Association for Public Policy Analysis & Management

Research Objective:The United States spends more per-pregnancy on maternity care than other developed nations, yet experiences poorer birth outcomes. Preterm birth and low birthweight are leading causes of infant mortality, and in the United States, both are more prevalent among low-income women and some minority groups. CMS’ Strong Start for Mothers and Newborns initiative seeks improve birth outcomes while optimizing spending by offering enhanced prenatal care services in three innovative models: Birth Centers (BCs), Group Prenatal Care (GPC), and Maternity Care Homes (MCHs). Participant-level data collection, integrated into the Strong Start evaluation, offers unique opportunities for understanding women’s pre-existing risk factors, service use, and birth outcomes.

Study Design: Participant surveys are administered at intake, during women’s third trimester, and at their postpartum visit. Staff complete a detailed Exit Form within 10 weeks post-delivery based on program and medical records. Data are collected on demographic characteristics, psychosocial and medical risk factors, pregnancy and birth outcomes, and patient experience.

Population Studied:More than 38,000 pregnant and postpartum women enrolled in Medicaid or CHIP, and enrolled in Strong Start through one of the 27 awardees operating approximately 200 sites in 30 states, DC, and Puerto Rico. Sites include Federally Qualified Health Centers, nationally-certified birth centers, tribal health clinics, local health departments, and private physician practices.

Principal Findings: Descriptive analyses from the first three years of Strong Start implementation indicate that program participants struggle with a variety of psychosocial risk factors including high rates of depression (25%), anxiety (14%) and joblessness (60%). Many women are overweight or obese at their first prenatal care appointment (53%) and 15% of multiparous women have a history of previous preterm birth. Controlling for these and other for observable social, demographic, and medical risk factors, most of which are not reliably available in administrative data, regression adjusted comparisons across Strong Start models indicate that Birth Center and Group Prenatal Care participants are significantly less likely than Maternity Care Home participants to have a preterm birth (BC OR 0.44, p <.01; GC OR 0.77, p< .01) or a low birthweight infant (BC OR 0.40 p <.01; GC OR 0.69, p< .01). Birth Center participants were also less likely to have a cesarean section (OR 0.44, p <.01). Caution should be taken when interpreting these results, as effects are larger than observed in previous studies and likely indicate that results do not control for significant unobservable effects or selection bias. These results only consider approaches weighed against each other and do not have a controlled comparison group.

Conclusions: Preliminary participant-level results, available in advance of birth certificate or Medicaid data, suggest that alternative approaches to prenatal care may be associated with improved birth outcomes. Though selection bias remains a likely uncontrolled confounder, these rich descriptive data can be used to benchmark more rigorous impact findings planned for the evaluation.

Implications for Policy, Delivery or Practice: Participant-level data collection can be essential for monitoring program implementation, understanding population characteristics, benchmarking administrative data, and foreshadowing program impacts.