A healthy pregnancy has a direct influence on the health and development of a newborn child. Early Head Start (EHS) strives to have the greatest impact on participating children by offering supportive services as early in life as possible. The prenatal period of growth and development has a lasting impact on the child's potential for healthy growth and development after birth. Early Head Start programs provide services to pregnant women and their families and through the child's first three years of life. Early, continuous supports and services provide the best opportunity for:

It is expected that pregnant women and their families who receive EHS services will enroll their child in EHS following birth. The goal of serving pregnant women and their families in EHS is ultimately to provide EHS services to their children in the appropriate child development Program Option (Center Based, Home Based, or Combination Option). It is not the intention of the EHS program only to serve pregnant women without also providing services to the child upon delivery. Planning for the transition to the appropriate child development Program Option should begin at the time the pregnant woman is enrolled in the EHS program.

Management Systems

Effective management systems are necessary for quality services. EHS grantees are responsible for developing effective systems for the delivery of services to pregnant women and their families in the following ways:

• Planning comprehensive services and ongoing self-assessment. The Community Assessment drives the planning process for services to pregnant women. The planning process ideally includes input from community partners, program participants, and the Health Services Advisory Committee. Planning is an ongoing activity and program services evolve as information is gathered about the effectiveness of those services.
  
  
• Communicating relevant information to all the parties involved. Communication systems are developed to ensure that pregnant women receive comprehensive, individualized services, and that community partners are well prepared to work in collaboration with EHS. The issue of how much information should be shared and with whom is a sensitive matter that needs to be addressed within formal confidentiality guidelines. These guidelines will consider both the privacy of the family and what the professionals working with the family need to know in order to provide the best possible care. These decisions are often made on a case-by-case basis.
  
  

  Another aspect of communication systems involves sharing information with governing bodies, such as the Head Start Policy Council. Effective communication systems with governing bodies keeps the members informed about how the program is serving pregnant women and their families, and gives them adequate time to review materials and participate in decision-making.
  
  

• Record keeping and reporting to ensure that services are rendered in a timely manner and to monitor the outcome of the referrals to partnering agencies. Record keeping demonstrates how the program is meeting the Performance Standards and other state or federal regulations in regard to serving pregnant women. It also allows the program to monitor how the collaborative relationships with community agencies are working and make adjustments as necessary. Records of work with individual pregnant women and their families allow staff and families to follow their progress toward meeting their short and long term goals.

The Community Assessment and Program Planning Process

Program planning for services to expectant families begins with the Community Assessment. Regulation 45 CFR Part 1305 requires that each EHS grantee and delegate agency conduct a Community Assessment within its service area once every three years and update it annually. This process identifies community needs and resources, which are used to develop both long and short term objectives and goals for the program to meet the identified needs.

The Community Assessment drives the decision about how a program will provide services to pregnant women in their community. This process identifies the needs of the pregnant women in the community, the services they require, and the resources available to meet identified needs. EHS grantees use this information to develop the specific services for the pregnant women in their community. The Community Assessment paints a picture of a community at a point in time. It identifies community resources as well as needs or gaps in services. For example, a Community Assessment in a rural area might reveal that there is a shortage of obstetricians, and that pregnant women are not receiving adequate prenatal care because they do not have transportation to medical facilities in neighboring towns. The EHS program might address this need by assisting the EHS pregnant women in accessing transportation, or by developing partnerships with other agencies that could bring qualified health care providers into their community. Alternatively, a Community Assessment might reveal a high rate of teenage pregnancy. In this case, the EHS program might collaborate with local schools to offer supportive services that allow teens to remain in school while planning for the birth of their child and for the services they will need following delivery.

A Community Assessment may also reveal that services to pregnant women are readily available in the community and women have access to them. Under such circumstances a best practice in EHS might be to complement the services that are already available by serving as a point of referral to the existing services or by developing collaborative agreements with agencies serving pregnant women.

Eligibility and Enrollment (45 CFR 1305)

Eligibility

It is important to note that even when the Community Assessment reveals a need for services to pregnant women, not all pregnant women in the community will be suitable candidates for the EHS program. For example, a pregnant woman and her family should be informed prior to enrollment that the EHS program is intended to serve the family pre- natally and through the child's first three years of life. Parents should be informed of the program service delivery options, such as center- or home-based services, to determine the "match" between the family needs and what the program can offer after the child is born. Pregnant women who do not anticipate the need for EHS services for their children after birth are not appropriate candidates for EHS.

For the purpose of determining eligibility based on family income, the pregnant woman is counted as two members of the household. In the case of an unmarried teenage girl, her own income determines her eligibility regardless of her parents' income. The intent of the EHS program is to serve those with the greatest need, as indicated in selection criteria (45 CFR 1305.6). It is therefore important for a program to consider factors in addition to income, such as social supports or access to resources, when determining if a pregnant teen is an appropriate candidate for the EHS program.

Community Partnerships

Recruitment strategies play an important role in finding appropriate candidates for the EHS program. Community partners are some of the best resources for referrals. Formal agreements as well as informal relationships with service agencies that come into contact with pregnant women increase the exposure of EHS in the community. Formal agreements for collaboration might include agreements with programs such as WIC, La Leche League, Healthy Start, or a local mental health association. OB/GYN physicians, midwives, and clinics routinely come into contact with pregnant women and are excellent resources as well as providers of referrals.

A formal agreement for referrals between EHS and community agencies should include confidentiality guidelines about the kind of information to be shared, define who needs to receive specific kinds of information, and outline procedures to ensure that communication occurs in a timely manner. For example, an EHS program may receive a referral from WIC. The WIC representative would inform the EHS representative of the potential referral and have a protocol for arranging a meeting between the family and the EHS representative. Part of the collaborative agreement with WIC might include sharing information such as a nutritional assessment, and EHS ensuring that a dietician reviews the assessment and provides follow-up.

Enrollment

For the purpose of determining the number of individuals enrolled in an EHS program, the pregnant woman is counted as the one who is enrolled. Once the child is born, it is the child who is enrolled in the EHS program. Furthermore, pregnant women and their families are not enrolled in Head Start Program Options (45 CFR 1306). The Program Options are child development service delivery options. Thus, the regulations governing Program Options do not apply to pregnant women. For example, while many services to expectant families may be delivered through home visits, EHS staff are not required to follow the frequency and duration of home visits that are required in the Home Based Program Option for children. Program staff and families have the flexibility to determine how services will be provided through the individualized Family Partnership Agreement process.

The development of the Family Partnership Agreement [45 CFR 1304.40(a)(2)] is a process of collaborating with parents to develop a plan of program services that is driven by parents' identification of family strengths, needs, resources, and goals. The Family Partnership Agreement determines how the services for pregnant women required in the Head Start Program Performance Standards are individualized for each family. The development of the Family Partnership Agreement is a process of building trust with families, helping them identify their goals, and determining how the EHS program can support them in reaching those goals. It is important to be prepared to adapt EHS services to the particular circumstances of each pregnant woman and her family. Whenever possible, fathers are full participants in the EHS services to pregnant women. The circumstances of the pregnancy, cultural differences, and the nature of the relationship between the mother and father will determine how EHS staff works with the entire family. As Family Partnership Agreements are developed, EHS staff are encouraged to provide couples who choose marriage for themselves with the skills necessary to form and sustain healthy marriages, and refer them to marital enrichment classes and premarital counseling groups.

EHS programs provide services to pregnant women and their families in their homes, in community-based settings, and through referrals to community partners, depending on individual family need, resources, and goals. As described above, pregnant women may come to EHS through many different routes and each one will have a slightly different enrollment process. For example, if a pregnant woman is referred through a medical clinic, the program might begin with an assessment of the woman's current medical condition and ongoing needs. The EHS program representative might meet with the pregnant woman at the medical clinic and provide information about the EHS services. The EHS representative could invite the pregnant woman to visit the center, observe a socialization, or arrange to visit with the woman and her family in their home to further discuss the opportunities available through the EHS program. In whatever way the initial contact is made, the initial focus is on establishing a comfortable and trusting relationship. This process takes some time and staff should be sensitive to how much information families are willing to share before that relationship has had the time to develop. The Family Partnership Agreement process occurs as early as possible in the enrollment period so that the specific needs of each pregnant woman and her family can be determined, the goals set, and the services planned.

Head Start Program Performance Standards Requirements for Services to Pregnant Women

The Head Start Program Performance Standards [45 CFR 1304.40 (c) (1) - (3)] describe the services the EHS grantee must provide to pregnant women, and those services that they must assist pregnant women to obtain. EHS programs must provide prenatal education on:

• fetal development, including the risks from smoking and alcohol;
  
• labor and delivery;
  
• postpartum recovery, including information on maternal depression; and
  
• the benefits of breastfeeding.

EHS programs can, for example, provide this information through classes, support groups, or home visits. Published resources can assist EHS staff to develop a comprehensive approach to prenatal education that encompasses all of the required topics through resources such as videos, books, prenatal journals, and prepared child birth courses. Local libraries, organized groups such as La Leche League or Lamaze, health clinics, and county health departments may offer additional resources.

The topic of maternal depression is addressed as part of prenatal education to alert pregnant women and their families of the common signs and symptoms of the emotional changes during pregnancy, labor, and the postpartum period. This preparation is extremely important so that women are aware of both the common and milder form of "baby blues" as well as more serious forms of depression that require professional intervention.

The information that is presented in prenatal education efforts should be highly individualized to the particular family. Some of the variables that have an impact on the type of information given to pregnant women and how it is presented include: stage of the pregnancy; age of the pregnant woman; previous pregnancy or child birth experience; relationship with the child's father; mental health issues such as substance abuse or depression; and the pregnant woman's support systems and resources.

Services that the grantee must assist pregnant women to access include:

One of the first steps upon enrolling a pregnant woman in EHS is to ensure that she has access to prenatal health care, including dental care. EHS staff members serve as advocates and liaisons between pregnant women and health care providers. The Health Services Advisory Committee helps to develop linkages to service providers in the community. An important role for EHS staff is to ensure that prenatal and postpartum health care is delivered in a timely manner, is responsive to the family's needs, and that follow-up concerns are quickly attended to.

EHS grantees will collaborate with various community partners to provide the prenatal education and comprehensive prenatal and postpartum care specified in the Head Start Program Performance Standards. Developing a plan for services to pregnant women and their families is unique because of the amount of flexibility it gives programs to determine the frequency, duration, and location where services are provided. For example, for one woman it may be desirable to receive prenatal education in her home in a series of weekly visits. These visits could be of any duration necessary to meet the family goal. In one instance a 45 minute visit for following up on a prenatal appointment might be the goal; in another instance a 90 minute visit to discuss childbirth and delivery options could be the appropriate choice. In another example, a woman might elect to participate in prenatal education classes held at a community center and have EHS staff visit her home every other week for support and follow up. Alternatively, a pregnant woman may receive most of the EHS services in community settings. In this example, the EHS program might have a staff person working in the same building where an OB/GYN clinic operates. This EHS staff member could meet regularly with the pregnant women at the clinic following prenatal health care appointments, as well as during weekly support groups for pregnant women that are facilitated by the EHS staff. In every case, EHS staff have the flexibility to design a plan of services that fulfills the requirements of the Head Start Program Performance Standards while meeting the particular needs of participating families.

The Head Start Bureau supports the promotion of safe and stable families as part of the delivery of services to families, including Early Head Start pregnant couples. As such, services for pregnant couples may include activities and discussions that will seek to strengthen parental relationships and promote healthy marriages. Programs are encouraged to provide couples, who are either currently married or who have voluntarily indicated a desire to get married, with help in accessing the skills necessary to form and sustain healthy marriages, by guiding them to marriage education classes.

EHS Services to Pregnant Teens

EHS programs that provide services to pregnant teenagers will consider the particular needs of this population. Teenage girls and their partners are in a unique developmental stage that has implications for how EHS staff might design and deliver services. For example, recruitment efforts might focus on the school setting or a community recreational center where teens are likely to spend their time. In addition, teenagers tend to prefer to spend time with groups of peers and might be better served by prenatal education efforts in a group setting rather than one-on-one. When possible and appropriate, the father of the child will be involved in the program as well. Another consideration is the living arrangements of the teen mother. Many pregnant teens are living in the same household as their parents and perhaps other family members who must all be considered when offering and planning EHS services for the pregnant girl. EHS staff should be knowledgeable about the issues of working with multigenerational families. For example, the mother or grandmother of the pregnant teen may play an important role in child rearing values and expect to assume a certain amount of responsibility for the care of the new baby. In this case it would be important for EHS staff to help all the members of the family to clarify roles and expectations for the child's care prior to the birth of the child. EHS staff would simultaneously work to support the relationship between the teen mother and her newborn while validating the other important extended family relationships in the child's life.

Health Services Advisory Committee

The Health Services Advisory Committee (HSAC) is involved in all aspects of planning, delivering, and evaluating services for pregnant women in EHS. Members of the HSAC can assist with developing health care guidelines, identifying community resources, and developing effective collaborations for services to pregnant women. Ideally, health professionals from the field of obstetrics and gynecology are active participants in the HSAC. Committee members offer their professional expertise and experience in the community to address the issues affecting local families. They can be instrumental, for example, in identifying dental providers who are knowledgeable about oral health during pregnancy, recognize the link between the mother's oral health and her child's healthy development, and know how to provide safe dental care.

Transition Planning

The Family Partnership Agreement process also offers the opportunity to begin planning for EHS services following the birth of the baby. This requires long term planning at two levels. First, EHS programs should consider how they will simultaneously provide services to pregnant women while ensuring that there will be space available for the infants in one of the child development Program Options (Center-based, Home-based, or Combination Option), and that the available Option will meet the needs of the child and family. This type of planning begins when EHS programs are initially funded and are developing their program of services. The second level of long term planning occurs with the expectant family at the time of enrollment to determine the appropriate Program Option for the child after birth. EHS program staff work with the parents to identify family needs and prepare for a smooth transition for the family when the baby is born.

Following delivery there is a period of time during which the mother is recovering from childbirth and the newborn is adjusting to the early weeks of life. Within two weeks of birth, EHS programs are required to arrange for health staff to visit the newborn to ensure the well being of the mother and child [45 CFR 1304.40 (i)(6)]. Ideally, the individual who conducts this visit will have an existing relationship with the mother and family. If the EHS program does not have health staff with the necessary training and experience, this visit can be conducted in collaboration with a community partner. This could be accomplished, for example, by contracting with the clinic where the mother was receiving prenatal care, or in collaboration with a public health program which offers postpartum home visits. This first postpartum visit offers the opportunity to assess such things as success with nursing, sleeping and feeding issues, and the mother's emotional state, as well as the family's resources and social support for coping with challenges. The time frame for the child to begin EHS program services in the selected Program Option depends on family needs. State child care regulations may determine the earliest age at which a child can enter center-based care. Children transitioning into a home-based option have flexibility to begin program services when deemed appropriate by the EHS program and family.

Please see ACYF-IM-HS-00-22, Child Development Services During Home Visits and Socializations in the EHS Home Based Program Option, for additional information regarding transition planning from prenatal services to the Home Based Program Option.

Staff Development

Staff development and reflective or supportive supervision are essential elements of high quality services. Grantee and delegate agencies must provide a structured approach to staff training and development [45 CFR 1304.52(k)(2)]. Working with expectant parents requires specialized knowledge across a broad array of topics. Staff are trained in areas directly related to pregnancy and child birth such as fetal health and development, child birth, lactation, and mother and infant nutrition, as well as other areas that affect child health and development such as substance abuse, family functioning, and mental health. Local communities may have the opportunity to offer specific professional development opportunities such as certification as a lactation consultant, child birth educator, or labor support person.

In Summary

Pregnancy and the newborn period are recognized as opportune times to have a positive and lasting impact on the health and development of very young children. EHS programs are able to provide supportive services to expectant parents that are flexible, responsive to family needs, complement community resources and that build on family strengths and resources. This unique opportunity to support children and their families from the earliest possible point and through the first three years of life provides the greatest potential for healthy growth and development.

See also:
     Services to Pregnant Women Participatin in Early Head Start (ACYF-IM-HS-02-04)