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4P's Plus Pregnancy Support Project

  • Need: Pregnancy support services for Native American women struggling with substance use.
  • Intervention: An integrated behavioral health network implemented in Lake County, California.
  • Results: Fewer Native American babies exposed to alcohol, tobacco, and other drugs.


Promising (About evidence-level criteria)


Lake County Tribal Health logo In northern California, a county-wide screening revealed that 63% of women used tobacco, alcohol, drugs, or prescription medications a month prior to knowing they were pregnant. 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 Native American women in order to curb personal substance use and use by their partners. For this population, barriers such as transportation access, limited trust for non-Native prenatal providers, and insufficient knowledge about prenatal care importance all drove the need for this project.

The 4P's Plus Pregnancy Support project provided services to women specifically at risk for substance abuse. The program utilized the evidence-based 4P's Plus screen to evaluate substance use risks, often identifying clients missed by other perinatal screening methodologies.

The 4P's Plus Pregnancy Support Project offered additional services such as mental health counseling, increased social and educational interactions, and integrated behavioral health support for participants.

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

Due to insurance changes, the clinic's perinatal care is now guided by the California Department of Public Health's Comprehensive Perinatal Services Program (CPSP), a program that "provides a wide range of culturally competent services" during the interval from conception to 60 days postpartum. In addition to obstetrical care, nutrition, psychosocial and health education services are also provided.

Services offered

Services offered during the active grant cycle were:

  • Substance use screening during first and third trimester
  • Depression and domestic violence/intimate partner violence services
  • Prenatal care connection during first trimester and provision of incentives to ensure an adequate number of follow-up visits
  • Screening with professional and mental health counseling services
  • Substance use relapse prevention counseling sessions
  • Mom-to-be shower and special celebrations
  • Women's cultural wellness 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
  • 85% of pregnant women had at least one ACE (Adverse Childhood Experience) marker

Results for women served by the initial grant cycle from May 2012-April 2015 include:

  • 81% of women started first trimester prenatal care, a 75% increase from baseline measures
  • 76% of women who completed initial intake process also engaged needed services
  • Compared to a baseline, 52% more Native American pregnant women participating in the program completely abstained from alcohol use; 18% abstained from marijuana use; and 26% quit smoking
  • Participants attended an average of 13 prenatal visits
  • 68% of the pregnant women giving birth during participation indicated they were using substances at intake, but 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:

  • Ongoing connectivity with the Human Service Department
  • Ensuring client-service connections with all available support and referrals
  • Women declining offered referrals


In order to create a similar program, consider the following:

  • 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 the 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

Date updated or reviewed
December 13, 2017

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.