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Maternity care decision coach for rural America
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Maternity care decision coach for rural America
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Maternity Care Decision Coach for Rural America
Capstone Project Proposal
Lei Caine
University of Southern California
Suzanne Dworak-Peck School of Social Work
DSW Program
Dr. Michael Rank, Chair
June 2024
1
TABLE OF CONTENTS
Page Number
I. Abstract 2
II. Acknowledgements 3
III. Positionality Statement 4
IV. Problem of Practice and Literature Review 5
V. Conceptual/Theoretical Framework 13
VI. Methodology 16
VII. Project Description 20
VIII. Implementation Plan 25
IX. Evaluation Plan 27
X. Challenges/Limitations 29
XI. Conclusion and Implication 30
XII. References 32
XIII. Appendices 37
2
I. Abstract
For healthy pregnancies, which account for close to 90% of deliveries, cesarean sections (Csections) are the main cause of mortality and morbidity. The United States is grappling with
elevated rate of pregnancy related morbidity and mortality, a stark contrast to other developed
countries, and the impact is disproportionately affecting subpopulations. During the three years
prior to COVID pandemic, maternal mortality surged in both rural and urban areas reaching
nearly twice the rate in rural areas. This underscores a glaring disparity between reproductive
women residing in urban areas and those in rural regions. My capstone aims to fix the health gap
for maternity care in rural communities. The evidence-based practice of non-medical
interventions is the conceptual and theoretical framework that emphasizes the shared decisionmaking model for maternity care. To provide such evidence, I proposed a prototype focused on
the suburban and rural areas of Kaiser Permanente Southern California, where Kaiser hospitals
are not available within a 15-mile radius or 30-minute drive distance from the homes of
members. I have designed an online maternal care program, offering 24/7 support to pregnant
women and those of reproductive age residing in Kaiser Affiliated Hospital markets. Through
this virtual platform, individuals can access a wealth of educational resources empowering them
to make informed decisions spanning family planning, perinatal care, delivery options and
postpartum support. Moreover, the program facilitates direct connections with a
multidisciplinary team comprising midwives, doulas, maternity social workers, and obstetricians
for meaningful discussions and seek guidance on any challenges during their pregnancy journey.
Lastly, the online program offers an exclusive link for professional care team members to share
best practices on how to help patients avoid C-sections during the labor.
3
II. Acknowledgements
I would like to extend my heartfelt gratitude to everyone who has supported and
contributed to my doctoral capstone project. This journey would not have been possible without
your invaluable assistance, encouragement, and expertise.
Firstly, I thank the Tri-chairs and the founder of the Kaiser Permanente Affiliated
Hospital Council: Rich Snader, Dr. Johnathan Truong, Murtaz Sawari, and Karen Wells. Your
leadership has been instrumental in shaping the direction and success of this project.
In addition to USC professors, I am also deeply grateful to my doctoral program
colleagues: Jessie Shay, Ruth Vosmek, Gregory Gomez, and Jean Broadnax. Your camaraderie,
feedback, and relentless support have been essential for me to complete the doctoral program.
To the interviewees of my design lab, thank you for your time, honesty, and invaluable
insights. Your experiences and perspectives have been crucial in refining and validating the
project, ensuring it addresses real-world challenges and needs.
I am also profoundly grateful to Maya Hardigan, CEO of Mae Health. Your innovative
approach to healthcare and commitment to improving maternal outcomes have been incredibly
motivating. Your support and advice have been pivotal in driving this project forward.
Special thanks to Barbara Lau and Andrew Barrera, two long-term friends whose strong
support and references helped me gain acceptance into this program. Your optimism and
knowledge in business have been a role model in my pursuit of work-study-life balance.
Finally, I want to express my deepest appreciation to my family - Rio, Elleina, and Elliott
Caine – my late parents, Shi, Jia-Jing and Zhou, Xiao-Yun, and my late godmother, Lina Ma.
Your love, patience, and belief in me have been my foundation throughout this journey.
This capstone project is a collective effort of all of you. Thank you all!
4
III. Positionality Statement
As a mother of two teenagers, I vividly remember my two cesarean sections. Pregnant
without family support, I chose C-sections, naively assuming anesthetics would support a
painless delivery. Yet, recovery was challenging as I faced severe postpartum depression for
three months after my first baby. Uninformed about differences between natural birth and Csection, I opted for another C-section for my second baby. During the surgery, watching the
reflection of the gruesome surgical procedure in the light fixture, I realized my mistake. The
nerve pain from the stitches persisted for years, and I regretted not understanding the risks.
This regret inspired my capstone project on reducing C-section rates in maternity care.
For healthy pregnancies, C-sections are a major cause of mortality and morbidity. The U.S. faces
high pregnancy-related morbidity and mortality rates, disproportionately affecting certain
subpopulations. During the three years prior to COVID pandemic, maternal mortality nearly
doubled in rural areas, highlighting disparities between urban and rural regions.
My proposal is an evidence-based, non-medical intervention framework emphasizing
shared decision-making model for maternity care. I designed an online maternity care program
for remote areas of Kaiser Permanente Southern California, where Kaiser hospitals are
unavailable within a 15-mile radius or 30-minute drive. This virtual program offers 24/7 support
with educational resources, empowering pregnant and reproductive age women to make
informed decisions spanning family planning, perinatal care, delivery options and postpartum
support. The program also connects users with a multidisciplinary team comprising midwives,
doulas, maternity social workers, and obstetricians fostering meaningful discussions and
guidance throughout the pregnancy journey.
5
IV. Problem of Practice and Literature Review
Maternal mortality, as defined by the World Health Organization (WHO, 2009), refers to
the death of a woman while pregnant or within 42 days of termination of pregnancy, regardless
of the pregnancy’s duration or location, resulting from causes related to or aggravated by the
pregnancy’s management, but not from accidental or incidental causes. On the other hand, severe
maternal morbidity (SMM) is characterized by an index of 21indicators of significant lifethreatening events during delivery admission, including acute myocardial infarction, aneurysm,
acute renal failure, blood transfusion, hysterectomy, heart failure, eclampsia, respiratory distress,
and sepsis as defined by the Center for Decease Control and Prevention (CDC, 2019).
In recent years, the United States has witnessed a concerning rise in maternal mortality,
with approximately 700 deaths occurring in 2018 and a staggering increase to 900 in just two
years. Additionally, at least 50,000 cases of severe maternal morbidity are reported annually in
this country (Kozhimannil et al., 2019). The overall rate of SMM increased by almost 200%
between the beginning of the 21st century to 2014 (CDC, 2019), while maternal mortality rates
experienced a 37% increase between 2018 and 2020 (Hoyert, 2022). Notably, the United States
is facing higher rates of pregnancy-related morbidity and mortality compared to other developed
countries (Tikkanen et al., 2020), and the impact is disproportionately affecting subpopulations.
For instance, 28 million women of reproductive age residing in rural counties in America face a
9% higher probability of severe maternal morbidity and mortality compared to their urban
counterparts (Kozhimannil, et al., 2019). From 2016 to 2019, Maternal mortality increased in
rural areas from 66.9 to 81.7 deaths per 100,000 live births, whereas in urban areas, the increase
was from 38.1 to 42.3 per 100,000 live births. The number of deaths in rural areas was nearly 2
times higher in rural areas in 2019 (Harrington et al., 2020). In terms of SMM, the risk factors
6
for various-sized hospitals in rural counties are 28% to 52%, or 31% higher than those in urban
counties (Kozhimannil et al., 2023).
This alarming trend can be attributed to a myriad of factors including health, societal, and
economic factors, as highlighted by the March of Dimes (2022). Substance use disorder and
chronic illness in rural communities exacerbate the issue, while unequal access to healthcare and
a lack of financial support or insurance coverage are major contributing factors. In fact, the term
“Maternity Care Desert” has been coined by the March of Dimes to describe counties where
women’s access to maternity health services is limited or nonexistent. With 1119 US counties
identified as Maternity Care Deserts, 911 of them are rural counties (March of Dimes, 2022).
The consequences of these disparities are evident in the higher risk for childbirth complications
experienced by women living in rural areas, leading to increased maternal mortality and /or
severe maternal morbidity. As a result, a significant gap exists in maternal care between
reproductive women living in metropolitan areas and those in rural regions. The grand challenge
this project strikes to solve is to close this health gap.
Literature Review
As all literature authors agree, the loss of obstetrical services led to more adverse impacts
across various birth categories compared to counties with continuous obstetric care. For instance,
out-of-hospital births increased by 0.4% versus 0.07% in areas with continual obstetric care, and
births in hospitals without obstetric units rose by 2.1% compared to only 0.1% in areas with
continuous care. The year following the loss of obstetric services saw a 0.2% increase in preterm
births, a 4.37% spike in the rate of low prenatal care usage, and a 2.8% rise in the Cesarean
delivery rate. Low Apgar scores increased by 2.17% one year after the loss, with a continual
upward trend of 0.15% in subsequent years (Kozhimannil, et el., 2017).
7
There is also a shortage of overall healthcare providers in rural areas that exacerbates this
issue, leading to a significant number of rural hospital closures. Since 2010, 78 rural hospitals
have entirely shut down, and 73 others have converted into emergency units or skilled care
facilities that no longer offer in-patient care. Shockingly, over a fifth of rural hospitals in the US
are at high risk of facing closure (Germack, Kandrack & Martsolf, 2019). These findings
underscore the alarming decline in rural maternity care and the subsequent rise in maternal
mortality and SMM.
One of the primary causes is the funding source change leading to the closure of these
hospitals or obstetric care services. Federal funding, since the conclusion of the Hill-Burton
program in 1997, has transitioned from bolstering healthcare infrastructure to ensuring individual
coverage through Medicare and Medicaid, often sidelining community needs. The Hill-Burton
program, from its commencement in 1946 through 1997, contributed a total funding of
approximately $27.3 billion, in 2022 money worth, to construct non-profit and public hospitals
throughout the country. Areas with low-income, rural areas, and the South largely caught up with
areas that had greater hospital capacity (Chung, Gaynor, & Richards-Shubik, 2017). The
Hospital Survey and Construction Act of 1946, aka the Hill-Burton program, was enacted to
subsidize the construction of public and non-profit hospitals. It aimed to offer hospitals, nursing
homes, and other health facilities grants and loans for construction and modernization. In return,
these facilities agreed to provide a reasonable volume of services to low-income residents in the
community (HRSA, 2022).
As a result of the Hill-Burton program’s ending, communities with large populations can
yield revenue from public health insurance, Medicare, and Medicaid, to fund healthcare
institutions; while scarcely populated rural communities struggle to finance their healthcare
8
infrastructures, leaving them at the mercy of market forces. The shift towards “structural
urbanism” coupled with a market-oriented healthcare approach is identified as a primary driver
of rural healthcare disparities (Probst, Eberth & Crouch, 2019).
The View of Stakeholders
The issue of rural maternity care access initially drew attention from not-for-profit
organizations. The Commonwealth Fund publishes the annual “Mirror, Mirror” report comparing
the United States with other developed countries, including aspects of maternity care access in
rural America. The Kaiser Family Foundation focuses on Medicaid expansion and assesses the
improvement status by state, which includes rural maternity care conditions. The March of
Dimes reports annually on maternity care improvement in American counties identified as
maternity care deserts. They define a maternity care desert (MCD) as counties lacking maternity
care resources are lacking, with no hospitals or birth centers offering obstetric care or providers.
2.2 million women of childbearing age live in MCDs, with two-thirds of them reside in rural
counties (March of Dimes, 2022).
This project focuses on improving maternity care in rural Southern California,
emphasizing the definition of rural counties. Rural counties have a population of fewer than
5,000 or 2,000 housing units, are not adjacent to a metro area, or entirely rural (United State
Census Bureau, 2020). Over a million women of reproductive age live in the 900+ identified
MCD counties. These areas are typically remote, sparsely populated, with few healthcare
providers, limited medical facilities, and inadequate transportation infrastructure, hindering
access to maternity care for pregnant women.
Stakeholders in addressing this issue include pregnant women and their families,
healthcare providers, hospitals and care centers, health plans, government agencies, advocacy
9
groups, and non-profit organizations. A Stakeholders Mapping (Appendix C) visually represents
these stakeholders. Pregnant women and families are central to this issue, being directly affected
by limited access to or lacking financial support for maternity care in rural America. It’s crucial
to listen to their voices and keep them informed about resolution efforts, especially focusing on
under-represented groups such as undocumented immigrant women in rural Southern California.
Healthcare providers play a significant role, including obstetricians, midwives, nurses,
and others. They influence problem-solving and care provision but face challenges due to
disparities in Medicaid policies across the states, limiting maternity care for undocumented
pregnant women. Although California extends full Medicaid coverage for maternity care to
undocumented immigrant women, economic status, education gaps, lack of birth control access,
and limited specialty care for high-risk pregnancies remain barriers (J. Martin, MD, personal
communication, June 2023, Appendix A).
Government agencies at the federal and state levels are crucial in policymaking and
oversight, such as the Department of Health and Human Services and state health departments.
They allocate funding, enact policies, and enforce regulations to improve maternity care, yet
adoption of policy changes has been slow in some states, leaving pregnant undocumented
immigrants without coverage, particularly in rural areas. Advocacy groups and non-profit
organizations like the National Rural Health Association and March of Dimes influence public
opinion and government actions through awareness campaign, advocacy, and support for
healthcare providers and pregnant women in rural areas.
Health plans are pivotal stakeholders offering commercial insurance or managing
Medicaid benefits. They provide essential financial support to pregnant women and families,
facilitating their access to adequate insurance coverage throughout the childbirth journey.
10
Notably, Kaiser Permanente supports rural healthcare through organizational affiliations, but
challenges like varied quality standards and outdated facilities persist within their affiliated
hospitals.
Solution Landscape
The midwifery model of maternity care, encompassing prenatal and childbirth care, is
widely recognized as a normal and healthy process in European countries, such as Sweden and
the Netherlands. In Sweden, midwives administer 80% of prenatal and over 80% of family
planning. Dutch midwives play the same role and attend all normal births in public hospitals.
The Dutch and Swedish maternity and infant mortality rates are among the lowest in the world.
Additionally, in Wales, pregnant women not only benefit from exclusive care by midwives but
also have midwives who supported childbirth and provide well-baby check-ups, including
hearing assessment and newborn examination. Incorporating these procedures into postnatal care
reduces the fragmentation caused by involving multiple professionals and simplifies family
planning. Performing these procedures within the woman’s home enhances communication and
promotes overall public health (Ben-Noun, 2017).
While most women in the United States give birth in hospital settings, the geographic
availability of maternity hospitals, in-hospital capabilities, types of maternity care providers, and
access to minimal-intervention birth options vary. As such, home or birth center deliveries have
been considered by many pregnant women and families. Although the percentage is growing,
only 0.52% of women give birth in birth centers and 0.99% of women do so at home (National
Academies of Sciences, Engineering, and Medicine, 2020). Due to the very small percentage of
non-hospital setting births, it’s not clear whether birth center or home settings are less safe.
However, it has been noted that evidence-based care and quality vary across settings, and this
11
variation leads to issues of either insufficient or excessive care. Furthermore, problems are
exacerbated by a lack of care coordination among settings and providers, which can result in
suboptimal outcomes regardless of the chosen birth setting (Lowe, 2020).
One recent solution to rural hospital closures involves larger hospital system affiliating
and acquiring rural hospitals. This provides an influx of shared resources and improved clinical
integration. However, it also presents a challenge in striking a balance between local communitydriven decision-making and meeting health system requirements for affiliation (Germack,
Kandrack & Martsolf, 2019). The challenge is experienced by Kaiser Permanente SCAL region,
where some of the affiliated hospitals, mostly independent community facilities, have over 30%
C-section rate, much higher than the target rate 24% of Kaiser Permanente hospitals.
Telehealth has emerged as a promising solution for rural health care. It offers care
delivery in low-volume settings without requiring onside providers. Nonetheless, it comes with
challenges, such as unsolved broadband connectivity, issues of supervision, interstate licensure,
and medical data interoperability among others (Weeks, 2018). Additional challenges to
advancing telehealth in rural communities also include a lack of Medicaid reimbursement for
certain types of telehealth, state policies requiring providers to be licensed in the states where
their patients are, and state patient privacy regulations (Germack, Kandrack & Martsolf, 2019).
This is experienced also by Kaiser Permanente SCAL region. Per an interview with a vice
president of the Kaiser Home Care division, as our technologies advance, telemedicine is
available but access to telemedicine may not be available. Sufficient funding is required to
establish access so that pregnant women can access care at home via telemedicine (A. Vargas,
personal communication, July 2023, Appendix A). During the COVID-19 pandemic, telehealth
emerged as a widely acceptable medical consultation channel. In California, Medi-Cal covers
12
synchronous video telehealth visits to establish new patient relationships, which requires a
broadband network that many rural areas do not have coverage (DHCS, 2023).
Several medical schools have started addressing the workforce shortage in rural areas.
For instance, the University of Wisconsin at Madison Department of Obstetrics and Gynecology
established the nation’s first rural obstetrics and gynecology residency program. Building upon
its success, the University of Iowa is now replicating the program, and leaders from other
academic medical centers expressed in adapting the program in their respective states (Hostetter
& Klein, 2021). These programs aim to address the annual reduction in the supply of
obstetrician-gynecologists in rural areas.
Policy advancement was made on March 11, 2022, with the passage of the Rural
Maternal and Obstetric Modernization of Services (RMOMS) Act by the U.S. Senate. The Act
aims to improve rural maternal and obstetric care data, provide new rural obstetric network
grants to establish regional innovation networks, enhance existing federal telehealth grant
programs to include prenatal, labor, birthing, and postpartum services, and establish a new rural
maternal and obstetric care training demonstration (Smith, 2023). The outcome is unclear as the
legislation is relatively new.
While the trend of increased healthcare affiliation, merger, and acquisition offers a
lifeline to rural hospitals, the downside is that the acquiring health systems may lack the financial
motivation to maintain these facilities within their portfolios (Weeks, 2018). Similarly, Medicaid
expansion was associated with improved financial performance and a significant reduction in the
likelihood of closure for rural hospitals, providers may be reluctant to offer care to pregnant
women covered under Medicaid programs due to significantly lower reimbursement rates
13
compared to other third-party payers. Regrettably, none of these solutions appear capable of
solving the problem without creating new challenges.
Among the rural populations in America, undocumented farm workers, as one of the
major groups under Medicaid, have mostly been overlooked. Approximately 50% of hired
farmworkers in the United States are undocumented and do not have the authorization to work in
the country; of these, 48% are women, and the majority of them are of reproductive age (Castillo
et al., 2021). In rural California specifically, maternity care for undocumented immigrants or
migrant farm workers is markedly limited. Undocumented immigrants in the United States are
generally ineligible for publicly funded health care, with a few notable exceptions (Fabi &
Taylor, 2019). California employs over 800,000 Mexican agricultural workers per year, of
whom approximately 400,000 are undocumented immigrants (Medel-Herrero et al., 2021).
Given the national statistic of 48%, it can be estimated that roughly 192,000 of these farm
workers are women. In 1988, the state of California extended eligibility for Medi-Cal to
undocumented pregnant immigrants. As a result, nearly two-thirds of undocumented immigrant
women of reproductive age have gained Medi-Cal eligibility since then. However, language
barriers, cultural differences, and discrimination can deter these women from effectively
navigating the healthcare system and receiving quality care. The complexity of the rules and
fears about the potential repercussions of using public benefits create barriers to enrollment
(Miller & Wherry, 2022).
V. Conceptual/Theoretical Framework
The evidence-based practice of non-medical interventions is the conceptual and
theoretical framework that emphasizes the shared decision-making model for maternity care.
This is especially pertinent for low-risk pregnant women in rural areas. Currently, there are more
14
than 28 million women of reproductive age living in rural America (Lewis, Paxton & Zephyrin,
2019). Alarmingly, one to two million of these women reside in counties devoid of prenatal care
or obstetricians. Furthermore, countless others live in locations where medical support is
severely constrained (March of Dimes, 2022). Given the scarcity of birthing facilities and
hospitals in these rural areas, evidence-based non-medical interventions such as the decision
coach program, grounded in the shared decision-making model, emerge as a critical solution.
These programs not only respect women’s autonomy but are also safe and cost-effective. When
implemented astutely, they can bolster the likelihood of natural vaginal births while concurrently
reducing the risk of premature and cesarean deliveries. This, in turn, mitigates maternity
morbidity and mortality rates.
In Kaiser Permanente Southern California region, there is a platform, the Affiliated
Hospital Council, an advisory body comprising voluntary executives, administrators, and
physician leaders who oversee patient care daily in a set of community hospitals contracted with
Kaiser Permanente. Affiliated Hospitals are a designated contracted community hospital which
provide covered services available at the hospital under the same terms and conditions as applied
at a Kaiser Foundation Hospitals (KFH). Most contracted Affiliated Hospitals are in expansion
service areas where there is not a KFH, such as the Coachella Valley, Ventura County and Kern
County in Southern California. Other contracted Affiliated Hospitals were added to provide
appropriate access to medical services, such as Rancho Springs and Temecula Valley in south
Riverside County.
The capstone project includes a web-based platform named Maternity Coach 24/7
developed to serve pregnant women in these affiliated hospital markets. The project will include
a standardized quality matric, the C-section rate, as the measurement to evaluate the
15
improvement. Effective communication and coordination will be initiated during prenatal care or
even as early as the family planning stages, laying the foundation for a positive patient
experience throughout the childbirth journey. At the time when those patients deliver babies in
the hospital, they will be much better prepared and suited to make informed decisions, and likely
feel more respected, and effectively communicated with, and that their personal needs and
preferences are well-catered.
The program will involve collaboration among patients, their families, and healthcare
providers to make well-informed decisions concerning birth settings, surgical interventions, and
lactation choices. To extend the program’s engagement beyond hospitals, an outreach initiative
will be proposed integrating health education, knowledge exchange, best practice dissemination,
and on-site consultation in rural communities where Kaiser members reside. The project team
will consist of midwives, nurses, and social workers, ensuring comprehensive support and care
for pregnant individuals. To facilitate effective communication and understanding within the
community, workshops will be organized offsite, bringing together physicians, nurses, and
midwives from the community hospitals. These workshops will focus on developing materials
that will be translated into Spanish and disseminated bilingually during community outreach
events.
At the community level, implementing the decision coaching program will follow several
essential steps. Firstly, the project team will need to identify partners within the communities to
establish strong collaboration. Conducting interviews with women of reproductive age or those
who are pregnant will help gain valuable insights into their specific needs and challenges.
Engaging with community-based organizations will further enrich the understanding of the local
context and ensure inclusivity in the overall approach. To ensure the sustainability and success of
16
the program, training designated individuals within the community to become skilled decision
coaches for pregnant women will be a key driver. Disseminating crucial public health
information among reproductive-age women in the communities can foster awareness and
empower them to make informed choices about their maternity care.
Throughout the program’s development and implementation, a logical model will be
followed encompassing exploration, preparation, implementation, and sustainability. This
comprehensive approach will guide the program effectively in selected rural communities in
Southern California with the vision of expanding its reach to other Kaiser regions and beyond,
benefiting communities across different states. By prioritizing shared decision-making and
community involvement, the aim is to enhance maternity care accessibility and quality while
promoting a positive and empowering childbirth experience for all individuals involved to
provide evidence for a scale-up decision coach program across other rural areas.
The decision coach initiative proposed for affiliated hospital service areas in the Kaiser
Permanente Southern California region will be presented under the framework of an evidencebased shared decision-making model. Under the “Thrive” spirit, Kaiser leadership understands
the intrinsic nature of childbirth and would prioritize its biological foundation and extend
innate respect to both mothers and babies. This is reflected in many maternal care initiatives
including setting a target of lowering the C-section rate to 24%, current target rate of KFHs.
The decision coach program will provide a low-cost effective measurement to enhance the
knowledge of pregnant Medi-Cal members in affiliated hospital service areas enabling them to
make high-quality informed decisions on their choice of delivery to lower the C-section rates.
VI. Methodology
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Human-centered design thinking is the cornerstone of this capstone project. The project
begins with an extensive literature review encompassing various works of literature. This method
enables chronological tracking of the problem, with a specific focus on changes in data and learn
from past research to identify the needs of end users and what are still missing. Furthermore, it
entails a scoping review that aims to identify potential solutions. Among the literature, the annual
reports published by the March of Dimes stand out as the most comprehensive and subjectfocused materials. Additionally, peer-reviewed journals, primarily in the most recent decade,
authored by renowned experts such as Kozhimannil et al. are studied and cited to support a
thorough exploration of the subject matter. To broaden the context, the bi-annual “Mirror, Mirror
Report” published by Commonwealth Fund serves as a valuable resource for understanding the
global aspect of the problem (Schneider et al, 2021). Lastly, considering the project’s location in
California, the body of work performed by State Prenatal Quality Collaboratives is reviewed to
identify comprehensive solutions specific to the home state. Moreover, for the interest of the
project, literature regarding maternity care for undocumented migrants, a representational group
of Medi-Cal members, were also reviewed to identify the magnitude and impact of the issue.
In addition to the literature review, interview is another method used to gather first-hand
information reflecting the empathetic design justice principle. These interviews also help
establish partnership with peer professionals and end users who became design team members of
the project. A diverse range of key informants included a Kaiser gynecologist serving rural
residents, a patient advisor residing in a rural county, who has given birth in a Kaiser Permanente
affiliated hospital, a community organization leader who is a subject matter expert, a chief
operation officer of Kaiser Antelope Valley Medical Office facility, a vice president of Home
Care of Kaiser Permanente Southern California region, a perinatal quality leader of Palomar
18
Health, one of the Affiliated Hospitals. As to end users of the program, four women, respectively
living in Palm Springs, Bakersfield, South Bay and Perris are interviewed to gather their birthing
experience. Though these individuals are not Medi-Cal members, three of them had limited
access to a Kaiser Permanente hospital due to the remote geographic location, for which the
challenges resemble those Medi-Cal members living on farms and ranches in remote counties.
These interviews provide valuable insight from different perspectives, reflecting real-life
experience dealing with the problem. Though questions vary when each interviewee was
interviewed, the focal view is on the impact, challenges, opportunities, and solutions everyone
would like to see taking place The key takeaways from these interviews (Appendices A) report
qualitative findings as part of the analysis and collaborate with the gaps identified through the
literature review.
While access to medical care is an essential component, it alone does not guarantee good
health outcomes (CDC, 2019). Human connectivity can complement adequate access to medical
care and warrants special attention in building in-person relationships within these communities.
Additionally, providing effective education that connects and resonates with pregnant women is
a critical healthcare need that extends beyond the walls of hospitals. During the two decades
around the turn of the 21st century, a persistently increasing rate of maternity morbidity and
mortality raised concerns about the potential impact of excessive medical interventions on
preterm and cesarean birth (Moore, 2016). The alarming statistic that one in three women in
America undergoes surgical birth emphasizes the heightened risk of adverse childbirth events
(Osterman, 2022). Pregnancy is not a medical condition. Medical interventions increase the risk
of adverse events.
19
On the other hand, a U.S. national survey reveals that 97% of women desired knowledge
about potential complications before agreeing to labor interventions (Declercq et al., 2007).
However, most women who underwent interventions lacked awareness of these potential
complications and experienced feelings of fear and powerless during labor and birth (Declercq et
al., 2007). Properly trained doulas, midwives, and social workers residing in rural communities
can establish connections with pregnant women, listen to their concerns, and provide perinatal
advisory services. The feedback received from providers, community advocates, healthcare
administrators, and women of reproductive age all point to a crucial and emerging need:
education and coordination. This indicates the potential for a new approach where a communitybased advisory group, staffed by social workers, may play a pivotal role in addressing these
concerns and improving maternity care. By fostering a community-focused approach, social
workers can contribute their expertise to enhance communication, education, and coordination
among healthcare stakeholders, resulting in better-informed decision-making and improved
maternal outcomes.
Since this capstone intends to focus on underserved population in rural areas covered
primarily under Medicaid, a prototype, which is the other method used in design thinking, is
developed to provide evidence to test the efficacy of non-medical intervention program by
focusing on Medi-Cal members in Kaiser Permanente SCAL’s affiliated hospital markets. Kaiser
has recently entered a direct Medi-Cal contract with the State Department of Health Care
Services (DHSC) effective January 1, 2024, which enabled Kaiser to manage and enroll qualified
individuals directly with Medi-Cal. This new contract also provides a more convenient and direct
access to managing the member data, monitoring the progress and measure the improvement
through designated quality matric.
20
VII. Project Description
With the goal of fixing the health gap in areas the access to maternity care is limited, the
capstone project Maternity Care Decision Coach brings together a team of decision coaches, led
by primary practitioners aiming to empower patients to make informed, high-quality decisions
with the essential knowledge they need regarding their prenatal care and childbirth. A significant
aspect of this project is catering to pregnant women, guiding them through three trimesters,
delivery, and postpartum period. Serving as decision coaches are certified doulas, social workers,
and licensed vocational nurses. Their role is to engage with these women and provide them with
relevant information. Behind this hands-on interaction are the primary practitioners, which
consisting of physicians, nurse practitioners, midwives, and pharmacists. They are responsible
for creating the training materials used to train the decision coaches. These materials are rooted
in real-world cases and crafted based on the needs of previous patients. By analyzing past patient
encounters, i.e., evidence-based instances, where patients faced decisional conflicts, the training
can reflect the type of decision support future patients might require.
To test the efficacy of the program, a prototype is designed to target pregnant women
who are both members and non-members of Kaiser Permanente Southern California’s affiliated
hospital markets. As an identified health gap, we place a significant focus on serving
underserved individuals, for example, immigrant farm workers, whether documented or
undocumented. Based on the design criteria (Appendix D), affordable insurance coverage is a
must to ensure all under-represented women are covered. Medicaid expansion is the key to
provide this coverage. California has extended eligibility for Medi-Cal to undocumented
pregnant immigrants since 1988 due to extensive labor needs in largely industrialized farms and
ranches. The Decision Coach program aims to collaborate among community hospitals, offering
21
maternal care information to immigrant farm workers in large, industrialized farms, and guiding
them on how to secure Medi-Cal for public health coverage in addition to provide obstetrician
care.
As the author of this capstone project, I currently manage an advisory body called the
Kaiser Permanente Affiliated Hospital Council (KPAHC). This council is comprised of
voluntary executives, administrators, and physician leaders dedicated to enhancing daily patient
care quality. The decision coach program will be presented to the council as a prototype with a
logic model (Appendix E) to showcase the course of design thinking from identifying
determinants to design the implementation strategies and mechanisms, and to projecting the
outcomes. Following this logic, the program will address conflicts, bridge knowledge gaps,
clarify values, and provide the necessary support. It offers tailored assistance based on evidencebased aids and coaching methods that cater to each client’s level of knowledge. After offering
this personalized support, the outcome and feedback will be continuously monitored and
evaluated in terms of the efficacy of the approach, assessing both the fulfillment of client needs
and the quality of the decisions made. The ultimate step is to evaluate the prerequisites for
enacting these decisions. The interactions between end users and care teams can be achieved on a
web-based platform, Maternity Coach 24/7, through which the need of travel can be minimized.
Subscribers can navigate the website to obtain needed information, and also enjoy the direct
access to obstetricians, midwives, social workers and doulas whenever they have questions or
need guidance. When the due date is approaching, a pregnant woman can schedule a virtual tour
of the Labor and Delivery room of designated hospital. When they’re leaving the hospital, all the
medication, care instruction and after-care visits can be provided on the website. The framework
of the website shows the flow of the interaction (Appendix G).
22
Theory of Change
The Theory of Change (TOC) serves as a foundational blueprint for the maternity care
Decision Coach initiative, directing the creation of evidence-based interventions that are nonmedical in this program. Its primary goals are to coach pregnant women in making informed,
high-quality decisions during the perinatal phase, and to enhance their experiences during
childbirth in hospitals and/or birth centers, thereby promoting the well-being of women,
babies, and their families. TOC meticulously delineates the logical progression of a program,
beginning with long-term objectives and tracing back to identify preliminary changes or
preconditions vital for success (Taplin, Clark, Collins & Colby, 2012). Essentially, the TOC
offers an analytical framework detailing the mechanisms and rationales underpinning an
initiative. This framework can be empirically tested by measuring indicators corresponding to
each step in the assumed causal pathway leading to the desired impact.
Within its structure, the TOC introduces a logic model (Appendix E) that encapsulates
hypotheses and assumptions regarding the most efficacious actions to achieve projected
outcomes. It necessitates that Evidence-Based Practice (EBP) amalgamate core components
with discernible and measurable success indicators for precise monitoring and evaluation.
From the TOC perspective, the fundamental elements of EBP encompass empirical research
evidence, clinical expertise, and patient preferences.
Shared Decision-making represents a collaboration between a pregnant woman and her
healthcare provider. Together, they identify treatment pathways that synergize clinical
evidence with the woman’s personal values and beliefs. This process underscores the
importance of presenting evidence-informed options, discussing potential outcomes and
uncertainties; empowering decision-making autonomy; and crafting a structure to record and
23
implement the woman’s informed choices (Lagrew et al., 2018). In this light, shared decisionmaking aligns closely with the logic model proposed by the TOC.
One model within Shared Decision-making focuses on decision coaching for prenatal
care and delivery decisions. While the alliance between a pregnant woman and her healthcare
provider might appear to be seamless, the stark reality is that many women feel overwhelmed
when faced with making crucial decisions. Numerous studies indicate that a significant number
of women lack the requisite knowledge to make informed choices about their pregnancies and
maternity care. For instance, a study of 650 postpartum women showed that 24% of them
considered a fetus of 34-36 weeks of gestation to be full term, while 50.8% believed the full
term was 37-38 weeks (Gee & Corry, 2012). Contrary to these beliefs, the American College
of Obstetricians and Gynecologists defines a full-term pregnancy as one lasting between 39
weeks and 40 weeks and 6 days (ACOG, 2022). A poignant example of the ensuing decisional
conflicts is the choice of undergoing prenatal screening. Deciding between accepting or
declining prenatal diagnostic testing is emotionally complex, often requiring women to balance
risks, benefits, and personal values. Decision coaches are trained to identify patients grappling
with such decisional conflict and assist them in navigating the decision-making journey
(Stacey et al. 2008).
Revised Logic Model, Ethical Consideration and Likelihood of Success
The objective of this capstone is to develop a shared decision-making program aimed at
guiding women of reproductive age, including pregnant individuals, in making informed
choices based on their health, priorities, and personal values. Shared decision-making
embodies a collaborative process between healthcare practitioners and patients to achieve
24
high-quality healthcare decisions rooted in the best available evidence and reflecting the
patient’s individual values (Stacey et al., 2008).
Kaiser Permanente is among the largest integrated healthcare systems in the U.S.,
committed to delivering high-quality and cost-effective healthcare services to all members of
its communities. However, constructing a hospital in every rural community presents
significant challenges and often proves impracticable. As analyzed in the design criteria,
securing sufficient funding in sparsely populated areas remains a primary obstacle to establish
medical facilities. To address this challenge, Kaiser Permanente has formed affiliation
agreements with community hospitals. This strategy allows Kaiser to leverage the
infrastructure and resources of these hospitals, along with Kaiser’s cadre of physicians, stateof-the-art technologies, and management prowess, to better serve residents of these
communities. The Kaiser Permanente Affiliated Hospital Council (KPAHC) has been
chartered to coordinate and streamline these collaborative efforts, ensuring consistent quality
of care despite geographical disparities.
However, challenges persist. For instance, quality outcomes such as Sepsis I score and
C-section rate, etc., vary among these community hospitals. C-section rates for Kaiser
members in some of these hospitals are significantly higher than Kaiser-owned Hospitals,
partially due to 50% higher revenue generated from C-sections to vaginal deliveries. Balancing
financial considerations with patient health outcomes raises ethical concerns. For example,
while one community hospital has an overall C-section rate of 19%, the rate among Kaiser
members is 30%. The conflict of interest may hinder the adoption of the decision coach
program by community hospitals. Therefore, standardizing and improving quality across rural
Southern California regions for all members remains a challenge for the KPAHC.
25
As an embodiment of the shared decision-making (SDM) frameworks, the decision
coach initiative aims to foster well-informed choices in domains such as family planning,
prenatal attention, determining suitable delivery methods, and postpartum support. Given its
comprehensive approach and goal of reducing C-section rates, the initiative may appear
daunting or potentially impact the financial bottom line of affiliated hospitals. The revised
logic model (Appendix E) prioritizes a prototype of web-based decision coach program that
aligns with Kaiser Permanente’s overall direction and is likely to be more acceptable due to its
educational and informational focus.
VIII. Implementation Plan
Numerous stakeholders play essential roles in the intricate landscape of this wicked
problem. These stakeholders include pregnant women and their families, healthcare providers,
certified doulas, hospitals, and health plans, which, function as pivotal stakeholders. Some offer
commercial insurance coverage, while others manage Medicaid benefits. Efforts from all sectors
of society have been directed toward solving the challenge of rural maternity care. In response to
the workforce shortage, several medical schools have launched rural obstetrics and gynecology
residency programs. Telehealth has emerged as a vital solution to address distance barriers, but
only in areas with broadband coverage. One recent solution to combat rural hospital closures
involves larger hospital systems affiliating with and acquiring rural hospitals. Moreover, the
passing of the Rural Maternity and Obstetrics Management Strategies Act in March 2022 has
made federal funding available to help address this challenge. Lastly, a few startup companies
have initiated certified doula programs to provide advisory services on childbirth and postpartum care. However, none of them have made a widespread impact on rural residents.
26
Apart from all these developments, this capstone proposes a non-medical intervention
initiative framed within a shared decision-making approach, focusing on Medi-Cal beneficiaries
such as farm workers in rural Southern California. Barriers to implementing shared decisionmaking practice primarily arise from the competency of the health professionals. Factors such as
a lack of awareness, knowledge, and skills; inadequate training; time constraints in clinical
practice that interfere with skill development, and ambiguous administrative directives (Stacy et
al. 2008) all impede health professionals’ ability to engage in shared decision-making practice
with patients. For advocacy groups serving as decision coaches, competence in providing
decision coaching demands specific knowledge and skill-building. The influence of practice
environments, regulatory bodies, educational systems, and professional and accreditation
organizations is crucial for successfully integrating decision-coaching skills into practice. For
optimal outcomes, it’s vital to establish practical, transparent, accessible, evidence-based
regulations and policies that are enforced equitably and advocate for patients’ decision-support
interventions. The design partners will include subject matter experts, i.e., the professionals and
senior leaders at Kaiser Permanente Southern California region that will provide professional
training and policy guidance.
The prototype for the capstone will require a budget of $370,755, covering primarily
labor, multimedia, equipment, and travel costs (Appendix F). A grant application based on the
prototype will be submitted to Kaiser Permanente Community Benefit to subsidize the program’s
implementation. In the first year, the website subscription will be tested in at least one of the five
affiliated hospital markets. Following the initial testing and user feedback, the website will be
refined and upgraded for the second year. If the C-section rate begins to decline or reaches the
regional average of 24% for three consecutive years, a scaling-up plan will be reviewed with
27
Kaiser Permanente program office to promote the website to other Kaiser regions with Affiliated
Hospital markets. Once the scale-up is successful, Kaiser Permanente Marketing will be engaged
to create a logo and promotional materials to further promote the project. Additionally, Kaiser
Family Foundation will publish the paper to share best practices with other healthcare systems,
aiming to further promote the project to rural areas across the country.
IX. Evaluation Plan
Regarding the capstone project, a business-to-business-to-customer (BBC) model will be
used to implement the program. Kaiser will collaborate with community hospitals that provide
care to Medi-Cal members, who are primary customers of the decision coach program. The
program will be implemented on a website supported by obstetricians, midwives, doulas, and
maternity-specialized social workers. Medi-Cal members who are pregnant or plan to have
babies can access the website subscribing as members or ordering specific educational or
consulting services. In addition, educational sections or health fairs in local event venues can
also be delivered periodically to rural communities partnered with local community sponsors,
private companies with women workforces, and municipalities. These sections will provide
pertinent information for each trimester along the member’s maternity trajectory. Additionally,
when the pregnant woman visits the hospital, the same group of doulas, midwives, or social
workers who have educated her online will make them aware of what to expect and how to
deliver the babies naturally. With a familiar group of caregivers, the pregnant woman would be
less anxious and likely can make informed decisions at the hospital, as well, as knowledgeable
about postpartum care. Furthermore, these caregivers will accompany the woman through the socalled “fourth trimester”, the postpartum stage.
28
According to 2022 claims data, there were 5,064 deliveries in non-Kaiser hospitals in the
aforementioned areas with an average cesarean section (C-section) rate of 30%. The objective of
my project is to reduce the C-sections of childbirth from an average of 30% to 24%, which is a
quality standard for KFHs, and also aligned with Health People 2020 – a framework designed to
address health disparities across the US (Sakai-Bizmark, et. al., 2021). The 6% decrease equates
to 320 fewer C-section deliveries. Using the market cost in 2022, the childbirth cost for vaginal
delivery is $14,768 and the C-section is $26,280 with a difference of $11,512. If the 6% decrease
in C-section delivery can be realized, total savings from the 320 deliveries would be $3.68
million each year. Though if the costs are based on actual claims payments Kaiser made to these
Affiliated Hospitals, the cost saving would also be over one million per year. The utilization data
are collected by the National Claims Administration of Kaiser Permanente. The analytic team
has access to these data and can produce the comparison ad hoc or on a quarterly basis.
To address these challenges head-on, a strategic approach is imperative. A robust
communication plan is vital to rally support and secure buy-in from key stakeholders. On a
quarterly basis, Affiliated Hospitals report their quality data including the C-section rates to all
stakeholders including leaders of both Kaiser Permanente and community hospitals along with
KFHs on the SharePoint site of southern California Quality Committee. The report-out fosters
collaboration and healthy competition that emphasize the shared benefits including reduced Csection rates and improved maternal outcomes reflected in other indicated such as patient
experience scores, the groundwork is laid for successful implementation. Furthermore, enlisting
the support of physicians proves instrumental in driving adoption and utilization among their
patient bases. Through physician advocacy and recommendation, pregnant women are
29
encouraged to embrace the wealth of resources offered by the Maternity Coach 24/7, paving the
way for a paradigm shift in maternal care.
X. Challenges/Limitations
Despite its noble intention, the road to realization is not without its challenges. One of the
primary hurdles lies in garnering participation from pregnant women within affiliated hospital
service areas. Without the crucial backing of stakeholders, particularly from affiliated hospital
leaders, the project faces resistance stemming from potential revenue shifts and conflicting
interests. Furthermore, there are other web-based educational site may compete with this
initiative and the resource for maternity coaches will become scarce. In any case the utilization
of the website in affiliated hospitals is not supported or prioritized by their leadership, a free
subscription website will still be launched enabling obstetricians, who are Kaiser Permanente
Medical Group physicians, to recommend to their patients to test the efficacy of the website.
On the other hand, while educating and coaching patients is crucial, it alone may not
effectively reduce the cesarean section rate. The clinical workforce must receive comprehensive
training to adhere to precise algorithms for managing various stages of labor. Whether it be
Gynecologists or midwives responsible for deliveries, adherence to maternal quality care
protocols is paramount. For example, as Megahn Andrews, Perinatal Quality Leader indicated, if
any of the criteria outlined in the Labor Dystocia Checklist are not fulfilled, the cesarean section
should not be presented as an option (Andrew, M, personal communication, March 2024, Appendix
A). As such, sharing best practices among maternity coaches via the website would provide
additional tools to care teams to have clear guideline as to when to offer C-sections during the
labor delivery while vaginal delivery is strongly encouraged.
30
VI. Conclusion and Implementation
The capstone project follows a business to business to customer (B2B2C) structure. Due
to the varying patient experience at affiliated hospitals, Kaiser Permanente has experienced
membership decline. This is also reflected from feedback received from the interviews of the two
women, Kaiser members in Palm Spring and South Bay, who indicated that they were not given
clarity as to what to do when approaching due date or leaving the hospital after delivery (Lubas,
J. and Rodriguez, M. Personal Communication, July 2023 and July 2024, Appendix A). The
confusion from a less-than-optimal hospital experience would likely casts a doubt of continuing
their membership with Kaiser.
As a lesson learned, market research pointed out that mothers often play a pivotal role in
making health plan decisions. By advocating an outstanding hospital experience during
childbirth, Kaiser Permanente can bolster a patient’s confidence in its care quality. This could
lead to increased retention and positive word-of-mouth recommendations about Kaiser as a
health plan choice. To accomplish this, the decision coach initiative offers prenatal care
information and insights to pregnant women early in their pregnancies, helping alleviate any
anxieties about upcoming childbirth to contribute to a positive hospital stay experience. In
addition to a positive hospital stay, pregnant women can partner with care team to make
informed decision on their delivery method avoiding C-sections and reduce the risk of birthrelated complications, which can lead to morbidity or mortality. Care team members can also
access and benefit from the best practices shared on the website to improve their performance.
To implement this business model, the following key actions will be initiated:
1. Draft a business proposal and seek approval from Kaiser SCAL leadership.
31
2. Charter a team of primary practitioners including gynecologists, midwives, registered
nurses, and pharmacists, to craft a decision coach training manual during a structured
one-day workshop.
3. Develop a communication strategy to engage all stakeholders in the initiative. For
instance, nurses, physicians, and in-take case managers will actively promote the
Decision Coach program by distributing flyers and providing website and contact
details to newly pregnant patients.
4. Design a web-based virtual information site as a platform (Appendix G) to enable
members to utilize as recommended by Kaiser Permanente affiliated hospitals.
5. Establish metrics to assess the Decision Coach program’s effectiveness, including
survey questionnaires, and define clear milestone targets.
6. Hire certified doulas, social workers, and licensed vocational nurses to create a robust
Decision Coach team.
7. Conduct market research and strategize outreaches to large farming corporations in
rural Southern California.
8. Engage with selected farming companies to discuss plans for regular on-site sessions,
focusing on family planning information for women of reproductive age.
9. Collect data on pregnant women and arrange regular sessions led by designated
decision coaches.
10. Measure and trend the C-section rates for each affiliated hospital market over periods
of time.
The timeline of these key actions is depicted in the Gantt Chart (Appendix H).
32
In conclusion, the capstone project, which will be initially implemented through a
prototype in the Kaiser Southern California’s Affiliated Hospital markets, will serve as a model
of rural healthcare systems. Though it primarily focuses on maternity care and childbirth, its
impact spans all aspects of care, including physicians, nurses, heath record systems, reporting
functions, and concerns about profitability and affordability. The prototype will act as a
cornerstone for affiliation among community hospitals, as the improvement will be quantified
and shared across these healthcare systems. Furthermore, the knowledge gained will be
disseminated broadly across rural areas nationwide. With generous funding anticipated from
Kaiser, the capstone project is poised to become a major force, alongside organizations like
March of Dime, in fixing the health gap in counties identified as maternity care deserts.
33
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38
Appendices
A. Information Gathering Plan and Key Takeaways
Note: This information-gathering plan and its key takeaways are based on identifying missing voices in the literature review. In addition to
missing voices, first-hand information is gathered through interviews. A diverse range of individuals from various disciplines were interviewed,
including a gynecologist, a patient advisor, a community organization leader, a hospital chief operation officer, a vice president of Home Care at
Kaiser Permanente, a woman who recently gave birth living in a high desert and a reproductive-age woman in LTGBQ community. These
interviews provide valuable insight from different perspectives, reflecting current societal views on the significant need for improvement in
maternity care in remote areas of Southern California. Furthermore, the situation is particularly dire for populations such as reproductive women in
LTGBQ communities, undocumented migrant workers, and those individuals who live in remote areas and lack sufficient financial support for
them to travel outside of their communities to receive care. While the specific questions asked during each interview varied, the focus remains on
understanding the impact, challenges, opportunities, solutions, and desired improvements expressed by each interviewee.
Stakeholder: who
do you want to
hear from?
Rationale: why is it
important to
capture their
voice(s)?
Format (ex: interview, observation)
with appendices [ex: questions,
observation checklists] as appropriate
Key Takeaways (complete for Assignment 2)
I. Community
Organization
Practice Leader –
Ann Lefbvre,
Associated
Director of the
North Carolina
Area Health
Education
Centers Program
Advocacy groups
and communitybased non-profit
organizations are
the stakeholders
that should be
managed closely.
They are the
conduit connecting
healthcare
providers, health
plans, hospitals,
and productive-age
women. With their
dedication,
1. Can you discuss any positive
examples or success stories that
have addressed the challenges of
maternal care in rural counties?
What made those initiatives
successful?
2. How would you characterize the
role of community support or
resources in improving
maternal care in rural counties?
What community-based initiatives
have you observed or been involved
in?
Key Takeaway: To leverage existing community organizations’ connection
and relationship with reproductive age and/or pregnant women, provide the lay
healthcare officers of the organization with maternity health education
materials and let them run the education program.
1. Example: Dr. Oscar is a third-generation family doctor in rural South
Carolina. He not only practices family medicine but also delivers babies.
Currently, he works in a private hospital that has a delivery ward and
privileges He wants to cultivate medical school students to become rural
doctors. With his deep community root, he can connect with patients, win
their trust, and become part of their lives.
2. Community support is essential for rural health. It means resources, mental
support, and opportunities to obtain prenatal care. Ann is proposing to
partner with Lay Health Advisors at 139 black churches in rural South
Carolina to provide prenatal education. In addition, as those churches all
have vans not utilized during weekdays, the churches can give rides to
pregnant women in the communities to see OB doctors every Wednesday
39
creativity, and hard
work, the voice of
those women, their
children, and their
families can be
heard.
3. Are there any cultural or social
factors unique to rural areas that
influence material care? How do
these factors impact the experience
of mothers and their access to care?
4. From your perspective, what are the
gaps or deficiencies in current
healthcare policies or programs that
hinder the provision of effective
maternal care in rural counties?
5. How can policymakers play a role in
improving maternal care access and
outcomes in rural counties? Are
there any specific recommendations
or approaches that you believe are
promising?
and Thursday. Those women normally would not have opportunities to see
doctors until they are in labor.
3. Yes. In rural South Carolina, Black communities have deep roots in
churches, family networks, and generational relationships. It needs not only
the will of healthcare professionals to offer medical care but also trust and
understanding as the prerequisite for them to be part of the lives of those
rural communities.
4. Capitalism is the major obstacle to having a sound healthcare system. Lack
of infrastructure is a major issue. Building clinics in rural areas should be
like providing postal services or constructing roads deep into rural counties.
It needs to be subsidized by the federal government. Large organizations
could play an important role in a rural healthcare establishment, but they
choose not to because the costs might never be recovered.
5. Policymakers need to play a major role to promote the change of the system
and advocate for federal subsidization of the rural healthcare system. Ann
also proposes a 10-year plan to build a state-funded medical system.
Regarding engaging communities, a suggestion is to acknowledge the
expertise of the community organizers because they understand their
community. Let them work with their community members and we (e.g.,
medical schools) provide them with the materials and then stay out of it.
II. Physicians –
Jeffery Martin,
MD, OBGYN
Physicians are one
of the stakeholders
who need to be
managed closely.
They are one of the
most essential care
providers whose
skills, knowledge,
and advice will
lead the care team
to give possibly the
best care.
1. Based on your practice experience,
what specific challenges do
pregnant women in rural counties
face when accessing maternal care?
2. Are there specialized services or
programs available for high-risk
pregnancies in rural counties?
3. Can you provide examples of
successful collaborations between
yourself and local healthcare
providers, hospitals, and/or
community organizations to
improve maternal care in rural
areas?
Key Takeaway: A highly coordinated maternity specialty care team is needed
to ensure high-risk pregnant women in rural areas are provided with the right
care at the right time and in the right place. To prevent unintended pregnancy,
contraceptive and reproductive education needs to be provided to under-aged
women in rural areas.
1. Economic status, lack of education, lack of birth control on unintended
pregnancy, lack of access to specialty care for high-risk pregnancy,
Medicaid patients would have challenges as many specialty physicians
refuse to take Medicaid insurance. More high-risk pregnancy women are
diabetic and many of them lack education in prenatal care.
2. Rare and need coordination of arranging high-risk pregnancies to
specialized facilities for care. For example, if a KP patient is a high-risk
pregnancy, we would pre-arrange the patient to deliver at LAMC. But
women in rural areas would not have the privilege because a county hospital
40
4. How does the distance to healthcare
facilities impact the emergence of
obstetric care in rural communities?
5. Are there telehealth or telemedicine
options available for prenatal care
consultations or postpartum followups in rural communities?
might be 100 miles away and cost a lot to have transportation and lodging
arranged.
3. Affiliation with community hospitals is an example of when we do not have
KP hospitals for inpatient care.
4. It’s a problem for low social economic status pregnant women as they have
to take buses to be seen. Especially for 1st
-time mothers, telehealth may not
be preferred as they want to have an ultrasound to hear the heartbeat of the
baby.
5. For low-risk, first 24 months pregnancy or 2nd
-time pregnancy, telehealth
works. More sophisticated assistance such as blood pressure and heart
monitors are provided for telehealth care.
III. Home Health
Intervention
Leader –
Angel Vargas,
VP, Care at
Home, Kaiser
Permanente
SCAL
The literature
review suggested
care at home as one
of the solutions for
maternity care in
rural areas, it’s
important to hear
the voice of the
leader who has
implemented this
solution to
understand the
challenges and
outcomes
1. Based on your experience or
observation, what specific
challenges do pregnant women in
rural counties face when accessing
maternal care?
2. Are there specialized services or
programs available for high-risk
pregnancies in rural counties?
3. How does the distance to healthcare
facilities impact the emergence of
obstetric care in rural communities?
4. Are there telehealth or telemedicine
(or Home Care) options available
for prenatal care consultations or
postpartum follow-ups in rural
communities?
5. If home care is one of the solutions,
can you provide examples of
successful home health services
provided or a collaboration between
KP HH and local healthcare
providers, hospitals, and/or
community organizations to
improve maternal care in rural
areas?
Key Takeaway: Having telehealth or home care available is one thing; having
access to those services is another. The funding source is crucial to support
transportation and technology infrastructure.
1. Providing comprehensive care involves a coordinated effort among
physicians, registered nurses (RNs), licensed vocational nurses (LVNs),
and aides. However, the shortage of essential resources, such as hospital
closure, nurses taking leaves, and funding issues, has created significant
challenges in the delivery of quality care including primary, specialty, and
prenatal care for rural maternity patients.
2. Specialty services are available, but they are often located far away from
rural areas. Collaborating with affiliated healthcare facilities becomes
crucial since Kaiser Permanente (KP) facilities are predominantly situated
in urban and suburban areas, with limited direct access in geographically
spread areas.
3. Transportation poses a major obstacle in rural counties, requiring financial
support to facilitate the transfer of patients to specialized care; especially
for those low-income families, long-distance transportation creates a
financial burden. The distance factor can result in untimely care,
potentially leading to trauma, and long-term disability for both the child
and the mother.
4. While technology exists, equal access and/or ability to utilize said
technology is a challenge. Additionally, the availability of virtual care is
limited, given access and payment challenges. Broadband and cellular
infrastructure can also be a challenge. While audio phone calls can
facilitate basic communication, video calls require steady and consistent
41
broadband access, which is often lacking in rural areas. This limitation
hinders also the provision of in-home health services.
5. Merely having home care services available is not sufficient; ensuring
access to those services is equally important. For high-risk pregnancies in
rural areas, an opportunity exists to provide kits for them to measure blood
pressure, glucose screening testing, etc. to mitigate access gaps (all settings
of care). However, access to these kits is unevenly distributed across
different areas. For instance, San Diego County remote areas have better
access/broadband than some areas of Coachella Valley.
6. The lack of staffing resources for telehealth further compounds the
challenges, preventing rapid/sustained expansion of KP services to rural
counties.
IV. Health Plan
Administrator –
Suzy
Ghazarossian,
COO, KP
Antelope Valley
Medical Center
Commercial
insurance and
Medicaid are
managed by Health
Plan administrators
who are the
decision makers of
the coverage. These
commercial or
managed Medicaid
programs are the
primary funding
source of maternal
care. As such, their
perspectives are
extremely
important to be
factored in the
initiatives for rural
area maternal care.
1. Based on your experience, what
specific challenges do pregnant
women in rural counties face when
accessing maternal care?
2. Are there specialized services or
programs available for high-risk
pregnancies in rural counties?
3. Can you provide examples of
successful collaborations between
yourself and local healthcare
providers, hospitals, and/or
community organizations to
improve maternal care in rural
areas?
4. How does the distance to healthcare
facilities impact the emergence of
obstetric care in rural communities?
5. Are there telehealth or telemedicine
options available for prenatal care
consultations or postpartum followups in rural communities?
Key Takeaway: Educating the communities on family planning, prenatal care,
healthy habits, etc. 1) Educating the communities on where to get care and
what services are available to them – federally grant-funded programs in their
community offering classes, transportation, etc. 2) Increased telehealth,
flexible hours, and modes to increase access whether at home or in the clinics.
3) Continue support of grants for transportation programs, recruiting
healthcare providers into the communities, education, etc.
1. Although Antelope Valley (AV)is not considered a rural county, there are a
few challenges pregnant women face in both rural and less rural counties
such as AV:
a. Hospital closures/ access to care in all phases of pregnancies – the number
of hospitals and clinics, hours of operations clinics in the area. Women in
these communities with one or multiple jobs may not be able to visit the
clinic during regular business hours.
b. Cost of Care/affordability – women not able to afford health care coverage,
or not being aware of affordable care available to them
c. Transportation/Social Determinants – distance of clinics/hospitals, women
not having access to transportation, women not being able to get to inperson appointments because they have other children or dependents they
cannot leave home alone.
d. Family Planning Services – minimal education on the importance of
perinatal care resulting in women not getting timely care. Lack of health
classes to include prenatal care, lactation counseling,
weight/diabetes/blood pressure management, exercises/diet, mental health,
42
parenting, smoking, etc. or classes offered during regular business hours or
in person only.
2. With the recent number of hospital closures, and fewer providers entering
the profession, there is even less access to appropriate labor and delivery
facilities. There are also fewer family physicians providing obstetric care
in rural areas. This leads to an increased number of out-of-hospital births,
and as a result, a poorer outcome for these moms and babies. There is
work being done to address this issue by leveraging the use of telemedicine
to help rural areas manage high-risk pregnancies. Tuition reimbursement
programs for healthcare professionals who practice in rural communities in
another lever the federal government has pulled to address shortage.
3. Kaiser Permanente nationwide is working on partnering with communities
to improve health care in rural areas. Below are some links showing the
work Kaiser Permanente is committed to.
Health in the Community – Kaiser Permanente Georgia
Improving health for Black moms and babies - Kaiser Permanente Look
inside Northern California
4. Distance to obtaining care for these communities has a great impact on
women not completing their prenatal or postpartum visits. In addition to
distance, women in these communities may not have reliable transportation
to get to their clinic visits. Education, transportation, and social
determinants are significant barriers for women in rural communities to
access maternal health care. Grants can be a great way to introduce
educational and transportation programs to improve the maternal-child
journey in these communities.
5. Yes, there are several telehealth program options for maternal health care
at Kaiser Permanente that can be applied to rural communities:
a. Centering: this program brings together a cohort of patients and their
partners on a monthly 90-minute virtual meeting. These virtual sessions are
hosted by a physician or midwife.
b. Hybrid perinatal care: this program allows patients to do a portion of the
average 10 appointments within a 40-week pregnancy via telehealth –
including counseling along with tracking weight, fetal movements, and
blood pressure at home. In-person appointments are still required for
physicals, vaccines, ultrasounds, and high-risk pregnancy concerns.
43
Online health and wellness courses: a list of courses women can access to learn
about including prenatal care, lactation counseling, weight/diabetes/blood
pressure management, exercises/diet, mental health, parenting, smoking, etc.
V. Pregnant
Woman – Magda
Rodriguez,
Kaiser South Bay
HMO member
To provide firsthand information
regarding her
pregnancy, delivery
and post-partum
journey helping
understand the
needs, expectations
of end users.
1.How far along are you in your
pregnancy?
2.Have you received any prenatal care
so far? If yes, what care have you
received?
3.Have you experienced any
complications or concerns during
your pregnancy?
4.Have you experienced any challenges
in accessing those care? If yes, how
do you handle them?
5.Are you aware of any supporting
system nearby or in your area that
can help during your pregnancy?
What are they?
6. Are there any financial constraints
or transportation challenges that
hinder your access to prenatal care or
medical services?
7.Are you familiar with the signs of
preterm labor or other pregnancyrelated emergencies?
8.Are you receiving emotional support
from your family or community?
Key Takeaway: Consistent advice throughout a woman’s maternity care is
extremely important. Also, a virtual tour of the labor and delivery department
of the hospital would be helpful but was discontinued for a few years. 1)
Magda wished Kaiser could have only 1-2 assigned obstetricians who give
consistent care advice throughout her pregnancy. For example, her first
obstetrician warned her that she might develop preeclampsia, but another
obstetrician told her she was healthy. Even vitamins were recommended
differently by varying obstetricians. 2) Magda’s husband had to drive her
around the hospital ahead of time to get familiar with the L&D department
foreseeing possible disorientation on the way to delivery.
1. Magda has just given birth.
2. Yes, her prenatal care was provided by Kaiser Permanente, and it was
regular prenatal care.
3. Magda was diagnosed with preeclampsia during third trimester. As such,
she was hospitalized two days before due date and went through cesarean
section.
4. Yes, the challenge is to have a designated obstetrician. Magda had different
doctors throughout her pregnancy and received inconsistent information and
vitamins.
5. Kaiser has been helpful once got hold of someone over the phone, but it was
hard to get the help.
6. No. Magda is fully covered with HMO.
7. Magda was not very familiar with the signs and was very nervous during the
pregnancy. She was shocked by the diagnosis with the preeclampsia at late
stage of the pregnancy.
8. Yes. Her husband was very helpful and made a special trip to find out where
the L&D building is so as not to waste time on the way to delivering baby.
VI. Pregnant
Woman –
Angelica
Alveraz, Perris,
CA, Blue Shields
To provide firsthand information
regarding her
pregnancy, delivery
and post-partum
journey helping
1.How far along are you in your
pregnancy?
2.Have you received any prenatal care
so far? If yes, what care have you
received?
Takeaway: 1) Timely scheduling for OB checkup. 2) Blue Shields Arizona has
one hour difference making it difficult to call them after work. 3) wish there
was a Dos and Don’ts List to learn. 4) provider list seems not accurate.
Insurance company advised her to call to verify if the provider is still active
prior to schedule appointment. 5) wish only had to go to one place for doc
appointment, testing and Rx. It’s tiring to travel to various places to get
44
Arizona PPO
member
understand the
needs, expectations
of end users.
3.Have you experienced any
complications or concerns during
your pregnancy?
4.Have you experienced any
challenges in accessing those care? If
yes, how do you handle them?
5.Are you aware of any supporting
system nearby or in your area that
can help during your pregnancy?
What are they?
6. Are there any financial constraints
or transportation challenges that
hinder your access to prenatal care or
medical services?
7.Are you familiar with the signs of
preterm labor or other pregnancyrelated emergencies?
8.Are you receiving emotional support
from your family or community?
services. E.g., don’t have to go Quest for lab testing. Not to getting various 3rd
party involved. No need to do research by herself. Breast pump needs
prescription and need insurance to approve to get the breast pump. Need more
information for first time pregnancy. Instead from social media, it’s good to
get the truth from the source of professionals.
1. 32 weeks pregnancy with due date August 3
2. Yes, but inconsistently as every appointment was with a different doctor.
3. Weighs 351lb but no other health issue. But the baby seems having a hole in
his heart. Ultrasound cannot always identify the hole. This makes her very
concerned.
4. Have encountered a lot of challenges. Started bleeding during 5th week of
pregnancy. Went to Kaiser ER but got a bill to pay 20% of the costs as her
insurance is Blue Shields Arizona. There are no other hospitals close by. Very
concerned and stressed about possible next ER situation.
5. Not aware of any supporting system. It’s difficult to schedule OB check-ups.
Every time, got to see a different doctor and received different advice. OB
does not understand her benefit coverage and recommended a delivery hospital
in San Diego, which is > 1 hour drive from Perris.
6. Yes; unclear insurance coverage is concerning. Don’t know how much will
be out of pocket for the labor and delivery. Blue Shields Arizona never could
provide concrete answers on coverage. For providers, they advised call
designated provider first before going to visit because the provider might be
inactive.
7. Not she is aware of any family preterm labor or other complications.
8. Only supported by her husband. She still has to work as a special education
teacher. Sometimes her students become violent that makes her nervous about
her baby, but she has to work to make the ends meet.
VII. Pregnant
Woman – Janet
Lubas, Kaiser
Riverside HMO
Member
To provide better
maternal care in
rural areas, we
must understand
the needs of
pregnant women in
the area firsthand.
We need to
understand why,
1. How far along are you in your
pregnancy?
2. Have you received any prenatal care
so far? If yes, what care have you
received?
3. Have you experienced any
complications or concerns during
your pregnancy?
Key Takeaway: Insurance coverage should be extended to IUI and IVF for
LGBTQ members to have babies. Non-biological mothers should be entitled to
maternity leave. Kaiser Permanente provides good care but only providing
educational materials for prenatal care or postpartum care is not enough. Inperson training is even more important for pregnant women or new moms to
do the right thing.
1. Janet has just given birth.
2. Yes, her prenatal care was provided by Kaiser Permanente, and it was
regular prenatal care.
45
what, and how
maternal care is or
is not accessible
and the quality of
those care if they
are accessible.
4. Have you experienced any
challenges in accessing those care?
If yes, how do you handle them?
5. Are you aware of any supporting
system nearby or in your area that
can help during your pregnancy?
What are they?
6. Are there any financial constraints
or transportation challenges that
hinder your access to prenatal care
or medical services?
7. Are you familiar with the signs of
preterm labor or other pregnancyrelated emergencies?
8. Are you receiving emotional support
from your family or community?
3. No complications. I was given brochures but rarely any explanation but let
me read the materials.
4. The cost is challenging as I went through Intrauterine Insemination (IUI) 4
times until got pregnant. It costs $2K each time. Additionally, it cost the
other ~$2K to purchase the sperms for each IUI. Insurance only covers
50%. It’s very costly to get pregnant to go through the procedure.
5. I did have family support, but my partner had psychological issues because
my son is biological to me.
6. It’s challenging to find daycare options. I did have support for
breastfeeding.
7. Financial constraints were more on getting pregnant but not much to hinder
access. For a lesbian mother, there is double emotional labor.
8. Yes, but my partner had an issue in caring for the baby. I had the same
maternity leave benefit, but my partner didn’t have the paternity benefit.
VIII.
Reproductive
Age Woman
living in
Bakersfield -
Nicole Henry,
Kaiser
Bakersfield
Member and
Kaiser SCAL
Patient Advisory
Board Member
A mother of three
in central
California who has
been involved in
providing feedback
on prenatal and
baby delivery
experiences at
Kaiser Permanente
and its Affiliated
Hospital.
1. What would be your
recommendations in terms of how
to provide maternity care in rural
counties?
2. If I would like to provide education
to reproductive-age women in rural
areas, what would be the best place
to start?
3. When you were pregnant and
identified as having type III
diabetes, what were your
expectations from Kaiser?
4. From your observation and
experience, who in the rural area
needs the most attention and why?
Key Takeaways: For women with high-risk pregnancies, individualized care
should be designed to suit the special needs of those women. For general
prenatal care education, it’s best to reach out to large agricultural companies in
central California to provide the information to their employees that many are
migrants.
1. Individualized care is needed because each pregnancy could be different.
Providers need to understand each pregnant woman’s needs especially
those who need specialty care. For those who do not have family support,
Kaiser should do more to make prenatal care easier for the member.
2. Educate pregnant women to keep their expectations realistic. Telehealth
could be a solution but only if the patient has the device and is willing to
take advice via phone calls.
3. Suggest having a hybrid of home health and telehealth. Transportation
should be provided to pregnant women who do not have cars.
4. For central California, there are a lot of migration workers who need health
care education. Their employers should provide support. Grimmway, Sun
Pacific, Domthouse Farms, Poms are large agricultural companies who can
support the dissemination of prenatal care information.
46
Meghan
Andrews, MSN,
C-EFM, Perinatal
Safety Nurse –
Women’s
Services,
Palomar Health
C-section rate
reduction needs
consistent
monitoring by
quality leaders of
Labor and Delivery
Department
1.As a quality leader of Perinatal
Safety, how do you monitor
deliveries and reduce C-section rate
in your hospital?
2.What information do you go by to
discipline the process and the care
team?
Takeaway: Patient education alone would not be sufficient to reduce improve
C-section rate. Care team needs to follow the professional guidelines and use
maternity quality care tools to encourage vaginal deliveries and avoid Csections.
Meghan monitors the number of C-sections daily according to the guidelines
and tools provided by California Maternal Quality Care Collaborative
(CMQCC). She felt that the close monitoring is extremely important. For
example, at least 6 criteria of labor dystocia must be present to trigger the Csection. But sometimes, a woman might not be patient enough to endure the
labor and ask for resorting to C-section while only 3 out of 6 criteria are
present. Obstetricians, midwives and nurses need to encourage them to pursue
vaginal delivery for women’s own health benefit.
Examples of these guidelines are, but not limited to:
1) Delay of Laten (Early) Labor Admission - for Providers and Hospitals
2) Fetal Surveillance – for Provider and Hospitals
3) Pre-cesarean Checklist for Labor Dystocia or Failed Induction
4) Algorithm for Management of Category II Fetal Heart Rate Tracing
47
B. Solution Landscape Analysis
DESIGN CRITERIA
FEATURES
BIRTH CENTER
MIDWIFERY
MEDICAID
EXPANSION
AFFILIATION
COLLABORATION
TELEMEDICINE
HOME HEALTH
DISTANCE
TRANSPORTAITON
X X
FINANCIAL
OBSTACLES
X X
SHORTAGE OF
SPECIALISTS
X X X
CHRONIC HEALTH
ISSUES
X X
48
C. Stakeholders Mapping – Maternity Care Desert in Rural America
49
D. Design Criteria
CRITERIA WIDER OPPORTUNITY SPACE
MUST OVERCOME FINANCIAL OBSTACLES MEDICAID EXPANSION, INCREASE MIDWIFERY
SERVICES, PROMOTE
AFFILIATION/COLLABORATION
COULD ELIMINATE EXTENSIVE LONG-DISTANCE
TRAVEL
MIDWIFERY SERVICES, HOME HEALTH,
TELEMEDICINE
SHOULD PROVIDE SERVICES W/O DISCRIMINATION MEDICAID EXPANSION TO THOSE CURRENTLY
UNCOVERED POPULATIONS, E.G.,
UNDOCUMENTED FARM WORKERS, LGBQ
COMMUNITIES
WON’T CONSTRUCTION OF RURAL HOSPITALS
BASED ON CURRENT AVAILABLE
RESOURCES.
COMMUNITY BIRTH CENTER - SOCIAL
WORKERS PROVIDE EARLY EDUCATION AND
PRENATAL CARE TRAINING VIA COMMUNITY
OUTREACH
50
E. Implementation Logic Model: Non-Medical Intervention for Maternity Care Improvement in Rural America
(Blue font – revision of the logic model)
DETERMINANTS
IMPLEMENTATION
STRATEGIES
MECHANISMS OUTCOMES
CHARACTERISTICS OF THE INTERVENTION 1. Obtain leadership
alignment
2. Develop an agreedupon quality monitoring
system and time-bound
targets
3. Tailor strategies
according to the current
state of each hospital
4. Develop tool kits and
playbooks
5. Share resources,
feedback, and best
practices
6. Monitor progress and
outcomes based on
agreed-upon targets
Steering committee - design
overall strategic directions and
allot resources as needed
Spring workshop – training
and best practices sharing
Quality meetings - compare
quality improvement progress
Winter collaborative event -
recognize high performers
Create tools and playbooks in
English and Spanish to train
the trainers in communities
Create a website to test the
feasibility of the capstone
project. The website is a
platform for end users to
obtain knowledge and
communicate with the care
team 24/7.
Prototype: Test the outcome of the
implementation of the prototype
and refine the website along 2-3
years of utilization and document
the tracking records as evidence.
Sustainability: Meet one-to-fiveyear C-section rates Improvement
Fidelity: After 3 years of continuous
improvement, expand to other
communities with the same
playbook and knowledge to train
the trainers
Penetration: Quality
measurements, besides C-section
rates, may vary but the same tool
and playbook are integrated in each
setting.
Appropriateness: Keep patientcentered at the core and stay
relevant
Barriers: Complex, costly, unclear on the
purpose, dependencies on interactions
Facilitators: Abiding by the principle of
respectful maternity care, working together
to provide better community services.
INNER CONTEXT
Barriers: Varying organizational culture,
leadership style, and strategic priorities; and
different provider-patient relationship
Facilitators: Leadership commitment and
regular quality data feedback
OUTER CONTEXT
Barriers: Market factors, relationships, and
policies
Facilitators: Healthy competition and
positive influence
51
Note: Salary and wages information is based on the average rate for each professional on www.salary.com.
Cost Category Salary & Wages Tax & Benefit Total Cost
Certified Doula 60,000 29,268 89,268
Maternity Social Worker 75,000 36,585 111,585
Maternity Registered Nurse 90,000 43,902 133,902
Multimedia 20,000
Travel 10,000
Equipment - laptops, monitors, cell phones 6,000
Grand Total 370,755
F. Annual Budget for Maternity Care Program
52
G. Prototype Framework - Maternity Coach 24/7 Website
53
TASK ASSIGNED TO PROGRESS TO START END DAYS
60
60
15
30
30
60
30
on-going
on-going
KPSC Maternity Care Decision Coach Inititive Gantt Chart
1. Draft a business proposal and seek approval from Kaiser SCAL leadership.
2. Charter a team of primary practitioners including gynecologists, midwives, registered nurses, and
pharmacists, to craft a decision coach training manual during a structured one-day workshop.
3. Develop a communication strategy to engage all stakeholders in the initiative. For instance, nurses,
physicians, and in-take case managers will actively promote the Decision Coach program by distributing
flyers and providing website and contact details to newly pregnant patients.
4. Design a website and brochures to inform hospitals and medical offices about the initiative.
5. Establish metrics to assess the Decision Coach program’s effectiveness, including survey questionnaires,
and define clear milestone targets.
6. Hire certified doulas, social workers, and licensed vocational nurses to create a robust Decision Coach
team.
7. Conduct market research and strategize outreaches to large farming corporations in rural Southern
California.
8. Engage with selected farming companies to discuss plans for regular on-site sessions, focusing on family
planning information for women of reproductive age.
9. Collect data on pregnant women and arrange regular sessions led by designated decision coaches.
H.
54
I. Infographic – Maternity Care Decision Coach in Rural America
Abstract (if available)
Abstract
For healthy pregnancies, which account for close to 90% of deliveries, cesarean sections (C-sections) are the main cause of mortality and morbidity. The United States is grappling with elevated rate of pregnancy related morbidity and mortality, a stark contrast to other developed countries, and the impact is disproportionately affecting subpopulations. During the three years prior to COVID pandemic, maternal mortality surged in both rural and urban areas reaching nearly twice the rate in rural areas. This underscores a glaring disparity between reproductive women residing in urban areas and those in rural regions. My capstone aims to fix the health gap for maternity care in rural communities. The evidence-based practice of non-medical interventions is the conceptual and theoretical framework that emphasizes the shared decision-making model for maternity care. To provide such evidence, I proposed a prototype focused on the suburban and rural areas of Kaiser Permanente Southern California, where Kaiser hospitals are not available within a 15-mile radius or 30-minute drive distance from the homes of members. I have designed an online maternal care program, offering 24/7 support to pregnant women and those of reproductive age residing in Kaiser Affiliated Hospital markets. Through this virtual platform, individuals can access a wealth of educational resources empowering them to make informed decisions spanning family planning, perinatal care, delivery options and postpartum support. Moreover, the program facilitates direct connections with a multidisciplinary team comprising midwives, doulas, maternity social workers, and obstetricians for meaningful discussions and seek guidance on any challenges during their pregnancy journey. Lastly, the online program offers an exclusive link for professional care team members to share best practices on how to help patients avoid C-sections during the labor.
Linked assets
University of Southern California Dissertations and Theses
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Asset Metadata
Creator
Caine, Lei Shi
(author)
Core Title
Maternity care decision coach for rural America
School
Suzanne Dworak-Peck School of Social Work
Degree
Doctor of Social Work
Degree Program
Social Work
Degree Conferral Date
2024-12
Publication Date
09/30/2024
Defense Date
07/31/2024
Publisher
Los Angeles, California
(original),
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
affiliated hospital,c-section,design lab,logic model,maternity care,OAI-PMH Harvest,prototype,theory of change
Format
theses
(aat)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Rank, Michael (
committee chair
), Broadnax, Jean (
committee member
), Newmyer, Richard (
committee member
)
Creator Email
lcaine@usc.edu,lei.shi.caine@gmail.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-oUC11399BCTF
Unique identifier
UC11399BCTF
Identifier
etd-CaineLeiSh-13537.pdf (filename)
Legacy Identifier
etd-CaineLeiSh-13537
Document Type
Capstone project
Format
theses (aat)
Rights
Caine, Lei Shi
Internet Media Type
application/pdf
Type
texts
Source
20241001-usctheses-batch-1215
(batch),
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Repository Email
cisadmin@lib.usc.edu
Tags
affiliated hospital
c-section
design lab
logic model
maternity care
prototype
theory of change