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March 16, 2016
by Patrick Conway, M.D., CMS Principal Deputy Administrator and Chief Medical Officer
CMS Strong Start for Mothers and Newborns Strategy II Initiative
Second Annual Evaluation Report
Today, we at the Centers for Medicare & Medicaid Services (CMS) are pleased to announce findings from the second annual evaluation report for the Strong Start for Mothers and Newborns Strategy II Initiative. As noted with the release of our first annual report, Strong Start Strategy II seeks to build on work conducted by the Partnership for Patients and Strong Start Strategy I to improve newborn health through a reduction in early elective deliveries. Babies are generally healthier and have better long-range outcomes when they are born full-term. Strategy I contributed to a 64.5% nationwide drop in early elective deliveries from 2010 to 2013.
The Strong Start II (hereafter referred to as Strong Start) builds on this success through prenatal care enhancements addressing the psychosocial needs of pregnant women eligible for Medicaid and CHIP. Strong Start is an important federal initiative geared toward testing innovative approaches to improve maternal and infant health outcomes in low-income families.
Research consistently shows that infants born preterm (before 37 completed weeks of gestation) have higher mortality risks and may endure a lifetime of developmental and health problems when compared to their counterparts born after 37 weeks’ gestation.
Prenatal care enhancements provided through Strong Start are designed to promote overall maternal and infant health and particularly to reduce incidence of preterm birth and low birth weight. The second annual report presents the progress Strategy II has made since its inception.
Strong Start has continued its partnership with 27 organizations representing nearly 200 provider sites in 32 states, Washington, D.C., and Puerto Rico. The program continues to provide enhanced services through three approaches:
- Group Care – Group prenatal care that incorporates peer-to-peer support in a facilitated setting for three components: health assessment, education, and support.
- Birth Centers – Comprehensive prenatal care facilitated by midwives and teams of health professionals, including peer counselors and doulas.
- Maternity Care Homes – Enhanced prenatal care at traditional prenatal sites with enhanced continuity of care and expanded access to care coordination, education, and other services.
Enrollment increased dramatically in the second year of program operations, with a total of 23,000 women enrolled from March 2013 to the end of the first calendar quarter of 2015. Enrollment is expected to continue to grow to more than 40,000 participants by the program’s end in February 2017. Additionally, participants continue to express overwhelming satisfaction, with 90% stating that they were either very satisfied or extremely satisfied with their prenatal care.
In addition to their standard schedule of prenatal care visits, Strong Start participants receive enhanced care visits in accordance with their psychosocial needs. Enhanced visits provide services such as care coordination, referrals to local resources, prenatal health education, and peer support.
Upon enrollment, Strong Start participants have several risk factors, including many pertaining to psychosocial needs:
- Depression upon enrollment (nearly a quarter of participants report being depressed at intake)
- Unstable housing
- Unmet mental health and dental needs
- Food insecurity
- Unmarried or unpartnered status
Results from the second year evaluation indicate that, as was found in the first year, Strong Start participants have:
- Lower rates of cesarean section than national averages, though there is wide variation among and within models
- Higher rates of breastfeeding than national averages among similar populations
In addition, the new report finds that Strong Start participants have:
- Overall preterm birth rates similar to national averages despite the high-risk population served
- Lower preterm birth rates than national averages within racial-ethnic groups (Black , White, Hispanic)
- Vaginal birth after cesarean rates that are nearly twice the national average
Although findings must be interpreted with caution because they are descriptive, we are pleased with what we have found thus far.  Substantial progress was made during the second evaluation year in developing resources, particularly obtaining state Medicaid claims linked to vital records, which will enable development of a control group and an analysis of costs. The third annual report is anticipated to contain analysis of further participant-level data, case studies based on site visits, and an initial analysis of linked data from states.
Much work remains to be done to reduce significant risks and complications for pregnant women and infants, but these early results from the Strong Start evaluation show promise for improving pregnancy outcomes. We remain committed to working together to deliver higher quality care, smarter spending, and better health outcomes for low-income pregnant women and their newborns.
 Findings thus far cannot be directly attributed to Strong Start. Comparisons with national averages do not control for important factors, such as risk profiles or demographics. In future reports, linked Medicaid claims and vital records data will be the basis for a controlled comparison.