The Federal Healthy Start program was started in 1991 to address the factors that contribute to the Nation's high infant mortality rate, particularly among populations with disproportionately high rates of adverse perinatal health outcomes. The goals of Healthy Start are to reduce disparities in access to and utilization of health services by using a lifespan approach, improving the local health care system, and increasing consumer and community input into health care decisions. In 2007, Healthy Start served 99 communities in 38 states, the District of Columbia, and Puerto Rico. Most Healthy Start grantees are nonprofit organizations. Since 2005, all 97 Healthy Start grantees (and the 2 additional grantees funded in 2007) have been required to include an interconception care component. Three quarters of grantees enrolled the majority of their interconception clients during the prenatal period. Most grantees used care coordination and case management as the primary approach to improving interconception health care. In 2007, 93 interconception projects reported that 9 out of 10 women had an ongoing source of primary care. Grantees screened to detect health conditions and risks, as well as provided an opportunity to provide vital information to women about their risks for chronic conditions such as obesity, hypertension, and diabetes. The Healthy Start interconception components demonstrate a critical need for and the potential impact of a strong interconception care program for high-risk populations such as women living in poverty, in medically underserved communities, and without health coverage.
In the United States each year, approximately 6 million women become pregnant (
Ventura et al., 2004
). Although most women have a safe pregnancy and deliver a healthy, full-term infant, that is not the experience for all women. Major and persistent racial and ethnic disparities exist in rates of pregnancy-related mortality and morbidity, preterm birth, low birthweight, and infant mortality (Mathews and MacDorman, 2007
). Despite considerable research efforts to understand and prevent these adverse outcomes, the factors that make some pregnancies more vulnerable than others have not been clearly defined. Emerging research indicates that environmental, biological, and behavioral stressors occurring over the life span of the mother from the moment she herself was conceived until she delivers her own child may explain a portion of the disparities (Lu and Halfon, 2003
, Ventura et al., 2004
). Moreover, consistently providing interventions to several generations may be necessary before the factors responsible for the disparities in adverse birth outcomes have been overcome (Misra et al., 2003
).The interconception period (the time between the end of a woman's pregnancy to the beginning of her next pregnancy) is a critical time to modify risk factors—disease processes, health behaviors, and environmental hazards—that are causally associated with infant mortality and other adverse pregnancy outcomes. Clinical care and support services effectively provided to women during the interconception period may reduce risks, address complications from a recent pregnancy, and/or prevent the development of a new health problem (obesity, diabetes, depression, and hypertension;
Lu et al., 2006
). Additionally, interconception care provides an opportunity to reduce or eliminate risks before future pregnancies occur to ensure healthier mothers and infants.The leading causes of infant mortality and long-term disabilities in the United States are preterm birth (birth of an infant before 37 weeks gestation) and low birthweight (weighing <2,500 g at birth). Experiencing a preterm birth in a previous pregnancy is the strongest predictor of subsequent preterm birth. Thus, because women with prior adverse pregnancy outcomes can be readily identified, targeted interventions in the interconception period have the potential to decrease preterm births and reduce infant mortality.
This paper describes the interconception care efforts of grantees of the Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB)’s Federal Healthy Start Infant Mortality Reduction program. The pilot and full implementation experience of grantees is described, as well as the overall approach and methods.
Background on Healthy Start
The Healthy Start program was started in 1991 to address the factors that contribute to the Nation's high infant mortality rate, particularly among African-American and other populations with disproportionately high rates of adverse perinatal health outcomes, such as Native Americans and Puerto Ricans. Healthy Start provides intensive services tailored to the needs of vulnerable mothers and women in geographically, racially, ethnically, and linguistically diverse communities with exceptionally high rates of infant mortality. The goals of the program are to reduce racial and ethnic disparities in access to and utilization of health services through a lifespan approach, improve the quality of the local health care system, and to increase the consumer and community voices and participation in health care decisions.
In 2007, Healthy Start served 99 communities in 38 states, the District of Columbia, and Puerto Rico. Most Healthy Start grantees (44%) are nonprofit organizations with the majority of these being federally qualified health centers, 37% are local health departments, 11% state health departments, and 8% are categorized as “other” (usually universities and tribal organizations (n = 3). Sixty-six percent of all of Healthy Start grantees serve an urban population, whereas 21% serve a rural and 13% a rural/urban mix. Six of the grantees are located within 62 miles of the United States–Mexico border.
Through the implementation of evidence-based practices and innovative, community-driven interventions, Healthy Start works with individual communities to build on their existing, effective resources (outreach, health education, case management, and utilization of prenatal/interconception care) to improve the quality of and access to health care for women and infants at both the service and system levels. At the service level, beginning with direct outreach by community health workers to women at high risk, Healthy Start projects ensure that mothers and infants have ongoing sources of primary and preventive health care and that their basic needs (housing, psychosocial, nutritional and educational support, and job skill building) are addressed. After risk assessments and screening for perinatal depression, domestic violence, and other behavioral risk factors, case managers facilitate women's and infants’ access to appropriate health care and other services. Case managers and other Healthy Start staff also provide health education for risk reduction and prevention. Mothers and infants are linked to a medical home and followed, at a minimum, from entry into prenatal care through 2 years after delivery.
At the systems level, every Healthy Start project has developed a consortium composed of neighborhood residents, perinatal care clients or consumers, medical and social service providers, and other key community leaders, including faith and business community representatives. Together these key stakeholders and change agents address the system barriers in their community, such as fragmentation in service delivery, lack of culturally appropriate health and social services, and barriers to accessing care. Healthy Start projects also have collaborative linkages with state programs including Title V (the Maternal and Child Health block Grant), Medicaid, State Children's Health Insurance Program, and regional perinatal care systems.
Linkages and partnerships with safety net providers, including Community Health Centers and other federally qualified health centers offering primary care, extend Healthy Start service capacity, particularly for uninsured women. These relationships can assist in reducing significant risk factors such as smoking, obesity, or diabetes, while promoting behaviors that can lead to healthy outcomes for women and their families. These positive relationships and effects, which begin during the prenatal period, continue to be monitored for both mother and baby for 2 years postdelivery to ensure that they remain linked to ongoing sources of primary care.
The women served by Healthy Start represent the diversity of the United States: racially, 60% of the women are Black; 25% are White; 4% American Indian; 1% Native Hawaiian or Other Pacific Islanders; and the remaining 9% multiracial. Ethnically, 21% of the women participating in Healthy Start identified themselves as Hispanic. A majority are poor or near poor (Table 1.) The Healthy Start population reflects women of reproductive age: On average, 36% are women aged 24–34, 28% are between 20 and 23 years, and 27% are teens (14% are aged 18–19 and 13% are <17 years of age; MCHB, 2006).
Table 1Distribution of Women in Healthy Start, By Race/ethnicity and Income, 2006
| Race/ethnicity | Poor (<100 FPL) | Near Poor (100%–185% FPL) | Total Served |
|---|---|---|---|
| All racial/ethnic groups | 54% | 31% | |
| By race | |||
| White | 53% | 31% | 25% |
| Black | 58% | 27% | 60% |
| American Indian | 38% | 12% | 4% |
| Native Hawaiian/Pacific Islander | 36% | 38% | 1% |
| By Hispanic origin | |||
| Hispanic | 18% | 80% | 21% |
Because of the diverse social and medical needs and risks for adverse perinatal outcomes among the clients served by the Healthy Start projects, grantees employ a multidisciplinary staff. For example, in staffing case management, 71% of the grantees employ indigenous community workers, 66% social workers, 60% nurses, and 14% public health professionals (
Health Resources and Services Administration (HRSA), 2006
). The staffing for the projects reflects the cultural diversity of Healthy Start clients. All projects are required to ensure a culturally competent program and staff. Annually Healthy Start grantees report on a series of performance measures, one of which addresses the degree to which the projects are culturally competent. In 2006, 79% of the grantees report employing a culturally diverse and linguistically appropriate staff, with an additional 27% of the grantees reporting “almost meeting” this element. Seventy-six percent of the grantees indicated that they ensured the provision of training in the area of cultural and linguistic competence. This included both orientation and ongoing professional development for staff, volunteers, contractors, and subcontractors involved in service delivery. An additional 23% reported that they “almost met” this requirement for those involved in service delivery (Maternal and Child Health Bureau MCHB, 2006
).Evolution of Healthy Start's Interconception Care Component
In recognition of the growing evidence in support of interconception care, the HRSA's MCHB has advanced interconception care as a core strategy of the Healthy Start program. In this context, interconception refers to the time from the end of 1 pregnancy to either the next pregnancy or 24 months postpartum, whichever comes first (
Health Resources and Services Administration (HRSA), 2001
).The additional elements of high-risk interconception care over and above the customary services provided by Healthy Start grants included 1) outreach for early identification of high-risk women and high-risk infants during hospitalization; 2) linkage to primary care and specialty care for high-risk women of reproductive age; 3) linkage to Maternal and Child Health Services Block Grant (Title V), Medicaid, and other early intervention services for high-risk infants; and 4) case management and health education focusing on both appropriate and ongoing interventions for the woman's existing chronic conditions as well as risk reduction activities including smoking cessation.
During project years 2001–2005, HRSA's MCHB challenged 35 Healthy Start grantees to design and enhance their interconception care components. These 35 grantees were to pilot and identify the essential elements of implementing interconception care in Healthy Start. Most of these projects were asked to undertake this challenge without additional funding. The methods of the original 35 interconception care Healthy Start grantees varied in approach, intervention scope, community engagement, and intensity. Together, however, their strategies and results provide important, new information for future planning and delivery of interconception care to improve the health of high-risk women, their infants, and their families. Healthy Start is a gap-filling, community-based model. Yet, Johnson in her review of these 35 grantees found that few of the 35 original sites focused their interconception care efforts on community-wide barriers or used an ecological model (i.e., focusing simultaneously on individual client, community, and larger systems) that many used in their prenatal care efforts (
Health Resources and Services Administration (HRSA), 2007
). Between 2001 and 2005, several of these projects developed unique case management protocols, tailoring the level of service and staffing based on the risk status of the woman and her infant. All focused specific attention on postpartum clinic visits, family planning visits, and well-woman visits in the postpartum period; some of the sites delivered this service via case management while others directly provided the services through their parent organization, usually a Community Health Center or local health department (Health Resources and Services Administration (HRSA), 2007
).Interim reports from the original 35 interconception Healthy Start grantees indicated a need to involve other grantees. Beginning in 2005, HRSA–MCHB required that all 97 Healthy Start grantees (and the 2 additional grantees funded in 2007) include an interconception care component.
While some Healthy Start programs have special grants to enable them to serve women who are considered at “high risk” during the interconception period, all Healthy Start programs must demonstrate that the program's core and high risk interconception activities include the following:
- •Knowledge, throughout the community, of what interconception care is, and what the related health outcomes are;
- •An understanding of the gaps that exist in providing interconception care services;
- •A record of completed referrals for both interconception and specialty health care services for those women who are identified as needing these services. (Health Resources and Services Administration (HRSA), 2005)
Interventions and Impact
Enrollment
One challenge reported by Healthy Start grantees that added an interconception care component to their existing strong prenatal services was identifing the best strategies to engage women beyond the end of pregnancies. In some cases, this was a continuation of services to those served prenatally and in other instances new clients were identified during the interconception period. Findings from a survey of all Healthy Start Project Directors conducted as part of a National Evaluation of the program found that three quarters of grantees (74%) enrolled the majority of their interconception clients during the prenatal period, with the remainder enrolling additional clients after delivery (
Health Resources and Services Administration (HRSA), 2006
). The survey also found that through case management, interconception clients receive counseling and education on the importance of interconception care (98% of the grantees), family planning (97%), and the risk of short birth intervals (97%; Health Resources and Services Administration (HRSA), 2006
).Case management and care coordination
Most grantees used care coordination and case management as the primary approach to improving interconception health and health care. Case management has a variety of definitions in the field. For these Healthy Start grantees, case management generally has a core common definition, with some variations. For interconception care components, it typically includes the following:
- 1.a risk assessment;
- 2.a care/services plan corresponding to identified risks, with regular updates over the 12- to 24-month interconception care service period;
- 3.referrals and follow-up assistance in linking to other services (e.g., appointments with medical providers, support for completing Medicaid applications, help in finding child care or transportation to medical appointments);
- 4.health promotion, education, anticipatory guidance, and counseling;
- 5.behavioral screening (e.g., depression screening); and
- 6.monitoring milestones for mother and baby (e.g., completion of the 4- to 6-week postpartum visit, selection and use of a family planning method, immunizations).
Care coordination and case management is generally delivered through individual home visits, although some grantees relied on group care methods.
Notably, Healthy Start grantees have devised approaches to tiered levels of care coordination and case management. They are using a variety of neighborhood/community-based lay health workers and professionals (nurses, social workers, etc.) to identify, engage, and support low-income, high-risk women. These tiered approaches—often based on levels of client need or intensity of the service protocol—are promising practices that should be discussed and considered by other community and state perinatal care coordination/case management projects.
Services, referrals, and linkages
An important indicator of the effectiveness of care coordination is a completed referral for specialty services for the mother and/or infant. Grantees annually report on this performance measure. Whereas 44% of the grantees reported that more than three quarters of all referrals for pregnant women were completed in 2006, only 32% reported that their postpartum clients had a completed referral in the interconception period (
Health Resources and Services Administration (HRSA), 2006
). This finding of a lower completed referral rate for interconception clients may reflect the challenges in delivering services to this population. Insights from the 35 original interconception grantees may explain this. Virtually all 35 of the original interconception grantees documented systemic barriers to interconception care for the families they serve. The most commonly cited barrier was the loss of Medicaid coverage 60 days postpartum, resulting in higher rates of low-income women becoming uninsured soon after pregnancy. Linking low-income women with an ongoing source of primary care is a major challenge. Although local health departments, publicly available family planning clinics, and similar clinics can provide some screening, these grantees found they generally did not have the capacity to provide ongoing primary care. Clinical capacity to serve uninsured women with postpartum depression or other mental health problems was found to be even more limited (Health Resources and Services Administration (HRSA), 2007
). Rural grantees have had the most difficulty in accessing medical care for interconception women with chronic health conditions (Health Resources and Services Administration (HRSA), 2006
). Healthy Start projects have focused more intensely on the provision of interconception services since 2005 and some improvements have been reported. In 2007, the 6 border projects reported that 96% of women participating in their Healthy Start interconception services have an ongoing source of primary and preventive care services for women; the remaining 93 projects report that 89% of the women served have an ongoing source of primary care (Maternal and Child Health Bureau MCHB, 2006
).Identifying and addressing medical conditions and behavioral risks
Although the interconception period provides an opportunity to address chronic medical conditions, it also provides an opportunity to provide vital information to women about their risks for chronic conditions such as obesity, hypertension, and diabetes. The experiences of all 99 Healthy Start projects support this. Consistent with national recommendations, Healthy Start projects screen high-risk, low-income women during the interconception period for risks and acute and chronic health conditions. If the woman screens positive for a specific health condition and is not currently being treated, she is referred to a primary care provider for intervention services. In 2006, projects found that 14.7% of the women screened during the interconception period were in need of treatment for asthma. This compares with estimates of the incidence of asthma from the National Health Interview Survey of 5.6 per 1,000 for women (
Rudd and Moorman, 2007
). Nationally the 12-month incidence rate for diabetes was 7.5 per 1,000 women; in the Healthy Start population the rate for diabetes was 15.6%. Additionally, Healthy Start projects reported in 2006 that, among women served through Healthy Start interconception services (Maternal and Child Health Bureau MCHB, 2006
):- •15% were in need of education and intervention to promote improved health through increased physical activity;
- •13.3% were underweight and 16.8% were obese;
- •15.4% had elevated cholesterol for which they were not receiving treatment;
- •14.8% had untreated hypertension;
- •15.6% had untreated diabetes;
- •13.3% had undiagnosed or untreated breast cancer;
- •14.4% screened positive for fecal occult blood;
- •16.8% screened positive for Group B Strep or bacterial vaginosis;
- •17.1% screened positive for other sexually transmitted infections;
- •12% screened positive for HIV; and
- •19.8% screened positive for periodontal infection.
In the behavioral risk area, the projects found the following previously unrecognized conditions: 15.4% of the women had problems with alcohol use; 16% were experiencing domestic violence; 12.4% were homeless; 18.6% used illicit drugs; and 20.7% used tobacco. In addition, 26.3% of the women were diagnosed with depression and required medical treatment and 19.9% were diagnosed with ≥1 other mental health disorders that required care (
Maternal and Child Health Bureau MCHB, 2006
).Community system change
In addition to the screening services provided to high-risk women, Healthy Start communities also focus on reducing barriers to ongoing access to quality care through targeted, local systems-building activities. One of the key performance measures that Healthy Start projects annually report on is their local activities to improve the capacity of health providers to screen Healthy Start participants for risk factors. Projects utilize several strategies including incentives; memorandums of understanding that create linkages with primary and specialty care; policy improvements; and provider training on effective and emerging screening tools. In 2006, 57 (58%) of Healthy Start projects reported that they were meeting their performance objectives in this area (
Maternal and Child Health Bureau MCHB, 2006
).Conclusions
For community-based projects serving the highest risk women in medically underserved communities, there are important lessons to be learned from the experience of Healthy Start in providing interconception care and support. Chief among these is the value of case management and care coordination for linking women and their infants to services. Similarly, the experience in using multidisciplinary and multilevel teams provides valuable examples of how to both maximize resources and tailor services to individual client needs. Another lesson is that a focus on postpartum visits and family planning could be effective in improving utilization rates, and in lengthening pregnancy intervals. A third lesson is that women have health risks and conditions that stretch far beyond reproductive health and screening. Detecting and treating underlying disease and health conditions is essential in interconception care projects seeking to improve health and pregnancy outcomes for low-income, high-risk women. Healthy Start grantees have developed valuable tools for training and implementation of interconception care projects; however, this must be determined through further testing and validation. Other programs also may learn from the experiences of Healthy Start in selection of performance measures and realistic objectives, a critical component of community projects. Finally, projects should be aligned with Community Health Centers and other publicly available primary care clinics, because many low-income women lose Medicaid coverage at 60 days postpartum.
As documented elsewhere in the work of the Grady Interconception Care Project in Atlanta, Georgia, and the Magnolia Project in Jacksonville, Florida (
Biermann et al., 2006
), the Healthy Start interconception components demonstrate a critical need for and the potential impact of a strong interconception care program for high-risk populations such as women living in poverty, in medically underserved communities, and without health coverage. Many such women have had prior adverse pregnancy outcomes and have medical conditions or risks that will affect any future pregnancies, as well as the woman's own health. Healthy Start grantees have explored approaches for identification of risk factors common in the community they serve, community-based outreach to women of reproductive age, tailored case management, and system-building activities. It is the synergy of these elements together that has led to improvements in both the health of high-risk women and their families within Healthy Start communities.References
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Biography
Maribeth Badura is Director, Division of Healthy Start and Perinatal Services, with program responsibility for the Maternal and Child Health Bureau's Women's and Perinatal Health Programs along with the Healthy Start Initiative. She is also a co-Chair of CDC/HRSA/March of Dimes Preconception Care Initiative. Maribeth holds a BS in Nursing from St. Xavier University and an MS in Nursing from Loyola University of Chicago.
Kay Johnson serves as the Senior Advisor to the CDC Preconception Health Program. She is a Research Associate Professor of Pediatrics at Dartmouth Medical School and president of Johnson Group Consulting, Inc. She has been a health services researcher, policy advisor, and advocate on maternal and child health issues for the past 25 years.
CAPT Karen Hench is the Deputy Director, Division of Healthy Start and Perinatal Services (DHSPS) for the Maternal and Child Health Bureau, HRSA. She co-chairs the HRSA Bright Futures for Women's Health and Wellness Perinatal Subcommittee. She also serves on the Public Health Committee of the HRSA/CDC/March of Dimes Preconception Care Initiative. She holds a BS degree in nursing from Indiana University of Pennsylvania, an MS degree in healthcare administration and clinical pediatrics from the University of Maryland and is currently a doctoral candidate at the Johns Hopkins University, Bloomberg School of Public Health.
CDR Madelyn Reyes received her Masters of Public Administration from Troy State University and her BSN from the College of Mount Saint Vincent. She is currently a Senior Nurse Consultant in the Health Resources and Services Administration (HRSA) in the Maternal and Child Health Bureau (MCHB) where she provides oversight and management for 14 multifaceted community-based Healthy Start programs. She is also the Project Officer for the National Fetal Infant Mortality Review Program. She also serves as the MCHB staff member to the Secretary's Advisory Committee on Infant Mortality (SACIM).
Article info
Publication history
Accepted:
July 25,
2008
Received:
July 8,
2008
Footnotes
This paper was prepared by Federal agency staff responsible for the Healthy Start program with substantive and editorial input from Kay Johnson. Note: The opinions expressed in this paper are the authors' and do not necessarily reflect the views of the institutions with which the authors are affiliated. No financial interests to disclose.
Identification
Copyright
© 2008 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
