Background:
Closely-spaced pregnancies play a significant role in poor pregnancy outcomes. The ideal inter-pregnancy period is at least 18 months, yet in Grand Rapids, Michigan, one-quarter of African American women become pregnant within 18 months of delivery. Fear, discrimination, misconceptions, lack of insurance and lack of transportation are some of the barriers that prevent many women from accessing reproductive health services.
Strong Beginnings is a Healthy Start program that targets African American women to improve maternal-infant health, with the capacity to serve 300 women at any one time through case management services. Community health workers (CHWs) represent the community they serve. They conduct outreach to engage hard-to-reach women and act as peer advocates and peer educators. We believe CHWs are a key component of the case management team since they relate to program participants as peers and build special trust relationships.


Objectives:
To increase the percent of program participants who prevent a subsequent pregnancy for at least 18 months after delivery.

Methods:
Employ nine full-time CHWs who partner with approximately 35 women each from pregnancy until two years after delivery.
In collaboration with case managers, CHWs help women develop a birth control plan during pregnancy, ensure they actually access family planning services within 6-8 weeks of delivery, and discuss family planning during home visits (every 2 – 4 weeks). They verify clients have sufficient supply of birth control, review Emergency Contraception information and include male partners when appropriate.
CHWs help make appointments, provide transportation and arrange child care when needed. If necessary, CHWs accompany clients to appointments.


Results:
Since 2005 over 500 women have been enrolled in the program. While in Grand Rapids 25% of African Americans become pregnant within 18 months of delivery, in 2005 the percent of Strong Beginnings program participants who became pregnant within 18 months of delivery was 5.3%, and this dropped to 3.6% in 2006.

Conclusion and implications for practice:
Developing a long-term trust relationship with CHWs or peer advocates, frequent home visits that include discussion of reproductive health, and help overcoming barriers can give clients the support they need to access and utilize family planning services. This in turn results in improved child spacing.