Introduction
Objective
Methods
Eligibility criteria, information sources, search strategy
Study selection
Data extraction
Study quality assessment
Data synthesis
Results
Study selection
Study characteristics
Author Publication Year | Study Design Study Years | Country/Setting | Inclusion/Exclusion for Group Care at the site | Inclusion/Exclusion for the study of group care at the site | Participant demographics | BMI, GWG, and GWG goal definitions | Prenatal care model |
---|---|---|---|---|---|---|---|
Randomized Controlled Trials | |||||||
Kennedy 2011 [29] | RCT 2005–2007 | US Military Naval Hospital in Pacific Northwest | < 16 weeks, ≥18 years, no severe medical problems, understand English | < 16 weeks, ≥18 years, no severe medical problems, understand English | 58–60% white Mean age 25 years 45–59% nulliparas Mean BMI range 26.0–26.4 kg/m2at study baseline | BMI: not stated GWG: difference between time 1 (12–16 weeks) and delivery GWG goals: not stated | CP |
Harden 2014 [22] | Feasibility pilot study with “random assignment” Years not stated | Country not stated Low-income families | Pre-pregnancy BMI ≥ 30 kg/m2, attended clinic that served low-income families, physician clearance, 21–35 years, < 21 weeks, no medical contraindication to physical activity, English speaking | Pre-pregnancy BMI ≥ 30 kg/m2, attended clinic that served low-income families, physician clearance, 21–35 years, < 21 weeks, no medical contraindication to physical activity, English speaking | 61.5% Caucasian Mean age 22 years 100% obese with mean BMI 37.64 kg/m2 | BMI: pre-pregnancy weight GWG: week 4,8,12,16,20 of intervention minus beginning of intervention GWG goals: 2009 IOM | Prenatal group visits in group-based lifestyle sessions |
Magriples 2015 [25] | Secondary analysis from RCT 2008–2012 | US 14 Community Health Centers and hospitals in New York City, New York serving low-income minorities | 14–21 years, < 24 weeks, no severe medical problems, English or Spanish speaking | Excluded: multiple births, history of heart disease, CHTN, DM, no BMI data, missing or invalid weight data | 63.5% Latina Mean age 19 years 85% nulliparas 12% underweight 53% normal 20% overweight 16% obese | BMI: self-reported pre-pregnancy weight GWG: not stated GWG goals: 2009 IOM | CP Plus (Structured reproductive health promotion activities during 4 of the 10 sessions including activities to improve sexual self-efficacy, HIV knowledge, interpersonal sexual communication, perceived risk, and social norms) |
Cohort studies | |||||||
Klima 2009 [26] | Retrospective cohort 2004–2006 | US Low-income Chicago, Illinois public health clinic, all women eligible for Medicaid | Continuing care at site, < 18 weeks, no high risk obstetric conditions | Exclusions: fetal demise < 28 weeks, delivered before attending 4 group or individual visits, delivery at other hospital | 100% African-American Mean age range 20.8–22.1 years | BMI: not stated GWG: not stated GWG goals: not stated | CP |
Holbrook 2010 [31] | Pilot chart review 2009 | US Northern California | Not stated | Spanish-speaking | 100% Hispanic | BMI: not stated GWG: first recorded weight to last recorded weight GWG goals: excessive defined as > 1 pound/week in the 3rd trimester | CP |
Trudnak 2013 [27] | Retrospective cohort 2006–2010 | US Southern Florida public health clinic | Spanish-speaking, Hispanic ethnicity | Initial visit completed before 4 months gestation, completed at least 50% of visits | > 90% Hispanic Mean age range 25–26.0 years 33–54% nulliparas 2% underweight 50% normal weight 33% overweight 13% obese 1% morbid obese | BMI: pre-pregnancy weight GWG: weight at last prenatal visit minus pre-pregnancy weight GWG goals: 2009 IOM | CP |
Tanner-Smith 2014 [35] | Retrospective cohort 2008–2011 | US Faith-based community health center in Southern metropolitan area | English speaking, no high risk conditions (prior CD, prior LBW, DM, SLE, heart disease, clotting problems, seizures, kidney disorder, cervical incompetence, mental health disorder) | Not stated | 76% non-Hispanic black, 13% Latina, 11% White 88% public insurance Mean age 22 years Median gravidity 2 43% healthy weight 30% overweight 27% obese | BMI: pre-pregnancy weight GWG: last prenatal visit minus 1st prenatal visit GWG goals: IOM 2009 based on pre-pregnancy weight | CP |
Zielinski 2014 [34] | Case-control retrospective 2010–2012 | US CNM hospital-based practice in southwest Michigan | < 20 weeks, eligible for CNM care | < 20 weeks, eligible for CNM care | Mean age range 24–25 years 49% private insurance 78% white 4% underweight 41–42% normal 29–30% overweight 25% obese | BMI: self-reported pre-pregnancy weight GWG: not stated GWG goals: 2009 IOM | CP |
Walton 2015 [28] | Retrospective cohort 2009–2013 | US Military Naval Medical Center in San Diego, California in a tertiary care teaching hospital with outpatient clinics | Not stated | Included: Delivery at Naval Medical Center in San Diego, > 20 weeks at delivery Excluded: “late to care”, transfer of care, dependent daughters of active duty members | 48% Caucasian Mean age range 25–26 years 57–75% nulliparas Mean range of pre-pregnancy BMI 24.3–25.0 kg/m2 | BMI: pre-pregnancy weight GWG: not stated GWG goals: 2009 IOM | CP |
Trotman 2015 [24] | Retrospective cohort 2008–2012 | US MedStar Health Research Institute Washington, D.C. in a teaching urban hospital with adolescents | Not stated | 11–21 years, No significant medical history or pregnancy complication requiring high risk care | 96% African-American Mean age 17 years 70% nulliparas | BMI: not stated GWG: not stated GWG goals: 2009 IOM | CP |
Mazzoni 2015 [23] | Prospective observational 2013–2014 | US Hospital based clinic in Denver, Colorado affiliated with integrated safety net healthcare system | GDM, English or Spanish speaking, singleton | ≥ 2 of the 4 group visits | Mean age 31 years 89% Hispanic Mean pre-pregnancy BMI range 30–33 kg/m2 5–6% CHTN | BMI: pre-pregnancy weight GWG: not stated GWG goals: not stated | Group care for GDM at 26–32 weeks with 4 sessions |
Brumley 2016 [36] | Retrospective cohort 2011–2013 | US University of South Florida, academic center | Excluded: pregestational DM, CHTN, uncontrolled psychiatric disorders, multiple gestations, other major medical problems, > 20 weeks | ≥ 3 group visits | 62–76% white 57–79% nulliparas 2.1% underweight 60% healthy weight 22.6% overweight 15.4% obese | BMI: initial weight or self-reported pre-pregnancy weight if 1st visit occurred after the 1st trimester GWG: weight at last visit minus weight at 1st visit GWG goals: IOM, year not stated | CP |
O’Donnell 2016 [32] | Retrospective cohort 2011–2014, abstract only | US University of California-San Francisco Medical Center, CA | Not stated | 18–45 years, singleton, no fetal anomalies, no chronic medical problems, 1st prenatal visit < 20 weeks, attended ≥5 prenatal visits | Mean age 33 years 51% white, 25% Asian Mean pre-pregnancy BMI 24 kg/m2 | BMI: self-reported pre-pregnancy weight GWG: weight at delivery minus self-reported pre-pregnancy weight GWG goals: 2009 IOM | CP |
Schellinger 2016 [30] | Retrospective cohort 2010–2015 | US Inner city county hospital in Indiana | GDM, English or Spanish speaking | ≥ 18 years, singleton, no major fetal anomalies | Mean age 31 years 100% Hispanic for group 7% CHTN | BMI: not stated GWG: not stated GWG goals: not stated | Adapted CP for GDM with 4 sessions after GDM diagnosis |
Kominiarek 2017 [33] | Retrospective cohort 2009–2015 | US Greenville Health System, South Carolina | Exclusion: high risk medical conditions, multiple gestations, pre-pregnancy BMI > 45 kg/m2, entry to prenatal care after 24 weeks. | Inclusion: Pre-pregnancy height and weight and final pregnancy weight available, eligible for Medicaid coverage at the time of delivery Exclusion: Fetal demise, delivery outside of Greenville Health System | Mean age 23–26 years 22–24% Hispanic Mean pre-pregnancy BMI 26 kg/m2 16–18% tobacco use | BMI: self-reported pre-pregnancy weight GWG: weight at delivery minus self-reported pre-pregnancy weight GWG goals: 2009 IOM | CP |
Risk of bias of included studies
Author, Year | Threats to validity a | Total | ||||
---|---|---|---|---|---|---|
Reporting (11) | External validity (3) | Internal validity (7) | Confounding or selection bias (6) | Power (1) | ||
Randomized trials | ||||||
Kennedy 2011 [29] | 9 | 2 | 3 | 5 | 0 | 19 |
Harden 2014 [22] | 5 | 0 | 2 | 2 | 0 | 9 |
Magriples 2015 [25] | 9 | 1 | 2 | 5 | 0 | 17 |
Cohort studies | ||||||
Klima 2009 [26] | 6 | 1 | 3 | 2 | 0 | 12 |
Holbrook 2010 [31] | 3 | 1 | 3 | 2 | 0 | 9 |
Trudnak 2013 [27] | 7 | 1 | 4 | 2 | 0 | 14 |
Tanner-Smith 2014 [35] | 8 | 1 | 4 | 3 | 0 | 16 |
Zielinski 2014 [34] | 8 | 2 | 0 | 2 | 0 | 12 |
Walton 2015 [28] | 7 | 2 | 1 | 2 | 0 | 12 |
Trotman 2015 [24] | 6 | 2 | 2 | 2 | 0 | 12 |
Mazzoni 2015 [23] | 8 | 1 | 3 | 2 | 0 | 14 |
Brumley 2016 [36] | 7 | 0 | 3 | 2 | 0 | 12 |
O’Donnell 2016 [32] | 8 | 1 | 4 | 3 | 0 | 16 |
Schellinger 2016 [30] | 5 | 1 | 2 | 2 | 0 | 10 |
Kominiarek 2017 [33] | 9 | 1 | 4 | 3 | 0 | 17 |
Synthesis of results
Author, Year | Group PNC GWGa | Traditional PNC GWGa | p-value or OR (95% CI) | Selection of controls and analysis details | Preterm births | GA at delivery or preterm birth in GWG analysis | Total Number of PNC visits | Provider types |
---|---|---|---|---|---|---|---|---|
Kennedy 2011 [29] | n = 162 33 pounds (mean) | n = 160 33.6 pounds (mean) | p = 0.71 | RCT | 7–10% | No correction for GA at delivery | 12.9% group vs. 46.9% < 9 visits, p < 0.001 | Physicians, midwives, and NP for both |
Harden 2014 [22] | n = 8 5.29 ± 5.33 kg | n = 8 8.64 ± 3.88 kg | p < 0.01 | “randomly assigned” | Not stated | No correction for GA at delivery | Not stated | Physicians for group |
Magriples 2015 [25] | n = 495 48.8% excessive | n = 489 51.6% excessive | p > 0.05e | Secondary RCT | Not stated | Multilevel modeling accounted for variability in timing of delivery | 9.3 group vs. 8.9, “not significant” | Physician or midwife for groups |
Klima 2009 [26] | n = 61 32.2 ± 13.6 pounds | n = 207 28.5 ± 15.6 pounds | p < 0.05 | All women who delivered at same hospital during study period | 11–13% | No correction for GA at delivery | 9.7 ± 2.7 group vs. 8.3 ± 3.4, p < 0.05 | CNM for both |
Holbrook 2010 [31] | n = 50 24 pounds (mean) | n = 50 28 pounds (mean) | “Not significant” | “convenience sample of the most recent 100 prenatal panel” | Not stated | No correction for GA at delivery | Not stated | Not stated |
Trudnak 2013 [27] | n = 247 15.5% below healthy 35.6% healthy 41.3% above healthy 2% missing | n = 240 33.4% below healthy 31.3% healthy 29.6% above healthy 3.8% missing | p < 0.01b aOR = 1.45 (0.79–2.62)c aOR = 0.41 (0.22–0.78)d | Matched for Hispanic ethnicity, primary language Spanish, month/year of prenatal care entry | 2.1–5.7% | No correction for GA at delivery | 91.9% group vs. 63.8% adequate APNCU index, p < 0.01 | Not stated |
Tanner-Smith 2014 [35] | n = 242 25.5 ± 13.99 pounds 30.2% low 33.5% healthy 36.4% excessive | n = 327 21.32 ± 14.50 pounds 44.0% low 29.4% healthy 26.6% excessive | Not statede | Propensity score matching for age, race, Spanish language speaker, education level, marital status, government insurance, current employment, gravidity, height, GA and weight at entry to care, pre-pregnancy BMI, systolic blood pressure, histories of non-gestational DM, depression, drug use, gynecological surgery, HTN, kidney problems, operations, blood transfusions, trauma | 8–16% | Accounted for GA at delivery with multiplicative interaction terms | 17.03 ± 5.83 group vs. 8.38 ± 4.13, no statistics in the unmatched sample | 1 CNM and 1 physician for group |
Zielinski 2014 [34] | n = 173 33.1 pounds (mean) 22% low 25% met 53% exceeded | n = 170 33.7 pounds (mean) 23% low 28% met 49% exceeded | p = 0.84 (mean) p = 0.24 (category) | Propensity score matching for age, insurance, race from n = 1427 women | 5.8–5.9% | No correction for GA at delivery | 14.2 ± 7.2 group vs. 13.4 ± 10.7, p = 0.27 | CNM for both |
Walton 2015 [28] | n = 202 14.9 ± 6.53 kg 52.7% excessive | N = 202 15.9 ± 6.53 kg 61.9% excessive | p = 0.11 (mean) p = 0.07 (category) | Selected from 2011 to 2013 | 5.5–6.9% | No correction for GA at delivery | “9 group visits” | CNM for both |
Trotman 2015 [24] | n = 50 2.0% met | n = 50 38.0% met single provider n = 50 38.0% met multiple provider | p = 0.02 (single provider) p = 0.02 (multiple provider) | Selected from either single or multiple provider according to age, time, and delivery criteria | 10–16% | No correction for GA at delivery | 62% group vs. 40.8–51.9% attended 100% of appointments | CNM or physicians for group |
Mazzoni 2015 [23] | n = 62 19.2 ± 13.0 pounds 3rd tri weight gain 6.7 ± 7.0 pounds | n = 103 18.0 ± 15.0 pounds 3rd tri weight gain 7.3 ± 6.6 pounds | p = 0.57 (total) p = 0.55 (3rd tri) | Women with GDM who delivered in 2012 at same hospital | 3–5% | No correction for GA at delivery | 12.4 ± 2.2 group vs. 14.0 ± 4.3 scheduled appointments, p = 0.002 | Obstetrician, CNM, psychologist, medical assistant for group; Obstetrician or MFM specialist for traditional |
Brumley 2016 [36] | n = 65 32.8 ± 10.7 pounds 33.8% met | n = 130 31.4 ± 12.7 pounds 36.2% met | p = 0.18 (mean) p = 0.24 (category) | Matched for age and pre-pregnancy BMI in 1:2 ratio | 1.5–6% | No correction for GA at delivery | Not stated | Midwives for group |
O’Donnell 2016 abstract only [32] | n = 125 46.4% excess | n = 2873 43.3% excess | p = 0.49 | Women who declined CP | Not stated | Not stated | Not stated | Not stated |
Schellinger 2016 [30] | n = 203 9.3 ± 4.5 kg | n = 257 10.2 ± 6.7 kg n = 120 (Hispanic women) 10.3 ± 5.7 kg | p = 0.21 (all women) p = 0.26 (Hispanic women) | Women who declined CP | 8–11% | No correction for GA at delivery | Not stated | Health educator, diabetic educator and physician for group |
Kominiarek 2017 [33] | n = 2117 30 pounds (18–18) median (IQR) 20% low 25% met 55% excessive | n = 4234 28 pounds (20–40) median (IQR) 26% low 26% met 48% excessive | p < 0.001 p < 0.001 (category) | Matched 1:2 with the next 2 women in traditional PNC who delivered with the same payer type, within 2 kg/m2 pre-pregnancy BMI units, and within 2 weeks of gestational age at delivery | 5–7% | Weekly rate of GWG calculated and then multiplied by 40 | 13.6 ± 3.2 group vs. 10.3 ± 3.9, p < 0.001 | NP or CNM for group |