By Melinda Young
Recent research shows a prenatal care initiative, called Strong Start for Mothers and Newborns, can produce positive health results.1
The program works with Medicaid beneficiaries in more than 30 states through maternity care homes (MCHs). In group prenatal care, there were lower rates of preterm birth recorded among white participants and lower rates of low birth weight among Black participants, relative to MCH participants.
To learn more about the program, Hospital Case Management asked for answers from the study’s lead author, Caitlin Cross-Barnet, PhD, a social science research analyst with the Center for Medicare & Medicaid Innovation in Baltimore. Cross-Barnet conduced her work solely through CMS, but she also is a policy fellow at the University of Maryland. Cross-Barnet and colleagues studied Strong Start sites, which added care managers to provide care coordination, community resource referrals, and psychosocial support.
HCM: What are MCHs? How do they work, from the perspectives of both Medicaid patients and the care managers who helped them?
Cross-Barnet: MCHs assist Medicaid beneficiaries in getting the care and services they need. The MCHs in Strong Start hired care managers, conducted needs screenings, and tried to connect people to resources. As patients’ pregnancies progressed, care managers also would try to facilitate attendance at any additional health services the person needed, and they would also try to address other emergent needs. Some of the programs offered enhanced services, such as nutritional consultations for those who were under- or overweight, classes on topics such as childbirth preparation or newborn care, or they expedited referrals. Care managers usually loved their work and tried hard to help their patients. Many expressed frustration about the lack of community resources and their lack of integration into clinical care teams.
Generally, patients liked the care managers and appreciated their time and attention. Often, the care manager was just someone to talk with who was empathic and had time to listen. Some beneficiaries felt they got useful help, such as obtaining a car seat or help getting to a food bank, but a care manager really couldn’t provide for all of the needs the beneficiaries had.
HCM: In your paper, you describe Strong Start and how participants recorded lower rates of preterm birth, low birth weight, and cesarean deliveries. How were these results achieved?
Cross-Barnet: Strong Start offered three models of prenatal care: midwifery-led care in birth centers, group prenatal care (a brief clinical check followed by a patient-focused discussion for 60-90 minutes), and MCHs. Relative to the beneficiaries in the MCH model, after we controlled for medical, demographic, and social risks, people in our other two models of care — birth centers and group prenatal care — had lower rates of preterm birth, low birth weight, and cesarean deliveries. Results were especially strong for the birth center model, which offered midwifery-led prenatal care in community settings (about half of these beneficiaries gave birth at a hospital).
Another analysis we published that looked at results against a risk-matched outside comparison group showed that people in MCHs did not have better outcomes than the comparators, but the birth center participants did. We ran the analysis for this paper so that we could control for social factors, such as food insecurity, that we couldn’t account for in Dubay’s analysis. The MCH model just didn’t seem to improve outcomes no matter how we analyzed the data.1
HCM: Strong Start participants reported appreciation for care managers’ support but noted long waiting lists and other access barriers. Could you please elaborate on those barriers and whether they were caused by long-term provider shortage trends? What are possible ways to improve access?
Cross-Barnet: Waiting lists were not for the care managers, but for other services the care managers referred to. Waiting lists for programs that are not entitlements, such as housing vouchers, can be years long or may not even be taking more people onto their waiting lists. Behavioral health services were another area where waits often were long. We had a large proportion of beneficiaries screening positive for both depression and anxiety.
Many of the MCH sites hadn’t done these screenings routinely before Strong Start and were overwhelmed by the level of need. For an MCH model to work, services have to be available. Pregnancy lasts a fixed amount of time, and to impact birth outcomes, people have to be able to get services quickly. The infrastructure just doesn’t exist to support that. In addition, many Medicaid beneficiaries already struggle to get to appointments because they have transportation and child care needs, and often don’t have flexible work schedules. They face those same barriers for any kind of appointment or service. Going to multiple appointments at different locations just isn’t possible for many Medicaid beneficiaries. If they can’t even get the service right away, a referral may just add to their stress. Beneficiaries liked having someone to talk to about their problems, but care managers faced infrastructure barriers to addressing the problems.
HCM: Is there anything else about this topic and its implications for improving patient care that you would like to add?
Cross-Barnet: We saw benefits to practices, such as longer appointments with prenatal care providers and continuity of provider, which were both typical in the birth center and group prenatal care models. In the typical clinical settings at MCHs, many Medicaid beneficiaries saw a different prenatal care provider at each visit, and short visits didn’t allow for relationship-building. Our research indicates building a relationship with a care manager can’t substitute for building a relationship with the clinical prenatal care provider.
But providing the kind of care offered through birth centers and prenatal care would require restructuring of the current maternity care system and training (or retraining) a workforce to offer that kind of care.
However, providing the kind of infrastructure needed for an MCH model to have a chance at success would require building significant resources outside of the healthcare system. The takeaway is that improving birth outcomes is likely to require structural changes that may be challenging to implement.
REFERENCE
- Cross-Barnet C, Benatar S, Courtot B, Hill I. Limits of prenatal care coordination for improving birth outcomes among Medicaid participants. Prev Med 2022;164:107240.
Recent research shows a prenatal care initiative, called Strong Start for Mothers and Newborns, can produce positive health results. The program works with Medicaid beneficiaries in more than 30 states through maternity care homes.
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