Arch Gynecol Obstet (2015) 291:499–507 DOI 10.1007/s00404-014-3467-2

REVIEW

Centering Pregnancy: practical tips for your practice Julie Z. DeCesare • Jessica R. Jackson

Received: 14 July 2014 / Accepted: 9 September 2014 / Published online: 15 October 2014 Ó Springer-Verlag Berlin Heidelberg 2014

Abstract Importance With increased access to care, current health delivery systems will need expansion to meet higher demands and needs. Purpose To define Centering Pregnancy and practical tips for implementation into both private and academic practices. Methods/evidence acquisition Evidence was gathered through literature reviews. Results It was found that Centering Pregnancy offers a patient-centered, evidence-based approach to helping with access issues, as well as improving outcomes. Conclusions This article describes the benefits of Centering Pregnancy to the practice, the provider, and the patient. Relevance Practical implementation tips will be offered, with suggestions for negating common implementation barriers. Keywords Obstetrics

Centering Pregnancy  Group prenatal care 

Introduction Target Audience: Obstetricians and gynecologists, and family physicians, both in academic and private practice. J. Z. DeCesare  J. R. Jackson OBGYN Residency Program, Florida State University College of Medicine, Pensacola, Florida e-mail: [email protected] J. R. Jackson (&) 5045 Carpenter Creek Dr, Pensacola, FL 32503, USA e-mail: [email protected]

Learning Objectives: The learner should be able to understand the importance of collaborative practice; articulate the concept of group prenatal care, and its benefits for providers, ambulatory staff, and patients; glean practical tips for implementation of this model in an ambulatory setting; obtain educational pearls for private practice as well as an academic setting; and understand current evidenced-based clinical outcomes associated with Centering Pregnancy. We certify that human and animal rights were respected in accordance with the Helsinki Declaration of 1975. The Affordable Care Act (ACA) has offered expansive medical benefits to over 40 million Americans [1]. The focus of this act is to ensure coverage of all Americans, and the National Healthcare Expenditure (NHE) for USA is $3.5 trillion per year—and growing at about 5 % per year numbers from Organization for Economic Co-operation and Development. The expansion in benefits form the ACA, and the rising costs of health care are creating a climate in which many predict that reimbursements will decline [2]. There are concerns that the current health care delivery system cannot adsorb the additional patient load, and even without increasing the access to services there is a predicted workforce shortage of physician obstetricians and gynecologists by 25 % by the year 2030 [3]. Centering Pregnancy was developed in the 1990s by Sharon Schinldler Rising, a Yale- educated Certified Nurse Midwife. The concept was conceived as a way to prevent provider burnout and to increase patient satisfaction [4]. Named after the concept of care centering on the patient, Centering Pregnancy is currently available at over 300 sites throughout the world [5]. This care delivery model is a method of collaborative practice, which can allow a provider of obstetrical health care to increase the volume of patients seen, improve outcomes and open up clinic space

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Table 1 Centering Pregnancy visit scheduling

Table 2 Outcomes associated with collaborative obstetric care

Four sessions every 4 weeks starting at 16 wega

Increased rate of vaginal deliveries [11]

Six sessions every 2 weeks starting at 30 wega

Lower rate of cesarean deliveries [12]

Postpartum Reunion 1–3 weeks postpartum

Shorter length of hospital stay [12]

Additional visits scheduled as need for medical or psychological needs

Increased rate of breastfeeding [12]

to see other patients. This unique and dynamic model of care is a strategy to help a practice stay competitive in a vastly changing health care landscape.

Table 3 Organizational benefits to Centering Pregnancy

Similar perinatal outcomes in low technology facilities when compared to high technology facilities [13]

Decreased patient wait time Scheduling appointments for entire pregnancy Group check in the EMR

What is Centering Pregnancy? The concept of Centering involves two main aspects of care-assessment and education. This is delivered in a facilitative rather than didactic method, and enhancing these aspects of care is the added benefit of support. These aspects of care should be provided in traditional care, but often get lost in the daily grind of the office. One of the most important benefits of Centering Pregnancy is the potential for continuity care with one provider in the midst of a busy group practice. This community of support that is focused on the centering group, not the provider, promotes the patient empowerment and outcomes [6]. In Centering Pregnancy, 8–12 women with similar due dates are assigned to a single group, with two health care providers facilitating. The groups meet for a total of ten sessions, beginning in the second trimester. (See Table 1) These sessions meet on the same schedule as traditional obstetric care. Each session has a preset patient educational curriculum, but the actual content of each session is set by the group. Educational topics include nutrition, toxins of pregnancy, domestic violence, and contraception. Such fluidity allows for discussion of alternative topics the group may find important. Use of evaluation tools after the session allows identification of missed topics, which can be covered during future visits.

Collaborative practice ‘‘Great minds don’t think alike.’’ This quote by Margaret Hutchison, in her 2011 article in Obstetrics and Gynecology, illustrates the concept of positive collaborative efforts [7]. Collaboration between care providers from different professions provides opportunities to capitalize on the strengths and differences of each provider, and as described above will be crucial for successful modern obstetrics and gynecology (OBGYN) practices. Most medical specialties have physician assistants (PA) and nurse practitioners (NP)

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Increased exam room availability Marketing platform

to assist physicians in caring for patients. Exclusive to OBGYN is the certified nurse midwife (CNM). Certified nurse midwives are registered nurses with advanced training in women’s health, health promotion and education, and primary care. They are licensed, independent practitioners with prescribing power. Recognized in all 50 states, the District of Columbia, Guam, Puerto Rico and American Somoa, CNMs are an integral part of the obstetric team. The ACGME recognizes nurse midwifes in a supervising and teaching role over residents physicians within their scope of practice. Although many people continue to conceptualize midwives only performing home births, 94.4 % of deliveries performed by CNMs in 2012 were in hospitals. Currently, half of CNMs report working solely in physician offices or hospital-based practices [8]. In February 2011, the American College of Obstetricians and Gynecologists and the American College of Nurse Midwives developed a joint statement encouraging interdisciplinary team work to accomplish a common goal [9]. This collaboration has proven to increase efficiency, improve clinical outcomes and enhance patient satisfaction [10–14] (see Table 2). Centering Pregnancy, an established method of group prenatal care, is an excellent method for any type of obstetrical practice, private or academic, to build and maintain a multidisciplinary collaborative practice (Table 3). Building a collaborative practice with many levels of care providers enhances learning for all. The art of listening is an important skillset for health care providers, and is sometimes a challenge to develop. Many physicians are only familiar with didactic education. Collaboration between physicians and other professionals is of great value, and has been demonstrated to improve quality outcomes. Physicians can learn holistic care models; group sharing helps to normalize common problems. Grouping

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women by gestational age allows facilitators to focus on stages of pregnancy and allows them the ability to focus on patient assessment skills.

Organizational benefits What are the organizational benefits that Centering Pregnancy brings to your practice? These are summarized in table, and we will review them in specific in this next section. Patient flow and excessive wait time are often cited as reasons for patient dissatisfaction with current ambulatory care for obstetrics. Centering pregnancy eliminates wait times for office-based obstetrics. From a patient flow standpoint, all patients are scheduled to arrive and leave at the same time. This allows office personnel to check patients in batched groups rather than one at a time. Appointments are scheduled for the entire pregnancy, facilitating compliance and scheduling. We have found it most successful to book templates out on an annual basis. We can adjust and add groups, or combine small groups as needed. We have identified five specific ways by which office efficiency can be improved. The following paragraphs describe them in detail. Number one: clerical processes for office staff is simplified and enriched. Patients can be acknowledged or checked into the electronic medical record (EMR) as a group, rather than individually. This enhances convenience for office staff, and allows them to handle other issues such as address, phone number, insurance verification, or other administrative concerns during the 30-minute check in. We have found it helpful to assign a different medical office secretary to each group. This allows one secretary to interact routinely with the same patient group. In our experience, this level of personal involvement adds to overall satisfaction with care. Number two: Patients are empowered to take ownership of their pregnancy and health care. Teaching women selfcare is an important part of the Centering Pregnancy philosophy. Patients record their own vital signs in their chart, and are taught basic health care skills, such as taking their own blood pressure and weight. This emboldens patients to take an active role in their health care. The medical assistant or nurse supervises these functions, allowing one nurse to efficiently care for many patients at once. This takes the mystery out of the medical records, and frees paid staff to perform important office tasks. One medical assistant can supervise 8–12 women in the self-care position of the Centering Pregnancy visit (blood pressure, weight), rather than seeing the patients individually in a concurrent fashion. Number three: A midlevel provider can be used to free physicians to see additional patients. Centering is

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performed in a group space away from the examination rooms. A busy clinician can improve office efficiency as well as revenue opportunities by having a midlevel provider trained and facilitating Centering Pregnancy groups, while she is seeing complex gynecology patients. Number four: Market differentiation and marketing is another major benefit for the organization. Studies show that patients in group prenatal care had higher compliance, lower rates of inadequate prenatal care when compared to traditional models [15]. In our experience, we have found this concept a rich marketing tool, as it adds an alternate to the traditional models that are available. Patients enjoy the scheduled format, and the benefit of enhanced provider time. Number five: Provider time and efficiency are enhanced. Some providers struggle to provide high quality care, in a revenue-driven, production-based model. Centering Pregnancy allows better outcomes, and neutralizes time inefficiencies in an office setting. As long as the groups maintain the same volume as a traditional obstetric clinical volume of patients one would a lot in a usual clinic schedule, the revenue model trends in a positive fashion. For example, if return obstetrical patients are booked every 15 min, then a minimum of 8 women in each group is needed [16].

Benefits This model of care offers many benefits to several groups of people including private practice practices, academic practices, office staff, and patients. Benefits to the private practice In private practice, staying current with current and striving for improved clinical outcomes are part of modern medical culture. Centering Pregnancy offers a method to improve clinical outcomes while increasing clinical revenue. By training a nurse midwife/nurse practitioner in this model, the practice can expand its capacity for obstetrical patients. This model can provide a practical much-needed source of new clinical revenue, at less cost than hiring an additional physician. Some of the biggest office stressors in private practice are lack of adequate time with patients, and repeating educational caveats to multiple patients in 1 day. Burnout in the obstetrician-gynecologist has been linked to stress from lack of time with patients [17]. Centering allows the physician to discuss the topic once and allows the patients to learn from each other in a facilitative discussion. This model empowers the patients to participate in their care, and improves provider satisfaction with care [18].

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Benefits to the academic practice Not only does Centering Pregnancy have the potential to benefit a private practice, but also it has extremely advantageous implications for an academic practice. Continuity clinics are a component of program requirements set by the Residency Review Committee (RRC) for accredited Obstetrics and Gynecology (OB/GYN) residency programs [19]. Longitudinal experiences in obstetrics are also a part of the requirements for Family Medicine residency programs [20]. With new duty hour restrictions, continuitybased residency clinics can be difficult to establish. Equally challenging to establish is provider satisfaction with the clinic experience. Provider inconsistency can lead to patient dissatisfaction and decreased retention rates. Unpublished data suggest that rates of resident physician continuity are dramatically improved with the Centering Pregnancy model. Resident mentors or student preceptors benefit from the Centering experience. Centering is an effective way to expose residents to many facets of prenatal care. Formally educating patients on prenatal care, breastfeeding, newborn care, depression and contraception is an outstanding way to sharpen communication, research, and public speaking skills. Residents’ educational process as well as maternity outcomes have been shown to improve in this care model [21]. Benefits to office staff Staff members benefit from the Centering experience by getting to know the patients and their support people on a more intimate level. They take ownership of the group and are more committed to ensuring their groups are well cared for. Centering is usually conducted away from the clinical setting, either in a conference room or other facility, waiting rooms are less crowded and examination rooms are freed up for other visits, such as gynecologic well women exams or gynecological procedures. In an era of EMR, many offices have medical records storage space that can be converted into a small room for groups. Additionally, evening sessions are very popular with our working patients. This allows them an alternate experience, and uses office space at non-peak times. Shifting the patients from busy peak clinic times into a time spot that is usually not booked improves patient flow through a busy practice. Benefits to patients In addition to the organization and staff benefits, patients also benefit tremendously from the Centering experience. We will review the outcomes data later in this article, but on a conceptual level, research has shown that being part of

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Arch Gynecol Obstet (2015) 291:499–507 Table 4 Implementation tips Form a steering group 3–6 months before official implementation Market the concept, with local media and social networking Have key clinicians and office personal attending facilitative training Order supplies, including Mom’s notebooks and facilitator guides Obtain/plan educational aids, games, icebreakers. Have these organized in the Centering room

Table 5 Costs associated with centering [25] Initial cost

$20,000

Centering Health care Institute training for a small practice with few staffa

$850/participant (plus travel expenses)

Centering Health care Institute training for a large practice with many staffa, b Facilitator guides

$6,500 for up to 25 participants $75 each

Mom’s notebooks

$22 each (discount if buy-in bulk)

Advanced workshops

$500 per participant

Osteopathic manipulation table for physical examination (optional)

$260 (clay OMT)

Total cost for our practice (example institution)

$30,000

a

Facilities choose one of these options only

b

Centering Healthcare Institute will send a trainer to the facility, eliminating travel and lodging costs for trainees

a community is good medicine. Patients become more involved in their own care and acquire the skills and confidence necessary to care for themselves and their babies, and providing support to each other was found to be just as therapeutic as the support patients received from health care providers [22].

Implementation plan We have discussed organizational, staff and patient benefits. Now we will switch focus to implementation. This concept takes a complete paradigm shift in care delivery. In any setting, organizational change requires careful thought, planning and buy-in at every level of the organization. (see Table 4) A critical component of implementing Centering Pregnancy is the period of three to 6 months prior to execution. During this time, it is important to identify key stake holders, and form an implementation group or committee. The stake holders of this committee will naturally evolve into the Centering Pregnancy Steering Committee. This committee should, at a minimum, consist of a program champion, clinical lead, office manager, and other clinical and clerical personnel. Initially, the committee should meet monthly. This is an

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opportunity to discuss challenges, allowing all members opportunity to solve problem and ensure a self-sustaining and successful implementation. The Centering Healthcare Institute (CHI) is a valuable asset to assist in system redesign and model implementation. CHI provides training courses for future providers. This training enables members to fully understand the Centering Pregnancy Model [23]. It is important for as many members of this committee to attend the Centering Pregnancy 2-day facilitator training. When beginning program implementation, it helps to have a good understanding of the 13 essential elements to the Centering Model. (see Table 5) Maintaining fidelity to the model helps to ensure positive outcomes, including the reductions in preterm birth as well as utilization of care [24]. Finding a peer who has implemented a program can be very useful, and Centering Healthcare Institute’s facilitator training is the perfect place for finding a mentor.

Table 6 Positive outcomes of centering pregnancy

Overcoming common implementation challenges

practice. The Centering Healthcare Institute has a two-tiered facilitator training program. The cost for a basic workshop is $850 per participant. Advanced workshops cost $500 per participant. The cost of travel, lodging and meals will need to factor into the overall cost of training. For a large practice desiring to train many staff, CHI will provide training at your location for up to 25 participants. This training costs $6500. Some facilities with fewer than 25 staff members can open the training session up to participants from other locations. The fee charged to these participants can offset some of the facility’s cost. Facilitator guides are $75 each and should be purchased for each facilitator. Mom’s notebooks are needed for each patient participating in group. These notebooks are rich in information and Self-Assessment Sheets (SAS), which help to guide the topic and format of each session. Notebooks cost $22 each, but bulk copies are available at a discounted rate. Another financial consideration is the cost of a Centering Coordinator. This person coordinates all aspects of the program, including Steering committee meetings, schedules, patient selection and scheduling, as well as keeping statistics necessary for site approval and site approval continuation. The group space is a very important aspect of the Centering experience. A place for ‘‘mat time,’’ or the patient assessment can be done with a folding mat and pillow on the floor. Our practice purchased an osteopathic manipulation table at a cost of $260 (Clay OMT). Comfortable chairs are a wise investment, but some practices purchase beanbags, birth balls or folding chairs to decrease the cost. Privacy can be provided around the ‘‘mat area’’ with screens or plants. Both are a simple and inexpensive purchase. An iPod with player or compact discs with soothing music increase privacy and complete the milieu.

There are many challenges in implementing this program, and in this next section we will review many of these common problems, and offer up practical solutions. Space issues Finding an appropriate space within the confines of a traditional office can be difficult. A comfortable Centering space includes room for 15–20 group participants. For most practices, Centering Pregnancy including 8 to 10 patients is cost-neutral when compared to traditional 15-min prenatal visits. In an era of EMR conversion many practices find group space in the old chart room. An alternate solution is the waiting room after hours. This model has great appeal and flexibility for working moms and students, and also adds revenue by running a productive clinic in off time. In our experience, classic folder charts work best for patient recording of self-care information. Alternately, a computer with EMR access can be placed in the group space to directly record data at the delivery point. Capital A practice desiring to implement the Centering model must be willing to commit to an initial investment [25]. An example cost breakdown is detailed in Table 6. After a readiness assessment survey, a consultant will assist your practice with a Model Implementation Plan, and the initial cost for implementation is $20,000 [23]. Additional facilitators will need to be trained based on the organization of the

Reduction in preterm birth [26] Increased maternal satisfaction with care [26] Increased maternal compliance with care [26] Extended time with provider [26] Increased knowledge of pregnancy [26] Increased breastfeeding [30] Lower no-show rate for adolescent patients [31] Increased probability of choosing a pediatrician at postpartum discharge [31] Fewer feelings of guilt and shame within military population [33] Increased probability of minorities choosing family planning postpartum [37] Increased condom use among HIV positive women [34] Increased provider satisfaction [27] Improved mental and social health [40] Improved resident physician team collaboration skills [41]

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The total investment for our practice was approximately $30,000.

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This preserves educational exposure to complex surgical cases. Resident satisfaction with continuity clinics and with general patient care has improved since implementing this model of care at our residency program.

Private practice models There are many different ways by which Centering Pregnancy can be adopted in private practice settings. The provider may be an obstetrician, who chooses to flex his or her hours to see a full group during the evening. This is particularly ideal for physicians who treat groups of professional patients. This model allows other partners in the group time during routine business hours to use additional patient rooms. Alternatively, a collaborative practice approach may be used, utilizing a midlevel provider such as a certified nurse midwife. This model allows a practice to increase patient volume and appointments without the expense of hiring an additional physician. As supply of obstetricians decreases, this model can help offset the need for increased physician time with other patients, such as those with complex gynecologic complaints.

Academic/teaching models Centering Pregnancy can provide an innovative and educational experience in a residency program. Resident physicians co-facilitate Centering Pregnancy groups with another trained facilitator. This provides a rich, hands-on learning experience for the resident, who is tasked with patient assessment and education. When planning resident continuity clinics, we found it easier to have a daytimebased continuity schedule, as opposed to a resident rotation-based schedule. Clinic schedules and night float schedules can be set at the beginning of the academic year. The Centering Pregnancy visits are planned around the resident facilitators’ selected vacations and assigned night floats. The Centering schedules are assigned by the Centering coordinator and are based on patient volume or need. On average we start one or two groups per month. When planning group, we may extend or shorten the interval between sessions to accommodate the resident schedules. For example, we may have a visit in 3 weeks rather than 4, or 3 weeks rather than 2. Competency in basic obstetrics can be concentrated in the first and second year of residency, so Centering Pregnancy is a natural fit for an obstetrical clinic in these 2 years. Our Centering Pregnancy continuity clinics are for the PGY1 and PGY2 residents. Primary surgery and specialty focus, such as oncology and maternal fetal medicine rotations are during the PGY3 and PGY4 years, and therefore this model prescribes a rotational-based clinic.

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Outcomes data Centering Pregnancy has been shown to improve outcomes in many different arenas (Table 6). Demonstrated improvements include reductions in preterm birth, increases in maternal satisfaction, and increase in maternal compliance with healthcare. Studies have shown positive outcomes from Centering Pregnancy, spanning across several socioeconomic, racial, and age groups. One of the perks of Centering Pregnancy is extended time with a health care provider. This increases the knowledge of pregnancy [26]. Group prenantal care has been shown to have positive outcomes in the general populations, as well as in specific populations such as adolescents, racial minorities, the military, and underserved populations globally. One major benefit of Centering Pregnancy is increased provider satisfaction. This model appeals to nurses, midwives, and other health care providers as it adds efficiency to a busy office practice. Time management is enhanced as providers are able to educate multiple patients at once. Providers are also able to spend more time with patients, increasing both provider and patient satisfaction [27]. Within the general population, Centering Pregnancy has had positive outcomes. A 2012 Cochrane review of the group versus conventional antenatal care found no adverse outcomes associated with group prenatal care for women or their babies. Mean satisfaction with group care was almost five times higher compared to conventional prenatal care [28]. A randomized control trial of over 1,000 women showed women enrolled in group prenatal care versus traditional prenatal care were less likely to have suboptimal prenatal care, had better prenatal knowledge, felt more ready for labor and delivery, had better satisfaction with their care, and had higher rates of breastfeeding initiation [29]. Additionally, a cohort study of over 400 women found that those enrolled in group prenantal care versus traditional prenatal care had higher birth weight infants, especially for those infants delivered preterm [30]. We have identified five specific subsets of the general patient population that benefit from group prenatal care. They are described in detail in the following paragraphs. Population one: adolescents. A subset of the general patient population, pregnant adolescents represent a distinct challenge to the prenatal care provider. Adolescent pregnancy is a significant health issue in the United States. The teenage years are key to forming healthy self-esteem

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and life habits. In addition to dealing with a changing body, growing emotionally, and preparing for a role in society, the pregnant teenager must also develop her identity as a mother and form a bond with her fetus. This task can be daunting. Centering Pregnancy has been shown to have positive outcomes in this patient population, including lower no-show rates, lower incidence of preterm birth, decreased rate of low birth weight infants, increased breastfeeding rates, and increased probability of choosing a pediatric care provider at time of postpartum discharge [31]. Population two: military. Another specific subset of the population is the military. Both women who are themselves in the service and those who have significant others in the service have unique needs during their pregnancies. With significant others sometimes thousands of miles apart and with particularly trying psychological issues surrounding warzones, the pregnant military patient may feel isolated during her pregnancy. Studies have shown success of group prenatal care within the military population. A study of over 200 women receiving prenatal care through the military found their greatest concern with individualized prenatal care to be lack of time with their provider [32]. A 3-year randomized control trial showed military women in group prenatal care versus traditional prenatal care were more likely to have adequate prenatal care, and were less likely to report feelings of guilt or shame [33]. Population three: patients with infectious disease. Patients with infectious diseases pose specific challenges during pregnancy. A randomized control trial conducted on over 1,000 women showed group prenatal care with a specific focus of HIV-prevention to be associated with reduced pregnancy rates at 6 months postpartum, increased condom use, decreased unprotected sexual intercourse, and reduced sexually transmitted infection rates [34]. Population four: minorities. Racial disparities are unfortunate reality of health care. Racial minorities sometimes have poorer quality health care, more difficult access, and decreased utilization than others. A study of lowincome Latinas in south Florida found that group prenatal care resulted in greater satisfaction in prenatal care, increased patient engagement, increased adequate prenatal care, greater likelihood of establishing pediatric care for their child, and greater likelihood of following up postpartum [35]. Another study of Centering Pregnancy introduced at a public health clinic with patients comprised predominately of low-income African–American women showed that group prenatal care was associated with more prenatal visits, more weight gain, increased breast feeding rates, and higher overall satisfaction when compared to traditional prenatal care [36]. Women who attended group prenatal care were more likely to choose family planning at 3, 6, and 12 months postpartum. When this analysis was

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restricted to non-Hispanic black women compared with non-Hispanic white counterparts, this benefit was magnified [37]. Population five: international peoples. Group prenatal care is also being used globally. Subsaharan Africa has the highest disease burden in the world, but the fewest number of health care workers. Prenatal care in these areas is sparse. Centering Pregnancy—Africa was recently introduced in Tanzania and Malawi. Preliminary data suggest it to be feasible for use in these low-literacy, low-resource, high-HIV settings. An added benefit is potential reduction in health care worker stress when dealing with multiple HIV-infected patients all in one setting [38]. Group prenatal care has many benefits for all patients. A study published in the American Journal of Obstetrics and Gynecology demonstrated an improvement in patients’ decisions to pursue family planning during the postpartum period. This was true at 3, 6, 8, and 12 months postpartum. This study demonstrated the potential group prenatal care has for optimizing postpartum follow-up and preconception counseling [39]. Another study, published in BMC Pregnancy and Childbirth, compared Centering Pregnancy to traditional prenatal care coupled with individual patient education. Patients who enrolled in group prenatal care were statistically more likely to have poor psychosocial health than their counterparts in traditional care, with higher rates of depression, stress, and anxiety. However, these difference no longer reached statistical significance at 4 months postpartum, suggesting that Centering Pregnancy may be a care strategy to improve mental and social health [40]. An additional article, published in the Journal of Graduate Medical Education, showed benefit to resident education when third year residents collaboratively provided prenatal care in a group model. After a 6-month period, residents showed improved competency-based outcomes in facilitation and effective team collaboration. These skills are directly applicable to future medical practice [41].

Conclusions Centering Pregnancy is showing itself to be a wonderful opportunity for collaborative practice. In 2011, ACOG and ACNM issued a joint statement encouraging collaboration and evidence-based women’s health care. Centering offers physicians and midwives the ability to provide this care and eliminate barriers to practicing together. Although designed by a Nurse Midwife, Centering affords clinicians of all experience and educational levels to integrate this program into practice. This

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program has proven to increase resident satisfaction and is an amazing opportunity for residency programs to introduce collaboration and increase resident’s obstetrical knowledge and experience. Research has been done on many aspects of the Centering Pregnancy paradigm. Multiple studies, many in collaboration between physicians and other clinicians, have shown Centering to be an excellent care model for increasing clinic efficiency and provider time management. Patient, as well as provider satisfaction, is improved. Patient compliance with care, an issue with many high risk, socioeconomic backgrounds, is strengthened when patients participate in group prenatal care. This model of care has been proven to be effective with the military and teenagerstwo high risk populations that can be difficult to manage. A significant decrease in the preterm birth rate and low birth weight is also noted at institutions that provide Centering Pregnancy care. This decrease is an important factor to consider when determining whether to undergo the system redesign necessary to transform from traditional care to the Centering Pregnancy model. A decrease in preterm birth can have significant financial and social impact on women, families and communities. Breastfeeding initiation and continuation are also increased in women who participated in Centering Pregnancy groups. This is another opportunity for providers to greatly impact society. Centering Pregnancy is a proven method of providing prenatal care. The program is distinct and affords providers ample opportunity to increase office revenue, efficiency and time management. This care concept is an evidencedbased approach to patient-empowered and patient-centered care, and allows a practical way to adapt in the changing health care delivery system. This model also increases patient compliance with care as well as patient and provider satisfaction. The Centering Pregnancy model is an excellent opportunity to provide physician, resident, student, midwife collaboration. Our experience with Centering Pregnancy has been only positive; we wholeheartedly recommend this model of prenatal care. Conflict of interest

Dr Julie DeCesare is a paid speaker for Bayer.

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Centering Pregnancy: practical tips for your practice.

With increased access to care, current health delivery systems will need expansion to meet higher demands and needs...
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