Comparison of Outcomes in Maternal Opioid Medical Support Using Centering Pregnancy Versus Maternity Care Home

Adams J¹, Kenny T¹, Frantz K¹, Craig M¹, Eden R¹, Bellante A¹, Silber A¹, McCarroll ML^1,2*, von Gruenigen VE^1,2 and Gothard MD³

¹Summa Health, Department of Obstetrics and Gynaecology, Akron, OH, USA

²Northeast Ohio Medical University (NEOMED), Rootstown, OH, USA

³Biostats, Inc. North Canton, OH, USA

*Corresponding Author:

Mc Carroll ML
Summa Center for Women's Health
Research Summa Health, Akron
OH 44304, USA
Tel: 3303754880
E-mail: mccarrollm@summahealth.org

Received Date: June 25, 2016; Accepted Date: July 20, 2016;; Published Date: July 26, 2016

Citation: Adams J, Kenny T, Frantz K, Craig M, Eden R, et al. (2016) Comparison of Outcomes in Maternal Opioid Medical Support Using Centering Pregnancy Versus Maternity Care Home. J Preg Child Health 3:271. doi:10.4172/2376-127X.1000271

Copyright: © 2016, Adams J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Objective: To implement and evaluate two enhanced models of prenatal care in a high-risk population. Design: A non-randomized, retrospective case-control study was conducted with a 1:1 matching selection of participants by age, race, insurance status and marital status. Materials and methods: This study examined two types of prenatal visit models at the same center under the same perinatology service. One involved a group medical visit format using Centering Pregnancy (CGC). The other used standard individualized one-on-one Maternity Care Home (MCH) medical visits. The CGC prenatal visits met weekly or biweekly in lieu of regular MCH prenatal visits. The MCH prenatal visits occurred based on the prenatal care plan for high-risk opioid addicted pregnant women. Outcomes of maternal age (MA), gestational age (GA), Neonatal Intensive Care Unit admission (NICU), APGAR 5-min (APGAR-5), total number of prenatal visits (TPV), ultrasound visits including antenatal testing (USV), emergency room obstetrical triage visits (ERV), and breastfeeding at discharge (BF) were analysed using SPSS 22.0. Results: The CGC and MCH groups were matched cases (p=0.938) in age: 27.8 ± 3 years; race: 98% Caucasian; insurance type: 100% public and marital status: married 15%, single 78%, divorced 3%. Statistically significant differences were noted in TPV: 17.4 ± 6 versus 8.6 ± 7, (p<0.001); USV: 6.7 ± 4 versus 3.7 ± 3, (p<0.003) and ERV: 1.8 ± 2 versus 3.2 ± 2, (p<0.02). No statistically significant differences were noted between CGC versus MCH matched cases in GA: 75%, versus 69% full term, (p=0.580); APGAR-5: 8.9 ± 0.2, 8.5 ± 1.6, (p=0.121); NICU: 12 versus 11, (p=0.795); and BF: 79% versus 64%, (p=0.174), respectively. Conclusion: These results indicate that the CGC group prenatal visit model for opioid addicted pregnant women is clinically advantageous over MCH for ensuring prenatal visit compliance and reducing ERV in a high-risk population. Further research is warranted to investigate a cost-benefit analysis and the effects on maternal fetal outcomes postpartum.

Keywords

Opioid-addicted; Pregnant; High-risk; Centering; Maternity care home

Introduction

Over the last 15 years, opioid abuse has been a rapidly expanding problem in the United States arising from prescription pain relievers and/or heroin usage [1]. Unger et al. reported that there are an estimated 140,000 new heroin abusers each year with greater than 70% of these being women of reproductive age [2]. Opioid addiction in pregnancy has become a national health crisis with up to 4.4% of pregnancies complicated by illegal drug use within the last thirty days [3]. Pregnant women who are using opioids during their pregnancy are posing substantial risks to the health of their pregnancy and their unborn child, as well as their own personal health. Opioid abuse and addiction can lead to future sudden infant death syndrome (SIDS), neonatal abstinence syndrome (NAS), low birth weight, and preterm delivery [4]. Medically assisted therapy (MAT) has been the preferred management for women who are pregnant and abusing opioids due to the risks of withdrawal, namely placental abruption and preterm labor. In the past, this was almost exclusively accomplished using methadone. Recent research has shown that MAT using buprenorphine may decrease neonatal abstinence syndrome and improve neonatal outcomes [5].

Two widely accepted but different methods of prenatal care delivery are Centering Pregnancy (CGC) and Maternity Care Home (MCH). The MCH model is a typical one-on-one office visit. The patient in MCH has access to the same information/resources but not in a group fashion [6]. Typically, the topics of labor, nutrition, dental care, labs and diagnostic testing, breastfeeding, childcare, and smoking cessation are covered by a nurse, medical assistant, social worker, or other office staff [7]. Meanwhile, Centering Pregnancy is conducted in a small group setting where pregnant women receive prenatal care and also have the opportunity to meet one-on-one with a health care provider [8]. The recommended Centering Pregnancy curriculum follows 10 prenatal visits, each lasting between 90 min and 2 h, to allow mothers to engage in their prenatal care and have facilitated discussions on topics such as labor, nutrition, dental care, labs and diagnostic testing, breastfeeding, childcare and smoking cessation [8]. Centering Pregnancy care has demonstrated successful outcomes in a variety of cultures, communities, and demographics [9]. Specifically, CGC has led to increased self-esteem, decreased stress and social conflict, decreased rates of preterm delivery, improved breastfeeding rates, better weight management for the mother, and decreased depression at one year postpartum [10,11].

Unfortunately, only 34% of health care providers are even aware of Centering Pregnancy [12]. As a result, there is a dearth of evidence in applying the CGC and MCH models in high-risk opioid-addicted pregnant women. Moreover, Centering Pregnancy in low-risk pregnant women is an underutilized method of prenatal care despite its record of positive maternal-fetal outcomes. The purpose of this study was two-fold: 1. Assess maternal-fetal outcomes and 2. Assess feasibility in implementing the CGC model in high-risk opioid addicted women using compliance to visits.

Design

A non-randomized, retrospective case-control study was conducted with a 1:1 matching selection of participants by age, race, insurance status and marital status.

Materials and Methods

This study examined two types of prenatal visit models at the same center under the same perinatology service: CGC and MCH. The CGC prenatal visits met weekly or biweekly following the Centering Pregnancy curriculum in lieu of MCH style visits with their providers. The MCH model-conducted visits follow the current American Congress of Obstetrics and Gynaecology (ACOG) guidelines [13]. The eligibility criteria included pregnant women over the age of 18 with a known history heroin and/or prescription opioid use who partook in group therapy involving a one-on-one, provider-patient meeting. Eligible participants were also <30 weeks gestational age at the time of enrolment. Exclusion criteria included pregnant women who used drugs other than heroin and prescription opiods, such as alcohol and cocaine. Pregnant women who could not speak English were also excluded

A total of 66 retrospectively matched eligible women participated in this study. Thirty-three participants took part in the CGC prenatal visits and the other 33 partook in the MCH prenatal visits. No sample size analysis was performed. Thus, the sample size for this study was n=66 because there were only n=33 individuals participating in CGC at the beginning of the study. The data about CGC participants was retrieved from opioid addicted pregnant women enrolled in the Centering Pregnancy from June 10, 2014 to June 30, 2015. The study then retrospectively matched 33 MCH participants, who were selected from a group of 171 opioid addicted pregnant women attending the women’s health clinic from January 1, 2010, to June 30, 2015, with the 33 CGC participants. The MCH participants were selected using an electronic database search performed by a research associate. If data was missing, it was excluded from the final analysis.

Participant in both prenatal visit model groups had Maternal Fetal Medical (MFM) consults where physicians provided them with care plans. They received intensive treatment in either inpatient or outpatient treatment programs, mostly in community health centers. All participants were treated with buprenorphine. Urine screening occurred at each visit along with other typical screenings, such as weight and blood pressure. The treatment programs were separate from the prenatal care programs.

Prenatal visits were defined as either MCH visits or CGC visits. The cases were matched by age, race, insurance status, and marital status. Demographics and clinical outcomes were assessed. The clinical outcomes included gestational age at birth (GA), Neonatal Intensive Care Unit admission (NICU), APGAR 5 min (APGAR-5), total number of prenatal visits (TPV), ultrasound visits including antenatal testing (USV), emergency room obstetrical triage visits (ERV) and breastfeeding at discharge (BF). Appointments for formal ultrasounds, as well as appointments for weekly modified biophysical profiles, were also tracked, as this is the standard of care at our institution for women in MAT for opioid addiction.

Statistical analyses were performed using SPSS 22.0 software to conduct a paired samples Student’s t-test and Chi-Square (Fischer’s Exact) for changes between continuous and categorical data. Statistical testing was two-sided with p<0.05 considered statistically significant. Pearson's product–moment correlations were used to evaluate the association between outcomes. Institutional review board approval was obtained for conducting human subject’s research.

Results

The CGC and MCH groups were found to be statistically equivalent in the matched categories of age: 27.8 ± 3.74 years, p=1.000; race: n=33 white, p=1.000; marital status: p=0.753 and insurance status: 100% public insurance, p=1.000 (Table 1). In regards to patient reported and electronic medical records documentation of opiod use history, there was a significant difference (p=0.03) between the CGC and MCH groups whereby the CGC group had a 27.3% higher rate of multiple drugs used at the same time.

Table 1: Demographics and patient characteristics (SD: Standard Deviation; MCH: Maternity Care Home; CGC: Centering Pregnancy; *p-value<0.05 from chi-square test likelihood ratio).

Maternal-fetal outcomes of high-risk opioid addicted pregnant women revealed a significant difference in admission to emergency room (ER) triage during pregnancy with CGC 1.8 ± 2.03 visits versus MCH 3.2 ± 2.47 visits, p=0.020 (Table 2).

Table 2: Outcomes (SD: Standard Deviation; MCH: Maternity Care Home; CGC: Centering Pregnancy; ER: Emergency Room; NICU: Neonatal Intensive Care Unit; CHMCA: Children’s Hospital Admission).

There were no statistically significant differences noted between CGC and MCH matched cases in gestational age >37 weeks at delivery (GA): 75.8% versus 69.7%, (p=0.580); APGAR scores at 5 min (APGAR-5): 8.9 ± 0.2 versus 8.5 ± 1.6, (p=0.121); NICU admissions (NICU): 12 versus 11, (p=0.795); and breast feeding at discharge (BF): 79% versus 64%, (p=0.174), respectively (Table 3).

Table 3: Visit compliance (SD: Standard Deviation; MCH: Maternity Care Homel; CGC: Centering Pregnancy).

In Table 3, significant differences were noted in prenatal visit compliance in the CGC and MCH groups TPV: 17.4 ± 6 versus 8.6 ± 7, p<0.001; USV: 6.7 ± 4 versus 3.7 ± 3, p<0.003; and number of Centering Pregnancy visits 7 ± 4.02 versus 0 ± 0.0, p<0.001, respectively. There was no significant difference (p=0.224) between PCV between the two groups.

Discussion

The aim of this study was to assess feasibility of a previously low-risk prenatal care model (CGC) in a high-risk population consisting of opioid addicted pregnant women. We hypothesized that participating in CGC would result in favourable outcomes for women with pregnancies complicated by opioid addiction. The results indicated that there was a significant increase in compliance with antenatal testing and prenatal care appointments. Furthermore, the improved compliance rates resulted in positive effects on maternal-fetal outcomes. In a population where prenatal compliance and maternalfetal outcomes are known to be poor, any attempt to improve prenatal care is important.

The positive results observed in the CGC model are not surprising. Pregnant women strongly desire to feel in charge of their care and be comfortable at their place of delivery, especially at-risk women [14]. Centering Pregnancy in other high-risk groups, such as adolescents and women with low English proficiency, have demonstrated lower rates of preterm births, fewer LBW infants, improved patient satisfaction as well as a lower no-show rate [15-17]. Specifically, Robertson et al. presented that 87% of women participating in the Centering Pregnancy model indicated that they would participate in Centering® again for their next pregnancy [17]. In addition, Picklesimer et al. demonstrated a statistically significant decrease in preterm births <37 weeks with the implementation of CGC [18]. The current study revealed similar improved maternal results in high-risk opioid-addicted pregnant women.

Of note, the study had several limitations. For example, the study data is still in the first two years of collection and, therefore, our sample size is low. The opiate addicted pregnant sample selection and population was exclusively Caucasian, limiting the inferences to other racial/ethnic groups. In addition, the study was not a randomized design whereby women could choose to opt-out of the CGC program and only receive MCH services. Thus, there could be bias due to the participants’ known willingness to complete the CGC plan of care versus the MCH plan of care, attributing to the fact that women whos chose CGC may have been more motivated and health conscience. In addition, participant incentives to increase compliance and retention were distributed in both groups; however, there may have been more incentives perceived by those in the CGC group thereby having a “Hawthorne” type effect in addicted patients [19,20]. Another limitation may be the result of the CGC group data being more recent (2014-2015) than the MCH group (2010-2015). Over time, as a health problem worsens or becomes more prominent, health care professionals obtain more experience in dealing with the health issue, allowing them to better address that issue. As such, women in the CGC group may have received improved care when compared to women who were treated in the MCH group in the earlier years of opiate addiction treatment.

In summary, these results indicate that a group prenatal visit model for opioid addicted pregnant women is a clinically viable and feasible option to elicit positive maternal and neonatal outcomes. We anticipate expanding our findings to other at-risk populations, such as refugee populations, African-American focus groups, and communities with limited English proficiency. Further randomized studies are warranted to assess perinatal and neonatal outcomes in this and other high-risk populations.

Acknowledgement

We wish to thank the following for their partial support of this study: Strong Start Ohio, Reinberger Foundation and Women’s Endowment Fund.

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