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Whether it is someone’s first or fourth child, pregnancy is a journey with each and every time. Questions are aplenty, and often pregnant moms only get a short time to spend with their providers each visit. They may forget their questions, be embarrassed to address issues, or just be overwhelmed and fail to ask all they had hoped to. In addition, the prenatal world is full of books, websites, unsolicited advice, and misinformation that can lead our patients down the wrong path at times. In order to provide holistic and fulfilling prenatal care as well as a built-in support system, centering group prenatal visits have been slowly introduced into healthcare. In an effort to share their success and grow support, this article will describe their benefits. 

Introduction 

It’s 2 a.m.  

Janey sits up in bed, choking on her gastric acid. She rushes to the bathroom to get a glass of water; she is out of breath, and the burning sensation she is feeling in her throat is so painful that she wants to vomit. Her significant other sleeps through it all, and for a moment, it is hard to breathe as she chokes the liquid back down. 

Janey is four months pregnant with her first child. She is experiencing a common nighttime symptom related to gastric reflux as the baby grows bigger and takes up more room in her abdomen. Acid reflux symptoms are prevalent in pregnancy and have very few complications (6). In fact, as many as two-thirds of pregnant women experience these symptoms during their pregnancy (6).  

During one’s first pregnancy, it can be hard to know what symptoms, including sometimes vicious ones, to expect. The ability to talk about these experiences with other pregnant women can help prepare a newly pregnant woman with what to expect. But what if they need more support systems? What if they are the first pregnant female in their immediate peer group? Who do they turn to? Centering prenatal care aims to support these exact questions and conversations in a safe and mentored setting with other pregnant women and your care team. ​

Current Prenatal Statistics 

In recent decades, various organizations of perinatal healthcare providers in the United States have worked to change the goals of prenatal care beyond just biological reproduction and to include the holistic care of the pregnant woman (e.g., 5). The goals expanded their reach to include looking at the entire pregnancy, fetal development, and the care and well-being of the mom. CDC data published in 2023 suggests that 8.52 % of babies are born with low birth weight (LBW), a rise from previous years, and 10.49% are born prematurely (less than 36 weeks gestation), the highest increase in 17 years (8).  

Low birth weight (LBW) is an initial post-birth weight of less than 2,500 grams per the World Health Organization (7). Having a baby delivered at a healthy weight –that is, not LBW– is an essential indicator of a healthy mom, pregnancy, and baby. LBW can be associated with long-term neurological issues, so prevention remains paramount to successful maternal health 7). Everything from infectious diseases to poor nutrition can lead to a subsequent preterm birth, usually resulting in LWB (7). 

Additionally, though the United States has a highly high expenditure on maternity care compared with other industrialized nations, it also has one of the highest maternal mortality rates among this group as well (3). At particular risk are women of color, particularly Black women, who have pregnancy-related mortalities at over twice that of their white counterparts, even when controlling for high education levels (3).  

Prenatal Care Goals 

Despite the approach to prenatal care as defined by the goals of the U.S. Public Health Service Expert Panel on the Content of Prenatal Care, which was updated in 1989, many aspects of prenatal care remain the same in the 2020s (5). 

The goals developed in 1989 include: 

For the pregnant woman: 

1. To increase her well-being before, during, and after pregnancy and to improve her self-image and self-care.
2. To reduce maternal mortality and morbidity, fetal loss, and unnecessary pregnancy interventions.
3. To reduce her health risks before subsequent pregnancies and beyond childbearing.
4. To promote the development of parenting skills.

For the fetus and infant: 

1. To increase well-being.
2. To reduce preterm birth, intrauterine growth restriction, congenital anomalies, and failure to thrive.
3. Promote healthy growth and development, immunization, and health supervision.
4. To reduce neurological, developmental, and other morbidities.
5. To reduce child abuse and neglect, injuries, preventable acute and chronic illness, and the need for extended hospitalization after birth.
   

For the family: 

1. To promote family development and positive parent-infant interaction.
2. To reduce unintended pregnancies.
3. To identify and provide treatment for behavior disorders leading to child neglect and family violence.

Adapted from the United States Public Health Service Expert Panel on the Content of Prenatal Care (9) 

These lofty goals are appropriate for the health and well-being of our pregnant women and their children, but they are hard to meet with all of the barriers in our current ways of practicing: quick visits, reimbursement for care models, and health disparities in reaching all pregnant women.  

Group Prenatal Care Explained  

Since the U.S. has several tiers of healthcare insurance (none, Medicare, Medicaid, and private), prenatal care options are linked to this issue. Historically, Medicaid has been the largest insurer of pregnant people, though it does not cover many non-hospital-based births and ends just 60 days postpartum (3). To combat this, some have proposed alternative options, such as group prenatal care, pregnancy medical homes, and freestanding birth centers (3). 

In group prenatal care, pregnant people attend in-person wellness checks at the same intervals as the traditional 10-minute prenatal appointments adhered to since the 1930s but do so with others at approximately the same gestational period of the pregnancy (1, 3). In this setting, physicians can dive deeper into explanations of risks associated with childbirth or other topics they may need more time for during regular practice. Rather than seeing them individually, they will reach more mothers with these potential questions at once.  

Sharon Schindler Rising, a certified Nurse-Midwife, developed the group prenatal care model, Centering Pregnancy, in 1998 (4). This approach has grown substantially over the years as offices become shorter on staff and time but have an increased need for productivity (1). Group care models like Centering Pregnancy have often been shown to reduce preterm births significantly, LBW, NICU stays, and emergency department use during pregnancy; they also demonstrate higher breastfeeding rates, patient and provider satisfaction, and increased parental knowledge of childbirth and child-rearing (3). 

Case Study 

You are the nurse in a busy, urban OB/GYN clinic. You work alongside several physicians and a couple of midwives each shift. You provide care to a 16-year-old who has a positive pregnancy test, and she is in tears in the exam room when you re-enter to get vital signs. She is alone, and you sit down to offer comfort. As you talk with her, you learn that she is living with her grandparents because her parents passed away when she was 12. She has a boyfriend, but her grandparents don’t know about him. She is so scared to share the truth with them because her grandmother just thinks she is here for a routine visit. She wants to keep the baby but doesn’t know where to begin. 

Centering in Detail 

The typical pregnant woman is seen about ten times by the physician or midwife team for 10-15 minutes each visit throughout their pregnancy (5). Centering group prenatal care still follows the recommended schedule of 10 prenatal visits for low-risk pregnancies, but each visit is up to two hours long; that’s ten times the time with their provider than traditionally done (2). Since its status as a non-profit organization, Centering Healthcare initiatives have expanded and have been able to serve more and more families. 

Centering, offered in almost all U.S. States at nearly 500 certified Centering Pregnancy practices, provides care and services for about 60,000 patients yearly (2,4). During these sessions, patients are placed into groups of 8-10 people according to their stage of pregnancy.  

At the start of the centering visit, the moms have an individual health assessment with a provider. The mom is taught and encouraged to take her weight and blood pressure and monitor in a notebook (1). This empowers them to be active in their care and have direct knowledge of their status. They get private time with the provider or midwife before meeting in their group setting. Certified providers lead the sessions, and if someone expresses a concern that requires more of a need to address, the patient is set up with a 1:1 visit with a provider (2). 

The prenatal group visits last up to 90 minutes to two hours and allow for discussions on prenatal health, nutrition, common health concerns, stress management, labor techniques, breastfeeding, infant care, postpartum care, and complications. Essentially, patients can spend 23 hours with providers throughout their pregnancy as opposed to just under two hours (2,  

Some specific benefits of group prenatal care include, but are not limited to (1, 2, 4, 10): 

• Allowing women to feel more comfortable in a group setting, fostering support and friendships 
• Significantly more time with O.B. providers 
• Resources provided on:  
• Nutrition 
• Common discomforts 
• Stress management 
• Labor and delivery 
• Breastfeeding 
• Infant care  
• Reaching those particularly at risk and connecting people from diverse ages, races, and socioeconomic backgrounds  
• Continued care for two years in the Centering Parenting program 
• Significant reduction in healthcare racial disparities 
• Mothers become more actively engaged in their healthcare and well-being  

Case Study

Think back to Janey from the opening paragraph.  

Choking on your acid reflux at 2 a.m. is quite scary. If she could have participated in a centering visit, she may have heard about these symptoms, been more prepared, or even started taking measures to avoid GERD during pregnancy. Being more prepared, calm, and supported are expected outcomes of Centering visits. 

A quote from a mom participating in group prenatal care was found online, “My doctor and nurse would lead the group on various topics, but it wasn’t like a class: it was a discussion, a group of pregnant women together on a journey with health care providers investing in our well-being, our health, the health of our babies, and most importantly giving us a safe environment to learn the facts that would get us to our goals” (2). This speaks so much to the pregnancy journey; the stress of trying to do all the right things while pregnant can diminish as one learns from others in a safe environment. 

Barriers to Centering 

As with any innovative practice in our complex healthcare environments, barriers exist. The time spent in group prenatal care-centering sessions may need to be more attainable for women with demanding jobs, other children, and limited support systems (2). This practice has not thoroughly reviewed billing and insurance, though Medicaid is covering more costs than ever (2, 4, 10).

Space to hold sessions, especially now with social distancing and virtual visits standard after the COVID-19 pandemic, may be difficult to find in some clinics. Also, adapting to any new and innovative practice with consistency and certainty may take much work for providers. In addition, pregnant moms may not want to participate in a group setting or be wary of this approach. Implementation methods can overcome these barriers if a team commits to this kind of care. 

Conclusion 

It is well known that it takes about 17 years for evidence to go from “bench to bedside” formally (e.g., 11, 12). This downfall in adapting to innovative practices leads to delays in optimizing the best patient care. Centering and other elements of group prenatal care are valuable in meeting those 1989 public health goals, including high patient and provider satisfaction. 

Despite all of that, it is not a traditional way of practice, and there continue to be delays in the overall pursuit of group prenatal care. The benefits are endless, especially to the underserved and under-supported women who are pregnant, and this care should continue to be offered as much as possible. In addition, as we address the many public health needs facing our nation today, let’s consider how innovative group practices could help build relationships and strengthen the care of all kinds of diagnoses and conditions. Learning from, with, and about each other and how to manage illnesses and promote health may improve when working in group settings focused on health and well-being! 

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