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Objectives: Evaluating population health initiatives at the community level necessitates valid counterfactual communities, which includes having similar population composition, health care access, and health determinants. Estimating appropriate county counterfactuals is challenging in states with large intercounty variation. We describe an application of K -means cluster analysis for determining county-level counterfactuals in an evaluation of an intervention, a county perinatal system of care for Medicaid-insured pregnant women., Methods: We described counties by using indicators from the American Community Survey, Area Health Resources Files, University of Wisconsin Population Health Institute County Health Rankings, and vital records for Michigan Medicaid-insured births for 2009, the year the intervention began (or the closest available year). We ran analyses of 1000 iterations with random starting cluster values for each of a range of number of clusters from 3 to 10 with commonly used variability and reliability measures to identify the optimal number of clusters., Results: The use of unstandardized features resulted in the grouping of 1 county with the intervention county in all solutions for all iterations and the frequent grouping of 2 additional counties with the intervention county. Standardized features led to no solution, and other distance measures gave mixed results. However, no county was ideal for all subpopulation analyses., Practice Implications: Although the K -means method was successful at identifying comparison counties, differences between the intervention county and comparison counties remained. This limitation may be specific to the intervention county and the constraints of a within-state study. This method could be more useful when applied to other counties in and outside Michigan.

Introduction: Enhanced prenatal/postnatal care home visiting programs for Medicaid-insured women have significant positive impacts on care and health outcomes. However, enhanced prenatal care participation rates are typically low, enrolling <30% of eligible women. This study investigates the impacts of a population-based systems approach on timely enhanced prenatal care participation and other healthcare utilization., Methods: This quasi-experimental, population-based, difference-in-differences study used linked birth certificates, Medicaid claims, and enhanced prenatal care data from complete statewide Medicaid birth cohorts (2009 to 2015), and was analyzed in 2019-2020. The population-based system intervention included cross-agency leadership and work groups, delivery system redesign with clinical-community linkages, increased enhanced prenatal care-Community Health Worker care, and patient empowerment. Outcomes included enhanced prenatal care participation and early participation, prenatal care adequacy, emergency department contact, and postpartum care., Results: Enhanced prenatal care (7.4 percentage points, 95% CI=6.3, 8.5) and first trimester enhanced prenatal care (12.4 percentage points, 95% CI=10.2, 14.5) increased among women served by practices with established clincial-community linkages, relative to that among the comparator group. First trimester enhanced prenatal care improved in the county (17.9, 95% CI=15.7, 20.0), emergency department contact decreased in the practices (-11.1, 95% CI= -12.3, -9.9), and postpartum care improved in the county (7.1, 95% CI=6.0, 8.2). Enhanced prenatal care participation for Black women served by the practices improved (4.4, 95% CI=2.2, 6.6) as well as early enhanced prenatal care (12.3, 95% CI=9.0, 15.6) and use of postpartum care (10.4, 95% CI=8.3, 12.4)., Conclusions: A population systems approach improved selected enhanced prenatal care participation and service utilization for Medicaid-insured women in a county population, those in practices with established clinical-community linkages, and Black women., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: To better address physical, emotional, and social needs of Medicaid-insured pregnant women, a Federally Qualified Health Center and a hospital-based obstetrics and gynecology residency practice collaborated with their agency-based state Medicaid-sponsored home visiting program, the Maternal Infant Health Program (MIHP). In partnership, both practice sites created patient standards of care to identify and engage eligible pregnant women into underutilized home visiting services for enhanced prenatal care coordination. The purpose of this study was to describe how each practice operationalized clinical-community linkage strategies that best suited their setting and to determine if efforts resulted in improved MIHP participation and other service use., Methods: Using linked administrative data, a quasi-experimental pre-post difference-in-difference design was used to examine changes in MIHP participation, adequate prenatal care, emergency department use, and postpartum care among patients in each practice compared with the same birth cohorts between 2010 and 2015 in the rest of the state., Results: When compared with similar women from the rest of the state, the Federally Qualified Health Center observed a 9.1 absolute percentage points (APP; 95% confidence interval [CI], 8.1-10.1) increase in MIHP participation and 12.5 APP (95% CI, 10.4-14.6) increase in early first trimester enrollment. The obstetrics and gynecology residency practice experienced increases of 4.4 APP (95% CI, 3.3-5.6) in overall MIHP participation and 12.5 APP (95% CI, 10.3-14.7) in first trimester enrollment. Significant improvements in adequate prenatal care, emergency department use, and postpartum visit completion were also observed., Conclusions: Clinical-community linkages can significantly improve participation of Medicaid-insured women in an evidence-based home visiting program and other prenatal services. This work is important because health providers are looking for ways to create clinical-community linkages., (Copyright © 2021 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate whether participation in a statewide enhanced prenatal and postnatal care program, the Maternal Infant Health Program (MIHP), reduced infant mortality risk., Methods: Data included birth and death records, Medicaid claims, and program participation. The study population consisted of Medicaid-insured singleton infants born between January 1, 2009, and December 31, 2012, in Michigan (n = 248 059). The MIHP participants were propensity score-matched with nonparticipants based on demographics, previous pregnancies, socioeconomic status, and chronic disease. Infant mortality, neonatal mortality, and postneonatal mortality analyses were presented by race., Results: Infants with any MIHP participation had reduced odds of death in the first year of life compared with matched nonparticipants (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.63-0.84). Infant death odds were reduced both among black infants (OR 0.71, 95% CI 0.58-0.87) and infants of other races (OR 0.74, 95% CI 0.61-0.91). Neonatal death (OR 0.70, 95% CI 0.57-0.86) and postneonatal death odds (OR 0.78, 95% CI 0.63-0.96) were also reduced. Enrollment and screening in MIHP by the end of the second pregnancy trimester and at least 3 additional prenatal MIHP contacts reduced infant mortality odds further (OR 0.70, 95% CI 0.58-0.85; neonatal: OR 0.67, 95% CI 0.51-0.89; postneonatal: OR 0.74, 95% CI 0.56-0.98)., Conclusions: A state Medicaid-sponsored population-based home-visitation program can be a successful approach to reduce mortality risk in a diverse, disadvantaged population. A likely mechanism is the reduction in the risk of adverse birth outcomes, consistent with previous findings on the effects of the program., (Copyright © 2015 by the American Academy of Pediatrics.)

Importance: Policy makers and practitioners need rigorous evaluations of state-based Medicaid enhanced prenatal care programs that provide home visiting to guide improvements and inform future investments. Effects on adverse birth outcomes are of particular interest., Objective: To test if participation in the Michigan statewide enhanced prenatal care program, the Maternal Infant Health Program (MIHP), accounting for program timing and dosage, reduced risk for low birth weight (LBW) and preterm birth, particularly among black women who are at greater risk for adverse outcomes., Design, Setting, and Participants: Quasi-experimental cohort study. Data, including birth records, Medicaid claims, and monthly program participation, were extracted from the Michigan Department of Community Health warehouse. Participants included all 60 653 pregnant women who had a Medicaid-insured singleton birth between January 1 and December 31, 2010, in Michigan. The MIHP participants were propensity score-matched with nonparticipants based on demographics, previous pregnancies, socioeconomic status, and chronic disease., Exposure: An enhanced prenatal care program., Main Outcomes and Measures: Low birth weight, very low birth weight (VLBW), preterm birth, and very preterm birth., Results: In the propensity score-matched models, black women who enrolled and were screened in the MIHP by the end of the second trimester had lower odds of VLBW (odds ratio [OR], 0.76; 95% CI, 0.59-0.97) and very preterm births (OR, 0.68; 95% CI, 0.54-0.85) than matched nonparticipants. Black MIHP participants who enrolled and were screened in the program by the second trimester and had at least 3 additional prenatal MIHP contacts had lower odds of LBW (OR, 0.76; 95% CI, 0.65-0.89), VLBW (0.42; 0.30-0.61), preterm birth (0.71; 0.61-0.83), and very preterm birth (0.41; 0.30-0.57) compared with matched nonparticipants. The MIHP participants of other races and ethnicities who enrolled and were screened in the program by the second trimester and had at least 3 additional prenatal MIHP contacts had lower odds of LBW (OR, 0.78; 95% CI, 0.66-0.93), VLBW (0.38; 0.22-0.66), preterm birth (0.77; 0.66-0.89), and very preterm birth (0.63; 0.43-0.91) compared with matched nonparticipants., Conclusions and Relevance: Participation in MIHP reduced the risk for adverse birth outcomes in a diverse, disadvantaged population. The study adds to the evidence base for enhanced prenatal care home visiting programs and informs state and federal investments.

Context: Medicaid enhanced prenatal service (EPS) programs, including care coordination, were developed to improve birth outcomes for low-income pregnant women. In Michigan, less than a third of eligible pregnant women are enrolled in services. Physician or medical clinics provide referrals to community-based EPS., Objective: The objective of this study was to examine physician knowledge and perceptions of EPS., Design: A cross-sectional survey of obstetric providers was conducted in 2009. A questionnaire was created to assess understanding of the EPS program., Setting: The study was conducted in an urban Michigan community., Participants: Participants included a convenience sample (N = 56) of community Obstetrics and Gynecology attending physicians and resident physicians within a single, large health system., Main Outcome Measures: Outcome measures included knowledge of the program and patient participation, referral practices, perceptions of the program, value for patients and providers, appropriateness of physicians to provide program referrals, and barriers to referring., Results: Findings indicated that most physicians (84%) had little familiarity with EPS, 60% did not personally refer to EPS, 54% did not know whether other office staff referred to EPS, and 65% were unaware whether their patients received EPS. Yet, more than 90% of physicians reported that EPS would benefit their patients and believed that it was appropriate for them to refer all their eligible patients., Conclusion: Further efforts should be made to better understand how physicians and EPS providers could function together on behalf of patients. Statewide Medicaid-sponsored EPS programs could serve as a valuable patient and physician resource for psychosocial risk screening, care management, education, and referral support if better utilized.

Objectives: To document psychological and physical abuse during pregnancy among women enrolled in enhanced prenatal services (EPS); explore the associations between maternal risk factors and type of abuse; and examine the relationship between abuse and EPS participation., Design and Sample: Cross-sectional study utilizing screening data collected between 2005 and 2008. Convenience sample of Medicaid-insured pregnant women enrolled in EPS selected from urban and rural providers., Measures: A prenatal screening tool that included measures such as Cohen's Perceived Stress Scale-4, Patient Health Questionnaire-2, and Abuse Assessment Screen was used., Results: Logistic regressions showed that high perceived stress and lack of father support were associated with all types of abuse and abuse history. Women with risk factors, such as a positive depression screen (odds ratio [OR]=2.36), were associated with psychological abuse but not with physical abuse during pregnancy. Less than a 12th-grade education was associated with physical abuse (OR=1.64) but not psychological abuse during pregnancy. The amount or the timing of EPS participation was not significantly associated with abuse history or abuse during pregnancy., Conclusions: Risk factors, such as high perceived stress and lack of father support, may alert nurses to further explore abuse during pregnancy. Additional research is needed for understanding the relationship between abuse and EPS participation.

Medicaid insures an estimated 43% of all births in Michigan and provides additional funding for enhanced prenatal services (EPS). The objectives of this study are to report on the (1) use of statewide administrative data to examine risk characteristics and EPS enrollment of Medicaid-insured pregnant women in Michigan; and (2) presence and extent of a broad range of risk factors in a sample of EPS participants in Michigan, using a newly developed two-tier, risk screener and assessment tool. This study uses Vital Records, Medicaid and other data to describe EPS participation by maternal risks in the statewide population of Medicaid-insured pregnant women (54,582 in the fiscal year 2005). The screener study data is a convenience sample of 2,203 women screened between February 2005 and October 2007. The administrative data indicates that 26% of Medicaid-eligible pregnant women had EPS contact. Most women with health behavior risks, such as smoking and drug use, had no contact with EPS (68–72%). Approximately 58% of all Medicaid-insured women had zero to two co-occurring risks, while 42% had three or more of the analyzed risks. Among screened women who smoke, 9% smoked more than a pack a day. Approximately 34% of women with a depression screen scored in the moderately or severely depressed range. The results of this study suggest great opportunity for EPS enhancement by improving the capacity to identify and engage women with modifiable risks, match interventions to specific health problems, and deliver services at an intensity warranted by the risk level. [ABSTRACT FROM AUTHOR]