Monday, September 16, 2013

Can Legal Care Improve Infant Mortality? Incorporating Medical-Legal Partnership in Healthy Start Programs

By Shannon Mace Heller, JD, MPH, Public Health Law Specialist at HELP: MLP & Adjunct Professor at Temple University and Dan Atkins, JD, Director of HELP: MLP & Adjunct Professor at Widener University School of Law

Can lawyers help prevent infant mortality?  Promising data from a Healthy Start program that has incorporated medical-legal partnership (MLP) into its services suggest legal care can be critical in reducing the maternal stress often at the root of infant mortality.  And Healthy Start programs looking to address infant mortality are beginning to see MLP as a critical part of how they operate.

In 1991, African American babies were dying at twice the rate of Caucasian babies, comprising nearly 2% of live births.  It was a public health crisis that required a national response.  Prevailing maternal and child health research follows two theories.  The first is life course theory, described by the Maternal and Child Health Bureau (MCHB) as the idea that, “today’s experiences and exposures influence tomorrow’s health,” and that many of these factors are environmental.  This highlights the necessity of providing a healthy, safe environment for a woman throughout preconception, pregnancy and post-conception.  The second theory is that long-term chronic stress has detrimental effects on pregnancy and birth outcomes.  Researcher Dr. Michael Lu hypothesizes that the everyday racism and prejudice faced by African American women causes a more stressful environment.  This chronic stressful environment leads to an imbalance of what is known as allostatic load that could lead to higher rates of hypertension, other chronic diseases, and poor birth outcomes for pregnant women.  

Building on this research, in 1991 the federal Healthy Start initiative set out to assist vulnerable communities, those in which the infant mortality rates are 1.5 to 2.5 times higher than the national average, by providing transportation, nutrition, education, screenings, counseling and linkages to healthcare and basic necessities.  The initiative has shown to reduce infant mortality.  While core services include direct outreach, case management, health education, interconceptional care, and screening for depression, one service that was noticeably absent from Healthy Start, until recently, was legal services.

In 2010, the federal Health, Resources and Services Administration (HRSA) funded the National Center for Medical-Legal Partnership to coordinate the integration of legal care into Healthy Start projects.  Among the funded projects was Crozer-Keystone Healthy Start (CKHS) in Chester, Pennsylvania.  CKHS partnered with Widener University School of Law’s Health, Education and Legal assistance Project:  A Medical-Legal Partnership (HELP: MLP) to provide legal services to CKHS participants and their family members.  Chester is one of the most impoverished cities in the nation with over thirty-two percent of residents living below the federal poverty line according to the U.S. Census.  Residents face the threat of violence every time they leave their homes and access to basic necessities including food is not guaranteed, and stress can be a constant factor in the lives of residents.

Prior to integrating medical-legal partnership as part of the Healthy Start’s core services, CKHS staff and case managers already provided an impressive set of comprehensive services to its participants and demonstrated positive results.  Since its establishment in 1997, CKHS has shown improvements in birth outcomes, contributed to lowering the community’s infant mortality rate, established a medical home for all participants, and increased use of data collection and evaluation.  The establishment of the CKHS HELP: MLP partnership in 2010 provided an avenue to resolve participants’ most complex, critical needs that were often beyond the resources or expertise of CKHS case managers alone. 

Since having legal care and medical-legal partnership as part of the core services at CKHS, hundreds of health-related legal  problems have been solved benefiting Healthy Start participants and family members.  MLP attorneys provided an additional 150 consultations to Healthy Start case managers to help with other legal problems that arose, increasing case managers’ expertise and expanding their capacity.  The impact of this legal assistance is being measured through public health evaluation conducted by public health evaluators at Thomas Jefferson University.  Initial findings show: 
  • Decreased participant-client stress.  84% of respondents in phone interviews following services report lower stress following legal help, often relating it directly to the legal help they received.  For example, one client stated, “Just having someone there helps you. The services were highly effective. Before agencies were giving me a run around, but having a lawyer there gets things done. Her help is very effective and had a huge impact on my family.”  Many of the clients received assistance from HELP: MLP for issues that they had been struggling with for months and even years. 
  •  Decreased stress and increased advocacy capacity of CKHS staff.  By adding a lawyer to the Healthy Start team, resources that were once devoted to difficult, complex cases can now be resolved by the lawyer increasing the capacity of case managers to address other situations.
The impact of adding MLP to Healthy Start services is felt by program administrators.  “I cannot imagine not having legal assistance as part of Healthy Start,” said Joanne Craig, Administrative Director of Women and Children's Health Services for Crozer-Keystone Health System and Project Director and Principle Investigator for Crozer-Keystone Healthy Start.  “If you are designing a program to reduce infant mortality, medical-legal partnership needs to be part of it.  Poor and vulnerable people have many problems.  Medical-legal partnerships are an ally and tool to assist with addressing the social determinants that clearly impact health."

The data currently being collected by HELP: MLP and its evaluators are preliminary, but promising.  It shows that the integration of legal services can have a positive effect on individuals by reducing their stress, a critical component to a healthy pregnancy and delivery.  A need exists for research that examines the impact of programs like Healthy Start and HELP: MLP over time including analyzing birth outcomes and the impact interventions early in life and during pregnancy have over the life course.  We believe that over time Healthy Start MLPs will continue to prove that they are extraordinary partnerships able to affect change at the individual and policy levels especially as evidence continues to prove that environment and social determinants are largely responsible for the health inequities that exist today.

The National Center for Medical-Legal Partnership will publish additional results from the Healthy Start / MLP projects in the Journal of Legal Medicine, spring 2014.

For more information on HELP: MLP, visit:

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