Sarah Benatar

Midwifery Care at a Freestanding Birth Center: A Safe and Effective Alternative to Conventional Maternity Care

OBJECTIVE To estimate the effect of a midwifery model of care delivered in a freestanding birth center on maternal and infant outcomes when compared with conventional care. DATA SOURCES/STUDY SETTING Birth certificate data for women who gave birth in Washington D.C. and D.C. residents who gave birth in other jurisdictions. STUDY DESIGN Using propensity score modeling and instrumental variable analysis, we compare maternal and infant outcomes among women who receive prenatal care from birth center midwives and women who receive usual care. We match on observable characteristics available on the birth certificate, and we use distance to the birth center as an instrument. DATA COLLECTION/EXTRACTION METHODS Birth certificate data from 2005 to 2008. PRINCIPAL FINDINGS Women who receive birth center care are less likely to have a C-section, more likely to carry to term, and are more likely to deliver on a weekend, suggesting less intervention overall. While less consistent, findings also suggest improved infant outcomes. CONCLUSIONS For women without medical complications who are able to be served in either setting, our findings suggest that midwife-directed prenatal and labor care results in equal or improved maternal and infant outcomes.

CHIP and Medicaid: Evolving to Meet the Needs of Children.

OBJECTIVE To examine the evolution of Childrens Health Insurance Program (CHIP) and Medicaid programs after passage of the Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA), focusing on policies affecting eligibility, enrollment, renewal, benefits, access to care, cost sharing, and preparation for health care reform. METHODS Case studies were conducted in 10 states during 2012-which included key informant interviews and consumer focus groups-and a national survey of state CHIP program administrators was conducted in early 2013. RESULTS Despite the recession that persisted during much of the study period, many states expanded childrens coverage by raising upper income eligibility limits or by covering new groups made eligible by CHIPRA. Simplifying rules and procedures for enrollment and renewal continued to be a major priority for CHIP and Medicaid, and CHIPRA played a direct role in spurring innovation. CHIPRAs outreach grants played an important role in supporting and supplementing state outreach efforts. Important legacies of CHIPRA are the laws mandatory requirements for comprehensive dental benefits coverage and mental health parity for all types of CHIP programs. Although most states already offered generous coverage of these benefits, the mandate may have protected them from cuts during the economic downturn. Federal Maintenance of Effort rules were a crucial protection for CHIP, especially during the recession when state budget shortfalls could have led to program cuts. CONCLUSIONS Passage of the Affordable Care Act has raised questions surrounding the future role of CHIP in a reformed health care system. A growing number of stakeholders have recommended a 2-year extension of federal CHIP funding to allow complex transition issues to be resolved.

Potential Medicaid Cost Savings from Maternity Care Based at a Freestanding Birth Center

OBJECTIVES Medicaid pays for about half the births in the United States, at very high cost. Compared to usual obstetrical care, care by midwives at a birth center could reduce costs to the Medicaid program. This study draws on information from a previous study of the outcomes of birth center care to determine whether such care reduces Medicaid costs for low income women. METHODS The study uses results from a study of maternal and infant outcomes at the Family Health and Birth Center in Washington, D.C. Costs to Medicaid are derived from birth center data and from other national sources of the cost of obstetrical care. RESULTS We estimate that birth center care could save an average of

Inequality and Innovation: Barriers and Facilitators to 17P Administration to Prevent Preterm Birth among Medicaid Participants

1,163 per birth (2008 constant dollars), or

CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings

11.6 million per 10,000 births per year. CONCLUSIONS Medicaid is the leading payer for maternity services. As Medicaid faces continuing cost increases and budget constraints, policy makers should consider a larger role for midwives and birth centers in maternity care for low-risk Medicaid pregnant women.

CHIPRA Evaluation of the Children's Health Insurance Program: Cross Cutting Report on Findings from Ten State Case Studies

Objectives Strategies to prevent preterm birth are limited. 17 Alpha-Hydroxyprogesterone Caproate (17P) injections have been shown to be effective, but the intervention is under-used. This mixed methods study investigates barriers and facilitators to 17P administration among Medicaid and CHIP participants enrolled in Strong Start for Mothers and Newborns, a federal preterm birth prevention program. Methods Twenty-seven awardees with more than 200 sites in 30 states, the District of Columbia, and Puerto Rico enrolled approximately 46,000 women in Strong Start from 2013 to 2016. Participant data, including data on preterm birth and 17P, was collected for each woman. Intensive interviews (n = 211) conducted with Strong Start program staff and providers (n = 314) included questions about 17P provision. Results Of women whose data included a valid response regarding 17P initiation, 3919 had a prior preterm birth and current singleton pregnancy; 14.95% received 17P. Barriers to 17P administration include late entry to prenatal care, administrative burden of preauthorization, cost risks to providers, limits in scope of practice for non-physician providers, and social barriers among participants. Facilitators for provision include streamlined work flows and the option of home administration. Conclusions for Practice A universal insurance authorization process could mitigate many barriers to 17P use. Providers need continuing education regarding the effectiveness of 17P, and expanding scope of practice for non-physician prenatal care providers would increase access. Targeted program interventions can help to overcome social barriers Medicaid participants face in accessing care. Streamlined work processes and the option of home health services are two effective program-based facilitators for providing 17P to a Medicaid population.