Medicaid expenditures for maternity and newborn care in America

An Alan Guttmacher Institute (AGI) survey of the Medicaid programs in each state and the District of Columbia found that some 542,000 low-income women have a Medicaid-subsidized delivery each year--about 15 percent of all women who give birth. The proportion ranges from three percent in Alaska to 25 percent in Michigan. The federal and state governments spend almost $1.2 billion annually for maternity care (including prenatal, postpartum and newborn care); the average expenditure per patient is $2,200. Tennessee reports the highest expenditure per patient ($3,500) and Louisiana the lowest ($1,300). Only the highest payments under Medicaid are close to charges for maternity care in the open market, a fact that results in a significant disincentive for physicians and hospitals to accept Medicaid patients. The $1.2 billion spent for Medicaid-subsidized maternity care compares with an estimated $11.5 billion spent for such care nationwide. Thus, Medicaid pays for about 10 percent of the nation's maternity care bill, although Medicaid subsidizes deliveries for 15 percent of all women who give birth. The figures for maternity care do not include Medicaid expenditures for neonatal intensive care, which, for the 17 states reporting data, average about $11,800 per infant. Although only about six percent of all newborns whose deliveries are subsidized by Medicaid require neonatal intensive care, such care is so expensive that it adds about 30 percent to all Medicaid expenditures for maternity care. Increased Medicaid payments for maternity care, including prenatal care, could have a positive impact on health outcomes for low-income mothers and their babies, and could reduce the necessity for massive and expensive medical treatment for newborns.     

Explaining suicide: Identifying common themes and diverse perspectives in an urban Mumbai slum

Rates, demographics and diagnostics, which are the focus of many studies of suicide, may provide an insufficient account without adequate consideration of psychological, social and cultural contexts and motives. Furthermore, reported explanations of suicide are shaped not only by events but also the relationship of survivor respondents explaining the suicide. An explanatory model interview for sociocultural autopsy has been used to assess underlying problems and perceived causes. This study in a low-income community of Mumbai in 2003–2004 compared accounts of the closest family survivors and more distant relationships. Our study design distinguished series-level agreement (i.e., consistency of accounts within a group) and case-level agreement for particular cases. Serious mental illness was the perceived cause reported by a respondent in either group for 22.0% of index suicides, but case-level agreement was only 6.0%. Regarding financial stressors, more closely related family respondents focused on acute stressors instead of enduring effects of poverty. Case-level agreement was high for marital problems, but low for other sources of family conflict. Tension was a feature of suicide reported in both groups, but case-level agreement on tension as a perceived cause was low (kappa = 0.14). The role of alcohol as a perceived cause of suicide had high series level agreement (46.0% in both groups) and case-level agreement (kappa = 0.60), suggesting comparable community and professional views of its significance. The study shows that it is relevant and feasible to consider general community patterns and particular survivor interests. Findings from this study recommend an approach to sociocultural autopsy to assess reasons for suicide in community studies. Findings clarify diverse views of underlying problems motivating suicide that should be considered to make mental health care more effective in assessing risk and preventing suicide.     

Out-of-hospital births and the supply of maternity units in France

Maternity unit closures in France have increased distances that women travel to deliver in hospital. We studied how the supply of maternity units influences the rate of out-of-hospital births using birth certificate data. In 2005–6, 4.3 per 1000 births were out-of-hospital. Rates were more than double for women living 30 km or more from their nearest unit and were even higher for women of high parity. These associations persisted in multilevel analyses adjusting for other maternal characteristics. Long distances to maternity units should be a concern to health planners because of the maternal and infant health risks.     

Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use.

OBJECTIVES: This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS: Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS: Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS: These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources.     

Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries

OBJECTIVE: Progress towards the Millennium Development Goals for maternal health has been slow, and accelerated progress in scaling up professional delivery care is needed. This paper describes poor-rich inequalities in the use of maternity care and seeks to understand these inequalities through comparisons with other types of health care. METHODS: Demographic and Health Survey (DHS) data from 45 developing countries were used to describe poor-rich inequalities by wealth quintiles in maternity care (professional delivery care and antenatal care), full childhood immunization coverage and medical treatment for diarrhoea and acute respiratory infections (ARI). FINDINGS: Poor-rich inequalities in maternity care in general, and professional delivery care in particular, are much greater than those in immunization coverage or treatment for childhood illnesses. Public-sector inequalities make up a major part of the poor-rich inequalities in professional delivery attendance. Even delivery care provided by nurses and midwives favours the rich in most countries. Although poor-rich inequalities within both rural and urban areas are large, most births without professional delivery care occur among the rural poor. CONCLUSION: Poor-rich inequalities in professional delivery care are much larger than those in the other forms of care. Reducing poor-rich inequalities in professional delivery care is essential to achieving the MDGs for maternal health. The greatest improvements in professional delivery care can be made by increasing coverage among the rural poor. Problems with availability, accessibility and affordability, as well as the nature of the services and demand factors, appear to contribute to the larger poor-rich inequalities in delivery care. A concerted effort of equity-oriented policy and research is needed to address the huge poor-rich inequalities in maternity care.     

A study of pregnancy outcomes in a maternity center and a tertiary care hospital.

This study compares 796 pregnancy outcomes at a maternity center (BMC) with 804 hospital (TJUH) pregnancy outcomes. The samples of pregnant women from the participating institutions were matched on sociodemographic characteristics; analysis of outcomes was performed controlling for medical-obstetric risk. Differences between the institutions were found mainly among women with low intrapartum risk. For these women, neonatal morbidity and length of infant nursery stay were lower at BMC than at TJUH. The percentage of infants with one-minute Apgar scores less than 7 or requiring resuscitation at birth was greater at BMC, but the percentage of infants with five-minute Apgar scores less than 7 as well as neonatal mortality rates did not differ between the two institutions. The number of women with intrapartum or postpartum fever was too small to permit comparison. The study results suggest that care delivered at BMC is safe with regard to the evaluative criteria used.     

Evaluating satisfaction with maternity care in women from minority ethnic communities: development and validation of a Sylheti questionnaire.

OBJECTIVE: To develop a reliable and valid questionnaire to evaluate satisfaction with maternity care in Sylheti-speaking Bangladeshi women. DESIGN: Two-stage, psychometric study. Firstly, focus groups, in-depth interviews and iterative methods for translation and cultural adaptation were used to develop a Sylheti questionnaire, called the survey of Bangladeshi women's experience of maternity services from an English language questionnaire. Secondly, quantitative psychometric methods were used to field test and evaluate the acceptability, reliability and validity of this questionnaire. SETTING: Four hospitals providing maternity services in London, UK. STUDY PARTICIPANTS: Two hundred and forty-two women from the London Bangladeshi communities, who were in the antenatal (at least 4 months pregnant) or postnatal phase (up to 6 months after delivery). Women spoke Sylheti; a language with no accepted written form. Two purposive samples of 40 women in the antenatal or postnatal phase, one convenience sample of six women in the antenatal phase and three consecutve samples of 60 women in the postnatal phase participated in stage one. In stage two, 135 women (main sample) completed the questionnaire two months after delivery (82% response rate); 50 women (retest sample) from the main sample completed a second questionnaire two weeks later (96% response rate). MAIN OUTCOME MEASURES: Women's views about maternity care elicited by qualitative methods and measured quantitatively using the survey of Bangladeshi women's experience of maternity services. RESULTS: The 121-item questionnaire was acceptable to women and showed good internal consistency (Cronbach's alphas 0.76-0.91), stability (test-retest reliability 0.72-0.84) and construct validity (e.g. able to detect group differences). CONCLUSION: By combining qualitative and quantitative methods, it is possible to adapt an instrument to provide an acceptable, reliable and valid Sylheti questionnaire. The approach taken in developing this questonnaire provides a model for developing outcome measures for use with other minority ethnic communities.     

Incantations in the dark: Medicaid, managed care, and maternity care

Public program reforms in the 1980s have substantially increased the numbers of poor pregnant women potentially eligible for Medicaid coverage. Structural deficiencies in the Medicaid program, together with inadequate arrangements in managed-care plans, however, have not led to generally acceptable levels of maternity care. Demonstration projects indicate that Medicaid can be modified cost effectively to underwrite early, continuous, and comprehensive care delivery. Recommendations are suggested for eligibility guarantees, enrollment safeguards, benefit and treatment protocols, provider recruitment, quality control, and sufficient payment rates to overcome barriers to adequate levels of material health care.     

Perinatal outcomes of multiple births in southwest Nigeria

Compared to singletons, multiple births are associated with a substantially-higher risk of maternal and perinatal mortality worldwide. However, little evidence exists on the perinatal profile and risk of neurodevelopmental disabilities among the survivors, especially in developing countries. This cross-sectional study, therefore, set out to determine the adverse perinatal outcomes that are potential markers for neurodevelopmental disabilities in infants with multiple gestations in a developing country. In total, 4,573 mothers, and their 4,718 surviving offspring in an inner-city maternity hospital in Lagos, Nigeria, from May 2005 to December 2007, were recruited. Comparisons of maternal and infant outcomes between single and multiple births were performed using multivariable logistic regression and generalized estimation equation analyses. Odds ratio (OR) and the corresponding 95% confidence interval (CI) for each marker were estimated. Of the 4,573 deliveries, there were 4,416 (96.6%) singletons and 157 (3.4%) multiples, comprising 296 twins and six triplets together (6.4% of all live 4,718 infants). After adjusting for maternal age, ethnicity, occupation, parity, and antenatal care, multiple gestations were associated with increased risks of hypertensive disorders and caesarean delivery. Similarly, after adjusting for potential maternal confounders, multiple births were associated with low five-minute Apgar score (OR: 1.47, 95% CI 1.13-1.93), neonatal sepsis (OR: 2.16, 95% CI 1.28-3.65), severe hyperbilirubinaemia (OR: 1.60, 95% CI 1.00-2.56), and admission to a special-care baby unit (OR: 1.56, 95% CI 1.12-2.17) underpinned by preterm delivery before 34 weeks (OR: 1.91, 95% CI 1.14-3.19), birthweight of less than 2,500 g (OR: 6.45, 95% CI 4.80-8.66), and intrauterine growth restriction (OR: 9.04, 95% CI 6.62-12.34). Overall, the results suggest that, in resource-poor settings, infants of multiple gestations are associated with a significantly-elevated risk of adverse perinatal outcomes. Since these perinatal outcomes are related to the increased risk of later neurodevelopmental disabilities, multiple-birth infants merit close developmental surveillance for timely intervention.     

Managing care across systems to improve outcomes for families and communities

Behavioral health administrators deserve much credit for their efforts to integrate services for children with serious emotional disturbances and to instill a concern for efficiency through the concept of managed care. Recent changes in federal policy signal the next stage of development in systems of care. Issues of accountability now are shifting toward comprehensive systems of care and improving outcomes for families and communities, not just individuals. As they help build such systems in their states and communities, behavioral health administrators can help their colleagues in other systems understand the potential usefulness of concepts and practices associated with managed care and the broader notion of a system of care. In turn, they will be asked to expand their conception of the accountability of the mental health agency for the outcomes being experienced by families, neighborhoods, and the community as a whole.     

Preventable infant deaths,lone births and lack of registration in Mexican indigenous communities: health care services and the afterlife of colonialism

ABSTRACT

Mexico’s indigenous communities continue to experience higher levels of mortality and poorer access to health care services than non-indigenous regions, a pattern that is repeated across the globe. We conducted a two-year ethnographic study of pregnancies and childbirth in an indigenous Wixárika community to explore the structural causes of this excess mortality. In the process we also identified major differences between official infant mortality rates, and the numbers of infants born to women in our sample who did not survive.

We interviewed 67 women during pregnancy and followed-up after the birth of their child. At baseline, socio-demographic data was collected as well as information regarding birthing intentions. In depth-interviews and semi-structured interviews were conducted with 62 of these women after the birth of their child, using a checklist of questions. Women were asked about choices regarding, and experiences of childbirth.

Of the 62 women we interviewed at follow-up 33 gave birth at home without skilled attendance and five gave birth completely alone in their homes. Five neonates died during labour or the perinatal period. Concerns about human resources, the structure of service delivery and unwanted interventions during childbirth all appear to contribute to the low institutional childbirth rate. Our data also suggests a low rate of death registration, with the custom of burying infants where they die. This excess mortality, occurring in the context of unnecessary lone and unassisted childbirth are structurally generated forms of violence.     

Rural maternity care and health policy: parents' experiences

Objective: To explore rural residents' experiences of access to maternity care with consideration of the policy context. Design: This paper describes findings from focus groups with parents which formed part of case study data from a larger study. Setting: Four north Queensland rural towns. Participants: Thirty‐three parents living in one of the four rural towns. Main outcome measures: Identifying prevalent themes in case studies regarding rural parents' expectations and experiences in accessing maternity care. Results: Parents desired a local, safe and consistent maternity service. Removing or downgrading rural services introduced new barriers to care for rural residents: (i) increased financial costs; (ii) family issues; and (iii) safety concerns. Conclusions: Although concerns about rural residents' health status and health care access have received significant policy attention for over a decade, many of the problems which prompted these policy initiatives remain today. Current policy approaches should be re‐evaluated in order to improve rural Australians' access to vital health services such as maternity care.     

Pakistani women and maternity care: raising muted voices

The paper explores the potentiality of an empowering research strategy to raise the muted voices of Pakistani women, with particular reference to experiences of maternity care. It focuses on research carried out with Pakistani women in Glasgow in 1991. It is argued that issues of power negotiation need to be addressed at all stages of the research process, including the framing of research questions, during data collection through interviews, and in the analysis and presentation of results. Women's comments on maternity care were very varied, some being very satisfied, many not so. Three particular cases illustrate variation at the individual level, and muting interpretations are considered. In conclusion, it is suggested that an empowering research strategy may indeed raise muted voices, but that it can also give researchers more power. And the issue of the response to muted voices, a key aspect of the concept of muting, remains.     

An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina.

BACKGROUND. Care coordination is an important component of the enhanced prenatal care services provided under the recent expansions of the Medicaid program. The effect of maternity care coordination services on birth outcomes in North Carolina was assessed by comparing women on Medicaid who did and did not receive these services. METHODS. Health program data files, including Medicaid claims paid for maternity care coordination, were linked to 1988 and 1989 live birth certificates. Simple comparisons of percentages and rates were supplemented by a logistic regression analysis. RESULTS. Among women on Medicaid who did not receive maternity care coordination services, the low birth weight rate was 21% higher, the very low birth weight rate was 62% higher, and the infant mortality rate was 23% higher than among women on Medicaid who did receive such services. It was estimated that, for each $1.00 spent on maternity care coordination, Medicaid saved $2.02 in medical costs for newborns up to 60 days of age. Among the women who did receive maternity care coordination, those receiving it for 3 or more months had better outcomes than those receiving it for less than 3 months. CONCLUSIONS: These results suggest that maternity care coordination can be effective in reducing low birth weight, infant mortality, and newborn medical care costs among babies born to women in poverty.