Transforming practices to prevent trauma before birth

Transforming practices to prevent trauma before birth

Fellow Lisa Cushatt, Program Manager, Iowa ACEs 360

This post shares Lisa's journey as a fellow in the first cohort and was first published in September 2019. Lisa continues to work on this issue as part of the second cohort of fellows.


Lisa was invited into the fellowship because of how interconnected her work is with the other fellows’ projects. Her work also models how to change systems to address childhood trauma.

“Lisa is the epitome of a generator, cultivator, and leader of long-term strategic thinking when it comes to improving the health and well-being of Iowa’s kids. It was not only her level of expertise, but also her ability to be in community with others to create that change,” says Suzanne Mineck, president of Mid-Iowa Health Foundation.

Lisa was already working on integrating research on how adverse childhood experiences (ACEs) impact health outcomes in the pediatric sector and wanted to expand the work into the prenatal space. The fellowship gave her time to dedicate to this project.

Along her fellowship journey, Lisa wrestled with whether to focus on implementing programs to influence practice change or advocating for policies to influence systems change. She found opportunities to move forward in both directions.


More than half of Iowa adults have experienced at least one of eight types of ACEs and one in six have reported four or more ACEs. Recent studies show that not only are individuals’ lives impacted by early traumatic experiences in childhood, but the effect can span generations as these experiences are woven into genetic code. Connecting with a mom in the prenatal setting can address stressors and improve health outcomes for mom and child.

Many organizations, especially those already providing services to families after the birth of a child, are expanding into prenatal care. “In some cases, they’re already trying to figure out how to do it on their own, or doing it without getting paid, because they know the outcomes will not be effective if they don’t,” Lisa says.

Lisa’s fellowship focused on the systems changes necessary to connect expecting mothers to evidence-based, wrap-around services, and she is advocating with policymakers and funders to support home visiting services starting before a baby is born. Her work is informed by research, using data from Iowa’s Pregnancy Risk Assessment Monitoring System, which is documented in a white paper about ACEs and prenatal care.


Lisa has seen success in several ways.

Lisa connected with EveryStep about using the 1st Five model in a prenatal care setting. The idea was that a nurse case manager would screen an expecting mother for risk factors at a prenatal visit, and if the mother identified stressors and needs for support, EveryStep would coordinate and connect to services, including home visiting. EveryStep already had a program developed and was providing similar services to mothers after birth but lacked funding to launch the prenatal part. Lisa helped tweak the Nine2Thrive program to align with best practices and MIHF funded a pilot phase with Broadlawns Medical Center. Lisa is working with EveryStep to evaluate the project to support future funding.

Another success was that the Iowa ACEs Coalition included prenatal home visitation on its 2019 legislative agenda and spent the session educating legislators about the importance of family support services. An ACEs prenatal collaborative is identifying opportunities to partner across public and private sectors and to continue research in this area.

The prenatal work coincided with efforts to educate the pediatric field on ACEs and trauma-informed practices. She worked with a contractor to develop a pediatric provider curriculum and a Trauma-Informed Pediatric Care Guide, giving providers the tools and messages to become champions in the pediatric practice. She also has led efforts to develop a web-based learning module for this field.


Lisa remembers Ralph Smith, managing director of the National Campaign for Grade-Level Reading, talking about positive stressors in collaborations and how tension can be a helpful tool to make sure the work is right. “I don’t mind making waves,” Lisa says, “and I’m getting much better at doing it in a productive way.”

She also has become more comfortable with never feeling like she’s accomplished enough to keep up. “I remember our mentor Rick Kozin saying, ‘You are never going to be able to work fast enough and you are going to have to get over it,’” she says. “I was feeling like a hamster going around and around, and it helped to step back and think what’s the strategic way to do it, not the competitive way to do it.”

Her work in helping to connect Gov. Kim Reynolds with First Lady Tonette Walker of Wisconsin to talk about ACEs also became a lesson on how important fostering connections outside of the legislative session is to moving policies forward, even though the one meeting took a year and a half of planning. Lisa encourages students in the social work classes she teaches to see the value of their relationship-building skills beyond just providing direct care.


Even though Lisa coordinates a collaborative effort, she can feel isolated as a contractor. The fellowship gave her time to learn while getting paid and created a sense of having coworkers, especially with Chaney Yeast and Mary Nelle Trefz, whom she now meets with nearly every week.

“It’s the ability to not just make new connections but to have deepened relationships,” says Lisa. “I can process ideas or challenges or come up with grand schemes for the work.”

The fellowship also allowed Lisa to leverage more resources for the prenatal pilot, to bring on a student intern who is helping evaluate this pilot project, and to be invited to more meetings to engage with health leaders.


Lisa plans to advocate to expand prenatal education and family support, potentially replicating the Nine2Thrive model she worked with EveryStep to launch. She is looking into public and private funding to support its expansion and plans to continue to advocate with elected officials on the importance of supporting expecting mothers.

One challenge has been connecting with health care providers, and she is looking at how to expand the audience for trainings on childhood trauma and health outcomes to include the broader health care field. She also is coordinating partnerships to develop trainings on ACEs and resiliency for educators after a new Iowa law requires them to have training on the topic once a year.

She is hopeful that the recent law requiring educators to be trained on ACEs shows that stakeholders are willing to make greater changes. Through the fellowship, she’s become more comfortable offering her expertise to those decision makers. “I’ve gotten over asking for permission part,” she says.