“The Centering model is anchored by three components: healthcare, interactive learning, and community building.”
– Sharon Schindler Rising
Interview with Sharon Schindler Rising
Sharon Schindler Rising is a certified nurse-midwife, founder of the Centering Healthcare Institute, and founding member of nonprofit Group Care Global. She was first inspired to create Centering to improve maternal and infant health as a graduate nursing student at Yale.
During her studies, Sharon spent time in a waiting room at a New Haven clinic, listening to the concerns of expectant mothers. The dynamic conversations and the women’s support for each other planted the seed for a new approach to prenatal care: Centering, where groups of mothers-to-be with similar due dates meet for their routine appointments together, having short private visits with a healthcare practitioner and longer sessions as a group, discussing questions and concerns. We spoke with Sharon about the value of Centering in improving maternal and infant health.
Why did you want to spend time in the prenatal clinic waiting room during your studies?
I had decided that didactic education doesn’t work terribly well, and that there is so much to be gained by truly listening to people. I was a graduate nursing student, hadn’t had a baby yet, and thought it would be instructional for me to listen to what women were experiencing at home. How was their environment? What were their challenges? I also recognized that their medical visits with clinicians were short and didn’t really support in-depth discussions.
Little did I know that this was going to be a re-occurring theme for me! When I worked in Minnesota with the Childbearing Childrearing Center, I had another opportunity to think about what prenatal care should look like. We had the freedom to design a different look to care and I thought back to the New Haven clinic and how nice it was for me and the pregnant women to sit together in a circle and talk.
That helped inspire the Minnesota programming. We had groups that people joined during the last trimester of pregnancy and continued through 3 months postpartum. In total, it was a 6-month group experience. The groups consisted of 7 to 9 couples, who were already coming to us for care, and they got together regularly through our group just to share experiences. There was a nurse midwife there and, in the postpartum period, our pediatric nurse practitioner joined the group because we were talking about parent-baby care.
My own past midwifery experience also influenced me. As I cared for so many pregnant people, I would think about how there was so much more to prenatal care than what we fondly call “the belly check.” I would have similar discussions with patients all day and realized one person’s question is another person’s question. Even seeing the chart racks outside my door filled with charts of 4 or 5 women who were just waiting—when they could have been speaking with each other in a group—that was something that I didn’t feel great about, and I knew we could do better.
Describe what it’s like to be in a Centering session for both the facilitator and the other participants.
Pregnant patients are invited to join a group based on their gestational age, so a group of about 8 to 12 people are invited to come starting around 12 to 16 weeks of their pregnancy. They come directly to the group space, where there’s music playing. At the first session they’re shown how to take their blood pressure and encouraged to check their weight. Participants keep track of their own health data.
In a corner of the room, there’s a place where the actual 3-minute health assessment piece is done, usually on something low to the floor like a mat or cot. You might have a tree or plant in that space to create some privacy. The actual “belly assessment” of listening to the heartbeat and determining that the baby is growing doesn’t take much time at all. The focus there is on making sure that things are going fine with this person, including looking very briefly at the health data that she herself has collected. You can see how the participant is starting to understand what it means when her blood pressure is different from time to time or how she is doing with her weight.
When the assessments are done, we gather in a circle for an opening discussion. I have a co-facilitator, but we don’t sit together. After our interactive opening, where everyone’s voice is heard, a facilitator might begin by saying, “Roberta, you had a question that you put up on the board. Would you share a little more with us about that?” And she would typically share. I’d listen and make sure that it’s clear what the issue is and then say, “I’m guessing this may be something that some of the rest of you also are experiencing. Is that true?”
There’s this very rich discussion that often happens. There may be a self-assessment sheet that participants have filled out that helps to spring a discussion topic, such as “common discomforts.” And we might say, “Let’s talk a little bit about that.” And then we might come up with some strategies. I might have some thoughts and my co-facilitator might as well. But it’s not a didactic presentation going down the list. People speak up with things that have worked for them.
From a facilitated model led by the clinician, Centering transformed to where the clinician is a member of the group. In our early publications, we called what happened in the group “education,” which we then changed to “interactive learning.” And we made that change because I said, “I’m learning as much or more as anybody else in the group.” I would sit in the group and say, “Oh so that’s why that strategy never worked!” I never truly understood some of the cultural beliefs and values that guide behavior before these group discussions.
It’s important to remember that the Centering model is anchored by three components: healthcare, interactive learning, and community building. Why healthcare? It was so important to me to have healthcare be part of it because healthcare is reimbursable, and I didn’t want to work on developing something that was going to go away due to lack of funding.
Can you talk about the community building component of these groups?
You have this time together and get to appreciate the kinds of issues that the people in the group are dealing with. Perhaps today there’s been a shooting down the street, or the local grocery store is going out of business, or there’s something else directly affecting the lives of the people in the group. So that’s what you talk about. The community building then just really happens. The participants look at each other and say, “I didn’t know you lived down the street.” “You’ve got 3 other kids. How are you going to manage that? I’m 2 blocks away. Here’s my number. Here’s how you can reach me.”
The community then starts building as the participants reach out to each other. The internal community really develops. I have a lot of interest in how this affects the external community, meaning the other groups within the community that are there to support parents, with breastfeeding or consignment shops, or healthy food, for example. We’d like to have more attention paid to whether groups like this have an effect on the community itself. We think they do. For example, several years ago there was a group that wanted to have a safe, local playground and worked with the community to get that developed.
The data show that Centering reduces preterm births by 33%. Can you explain the dangers related to preterm birth and what it is about Centering that has led to improvements in this area?
Preterm birth provides lots of challenges for parents. They lead to stays in the NICU, which are very expensive. Preterm birth can lead to developmental challenges where babies are slow to gain weight, and to reach the developmental milestones we want for children. For families, it’s a lot of worry—often about their baby’s survival. And then there’s the additional care and attention that many of these babies continue to need. Many of them do really well. We’ve gotten so much better at providing NICU care with the medical advances during the past 20 years. But ultimately, we want babies to be born full term.
How does Centering help reduce preterm births? I’m convinced that the mind-body relationship is pretty strong. I’ve heard many people come into group and say, “Oh, I’m getting so big. Everyone in my family is saying, ‘You couldn’t possibly be due in January. You’re going to have your baby before Christmas!'” If a lot of people around you are telling you, “You’re going to give birth early,” there’s a way that perhaps you start letting go of your pregnancy and maybe letting go of your baby a little early. I don’t know if that happens, but I think in a group where everybody is due during the same time frame, people think “Okay, I don’t want to be an outlier. I want my baby to be born during January just like everybody else’s.”
In the group, people are sharing strategies and they’re all talking about how uncomfortable they are toward the end—it’s a shared experience. Maybe they’re singing songs or doing some movement work together. There’s just a different kind of atmosphere that happens in the group. Participants want full-term babies. They know that a baby born full term is healthier than a baby born earlier.
What are the reasons you’ve found why some providers are reluctant to incorporate Centering in their practices? What would be the best way to encourage providers to adopt Centering or a similar group approach?
It requires a lot of change, and people—and systems—don’t like change. Just think about all that it entails. For example, schedules need to be different. In a group, it’s the same clinical provider for 10 sessions, because that consistency creates stability in the group and it’s important for the development of trust. You have to ideally get 10 to 12 pregnant people of similar gestational age together. And you have to run the kind of group that will meet productivity demands of the institution.
Clinicians have spent a lot of time learning and want to pass along their knowledge. With something like Centering, you still bring that expertise, but it comes out in a whole different way. Clinicians have traditionally felt, “We can’t trust a pregnant person to take their own blood pressure or accurately record their weight.” Group care is about letting go of that, taking off your lab coat and sitting in the circle and listening. These are skills we’re not taught. There is a process of facilitation that doesn’t come easily for some.
I remember that in a site where I was working I was seeing 26-28 women individually each day and answering the same questions again and again. You can imagine what that was like. For me and for the many providers who participate in Centering, being able to sit in the group and listen and really get to know the 10 to 12 participants over time, is incredible. We hear from participating midwives and nurses who say, “This is why I wanted to do this work. This is the kind of care I want to give.” An OB resident remarked, “Every resident should have the opportunity to be with the group during their whole pregnancy. Otherwise, how do we know what pregnancy is really like?” The satisfaction of the participants and the providers is always very high.
How can CenteringPregnancy and CenteringParenting help in addressing parental stress and mental health?
I’m adamant about the importance for the groups to continue in the postpartum period. I can’t think of any reason why groups should stop at the 6-week marker or at the birth marker. I’m sort of this “First 1,000 days” person now—from the beginning of pregnancy through age 2. This is not an easy time for most families. They struggle. There are relationship struggles during this time. Interpersonal violence increases during this time. Sometimes it’s hard to continue with breastfeeding and there are hormonal changes for the pregnant and parenting person to manage. Depression is one very concerning issue that we know is present for many people.
The group provides some support for that. There’s a story that comes to mind. A family practice doctor who had a postpartum group said, “The women came to me and said, so-and-so is really depressed, and we need to figure out a way to be helpful to her.” The women themselves had figured that out. It wasn’t that the woman self-disclosed. Another time the group said, “So-and-so over here didn’t have a contraceptive plan. Well, we fixed that.” The group comes together and does things for each other.
We have some data, but not a lot. This is an area that needs a lot of further study. But there’s no reason for us to think some of the mental health issues won’t be better served by a person being in a group and having the support of the group.
What’s happening globally with Centering? What kind of reception has it received?
I had done some international workshops during earlier years. With a small group of people, we formed Group Care Global in 2017 to respond to the international interest. Since that time, we worked with the Chinese Midwifery Association. Their goal has been to get groups going in every one of their provinces, and they’ve done a lot of work in that regard. We’ve been part of what we call Centering-Based Group Care in Malawi and have trained in-country trainers who’ve taken over and now are in the process of moving forward with the Ministry of Health. The goal in every country is to get the Ministry of Health on board and to get their support. We started working in the Netherlands many years ago. They just had their 11th anniversary and finally are getting reimbursement, but it has taken this long to do that. We’ve been working as well in Ghana, South Africa, and Zanzibar. We were working in Ethiopia until the tribal wars in the north happened but we’re still in touch with them.
We’ve just finished a European Union-funded grant to implement Centering-Based Group Care in 7 countries with a focus on vulnerable women. This includes Kosovo, a very new country that had no protocols for prenatal care. We’ve also worked across the UK and in Belgium. It’s been very exciting work. Our middle name has been “sustainability.” This is a model that works for any person who is pregnant. It doesn’t matter. Women in Malawi wrote songs and they end every group in circles singing, “This is wonderful. We’re together. We’re a group when we are in Centering together.”