The findings of this analysis indicate that there are differences, both prenatally and in the postpartum period, between the women who received individual physician care and chose to attend prenatal education classes and those who chose to take part in CenteringPregnancy®. Women who attended CenteringPregnancy® had a different demographic profile than women in the standard care and prenatal education group in that they had completed less education, were of lower income, and were more likely to be non-Caucasian and foreign-born, and to speak a language other than English in their home. These differences could reflect the recruitment site for women in CenteringPregnancy®, which was located in a neighborhood with high representation of immigrant groups and lower socioeconomic status (SES) families [41
], They were also more likely to use a walk-in clinic for their first prenatal visit, suggesting potential difficulties in becoming engaged in the health care system. Previous research has indicated that women of lower SES are less likely to have a regular family physician and are more likely to seek routine care from an emergency or walk-in facility [8
At baseline, women participating in CenteringPregnancy® were also more likely to have poorer psychosocial health than women attending prenatal education. However, at 4 months postpartum, there were no longer any significant differences in any of the psychosocial health variables between the two groups. An analysis of change in psychosocial health status between the two time points indicated CenteringPregnancy® women were more likely to have improved psychosocial health across time. Although the change analysis for improvement in social support was not significant, there was a greater proportion of women in CenteringPregnancy® than in the comparison group that reported an improvement in their perception of social support. The non-significant result could be due to low power or insensitivity in the social support measure used (i.e., total social support) and its cut-off. Indeed, established cut-offs as per the literature are developed among the general population and not for pregnant women per se.
Improved psychosocial health is particularly remarkable given the financial, language and social disadvantage this group of women reflected. However, given that the Centering Pregnancy program places significant emphasis on building social support within the group, this data suggest that participation in CenteringPregnancy® helped to improve women’s psychosocial health, which aligns with findings reported in a recent study in the area [42
]. These findings could have important implications given that maternal mental health during the prenatal period is an important contributor not only to an infant’s birth status, but has also been correlated with the continued health and development of the infant throughout their childhood [30
]. Current guidelines from the Society of Obstetrics and Gynaecology of Canada also emphasize the importance of caring for psychosocial health during pregnancy [7
], and these findings indicate that CenteringPregnancy® may provide care that improves women’s psychosocial well-being.
An important finding gleaned from the comparisons pertains to information received during pregnancy. When asked in late pregnancy, women in CenteringPregnancy® reported that they were more likely to have received information on nutrition, alcohol, and smoking than women in prenatal education, suggesting that women may receive more information on these topics in CenteringPregnancy® or may more readily retain the information gained in CenteringPregnancy®. Although difficult to tease out, further analyses controlling for markers of maternal literacy would be of value. Further exploration of these findings needs to also consider issues of timing, uptake, and delivery of information as these factors may influence information recall differences. Indeed, CenteringPregnancy® is more flexible than regular classes, and this type of structure may be better suited to retention and uptake of information.
In terms of health behaviours, a greater proportion of women in CenteringPregnancy® continued to smoke during their pregnancy; given the psychosocial health and SES profile of the CenteringPregnancy® women this finding may be due to confounding factor rather than insufficient support for smoking cessation. Rates of alcohol consumption during and after pregnancy among pre-pregnancy drinkers were similar in the two groups, which also may reflect the demographic profile and differences in attitudes towards alcohol between the two groups, as the northeast quadrant of Calgary has a higher population of immigrants and people belonging to cultural groups who abstain from alcohol [41
]. Indeed, the demographic profile of the CenteringPregnancy® women provides context for interpreting the results for a number of the comparisons. Women of lower SES have been found to be less likely to initiate breastfeeding and less likely to have positive nutritional habits [26
]. However, despite differences in their demographic profiles, women in CenteringPregnancy® and women in prenatal education had similar nutritional habits as well as similar levels of intentions to and initiation of breastfeeding. If the women of the CenteringPregnancy® group are assumed to have a similar baseline to other groups of vulnerable women that are reported in the literature, then it is possible that the lack of difference in breastfeeding initiation and nutritional habits could be attributed at least in some part to the prenatal care program. Nevertheless, women in CenteringPregnancy® were less likely to still be breastfeeding at 4 months postpartum and were more likely to start solid foods earlier than is considered optimal [23
], consistent with earlier studies that established, that women of lower SES are less likely to breastfeed and engage in optimal feeding practices [26
]. Cultural practices may also be a factor to consider. For these reasons, without a demographically matched group or analytic control, it is impossible to separate the effects of CenteringPregnancy® or prenatal education from that of socioeconomic, cultural, and sociodemographic factors.
Women in prenatal education were more likely to use a number of community resources in the postpartum period and overall more likely to access a wider range of community resources than were women in CenteringPregnancy®. This finding is challenging to interpret, as it could indicate that women in CenteringPregnancy® perceived less of a need to access community resources as they had developed social and informational networks through CenteringPregnancy®, or that as a consequence of accumulated poorer mental health, low proximity to services, transportation barriers, and financial and work related circumstances, these women were less likely or able to access these resources.
Considering the differences in the sociodemographic profile of the two groups, we are unable to determine if any differences in late pregnancy or postpartum variables are due to the model of care and education or socio-demographics and baseline differences between women in CenteringPregnancy® and those in the comparison group. Further analyses using multivariable regression models to adjust for socioeconomic and sociodemographic confounding variables are clearly warranted. In addition, many of the outcomes point to areas that need further exploration, which may not be possible using the survey data available. In particular, the positive change seen in the psychosocial domain warrant further exploration. Not all issues related to maternal mental health and well-being were explored in this study. In particular, the idea of empowerment was not addressed in this study, due to a lack of available data. If a perceived sense of empowerment can be understood to have a positive effect on other psychosocial health variables, such as stress or anxiety, then future research should attempt to identify disentangle its effects. Empowerment should be explored qualitatively, so that researchers can identify what lived experiences of prenatal care help a woman gain a sense of empowerment, and how such a sense enhances her capacity to cope in both the prenatal and postpartum periods.