Model
The core of the Baltimore model is a concerted focus on preconception, pregnancy and early postpartum care, and care coordination. BHB primarily identifies women who would benefit from the program through the Maryland Prenatal Risk Assessment (PRA), a universal and statewide screening tool deployed by the state’s Medicaid program. Specifically, health care providers via the PRA process refer individuals to a centralized intake system managed by HCAM, which provides pregnant women and women with infants with a single point of access to services.15 From July 2023 to June 2024, the initiative received 2,258 PRAs; 81 percent of these individuals received care coordination, including education and referrals to programs; services such as home visiting; and other more specific support.16 Referrals to the centralized intake system also may occur through CBOs or self-referrals — as one example, HCAM has placed community health advocates in several Judy Center Early Learning Hubs across Baltimore City to help connect pregnant women who are unable to be located through the centralized intake system and traditional outreach mechanisms.17
BHB offers a wide range of programs and services to eligible individuals and their families, including BHB’s home visiting program — an evidence-based model where trained home visitors meet regularly with expectant parents or families with young children to provide in-home support — and their group programs such as prenatal education, grief support, and nutrition or fitness classes.18 They also connect people to support services such as the Special Supplemental Nutrition Program for Women, Infants, and Children and other income supports, mental health and substance use services, adolescent reproductive health services; housing, education, and family violence prevention services; as well as health care services including navigation of health benefits.19 Through a partnership with Baltimore Community Doulas, BHB provides sliding-fee-scale doula services to pregnant and postpartum women.
A continuing concern for pregnant women is substance use disorders, which include cannabis use and the growing problem of fentanyl. There are ongoing screenings for behavioral health overall, new public awareness and messaging campaigns, training for providers, and treatment. For people who have substance use disorders and are ongoing users, there are also programs to prevent unintended pregnancies.
BHB also offers focused outreach and services in two Baltimore neighborhoods through trusted backbone organizations, which mobilize community partners, leverage shared resources, and fulfill essential administrative and coordination functions.20 The University of Maryland School of Social Work’s Promise Heights initiative serves as the backbone organization in Upton and Druid Heights, offering critical services including employing community health workers trained in trauma-informed care and lactation counseling. These services operate out of the Payne Memorial African Episcopal Methodist Church as well as local schools, barber shops, and housing complexes. Additional Promise Heights programs include Prenatal and Postpartum Moms Clubs, early childhood literacy programs, and a peer-support network of primarily Black moms. Similarly, the Baltimore Medical System serves as the backbone organization in Patterson Park North and East and employs bilingual community health workers in the primarily Hispanic neighborhood. Additional programming, such as Moms Clubs, community events, and peer-support groups, reflect community resident priorities.
Governance, Infrastructure, and Community Partnership
There are three main bodies that have complementary roles in governing the citywide collaborative — the Core Implementation Team (CIT), Community Advisory Board (CAB), and a citywide Steering Committee. The CIT includes staff from key local agencies. The CAB is composed of community members who use or provide services, and over the past five years they have informed BHB’s strategic priorities. The Steering Committee is cochaired by the Baltimore City Health Commissioner and the Senior Vice President of the largest delivery hospital in Baltimore City, Mercy Health Services, and it includes health care and public health leaders as well as philanthropic funders. Aided by its composition and its members’ shared vision, the Steering Committee is able to bridge gaps across government agencies, policies, and providers.21
As the city was implementing the citywide infrastructure for the BHB in 2009, they built neighborhood backbones and infrastructure in two areas of the city: Upton and Druid Heights in the west part of the city, and Patterson Park North and East in the east.22 In Upton and Druid Heights, the backbone is coordinated by the University of Maryland School of Social Work and their Promise Heights project. In Patterson Park, the backbone is the Baltimore Medical System (BMS) which is a federally qualified health center (FQHC). A third community, Cherry Hill, has recently launched with backbone support by MedStar Health.
The city of Baltimore also supports strong citywide mortality reviews, which are multidisciplinary committees that convene to comprehensively review deaths and inform recommendations to prevent future deaths from occurring.23 These include the Fetal Infant Mortality Review, the Child Mortality Review, and the Maternal Mortality Review. Beyond health providers and representatives from participating organizations, impacted families are contacted for input into these reviews and case studies. Findings and recommendations from the review committees inform policies and practices for BHB.
Funding
For 2024, the annual budget for BHB is approximately $30 million. Of this amount, 95 percent of the funds are public, and 5 percent are philanthropic. Of the public funds, 73 percent are from federal sources, passed through the Maryland Department of Health, Maryland Department of Education, and Maryland Family Network; 10 percent are state funds; and the remainder come from local sources. Most of these public funds support direct services, including care coordination; home visiting; Special Supplemental Nutrition Program for Women, Infants, and Children; early intervention; and Title X family planning services. Philanthropic support has been leveraged, in particular, for the neighborhood backbone organizations, social marketing and communication, and piloting new approaches.
Results and Future Direction
BHB is a place where pregnant and postpartum individuals get the support they need for healthy pregnancies, optimal birth outcomes, and positive parenting. Diverse partners come together to address top priorities of mental health and stress, substance use, nutrition, parenting, safe infant sleep, sexual health, and child social and emotional health and development. Since BHB’s inception in 2009 to the latest data available in 2021, Baltimore’s overall infant mortality rate has decreased from 13.5 to 7.5 deaths per 1,000 live births. Notably in 2019, BHB eliminated the Black-white disparity in infant mortality in Upton and Druid Heights and Patterson Park North and East, with infant mortality rates trending at 4 per 1,000 live births or lower.24 From 2009 to 2020, BHB also demonstrated a 48 percent decrease in sleep-related infant deaths, a 56 percent decrease in the teen birth rate, and a 61 percent decrease in Black-white disparity in the teen birth rate. An estimated 70 percent of obstetric providers were also trained to refer to the BHB intake system.25 Additionally, breastfeeding at discharge has increased by 36 percent and smoking during pregnancy has decreased by 41 percent.26
Providers — such as physicians conducting deliveries, home visiting staff and community residents — are now engaged and collaborating to transform the system for delivering the needed care to pregnant women. People in community organizations and city public agencies have a greater understanding of their role in improving maternal and infant care in their neighborhoods.27 The collaborating organizations and people are committed to an antiracism approach to needed change.
BHB has contributed to several legislative accomplishments, including mandatory education on infant safe sleep in all delivery hospitals, required implicit-bias training for perinatal health care workers, and required local maternal mortality review to inform system-level responses to maternal health. The Baltimore City Health Department plans to provide technical assistance to other communities in Baltimore City and Maryland, and with funding from the Pritzker Foundation, will develop a tool kit that can be used nationwide.
I support a focus group with the [University of Maryland School of Dentistry], and four moms from [B’more for Healthy Babies] are a part of the board . . . . [The moms] are leading a lot of that work, and they’re training right now to be community health workers. And they’re from the community. That’s what that looks like: they’re advocating for the moms in the community and also trying to . . . provide resources for the families in the community. It’s powerful, because that’s what you’re supposed to do. You come in to support people in the community, and you give them the tools and the resources to do what they need to do, and now they’re actually doing that work from their own autonomy.
Testimonial from Giselle Joseph, Community Health Outreach Worker at B’more for Healthy Babies and Certified Lactation Specialist
Dana Ferrante, “Why Investing in Community-Led Initiatives Is Crucial to Helping Families Thrive,” feature, Urban Institute, Sept. 25, 2024.
Cradle Cincinnati (Cincinnati, Ohio)
Impetus
In 2013, Hamilton County, Ohio, families were 70 percent more likely to experience infant loss than families nationwide, with Black families disproportionately impacted.28 Largely preventable causes of infant mortality, like preterm births and unsafe sleep, accounted for 69 percent of infant deaths.29 With Black babies dying at more than three times the rate of other babies in Cincinnati — regardless of their parents’ socioeconomic status or health behaviors — it became evident that structural racism was playing a role in Black women’s health and birth outcomes.30
Doctors from Cincinnati Children’s Hospital Medical Center and UC Health came together to launch Cradle Cincinnati (CC) as a collective impact collaborative. CC partners include the Ohio Department of Health, Ohio Department of Medicaid, Medicaid managed care plans, the United Way of Greater Cincinnati, and The Greater Cincinnati Foundation and bi3 Fund (among other philanthropic funders). Its cross-sector network of organizations and community members seeks to improve the infant mortality rate and ensure every baby born in Hamilton County lives to see their first birthday. CC also works in collaboration with related statewide initiatives — CelebrateOne, First Year Cleveland, and the Ohio Collaborative to Prevent Infant Mortality.31 While the catalyst for CC’s efforts was improvement of infant health outcomes, importantly, its approach centers Black women by listening to them and cocreating solutions to make individual- and system-level impact on both maternal and infant health outcomes.
Model
Cradle Cincinnati’s model centers the mother, focusing on not only improving individual outcomes but also addressing racism and other underlying structural and social drivers of health.32 It has four key pillars of work, with an overarching focus on movement building toward systems change, including:
- Connecting to Resources (Cradle Cincinnati Connections). A team of community health workers facilitates families’ access to critical resources that improve pregnancy, birth, and infant outcomes, such as baby items, stable housing, breastfeeding support, and mental health care, among other services and supports. In 2023, 1,138 clients were served.
- Amplifying Community Voices (Queens Village). An initiative of CC, Queens Village fosters a supportive, safe, and trauma-informed community for Black women so they can empower and support one another and practice self-care. In 2023, 1,995 Black women were engaged in Queens Village events and programming.
- Advocating for Policy Change (Cradle Cincinnati Policy Committee). As described in further detail below, CC has a Policy Committee that identifies and advocates for local and statewide policy changes.
- Transforming Systems (Cradle Cincinnati Learning Collaborative and Mamas Certified). CC convenes a network focused on quality improvement of prenatal care, which connects more than 500 health care professionals representing hospitals, FQHCs, home health agencies, and social support systems. In 2020, CC, Queens Village, The Health Collaborative, local birthing hospitals, and Black mothers cocreated and launched Mama Certified to increase visibility into how hospitals address racial inequities in birth outcomes.33
Governance, Infrastructure, and Community Partnerships
Cincinnati Children’s Hospital Medical Center serves as the backbone organization for the CC collaborative, providing operational and administrative support. Cincinnati Children’s also houses the initiative All Children Thrive, which focuses on outcomes throughout childhood.34 The city and county health departments assist CC with real-time data collection, particularly documenting infant mortality rates and underlying causes.
The Cradle Cincinnati Advisory Board, launched in June 2013, includes representation from health care, public health, social service agencies, funders, and the community. Twelve of the board members have either personally experienced pregnancy or infant loss or live in neighborhoods with poor birth outcomes. The Queens Village Advisory Board is composed of Black women from different generations and with diverse socioeconomic backgrounds. This board provides direct feedback to CC and other stakeholders to improve health care services and build a community to support Black families through life stressors and to combat isolation.
Community members and local leaders shape the advocacy agenda of the Cradle Cincinnati Policy Committee, which in turn pushes for local and statewide policy changes that would improve pregnancy and related outcomes. CC also has a community research team focused on unpacking sleep-related infant death outcomes. It is composed of six Queens Village board members who have been trained to engage directly with mothers to better understand factors contributing to sleep-related infant deaths and possible solutions.35
Funding
For 2025, the annual budget for CC is approximately $6.8 million. Of this amount, 33 percent of the funds are public, 56 percent are philanthropic (including hospital support), and the rest come from local sources. Of the public funds, only $240,000 are from federal sources (a 2024 grant from the Health Resources and Services Administration), and 89 percent are state funds. Most of these public funds support direct services and programming for Black pregnant women and families in zip codes with the highest infant mortality rates. As is the case with BHB, philanthropic support has been leveraged, in particular, for administrative and infrastructure support.
Results and Future Direction
The infant mortality rate in Hamilton County is now on par with the national average, and in 2023, the Black infant mortality rate fell into the single digits for the first time on record. Between 2022 and 2023, the overall infant mortality rate decreased from 8.7 to 5.5 per 1,000 births, and the Black infant mortality rate decreased from 13.7 to 9.0 per live births.36 CC has also observed measurable improvements in other pregnancy, birth, and infant health indicators, including breastfeeding rates, access to prenatal care in the first trimester, maternal smoking rates, and engagement with someone to discuss stress-related problems during pregnancy. CC credits this progress, in part, to federal, state, and local prioritization of specific issues, like opioid use, tobacco use, and mental health, during the COVID-19 crisis and the corresponding influx of categorical funding. Specifically, CC noted that post-pandemic, there seems to be greater community awareness of mental health challenges that occur during and after pregnancy, and subsequently more opportunities to discuss them with mothers and families, particularly through Queens Village. This has resulted in increased demand for mental health services amid shortages of mental health providers.
On a systems level, Mamas Certified put in place scoring, focus area badging, and annual recertifying processes to ensure birthing hospitals are held accountable for their progress on maternal- and infant-related health outcomes. This information is shared with Black parents so they can make informed decisions.37 Additionally, CC’s participation in the statewide collaboration with related Ohio initiatives resulted in the creation of Infant Vitality Advocacy Day, an event with state elected officials focused on advocating for budget and policy priorities to support better maternal and infant health outcomes.
We know that Black mothers experience poorer maternal and infant health outcomes than their white counterparts, and we want to be a part of bridging that gap and changing that narrative.
Gina Hemenway, Mercy Health
Cradle Cincinnati, Celebrating More First Birthdays: 2023 Hamilton County Maternal and Infant Health Report (Cradle Cincinnati, 2023).
Lessons Learned
The B’more for Healthy Babies and Cradle Cincinnati case studies offer some key lessons for federal, state, and regional or local stakeholders committed to advancing maternal and infant health outcomes through policymaking, funding, and related support.
A life-course approach to maternal health efforts facilitates earlier intervention and builds trust. The life-course organizing framework acknowledges the role of social, environmental, and economic factors on health outcomes and emphasizes the need to support improved health outcomes before, throughout, immediately after, and between pregnancies. Continued support for both health and social needs during the postpartum period, together with more seamless integration with early childhood and other educational settings, leads to strengthened relationships with the community and, in turn, higher levels of trust. This framework also addresses a common perspective of postpartum women that medical attention is often focused solely on the baby rather than addressing the range of health and social needs for both mother and baby.38
Community partnership and collective action approaches drive individual- and systems-level impact. ACHs and related multisector, community-driven partnerships are uniquely positioned to address the complex and multifaceted causes of poor maternal health outcomes. Inherent in their governance structure is a multisector approach and authentic engagement of community members in decision-making and leadership roles, which upends the top-down power dynamic that reinforces systems of oppression and mistrust.
Partnership with state and local health departments, hospitals and health systems, and mortality review committees facilitates evidence-driven approaches. Data-sharing with health departments and health systems is critical for the design of both BHB and CC’s initiatives and for ongoing monitoring of progress. A more in-depth understanding of the causes of maternal, infant, and child deaths through mortality review committee insights provides direction for training and changing practices for providers to prevent these tragic deaths and improve health outcomes. For example, trainings have included preventing overdose deaths, early signs of hemorrhage, and health impacts of discrimination — all issues surfaced through mortality reviews.
Housing is a critical need for pregnant women. BHB and CC have identified access to stable housing as a top need for the women in their programs and, in turn, have prioritized offering housing supports. These supports include finding affordable and safe rentals as well as permanent housing for homeless pregnant women along with training in financial management.
Growing cannabis use among pregnant women suggests the need to expand maternal behavioral health initiatives. Cannabis is the illicit drug most commonly used during pregnancy with self-reported ranges between 2 percent and 5 percent.39 The confluence of stressors and social isolation during the pandemic contributed to increased mental health and substance use challenges. Infusions of federal funding to address these issues contributed to progress on certain mental health and substance use indicators. However, as noted by both CC and BHB, maternal cannabis use is a growing concern, exacerbated by a siloed, opioids-focused approach to substance use prevention, risk reduction, treatment, and recovery efforts, as well as increased access owing to legalization.
Policy Recommendations
Accountable communities for health and related multisector, community-driven partnerships are uniquely positioned to drive the individual- and systems-level change needed to improve maternal and infant health outcomes, a bipartisan priority at federal, state, and local levels. Even as we assess the health policy landscape following the recent federal election, several policies warrant consideration to sustain and strengthen these efforts:
Adequate support for midwives, community health workers, and doulas. These members of the perinatal workforce play an instrumental role in addressing the holistic needs of moms and their babies. Reimbursement for their services is key to their sustainability. While the Medicaid program is the payer for approximately four in 10 U.S. births, it encourages but does not require coverage of nontraditional, pregnancy-related services like doulas.40 There are two proposed or ongoing initiatives that would help expand Medicaid coverage for these services.41 First, the Center for Medicare and Medicaid Innovation’s Transforming Maternal Health Model will be implemented in up to 15 states and requires the coverage of Medicaid doula services as well as increases access to the midwifery workforce and birth centers, and supports coverage of perinatal community health worker services. This model will yield important learnings for Medicaid and other payer approaches to ensure adequate support for these critical providers.42
Second, a recent budget proposal includes an optional Medicaid maternal health benefit that, if adopted by Congress, would provide enhanced federal matching funds for state coverage of services provided by doulas, community health workers, nurse home visiting, and peer-support workers.43
Sustained and strengthened investments in evidence-based home visiting services. Home visiting is a longstanding and proven model to improve the health of women, children, and families.44 The Health Resources and Services Administration’s Maternal and Infant Early Childhood Home Visiting (MIECHV) Program is the primary federal source of funding support for home visiting models that facilitate direct and continued engagement with pregnant women and children, build trust, and leverage the life-course framework.45
However, only an estimated 15 percent of eligible families receive funding support through MIECHV.46 Additionally, Medicaid does not cover the full scope of home visiting services, leaving states to seek federal approval in order to cover common home visiting services, including screening, case management, and family support counseling.47 Proven home visiting approaches could be more widely adopted through increased congressional appropriations and expanded Medicaid coverage.48
Facilitation of multisector, community-driven partnerships through funding of CBOs and other backbone organizations. Community-based organizations often serve as backbone organizations for multisector, community-driven partnerships — providing essential administrative and operational functions and serving as a trusted convener of health care, public health, social service, other sectors, and community members. However, CBOs and other backbone entities frequently lack dedicated funding support for these central coordination functions.49
The Office of Management and Budget (OMB) and the U.S. Department of Health and Human Services can continue efforts to ensure CBOs and other backbone organizations are well positioned to promote partnership development and carry out key administrative functions like improved data and pertinent information-sharing among partners. For example, OMB can facilitate a governmentwide set of guidance to federal agencies regarding adding requirements in their notices of funding opportunities that direct grantees to partner with and fund CBOs.50 New Center for Medicare and Medicaid Innovation models, including Transforming Maternal Health, can build on critical infrastructure support provided through the initial planning phase and encourage state Medicaid agencies to partner with local providers and CBOs by requiring such a partnership or making it a preference in model selection criteria.51
Guidance and direction from OMB regarding opportunities to pool federal funding sources. While B’more for Healthy Babies and Cradle Cincinnati have successfully pooled private and public funding sources to support their work, doing so increases their administrative burden and there is limited flexibility to reprogram or shift funds to address emerging maternal health concerns, such as growing cannabis use. OMB can play an important role in promoting streamlined applications and reporting requirements.52
Community-engaged research to better understand the prevalence, causes, and potential risks of cannabis use during pregnancy.53 Ongoing federal initiatives could focus on understanding the impact of cannabis use among pregnant women, including the Implementing a Maternal health and PRegnancy Outcomes Vision for Everyone Initiative, Initiative on Women’s Health Research, and Pregnancy Risk Assessment Monitoring System.54 Community-based participatory research has also been cited as an effective partnership mechanism to ensure robust, equity-focused, representative, culturally relevant, and trauma-informed research and reporting on perinatal mental health and substance use.55
