Background

Preterm birth, or delivery before 37 weeks gestational age, is a major cause of illness and death in newborn babies’ first month. In the U.S., about one in ten pregnancies results in preterm delivery. About one in three preterm deliveries is preceded by preterm prelabor rupture of membranes (PPROM). Management of PPROM often involves hospital admission to the antepartum unit until delivery, which can last weeks or even months. Pregnant people admitted to the antepartum unit often experience loss of their normal psychosocial support systems, ability to work and sense of autonomy in their health decision-making. 

Preterm birth and PPROM disproportionately affect Black mothers in the United States. Non-Hispanic Black women have nearly two-fold greater risk for preterm birth compared with non-Hispanic white women. Causes for this disparity are poorly defined, but increased psychosocial stress and inadequate access to prenatal care for Black women are often cited as reasons. 

In recent years, the U.S. has placed maternal/child health as one of its three main global health goals through policy interventions to increase access to prenatal and emergency obstetric care. Additionally, new care models are aiming to address the psychosocial and socioeconomic factors contributing to preterm birth.

In the outpatient setting, group prenatal care models such as CenteringPregnancy© have shown improved pregnancy outcomes such as decreased racial disparities in preterm births. No studies to date have attempted to apply the concepts of connectedness and group prenatal education in the inpatient setting. In a pilot study of an inpatient centering model for the Duke Hospital antepartum service, women enjoyed being brought together to create a community. Participants had significantly longer pregnancies, with greater effect among Black women. There were also improvements in breastfeeding rates after the women gave birth.

Project Description

This multiyear project adapted the CenteringPregnancy group model — traditionally used as an outpatient service — to an inpatient antepartum service by expanding a pilot study performed in 2019-2020. In 2023-2024, team members will continue this work by developing and implementing a sustainable inpatient antepartum intervention through virtual antenatal patient sessions (“CAP sessions”) that can benefit pregnant women and their babies by increasing length of pregnancy and breastfeeding rates. 

The intervention will foster community in a way that supports emotional and mental well-being. Providers and team members will recruit admitted patients and enroll them in the CAP program. Patients will participate in weekly one-hour virtual CAP sessions. Sessions will consist of a brief mindfulness activity followed by discussion and education about a particular topic or concern. These could include common antepartum diagnoses, pregnancy loss, breastfeeding, coping with separation from family and caring for a baby in the neonatal intensive care unit. Team members will be directly involved in the weekly sessions, rotating roles on a monthly basis. 

The team will also initiate a quality improvement project with the goal of identifying areas in which the CAP program can better meet the needs of antepartum patients and foster meaningful relationships. Team members will increase interactions with antepartum patients — visiting with patients the day after CAP sessions to check in and perform an informal needs assessment based on the qualitative method of semistructured interviewing. Through this initiative, team members will uncover aspects of the CAP program that are functioning well, barriers to participation and potential areas for program improvement. 

The insights learned from this initiative will help to advise future program topics, identify specialists to join sessions and adapt program activities. Information gained from this pilot project may also inform future Institutional Review Board (IRB) development to further identify opportunities to improve the CAP program.

Anticipated Outputs

Sustainable inpatient antepartum group model that can be implemented across other institutions; quantitative data on obstetric knowledge for undergraduates; interdisciplinary undergraduate curriculum on obstetrics; quality improvement report based on internal QI project to outline future needs; manuscripts and publications

Student Opportunities

Ideally, this project team will include 3-4 graduate students and 4 undergraduate students. Interested students will likely be from health-related, humanities or bioethics majors and programs. Prospective team members should be prehealth and in interdisciplinary medical-related fields. Bilingual members with Spanish fluency are welcome given the diverse population of patients the team will engage. Ideally one member of the team will be artistically inclined and contribute to the art therapy component of curriculum design and design advertisement and recruiting for the project.

In addition to graduate and undergraduate students, the team will include antepartum nurses, midwives, residents, fellows and attending physicians, NICU physicians, lactation consultants, family support staff and social workers. Student team members and the CAP team advisor will meet weekly to discuss each week’s CAP plan, and the entire team will meet monthly to discuss overall progress and feedback. 

In Fall 2023, the whole team will meet on the first Wednesday of each month from 3:00-4:00 p.m. Graduate student leaders will meet biweekly on Mondays from 1:30-2:30 p.m. to discuss challenges, successes and hand-off roles at the end of each month. 

Students will participate in rounding with the antepartum service to recruit patients and lead the sessions, create flyers and publicize the sessions, develop the curriculum and conduct surveys and interviews. Students will have the opportunity to participate directly in research and quality improvement projects. All students will have the unique opportunity to receive basic facilitation training, which is applicable for facilitating sessions and learning critical skills useful in any group setting. 

Graduate students will have the unique opportunity to strengthen their communication and facilitation skills by recruiting patients, working with an interdisciplinary team and leading CAP sessions. They will also gain leadership experience by working in each of the domains of this project.

Timing

Summer 2023 – Summer 2024

• Summer 2023 (optional): Complete facilitation certifications; continue weekly CAP sessions led by outgoing third-year medical students while transitioning oncoming board members to leadership positions
• Fall 2023: Continue weekly sessions; bring undergraduate students to labor and delivery for recruitment; begin undergraduate course concerning basics of obstetric care and pilot multidisciplinary course content; begin collecting information for quality improvement project
• Spring 2024: Continue with weekly CAP sessions; develop formal curriculum with multidisciplinary focus; continue collecting information for quality improvement project and assess findings; gather postcurriculum assessment on obstetric knowledge from undergraduates
• Summer 2024 (optional): Continue weekly CAP sessions; reach out to new CAP “experts” to create CAP curriculum for the year 

Crediting

Academic credit available for fall and spring semesters; summer funding available

See earlier related team, Community for Antepartum Patients (CAP): Establishing an Inpatient Model for Group Prenatal Care at Duke (2022-2023).

Image: Video still from CenteringPregnancy® at Duke Family Medicine Center, by Duke Family Medicine and Community Health