American Psychologist

Manuscript version of

Transforming Prenatal Care: Multidisciplinary Team Science Improves a Broad

Range of Maternal–Child Outcomes
Jeannette R. Ickovics, Jessica B. Lewis, Shayna D. Cunningham, Jordan Thomas, Urania Magriples

Funded by:
• National Institute of Mental Health
• National Institutes of Health
• Office of AIDS Research

© 2019, American Psychological Association. This manuscript is not the copy of record and may not exactly
replicate the final, authoritative version of the article. Please do not copy or cite without authors’ permission.
The final version of record is available via its DOI: https://dx.doi.org/10.1037/amp0000435

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
 Transforming Prenatal Care/1

Transforming Prenatal Care: Transdisciplinary Team Science Improves a Broad Range of

Maternal-Child Outcomes
 Transforming Prenatal Care/2

Abstract

Every eight seconds a baby is born in the United States. Maternal and newborn care are

the nation’s most expensive clinical services, and despite spending more per capita on health

services, the United States experiences worse perinatal outcomes than most other developed

countries, and even worse than many developing countries when it comes to maternal and infant

mortality, preterm birth, and other co-morbid conditions. We established a transdisciplinary

clinical research team nearly two decades ago to improve maternal and child health through an

innovative approach to maternal care delivery: group prenatal care. Our team has included

psychologists (social, health, clinical, community), physicians (obstetrics, maternal fetal

medicine, pediatrics), nurse-midwives, epidemiologists, biostatisticians, sociologists, social

workers, and others. Though we come from different disciplines, we share a commitment to

women’s health, to using empirical evidence to design the best interventions, to social justice

and health equity, and to transdisciplinary team science. In authentic collaboration, we have

drawn on the best of each discipline to meet the triple aim (enhanced quality, improved

outcomes, lower costs) for maternal care and to develop a deeper understanding of risk and

protective factors for pregnant women and their families. This manuscript describes how we

leveraged and integrated our diverse perspectives to achieve these goals, including the

theoretical and clinical foundations underlying the development and evaluation of the group

prenatal care approach, research methodology employed, impact on the field, and lessons

learned.

Keywords: Maternal child health, prenatal care, group care, transdisciplinary, team science
 Transforming Prenatal Care/3

Every eight seconds a baby is born in the United States (US Census Bureau, 2018).

Despite spending more per capita on health services (Bradley, Elkins, Herrin & Elbel, 2011), the

United States experiences worse perinatal outcomes than other developed countries (Matthews,

MacDorman & Thoma, 2015). Psychologists have been involved in understanding determinants

and consequences of perinatal health for decades. Dunkel Schetter (2011) conducted a review of

contributions made by psychological science on our understanding of pregnancy. She

synthesized the literature and concluded that a major focus for psychological science has been on

stress processes in pregnancy and effects on preterm birth and low birthweight. Highlighting the

need for multidisciplinary approaches, she goes on to identify important neuroendocrine,

inflammatory and behavioral mechanisms; coping and social support as protective factors; and

infant neurodevelopmental consequences of prenatal stress. Recent reviews and empirical

studies from Epel and colleagues confirm the “intergenerational transmission” of adverse effects

of maternal stress on infant development (e.g., Bush et al., 2017; Shalev et al., 2013).

Much of the work of psychological science during pregnancy has focused also on

understanding the risks of depression across the perinatal period – during pregnancy and post-

partum (Yim et al., 2015) – including the use of antidepressants among pregnant women

(Yonkers, Blackwell, Glover & Forray 2014). The APA journal Psychotherapy recently

published a special section on pregnancy loss: trauma and grief in response to the death of a

fetus or neonate before the 21st day of life (e.g., Jaffe, 2017; O’Leary & Henke, 2017) – along

with psychotherapeutic interventions for parents to help them cope with loss, mitigate social

isolation, and promote attachment (e.g. Diamond & Diamond, 2017; Wenzel, 2017).

Psychologists have been involved in developing and testing many interventions to improve

mental health and health behaviors (e.g., smoking cessation, addiction treatment) during the

perinatal period (e.g., Chamberlain et al, 2017; Velasquez et al., 2010; Yonkers et al., 2012).

However, we have been less involved in redesigning healthcare systems to promote healthier

pregnancies and prevent adverse outcomes. Prenatal care was designed more than one hundred
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years ago for reduction of maternal pregnancy complications; questions persist about the

function, structure, and significance of prenatal care to improve perinatal outcomes more broadly

(Alexander & Kotelchuck, 2001).

Pregnancy provides a “window of opportunity” for health promotion (Bloch &

Parascandola, 2014; Kapur, 2011; Kershaw et al., 2008). Even those with broader healthcare

access limitations (e.g., uninsured, undocumented) are eligible for health insurance programs

during pregnancy (e.g., Medicaid and Children’s Health Insurance Program). For many women,

prenatal care is the first time they are connected to the healthcare system, and it offers a

sustained period of contact. Further, most women want to assure the best possible outcomes for

themselves and their babies, and thus are highly motivated to make behavioral changes to

achieve positive outcomes. Women have diverse needs during pregnancy – medical, social,

psychological – and there are many opportunities to address these needs in an integrated care

setting at a time that can establish the health trajectory for personal and family life.

Reproduction is both a biological and a social process (Almeling, 2015). Most research

to date has not been integrated, with biological and psychological approaches largely distinct,

limiting a deeper understanding of risk and protective factors for perinatal outcomes (Dunkel

Schetter, 2011; Yim et al., 2015). We established a transdisciplinary clinical research team

nearly two decades ago to improve maternal and child health outcomes. We use the term

“transdisciplinary” to reflect our team science approach, whereby our work not only draws from

multiple disciplines, it is integrative and holistic, transcending traditional disciplinary boundaries

(Choi & Pak, 2006). Our transdisciplinary team worked to improve maternal and child health

through an innovative approach to maternal care delivery: group prenatal care.

Our team has included psychologists (social, health, clinical, and community

subdisciplines), physicians, midwives, epidemiologists, biostatisticians, sociologists, social

workers, public health professionals, and others (Table 1). Though we come from different

disciplines, we share a commitment to women’s health, to using empirical evidence to design the
 Transforming Prenatal Care/5

best interventions, to social justice and health equity, and to transdisciplinary team science. In

authentic collaboration, we draw on the best of each discipline to meet the triple aim (enhanced

quality, improved outcomes, lower costs) for maternity care and to develop a deep understanding

of risk and protective factors for pregnant women and their families. This manuscript describes

how we leveraged and integrated our diverse perspectives to achieve these goals.

Advent of Group Prenatal Care

Group prenatal care is an emerging health care innovation with the potential to result in

substantial improvements in perinatal outcomes (Ickovics et al., 2007; Ickovics et al., 2016;

March of Dimes, 2015; Picklesimer, Billings, Hale, Blackhurst, Covington-Kolb, 2012). As we

have described previously (e.g., Cunningham, Lewis, Thomas, Grilo & Ickovics, 2017; Rising &

Quimby, 2016), group prenatal care brings together 8-12 women of the same gestational age for

their prenatal care visits. Women enter group prenatal care in the traditional manner as they

would individual prenatal care. Formal intake (health history and physical examination) is

performed at an initial visit prior to group assignment. All prenatal care occurs within the group

setting except for this initial assessment, health concerns involving the need for privacy, and

cervical examinations late in pregnancy. Social support is interwoven formally and encouraged

informally between sessions and postpartum.

Over the course of a pregnancy, a woman will attend up to ten 120-minute group prenatal

care sessions, led by a prenatal care provider (e.g., obstetrician, midwife) and assistant. During

sessions, she will participate in self-care (e.g., take own weight, blood pressure); receive a brief,

individual medical check (e.g., fundal height, fetal heartbeat); and engage in a facilitated

discussion on the topics of pregnancy, childbirth, and parenting. Provider-led facilitated

discussions focus on building new skills, giving and receive social support, and changing group

norms toward healthier behaviors. In total, women in group prenatal care receive 20 hours

compared to only two hours for those in traditional individual care, a benefit in terms of quantity

and quality of care.

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First conceived in 1968 to improve well-child care (Feldman, 1974), the group or cluster

visit model was used to bring together people or patients either diagnosed with similar

conditions or experiencing similar changes across the developmental lifespan that influenced

their healthcare needs. The group model expanded to fields ranging from pediatrics to geriatrics,

and there is a robust effort to use group care to manage chronic disease (e.g., asthma, diabetes,

post-transplant recovery; Birrell et al., in press; Edelman et al., 2012). In 1998, midwife Sharon

Rising published her first paper about a group model for prenatal care: CenteringPregnancy.

CenteringPregnancy, the pioneering clinical model of group prenatal care, was

developed to integrate risk assessment, education, and support for pregnant women and their

families (Rising & Quimby, 2016). Rising transformed her own clinical practice in Minnesota,

and subsequently in Connecticut, to conduct prenatal care in groups. In 2001, she established

what is now the Centering Healthcare Institute and began to expand group care implementation

across clinical sites nationwide.

Also in 2001, the earliest members of our transdisciplinary team received funding from

the National Institutes of Health (NIH) to conduct the first randomized controlled trial to

evaluate group prenatal care. As part of the research funding agreement, we were required to

develop a structured intervention manual so that group prenatal care could be routinely and

systematically implemented and replicated. We developed a curriculum that exceeds clinical

guidelines for prenatal care as established by the American Congress of Obstetricians and

Gynecologists and American Academy of Pediatrics and the American College of Nurse

Midwives (Hanson, VandeVusse, Roberts, & Forristal, 2009; Kilpatrick, Papile, & Macones,

2017). Subsequent enhancements from our team included and evaluated the effectiveness of an

integrated sexual risk reduction intervention promoting risk assessment for sexually transmitted

infection (STI)/HIV, and building skills and promoting health norms for partner communication,

condom use, and post-partum contraception (CenteringPregnancy Plus; Kershaw, Magriples,

Westdahl, Rising & Ickovics, 2009).

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Finally, in 2013, we launched a novel “high touch-high tech” model of group prenatal

care, Expect With Me, with an evidence-based curriculum that integrates a HIPAA-secure IT

platform for training, education, data collection, scheduling, and social networking

(Cunningham, et al., 2017b). We enhanced earlier models by focusing on issues that our

research had demonstrated to be particularly important for healthy outcomes during pregnancy

and across the lifespan. The Expect With Me curriculum addresses many important

components of health, clinical, social, and developmental psychology, including but not

limited to identification and reduction of symptoms related to stress, depression, and anxiety

across the perinatal period; evidence-based approaches to behavior change (e.g., to promote

healthy diet, physical activity and sleep, as well as to prevent substance use, sexual risk);

interpersonal relationships and communication; early infant development and attachment.

Expect With Me has been recognized as “innovative” in the Harvard Health Acceleration

Challenge, Hemsley Challenge, and Yale Innovation Summit – where we were selected as

finalists across a range of health technology innovations.

Foundations of Our Work in Group Prenatal Care

Group Process. Group prenatal care is built on basic social psychological principles

regarding group processes and social learning (e.g. Bandura, 1978; Tuckman, 1965). It is based

on the premise that prenatal care is most effectively and efficiently provided in groups; that

learning and support are enhanced by group resources, and that this high quality of care is

difficult to achieve within the traditional structure of individual examination room visits.

Group prenatal care provides substantially more contact with providers, provides support

services, and is integrated to respond to the complex needs of pregnant women. General

advantages of group interventions include: improved learning and skills development, attitude

change and motivation, enhanced insight through sharing of common life experiences, and

social support (Gillies & Ashman, 2003; Hyde, Appleby, Weiss, Bailey, & Morgan, 2005). In

turn, groups facilitate development of new community norms for health-enhancing behaviors
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supported by members of the group (Tuckman, 1965).

Social Ecological Theory. Moreover, our team has taken a broad ecologic perspective,

considering individuals within nested spheres of influence (Sallis & Owen, 2015). Social

ecological models derive from Bronfenbrenner’s pioneering work examining the multi-level

determinants of human development (Bronfenbrenner, 1977; Bronfenbrenner, 1979). This

ecosystem of risk and protective factors extends from the intrapersonal (biology, psychology) to

the interpersonal (partner, family, peers) to the institutional (healthcare, employers), community

(culture, norms), and societal (law, policy, economics) levels. These levels of influence interact

to shape health and behavior (Richard, Gauvin, & Raine, 2011).

We have used the Ecological Model as a guiding framework to conceptualize, measure,

and intervene at multiple levels of influence to promote health and well-being throughout the

perinatal period (Figure 1). Social ecological theory lends itself to transdisciplinary team

science, allowing consideration of an array of interacting factors that impact health. Different

disciplines emphasize particular determinants of health—medicine emphasizes biology;

psychologists emphasize mental health and behavior; social work emphasizes social structures;

public health emphasizes population-level influences.

Clinical Approach. Group care clinical models are, by design, transdisciplinary.

Specifically, group prenatal care includes extensive education and skills development for an

array of issues, including, but not limited to “traditional” prenatal care content promoted by

obstetricians, midwives, and ancillary service providers (e.g., how to have a healthy and safe

pregnancy, preparation for labor and delivery). Our team’s health psychologists developed a

strong core curriculum on behavioral health and self-care such as nutrition, physical activity,

substance use and oral health; chronic disease prevention and healthy weight trajectories (i.e.,

pregnancy weight gain, postpartum weight loss); prevention and treatment of anxiety and

depression across the perinatal period. Clinical psychologists developed curricular components
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to include mindfulness for stress reduction and ways to promote more restful sleep/prevent

disordered sleep (Felder, Baer, Rand, Jelliffe-Pawlowski, & Prather, 2017; Vieten et al., 2018).

In addition, many of us have expertise in romantic partnerships and STI/HIV prevention,

and a central component of our group prenatal care curriculum includes nurturing healthy

relationships, integrating partner communication, addressing intimate partner violence, and safer

sex prevention. Finally, initiatives targeting postpartum behaviors – while women are actively

engaged in prenatal care – also are included to nurture best possible long-term outcomes. These

include breastfeeding, early infant care and child safety, as well as “building a healthy future,”

with topics such as mobilizing social support, postpartum contraception, and return to work.

Curricula for CenteringPregnancy and Expect With Me have been vetted by obstetricians,

maternal-fetal medicine specialists, and pediatricians to assure accuracy and clinical relevance.

It is worth noting that group prenatal care enables women to get more prenatal care

because healthcare providers can see a group of women together for a much longer period than

time spent with any individual patient. We see this as an essential benefit to the group care

model. Adequacy of care is typically measured with regard to number of prenatal care visits (not

length of visits). We take this into consideration in the design of our studies as well as in our

analyses and interpretation of outcomes (e.g., assessment or matching by number of visits).

Research Methodology Underpinning the Study of Group Prenatal Care

In addition to experts in clinical care and psychological science, our transdisciplinary

team includes epidemiologists and implementation scientists, who have played an integral role in

the design of the most rigorous research studies and conducted appropriately sophisticated and

controlled analyses. Both quantitative and qualitative methods have been employed. Our

research prior to our work on group prenatal care had focused on understanding psychological

and sexual risk among pregnant women; we were now ready to try to intervene.

Our research on group prenatal care began when we received an NIH grant supplement

(1999-2000) to conduct a pilot study of group prenatal care. In this prospective cohort study of
 Transforming Prenatal Care/10

458 pregnant women (matched by clinic, maternal age, race, parity and infant birth date), birth

weight was significantly greater for those in CenteringPregnancy groups versus individual

prenatal care, especially among those born preterm (>400 grams heavier, a statistical and

clinically meaningful difference; Ickovics et al., 2003).

Based in part on these results, NIH funded the team to conduct a randomized clinical trial

(2001-2006) to provide a more rigorous test (i.e., “gold standard”) of our clinical intervention

(ClinicalTrials.gov registration: NCT00271960). Prenatal care patients (N=1047), stratified in

two academic medical centers (The Women’s Center at Yale-New Haven Hospital/Yale

University and Grady Memorial Hospital/Emory University) were randomized to receive

traditional individual prenatal care, CenteringPregnancy group prenatal care, or

CenteringPregnancy Plus group prenatal care, which “bundled” sexual risk reduction as

described above (Ickovics, 2007; Kershaw et al., 2009). Reflecting our consistent

transdisciplinary focus, the Principal Investigator at Yale was a psychologist (Jeannette

Ickovics), and the Principal Investigator at Emory was an obstetrician-gynecologist (Michael

Lindsay) while the Co-PI was a nurse-midwife (Claire Westdahl). Findings were favorable with

regard to birth outcomes and sexual risk reduction (described in detail below).

NIH subsequently funded our team to conduct a cluster randomized controlled trial at 14

community hospitals and health centers in New York City (2006-2013) (Ickovics et al., 2016;

ClinicalTrials.gov registration: NCT00628771). The primary objective was to replicate and

extend our first trial, with an eye towards translation. Specifically, we wanted to determine

whether we could continue to achieve positive results in community settings with far less control

than the confines of academic medical centers. As before, outcomes included maternal and child

indicators (e.g., preterm birth, gestational age) and sexual risk reduction. Because we achieved

better outcomes with CenteringPregnancy Plus in our previous trial, this study was designed

with two-arms, comparing CenteringPregnancy Plus group care and traditional individual care.

We also evaluated implementation outcomes related to uptake, fidelity, and sustainability.

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We developed a “TIE Partnership” –Training, Implementation, and Evaluation–this time

even more explicitly codifying the roles in our transdisciplinary team. All partners had a strong

voice in the project from conception through publication. Following best practices for

transdisciplinary team work (Nancarrow et al., 2013), we specified primary areas of

responsibility. Centering Healthcare Institute, led by Sharon Schindler Rising, had primary

responsibility for training in cooperation with Yale, who trained on the HIV prevention

intervention. Clinical Directors Network, a practice-based research network dedicated to primary

care-based comparative effectiveness research in medically underserved communities, was

primarily responsible for implementation. CEO and President Jonathan Tobin (epidemiologist)

served as Principal Investigator along with Jeannette Ickovics (Professor of Public Health and

Psychology, Yale University). The Yale team took primary responsibility for evaluation.

Finally, our most recent study was designed as a multi-site prospective longitudinal

cohort study to examine the impact of a novel model of group prenatal care, Expect With Me, on

perinatal and postpartum outcomes, and to identify and address barriers to national scalability

(Cunningham, Lewis et al., 2017; Clinical Trials.gov registration: NCT02169024). This research

was conducted in partnership with clinical leadership at Vanderbilt University Medical Center

and Wayne State University/Detroit Medical Center. Moreover, it expanded our team yet again

to include industry experts from United Health Group. Our colleagues from United Health

challenged us to adapt the model to increase the likelihood of national uptake and sustainability.

They also were interested in an increasing focus on cost and cost savings.

We recruited more than 1,000 women into group prenatal care in Nashville and Detroit

along with a matched cohort of more than 2,000 women in individual care. Concurrently, we

conducted a historical analysis of more than 9,000 women with a live singleton birth who

received group (CenteringPregnancy or Expect With Me) or individual care at Vanderbilt

University Medical Center from 2009 through June 2016 (Cunningham et al., 2018).
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In all of our studies, psychological principles grounded in theories of self-care, group

processes, and social ecological theory guided decisions about measurement. Conducting large

trials, the cost to expand our measurement framework beyond primary and secondary outcomes

is nominal. Based on interests of the members of our transdisciplinary research team, including

graduate students and post-doctoral scholars, we added a series of measures that have enabled us

to examine mediating and moderating effects of medical, social, psychological, and behavioral

factors on birth outcomes as a result of group care. As described below, we have conducted a set

of analyses and published a large set of papers that also explore associations (often longitudinal)

between factors of interest. Our large studies and longitudinal prospective designs, following

women from early in pregnancy through one year postpartum, have enabled our team to provide

a deeper understanding of determinants and consequences of health during the perinatal period,

including co-morbid chronic conditions, mental health, intimate partner violence, sexual health,

immigration status, housing and food security, and experiences of discrimination.

Transformative contributions in prenatal care

Clinical outcome effectiveness. At a cost of more than $111 billion annually (Agency

for Healthcare Research and Quality, 2018), maternal and newborn care is the nation’s most

expensive clinical service (Wier & Andrews, 2011). Few models of prenatal care have

demonstrated improved birth outcomes (Allen, Gamble, Stapleton & Kildea, 2012).

In two clinical trials of group prenatal care in five cites (N>2400) and a large

retrospective cohort study in Nashville (N>9,000), our team has documented at least 33%

lower rates of preterm birth and small for gestational age babies (Cunningham, 2018; Ickovics

et al., 2007; Ickovics et al., 2016). Our preterm findings were more pronounced among

African American women (41% reduction) in one trial (Ickovics et al., 2007). Our historical

cohort study tracking outcomes over 8.5 years in Nashville provided further evidence of group

prenatal care’s effectiveness: we observed a 37% and 38% lower risk of having a preterm birth

and low birthweight baby, respectively, compared to receiving individual care only
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(Cunningham et al., 2018). STI/HIV prevention “bundled” with prenatal care improved sexual

and reproductive health outcomes for women at clinical sites randomized to group prenatal

care: lower risk of rapid repeat pregnancy (within six months), increased condom use and

decreased unprotected sexual intercourse; and among adolescents a 50% reduction in STI

incidence (new infections) up to one year post-partum (Kershaw et al., 2009).

In terms of chronic disease risk, group prenatal care also resulted in healthier maternal

weight trajectories, including significantly less weight gain during pregnancy and a 15-pound

weight loss differential one-year post-partum (Magriples et al., 2015). Finally, group prenatal

care improved mental health and consequent birth outcomes. Felder et al. (2017) found that

women at sites randomized to group prenatal care had fewer depressive symptoms and this, in

turn, was associated with reduction in preterm birth. Results from an earlier study did not find

an intention to treat effect for group prenatal care on psychosocial outcomes; however, women

in the top tertile of stress randomly assigned to group prenatal care reported increased self-

esteem, decreased stress and social conflict in the third trimester of pregnancy; social conflict

and depression were significantly lower 1-year postpartum (Ickovics et al., 2011).

Implementation outcomes. We have conducted a series of analyses that provide greater

insight into delivery of group prenatal care. Novick et al. (2013, 2015) added qualitative

interviews to our large randomized controlled trials to identify barriers and facilitators to

implementing group prenatal care as well as factors that influence model fidelity. Greater

process fidelity (i.e., how facilitative leaders were) was associated with a lower risk of both

preterm birth and intensive care use, and greater content fidelity (i.e., extent to which

recommended content was discussed in each session) was also associated with lower risk of

intensive care use (Novick et al., 2013). Creating an environment and organizational structures

that support clinical innovation requires adaptation, recognition that innovation can be

disruptive, and leadership commitment to implement and sustain change (Novick et al., 2015).
 Transforming Prenatal Care/14

We also documented the impact of group composition on satisfaction, engagement and

attendance. For example, more diverse group composition was associated with engagement in

care and ultimately with adherence to prenatal care appointments, especially for adolescents

(Earnshaw et al., 2016). And, while adherence is modest overall – an average of 5-6 of 10

scheduled group visits – adherence to group prenatal care (i.e., receiving a higher proportion

of prenatal care in a group setting) was associated with higher levels of satisfaction

(Cunningham et al., 2017a), and attending a minimum of five group visits does seem to be an

adequate “dose” (Ickovics et al., 2016). Nonetheless, to be consistent with clinical guidelines,

to assure minimal dose, and to account for non-adherence to medical appointments, we have

sustained the recommended 10-visit model (to date) – though recognize that fewer group visits

may be sufficient to promote better health outcomes.

Additional findings informing our understanding about health across the perinatal

period. Using data from these trials, we have had the opportunity to explore many empirical

questions beyond group prenatal care efficacy. These are of relevance to psychological science

and health at multiple levels of social ecology. Though these papers reflect disciplinary focus

areas, our transdisciplinary team process ensures the integration of perspectives for each.

Individual level. Our physician colleagues have examined data from a biomedical

perspective. Gould-Rothberg et al. examined excess gestational weight gain and inadequate

postpartum weight loss, documenting that only 22% of women gained gestational weight

within Institute of Medicine clinical guidelines (Gould-Rothberg, Magriples, Kershaw, Rising,

& Ickovics, 2010). Magriples et al. (2013) examined the impact of body mass index, weight

gain and race on blood pressure across the perinatal period. They found that African American

women with high pregnancy weight gain had the greatest increase in blood pressure during

pregnancy and postpartum, increasing cardiovascular risk across the developmental lifespan.

Pre-pregnancy body mass index also was associated with a nearly two-fold increase in risk of

caesarean delivery (Magriples, Kershaw, Rising, Westdahl, & Ickovics, 2009).

 Transforming Prenatal Care/15

Interpersonal level. We have documented high prevalence of interpersonal violence –

52% among our sample of young pregnant women in New York City – and associated health

risk behaviors (e.g., substance use, risky sex, stress, depression; Agrawal, Ickovics, Lewis,

Magriples & Kershaw, 2014; Udo, Lewis, Tobin, & Ickovics, 2016). We also have explored a

cluster of “syndemic risks” (intimate partner violence, substance use and depression) among

Latina women during and after pregnancy, documenting the importance of immigration status

and acculturation (Martinez et al., 2017; Martinez et al., 2018).

Community/Societal level. Our transdisciplinary research team is deeply committed to

using data from these studies to address health inequity. This is in line with recent evidence

highlighting the impact of material hardship on mental health symptoms among pregnant

women (Katz, Crean, Cerulli & Poleshuk, 2018). For example, we have documented adverse

impact of food insecurity (Grilo et al, 2015) and housing instability (Carrion et al., 2015) on

adverse birth outcomes, such as birth weight. We recently published a systematic review and

meta-analysis about the impact of racial residential segregation on adverse birth outcomes

(Mehra, Boyd & Ickovics, 2017).

We have worked with several post-doctoral scholars in social psychology with a deep

interest and commitment to understanding the impact of experiences of everyday

discrimination. Together, we have published a series of longitudinal analyses illustrating the

adverse consequences of discrimination among pregnant women on sexual risk (Rosenthal et

al., 2014), excess weight gain (Reid et al., 2016), mental health (Rosenthal et al., 2018), and

infant social-emotional development (Rosenthal et al., 2018).

Impact on the Field

Often citing the results from our initial randomized controlled trials, other research teams

have implemented CenteringPregnancy with notable success. South Carolina made a large

investment of state Medicaid dollars based on reduced risk of preterm birth and positive

psychosocial outcomes (Heberlein et al., 2015; Picklesimer et al., 2012). Importantly, this
 Transforming Prenatal Care/16

research team provided evidence for substantial cost savings. They documented more than

$22,000 for every preterm birth averted as a function of group prenatal care; with an investment

of $1.7 million, South Carolina estimated return on investment of $2.3 million (Gareau et al.,

2016). Others have adapted this model and shown favorable outcomes for use in special

populations such as military personnel (e.g., Kennedy et al., 2011) and Hispanic women with

gestational diabetes (e.g., Schellinger et al., 2017). Group prenatal care has been implemented in

clinical settings across the US and throughout the world (Rising & Quimby, 2016).

Although many studies of group prenatal care have demonstrated improved outcomes

relative to standard individual care, a recent meta-analysis indicated no difference across studies

(combined), in terms of preterm birth, low birthweight, and neonatal intensive care unit

admission, with the exception of certain subgroups, such as African American women, who do

benefit in terms of significantly lower rates of preterm birth (Carter et al., 2016). However,

authors note that among the most rigorous studies (i.e., two randomized controlled trials from

our research group), compared to standard individual care, group prenatal care results in lower

rates of preterm and small for gestational age babies. Importantly, there are no adverse effects

associated with group prenatal care (Catling et al., 2015). Based on this evidence-base, the

American College of Obstetricians and Gynecologists released its first committee opinion on

group prenatal care (McCue, Borders, & Choby, 2018), and the March of Dimes launched a

National Council on Financing Group Prenatal Care to accelerate nationwide adoption of this

important healthcare innovation (March of Dimes, 2016). Additional research is underway, from

our group and others, that will expand the empirical evidence base for group prenatal care.

Lessons Learned
Perspectives from our transdisciplinary team have contributed to our success in model

development as well as interpretation and dissemination of findings. Improved outcomes result

from a combination of better knowledge and skills, changed health behavior norms, social

support, and reduced stress and depression. Our collaborative efforts to date have produced a
 Transforming Prenatal Care/17

larger number and greater diversity of scientific publications (e.g., topics, publication venues)

than the participating members from any one discipline could have achieved independently.

Our transdisciplinary approach was essential to overcome research and dissemination

challenges on multiple levels. For example, barriers in communication between disciplines and

the hierarchy of healthcare delivery had to be addressed, as it affected both patient recruitment

and randomization. One of the first challenges of our first clinical trial on group prenatal care

was to convince our clinical partners that we must randomize patients to the care models being

compared. Those who believed in group prenatal care wanted it to be available to all patients.

Those who were skeptical wanted their patients to remain in individual care. Further, providers

often struggled with patients they believed could “really benefit from group” or those who

they did not want to “lose to group” if another provider was leading the group for which their

patient was eligible. The academic scientists among us had to convince clinicians of the

broader scientific considerations that would allow group care to flourish. Additionally,

changing how healthcare is delivered in a clinical setting and translating science into practice

requires champions for this change who are responsible for daily operations. Therefore, direct

involvement of hospital and nursing administration, as well as clinicians, was critical to

determine what would be feasible in real-world practice settings, to address logistical barriers

(e.g., scheduling, space), and to identify and implement strategies to overcome ingrained

systems to achieve transformative change.

Part of our dissemination challenge involved assuaging concerns of new partners about

anticipated implementation challenges, such as recruitment, group dynamics, and

sustainability. Clinicians and system administrators worried patient recruitment would be

difficult because of logistics, such as work schedule or child care. Our provider colleagues

taught us that wait times for traditional care appointments (i.e., 2-3 hours in many settings)

often created the same logistic issues, and a 2-hour visit that starts and ends on time with a set
 Transforming Prenatal Care/18

schedule for prenatal care appointments throughout the entire pregnancy is easier to manage

for work and child care than unproductive wait times and unpredictable scheduling.

We have addressed group facilitation challenges, such as confidentiality, too quiet (or too

talkative) patients, and addressing difficult topics (e.g., partner violence) through our

established training curriculum. These techniques mirror those used in group psychotherapy.

Patients only reveal what they choose and trust is built over time, allowing patients to share far

more about their lives than during traditional care. Program sustainability tends to be the most

persistent problem for practices that must continually justify their existence to financial

decision makers. After all, cost savings of improved outcomes are not accrued to prenatal

practices, but rather to payors (e.g., insurers, Medicaid).

Dissemination challenges involved in bringing an effective model of care to scale have

required a new set of transdisciplinary partners, including those from industries like health

insurance, technology, and marketing. Because the cost savings of improved outcomes are

largely accrued to payors (e.g., insurers, Medicaid), not provider practices, it was important for

us to activate industry partners to fund the expansion of group prenatal care and to address

long term stability of these programs. As Expect With Me continues to grow, we are working

with technology partners to continue to improve user experience of the IT portal and add

features that increase usage and expand access.

Finally, our program of research has provided extraordinary training opportunities for

many undergraduate, graduate, and professional students and postdoctoral fellows across

disciplines (e.g., public health, psychology, sociology, medicine, nursing). We have integrated

students and fellows in numerous capacities, including field work, intervention

implementation, data analyses, and as authors in peer-reviewed publications. We have

supported theses and dissertations. And, we have inspired many undergraduate research

assistants to go on to pursue graduate and clinical study, thereby fostering the next generation

of psychologists and transdisciplinary researchers.

 Transforming Prenatal Care/19

Future Research

There has been limited research that directly examines the mechanisms of the effects of

group prenatal care. “Process fidelity” (e.g., facilitative leadership style, patient engagement)

appears to be more important than content alone (Novick et al., 2013). And, we hypothesize

that biological mechanisms may involve a cascade that links enhanced social support in group

settings to reductions in stress and depressive symptoms, consequently resulting in a healthier

endocrine milieu, cervical length, and sustained pregnancy. We intend to test these

mechanisms in our ongoing dissemination study, using biomarkers from women enrolled as

part of the Perinatology Research Branch at Wayne State University School of Medicine.

It is important to continue to explore potential differences with regard to patient

characteristics such as race, ethnicity, acculturation and class. Our research has included

predominantly women of color and those of lower socioeconomic status. There could be

cultural barriers to group participation (always voluntary) and engagement; however, we have

no reason to believe there would be differences in effectiveness. Carter et al. (2016) note better

outcomes for African American women in group prenatal care: likely a function of higher

biological risk and base rates (i.e., more statistical power to measure change).

Conclusions

Our transdisciplinary team approach has enabled us to break down silos and engage diverse

stakeholders across public, private, and academic sectors to improve maternal-child health and

address dissemination challenges. Clinicians are increasingly pressed to address an ever-broader

range of health and psychosocial issues of patients during pregnancy. Group prenatal care

innovations emerging from academia provide an evidence-based mechanism to address these

clinical pressures; however, these must be carefully integrated in a way that will be acceptable to

health systems. Our transdisciplinary team and partners created innovative solutions, conducted

rigorous trials, and aligned incentives to meet the triple aim – enhanced healthcare quality,

improved outcomes, lower costs – for pregnant women and their families.
 Transforming Prenatal Care/20

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Table 1. Expertise and Contributions of Selected Transdisciplinary Team Members

Team Member Discipline Role Content Expertise/Skills
Jeannette Social and Health Psychology Principal Investigator Leadership; Study design;
Ickovics Intervention development;
Innovations in clinical care;
Women’s health and mental
health; Health equity; HIV
prevention; mixed methods and
analysis

Jessica Lewis Social Welfare/Family Project Protocol development; Clinical

Therapy Director/Investigator trials management; Intervention
development; Ecologic
measurement; Intimate partner
violence; Adolescence;
Reproductive health

Shayna Public Health Investigator Implementation Science; Health

Cunningham disparities; Program evaluation;
Quantitative and qualitative
analysis

Jordan Thomas Clinical Psychology Statistician Women’s health; Mixed

methods
Urania Maternal Fetal Medicine Medical Director Perinatology; Group prenatal
Magriples care delivery; Clinical Training;
Pregnancy weight trajectories;
Perinatal blood pressure
trajectories

Heather Cole- Epidemiology Pre-Doctoral Student Mental health; Pregnancy; HIV

Lewis risk

Valerie Social Psychology Post-Doctoral Fellow HIV risk; Stigma;

Earnshaw Discrimination; Quantitative
analysis

Elissa Epel Clinical Psychology Investigator Stress; Pregnancy; Mindfulness

Jennifer Felder Clinical Psychology Post-Doctoral Fellow Perinatal depression; Preterm

birth

Bonnie Gould Internal Medicine/ Pre-Doctoral Student Gestational weight gain;

Rothberg Epidemiology Postpartum weight loss;

Stephanie Grilo Sociomedical Sciences Statistician Psychosocial risk; Food

insecurity; HIV risk;
Reproductive health; Health
disparities

Trace Kershaw Social Psychology Investigator HIV prevention; Research

methodology; Quantitative
analysis
 Transforming Prenatal Care/34

Isabel Martinez Epidemiology Pre-Doctoral Fellow HIV prevention; Immigration

and generational status

Gina Novick Nursing/Midwifery Investigator Prenatal care; Qualitative

methods; Process evaluation;
Implementation science

Allecia Reid Social Psychology Post-Doctoral Fellow Discrimination; Health

disparities; Quantitative
analysis

Sharon Rising Nursing/Midwifery Investigator Health system redesign; Group

prenatal care design; Clinician
training; Curriculum
development; Non-profit
management

Lisa Rosenthal Social and Health Psychology Post-Doctoral Fellow Discrimination; Stigma; Health
disparities; Sexual behavior;
Pregnancy; Infant health;
Quantitative analysis
Emily Stasko Clinical Psychology Project Manager HIV prevention; Sexual health;
Mental health

Jonathan Tobin Epidemiology Co-Principal Leadership; Epidemiology;

Investigator Practice-based research;
HIV/AIDS

Ifeyinwa Udo Epidemiology Post-Doctoral Fellow Intimate partner violence; HIV

prevention; Global health

Claire Westdahl Nurse-Midwifery/ Public Investigator Breastfeeding; Prenatal care;

Health Social support
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Figure 1. Using the Ecological Model as a guiding framework allows us to measure risk and protective factors for a myriad of maternal and child
health outcomes within an integrated framework that considers transdisciplinary priorities.

IMPROVED OUTCOMES
• Longer gestation
• Healthier
birthweight
• Shorter NICU length
of stay
• More breastfeeding
• Pregnancy weight
gain within
recommendations
• Better postpartum
weight loss
• Better perinatal
mental health
• Optimal birth
spacing
• Condom use
• Prevention of STIs
• Improved patient
satisfaction
• Improved provider
satisfaction
• Reduced healthcare
costs