About 10.5% of U.S. households are food insecure. But when it comes to pregnant women, that number jumps to nearly 20%.

Food insecurity has been linked to an increased risk of pregnancy complications, such as high gestational weight gain, gestational diabetes, high blood pressure, preterm birth, and postpartum depression. It also complicates managing preexisting health conditions, such as diabetes.

“Social determinants of health, such as food insecurity, absolutely shape disparities in health outcomes,” says Craig Syrop, MD, an obstetrician-gynecologist at University of Iowa Hospitals & Clinics. “People may not know that 80% of health outcomes lie outside clinical interventions. We like to think that the care we provide in clinics makes a big difference—and we do make a big difference—but if you’re going to really help people change their lives, you have to also attend to those other aspects: food, housing, transportation, finances, those sorts of things.”

To help support patients who are facing challenges outside the clinical setting, Syrop and his colleagues, along with a group of interdisciplinary undergraduate and graduate students, began the Upstream Initiative.

In the program, now in its fifth year, student volunteers in the High-Risk Obstetric Clinic at UI Hospitals & Clinics connect patients with state and federal resources, as well as those in their hometowns, to address food insecurity and transportation needs.

Emily Boevers Solverson started working on the project that would become the Upstream Initiative during her third year as a medical student at the Carver College of Medicine. Over the next couple of years, Boevers Solverson helped facilitate patient surveys and data collection to determine patients’ primary needs outside the medical setting and put together a proposal to address two of the main identified needs: food insecurity and transportation.

“When patients are struggling with some aspects of their care plan, or recommendations from us, it’s often not a matter of noncompliance,” says Boevers Solverson, who graduated from Iowa with her medical degree in 2018 and is currently an OB-GYN medical resident at the University of Kansas Medical Center in Kansas City, Kansas. “There are so many factors and forces that are at play in people’s lives, and I saw that in Iowa and continue to see it in Kansas City. As physicians, we have to recognize those, first and foremost, and then try to find ways to come to people where they are.”

Patients who visit the High-Risk Obstetric Clinic answer questions about food insecurity and transportation needs as part of a standard intake questionnaire. If patients indicate they face one of those needs, an Upstream volunteer meets with them to discuss potential resources. This includes discussing eligibility requirements for federally funded health and nutrition programs, such as the Supplemental Nutrition Assistance Program (SNAP) and Women, Infants and Children (WIC), as well as resources in their local communities, such as food pantries, which the volunteers identify with help from Iowa Compass and 211 Iowa databases.

Between January 2018 and December 2021, the Upstream Initiative completed 6,143 screenings spanning 2,402 pregnancies. Of those, 684 screenings were positive for food insecurity. On average every year, they serve patients from 67 counties in Iowa.

Megan Sinik, a second-year medical student from Wichita, Kansas, who wants to focus on community health, says volunteering with Upstream gives her the opportunity to discuss factors that aren’t always addressed during a typical doctor’s appointment. While the issues they talk about are sensitive, Sinik says patients overall are open to speaking with the volunteers.

“A lot of patients already know about SNAP and WIC, but they don’t always know about some of the resources that each city and county offers,” Sinik says. “Social support is often hidden behind a lot of bureaucracy and layers. I think they appreciate that we’re able to bring some of these to their attention, and that we’re even thinking about these issues.”

Syrop says in his experience, addressing these types of issues means a lot to patients.

“I’ve had couples who cried because they were mortified that they had food insecurity. And you know, these are people who are working full time. They just weren’t making enough money to handle both the expenses of chronic medical conditions and living expenses,” Syrop says. “Also, Iowans tend to be culturally proud people, and they don’t always want to admit they need help, at least not publicly. But to have someone say, ‘You know what? One in five of your peers is experiencing the same thing,’ helps normalize it.”

Students’ experiences influence their future in health care

While the Upstream Initiative’s main objective is to help patients, students involved in the program also benefit. Volunteering allows them to gain early exposure to working with patients and providers at UI Hospitals & Clinics, and provides opportunities for leadership, research, and service projects.

“We like to call it a student-run/faculty-mentored program, because the students are the ones who do the work,” says Syrop, who also cites the hard work of his co-faculty, Michael Haugsdal, MD, obstetrician-gynecologist at UIHC, and Diane Reist, a pharmacy practice specialist in the College of Pharmacy. “We let the students be the leaders, and we faculty help with some of the strategic issues and advice. But the program only works because of the phenomenal work of the students. They truly care about social issues and want to make the world better. They’re very inspiring.”

Johanna Knutson grew up in the small town of Amery, Wisconsin. The first-year master of health administration student in the UI College of Public Health plans to work in rural health care. She has served as administrator of the Upstream Initiative for the past year and says the experience will serve her—and her future community—well.

“In areas like Iowa City, there may be multiple food pantries within a couple miles. But, for example, in my hometown, the nearest food pantry is maybe 30 minutes away,” Knutson says. “What I learn here I’ll be able to take back to better provide acute resources for the patients that we serve.”

Sinik isn’t sure what area of medicine she plans to pursue yet, but she says the Upstream Initiative undoubtably will affect how she practices medicine.

“I want to be a physician who is acutely aware of how people’s everyday lives intertwine with their health, because you can’t really separate the reason someone is coming to see you in the office and the rest of their life,” Sinik says.

Boevers Solverson is from Readlyn, Iowa, and after finishing her residency in Kansas, will return close to home in Iowa to work as an OB-GYN at Waverly Health Center. She says her experience in helping set up the Upstream Initiative had a profound impact on her decision to become an OB-GYN.

“A lot of people who go into medicine have ideals and things that they care about, but haven’t necessarily had an opportunity to do something big with their ideals yet,” Boevers Solverson says. “Getting this kind of opportunity as a medical student was completely formative. It is something that is imprinted on my heart, and I hope it guides my future practice and interactions with patients.”

The students come from disciplines across the health care field, from medicine and nursing to pharmacy and public health.

“If you really want to train people to provide best outcomes of health care in the future, you want them to learn and train and practice as multidisciplinary or interdisciplinary teams,” Syrop says. “It’s good for students from different fields to have an opportunity to work as co-equals in providing patient care and building a community that supports that effort.”

Knutson says having multiple perspectives makes health care stronger, and she learns a lot from her fellow students.

“I may come at something from a very logistical standpoint, but the med students ground me and say, ‘This isn’t quite feasible and we have to change a couple things to make it work,’” Knutson says. “Everyone works as a team because at the end of the day we all want what’s best for the people we serve.”

Getting involved in programs such as Upstream or other organizations that address community needs is important for health care providers, Sinik says.

“It’s important to understand the community that you’re operating in beyond the walls of the hospital. While the hospital may be our day-to-day reality, it’s an alternate reality for most people,” Sinik says. “Getting more of that outside perspective is really important. Upstream helps deliver at least a small slice of that puzzle.”

While the current health care system is not set up to adequately address social determinants of health such as food insecurity, Boevers Solverson is optimistic that programs such as the Upstream Initiative are a step in the right direction.

“Hopefully the students who are involved—tomorrow’s health care providers—can make strides in changing things,” Boevers Solverson says. “It’s been incredible to watch this unfold over several years. With projects like this, it’s about the long game. If you have an eye on the long game, over time, you can make a real difference, and I think that’s what they’re doing there.”