CenteringPregnancy: Better Birth Outcomes, Happy Caregivers, Satisfied Patients

 

The women trickle in, one by one, into a brightly lit ground floor conference room at Providence Hospital, a large urban hospital in Washington, DC. A vibrant social worker greets each one as “honey” as they take their seats in a circle of chairs. Each is pregnant and in her third trimester; some are alone, a few with male partners by their side. A teenager has brought her mother. Refreshments and gifts sit waiting for them on a table at one corner of the room.
The warm atmosphere couldn’t resemble a waiting or examination room any less, yet this space functions as both. All of the women are here for their prenatal checkups, one of many they will experience together leading up to their deliveries a month from now. They are participating in a “centering” pregnancy group, an innovative form of prenatal care that Providence—and other hospitals around the country—are offering to pregnant women. By moving them out of the clinic and into a group space, centering seeks to revolutionize prenatal care by reducing racial disparities in birth outcomes, boosting caregiver morale, and controlling costs.
Centering is the brainchild of Sharon Schindler Rising, CNM, MSN, FACNM, president/CEO of the Centering Healthcare Institute based in Silver Spring, Maryland, and Boston, Massachusetts. She dreamed up the word “centering” to describe the model of care she wanted to provide while driving her daughter to school one morning and formally introduced it to her colleagues at a national conference for nurse-midwives in 1995. In her own words, Rising says centering brings together three components of prenatal care: the medical assessment or checkup, patient education, and community building. The last feature is at the heart of what centering is about as it erases the hierarchy between clinicians and patients and encourages women to seek out expertise in one another.  
Centering empowers women, says Rising, allowing them “to make friends and to sort out problems with each other and get solutions that are more appropriate than what a provider would be able to give in this very short touchpoint of a traditional visit.”  
 
A Circle of Support
Over a two-hour period, the freewheeling conversation in the conference room ranges from the serious to the lighthearted, covering everything from cervical mucus to coping with sibling jealously after the baby comes home to having a game plan for when contractions start. How will first-time mom Lawanne Johnson remain calm in the final stretch towards delivery? “Keeping people who annoy me away from me,” she says, eliciting smiles and nods of agreement from her peers.
Indeed, this last phase of pregnancy is making everyone—moms and dads alike—a bit high-strung. Group facilitator Alexandra Ebken, MSW, encourages the group to let loose. “I have this terrible attitude,” admits DeWayne Felder, 25, adding, “I don’t know where it’s coming from. I just be spazzing. I’m just snapping at everyone.” His partner, Takia Hungerford, 24, admits to running hot-and-cold, making it difficult for Felder to guess her mood. “Sometimes I’m like, ‘leave me alone, I don’t want to be bothered,’” says Hungerford. “And then some days, I just want to be cuddled with or paid attention to.”
The centering group has offered some desperately needed continuity for 19-year-old Johnson, who has recently experienced more than her fair share of upheaval. Her pregnancy was unplanned and she is no longer in a relationship with her baby’s father. In the spring, she and her family were evicted from a home they were renting in DC’s Brightwood neighborhood that was foreclosed upon. Johnson came home to find their belongings strewn on the sidewalk stretching across an entire city block. The family’s church paid for the family to stay in a hotel while they found new housing.
Not only does the centering group feel like a refuge from the stresses of her personal life, but it has given her more courage to ask questions she might have been too intimidated to ask during a one-on-one doctor’s visit. Plus, women in the group who are already parents share their tips on childbirth and parenting.
“Coming in that first time, it felt warm,” she recalls. “Everyone was interacting. They welcomed me in. Everyone was so helpful to each other. I felt like I was better off with the group.”
Every centering group gets a workbook covering pregnancy basics, yet they are not opened even once during the group. In fact, Rising insists that centering group should never be called “class,” as it was created to stand in sharp contrast to the didactic model of clinician-knows-best. Centering’s emphasis is on sharing lessons gained from day-to-day experiences, and receiving wisdom from family members, friends, and folk traditions that may not be sanctioned by the medical establishment. Even when a practice is mentioned that gives a clinician pause, the corrective message is never preachy, but always delivered using the Socratic method where facilitators ask more questions instead of providing ready-made answers.  
Rising recalls a centering group she attended in Atlanta where women discussed the virtues of eating clay for nutritional purposes during pregnancy – a practice known as geophagy. She insisted they take her to a market where varieties of clays were sold because she was more interested in understanding their worldview than correcting them. Centering’s way of challenging certain deeply held beliefs or practices during pregnancy—particularly if they are harmful—is to discuss their origins and to provide another perspective. “It’s not going to win us any friends if we just say, ‘this is bad and you need to stop doing this,’” she says.
Ebken maintains a light touch by broaching necessary topics with open-ended questions, drawing in quieter participants by directly asking their opinion. She tries to get the group to anticipate the long road of parenting ahead of them by asking, “have you thought about how you are going to raise your babies?” What follows is a spirited discussion on how not to spoil your child, how to keep kids away from sexual predators, and what to do when kids become sexually active.
“At the end of the day, their agenda is more important than mine,” says Ebken. “As a facilitator, my job is to make sure everyone feels like they have a voice. Giving the group power is way more important. So often their voices go unheard a lot of the time.”
 
Greater Personalization of Care through the Group
It’s clear that everyone is enjoying the camaraderie and commiseration. Yet mixed in is the serious business of making sure each woman’s pregnancy is on track. As the morning progresses, nurse-midwife Suz Brown, CNM, MSN, calls each woman to an examination bed set up at one end of the room where she checks fetal heart beats and chats with mothers about how they are feeling.  
The paradox of centering is that caregivers seem to feel a deeper connection to patients who participate in groups over those whom they see individually. Nurses and nurse-midwives have more time to get to know patients’ individual histories since centering is spread out over ten two-hour sessions and usually facilitated by the same two individuals. It’s easier for Brown to notice changes or milestones when she gets consistent exposure to the same cohort of patients. Trust and rapport develop not only among women but between them and the group’s facilitators.   
“There’s a bond that gets established,” says Brown. “You worry about them when you wake up in the morning. It’s more intimate in a way; you have that time with the group.” She also feels more invested in making sure a centering member has a positive experience with delivery.
By contrast, Brown says that it can be difficult to remember patients’ names in a clinic due to the sheer volume of appointments each day brings. Centering groups tend to consist of 10 to 12 participants, but can sometimes be as large as 20. In her position at Providence, Brown sees patients one-on-one in the clinic and co-facilitates a number of groups. “It becomes really focused on what do I have to get done [in the clinic],” she says, such as administering tests or reading charts rather than building a relationship with the patient. “When I first started at Providence, I was notorious for running behind. I just didn’t feel right doing the ten-minute visit.”
Centering, Brown says, makes explicit the mind-body connection that traditional care often does not. “We medicalize [obstetric care] so much, but there’s such an emotional and spiritual component that you can bring out in the whole group.” There is also an emotional payoff. “The interaction for people never gets old,” she says. “It gives me new energy because it’s always different.”
One of the main reasons Rising began centering is that she’d grown weary of repeating the same answers to the same questions day in, day out with her patients. “One woman’s question is another woman’s question, and so you don’t just continue with the repetitive question-answering that is so much a driver in traditional care,” she says. 
The other critical piece of centering is that patients take a more active role in their own care. At the beginning of each session, each woman weighs herself and takes her own blood pressure. They keep track of their own data and often read their own lab results. They understand what’s happening to their bodies better and can use the proper terminology to behave and speak with confidence when they deliver.  
“We hear anecdotally time again and again that…when a woman who has been in centering arrives, [the hospital staff] know it without looking at the chart because she just behaves differently,” says Rising. And because centering groups always meet at the same time for a two-hour period, it makes it less likely that a patient will miss her checkups, improving her chances of having a full-term delivery. This consistent scheduling makes centering an attractive choice for women who rely on public transportation, have inflexible work schedules, or depend on child care. “Traditional care runs around the needs of the agency and the clinicians,” says Rising. “It really doesn’t revolve around the needs of patients. With centering, groups start and end on time. It’s honoring a woman’s time.”
 
Centering: Does it Actually Work?
While centering doesn’t target a specific demographic, practitioners and researchers have found it works particularly well with high-risk groups: women who are low-income, Latinas and African American women, and teen mothers.
“It works particularly well with vulnerable populations,” says Debra Keith, CNM, MSN, and the director of Providence Hospital’s Center for Life. “Groups that we have have…a lot of issues at home, they may be struggling in school and not have a lot of support. Group just does wonders for them. It gives them an opportunity to feel like they’ve been heard.” Providence, like other hospitals in major cities, offers centering groups conducted entirely in Spanish. Other hospitals around the country offer groups conducted in Vietnamese and Arabic.
A 2007 study in Obstetrics & Gynecology co-authored by Rising found that among 1,047 women participating in centering groups at hospitals at Yale and Emory Universities, the risk of preterm birth lowered to 9.8% from the 13.8% risk women receiving conventional prenatal care face.1 The average age of the study’s participants was 20.4 years, and 80% of the women were African American. The risk reduction among African American women was more dramatic with the centering participants having a 10% chance of a preterm birth compared to 15.8% for those in conventional care.
More recently, a 2012 study published in the American Journal of Obstetrics & Gynecology that followed 316 low-income women in a CenteringPregnancy group at the Greenville Hospital System Obstetrics Center in Greenville, South Carolina, found a 47% reduction in preterm delivery among centering participants compared with women receiving traditional care. 2
Other studies show higher rates of breastfeeding among centering participants, lower rates of sexually transmitted diseases, and greater spacing between pregnancies, particularly among teens. At the end of the day, all the preterm births and complications from STDs that are averted translate into cost-savings for hospitals, says Rising, who estimates that centering saves hospitals $2,000 per pregnant woman.
Most telling, moms and dads who participate in centering report consistently higher levels of satisfaction with their prenatal care. As Felder, the young father who participated in Providence Hospital’s centering group, put it: “It’s almost like a therapy session. You rarely come out of here upset. You were mad out there, but not in here.” 
 
 
References
1.      Ickovics JR, Kershaw TS, Westdahl C, et al. Group Prenatal Care and Perinatal Outcomes. Obstet Gynecol. 2007 August; 110(2 Pt 1): 330–339.
2.      Picklesimer AH, Billings D, Hale N, et al. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obstet Gynecol. 2012;206:415.e1-7.