Association for Public Policy Analysis & Management

Research Objective: Gestational diabetes mellitus (GDM) and preeclampsia are serious pregnancy-related conditions. Women who develop GDM are at increased risk of developing type 2 diabetes postpartum and GDM in subsequent pregnancies and having macrosomic infants. Their children are at increased risk for impaired glucose tolerance and metabolic complications. Untreated preeclampsia can lead to maternal or infant death, but more commonly require immediate—and often preterm—delivery. Improved nutrition and physical activity reduce women’s risk of developing gestational diabetes and are also recommended to reduce the risk of developing preeclampsia. Understanding how to support low-income women to minimize their risk of developing GDM or preeclampsia could be of critical importance to the field of obstetrical care, the women these providers serve, and their children.

Study Design: The federal Strong Start for Mothers & Newborns initiative tested prenatal care enhancements for Medicaid-eligible pregnant women through three models: group prenatal care (GPC), maternity care homes (MCH), or birth centers (BC). We used data collected from participant-level process evaluation (PLPE) forms, case studies of implementation, and client focus groups to examine rates of GDM among Strong Start participants and awardees’ efforts to mitigate the risk. PLPE data were collected throughout women’s pregnancies and postpartum and include information on pre-pregnancy risk factors, pregnancy-related conditions, encounters and birth outcomes. We conducted risk-adjusted regression analyses to see if rates of GDM and pre-eclampsia varied by model.

Population Studied: Pregnant women enrolled in Strong Start (N=32,593) with non-missing data were included in this analysis

Principal Findings: After adjusting for observed characteristics and risk factors, including demographic, psychosocial and medical risk factors, we find that women enrolled in Birth Center and Group Prenatal Care models are significantly less likely to develop gestational diabetes than women in Maternity Care Homes (by 4 percentage points, p < 0.01 and by 2 percentage points p < 0.05 respectively). Women enrolled in Birth Center care are also significantly less likely to develop preeclampsia than Maternity Care Home participants when controlling for specified covariates (2 percentage point difference; p < 0.01).

Conclusions: Transformative models of enhanced prenatal care, such as group prenatal care and birth centers’ midwifery model of care, may help mitigate women’s risk of developing GDM and preeclampsia along with the postpartum sequelae associated with these pregnancy conditions.

Implications for Policy, Delivery or Practice: These findings support existing evidence that GDM can be moderated by encouraging lifestyle changes, providing enhanced psychosocial support, and practicing the holistic midwifery model of prenatal care. Enhanced prenatal care that supports women in reducing GDM and preeclampsia could have health impacts that extend beyond pregnancy and may reduce lifelong healthcare costs.