Association for Public Policy Analysis & Management

The Strong Start for Mothers and Newborns initiative aims to improve maternal and infant outcomes for pregnancies covered by Medicaid and the Children’s Health Insurance Program (CHIP).  The initiative funds three evidence-based enhanced prenatal care approaches – maternity care homes, group prenatal care, and birth centers – and is currently supporting service delivery through 27 awardees and nearly 200 provider sites operating in 30 states, the District of Columbia, and Puerto Rico. The sites providing Strong Start services include Federally Qualified Health Centers, nationally-certified birth centers, local health departments, private physician practices and tribal health clinics. This Strong Start evaluation employs a mixed methods design using qualitative case studies of implementation, a participant-level process evaluation, and a quasi-experimental analysis of the program’s impact on rates of premature births, low birth weight, and Medicaid/CHIP costs using linked birth certificate and Medicaid data for Strong Start participants and comparison groups. The Strong Start initiative is funded by the Center for Medicare and Medicaid Innovation (CMMI) of the Centers for Medicare and Medicaid Services (CMS). CMMI was established by Section 3021 of the Affordable Care Act.

This presentation provides interim findings from the evaluation and summarizes the status of the evaluation’s research efforts. At the end of the second year of this five-year study, key findings include:

 

• Strong Start enrollment surpassed 23,000 pregnant and postpartum women enrolled in Medicaid or CHIP. Participant data illustrate that the program is serving a disadvantaged population typified by low levels of educational attainment, high rates of unemployment, persistent food insecurity, unstable housing, and high rates of previous preterm birth. Roughly one quarter of enrollees exhibited depressive symptoms at intake, a rate that is nearly twice that of the general antenatal population. Strong Start interventions appear well designed to support women with psychosocial stressors; common elements among the three approaches are an emphasis on relationship-centered care, psychosocial support, education and care coordination.

   

• Strong Start programs have overcome many initial implementation challenges and adapted and refined their approaches to care. Strong Start providers have become more comfortable delivering enhanced services and believe they are achieving positive results. Examples of program maturation include improved enrollment systems; more coordinated staff roles and enhanced relationships with obstetrical providers; and service provision adapted to better fit the needs of patients.

   

• Strong Start participants express overwhelming satisfaction with the prenatal care they are receiving under Strong Start. Preliminary evidence also suggests that participants experience better birth outcomes compared to national benchmarks, including lower rates of Caesarean section and labor induction, higher rates of vaginal birth after cesarean, higher rates of breastfeeding, and in some cases lower rates of preterm births.

Prenatal care enhancements such as maternity care homes, group prenatal care, and birth centers have the potential to improve the country’s persistently high rates of poor maternal and infant birth outcomes. Since Medicaid covers almost half the births in the U.S. and most births to low-income women—who have disproportionately poor outcomes—Medicaid programs may have significant new opportunities to address these problems.