How community health workers navigate the infant and maternal health space in Ohio

How community health workers navigate the infant and maternal health space in Ohio

By: Natasha Takyi-Micah, Public Policy & External Affairs Associate

Key Takeaways

• Community health workers (CHWs) who specialize in infant and maternal health in Ohio utilize many interventions to reduce mortality rates such as connecting clients to resources, effectively educating clients, and emphasizing the significance of mental health.
• The challenges both CHWs and their clients face range from poor interactions with healthcare professionals to lack of resources in the community.
• Solutions to address the challenges mentioned in this report are geared towards the suggestions participants have for doctors, how to address the social determinants of health, and how to improve policies for CHWs.

*Although we use the terms ‘women’ and ‘mothers’ in some cases due to how previous data was reported, we acknowledge and recognize that not everyone who could carry a pregnancy refers to themselves this way. We respect the identity of all pregnant or birthing people.

Introduction

The public health field is rapidly growing as more people enter to help the general public live their healthiest lives. One of the professions, community health workers (CHWs), help the community in many ways. CHWs are frontline public health workers who act as liaisons “between the health/social services and the community to facilitate access to services and improve quality and cultural competence of service delivery.”^[1] Also known as Community Health Aid, Health Coach, Promotora, and Community Navigators, CHWs are trusted members of the communities they serve.^[2] Some of their responsibilities coordinating care services with health providers, improving access to community-based services, addressing the social determinants of health, and offering health education.

Also known as Community Health Aid, Health Coach, Promotora, and Community Navigators, CHWs are trusted members of the communities they serve.

CHWs perform other functions such as monitoring vitals and educating on nutritional habits to reduce the number of emergency visits (see footnote 2). Payment for these services is usually through Medicaid, managed care organizations, or grants. Other CHWs are not compensated, or they get paid through private models.^[3],[4] CHWs specialize in serving specific groups such as older adults, individuals with chronic diseases, women and birthing people, and infants. This report will focus on CHWs specializing in the infant and maternal health space.

Literature review

CHWs across the globe and in the United StatesInternationally and in the United States, CHWs who specialize in infant and maternal health are making a difference in the communities they serve. To understand the roles of CHWs internationally, researchers reviewed policy documents and conducted focus groups with CHWs and key informants including provided maternal and newborn in primary healthcare facilities across five countries.^[5] The five countries include Bangladesh, Malawi, Nigeria, India, and Kenya. CHWs in those countries performed various functions based on how long they have trained to become a CHW. For instance, CHWs with level one paraprofessional training (less than three months of training) focused on community mobilization and patient tracking. Whereas individuals with level two paraprofessional training (more than three months of training) provided long-acting reversible contraceptives, therapeutic care, and birth attendance. Some level two paraprofessional CHWs in Bangladesh, India, and Nigeria with more than six months of training were able to determine pregnancy and identify normal and high-risk pregnancies by administering pregnancy tests, and interpreting ultrasounds and laboratory reports.CHWs labeled as level one paraprofessionals in India acted as birth companions by coordinating transportation for patients/clients to healthcare facilities and providing psychological support. Regardless of the amount of training, all CHWs must support and promote breastfeeding, work on appropriate position for breastfeeding, and newborn attachment.CHW programs in the United States have been shown to be successful in producing positive health outcomes for mothers, birthing people, and babies. Researchers conducted a study to examine the effectiveness of the Arizona Start Program, a CHW program in Arizona.^[6] After comparing 7,212 women who participated in the program, and 53,948 who had not participated, between 2006-2016, women in the program had better birth outcomes, prenatal care attendance and child immunization rates compared to their counterparts. The positive results derived from CHWs of the Arizona Start Program consistently conducting home visits and educating their clients about the significance of immunizations, while dismantling the mothers’ fears.CHW programs from other states were studied as well. In a study, scholars selected three states—New Jersey, New York, and Pennsylvania— to identify the community and institutional factors that contributed to sustainability in CHW programs that improve maternal health outcomes.^[7] After completing focus groups and interviews with 54 CHWs, CHW program staff, and community partners, the researchers pointed out three themes:

• CHW support from supervisors, providers, and peers;
• Relationships with healthcare systems and insurers; and
• Securing adequate, continuous funding.

Pertaining to the first theme, some CHW program staff supported CHWs by addressing their concerns. CHWs regularly participated in care team meetings with providers to make sure they have the assistance they needed from providers and vice versa. For example, a doctor and the care team review patients with the CHW. In return, the CHW will provide updates to the doctor about what their patients are doing outside of the clinic. This creates a feedback loop between the CHW and the providers. The second theme—relationships with healthcare systems and insurers—describes ways CHWs and the other entities collaborate successfully.Two of the CHW programs that established formal relationships with healthcare systems received access to electronic health records, which helped them recruit new clients. Also, because they have their clients’ electronic health records, they can take them to their appointments. The final theme discusses the challenges of funding and how to develop a sustainable CHW program. Some CHWs left their jobs because of low annual wages and worked for other programs and local organizations because they offered more pay. Some CHWs sustained their programs by seeking funding from other sources like managed care organizations.Some states conduct CHW assessments to understand the landscape of this field. The Nebraska Department of Health and Human Services (NE DHHS) and the Center for Reducing Health Disparities (CRHD) at the public health school of the University of Nebraska Medical Center conducted a statewide assessment specifically about CHWs in infant and maternal health.^[8] They completed focus groups of CHWs and administered an online survey for CHWs across Nebraska.

After gathering and analyzing data, CHWs pointed out some health issues that threaten the well-being of women and children, including the high prevalence of chronic conditions, domestic violence and abuse, mental health needs, and lack of nutrition.

After gathering and analyzing data, CHWs pointed out some health issues that threaten the well-being of women and children, including the high prevalence of chronic conditions, domestic violence and abuse, mental health needs, and lack of nutrition. For instance, some CHWs explained there is a lack of training about domestic violence and how to address the issue (see footnote 8). In addition, some CHWs in Nebraska faced some challenges while promoting maternal and child health services including clients not having health insurance because of lack of immigration status, poverty, transportation, and language barriers (see footnote 8).To solve these challenges in Nebraska, CHWs made recommendations such as utilizing information technology to better serve and connect with their clients, providing additional training about different health issues (e.g., mental health), and “education on and provision of culturally and linguistically relevant health education” (see footnote 8).

Concerns of community health workers in Ohio

Studies have been conducted to investigate the landscape and benefits of CHWs in Ohio. The Ohio Colleges of Medicine Government Resource Center completed a statewide community health worker assessment in 2018 to figure out “how CHWs are currently being trained, certified, employed, reimbursed, and utilized in Ohio.”^[9] The assessment team conducted the study by leading secondary data collection, five focus groups of CHWs, 11 key informant interviews, and two statewide surveys (one targeting CHWs and the other for employers/supervisors of CHWs) to understand the needs of CHWs and capacity in the state.The assessment produced some interesting findings. According to one of the surveys, the top target populations and/or topics that CHWs in Ohio worked with were adult women, pregnancy/prenatal care, children, infants, and adult men. CHWs targeted underserviced and low-income populations and people of color. Some challenges that CHWs noted in their profession were:

• The difficulty to search for and keep employment in Ohio because of grant funding
• Many positions requiring at least a bachelor’s degree to apply
• Life experience not being considered as much in the hiring process
• Costs associated with keeping certification
• The expense of traveling to training programs that were far away

CHWs reported a list of items that they wanted and needed over the next five years. This includes improving salaries, the need for stronger advocacy for the CHW profession in the state enhancing training that reflects what they are doing in the field and self-care needs and having the CHW profession and role understood by all professions and providers throughout Ohio (i.e., beginning with provider training on the role of CHWs). This assessment highlighted a broader scope of CHWs in Ohio that cater to the needs of various populations in addition to pregnant individuals, moms, birthing people, and infants. Other studies have specifically looked at how successful CHWs are in the maternal and health space in Ohio.

This assessment highlighted a broader scope of CHWs in Ohio that cater to the needs of various populations in addition to pregnant individuals, moms, birthing people, and infants.

Edward Chiyaka studied the effectiveness of a Pathways Community HUB approach in decreasing low birth weight, reducing preterm births, and improving prenatal care utilization.^[10] Data was obtained from the Community Health Access Project (CHAP), a Pathways Community HUB in Richland County, OH. After comparing women who participated in the CHAP program from 2014-2017 compared to women who were non-participants (also based in Richland County), the study produced positive results. Roughly eight and a half percent of women who participated in CHAP delivered babies with low birth weight compared to 12.38 percent of women who did not participate in the program. Hence, it has been shown that partaking in the Pathways HUB program is correlated with a decrease in low birth weight. Also, 36 percent of CHAP participants were less likely to experience a preterm birth. Prenatal care utilization—examining how often participants received adequate care and the number of prenatal visits—was examined between CHAP participants and non-CHAP participants.The results showed that “the average number of [prenatal] visits for CHAP participants are greater than that of non-CHAP participants over the period between first visit and delivery” (see footnote 10). It is important to note that this study did not directly inspect the impact of using CHWs, yet the success of the Pathways HUB framework is carried out by them because they help “patients navigate the health care system with outcomes such as reduction of emergency department utilization, unwarranted inpatient admissions, fewer hospital readmissions” (see footnote 10).Researchers also studied the success of a local CHW program in Cleveland, OH. In partnership with the Cleveland Department of Public Health MomsFirst Project and Community Endeavors Foundation, Inc., the researchers described a breastfeeding intervention used during CHW home visits to high-risk expectant mothers in Cleveland and pointed out which components of the intervention increased the chances/odds of a mother breastfeeding.^[11] The intervention's components were modules that CHWs learned to implement during home visits. The mothers received a binder with the modules, Women, Infants & Children (WIC) breastfeeding material, a five-minute DVD about latching and a refrigerator magnet with recommendations on how to increase milk supply.Participants had the option to be involved in a doula program (where a mother identified a support person like the father of the baby or a grandmother to learn about breastfeeding during home visits and to help with breastfeeding) as another component of the intervention. Lactation counselors, who were part of the intervention, made postpartum phone calls to the mothers. The results showed that curricular modules administered by CHWs increased the odds of breastfeeding at one month and a postpartum phone call was significantly correlated with exclusive breastfeeding. Selecting a doula was not associated with breastfeeding because it was difficult to implement (there was a lack of personal support and that is one of the criteria to enroll into the MomsFirst program).

Study explored how CHWs in Ohio help decrease infant and maternal mortality and work with medical professionals

Although useful information, there were gaps in the literature. The Ohio statewide assessment was conducted five years ago and did not specifically look at CHWs who specialized in infant and maternal health as the sole population of interest (see footnote 9). The COVID-19 pandemic, which started in 2020, impacted CHWs work with their clients. Also, the studies previously mentioned did not examine challenges that clients of CHWs experience in infant and maternal health.Besides the MomsFirst study, other studies about CHWs in Ohio did not specifically identify the interventions they have practiced reducing infant and maternal mortality rates. Hence, the purpose of this study is to explore how CHWs in Ohio work with their clients to decrease infant and maternal mortality rates, any challenges both parties have within this space and while also interacting with medical professionals, and solutions. The research questions are:

1. How do CHWs in Ohio reduce infant and maternal mortality rates?
2. What types of challenges do both CHWs and their clients experience in the infant and maternal health space in Ohio?
   1. What are the challenges that CHWs in Ohio face while working with medical professionals?
   2. What are the challenges that patients face when interacting with medical professionals?

3. What are the solutions to address the challenges CHWs and their clients face in the infant and maternal health space in Ohio?

Methodology

To seek answers to the proposed research questions, Community Solutions conducted key informant interviews and focus groups from spring 2023 until summer 2023. Community Solutions staff from both the research and policy teams implemented the study. They also created various types of facilitation guides for focus groups and key informants. Each facilitation guide comprised the same questions that were asked of all participants. Some of the questions included:

• What are the major challenges you (or your CHWs/students) experience as a CHW in the infant and maternal health space?
• How has the pandemic impacted your (or your CHWs/students) work with birthing people and babies?
• In maternal and infant health, which CHW intervention do you (or your CHWs/students) implement often when working with your clients?
• Do you advocate for any issue about CHWs or infant and maternal health at the city, state, or federal levels? If so, what do you advocate about?

Other questions include experiences working with medical professionals, advocacy efforts, signs that medical professionals should notice in patients to prevent negative maternal health outcomes, and clients’ success stories.To recruit participants, we created a recruitment flyer and sent it to community-based organizations. In addition, focus groups participants or key informants shared the recruitment flyer with their colleagues and partnered organizations. After the key informant interviews and focus groups were completed, data was analyzed into codes which were then grouped into themes.

Participants

Community Solutions conducted 13 key informant interviews and three focus groups, with nine focus group participants. The 13 key informants included CHWs, CHW supervisors (both current and former), CHW trainers, a case manager (who is also a CHW), and a state governmental director who works with CHWs. Some CHW supervisors and one trainer were also CHWs themselves. Most focus group participants were CHWs, with two individuals were doubled certified as both a CHW and doula, and one of them recently completed a CHW program. Both key informants and focus group participants who were CHWs worked for either non-profit organizations, a local governmental maternal and infant health program, or a healthcare clinic.

The 13 key informants included CHWs, CHW supervisors (both current and former), CHW trainers, a case manager (who is also a CHW), and a state governmental director who works with CHWs.

How CHWs in Ohio reduce infant and maternal mortality rates

Theme 1: CHWs help reduce infant and maternal mortality rates by emphasizing the importance of mental health. Many participants explained how they or their CHWs applied mental health interventions/activities while working with their clients. One key informant explained that their CHWs offered emotional support to their clients and referred them to mental health resources. The participant does not diagnose their clients with mental health conditions. A CHW explained that they provided education about self-care for their client as one of the ways they provided support.Another CHW explained how one of the interventions that is practice is to help mothers understand their options and resources but being aware of their feelings about getting help. While useful for some of their clients, others think they are too prideful to receive them. So, the CHW usually tells their clients that they do not need to feel like they are too strong to receive help. “It’s ok to not be ok: it’s ok to get help,” the CHW stated.Other participants described how mental health is one of the most key factors for positive birth outcomes. The case manager explained that their CHWs alleviate stress for their clients to prevent preterm labor. One of the CHW supervisors believed that it is important for their clients to delay stress so they can realize that some of the situations they worry about were not as serious. As an alternative, the CHW supervisor encourages their clients to enjoy the pregnancy journey and to love themselves.Theme 2: CHWs help reduce infant and maternal mortality rates by effectively educating and communicating with their clients.Key informants and focus group participants mentioned how they effectively communicated with their clients. One of the key informants explained how HUBs train CHWs. This is done by training CHWs who work through HUBs that specialize in applying cultural linguistic competency and interviewing practices needed when serving clients.One CHW supervisor teaches their CHWs how to build trust with clients. For example, the supervisor stated how their CHWs should call their clients according to the time they agreed upon because some of them did not previously receive follow-up from people. Another CHW supervisor meets their clients based on their work schedule which is sometimes after work.

One focus group participant empowers clients by teaching decision-making, so they have the evidence to support their decisions.

Other CHWs utilize empowerment techniques while communicating with clients. One focus group participant empowers clients by teaching decision-making, so they have the evidence to support their decisions. When asked about how the pandemic affected their work, some participants explained that virtually communicating with their clients was helpful. Hence, it is important for CHWs to meet the clients where they are, be flexible, and encourage them to make decisions.Participants teach their clients how to make positive lifestyle changes for themselves and their infants. Some of the CHWs explained that they educate their clients about breastfeeding, reading to their child/children, and family planning. Other participants utilize safe sleep practices as an intervention. For example, a CHW explains to their clients the meaning of safe sleep and its statistics.One of the CHW trainers is teaching their CHWs about the FAN (Facilitating Attuned Interactions) Approach.^[12] FAN is a communications style to connect parents with children and infants. This helps people meet their child and to respond to where they are. Regarding positive lifestyle changes, a focus group participant stated that they inform their clients about accountability and goal setting. The topics mentioned by participants are common interventions that CHWs implement when interacting with their clients.Theme 3: CHWs help reduce infant and maternal mortality rates by connecting their clients to resources, whether it is programs or other professionals as part of the care team.One of the major roles of CHWs is to connect their clients to resources. The resources can be either programs or other healthcare professionals. Some CHWs connect their clients to food programs so that they can get enough nutrition for themselves during pregnancy and after pregnancy. A key informant, a CHW trainer, said there is a food delivery program for new mothers. Some CHWs connect their clients to job and education opportunities.CHWs in the study expressed that they connect their clients with other healthcare professionals during pregnancy. Some participants believed that doulas as part of the care team can help their clients. Another participant usually asks if their clients have a primary care doctor, OBGYN, dentists, etc. If they do not have any medical providers, then they would make referrals. CHWs focus on community resources to ensure that their clients’ basic and medical needs are met.

Challenges both CHWs and their clients experienced in the infant and maternal health space

Theme 1: The difficulties for CHWs to establish a work-life balanceParticipants described that it is challenging to create a work-life balance in their professions. Due to assisting their clients based on their (the clients) schedules and personal circumstances, they must be flexible. However, CHWs sometimes have difficulty setting boundaries. One of the key informants explained that one year during Thanksgiving dinner, they had to answer phone calls from their clients. They further described that some CHWs are never off work and that is one of the reasons why the CHW retention rate is low.

Even though CHWs feel like part of the family with their clients, they still need to have boundaries which can be hard.

Another key informant stated even though CHWs feel like part of the family with their clients, they still need to have boundaries which can be hard. For instance, they went to an appointment with their client who was continuously going to the emergency room. They had to advocate for their client so they could be admitted into the hospital. The key informant also described that they do not allow their CHWs to attend their client’s baby showers or birthdays because that would mean they would have to attend all their clients’ celebrations. The work-life balance of CHWs can be blurred which can affect their well-being.Theme 2: Job security due to low wagesCHWs often do not get paid enough for the demanding work they are doing in the community. Some participants commented that low wages are a barrier for them. A key informant who was a CHW supervisor explained that it was difficult to recruit and retain CHWs because of low funding and the wages are granted funded. Grants do not provide sustainability.Another key informant simply stated they are not adequately compensation for their work. Although some participants briefly point out this issue, the challenge of funding is like responses from CHWs according to the 2018 statewide CHW assessment for Ohio.Theme 3: Challenges with partnered OrganizationsCHWs collaborate with various organizations to address their clients’ needs. However, there are challenges when working with partnered organizations. For example, a key informant would refer their clients to other organizations because they specialize in certain services, but sometimes there are waiting lists to join their programs. Both key informants and focus groups participants noticed there is a lack of coordination when trying to work with other organizations.Many CHWs in a focus group explained that an action network that they usually interact with is not working. This network includes all providers for the client like doulas, doctors, CHWs, and mental health professionals, but there is a lack of coordination. A key informant stated that many hospitals have their own CHWs, and they are not crossing paths with CHWs from other organizations. This can cause many organizations to be in the client’s house at the same time because there is not a lot of communication between hospital based CHWs and CHWs from community-based organizations.Theme 4: It was difficult to for CHWs to effectively communicate with clients due to the pandemicAlthough this problem was temporary, CHWs had difficulties fully communicating with their clients due to the pandemic. This is because COVID-19 is a transmissible illness that was new in society a few years ago, which forced everyone to virtually communicate with each other instead of traditional face-to-face work. Some participants thought that using virtual communication was good with clients, but others noticed some challenges.One key informant could not conduct home visits, so they had to talk to their clients over the phone and dropped off items at their homes (while practicing social distancing). Moreover, the key informant believed this was difficult because they were not able to see their clients’ babies in person. A focus group participant could not advocate for her client in the hospital, but they were on Facebook. Her client ended up having a c-section, which is a procedure CHWs and doulas try to prevent their clients from experiencing.

Challenges clients face in the infant and maternal health space

Theme 1: Clients are negatively impacted by the social determinants of healthAll participants explained how clients are negatively impacted by the social determinants of health. When asked which social determinants of health they think have the greatest impact on their clients’ birth experiences, many participants listed housing, economic stability, and access to health care (i.e., health care and quality). Regarding housing, focus group participants agreed that homelessness is a major issue, especially for clients with multiple pregnancies. A key informant said that sometimes homelessness does not necessarily mean living on the streets but living with other family members or their partners’ homes.According to some key informants, economic stability is a major concern because mothers and birthing people often worry about finances like how to feed their children while maintaining basic needs. Instead of recovering after giving birth, mothers and birthing people return to work quickly. One key informant stated that “the moms are consistently worried about money and how am I going to afford this and how am I going to keep the lights on if I can’t work for those six to eight weeks, and how am I going to feed the kids.” The key informant further explained that they knew some mothers who return to work two weeks after giving birth.Other participants stated that access to healthcare is problematic for their clients. A focus group participant described that there are long wait lists for mental health services if a client needs them. Transportation is part of access to health care because some clients lack reliable transportation. A CHW key informant stated that lack of transportation affects birth experiences while a focus group participant exclaimed that no one should have to take three bus rides to their doctor’s appointment.Some participants explained that all social determinants of health are interrelated, and they cannot list one that has the greatest impact on their clients. Unfortunately, issues regarding the social determinants of health are magnified because some participants explained there is a lack of resources after the pandemic.

Challenges CHWs in Ohio face while working with medical professionals

Theme 1: Medical providers do not know the roles of CHWsA major challenge that CHWs in infant and maternal health face while working with medical providers is that medical providers do not know the roles of CHWs. According to a key informant, CHWs are seen as social workers in training. Another key informant mentioned that it is important to treat CHWs as a partner in an interdisciplinary team. However, the key informant further described that they are not recognized as a partner to import birth outcomes. Other key informants explained how medical providers would create roles or job descriptions for CHWs that they hire simply because they do not know their functions. Hence, CHWs have trouble gaining respect from medical professionals because they do not know the true definition of their profession.

Other key informants explained how medical providers would create roles or job descriptions for CHWs that they hire simply because they do not know their functions.

Challenges patients face when interacting with medical professionals

Theme 1: Clients experience racism in the healthcare system and mistrust in the medical community.Pregnant individuals, mothers, and birthing people experience racism when trying to seek health care services. A key informant who is a CHW reported that systemic racism exists because hospitals are enforcing c-sections, especially towards minorities. Another key informant mentioned that Ohio struggles with poor birth outcomes. The key informant then talked about how Ohio could be in the bottom five although they have good healthcare centers; they suggested when one compares Ohio to other states that also struggles with poor health outcome, like Alabama or other southern states, he/she/they must investigate systemic racism and other institutional barriers as the reason.A focus group participant stated a challenge is when medical providers have preconceptions about their clients and show implicit bias. In their role, the key works informant works to break those racist barriers down. Because of systemic racism, some clients have mistrust in the medical community.Theme 2: Clients’ relationships with doctors are poor due to interaction challenges, lack of proper treatment, and lack of doctors.CHWs’ clients have negative relationships with doctors because of ineffective interaction. Some participants explained that their clients are not being heard by doctors and they rush them through appointments, resulting in a lack of quality time and proper treatment. Participants also reported that clients do not understand medical jargon from providers during appointments. One key informant combats this issue by asking the nursing staff to help clients understand the medical information and they sometimes write details for them.Clients also deal with a lack of proper treatment from medical providers. One focus group participant said clients’ births and babies are overmedicated, while another said there is an increase of c-sections. Moreover, many participants mentioned the doctor shortage. Some explained there is a lack of doctors that look like the clients’ race(s). In addition, it was mentioned that providers are overbooked. Culminated with the lack of diversity in the medical provider field, there are increased health disparities for pregnant individuals, mothers, and birthing people of color.

Solutions to address the challenges CHWs and their clients face in the infant and maternal health space

Theme 1: Doctors should listen to patients’ concerns and monitor any behavioral changes.A solution to address the issues that pregnant individuals, mothers, and birthing people face in the infant and maternal health space, doctors should listen to patients’ concerns and note any changes in their behavioral health. This is an important skill for medical providers because they can prevent negative birth outcomes. Unfortunately, this was not the case for one focus group participant’s client. They expressed pain to her doctors, but they did not listen to her. This led to her giving birth early.Participants reported that doctors should ask proper questions to clients and listen to them if they are not feeling well. “The last thing I want any medical professional to do is to disregard what that person is saying, send them outside and then a week later you found out that they’re in the hospital because of some big issue that was never paid attention to, or worse, they’re dead,” stated one of the key informants. They further described that doctors should acknowledge patients when they say they are not feeling and run tests.

Medical providers should also monitor any behavior changes in their patients.

Medical providers should also monitor any behavior changes in their patients. Participants discussed the importance for providers to follow-up with patients if they are not attending prenatal appointments. One key informant recommended that if a patient misses an appointment, then a nurse should call the patient to figure out the reason. Other participants suggested that providers should note other behavioral changes in their patients such as apathy, lack of conversations from patients, if the patient is quiet, or if they ask many questions. Paying attention to these changes can help doctors address issues sooner than later.Theme 2: Doctors should notice physical signs while examining patients.Participants described various physical signs that doctors should notice in their patients to prevent negative health outcomes. Signs include back pain, charley horses, blood clots, postpartum hair loss, bleeding, symptoms of preeclampsia and high blood pressure. A focus group participant mentioned that mothers should be sent home with blood pressure cuffs.Another physical sign that should be examined by doctors is fetal movement. If a pregnant individual does not notice any fetal movement, then that is a red flag that needs to be attended to as soon as possible. A key informant’s client lost their baby after she was not having any fetal movement. In addition, this participant also mentioned that doctors should educate patients about fetal movement.Theme 3: Medical professionals need to improve relationship building skills when interacting with CHWs and patients.To improve their experiences with patients, medical professionals should work on enhancing their relationship building skills. They can do this by speaking to patients in simpler terms, avoiding medical jargon and for both parties to ask “why” during conversations (e.g., reasoning for creating a certain treatment plan or the root cause of health issues). Likewise, medical professionals should get their patients involved in the health care team. A key informant said this is a practice they use with their patients as they are in meetings with doctors and social workers. Patients becoming part of the health care team can help them become empowered in their pregnancy and postpartum journeys.Participants discussed ways medical professionals can improve their relationships with CHWs. For instance, doctors can hire CHWs as consultants. A key informant explained if they were hired as a consultant, then they could have helped them identify gaps and provide guidance on how CHWs can close those gaps. Another key informant stated that medical providers can create feedback loops with CHWs, like what the Athens City County Health Department has done. Hospitals can also partner with CHWs from community-based organizations, as suggested by a key informant. They further explained that by doing so, there can be more trust and sharing of data between the community based CHWs and hospitals.Theme 4: Implement strategies to combat systemic racism in the healthcare system.There are many strategies to address systemic racism in healthcare systems. Some participants expressed that medical professionals should get involved in sensitivity training. A key informant reported that clinicians should not stereotype about their patients. They explained that because a patient dresses in a particular way does not mean they should expect them to behave in a certain manner. They also stated that medical professionals should know the community resources that their patients need first before thinking about drastic treatment plans, like sending them to a mental health facility.

Medical professionals should learn about their patients’ culture.

Most importantly, medical professionals should learn about their patients’ culture. By doing so, they can become culturally competent and effectively communicate and treat their patients.Theme 5: The need for more resources to address social determinants of healthThere are various resources to address the social determinants of health. Some CHWs provide community baby showers for mothers, birthing people, and pregnant individuals. Participants mentioned there are ways to address transportation. One of the key informants has written transportation grants and stated that they are successful in utilizing them.Another key informant thinks that hospitals and medical professionals should be responsible for transportation so they can bridge the gap between themselves and the communities they serve. They explained that doctors and hospitals tabling at community events and providing health services in patients’ neighborhoods could also help. To address the fact there are food desserts, a focus group participant educates clients about the Cleveland Clinic farmers market, pop-up markets and churches that give out produce.A focus group participant advocates for housing and suggested a program where individuals can get support with emergent needs. Other participants listed resources which address financial difficulties and make connections with doulas can address the social determinants of health for their clients.Theme 6: Advocating for funding and independent billingMany participants advocate for funding so they can obtain livable wages. According to O*Net OnLine, the average income for CHWs in Ohio is $40,360.^[13] One of the key informants advocated for more funds at the federal level and was able to achieve that goal. Another key informant actively participates in Zoom meetings with stakeholders every month about what they need. He also visited state legislators in Columbus about CHWs activities and requested funding.A key informant advocates for funding and insurance access for CHWs who work in startup agencies. Other participants are advocating for independent billing. A participant is currently working with a foundation to allow CHWs to bill through Medicaid and Medicare. In addition, the participant's organization was planning to meet with a state legislator to discuss how to achieve that goal.

Conclusion

CHWs in Ohio who specialize in infant and maternal health work tirelessly to produce positive birth outcomes and reduce mortality rates. The findings from this study show that CHWs implement various interventions that impact infant and maternal mortality rates such as mental health, connecting clients to resources, and providing education. CHWs and their clients experience challenges in infant and maternal health based on interpersonal and societal factors.

CHWs in Ohio who specialize in infant and maternal health work tirelessly to produce positive birth outcomes and reduce mortality rates.

Due to the various issues that they face, participants of the study suggested many solutions such as medical providers recognizing physical and mental health changes in clients, the need for more resources to address the social determinants of health and advocating for more funding. Even though the work can be challenging, CHWs in Ohio have been successfully working with clients to ensure that they do not have to deal with negative health outcomes.[1] Ohio University. (2023). About Community Health Workers. Ohio University. https://www.ohio.edu/chsp/alliance/resources-and-trainings/about-community-health-workers[2] National Academy for State Health Policy (2021, December 10). State community health worker models. NASHP. https://nashp.org/state-community-health-worker-models/[3] Ballard, M., Westgate, C., Alban, R., Choudhury, N., Adamjee, R., Schwarz, R., Bishop, J., McLaughlin, M., Flood, D., Finnegan, K., Rogers, A., Olsen, H., Johnson, A., Palazuelos, D., & Schechter, J. (2021). Compensation models for community health workers: Comparison of legal frameworks across five countries. Journal of Global Health, 11, 1-10. https://doi.org/10.7189/jogh.11.04010[4] Community Health Impact Coalition. (2023). Pay CHWS. Community Health Impact Coalition. https://joinchic.org/resources/pay-chws/[5] Olaniran, A., Madaj, B., Bar-Zev, S., & van den Broek, N. (2019). The roles of community health workers who provide maternal and newborn health services: case studies from Africa and Asia. BMJ Global Health, 4(4), 1-11. https://doi.org/10.1136/bmjgh-2019-001388[6] NAU Communications. (2022, March 7). Arizona researchers find community health workers improve health for mothers and babies. The NAU Review. https://news.nau.edu/community-health-workers/[7] Mehra, R., Boyd, L. M., Lewis, J. B., & Cunningham, S. D. (2020). Considerations for building sustainable community health worker programs to improve maternal health. Journal of Primary Care & Community Health, 11, 1-8. https://doi.org/10.1177/2150132720953673[8] The Center for Reducing Health Disparities. (2021, December). Developing the community health worker workforce to promote maternal and child health in Nebraska. College of Public Health University of Nebraska Medical Center. https://dhhs.ne.gov/MCAH/Developing%20CHW%20Workforce%20to%20Promote%20Maternal%20and%20Child%20Health%20in%20NE%20(2021).pdf[9] Ohio Colleges of Medicine Government Resource Center. (2018, September). The 2018 Ohio community health worker statewide assessment: Key findings. Ohio Department of Health. https://grc.osu.edu/sites/default/files/inline-files/CHW_Assessment_Key_Findings.pdf[10] Chiyaka, E. T. (2019 August). Effectiveness of the Pathways Community HUB model in reducing low birth weight among high-risk pregnant women [Doctoral dissertation, Kent State University]. https://www.pchi-hub.org/_files/ugd/2e5591_b1b83cd7dc744e608ee9710cc8198851.pdf[11] Furman, L., Matthews, L., Davis, V., Killpack, S., & O’Riordan, M.A. (2016). Breast for success: A community–academic collaboration to increase breastfeeding among high-risk mothers in Cleveland. Progress in Community Health Partnerships: Research, Education, and Action10(3), 341-353. https://doi.org/10.1353/cpr.2016.0041.[12] Erikson Institute. (2023). Facilitating Attuned Interactions (FAN). Erikson Institute. https://www.erikson.edu/academics/professional-development/early-childhood-workshops-training/facilitating-attuned-interactions/[13] National Center for O*NET Development. (2023, November 13). Ohio wages 21.1094.00- Community health workers. O*NET OnLine. https://www.onetonline.org/link/localwages/21-1094.00?st=OH&p=annual