By Kathryn Trotter, DNP, CNM, FNP, FAANP

What is CenteringPregnancy^®?

It is an evidence-based model of group prenatal care (GPC).

How does it work?

CenteringPregnancy brings together 8-10 women due in the same month for their prenatal care in group visits. Providing care in this way allows members and their healthcare providers (HCPs) to relax and get to know one another on a deeper and more meaningful level than they might attain if they received traditional prenatal care. Group members can form lasting friendships and are connected in ways not possible with traditional care. Furthermore, HCPs can facilitate conversations that inform all women in the group at one time instead of repeating what they say in separate exam room visits.

CenteringPregnancy, which adheres to the GPC model, follows the recommended schedule of 10 prenatal visits. Each visit lasts 90 minutes to 2 hours, giving group members much more time with their HCP than they would otherwise receive in individual visits. Group members engage in the healthcare process by weighing themselves, taking their own blood pressure, and recording their own health data. During each session, time is also allotted for private, one-on-one visits with an HCP.

Once the health assessments are complete, the HCP and support staff circle up with the members to facilitate discussions and lead interactive activities that address important and timely health topics. Members also have time to discuss topics that are important to them. They receive CenteringPregnancy notebooks and materials covering topics such as nutrition, common discomforts, stress management, labor and delivery, breastfeeding, and infant care. Providing group members with this type of educational content not only helps foster self-efficacy but also decreases the need for clinic phone calls and triage visits.

Of note, the Centering^® concept can be adapted to patient populations such as women with diabetes or breast cancer survivors.^1,2 Centering groups themselves comprise women of many different ages, races, and socioeconomic backgrounds. Over time, group members see these differences diminish in importance as they discuss the common experiences of the health condition that they share. Many women who have benefited from the CenteringPregnancy experience join CenteringParenting^® so that they can continue with pediatric HCPs who provide family-centered well-child care through the first 2 years of their children’s lives.

What does the evidence say about this GPC model?

In addition to high patient satisfaction, participation in CenteringPregnancy confers major health benefits on both mother and newborn. Most striking of these benefits is a reduced rate of preterm birth.^3-6 In one randomized controlled trial, 9.8% of women assigned to GPC had a preterm birth, compared with 13.8% of those receiving individual prenatal care, a 33% risk-reduction.⁶ A 2012 retrospective analysis reported a 47% reduction in preterm births among women in GPC versus those in traditional care.⁴ In addition, in both studies, disparities in preterm birth rates between white and black mothers in the GPC groups were significantly reduced.

Furthermore, studies have shown that breastfeeding rates are higher among GPC participants, who also have better attendance at postpartum visits, than among traditional care recipients.^5-8 This difference is particularly notable among teen and Latina populations.^8,9 Finally, women in CenteringPregnancy groups, compared with those receiving individual prenatal care, have significantly higher utilization of family planning services (P  <.05).¹⁰ Engaging and empowering women in their healthcare is a strong point of this model.

The Table summarizes the benefits of participating in CenteringPregnancy for three childbirth-related outcomes.¹¹

Do nurse practitioners facilitate Centering group sessions?

Yes, as do midwives, physicians, nurses, medical assistants, social workers, and other healthcare team members (e.g., health educators, case managers). Any new type of interaction between HCPs and their patients, including the Centering programs, can help prevent practice burnout by offering a fun and creative way to connect with women.¹²

How do HCPs implement Centering groups in their practice? How do they get started?

Centering Healthcare Institute (CHI) has a free Readiness Assessment survey that administrators and clinicians can complete. Practice service managers are available by phone to start HCPs on the implementation pathway, and consultants can set up 1- to 2-year contracts to assist their clinic or system in integrating Centering into their services. Watching this video is a good way to get started.

Where can HCPs get facilitation training?

Basic Facilitation Workshops offer a 2-day intensive review of group care, with a large focus on practice of facilitation skills. These workshops are offered throughout the country each month. HCPs can log onto the CHI website for the latest schedule and costs.

How do HCPs bill for Centering visits?

Billing is the same as that for traditional prenatal care. A few payers offer incentive supplemental payments to HCPs who provide care in groups, partly to encourage future savings in preterm birth costs (e.g., neonatal intensive care unit costs).

Will HCPs increase their relative value units or practice revenue?

In general, GPC is revenue neutral unless the payer is incentivizing CenteringPregnancy care. Downstream revenues occur with increased patient referral because excitement is contagious when women share their stories.

Will HCPs enjoy facilitating GPC visits? Why or why not?

Once trained, most facilitators get comfortable with the style and format within a few sessions. It can take time and effort to avoid the temptation to simply answer every question or provide education via lecturing, which is taboo in this group visit format. The wisdom is usually found within the group.

Is there a support network for HCPs contemplating or already conducting Centering groups?

Support is available from CHI consultants, practice service managers, and the CenteringConnects webpage. This support network enables new and established sites to share what works, link to local resources, gain recruitment and retention pearls, and join the national conversation about evidence-based care. Social media links to Centering are available in the Box.

Box. Centering social media links
	facebook.com/CenteringHealthcare
	@CenteringHealth
	linkedin.com/company/centering-healthcare-institute
	info@centeringhealthcare.org

Kathryn Trotter is Associate Professor and Lead Faculty, Women’s Health Nurse Practitioner Major, at Duke University School of Nursing in Durham, North Carolina. The author states that she is a consultant and trainer for the CenteringPregnancy model but not an employee of Centering Healthcare Institute.

References

1. Parikh LI, Jelin AC, Iqbal SN, et al. Glycemic control, compliance, and satisfaction for diabetic gravidas in Centering® group care. J Matern Fetal Neonatal Med. 2017;30(10):1221-1226.
2. Trotter KJ, Schneider, SM, Turner BS. Group appointments in a breast cancer survivorship clinic. J Adv Pract Oncol. 2013;4(6):423-431.
3. Strickland C, Merrell S, Kirk JK. CenteringPregnancy: meeting the quadruple aim in prenatal care. N C Med J. 2016;77(6):394-397.
4. 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(5):415.e1-7.
5. Zielinski R, Stork L, Deibel M, et al. Improving infant and maternal health through CenteringPregnancy: a comparison of maternal health indicators and infant outcomes between women receiving group versus traditional prenatal care. Open J Obstet Gynecol. 2014;4(9):497-505.
6. Ickovics JR, Kershaw TS, Westdahl C, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol. 2007;110(2 pt 1):330-339.
7. Klima C, Norr K, Vonderheid S, Handler A. Introduction of CenteringPregnancy in a public health clinic. J Midwifery Womens Health. 2009;54(1):27-34.
8. Trotman G, Chhatre G, Darolia R, et al. The effect of CenteringPregnancy versus traditional prenatal care models on improved adolescent health behaviors in the perinatal period. J Pediatr Adolesc Gynecol. 2015;28(5):395-401.
9. Trudnak TE, Arboleda E, Kirby RS, Perrin K. Outcomes of Latina women in CenteringPregnancy group prenatal care compared with individual prenatal care. J Midwifery Womens Health. 2013;58(4):396-403.
10. Hale N, Picklesimer AH, Billings DL, Covington-Kolb S. The impact of Centering Pregnancy Group Prenatal Care on postpartum family planning. Am J Obstet Gynecol. 2014;210(1):50.e1-7.
11. Centering Healthcare Institute. Setting the Stage: Centering Saves Lives & Money.
12. Trotter KJ. The promise of group medical visits. Nurse Pract. 2013;38(5):48-53.

*Permission to publish the photos appearing in this article has been granted by the Centering Healthcare Institute.