Healthy babies begin with healthy, supported parents. Pregnancy is a period of change; in addition to profound physical changes for the expectant parent, giving birth to a healthy baby often requires the transformation of families’ homes, relationships, and schedules throughout pregnancy. Dealing with these changes can be difficult, and all families benefit from additional help navigating the transition.
Currently, prenatal care is the most routine source of care, pregnancy education, and support for expectant parents in the United States. However, barriers to this care remain, especially for younger people, people of color, people with low incomes, linguistic minorities, and other marginalized groups. Moreover, prenatal care often focuses on the medical aspects of pregnancy, including prenatal screening and management of chronic conditions such as diabetes, to the detriment of other nonmedical aspects—for example, mental health and obstacles to seeking care. Yet nonmedical facets are critical to pregnant peoples’ overall health and, by extension, the health of their infants.
This issue brief highlights three different programs that provide prenatal care and/or support, exploring what happens when this care is reimagined as a broader, holistic system of supports throughout pregnancy in order to improve birth outcomes and ensure optimal health for parents and infants. The approaches of each of these programs have been shown to improve infant health outcomes, particularly among communities at higher risk for poor maternal and infant health outcomes.
Author’s note: CAP uses “Black” and “African American” interchangeably throughout many of our products. We chose to capitalize “Black” in order to reflect that we are discussing a group of people and to be consistent with the capitalization of “African American.”
In the United States, experts recommend 13 to 14 prenatal visits with an obstetrician or a midwife, starting between weeks eight and 10 of pregnancy.1 This allows for early detection and treatment of certain medical conditions that can harm a pregnant person or an infant—such as infection, gestational diabetes, and preeclampsia—while also providing opportunities to address parents’ questions or concerns.
Prenatal care is critical in ensuring healthy outcomes for all. Compared with infants born to mothers who received prenatal care, infants whose mothers did not receive prenatal care are three times more likely to have a low birth weight—defined by the World Health Organization as a weight of less than 5.5 pounds—and are five times more likely to die in infancy. Low weight and preterm birth in infants contribute to additional complications, including an increased risk of sudden infant death syndrome (SIDS), respiratory and gastrointestinal problems, and other long-term health complications. Women who do not receive prenatal care are also three to four times more likely to die from pregnancy-related complications than those who do receive care.2
Despite the importance of prenatal care for maternal and infant health, not all people receive adequate or timely care. In 2016, nearly 1 in 4 women—24 percent—started care late or received fewer than the medically recommended number of visits. Health insurance plays a critical role in accessing prenatal care, and people living in states that refused the Affordable Care Act’s Medicaid expansion are more likely to remain uninsured and therefore struggle to access prenatal care. The share of women receiving inadequate care is higher for women under age 20 (37 percent), women with less than a high school degree (37 percent), and women of color—including Hispanic women (29 percent), Black women (34 percent), American Indian or Alaska Native women (41 percent), and Native Hawaiian or other Pacific Islander women (50 percent).3 Barriers to care have both structural and individual dimensions. Structural dimensions include high service costs, poor transportation options to and from care settings, long wait times, a lack of child care for other children, and unwelcoming provider attitudes. Individual dimensions include fear or distrust of medical providers and procedures, lack of health insurance, lack of social support, and mental health conditions—such as depression—that make seeking care difficult. All of these barriers overlap and intersect. Structural barriers to care can best be addressed through changes to clinic or program policies, provider training, and care format, whereas community outreach, support, and education can most effectively address individual barriers.4
- 1. Expectant parents experiencing pregnancy complications may receive more frequent visits. See Mamie J. Meylor de Mooji and others, “OB Nest: Reimagining Low-Risk Prenatal Care,” Mayo Clinic Proceedings 93 (4) (2018): 458–466, available at https://www.mayoclinicproceedings.org/article/S0025-6196(18)30075-2/pdf; American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, “Guidelines for Perinatal Care: Seventh Edition” (Elk Grove Village, IL, and Washington: 2012), available at https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/medicaid/pdfs/ACOG-Guidelines-for-Perinatal-Care.pdf.
- 2. Association of Maternal & Child Health Programs, “Opportunities to Optimize Access to Prenatal Care through Health Transformation” (Washington: 2016), available at http://www.amchp.org/Policy-Advocacy/health-reform/resources/Documents/Pregnancy%20Issue%20Brief_Final%202016.pdf.
- 3. Osterman and Martin, “Timing and Adequacy of Prenatal Care in the United States.”
- 4. For further discussion of these barriers, see Jamila Taylor and others, “Eliminating Racial Disparities in Maternal and Infant Mortality: A Comprehensive Policy Blueprint” (Washington: Center for American Progress, 2019), available at https://www.americanprogress.org/issues/women/reports/2019/05/02/469186/eliminating-racial-disparities-maternal-infant-mortality/; Julia C. Phillippi, “Women’s perceptions of access to prenatal care in the United States: a literature review,” Journal of Midwifery & Women’s Health 54 (3) (2009): 219–225, available at https://www.ncbi.nlm.nih.gov/pubmed/19410214.
Around the country, communities are developing innovative approaches to providing prenatal care and supporting families in accessing this care. This brief details the approaches of three different innovative programs: The JJ Way, CenteringPregnancy, and the HealthConnect One Community-Based Doula Program. These programs have been identified as emerging, promising, or best practices by organizations such as the Association of Maternal & Child Health Programs (AMCHP) and the American College of Obstetricians and Gynecologists (ACOG). Although the approaches of these models vary, a growing body of research suggests that all three broadly appeal to families and are associated with fewer numbers of preterm births, higher birth weights, increased breastfeeding, and other improved health outcomes.
This track record makes the programs broadly appealing to communities across the United States. Indeed, many communities already implement them: The HealthConnect One Community-Based Doula Program operates in 74 sites across 29 states; CenteringPregnancy currently has sites in nearly every state; and The JJ Way is based in Florida, providing in-person and online training for providers.
The JJ Way
The JJ Way, created by midwife Jennie Joseph, is a patient-centered, team-based model that emphasizes developing relationships with parents and addressing unmet needs or barriers to care. The program, which primarily operates out of a clinic in the greater Orlando area of Florida, aims “to eliminate racial and class disparities” in infant health outcomes through accessible, culturally competent care. The program is known in the community for serving all families, regardless of their ability to pay, a reputation that makes it easier for women to initially seek services. This policy, coupled with the program’s efforts to raise community awareness through outreach, helps families overcome both structural barriers, such as service costs, and individual barriers, such as fear or avoidance of care due to inability to pay. Once in the door, expectant mothers and families are welcomed by staff members, who provide information about their options while respecting their agency and choices as equal partners in their care. This approach also makes it more likely that expectant mothers will continue to seek care and make the clinic a source of continuing maternity care. Staff identify structural barriers to care, such as a lack of child care for other children or a lack of health insurance, and offer practical solutions tailored to each individual. Throughout the pregnancy, staff engage parents’ support network, including their partners, extended family, and friends.
In a recent evaluation, women who received maternal care through The JJ Way had lower rates of preterm and low-weight births compared with the county and state averages. Importantly, this model also eliminated racial disparities in preterm birth and significantly reduced low birth weights for at-risk populations, such as low-income people and people of color.1
CenteringPregnancy is a group-based model of care in which trained facilitators guide a group of eight to 10 women of similar gestational age through a curriculum of 10 interactive group prenatal care visits that are 90 to 120 minutes long. Like parents in traditional care, women receive individualized assessments; however, in the CenteringPregnancy model, these assessments are followed by a facilitated group discussion. Although these sessions address many of the same aspects of pregnancy covered by traditional prenatal care—such as nutrition, stress management, labor and birth, and infant care—they are intentionally designed to involve women in their own care. For example, women practice taking their own weight and blood pressure and learn to look out for warning signs of pregnancy complications such as preeclampsia.
These group sessions also give mothers opportunities to bond over shared experiences, hopes, and concerns around pregnancy and parenthood, helping foster deeper relationships that motivate parents to continue participating in the program and that can continue long past childbirth. By changing the care format to engage women in their own care and by providing opportunities for parents to connect, CenteringPregnancy aims to make prenatal care more meaningful, enjoyable, and informative for families. Increasing mothers’ social support through facilitating relationships with peers also improves self-efficacy and mental health.
Research shows positive impacts for mothers and infants, including lower rates of both preterm birth and low birth weight. Moreover, a recent meta-analysis showed that group prenatal care was associated with lower preterm birth rates, greater breastfeeding rates, and increased satisfaction of care among African American women. And in South Carolina, a state where providers can reliably seek reimbursement for CenteringPregnancy through Medicaid, researchers are conducting a large randomized control trial to assess whether the statewide implementation is reducing infant deaths.2
HealthConnect One Community-Based Doula Program
Beginning as a grassroots movement to promote breastfeeding in Chicago in the mid-1980s, HealthConnect One (HC One) has since evolved into a model program for community-based maternal and child health promotion. In 1996, the organization launched the Chicago Doula Project to support underserved families during the prenatal and early postpartum periods, and this program is now being replicated nationwide as the Community-Based Doula Program. It is important to note that doulas—nonmedical professionals who provide emotional, physical, and informational support during pregnancy, birth, and postpartum—do not themselves provide traditional prenatal care. But by providing peer-to-peer support and outreach, these doulas support and advocate for families as they navigate the health care system and access prenatal care. For example, doulas accompany mothers to prenatal appointments in order to provide the family support and help bridge cultural, linguistic, or structural barriers to care. They also conduct home visits in which they help families develop a birth plan, assess family strengths and needs, and provide parenting education. Although HC One is no longer a direct service organization, it collaborates with programs across the country to train, credential, and evaluate community-based programs.
In an evaluation of eight HC One Community-Based Doula programs from around the country, Hispanic and Black mothers who participated in the program were less likely to undergo a cesarean section and more likely to breastfeed exclusively and for longer periods of time, compared with the general population.3
- 1. Miriam Zoila Pérez, “Making Pregnancy Safer for Women of Color,” The New York Times, February 14, 2018, available at https://www.nytimes.com/2018/02/14/opinion/pregnancy-safer-women-color.html; Commonsense Childbirth, “The JJ Way®,” available at https://commonsensechildbirth.org/jjway/ (last accessed January 2020). Association of Maternal & Child Health Programs, “The JJ Way™ Model of Maternity Care” (Washington: 2009), available at http://www.amchp.org/programsandtopics/BestPractices/InnovationStation/ISDocs/JJ%20way_2015.pdf; Visionary Vanguard Group Inc., “The JJ Way®: Community-based Maternity Center, Final Evaluation Report” (Winter Garden, FL: Commonsense Childbirth, 2017), available at http://www.commonsensechildbirth.org/wp-content/uploads/2019/07/The-JJ-Way%C2%AE-Community-based-Maternity-Center-Evaluation-Report-2017-1.pdf.
- 2. Breanna Lathrop, “A Systematic Review Comparing Group Prenatal Care to Traditional Prenatal Care,” Nursing for Women’s Health 17 (2) (2013): 118–130, available at https://nwhjournal.org/article/S1751-4851(15)30740-6/fulltext.; Centering Healthcare Institute, “CenteringPregnancy,” available at https://www.centeringhealthcare.org/what-we-do/centering-pregnancy (last accessed January 2020); Amy H. Crockett and others, “Effects of a Multi-site Expansion of Group Prenatal Care on Birth Outcomes,” Maternal and Child Health Journal 23 (10) (2019): 1424–1433, available at https://www.ncbi.nlm.nih.gov/pubmed/31230168; Sarah Gareau and others, “Group Prenatal Care Results in Medicaid Savings with Better Outcomes: A Propensity Score Analysis of CenteringPregnancy Participation in South Carolina,” Maternal and Child Health Journal 20 (2016): 1384-1393, available at https://link.springer.com/article/10.1007/s10995-016-1935-y.; Brittany M. Byerley and David M. Haas, “A systematic overview of the literature regarding group prenatal care for high-risk pregnant women,” BMC Pregnancy and Childbirth 17 (1) (2017), available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5622470/; Sarah Kliff, “Sit in a circle. Talk to other pregnant women. Save your baby’s life?”, Vox, November 2, 2018, available at https://www.vox.com/future-perfect/2018/11/2/18040070/infant-mortality-south-carolina-amy-crockett.
- 3. Home Visiting Evidence of Effectiveness, “Implementing HealthConnect One’s® Community-Based Doula Program,” available at https://homvee.acf.hhs.gov/implementation/HealthConnect%20One%27s%C2%AE%20Community-Based%20Doula%20Program/Model%20Overview (last accessed January 2020); Association of Maternal & Child Health Programs, “The HealthConnect One Community-Based Doula Program” (Washington: 2015), available at http://www.amchp.org/programsandtopics/BestPractices/InnovationStation/ISDocs/HealthConnect.pdf
Although these three models were independently developed and differ in scope and emphasis, studies show that they have all been successful in preventing preterm births, increasing birth weights, and improving breastfeeding rates. These outcomes are a key part of ensuring healthy beginnings for babies. Moreover, families are satisfied with the services they receive through these programs, and some research shows that maternal health outcomes and birth experiences also improve.
The models highlighted in this brief have three things in common that help make them successful:
- They increase access to high-quality preventive health care. All three programs increase access to preventive, comprehensive care. The JJ Way does this through its policy of serving all families, whereas the HC One model does this by training community health workers and doulas who can help families navigate the existing health system and overcome hurdles to care. By extending the length of prenatal visits, CenteringPregnancy also increases access to preventive health care; longer sessions mean that mothers spend up to 10 times more time with their prenatal care provider.
- They provide critical social support through relationship-centered care. The three programs treat relationships as central to their success, including relationships between the families and their providers. HC One’s Community-Based Doula Program, for example, sees its employment of trusted community members and its collaboration with community stakeholders as central to its success. Similarly, The JJ Way emphasizes a supportive, team-based approach, as well as the role of the mother’s support network in the pregnancy. CenteringPregnancy likewise fosters connections between mothers through group sessions. This is key to improving perceptions of the quality of care and incentivizing people to continue to seek prenatal services throughout their pregnancies.
- They empower families. Finally, all three programs seek to empower and educate families. CenteringPregnancy, for example, teaches mothers to take vital signs and look for warnings of health complications, skills that allow them to take an active role in their care by identifying issues early and seeking care when needed. Similarly, both HC One and The JJ Way describe building personal connections, self-esteem, and empowerment as ways through which they achieve successful outcomes for families.
As policymakers and advocates seek to ensure healthy births for all parents and their infants, holistic models of prenatal care such as those offered by The JJ Way, CenteringPregnancy, and the HC One Community-Based Doula Program should be part of their agenda. Funding for these programs varies widely, and communities must consider their own unique needs and resources when seeking to use any of these models. For example, some states—notably South Carolina—allow providers to seek reimbursement for CenteringPregnancy from Medicaid. In contrast, HC One receives most of its funding through philanthropy. Meanwhile, funding for The JJ Way comes from contracts secured through Florida’s Medicaid managed care organizations, as well as funds raised through Commonsense Childbirth, an associated nonprofit. As communities consider how to ensure that all babies are born healthy and have a strong start in life, it is critical to recognize that all families could benefit from additional help during pregnancy, including comprehensive prenatal support.