The Columbia Heights neighborhood in Washington, D.C., is in transition. Shiny new condos have sprouted up in recent years, attracting a rush of new restaurants and national retail chains — Target, Best Buy, Bed Bath and Beyond.
The building boom almost swallows up the pockets of poverty. An austere cement medical building — which predates all the recent gentrification — is one of those pockets.
It's a health center run by Unity Health Care. The majority of patients here are uninsured or receive Medicare, and more than 90 percent live below the poverty line.
We came here to learn more about a growing trend in prenatal care called centering. Here's how it works: A group of women have collective, two-hour-long medical visits throughout their pregnancies. It's a model that combines traditional prenatal care with something much like a coffee klatch.
In this group at Unity, all six patients are Hispanic, and all are in the same late stage of pregnancy. They're in a tight, windowless, cinderblock room — a circle of bulging bellies.
There's no idle time spent thumbing through waiting room magazines — these women get down to business as soon as they arrive. As music plays in one corner, they check their own vital signs at a table behind the door.
"It's awesome to see them take their blood pressure and say, this is my blood pressure and it's normal, or my urine dip's a little bit off," says Ana Luisa Ralston, a nurse-midwife at Unity. "It's like, wow, that's pretty cool they know that."
A Circle Of Support
Through the course of the visit, the mothers-to-be take turns on a low metal cot and have their bellies measured by Ralston. She also listens for fetal heartbeats.
After all the vitals are checked, a discussion. The women settle into comfortable chairs, most with hands resting on their belly bump.
This, too, is part of that centering model. Women get advice from nurses and each other on things like nutrition, postpartum depression and breastfeeding.
To help the women understand how to position a newborn at their breast, Ralston talks about how far a newborn can see — 12 inches, she says, about the distance between a mother's breast and her baby's face. "The only thing that matters for that baby when it leaves its mom's belly is seeing its mom," she says. "It's just incredible."
And since the women spend so much time together, they build enough trust to tackle sensitive subjects like domestic violence or family tension — things that doctors can't easily address in a quick office visit.
The goal is to provide a place where women — who often live far away from immediate family — can find support.
"When you don't know about this, or you don't have other pregnant ladies going through the same thing, you freak out, you don't know if what's happening to you is normal [or] what if something's wrong. And then you come here, and everybody's like, oh yes, I'm tired, I can't eat this, I can't smell that," says Ruth Lopez. "And you're like, oh, then I guess it's normal."
When we meet Lopez, she's 34 weeks pregnant. Her black hair hangs straight and long. She, like most of the other women in the program, was referred by a doctor who thought she might benefit from a circle of support.
The centering model offers benefits for health care workers, as well, by maximizing the time they spend with patients. There are more opportunities to eavesdrop, to give advice, and to help women become advocates for themselves and their children.
That last thing will potentially have a lasting impact, says Dr. Andrea Anderson, who's worked as a family physician at Unity for seven years.
"It's important to us to encourage our patients, to help them take ownership over their own bodies, their own pregnancies, be able to plan their pregnancies, be able to have healthy babies, and to really feel like they're a player at the table in their own health care," she says.
The Power Of Peer Pressure
Putting health care in the patients' hands is one of the main goals behind centering. The model was created in 1993 by nurse-midwife Sharon Schindler Rising.
Rising says she got tired of answering the same questions over and over again.
"I just felt women have so much wisdom inside, but not a lot of opportunity to test it out with the health care system," she says. "The big challenge for the provider is to be quiet and not answer questions, because the minute you answer a question, you won't know the group wisdom.
"So what happened to me, as I was listening to women talking in the groups, is I started having a real appreciation for cultural beliefs and values that I just didn't understand, and I would be thinking to myself, 'Well, that's why that strategy never worked.' Because I didn't really understand."
Rising says peer pressure also plays a role in the centering model, by providing support for behavioral changes. "In one of the groups, I heard one woman look at another woman and say, 'I don't know how you can continue to keep smoking, putting that horrible stuff in your body — you know where it goes, and I stopped when I got pregnant, and I'll just tell you that if I can stop, you can stop, and I'm here to help you with that.' "
That's something Rising says she could never say to a patient. "There's a tremendous power in the group," she says, "and that doesn't happen in individual care."
The model might not work for everyone. Some women prefer more privacy than a group setting allows. Private insurers might not cover this kind of care, and not all women can carve out two hours for an office visit.
The program is often offered to low-income women, a "vulnerable population" who Rising says have the most to gain.
The team at Unity says this model has improved birth outcomes for the 98 women who've completed the program over the past two years. They hope it will be available to more pregnant women in the future, and they hope it eventually might also become a model for pediatric visits once children are born.