The Promise and Challenge of Implementing a Community Health Worker Strategy to Reduce Infant Mortality

Research Brief

The authors would like to thank: current and past program leadership and support staff; the outstanding team of Community Health Workers who serve as Community Neighborhood Navigators; and the WIN Network program participants who freely and enthusiastically shared their experiences.

Detroit has a serious infant mortality problem. Infants die there at a rate that is comparable to those in some less developed countries,[1] and the rate for African-American infants is even higher. According to the Annie E. Casey Foundation’s Kids Count data on infant mortality, Detroit consistently ranks as highest or second highest among the 50 largest cities in the nation. Detroit, Baltimore, Cleveland, and Memphis were the only cities that had infant mortality rates higher than 10 per 1,000 births each year between 2009 and 2011.[2]

In 2008, the four major health systems in Detroit (Detroit Medical Center, Henry Ford Health System, St. John Providence Health System, and Oakwood Healthcare System, now Beaumont Health—Dearborn) came together with other community partners to form the Detroit Regional Infant Mortality Reduction Task Force. One of its major initiatives was the development of what became the Women-Inspired Neighborhood (WIN) Network. WIN Network used community health workers (CHWs) to connect women in select neighborhoods of Detroit to health and social services, with the goal of empowering them to have healthy pregnancies, raise healthy babies and improve their lives.

CHWs have been shown to have a positive impact on a variety of maternal and child health outcomes such as a greater likelihood of initiating breastfeeding, more frequent use of nonviolent discipline methods, higher parenting efficacy scores, and lower rates of postpartum depression. While results vary by study, in general CHWs have been shown to be at least as effective as nurse interventions for maternal and child health outcomes. However, studies to date examining improvements in birth outcomes such as preterm births, low birthweight, and infant mortality have yet to show significant positive effects. While the lower cost of CHWs compared to nurse interventions is often assumed to be a benefit, there have not been enough rigorous cost-effectiveness studies to draw conclusions on that issue either.[3] While analysis is still being conducted, the WIN Network does appear to have produced positive outcomes suggesting that at least in some circumstances CHWs can help improve birth outcomes. There have been zero preventable infant deaths[4] among participants in WIN Network and the program is showing better rates of preterm and low birthweight births compared to the general population in Detroit. Future work under this project will include an assessment of the potential costs and benefits of programs such as WIN Network. Preliminary findings on the intervention are promising. Below we describe a variety of the benefits that have been found for program participants.

This research brief examines the development and implementation of WIN Network as an initiative designed to support individuals and create both neighborhood and systems change. Data was obtained through interviews with multiple key informants and focus groups with participants, as well as with the CHW staff members, called Community and Neighborhood Navigators (CNNs). Findings from this research show how CHWs offer a promising approach to addressing infant mortality and improving maternal and child health and well-being, while identifying the challenges of implementing such a strategy. Two dozen people participated in the focus groups and interviews conducted for this project. The report draws heavily on transcripts of these focus groups and interviews, which are unedited except to drop words that clarify sentences without changing the meaning and to add parenthetical words, phrases, or explanations as needed. Future briefs will examine some of the data that have been collected to assess the effect of WIN Network on the lives of the women and children in the program and the potential impact of improving those lives over the long run through programs like WIN Network.

Program Development

WIN Network was developed through a collaboration among members of the Detroit Regional Infant Mortality Reduction Task Force (henceforth referred to as the Task Force), which included representatives from the four Detroit-based tertiary and quality care health systems mentioned above, the state and local health departments, various community health coalitions, academic partners and the state health insurer’s association. Collaboration of this extent amongst the competing health systems was unprecedented. Henry Ford Health System had recently hired the former state Surgeon General in a leadership position, and her influence and connections played an important role in bringing the group together. The group sought to develop an innovative initiative to address the infant mortality disparity among the African-American population of Detroit. Eventually the Task Force settled on an initiative they named “Sew Up the Safety Net for Women and Children.” The motivation for the program stemmed from the realization that there were already an abundance of programs in Detroit—over 100 were inventoried—focused on providing resources to address infant mortality, and that many of them were undersubscribed. The goal was to link women in particular neighborhoods in the city with those existing resources by connecting them to Community/Neighborhood Navigators (CNNs) who were trained CHWs. As part of its efforts to avoid duplication, the program focused on women who already had a child because Detroit had a Nurse Family Partnership home visiting program that served first-time mothers.

The Task Force obtained funding from the Robert Wood Johnson Foundation Local Funding Partnerships, The Kresge Foundation, the W.K. Kellogg Foundation, the PNC Bank Foundation, March of Dimes Foundation—Michigan Chapter and The Jewish Fund. Each of the health system partners also contributed a collective $260,000 at the beginning of the program.[5] The program was based at Henry Ford Health System. Three objectives were defined:

  • Engage six Community & Neighborhood Navigators to recruit 1,500 at-risk women in three Detroit neighborhoods (Brightmoor, Osborn, Chadsey-Condon) and link them to safety net resources.
  • Provide educational sessions on healthcare equity to 500 physicians, nurses, social workers, and other health care professionals in Detroit’s major health systems.
  • Establish technologically relevant educational and supportive products to engage the broader community in promoting good health status prior to and during pregnancy.

This brief focuses on the first objective because it most directly impacted program participants. Though not explicitly stated, the program has operated to further a fourth objective, also covered in this brief, of supporting the development of CHW infrastructure in Detroit and in Michigan as a whole. The program sought to hire trained CHWs and worked with the Detroit Health Department and the Institute for Population Health to conduct the training of candidates for the position. This core competency training consisted of 160 hours of instruction over a 4-week period. WIN Network recruited about 17 participants for the training and provided $1,000 stipends to attend. WIN leadership deliberately chose to train more participants than the six they needed because they wanted to have the opportunity to select the best in the group and they saw the training as a way of building community capacity. In addition, the program’s leadership has supported the efforts of the Michigan Community Health Worker Alliance to build CHW infrastructure in regard to training, certification, and establishing sustainable funding sources.

The program chose to focus its efforts in three neighborhoods in Detroit: Brightmoor, Chadsey Condon, and Osborne. These neighborhoods were chosen because they had a large number of African-American women at risk for poor birth outcomes and because they were included in the Skillman Foundation Good Neighborhoods Initiative, a 10-year $100 million commitment by the Skillman Foundation to six Detroit neighborhoods with large numbers of children living in poverty that began in 2006. WIN Network was able to take advantage of the infrastructure and connections that had been developed in the Good Neighborhood Initiative in the three neighborhoods it selected for the initiative, and could complement Good Neighborhood’s focus on children and youth with its emphasis on improving birth outcomes.

Program Roll-out

Once the initial hiring was complete, attention turned to publicizing the program in the communities and recruiting women to participate. In the course of sharing information about the program with the CHWs and the community, it became clear that the “Sew Up the Safety Net” name, which had been enthusiastically endorsed by the planning group and funders, did not resonate with the community members who would be staffing and participating in the program.

They [community members participating in a focus group] were like, “What are you sewing up? Why is it called Sew Up the Safety Net? Are we slipping between some cracks or something? And are you going to sew up part of our body or is this a quilting club?” So, we thought it was brilliant. They thought it was terrible. [In the] focus groups the women said, “You know we’re winners, we’re resilient, we’re resourceful, we’re keepers of our community.” So, we thought we would reflect that positive side and call it WIN Network Detroit. One of our community health workers [came up with the name].
—Key Informant Interview

By embracing community engagement as a key strategy from the outset, WIN Network was able to avoid the problem of trying to recruit participants to a program whose name would have had little appeal to its intended audience.

Recruitment posed a greater challenge than was initially anticipated. Based on past success, one of the key initial strategies was having CHWs go door-to-door to talk about the program and let people in the neighborhoods know about it. But the city and context had changed in ways that made the door-to-door strategy less effective.

The door-to-door campaign did not necessarily work as well when we started WIN Network, as it had worked in past endeavors and I think it was because of the whole changing climate; with the economic downturn people were way more suspect of individuals coming to their door. The actual landscape of Detroit changed drastically. You had some blocks with one or two houses, some blocks with no houses, some blocks full of houses but only two were occupied or one of three occupied homes. Whereas before [for past programs] you walked up to some [houses], you knocked on the door they did not necessarily always let you in but they at least opened the door and would have a conversation with you. We did not find that to be the case when we first set out to do this program. So, we eventually stopped doing door-to-door campaigns.
—Key Informant Interview

The recruiting effort shifted to other strategies including community educational and screening events known as the Real Moms of Detroit Expos and CHWs reaching out to women they encountered in their day-to-day rounds at bus stops and grocery stores. The strategy had mixed results in terms of enrolling women into WIN Network.

In facilitating these events we would notice that we would have to engage hundreds of women just to enroll ten.
—Key Informant Interview

However the events were critical in getting WIN Network’s name out to the community and establishing its credibility. The events themselves were a form of support in that they provided important resources to women and community members.

Our community baby showers were awesome; everybody wanted to come, [people often asked], “When are you giving the next one?” We gave awesome gifts, you know, we embrace the women. We gave them what they needed. Some of them needed car seats, you need a car seat in order to bring your child home; we gave away car seats. So things that they needed and couldn’t get, we were able to give it to them. Then we had raffles. It made it fun; women like fun and bonding and we had food trucks. They came to our event and they distributed food. So it was for the community and you didn’t have to be pregnant; it was for the families and they came and we gave out a lot of food, a lot of stuff.
—Community Health Worker Focus Group

As people heard about these events they became more interested in being part of the WIN Network.

People were starting to recognize the brand of WIN Network and we got a lot of calls after that [community baby shower] and by that time our Facebook and social media pages were up and running so we got a lot of hits on Facebook after that as well. The event as well as the social media those were the more successful ways [of recruiting participants].
—Key Informant Interview

The program eventually succeeded in reaching its intended population. Intake surveys on the pregnant participants showed that almost 50% of pregnant participants were in unstable housing situations with one-third staying in a family member’s home and the rest staying with friends, living in a shelter, or describing themselves as being “between homes.” Just under 30% of the pregnant participants (29%) had less than a high-school education and 38% had a high-school diploma. The next most common level of educational attainment was some college or an associate degree (26%), with 8% having completed a bachelor’s or obtained a graduate degree. The vast majority of participants were age 20 or over (87%) and not married (91%) when they had the child that qualified them for the program.

In addition to the pregnant women, the program was able to engage large numbers of nonpregnant women, many of whom already had children or later became pregnant, but it did not necessarily formally recruit them into the program.

Events for the non-pregnant women did not work as well when it came to recruiting them. But they received education and information so they were given resource guides and we educated them on pre- and inter-conception health, how to be healthy before and in between pregnancies and that included nutrition, stress relief, that included pregnancy spacing and even budgeting but that was usually either a onetime session or one to three time sessions. We gave them information and education and then sent them on and so you might not ever see that non-pregnant woman again.
—Key Informant Interview

Despite this comment, the findings from a focus group with non-pregnant participants indicate that the program did have a strong influence on a considerable number of the non-pregnant women who did participate. Many would later become pregnant and become fully engaged with the CHWs.

Perceived Program Benefits

Program participants and staff described a number of ways in which the program benefited participants. The CHWs were well positioned in the community and because of that, were able to fulfill their goal of connecting program participants to services. One CHW indicated that program leadership was successful in identifying key neighborhood hubs where the CHWs were stationed and that the CHWs could then make the connection that enabled their clients to get services.

One thing that made us really good is they highly strategized and put us in the community hubs in our areas. I was at the [service center name] which is a major community hub and that is like a plethora of different agencies in one. My responsibility is to get to know these different agencies and listen to the women, [and find out] what they need. They need housing, they need different mental health resources and so that was my starting point, getting to know these agencies, going out, seeing how I can add more connections and personally introducing myself to the directors of the agencies. So when I do make a referral, they know, oh it’s coming from [CHW name] from WIN Network, not just another person.
—CHW Focus Group

Many of the program participants who were interviewed reported facing multiple challenges during their pregnancy including homelessness, lack of social support, and health issues. Both they and the CHWs noted the large amount of stress this entailed. Maternal stress has been associated with increased rates of infant mortality, low birthweight and preterm birth.[6] One CHW described how she saw her goal as being to reduce stress during pregnancy.

If [you’re] in a high stress situation, [you’re] in a shelter, your kids are not with you, you’re about to deliver, let’s see how we can alleviate some of that stress. I feel like if [I/WIN Network] didn’t come in her life and she had to deliver the baby and go back to the shelter, that would have been…that’s a traumatic experience. My goal, my personal goal is to make sure that baby was not delivered [to] the shelter and I made it happen.
—CHW Focus Group

Another participant described how her CHW helped her through a mental health crisis that was precipitated by the loss of her first child a few years before being introduced to WIN Network.

A couple of years ago I lost my first son so I was in a real depressed mood. I did not want to go outside. I did not want to be bothered, but [CHW name] she made sure that I came out to the events being with the other ladies that had been in different situations and stuff like that. She would make sure that I was always around other people, always around other women that had been in similar situations. She did everything that she could possibly do to help me motivate myself to get back out there and live life because it was bad.
—WIN Network Participant Focus Group

Both program staff and program participants talked about how the program provided social support to women who lacked it because of their family and neighborhood situations.

Our best accomplishment is unfortunately one [that] is undocumented. We were able to foster hope for so many women. Social isolation is such a huge problem in Detroit. People feel like because you come from a big family or because you live around neighbors that you constantly could not be socially isolated, but in all actuality a lot of people still feel alone and having a community neighborhood navigator who is willing to go to someone’s home, hold their hand through their pregnancy and just foster that hope, help them set that vision more and do the visioning exercises that foster hope.
— Key Informant Interview

When you come into a community that you see nothing but devastation, I mean burnt out homes, you know, that plays on your mind. But when you have somebody positive, like the WIN program then you got women coming up and saying, you know what, I never had a baby shower and they got four kids and that was their first baby shower. You see what it does to the mentality; it changes and gives them hope.
—Community Health Worker Focus Group

Program participants described how program activities helped them become healthier by educating them about how they can better take care of themselves and their babies.

Another thing about the program that I loved was that it talked about infant mortality and a lot of women did not understand the things that they were doing to themselves that would cause the high death rate in our communities. Whether it was environmental issues in the home, people smoking or chemicals being used, it was to teach young women things they should do to be able to carry their babies to term and then how to properly take care of their child and themselves after the child is born.
—WIN Network Participant Focus Group

I did not eat cheeseburgers I just snacked on fruit and I had a really, really good pregnancy and went to full term. The little books they gave us and all the stuff I learned. So, due to the program I had a really good pregnancy.
—WIN Network Participant Focus Group

I would probably [have] had several strokes by now because of my blood pressure, but by me volunteering with the program and watching the demonstrations on how to eat nutritional, it changed me. I mean, when I say 20 points in your blood pressure is a big drop, I’ve even lost a hundred pounds because of the way that they showed me how to prepare my food.
—WIN Network Participant Focus Group

In addition to addressing health issues, the women in the program were taught to make better financial and budget decisions.

We went on a trip to the grocery store where everybody had to be at the grocery store and they gave us like $10.00 per person to go through the grocery store. It changed the way I shopped. I wanted to basically save money by getting more quality things. Getting more quality food items and keep[ing] my kids fuller longer.
—WIN Network Participant Focus Group

They did teach us how to budget our money as far as if you have to pay bills and other things. So, I’m learning how to budget and save money a little more and I like it, because now when I am on my knees I will have something to fall back on instead of having to go back to my mom or have to ask somebody for this or that.
—WIN Network Participant Focus Group

The health and financial education was viewed as being effective at helping women to change by providing the skills and knowledge they needed to make healthier choices.

Because they don’t just give you paperwork to read over, they give you facts, they give you details. They show you where you’re going wrong. They show you how to change what you’re doing.
—WIN Network Participant Focus Group

Program staff mentioned that part of the goal of WIN Network was to encourage and empower participants to play a positive role in their community. Comments from WIN Network participants indicated that some of them frequently share what they learned with other women in their community and that participating in the program gave them the confidence to speak out to other women who they see engaging in harmful behaviors or who are struggling with postpartum mental health issues.

The awareness that I got from WIN in reference to how certain things affect the lives of these children encouraged me to be more outspoken about the risk factors that some of these young women are not aware of, even if they can’t sign up for the program, I’m going to approach them and let them know, listen, this can kill your child, it could harm you, but it could definitely kill this child.
—WIN Network Participant Focus Group

They helped me notice postpartum [mental health problems], because it is real, most people forget about that after you have a baby you might just be going crazy but postpartum is real and helped me better to help my friends recognize it. I’m like, girl, you need to calm down, take a breath, you know, you going through postpartum, it’s normal.
—WIN Network Participant Focus Group

Program Challenges and Responses

Despite the positive reviews the program did face a number of challenges that program staff and leadership had to respond to during implementation.

Program evaluation impeded program operations. The program evaluation presented a challenge partly because it was designed without extensive input from the program manager and the CHWs. In an effort to use comprehensive, validated, reliable tools, the researchers imposed a survey burden that impeded program effectiveness. The initial evaluation design involved an extensive survey during the first encounter between the CHW and the participant, a time when the CHW was focused on developing trust and rapport with the participant. The participants and the CHW found the experience frustrating, and the data collection protocols had to be revised early in the program to address the problem. One of the resulting effects of this challenge was that more data was missing than otherwise might have occurred if survey burden had been taken into account initially. One of the program staff summed up the lessons learned from the experience:

The evaluator needs to understand the community, they need to understand survey burdens and its impact on the program overall and the evaluator also needs to involve the program manager and to the extent possible the community health worker in evaluation design. I think it would be really good if the evaluator can spend the day in the shoes of a community health worker when trying to understand what it is that community health workers do and how do you evaluate that so we can tell our story effectively.
—Key Informant Interview

There was skepticism about programs that were constantly coming and going and that were perceived as being judgmental rather than supportive. Engaging participants was also challenging because the neighborhoods that WIN Network worked in had seen a lot of programs come and go and there was an initial skepticism about any new effort.

Whenever I was able to engage people one of the things that I heard over and over, is that they see programs come and go all the time. And so they had this apathetic disposition around new programs.
—Key Informant Interview

WIN Network was able to counter this by engaging and supporting clients and through its ties to the health care systems.

The more we did over there the better they felt about us. And then when they realized that we were connected to Henry Ford Health System that did help us a lot. So, people started to recognize [to] know our brand in their community. They know that we are not just going to start up today and then by next week we are done. They learned to trust us but I believe that a lot of them are tired of programs basically.
—Key Informant Interview

They were also successful because participants contrasted the way the CHWs operated with other programs that seemed more focused on judging or evaluating them than supporting them.

When they [the caseworker from the other program] did come, all they was doing was [being] in my business, come to my house all looking, and you know how people [are]. I’m like, “I’m straight,” I don’t even want them. At least with WIN they ask you, “Is it okay for me to come in?”
—Participant Focus Group

It is good that they do have a program like this where it is just not somebody in your business and judging you. They are actually there to help and they care about you. And you can feel the protection of the WIN family.
—Participant Focus Group

The transient nature of the population being served made a neighborhood focused strategy more challenging than initially expected. WIN Network leadership found out fairly quickly that a place-based initiative focused on serving only people who lived in specific neighborhoods was not going to work in Detroit. The community members they engaged to advise them made that clear as soon as they started facing challenges with recruiting and retention.

[Community leaders told us,] “Look, you all have this all wrong with these zip codes, you know because people they are transient. I know you guys have written it [the grants] like this, but this is how it really is.”
—Key Informant Interview

Changing the program criteria to open it to women who had a connection with the target neighborhoods, even if they did not currently live in them, helped with the problem of working with a transient population but it did not solve it completely, because the program could lose contact with participants when they moved. CHWs did find that email addresses tended to be more permanent than phone numbers and began to collect those and regularly send out emails to women who they had reached out to. Even then, CHWs spent a lot of time and effort trying to track down the women they worked with.

Some key resources were hard to find. When asked which resources were hardest to find, the two that came up most frequently were housing and transportation. Housing was a problem because for women with no income the only real initial option was the shelter system, but if the woman already had children, the system was poorly equipped to meet their needs.

The system is set up for single people and if you have kids of multiple ages, and especially if you’re in a shelter, there’s no space.
—Community Health Worker Focus Group

Transportation was another major challenge according to both CHWs and program participants. The shortcomings of mass transit in Detroit were considered so extensive that when the subject came up one WIN Network participant said, “That is a whole other focus group” and another elicited nods from many group participants by saying, “The Detroit bus system is horrible.”

It is a credit to the resourcefulness of the CHWs that despite noting that housing and transportation were significant challenges multiple participants indicated that part of the program’s success was the help it provided specifically in these areas.

For me I did not have transportation and I did not have a lot of support so she would actually come get me and take me, and stay there with me to make sure everything was okay. She helped me find housing. I did not have nowhere to go. So, my case worker [i.e., CHW] was really on it.
—Participant Focus Group

Integration with clinical care did not occur. Despite being a partnership that was built from collaboration among major health systems, the program did not have strong connections to the clinical care that the women received. By design, the CHWs were mostly focused on social determinants of health and were based in the neighborhoods that were the focus of the programs. While the health systems did support the programs financially, helping to provide space and other resources for events, the ability to refer and support women in their clinical care experience was limited in scope.

The collaboration happened on very, very high levels. You had the CFOs or the CEOs of each one of these entities that came together. But quite often it just never trickles down to the daily operations. So things that, if we were working with a mom and she said “Well, I don’t have an OB/GYN” or “I don’t have an OB” the single pregnant mother or “I have problems with my OB” it would have been good if the navigators could reach out to that medical professional and say “Hey, here is a potential person we need you to fit her in” or “What would you recommend” or “Can she call you?”
—Key Informant Interview

Lessons Learned

There are some useful lessons that emerge from WIN Network’s experience. These are summarized here:

  • Well-trained, carefully selected CHWs who focus on helping pregnant women and mothers to access resources are viewed very positively by low-income woman.
  • CHWs can be very successful at connecting women to available resources, providing critical social support, and creating a sense of greater stability in their lives.
  • Continuous gathering of input from community members and CHWs can head off or help solve problems. This is evidenced by the fact that involving community members early prevented the program from promoting a name that did not resonate with community members, while not fully engaging the community in evaluation planning resulted in an evaluation design that impeded program implementation and resulted in more missing data than might otherwise have occurred.
  • Women who were involved with WIN Network shared what they learned with others in their family and neighborhood networks.
  • The transient nature of the low-income population is an obstacle to building long-term relationships based on neighborhood residence. In order to ensure they were able to reach enough women and to account for the transient nature of the population they were serving, WIN Network had to loosen its residency criteria and provide services to women who had ties to the targeted neighborhoods even if they did not live there.
  • Buy-in from high-level health system leadership is critical to success in accessing resources and funding, but it does not necessarily translate to partnerships with clinical providers, especially when the majority of providers used by the participants were private practitioners rather than employees of the health systems.
  • It is a challenge to maintain funding and support for CHWs without an institutionalized source of funding. WIN Network has relied on contributions from health care system partners and grant funding to develop and implement its strategy. Neither of these types of funding are long-term solutions. While the health care systems were generous in their initial contribution, like grant funders, they are not inclined to provide sustained support for ongoing programs of this nature.
  • Long-term survival and success of programs like WIN Network require having a systems change strategy that seeks to institutionalize the role of CHWs within the community health care system. Organizations like the Henry Ford Health System are able to use their influence to secure a platform where these issues are discussed, and where the lessons learned from programs like WIN Network can effect the kinds of changes needed to develop a place for CHWs in the health care system. In places where more grassroots or smaller nonprofits take the lead on programs, there will still be a need to determine a strategy for making the systems changes that ensure the long-term sustainability of CHW support.

An Evolving Strategy

WIN Network is in the process of using the lessons learned from its first few years to create a modified strategy for addressing the needs of pregnant women using CHWs. This evolving strategy involves an explicit effort to integrate the CHWs into the clinical care team. Program leadership believes that changes in the context in which the health care system operates makes this strategy more likely to succeed then if it had been tried when WIN Network initially rolled out.

The things that I think could have worked better on behalf of the women would be the direction that we are headed right now which is to have better alignment with the clinical care system so it does not seem like two separate things. We are trying to integrate those experiences. And it is not as challenging as it may have been four years ago now because now the health care world is moving into population health perspectives and having more accountability around social determinants of health so they are more receptive to these ideas.
—Key Informant Interview

As implied in the comment, the Affordable Care Act has opened up opportunities to integrate CHWs into the health care system. As new payment models are rolled out there is an opportunity to incorporate CHWs into a health care team focused on increasing the use of preventive services and reducing costs.[7] This integrated care model may have greater potential to impact birth outcomes than previous efforts to use CHWs have in addressing infant mortality. The new WIN Network model is going to be focused within the Henry Ford Health System rather than attempt to cross health care systems, because this is a more feasible and manageable approach, while still being able to provide lessons that other systems in the city and across the country can replicate.

Financing for the support provided by CHWs may require additional system changes or may be possible in evolving payment frameworks that will cover those costs along with medical care. Regardless, there is recognition of a need to continue to engage at the policy level to ensure that CHW support can be sustained.

WIN Network represents an important effort to try to better support a population that has not been well served by the existing health and social services system. It will be useful to assess whether the evolving program is able to continue its effectiveness in helping women access community resources, as the focus shifts more toward ensuring that CHWs are integrated into the health care team within the health care system. This approach has the potential to not only affect the lives of these women, children and families, but to be truly transformative for the health system and the communities where they operate.


  1. Bouffard, Karen (2014). Infant mortality rate in Detroit rivals many third world countries. Detroit News January 31. Retrieved from:
  2. Annie E. Casey Foundation (2015). Infant mortality. Kids Counts Data Center. Retrieved from:,55-56,58-61,64-77,79-84,86,88-94,96-109,9428-9429/false/867,133,38,35,18/any/12718,12719
  3. Viswanathan, M., Kraschnewski, J., Nishikawa, B., Morgan, L. C., Thieda, P., Honeycutt, A., Lohr, K., Jonas, D. (2009). Outcomes of Community Health Worker Interventions. Rockville, MD: Agency for Healthcare Research and Quality.
  4. One very high-risk program participant who enrolled later in her pregnancy did lose her baby, but due to her health condition at time of enrollment her physician indicated the program could not have done anything to prevent the loss.
  5. Additional contributions came from the PNC Bank Foundation, the March of Dimes Foundation, and The Jewish Fund.
  6. Hobel CJ, Goldstein A, and Barrett ES. (2008). Psychosocial Stress and Pregnancy Outcome. Clinical Obstetrics and Gynecology 51(2):333-48.
  7. Martinez, J., Ro, M., Villa, N. W., Powell, W., & Knickman, J. R. (2011). Transforming the Delivery of Care in the Post–Health Reform Era: What Role Will Community Health Workers Play? American Journal of Public Health,101(12), e1–e5.