Innovations in Maternity Care forum by National Coalition on Health Care (www.nchc.org)

1. AABC Strong Start for
Mothers and Newborns
NCHC Forum: Innovations in Maternity Care
Jill Alliman, CNM, DNP
American Association of Birth Centers

2. Centers for Medicare and Medicaid Innovation
• Strong Start for Mothers and Newborns Initiative – joint effort
between CMS, HRSA & ACF
• Began in 2012 with effort to decrease elective births <39 weeks
• Test 3 models of enhanced prenatal care to reduce preterm birth
~ Birth centers ~ Centering or Group PNC ~ Maternity Care Home

3. Strong Start for Mothers and Newborns
Initiative
• 4-year initiative to evaluate 3 maternity care models of enhanced PNC for
women enrolled in Medicaid or CHIP who are at risk for having a preterm
birth
• Goal - determine if these approaches can
– reduce the rate of preterm births
– improve the health outcomes of pregnant women & newborns
– decrease anticipated cost of care during pregnancy, birth & over 1st
year of life for children born to mothers in Medicaid or CHIP.

4. Preliminary Data from AABC Strong Start

5. AABC Strong Start Enrollment
45 birth centers in 19 states
Enrollees: Medicaid/CHIP
• 8387 women enrolled
• 6007 Other Medicaid mothers
• Total 14,394 women BC care
• 6139 Strong Start newborns
• 3611 Other Medicaid newborns
• Total 9750 infants with Medicaid/CHIP coverage

6. AABC Preliminary Data: Demographics
Diversity of AABC Medicaid
Sample
• African American - 13%
• Hispanic – 23.6%
• Medicaid or CHIP beneficiary -
100%
• High School or less education -
52.1%
Diversity of previous birth center
study population
• African American 5.5%
• Hispanic 11.2%
• Medicaid beneficiaries 23.8%
• High School or less education -
28.3%
(Stapleton et al., 2013)

7. Race and Ethnicity US/AABC Strong
Start Sample
US AABC Strong Start
Hispanic/Latina 23.2%i 23.6%
Black 14.8%i 13.1%
White 54%i 64.8% (includes White
Hispanics)
American Indian, Native AK 1.1%i 1.1%
Asian 7%i 1.2%
i Hamilton, B., Martin, J., Osterman, M.
(2016)

8. Outcomes US/AABC Strong Start Sample
Maternal/Infant Health Indicator US
AABC Strong Start
Preliminary
Preterm Birth 9.62%i 4.66%
Low Birth Weight 8.07%i 3.6%
Very low birthweight 1.39%i 0.31%
Primary Cesarean 21.5%ii 8.7%
Total Cesarean (includes repeat) 32.0%i 12.4%
ii Osterman, M., Martin, J. (2014)
i Hamilton, B., Martin, J., Osterman, M. (2016)

9. AABC Strong Start Birth Centers & National Data

10. Birth Centers Exceed Quality Benchmarks

11. 365 Women with previous preterm birth(s):
Current pregnancy:
 8 gave birth at < 32 weeks
 44 gave birth between 32 -37 weeks
 313 gave birth at term
Total PTB rate for women with previous PTB – 14.25% *
Sub-Group Analysis of Women at
Highest Risk for Preterm Birth

12. African American Women at Highest Risk
for Preterm Birth in U.S.
• Black women have 1.5 x risk of PTB
• Black women in the US have almost 2x
risk of having a low birth weight infant
• In Strong Start preliminary birth data:
o Black women = 742 of 6139 births
o Current pregnancy in AABC Strong Start 39 of 742 =5.26%
o VPTB = 9 (1.21%); MPTB = 30 (4.04%)

13. Where can we go from here?
Challenges and Opportunities

14. Strong Start Data Demonstrate that
Birth Center Care is High Value Care
• BC Prenatal care is time intensive and relationship-based
• Enhanced prenatal care includes referrals to needed resources,
health education and emotional support
• Midwives see fewer women per day to achieve these outcomes
• Incentivizing birth center prenatal care results in savings to
employers and payers
• Cost savings occur in better prepared mothers, healthier breastfed
babies, lower rates of cesareans and interventions

15. Estimated Cost Savings
• Lower cesarean rates and fewer medical interventions,
reductions in preterm, low birthweight births when care
provided in the birth center
• Estimated Medicaid savings cesareans prevented per
10,000 births $4.35 million
• Estimated savings reduction in preterm births per 10,000
births $24.25 million

16. Alternative Payment Models
• Pay for performance, incentive payments, episode of care
• Birth Centers in HCP-LAN White Paper on Maternity Care
episodes of care and AABC in Maternity Action
Collaboration
• Seeking demonstration project with Medicaid MCO as next
step

17. Federal Model Birth Center
• Proposed federally qualified birth and women’s center
would provide maternity care in underserved areas
• Improve outcomes of care in rural or urban areas with
severe disparities
• Providing local access to maternity care improves
outcomes for mothers and babies & lowers the cost of care
• Give more mothers and babies a Strong Start Birth Center

18. References
Hamilton, B., Martin, J., Osterman, M. (2016). Births: Preliminary data for 2015. National Vital
Statistics reports; Vol 65 (3). Hyattsville, MD. National Center for Health Statistics.
Laughon SK, Albert PS, Leishear K, et al. The NICHD Consecutive Pregnancies Study: recurrent
preterm delivery by subtype. Am J Obstet Gynecol 2014;210:131.e1-8.
Osterman, M., Martin, J. (2014). Primary cesarean delivery rates, by state: Results from the
revised birth certificate, 2006-2012. National Vital Statistics Reports; Vol 63 (1). Hyattsville,
MD. National Center for Health Statistics.
Stapleton, S. R., Osborne, C., & Illuzi, J. (2013). Outcomes of care in birth centers:
Demonstration of a durable model. J Midwifery Womens Health 2013;58:3–14.
Washington State Healthcare Authority (2016). Reimbursement of births performed at birth
centers. Clinical Quality Transformation. Olympia, WA.
https://www.hca.wa.gov/assets/program/2eshb-2376-birth-centers.pdf