Improve Access and Quality of Prenatal Care for Latinas


For Mothers, Babies, Families, and Communities

Latinas not only need information but they also need to have a sense of community and to feel empowered and respected …to feel that people are truly interested in their well-being. 

                          Mélida Colindres 

Prenatal social support and less stress have been linked with improved patient satisfaction and prenatal attendance, fewer pregnancy complications, less postpartum depression, and improved birth outcomes.[1,2]  

Although further research is needed, structural and functional (such as tangible and emotional) social support provided through community-based interventions have shown to be beneficial in overcoming limitations related to low health literacy of individuals and for improving the health status of individuals and the community.[3,4]

The central role women have in Latino culture with respect to the health of their families, along with their high fertility rates, make reaching and engaging Latinas a critical strategy in efforts to reduce disparities and improve health outcomes for adults and children in these communities. [5,6]


Overcome System Barriers with the TWS Prenatal Program

  • While a traditional 15 minute prenatal visit may be sufficient to screen for potential medical problems, there is no time for in-depth education and counseling or an opportunity to meet social support needs.  
  • Traditional didactic educational approaches and clinician-centered models of care can be ineffective, or worse, can disempower and further marginalize women and ethnic minority groups, especially those who are poor and have low literacy skills. [7-10]  
  • The shortage of bilingual, bicultural health professionals and interpreters creates additional barriers to accessing and providing quality care for Latinas. [11-12]

Currently at 11 million, over the next several decades the proportion of Latinas in their childbearing years is projected to increase 92%.[6] This demographic shift will increase demand for reproductive care and magnify the healthcare challenges and potential adverse economic, social, and health impact of disparities experienced by Latina/os.[5,13] 

Transforming our approaches and thinking about service delivery strategies today can help improve access and quality of care now and build our capacity of care for the future.


The TWS Method™ PLUS our De Madre A Madre Prenatal Care photonovels

A FUN, Effective, Innovative Way to Provide Group Prenatal Education 

An empowerment-based group approach can help Spanish-speaking staff use their time more effectively, while providing more comprehensive education in a culturally appropriate way. 

Participants receive and provide social support during the group and have an opportunity to build relationships with other women for greater support in their community.

National Recognition

Improving the Quality of Prenatal Care for Hispanic Women

Included in the Center for Health Care Strategies' Toolkit for Reducing Racial and Ethnic Disparities: Quality Improvement in Medicaid Managed Care

International 'Best Practice' Model

Selected by the Ludwig Boltzmann Institute for the Sociology of Health and Medicine, University of Vienna as a 'best practice' for incorporating health literacy and health empowerment principles in prenatal education.


What is a typical TWS prenatal group like?

How is the TWS Method culturally appropriate for Latinos?

How is the TWS Method culturally appropriate for Latinos?


One story is read each session. Group members volunteer to read the characters' parts, creating a play. Those that can't read, listen and participate in the discussion.

  • The facilitator uses the teaching points and health issues embedded in the story to spark dialog.
  • The characters' and participants' life experiences, feelings and beliefs are vital to the critical thinking and reflection process.
  • The process is flexible and makes it easy to tailor the discussion to the unique needs of each group.
  • You can easily incorporate other educational resources and activities as needed.
  • Each is story is complete. This allows you to use one or a series of photonovels, in any order. Tailor the series to meet the mothers where they are and/or address resource constraints.

How is the TWS Method culturally appropriate for Latinos?

How is the TWS Method culturally appropriate for Latinos?

How is the TWS Method culturally appropriate for Latinos?


The TWS Method honors and builds on primary Latino values and norms as members move through a session. 

Respect/Respeto: The group is founded on respect. Each group defines how to practice and show respect towards each other. This allows the members to tailor their communication guidelines to be culturally and linguistically appropriate to their unique needs and preferences.
Personal Connection & Kindness/ Personalismo & Simpatía:  The TWS Method emphasizes and facilitates personal connections, in the spirit of simpatía. The steps make the learning process feel 'personal' easily and naturally. Kindness is the cornerstone of how the group members listen, share, challenge and learn from each other as they read the photonovels and tell their stories. 

Present Time/Tiempo Presente: The participatory process helps keep the focus on group members' present realities, immediate needs, and priorities. Learning that is relevant and that can be applied immediately to one's life, is important not just from a Latino cultural perspective but also for women as adult learners and for those who live in a culture of poverty.

Communication/Comunicación: The facilitator training, room set-up, and TWS Method are designed to help ensure that different verbal and nonverbal communication styles and norms are accommodated. 

Family/Familia: The TWS Method invites inclusion of family members in the learning process whenever possible. 

Trust/Confianza: By following the five steps each session, trust among the facilitators and participants grows over time. It is reinforced by on-going respect, mutuality, caring and kindness. The bonds that develop often extend outside of the groups and last after the sessions are over. 

Why is the TWS Method an effective approach for women as learners?

What if we do not have a bilingual person on staff to facilitate a TWS prenatal group?

What if we do not have a bilingual person on staff to facilitate a TWS prenatal group?


  • Techniques are used to help women identify their own concerns and develop their own strategies, using their personal experience.
  • Collaborative, non-confrontational learning, like sharing stories, is important for women in general, as well as being culturally appropriate for Latinos. 
  • Women also benefit from the chance to explore their identities in relationship with others and in their societal roles.
  • Linking information to emotional content by acknowledging feelings during the groups, through self-disclosure, storytelling, role-playing, and literature is beneficial to the learning process too.

These more nurturing, 'feminine' ways of knowing and learning, typically devalued or absent in traditional pedagogy, help validate and empower women learners.[14,15]   

What if we do not have a bilingual person on staff to facilitate a TWS prenatal group?

What if we do not have a bilingual person on staff to facilitate a TWS prenatal group?

What if we do not have a bilingual person on staff to facilitate a TWS prenatal group?

Lay educators

With proper training and assistance, lay health educators, also known as promotoras (or community health workers) can be valuable and effective partners on your team. 

See the TWS LEARNING COMMUNITY for training resources.

In the TWS SBIR study, promotoras were trained and coached by a TWS program coordinator from a local Latino community-based organization. The TWS program was implemented in partnership with the local health clinics in familiar community settings. Clinic staff assisted with member recruitment, medical/referral support as needed, and educational collaboration. For instance, a lactation consultant and family planning educator were guest presenters to build relationships and to offer more in-depth information and Q&A.

The Center for Health Care Strategies' demonstration project at the Neighborhood Health Plan of Rhode Island (NHPRI) was a clinic-based TWS prenatal program for Latinas with high-risk pregnancies. The facilitators were bilingual lay educators. A nurse supervisor who spoke only English coordinated the project and provided on-site medical/educational support as needed.


  • 91% of the TWS participants received optimal prenatal care compared to 65% of women who received usual care. 
  • TWS participants also had slightly higher rates of kept postpartum visits.


A Catalyst to Reach and Engage Latinas

Effective Way to Create and Use Teachable Moments...

Effective Way to Create and Use Teachable Moments...


"The De Madre A Madre photonovels and the Teach-With-Stories (TWS) Method™ served as a catalyst to reach and engage the Latina Neighborhood Health Plan of Rhode Island members...

We have recognized the value of the personal interaction that TWS supports. The high level of participation and obvious comfort of those participating in the TWS approach was noticeable...

The highly adaptable TWS Method and use of the De Madre A Madre photonovels allowed the NHPRI's professional and lay health educators to connect with the participants based on their cultural and educational needs.

Unlike most experiences in healthcare, the TWS groups were totally driven by the participants allowing them to develop their learning experience. This ability provided the NHPRI staff with a sense of accomplishment and job satisfaction that traditional education has not historically provided."

Neighborhood Health Plan of Rhode Island
Beth Marootian, MPH  
Michelle Lupoli, RN, MS, CCM


Effective Way to Create and Use Teachable Moments...

Effective Way to Create and Use Teachable Moments...

Effective Way to Create and Use Teachable Moments...

"I have used the Teach-With-Stories Method and photonovels for several years for prenatal education with Latina women.  It was always delightful to see how engaged the participants became with the material, and how the characters in the stories became real to the group.

The discussions were lively and covered a lot of important material.  Participants were more likely to make changes and use something they learned from another group member, and they made a lot of changes -- eating healthier, making a list of questions to ask their doctor at prenatal checkups, quitting drinking, leaving an abusive marriage.

Reading and discussing the photonovels together created a very safe and comfortable environment for group members to freely share their questions and concerns, as well as their knowledge and experience with one another.

The groups also bonded well, and many long lasting friendships and mutual support systems were formed. I think teaching with stories, using photonovels is a deceptively simple, and extremely effective way to create and use teachable moments."

Mary DeCoster, MLS, IBCLC, ICCE, MPH 

Real-Life Story: Support Beyond the Group

Effective Way to Create and Use Teachable Moments...

Able to learn and feel more confident...a vital part of promoting healthy pregnancies


The photonovel was 1st Week Home with Baby. The discussion focused on depression, anxiety, and the stress of having a new baby at home. 

One participant, who was six

months pregnant, identified with many of the issues that were discussed during this session. 

She did not feel comfortable discussing her feelings in an open forum, but contacted the facilitator two days later. The mother explained that she was experiencing a lot of stress, depression, that she had trouble sleeping and had suicidal thoughts.

The facilitator asked for permission to contact Beacon, their behavioral health partner to arrange an immediate intervention. The facilitator contacted the agency and served as an interpreter during the initial screening interview. 

After being assessed, the staff immediately contacted the local hospital and arranged for transportation by taxi. The agency personnel and the facilitator stayed on the line with the member until her cab arrived.

The mother was treated at the hospital and released. As she spoke limited English, the group member took the photonovela with her to the hospital to help her explain what she was experiencing. She was prescribed appropriate medication. A family therapist from Beacon met with the mother at her home, and enrolled her in the Day Program at Women and Infants Hospital.

Source (p. 14)

Able to learn and feel more confident...a vital part of promoting healthy pregnancies

Able to learn and feel more confident...a vital part of promoting healthy pregnancies

Able to learn and feel more confident...a vital part of promoting healthy pregnancies


 "I have been very impressed with the results I have seen in the women attending these classes.  Having taught childbirth classes myself using a traditional childbirth class curriculum, I would like to highly recommend this model…The participants are able to learn the material and feel more confident rather than fearful. I feel this is a vital part of promoting healthy pregnancies."    

North Carolina Maternity Care Coordinator (MCC)  

Positive Impact on Community Reputation

Able to learn and feel more confident...a vital part of promoting healthy pregnancies

For More on Participants' Experiences & Perspectives...


 "All participants were thrilled with the experience provided by NHPRI. They raved about the facilitators, especially their sincere concern for the participants' well-being. According to these women, the staff’s courtesy, and attention to individual needs as well as education provided makes NHPRI “lo mejor que existe” (the best there is)."      

based on NHPRI Focus Group Feedback

For More on Participants' Experiences & Perspectives...

Able to learn and feel more confident...a vital part of promoting healthy pregnancies

For More on Participants' Experiences & Perspectives...

mother with newborn



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  2. United States Public Health Service. (1989) Caring for our future: The content of prenatal care. Washington, DC: DHHS. 
  3. Lee, D.S., Arozullah, A.M., & Cho Y.I. (2004). Health Literacy, social support and health: A research agenda. Social Science & Medicine, 58, 1309-1321.
  4. de Wit, L., Fenenga, C., Giammarchi, C., di Furia, L., Hutter, I., de Winter, A., & Merjering, L. (2018). Community-based initatives improving crital health literacy: A systematic review and meta-synthesis of qualitative evidence. BMC Public Health, 18:40
  5. Arellano-Morales, L., & Sosa, E.T., (2018). Latina/o America Health and Mental Health: Practices and Challenges. Santa Barbara, CA: Praeger.
  6. March of Dimes. (2005, November). Born too soon: Prematurity in the U.S. Hispanic population. White Plains, NY: Author.  
  7. Airhihenbuwa, C. O. (1995). Health and culture: Beyond the western paradigm. Thousand Oaks, CA: Sage Publications, Inc.
  8. Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, D.C.: National Academies Press.
  9. Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington, D.C.: National Academies Press.
  10. National Quality Forum. (2017  Effective Interventions in Reducing Disparities in Healthcare and Health Outcomes in Selected Conditions. Washington, D.C.: Author
  11. Olivares-Ureta, M. (2012). The Latino/as health professions pipeline: An overview. 
  12. National Research Council. (2006). Multiple origins, uncertain destinies: Hispanics and the American Future. Washington, DC: National Academies Press. [Electronic version]
  13. Dall, t.M., Chakrabarti, R, Storm, M.V.,  Elwell, E.C., & Rayburn, W.F. (2013).  Estimated Demand for Women’s Health Services by 2020, Journal of Women's Health, 22,7.  
  14. Collard S., & Stalker, J. (1991). Women's trouble: Women, gender, and the learning environment. In R. Hiemstra (Ed.), New Directions for Adult and Continuing Education (pp.71-80). San Francisco, CA: Jossey-Bass.     
  15. Hayes, E. & Flannery, D.D. (2000). Women as learners: The significance of gender in adult learning. San Francisco, CA: Jossey-Bass.