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Written in response to Michigan Health Endowment Fund’s

Healthy Communities Special Projects
RFP# DA-13-000J-07-2017-001
http://healthendowmentfund.org/

This proposal was written by students at the University of Michigan School of

Public Health as part of Professor Paul Fleming’s HBHE 651 Course. For more
information, contact Paul at pauljf@umich.edu or 734-647-2683.

Agency/Organization: Packard Health

Mailing Address: 3174 Packard St, Ann Arbor, MI

48108

Phone Number: (734) 971-1073

Email Address: rfleming@packardhealth.org

Agency/Organization Website: https://packardhealth.org/

UM-SPH Student Grant Writing Team:

Janae Best - jnbest@umich.edu
Madeline DeMarco - mndemarc@umich.edu
Janie Felton - jlfelton@umich.edu
Molly Hutchison - hutchme@umich.edu

Total Amount Requested $100,000

(Direct + Indirect Costs):

Start Date: June 2019 End Date: June 2021

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I. Proposal Abstract
In Washtenaw County, 50% of Latina women have never been talked to by a health care
worker about preparing for a healthy pregnancy. This is important to note because compared to
White women, Latina women have been found to have higher odds of having delayed prenatal
care or inadequate prenatal care, and their children have higher odds of not having a 1-week
check up. To increase Latina women’s knowledge of prenatal and postnatal care, trust in Packard
Health, and self-efficacy to seek prenatal and postnatal services provided by Packard Health, the
creation of a doula program in Ypsilanti is being proposed. As part of executing this program,
there is a need to (1) recruit four women from the community who are already trained doulas to
provide prenatal and postnatal care services, (2) have doulas host community events sponsored
by Packard Health to increase both trust and knowledge, and (3) have doulas facilitate support
groups called “Ladies Night” for Latina women to increase their knowledge of services.
Additionally, doulas will assist with transportation to Packard Health, attend doctors
appointments, and conduct home visits. Our program is designed to connect Latina women in
Ypsilanti to Packard Health in order to reduce barriers to healthcare and increase maternal
health.
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II. Defining the Problem

Compared to White women, Latina women have been found to have higher odds of
having delayed prenatal care or inadequate prenatal care, and their children have higher odds of
not having a 1-week check up (Bromley, Nunes, & Phipps, 2011). Obtaining early and regular
prenatal care can be an instrumental tool for ensuring a healthy pregnancy. Prenatal care is used
to monitor mother and fetus for potential complications, help manage risk factors, and to
promote healthy behaviors during pregnancy (NICHD, 2017). The benefits of prenatal care are
tangible. Not only are babies born to mothers who get prenatal care at a lower risk for low birth
weight when compared to babies born to mothers who did not get prenatal care, but they are also
five times less likely to die in infancy (Office on Women’s Health, 2018). In fact, prenatal care is
so important that one of Healthy People 2020’s goals is to increase the proportion of pregnant
women who receive early and adequate prenatal care (Healthy People 2020, 2011).
However, not every mother is getting the proper prenatal care she needs. Studies show
that 15% of pregnant women in the United States receive no or inadequate prenatal care
(Osterman et al., 2018). This is a problem because lack of prenatal care puts both mother and
baby at risk. It is possible to identify 80% of women at high risk for having a low birth-weight
infant at their first prenatal care visit. Appropriate interventions to prevent low birth-weight
could then be taken with proper prenatal care (Lia-Hoagberg et al., 1990). Instead, when a
woman is not getting adequate prenatal care, she is three times more likely to deliver a low birth-
weight baby (Office on Women’s Health, 2018). Infants born at a low birth-weight are also
more likely to develop disabilities, creating a larger burden on the healthcare system due to the
cost of treating those disabilities (Lia-Hoagberg et al., 1990).
In the state of Michigan, Washtenaw County in particular is experiencing a problem with
women not obtaining early and regular prenatal care, and greater disparities exist for the county’s
Latino, Hispanic, and immigrant communities. One in four pregnant women in Washtenaw
County receive no or inadequate prenatal care, which is substantially higher than the nation’s
average (Washtenaw County Health Department, 2013). Latina women bear a disproportionate
burden of this health disparity. Over half of Latina women living in Washtenaw County have
never been talked to by a health care worker about preparing for a healthy pregnancy (Waller,
Ledón, & Kruger, 2015). Additionally, as of the 2010 census, about 4% of residents identified as
Hispanic or Latino, and that number is expected to increase after the 2020 census due to rising
immigration rates across the country (Washtenaw County Health Department, 2013). Since the
proportion of Hispanic children born in the United States is projected to grow rapidly in the next
ten years, something must be done to improve their mothers’ access to prenatal care so that both
mothers and children can thrive (Murphy, Guzman & Torres, 2014).
There are a variety of barriers that women face in regard to accessing prenatal care,
including lack of financial resources or insurance coverage, inadequate child care, and lack of
transportation (Lia-Hoagberg et al., 1990; Roozbeh, Nahidi, & Hajiyan, 2016). In addition,
individual level psychosocial factors that were found to influence obtaining prenatal care or
keeping their appointments include considering abortion, her feelings about the pregnancy, and
timing of pregnancy recognition (Lia-Hoagberg et al., 1990). There is need for interventions that
focus on the concerns of the woman because when a woman’s needs are met then she will be
more likely to focus on the needs of the fetus. This is especially important when examining ways
to encourage Latina women to access prenatal care.
Through observation, Packard Health staff noticed that Latina women in Washtenaw
County in Michigan are not coming to doctor’s appointments and are not signing up for services
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they are eligible for because they are apprehensive of giving out personal information. Many
Latina women are afraid that they may put themselves or others at risk over undocumented
immigration status (Pedraza, Nichols, & LeBron, 2018). It is not solely that women are unaware
of Packard Health or that women do not understand the importance of prenatal care. Rather,
women are afraid, and in order to effectively serve the health needs of Latina women, their
concerns surrounding their immigration status must simultaneously be addressed (Novak,
Geronimus, & Martinez-Cardoso, 2017; Pedraza et al., 2017; ). Additionally, immigration policy
and enforcement has been shown to negatively impact the birth outcomes and general health of
Latina women, making it especially important for Latina immigrant women to receive prenatal
care (Novak et al., 2017; Pedraza et al., 2017; Viruell-Fuentes, Miranda, & Abdulrahim, 2012).
Latina women are especially vulnerable to experiencing poor physical, psychological, or
social health because of barriers related to their immigration status (Marshall, Urrutia-Rojas,
Mas, & Coggin, 2005). Latina immigrants must adapt to new culture, new society, overcome the
language barrier, and achieve economic stability all while facing institutional racism within the
health care system (Marshall et al., 2005). Two of the main barriers that affect immigrants are
access to and culturally appropriate (language and practices/beliefs) health care (Marshall et al.,
2005). Additionally, many health facilities require proof of residency status at the health care
facility which can deter undocumented immigrants from seeking health care due to fear of
deportation (Aday, 2001). Potential facilitators to Latina women accessing prenatal care include
culturally appropriate care, utilization of a family-centered approach, and trust-building.
Two programs that have successfully worked to address issues surrounding Latina
women’s access of prenatal services are CenteringPregnancy and Healthy Start. Centering-
Pregnancy replaces routine, individual prenatal care with group prenatal care (Trudnak, 2011).
This program is designed to empower women and offer support by dividing women into small
discussion groups with 8-10 other women. The groups are centered around topics of risk
assessment, education, and support. The program uses social support to provide stress relief,
encourage positive relationships, and empower women to help facilitate healthy pregnancies.
Women in CenteringPregnancy had an increased odds of attending prenatal care visits and
postpartum visits as compared to women who received individual care. Additionally, Healthy
Start is a federally-funded community-driven program that aims to reduce maternal and infant
health disparities (Escarne, Atrash, Cruz, Baker, & Reyes, 2017). Healthy Start works in
communities with high infant mortality rates, rates of low birth weight, preterm birth, and
maternal morbidity and mortality (Escarne et al., 2017). Healthy Start uses community health
workers to provide referrals, ongoing health care coordination, outreach, case management,
home visiting, father involvement, job training programs, and more. Latina Healthy Start
participants in Texas were found to have higher rates of prenatal care and lower rates of late or
no prenatal care (Selchau, 2017). Taken together, these programs are promising models to draw
from in developing a plan to increase prenatal care among Latina women in Washtenaw County.

III. Characteristics of the Priority Population

Ypsilanti is a city of approximately 21,000 people located in eastern Washtenaw County
(U.S. Census Bureau, 2017). Geographically, it sits to the southeast of Ann Arbor and west of
Detroit. Unlike these cities, Ypsilanti is neither well-resourced or a site of national attention, and
because of this, residents face unique challenges related to income and health. Nearly one-third
(30.9%) of all residents in Ypsilanti live in poverty, and 11.9% of those under age 65 do not have
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health insurance (U.S. Census Bureau, 2017). Because of these challenges, Federally Qualified
Health Centers like Packard Health are a necessary resource to the community.
Inequities facing Ypsilanti residents are exacerbated by issues of citizenship, language,
and race. It is estimated that 6.1% of people living in Ypsilanti are foreign-born, and this is likely
an underestimate due to the sensitivity of citizenship information in the U.S. The term “foreign-
born” refers to anyone who is not a U.S. citizen at birth, and includes those who are naturalized
U.S. citizens, permanent residents, and temporary, humanitarian and undocumented migrants.
The majority of foreign-born persons in the U.S. have migrated from Latin America (U.S.
Census Bureau, 2010). In the U.S., about 73% of all Latino people and 95% of immigrants who
are Hispanic speak Spanish at home (Krogstad, Stepler, & Lopez, 2015).
Latino residents of Washtenaw County have worse socioeconomic and educational
outcomes than their non-Latino peers. For example, the poverty rate among Latino folks in
Washtenaw County is nearly double that of the total Washtenaw County population. This
disparity is likely the result of many systems of oppression manifesting in limited opportunities
for employment. Looking upstream, it is also likely influenced by the educational outcomes of
Latino youth. The rate at which Latino individuals drop out of high school is nearly three times
that of the total Washtenaw County population.
These disparities can also affect birth outcomes among Latina mothers and create
generational hardship within families and communities. Latina women in Washtenaw County are
more likely to have more children earlier and without having finished high school than their
Black and White peers. In fact, the proportion of births in Washtenaw County among Latina
women who did not complete high school is 75% higher than Black births and seven times
higher than White births (Waller et al., 2015). Furthermore, “births to women less than twenty
years who were giving birth to a child of second order or higher was 35% for Hispanic births,
20% for Black births and 11% for White births” (Waller, 2013b). And the number of births in the
Hispanic population in Washtenaw County is much higher than that of other racial and ethnic
groups. While births among White women decreased by 13% from 2000-2011 and births among
Black women increased by 10%, births among Hispanic women increased by a staggering 68%
(Waller, 2013a). The differences in timing, spacing, and frequency of births between women in
Washtenaw County alerts us to an area for public health inquiry and intervention.
There are many strengths present within Ypsilanti’s Latino community that will guide our
intervention. Providers at Packard Health state that the community members take adherence to
treatment very seriously and are likely to return after an initial appointment. Providers are also
aware of the strong familial values of the community and try to schedule all family members’
appointments on the same day so they can come together (R. Fleming, personal communication,
January 23, 2019). Attention to these strong familial values will drive our communication about
the program; namely exploring how the benefits of prenatal care not only influence the mother
and infant as individuals, but also strengthen the mother-child relationship.
There are also several agencies and organizations that specifically serve the Latino
community of Ypsilanti, and we hope to engage them as community partners in the intervention
to build trust, gain insight, and connect with members of our target population. First, MHP Salud
provides culturally-appropriate technical assistance to agencies who serve Latino and Hispanic
communities and wish to integrate a community health worker model into their programs.
Despite serving agencies across the U.S., MHP Salud is based in Ypsilanti. They launched a
doula program with migrant farmworkers in Sparta, MI in 2001 and it has expanded to serve
Latino communities in south Texas (History of MHP Salud, 2014). In efforts to build rapport and
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meet people where they are, we also hope to partner with two local churches: The First United
Methodist Church of Ypsilanti (FUMCY) and St. John the Baptist Catholic Church. Both
churches offer weekly services in Spanish, and FUMCY also offers English language classes and
monthly Justice for Our Neighbors clinics where undocumented community members can get
free legal advice (“Hispanic ministry,” 2019; “Latino ministry,” 2019). Seeking out and
strengthening these community partnerships during planning, decision-making, and
implementation is imperative to the success of our program.

IV. Program Goals and Objectives

Latina women seek less prenatal care than other groups in Ypsilanti; thus, are at an
increased risk of adverse maternal health outcomes (Bromley et al. 2011). Therefore, the goal of
our proposed program is to improve the maternal health outcomes of Latina women in Ypsilanti.
Specifically, by June 2021 we plan to increase the number of pregnant Latina women in
Ypsilanti that receive pre- and postnatal care from Packard Health by 10%. We plan to work
towards this outcome objective by 1) increasing trust in Packard Health among Latina women
that live in Ypsilanti and are participating in our program to 75%; 2) increasing knowledge about
prenatal care among Latina women of childbearing age living in Ypsilanti that are participating
in the community events attached to our program to 75%; and 3) increasing self-efficacy to seek
prenatal and postnatal services provided by Packard Health among at least 50% of Latina women
in Ypsilanti that are pregnant or considering becoming pregnant and are participating in our
program. We aim to reach these three impact objectives by June of 2021.

V. Capacity and Experience of Partner Organization

Packard Health is a not-for profit, Federally Qualified Health Center focused on health
and wellness for families in Washtenaw County. Jerry Walden established Packard Health in
1973 as a result of his passion to focus on patient-centered health care for those in need. The
organization’s vision is “a healthy community in which every individual has a dependable
quality health care home” (“Mission and values,” 2017). Packard Health’s mission is “to provide
the best possible care to our patients and community, including people whose economic, social
or cultural conditions might otherwise prevent them from accessing health care” (“Mission and
values,” 2017). Packard Health pursues their vision and mission statements by valuing whole-
person health, excellence in care, health justice, caring environment, diversity of patients and
staff, and partnerships in the community (“Mission and values,” 2017). Packard Health’s
targeted health problem of Hispanic and Latino immigrants not obtaining prenatal care aligns
with their mission to provide excellent healthcare to those facing social or cultural barriers to
care.
Packard Health provides healthcare and community health resources to Washtenaw
County residents of all ages, from infants to seniors. A large portion of their population are in the
age range of of 20-44 (47%) and 45-64 (32%) (“Michigan health centers,” 2017). Furthermore,
their patients are primarily Hispanic/Latino (3%), Black/African American (19%), and White
(39%). In addition, 78% of patients are at or below 200% federal poverty line (“Michigan health
centers,” 2017). Forms of insurance used by patients include Medicaid (35%), Medicare (15%),
private (48%), and uninsured (9%) (“Michigan health centers,” 2017). Therefore, Packard Health
focuses on assisting patients with economic, social, or cultural barriers to gain access to
insurance, food, medication, and transportation.
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Packard Health has established staff and services that will be beneficial to manage a
program focused on Latina pregnant women. Packard Health has organized a prenatal care team
that includes five providers: Lindsey Kotagal, Ron Romero, Elizabeth Orlowski, Niyati Shah,
and Kaila Queen. Four of these providers are able to speak Spanish which will allow for
effective communication with the large proportion of immigrants who speak Spanish as their
primary language (Krogstad et al., 2015). In addition to their prenatal care team, Packard Health
has a partnership with the University of Michigan (U-M) Department of Family Medicine.
Together, the partnership provides pregnancy and prenatal testing, regular checkups, laboratory
services, nutritional counseling, parenting education, childbirth classes, delivery at U-M
Women’s Hospital, postpartum care, family planning, and breastfeeding support (“Prenatal care
services,” 2016). Therefore, pregnant patients at Packard Health have access to a comprehensive
medical care team that will provide them with an educational, supportive, and nurturing
experience.
At Packard Health, all patients have access to language services to ensure effective
communication and a comfortable environment. Eight of the providers and several office staff
can speak Spanish and can assist in exam rooms or on the phone if necessary. Patients also have
telephone access to Trained Medical Interpreters that are able to deliver effective patient care in
any language (“Language services,” 2016). Lastly, Packard Health ensures their standard forms
and patient education materials are available in English, Spanish, Arabic, Mandarin Chinese, and
French (“Language services,” 2016). With these services, Packard Health can successfully
manage a project focused on increasing access to prenatal services for Latina women.
Packard Health aims to treat the whole patient to ensure complete well-being. Latina
women will not only have access to comprehensive prenatal services but also to assistance
programs through Packard Health’s resources and partnerships. Assistance programs are
facilitated by certified patient advocates that can help solve many basic needs issues.
Specifically, patients in need can be connected with food pantries, medication assistance
programs, and transportation vouchers (“Food, medication, transportation assistance,” 2016). If
other issues arise such as needing a place to stay, or trouble paying an electric bill, patient-
advocates strategize to help relieve the patient of the problems (“Food, medication,
transportation assistance,” 2016). Moreover, Packard Health’s patient advocates are also
Certified Application Counselors for insurance enrollment assistance. Current insurances
available are through the Washtenaw Health Plan, Insurance Marketplace, Medicaid, and
MIChild (“Food, medication, transportation assistance,” 2016). Thus, by increasing awareness of
Packard Health within the targeted community, Latina women will be able to access these
assistance programs to help promote health and wellness for the entire family.

VI. Program Strategy and Activities

We plan to use a doula model to achieve our goal of improving maternal health outcomes
among Latina women of childbearing age in Ypsilanti. We believe that this model is most
appropriate for addressing the three main barriers that have been identified as preventing our
target population from utilizing Packard Health: trust, knowledge, and self-efficacy. To build
these three areas, we will be hiring women from the community to serve as doulas. The doulas
will serve in a role similar to that of community health workers, or more specifically,
promotores. This strategy was chosen because it aligns with Packard Health’s current capacity,
has been shown to improve maternal health outcomes in a variety of settings, and employs
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several theories related to social support and behavior change that are relevant to our target
population.
Packard Health currently has capacity to serve Latina women in Ypsilanti in our offices,
but we have had difficulty keeping in contact with members of our target population after their
initial appointment. Increasing Packard Health's capacity for outreach and education would
increase knowledge among community members and connect women seeking services to
Packard Health. While providers have previously volunteered time where possible to improve
outreach and education, the proposed intervention will incorporate these activities into a
sustainable practice developed on a foundation of evidence and theory. In the past, low capacity
for targeted follow-up and outreach have led to low rates of continued care, weakened
community trust, and knowledge gaps about prenatal care in our community. We believe that by
integrating doulas into our care teams, Packard Health will be better positioned to provide
patients with in-home support services and follow-up medical care at our offices.
Research has shown the merits of doula care in a variety of settings and across
demographics, yet doula services are widely underutilized. A recent Cochrane review of over 20
randomized control trials found that doula-supported women were more likely to have a
spontaneous vaginal birth, more likely to have a shorter labor with less pain, and less likely to
rate their birth experience negatively than women who had usual care (Bohren, Hofmeyr, Sakala,
Fukuzawa, & Cuthbert, 2017). Doula-supported women also did better on all of these measures
than women who received continuous care from a nurse, family member, or friend. Despite these
benefits, only 6% of women employ a doula while pregnant (Declercq, Sakala, Corry,
Applebaum, & Herrlich, 2013). While this is partially a matter of preference, many women face
barriers to accessing doula care. For example, only three states require that Medicaid cover
services provided by doulas, and Michigan is not one of those states. This means that women
who are publicly insured or uninsured are less likely to have a doula despite their desire for one
(Kozhimannil et al., 2014). By employing doulas through Packard Health, our program seeks to
connect women facing these barriers in our community with doula care at low or no-cost.
Several theories have informed our program structure and implementation plan. First, we
have drawn upon theories of social support to inform the doula roles and responsibilities. By
developing relationships with their patients from initial appointment to postpartum care, doulas
are creating a trusting relationship where patients can express needs that doulas can then
advocate for. Research shows that young, low-income pregnant women who are matched with a
culturally sensitive, community-based doula benefit from having a continuous external support
person (Breedlove, 2005). Specifically, they viewed these relationships as being similar to
mother-daughter, sister, or friend relationships with the added benefits of doulas having direct
conversations about healthcare challenges and needs, respecting the woman’s rights and
responsibilities around pregnancy, and understanding the challenges facing the community
(Breedlove, 2005). Lastly, community-based doulas have been shown to have greater “sensitivity
to culture, identification and response to community socio-demographic barriers, and emphasis
on identification of goals with orientation toward a positive future” (Breedlove, 2005). For these
reasons, we believe that employing community-based, culturally sensitive doulas will foster a
sense of social support, improve patients’ experience with Packard Health, and encourage
patients to engage in follow-up care throughout their pregnancy.
The Theory of Planned Behavior (TPB) has also informed our program goals and
activities. One of our objectives is to increase self-efficacy, a core component of TPB, among
pregnant women in our target population (Glanz, Rimer, & Viswanath, 2015). Research
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examining the experiences of disadvantaged pregnant women who had support from community-
based, volunteer doulas has shown that this model is effective at increasing self-efficacy in
regard to seeking out and engaging with local prenatal care services. In fact, a qualitative study
of a volunteer doula program found that doula support made pregnant and new mothers feel
more knowledgeable, more confident in their skills, more capable of accessing maternity
services, and more connected to their community (McLeish & Redshaw, 2019). By adopting a
similar model, we will employ doulas to improve women’s self-efficacy around seeking prenatal
care through support, education, and empowerment.
The intervention we have designed revolves around working with doulas to encourage
and help ensure that Latina women in Ypsilanti receive proper prenatal care. We have named
the program MADRES (the Spanish word for “mother), which is also a Spanish acronym for
“MAdres y Doulas REalizando Salud” or “Mothers and Doulas Achieving Health”. We chose
this title to convey the positive relationships we hope will arise between our program participants
and doulas as they work together to achieve better prenatal health outcomes. Our goal of
achieving better prenatal health outcomes for Latina women in Ypsilanti will be accomplished
by utilizing doula services to address the three primary obstacles that have been identified as
preventing our priority population from receiving adequate prenatal care. These three obstacles
are: lack of trust in healthcare organizations such as Packard Health; access to transportation; and
lack of knowledge about proper prenatal care.
The first component of our intervention is recruiting women from the Ypsilanti area to
work as doulas for our program. We will be recruiting four women at the beginning of our
program who are registered doulas already or just completing their doula training by contacting
existing doula organizations and training organizations such as Southeast Michigan Doula
Project and Dial-A-Doula. If possible, we prefer to recruit doulas who are members of our
priority population or have prior experience working with our priority population in order to help
establish the community’s trust in Packard Health. Otherwise, we will hire women with similar
doula experience from outside of our priority population. Before the doulas begin working with
patients, we will provide them with an additional training session to educate them about the core
competencies required by community health workers. We will partner with MHP Salud to
provide this training. The specific training MHP Salud will provide for our doulas will be one
day long and will also include a segment on cultural competency specific to the Latino
community in Ypsilanti so that our doulas (especially those not from our priority population) can
better work in and serve our priority population. The crux of MADRES is that the women
serving as doulas will not only be working with our priority population as doulas, but they will
also be working in an outreach capacity as a bridge between Packard Health and Latina women
in Ypsilanti. Thus, the community health worker training will be important for our doulas so that
they have the competencies required to educate Latina women in their community about proper
prenatal care and to empower them to obtain that care.
Once the doulas are hired and trained, they will work together to host at least 3
community events sponsored by Packard Health in collaboration with other organizations trusted
by our target population in Ypsilanti. The purpose of these community events is to establish a
relationship between Packard Health and Latina women and their families in Ypsilanti. It is
especially important that women’s partners are involved in this process as well. Since men are
often the head of the household in our priority population and may be making many decisions for
their family, it is vital that men also trust Packard Health and feel involved in their partner’s
pregnancy if the women are to obtain care at Packard Health (Miranda, Bilot, Peluso, Berman, &
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Van Meek, 2006). Through establishing a relationship and sense of trust between Packard Health
and our priority population, we hope that Latina women in Ypsilanti will be more likely to obtain
prenatal services from Packard Health. Types of community events that will be held include a
family fun night, a potluck dinner, and a holiday party for a culturally relevant holiday for our
priority population. Some of the trusted community organizations we will be working with to
host these events include Latino Family Services, Venezolanos Unidos en Michigan, and local
churches frequented by our priority population. These community events will be held at some of
these community partner locations such as church recreational centers and at other community
spaces such as parks. Our doulas will have a booth at these events to provide attendees with
information about prenatal services provided by Packard Health. The doulas will primarily be
there to answer questions from our priority population so that the community recognizes Packard
Health as a safe, inclusive place to receive prenatal care. The information doulas will provide at
these events will be developed by the doulas from existing health information produced by
Packard Health in order to better tailor it to our priority population.
Doulas will then be paired with an OB-GYN at Packard Health and will work with the
pregnant Latina women (with the women’s consent) that receive prenatal services at Packard
Health from the doula’s paired OB-GYN both during and for three months after their pregnancy.
Paired doulas will serve as a source of social support and advocate for their patient throughout
and after the patient’s pregnancy. In order to overcome language barriers and power dynamics
that exist in the medical world, doulas will accompany their patients to prenatal appointments at
Packard Health (Gruber, Cupito, & Dobson, 2013). Doulas will additionally help involve their
patient’s partner in the pregnancy by encouraging them to participate in pregnancy-related
activities such as attending appointments with their partner. If needed, doulas will also provide
transportation to their clients by helping clients obtain transportation vouchers provided by
Packard Health or by even driving their clients to and from appointments themselves. This will
help eliminate the barrier to accessing prenatal care that a lack of transportation causes for our
priority population. Additionally, doulas will schedule check-ins with their patients once a month
that can either be done at the patient’s home or virtually to alleviate the burden of transportation
on their clients. These check-ins will allow the doulas to ensure that patients are following proper
prenatal care recommendations as well as to address any questions or worries their patients have
about their pregnancy, and then after the baby is born to help with things such as breastfeeding.
Check-ins will also give the doulas the opportunity to acknowledge other challenges their
patients are facing such as food insecurity and provide patients with information about additional
resources they can access to help mitigate those challenges.
To promote knowledge of proper prenatal care, doulas will lead a social group or “Ladies
Night” for Latina women in Ypsilanti at a local church once a month. There will be one meeting
every month that the women can show up to as desired, for a total of 15 meetings over the course
of two years (the meetings will begin in the 10th month of our program). Women will be able to
register for Ladies Night at the community events hosted by doulas, at Packard Health when they
come in for appointments, online through Packard Health’s website, or even in-person at the
meetings themselves. Ladies Nights will provide our priority population with a space to build
social connections and learn more about health. Every meeting will focus on a different aspect of
women’s health, with specific meetings focused on prenatal care, pregnancy, breastfeeding,
postpartum care, and motherhood in general. Employees from Packard Health such as physicians
and nutritionists, as well as other experts from the community will come in to talk about their
area of expertise. Women will get the opportunity to ask questions, share personal stories and
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experiences, and learn about a variety of health resources available to them at Packard Health
and the community. Child care will also be provided at these meetings by community volunteers
or existing child care resources at the event space.

VII. Monitoring and Evaluation

The process, impact, and outcomes of MADRES will be evaluated by the quality team at
Packard Health along with the help of unpaid interns from the University of Michigan School of
Public Health (UMSPH). The quality team will be in charge of distributing and collecting
evaluation instruments such as surveys, as well as analyzing the quantitative data. Interns will be
responsible for putting together and analyzing qualitative data. In order to evaluate what services
are actually provided by the program and to whom, records will be kept about when program
activities were held, other data related to putting on the event, as well as attendance at each
event. That information will be compared to our program’s goals and objectives to evaluate
success. To evaluate the impact of MADRES on its participants, participants will be given a pre-
and post-program survey, as will as a mid-point evaluation that will ask them questions such as
their knowledge of prenatal care and trust of Packard Health. Packard Health will also keep track
of prenatal appointments to verify that participants are actually utilizing their services. Pre- and
post-program results will be compared, and if post-program levels of knowledge, trust, and
attendance are higher than pre-program levels, the program is likely to have been successful.
Finally, Packard Health will track the health outcomes of their prenatal patients from our target
population throughout the program and compare them to health outcomes at baseline. This will
be done by looking at each participant’s medical record with the participant’s consent. If the rate
of outcomes such as attendance at prenatal appointments and healthy birth weight has increased,
and the rate of outcomes such as gestational diabetes and preterm birth has decreased, it is likely
that the program has made a long-term impact on health outcomes.

VIII. Project Management and Timeline

MADRES will be managed by the four doulas with guidance from Packard Health care
teams and project manager. Doulas will be responsible for connecting with Latina women from
Ypsilanti and fostering relationships. Doulas will also conduct Packard health sponsored events,
Latina women support groups (Ladies Nights), and home-visits. Because the doulas’ main role is
to connect the target population to Packard Health, it is imperative they are at the center of all
community events and Ladies Nights. They will be knowledgeable of the populations’ concerns
and needs, and thus, will be the best individuals to implement these events. Doulas will meet
monthly to assess overall progress.
Doulas will be assigned to Packard Health’s pre-existing interprofessional care teams
focused in prenatal services. These teams include a combination of physicians, behavioral health
professionals, and patient advocates. These teams are responsible for clinical services, nutrition
education, food, medication, transportation, and insurance assistance. Dr. Romero, a prenatal
care physician will oversee and assist in hiring and organizing doulas. He is best for this role
because he speaks Spanish fluently and already works with current Latina patients. Katie
Marquez, Packard Health’s Development Coordinator, speaks Spanish and has specific interest
in serving families, refugees, and immigrant populations. For this grant, Katie Marquez will be
serving in the project manager role. Thus, she will be able to assist and connect Doulas with
resources for community events and Ladies Nights. A public health intern will be hired to create
educational materials regarding doula services and help at community events.
 12

IX. Dissemination and Sustainability

The successes and lessons learned from the implementation of the MADRES program
will be disseminated through several avenues. First, we will communicate results of our program
to stakeholders in University of Michigan Medicine and across Packard Health’s offices after
one year and again at the end of the funding period. We also believe it is imperative to share our
progress with the communities we aim to serve, and we will do this by providing information
about the MADRES program via poster, flyers, and/or word of mouth at Community Event #2
and #3. Finally, UMSPH students we anticipate assisting with the evaluation will also have
opportunities to communicate their findings through written products which can be widely
disseminated such as a poster presentation at UMSPH.
There are several components to maintaining the MADRES program after the grant
funding. The program manager and the doulas that will be running the program will continue to
have responsibility after the funding has ended. Therefore, the structured activities of the
monthly doula meetings and check-ins with the program manager will continue, to ensure the
program does not dissolve. To support MADRES after the grant funding, the program staff will
continue partnerships with community organizations. These partnerships can be utilized for
assistance and support to sustain further community-wide Packard Health events. Thus, usage of
their space can be a potential option to keep costs low.
To continue program staff funding, Packard Health will host fundraisers, apply to other
sources of funding, and utilize partnerships. In order to create and implement successful
fundraisers, Packard Health will recruit a UMSPH student as an intern. An unpaid intern will be
able to take on work so that other staff at Packard Health will not be burden with the role.
Furthermore, Packard Health will apply to other funding detailed at the beginning of the
document. Current funding opportunities include: The Community Health Matching Grant
Program, The Michigan State Medical Society Foundation, and Blue Cross Blue Shield of
Michigan grant. Lastly, to reduce staff costs and/or to expand the program, Packard Health will
partner with doula volunteer organizations within the community such as Dial-a-Doula and
Southeast Michigan Doula Project. These organizations provide volunteer doulas for free for
patients that are needing services. Thus, if funding is minimal, Packard Health could partner with
these organizations.
 13

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Waller, A., Ledón, C., & Kruger, D. (2015). Latino health equity is essential for
Washtenaw County health, wellbeing And prosperity: The Washtenaw County Encuesta
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Economic-Factors-PDF
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XI. Appendices
A. Goal and Objectives
 17

B. Logic Model

C. Gantt Chart
 18

D. Budget and Budget Justification

Personnel:
Doulas: The program will require the hiring of four doulas to serve pregnant Latina women in
the Ypsilanti community. Doulas will be providing in-home care to patients, providing
transportation to patients when needed, facilitating monthly support groups (Ladies Nights) and
serving as community health workers at our community events. Overall, we expect the doulas to
work ten hours a week.
Program Manager: The program manager will supervise the doulas and match doulas to patients.
They will oversee the program’s implementation and provide support to the doulas as they
integrate into the care teams.
Physician Oversight: The costs of Dr. Romero’s oversight and assistance with doulas will be
absorbed by Packard Health.

Consultants: MHP Salud will provide their 16-hour Foundations of Community Health Work
training to the doulas. The training covers the role of community health workers, educating in the
community, the impact of culture on health, and ethical responsibilities and confidentiality. The
training can be conducted in Spanish or English. MHP Salud is a national leader in Community
Health Work training, specifically within the Latino and Spanish-speaking communities.

Supplies: Five major supply items will be required. Printing costs associated with flyers and
brochures will account for $500 of the budget each year. Space rental for community events will
account for $400 of the budget each year. We predict that there will be a cost of about $100
associated with each event we plan, with an estimated 3 events we will execute each year. This is
a fairly low cost because we plan to utilize churches in the community. We expect that there will
be a cost of $1,000 associated with supplies for community events. These supplies will include
food and games. Additionally, we expect that there will be a cost of $600 associated with space
 19

rentals for the Ladies Nights each year. These spaces may include parks and spaces within
churches. Also, supplies for Ladies Nights will include food which will account for $250 of the
budget each year.