Jolles DR, Langford R, Stapleton S, Cesario S, Koci A, Alliman J
Abstract
BACKGROUND:
Variations in care for pregnant women have been reported to affect pregnancy outcomes.
METHODS:
This study examined data for all 3136 Medicaid beneficiaries enrolled at American Association of Birth Centers (AABC) Center for Medicare and Medicaid Innovation Strong Start sites who gave birth between 2012 and 2014. Using the AABC Perinatal Data Registry, descriptive statistics were used to evaluate socio-behavioral and medical risks, and core perinatal quality outcomes. Next, the 2082 patients coded as low medical risk on admission in labor were analyzed for effective care and preference sensitive care variations. Finally, using binary logistic regression, the associations between selected care processes and cesarean delivery were explored.
RESULTS:
Medicaid beneficiaries enrolled at AABC sites had diverse socio-behavioral and medical risk profiles and exceeded quality benchmarks for induction, episiotomy, cesarean, and breastfeeding. Among medically low-risk women, the model demonstrated effective care variations including 82% attendance at prenatal education classes, 99% receiving midwifery-led prenatal care, and 84% with midwifery- attended birth. Patient preferences were adhered to with 83% of women achieving birth at their preferred site of birth, and 95% of women using their preferred infant feeding method. Elective hospitalization in labor was associated with a 4-times greater risk of cesarean birth among medically low-risk childbearing Medicaid beneficiaries.
CONCLUSIONS:
The birth center model demonstrates the capability to achieve the triple aims of improved population health, patient experience, and value.
Insights Results
Overview of model
This study examined data for all 3,136 Medicaid beneficiaries enrolled at American Association of Birth Centers (AABC) Center for Medicare and Medicaid Innovation Strong Start sites who gave birth between 2012 and 2014
In 2012, the Center for Medicare and Medicaid Innovation began Strong Start for Mothers and Newborns, a 4-year initiative to test innovative models for improving childbirth outcomes for Medicaid beneficiaries. Data from the Strong Start grant sites provides an opportunity to evaluate Level 1 care as the appropriate level of care for the majority of childbearing Medicaid beneficiaries
AABC model of care is a risk appropriate, Level 1 model of care serving a socio-demographically diverse, predominantly low risk population
Methods
Authors analyzed data from the AABC Perinatal Data Registry. This analysis includes all 3,136 Medicaid beneficiaries enrolled in prenatal care with AABC Strong Start sites between 2012 and 2014 who gave birth during this 3-year time period
A descriptive analysis of socio-demographic and medical characteristics of the sample were compared with publicly available national birth certificate data and analyzed for similarities. Next, the core perinatal outcomes of all 3,136 childbearing Medicaid beneficiaries giving birth at Strong Start sites, including medically indicated transfers of care, were analyzed and compared with national birth statistics from 2013 and 2014. Finally, cases coded as low risk on admission in labor were analyzed, using descriptive and inferential statistics to evaluate care processes, variations in care processes, and core quality outcomes
Results
The enrollees exhibited a similar socio-behavioral and medical risk profile as women giving birth in the United States during the same study time period
Enrollees exhibited: lower induction ( there were no elective inductions of labor before 39 weeks), episiotomy (2.1%, below the national benchmark of 5%), cesarean delivery (one-half of the national rate of 26.9%), and higher breastfeeding (92.7% higher than the national average of 41.5%) than national benchmarks
The AABC model of care demonstrated good accountability to patient preferences, specifically for preferences around infant feeding and elective use of hospitalization in childbirth among medically low-risk women. Additionally, the majority (83%) of childbearing women who were at low medical risk delivered at their intended birth site
Key takeaways/implications
Care conversations (i.e., conversations between patients and providers about their care) through the AABC model suggest the potential for protection against disparities in breast feeding and cesarean sections
Overall, the AABC model is appropriate for socio-demographically diverse, low-risk, childbearing Medicaid beneficiaries. Further, it is aligned with the national quality movement, showing adherence to effective
More research is needed to understand the underutilization of birth centers within communities of color and the potential for the model to reduce racial and ethnic disparities in birth outcomes. Additionally, research on elective hospitalization is warranted as 80% of costs of childbirth are consumed by the hospital facility fees associated with birth
