By Darcy Dreyer
Maternal and Child Director, March of Dimes
A 23-year-old pregnant woman, Shawna was referred to WHEN by her prenatal care provider. At 25 weeks gestation, hers was considered a high-risk pregnancy due to a previous preterm birth, her race, poverty, a history of mental health issues, addiction to drugs and tobacco, and high blood pressure. She was living in a single room with all of her belongings and searching for a larger apartment before giving birth. Shawna was also involved in family court and working to regain custody of her 7-year-old son.
The WHEN patient navigator assisted Shawna in successfully applying for WIC benefits and made a referral to the Baby and Me Tobacco Free Smoking Cessation Program. With the help of the patient navigator, Shawna applied for several housing resources. She received education about prenatal care and health, the importance of the pregnancy reaching at least 39 weeks, breastfeeding and nutrition, healthy relationships, and a continued smoking cessation intervention provided by the patient navigator.
Shawna is attending classes to obtain her GED and is in mental health counseling as well as parenting classes. Through the work of the WHEN patient navigator, she is smoke-free and has done everything she can to have the best chance of delivering a healthy, full-term baby.
Women are the fastest growing segment of the jail population. Most crimes committed by women are nonviolent, drug-based, and/or poverty driven. A woman's path into the justice system is often very different from that of a man and likely includes intimate partner violence, sexual abuse, and substance abuse.1 In 2011, nearly half (45 percent or 2.8 million) of the 6.1 million pregnancies in the United States were unintended.2 At any given time, 6 to 10 percent of the female jail population is pregnant.1 Among justice-involved women, these pregnancies are often high-risk due to a lack of prenatal care, poor nutrition, smoking, domestic violence, mental illness, drug and alcohol abuse, and high rates of HIV and chronic disease. The judicial system is not positioned to effectively link these women to their many health care and social service needs.
The Women's Health Education Navigation (WHEN) program fills a void between health, social, and judicial sectors by providing patient navigation and case management to this high-risk population. The program, co-funded by March of Dimes and The Health Foundation for Western & Central New York, has been in operation since 2011 at four sites. The WHEN program aims to increase the incidence of healthy pregnancies, positive birth outcomes, and healthy infants for justice-involved women who are pregnant and/or parenting an infant.
Women who are justice-involved generally have lower incomes, with the majority on Medicaid or other public health insurance. In three of our four WHEN program sites, the patient navigator is an employee of the Center for Court Innovation, a nonprofit arm of the New York state judicial system tasked with improving services for marginalized populations. The fourth site is housed out of Niagara Falls Memorial Medical Center, a progressive hospital in a community with some of the poorest health outcomes in the state.
The WHEN patient navigator works first to ensure a client's basic needs are met: housing, food, and transportation. He or she makes sure the client establishes a medical home and assists with applications for public assistance.By helping women satisfy physiological and safety needs first, the WHEN program works to improve prioritization of health care and equity in access. Navigators can provide referrals for social services, community programs, and health care as well as attend court, medical, and social service appointments with clients. Navigators also provide health education including preconception and interconception information.
Since the program's inception in 2011, 463 clients have been provided with services. The majority (95 percent) had a mental health diagnosis, and 59 percent had substance abuse issues. In terms of birth outcomes, 40 percent were pregnant, and 77 percent of pregnant clients received comprehensive case management. As one sign of program success, among the case-managed population of women, the preterm rate was only 2.8 percent, compared with 7.4 percent among all clients and 9 percent in the state overall. The differences cannot be tested for statistical significance due to the small number of case-managed women, but this outcome is still quite promising. Housing was the most common referral provided to clients, followed by clothing/bedding/supplies, legal services, and transportation.
WHEN program impacts on the justice system include reductions in recidivism, termination of parental rights, and pregnancies in jail/prison. On health care we see improved access to prenatal care, improved birth outcomes and reductions in chronic disease. In social services, we see increased connections to mental health and substance abuse services. Success stories include diversion, reduced/dropped charges, erasing of a criminal record, and increased access to care and managed chronic and mental health conditions leading to better birth outcomes. A WHEN Patient Navigator Program (PNP) Network was formed to share challenges and best practices while working toward consistency in program delivery. Members include patient navigators from each site, staff from each of the funding partners, a program evaluator, and March of Dimes volunteers.
1. From National Resource Center on Justice Involved Women, "Ten Truths that Matter when Working with Justice Involved Women," April 2012.
2. Finer, L.B., and Zolna, M.R., Declines in unintended pregnancy in the United States, 2008–2011, New England Journal of Medicine, 2016, 374(9):843–852, http://nejm.org/doi/full/10.1056/NEJMsa1506575.
3. From Women in Prison Project of the Correctional Association of New York, "Reproductive Injustice: the State of Reproductive Health Care for Women in New York State Prisons," 2015.