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 10 percent of pregnancies result in preterm deliveries. About one-third of preterm deliveries are preceded by preterm prelabor rupture of membranes (PPROM). Management of PPROM often involves hospital admission to the antepartum unit until delivery, which can span weeks to 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 affects Black mothers in the U.S. Non-Hispanic Black women have nearly twofold greater risk for preterm birth compared with non-Hispanic white women. Causes for this disparity are multifactorial and 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 project team originally 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. Since its inception, this program of antenatal inpatient sessions (i.e., “CAP sessions”) has grown to become a sustained and valuable offering that has helped to build community and solidarity during what can be a stressful and isolating experience of being hospitalized while pregnant. 

In the 2022-2023 academic year, this program was modified to meet the safety needs of the evolving COVID-19 pandemic by offering weekly virtual sessions for interested patients using tablets. Since the Fall of 2023, hospital COVID-19 guidelines have allowed team members to return to in-person weekly sessions, during which the team has observed increased participation by patients and consistent positive feedback on the program from patients regarding the mental and emotional benefits of CAP sessions.

Each week providers and CAP team members (medical students and undergraduates) recruit admitted patients for the weekly program. Interested patients then participate in a one-hour in-person CAP session held in the antepartum unit of Duke University Hospital. Sessions begin with introductions and a brief mindfulness activity followed by discussion and education about a particular topic or concern that is relevant to our antepartum patients. This can include common antepartum diagnoses (e.g., preeclampsia), pregnancy loss, breastfeeding, coping with stress and separation from family, caring for a NICU baby or pelvic floor physical therapy. Each CAP session is attended by both a medical student and undergraduate team member, with rotating participation that allows all CAP team members to participate in our sessions.

In 2022-2023, Team members added new session topics, such as navigating postpartum changes, self-advocacy during hospitalization, peripartum and postpartum mental health, and building strong parent-infant attachment relationships. As CAP has grown, the team continues to receive requests from individuals throughout the health system who are excited about this work and are hoping to offer their expertise. The network of topic experts has continued to grow to meet the evolving needs and requests of patients.

In 2024-2025, team members will intentionally grow and improve the program in three ways:

1. Make leadership development a priority for undergraduate students by providing formal opportunities for growth. This will include supporting students in designing and leading a patient CAP session as well as teaching a portion of one didactic session on a topic of their interest each semester. The team will provide structured feedback and mentorship so that students can improve skills such as project planning, group facilitation, interprofessional communication with health providers and patients, and teaching complex topics in engaging and accessible ways.
2. Strengthen the didactic curriculum to include the social, cultural, political and ethical domains of obstetric healthcare in addition to the clinical. This new interdisciplinary curriculum is currently being piloted. Team members will collect formal feedback in order to refine the didactic curriculum to best meet the needs of undergraduate learners and to appropriately reflect the complex landscape of reproductive healthcare.
3. Develop a formal CAP Session Guidebook to be used by future group leaders to better streamline and facilitate sessions going forward. This will include synthesizing all of the resources that have been developed over the years, including lesson plans, activities and group contacts. 

Anticipated Outputs

Sustainable inpatient antepartum group model that can be implemented across other institutions; quantitative data on obstetric knowledge for undergrads; undergraduate curriculum on obstetrics with an interdisciplinary lens; manuscripts and publications

Student Opportunities

Ideally, this project team will comprise 2-3 graduate students and 3-4 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. 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.

The interdisciplinary team will consist of graduate and undergraduate students, antepartum nurses, midwives, residents, fellows and attending physicians. Other team members include NICU physicians, lactation consultants, family support staff and social workers. The students 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 2024, the team will meet on the first Wednesday each month from 3-4 p.m. 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 visit the antepartum service to recruit patients and lead the sessions, create flyers and publicize the sessions, develop curriculum and propose new topics. Students will have the opportunity to participate directly in research and quality improvement projects if desired. All students will have the unique opportunity to receive Basic Facilitation Training. This training is applicable not only for facilitating sessions such as these but teaches 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 2024 – Summer 2025

• Summer 2024 (optional): Collect feedback on multidisciplinary curriculum piloted in 2023-2024. Complete facilitation certifications; continue weekly CAP sessions led by outgoing third-year medical students while transitioning oncoming board members to leadership positions
• Fall 2024: Continue weekly sessions, bring undergraduate students to labor and delivery for recruitment; begin undergraduate interdisciplinary obstetrics course with adjustments based on pilot course feedback; meet with undergraduates one on one to plan which CAP session and didactic session they will lead this semester; pilot undergraduate-led CAP and didactic sessions; provide feedback
• Spring 2025: Continue with weekly CAP sessions; develop CAP Session Guidebook; meet with undergraduates one-on-one to plan which CAP session and didactic session they will lead this semester; repeat undergraduate-led CAP and didactic sessions; provide feedback; gather post-curriculum assessment on obstetric knowledge from undergraduates
• Summer 2025 (optional): Continue weekly CAP sessions; finalize CAP Session Guidebook 

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 (2023-2024).

Image: Centering Pregnancy at Duke was created to bring expectant mothers and families together during pregnancy, by Duke Health