Jennifer E. Raffo

A statewide Medicaid enhanced prenatal care program: impact on birth outcomes.

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.

Medicaid Home Visitation and Maternal and Infant Healthcare Utilization

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.

Who Participates in State Sponsored Medicaid Enhanced Prenatal Services

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.

Infant health effects of a nurse–community health worker home visitation programme: a randomized controlled trial

BACKGROUND   Home visiting is supported as a way to improve child health and development. Home visiting has been usually provided by nurses or community health workers (CHWs). Few studies compared the child health advantages of a nurse-CHW team approach over nurse prenatal and postnatal home visiting. METHODS   A randomized trial was conducted with Medicaid-insured pregnant women in Kent County, Michigan. Pregnant women were assigned to a team intervention including nurse-CHW home visitation, or standard community care (CC) including nurse home visitation. Morbidity was assessed in 530 infants over their first 12 months of life from medical claims and reported by the mother. RESULTS   There were no differences in overall child health between the nurse-CHW intervention and the CC arm over the first year of life. There were fewer mother-reported asthma/wheezing/croup diagnostics in the team intervention group among infants whose mothers have low psychosocial resources (13% vs. 27%, P = 0.01; adjusted OR = 0.4, P = 0.01). There were no differences in diagnosed asthma/wheezing/croup documented by medical claims. There were no differences in immunizations, hospitalizations and ear infections. CONCLUSIONS   There was no strong evidence that infant health was improved by the addition of CHWs to a programme of CC that included nurse home visitation. Targeting such interventions at common health problems of infancy and childhood or at diagnosed chronic conditions may prove more successful.

Psychological and Physical Abuse Among Pregnant Women in a Medicaid-Sponsored Prenatal Program

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 Cohens 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.

Populations at Risk Across the Lifespan: Case Studies: Psychological and Physical Abuse Among Pregnant Women in a Medicaid-Sponsored Prenatal Program

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 Cohens 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.

Moving toward evidence-based federal Healthy Start program evaluations: accounting for bias in birth outcomes studies.

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.

Maternal Perceptions of Help From Home Visits by Nurse–Community Health Worker Teams

We used data from a home visiting trial to examine low-income womens 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.

Statewide Medicaid Enhanced Prenatal Care Programs and Infant Mortality.

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.

Defining the Role of the Community Health Worker within a Federal Healthy Start Care Coordination Team

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.