Supportive Pregnancy Care
What is Supportive Pregnancy Care?
Supportive Pregnancy Care is a flexible group prenatal care program that aligns with prenatal care guidelines established by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP). Supportive Pregnancy Care is delivered in a group and includes all elements of prenatal care and education.
Group size can vary, but optimal size is approximately 8-12 women with similar due dates, to maximize interaction and provide a rich experience to all women. Group sessions are co-led by two facilitators using a patient-centered leadership style. Group sessions focus on issues of pregnancy, labor and delivery, infant care, family planning and post-partum maternal care. A woman can expect to attend approximately 10 group sessions during her pregnancy, each lasting 90-120 minutes.
At each group session, women are empowered to perform their own self-care by measuring and recording their own weight, blood pressure and gestational age. A licensed obstetric provider meets individually with each woman to perform a physical assessment and discuss specific concerns. This occurs in a semi-private area within the group space.
Did the March of Dimes create Supportive Pregnancy Care?
Yes. A team of March of Dimes staff and consultants created the conceptual framework of Supportive Pregnancy Care as an innovative vehicle to achieve equity in birth outcomes. All materials to support the marketing, implementation, and evaluation of the program were created by March of Dimes. Funding to support the development of the program was provided by UnitedHealth Group.
How is Supportive Pregnancy Care different from traditional prenatal care?
Supportive Pregnancy Care couples the clinical care received in traditional prenatal care with a significant amount of prenatal education, all in a group setting where women and the health care providers form a network of mutual support. Women in SPC on average will spend 90-120 minutes per month with their health care provider, as compared to the average of 15 minutes of direct time with the provider that most women experience in traditional individual prenatal care.
Does Supportive Pregnancy Care meet the national guidelines for prenatal care?
Yes. Supportive Pregnancy Care is in alignment with prenatal care guidelines set forth by ACOG and AAP.
Is there evidence to support group prenatal care?
Yes. Evidence shows that prenatal care delivered in a group leads to better care with better outcomes. For example, when compared to women receiving traditional individual prenatal care, women who participate in group care:
- Are at reduced risk for preterm birth and having a baby with low birthweight or small for gestational age (Ickovics, Earnshaw, Lewis, Kershaw, Magriples, Stasko et al., 2016)
- Have babies who spend fewer days in a newborn intensive care unit (NICU) (Ickovics, Kershaw, Westdahl, Magriples, Massey, Reynolds et al., 2007)
- Have higher breastfeeding initiation and duration (Ickovics et al., 2007)
- Demonstrate better prenatal knowledge, greater readiness for labor and birth and higher satisfaction with their prenatal care services (ACOG, 2018; Ickovics et al., 2007).
- Are less likely to have a repeat pregnancy at 6 months postpartum, thus reducing the risk of a subsequent preterm birth (Kershaw, Magriples, Westdahl, Rising & Ickovics, 2009)
These improved health outcomes have the potential to save millions of dollars in U.S. health care costs by reducing preterm birth rates and NICU admissions (Crockett, Heberlein, Glasscock, Covington-Kolb, Shea & Khan, 2017; Gareau, Lòpez-DeFede, Loudermilk, Cummings, Hardin, Picklesimer et al., 2016).
What are the benefits of Supportive Pregnancy Care? Why should my clinic implement it?
Supportive Pregnancy Care is a provider-driven, flexible, economical model that allows clinicians to determine how to form groups, for example, by trimester or by a shorter window of gestational age. SPC encourages sites to have groups that include women with risk factors such as diabetes, hypertension, substance use disorders, or HIV. SPC welcomes a broad variety of professionals to serve as co-facilitators with the licensed obstetrical provider—nurses, social workers, health educators, promotoras, patient navigators, community health workers, and medical assistants. Materials are available as resources, and clinicians determine if and how to use the materials. For example, there is a Session Guide with topic outlines that can be mixed and matched by providers during the course of group sessions to best meet the current needs of that specific group.
All program implementation materials are available electronically, thereby reducing the cost to implement the program.
Who might implement Supportive Pregnancy Care?
Each Supportive Pregnancy Care group requires one facilitator that is a licensed obstetrical provider (physician, nurse-midwife, or nurse practitioner). It is through this provider that the care is billed. Physician assistants and licensed professional midwives may also be considered billable obstetrical providers in your state. A co-facilitator is also required and can include any of the types of professionals listed in the previous answer.
+Budget, Billing, and Cost
Who pays for Supportive Pregnancy Care? How is it billed?
Supportive Pregnancy Care is billed the same way as traditional individual prenatal care. In most states, Medicaid should cover SPC and other models of group prenatal care.
Your state's Medicaid program as well as private insurers may also reimburse for other services provided during SPC, such as prenatal education, childbirth preparation, and breastfeeding education.
Does private insurance pay for SPC?
SPC is prenatal care, so if a private insurance plan covers traditional prenatal care, it should also cover SPC.
How much does Supportive Pregnancy Care cost to implement?
There are varying prices for multiple implementation options including a self-implementation option, train-the-trainer option, and full-service option including in-person training, technical assistance, and patient materials.
Is there a cost to women to participate?
Supportive Pregnancy Care is prenatal care, so the cost for the individual woman is generally covered by her insurance. If she is a self-pay patient, the charge for SPC would be the same as the clinic charges for a traditional individual prenatal care visit.
Are there ongoing costs to maintain the program?
Once established, the licensed obstetrical provider’s time is reimbursable through Medicaid and other insurance. Ongoing costs include healthy snacks for each session and any consumable materials a site chooses to use (educational materials or activity materials). There will be a modest annual fee to retain access to updated March of Dimes training and patient materials and resources. March of Dimes can provide assistance in your budget development process.
Are there grants available to help us implement SPC?
In order to make the program operational within an organization’s budget from the start, and therefore more sustainable, March of Dimes is not providing community grants to implement SPC. Instead, local March of Dimes can consider underwriting some of the costs of SPC for a site that needs the program but can’t purchase it.
+Planning and Implementation Logistics - Space, Equipment, Staffing
What are the critical steps our clinic must complete to implement SPC?
- Assess your site’s readiness using the SPC Organizational Readiness Assessment form.
- Gain buy-in from leadership and staff.
- Define anticipated outcomes.
- Organize an implementation team, including key clinical, administrative and marketing leaders.
- Assess space and equipment.
- Identify facilitators.
- Train and prepare staff.
- Schedule sessions.
- Decide how to bill for services.
- Determine your operating budget.
Is there a minimum or maximum size our practice should be to successfully implement Supportive Pregnancy Care?
There’s no hard and fast rule for how large or small a practice needs to be to be successful in implementing SPC. In general, an average of 8-10 new OB patients a week should constitute a large enough pool of patients to draw from to recruit enough women to form a cohort. The more licensed obstetrical providers you have facilitating groups, the more groups you can have. It’s recommended that at least two providers facilitate at least one group each.
What size space is needed for Supportive Pregnancy Care? What size space is needed for Supportive Pregnancy Care?
Supportive Pregnancy Care requires a room large enough to comfortably accommodate an average of 22 people: 2 facilitators and 10 women along with their support persons. You will also need adequate space within the group room to set up a semi-private area to conduct individual physical assessments with each woman. Bathrooms should be easily accessible.
Can SPC be facilitated outside the clinical space?
Yes. If a clinical site does not have sufficient space to hold the group sessions, the site can partner with a neighboring facility such as a community center or house of worship. However, it should always be easily accessible to the clinic site proper in the event of a medical emergency.
How long does it take to implement/ get SPC up and running?
It takes approximately 6 months to plan for implementing Supportive Pregnancy Care. March of Dimes offers a Six Month Timeline & Check List that identifies the specific steps to take to plan and prepare.
What does the group room look like?
The group room should be large enough to accommodate an average of 22 people. Chairs should be placed in a circle to encourage conversation. A semi-private area is created with a privacy screen and used for physical assessments. An area is also created for women to take and record their blood pressure, weight and gestational age. Nutritious snacks should be available in an accessible location within the space. Educational posters and other prenatal information can be hung on the walls.
What equipment and supplies are needed to implement SPC?
Minimal equipment and supplies are needed to implement Supportive Pregnancy Care including:
- Comfortable chairs for at least 22 people
- A privacy screen to partition off a section of the room for physical assessments
- A massage table or yoga mat to use for physical assessments
- A body weight scale for women to weigh and record their weight
- A blood pressure monitor and cuff that women can use to take their own blood pressure
- Doppler to check fetal heart tones
- Healthy snacks for participants
- Device to play music or white noise during physical assessments to enhance privacy
- Routine supplies utilized for prenatal exams at your facility including measuring tape, gloves, urine collection containers and dip sticks
- Wi-Fi accessibility so that mobile devices can be used to direct women to trusted resources during group meetings
- Patient handouts (optional)
- A variety of educational materials, games, icebreakers, stress management activities and a list of special guests to invite to group sessions
- Storage space for equipment and patient handouts; use a rolling cart if a permanent space is not available
Where do physical examinations take place?
Prenatal physical examinations are performed within the group space. A privacy screen is used to create a semi-private examination area within the room. A massage table or yoga mat can be used during the physical assessment. Playing music on a radio or mobile device during the physical assessments will enhance privacy. Playing music on a radio or mobile device during the physical assessments will enhance privacy.
What is the role of the SPC facilitator?
The role of the Supportive Pregnancy Care group facilitator is to:
- Serve as a group moderator by establishing a comfortable learning environment, allowing participants to introduce themselves, setting ground rules, introducing topics and closing sessions
- Encourage participation by allowing all participants to discuss their concerns, interests, knowledge and experiences
- Guide discussion while allowing participants the freedom to explore aspects of the topic that interest them
- Maintain a participant-centered approach and resist the temptation to teach or lecture
- Be aware of what is most important to the participants and respond accordingly, rather than merely following a predetermined agenda or script
Who can be a facilitator of SPC?
Group sessions are co-led by two facilitators. At least one facilitator must be a licensed obstetric provider (physician, certified nurse-midwife, or advanced practice nurse). It is through this provider that the care is billed. Physician assistants and licensed professional midwives may also be considered billable obstetrical providers in your state. Co-facilitators can be a registered nurse, health educator, medical assistant, community health worker, social worker, promotora or other licensed professional or paraprofessional.
Can Supportive Pregnancy Care be co-facilitated?
Yes, Supportive Pregnancy Care should be co-facilitated by two facilitators at each session. At least one facilitator must be a licensed obstetric provider (a physician, certified nurse-midwife or advanced practice nurse). The second facilitator can be a registered nurse, health educator, medical assistant, community health worker, social worker, promotora or other licensed professional or paraprofessional.
Can SPC be adapted or co-implemented for specific cultural considerations?
Yes! One of the hallmarks of SPC is its flexibility and adaptability to different communities with varying levels of resources and needs. Providers and health systems should be sure to address cultural beliefs and practices regarding pregnancy and integrate them into group sessions whenever possible. For example, the inclusion of dads in prenatal care or at delivery can vary greatly by culture.
Should we dedicate some staff FTE to implement SPC?
To foster the long-term sustainability of the program, it is recommended that the various staff responsibilities relative to implementing SPC be integrated into existing staff positions—unless the site can permanently add a staff position such as an SPC Coordinator to its budget.
What other staff support is needed to implement SPC in addition to the facilitators?
All staff can help “market” the program to patients and recruit them for groups. Front-desk staff play a big role in this, as do intake staff for new OB patients in assigning women to groups and establishing the schedule of group sessions. Clinic practice managers help secure the group space, provide materials, and can assign staff to help with charting the women’s medical information during the session. Billing staff ensure that all paperwork is in order so that SPC can be reimbursed.
How does this model address HIPAA rules with the patients recording their own information and nurses charting this information?
Any information is shared voluntarily by patients in the group, so HIPAA is not a concern. We also have a confidentiality agreement that all participants sign at the beginning agreeing that whatever information is shared in the group stays in the group. We discuss privacy concerns in the training.
How is a group formed?
You can form groups in different ways, based on your patient population. Examples include:
- By due date (for example, all women whose due date is in a certain month)
- By trimester
- By a woman’s age (for example, a teen group or an over-30 group
- By risk factor (for example, women who have a substance use disorder)
- By high- or low-risk or mixed risks together
However you decide to form your groups, women will have a variety of backgrounds and experiences, which will enhance the richness and dynamic of the group.
How many women should be in a Supportive Pregnancy Care group?
Group size can vary based on your patient population. Optimal size is approximately 8-12 women with similar due dates.
When do groups meet?
A typical group will meet 10 times during a 40-week pregnancy:
- Once a month during the first and second trimester
- Every two weeks during the third trimester
How do you recruit patients into Supportive Pregnancy Care?
Every pregnant woman attending her first prenatal visit or intake visit should be informed about Supportive Pregnancy Care and the benefits of receiving her care in a group setting. She should be given the option to receive group care and enrolled immediately. The woman will then be given an appointment schedule with dates and times of all of her group sessions for the remainder of her pregnancy.
Are incentives provided to SPC participants?
No, incentives are not routinely provided to Supportive Pregnancy Care patients and, frankly, are not needed. Patients enrolled in group care are more compliant with their prenatal visits – they want to attend their group sessions! However, if you have access to incentives that may be useful to the women, such as transportation vouchers, please feel free to utilize them.
What happens if a woman doesn’t want to participate in SPC or wants to quit?
If a woman chooses not to participate in group care or decides to withdraw from the group, you should refer her to a provider in your practice or in the area who offers traditional individual care.
Can medically high-risk women participate?
Yes, medically high-risk patients can participate in Supportive Pregnancy Care. Depending on her medical condition, a high-risk woman may need to attend more frequent medical visits than other women, but she should be encouraged to also attend the group sessions for additional education and support.
Can I partner with other agencies to implement SPC?
Yes! March of Dimes encourages you to work with other community agencies that can provide additional resources to your patients, such as local grocery stores or social organizations that might donate snacks, your local WIC clinic, incentive programs, child care agencies, and others.
How long does each SPC last?
Each Supportive Pregnancy Care session is approximately 90-120 minutes. The first 30 minutes is when each woman meets with the licensed obstetrical provider and the provider conducts individual physical assessments. The women meet as a group for the remainder of the session to discuss pregnancy, labor and delivery, infant care, family planning, post-partum maternal care and stress management.
What happens during a group session?
During the first approximately 30 minutes of each session, the licensed obstetric provider meets individually with each woman to perform a physical assessment and discuss specific concerns. This occurs in a semi-private area within the group space.
How many sessions are necessary?
A woman can expect to attend 10 sessions during a 40 week pregnancy.
Is there a set curriculum for SPC sessions?
March of Dimes provides fifteen “Session Guides” on individual topics pertinent to pregnancy health, such as nutrition, chronic health conditions, and preparing for labor and delivery. Facilitators determine when they cover each topic, based on the needs and interests of a particular group.
How is privacy protected in the group session?
Individual physical assessments are done behind a privacy screen. Sites are encouraged to have soft background music playing to decrease the likelihood that private conversations between the provider and a woman can be overheard. Please see the question and answer above regarding HIPAA.
What happens in the case of an emergency?
Every SPC site should have a plan for cases of emergency. A back-up licensed obstetrical provider should be available to take care of any woman who presents with emergent symptoms of complications or fetal or maternal distress. This is also why the co-facilitator is so important, as that person can provide continuity with the remainder of the group while the provider addresses the medical or other emergency.
Are partners/significant others welcome to come to group sessions?
This is a decision reserved for the clinic and the group. From a philosophical perspective, SPC encourages the participation of fathers and other support persons. Some groups determine that they want to invite supporters to attend some but not all sessions.
Are children welcome to come to the group sessions?
This is a decision reserved for the clinic and the group. SPC is open to having small children (approximately three and under) accompany their mom to a group session, so long as they don’t become disruptive or distracting for the group. Also, the group should make this decision together, based on the feasibility and comfort level of the clinic management as well.
What does a typical group prenatal visit schedule look like?
A basic session schedule includes:
- ~30 minutes: Individual physical assessments with the provider while co-facilitator assists other women to take and record their vitals
- ~10 minutes: Session starts with an icebreaker
- ~40 minutes: First session topic conversation and activity
- ~10 minutes: Share and practice a stress management technique
- ~20 minutes: Second session topic conversation and activity
- ~5 minutes: Wrap up and set direction for next session
The duration of the session can be from 90-120 minutes depending on how many women are in the group.
+Monitoring & Evaluation
How do you monitor the effectiveness of SPC?
Program implementation data and group level aggregate data on the participants are collected using standard forms that are then entered into an online REDCap database.
What types of data need to be collected?
Program implementation data collected include:
- Number and type of facilitators
- Session schedule (days of week and times of day)
- Topics covered
Group level aggregate data collected include:
- Basic demographics on the women participating—age, race/ethnicity, insurance status
- Number of women attending each session
- Basic pregnancy outcomes—gestational age and birthweight
Do you measure SPC program fidelity in sites?
The program implementation data helps March of Dimes ensure program quality.
Is there technical support for data entry or evaluation?
Yes. March of Dimes can provide training to staff tasked with collecting and entering data, as well as technical assistance during the implementation period. There is a fee for this technical assistance.
+Resources & Training
What resources are available to help with implementing SPC? How much do those cost?
Both online and in-person training are available, as well as a number of tools including the SPC Implementation and Session Guides. Fees vary depending on the level of support needed.
Online training modules and resources can be accessed by multiple staff members, to reduce barriers to sustainability.
Are SPC materials available in Spanish or other languages?
The patient magazine used in SPC is bilingual English-Spanish. There is also an online social media platform, Share Your Story, where women can connect with others from their group during and after pregnancy. This site is also bilingual English-Spanish. Program implementation materials are only available in English.
Can I connect with other clinics implementing SPC?
Yes, beginning in late 2018, March of Dimes will be hosting periodic technical assistance webinars for all participating clinics to share best practices and receive additional support.
Is training or certification required to implement SPC? What training materials are available?
Yes, some level of training is required to implement SPC. There are online training videos and guides available, as well as in-person training options.
Certification is not currently available, but is being considered for the future.
Who needs to be trained?
We recommend that all staff that interact with pregnant women participate in at least part of the training about the evidence behind group prenatal care. A full training is about seven hours. We can make it somewhat longer or shorter as needed to accommodate the clinic’s schedule. Any staff that will interact with pregnant women should be trained, including front desk staff, call center staff, health care providers, administrators, and other clinic staff. The more people who are familiar and “onboard,” the more likely it is for the program to succeed and be sustainable. However, the training is broken into several pieces, and not every single staff person needs to attend every single piece. For example, there is facilitator skills training that is only applicable to those who will actually be facilitating the groups. March of Dimes can help you determine which staff members should attend which portions of the training.
Are there any materials that can help better conceptualize the flow of the model?
Yes, beginning in July 2018, a video showing “What Supportive Pregnancy Care Looks Like” will be available at marchofdimes.org/supportivepregnancycare.
Who in my community is implementing Supportive Pregnancy Care?
For a list of providers implementing Supportive Pregnancy care in your area, contact your local March of Dimes or email us at [email protected].
Who do I contact for more information about Supportive Pregnancy Care?
For more information on Supportive Pregnancy Care contact your local March of Dimes or email us at [email protected].