Safe Start Community Health Worker Program: A Multisector Partnership to Improve Perinatal Outcomes Among Low-Income Pregnant Women With Chronic Health Conditions

Abstract

Safe Start is a community health worker program representing a partnership between a high-volume, inner-city, hospital-based prenatal clinic; a community-based organization; a large Medicaid insurer; and a community behavioral health organization to improve perinatal outcomes among publicly insured pregnant women with chronic health conditions in Philadelphia, Pennsylvania. As of June 2019, 291 women participated in the program. Relative to a comparison group (n = 300), Safe Start participants demonstrate improved engagement in care, reduced antenatal inpatient admissions, and shorter neonatal intensive care unit stays.

Chronic diseases such as obesity, diabetes, hypertension, and cardiovascular disease during pregnancy are associated with adverse maternal and neonatal health outcomes. Prevalence of these conditions is increasing in the United States, with higher rates among low-income and minority populations.¹ The use of community health workers (CHWs) is a promising strategy to reduce the incidence and impact of chronic disease during pregnancy.² The following analysis describes the implementation, evaluation, sustainability, and public health significance of Safe Start, a CHW program designed to improve outcomes for pregnant women with chronic health conditions through comprehensive and integrated medical care.

INTERVENTION

Safe Start represents a new model of collaborative care between a high-volume, inner-city, hospital-based prenatal clinic in Philadelphia, Pennsylvania (Helen O. Dickens Center at the Hospital of the University of Pennsylvania); a community-based organization (Maternity Care Coalition); the largest Medicaid managed care organization in the region (Keystone First); and the county behavioral health insurer and service provider (Community Behavioral Health). Safe Start CHWs (called advocates) provide patient navigation and case management services to publicly insured pregnant women with chronic health conditions, and engage in systematic case reviews with health care providers and insurers. The ability of the partner organizations to share information and jointly address barriers was critical to the success of the program.

PLACE AND TIME

Concern over Philadelphia’s maternal mortality rate—53% higher than the national rate³—led Maternity Care Coalition to conduct focus groups documenting low-income pregnant women’s prenatal and postpartum care experiences; these focus groups drove Safe Start’s design and implementation. Findings included that women did not feel “heard” by providers, faced social and economic difficulties exacerbated by pregnancy, and experienced challenges with insurance, transportation, and child care. Maternity Care Coalition formed an advisory group composed of members from across Philadelphia representing expertise in obstetrics, nursing, primary care, public health, domestic violence, mental health, pregnant women, managed care, and advocacy, to provide additional input. After identifying a committed clinical partner in the Hospital of the University of Pennsylvania and securing funding, Safe Start was implemented in Philadelphia in March 2015.

PERSON

As of June 2019, 291 women had completed the Safe Start program. Eligibility criteria are as follows: pregnancy with preexisting obesity, hypertension, diabetes, depression or a substance use disorder, and evidence of one or more missed medical appointment. Many Safe Start clients also face challenges related to housing, food insecurity, and other social determinants of health.

PURPOSE

Safe Start aims to improve health outcomes for pregnant women with chronic health conditions by ensuring that they receive the care and support they need before, during, and after childbirth. This includes addressing social determinants that are obstacles to women having a healthy pregnancy and taking care of their postpartum health needs.

IMPLEMENTATION

Recruitment into Safe Start occurs via face-to-face meetings between prospective clients and CHWs at the Dickens Center, referrals from the hospital social worker, and direct outreach to high-risk patients by the CHWs. The CHWs initiate care by meeting a client in her home or community and discussing her current health needs and goals. Clients are assessed for depression, trauma, intimate partner violence, and social determinant needs. They choose priority goals, such as building family relationships, finding employment, or losing weight. The CHWs assist in planning and supporting their steps to achieve these goals.

The CHWs provide comprehensive case management, care coordination, and emotional support to clients through three months postpartum. CHWs receive extensive training (see Appendix, available as a supplement to the online version of this article at http://www.ajph.org). Trained as birth doulas, they help women prepare for birth and breastfeeding, accompanying them through labor and delivery. They visit clients’ homes, accompany them to appointments, and regularly communicate through phone calls and text messaging. Each week the clinical care teams review scheduled patients, and the CHWs provide real-time updates on Safe Start clients and their progress outside of the clinic. Their contributions enable all care team members to better understand and serve their patients. Furthermore, CHWs communicate women’s progress and barriers to partner organizations.

EVALUATION

We conducted a prospective cohort study to assess the effectiveness of Safe Start to improve perinatal outcomes. Data came from the CHW client database and electronic health record data maintained by staff at Maternity Care Coalition and Hospital of the University of Pennsylvania, respectively. The two data sets are merged quarterly, along with a comparison group (n = 300) of Dickens Center patients who were eligible for Safe Start but declined to participate, did not complete intake, or were not approached because of CHW patient load.

We used multivariable logistic and Poisson regression to compare adequacy of prenatal care,⁴ inpatient admissions and emergency visits during pregnancy, delivery mode, preterm birth, neonatal intensive care unit admission and length of stay, neonatal abstinence syndrome, and postpartum visit attendance and contraceptive use among Safe Start participants and the comparison group, controlling for potential confounders.

Safe Start participants were significantly more likely to be African American and have hypertension and less likely to report substance use than the comparison group (Table 1). Controlling for these differences, Safe Start participants had lower odds of inadequate prenatal care (adjusted odds ratio [AOR] = 0.37; 95% confidence interval [CI] = 0.27, 0.53) and antenatal inpatient admissions (AOR = 0.58; 95% CI = 0.35, 0.96) and higher odds of postpartum visit attendance (AOR = 1.47; 95% CI = 1.05, 2.06) and contraception use (AOR = 1.57; 95% CI = 1.06, 2.34) than the comparison group (Table 2). We observed no differences in rates of neonatal intensive care unit admissions; however, length of stay among babies admitted to the neonatal intensive care unit was significantly shorter among babies born to Safe Start participants (adjusted incidence rate ratio = −0.14; 95% CI = −0.23, −0.05).

TABLE 1—

Participant Characteristics: Safe Start Community Health Worker Program, Philadelphia, PA, 2015–2019

	Safe Start, No. (%)a (n = 291)	Comparison Group, No. (%) (n = 300)	Pb
Demographic
Race			< .001
African American	281 (97)	267 (89)
Other	10 (3)	33 (11)
Hispanic	8 (3)	12 (4)	.4
Age, y			.27
14–18	13 (5)	9 (3)
19–35	254 (87)	256 (85)
36–50	24 (8)	35 (12)
Married	33 (11)	27 (9)	.35
Clinical
Nulliparous	41 (14)	47 (16)	.59
Prior preterm birthc	50 (20)	52 (21)	.88
Hypertension	91 (31)	66 (22)	.011
Diabetes	38 (13)	25 (8)	.06
Obesed	133 (46)	130 (43)	.56
Behavioral healthe	168 (58)	152 (51)	.09
Substance usef	77 (26)	114 (38)	.003

^aMean gestational age of enrollment for Safe Start clients was 28.3 weeks (SD = 5.89).

^bP values represent χ² test in cells > 5 and Fisher exact test in cells ≤ 5.

^cAmong multiparous women (n = 503).

^dPatients with a body mass index ≥ 35 kg/m² prior to pregnancy.

^eReported anxiety, depression, posttraumatic stress disorder, panic attacks, or bipolar, during pregnancy in the electronic medical record problem list or patient’s report.

^fReported drug, alcohol, or tobacco use during pregnancy in the electronic medical record problem list or patient’s report.

TABLE 2—

Association Between Safe Start Participation and Perinatal Outcomes: Philadelphia, PA, 2015–2019

	Women, No. (%) or Mean ±SD
	Safe Starta (n = 291)	Comparison Group (n = 300)	AOR (95% CI)b or AIRR (95% CI)c
Prenatal period
Inadequate prenatal cared	61 (21)	127 (42)	0.37 (0.25, 0.53)
Inpatient admissions	31 (11)	49 (16)	0.58 (0.35, 0.96)
Emergency visits	110 (38)	117 (39)	0.80 (0.56, 1.13)
Delivery, postpartum
Cesarean deliverye	99 (34)	97 (32)	0.97 (0.64, 1.46)
Preterm birth (< 37 wk)f	54 (19)	54 (18)	1.07 (0.69, 1.66)
Preterm birth (< 34 wk)f	15 (5)	19 (6)	0.82 (0.39, 1.69)
NICU admission	50 (17)	63 (21)	0.85 (0.55, 1.29)
NICU length of stay,g d	15.9 ±3.0	18.3 ±3.5	−0.14 (−0.23, −0.05)
Neonatal abstinence syndromeh	1 (1)	11 (10)	−1.49 (−3.2, 0.25)
Postpartum visit	169 (58)	143 (48)	1.47 (1.05, 2.06)
Postpartum contraception	232 (80)	219 (73)	1.57 (1.06, 2.34)

Note. AIRR = adjusted incidence rate ratio; AOR = adjusted odds ratio; CI = confidence interval; NICU = neonatal intensive care unit.

^aApproximately 7% of participants withdrew from the Safe Start program. There were no maternal deaths.

^bUnless otherwise specified, all models are logistic regression and control for participant factors that were significantly different between the Safe Start and comparison group cohorts (i.e., race, hypertension, and substance use).

^cPoisson regression.

^dRevised-Graduated Prenatal Care Utilization Index (R-GINDEX), collapsed into groups: inadequate versus intermediate and adequate.

^eAdjusted for prior cesarean, race, hypertension, and substance use.

^fAdjusted for prior preterm birth, race, hypertension, and substance use.

^gAmong patients with a NICU stay (n = 113).

^hFirth logistic regression among patients with documented substance use (n = 191).

ADVERSE EFFECTS

We observed no adverse effects or unintended consequences associated with Safe Start participation.

SUSTAINABILITY

Important strides have been made toward sustaining the Safe Start program, yet challenges remain. Efforts by the Pennsylvania State Medicaid office to transition Medicaid managed care contracts to value-based payment contracts are promising steps toward ensuring future sustainability, as Safe Start is clearly aligned with the quality improvement and community-based care components needed to make this transition. In January 2017, Maternity Care Coalition established a contract for reimbursement for services with Keystone First that currently provides critical revenue to support implementation of the program. Although critical, it covers less than one third of Safe Start’s operating costs and is not sufficient to support scaling the model. Negotiations are likewise under way with Community Behavioral Health. However, establishing these contracts is a multiyear process, requiring local and state review of proposed services.

The most significant challenges to the continued success of Safe Start include the following: uncertainty at the national level about existing and future health care policy, which may affect incentives for community health models; uncertainty about how rapidly health care delivery will evolve in terms of reducing silos in different systems (e.g., data sharing among health systems and insurers); and engagement of Pennsylvania decision-makers, including the Office of Medical Assistance and the Office of Mental Health and Substance Abuse Services, in new reimbursement approaches. Safe Start partners are working with city and state representatives to achieve greater support for perinatal interventions. Pennsylvania’s Department of Human Services recently established a statewide Maternal Mortality Review Committee, providing a critical pathway for further understanding and addressing maternal health needs.

PUBLIC HEALTH SIGNIFICANCE

Women are increasingly entering pregnancy with preexisting chronic health conditions.^5,6 The scale-up and sustainability of evidence-based CHW programs, driven by community partnership, to improve maternal and child health outcomes is a national imperative.