A Statewide Perinatal Coaching Program
A Sunday, September 28, 1997 - Address by Dr. Jack M. Stack

In 1594 William Shakespeare published his play, Romeo and Juliet. When discussing the upcoming marriage of his daughter Juliet her father, Capulot, said to her suitor, Paris:


But saying over what I have said before
My child is but a stranger in the world
She has not seen the change in 14 years
Let 2 more summers wither in their pride
Ere we may think her ripe to be a bride


Younger than she are happy mothers made


And too soon married are those so early made

Shakespeare expressed concern for young mothers over 400 years ago in this elegant tragedy of young lovers. Many people in our culture are currently concerned about the problems of teenage pregnancy, single parenting, pregnancy in the poor and in the under educated. These are the most vulnerable women and children in our society.

20 year ago John Kennel, M.D. and Marshal Klaus, M.D. of the Rainbow Children's Hospital in Cleveland made a number of powerful observations. These physicians were neonatalogists working with premature and injured babies in a neonatal intensive care unit. They noted that a woman who had a coach, which they called Doula assist her in labor had a much lower incidence of fetal distress, much higher Apgar scores in their newborns and they had much shorter labors. They also noted that women had difficulty bonding to their babies and often were unable to care for their babies when their babies were premature or were sick and in neonatal intensive care unit.

In primitive cultures, women are not alone during labor and delivery. They are surrounded by helpers including their mothers, their grandmothers, their sisters and their aunts.

Many women in our culture are isolated from family and friends by factors which include distance, poverty and alienation. Our young mothers, our poor mothers, our undereducated mothers, our isolated mothers are all at risk for poor prenatal nutrition, inadequate prenatal care, complications of pregnancy, prematurity, repeat pregnancies, child abuse, neglect and abandonment.

We have in our culture an epidemic of child abuse and neglect, and prematurity. We have a higher infant morbidity and mortality rate than many third world countries. We have an inordinate number of babies who are born addicted to heroin, who are born with strokes from cocaine, who have low birth weights from nicotine addiction and poor nutrition, who suffer from fetal alcohol syndrome and who are the offspring of repeated teenage pregnancies. In Michigan, in 1995 there were 21,165 children confirmed suffering from child abuse/neglect. In Oakland County there were 1300, in Wayne County there were 6,218. Wayne County 6,218 1:100 Oakland County 1,300 1:200 Statewide 21,165 1:100

A Statewide Perinatal Coaching Program would provide prenatal home visits by a trained indigenous woman who would accompany pregnant women to their prenatal visits, who would assist them with getting off drugs, alcohol and tobacco. They would assist them in labor and delivery and continue working with the mother and baby for the first three years after the baby’s birth. They would do home visits on a regular basis, accompany the baby and mother to the well-baby care clinic and family planning clinics.

The benefits of a Perinatal Coaching Program would be to improve prenatal nutrition, reduce drug and alcohol use, improve prenatal care, reduce prematurity, improve well baby care, improve immunization rates, reduce child abuse and neglect, reduce infant abandonment, and provide employment for indigenous poor women and women on welfare.

How does such a program work? Perinatal Coaching Program works because providing personalized care for a pregnant woman increases her knowledge about herself and the process of her pregnancy. It helps to increase her self-esteem. It helps to endow the baby with value. It helps to promote bonding. In addition, the perinatal coach often bonds to the mother and the baby as a surrogate aunt.

Many people acknowledge that this is a good idea but fear that it would take a long time to prove that it works. The data is already available as to the outcome of such a program. In Kentucky they have had a Statewide Perinatal Coaching Program for pregnant teens where trained, experienced women have been matched to pregnant teens during their pregnancy and the first year postpartum. This program provides monthly home visits, prenatal visits, health education, parenting information and well baby care. In the Kentucky outcome, in 1995 they treated 5,170 teens with the following documented results:

  1. 93% of the pregnant teens had prenatal care
  2. 73% returned to school or work following the birth of their baby
  3. 79% attended family planning clinics prior to eight weeks postpartum
  4. 73% demonstrated consistent use of contraceptives only 5% had a repeat pregnancy during the first postpartum year
  5. 90% of babies were enrolled in well baby programs
  6. 90% kept their well baby appointments
  7. 90% were immunized which is in great contrast to Michigan where we were 50th in the nation and spent over a million dollar campaign to improve Michigan to 65% as compared to
  8. 90% in the Kentucky teenagers
  9. 1.2% went to the Emergency Room for treatment in the first year.
  10. There was an increase of participation in the Women Infant Children (WIC) nutrition program 66% of pregnant teens participated; 86% postpartum teens participated; and 97% of infants participated.
  11. The prematurity rate among the participants of the program was only 5.3%. The general population prematurity rate is 9.7%. 5,170 women in the program had 264 premature babies. 9.7% of the general population would be 501 premature babies with a difference of 237. It's estimated that neonatal intensive care unit cost for prematurity is approximately $250,000 per baby. If this figure is correct it is possible that the Kentucky program saved $59,250,000 with the reduction in prematurity alone.
  12. There was an infant mortality rate in the service group of 7.4% as compared to the general population where the infant mortality rate was 11.1%. 192 more babies survived in the study group than in the general population.

In a study from Tennessee reported in the August 27, 1997 issue of the Journal of the American Medical Association similar results were described. They had a home visitor program where they served pregnant women from the prenatal period to 2 years of age. 1,139 first time mothers were served. They were unmarried, unemployed and undereducated. They were compared to a control group. The study reported a lower rate of pregnancy-induced hypertension, a lower rate of infant injuries and a lower rate of subsequent pregnancies. In another study reported in the Journal of the American Medical Association on 8-27-97 from a semi-rural area of New York, 324 first time mothers were served with 9 prenatal home visits and 23 0-3 visits. They demonstrated a decreased number of subsequent pregnancies, decreased use of welfare, decreased child abuse and neglect and of considerable interest they demonstrated decreased criminal behavior on the part of the mothers when compared to the control group. Follow up in this study was done 15 years after the intervention. This is an indication that the program had a profound effect on the mothers in improving their self-esteem. There is a program in Michigan called Day One where trained home visitors visit pregnant women. They have demonstrated a decreased repeat pregnancy rate of only 7% compared to 40% in a matched population, an improved immunization rate of 99% compared to 65% in the population, and a dramatically reduced child abuse rate of 1% as compared to 19% in a group of women who were equally at risk. There are presently programs of perinatal coaching In the Traverse City area, in Ann Arbor, Grand Rapids, Pontiac, Howell, Alpena County, Presque Ile County, Montmorency County and Cheboygan County, Genessee County and Gratiot County. Since January 1997, 10 counties in the northwest Michigan area have served 72 families through the Northwest Michigan Human Services Agency with a grant from Head Start.

Funding for the Perinatal Coaching Program could be provided through block grants from the federal government to provide education, training and employment for welfare women consistent with the federal philosophy of returning these women to meaningful work. Head Start has set aside 5% of federal Heal Start funds for 0-3 programs. The decreased prematurity and neonatal intensive care cost could be used to fund all of the health care programs for the Medicaid mothers. HMO's and insurance programs should mandate a perinatal coaching for their pregnant women as a method of improving the general well being of the mothers and babies and reduction of the incidence of prematurity, improve prenatal nutrition, reducing drug issues among their population. Foundation grants could be obtained particularly for the training and the research component of such a program. Public health funds could be diverted to this program such as the maternal support services and infant support services that are already mandated in the public health department and are included in the mandate to HMO's in the privatization of Medicaid. The Family Independence Agency could supply additional funding for coordination of services to welfare mothers and teenage mothers.

In our culture and in our time we should not allow our women and infants to be strangers in our world. We know what to do; we know how to improve the health and well being of our mothers and infants. We must have the will to do it. We must influence public policy to improve care of our mothers and infants. We must help in our own communities to create perinatal coaching programs. We must create a statewide perinatal coaching program for all mothers and babies at risk.

Jack M. Stack, M.D.
501 N. State St.
Alma, Ml 48801