Panel Paper: Better Preparing Women for Childbirth: Strong Start Innovations

Saturday, November 10, 2018
Hoover - Mezz Level (Marriott Wardman Park)

*Names in bold indicate Presenter

Ian Hill1, Brigette Courtot1, Sarah Benatar1, Caitlin Cross-Barnet2 and Sarah Thornburgh1, (1)Urban Institute, (2)Centers for Medicare & Medicaid Services

Childbirth preparation helps women learn self-advocacy, reduces inappropriate emergency department use, and increases likelihood of receiving appropriate and timely care while avoiding unnecessary interventions (e.g., C-section deliveries among low-risk women). Childbirth preparation was a key component of Strong Start enhanced prenatal care programs. We investigate the effectiveness of Strong Start in better preparing women for childbirth compared to typical prenatal care.

Strong Start for Mothers and Newborns, implemented in approximately 200 sites across 30 states, DC, and Puerto Rico, aimed to improve birth outcomes for pregnant women and infants covered by Medicaid and CHIP by field-testing three enhanced approaches: group prenatal care, maternity care homes, and birth centers. Qualitative data from key informant interviews (with ~300 Strong Start providers and staff) and participant focus groups (with ~800 women) from the Strong Start evaluation’s four years of case studies are used to assess Strong Start’s effects on childbirth preparation, while quantitative participant-level process evaluation data (for nearly 46,000 Strong Start enrollees) are used to report on women’s rates of low-risk C-sections and vaginal birth after cesarean (VBAC).

Key informants reported that childbirth preparation was a key component of Strong Start programs, particularly birth centers and group prenatal care. Birth centers’ midwifery model of care embraces a more holistic and time-intensive approach than typical prenatal care, thus allowing more focus and formal education on childbirth preparation. Women’s discussions with midwives often focused on their birth plans and preferences, while often mandatory classes encouraged patient autonomy in the birth process. Meanwhile, group prenatal care programs typically used a full 90-minute session for participants to discuss childbirth preparation and create birth plans. Some providers attending deliveries reported they could identify women who participated in group prenatal care because they seemed more informed, better prepared, and had a vision for how their deliveries should proceed. Focus group participants reported that Strong Start-based education taught them when they should go to the hospital for delivery, when not to go (e.g. false signs of labor), and how to advocate for themselves at delivery (e.g., comfort and pain relief through stages of labor). Individual-level data indicate that Strong Start enrollees had lower rates of C-section than those reported nationally (27% vs. 32%), including lower rates of low-risk C-sections (based on first time mothers with term and singleton pregnancies): 24% vs. 26%, a rate close to the Healthy People 2020 goal (MICH-7). Cesearean rates were particularly low among women receiving prenatal care at birth centers. Participants with a prior C-section were nearly twice as likely to have a VBAC than women nationally (19% vs. ~10%).

Women prepared for childbirth may be more aware of their risk factors and thus better equipped to advocate for themselves. In addition to improving women’s perceptions of their birth experiences, self-empowerment may help to reduce inappropriate emergency department visits and medically unnecessary interventions such as low-risk C-sections which, in turn, may reduce healthcare costs. Reducing primary C-sections and increasing VBACs can particularly reduce financial burdens for Medicaid.