Centering — Better Health Care Without Higher Costs

Eight months pregnant, Elvira, 28, was poised, articulate and confident through a two-hour prenatal class. Then she formed a circle with 10 other mothers-to-be, caught a skein of bright pink yarn a nurse tossed to her, and burst into tears of gratitude.

“Thank you, thank you, you have taught me so much,” Elvira said, clasping one strand of the yarn and tossing the skein on to another young woman, who gripped her strand, and tossed it on. The yarn crisscrossed their circle, binding them together in a flash of hot pink.

The yarn ritual ended the last of their nine two-hour sessions in this sunlit room in Providence Hospital in Northeast Washington, part of a new model of prenatal care called “Centering Pregnancy.” It’s a form of shared, or group, medical care, but Centering’s format is more group exploration than classroom lecture. Centering programs are emerging in health care settings across the country, and I first learned about them at an IHI conference about two years ago, and Providence Hospital later allowed me to sit in on two groups here in Washington. (The women consented to my presence, too, of course. The only condition was that I identify them only by their first names.)

In Elvira’s group, the women were all near their due date and had been together for months. In the second group, they were about five months pregnant and still getting to know one another.  I was interested because the centering approach brought to life concepts like self-care and patient-centered care, while creatively stretching limited resources to meet multiple needs. And I’m always interested in seeing, and sharing, what works in a nation that seems irrationally unexuberant about our ability to find better ways of delivering health care.

Around 650 women, mostly poor and many Spanish-speaking, have gone through the Centering programs at Providence Hospital according to Debra Keith, a nurse-midwife who directs the hospital’s Center for Life. Her team has run more than 50 groups since July 2007, some in English, some in Spanish, and about 10 of them just for teens. Keith’s team is also piloting a Centering Parenting program, transitioning teenage mothers and their infants from a pregnancy setting into a new mom and well-baby group.

Providence, a nonprofit Catholic hospital in a working class section of Northeast Washington, is not an affluent hospital. Keith runs her program on a shoestring, and has gotten grants from places like March of Dimes to help her work with some high risk populations. Her results are good.

“Our preterm birth and low birth weight rates remain below national and DC rates,” she emailed me in a recent update. “Patient satisfaction continues to be very high.”  Keith has also found that the women who go through Centering have low rates of gestational diabetes, high rates of breastfeeding, and fewer false alarm emergency visits to the hospital OB ward. All that can save the health care system money overall, even if it doesn’t show up directly on Keith’s department’s bottom line.

Centering Pregnancy is a specific approach and philosophy, but it’s part of a broader shared medical appointment movement. The goal is to give patients and their health care providers longer, more fruitful encounters, while also giving patients a role in their own care management, said Brent Jaster, M.D., who has practiced in group settings and who helps other practitioners establish groups ranging from well-baby care to diabetes to chronic pain management. I talked to John Scott, M.D., one of Jaster’s mentors and associates, back when I was first learning about this topic. Scott told me he began developing shared visits in the early 1990s when he realized there had to be a better way to practice medicine than “racing from (examining) room to room to see how fast I could get to the next room.” He believes the group model has particular promise for older people with multiple chronic diseases. Just getting to the doctor can be a challenge for them, and in a group visit they get more time to learn about managing and monitoring their conditions (and less time sitting in waiting rooms). The social interaction is also welcome to older people whose poor health and limited mobility may isolate them.

The women at Providence, who are given the choice of Centering or traditional prenatal care and screened at the outset to make sure they are not at high risk, had similar reasons for opting for the shared care. They know what it’s like upstairs in the traditional OB-GYN wing — crowded waiting rooms, long delays, and brief appointments. Here, in the centering room, the discussion is richer. They have hours, not minutes, to ask questions about their bodies and their developing babies, and to learn from the questions that other women ask. Many are poor, with limited English, far from their extended families. As Elvira and the other women clutching that hot pink yarn found, here, they don’t feel so alone.

Positive peer pressure from the group probably reinforces some good habits, such as smoking cessation or good nutrition, the midwives who help facilitate the group said. To my untrained eye, the women certainly appeared happy and healthy. One showed up five months pregnant in a fire-engine-red spandex and rhinestone maternity outfit with matching red flip flops. One of the women, Glenda, had had routine prenatal care in a distant suburb with her first child, but after hearing about Centering from a friend, traveled an hour to get to Providence during her second pregnancy.

“I learn here, and I can express myself here. I’ve learned more about nutrition. And even after one pregnancy, I have questions, I get pains sometimes and I need to know what’s normal,” she told me. The first-time moms learned from the veteran, too: Glenda explained to the other women why she had had trouble breastfeeding her first baby, what she did about it, and how she’d be better prepared this time.

At Providence, it’s not just the women who prefer the Centering approach to standard clinic visits. The nurses and midwives, too, love the group interaction, the chance to go into more depth on prenatal care topics, an opportunity to spend hours getting to know the women.

“It gives a lot to us, as providers,” said Suz Brown, one of the midwives. “It’s a very meaningful thing to these women,” said Anaxidalia Gonzalez, a nurse, group leader, and keeper of the hot pink yarn.

Centering Pregnancy follows a set written curriculum – usually 10 sessions, although it can vary slightly, according to Sharon Rising, founder and executive director of Centering Healthcare Institute in Connecticut, which developed the course materials and trains the nurses and midwives. Women start when they are around 12 to 16 weeks pregnant and the sessions touch on the usual prenatal topics like weight, nutrition, fetal development, round ligament pain, indigestion, Braxton Hicks contractions, labor, delivery and newborn care. It also helps the women explore a bit about how they feel about motherhood, about how to become the kind of mother they hope to be.

Rising and colleagues at Yale have published small studies that found that the Centering women and their babies had good outcomes at no higher costs. One of the studies found it lowered the risk of preterm birth for inner city women aged 14 to 25 by one-third compared to the traditional care model, and also encouraged more breast-feeding.

Groups are often run at clinics that serve young, low-income, immigrant, or minority women. But the model is also used in a few military bases, and has been adopted by OB-GYN practices that draw older and more affluent women. Rising has worked with a practice in Seattle, for instance, that sets up blogs, reunions, and pot luck dinners.

At Providence, women seldom miss a session, and by and large they show up on time. Upon arrival, they chat, weigh themselves, provide a urine sample, check their own blood pressure, and update their own charts. During the session, they each get a mini-checkup in a discreet corner of the room. Other than exposing their bellies, they remain clothed; any problems that are detected or suspected will be followed up privately with an appointment upstairs in the regular obstetrics clinic, and the women will also have private exams upstairs as their due dates approach. Elvira, for instance, made her appointment before leaving the final session. She gave birth to a healthy 7 pound 6 ounce baby girl one week later.

The yarn exercise, which marks the final session, means a lot to the women who grow emotional as they say their goodbyes. Some hold on to that yarn, and when the time comes they bring it with them to the delivery room, Suz Brown said, a good luck omen for their newborn babies.

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Special Contributor Joanne Kenen is a senior writer for the New America Foundation and the editor of the New Health Dialogue blog. Her bi-monthly column for the Health Policy Forum discusses health policy innovation and “what works” in our health care system. “Special Contributors” are regular contributors to the Health Policy Forum who pose their own opinions and policy positions in the realm of health care and health policy. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions. Read more.