From Detroit to Kansas City: Adapting the WE CARE Model to Improve Maternal and Infant Health

Abstract

Background:

The United States lags peer nations in infant mortality, with persistent racial and geographic inequities. In Missouri, Black infants experience mortality rates more than double those of White infants. Addressing these disparities requires community-driven interventions beginning before conception and extending beyond routine perinatal care.

Objectives:

We describe the development and feasibility of Women & Person-Empowered Community Access for Reproductive Equity (WE CARE)-Jackson County (JC), a reproductive justice-informed intervention adapted from the Detroit WE CARE model to address reproductive health and infant mortality disparities.

Design/Setting:

WE CARE-JC used a two-phase, mixed-methods design. Phase 1 included listening sessions with advocacy groups and reproductive-age women, and a community survey (N = 537) to identify needs, barriers, and engagement strategies. Phase 2 piloted the intervention in a safety-net hospital’s emergency department. Intervention components included the “One Key Question,” MyPath decision-support tool, community health worker-led counseling, and follow-up care navigation.

Results:

Listening sessions identified trusted providers as preferred sources of family planning guidance, while stigma, limited provider access, and knowledge gaps were key barriers. Survey data showed social (13% housing, 22% food, and 35% transportation insecurity) and medical (51% comorbid condition) vulnerability. In the pilot, 45 women were enrolled (85% of those approached), of whom 58% scheduled follow-up care and 10 (39%) attended appointments. Feedback from eight attendees showed high acceptability of the MyPath tool, counseling, and navigation support.

Implications for Health Equity:

WE CARE-JC demonstrated feasibility and acceptability of a reproductive justice-informed, community-engaged model to reduce barriers and improve equitable access to reproductive health care. This model provides a scalable framework for addressing upstream drivers of infant mortality inequities.

Introduction

Infant mortality is a key indicator of population health, reflecting the combined effects of maternal health, health care quality and access, and broader social and economic conditions. Over the past two decades, infant mortality has declined steadily across high-income countries. However, the United States continues to lag (ranking 33rd out of 38 wealthy nations) and has failed to achieve comparable improvements. In 2023, the U.S. infant mortality rate (IMR) was 5.61 deaths per 1,000 live births, unchanged from 2022 after decades of gradual improvement, and following a rise from 5.4 to 5.6 per 1,000 between 2021 and 2022—the largest single-year increase since 2002. ¹ This level sharply contrasts with leading peer countries. For example, the U.S. IMR is 2.7 times higher than Norway’s and 3.1 times higher than Finland’s and Japan’s. ¹

Persistent and profound racial inequities drive much of the U.S. infant mortality burden.^2,3 Infants of Black non-Hispanic women experience mortality rates more than double those of White non-Hispanic infants (10.9 vs. 4.5 deaths per 1,000 live births in 2023), with similarly elevated risks observed among American Indian and Alaska Native, and Native Hawaiian or Other Pacific Islander populations. ⁴ These disparities are rooted in structural racism, cumulative stress, and unequal access to high-quality care, extending well beyond individual risk factors. ⁵ Geographic residence further compounds these inequities. ⁶ Missouri ranks 35th worst in the nation with an IMR of 6.3 per 1,000 live births. In Jackson County, Missouri, the overall IMR is 4.7 per 1,000, but disparities persist, with rates of 3.8 per 1,000 for White infants and 8.6 per 1,000 for Black infants. ⁴

These persistent disparities underscore the need for interventions that begin before conception and extend beyond routine perinatal care. Current perinatal interventions primarily focus on individual risk; however, this approach alone cannot address structural drivers of inequity.^7,8 Multilevel community-driven preventive interventions that support access to timely family planning and primary care may reduce upstream barriers and improve maternal and infant health outcomes.

WE CARE-Jackson County (JC) adapts the Detroit Women & Person-Empowered Community Access for Reproductive Equity (WE CARE) ⁹ intervention, which focused on supporting women seeking to prevent pregnancy through education and linkage to care, and expands the intervention to include pregnancy planning education and referral to health care for women who wish to become pregnant. This study describes the community-informed adaptation and pilot implementation of WE CARE-JC to demonstrate feasibility and acceptability of a scalable intervention to address infant mortality inequities.

Methods

Conceptual framework

The development and implementation of the WE CARE-JC project are informed by the Reproductive Justice framework. ¹⁰ This framework emphasizes reproductive autonomy and access to the social, structural, and health system supports needed to act on reproductive decisions. Consistent with these principles, WE CARE-JC was developed using a community-engaged approach in which community members, partners and stakeholders informed the identification of barriers to sexual and reproductive health care and the design of an adapted intervention through listening sessions and a community survey. This approach ensured that community voices informed intervention development, acceptability, and implementation. ¹¹

Intervention design

The WE CARE-JC pilot intervention focuses on reproductive-age women prior to pregnancy by supporting reproductive health decision-making and access to care. WE CARE-JC uses a person-centered decision-making approach relying on one simple question: “Do you want to get pregnant in the next year?” Participant responses guide counseling, education, and referral to reproductive health care services aligned with their preferences, as shown in Figure 1.

FIG. 1.

WE CARE-JC Care model.

To address responses to this question, key project components include: (a) ongoing person-centered contraceptive or family counseling by a community health worker peer trained in reproductive health education; (b) use of the MyPath reproductive health decision-support tool (https://www.mypathtool.org/en/intro_mp); (c) fast-tracked care navigation, including scheduling appointments with hospital obstetrics and gynecology (OB/GYN) or primary care clinics for preventive reproductive and family planning services; and (d) follow-up support to address health care needs.

MyPath is an interactive, web-based reproductive health decision support and navigation tool to help participants clarify reproductive goals, increase knowledge, and prepare for conversations with providers. The tool includes modules on pregnancy intention and reproductive goals, menstrual cycle and fertility information, preconception health, and contraceptive decision making. Participants are asked about pregnancy timing preferences, feelings about pregnancy, contraceptive use and satisfaction, and priorities related to contraceptive method characteristics including effectiveness, frequency of use, route of administration, side effects, and perceived benefits. The tool also includes educational and screening content related to preconception and reproductive health, including medical and mental health conditions, nutrition, folic acid use, exercise, prior pregnancy complications, birth spacing, health care access, financial or housing concerns, and safety considerations. The MyPath modules took 15–20 minutes to complete and generated summaries that participants could use to guide discussions with health care providers about reproductive goals and care preferences.

Two-phased WE-CARE project: Design and intervention delivery

A two-phased, mixed-methods design was used to develop and test the WE CARE-JC intervention tailored to the needs of reproductive-age persons with potential to give birth in Jackson County, Missouri. Phase 1 included listening sessions and a large community survey to gather perspectives on family planning services, barriers, and strategies for engagement. Insights from this phase informed the adaptation and tailoring of program components. Phase 2 built on these findings by pilot testing the intervention in a safety net academic hospital to assess feasibility, refine recruitment and consent procedures, and evaluate the acceptability and feasibility of the WE CARE intervention. Both phases were reviewed and approved by the University of Missouri-Kansas City Institutional Review Board (#2061766 Phase 1 community survey; #2101311 Phase 1 listening sessions and Phase 2).

Phase 1: Listening sessions and community survey

In Phase 1, we gathered input from eight reproductive-age participants and representatives from four community organizations that serve reproductive-age women to better understand prior experiences with family planning services, patient needs, and recommendations for improving service acceptability. Data were collected through listening sessions held in two formats: (a) in-person with community-based organizations and advocacy groups addressing infant mortality, paternal support, and reproductive health equity for Black and Brown childbearing families, as well as a federally qualified health center; and (b) virtually with reproductive-age women from diverse backgrounds. Participants were recruited via flyers and emails disseminated through community-based and health organizations; interested individuals completed an online form and were subsequently invited to attend.

Discussion guides included structured questions assessing comfort discussing family planning, preferred discussion partners, willingness to receive service invitations across clinical and community settings, perceived support for accessing services, and strategies to improve engagement, and participatory activities (e.g., a word cloud defining family planning). Listening sessions were conducted by the principal investigator (J.B.P.), lasted an average of 1.5 hours and were audio-recorded. During sessions, one team member moderated questions raised in the chat and three team members took notes.

Between August 19, 2023, and March 9, 2025, the Our Healthy Jackson County (OHJC) initiative collected 1,916 complete surveys from Kansas City residents across 39 community-based clinic events held in collaboration with community partners. The survey assessed health and social determinant topics, including demographic and household characteristics, housing and transportation stability, employment and insurance coverage, food security, self-rated health and disability status, vaccination history and attitudes (SARS-CoV-2 virus [COVID-19], influenza, and Human papillomavirus [HPV]), health care utilization, medical history and risk factors, neighborhood environment and recreation, tobacco and technology use, and perceptions of community health priorities. In addition, women of reproductive age were asked about pregnancy history and current pregnancy status, receipt of prenatal care, contraceptive use, pregnancy intentions, interest in support for preventing pregnancy or planning a healthy pregnancy and timing of well-woman visits. After excluding non-females (N = 735) and females missing age or outside the 18–44 age range (N = 644), data from 537 women aged 18–44 years were analyzed to inform study design.

Phase 2. WE CARE-JC pilot intervention feasibility in the emergency department

Participants, and procedures

Patients presenting to the emergency department (ED) at a safety net academic training hospital, which serves the greater Kansas City/Jackson County region, were eligible to participate if they were biological females between 18 and 44 years of age and triaged as stable and not in immediate life-threatening danger (Emergency Severity Index [ESI] levels of 2–5). ¹² Additional inclusion criteria included willingness to receive information and/or counseling about pregnancy or birth control. Patients were excluded if they were in acute physical, mental, or emotional distress; currently pregnant; had a history of tubal ligation or hysterectomy, unable to provide informed consent; or non-English speaking.

Potentially eligible patients were identified by study staff through electronic medical record (EMR) review and consultation with ED providers. After completion of initial clinical triage and provider evaluation, and once patients were deemed medically stable, trained study staff approached patients to introduce the study and confirm eligibility criteria. Eligible patients who expressed interest were invited to participate. Written informed consent and Health Insurance Portability and Accountability Act authorization were obtained prior to initiation of study procedures.

After enrolling, participants completed a self-administered baseline survey on a tablet device. The survey assessed pregnancy intention, reproductive history, contraceptive use, health behaviors, access to care, barriers to reproductive health services, and sociodemographic characteristics. Next, participants were guided through MyPath, the web-based family planning decision support tool that generates a personalized summary for each patient. Personalized summaries include information on thoughts about pregnancy, desired family size, knowledge of menstruation and fertility, health before pregnancy and contraceptive options. Based on the discussion of the MyPath summary, participants were offered referrals to OB/GYN for contraceptive services or a primary care provider for preconception planning, along with assistance scheduling appointments. A copy of the MyPath summary was provided to each participant and uploaded to the electronic medical record. When needed, staff provided technical assistance for the completion of the baseline survey and MyPath tool but did not influence responses.

Additional information on ED utilization social determinants of health, and health behaviors were abstracted from the EMR using a standard data collection protocol. Social determinants of health measured included food insecurity, housing instability, or challenges with transportation, childcare, education, and employment. Measures of health behaviors included social isolation and mental health challenges.

Approximately 1 week after the scheduled outpatient appointment, participants were contacted by telephone for follow-up. During this structured call, study staff documented whether the scheduled appointment was completed. For participants who did not attend, barriers to appointment completion were assessed. For those who attended, the provider type and reproductive or primary care services received were recorded.

Patients were compensated up to $90 for study participation. Individuals received $40 upon completion of the ED session, which included informed consent, baseline survey, and use of the MyPath tool. Participants who completed the telephone follow-up received an additional $50. Compensation was provided irrespective of referral uptake.

Setting

The pilot was conducted within a safety-net health system that routinely provides training in cultural competency, trauma-informed care, and implicit bias to support responsive and equitable care delivery for a diverse patient population, including individuals from historically marginalized communities. Language access services, community health worker programs, and partnerships with community organizations further support culturally responsive care. Participating OB/GYN and primary care providers attended a one-time training session with a team member (T.N.J.) on integrating the MyPath summary into clinical encounters to support patient-centered reproductive care.

Statistical analysis

Qualitative analysis

Audio recordings from listening sessions were transcribed verbatim, and session notes were compiled and reviewed alongside the transcript. Qualitative data were analyzed using inductive thematic analysis. ¹³ Two team members independently reviewed the transcripts and notes to develop initial codes. Codes were then compared, discussed, and refined, and grouped into broader themes reflecting sources of family planning information, perceived barriers and stigma, preferred settings for engagement, types of support needed, and recommendations for improving family planning services. These themes informed tailoring of the WE CARE-JC program.

Quantitative analyses

Phase 1 community survey and Phase 2 pilot data were analyzed using Stata/MP version 17 (StataCorp, College Station, Texas [TX]). Participant characteristics were summarized using frequencies and percentages overall and by reproductive health outcomes. Group differences were assessed using chi-square tests. Multivariable Poisson regression models with robust error variance were used to estimate adjusted associations for interest in support during pregnancy, support to prevent pregnancy, and pregnancy planning. Multinomial logistic regression was used to examine factors associated with well-woman examination status. Results are presented as exponentiated coefficients or relative risk ratios with 95% confidence intervals. All tests were two-sided with α = 0.05.

Feasibility was defined as the ability to screen, enroll, and follow participants in an urban safety net hospital ED setting, and acceptability was assessed through participant feedback in follow-up interviews. Phase 2 pilot outcomes were summarized descriptively to assess feasibility and acceptability, without formal hypothesis testing.

Results

Listening sessions

Findings indicated participants felt most comfortable receiving information/feedback on family planning from their OB/GYN or primary care doctor, followed by peers such as friends, health departments, community-based health centers, pediatricians, and social media platforms, including TikTok and Facebook. Barriers included lack of an established OB/GYN before becoming pregnant and the fear/shame due to stigma associated with sexual activity when visiting their OB/GYN. Among those who had children, nearly all had unplanned pregnancies. Those with unplanned pregnancies noted limited knowledge on the steps needed to prepare for pregnancy beyond stopping contraceptives and expressed that having prepregnancy support would have been highly valued.

When asked about willingness to receive an invitation to participate in family planning services, responses varied by setting. Opinions were split on receiving such services in the ED. Some participants were open to receiving information and support in the ED if it did not interfere with the primary reason for their visit, while others preferred not to be approached in this setting. In contrast, participants were more inclined to engage at community events, particularly when health improvement information was included, and many considered clinic settings to be the most appropriate venue for family planning discussions.

The types of support that participants viewed as most valuable for family planning included having a trusted person with prior childbirth experience, consistent ongoing support, providers who were age- and demographically appropriate, and information delivered gradually rather than all at once. Additional recommendations focused on the inclusion of men in family planning and that men often must learn independently, face distinct stigma in accessing information, and therefore require tailored approaches. Suggestions included holding separate community conversations with men to reduce stigma for both genders and integrating men into broader family planning conversations to reinforce shared responsibility.

Finally, participants identified diverse strategies to more effectively engage women of reproductive age in family planning. Suggestions included breaking conversations into smaller, more accessible discussions including using social media to bridge information gaps; creating youth-oriented programming in which adolescents and young adults discuss real community situations; and providing relaxed, open settings to facilitate conversations among older groups.

Community survey

Across the full sample (N = 537 reproductive-age women), most participants were between ages 25–44 (74%), identified as Black/African American (59%), and had at least a high school education (84%). Just over half (54%) lived in households with children. Health insurance coverage was mixed, with 46% on public health plans, 29% with private coverage, and 20% uninsured. Nearly one in four participants (22%) reported experiencing hunger in the past year, 13% worried about losing housing in the next 2 months, and more than one-third (35%) reported transportation challenges in the past 6 months. Half reported at least one comorbid physical (37%) or mental (32%) condition (data not shown). Women reported interest in receiving reproductive health services in the coming year: 12% were interested in pregnancy support, 19% in support to prevent pregnancy, and 78% of those who had not had a well-woman visit were interested in free visits.

Significant differences emerged across several domains (see Tables 1 and 2). Interest in pregnancy support varied by age, race, insurance, hunger, housing insecurity, and transportation challenges, with 18–24-year-olds, Black participants and those reporting economic hardships more likely to express interest in receiving support. Interest in pregnancy prevention differed significantly by age, with 18–24-year-olds more often seeking prevention. Interest in well-woman visits demonstrated the strongest associations, with differences by age, race, education, household children, insurance, and multiple socioeconomic indicators (all p < 0.001).

Table 1.

Our Healthy Jackson County Participants by Interest in Reproductive Health Services and Planning Pregnancy, N = 537

Variable	Total	Support during pregnancy			Support to prevent pregnancy			Well woman exam in the last 12 months
		No	Yes	p	No	Yes	p	Had well woman last 12 months	No well woman last 12 months	No well woman last 12 months-want free exam	p
N	537	250	102		354	67		288	51	182
Age				0.02			0.002				<0.001
18–24	142 (26%)	57 (23%)	32 (31%)		86 (24%)	29 (43%)		51 (18%)	18 (35%)	69 (38%)
25–34	204 (38%)	96 (38%)	46 (45%)		127 (36%)	24 (36%)		124 (43%)	15 (29%)	60 (33%)
35–44	191 (36%)	97 (39%)	24 (24%)		141 (40%)	14 (21%)		113 (39%)	18 (35%)	53 (29%)
Race				<0.001			0.74				0.01
White	134 (25%)	75 (30%)	16 (16%)		99 (28%)	16 (24%)		78 (27%)	14 (27%)	41 (23%)
Black/African American	316 (59%)	122 (49%)	72 (71%)		194 (55%)	40 (60%)		175 (61%)	33 (65%)	97 (53%)
Other	87 (16%)	53 (21%)	14 (14%)		61 (17%)	11 (16%)		35 (12%)	4 (8%)	44 (24%)
Hispanic ethnicity				0.14			0.77				0.01
No	410 (76%)	174 (70%)	79 (77%)		265 (75%)	49 (73%)		231 (80%)	42 (82%)	126 (69%)
Yes	127 (24%)	76 (30%)	23 (23%)		89 (25%)	18 (27%)		57 (20%)	9 (18%)	56 (31%)
Education				0.85			0.70				<0.001
Less than high school	87 (16%)	43 (17%)	18 (18%)		50 (14%)	11 (16%)		33 (11%)	18 (35%)	29 (16%)
High school/GED	195 (36%)	85 (34%)	38 (37%)		135 (38%)	25 (37%)		97 (34%)	19 (37%)	77 (42%)
Some college	139 (26%)	70 (28%)	24 (24%)		91 (26%)	20 (30%)		90 (31%)	7 (14%)	40 (22%)
College degree	116 (22%)	52 (21%)	22 (22%)		78 (22%)	11 (16%)		68 (24%)	7 (14%)	36 (20%)
Household includes children <18 years				0.48			0.24				0.001
No	245 (46%)	117 (47%)	52 (51%)		152 (43%)	34 (51%)		109 (38%)	27 (53%)	99 (54%)
Yes	292 (54%)	133 (53%)	50 (49%)		202 (57%)	33 (49%)		179 (62%)	24 (47%)	83 (46%)
Insurance				0.04			0.09				<0.001
No insurance	109 (20%)	53 (21%)	20 (20%)		69 (19%)	10 (15%)		36 (13%)	12 (24%)	54 (30%)
Private	149 (28%)	82 (33%)	24 (24%)		105 (30%)	17 (25%)		106 (37%)	9 (18%)	33 (18%)
Public	247 (46%)	107 (43%)	48 (47%)		167 (47%)	33 (49%)		136 (47%)	26 (51%)	78 (43%)
Missing	32 (6%)	8 (3%)	10 (10%)		13 (4%)	7 (10%)		10 (3%)	4 (8%)	17 (9%)
Hunger in the last 12 months				0.03			0.66				0.24
No	383 (71%)	191 (76%)	66 (65%)		268 (76%)	49 (73%)		219 (76%)	33 (65%)	124 (68%)
Yes	122 (23%)	46 (18%)	32 (31%)		70 (20%)	16 (24%)		58 (20%)	14 (27%)	47 (26%)
Missing	32 (6%)	13 (5%)	4 (4%)		16 (5%)	2 (3%)		11 (4%)	4 (8%)	11 (6%)
Worried about losing housing next 2 months				0.002			0.25				0.15
No	437 (81%)	214 (86%)	71 (70%)		303 (86%)	52 (78%)		240 (83%)	40 (78%)	144 (79%)
Yes	68 (13%)	26 (10%)	21 (21%)		36 (10%)	11 (16%)		37 (13%)	5 (10%)	24 (13%)
Missing	32 (6%)	10 (4%)	10 (10%)		15 (4%)	4 (6%)		11 (4%)	6 (12%)	14 (8%)
Transportation challenges in last 6 months				0.004			0.06				0.37
No	347 (65%)	171 (68%)	53 (52%)		248 (70%)	39 (58%)		188 (65%)	35 (69%)	109 (60%)
Yes	190 (35%)	79 (32%)	49 (48%)		106 (30%)	28 (42%)		100 (35%)	16 (31%)	73 (40%)

Table 2.

Predictors of Interest in Support for Reproductive Health Services and Planning Pregnancy from Reproductive-Aged Women in Our Healthy Jackson County, N = 537

Variable	Support during pregnancy	Support to prevent pregnancy	Well-Woman visit a
			No exam	No exam—interested in free
N	301	401	490
Age
18–24	2.17** (1.37,3.45)	2.79** (1.50,5.17)	2.07 (0.90, 4.74)	2.09* (1.19, 3.68)
25–34	1.50 (0.95,2.37)	1.71 (0.90,3.26)	0.90 (0.41, 1.94)	0.94 (0.58, 1.53)
35–44	Referent	Referent	Referent	Referent
Race
White	Referent		Referent	Referent
Black	3.01*** (1.58,5.73)		1.05 (0.47, 2.34)	0.94 (0.56, 1.60)
Other	1.48 (0.68,3.20)		0.64 (0.17, 2.35)	1.69 (0.86, 3.34)
Hispanic ethnicity			0.82 (0.28, 2.37)	1.08 (0.58, 2.03)
Household includes children <18 years			0.54 (0.27, 1.07)	0.59* (0.37, 0.92)
Health insurance
No insurance	1.39 (0.85,2.29)	0.78 (0.41,1.51)	4.87** (1.81, 13.1)	4.63*** (2.48, 8.65)
Public	1.00 (0.64,1.58)	0.98 (0.57,1.67)	2.27 (0.98, 5.23)	2.04** (1.22, 3.41)
Private	Referent	Referent	Referent	Referent
Hunger in the last 12 months	1.03 (0.67,1.60)
Worried about losing housing next 2 months	1.67* (1.07,2.59)
Transportation challenges in last 6 months	1.44 (0.99,2.08)	1.59 (0.99,2.56)

Exponentiated coefficients; 95% confidence intervals in brackets; *p < 0.05, ^** p < 0.01, ^*** p < 0.001.

^a Interested in a free well-woman examination stratified by receipt of a well-woman examination in the last year, referent is women who received a well-woman exam.

Of the sample, 64% of participants had ever been pregnant, and 74 women (14%) were currently planning to become pregnant in the next year (data not shown). While age was not associated with planning pregnancy, socioeconomic disadvantage was, with clear evidence of economic need among those intending pregnancy. Planning pregnancy was more common among African American participants (relative risk [RR] = 2.19, 95% confidence interval [CI] 1.10, 4.34), those without health insurance (RR = 1.95, 95% CI: 1.13, 3.37), and those with transportation challenges (RR = 2.15, 95% CI: 1.34, 3.46). Planning pregnancy was slightly more common (RR = 1.48, 95% CI: 0.87, 2.50) among those with housing instability, although this difference was not statistically significant.

WE CARE-JC pilot intervention

Feasibility was demonstrated by successful screening, enrollment, and follow-up of participants. A total of 53 eligible patients were identified through the EMR and approached in the ED after clinical evaluation. Of these 45 patients (85%) consented to participate. Most participants reported being single (60%) and having a high school education or some college education (84%). More than half of the participants (58%) identified as non-Hispanic Black or African American, followed by non-Hispanic White (29%), and other racial groups. Public health insurance (Medicaid, Medicare, or Tricare) was reported by 40% of the participants, while 20% were uninsured, and 7% self-paid medical services and fees. Ninety-six percent of patients were stable (ESI 3–4) with a variety of chief complaints including gynecologic (20%; e.g., menstrual pain, vaginal bleeding) and urogynecologic (10%; e.g., painful urination, abdominal pain) complaints, as well as chest or back pain, symptoms of infectious or injury.

Slightly more than half of participants (58%) scheduled their follow-up with a primary care provider or OB/GYN. Of these, 10 participants (39%) attended follow-up appointments, 19% cancelled their appointments, and 39% no-showed their appointments. Participant feedback was obtained from 8 of the 10 individuals who attended follow-up appointments; all of whom recommended the MyPath tool.

Discussion

Previous efforts to improve maternal and infant health outcomes have integrated multidisciplinary care across the reproductive continuum, addressed social determinants of health, implemented hospital-centered initiatives, enhanced pre-pregnancy education, and regionalized maternal care.^14,15 However, few interventions have focused specifically on addressing reproductive health decision-making needs before conception through community-informed linkage to care and education. Using a reproductive justice-informed and community-engaged approach, we conducted listening sessions and a county-wide survey to inform the design of WE CARE-JC, a multicomponent intervention focused on reproductive health education, decision support, and linkage to reproductive health services. This approach may be particularly important for medically underserved populations that experience disproportionate sexual and reproductive health inequities,^4,5,16,17 reduced reproductive autonomy,^18,19 and barriers to accessing reproductive health services.

Findings from listening sessions underscored the importance of supporting women and their partners to make informed sexual and reproductive health decisions. Consistent with past research, participants identified access to care and reproductive autonomy as central to their reproductive health experiences and expressed strong interest in receiving services across multiple settings, including clinical and community environments.^20–22 They also expressed interest in engaging their male partners in health decisions; however, prior research presents mixed findings, with women’s preferences varying by relationship quality, safety, and autonomy.^23–25 These findings directly informed the WE CARE-JC intervention components, including use of the MyPath decision-support tool, community health worker-led counseling, and facilitated linkage to OB/GYN and primary care services for contraception or pregnancy planning.

Similar to prior research, nearly all listening session participants had experienced unplanned pregnancies and reported that pregnancy planning support would have been helpful. ²⁶ Despite the high prevalence of unplanned pregnancy, participants did not identify stigma as a barrier to discussing pregnancy planning or reproductive goals. These findings highlight the importance of addressing preconception planning needs across diverse populations, particularly among individuals who experience barriers to care and are at elevated risk for poor birth outcomes. Future research should examine interest in prepregnancy planning information and strategies to support these needs across clinical and community settings in collaboration with community and health partners.

Findings from our community survey suggest community-based clinics in socially vulnerable areas may be an important setting to reach reproductive-age women affected by multiple social determinants that create barriers to accessing sexual and reproductive health services. Consistent with past studies, the community survey indicated that participants often had limited health insurance, challenges accessing health care and transportation services, and comorbid health conditions.^27,28 Such barriers to reproductive health care are common nationwide and, according to recent evidence, may be increasing amid widening socioeconomic inequities and changes in coverage policies. ²⁹ Those who were uninsured were less likely to have completed their well-woman exam in the past year. This finding is not surprising given the well-established association between health insurance and the likelihood of receiving preventive health care services.^30–34

Regular well-woman care is an upstream preventive service that supports reproductive health, facilitates family planning, and improves pregnancy outcomes. Overall, demographic patterns in our survey highlighted socioeconomic barriers among young and mid-life minority women, with significant disparities evident in pregnancy support and access to well-woman care.^35–37 These findings underscore the need for accessible, community-based sexual and reproductive health services that also address basic needs, such as transportation and housing security. Addressing these social needs has been shown to enhance access to reproductive care and improve maternal and infant health outcomes.^37–41

WE CARE-JC addresses reproductive health inequities by engaging participants through “One Key Question”: “Are you planning to get pregnant in the next year?” This question encourages informed decision making about pregnancy planning, folic acid use, and contraception. ⁴² Listening sessions revealed that participants preferred pre-pregnancy discussions in clinical settings but were also comfortable in community clinics and EDs once their immediate concerns were addressed.

The WE CARE-JC pilot demonstrated feasibility and acceptability in a safety-net hospital ED serving predominantly low-income and uninsured populations, similar to the original WE CARE study, ⁹ with 85% of women agreeing to screening, navigation services, and linkage to care. This rate of uptake is comparable to the original WE CARE study, in which 81% of participants accepted support when offered contraceptive counseling. WE CARE-JC extended this model beyond contraceptive care to include women interested in becoming pregnant and in need of linkage to future obstetrical services.

The current study’s findings also suggest that the WE CARE empowerment model has the potential to improve engagement with potentially hard-to-reach populations and that this marginalized population has a strong interest in receiving sexual and reproductive health support and services. However, attendance at scheduled follow-up appointments was low. Appointment completion rates were not reported in the original Detroit WE CARE study, limiting direct comparison. ⁹ Attendance in the current pilot was consistent with no-show rates reported in comparable safety-net health systems,^43,44 highlighting the need for future research on motivations, facilitators, and barriers to engagement. Participants who completed follow-up appointments reported that they would recommend the MyPath tool, indicating its acceptability and usefulness for preconception and contraceptive planning.

While ultimately we seek to implement this intervention in diverse clinical and community settings, this pilot study focused on the ED setting. EDs represent important points of contact with reproductive-age women. In 2022, this population accounted for nearly 35 million visits, representing approximately 40% of all female ED visits. ⁴⁵ Because EDs at safety net hospitals serve as critical access points for individuals with unmet health and social needs, this high utilization underscores the ED as a strategic setting to identify health care needs and connect women to supportive services. ⁴⁶

Future qualitative work with WE CARE-JC participants should explore participant needs and preferences to refine intervention components, enhance sustained engagement, and identify barriers to appointment attendance. Further, rigorous evaluation of the WE CARE model in trusted community settings, such as faith-based institutions, is needed to assess feasibility, acceptability, and implementation fidelity outside clinical environments. Embedding the model within these settings may expand access to family planning, preconception, and prenatal care services and help reduce infant mortality disparities in medically underserved communities. ²²

This pilot study has several limitations. The sample size limited statistical power and the ability to assess subgroup differences; however, the primary goal was to adapt an existing intervention to a local context through a community-engaged process. Participants may not represent the broader population of reproductive-age women, introducing potential selection bias. Additionally, community feedback highlighted the need to engage men in reproductive health. The current intervention was not designed for male participants and did not address their roles in women’s reproductive care or joint decision-making. Future iterations should incorporate male sexual health, including sexually transmitted infection screening, sexual health education, and group-based reproductive planning and collaborative reproductive planning.

Conclusion

Looking ahead, research should explore how this model can be implemented across diverse health systems that vary in resources, staffing, and infrastructure. Evaluating long-term sustainability, particularly beyond safety net hospitals and community clinics, remains an important priority. Broader adoption will require adaptation to local patient preferences, cultural norms, and lived experiences to ensure relevance and acceptability. Finally, supportive policy environments, reimbursement mechanisms, and the use of implementation science frameworks will be critical to promoting equitable and sustainable scaling to broadly improve infant mortality.

Authors’ Contributions

J.E.A. advised on study design, assisted with protocol development, conducted all quantitative analyses, managed community survey data, created REDCap forms for the community survey, and led the writing and revision of the article. J.B.-P. co led the conceptual adaptation of the intervention with T.N.J. integrated findings from the community survey and listening sessions into the adapted study design, developed the qualitative coding schedule with B.N. oversaw implementation and adaptation, supervised research staff for the overall initiative, obtained grant funding, and served as Principal Investigator. B.N. led the Phase 2 trial, obtained human subjects’ approval, drafted consent documents and study protocols, assisted with study design and protocol development, created REDCap forms for the Phase 2 pilot, recruited participants, conducted and analyzed listening sessions, and co-developed the qualitative coding schedule. T.N.J. co-led the intervention adaptation with J.B.-P., integrated findings from the community survey and listening sessions into the adapted study design, contributed to study design, led the WE CARE project within the overall initiative, oversaw staff for adaptation of the intervention and development of the Phase 2 study protocol and materials, and led Phase 2 pilot implementation. A.R.P. assisted in the conduct of the Phase 2 pilot and listening sessions and supervised research assistants collecting pilot data. A.T.N., G.J.P., and K.P. recruited Phase 2 pilot participants, obtained informed consent, and facilitated data collection. S.R.E. provided clinical supervision and oversaw research staff recruiting, consenting, and interviewing participants in the ED. M.T.C. developed the original Detroit WE CARE intervention and advised investigators on its adaptation to the Kansas City implementation. J.E.A., J.B.-P., B.N., T.N.J., A.R.P., A.T.N., G.J.P., K.P., and S.R.E. contributed to drafting and revising the article and approved the final version.

Abbreviations Used

CI

Confidence interval

COVID-19

SARS-CoV-2 virus

ED

Emergency department

EMR

Electronic medical record

ESI

Emergency severity index

HPV

Human papillomavirus

IMR

Infant mortality rate

JC

Jackson County

N

Number

OB/GYN

Obstetrics and gynecology

OHJC

Our Healthy Jackson County

p

p-value

RR

Relative risk

TX

Texas

US

United States

WE CARE

Women & Person-Empowered Community Access for Reproductive Equity

Cite this article as: Allsworth JE, Berkley-Patton J, Nguyen B, Johnson TN, Primgaard AR, Nguyen AT, Pietrusinski GJ, Patel K, Caldwell MT, Ellison SR (2026) From Detroit to Kansas city: Adapting the WE CARE model to improve maternal and infant health, Health Equity, 2026, 10, 24731242261455680, DOI: 10.1177/24731242261455680.