Association for Public Policy Analysis & Management

Research Objective:The Strong Start for Mothers and Newborns initiative aims to improve pregnancy outcomes for women and infants covered by Medicaid and the Children’s Health Insurance Program (CHIP). Strong Start is field-testing three enhanced prenatal care approaches: group prenatal care, maternity care homes, and birth centers. The national Strong Start evaluation is identifying the key features of enhanced models and how they differ from standard Medicaid prenatal care, the characteristics and outcomes of program participants, and the impacts of Strong Start on rates of preterm birth, low birthweight, and costs.

Study Design: The mixed-methods evaluation includes qualitative case studies of implementation, a participant-level process evaluation, and analysis of Strong Start’s impact on birth outcomes and Medicaid/CHIP costs using linked birth certificate and Medicaid data for Strong Start participants and comparison groups.

Population Studied:Pregnant and postpartum women enrolled in Medicaid or CHIP and Strong Start (n=38,149), and the 27 Strong Start awardees operating in 30 states, DC, and Puerto Rico. Approximately 200 sites provide services, including Federally Qualified Health Centers, nationally-certified birth centers, tribal health clinics, local health departments, and private physician practices.

Principal Findings: Case studies reveal that all three Strong Start models emphasize relationship-centered care, with caregivers spending considerable time helping women address key issues including depression, obesity and nutrition, breastfeeding, family planning, and childbirth preparation. Where community resources permit, Strong Start staff work to connect women with mental health services, housing assistance, and job training (among other supports). Using participant data from Years 1 through 3 and employing multivariate regression-adjusted analyses controlling for demographic, social and health risk factors, a preliminary analysis finds that women receiving birth center and group prenatal care are significantly less likely to have a preterm birth or low birthweight baby compared to women receiving care through maternity care homes, a model that more closely resembles “traditional” prenatal care. Participant data also show Strong Start women having lower rates of C-sections and much higher rates of vaginal birth after C-section (VBAC) than women nationally. A more rigorous impacts analysis (that includes comparison groups) will more precisely isolate the effect that Strong Start has had on birth and maternal health outcomes in the coming years.

Conclusions and Policy Implications: Case study findings indicate that Strong Start programs are providing valuable enhancements to traditional prenatal care in the form of psychosocial support and intensive education, while participant-level data suggest the models may be having positive effects on birth outcomes compared to national benchmarks. However, outcomes findings are preliminary, and will be supplemented by impacts analyses based on birth certificates in future years of the evaluation. Enhanced prenatal care models such as group prenatal care, maternity care homes, and birth centers has the potential to improve delivery of prenatal care and the country’s persistently high rates of poor birth outcomes. As lower income women have disproportionately poor outcomes and Medicaid covers almost half of births in the U.S., Strong Start offers potential avenues for ongoing reforms to optimize prenatal care.