Voices From the Field: Informing Maternal Child Health Navigator Training Through Rural Practice Insights

Texas as a High-Need Context

Texas has one of the highest maternal mortality rates in the United States. In 2021, the state reported 43.9 maternal deaths per 100,000 births, compared to 9.7 in California. ⁴ Women living in rural communities face significantly higher risks of severe maternal morbidity and mortality, ⁵ with racial and ethnic disparities further compounding these risks. ⁶ A report by the U.S. Government Accountability Office documented substantially fewer maternal health providers per capita in rural Texas compared to similar states, exacerbated by hospital and obstetric unit closures that disproportionately affect minority populations. ⁷

Training as a Bottleneck in CHW Deployment

Given the maternal health crisis and ongoing workforce shortages, ¹ CHWs offer an innovative opportunity to expand maternal health support, particularly in rural settings. ⁸ However, one of the most persistent challenges to deploying CHWs effectively is the lack of standardized and specialized training. Only 19 states have implemented statewide CHW certification programs, resulting in wide variation in role expectations, competencies, and preparation. ⁹ A statewide study of CHWs in Texas identified significant gaps beyond basic certification, with CHWs expressing a need for supplemental training tailored to emerging and context-specific health needs. ¹⁰ Inconsistent training can translate into uneven service quality and reduced effectiveness across communities.

Training as an Intervention

To understand how training shapes navigator readiness and practice, it is essential to situate findings within the design and delivery of the training itself. Training for CHWs is not a neutral backdrop; rather, it functions as an active intervention that influences how navigators interpret their roles, respond to complexity, and apply relational skills in real-world settings.

Training Design: A Tailored, Experiential Approach

Training for CHWs has traditionally emphasized content acquisition and certification requirements. However, adult learning and workforce development literature indicates that effectiveness in community-based roles depends not only on knowledge acquisition but also on experiential learning, reflection, and relational engagement.^12-15 These elements are especially critical in community health contexts, where relational trust and real-world application shape outcomes. The MCH Navigator training model was intentionally designed to balance standardized foundational content with experiential components that support skill enactment in complex social contexts.

The training program addressed gaps in maternal health services by preparing certified CHWs—who lived in the communities they served—to conduct home visits and connect at-risk women to pregnancy and postpartum resources. CHW certification served as a critical foundation, supporting sustainability through reimbursement eligibility and alignment with statewide credentialing requirements.

Recognizing the varied educational backgrounds of CHWs,^16,17 an interdisciplinary team from the Texas A&M University College of Nursing and the Texas A&M National Community Health Worker Training Center conducted an extensive scan of publicly available, no-cost maternal and child health trainings. Resources were evaluated for quality, relevance, and credibility and organized into thematic modules aligned with stages of the perinatal continuum.

The resulting MCH Navigator course consisted of five sequential modules: pre-pregnancy, pregnancy, postpartum, infant development, and prevention/intervention resources. Content was delivered through a Canvas-based asynchronous platform and incorporated webinars, videos, case studies, and facilitator-led materials to enhance engagement and practical application. The curriculum included 34 continuing education units (CEU) and 20 non-CEU hours, supporting biennial CHW certification renewal requirements. ¹⁸

To complement asynchronous learning, the training incorporated experiential components. The lead MCH Navigator participated in in-person training with subject matter experts and engaged in shadowing experiences through the Nurse–Family Partnership® program. Because real-world scenarios were not available for all content areas, facilitated group debriefs were conducted daily to support reflection, contextualization, and peer learning. This hybrid approach allowed the training to evolve in response to learner feedback and emerging community needs.

Because of their close ties to the communities they serve, MCH Navigators are well positioned to address social and structural barriers to maternal health. Their role focuses on building trust, connecting individuals to resources, and supporting patient empowerment rather than providing clinical care. In the context of ongoing shortages of maternal and mental health providers, ¹ this training model offers a potentially scalable and sustainable approach to strengthening the maternal health workforce.

Research Questions

Given the uniqueness of the MCH Navigator program and the need for similar workforce models in rural communities, this study sought to address two research questions:

1. What are the lived experiences of community health workers piloting a maternal health navigation program in rural Texas?

Participants

This qualitative study involved individual, semi-structured interviews with all four MCH Navigators employed in a pilot community-based maternal health program who completed the MCH Navigator course. While this sample may be small, it includes all MCH Navigators in the program. Following Institutional Review Board approval, we asked every MCH Navigator in the program for their consent to participate. Prior to participation, each navigator received a detailed explanation of the study’s purpose and procedures, had the opportunity to ask questions, and provided written informed consent. All interviews were conducted in private settings by trained members of the research team, audio-recorded, and transcribed verbatim.

Questions

A semi-structured interview guide was developed to elicit rich, reflective narratives across key domains relevant to the navigator role (See Supplemental Material). These domains included: (1) training and preparedness; (2) learning preferences; (3) use of trauma-informed care principles; (4) support for families with substance use disorders; (5) confidence in addressing behavioral health needs; (6) strategies for identifying and responding to drivers of health; (7) peer collaboration and support mechanisms; (8) challenges and resource gaps; and (9) navigator-defined indicators of success.

The semi-structured interview guide was developed based on the study aims, relevant literature related to community health workers and maternal-child health navigation, as well as the training objectives of the MCH Navigator program. To support content relevance and qualitative rigor, the guide was reviewed by members of the research team with expertise in maternal-child health and qualitative methods. Questions were refined iteratively during early interviews to improve clarity, depth, and responsiveness to participants’ experiences. The use of both structured prompts and open-ended questions ensured consistency across interviews while allowing flexibility to explore participants’ lived experiences in greater detail. Because this study used a qualitative interview guide rather than a psychometric questionnaire, formal pilot testing procedures and associated pilot testing percentages were not applicable.

Analytic Strategy

This study was conducted in accordance with the Standards for Reporting Qualitative Research ¹⁹ (SRQR) guidelines to enhance transparency and rigor in qualitative reporting. Data were analyzed using reflexive thematic analysis, as outlined by Braun and Clarke.^20,21 The approach emphasizes the active role of the researcher in theme development and allows for deep engagement with both explicit and latent meanings. Reflexivity was maintained throughout the analytic process to ensure transparency and interpretive rigor.

An in-person member-checking was conducted wherein the MCH Navigators reviewed the synthesized findings to validate the accuracy and resonance of the themes. Representative quotations have been selected to illustrate key findings and preserve participant’s voice, with aliases used to ensure confidentiality.

Real-World Preparedness

Across all four navigators, training was viewed as foundational but insufficient to prepare them for the dynamic, nuanced demands of fieldwork. While the Canvas-based modules were described as “valuable” or “great information,” they lacked the depth and contextual sensitivity needed for real-time client encounters. Nav 1 and Nav 2 specifically noted the disconnect between structured content and the unpredictability of home visits. Nav 4 and Nav 3 emphasized that only real-life exposure truly prepared them: “Nothing replaces that first real visit” (Nav 4), and “It felt like a firehose at first” (Nav 3).

Learning by Doing

A preference for experiential learning emerged, suggesting asynchronous modules with in-person opportunities, especially shadowing and interactive, case-based approaches. Each navigator identified hands-on experience and shadowing as critical to skill development. Nav 1 described shadowing Nav 4 as transformational: “Watching Nav 4 helped so much. Seeing it live is different from reading about it” making concepts “click.” Nav 2 emphasized the importance of observing others before taking independent cases, and Nav 4 advocated for scenario-based learning: “I need to see it and try it myself—just reading about it doesn’t cut it.” All navigators expressed a desire for more shadowing and hybrid training” to better equip them with context-sensitivity before managing their own caseloads independently.

Living the Principles

Trauma-informed care (TIC) was not only recognized as a conceptual framework but also described as intuitive - embodying aspects of the navigators’ interactions. Nav 1 noted, “You just know when someone’s been through a lot… you move a little slower, talk a little softer.” Nav 4 echoed this sentiment, sharing, “Trauma doesn’t always show. You have to listen carefully to what’s not said.” She described listening for what is not said, emphasizing quiet presence and emotional safety. Nav 1 mentioned softening her voice and pacing interactions based on clients’ cues, while Nav 3 described developing “a feel” for unspoken trauma.

Nav 2 shared a poignant story of supporting a grieving mother: “Even if we’re adults, you still want your mom. I lost my mom six years ago, and I told her, ‘Talk to her. She’s listening to you.’” Though she did not label it as TIC in the moment, she later reflected that this was precisely what guided her actions.

All participants reported confidence in their ability to initiate behavioral health discussions, often drawing on personal or family experiences. Nav 4 framed mental health as integral to her practice: “Mental health is health—I tell them that right away, so they know it’s okay to talk.” Nav 1 and Nav 2 also described feeling at ease addressing mental health, with Nav 2 recounting a moment of family advocacy: “I sat her down and told her, ‘You’re not yourself. Let us help you get back.’” Nav 3 added that effective conversations don’t have to be complex: “You just listen and say, ‘I’m here.’ It doesn’t have to be complicated.”

Navigating Complexity

While training improved navigators’ understanding of substance use disorder (SUD) as a chronic condition, participants identified a need for more practical, real-world guidance. Navigators appreciated the structured content provided but emphasized challenges in applying this knowledge in complex situations. For example, Nav 4 described discomfort in managing relapse conversations, noting, “I sometimes freeze when they say they’re using again—I want to be supportive but firm.” Nav 2 similarly expressed a desire for more guidance on identifying and responding to neonatal abstinence syndrome (NAS), stating, “I would want as much information as I could get on that.” Other participants highlighted the need for ongoing reinforcement and applied tools, with Nav 1 suggesting periodic training refreshers and Nav 3 requesting more situational scripts to guide interactions with clients experiencing impairment. Together, these findings suggest that while foundational knowledge was established, navigators would benefit from more applied, skills-based training to support confidence and effectiveness in practice.

Addressing the Context

Navigators consistently encountered drivers of health (DOH) such as food insecurity, transportation barriers, and limited healthcare access. Effective identification of needs was often contingent upon relationship-building. Nav 4 described one mother who initially withheld information: “She didn’t have food or a ride—but wouldn’t say it at first. You have to earn that trust.” Nav 2 emphasized promoting self-sufficiency: “I don’t like doing things for them. I like to show them what they need to do.” Nav 1 described working creatively within her community to address barriers: “One of my moms had no car, no grocery store nearby—we had to get creative.” Across cases, action often required advocacy and knowledge of localized systems.

Peer Support

Peer collaboration was widely appreciated, though access to structured support varied. Nav 4 and Nav 1 found team huddles grounding and affirming. Nav 3 expressed a desire for regular peer reflection: “I’d love a space to talk through these hard situations. Even just once a month.” Nav 2 suggested a team-based strategy for emergent needs: “Let’s get somebody to train us on that,” referencing unfamiliar issues encountered during visits.

Real-World Preparedness

Consistent with the theme Real-World Preparedness, navigators described formal training as an essential starting point, yet insufficient for preparing them for the realities of field-based maternal health work. Navigators described formal training as an essential starting point but insufficient for real-world preparedness. This gap between didactic content and practice reflects broader challenges in CHW workforce development, including variability in training depth and limited opportunities for applied learning.^11,16 Consistent with experiential learning theory,^15,22 participants reported that confidence and competence developed primarily through observation, shadowing, and repeated client interactions.

These findings align with literature on maternal health navigation and peer-support roles, which emphasize practice-based learning and relationship-centered skill development, particularly in behavioral health and psychosocial contexts.^22-24 Together, this evidence supports hybrid training models that intentionally integrate experiential learning with foundational content to better prepare navigators for practice.

Living the Principles

The theme Living the Principles illustrates how navigators enacted TIC primarily through relational awareness, lived experience, and situational judgment rather than formalized protocols. Participants emphasized pacing, tone, emotional presence, and responsiveness to unspoken needs—core elements of trauma-informed engagement described in the literature.^25,26 These findings suggest that navigators often operationalize TIC intuitively, even in the absence of shared language or structured opportunities for reflection.

Relational connection emerged as central to navigator effectiveness. Participants described building trust through shared experience, authenticity, and sustained presence, consistent with relational–cultural theory and other community-based care frameworks that position connection as a mechanism for change.^27,28 Similar patterns have been observed in peer-support roles such as breastfeeding peer counselors ²⁹ and home visiting paraprofessionals, where strong working alliances are associated with engagement and retention.^30,31 The present findings extend this literature by illustrating how relational competence develops through lived experience and peer observation in rural maternal health contexts.

Navigating Complexity

Consistent with the theme Navigating Complexity, participants frequently encountered complex situations involving behavioral health concerns, substance use, and NAS, underscoring the importance of clearly defined scope of practice. While participants expressed confidence initiating conversations, providing emotional support, and connecting families to resources, they also described uncertainty in responding to relapse, crisis situations, or potential child welfare involvement. This tension reflects broader challenges in the CHW field, where role boundaries are often context-dependent and inconsistently articulated.^16,32

Importantly, navigators did not describe engaging in clinical assessment or treatment. Rather, their role centered on recognizing needs, offering relational support, providing education, and facilitating referrals. These findings highlight the need for training that explicitly addresses scope-of-practice boundaries while incorporating decision-support tools to guide escalation to clinical, behavioral health, or child welfare professionals. Clarifying these boundaries may reduce role strain while strengthening confidence and effectiveness.

Addressing the Context

The theme Addressing the Context highlighted the extent to which social and structural drivers of health—including food insecurity, transportation barriers, and limited access to services—were consistently identified as central challenges. Navigators emphasized that these needs often emerged only after trust had been established, reinforcing the relational nature of effective screening and intervention. This aligns with evidence that CHW-led interventions are effective not solely through service linkage, but through sustained engagement that facilitates disclosure, advocacy, and follow-through. ³³

Participants also highlighted the importance of community-embedded knowledge and localized resource navigation. Rather than resolving needs on behalf of clients, navigators emphasized empowering families to access resources independently, reflecting a strengths-based, capacity-building approach consistent with CHW core competencies. ³⁴

Strengths and Limitations

This study provides in-depth insight into navigator experiences within a rural, community-based program. Inclusion of all navigators and use of member checking strengthen the credibility of findings.

However, the small sample size and single-program context may limit transferability. Findings are based on self-reported experiences and may be subject to bias. Future research should examine training models across diverse settings and include outcome-based evaluation.

Implications for Training and Support

These findings suggest that effective MCH Navigator preparation requires a deliberate balance between standardized foundational training and experiential, relational learning. While asynchronous curricula, such as self-paced online modules that can be delivered consistently across settings, support scalability and credentialing, navigators’ experiences demonstrate that observation, guided practice, and reflective peer engagement are essential for translating knowledge into effective action. Literature on CHW professionalization and continuing education similarly emphasizes the need for ongoing, context-responsive training models that evolve alongside role complexity. ³²

Finally, the theme Peer Support underscored the importance of shared problem-solving, reflective discussion, and emotional support in sustaining navigator confidence and professional growth. Evidence from home visiting and peer-support literature indicates that coaching and reflective supervision can enhance skill development, reduce isolation, and support workforce sustainability when roles involve emotional labor and complex client needs. ³⁵ Integrating these supports may strengthen navigator resilience while preserving the relational qualities central to effective maternal health navigation.

Practice Recommendations

Grounded in participant experiences and supported by current literature, the following recommendations are offered to strengthen MCH Navigator training and support:

• Expand experiential and scenario-based training: Incorporate structured shadowing, role-play, and case-based simulations focused on high-complexity encounters such as substance use disclosure, crisis situations, and navigation of social services.