Programs
December 16, 2024
Strong Start
Program overview
- Enhancing pre-natal care: The Strong Start for Mothers and Newborns initiative (Strong Start), sponsored by the U.S. Department of Health and Human Services (HHS), helped new mothers access one of three enhanced prenatal care models: maternity care homes, group prenatal care, and birth centers following the midwifery model of care. The five-year Strong Start evaluation, led by the Urban Institute, studied the implementation and impacts of Strong Start on access to care, birth outcomes, and costs.
- Federally funded, locally operated: As part of its Strong Start model, HHS awarded funding to a variety of local partners, ranging from large healthcare systems to freestanding birthing centers, to implement one of the three approved models. Strong Start programming targeted pregnant and parenting people who received Medicaid or CHIP. All sites pursued goals of reducing rates of preterm birth and low birth weight among Strong Start participants.
- Choosing a model according to existing strengths: Strong Start sites implemented one of the three approved enhanced prenatal care models: (1) Birth Centers where midwives delivered a more time-intensive, holistic, person-centered model of prenatal care; Group Prenatal Care where prenatal care was provided in group setting with emphasis on education and building supportive peer relationships; and Maternity Care Homes where all or most services are provided under one roof and women have the support of a care coordinator.
- Holistic, relationship-centered care: All Strong Start models emphasized the relationship between the participants and their care provider, which provided a vehicle for education as well as social and emotional support, including routine health assessments, health education (e.g., covering nutrition, stress management, and more), and social services (e.g., transportation assistance).
One study with a less-rigorous design suggests that the Birth Centers model is a promising strategy for improving maternal health.
- A 2018 impact evaluation found that, compared to “typical” Medicaid prenatal care (i.e., medical model of care):
- For two of the models tested – Group Prenatal Care and Maternity Care Homes – few, if any, impacts on birth outcomes or costs were found.
- For Birth Centers, however, the evaluation found women receiving care in the model experienced significantly improved outcomes, including:
- 20% lower rates of low birthweight births (5.9% vs. 7.4%)
- 40% fewer C-section deliveries (17.5% vs. 29%)
- 20% lower costs in the delivery period (about $1,800)
- 16% lower costs for mothers and infants during the baby’s first year of life (just over $2,000)
- Investing in relationship-based care is critical: All three models used in Strong Start, to varying degrees, emphasized the importance of relationships in supporting pregnant people, answering their questions, addressing their concerns, and sharing in decision-making. For birth centers, the midwife was the key partner for pregnant women, though Strong Start models also involved peer counselors. For group prenatal care, it was the peers involved in the series of group visits. And for maternity care homes, the care coordinator typically filled this role. The Strong Start evaluation found that participants consistently said the quality of these relationships was critical to the success of the models. To ensure peer counselors are developing strong relationships with their patients and that their knowledge base is useful to participants, replicating organizations should focus on a holistic approach to building strong patient centered care using peer counselors.
- Moving the Needle Forward: Maternity care in the US continues to be dominated by medical model of prenatal care delivered by physicians and hospitals, but we know that when not complemented by a robust social safety net, this system consistently produces worse outcomes at higher cost, relative to costs and outcomes in similarly developed countries. At the same time, it’s unrealistic to expect birth centers to become dominant maternity care provider under Medicaid (or in US) any time soon, thus typical maternity care settings—where vast majority of women of all incomes receive care—will continue to face challenges in improving outcomes for women and their infants. To move the needle:
- Traditional maternity providers can adopt more comprehensive time-intensive approaches that address both medical AND social determinants of health, that go beyond medical care to focus on education and psychosocial support; and
- Medicaid programs can require and facilitate managed care contacts with birth centers that reimburse midwives and birth centers adequately.