Specifications include, but are not limited to: To identify, screen and enroll pregnant women at risk of having a preterm or low birth weight birth at any time during their pregnancy and to ensure that they are linked to and initiated early and consistent prenatal care in the first trimester or as soon as possible through the provision of home based, family centered, strength based culturally appropriate education and referral services; 2.2 To identify, screen and enroll postpartum women and families with children up to age two (2) with medical and social risk factors that increase the likelihood that they or their children will experience future poor health outcomes; 2.3 To establish a network of health and social service providers in communities and neighborhoods that are accessible to all women, children and their families in an effort to link program participants to adequate prenatal care, adequate infant care, and other services that reduce illiteracy, reduce dependency on welfare, encourage employment, and encourage self-sufficiency and community involvement.