Group Multimodal Prenatal Care and Postpartum Outcomes

Abstract

Importance: An increasing body of evidence suggests equivalent if not improved postpartum outcomes of in-person group prenatal care compared with individual prenatal care. However, research is needed to evaluate outcomes of group multimodal prenatal care (GMPC), with groups delivered virtually in combination with individual in-person office appointments to collect vital signs and conduct other tests compared with individual multimodal prenatal care (IMPC) delivered through a combination of remotely delivered and in-person visits.

Objective: To compare postpartum outcomes between GMPC and IMPC.

Design, setting, and participants: A frequency-matched longitudinal cohort study was conducted at Kaiser Permanente Northern California, an integrated health care delivery system. Participants included 424 individuals who were pregnant (212 GMPC and 212 frequency-matched IMPC controls (matched on gestational age, race and ethnicity, insurance status, and maternal age) receiving prenatal care between August 17, 2020, and April 1, 2021. Participants completed a baseline survey before 14 weeks' gestation and a follow-up survey between 4 and 8 weeks post partum. Data analysis was performed from January 3, 2022, to March 4, 2024.

Exposure: GMPC vs IMPC.

Main outcome measures: Validated instruments were used to ascertain postpartum psychosocial outcomes (stress, depression, anxiety) and perceived quality of prenatal care. Self-reported outcomes included behavioral outcomes (breastfeeding initiation, use of long-acting reversible contraception), satisfaction with prenatal care, and preparation for self and baby care after delivery. Primary analyses included all study participants in the final cohort. Three secondary dose-stratified analyses included individuals who attended at least 1 visit, 5 visits, and 70% of visits. Log-binomial regression and linear regression analyses were conducted.

Results: The final analytic cohort of 390 participants (95.6% follow-up rate of 408 singleton live births) was racially and ethnically diverse: 98 (25.1%) Asian/Pacific Islander, 88 (22.6%) Hispanic, 17 (4.4%) non-Hispanic Black, 161 (41.3%) non-Hispanic White, and 26 (6.7%) multiracial participants; median age was 32 (IQR, 30-35) years. In the primary analysis, after adjustment, GMPC was associated with a 21% decreased risk of perceived stress (adjusted risk ratio [ARR], 0.79; 95% CI, 0.67-0.94) compared with IMPC. Findings were consistent in the dose-stratified analyses. There were no significant differences between GMPC and IMPC for other psychosocial outcomes. While in the primary analyses there was no significant group differences in perceived quality of prenatal care (mean difference [MD], 0.01; 95% CI, -0.12 to 0.15) and feeling prepared to take care of baby at home (ARR, 1.09; 95% CI, 0.96-1.23), the dose-stratified analyses documented higher perceived quality of prenatal care (MD, 0.16; 95% CI, 0.01-0.31) and preparation for taking care of baby at home (ARR, 1.27; 95% CI, 1.13-1.43) for GMPC among those attending 70% of visits. No significant differences were noted in patient overall satisfaction with prenatal care and feeling prepared for taking care of themselves after delivery.

Conclusions: In this cohort study, equivalent and, in some cases, better outcomes were observed for GMPC compared with IMPC. Health care systems implementing multimodal models of care may consider incorporating virtual group prenatal care as a prenatal care option for patients.

Figure 1.. Study Follow-Up Flow Diagram

^aIncludes 3 partially completed.

Figure 2.. Associations Between Group Multimodal Prenatal Care (GMPC) and Postpartum Psychosocial and Behavioral Outcomes and Perceived Quality of Prenatal Care

Associations between GMPC and postpartum mental health outcomes (A) and postpartum sleep and social support (B). ARR indicates adjusted relative risk; DS1, dose-stratified, at least 1 visit required; DS5, dose-stratified, at least 5 visits required; DS70%, dose-stratified, at least 70% of visits required; IMPC, individual multimodal prenatal care; and MD, mean difference. ^aDifference in sample sizes due to partial completions of postpartum survey. ^bAdjusted for race and ethnicity, age at pregnancy onset, annual household income level, parity, gestational age at baseline survey completion, and baseline score category on outcome scale. ^cScore of 14 or greater on the Perceived Stress Scale. This indicates moderate to severe perceived stress. ^dScore of 10 or greater on the Patient Health Questionnaire depression scale.This indicates clinically significant depressive symptoms. ^eScore of 10 or greater on the Generalized Anxiety Disorder 7-item scale. This indicates clinically significant depressive symptoms ^fPittsburgh Sleep Quality Index Score. Range: 0 (better) to 21 (worse). ^gMedical Outcomes Study Social Support Survey score. Range: 1 (low) to 5 (high).

Figure 3.. Associations Between Group Multimodal Prenatal Care (GMPC) and Breastfeeding and Postpartum Long-Acting Reversible Contraceptive (LARC) Intention

ARR indicates adjusted relative risk; DS1, dose-stratified, at least 1 visit required; DS5, dose-stratified, at least 5 visits required; DS70%, dose-stratified, at least 70% of visits required; and IMPC, individual multimodal prenatal care. ^aAdjusted for race and ethnicity, age at pregnancy onset, annual household income level, parity, and gestational age at baseline survey completion. ^bAny self-reported breastfeeding since birth. ^cSelf-reported intention to use an LARC method in the postpartum period.

Figure 4.. Associations Between Group Multimodal Prenatal Care (GMPC) and Perceived Quality of and Satisfaction With Prenatal Care

Outcomes assessed at postpartum survey for association between GMPC and perceived quality of care (A) and satisfaction with prenatal care (B). ARR indicates adjusted relative risk; DS1, dose-stratified, at least 1 visit required; DS5, dose-stratified, at least 5 visits required; DS70%, dose-stratified, at least 70% of visits required; and IMPC, individual multimodal prenatal care. ^aQuality of Prenatal Care Questionnaire assessed at postpartum survey. Total 46-item mean score, range: 1 (worse) to 5 (better). ^bAdjusted for race and ethnicity, age at pregnancy onset, annual household income level, parity, and gestational age at baseline survey completion.