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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. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Objectives To address disparities in adverse birth outcomes, communities are challenged to improve the quality of health services and foster systems integration. The purpose of this study was to explore the perspectives of Medicaid-insured women about their experiences of perinatal care (PNC) across a continuum of clinical and community-based services. Methods Three focus groups (N = 21) were conducted and thematic analysis methods were used to identify basic and global themes about experiences of care. Women were recruited through a local Federal Healthy Start (HS) program in Michigan that targets services to African American women. Results Four basic themes were identified: (1) Pursuit of PNC; (2) Experiences of traditional PNC; (3) Enhanced prenatal and postnatal care; and (4) Women's health: A missed opportunity. Two global themes were also identified: (1) Communication with providers, and (2) Perceived socio-economic and racial bias. Many women experienced difficulties engaging in early care, getting more help, and understanding and communicating with their providers, with some reporting socio-economic and racial bias in care. Delays in PNC limited early access to HS and enhanced prenatal care (EPC) programs with little evidence of supportive transitions to primary care. Notably, women's narratives revealed few connections among clinical and community-based services. Conclusions The process of participating in PNC and community-based programs is challenging for women, especially for those with multiple health problems and living in difficult life circumstances. PNC, HS and other EPC programs could partner to streamline processes, improve the content and process of care, and enhance engagement in services. [ABSTRACT FROM AUTHOR]

Introduction Federal and state policies often require utilization of evidence-based home visiting programs. Measurement of specified interventions is important for tracking program implementation and achieving program outcomes. Thus, the Strong Beginnings program worked to define community health worker (CHW) interventions, a core service of the program to improve maternal and child health. Methods A workgroup consisting of CHWs, supervisors and other program staff was created in order to develop and define specific CHW interventions within a nurse or social worker care team. Basic interventions were first compared to the nurse or social worker care coordinator home visiting interventions by risk topic. The evaluator then grouped each CHW intervention into categories per risk domain using thematic analysis and assigned a CHW core function or role based on literature review findings. The workgroup confirmed the results. The workgroup then continued discussions to further enhance CHW interventions per risk domain once the general structure was created. Results The workgroup identified seven core functions and 28 maternal and child health risk topics to be addressed by the CHW. The process resulted in a detailed document of program interventions that the CHWs use to guide care. Conclusions The process helped CHWs feel more valued with their role in team care. The specified interventions will help others understand the CHW role within the care team, ensure consistent interventions are delivered across program partners, provide a foundation to better understand how specific CHW contributions are related to health outcomes, and support program sustainability. [ABSTRACT FROM AUTHOR]

Background: The Michigan Maternal and Infant Health Program (MIHP) is a population-based home-visitation program providing care coordination, referrals, and visits based on a plan of care. MIHP is available to all Medicaid-eligible pregnant women and infants aged ≤1 year in Michigan. Purpose: To assess the effects of MIHP participation on maternal and infant healthcare utilization. Methods: Propensity-score matching methods were used to assess differences in healthcare utilization between MIHP participants and nonparticipants using 2009—2010 Medicaid claims and administrative data obtained from the Michigan Department of Community Health. Data were analyzed between October 2011 and March 2013. Results: MIHP participants had higher odds of receiving any prenatal care compared to matched women not participating in MIHP (OR=2.94, 95% CI=2.43, 3.60) and higher odds of receiving adequate prenatal care (OR=1.06, 95% CI=1.01, 1.11). MIHP participants had higher odds of receiving an appropriately timed postnatal visit (OR=1.50, 95% CI=1.43, 1.57). Infants participating in MIHP had higher odds of receiving any well-child visits over the first year of life (OR=1.70, 95% CI=1.51, 1.93) and higher odds of receiving the appropriate number of well-child visits over their first year of life (OR=1.47, 95% CI=1.35, 1.60) compared to matched nonparticipant infants. Conclusions: The results from Michigan provide strong evidence for the effectiveness of a Medicaid-sponsored population-based home-visitation program in improving maternal prenatal and postnatal care and infant care. This evidence is important to consider as the federal healthcare reform is implemented and states are making decisions on the expansion of the Medicaid program. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Few studies have examined whether neighborhood deprivation is associated with severe maternal morbidity (SMM) in already socioeconomically disadvantaged populations. Little is known about to what extent neighborhood deprivation accounts for Black–White disparities in SMM. This study investigated these questions among a statewide Medicaid-insured population, a low-income population with heightened risk of SMM. Data were from Michigan statewide linked birth records and Medicaid claims between 01/01/2016 and 12/31/2019, and were analyzed between 2022 and 2023. Neighborhood deprivation was measured with the Area Deprivation Index at census block group and categorized as low, medium, or high deprivation. Multilevel logistic models were used to examine the association between neighborhood deprivation and SMM. Fairlie nonlinear decomposition was conducted to quantify the contribution of neighborhood deprivation to SMM racial disparity. People in the most deprived neighborhoods had higher odds of SMM than those in the least deprived neighborhoods (aOR [95% CI]: 1.27 [1.15, 1.40]). Such association was observed in Black (aOR [95% CI]: 1.34 [1.07, 1.67]) and White (aOR [95% CI]: 1.26 [1.12, 1.42]) racial subgroups. Decomposition showed that of 57.5 (cases per 10,000) explained disparity in SMM, neighborhood deprivation accounted for 23.1 (cases per 10,000; 95% CI: 16.3, 30.0) or two-fifths (40.2%) of the Black–White disparity. Analysis on SMM excluding blood transfusion showed consistent but weaker results. Neighborhood deprivation may be used as an effective tool to identify at-risk individuals within a low-income population. Community-engaged interventions aiming at improving neighborhood conditions may be helpful to reduce both SMM prevalence and racial inequity in SMM. [ABSTRACT FROM AUTHOR]

We used administrative and screening data from 2009 to 2010 to determine if Healthy Start (HS), an enhanced prenatal services program, is reaching the most vulnerable African American women in Kent County, Michigan. Women in HS are at higher risk of key predictors of birth outcomes compared with other women. To advance toward evidence-based HS program evaluations in the absence of randomized controlled trials, future studies using comparison groups need to appropriately establish baseline equivalence on a variety of risk factors related to birth outcomes. [ABSTRACT FROM AUTHOR]

We used administrative and screening data from 2009 to 2010 to determine if Healthy Start (HS), an enhanced prenatal services program, is reaching the most vulnerable African American women in Kent County, Michigan. Women in HS are at higher risk of key predictors of birth outcomes compared with other women. To advance toward evidence-based HS program evaluations in the absence of randomized controlled trials, future studies using comparison groups need to appropriately establish baseline equivalence on a variety of risk factors related to birth outcomes. [ABSTRACT FROM AUTHOR]

We used data from a home visiting trial to examine low-income women's perceptions of services received from nurses (the community care [CC] group) and from a nurse-community health worker (CHW) team. More mothers in the nurse-CHW group than in the CC group reported receiving help in all of the categories assessed. For both groups, assistance with health education ranked highest among the types of assistance received. A higher percentage of women in the nurse-CHW group than the CC group reported that they received psychosocial help. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Smoking during pregnancy is the single most modifiable risk factor for poor birth outcomes, yet it remains prevalent among low-income women. This study examined factors associated with continued smoking and quitting among pregnant women. A total of 2,203 Medicaid-eligible pregnant women were screened at their first enhanced prenatal services visit for risk factors including demographics, health behaviors (smoking, alcohol and drug use), mental health (history of mental health disorders, current depressive symptoms), and stress. Smoking status was divided into non-smokers, quitters (quit smoking since learning of pregnancy), and continuing smokers. Descriptive statistics and logistic regression models were used to describe the sample and analyze relationships between smoking status and other characteristics. Overall, 57% were non-smokers, 17% quitters, and 26% continuing smokers. Approximately 18% had severe depressive symptoms, 53% had a high stress score, and 33% had a history of mental health problems. Younger women had lower odds of continued smoking as compared to both non-smokers (OR = 0.48, p < 0.01) and quitters (OR = 0.56, p < 0.05). Older women with less than a 12th grade education had higher odds of continued smoking (OR = 2.17, p < 0.01) and quitting (OR = 1.62, p < 0.05) as compared to non-smokers. Alcohol use (OR = 2.81, p < 0.05) and drug use before pregnancy (OR = 5.32, p < 0.01) predicted continued smoking compared to non-smoking. Women with a mental health history (OR = 1.81, p < 0.01) and high stress scores (OR = 1.39, p < 0.05) had higher odds of continued smoking compared to non-smokers. Mental health history, stress, demographics, current alcohol and past drug use are strongly related to continued smoking in this population. [ABSTRACT FROM AUTHOR]

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]

To test the effectiveness and cost-effectiveness of a multilevel intervention for population-level African American (AA) severe maternal morbidity and mortality. Severe maternal morbidity and mortality in the U.S. disproportionately affect AA women. Inequities occur at many levels, including community, provider, and health system levels. Intervention. Throughout the two intervention counties, we will expand access to enhanced prenatal care services using telehealth and flexible scheduling (community level), provide actionable maternal health-focused anti-racism training (provider level), and implement equity-focused community care maternal safety bundles (health system level). Partnership. Interventions were developed/co-developed by intervention county partners, including AA women, enhanced prenatal care staff, and health providers. For equity, 46% of project direct cost dollars go to our partners. Most study investigators are female (75%) and/or AA (38%). Partners are overwhelmingly AA women. Sample, measures, analyses. We use a quasi-experimental difference-in-differences with propensity scores approach to compare pre (2016–2019) to post (2022–2025) changes in outcomes for Medicaid-insured women in intervention counties to similar women in the other Michigan, USA, counties. The sample includes all Medicaid-insured deliveries in Michigan during these years (n ~ 540,000), with women observed during pregnancy, at birth, and up to 1 year postpartum. Measures are taken from a linked dataset that includes Medicaid claims and vital records. This study is among the first to examine effects of any multilevel intervention on AA severe maternal morbidity and mortality. It features a rigorous quasi-experimental design, multilevel multi-partner county-wide interventions developed by community partners, and assessment of intervention effects using population-level data. [ABSTRACT FROM AUTHOR]

INTRODUCTION: A Michigan integrated health system used clinical–community partnerships to promote health equity and improve population health by increasing referrals and participation in a Medicaid-sponsored enhanced prenatal care (EPC) home visiting program. The statewide program is federally designated and evidence based for reducing the risk for adverse birth outcomes, with a quarter of eligible women enrolled. The objective of this study was to explore early implementation of a quality-improvement initiative to increase EPC referral and enrollment in 16 obstetrics and gynecology practices in eight counties. METHODS: The strategies used were dashboard tracking, shared goals, engagement of OB nurse educators/social workers, and electronic medical records. Referrals and enrollments were tracked from January 1, 2021 to September 30, 2021 in nine obstetrics and gynecology practices, with the goal of referring all Medicaid-insured women and enrolling 50% of eligible referrals, especially women of color at greater risk, to the health system's internal EPC program. From June 1, 2021 to September 30, 2021, seven practices in six counties linked to external health department EPC programs and targeted a 50% referral rate. RESULTS: Overall, practices connected to internal EPC services achieved the 50% enrollment target (1,247 referrals, 744 eligible [60%], with 394 enrolled [53%]). Enrollment ranged from 24% to 62% by site; of these, 49.5% of participants were women of color. Practices connected to external EPC programs achieved a 51% referral rate (568 eligible, 289 referrals). CONCLUSION: The health system increased referral and enrollment of Medicaid-insured pregnant women, many of whom were women of color, into prenatal home visiting. Clinical–community linkages, aligned with Alliance for Innovation on Maternal Health Community Care Initiative goals, can help practices address equity in maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]