The Stork's Nest Program Benefits At-Risk Mothers and Their Babies

There is considerable evidence (American Dietetics Association, 1994, Paneth 1995; Shiono & Behrman, 1995; Story, 1990; Story & Alton, 1995; Trouba, Okereke, & Splett, 1991; U.S. Department of Agriculture, 1994) that effective nutrition education interventions lead to satisfactory maternal weight gain during pregnancy and ultimately to reduced low birth weight and reduced infant mortality rates. These findings provided the basis for the implementation of the Stork's Nest project in Iowa, an educational intervention to teach women early in their pregnancies about proper nutrition; adequate weight gain; dangers of smoking, alcohol and illicit drug use; and importance of exercise.

Through Extension Service/Womens, Infants, Children (WIC) plan of work dollars made available through Iowa's Expanded Food and Nutrition Education Program, Iowa State University Extension took leadership in developing Stork's Nest programs in three counties. Polk, Johnson, and Des Moines counties were selected because of high percentages of low birth weight (6.2%, 5.4%, and 5.2% respectively) (Iowa Kids Count, 1994). All were above the Healthy People 2000 goal of 5% low birth weight infants. The target population was pregnant women with one or more of the following risk factors: low income (below 125% of poverty), current or recent consumption of illicit drugs, current or recent consumption of alcohol, current smoker, less than 18 or greater than 35 years of age at the time of conception, pregnancy weight gain below recommended standards for normal/underweight women, pre-pregnancy weight below 90% standard, history of low birth weight baby or prematurity, parity greater than four, history of fetal or neonatal death, and less than 18 months between pregnancies.

The program was publicized through posters and brochures distributed to doctors' offices, hospitals, and social service agencies; articles in the press; and newsletters to service organizations. Presentations were scheduled with different social and health organizations to share information about the program with potential collaborators.

Personnel from diverse organizations participated in the Stork's Nest program by teaching, providing referrals, volunteering, and advising. Professionals from Extension and other agencies provided weekly educational classes at the Stork's Nest sites. Classes were offered in English and Spanish on nutrition, parenting, family planning, importance of seeking medical help, breast feeding, fetal development and child birth, safety, and prenatal and postnatal exercising, development of infants and toddlers, emotional health, and money management. The topics were covered in rotation over four or five weeks so participants entering the program at any time could receive information in all subjects. A local coordinator and a supervisor administered the program at each site. While the local coordinator was responsible for day-to-day management of the Stork's Nest, the supervisor was responsible for providing leadership that would determine program development.

Participants were recruited at WIC clinics, churches, and schools and assigned a case manager. Case managers referred clients to the local Stork's Nest coordinator, who followed up referrals with a telephone call or a letter of information about the project and enrolled interested participants. Case managers then worked with participants to set healthy behavior goals and to encourage healthy behaviors, such as attending WIC programs, keeping doctor appointments, stopping smoking, making healthy food choices, continuing or completing education, and using existing helping agencies to meet individual and family needs. Case managers kept a record of observed healthy behaviors in each participant's record book, awarding points for healthy behaviors recorded, based on predetermined guidelines. Participants could redeem their points at the Stork's Nest store for necessary supplies for the mother and baby.

Program effectiveness was evaluated using the pre-test-post- test evaluation design. Case managers collected demographic data from all participants at entry. One survey assessed practices relating to nutrition, food safety, and food resource management. A separate survey assessed knowledge regarding prenatal and infant diet. The exit survey included open-ended questions designed to elicit data on the perceived impact of the program. Exit data were collected when the baby was a year old or when the client informed the local Stork's Nest coordinator or case manager that she wished to exit the program.

The Stork's Nest coordinators reported facing challenges collecting data from the multiple instruments at two points in time because of practical difficulties involved. The estimated time for administering the instruments at entry for each client was one hour and sometimes more, depending upon the clients' literacy level. The clients were not always available and agreeable to commit their time for the post-test. So, although a total of 133 clients between January 1994 and August 1996 responded to evaluation instruments at program entry, exit information was not available for all 133. The results of the evaluation of knowledge of prenatal and infant nutrition and nutrition, food safety, and food resource management practices were based on the pre-test and post-test data provided by only a small number of participants from the Polk County site.

The qualitative data concerning perceived program impact was based on responses of clients from all three sites. Table 1 summarizes the participation of clients in each city and the numbers who provided evaluation data.

Of the 133 participants providing entry data, 56% were Caucasian, 22% were African American, and 9% were Hispanic. Seventy-one (53%) of the respondents were twenty years of age or younger, nearly 50 (38%) were between 21-30 years of age, and 12 (9%) were over 30 years of age. Ninety-eight percent of the respondents from the Polk County Stork's Nest were 20 or younger, while the majority of clients in the other Stork's Nests were between 20 to 30.

Survey findings from pre-test to post-tests indicate that the percent of participants answering correctly increased for 14 out of the 20 items on the survey of knowledge about prenatal and infant diets. The mean post-test scores (mean = 15.03) was significantly higher than the mean pre-test scores (mean = 14.26) for the 37 clients who provided complete post-test data (t = - 2.59; p < .01), indicating a significant increase in knowledge of prenatal and infant nutrition.

Forty-two clients provided complete pre-test and post-test data on the 24-hour food recall. The data were analyzed using the EFNEP Evaluation Reporting System to compare the reported food intake to the minimum recommended number of 6-3-2-2-2 servings and to measure nutrient adequacy.

Eighty-six percent demonstrated a positive change in the in- take of one or more nutrients at exit. The mean number of servings of breads/cereals, fruits, meats, and dairy products increased. The dietary intake of grams of protein and dietary fiber of project participants was found to be higher at program exit when compared to program entry. The mean nutrient adequacy ratios from entry to exit were as follows: for protein .86 to .92; for iron .61 to .67; for calcium .58 to .59; for vitamin C .75 to .78; for B6 from .69 to .71. Although the mean number of servings of breads/cereals, fruits, meats, and dairy products increased in the positive direction, the participants did not meet the minimum requirements of a 6-3-2-2-2 diet.

A survey of practices related to nutrition, food safety, and food resource management was completed at both entry and exit by 20 participants. Findings showed that 12 (60%) clients more often thought about healthy food choices when deciding what to feed their family, 14 (70%) more often or always followed the recommended practice of not thawing food at room temperature, 9 (45%) more often compared prices before shopping.

To assess impact from a qualitative perspective, participants were asked two open-ended questions. In response to the first question "What impact did the educational component of the Stork's Nest have on you?" participants reported learning the importance of medical check-ups and immunizations, acquiring good parenting skills, changing their eating habits, comparing food labels, choosing more healthy foods, and following guidelines for preparing children's meals. Several participants reported that they stopped smoking.

The second question asked was "What impact did the program have on your baby?" Participants reported that the program helped them to make better personal decisions that would affect the health of their baby. Several mothers expressed appreciation for the baby supplies they received in exchange for educational points accumulated. The mothers also expressed thankfulness for the continued support offered after the birth of their babies. Several mothers stated that they obtained professional advice on the importance of prenatal care and the advantages of breast feeding. The Stork's Nest coordinator in Johnson County reported that 70% of clients were still breast feeding at two months, and breast pumps were among the top five "Most Wanted Incentive Items." She also reported that first-time moms regularly expressed how much they learned and looked forward to their own support group each week.

The evaluation results need to be interpreted with caution in view of the small sample size and lack of validity -- internal and external -- of the experiment. The lack of validity is attributed to the relatively less rigorous nature of the pre-test -post-test design.

The results of the Stork's Nest Program revealed a significant increase in knowledge of prenatal and infant nutrition of participants from pretest to post-test. Participants also learned the importance of healthy diets, food safety, food labels, medical check-ups and immunization, breast feeding; and dangers of alcohol and substance abuse.

Similar programs promoting prenatal and post-natal health, and well being of babies are critical to attaining the goals of Healthy People 2000. However, when evaluating future programs, researchers may consider using a control group to ensure the validity of program evaluation results.

Personnel at each of the three Stork's Nest sites have been successful in getting local health care organizations to assume management of the Stork's Nest after the grant funding ended. The programs are on-going, and Extension personnel continue to provide nutrition education and serve on advisory boards.

Others who may want to replicate the program should recognize that the success of a collaborative Stork's Nest program depends on the commitment and wholehearted support of the members of collaborating agencies. Based on experience with the program, the following for successful program development is recommended:

Establish an advisory board of members representing the cooperating agencies that have a concern for the well-being of mothers and babies, and have experience in successful fund raising, networking, and program development. All program development decisions need to be made collaboratively by members of the board.

Appoint a local coordinator preferably with a nursing or counseling background, and experience in program planning and implementation.

Enlist the support of the medical community to ensure continued funding for the coordinator's position, a continuous flow of referrals, more program visibility and credibility, and sustained enthusiasm from the community.

Assure of a continuous supply of incentives in the Stork's Nest store; office equipment such as a computer, printer, and a photocopy machine; and office supplies.

Develop an effective point tracking and monitoring system.

Appoint and train case managers, including medical professionals.

Ensure availability of a site in a safe and easily accessible location.

Involve skilled program participants and other volunteers in activities and maintenance of the Stork's Nest.

Arrange for donations of furniture for the Stork's Nest office and store and for seating clients and volunteers.

Anticipate a large enrollment of program participants.

Hold periodic successful fund raisers and baby showers involving local businesses and philanthropic organizations to ensure that the Stork's Nest store is well stocked at all times.

Arrange transportation for those clients who may experience transportation problems.

Develop a quarterly educational program schedule, which should be easily available and accessible at the Stork's Nest, doctors' offices, WIC clinics, and offices of other service providers.

Give frequent publicity to the program through the use of multiple media outlets such as television, radio, and newspapers.

Make arrangements for child care during Stork's Nest classes using adult and youth volunteers.

Develop a quarterly monitoring system to track indicators of project activity, such as number of advisory committee meetings held, referrals that have been received, enrollment, attendance, graduation rates, number of volunteers and hours volunteered, and hours of educational programming.

Develop a home visitation system for clients who have been absent from classes for a prolonged period of time.

Develop a monthly newsletter of current and upcoming events in the Stork's Nest and tips for prenatal and postnatal mothers.

Encourage all participants to continue in the program beyond three months so as to benefit from educational programming.

Train personnel in data collection using program evaluation instruments.

American Dietetic Association (1994). Position of the American Dietetic Association: Nutrition care for pregnant adolescents. Journal of the American Dietetic Association, 94(4), 449-450.

Iowa Kids Count (1994). Family Matters: Indicators of well being for Iowa's children. Iowa Kids Count.

Paneth, N. S. (1995). The problem of low birth weight. The Future of Children, 5(1). Article accessed through the Internet. http://www.futureofchildren.org/LBW/03LBWPANA

Shiono, P. H., and Behrman, R. E. (1995). Low birth weight: Analysis and recommendations. The Future of Children, 5(1), 1c- 18c. Article accessed through the Internet. http://www.futureofchildren.org/LBW/03LBWPANA

Story, M. (Ed.) (1990). Nutrition management of the pregnant adolescent: A practical reference guide. Washington DC: National Clearinghouse.

Story, M., & Alton, I. (1995). Nutrition issues and adolescent pregnancy. Nutrition Today, 30, 142-151.

Trouba, P. H., Okereke, N., & Splett, P. L. (1991). Summary document of nutrition interventions in prenatal care. Journal of the American Dietetic Association, 91(11, suppl.), S-21-S-26.

U.S. Department of Agriculture (1994). Nutrition education for pregnant women and caretakers of infants: A review of research. Alexandria, VA: U.S. Department of Agriculture, Food and Consumer Service, Office of Analysis and Evaluation viii, 77.