Division of Healthy Start and Perinatal Services

The work of all Maternal and Child Health Bureau divisions, programs, and staff is in support of the Bureau’s Strategic Plan (2003-2007) for meeting the needs of the maternal and child health populations of the United States and its Jurisdictions. The Bureau focuses—through leadership, performance, and accountability—on accomplishment of five over-arching goals: 1) Provide National Leadership for Maternal and Child Health; 2) Promote an Environment that Supports Maternal and Child Health; 3) Eliminate Health Barriers and Disparities; 4) Improve the Health Infrastructure and Systems of Care, and 5) Assure Quality of Care. The Bureau’s progress—or accountability—toward goal achievement is reported annually.

The Division of Healthy Start and Perinatal Services (DHSPS) is one of five divisions of the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB).  The Division’s programs and activities underscore its mission to provide national leadership in improving the health of women across the lifespan and decreasing infant and maternal morbidity and mortality during or associated with the perinatal period. DHSPS collaborates with Federal,  State, and local governments, public/private organizations and consumers on programmatic and policy efforts to define and address the health needs of women before, during, and after pregnancy (e.g., the Perinatal Period) and of their infant through the baby’s second birthday.  The Division develops and implements initiatives that focus on eliminating racial/ethnic and other disparities in perinatal and women’s health through demonstration programs, public/private partnerships, technical assistance, educational resource development and dissemination, and Inter/Intra-Departmental collaborations. Major programs and initiatives within DHSPS include: the Federal Healthy Start program; Innovative Approaches to Women’s Health (Healthy Weight); Perinatal Depression; Maternal Wellness; the National Fetal and Infant Mortality Review Resource Center; Breastfeeding Education Resources, particularly for working women and their employers; the Secretary’s Advisory Committee on Infant Mortality, and other risk reduction demonstration programs.

The Healthy Start Program 

Based on the premise that community-driven strategies are needed to address factors contributing to infant mortality, low birth weight, and other adverse perinatal outcomes in high-risk populations, Healthy Start (HS) projects focus on improving maternal and child health outcomes by increasing access to and use of health services for women and their families while strengthening local health systems and increasing consumer input into these systems of local care. Indeed, a unique program hallmark is Healthy Start’s focus on developing and mobilizing strong community coalitions, local and State governments, the private sector, providers, and neighborhood organizations.

To reduce the factors that contribute to the Nation’s high infant mortality rate, particularly in African-American and other disparate minority groups, HS provides intensive services. Services are tailored to the needs of high risk pregnant women, infants and mothers in geographically, racially, ethnically, and linguistically diverse communities with exceptionally high rates of infant mortality.

Core Strategies: Through the implementation of evidence-based practices and innovative community-driven interventions, HS works with individual communities to build upon their resources (outreach, health education, case management, utilization of prenatal/postnatal care) to improve the quality of and access to health care for women and infants at both service and system levels.  At the service level, beginning with direct outreach by community health workers to women at high risk, HS 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 met.  Following risk assessments and screening for perinatal depression and other risk factors, case managers provide linkages with appropriate services and 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 (interconceptional). 

At the system level, every HS project has developed a consortium composed of neighborhood residents, perinatal care clients or consumers, medical and social service providers, as well as 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.  HS projects also have strong collaborative linkages with state programs including Title V MCH Block Grant, Medicaid, State Child Health Insurance Program, and with local perinatal systems such as community health centers. 

The close connection between these services can assist in reducing significant risk factors such as smoking and alcohol use, while promoting behaviors that can lead to healthy outcomes for women and their families. These positive relationships and risk-reduction interventions, which begin during the perinatal period, continue to be monitored for both mother and baby for two years after delivery to sustain positive health benefits and to ensure that mothers and infants remain linked to ongoing sources of primary care.

Background: Originally established in 1991, 15 locations around the country were funded as HS Demonstration Projects. Since then, the program has been authorized and has grown to include 99 communities in 38 States, the District of Columbia, and Puerto Rico.  Communities that are served by HS have large minority populations with high rates of unemployment, poverty and major crime.  Parents at highest risk for adverse perinatal health outcomes typically have less than a high school education, low income and limited access to safe housing.  Within their community, the number of perinatal providers is limited; regular access to these providers is challenged by long commutes accomplished only with help from friends for those living in rural areas or on crowded public transportation in urban areas.  While each project is unique, using local input to shape strategies, all projects share the same “core” program goals:  to reduce racial and ethnic disparities in access to and use of health services; to improve local health care systems; and, to increase consumer or community voice in health care decisions. 

Current Activities:  The HS Eliminating Disparities in Perinatal Health B General Population and Border Community projects focus on enhancing a community=s service system to reduce disparities in infant mortality and other perinatal health indicators among different sub-populations in a community.  Although different sub-populations can be defined along ethnic/racial lines, they can also be identified by socio-economic, geographical or disability groupings.  Border community projects focus on the perinatal service system that exists within their communities; these communities must be within 62 miles (100 kilometers) of the U.S. - Mexican border and have a high incidence of poor perinatal outcomes. 

All projects address the needs of their respective community by implementing a set of five core services and four system-building interventions.  The five core services are direct outreach services and client recruitment; case management; health education services; screening and referral for maternal depression; and interconceptional continuity of care through the infant’s second year of life.  In addition, projects are expected to engage in a number of system-building efforts to strengthen local health systems and to bring a consumer or community voice to efforts to improve maternal and infant health.  The four system-building interventions that grantees are expected to establish are:  utilization of community consortia and provider councils to mobilize key stakeholders and advise local grantees; development of a local health action plan; collaboration and coordination with Title V services; and development of a plan for continuation of services and project work beyond the grant period.  All of these projects provide services that cover prenatal and interconceptional care for women and health care for infants for populations in the target areas.

Women’s Health Activities

Since 2002, the MCHB has awarded 15 Integrated Comprehensive Women’s Health Services in State MCH Programsdemonstration grants.  The aim of the Program is to strengthen the infrastructure for women’s health services at the state level by expanding the capacity of state MCH programs.  Strategies employed include creating sustainable partnerships among local, State, and Federal programs as well as private organizations to reduce services fragmentation and to develop ways that ensure women have access to comprehensive preventive health care.  Over the years, the 3-year grants have been awarded to: Alaska, Florida, Hawaii, Iowa, Indiana, Massachusetts, Maryland, Maine, Minnesota, Montana, Nebraska, New Mexico, New York, Oregon and Texas.

Complimenting this infrastructure program at the local level, two 3-year grants were awarded in 2004 to foster collaboration between mental health, addiction services and primary care agencies.  The Women’s Behavioral Health Systems Building: Innovative Ideas for Local and State Collaboration grantees (Maine and Oklahoma) uniquely included consumers of mental health and addiction services as partners in the process of policy development for women of reproductive age at the State and local level.

In FY 2003, the MCHB began addressing a major health problem for women and their families, the prevalence of overweight/obesity, through the Innovative Approaches to Promoting a Healthy Weight in Women demonstration grant program.  The purpose of the Program is to support the development of novel approaches to increasing the number of women who adopt positive health lifestyles.  The interventions, which include physical activity, nutrition and wellness components must be substantive in nature and positively impact the women’s knowledge, attitudes, and behaviors. The projects aim serve women in communities who have limited access to preventive health.  Since its inception, twelve 3-year grants have been awarded to projects across Texas, Ohio, Massachusetts, Florida, Arizona (2), Delaware, Wisconsin, Alaska, Michigan (2), and Illinois.

In an effort to highlight the health needs of women in the prison system, a partnership was formed in September 2005, with the Jacobs Institute of Women’s Health-George Washington University. Through the partnership, a special edition of Women’s Health Issues Journal was commissioned on the health of incarcerated women. The special edition issue, due to be published in July/August 2007, will include articles that address the needs of women in the prison system and highlight approaches to addressing the needs of this population of women. 

Perinatal Activities

From 2000-2003, MCHB funded projects under the Improving Systems of Care for Pregnant Women Experiencing Domestic Violence Demonstration Program. Projects employed a systems approach to identify pregnant women experiencing domestic violence in sensitive, effective ways and to provide them access to an essential network of services to improve their health and safety.  Four 3-year projects were funded in Illinois, Maryland, New York and Washington. 

A second demonstration program, Developing a System of Care to Address Family Violence during or around the Time of Pregnancy was supported from 2002-2005.  Four 3-year projects were awarded in Healthy Start communities that focused on improving systems of care to address the needs of preconceptional, pregnant, and postpartum women experiencing domestic violence. In addition, these projects broadened the care system by collaborating with programs addressing child/adolescent abuse, parent/elder abuse, and perpetrator intervention programs.  Projects were awarded in Illinois, North Carolina, Oregon, and Pennsylvania. 

The Improving Screening for Alcohol Use During Pregnancy Among Providers Demonstration Program funded 3-year projects in Illinois, Massachusetts, Nebraska, and Puerto Rico from 1999 - 2002.  The goal of this program was to identify the most effective methods to motivate providers to systematically screen for alcohol use during pregnancy, to provide information on associated risks, and to refer for interventions, if needed.  By screening all women for alcohol use in the prenatal period, women who use alcohol will be identified and offered appropriate supports or interventions that improve pregnancy outcomes. 

The Replicating “Lessons Learned” in Alcohol Screening During Pregnancy Demonstration Program, funded from 2002-2005, expanded on lessons learned from the Improving Screening for Alcohol Use During Pregnancy Among Providers demonstration program. The Program’s emphasis was to build on the findings of the previous alcohol screening grants, and evaluate the same effective interventions in new health clinics in the same states.  The two replication projects were located in Illinois and Massachusetts.

From 2003-2006, MCHB awarded three 3-year grants under the Screening for Multiple Risk Factors during Preconception through Postpartum Period program in order to develop a concise, easy to use, instrument to screen for multiple behavioral risk factors during the perinatal period including domestic violence, alcohol use and depression.  Grants were awarded in Illinois, Massachusetts, and New York.

From 2002-2005, the MCHB funded four 3-year State Mortality/Morbidity Review Grants to develop strategies for States to improve coordination between two or more co-existing internal review processes to make them more efficient.   Review processes included fetal and infant mortality review (FIMR), child fatality review, and maternal mortality review.  The grantees also identified ways to integrate some of their findings into their state’s MCH Block Grant.  The funded states were Connecticut, the District of Columbia, Illinois and New Jersey.

Since 1990, MCHB has funded the National Fetal and Infant Mortality (FIMR) Resource Center with the most recent 5-year funding beginning in 2002.  FIMR is a community-based action method that examines a fetal or infant death as a sentinel event and mobilizes community action to improve services and resources for women, infants, and their families.  Current goals of the Resource Center include: providing technical assistance about FIMR to states and communities; promoting the use of the FIMR process in concert with other mortality/morbidity analytic or review processes; refining the FIMR method/process when necessary; and promoting and supporting application of the process to address other adverse MCH events.  The FIMR Resource Center is a joint partnership between the MCHB and the American College of Obstetricians and Gynecologists (ACOG).

Perinatal Depression 

Since 2004, a Congressional appropriation provided funding for programs on Perinatal Depression.  In FY 2004 and 2005, 1-year grant programs for perinatal depression were awarded by HRSA to 10 states: Arkansas, Connecticut, District of Columbia, Illinois, Indiana, Maryland, Massachusetts, Nebraska, New York, and Virginia. The purpose of Statewide Perinatal Depression grants was for State MCH programs to launch intensive multi-lingual public education activities that, at the grassroots level, would promote mental wellness for mothers and their families, as well as a better understanding of perinatal depression and the warning signs associated with it.  The statewide efforts focused on reducing the stigma associated with perinatal depression; increasing the number of women and their families who seek treatment; and, increasing the number of health and community-based providers who can recognize the signs and symptoms of perinatal depression, provide screening for perinatal depression and related mental health problems, and refer for further assessment and treatment as necessary.  This initiative required States to work to decrease barriers to care for low-income families with signs of perinatal depression and related mental health problems.  In 2006, the program was expanded to encompass services for maternal and infant mental health program.  Six state grants were awarded to provide comprehensive, coordinated services for maternal depression and other mental health problems (particularly anxiety disorders such as post-traumatic stress disorder and obsessive-compulsive disorder) during pregnancy and at least through the first year after pregnancy. In this program, maternal mental health services must be combined with services for infant mental health within a service system model that focuses care on the mother-infant pair or dyad. Grants were awarded to: Illinois, Iowa, Louisiana, Kentucky, Massachusetts, and Pennsylvania.

Breastfeeding

DHSPS staff participates in several activities in support of the Healthy People 2010 Objectives to increase breastfeeding initiation and duration, particularly among populations least likely to meet these objectives. Activities target enhancing provider capacity to offer breastfeeding education and support and facilitating continuation of breastfeeding among women who return to work or school. Staff is completing a new five-sectioned employer-based resource kit, tentatively entitled The Business Case for Breastfeeding and companion train-the-trainer curricula on the use of the kit. The purpose of the kit is to: increase awareness among employers of the economic benefits of breastfeeding; increase the number of US employers that utilize a worksite breastfeeding support program; and, outline manageable, flexible models for implementing or enhancing a worksite breastfeeding support program.

Publications

Through a Congressional mental health earmark, HRSA/MCHB has published a 22-page booklet titled, “Depression During and After Pregnancy:  A Resource for Women, Their Partners, Family and Friends”.  This booklet is part of MCHB’s ongoing efforts to promote a better understanding of perinatal depression, a condition that encompasses major and minor depressive episodes that occur either during the pregnancy or within the first 12 months after delivery.  The booklet is intended to reduce the stigma associated with perinatal depression and, most importantly, increase the number of women and their families who will take proactive measures to seek help.  The booklet will also serve to educate primary care and other community-based providers to: recognize the signs and symptoms of perinatal depression; provide screening for perinatal depression and related mental health problems; and, refer women as need to further assessment and treatment The booklet is available online at www.mchb.hrsa.gov/pregnancyandbeyond/depression

MCHB has developed two publications on women’s oral health.  The first, Improving Women’s Health and Perinatal Outcomes: the Impact of Oral Diseases seeks to highlight the status of oral health in women, its impact on women’s reproductive and general health, and its impact on children. The publication was prepared by the Perinatal and Women’s Health Policy Project at Johns Hopkins University and the National Oral Health Policy Center for Maternal and Child Health at Columbia University. The second publication, Women’s Oral Health Resource Guide, is intended to assist health professionals, program administrators, and others to improve oral health guidance and care for women.  This document was prepared by the National Maternal and Child Oral Health Resources.