Skip to main content

Perinatal Health Partners Southeast Georgia

Summary 
  • Need: In the 11 rural southeast Georgia counties, high-risk pregnant women potentially face adverse birth outcomes, including maternal or infant mortality, low birthweight, very low birthweight, or other medical or developmental problems.
  • Intervention: An in-home nursing case management program for high-risk pregnant women in order to maximize pregnancy outcomes for mothers and their newborns.
  • Results: Mothers carry their babies longer and the babies are larger when born, leading to improved health outcomes.

Evidence-level

Effective (About evidence-level criteria)

Description

Perinatal Health Partners logoPerinatal Health Partners (PHP) is an in-home nursing case management program for high-risk pregnant women with the goal of maximizing pregnancy outcomes for mothers and their newborns and decreasing the infant mortality rate and infant illnesses. Through assessments and care coordination, outcomes are improved for these women, many of whom face significant barriers to care.

Operating in the 11 southeast rural counties of Georgia, PHP partners with local OB/GYNs, birthing hospitals, county health departments, and others involved in perinatal care to identify early in the pregnancy those women considered high-risk. While only OB/GYNs, nurse practitioners, physician assistants, or primary care physicians are able to make referrals to the program, other healthcare professionals can fill out and submit a Patient Advocacy Form on behalf of the pregnant woman they would like to see participate in PHP.

A woman is identified as being high-risk if she has:

  • History of miscarriage or later pregnancy loss
  • Prior premature labor/delivery
  • Previous fetal/neonatal death
  • Gestational diabetes or type 1 or type 2 diabetes
  • Pre-eclampsia
  • Incompetent cervix
  • A multiples pregnancy (more than one fetus) with complications
  • A fetal abnormality in the current pregnancy
  • Other pre-existing medical conditions such as an autoimmune disease, epilepsy, or HIV

PHP is a line item budget at the state, and much of its funding comes from that source. In the past, PHP secured additional funding in the form of March of Dimes grants and a 2006-2009 Federal Office of Rural Health Policy (FORHP) Rural Health Care Services Outreach grant.

Services offered

  • Clinical assessments of mother and baby
  • In-home case management
  • Care coordination including referrals for medical costs, prenatal care, prenatal education, WIC services, and other needed services
  • Education for women and their families
  • Connection to needed resources

The case manager follows the mother and infant until 10 weeks postpartum. At this point, if the mother doesn't have a permanent method of birth control, an outreach worker (with the mother's permission) continues to follow the mother and baby until 2 years postpartum, monitoring birth control compliance as well as the baby's growth and development.

Results

According to the 2013-2014 PHP Annual Evaluation:

  • 215 women were served and 134 live births occurred from July 1, 2013, to June 30, 2014.
  • The recorded mean birthweight of singleton births was 6.83 lbs., with a mean gestational length of 37.7 weeks. Prior birth outcomes for this same group had a mean birthweight of 6.34 lbs. with a mean gestational length of 27.9 weeks.
  • On average, women were about 8.1 weeks into the pregnancy when referred to PHP.
  • 20.1% of all births were low birthweight, including pregnancies with multiples.
  • Two infant deaths were recorded.
  • 14% of referred patients who agreed to participate were lost to follow-up (for example, patients moved away or missed follow-up appointments). Only 1.4% of referrals refused service.
  • Surveys completed by PHP participants indicate a high level of satisfaction with PHP staff.

Results from the 14th year of operation can be found in the 2014-2015 PHP Annual Evaluation.

According to the 2015-2016 PHP Annual Evaluation:

  • 175 women were served and 105 live births occurred from July 1, 2015, to June 30, 2016.
  • The recorded mean birthweight of singleton births was 6.6 lbs., with a mean gestational length of 37.5 weeks. Prior birth outcomes for this same group had a mean birthweight of 6.24 lbs., with a mean gestational length of 27.5 weeks.
  • On average, women were 7.5 weeks into the pregnancy when referred to PHP.
  • 21% of all births were low birthweight, including pregnancies with multiples.
  • 0 infant deaths were recorded.
  • 20.6% of referred patients who agreed to participate were lost to follow-up. Only 0.6% of referred patients refused service.
  • Surveys completed by PHP participants show a very high level of satisfaction with the program.

For more information about PHP:

Raychowdhury, S., Tedders, S.H., O'Steen, G., & Jones, S. (2007). Multi-Level Evaluation of a Perinatal Health Program in Rural Southeast Georgia. Journal of the Georgia Public Health Association, 1(1), 34-42. Article Abstract

Barriers

It's a challenge to keep PHP in the forefront of physicians' minds so that they continue to make referrals to the program. Because PHP only serves certain counties in one health district, the physicians need to think about which of their patients are eligible to participate in PHP.

Replication

Major buy-in from local OB/GYNs is extremely important for a program like this because they are the source for referrals. Without referrals, there is no program. Referrals can come from a variety of health professionals, but not from nurses.

It is critical to have nurses who have the heart to do home visits and who either have perinatal experience or who are willing to become educated about perinatal issues. Nurse case managers should have a passion for pregnant women and babies and shouldn't be afraid in any way to provide home visits in all types of environments.

This program shows great outcomes for women with high-risk pregnancies.

Contact Information

Becky Mitchell, Program Manager
Southeast Health District
912.389.4623
becky.mitchell@dph.ga.gov

Topics
Care coordination
Children and youth
Home health
Prenatal care and obstetrics
Women

States served
Georgia

Date added
January 12, 2007

Date updated or reviewed
March 8, 2019


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.