IHI Innovation Director Marian Bihrle Johnson, IHI Research Associate Jeff Rakover, and IHI Fellow Lucy Pickard provide an overview of IHI’s theory for how a community might improve health and health outcomes for women of childbearing age, reduce rates of preterm birth, and decrease per capita costs of care.
Half of all births each year in the US are financed by Medicaid, and poor birth outcomes are more prevalent in the Medicaid population. Specifically, the rate of preterm birth, a major cause of excess neonatal mortality and morbidity, high costs, and family disruption, is 25% higher in the Medicaid population than in the commercially insured population.
Amid changes in access, payment, and delivery models, many states, communities, and organizations are developing strategies to improve care and reduce costs for Medicaid populations; however, no state or region has developed a comprehensive population health approach for pregnant women. Given the large proportion of Medicaid costs related to perinatal care and the substantial potential to reduce disparities, a focused effort on prevention in this population represents a significant opportunity for improvements in outcomes, costs, and social cohesion.
In April 2015, IHI began to develop a population approach to maternal health, with a focus on reducing disparities in outcomes and reducing preterm birth for pregnant Medicaid beneficiaries. Methods for this work include: a national scan for best practice models; a thorough evidence scan of risk factors and interventions to reduce preterm birth; interviews with 40 experts in 15 states to understand state and regional approaches to perinatal care; and an expert design meeting in September 2015 that brought together payers, providers, leaders of community-based organizations, health services researchers, national policy experts, and patient representatives to vet and further develop a theory of change for how to improve birth outcomes among Medicaid beneficiaries.
A Theory of Change
Based on the research completed to date, IHI produced a validated theory for how a community might improve health and health outcomes for women of childbearing age, reduce rates of preterm birth, and decrease per capita costs of care. The vision for this work is women who are supported across the reproductive life span; connected and served by integrated resources to overcome barriers to health and well-being; and reliably receive evidence-based, population-specific care.
To help achieve this vision, IHI proposes an integrated testing approach of four evidence-based interventions in a community. While these practices have been deployed previously on individuals, on a limited basis, they have not been tested together as part of a reliable system of care. We believe that “bundling” these four interventions will enhance their impact on maternal and newborn outcomes.
Testing Four Evidence-Based Interventions
Currently, IHI is testing four interventions with a small number of organizations and communities serving populations of Medicaid beneficiaries. The aim is to develop a refined and validated population health model and package of changes to implement this model in underserved communities that may be ready to be spread in the near future.
The Pregnancy Medical Home Model
This model adapts the principles of the patient-centered medical home to pregnancy, particularly in addressing the integration of clinical and social needs, but also serving as a system to ensure that risk factors are evaluated and the best clinical evidence is reliably delivered to all women. (The principles include a personal physician; a physician-directed medical practice; whole person orientation; care is coordinated and integrated; quality and safety; enhanced access; and payment that recognizes the value offered to patients by the model.) The states of North Carolina and Wisconsin, as well as other states pursuing smaller scale efforts, have piloted or established pregnancy medical home programs, and this model is a part of the Center for Medicare and Medicaid Innovation Strong Start for Mothers and Newborns Initiative. Adopting these elements is central to a population-focused model of perinatal care, and further research is needed to help illuminate how best to implement the model in different payer and provider contexts, particularly in resource-poor settings with a focus on reducing disparities.
Peer Support, Including Group Prenatal Care
Group prenatal care has emerged as an intervention with relatively strong evidence supporting both improved perinatal outcomes overall and reduced racial and ethnic disparities in birth outcomes. A recent review found significant support for group prenatal care as an intervention leading to reductions in preterm birth and a 2012 study found group prenatal care improved adverse birth outcomes among African American women. Testing for this intervention would focus on increased access to peer support systems in socially disadvantaged communities and would test ways to engage pregnant and postpartum women.
Pregnancy Intention and Access to Effective Contraception
Unintended pregnancies account for half of all births. Recent evaluations of long-acting reversible contraceptive (LARC) use have shown impressive results in dramatically reducing unplanned pregnancy and the associated adverse birth outcomes, including preterm birth. Still, reproductive life course planning and the use LARCs remain underutilized in the United States. There exist clear gaps in knowledge around integrating LARC access into existing workflows, developing culturally competent approaches to improving LARC access, and evaluating the impact of improved access on disparities in perinatal outcomes.
Integrating Substance Abuse Treatment with Perinatal Care
In the past decade, many communities have seen vastly increased rates of substance abuse. The incidence of neonatal abstinence syndrome rose 300 percent between 2000 and 2009. Several models exist to integrate substance abuse management programs with perinatal care, with promising results. Deeper testing is needed to determine the key elements of integrating substance abuse treatment with perinatal care, with a focus on reducing racial and ethnic health disparities.
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The Maternity Medical Home: The Chassis for a More Holistic Model of Pregnancy Care?
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Impact Evaluation of a Quality Improvement Intervention on Maternal and Child Health Outcomes in Northern Ghana: Early Assessment of a National Scale-up Project
The IHI Virtual Expedition: Advancing Safer Maternal and Newborn Care, one of the benefits included in the Passport to IHI Training membership.