s confidence, mitigates stress, and teaches wellness and self-care would yield psychosocial benefits. What a medicalized view of pregnancy and birth too often fails to recognize, however, is that these same elements contribute to optimal clinical outcomes as well.

In pregnancy, as in birth, an approach that values medical intervention and constant technological surveillance for problems is unlikely to be effective at enhancing an essentially healthy process. In pregnancy, as in birth, building a circle of support for an expectant mother enhances her ability to care for herself and her baby and cope with unfamiliar but normal emotional and physical changes. Caring for women holistically is not just “nice,” it is good medicine.

Pregnancy is a normal physiologic state, though vulnerable to disruptions from chronic or acute stress, unhealthy behaviors such as smoking, and harmful conditions such as malnutrition or violence in the home. In the current prevailing model of prenatal care, visits are brief and counseling for nutrition, smoking cessation, and domestic violence concerns are often provided separately, contributing to fragmentation of care and creating unnecessary barriers to access. CenteringPregnancy does not demand that the woman accommodate institutional routines and navigate complex systems but arranges care around her needs instead.

This study reveals a forgotten outcome of putting the woman at the center and constructing a supportive environment around her: babies benefit, too.

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Postscript: We invite your critique of this post and its relevance to this movement. Are there weaknesses in the reasoning? While these findings seem encouraging for the cause of better outcomes, we want to be rigorous.

One thing I see is that empowering the patient (in this case the mother, mostly) to know and trust her body, and learn to care for it, seems beneficial. I know that’s an inference. What can we learn? What needs more study? —Dave