Supporting Pregnant Parents and Their Children Through Care Coordination in Marginalized Communities

By Heidi Christman, Chief Operating Officer, Health Impact Ohio

Maternal and infant health have long been a top priority of Health Impact Ohio’s (HIO’s) care coordination program, The Central Ohio Pathways HUB (the HUB). When the United States Supreme Court announced its decision in Dobbs vs. Jackson Women’s Health by granting permission to individual states to determine the right to abortion access, the State of Ohio’s 2019 “Heartbeat” law went into effect, which restricts access to abortion access after six weeks. While we acknowledge the law, HIO and the HUB continue to focus efforts on the populations that we serve by supporting pregnant individuals, new parents, and their children in marginalized communities – and in many ways, the efforts do not change. Now more than ever in Ohio, it is vital that pregnant people are provided with the essential care and resources required to sustain a healthy and wanted pregnancy and provide for a sustainable life for all members of the family thereafter.

The Pathways HUB Model enables HUB CHWs to focus on helping perspective and new mothers navigate pregnancy, birth, and future family planning in a safe, successful way – putting the pregnant person in control of their health choices for the betterment of themselves and their families.  The Central Ohio Pathways HUB believes strongly that our CHWs' work is comprehensive and should cover the lifespan of clients rather than focusing solely on the healthy delivery of a child. This means supporting not just the pregnant person, but the people surrounding them, including their partners and children. This is why we proudly carry caseloads of all client types, including pediatric, adult, and maternal clients. Pathways available for connections to care and service for all HUB clients include:

• Adult Education

• Employment

• Health Insurance

• Housing

• Medical Home

• Medical Referral (Several care and service connections are encompassed under the medical referral pathway, including access to specialty and dental care.)

• Medication Assessment

• Medication Management

• Smoking Cessation

• Social Service Referral (Several care and service connections are encompassed under the social service referral pathway, including access to food, transportation, and personal items such as diapers, safe sleep spaces, and personal hygiene items.)

• Behavioral Health Referral

• Developmental Screening

• Developmental Referral

• Education

• Family Planning

• Immunization Screening

• Immunization Referral

• Referral Screening

• Pregnancy

• Postpartum

These Pathways are the main physical and social drivers that affect people's health and well-being outcomes, and we prioritize addressing our program from this whole-person perspective.

Regarding care coordination for pregnant people and new parents, the HUB has made specific goals since its inception under HIO’s leadership in 2019. CHWs in the HUB have heeded the call to achieve these goals with support, education, technical assistance, and community resources. In the nearly three and a half years that HIO has been managing the HUB, 86% of babies born to parents accessing HUB services with a CHW have been born post 37 weeks and at a healthy birthweight. It is especially exciting to report that in quarter two of this year, in our Ohio Commission on Minority Health funded work, 13 out of 13 babies born to parents working with a HUB CHW were delivered post 37 weeks and at a healthy birth weight. 

HUB CHWs understand that while ensuring pregnant parents make it to their prenatal appointments is very important, several other factors increase the likelihood of a healthy pregnancy and delivery. Data show that the most opened Pathways that accompany a Pregnancy Pathway include Education, Medical Referrals (usually for connection to a primary care practitioner), Family Planning, and Social Service referrals. The top five Social Service referrals in the program to date are for assistance in accessing nutritious food, transportation, financial services, clothing for new parents and babies, and legal services. These data show that there are a variety of risks associated with pregnant clients that must be addressed to ensure a healthy, successful pregnancy and birth for parents and babies.

The HUB aims to have every single pregnant client in the HUB receive education from their CHW on safe spacing and safe sleep. We know those are two critical considerations in positive health outcomes for parents and their children. The HUB also focuses heavily on meeting clients before they become pregnant so that the timing of any potential future children is a point of conversation as well. Clients who are consciously in control of the timing of when they have children are empowered to accomplish goals and meet needs that allow for them to be well prepared and ready for when a baby is on the way.

Equity is at the forefront of our CHWs' work with pregnant populations in the HUB’s service region. 65% of clients reached by HUB CHWs are Black or African American, a critical support in marginalized communities due to the public health crisis of racism. Health disparities amplified by the COVID-19 Pandemic have not gone unnoticed by CHWS in the HUB. To date, they have worked tirelessly delivering over 650 educations regarding COVID to pregnant clients alone. These educations include information on the COVID-19 vaccine and its safety for pregnant people and their babies, testing, treatment, and overall sharing of evidence-based, up-to-date information to combat misinformation. Pregnant clients, more than anyone, are eager to understand how the evolving pandemic is affecting their families, and HUB CHWs continue to engage on the issue.

Data collected in the HUB doesn’t just demonstrate successes; it also reveals gaps.  In our analysis of low-birth-weight babies born to HUB clients in 2021, the most significant barriers to pregnant parents were a lack of stable, safe housing resources and access to dental care. HIO and community partners, with HUB CHWs, are actively working to reduce these barriers. As we continue to work toward providing the best possible care coordination to pregnant clients, HUB efforts are also focused on reaching more clients earlier in their pregnancy, a sure way to improve infant and maternal outcomes. As of today, CHWs are reaching the most clients when they are in their second trimester. HUB staff continues to work with community partners to improve upon this data in hopes of reaching pregnant people as soon as possible, ideally in their first trimester. Finally, the HUB continues to focus efforts on engaging in educations with their clients about family planning and proper spacing of pregnancies to ensure safety and well-being, including helping educate clients to advocate for contraception when they are meeting with their physician. 

Support for programs like the HUB, that support people from all walks of life is more vital now than ever, given recent decisions regarding reproductive health and access to health for pregnant people. The HUB continues to find new ways to connect with clients and provide them with the best possible care coordination, keeping their health, well-being, and prosperity in mind. The HUB's CHWs connect individuals to care and service and empower our neighbors for long-term success and positive outcomes. To learn more about the HUB, visit the HUB page on the HIO website: https://www.healthimpactohio.org/central-ohio-pathways-hub.