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Service Delivery Innovation Profile

Urban Healthy Start Program Offers Support at Each Stage of Childbearing Cycle, Leading to Fewer Low- and Very Low–Birthweight Babies


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Snapshot

Summary

Baltimore Healthy Start, a nonprofit community-based organization, works to reduce infant mortality among the largely African-American population it serves by offering a comprehensive series of programs and services for women and their families. Offerings employ a "life-course" approach that covers each stage of the childbearing cycle: pregnancy, the post partum period, early childhood, and between pregnancies (with an emphasis on family planning during this stage). Staff from the local community (known as "neighborhood health advocates") play a major role in the program by reaching out to and enrolling at-risk residents, assessing their needs, offering relevant education, and connecting enrollees and their families with needed medical and social services. The program has enhanced access to pre- and postnatal services, generated high levels of satisfaction among clients, produced a lower infant mortality rate, and reduced the proportion of women delivering low- and very low–birthweight babies. This reduction, in turn, has led to significant cost savings.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of comparisons of the prevalence of infant mortality and low- and very low–birthweight babies among those served by the program to citywide averages for all women and for African-American women. Additional evidence consists of post-implementation data on the number of women served by the program and client satisfaction with these services, along with an estimate of the cost savings generated for each case in which a very low–birthweight baby is avoided.
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Developing Organizations

Baltimore Healthy Start, Inc.
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Date First Implemented

1991
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Patient Population

Roughly 90 percent of Baltimore Healthy Start clients are African American. One-third live at or below the Federal poverty line, just under two-thirds did not graduate from high school, roughly three-quarters read at or below a fifth-grade level, and many experience frequent episodes of homelessness. The communities in which they live tend to have high crime and juvenile arrest rates, low literacy levels, high unemployment (above 20 percent), high rates of poverty (with a median income of $22,277), and many vacant or run-down residences.Race and Ethnicity > Black or african american; Gender > Female; Vulnerable Populations > Racial minorities; Urban populations; Womenend pp

Problem Addressed

Pregnant African-American women face an above-average risk of their baby dying at birth or being born at a low or very low birth weight. Prenatal care, postnatal care, and family planning services can help reduce this risk, but many African-American women lack access to this type of support.
  • High infant mortality rate: In 2009, the infant mortality rate among African Americans was 12.4 deaths per 1,000 live births, much higher than for whites (5.33) and the general population (6.39).1 In Baltimore, this disparity was even larger, with the infant mortality rate among African Americans being more than 5 times that for whites (18.5 vs. 3.5 deaths per 1,000 live births).2
  • Greater risk of low birth weight: Infants with low birth weight (less than 2,500 grams) or very low birth weight (less than 1,500 grams) face a greater risk of early death and long-term health and developmental issues than infants born later in pregnancy or at higher birth weights. In 2011, the rate of low-birthweight babies among African Americans was 13.3 per 1,000 live births, well above that for whites (7.1) and the general population (8.1).3 A similar disparity exists in Baltimore, where in 2011 African-American women faced an above-average risk of delivering a low-birthweight baby (14 per 1,000 live births vs. 11.6 for the city's general population) or a very low–birthweight baby (3.7 vs. 2.6).4
  • Unrealized potential of pre- and postnatal care and family planning: Numerous studies have shown that family planning and pre- and postnatal care are associated with better pregnancy outcomes, particularly reduced risk of preterm delivery, low birth weight, and small-for-gestational-age infants.5 However, many African-American women lack access to these services. For example, African-American women are significantly less likely to use contraceptives,6 and more than twice as likely as white women to receive either late or no prenatal care.7

What They Did

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Description of the Innovative Activity

Baltimore Healthy Start works to reduce infant mortality among the largely African-American population it serves by offering a comprehensive series of programs and services for women and their families. Program offerings employ a "life-course" approach that covers each stage of the childbearing cycle: pregnancy, the post partum period, early childhood, and between pregnancies. Trained staff from the local community play a major role in the program by reaching out to and enrolling at-risk residents, assessing their needs, offering relevant education, and connecting enrollees and their families with needed medical and social services. A detailed description follows:

  • Proactive outreach and enrollment by trained staff from local community: The program is offered in several areas of the city: the Sandtown-Winchester and Greater Rosemont communities in West Baltimore and a portion of East Baltimore (under its Health Resources and Services Administration [HRSA] Healthy Start Funding) and four additional areas (funded for Healthy Families America by the State of Maryland and the city of Baltimore). Trained staff from these communities [known as "neighborhood health advocates" (NHAs)] identify eligible individuals, which include pregnant or post partum women with babies 6 months old or younger who live in one of the targeted communities. Four NHAs who specialize in recruitment identify potential enrollees by knocking on the doors of residences and through word of mouth. Whenever a potential client is identified, the NHAs describe program services and enroll those who express interest.
  • Detailed interview and assessment, assignment to NHA: Women who enroll come to one of Baltimore Healthy Start's three full-service community centers for a detailed interview. Based on this assessment, the case manager assigns the women to a team of at least three NHAs who will work with her throughout the program. When making home visits, NHAs typically work in pairs, both as a safety precaution and so they can provide more comprehensive services.
  • Initial home visit, determination of needed services: Within 1 week, the assigned NHAs visit the client at home to conduct an orientation and sign her up for specific activities and services that can help.
  • Comprehensive, ongoing services following life-course approach: Enrollees have access to a comprehensive suite of programs and services throughout each stage of the childbearing cycle. Assigned NHAs visit enrollees in their homes on a regular basis during each of these stages. During each visit, they follow a prescribed protocol, document that they have covered a list of potential client concerns and issues, and help provide education and support to address these issues and concerns, including connecting women to any needed medical and social services. Details on the programs and services offered at each stage appear below:
    • Prenatal care: NHAs typically visit the client twice a month during the pregnancy to provide basic prenatal care and identify and address potential complications. During the typical visit, the NHAs check the mother's weight, blood pressure, glucose level, and mental health; monitor the fetal heartbeat; discuss maternal health issues likely to lead to successful pregnancy (e.g., diet, sleep, exercise, prenatal vitamins); and test for sexually transmitted diseases (STDs). As necessary, they arrange appointments with the client's obstetrician/gynecologist (OB/GYN) and provide transportation to these appointments. For clients without their own OB/GYN, the NHAs can schedule an appointment with a Baltimore Healthy Start OB/GYN, who is also available for emergency care. Shortly after delivery, a certified registered nurse practitioner makes a home visit to check on the mother's health, discuss the delivery, and schedule the mother's first post partum visit with her OB/GYN. In addition to these at-home visits, clients may also enroll in any of several programs offered at one of the sites, as outlined below:
      • The Families into Nutrition and Exercise (FINE) Club: This group helps overweight women focus on weight loss through fitness by engaging in exercise classes, weekly weigh-ins, and counseling and education on healthy eating and meal planning, including sessions on reading labels, creating diet-friendly meals, and using a diary to track food intake.
      • Belly Buddies®: In this program, 8 to 10 pregnant women with similar delivery dates meet on a weekly basis for 10 weeks. Designed to be educational and reduce stress levels, these sessions provide an opportunity for women in the same stage of pregnancy to discuss their pregnancies and parenting concerns; participate in stress-reducing activities such as yoga, knitting, and massage therapy; and attend classes on parenting, nutrition, and childbirth.
      • La Vida Nueva CenteringPregnancy™ group prenatal program: To better meet the needs of a growing population that often accesses prenatal care late in pregnancy, a staff member provides family-oriented prenatal care in a group setting to Latina women.
    • Post partum: After a client gives birth, NHAs continue to meet with the mother twice a month for the first year of the child's life. After the baby's first birthday, these visits continue on a monthly basis for 6 months and then on a quarterly basis until the child turns 2. During these sessions, they identify and address any problems that may arise. For example, NHAs know how to recognize the signs of post partum depression and connect parents to mental health services if necessary. During this phase, parents may also access the following additional programs and services:
      • Breastfeeding assistance: Mothers who are having difficulty with breastfeeding may enroll in a program in which they meet with a lactation consultant and other mothers experiencing similar problems.
      • Support for parents facing special challenges: A staff member with expertise in helping parents who face especially difficult challenges provides voluntary home visits through a national program known as Healthy Families America. For example, she visits homes in which the parent is a substance abuser or the victim of sexual or domestic abuse. These visits continue beyond the post partum period as needed.
    • Early childhood: During the first 2 years of the child's life, clients may participate in the Early Child Development Program, in which certified childcare staff provide a range of programs at Baltimore Healthy Start centers for parents and their children. Parents participate with their children in activities such as storytelling, arts and crafts, exercise, and educational games, and also learn to do these types of activities at home. Parents can also leave their babies with staff while they attend onsite parenting classes or other activities.
    • Between pregnancies: The Baltimore Healthy Start OB/GYN and certified nurse practitioner offer several services to help parents avoid unintended pregnancies and extend the time between pregnancies, including family planning education, dispensing of birth control, physical examinations, and testing and treatment for STDs. Services are offered in clients' homes as well as in Healthy Start community centers.
  • Additional services through community partnerships: The program offers additional social services not directly related to the childbearing process that can help mothers and their families thrive. Many of these services are offered through longstanding partnerships with community-based organizations, as outlined below:
    • Food and clothing: Shortly after enrolling, clients meet with a Baltimore Healthy Start entitlement specialist who can arrange for the mother to receive additional food and clothing if needed, including signing up for the Women, Infants, and Children program. In addition, at each Baltimore Healthy Start Center mothers have access to a food and clothing pantry stocked with donations from community groups.
    • Housing assistance: NHAs connect clients with the Baltimore City Housing Authority, Mercy Supportive Housing, and other agencies that can help them find affordable housing or avoid eviction. In addition, pregnant clients involved in the criminal justice system who are eligible may live temporarily at a site run by a community-based organization (the Chrysalis House) as an alternative to incarceration. While there, residents receive medical and substance abuse counseling and attend classes on parenting, life skills, and job training.
    • Education and job training: Parents can also be connected to various education and job training programs offered in the community, including General Equivalency Diploma, literacy, computer, and employment readiness classes.

Context of the Innovation

Baltimore Healthy Start is a nonprofit corporation established by the Baltimore City Health Department in 1991 as one of the original 15 Federal Healthy Start sites. Serving a predominantly low-income, minority population, the organization seeks to prevent infant mortality by providing services and programs that help mothers deliver full-term, healthy weight babies. Before becoming a Healthy Start site, the organization existed for 3 years under the name Baltimore Project and had a similar focus.

The impetus for the life-course approach to services began in the late 1990s when organizational leaders recognized that high-quality prenatal care alone was not enough to support at-risk mothers. By providing additional support throughout the childbearing cycle (i.e., the first few years of the child's life and the time between pregnancies), these leaders felt they could better help mothers deliver healthy babies and improve their families' overall quality of life.

Did It Work?

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Results

The program has enhanced access to pre- and postnatal services, generated high levels of satisfaction among clients, produced a lower rate of infant mortality, and reduced the proportion of women delivering low- and very low–birthweight babies. This reduction, in turn, has led to significant cost savings.
  • Enhanced access to services: In 2012, Baltimore Healthy Start served 1,615 clients, and its staff made more than 9,400 home visits. These clients delivered nearly 500 babies, representing approximately 5 percent of the city's total births that year. Since its inception, the program has served more than 15,000 women. In the absence of this program, many of these women likely would not have had access to these services.
  • High satisfaction: In 2012, 95 percent of clients reported being satisfied or very satisfied with the programs and services. They also expressed high levels of satisfaction with specific aspects of the program, such as having a good relationship with their assigned NHAs (which rated 4.77 on a 5-point scale measuring level of agreement) and offering good service during pregnancy (4.67). Most clients also agreed that they would refer another pregnant woman to the program (4.77).
  • Lower incidence of infant mortality: From 2008 to 2012, the infant mortality rate among Baltimore Healthy Start clients was 3.0 per 1,000 live births, compared to a rate of 9.7 among all babies delivered in Baltimore during that time span and a rate of 12.6 for African Americans in the city in 2012.
  • Fewer low-birthweight babies: In 2011, 2.0 percent of babies delivered by Baltimore Healthy Start clients had a very low birth weight (less than 1,500 grams), compared to 2.6 percent of all babies delivered in Baltimore and 3.7 percent of African-American babies delivered in Baltimore. In addition, 12.9 percent of babies delivered by clients had a low birth weight (less than 2,500 grams), compared to 14.0 percent of African-American babies in Baltimore.
  • Associated cost savings: The decline in low- and very low–birthweight babies has resulted in significant cost savings. Although precise figures on the overall cost savings resulting from the program are not available, Medicaid typically pays $100,000 to cover care during the first year of life for a very low–birthweight baby in Baltimore (due primarily to the need for expensive neonatal intensive care and frequent hospital readmissions).

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of comparisons of the prevalence of infant mortality and low- and very low–birthweight babies among those served by the program to citywide averages for all women and for African-American women. Additional evidence consists of post-implementation data on the number of women served by the program and client satisfaction with these services, along with an estimate of the cost savings generated for each case in which a very low–birthweight baby is avoided.

How They Did It

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Planning and Development Process

The program has evolved and expanded over time, and continues to do so on an ongoing basis. Key developments in recent years related to the life-course approach include the following:
  • NHA training: Before beginning work, NHAs complete an intensive training and orientation period that includes an 80-hour course at a local community college. This course covers health issues (e.g., pregnancy, child development, contraception) and practical topics related to the job, such as how to conduct home visits and identify and address clients' problems.
  • Incremental increase in staff, services: Program staffing and services have grown over time. In 2003, Baltimore Healthy Start hired a certified registered nurse practitioner to conduct in-home family planning education. That same year, the organization secured Title X grant funding that allowed the nurse practitioner to conduct well-woman visits and offer access to birth control. In 2000, the organization launched the Growing Great Kids curriculum to support the Early Childhood Development program. In 2006, it hired an OB/GYN to enhance its ability to provide high-quality prenatal care, and in 2009, it implemented the Belly Buddies program.
  • Expansion of coverage area: Following a year-long community needs assessment, the organization received additional Federal Title V funding in 2008 that allowed the program to serve a significantly larger geographical area.
  • Ongoing review and evaluation of services: A quality committee made up of senior-level managers meets regularly to evaluate existing services and identify new programs and staff that can help the organization better achieve its goals. This committee also focuses on identifying funding sources to support this expansion, and on collecting accurate data to measure the effectiveness of specific program components.

Resources Used and Skills Needed

  • Staffing: Baltimore Healthy Start has 55 employees, including 27 NHAs, 4 case managers, 4 early childhood development staff, an OB/GYN, a certified registered nurse practitioner, a social worker, an entitlement specialist, a medical records specialist, a computer programmer, a program evaluator, and a number of executive and administrative staff. NHAs generally come from the local community, with many having been former clients. NHAs must have a high school degree, and some have completed additional college coursework to become certified nursing assistants. Each NHA reports to one of the four case managers.
  • Costs: Baltimore Healthy Start's total annual budget is approximately $3.7 million, with approximately $1.9 million devoted specifically to programs and services. Program services cost an average of $5,700 per family served.
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Funding Sources

Health Resources and Services Administration, Maternal and Child Health Bureau
Approximately 73 percent of funding comes from the Federal government (primarily HRSA). Other sources include the city of Baltimore and other local agencies (13 percent), the State of Maryland (10 percent), foundations (2 percent), and private donors (2 percent).end fs

Adoption Considerations

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Getting Started with This Innovation

  • Partner with community organizations: Partnerships with community groups can play a key role in helping an organization expand its breadth of programs and services. Over the years, Baltimore Healthy Start has developed partnerships with dozens of local organizations, many of which contribute to the life-course programs. For example, the Jewish Women's Giving Foundation worked with Baltimore Healthy Start to implement the Belly Buddies program.
  • Hire committed staff: Working with a population that faces numerous health, social, and economic challenges can be extremely demanding and stressful. To be effective over the long term, staff must be motivated by a genuine love and compassion for their clients.

Sustaining This Innovation

  • Emphasize ongoing assessment and evaluation: Because this type of program has many individual components, leaders need to take an evidence-based approach to evaluating each one. Consequently, before implementing any new component, leaders should assess whether there is evidence that the approach has worked elsewhere. If the decision is made to proceed, leaders must decide what data will be used to measure its effectiveness, and make sure that systems exist to collect this information. After implementation, leaders should examine on an ongoing basis whether the component is producing the desired results. This type of systematic, rigorous approach helps ensure that all ongoing program components play an effective role in helping the organization achieve its overall goal (in this case, the delivery of healthy babies). It also helps in securing funding to sustain those initiatives that work.
  • Provide opportunities for employee growth: To maintain employee morale and high-quality service delivery, provide employees with opportunities to learn new skills and take on new responsibilities. For example, NHAs frequently attend training sessions to learn new skills (such as phlebotomy, lead screening, and partner violence assessment), and successful NHAs can be promoted to case manager.

More Information

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Contact the Innovator

Alma Roberts, MPH, FACHE
President and CEO
Baltimore Healthy Start
2521 N. Charles Street
Baltimore, MD 21218
(410) 396-7318
E-mail: alma.roberts@baltimorecity.gov

Innovator Disclosures

Alma Roberts reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.

Footnotes

1 Centers for Disease Control and Prevention. QuickStats: infant mortality rates, by race and Hispanic ethnicity of mother—United States, 2000, 2005, and 2009. MMWR Morb Mortal Wkly Rep. 2013:62(05);90. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6205a6.htm.
2 Maryland Vital Statistics Administration. Maryland Vital Statistics Annual Report. 2009. Available at: http://dhmh.maryland.gov/vsa/Documents/09annual.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
3 Childstats.gov. America's children: key national indicators of well-being, 2013. Preterm birth and low birthweight. Available at: http://www.childstats.gov/americaschildren/health1.asp.
4 Maryland Vital Statistics Administration. Maryland Vital Statistics Annual Report. 2011. Available at: http://dhmh.maryland.gov/vsa/Documents/11annual.pdf.
5 Krueger PM, Scholl TO. Adequacy of prenatal care and pregnancy outcome. J Am Osteopath Assoc. 2000;100(8):485-92. [PubMed]
6 Jones J, Mosher WD, Daniels K. Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995. Natl Health Stat Report. 2012, No. 60. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr060.pdf.
7 Child Trends Data Bank. Late or no prenatal care: indicators on children and youth. Updated 2012 Nov. Available at: http://www.childtrends.org/wp-content/uploads/2012/11/25_Prenatal_Care.pdf.
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Original publication: March 26, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.