November 8, 2017

Nursing Initiatives Improve Prenatal Care Delivery

Highlighting two successful best practices


Two nursing-led initiatives at Cleveland Clinic are helping pregnant women experience better outcomes: (1) Centering appointments for prenatal care, and (2) labor and delivery units designed to support unmedicated births.


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Centering appointments are shared medical appointments for regular well-check visits of pregnant women. Group sessions are approximately two-hours in length and include about 10 other future moms. Moms-to-be learn about many aspects of pregnancy, delivery and infant care from specially trained nurse midwives and from each other. Guest speakers provide information on lactation and new infant care. Women also receive private check-ins with their midwife at each session.

“Moms absolutely love it. Face-to-face time with providers is enhanced over the course of a pregnancy from about two hours (based on ten 10-minute visits with providers) to 20 hours,” says Sue Hudson, MSN, CNM, Director of Midwifery Services in Cleveland Clinic’s western region, who headed up formation of the program.

“We certainly talk about the things you would expect, such as labor, but we also discuss what postpartum is like, intimate partner violence, depression, proper nutrition and exercise. By the time women get through 10 sessions of Centering, moms give birth with important knowledge,” Hudson says.

Cleveland Clinic started the program in early 2016 with a pilot group, and it was so well-received that many more groups have been formed since. It is being expanded to inner-city facilities in conjunction with a grant from the March of Dimes as part of Cleveland Clinic’s efforts to reduce infant mortality in the community.


“Research findings are also promising,” says Hudson. “In one report, women who participated in Centering groups had fewer premature delivery and fewer births at 32 weeks gestation.1 And we are also seeing satisfied participants.”

The goal is to make the program an “opt-out” ‒ all women are put into a Centering group at their first prenatal visit unless they decline. Some women resist initially because they think it will be difficult to fit a two-hour appointment into their schedule. Women who are unsure of their desire to attend are encouraged to attend one Centering visit before opting out. “If they come once, they will come back,” Hudson says, confidently. “The attrition rate is very low.”

The results of Centering are clearly visible in the Fairview Family Birth Place, a unit that was created about a year ago under the leadership of Joyce Arand, MS, CNS, RNC, NEA-BC, Director of Nursing Women and Children’s Services at Cleveland Clinic’s Fairview Hospital. This midwife-staffed low-risk unit, located close to the hospital’s traditional labor and delivery unit should an emergency arise, is equipped with birthing tubs, balls, stools and more. Women receive intermittent fetal monitoring, which allows them to move around as they labor. They have the option to use nitrous oxide to help ease pain and anxiety in labor.

“When moms come in after experiencing the Centering program, they are prepared, knowledgeable and calm, and often have a clear desire to try unmedicated birth,” Arand says. “Centering is a very successful way to provide prenatal care.”


1 Picklesimer AH, Billings D, Hale N, Blackhurst D, Covington-Kolb S. The effect of Centering Pregnancy group prenatal care on preterm birth in a low-income population. Am J Obstet Gynecol. 2012;206(5):415.e1-7.

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