Introduction

Prenatal care plays a crucial role in mitigating the occurrence of low birth weight, preterm birth, pregnancy-related morbidity and mortality, thereby facilitating transformation and happiness in family life.1 However, the conventional one-to-one consultation prenatal care model, which involves a single patient receiving unidirectional expertise from an obstetric provider during brief encounters, is currently facing challenges due to the growing demand from families.2 Women seek new prenatal care models with shorter wait times and longer time spent with care providers for supportive counselling and encouragement and to address their queries.3 Prior research has predominantly focused on characterising the present condition of prenatal care through the lens of women’s pregnancy experiences or by eliciting the opinions of healthcare providers.4 5 This restricted viewpoint constrains our comprehensive understanding of prenatal care, which should encompass the partner’s reaction to pregnancy occurrences and their influence on the family. This is crucial for successful implementation of any new woman-centred prenatal care measures.

CenteringPregnancy, a widely recognised group model of prenatal care, has been implemented in numerous countries, including the USA, the UK, Australia, Canada, Iran and Nigeria.6 One of the most successful implementations is by the Centering Healthcare Institute, which has scaled Centering to nearly 500 healthcare practices serving 60 000 families in the USA, with over two decades of experience.7 Additionally, Group Care Global, a non-governmental organisation dedicated to promoting a group care model based on Centering, has documented numerous countries that have embraced group care worldwide, providing comprehensive data on almost 30 countries where research on this model has been conducted.8 Through a fundamental restructuring of prenatal care provision, CenteringPregnancy has the potential to revolutionise the care of women.

CenteringPregnancy combines the conventional components of health assessment with a family- centred focus that includes health assessment, group interactive learning and the building of social support.9 CenteringPregnancy can be comprehended as a ‘pregnancy circle’,10 11 which includes two health providers, 8–12 pregnant women with similar expected due dates and their partners or support persons. In this circle, prenatal care adheres to the recommended schedule of 10 prenatal visits for pregnant women, with each visit lasting 90–120 min, and healthcare providers being able to afford 10 times more interactions with women.7 This model empowers women by recognising and valuing the knowledge, experience and support each member brings to the group. Centering emphasises that prenatal care should not focus solely on medical examinations or childbirth outcomes. Pregnancy is a period of intense self-reflection and personal growth.

Compared with individual prenatal care, CenteringPregnancy has demonstrated efficacy in improving health outcomes for both mothers and infants, including reduced rates of caesarean birth, low birth weight and preterm birth.12–15 Furthermore, CenteringPregnancy has led to heightened satisfaction among women, improved mental health and enhanced breastfeeding practices.16 17 This has recently been acknowledged by the WHO, which recommends that group prenatal care has the potential to enhance the utilisation and quality of prenatal care, achieve continuity of care and offer women a positive pregnancy experience.1

However, despite the established benefits and recommendations of CenteringPregnancy, access to its services for women in China has been lacking until recently. In 2021, the Midwives Branch of the China Maternal and Child Health Association and Group Care Global introduced group prenatal care in China. As of late 2022, the model was implemented at 11 sites, with an additional 27 scheduled to start.8 The focus is on the feasibility of implementing this model in the Chinese maternity healthcare system. Additionally, on-site CenteringPregnancy alone may not comprehensively address the immediate needs of expectant couples.

The Internet has effectively dismantled the temporal and geographical constraints of conventional medical service delivery. Smartphones, which serve as a conduit for mHealth, have emerged as promising instruments for disseminating health-related information and enhancing disease management capabilities. Over the last decade, prenatal care initiatives using smartphones have been developed. According to a recent multicentre randomised controlled trial, smartphone use for lifestyle interventions has demonstrated greater efficacy in promoting treatment adherence than standard clinical prenatal care alone.18 Encouraging health results have also been observed in terms of maternal and infant mortality, mental health and the prevention of communicable diseases during pregnancy.19–21

WeChat, an instant messaging platform with over 1.319 billion monthly active users worldwide,22 has gained increasing traction in the medical field. Social applications extend beyond message delivery and encompass online consultation, group management and live education. WeChat has considerable potential in mHealth applications. Leveraging social media platforms such as WeChat to disseminate information regarding pregnancy and childbirth may serve as a valuable supplement to prenatal care. However, we are unaware of any clinical trials that have explored social media as a strategy for group prenatal care, either in China or elsewhere.

This study aimed to describe the experiences and perceived barriers of pregnant couples in China who participate in CenteringPregnancy. In addition, it tried to understand the possible role of smartphones for couples in this new model. The specific question we sought to answer is, ‘Is group prenatal care acceptable to pregnant couples, and how does the integration of smartphones impact their participation in this care?’

MethodsStudy setting and design

The study employed a descriptive phenomenological approach using a constructivist/interpretivist paradigm to gain insight into the experiences of pregnant women and their partners participating in a smartphone-assisted CenteringPregnancy program. As Sandelowski discussed,23 a qualitative descriptive methodology is beneficial for obtaining straightforward descriptions of phenomena. This study adhered to the Standards for Reporting Qualitative Research guidelines for design and reporting.24

The study was conducted at two midwifery clinics located in Fujian, China, which have been providing smartphone-assisted CenteringPregnancy services since December 2021. The programme leader of this model in both hospitals was the same. The intervention team underwent standardised training, resulting in uniform qualifications among providers. Prenatal care processes and frequency remained consistent across both settings. A total of 47 families received this model care during their pregnancies. The interviews were conducted in quiet meeting rooms at both hospitals to ensure confidentiality.

Figure 1 presents an overview of the implementation process of smartphone-assisted CenteringPregnancy. The on-site Centering content retains all the core components of CenteringPregnancy, including health assessment, group interactive learning and the building of social support. Health self-assessment included monitoring blood pressure and weight and assessing recent sleep and psychological well-being. The on-site sessions were tailored towards addressing topics such as nutrition, exercise, relaxation techniques, comfort measures, communication and self-esteem, domestic violence, sexuality, childbearing, childbirth preparation, postpartum issues, infant care and feeding. The use of smartphones is also centred around the core components of CenteringPregnancy, encouraging daily health assessments and online interactive communication among participants to further promote social support for women. Online groups were established using WeChat to maintain continuous care and follow-ups. Online platforms provide open discussion for couples without time or location restrictions. Each online group was managed at regular intervals, at least three times a day, by one healthcare provider, who was familiar with the couple from on-site interactions. The healthcare provider’s primary role was to address unresolved medical inquiries, disseminate medical information, facilitate discussions and redirect conversations as required. Furthermore, healthcare providers encouraged participants to share their daily experiences and self-assessments, such as diet, exercise and weight control. Couples with inappropriate lifestyles or poor self-management would be reminded. As the healthcare providers were unavailable 24/7, the potential for lagging online information was emphasised at the outset. This is because, in prenatal care, early identification of emergency situations and seeking prompt medical attention is important. This continuous and integrated care allowed participants to initiate counselling and feedback, and healthcare providers to deliver messages and alerts.

Figure 1

The implementation process of smartphone-assisted CenteringPregnancy.

Recruitment

A purposive sampling strategy was employed to recruit couples who had undergone a smartphone-assisted CenteringPregnancy intervention within the past year and subsequently gave birth. Couples with varying characteristics such as education level, mode of delivery and childbearing experience were selected to ensure sample diversity. The inclusion criteria included (1) pregnant couples who were married (we did not recruit single-parent families and non-hetero couples because this study is a pilot of CenteringPregnancy in China), (2) Chinese-speaking, (3) aged 18 years or older and (4) experienced individual care before 12 weeks of pregnancy. The exclusion criteria were (1) attended on-site sessions fewer than six times and (2) never communicated with others in the smartphone group.

Of the 47 families, 44 couples met the inclusion criteria. A research assistant utsed phones to contact these individuals and invited them to participate in a dyadic interview regarding their experience with smartphone-assisted CenteringPregnancy care. Of the 14 couples selected for the study, 3 failed to attend the in-person interviews. Subsequently, two of these couples agreed to participate in the phone interviews. The remaining couple declined to participate because one partner was unavailable. Finally, 13 couples were interviewed (figure 2).

Figure 2

Participant recruitment process.

Patient and public involvement

The study was undertaken and analysed in collaboration with participants. We provided recordings, field notes and encoded contents and invited participants to correct errors or misinterpretations. Three participants were modified in response.

Data collection

The primary author collected data from December 2022 to March 2023 through semistructured in-depth interviews. The interview guide comprised questions to elicit information on participants’ experiences and perceptions of group prenatal care facilitated by smartphones (box 1). The interview guide was developed systematically, which involved identifying the participants, outlining the purpose and selecting the interview method. Subsequently, researchers collaborated to draft the guide after referring to previous literature,25–27 refining it further during semistructured interviews. Data analysis after each interview informed adjustments to the guide, ensuring its continuous refinement until reaching a stable version.

Box 1 Interview guides

Questions

What did you expect from prenatal care? Did it turn out as you expected?

How did you find out about the programme (Smartphone-assisted CenteringPregnancy)? Why did you join?

Which do you prefer between usual care and group care? Why?

What are your thoughts and feelings about being part of the Centering group?

How do you think the members in the group (doctors, midwives, peers) affect you and your partner?

Do you stay in touch with anybody through a smartphone? What do you think of the role of smartphones in Centering?

How do you feel about the arrangement of the programme (prompts: group model, mat time, group size, activity space)? Are there any improvements you would suggest?

The interviews lasted 20–53 min (33 min on average) and were recorded simultaneously via a mobile phone, recording pen and field notes. No substantial new themes emerged from the last two interviewees, indicating that data saturation had been achieved.

Data analysis

Verbatim transcripts of the interviews were uploaded to QSR NVivo V.11 (Windows).28 All data were read, re-read and coded separately by two authors following the content analysis approach and simultaneously with data collection. Any discrepancies in the naming of themes or data placement were discussed and resolved by mutual agreement between the two authors. Similar themes were then grouped, and controversial themes were resolved through discussions by the research team. The transcripts were then translated into English by a professional translator.

Since researchers bring their preconceptions, expectations, knowledge and experiences to the research process, reflexivity and replicability must be integral components of qualitative research.29 The research team in this study possessed clinical expertise in Centering care. All the interviews were conducted by the first author, a woman who has received national-level qualitative research training. The first author conducted in on-site sessions and established a rapport with the interviewees. The researchers engaged in ongoing reflections to mitigate the potential influence of their preconceptions.

Results

We interviewed 13 couples with diverse backgrounds, and their characteristics are shown in table 1.

Table 1

Demographic characteristics of participants

This study identified four distinct emerging themes from the analysis. These themes showed distinct and related characteristics. Table 2 provides a comprehensive summary of the primary themes and categories. online supplemental table 1 shows participant quotes.

Table 2

Themes and categories

In the transcript extracts, [ ] indicates explanatory text, () indicates field-noting text, and… indicates omitted text.

Theme 1. Motivation for participation

Before being introduced to the group, couples were typically unfamiliar with the CenteringPregnancy model prior to their introduction to the group. Women indicated that they were either referred to the programme by physicians via smartphones or had it recommended by midwives at prenatal clinics. The responses were as outlined below when asked about their impetus for participation.

Curiosity or wait and see

In China, it is common for men to wait outside the prenatal clinic while their partners receive care. Husbands frequently rely on secondhand information from their partners regarding the care that they were provided. Some participants expressed interest in the clinic’s novel approach to pregnancy care and were eager to try it out (quote 18). Additionally, the participants expressed keenness to use the facility to connect with other families undergoing similar experiences (quote 19).

However, some interviewees expressed reservations regarding the new model. Positive experiences resulted in continued participation (quote 20).

Convenience of accessing medical resources

During the interviews, couples stated that participation in the programme provided them with access to medical resources that were more convenient than those available through traditional individual prenatal care. This was due to the implementing doctors’ appointments that were otherwise challenging to schedule, which was made possible through the CenteringPregnancy programme (quote 21). Furthermore, Centering was perceived as requiring less time for physical examinations (quote 22).

Theme 2. Acceptance of CenteringPregnancy

None of the participants stated that they wanted to drop out or regretted participating in the programme. In their interviews, the couples confirmed that using a group-based model during pregnancy was beneficial. Continuous support from the same midwife and team members made them feel comfortable and allowed them to achieve a role transition quickly.

Participatory health support

The group sessions facilitated the exploration of a wide range of maternity care options, instilling a sense of empowerment in families navigating a disorganised and overwhelming information landscape (quote 1). The couples participating in the health support programme reported that it closely fits their needs (quote 2).

Positive psychological support

In addition to providing professional health support, CenteringPregnancy encouraged discussion and emotional exchange between group members. Participants reported that they could receive psychological support from healthcare providers, partners and other pregnant women, which was more important than professional healthcare (quote 3).

Moreover, CenteringPregnancy promoted empathy and psychological support between couples. Specifically, male partners were better equipped to comprehend the challenges faced by their pregnant spouses at a personal level (quote 4) and, subsequently, to support their spouse (quote 5).

Information flow and peer support also occurred among the male partners. They particularly appreciated the opportunity for peer discussion, which normalised their accompanying experiences and offered psychological support (quote 6).

Self-growth

Although self-growth is challenging to achieve, CenteringPregnancy contexts drive this phenomenon. The process of self-growth was based on a progressive trajectory, where the couples went through three stages: self-reflection, self-awareness and self-improvement.

Self-reflection can be facilitated in group social interactions through peer comparison (quote 7). Several participants noted a significant shift in their thoughts owing to this approach (quote 8).

Subsequently, self-awareness was generally followed and enhanced by self-reflection, embodied in family roles and individual responsibilities (quote 9). Responsibility is essential to the quality and stability of a couple’s relationship. CenteringPregnancy is needed to move beyond individualised care and recognise partners’ roles in care engagement (quote 10). The couple-oriented model posits that a positive impact on roles for both partners and parents is achievable.

More importantly, self-improvement gradually occurs in couples through group interaction, self-reflection and self-awareness over time. For example, sharing healthy lifestyles with other families prompted reflection and subsequent emulation, resulting in improved adherence to healthy lifestyle practices within the group. This affirmative exchange facilitated the efficacy of the role model within the group (quotes 11, 12).

Theme 3. Barriers and suggestions

Although participants reported the model’s benefits, barriers and inconveniences to its adoption in China are inevitable. The participants also made suggestions based on their perspectives.

Inflexible time

While working females could take partial or complete days of maternity leave during their pregnancy, some respondents noted that male employees faced occasional challenges in taking time off work (quote 23).

CenteringPregnancy espouses the notion that the primary support person is typically the husband, although this is not an absolute rule, and other family members, such as the mother or mother-in-law, may substituted. The participants also mentioned and endorsed this point (quote 24).

Insufficient space

The two health facilities in this cluster include a newly constructed hospital and a multiyear facility. Notably, only the latter facility was subject to concerns regarding inadequate space. Specifically, one female participant conveyed her experience of spatial inadequacy and expressed a desire for improvement. According to the participants, particularly during the pregnancy exercise session, the available space was inadequate to accommodate all activities (quote 25).

Conversely, the participants in a separate pilot study did not offer any recommendations for enhancing the spatial layout or environment.

Inadequate education

One female participant believed time limitations created a significant disparity between theoretical knowledge and practical applications (quote 26). The male respondents reported inadequate preparation for the postpartum period (quote 27). They expected midwives to pay more attention to childbirth coping and parental preparation.

Participants expressed those temporal constraints restricted the opportunity for in-depth discussions and knowledge acquisition, particularly during the initial phases of CenteringPregnancy. Several participants expressed a desire to increase the frequency of the sessions. They proposed incorporating online sessions as a supplementary measure to achieve this objective (quote 28).

Theme 4. Support for smartphone use of CenteringPregnancy

Smartphones were accepted and appreciated by almost all participants as an auxiliary instrument to the CenteringPregnancy intervention. This study revealed that participants derived enjoyment from the camaraderie of their peers and expressed a desire to maintain communication through WeChat. Additionally, several participants reported that smartphones provided a relatively convenient network environment for meaningful discussions, fostered trusting relationships and improved healthy lifestyle adherence.

More timely diversified support

Using instant messaging platforms allowed individuals to communicate with healthcare providers and other team members. Individuals conveyed that the providers rendered prompt medical aid (quote 13).

For some participants, the timely response from their peers met the need to be seen and supported in a special situation (quote 14).

Up-to-date healthcare providers frequently responded to couples’ inquiries beyond their regular work time. Excessive reliance on provider support may result in some individuals failing to recognise warning signs promptly (quote 15).

Tighter intergroup relations

After participating in the programme, the interviewed participants frequently expressed their approval of the initiative and acceptance of using smartphones for online connectivity. Participants attested to enhancing their interpersonal connections using smartphones and reported receiving additional social support within virtual groups (quote 16).

Furthermore, establishing these relationships may increase the participants’ attendance at prenatal visits (quote 17).

DiscussionSummary of key findings

Based on the perspectives of the couples who underwent the dyadic interviews, CenteringPregnancy care meets participants’ medical and psychological needs and is possible in a smartphone-assisted context. Couples who participated in the model reported positive pregnancy experiences and were satisfied with the prenatal care services that they received. They also used smartphones to acquire additional medical care and developed social links in the group. However, this objectively presented challenges in the adaptation process.

Comparison with theoretical literature

Prevailing prenatal care involves one-to-one consultations wherein a woman receives unidirectional expertise from an obstetric provider during brief encounters. The CenteringPregnancy approach, which emphasises interaction and companionship in a safe space, represents a shift away from didacticism and is considered a core strength compared with traditional prenatal care.30 The present study found the participants highly valued Centering care. During the on-site sessions, couples were encouraged to engage in peer-like communication with minimal interference from providers and didactic displays. The participants acknowledged that Centering facilitated knowledge sharing and emotional communication through multifaceted support, consistent with the findings of a systematic review.31 This approach is advantageous for enhancing our understanding of pregnancy. However, our study revealed that the Chinese participants remain relatively unaware of CenteringPregnancy or group-based prenatal care. In the initial invitation to couples to Centering, both low-risk and high-risk pregnant women were enrolled, excluding those with life-threatening severe complications or comorbidities. On invitation to participate, some individuals were motivated by the convenient access to medical resources, whereas others were ambivalent or intrigued by the care structure. Attending prenatal care together was a novel and potentially rewarding experience for couples. Accessibility of medical resources, interaction with providers and expectations of pregnancy also impacted the level of women’s satisfaction with prenatal care services.32 Inference from the binary outcome is that a considerable number families may refrain from participating in the initial session because of certain obstacles to recruitment. This is consistent with Ahrne et al33 who reported that approximately 39.3% of eligible Somali-Swedish women declined to participate in group prenatal care. Although this hypothesis warrants validation in China through high-quality surveys, diverse organisations or official institutions intensify efforts to disseminate information effectively promoting this novel model.

By actively including people who provide support in group prenatal care, Centering enhances familial bonds crucial for preparing and upbringing healthy children. Research has indicated that a significant proportion of men lack knowledge regarding pregnancy-related issues, changes and the needs of women during this period.34 These men anticipate receiving information and professional guidance to become more involved in prenatal care and support their partners.35 Similarly, seeking support from other women and their partners is equally important for many women.36 37 Building healthy families must include more than the mother alone. In a health system that has been transformed by the principles embedded in group prenatal care, all voices must be heard. The Centering process galvanised couples to realise their potential and responsibility to adapt and cope while cooperating with healthcare providers without overreliance. Centering stimulates role transitions in couples, particularly for men, and strengthens relationships through mutual support during pregnancy and childbirth. This support facilitates the establishment of parental roles. An appropriate model that facilitates clear roles for men is important for pregnant families.

On-site CenteringPregnancy alone struggles to address the immediate needs of expectant couples fully. Smartphones are increasingly used in intensive intervention settings and have demonstrated efficacy in improving perinatal outcomes.38 In the pilot study, a smartphone was employed as an additional online chat group tool to reinforce participants’ engagement and social support, potentially reducing attrition rates. Cultivating positive social interactions is a fundamental tenet of the CenteringPregnancy approach, with extant research indicating correlations between such interactions and improved psychological well-being.39 Furthermore, our findings indicated that the use of smartphones facilitated relationship development. However, running smartphone groups requires additional medical effort to conduct online counselling, which may increase healthcare providers’ workload and foster overreliance on participants. Individual manifestations of pregnancy-related danger signs may not be promptly addressed by waiting for answers online. A more effective approach to enhance early risk identification and intervention among participants may be by providing more comprehensive health education. Alternatively, a dedicated individual responsible for the real-time management of smartphone groups may offer a viable solution, although with the caveat of considering the associated human resource costs.

Although participants appreciated the continuous care that resulted from maintaining stable group compositions, perceived insufficient time may be a retention barrier for some participants. Requiring frequent leaves can prove challenging for employed couples, particularly men who lack accompanying maternity leave opportunities. Therefore, group composition should be stable but flexible, consistent with Massey’s viewpoint.40 If the group allows, a participant can join later and become a member of that group. A one-time participation to catch up on the session is not recommended. Several scholars have proposed that supporters’ participation in group sessions is discretionary and that women can elect whether to extend an invitation to their spouses or next of kin.41

Barriers regarding the physical space were also found, as echoed in a previous study.42 The adequacy of physical space is a crucial factor because not all healthcare facilities possess the necessary space with optimal features to enable group sessions. Space plays a pivotal role in executing this model in China. The allocation of appropriate physical space for a group session can pose a challenge in congested clinic consultation room settings. As recommended by the participants, online sessions may serve as a viable alternative and fulfil familial educational requirements. Investigating the practicality and prerequisites during the execution phase is imperative.

Strengths and limitations of the study

This is the first qualitative study focusing on couple’s social media experiences as a strategy for group antenatal care. Our findings suggest that implementing the smartphone-assisted CenteringPregnancy model carries both opportunities and challenges to prenatal care. This study used an innovative approach, a binary interview, and did not separate couples during this process. However, whether the presence of partners affected the depth of the interviews is unknown. Our interviews did not solicit the perspectives of couples who dropped out of the group, and their experiences may have been different. Couples participating in the interviews insisted on staying with the group. In addition, the new model of prenatal care is still in the exploratory stage in China, and the participants consist entirely of Chinese-speaking couples. This is a limitation of the present study. Moreover, this study only recruited pregnant couples who were married and not single-parent families and non-hetero couples. This could have resulted in some biases in the study results. We hope that the present findings provide a new understanding of CenteringPregnancy adaptation in China and promote similar studies in the future.