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4P's Plus Pregnancy Support Project

  • Need: To provide pregnancy support services to Native American women who struggle with substance use.
  • Intervention: An integrated behavioral health network was implemented in Lake County, California.
  • Results: As a result of this project, fewer Native American babies were exposed to alcohol, tobacco, and other drugs.
Promising (About evidence-level criteria)

Lake County Tribal Health logo The 4P's Plus Pregnancy Support project was organized by the Lake County Tribal Health Consortium, along with 10 local private and nonprofit agencies who serve pregnant and parenting Native American women. In northern California, a countywide screening revealed that 63% of women used tobacco, alcohol, drugs, or prescription medications a month prior to knowing they were pregnant. Substance use by Native American pregnant women and their partners, lack of access to transportation, limited trust for non-Native prenatal providers, and little knowledge about the importance of prenatal care, all drove the need for this project.

The 4P's Plus Pregnancy Support project provides pregnancy support services to women specifically at risk for substance abuse. The program utilizes the evidence-based 4P's Plus screen, which has been proven to reliably and effectively screen pregnant women for risk of substance use, including those who are missed by other perinatal screening methodologies.

The 4P's Plus Pregnancy Support Project offers additional mental health counseling, increased social and educational interactions, and integrated behavioral health support for participants. This is done to provide appropriate services and referrals to pregnant women for reduced substance use and to increase access to early and adequate prenatal care.

This program received support from a 2012-2015 Federal Office of Rural Health Policy Rural Health Care Services Outreach grant.

Services offered
  • First and third trimester screening for substance use
  • Depression and domestic violence/intimate partner violence services
  • Educational intervention early in the pregnancy
  • Connecting women to prenatal care in their first trimester and providing incentives to ensure an adequate number of follow-up visits
  • Pregnancy screening with professional and mental health counseling services
  • Relapse prevention counseling sessions
  • Mom-to-be shower and special celebrations
  • Women’s cultural wellness classes
  • GED and adult education classes
  • Parenting classes and groups
  • Job skills and job search classes

4P's initial screening revealed:

  • 76% of pregnant women had parents who had a problem with drugs/alcohol
  • 32% of pregnant women indicated their partners had a problem with substance abuse
  • 32% of pregnant women indicated depression was an issue for them
  • 85% of pregnant women had at least one ACE (Adverse Childhood Experience) marker

Results for women served from May 2012-April 2015 include:

  • 81% of women started their prenatal care in the first trimester, resulting in an improvement of more than 75%
  • 76% of women who completed initial intake process have engaged in services
  • 82% of live births were free of exposure to tobacco, alcohol, or drugs
  • Compared to the month before they knew they were pregnant, 52% more Native American pregnant women participating in the program abstained from any alcohol use; 18% more abstained from marijuana use; and 26% more quit smoking
  • Participants attended an average of 13 prenatal visits
  • 68% of the pregnant women who gave birth during their participation and indicated they were using substances at intake had abstained during their pregnancy

Lake County Tribal Health Consortium's work on this issue is also featured in RHIhub’s Rural Services Integration Toolkit Program Clearinghouse.


Some challenges this program faced include:

  • Getting pregnant women to make an ongoing connection with the Human Service Department
  • Making sure that pregnant women received and connected with all available support and referrals provided by the program and its consortium members
  • Women refusing referrals offered

In order to create a similar program, it is important to:

  • Grow the integration of behavioral and physical health services
  • Hire a mental health professional to provide counseling to pregnant women
  • Encourage community partner engagement
  • Develop a structured incentive program to encourage pregnant women to complete a desired number of prenatal visits
Contact Information
Patricia Hubbard, Program Director
Lake County Tribal Health Consortium
707.263.8382 Ext. 1303
American Indians, Alaska Natives, and Native Hawaiians
Behavioral health
Mental health
Prenatal care and obstetrics
Substance abuse
Wellness, health promotion, and disease prevention
States served
Date added
September 21, 2015

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.