An evaluation of a Medicaid managed maternity program: the impact of comprehensive care coordination on utilization and pregnancy outcome

The purpose of this study is to evaluate the effectiveness of the implementation of a Medicaid managed maternity care program in a public health department service population, analyzing race-specific models of WIC participation and risk of small-for-gestational age of term. There were 13,095 singleton deliveries during the period 1987-1990 to women with prenatal care in this managed maternity care program. The research design entailed comparison of the intervention group (those receiving regular prenatal care plus comprehensive care coordination in 1989-90) with an historical comparison group of women who received only regular prenatal care in the two years (1987-88).     

The Influence of Site of Care on the Content of Prenatal Care for Low-Income Women

Objective: To assess whether site of prenatal care influences the content of prenatal care for low-income women. Design: Bivariate and logistic analyses of prenatal care content for low-income women provided at five different types of care sites (private offices, HMOs, publicly funded clinics, hospital clinics, and other sites of care), controlling for sociodemographic, behavioral, and maternal health characteristics. Participants: A sample of 3405 low-income women selected from a nationally representative sample of 9953 women surveyed by the National Maternal and Infant Health Survey, who had singleton live births in 1988, had some prenatal care (PNC), Medicaid participation, or a family income less than $12,000/year. Outcome Measures: Maternal report of seven initial PNC procedures (individually and combined), six areas of PNC advice (individually and combined), and participation in the Women Infant Children (WIC) nutrition program. Results: The content of PNC provided for low-income women does not meet the recommendations of the U.S. Public Health Service, and varies by site of delivery. Low-income women in publicly funded clinics (health departments and community health centers) report receiving more total initial PNC procedures and total PNC advice and have greater participation in the WIC program than similar women receiving PNC in private offices. Conclusions: Publicly funded sites of care appear to provide more comprehensive prenatal care services than private office settings. Health care systems reforms which assume equality of care across all sites, or which limit services to restricted sites, may foster unequal access to comprehensive PNC.     

WIC Participation and Breastfeeding Among White and Black Mothers: Data from Mississippi

Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been associated with lower rates of breastfeeding; studies have suggested this relationship may be modified by race. The purpose of this study is to examine the association between WIC participation and breastfeeding behaviors among white and black women in Mississippi. Using data from the 2004–2008 Mississippi Pregnancy Risk Assessment Monitoring System, we calculated multivariable prevalence and hazard ratios to assess the relationships among WIC participation during pregnancy and breastfeeding initiation and duration through 10 weeks postpartum. Stratified analyses were performed for white and black women. 52.2 % of white and 82.1 % of black women participated in WIC. 60.4 % of white and 39.7 % of black women initiated breastfeeding, and 26.5 % and 21.9 %, respectively, were breastfeeding at 10 weeks postpartum. WIC participation was negatively associated with breastfeeding initiation among whites (APR: 0.87; 95 % CI 0.77–0.99), but not blacks (APR: 0.99; 95 % CI 0.28–1.21). WIC participation was not associated with breastfeeding duration for women of either race (white: AHR: 1.05, 95 % CI 0.80–1.38; black: AHR: 0.91, 95 % CI 0.65–1.26). The results among white women suggest that Mississippi WIC might benefit from an in depth evaluation of the program’s breastfeeding promotional activities to determine if aspects of the program are undermining breastfeeding initiation. High rates of participation in the WIC program among black women, and the overall low rates of breastfeeding in this population point to the potential the program has to increase breastfeeding rates among blacks.     

Factors associated with rates of participation in WIC by eligible pregnant women.

The relationship between sociodemographic, biological, and prenatal care characteristics, and participation rates of pregnant women in the Special Supplemental Food Program For Women, Infants, and Children (WIC) was studied by interviewing 200 postpartum patients in a Buffalo, NY, hospital between October 1988 and January 1989. Among the 136 women eligible for the program, 94 (69 percent) participated during their index pregnancies. WIC participation was found to be highly associated with source of prenatal care and having made more frequent prenatal visits. WIC was related to having fewer children and earlier initiation of prenatal care. Multivariate analysis showed that program participation remained highly associated with the source of prenatal care and the number of prenatal visits, when combined with other factors considered, such as age, education, marital status, number of living children, and timing of initial prenatal visit. The results suggest the need for a WIC enrollment effort directed to providers of prenatal care, who would be urged to encourage women to seek early and adequate prenatal care through the program.     

The effect of a preterm birth prevention program in 17 rural and three urban counties in northwest North Carolina.

The results of a program of low birthweight prevention in 17 rural (20,727 births) and three urban counties (15,561 births) for calendar years 1985 and 1986 are described. Records for women in the program were matched with birth certificate data by computer. Rural and urban women in and out of the program were compared by race on the following risk factors: age less than 18 years, unmarried, education less than 12 years, Medicaid recipient, not WIC recipient, inadequate prenatal care, and previous fetal or live born death. Adjusting for these risk factors, logistic regression was used to estimate program effects on low birthweight (LBW), very low birthweight (VLBW), and preterm low birthweight (PLBW) among rural women. There was a statistically significant difference (p less than or equal to 0.01) favoring women in the program for very low birthweight and preterm low birthweight in white women, and low birthweight and preterm low birthweight in nonwhite women. The differences in rural areas exceed those in urban areas for all but one mean, very low birthweight births among white women.     

An Assessment of the Use and Impact of Ancillary Prenatal Care Services to Medicaid Women in Managed Care

Objectives: Managed care plans under Medicaid are becoming a usual source of care for low-income pregnant women. This study describes an ancillary prenatal care service intervention developed by one managed care organization (MCO) for Medicaid-enrolled women, assesses the extent to which the intervention services were used, and appraises the influence of the intervention on prenatal care participation. Method: There were 226 intervention and 258 control women with a single live birth delivered between 28 and 44 weeks gestation who (1) were enrolled in the MCO's Medicaid program, (2) were high-risk based on a prenatal risk assessment, and (3) started prenatal care prior to 26 weeks gestation. Less than adequate and intensive prenatal care utilization were chosen as intervention outcomes measures. Results: Family planning, a 2-month postpartum baby visit, a maternal postpartum visit, and a WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) referral were among the most self-selected intervention services for this population; home health aide and breast-feeding support were the least requested services. Over 90% of those needing family planning or breast-feeding services received the services, while over 20% of the intervention group refused child care, food assistance and family violence referrals, and home health aide and smoking cessation services. The intervention group had a significantly lower risk of less than adequate utilization of prenatal care (OR = .32; 95% CI: 0.17–0.60) and was more likely to have an intensive number of prenatal care visits (OR = 1.61; 95% CI: 1.05–2.48). Conclusions: The ability of managed care organizations to provide ongoing prenatal care to Medicaid populations in a cost-effective manner depends partly on their development of packages of prenatal services that foster positive preventive health care utilization behaviors and good pregnancy outcomes. The results of this project suggest that the intervention was beneficial in the area of improving utilization of prenatal care.     

Piecing together the crazy quilt of prenatal care

The failure to provide adequate prenatal care for low-income pregnant women in the United States and the effects of this failure on infant mortality are well known. Many studies have identified institutional barriers against access to care as a major cause. To overcome these barriers, Public Health District V, South Central Idaho, has created a comprehensive prenatal health care model that has almost tripled participation in its program during the first year of implementation and increased it again significantly during the second year. This decentralized pregnancy program has succeeded in getting all of the physicians offering obstetrical care in the district to serve low-income pregnant clients on a rotating basis. The new program provides pregnancy testing as well as financial screening services. Also, it has combined support services into one-stop-shopping clinics that include an innovative expansion of the Women, Infants and Children (WIC) Program of the U. S. Department of Agriculture. WIC food vouchers help attract clients into the prenatal care system and keep them coming. Enrichment of the duties of the public health nurse provides case coordination that pulls together the patchwork of medical and support services for the pregnant client.     

WIC participation and pregnancy outcomes: Massachusetts Statewide Evaluation Project.

The effects of WIC prenatal participation were examined using data from the Massachusetts Birth and Death Registry. The birth outcomes of 4,126 pregnant women who participated in the WIC program and gave birth in 1978 were compared to those of 4,126 women individually matched on maternal age, race, parity, education, and marital status who did not participate in WIC. WIC prenatal participants are at greater demographic risk for poor pregnancy outcomes compare to all women in the same community. WIC participation is associated with improved pregnancy outcomes, including, a decrease in low birthweight (LBW) incidence (6.9 per cent vs 8.7 per cent) and neonatal mortality (12 vs 35 deaths), an increase in gestational age (40.0 vs 39.7 weeks), and a reduction in inadequate prenatal care (3.8 per cent vs 7.0 per cent). Stratification by demographic subpopulations indicates that subpopulations at higher risk (teenage, unmarried, and Hispanic origin women) have more enhanced pregnancy outcomes associated with WIC participation. Stratification by duration of participation indicates that increased participation is associated with enhanced pregnancy outcomes. While these findings suggest that birth outcome differences are a function of WIC participation, other factors which might distinguish between the two groups could also serve as the basis for alternative explanations.     

A proposal for detecting and managing gestational diabetes by coordinating existing services

A significant improvement in the quality of births by low-income women can be achieved by implementing a low-cost screening procedure and by coordinating private and public sector services that these women may already be receiving. This proposal outlines a screening program for gestational diabetes, coupled with multidisciplinary team management of this disorder through cooperative efforts of private sector medical practitioners and the public sector nutrition program for Women, Infants, and Children (WIC). The investment in this proposal is catalytic: the long-term intent is to persuade those in the medical community in the targeted geographic area to adopt the screening procedure and coordination with the WIC Program as a standard part of their prenatal care. If this proposed program is successful, it could be replicated in other parts of the country.     

Drawing women into prenatal care

Participation in prenatal care services in the United States is low relative to that in many other developed countries, and rates of use are declining among some high risk groups. In 1986, 18 percent of all U.S. infants were born to women who delayed care until the second trimester of pregnancy; four percent, to women who initiated care in the third trimester; and about two percent, to women who obtained no prenatal care at all. Among the major barriers to prenatal care are inadequate insurance coverage, limitations in the Medicaid program, inadequate capacity in the maternity care system, lack of coordination between health and social services for low-income women and inhospitable conditions at some sites where prenatal care is delivered. The personal beliefs, knowledge, attitudes, fears and lifestyles of some pregnant women also constitute obstacles to care. For example, having an unwanted pregnancy, attaching little value to prenatal care and having a tenuous connection to the health care system in general are important predictors of insufficient care. Encouraging universal participation in prenatal care will require a major overhaul of the maternity care system. However, while consensus for fundamental reform builds, several immediate steps should be taken--such as reducing financial barriers to care; expanding the capacity of the maternity care system; improving the policies and practices that shape prenatal services at the site where they are delivered; and increasing public information.     

Low Prenatal Weight Gain Among Adult WIC Participants Delivering Term Singleton Infants: Variation by Maternal and Program Participation Characteristics

Objective: To determine the association of maternal and prenatal WIC program participation characteristics with low prenatal weight gain among adult women delivering liveborn, singleton infants at term. Methods: WIC program data for 19,017 Black and White Alabama women delivering in 1994 were linked with birth certificate files to examine the association of anthropometric, demographic, reproductive, hematologic, behavioral and program participation characteristics with low prenatal weight gain. Results: One third (31.0%) had low prenatal weight gain as defined by the Institute of Medicine. The incidence of low weight gain was increased among women who had < 12 years of education, were single, Black, anemic, had low or normal pre-pregnancy body mass index (BMI), increased parity, interpregnancy intervals 24 months, used tobacco or alcohol, or entered prenatal care or WIC programs after the first trimester. After adjusting for selected maternal characteristics, the adjusted odds ratios (AOR) for low weight gain were increased with short interpregnancy intervals (AOR 1.21 to 2.20); tobacco use (AOR 1.16 to 1.40), anemia (AOR 1.20 to 1.25), and second trimester entry into prenatal care (AOR 1.14 to 1.20); the size of the AORs and 95% confidence intervals varied by BMI and racial subgroup. Conclusions: The results of this study suggest that WIC interventions targeting low prenatal weight gain be focused on risk factors present not only during pregnancy, but during the pre- and interconceptional periods as well. Interventions should target low BMI, tobacco use, and anemia, and include attention to nutrition screening and risk reduction among women in postpartum and family planning clinic settings.     

Perinatal health service use by women released from jail

Few studies have examined health care access for the growing population of pregnant women who cycle in and out of urban jails. The present study compared use of Medicaid-funded perinatal services for births to women who were in jail during pregnancy and births to women who had been in jail, but not while pregnant. Jail contact during pregnancy increased the likelihood women would receive prenatal care (odds ratio [OR] = 5.95; 95% confidence interval [CI] 2.18-16.23) and maternity support services (OR = 1.80; 95% CI 1.12-2.88), but was associated with fewer total prenatal and support visits. Jail contact during a previous pregnancy was associated with fewer prenatal care visits, more support service visits, and longer time receiving case management. Jail settings can become a place of coordination between public health and criminal justice professionals to ensure that pregnant women receive essential services following release. Service coordination may increase women's engagement in health services during future pregnancies, with or without subsequent incarceration.     

The effects of prenatal care upon the health of the newborn.

Data upon all births and infant deaths in New York City in 1968 are analyzed using methods for the analysis of multidimensional contingency tables. These methods provide estimates of the effect of variations in prenatal care upon the relative risks of low birth weight and neonatal and postneonatal mortality, controlling for a wide variety of factors which tend to "select" women into a program of prenatal care. Significant relationships between lack of prenatal care and infant mortality are estimated, but these occur mainly via the relationship of inadequate prenatal care to low birth weight. Furthermore, among white mothers who delivered on a private service, those receiving inadequate levels of prenatal care experienced only slightly increased risks of a low birth weight infant. In contrast, white mothers who delivered on a general service, and all black mothers, experienced substantially increased risks when receiving inadequate prenatal care. A variety of behavioral characteristics of mothers were not controlled in these analyses, and thus clear causal inferences concerning the efficacy of prenatal care cannot be drawn. These analyses do, however, identify a significant population of women at substantial risk.     

Savings achieved by giving WIC benefits to women prenatally.

The Special Supplemental Food Program for Women, Infants, and Children (WIC) provides supplemental food, nutrition and health education, and social services referral to pregnant, breastfeeding, and post-partum women, and their infants and young children who are both low-income and at nutritional risk. A number of statistically controlled evaluations that compared prenatal women who received WIC services with demographically similar women who did not receive WIC services have found WIC enrollment associated with decreased levels of low birth weight among enrolled women''s infants. Several also have found lower overall maternal and infant hospital costs among women who had received prenatal WIC services compared with similar women who did not receive prenatal WIC services. A meta-analysis of the studies shows that providing WIC benefits to pregnant women is estimated to reduce low birth weight rates 25 percent and reduce very low birth weight births by 44 percent. Using these data to estimate costs, prenatal WIC enrollment is estimated to have reduced first year medical costs for U.S. infants by $1.19 billion in 1992. Savings from a reduction in estimated Medicaid expenditures in the first year post-partum more than offset the cost of the Federal prenatal WIC Program. Even using more conservative assumptions, providing prenatal WIC benefits was cost-beneficial. Because of the estimated program cost-savings, the U.S. General Accounting Office has recommended that all pregnant women at or below 185 percent of Federal poverty level be eligible for the program.     

Prenatal care utilization in New York City: comparison of measures and assessment of their significance for urban health.

This paper considers policy and programmatic consequences of shifting measurement of prenatal care utilization from the Kessner Index (KI) to the Adequacy of Prenatal Care Utilization Index (APNCUI). In gauging the adequacy of prenatal care utilization, the KI considers the timing of prenatal care initiation and the number of prenatal visits. The APNCUI also considers both timing of initiation and number of visits, but the approach taken to conceptualizing and measuring these two aspects of prenatal care utilization is more refined. We used birth certificates to calculate the KI and the APNGUI for 217,183 New York City (NYC) births in 1991-1992. We used cross-tabulations and bivariate odds ratios to compare the classifications resulting from the respective indexes. The APNCUI detected some important dimensions of the problem of inadequate prenatal care use that are not evident when using the KI. The proportion of births with inadequate use increases from 18% with the KI to 35% with the APNGUI. Groups of women at elevated risk for inadequate use are the same, but the KI understates significantly the risk for Hispanic women, teens, women who are less well educated, and those on WIC and Medicaid. The APNGUI yields a fuller picture of the degree to which some urban women are at risk for inadequate prenatal care use. Use of the APNGUI in quality assurance, monitoring, and research is recommended.     

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.     

Low birthweight and maternity care for all

The decline in infant mortality in 1983-84 was less than the average decline the US has been experiencing since the mid-1960s, suggesting that infant mortality may be reaching a plateau. Moreover, indicators of timely provision of prenatal care decreased in 1983-84. 3 observations have been made regarding these new trends:) 1) the fact that infant mortality has been declining, albeit at a slower rate, despite relative stagnation in the rate of low birth weight infants, suggests that hospital-based intensive care is succeeding in preserving low birth weight babies; 2) the plateau in infant mortality may reflect the fact that the ability of neonatal intensive care to salvage low birth weight infants may be nearing its limit; and 3) Reagan's attack on social programs may be creating access problems that have a negative impact on infant mortality. Many feel that further reductions in neonatal mortality will be achieved only by reducing low birth weight, which accounts for 2/3 of infant mortality. Activities with potential for reducing low birth weight include: 1) risk identification, general health education, and family planning; 2) increased accessibility of early and regular prenatal care; 3) expansion of the content of prenatal care; 4) an extensive public information campaign; and 5) a multifaceted program of research on low birth weight. The Council on Maternal and Child Health of the national Association for Public Health Policy has proposed a universal maternity care program for the US aimed at assuring comprehensive prenatal and delivery care to all women and expanding the content of prenatal care to include nutrition, health education, and support services. Inadequacies in coverage for women with and without private insurance will be addressed by requiring insurrers to fully cover maternity care and offer coverage for the indigent. Such a program of universal maternity care would be a step toward a national health program.     

Determinants of inadequate prenatal care utilization by African American women

A convenience sample of city-dwelling African American women (n=246) was interviewed during each woman's postpartum stay at one of five hospitals in Washington, D.C. to determine their perceptions of factors influencing their prenatal care utilization. The Kotelchuck Adequacy of Prenatal Care Utilization Index was used to classify prenatal care utilization as either adequate (Adequate Plus and Adequate groups combined) or inadequate (Intermediate and Inadequate groups combined). Of the 246 women studied, 40% (99) had adequate prenatal care utilization. Using Classification and Regression Trees analysis, the following risk groups for inadequate prenatal care utilization were identified: women who reported psychosocial problems as barriers and who were not participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) (percent adequate=8.8); women who reported psychosocial problems as barriers, were participants of the WIC program, and reported substance use (percent adequate=13.8); and women who reported psychosocial problems as barriers, were participants of the WIC program, denied substance use, and reported childcare problems as barriers (percent adequate=20.0).     

Maternal Smoking and the Timing of WIC Enrollment

Objective: To investigate the association between the timing of enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and smoking among prenatal WIC participants. Methods: We use WIC data from eight states participating in the Pregnancy Nutrition Surveillance System (PNSS). We adjust the association between the timing of WIC participation and smoking behavior with a rich set of maternal characteristics. Results: Women who enroll in WIC in the first trimester of pregnancy are 2.7% points more likely to be smoking at intake than women who enroll in the third trimester. Among participants who smoked before pregnancy and at prenatal WIC enrollment, those who enrolled in the first trimester are 4.5% points more likely to quit smoking 3 months before delivery and 3.4% points more likely to quit by postpartum registration, compared with women who do not enroll in WIC until the third trimester. However, among pregravid smokers who report quitting by the first prenatal WIC visit, first-trimester enrollment is associated with a 2% point increase in relapse by postpartum registration. These results differ by race/ethnicity; white women who enroll early are 3.6% points more likely to relapse, while black women are 2.5% points less likely to relapse. Conclusions: Early WIC enrollment is associated with higher quit rates, although changes are modest when compared to the results from smoking cessation interventions for pregnant women. Given the prevalence of prenatal smoking among WIC participants, efforts to intensify WIC’s role in smoking cessation through more frequent, and more focused counseling should be encouraged.     

Fetal deaths in Mexican-American,black, and white non-Hispanic women seeking government-funded prenatal care

Hispanics of Mexican origin constitute the largest minority population in the Southwestern United States, yet little is known about their reproductive health. This study assessed ethnic differentials in fetal mortality at 20 or more weeks gestation and identified the social and behavioral predictors associated with this outcome among low-income Hispanic, black non-Hispanic and white non-Hispanic women. Records were used of 80,431 patients attending federally funded prenatal care clinics in California from 1984 through 1989. The fetal death rate per 1,000 liver births and fetal deaths was 7.8 for Hispanic, 8.4 for white non-Hispanic and 20.5 for black non-Hispanic women. These rates indicated favorable reproductive outcomes for Mexican Americans despite their social risk profile. An analysis of stillbirths by gestational age showed that Hispanic women stood a significantly lower risk of short-gestational stillbirths than non-Hispanics. In contrast, Hispanic women had a higher proportion of term stillbirths. Hispanic acculturation was a significant predictor of short-term gestation fetal deaths only. The inability to pay for health care was a strong predictor of fetal deaths for all ethnic groups, underscoring the need to ensure adequate access to maternity care for low-income women.This study was conducted under contract from the California Department of Health Services, Maternal and Child Health Branch, #90-11768. We appreciate the assistance and data support provided by Penelope Stephenson, Chief, Planning and Evaluation Section and the helpful comments provided by Dr. Rugmini Shah, Director, Maternal and Child Health Branch. The authors would also like to thank Connie Gee for her clerical support.