Proceedings in Obstetrics and Gynecology

Health disparities exist among Iowa’s childbearing women, with preterm birth affecting Hispanic and African-American women at disproportionate rates compared to white women. Black women are also more likely than whites or Hispanics to deliver a low-birthweight infant. CenteringPregnancy is a model of group prenatal care that may help reduce these disparities. Preliminary studies show increased birthweight, decreased incidence of preterm birth, and greater knowledge about pregnancy in Centering participants. This model should be considered for implementation and study in Iowa

Potter, Elizabeth M

Proceedings in Obstetrics and Gynecology, 2010 Oct;1(2):3 
Please cite this paper as: Potter, EM. CenteringPregnancy and Health Disparities in Iowa. Proc Obstet 
Gynecol. 2010 Oct;1(2): Article 3 [ 4 p.].  Available from: http://ir.uiowa.edu/pog/vol1/iss2/3/. Free full text 
article. 
 
Corresponding author:: Elizabeth M. Potter, Department of Obstetrics and Gynecology, University of Iowa 
51321 PFP, 200 Hawkins Drive, Iowa City, IA 52242. Telephone, (319)356-1956.  elizabeth-
potter@uiowa.edu 
 
This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 
Unported License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, 
and reproduction in any medium, provided the original work is properly cited. 
 
CenteringPregnancy and Health Disparities in Iowa 
Elizabeth M. Potter, CNM, WHNP, MS1 
Key Words: Centering pregnancy, group prenatal care, health disparities, low birthweight, 
preterm birth 
 
 
Abstract 
 
Health disparities exist among Iowa’s 
childbearing women, with preterm 
birth affecting Hispanic and African-
American women at disproportionate 
rates compared to white women. 
Black women are also more likely 
than whites or Hispanics to deliver a 
low-birthweight infant. 
CenteringPregnancy is a model of 
group prenatal care that may help 
reduce these disparities. Preliminary 
studies show increased birthweight, 
decreased incidence of preterm 
birth, and greater knowledge about 
pregnancy in Centering participants. 
This model should be considered for 
implementation and study in Iowa. 
 
1Division of General Obstetrics and 
Gynecology, Department of Obstetrics and 
Gynecology, University of Iowa Health Care, 
Iowa City, IA.   
 
Background 
 
An African-American woman in Iowa 
has nearly twice the risk of delivering 
a low-birthweight infant (LBW, <2500 
g) than a Caucasian woman, and is 
more likely to deliver preterm, before 
37 completed weeks of gestation.  In 
2008, 12 percent of African-
American infants were LBW, 
compared to 6.4 percent of white 
infants1. From 2004-2006, 16.3 
percent of black infants were born 
preterm, while 11.5 percent of white 
infants were born preterm2. 
Hispanic/Latina women in Iowa had 
a lower rate of LBW infants than 
black or white women (6.2 percent 
LBW), but the preterm delivery rate 
falls between that of black and white 
women, at 11.9 percent2. As the 
nation debates and implements 
change within the healthcare system, 
addressing such disparities is a high 
priority. The U.S. Department of 
Health and Human Services and the 
Institute of Medicine have 
recommended development and 
evaluation of better prenatal 
interventions to address 
disproportionate rates of poor 
outcomes in disadvantaged 
communities3,4. In the realm of 
prenatal care, the model of 
CenteringPregnancy should be 
explored as an approach to 
decreasing disparities and improving 
outcomes for all Iowa women.  
 
 
 
Proceedings in Obstetrics and Gynecology, 2010 Oct;1(2):3 
 
CenteringPregnancy and Health Disparities 2 
Discussion 
 
CenteringPregnancy (Centering) is a 
model of prenatal care created by 
certified-nurse midwives (CNMs) to 
provide risk assessment, education, 
and social support within a group of 
8 to 12 women with similar due 
dates5. After an initial individual visit, 
during which a complete history and 
physical exam are conducted, 
women meet together for 10 two-
hour sessions at regular intervals 
starting between 12 and 16 weeks 
gestation. Sessions are led by two 
consistent facilitators, one clinician 
and a nurse, social worker, or allied 
health professional.  Upon arrival, 
women take their own blood 
pressures and weights, and record 
them in their charts. During the first 
15-20 minutes of a session and 
during a snack break while the group 
may socialize, women take turns 
with brief individual assessments by 
a provider who reviews recorded 
vital signs, measures fundal height, 
listens to fetal heart tones, and 
screens for the need for private 
assessment after the group.  The 
rest of the time is spent in facilitated 
group discussion, with a flexible 
theme for each session. Topics 
include pregnancy discomforts, labor 
techniques, breastfeeding, family 
support, intimate partner abuse, and 
nutrition.  The structure allows for 
learning from peers, increased 
involvement and demystification of 
the process of prenatal care, 
community-building, and more total 
time spent with a provider over the 
course of the pregnancy5. The 
Centering model is guided by 
essential elements related to health 
promotion via group interaction, in 
contrast to traditional individual 
prenatal care (Table 1). 
 
How does Centering affect women’s 
knowledge, satisfaction with care, 
and pregnancy outcomes? Is there a 
role for Centering to reduce health 
disparities among Iowa women? 
Existing data are promising but 
mixed, reflecting the small number of 
available studies and difficulty of 
evaluation of qualitative variables. 
Evaluation of Rising’s pilot program 
showed client satisfaction with the 
model and a decrease in third-
trimester emergency room visits 
compared with a convenience-
chosen control group5.  A 
prospective, matched cohort study of 
458 women in urban public clinics 
found a statistically significant 
increase in birth weight among group 
prenatal care participants compared 
with those receiving individual care6. 
Although the study did not show a 
significant difference in preterm birth, 
the infants born preterm to mothers 
in group care did have significantly 
higher birth weights than those of 
mothers in individual care. 
Secondary analysis of a randomized, 
controlled trial comparing group and 
individual prenatal care found a 
significant reduction in preterm birth 
(33 percent risk reduction) among 
young, urban women involved in 
Centering7. Women in group care 
had higher rates of breastfeeding 
initiation, had better prenatal 
knowledge, and had better 
satisfaction with care.
 
 
Proceedings in Obstetrics and Gynecology, 2010 Oct;1(2):3 
 
CenteringPregnancy and Health Disparities 3 
Table 1: Some essential elements of 
CenteringPregnancy1 compared to 
traditional prenatal care 
 
Centering 
Pregnancy 
Traditional Prenatal 
Care 
Health assessment 
occurs within the 
group space. 
Health assessment 
occurs in private room. 
Participants are 
involved in self-care 
activities. 
Vital signs, weight, and 
urine dips are 
performed by clinic 
workers. 
A facilitative 
leadership style is 
used. 
Clinician usually guides 
communication and 
interaction. 
The group is 
conducted in a circle. 
Clinician may be 
standing while client is 
seated or lying down. 
Each session has an 
overall plan. 
Each visit may have 
certain goals. 
Attention is given to 
the core content, 
although emphasis 
may vary. 
Providers may vary 
their client education 
depending on questions 
or needs. 
There is stability of 
group leadership. 
Clients may see the 
same or different 
providers. 
Group conduct 
honors the 
contribution of each 
member. 
Depending on 
communication style, 
provider or client may 
do more talking. 
Group size is optimal 
to promote the 
process. 
Usually visits occur 
with one-to-one 
provider/client ratio. 
Involvement of 
support people is 
optional. 
Support people may or 
may not be welcome at 
individual visits. 
Opportunity for 
socializing with the 
group is provided. 
No opportunity exists 
for socializing with 
other pregnant women 
during routine visits. 
There is ongoing 
evaluation of 
outcomes. 
Evaluation of outcomes 
is done at provider and 
practice discretion, if at 
all. 
 
1 Essential elements. Centering Healthcare 
Institute. 
http://www.centeringhealthcare.org/pages/ce
ntering-model/elements.php.  Updated 2009. 
Accessed August 18, 2010. 
                                                
 
 
 
Baldwin8 also found that knowledge 
about pregnancy was greater among 
participants in a Centering group 
than those in traditional care. 
Robertson, Aycock, and Darnell9 
conducted a quasi-experimental 
prospective comparison study of 
Centering versus traditional care for 
Spanish- and English-speaking 
Hispanic women. Their results 
showed no difference in infant 
outcomes, including birth weight and 
gestational age at delivery, however, 
the sample size was small. 
Additional research is needed to 
incorporate greater numbers of 
participants, control for confounding 
factors, and increase research 
quality via randomization.   
 
Conclusion 
 
The literature to date shows that 
group care may improve rates of 
preterm birth and low birth weight, 
which are experienced at 
disproportionate rates by women of 
color in Iowa. Centering may be 
valuable throughout the state’s urban 
and rural communities. Existing data 
support outcome improvement for 
urban women in public clinics6,7. 
More research is needed on the 
effects of group care outside of 
urban settings. In rural communities, 
transportation may be a barrier to 
care, especially during periods of 
extreme winter weather. Group care 
may allow for shared transportation 
and easier rescheduling if clinics are 
closed due to storms. In areas where 
there are many Spanish-speaking 
women and a shortage of Spanish-
speaking providers, group sessions 
Proceedings in Obstetrics and Gynecology, 2010 Oct;1(2):3 
 
CenteringPregnancy and Health Disparities 4 
could increase clinic efficiency. They 
would also allow for more time to be 
spent on education in communities 
where Spanish-language childbirth 
preparation classes are unavailable.  
Establishment of Centering in Iowa 
would provide opportunities for 
research on acceptance and 
outcomes of this model in rural 
communities. Continued evaluation 
of the relationship between 
CenteringPregnancy and preterm 
birth would contribute to national 
goals set by the Institute of Medicine, 
which recommends research to 
understand the impact of the health 
care delivery system on preterm 
birth4. CenteringPregnancy should 
be explored as a method of 
increasing access to care, improving 
outcomes, and decreasing perinatal 
health disparities in Iowa. 
 
 References 
 
1. Iowa Department of Public Health 
Center for Health Statistics. 2008 
Vital Statistics of Iowa.  
http://www.idph.state.ia.us/apl/com
mon/pdf/health_statistics/2008/vital_
stats_2008.pdf. Accessed July 5, 
2010. 
 
2. March of Dimes. Perinatal data 
snapshots: Iowa. 
http://www.marchofdimes.com/perist
ats.  Updated October 2009. 
Accessed July 5, 2010.  
 
3. Improving Maternal Health Care: 
The Next Generation of Research. 
Conference Summary. AHRQ 
Publication No. 02-0025, June 2002. 
Agency for Healthcare Research 
and Quality, Rockville, MD. 
http://www.ahrq.gov/research/mater
nhlth/  
 
4. Behrman, R., Butler, A., Eds. 
Preterm birth: Causes, 
consequences, and prevention. 
Committee on Understanding 
Premature Birth and Assuring 
Health Outcomes, Board on Health 
Sciences Policy. Washington, D.C.: 
National Academies Press; 2007. 
 
5. Rising SS. Centering pregnancy. An 
interdisciplinary model of 
empowerment. J Nurse Midwifery. 
1998 Jan-Feb;43(1):46-54. 
 
6. Ickovics JR, Kershaw TS, Westdahl 
C, Rising SS, Klima C, Reynolds H, 
Magriples U. Group prenatal care 
and preterm birth weight: results 
from a matched cohort study at 
public clinics. Obstet Gynecol. 2003 
Nov;102(5 Pt 1):1051-7. 
 
7. Ickovics JR, Kershaw TS, Westdahl 
C, Magriples U, Massey Z, 
Reynolds H, Rising SS. Group 
prenatal care and perinatal 
outcomes: a randomized controlled 
trial. Obstet Gynecol. 2007 
Aug;110(2 Pt 1):330-9. Erratum in: 
Obstet Gynecol. 2007 
Oct;110(4):937. 
 
8. Baldwin KA. Comparison of selected 
outcomes of CenteringPregnancy 
versus traditional prenatal care. J 
Midwifery Womens Health. 2006 Jul 
Aug;51(4):266-72.  
 
9. Robertson B, Aycock DM, Darnell 
LA. Comparison of centering 
pregnancy to traditional care in 
Hispanic mothers. Matern Child 
Health J. 2009 May;13(3):407-14. 
 
 
 


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