Strong Start for Mothers and Newborns II First Annual Evaluation Report

By Patrick Conway, MD, Acting Principal Deputy Administrator of CMS

Today, we at the Centers for Medicare & Medicaid Services (CMS) are pleased to announce preliminary findings from the first annual evaluation report for Strong Start for Mothers and Newborns (Strong Start) strategy II cooperative agreements.  Strong Start is a federal initiative geared toward testing innovative approaches to improve maternal and infant health outcomes in low-income families. The work of the Partnership for Patients and the first strategy of Strong Start contributed to decreasing early elective deliveries 64.5 percent nationwide between 2010 and 2013, which may improve birth outcomes and increase numbers of healthy newborns. The second strategy seeks to build on this success by using innovative approaches to prenatal care for Medicaid and CHIP participants to promote maternal and infant health and to reduce preterm birth and low birth weight infants. Today’s preliminary results show the positive potential of strategy II to contribute to these goals.

We created the Strong Start initiative to leverage work conducted by the Partnership for Patients and decades of research that reiterate the health and financial risks associated with a lack of accessible, quality prenatal care available to Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. This research consistently shows that infants born preterm (before 37 completed weeks of gestation) have higher mortality risks and may endure a lifetime of developmental and health problems. In addition to having enormous medical needs, children born preterm often require early intervention services and special education and may have conditions that affect their productivity through adulthood.

To address this care need, we partnered with 27 organizations with 213 provider sites in 30 states, Washington, D.C., and Puerto Rico. The three year program tests evidence-based approached to reducing the rate of preterm births through three approaches:

• Group Care – Group prenatal care that incorporates peer-to-peer support in a facilitated setting for three components: health assessment, education and support.
• Birth Centers – Comprehensive prenatal care facilitated by midwives and teams of health professionals, including peer counselors and doulas.
• Maternity Care Homes – Enhanced prenatal care at traditional prenatal sites with enhanced continuity of care and expanded access to care coordination, education, and other services.

Preliminary results from the first year evaluation indicate that Strong Start participants have

• lower rates of cesarean than national averages,
• higher rates of breastfeeding than national averages, and
• overall lower rates of preterm birth than national averages.

The CMS evaluation indicates that when beginning the program, Strong Start participants had high levels of emotional and psychosocial needs such as food insecurity, chronic unemployment, unstable housing, lack of reliable transportation, unmet dental and behavioral health needs and low knowledge about self-care, nutrition, and healthy pregnancy. Preliminary results indicate that a common element among the three prenatal care models is an emphasis on relationship-centered care, including providing education on pregnancy, preterm risks, and self-care and connecting participants to community resources.

The initiative’s enhanced programs are designed to meet the specific emotional and psychosocial needs of their local populations. Strong Start participants expressed overwhelming satisfaction with their prenatal care, with nearly 90% of participants stating that they were either very satisfied or extremely satisfied with their care.

Although many awardees and provider sites faced common implementation challenges such as enrolling participants and integrating enhanced services into existing models, they also shared common promising practices. These included

• strategies to promote engaged relationships with providers and staff,
• adapting programs to the needs of the target population, and
• developing skilled and resourceful staff.

Results should be interpreted cautiously as awardees were in various stages of implementation during the first year.  Comparisons with national averages are descriptive only and are not controlled for important factors such as risk profiles or demographics.  We cannot yet be certain that results are a direct result of Strong Start or if these outcomes are similar to those found in these particular care approaches prior to the initiative.  Annual evaluations of the second and third years of operations are likely to indicate more definitive findings as more comprehensive data becomes available for analysis.

Much work remains to be done to reduce the risk of significant complications for women and infants.  As a practicing pediatrician, I know the importance of this work and its impact on patients and families.  We remain committed to working together to improve health delivery, health outcomes, and cost of quality care for low-income pregnant women and their newborns.