Models Addressing Perinatal Health

Rural programs addressing perinatal health focus on issues affecting women during pregnancy, delivery, and immediately after birth. For pregnancy health, the Community Preventive Services Task Force (CPSTF) recommends exercise programs and lifestyle interventions to reduce the risk of gestational hypertension and gestational diabetes, respectively.

Current recommendations are that pregnant women take childbirth education classes. These classes are typically taken during the second or third trimester of pregnancy. However, some classes may start during the first trimester and incorporate prenatal care and childbirth education. Studies have shown that childbirth education programs can reduce the fear of childbirth and increase childbirth-related maternal self-efficacy. Rates of medical interventions were lower in mothers who participated in childbirth education classes.

There are many methods of childbirth preparation classes. They vary in length of class, method of delivery, philosophies toward birth, and setting. The type of class a woman selects is largely based on what is available in the expectant woman's community.

Home visiting programs have been shown to improve birth outcomes, improve maternal health, reduce maternal postpartum depression, and — when begun during pregnancy — increase the use of prenatal care.

Since 2012, the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program has been the largest source of funding for home visiting programs in the U.S., supporting the implementation of four programs: 1) Early Head Start - Home Based Program Option, (2) Healthy Families America, (3) Nurse-Family Partnership, and (4) Parents as Teachers. Home visits from public health nurses or community health workers provide families with information, support, and access to early childhood resources. Families also receive tools for expanding social support networks.

Group prenatal care is designed to provide pregnant patients with education, resources, and social support during pregnancy. This model convenes a small group of pregnant patients with similar due dates. Healthcare providers facilitate multiple sessions to deliver education, training, and resources.

The March of Dimes Supportive Pregnancy Care Program offers group prenatal care via in-person or virtual group meetings. Sites implementing this program can tailor content and approaches to accommodate different organizational and community needs.

In-home nursing case management programs aim to prevent preterm births. High-risk pregnant women who are enrolled in these programs are more likely to give birth to infants with healthy gestational age and birthweight, leading to improved health outcomes.

Community-based mobile reproductive health clinics are medically equipped vans typically serving low-income or uninsured individuals in both urban and rural communities. Mobile health clinics provide reproductive health services such as screening tests, pre- and post-natal care, health education, and referrals.

Doulas are trained professionals who provide emotional and physical support to pregnant women. They do not provide medical advice, but provide support and explain medical procedures to families. Doulas are helpful when working with underserved and marginalized communities, as they can empower women and families to advocate for themselves. Community-based doulas can help rural families navigate the healthcare system, particularly if they are feeling some anxiety around giving birth in a non-local hospital.

Examples of Models Addressing Perinatal Health

Healthy Connections, Inc. is a federally-funded community program that offers in-person prenatal check-ups, education, transportation, well-baby checks, and child immunizations to expectant and young mothers in Arkansas. The program has demonstrated an increase in the rate of first-trimester prenatal care and child immunization as well as a dramatic decrease in confirmed cases of child abuse.
Kid One Transport, provided rides to medical appointments for pregnant women and their children who have no regular means of transportation. This programs has shown positive impacts by increasing ability to continue prenatal care and preventing children from developing life-threatening illnesses.
Some states have passed legislation to ensure services provided by midwives and doulas are covered under Medicaid. In 2019, Wyoming passed the Midwife Services Medicaid Act, requiring services covered by licensed midwives to be covered by Medicaid. Also in 2019, Indiana passed Senate Bill 416 allowing for Medicaid reimbursement of doula services.
CenteringPregnancy is a group prenatal care model. It convenes eight to ten pregnant women at similar points in their pregnancies for group discussions, education, health assessments, and support. Evidence suggests the program improves birth outcomes and the likelihood of receiving adequate prenatal care. The CenteringPregnancy program has been successfully implemented in rural communities and may be beneficial in rural communities where there is limited provider capacity. For example, mothers who participated in the Mountain Area Health Education Center's Centering Pregnancy program reported spending 12 times more time with their providers than women in traditional care.

Program Clearinghouse Examples

Considerations for Implementation

Childbirth education classes include information about the birth process, pain management, and variations in labor. Because of the social determinants of health in rural areas, there is often additional focus in rural childbirth education classes on logistics and transportation. Clinics and providers should be aware of childbirth education options available in their communities and provide information on how to access the classes.

The effectiveness of perinatal interventions may depend upon availability in the community as well as cost. Healthcare systems and health plans may consider offering low-cost programs to pregnant women. Many perinatal programs are most effective when they begin early in a pregnancy. Therefore, providers should be aware of options in their communities and be able to refer women early in their pregnancy.

Resources to Learn More

DONA International
Website
An international doula organization that offers certification, evidence-based training, continuing education and resources describing the benefits of, and how to hire, a doula.
Organization: DONA International

Home Visiting Evidence of Effectiveness (HomVEE)
Website
Collection of research literature assessing the effectiveness of home visiting programs. Includes reports detailing the models studied and their outcomes and measures. Offers implementation guidelines for home visiting programs and information about related federal grants.
Organization(s): Department of Health and Human Services, Administration for Children & Families (ACF)

Maternal Quality Improvement Toolkits
Website
A repository of toolkits developed for healthcare providers addressing the leading causes of preventable death among women during the perinatal period. Also identifies ways to reduce harm to infants and mothers from the oversue of obstetric procedures.
Organization(s): California Maternal Quality Care Collaborative

MotherToBaby
Website
A no-cost service providing evidence-based information on the benefit or risk of medications and other exposures during pregnancy and while breastfeeding. Provides guidance for healthcare providers and individuals, as well as fact sheets and other materials addressing medications, vaccines, chemicals, herbal products, substance use, maternal health conditions, and more. Also conducts observational studies on exposures.
Organization(s): Organization of Teratology Information Specialists (OTIS)

Patient Safety Bundles: Maternal Safety Bundles
Tutorial/Training
A repository of resources identifying best practices in maternity care shown to significantly reduce severe maternal morbidity and maternal mortality.
Organization(s): Alliance for Innovation on Maternal Health (AIM), Council on Patient Safety in Women's Healthcare