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Overview

The traditional model of medical care faces increasing challenges. Factors like increasing health care costs, limitations of provider availability, issues like dissatisfaction with wait times, and the minimal opportunity for education and support associated with the individual care model have given rise to interest in alternative models of prenatal care. Centering started in the 90s when nurse-midwife Sharon Rising started bringing expecting mothers together for group prenatal appointments. Put in the simplest terms, Centering Pregnancy means that your prenatal care is in a group setting. This episode dives into the research on how this model of group care can impact your pregnancy and birth.

Article and Resources

The Origins of Centering Pregnancy

The Centering Healthcare Institute is a non-profit group that works with healthcare providers. Their goal is to improve healthcare by transforming care through centering groups. Centering started in the 90s when nurse-midwife Sharon Rising started bringing expecting mothers together for group prenatal appointments. Put in the simplest terms, CenteringPregnancy means that your prenatal care is in a group setting.

How Centering Pregnancy Works

Under the CenteringPregnancy model, you start off with one-on-one care and complete a conventional medical history and a physical exam in a doctor’s office or clinic. Once you are in the second trimester you are invited to join a group for your routine prenatal appointments. Groups are made up of 8 to 12 expecting mothers who have relatively close due dates. Centering pregnancy is a trademarked term and the most well known and widely used. It is not the only model for this idea and there are other models focused around group care. Throughout this article when referring to centering pregnancy we are talking about the group model of care, whether it is sponsored by the Centering Healthcare Institute or another group.

The Components of Each Appointment

In the group care model, you can expect to have around 10 group appointments. If your pregnancy is high-risk you could have additional appointments with your care provider. Each appointment follows a similar format of a health check and a supported discussion.

Health Checks

Expecting mothers participate in managing their own care by taking their own weight and blood pressure and recording their own health data. They also get private time with their provider for a belly check. This involves measuring your belly and listening to your baby’s heart with a doppler or a fetoscope.

Discussion & Education

Each appointment is led by a midwife, doctor, and other staff who heads up the topic for that appointment. Group care is based on the principle that when people are actively engaged and involved in a discussion with their peers, they learn more and are more likely to change their behavior. This differs from traditional appointments where often education is viewed as a one-way conversation from a doctor or midwife or a pamphlet you are given to read. A key to this model of care is that you and the members of the group have a discussion around the topic and have the opportunity to expand on the aspects you want to know more about and have the opportunity to ask questions.

The CenteringPregnancy model has a curriculum that outlines the topics to be reviewed and discussed at each appointment. Other group care models may follow a similar format.

  1. Prenatal testing, nutrition, healthy lifestyle choices
  2. Body changes in pregnancy, common discomforts, oral health
  3. Relaxation and stress reduction, breastfeeding
  4. Family relationships, violence and abuse, family planning, preterm labor
  5. Labor, birth facility
  6. The birth experience
  7. Newborn care
  8. Pregnancy to parenting transition, postpartum emotions, kick counts
  9. Newborn safety, putting it all together
  10. Newborn care, growth and development, home and family changes

Involving Your Partner

Similar to any prenatal appointment your partner or support person is encouraged to attend these appointments with you. This also gives your partner an opportunity to meet other expecting parents, participate in the discussion and ask questions. The goal of your partner attending is to make them feel more involved in the pregnancy process and be better prepared to advocate for you during labor and birth. I am a huge advocate for including your partner in your prenatal appointments. I know it can be challenging to navigate busy schedules but you have a limited number of appointments and these should be a priority.

Building Community

Group care gives you and your partner a space to meet other expecting parents in your community who are on a similar timeline with their pregnancy. You may meet people who become friends for years to come. This setting also puts you in contact with other expecting parents who are going through some of the same challenges you are. Not everyone in your group will be first-time parents and you may benefit from hearing different perspectives from couples with varying levels of experience.

Changing the Provider-Patient Dynamic

A big plus of the group model is that it changes the power dynamic between patient and provider. You become more of an active participant than in a traditional doctor-patient relationship. That is not to say that all doctors do not foster this model of active participation. Traditionally patient care has been more of a one-sided sharing of information, rather than a shared format for discussion and shared decision making.

Adoption of Group Care in the United States

This movement is growing in the U.S. with major hospitals like the University of California San Francisco and Kaiser in the state of Washington offering this model of care. According to the Centering Healthcare Institute there are over 575 sites implementing this care model in 46 states serving 70,000 patients annually. These figures include all centering groups, not just those for prenatal care.

Benefits

The Centering Healthcare Institute claims that CenteringPregnancy decreases the rate of preterm and low weight babies, increases breastfeeding rates, and leads to better pregnancy spacing. They state that CenteringPregnancy has been shown to nearly eliminate racial disparities in preterm birth. African American women, who are at higher risk for preterm birth in the US, experience lower risk of preterm birth when enrolled in CenteringPregnancy than in traditional care.

The Evidence

You know that I like to look at the research and evidence, especially when there are big claims of how beneficial any model of care is.

Birth and Newborn Outcomes

A review and meta-analysis that reviewed 85 full-text articles and ultimately included 8 studies in the review. They found preterm birth rates were lower for women in the group care model in the randomized controlled trials, but no difference in the cohort studies. When examining the effects on low birth weight, those in group care in the RCTs showed almost no difference, while those receiving group care in the cohort studies were at a lower risk. There were no significant differences in the randomized data in rates of perinatal death, stillbirth, IUGR, Apgar scores, admission to a neonatal intensive care unit, or cost. In the RCTs there were also lower rates of Caesarean section, higher rates of breastfeeding, and more knowledge and satisfaction with care. The review concluded Studies comparing GPC with IPC are mostly of low quality and in high-risk groups. The takeaway here is that more research is needed. On the bright side, there were no adverse outcomes from those who participated in group care.

Education

The educational component is an obvious benefit to the group care model. Research in Canada aimed to compare women in CenteringPregnancy to women in individual prenatal care plus prenatal education. What they found was that there was a big difference in the socioeconomic profile of these two groups. The participants in the Centering Pregnancy group were more likely to have completed a lower level of education, have a lower household income, be of non-Caucasian ethnicity, be born outside of Canada, and to primarily speak a language other than English in the home. There were also differences in psychosocial health. Women in the CenteringPregnancy group had higher levels of depressive symptoms, stress and anxiety. Due to these differences, the researchers were 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.

Preterm Birth

Preterm birth is a common issue in the United States. 9.6% of babies were born preterm at less than 37 weeks gestational age in 2015. One aspect of this that has thankfully getting more attention is that there are huge racial disparities in prenatal care and black women have even higher rates of preterm birth at 13.4% in 2015. This is just one example of the big disparity between birth outcomes by race in the United States. There is a trial underway to investigate whether centering pregnancy can help close that gap.

Application in Low-Income Countries

One study in Nepal found women who had group pregnancy care found it more enjoyable and had better pregnancy knowledge. A study in Nigeria found women with group care showed higher utilization of prenatal and birth services. This is a big problem in third world countries where access to care is limited and many expecting parents are not regularly getting prenatal care, even when it is offered. Perhaps having prenatal care in a group setting increases your accountability to attend appointments.

Puerto Rico is a U.S. territory but has a very high poverty rate at 45%. This is significantly higher than the most impoverished state in the U.S. Mississippi comes in at 28.9%. A study in Puerto Rico found the mean birth weight of the infants for group care was higher (6.59 vs. 6.33 lbs.). The mean gestational age at delivery was higher (37.83 vs. 36.85 weeks). Infants had higher Apgar scores at 1 and 5 minutes in the Centering Pregnancy (7.69 vs. 7.23 and 8.66 vs. 8.38). The rate of preterm delivery, considered before 37 weeks, was 34.1% for women receiving traditional care versus 27.7% for women receiving Centering Pregnancy. Even the differences in preterm birth, at less than 31 weeks, was lower for Centering Pregnancy vs. traditional care (2.8% vs. 9.9%). It is possible that expecting mothers at higher risks or with more complicated pregnancies would be more apt to not participate in a group care model. Even considering some limitations there is quite a bit of evidence that this model of care can benefit lower-income areas.

The American College of Obstetricians and Gynecologists Opinion

The American College of Obstetricians and Gynecologists states that individual prenatal care remains standard practice. They note that factors like increasing health care costs, limitations of health care provider availability, issues like dissatisfaction with wait times, and the minimal opportunity for education and support associated with the individual care model have given rise to interest in alternative models of prenatal care. They go on to state that group prenatal care may be beneficial or preferred for some practice settings and patient populations. Overall, obstetric outcomes for women participating in group prenatal care are at least equivalent to traditional prenatal care. There is no evidence that suggests that group prenatal care causes harm. ACOG concludes their opinion by saying that larger, randomized trials are needed to identify subpopulations that might benefit from different models of prenatal care.

The Downside of Group Care

The upside looks fantastic, especially if further research can support all of the benefits touted by proponents of the group care model. In line with the opinion of ACOG, there is not a downside to receiving your prenatal care in a group setting. The only potential issue is if you are uncomfortable in a group setting.

Finding the Right Fit for You

Most importantly, you need to find prenatal care and a practitioner that is the right fit for you. Group care is not for everyone and there are expecting parents who would be more comfortable with one-on-one appointments and care. You know there is not a one size fits all for pregnancy and birth. It is awesome to see more options being offered and an overall trend toward more patient-centered care.

If you have the opportunity to participate in group care of centering pregnancy I encourage you to have an open mind. In my first pregnancy, I had this opportunity and was extremely skeptical about having appointments in a group. It turned out to be a great way to connect with some other expecting parents. Often other parents asked questions I had not thought about and I have no doubt I benefited from being in the group.

There is such a wide spectrum of the types of care available and every doctor and midwife vary on how they treat their practice. I hope you find a care provider who is the right fit. Keep in mind that you can always switch your care to someone you are more comfortable with, or who offers the type of care you think is best for you and your baby.

 

Thank you to Zahler for their support of this episode.

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