Association for Public Policy Analysis & Management

Research Objective: The United States spends more per-pregnancy on maternity care than any other developed nation 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 black women of all incomes. The root causes of poor birth outcomes are complicated but considering women’s life circumstances and medical histories can help us understand elevated risks for preterm births and low birthweight infants. Incidence of psychosocial and medical risk factors among Medicaid beneficiaries which may contribute to poor birth outcomes, is not well documented in the literature. Individual-level data collected for 46,000 women enrolled in Medicaid and CMMI’s Strong Start for Mothers and Newborns initiative provide a unique opportunity for understanding women’s medical, social and demographic risk factors.

Study Design: The federal Strong Start for Mothers and Newborns initiative tested enhanced prenatal care for Medicaid-eligible pregnant women through three models: group prenatal care, maternity care homes, and birth centers. Three surveys were administered to participants in the Strong Start program: at intake, during women’s third trimester, and at their postpartum visit. Staff completed a detailed program service and chart review within 10 weeks postpartum. Data included demographic characteristics, psychosocial and medical risk factors, pregnancy and birth outcomes, and patient experience.

Population Studied: Approximately 46,000 Medicaid or CHIP enrolled pregnant women participating in Strong Start through one of 27 awardees operating approximately 200 sites in 30 states, DC, and Puerto Rico.

Principal Findings: Descriptive analyses indicate that program participants psychosocial risk factors including high rates of depression (28%) and anxiety (35%). Nearly half of participants were neither employed nor in school (49%). Many were overweight or obese at their first prenatal care appointment (26% and 36% respectively) and among women with a prior birth, 20% had a history of preterm delivery. Many of these rates vary by race. For example, black women enrolled in Strong Start are significantly more likely than white women to screen positive for depression, while Hispanic women were significantly less likely. Black women were also most likely to be overweight or obese, followed by Hispanic, then white women. We observed that maternity care home participants were more likely to possess these risk factors than women enrolled in birth centers or group prenatal care. There were also differences observed across Strong Start models.

Conclusions: Descriptive analysis of the participant-level data collected for Strong Start indicate especially high psychosocial need among pregnant Medicaid beneficiaries, and substantial rates of overweight and obesity. These trends vary significantly by race/ethnicity that are consistent with the effects of structural racism and the social determinants of health, indicating that a “one-size fits all approach” to preventing preterm birth and low birthweight may not be appropriate.

Implications for Policy, Delivery or Practice: Participant-level data collection can be essential for understanding population characteristics, documenting underreported trends and ultimately using data to drive approaches to improving birth outcomes and overall maternal and infant health.