The REACH Pregnancy Programme team is evaluating a model of group antenatal care, which we have called ‘Pregnancy Circles’. The aim is to improve women’s experience and outcomes of antenatal care in areas with high levels of poverty and high ethnic and language diversity.
The Pregnancy Circles model:
The Pregnancy Circles model brings together around 8-12 pregnant women who are at similar stages in pregnancy and who live near each other, for clinical care, information-sharing and social support. The Pregnancy Circles aim to provide a woman-centred, community environment for antenatal care. Pregnancy Circles are designed to be diverse and reflect their local area. They will include:
· Women who are experiencing high-risk pregnancies, or low-risk pregnancies
· First-time mothers and women who have had previous children
· Women who speak English and women who do not speak English (interpreters will be made available as needed)
· Mixed ethnicities and backgrounds
The clinical content and schedule of appointments provided in Pregnancy Circles remains the same as per the NICE antenatal care guidelines, but the sessions are longer than traditional care (2 hours rather than a typical length of about 15-20 minutes). Pregnancy Circles also involve an additional “reunion” postnatal session.
Each Pregnancy Circle session is facilitated by the same two midwives - continuity of carer and of participants is considered to be a key component for relationships to
develop between midwives and the women, and between the women within the group. Continuity may also be provided by student midwives, health visitors, health advocates or GPs who might like to get involved.
The sessions involve information sharing, self-care activities (women are taught to check their own blood pressure and urine), and brief one-to-one sessions for individual health checks with a named midwife on a mat in a corner of the room.
The model is designed to be flexible to reflect local needs (for example, some Trusts may wish to include some specialist Pregnancy Circles). Decisions about the content and character of each Circle session will be decided by the women who take part (for example, methods of communication, the inclusion of partners, invited speakers etc.).
Training:Two models of training in group facilitation have been developed by the REACH Pregnancy Programme team for midwives who want to facilitate Pregnancy Circles:
· A 1-day training session facilitated by Nicky Leap, a midwife researcher with experience of implementing this type of care in Australia. The training is delivered by the research team.
· A Level 7 module at City, University of London, called ‘Advances in Midwifery: Facilitating Group Antenatal Care’.
Evaluation of Pregnancy Circles
Feasibility Study:We conducted a feasibility study of group antenatal care in 2015-16:
· Phase 1 involved (i) interviewing key members of staff working with/in the maternity services of Barts Health NHS Trust in north east London, as well as local commissioners and GPs, to identify barriers and facilitators to implementing this model of care within the service, and (ii) conducting workshops with local women to explore their opinions of the proposed group-based care. Findings were used to develop a tailored group model of antenatal care- Pregnancy Circles.
· Phase 2 involved the implementation of four ‘test’ Pregnancy Circles across the three Barts Health NHS Trust maternity services. These were evaluated using observations, focus groups and one-to-one interviews with participants, facilitating midwives and key members of staff.
· As part of our feasibility work we also conducted a realist review of the international literature to analyse the ‘programme’ theories and key principles informing group antenatal care (ANC) models to identify what works, for whom, in what circumstances.
Pilot Randomised Controlled Trial:A pilot trial of Pregnancy Circles is currently under way within the maternity services of Barts Health NHS Trust to assess the feasibility of a full trial, and determine the most appropriate outcome measures to examine effectiveness.
Randomised Controlled Trial:To understand if and how Pregnancy Circles may be better than usual individual care, a randomised controlled trial is planned in 2018 across different NHS Trusts. Around 2,100 pregnant women will asked to take part in either Pregnancy Circles or to continue with their usual care to compare experiences and health in themselves and their babies.
We will examine effectiveness through:
(i) maternal and infant health and safety outcomes
(ii) satisfaction with care
A process evaluation will be conducted alongside the trial. As well as observations, focus groups and interviews will be conducted with midwives and women participating in the intervention, to better understand the benefits and challenges of this model. We will also examine the process of implementing Pregnancy Circles as a complex intervention in the NHS.
We will conduct an economic evaluation to calculate the cost-effectiveness of Pregnancy Circles compared to standard care.