The United States struggles with high rates of premature births (11.4 percent of all births in 2013), low birth weight babies (8.0 percent of all births), and infant mortality (6.7 per 1000). These negative health outcomes are very costly; preterm birth alone cost the nation’s health care system at least $26.2 billion in 2005.
In addition, interventions in the natural birth process occur far more frequently in the United States than other countries and beyond rates that are clinically indicated, with about one third of infants delivered by Cesarean section. Furthermore, racial and socioeconomic disparities in maternal and infant health persist.
Enhancements to prenatal care have the potential to impact persistently high rates of poor maternal and infant birth outcomes and do so in a manner that is supportive of the circumstances experienced by women with different racial, ethnic, and socioeconomic backgrounds. Since Medicaid covers almost half the births in the United States and most births to low-income women, Medicaid programs have often taken on the responsibility of addressing these problems.
The Strong Start for Mothers and Newborns initiative, funded by the Affordable Care Act, aims to improve outcomes for pregnant women and babies covered by Medicaid and the Children’s Health Insurance Program. The initiative is testing three innovative, enhanced prenatal care models—maternity care homes, group prenatal care, and birth centers—and is supporting service delivery through 27 awardees and 213 provider sites across 30 states, the District of Columbia, and Puerto Rico.
The Urban Institute has been evaluating the initiative with our research partners since August 2013. While it is too early to make any definitive statements about Strong Start’s effects, preliminary data suggest some positive trends. For instance, participants have rates of Cesarean section that are lower than the national average, as well as higher rates of breastfeeding. Overall, participants also reported lower preterm birth rates than the national average. Though, none of these results controls for any health, risk, or demographic factors, future analyses will include these factors.
Strong Start participants have high levels of emotional and psychosocial needs, including food insecurity, chronic unemployment, unstable housing, unmet behavioral health needs, and low health literacy. All of these can lead to barriers to getting appropriate prenatal care. The initiative’s three prenatal care models are designed to help mothers address such needs, emphasizing relationship-centered care and patient education.
Thus far, nearly 90 percent of participants have been either “very satisfied” or “extremely satisfied” with their care. Focus group participants highlighted how important it was to them to have Strong Start support during their pregnancies.
“I didn’t have anything like this for my first pregnancy, and I really just wanted support from an outside source,” one participant said.
Similarly, participants in group prenatal care said that their group “feels like a pregnancy team” and they “like that other pregnant women can help [them] and that they can help other people too.”
We also found that, in the first year, Strong Start awardees faced common implementation challenges, including problems establishing an effective process for identifying and enrolling eligible patients, integrating Strong Start into the existing model of care, and ensuring that women stayed in the program. At the same time, many awardees had developed promising practices, including highly effective “opt out” enrollment processes, improved messaging for patients, and strategies to promote better relationships with providers.
Our mixed-methods evaluation of Strong Start is funded by the Center for Medicare & Medicaid Innovation and conducted in partnership with the American Institutes for Research, Health Management Associates, and Briljent. Over the next four years, we will continue to closely monitor implementation and rigorously measure Strong Start’s impacts on birth outcomes, prenatal care delivery, and costs.
The Year 1 Annual Report can be found here.