Strong Start for Mothers and Newborns Evaluation: Year 5 Project Synthesis Volume 1: Cross Cutting Findings

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1 g Star t f or Mothe rs and Newbor ns Evaluation: Stron YNTHESIS ROJECT S AR 5 P YE Volume 1 indings -Cutting F ross : C Prepared for: ss Caitlin Cro -Barnet Center fo HS nd Medicaid Innovation, DH r Medicare a 00 -5 Contract No.: HHS 0004 -T M 1 Deliverable N o. : 5. Prepared by: ll ( ubay, Brigette Co Project Director), Lisa D Ian Hi urtot, Sarah B well, red Blavin, Embry Ho arrett, F , Bowen G enatar nstitute Urban I ustin Morgan – nd J arkell, a enny M h Thornburgh, J n, Sara va Alle ohnston, E Emily J Carroll, J Sharon Silow- anagemen Health M ssociates l – odi B itterman, Diana R odin, and Robyn Ode ndah t A esearch d Kirsten F o, an cad ennifer Lu hompson, J e T Kathryn Paez, Le irminge r – American In stitutes for R Benita Sinnarajah, Lynn Paquin, and Mark Rouse – , LLC Briljent October 2018 :: : URBAN EALTH H ···• INSTITUTE MANAGEMENT ~AIR ASSOCIATES

2 Acknowledgments This report was funded by the Center for Medicare and Medicaid Innovation (CMMI) at the Centers for & Medicare . We are grateful to them and to all our funders, who make it Medicaid Services (CMS) to advance its mission. possible for the Urban Institute The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and ’s funding principles is recommendations of Urban experts. Further information on the Urban Institute available at https://www.urban.org/aboutus/support-urban -institute . The authors would like to thank the many Strong Start awardee staff and providers across the nation who gave so freely of their time and insights during our case studies, and who diligently collected evaluation and submitted the process evaluation data needed for this . Our sincere thanks also go out to the many state Vital Records and Medicaid staff who worked closely with us to provide birth certificate, Medicaid d our Impact Analysis. Without their diligent eligibility and claims/encounter data that enable able to complete this study. and painstaking efforts, we would not have en be Many evaluation team members who contributed to the Strong Start evaluation throughout the ve thanks, including Luis Basurto Alyssa Harris, year also deser , Sarah Coquillat, Nikhil Holla, Paul Rebecca Jeremy Marks, Sybil Mendonca, Peters, from the Urban Institute; Johnson, Jessica Kelly, and Brooke Ehrenpreis, Rebecca Kellenberg, Margaret Kirkegaard, and Ahn Pham from Health Marci Eads, Management Associates; Graciela Castillo, Lori Downing, Deepa Ganachari, Jazmine Orazi, Ushma from American Institutes for Research; and Emily Patel, Yan Wang, Manshu Yang, and Charis Yousefian . from Briljent, LLC Dunn and Andrea Light Finally , as ever, , Caitlin we are grateful to our federal contract officer at CMMI/DHHS Cross -Barnet, for her thoughtful guidance, helpful assistance, critical advice, and tireless support to CMMI’s Director of the throughout the conduct of this evaluation. Sincere t hanks go out as well and Director of the Division of the Research and Rapid Cycle Evaluation Group Renee Mentnech for their always helpful leadership and counsel. William Clark, Special Populations Research September 2018. Urban Institute. Permission is granted for reproduction of this file, with attribution to Copyright © the Urban Institute. Cover image via Shutterstock .

3 Contents I EXECUTIVE SUMMARY ... SUMMARY OF FINDINGS ... ... II Who Was Served By Strong Start? ii ... ... ii What Were the Strong Start Interventions? ... What Did Women Say About Their Experiences with Strong Start? iv ... What Outcomes Did Strong Start Participants Experience? iv ... Did Women’s Outcomes Compare Across Strong Start Models? How iv ... v What Were the Impacts of Strong Start on Birth Outcomes and Cost of Ca re? ... VI DISCUSSION ... INTRODUCTION 1 ... 3 OVERVIEW OF STRONG START ENHANCED PRENAT ... AL CARE MODELS 3 Birth Center Care ... Group Prenatal Care ... 4 Maternity Care Homes 5 ... ... STRONG START AWARDEE S AND SITES 6 ... EVALUATION DESIGN 10 Case Studies of Implementation 10 ... ... Participant 11 -Level Process Evaluation 12 ... ition Technical Assistance and Data Acquis ... 12 Impact Analysis ... 13 ESIS ORGANIZATION OF THE YEAR 5 PROJECT SYNTH 15 YEAR 5 RESULTS ... 15 CASE STUDIES ... ... 15 Description of the Strong Start Models ... 21 Intervention Intensity 23 Strong Start Implementation Challenges and Successes ... ... 35 Key Considerations for Replicating Strong Start Models ... Discussion 43 -LEVEL PROCESS EVALUATION FINDINGS: A DESCRIPTIVE LOOK AT PARTICIPANT PARTICIPANT RISK PRO 45 FILES, SERVICE USE AND OUTCOMES ... Introduction 45 ... PLPE Data Collection 45 ... 47 Completeness of PLPE Data ... 48 Methodology ... 49 Strong Start Participant Profiles ...

4 57 ity Visit Frequency and Intens ... 59 Interim Outcomes ... Strong Start Birth Outcomes ... 62 Limitations ... 66 67 Discussion ... ... 69 REGRESSION ADJUSTED OUTCOMES ANALYSES 70 ... Intermediate Outcomes ... Birth Outcomes 74 79 Depression ... ... 80 Limitations ... Discussion 81 ... TECHNICAL ASSISTANCE 83 AND DATA ACQUISITION ... Introduction 83 83 Summary of Progress: Data Approval and Receipt ... ... Summary of Technical Assistance & Data Acquisition Process and Timeline 85 ... 88 Lessons Learned ... 89 -Practices for Acquisition of State Agency Data Summary of Best IMPACT ANALYSIS 93 ... 93 ... Analytic Approach and Data Sources 103 ... Limitations of the Design del -Level Results 106 ... Mo Awardee -level Results 119 ... ... 125 Discussion 129 SUMMARY OF FINDINGS ... O WAS SERVED BY STRONG START? 129 ... WH 130 ? WHAT WERE THE STRONG START INTERVENTIONS ... WHAT DID WOMEN SAY A 133 ES WITH STRONG START? BOUT THEIR EXPERIENC ... WHAT OUTCOMES DID ST RONG START PARTICIPANTS EXPERIENCE? 134 ... HOW DID WOMEN’S OUTCOMES COMPARE ACROSS STRONG START MODELS? 135 ... WHAT WERE THE IMPACT COST OF CARE? S OF STRONG START ON BIRTH OUTCOMES AND 136 ... START ONDUCTING THE STRONG WHAT LESSONS DID EVALUATORS LEARN FROM C EVALUATION? 138 ... 141 SSION ... CONCLUDING DISCU ... 145 REFERENCES ... TECHNICAL APPENDICES 155

5 APPENDIX A: INTRODUC STRONG START STATE CHIP ELIGIBILITY, BY TION – MEDICAID AND 157 ... APPENDIX B: QUALITAT IVE CASE STUDY 161 HODOLOGY - MET ... Data Collection 162 ... 162 nalysis Coding and A ... Case Study Interview Guides 166 ... APPENDIX C: QUALITAT E STUDY INTERVIEWS C ONDUCTED IN YEAR 5 – CAS IVE CASE STUDY 185 ... 186 ative Case Study: Summary of Findings from South Carolina Medicaid Interview Qualit ... 187 Qualitative Case Study: Summary of Findings from Dr. Amy Crockett Interview ... Qualitative Case Study: Summary of Findings from Centering Healthcare Institute Interview . 189 Qualitative Case Study: Summary of Findings from Baby+Co. Interview 190 ... ALUATION 193 – INSTRUMENTS -LEVEL PROCESS EV ANT APPENDIX D: PARTICIP ... EASURES: – M OCESS EVALUATION -LEVEL PR PARTICIPANT APPENDIX E: PROCEDURES SCORING 211 ... CES 212 -D ... 212 GAD -7 ... Food Sufficiency 212 ... 213 Women’s Experience of Battery (WEB) ... 213 Slapped Threatened and Throw (STaT) ... APPENDIX F: PARTICIP GRAM MONITORING -LEVEL PROCESS EV ALUATION ANT – PRO 215 QUARTERLY PROGRESS R EPORT ... ANT 217 APPENDIX G: PARTICIP -LEVEL PROCESS EV ALUATION – DATA QUALITY SUMMARY ... 218 Data Quality Tables ... APPENDIX H: PARTICIP 221 GS, BY MODEL IN ALUATION – MAIN FIND -LEVEL PROCESS EV ANT .. Main Findings by Model and Overall 222 ... APPENDIX I: PARTICIP ANT -LEVEL PROCESS EV ALUATION – MAIN FIND INGS, BY AWARDEE 233 ... APPENDIX J: PARTICIP ANT -LEVEL PROCESS EV ALUATION MESTER AND – THIRD TRI POSTPARTUM FINDINGS, 249 BY MODEL ... Findings from the Third Trimester and Postpartum Surveys 250 ... ANT -LEVEL PROCESS EV ALUATION – THIRD TRI ME STER AND APPENDIX K: PARTICIP BY AWARDEE 253 POSTPARTUM FINDINGS, ... APPENDIX L: PARTICIP 257 ALUATION -LEVEL PROCESS EV – MULTIPLES ANT ... 258 Main Findings For Multiples ... 267 Findings from the Third Trimester and Postpartum Surveys ... APPENDIX M: REGRESSI ON-ADJUSTED OUTCOMES – REGRESSIO N SAMPLE AND 269 CS DESCRIPTIVE STATISTI ... Intermediate Outcomes Analysis 270 ...

6 Birth Outcomes Analysis 289 ... De ... 317 pression Analysis – FULL REGRESSION RESULTS ON-ADJUSTED OUTCOMES 347 ... APPENDIX N: REGRESSI 348 Intermediate Outcomes Analysis ... ... 355 Birth Outcomes Analysis 364 Depr ession Analysis ... CAID AND BIRTH APPENDIX O: TECHNICA L ASSISTANCE AND DAT – MEDI A ACQUISITION ... 373 CERTIFICATE DATA REQ UEST APPLICATIO NS: FREQUENTLY ASKED QUESTIONS ... General Project Information 374 ... 374 Project Description ... Data Request and Analyses 374 ... Data Security and Transfer Process 374 ... 375 APPENDIX P: IMPACT ANALYSIS – DETAILED D ESCRIPTION OF ANALYTIC APPROACH ... Computing Prop Weights ensity Scores and Propensity Score-Adjusted 376 ... 377 Estimating Impacts ... 379 Instrumental Variables Models Based on Distance to Site ... CISIONS – SUMMARY OF COMPARISON GROUP DE APPENDIX Q: IMPACT ANALYSIS 387 ... FOR PROPENSITY SCORE APPENDIX R: IMPACT ANALYSIS REWEIGHTING 391 – RATIONALE ... 392 core Reweighting vs. Matching for Estimating Strong Start Treatment Effects Propensity S ... PREPA APPENDIX S: IMPACT ANALYSIS – DATA RATION 395 ... Linking Birth Certificates to Medicaid Eligibility Data at the Urban 396 Institute ... Linking 398 ... Medicaid Claims and Encounter Data 401 ... – QU APPENDIX T: ALITY OF LINKING PRO CESS 409 IMPACT ANALYSIS ... Linking Datasets for the Strong Start Evaluation 410 ... Assessing Quality of Linkages 411 Linking Strong Start Participants to Birth Certificates, Medicaid Eligibility, and Medicaid Claims ... 413 Linking Birth Certificates to Medicaid Eligibility for Strong Start Participants and the ... Group 415 Comparison ... Linking Birth Certificates and Medicaid Eligibility to Medicaid Claims/Encounters 420 ... Discussion 421 APPENDIX U: IMPACT A AWARDEES, SITES, AND – COUNTS OF NALYSIS ... 423 D INCLUDE PARTICIPANTS ... 427 LITY STUDY ARISON GROUP FEASIBI – FINAL COMP APPENDIX V: IMPACT ANALYSIS ... 428 Strong Start for Mothers and Newborns Evaluation: Comparison Group Feasibility Study ... 445 APPENDIX W: IMPACT A NALYSIS – GROUP PREN ATAL CARE ENROLLMENT STRATEGIES ... APPENDIX X: SPECIAL STUDY – ENHANCED PRENATAL EDUCATION 447

7 IPANTS WITH A PARTIC APPENDIX Y: SPECIAL STUDY – CHARACTERISTICS OF BIRTH CENTER HOME BIRTH OR LICENSED PROFESSIONAL MIDW IFE AS THEIR ROUTINE PRENATAL ... 459 PROVIDER CARE AIN OCESS EVALUATION – M APPENDIX Z: SPECIAL STUDY – PARTICIPANT LEVEL PR ... TE FINDINGS, BY AABC SI 475 DIABETES MELLITUS STUDY APPENDIX AA: SPECIAL AND NUTRITION – GESTATIONAL ... COUNSELING SERVICES 511 – INTEGRATING STUDY APPENDIX BB: SPECIAL MENTAL HEALTH SERVICES INTO PRENATAL ... ARE HOMES CARE IN STRO NG START MATERNITY C 515 APPENDIX CC: SPECIAL STUDY – MATERNAL AND INFANT BIRTH, UTIL IZATION, AND IN FOUR STATE ONG TWIN PREGNANCIES AM EXPENDITURE OUTCOMES ... 527 MEDICAL PROGRAMS SE DISORDERS AMONG W – SUBSTANCE U STUDY APPENDIX DD: SPECIAL OMEN WHO ... DELIV - 2015 IN THREE STA TE MEDICAID PROGRAMS 529 ERED INFANTS IN 2014 Figures ... Figure 1: Research Questions By Evaluation Component 2 6 Figure 2: Strong Start Sites, By Model (N=219) ... Figure 3: Distribution of Strong Start Awardees and Sites Across the United States 7 ... ... Figure 4: Total Strong Start Enrollment, By Model (N=45,316) 9 ... 47 Figure 5: PLPE Form Submission, By Model and Overall 49 Figure 6: Participant Race and Ethnicity, By Model and Overall ... 50 ... Figure 7: Mother’s Age at Intake ... 51 Figure 8: Relationship Status of Strong Start Participants at Intake, By Model and Overall Figure 9: Employment and School Attendance at Intake for Strong Start Participants, By Model and Overall ... 52 ... 52 Figure 10: Highest Level of Education Completed By Strong Start Participants, By Model and Overall 53 Overall Figure 11: Numbers of Barriers to Prenatal Care Access Reported By Participants, By Model and ... roportion of Strong Start Participants Exhibiting Depressive Symptoms, Anxiety, or Both at Figure 12: P Intake, By Model and Overall ... 54 55 -Pregnancy Diagnosis of Diabetes, Hypertension, and Obesity, By Model and Overall Figure 13: Pre ... Figure 14: Medical Risk Factors Among Women with a Prior Birth, By Model and Overall 56 ... Related Hypertension and Preeclampsia, By Model and Figure 15: Rates of Gestational Diabetes, Pregnancy- ... Overall 61 Figure 16: Infant Estimated Gestational Age (EGA) at Birth Among Women with a Live Birth, By Model 63 ... Overall and ... Figure 17: Infant Birthweight Among Women with a Live Birth, By Model and Overall 64 65 Figure 18: Delivery Method Among Strong Start Participants with a Delivery, By Model and Overall ... Figure -Section, By -Section Among Women with a Prior C -Section and Repeat C 19: Vaginal Birth After C Model and Overall ... 66 ... Figure 20: Phases of Data Acquisition 86

8 Figure 21: Effect of S trong Start on Maternal and Infant Birth Outcomes, Differences Between Strong Start ... and Comparison Group, Birth Center Awardee- Level Analysis 120 Figure 22: Effect of Strong Start on Maternal and Infant Expenditure and Utilization Outcomes, Differences Between Strong Start and Comparison Group, Birth Center Awardee- 121 Level Analysis ... Figure 23: Effect of Strong Start on Maternal and Infant Birth Outcomes, Differences Between Strong Start ... Level Analysis 122 and Comparison Group, Group Prenatal Care Awardee- Figure 24: Effect of Strong Start on Maternal and Infant Expenditure and Utilization Outcomes, Differences Level Analysis 122 ... Between Strong Start and Comparison Group, Group Prenatal Care Awardee- Figure 25: Effect of Strong Start on Maternal and Infant Birth Outcomes, Differences Between Strong Start Level Analysis and Comparison Group, Maternity Care Home Awardee- ... 123 Figure 26: Effect of Strong Start on Maternal and Infant Expenditure and Utilization Outcomes, Differences ... Between Strong Start and Comparison Group, Maternity Care Home Awardee- 124 Analysis Level Tables 8 Table 1: Strong Start Sites Ever Enrolling Participants By Awardee ... 11 -4 Table 2: Strong Start Case Study Data Collection, Years 1 ... 12 Table 3: Cumulative Form Submission Through Year 4 ... Table 4: Common Features Defining Each Strong Start Model and Variations in Implementation 16 ... Table 5: Primary Challenges Reported During the Strong Start Award Period, By Model and 1,2 24 ... Year Evaluation 1,2 Table 6: P Year rimary Successes Reported During the Strong Start Award Period, By Model and Evaluation 29 ... 1 ost Important Strong Start Staff Attributes for Successful Program Implementation Table 7: M 33 ... 34 ustainability of the Strong Start Programs in Evaluation Year 4 Table 8: S ... Table 9: Most Important Program Replicability Factors Related to Providers and Practice Sites 36 ... Table 10: Most Important Program Replicability Factors Related to the Patient Population 39 ... Table 11: Most Important Program Replicability Factors Related to Community and Policies/Regulations 41 ... 58 Table 12: Strong Start Routine Prenatal Care Visit Type and Frequency, By Model and Overall ... 59 Table 13: Enhanced Encounter Type and Frequency, By Model and Overall ... 60 Table 14: RATES OF GESTATIONAL DIABETES BY PARTICIPANT CHARACTERISTICS ... 69 Table 15: Measures Included in Risk- Adjusted Regression Models ... Table 16: Differences in intermediate Outcomes by Strong Start Model, Full Sample 71 ... Table 17: Differences in Intermediate Outcomes by Strong Start Model, Excluding MUSC, UAB, and UPR 72 ... 72 Table 18: Differences in Intermediate Outcomes by Strong Start Model, White Women ... Table 19: Differences in Intermediate Outcomes by Strong Start Model, White Women Excluding MUSC, UAB, and UPR 72 ... Table 20: Differences in Intermediate Outcomes by Strong Start Model, Black Women 73 ... Table 21: Differences in Intermediate Outcomes by Strong Start Model, Black Women Excluding MUSC, 73 UAB, and UPR ... 73 Table 22: Differences in Intermediate Outcomes by Strong Start Model, Hispanic Women ... Table 23: Differences in Intermediate Outcomes by Strong Start Model, Hispanic Women Excluding MUSC, 73 UAB, and UPR ... 74 Table 24: Differences in Intermediate Outcomes by Strong Start Model, Other Women ... e 2 Tabl 5: Differences in Intermediate Outcomes by Strong Start Model, Other Women Excluding MUSC, ... UAB, and UPR 74

9 Table 26: Differences in Birth Outcomes by Strong Start Model, Full Sample 75 ... T ... 76 able 27: Differences in Birth Outcomes by Strong Start Model, Excluding MUSC, UAB, and UPR ... 77 Table 28: Differences in Birth Outcomes by Strong Start Model, White Women Table 29: Differences in Birth Outcomes by Strong Start Model, White Women Excluding MUSC, UAB, ... 77 UPR and 77 ... Table 30: Differences in Birth Outcomes by Strong Start Model, Black Women Table 31: Differences in Birth Outcomes by Strong Start Model, Black Women Excluding MUSC, UAB, UPR and ... 77 ... 78 Table 32: Differences in Birth Outcomes by Strong Start Model, Hispanic Women Table 33: Differences in Birth Outcomes by Strong Start Model, Hispanic Women Excluding MUSC, UAB, 78 ... and UPR ... Table 34: Differences in Birth Outcomes by Strong Start Model, Women of Other Race- Ethnicity 78 Ethnicity Excluding Table 35: Differences in Birth Outcomes by Strong Start Model, Women of Other Race- ... MUSC, UAB, and UPR 78 80 ... Table 36: Differences in Birth Outcomes by Depression Status, Full Sample Table 37: Status of Data Acquisition, By State 84 ... 90 Table 38: Summary of Best Practices to Facilitate Data Approval and Acquistion from State Agencies ... Table 39: Outcome Variables for the Impact Analysis ... 98 Table 40: Propensity Score Reweighting Variables for Impact Analysis 100 ... 107 -Level Analysis Table 41: Sites in Birth Center Model ... Table 42: Effect of Strong Start on Maternal and Infant Birth Outcomes, Differences Between Strong Start and Comparison Group, Birth Center Model ... 108 -Level Analysis Table 43: Effect of Strong Start on Maternal and Infant Expenditure and Utilization Outcomes, Differences ... Between Strong Start and Comparison Group, Birth Center Model -Level Analysis 110 -Level Analysis Table 44: Sites in Group Prenatal Care Model ... 112 Table 45: Effect of Strong Start on Maternal and Infant Birth Outcomes, Differences Between Strong Start Analysis -Level and Comparison Group, Group Prenatal Care Model ... 113 Table 46: Effect of Strong Start on Maternal and Infant Expenditure and Utilization Outcomes, Differences 114 Between Strong Start and Comparison Group, Group Prenatal Care Model -Level Analysis ... 116 nalysis -Level A ... Table 47: Sites in Maternity Care Home Model Table 48: Effect of Strong Start on Maternal and Infant Birth Outcomes, Differences Between Strong Start -Level Analysis n Group, Maternity Care Home Model and Compariso 117 ... Table 49: Effect of Strong Start on Maternal and Infant Expenditure and Utilization Outcomes, Differences Between Strong Start and Comparison Group, Maternity Care Home Model ... -Level Analysis 118

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11 Executive Summary In 2016 the United States spent an estimated $111 billion on pregnancy and newborn care (National is Center for Health Statistics, 2016). Despite th high spending, the U.S. continues to experience some of maternal developed countries, including high rates of the worst maternal and infant outcomes among and infant mortality (United Health Foundation, 2016). The Strong Start for Mothers and Newborns initiative, funded under Section 3021 of the Affordable Care Act (ACA), aimed to improve maternal and in covered by women fant outcomes for Medicaid and the Children’s Health Insurance Program (CHIP) during pregnancy. The initiative funded enhanced services through three evidence — -based prenatal care models Birth Centers, Group Prenatal Care, and Maternity Care Homes — and supported the delivery of these services through 27 awardees and 211 provider sites across 32 states, the District of Columbia, and Puerto Rico. Four- year edicaid were awarded on February 15, 2013 by the Center for Medicare and M cooperative agreements Innovation (CMMI) of the Centers for Medicare and Medicaid Services (CMS). The Strong Start a wide variety of organizations , including hospital and health systems, health awardees comprised -based plans, and community . providers and agencies ; only on e award directly contracted with a state CMMI contracted with the Urban Institute to conduct an independent, of evaluation -year five on maternal and infant health outcomes, health Strong Start implementation and the program’s impacts care delivery, and cost of care. Urban partnered with the American Institutes for Research (AIR), Health Management Associates (HMA), and Briljent to assist with the effort. Specifically, the evaluation set out to answer the following key research questions: How does Strong St 1. art prenatal care differ from typical Medicaid maternity practice? What are the characteristics of Strong Start participants? 2. What is the impact of Strong Start on outcomes (gestational age, birth weight, and costs)? 3. To answer these questions, the evaluati on included three primary components: Qualitative case studies , which provided an in-depth understanding of how Strong Start • approaches were designed, implemented, and evolved over time; information on the , which collected detailed level process evaluation (PLPE) Participant- • demographic and risk characteristics, service use, and outcomes of all Strong Start and participants; Impact analysis • , which assessed whether and to what extent Strong Start had an impact on rates of preterm birth, low birthweight births, and Medicaid/CHIP costs through pregnancy and the first year after birth. This Year 5 Project Synthesis presents final findings from the evaluation. EXECUTIVE SUMMARY I

12 SUMM ARY OF F INDINGS e years o trong Start, awardees’ erved by S omen s garding the w f findings re We synthesiz e fiv utcome experiences i g the initiative, o nd the i s am mplementin f Strong Start mpacts o ong participants, a on ra rthweight, Medicaid costs, and other rth, low bi f preterm bi tes o select o utcomes . VED B G START? STRON Y WHO WAS SE R The Strong Start evaluation collected detailed information on the demographic profiles and risk t characteristics of every wom a n tha was served under the initiative. arge and diverse grou p o tar t provided enhanced prenata Strong S f women . Strong Start l care to a l ta co y 46,00 f nearl ives o touched the l ccording to th llected by th e e P nd their infants. A 0 women a LPE da trong S evaluation, S 30 ispanic ( nd H k (40 percent) a lac isproportionately b ere d articipants w tart p eneficiaries o dicaid b t Me h pregnan mpared wit percent) co k and 20 lac l (who are 25 percent b veral he o verrepresentation of b lac k women was ispanic) ( Kaise percent H r Famil y Foundation, 201 6). T art, by th e large n umbe r of awardee s i n the s outheastern U .S., where there is a concentr ation driven, in p , and is n oss all income levels ar e black women acr e becaus otabl ts overall siden of black re e likely or e m come e pregnancy out dvers t ome n white or Hispanic w tha n to e ; Martin e t el. 2013 s (Zhang e xperience a al 2015). l challenge aced a s f articipant g Start p Stron large numb er o f s ocial and medica s th at p laced the m isk at r tron r b ir th e neither outcomes . Nearly h alf of w omen e rt wer g Sta eriencing poo d in S nrolle of exp t 15 , and jus ool or a GED d high sch omplete employed nor in schoo l, more th an a qu arte r had not c d a college de -third ne percent p ossesse an o gree . A fi fth experienced food insecurity, and more th most commonly n ccessing prenatal c reported barriers to a ar o r money to afford a g a c ot havin are ( rate more than depression—a ride). Nearly 28 percent of Strong Start participants screened positive for twice what is reported in the literature for pregnant women generally (Bennett et al. 2004; Melville et l. 2 aton et a 0; K hro al. 201 ls o suffered from c any Strong Start participants a . M l. 2005) nic 011; Gavin et a ere o f participants w ird o an a th bese a nd elated to p ons r health conditi oor birth o utcomes. More th ty o s had previously gi ven bi rth ( 61 anothe ajori r 26 p ercent were o f participant verweight. The m f these w nd many o percent) a e than 20 percent or irth outcome. M ad experienced a prior poor b omen h rth. t predictor of subsequent preterm bi rth, the s had a prior preterm bi tronges NG START INTERVENTIONS? WHAT WE RE THE STRO ddress p n signed to a ere de re m nhanced prenatal ca Strong Start’s e odels w d weaknesses i erceive . The v s offere are i aternity c f Medicaid m t majority o as are renatal c “typical” p n settings such a s d i private s utpatient , and hospital o nters ol y Qualifie , Federall an practices p physici o or grou d Health Ce department clinics, and i s delivered under pr f typical epaid managed care a rrangements. Criticisms o n to psychosocial risks t it i prenat al care i nclu de tha s o verly m edic al in f ocus , payin g insufficie nt attentio t in th r tribute t o poor b irth outcomes ; overly interventionis that con at provide rs may i nduce l abo r o d on education on such rm C-s ection d eliveries without m edical indication ; insufficient ly focuse perfo critical i ssue s as n utrition, exercise, childbirth p reparation, breastfeeding, a nd family p lanning; a nd lacking i n continuit y in t hat pregna nt women ar e usually s een b y many providers o ver t he course of II EXECUTIVE SUMMARY

13 their pregnancies, undermining the establishment of a strong, trusting relationship between each woman and her provider. of the three allowed the evaluation to develop a nuanced understanding case stud In ies -d epth Strong Start interventions, how they differed from “typical” Medicaid prenatal care, and how they were . implemented r c e supplemented by pee ar of c ed the midwifery model ) follow (BCs enters C Birth ho s w ounselor nter model w th provided suppor t, h eal o mplemented by tw as i ed he Birth Ce T . nd referrals , a ucation awardee eceived ts who r l Strong Start participan ercent of al 0 p s and served approximately 2 s in 47 site . T irth Ce nter regardless o f where th ey ga ve bi rth t the B he e valuati on’s case re a their prenatal ca un d that all s ites re flected tw o k ey characteristics : 1 ) p renatal c are f idwifery he m ollowing t studies fo han -intensive t me ore ti at is m nd birth th regnancy a pproach to p nd wellness a olistic a hich is a h model, w th education, a nd referrals to a dditional typical OB cial s upport, heal /GYN care ; and 2) psychoso peer counselor.” rovided by a “ resources p ided clinical c are Group P ) engaged group re (GPC s o f w omen over th renatal Ca pregnancie s and prov eir an d in- dept h education during two -hour facilitated ses sions . Group P renatal Ca re was im plemented b y 15 awardee ite 0 s s in 6 wardees hese a tart participants. T f Strong S ercent o 3 p s and served approximately 2 e ty etting (rather than th up s n a gro are i ve prenatal c d comprehensi provide l one pica -o n-o ne ca re roviders ed by o provid bstetrical p ) s coverin g a b f i ange o road r f f d session acilitate ssues, vi a a series o duction, family p ing nutritio , and includ iolence n and exercise, stress re , domestic v lanning, p arenting s we wardee are a renatal C . Group P reparation childbirth p emphasis on building lso uniform in their re a omen. regnant w nrolled p strong p eer r mong e elationships a ) augmented typica Maternity Care Ho mes (MCHs “care managers l prenatal c are w ith th e addition of ” to ere implemented b s w facilitate coordination and pro vide psychosocial s upp orts . Maternity Ca re Ho me y ercent. f Strong Start enrollees, 57 p e largest proportion o ites a t 112 s wardees a 17 a nd served th ell as t eir approach to Strong Start, as w ost varied in th e m es were th Maternity Care Hom he intensity of anagers” to p f “care m ddition o e a as th heir consistent feature w their interventions ; but, t rovide c are coordination a nd psychosocial s upport to e nrolled pregnant women . , p cation Intensive edu s were primar l service -medica o non s t y attributes , and referral upport sychosocial s cus to . e Strong Start models w ent beyond an e of all S edical fo Each of th trong S tart models xclusively m mprove o s designed to i ntervention f educational i nge o provide a ra s opics a g such t utcomes, addressin tion, exercise, family p anagement, smoking cessation, astfeeding, stress m lanning/bi rth spacing, bre nutri revention, childbirth regnancy s ymptoms, preterm bi rth p oral h ygiene, normal a nd abnormal p nd safety, among others. Furthermor preparation, and infant care a odels, Strong Start staff e, across m strived to m ossible ul ; y pregnancies d support health hat co ervices t edical s ) to non-m as p ak e referral s ( re, domestic re, dental ca services c ommonly in ealth ca d food support programs, behavioral h clude violence se inally, the rvices, housing support, tra nspor tation s ervices, childcare, and utili ty assistance. F hroug oup odels s hared a n emphasis on psychosocial support t three m h relationship -b ased c are. Fo r Gr up fa s an wardees, th is s upport was p rovided by gro re a cilita tor Prenatal Ca d by th e p articipants themselves. For Birth Ce nters, the m idwife a nd peer counselor provided psychosocial s upport; i n as f Maternity car omes, t his r ole w e h illed b y the c are m anager . EXECUTIVE SUMMARY III

14 worked hard to address a range of implementation challenges through creativity, Strong Start awardees Across models, common implementation challenges included identifying adaptability, and persistence. and enrolling eligible women into Strong Start, integrating enhanced prenatal care services into existing handling -related data burdens. Early in the demonstration, many awardees program and models of care, perceived that prenatal care providers did not support Strong Start because they made few referrals to the program. the full scope of client needs Especially intractable was the challenge of addressing because resources most communities had with mental health, substance women to help insufficient abuse, transportation, affordable childcare, and housing. Over time, however, Strong Start awardees care , succeeding in overcoming many, if not all, of these challenges. refined their approaches to WHAT DID WOMEN SAY A ? BOUT THEIR EXPERIENCES WITH STRONG START , who focus groups gave voice to the experiences of pregnant and postpartum women Participant Strong Start and education overwhelmingly said that they appreciated the extra time, support, provided. omen Most w with prior pregnancies said they were more satisfied with their prenatal and delivery experiences under Strong Start than they typical maternity care in the past . had with WHAT OUTCOMES DID STRONG START PARTICIPANTS EXPERIENCE? data the PLPE Descriptive analyses of patient risk profiles and rates of preterm birth that revealed varied considerably across the three Strong Start models, with women served by Birth Centers . Birth Center participants had dramatically lower rates of preterm the lowest risk levels iencing exper Group Prenatal Care (12 percent) either (4.5 percent) than women served by birth Maternity Care or Homes (12.9 among Birth Center participants were much Similarly, rates of low birthweight percent). lower (3.6 percent) than for Group Prenatal Care and Maternity Care Home participants (10 percent and 10.5 percent, respectively). Finally, Cesarean section deliveries fo r Strong Start participants were, est for women in Birth Centers (13 percent). by far, low In contrast, approximately 30 percent of Group . Prenatal Care and Maternity Care Home participants had C-sections HOW DID WOMEN’S OUTC STRONG START MODELS? OMES COMPARE ACROSS outcomes for all women who Regression adjusted analysis using the PLPE data compared the controlling for a host of participant characteristics and medical and participated in Strong Start while social risk factors commonly associated with poor birth outcomes , some of which not are not available . These results cannot convey the in data sources such as vital records (e.g. depression, food insecurity) impacts of Strong Start compared to typical Medicaid prenatal care (impact analysis is presented in the next sect ion ), but they can describe how mothers and infants in the three Strong Start models fared relative to one another. Linear regression models used Maternity Care Homes as the reference category when comparing models because this model had the largest number of Strong Start enrollees and was, arguably, the most similar to typical models of prenatal care. IV EXECUTIVE SUMMARY

15 Regressions of participant data show that Birth Center participants experienced significantly better (overall) did outcomes than their counterparts in Maternity Care Homes, but Group Prenatal Care enrollees enrolled in Birth C After demographic, medical and social risks were controlled, w not. enters were omen five percentage points less likely to have a preterm birth than women enrolled in Maternity Care ly to deliver a low Homes. Birth Center participants were also four percentage points less like likely to have a C-section delivery than Maternity birthweight infant, and seven percentage points less , overall, there were no significant differences in outcomes between women enrollees. While Care Home in Group Prenatal Care and their counterparts served by Maternity Care Homes, black Group Prenatal three participants were Care percentage points less likely to deliver a low birthweight baby, and white participants were five percentage points less likely to have a preterm birth . WHAT WERE THE IMPACTS OF STRONG START ON BIRTH OUTCOMES AND COST OF CARE? In the largest study of its type conducted to date, the evaluation used linked birth certificate, Medicaid to compare birth and eligibility, and Medicaid claims/encounter data cost outcomes for women participating in Strong Start enhanced prenatal care to outcomes for comparable, non -participating and f Medicaid -enrolled women. For each awardee or with sufficient sample size, we sites individual used propensity score re closely -weighting to develop a comparison group of women with risk profiles matched to those of women enrolled in Strong Start. We were able to include awardees and sites in 13 nine of these states states to estimate the impacts of Strong Start on birth outcomes, with also included in the cost outcomes analysis. Birth Centers had significantly more positive birth outcomes than women in in Strong Start participants comparison groups who received care from typical Medicaid providers. Regardless of whether women gave birth at the Birth Center or in a hospital, infants born to Birth Center parti cipants had an average almost half a week longer than that of infants born to comparison that was clinical estimate of gestation less likely to be preterm than comparison group infants (6.3 percent vs. significantly , were group women 8.5 percent), and were less likely to be born at low birthweight (5.9 percent vs. 7.4 percent). Rates of C- Strong Start women who received care in a Birth Center section deliveries were 17.5 percent for women in typical care matched 29.0 percent compared to for . Strong Start participants were more of likely to have weekend deliveries than women in the comparison group, indicating lower incidence -sections. Finally, rates of vaginal birth after C-section (VBAC) were 24.6 planned inductions or C Start Birth Centers compared to 12.5 percent for women in percent for women enrolled in Strong care typical Medicaid prenatal . Birth Center participants in Strong Start achiev at a lower overall cost. better birth outcomes ed Delivery expenditures were expenditures from delivery until the infant’s , on average, 21 percent lower and t otal first birthday were 16 percent less for women enrolled in Birth Centers than for women and infants in the comparison group. Lower costs appeared to be driven, in part, by changes in the approach to prenatal car e and associated outcomes (such as lower rates of C-sections ), and small reductions in the number of infant emergency department visits and hospitalizations following delivery. Lower costs were also likely due to lower reimbursement rates for professional fees and deliveries in Birth Centers relative to hospitals. EXECUTIVE SUMMARY V

16 were more likely to have a weekend delivery compared to women Group Prenatal Care participants a quarter (25.5 percent) of women in Group Prenatal Just over receiving typical Medicaid prenatal care. Care as compared to 22.0 percent of women in the comparison group, delivery a weekend had suggesting that women in Group Prenatal Care were less likely to have scheduled inductions or . There were no significant effects of Strong Start enrollment on the clinical estimate of cesareans gestation, rates of preterm or very preterm birth, average birthweight, rates of low birthweight, or the probability of having an Apgar score greater than or equal to seven. lower for Strong Start Group Prenatal Care enrollees compared to Prenatal care expenditures were Expenditures in the eight months prior to delivery for women women in typical Medicaid prenatal care. 5 percent lower than the average for women in the enrolled in Group Prenatal Care were about 1 comparison group. This l ower cost may have been driven, in part, by a reduction in the number of maternal hospitalizations during the prenatal period. Maternity Care Home participants were also more likely to have a weekend delivery compared to women in typical Medicaid prenatal care, but there was no evidence that Strong Start Maternity Care Homes improved birth outcomes or reduced costs relative to typical Medicaid prenatal care. There was a small increase in weekend deliveries for women enrolled in Strong Start Maternity Care Homes, suggesting that awardees may have been less likely to plan inductions for Strong Start women than typical prenatal care providers were with their patients. However, we found no other positive effects of enrollment in a aternity Care Home on birth outcomes M or cost of care. More than the other Strong Start models, s, with some there was considerable variation in effects across Maternity Care Home awardees or sites even though the pooled . Findings did not analysis did not demonstrating some positive outcomes appear correlated with the intensity of the intervention. DISCUSSION for Medicaid and both for esults from the Strong Start evaluation hold a range of implications The r prenatal care practice For Medicaid, -away is that if more pregnant the clear take more generally. beneficiaries accessed Birth Centers for their maternity care, on average they would likely experience significantly better birth outcomes and, as a result, the program could save money. Unfortunately, many barriers stand in the way of obtaining Birth Center care . The Strong Start evaluation’s case studies identified many reasons why only a small fraction of pregnant Medicaid beneficiaries receives their . maternity care from Birth Centers anaged care has become the dominant service delivery and payment model for Medicaid, M but told us that they often have difficulty contracting with Medicaid managed care Birth Center providers organizations (MCOs) . Even when Birth Centers succeed in obtaini ng contracts, reimbursement rates are often too low to cover the actual cost of care , especially given the time -intensive nature of prenatal care offered under the midwifery model . T raditional Medicaid fee-for -service reimbursement for The professional and fac ility fees are a fraction of what the program pays obstetricians and hospitals. or when financial strain of low payment rates can be exacerbated when Medicaid payments are delayed lengthy Medicaid eligibility determination processes delay pregnant wome n’s enrollment. Combined, In these factors cause many Birth Centers to limit the number of Medicaid beneficiaries they serve. some states scope of practice laws and licensing policies make it difficult for Birth Centers and midwives VI EXECUTIVE SUMMARY

17 to practice at all, which can further limit the availability of Birth Center care for pregnant women, regardless of Medicaid status. policies can also hinder the development of enhanced Exi prenatal care models sting M edicaid generally, such as Group Prenatal Care and Maternity Care Ho me models. This evaluation’s telephone officials in select states revealed that program policies rarely offer explicit survey with Medicaid and CHIP coverage of or incentives fo adopt to lexibility he f y retain t s currentl State r prenatal care enhancements. r Enhanced Prenatal Care services through the State Targeted Case Management for pregnant women o Plan Amendment process, but these options were more widely used by states when Medicaid was a fee- rvice program ominated by prepaid managed care (Hill et al, and are less viable in a program now d for-se care anaged f Medicaid m 2009). The proprietary nature o health plan information creates barriers to networks, pa y providers, and specif y the accessing informatio out how M COs manage their provider n ab under bundled payment arrangements. The proliferation of content of prenatal care services delivered managed care thus means that state and federal officials have fewer dir levers to influence ect policy changes in ervice delivery. health plan and provider s evaluation provides clear evidence that prenatal care in Strong Start’s Birth In conclusion, t his Ce nters –wit h their holistic model of care – succeeded in significantly improving almost every outcome we m easured, most importantly rates of preterm birth, low birthweight, and C-sec tion deliveries, when oup with similar risks. Impr oved outcomes, as well as participants parison gr were considered against a com reductions in health care utilization, likely contributed to re duced expenditures.,. It seems quite likely that, if progress could be made in addressing the barriers to Birth Center care described above, more Medicaid- could experience positive births, more infants born to Medicaid mothers could ered pregnant women cov ld reap levels—cou start their lives healthy, and the Medicaid program—at both the federal and state significant s avings. It is unrealistic for Birth Centers to become the dominant maternity care provider under Medicaid or soon Thus, more typical maternity care settings, where the vast majority of , however. th e U.S. any time in still receive care, will continue to face the challenge of women of all incomes and insurance types improving outcomes provide insights that r women and infants. The Strong Start evaluation’s findings fo model of care, which can be practiced by any provider idwifery may be helpful in this regard. Namely, the m women who face or etting, offers lessons for how to structure prenatal care to improve outcomes f in any s poverty, relationship host of other life-challenges. instability, depression, an d a EXECUTIVE SUMMARY VII

18 Across all Strong Start models, providers such care managers, group care facilitators, midwives , and peer counselors were praised for spending more time with patients and focusing on health education and psychosocial support services, areas often not addressed in typical clinical visits. However, Strong Start providers and staff also described the difficulties they encountered in addressing the most pressing needs of participants, in particular needs for mental health treatment, opioid and other substance use treatment, stable housing, healthy food, transportation, and personal safety (especially h regard to intimate partner violence), because resources to mitigate these needs were so often in wit short supply in their communities. Given the complex needs and high levels of medical and social risk equate community resources, it is among many Medicaid -enrolled women, accompanied by inad unsurprising that relatively small changes in clinical care practice, such as those adopted by Maternity Care Homes, were not sufficient to improve birth outcomes. Moving forward, comprehensively attending to the broader needs faced by low -income women, including many social determinants of health, will be necessary to achieve reductions in preterm birth and other improved outcomes. No model of care can sufficiently address the myriad needs of Medicaid-enrolled women, parti cularly those at higher risk, without broad community support and robust social support systems. VIII EXECUTIVE SUMMARY

19 Introduction In 2016 the United States spent a total of $3.2 trillion on healthcare, with an estimated $111 billion of that spent on pregnancy and newborn care (National Center for Health Statistics, 2016). However, e these high rates of spending, the United States continues to experience some of the worst despit maternal and infant outcomes compared to similar countries, with among the highest rates of maternal and infant mortality (United Health Foundation, 2016). According to the Centers for Disease Control and Prevention (CDC), 1 out of every 10 infants born in 2016 was preterm, and the infant mortality rate was 5.9 deaths per 1000 live births, ranking the United States last among 27 other wealthy nations of C, 2015; CDC, 2016; CDC, 2018). Within the United States, some of the worst outcomes the world (CD are concentrated in Southeastern states, such as Mississippi, Louisiana, South Carolina, and Alabama. thnicity, with black women faring There are also significant disparities among these outcomes by race -e particularly poorly. The rate of low birthweight births for babies born to black mothers is nearly twice the rate of babies born to white mothers, thirteen percent versus seven percent (Rothwell, 2015), while -half times higher than the rate for white the rate of preterm birth for black mothers is one -and -one mothers (13.3 percent vs. 9 percent); Hispanic mothers experience preterm birth rates that are essentially on par with those of white mothers (March of Dimes, 2016). 1 Th e Strong Start for Mothers and Newborns Initiative (Strong Start II), funded under Section 3021 of the Affordable Care Act (ACA), aimed to improve maternal and infant outcomes for women covered by Medicaid and the Children’s Health Insurance Program (CHIP) . The initiative during pregnancy funded services through three evidence – Birth Centers, Group Prenatal -based prenatal care models – and supported the delivery of enhanced services through 27 Care, and Maternity Care Homes 2 0 provider sites awardees and approximately 21 across 32 states, the District of Columbia, and Puerto 3 Rico. The Center for Medicare and Medicaid Innovation (CMMI) of the Centers for Medicare and $41.4 -year cooperative agreements, funded from a budget of awarded four Medicaid Services (CMS) million, on February 15, 2013 that were intended to fund three years of service provision. Most -cost extensions to prolong service provision by up to 12 months, but all had awardees received no completed Strong Start program operations by February 2017. At the time of this writing, any sustained services are no longer supported by Strong Start cooperative agreement funds. CMMI contra cted with the Urban Institute to conduct an independent evaluation of Strong Start; Urban partnered with the American Institutes for Research (AIR), Health Management Associates -year study was charged with evaluating the (HMA), and Briljent to assist with the effort. This five 1 ed by Strong Start II, which is the subject of this report, is one of two initiatives to improve birth outcomes that have been fund CMS. The other initiative, Strong Start I, was designed to reduce early elective deliveries. In addition, the Mother and Infant Home Visiting Program (MIHOPE) has a Strong Start component involving sites that provide care beginning in the prenatal period. The Strong Start II and MIHOPE -Strong Start programs are being evaluated separately. For the remainder of this document, references to Strong Start refer to Strong Start II. 2 This number reflects the total number of unique provider sites that ever participated in Strong Start, but excludes nine Birth Over and one Group Prenatal Care site that joined the program but never enrolled any women into the program. sites Center time, the number of provider sites in Strong Start declined, as some dropped out of the initiative. At the close of Strong Start, there were 175 active providers. 3 This number reflects the highest number of states where Strong Start providers ever operated. Over time, as some providers dropped out of the initiative, the number of states where Strong Start was operating also declined. At the close of the initiative, . Strong Start providers were operating in 29 states, DC, and Puerto Rico INTRODUCTION 1

20 implementation and impact of Strong Start on maternal and infant health outcomes, health care 1. re Figu very, and cost of care; key research questions are displayed in deli 1: RESEARCH QUESTIONS BY EVALUATION COMPONENT FIGURE Case Studies Qualitative What are the features of the Strong Start models operated by the study sites? 1. a. To w hat extent are features common, or different, across sites? b. Are the models being implemented as designed? How has implementation varied? c. How similar (or dissimi lar) are the context and delivery of prenatal care in the Maternity Care Home, Group Prenatal Care, and Birth Center Models? 2. How do prenatal care and delivery in Strong Start sites differ from usual Medicaid or CHIP prenatal/delivery care in the same geogr aphic areas? a. How does care in Strong Start sites differ from care provided in the same sites prior to the program’s implementation? 3. What are stakeholders’ (e.g., awardee, state, provider, beneficiary) views of how Strong Start emented? demonstrations are being impl What works best for patients and providers, and what are the most challenging aspects of a. implementation? What are the most important factors in successful implementation of Strong Start b. demonstrations, both within each model and across models? How 4. generalizable are the Strong Start models to other Medicaid and CHIP care settings across the country? What features are critical for successful replication and scaling up of Strong Start? a. - Participant Level Process Evaluation 5. W hat are the characteristics of Strong Start participants by model, site, time period, including demographic characteristics (age, race/ethnicity, family composition, income), eligibility group, risk characteristics (physical, behavioral, socioemotional), and prior pregnancy status? How many Strong Start services are provided to participating women, of what type, by time 6. period, site/approach, and participant characteristics? 7. What are participant outcomes (e.g., mode of delivery, gestational age, and birth weight), how do they change o ver time, and how do they compare across Strong Start models? Impact Analysis What is the impact of Strong Start on infant gestational age, birth weight, rate of Cesarean Section 8. f life? births, and cost for women and infants during pregnancy/over the first year o 9. Does the impact differ across awardees and across the three Strong Start models? a. Does it vary by characteristics of enrolled women (e.g., race/ethnicity, health risks)? If so, how? 10. How does the implementation analysis explain the impact findings? a. For example, which features of the models led to the greatest impact of the program? INTRODUCTION 2

21 To answer these questions, the evaluation included three primary components: qualitative case addition, the evaluation scope studies, a participant-level process evaluation, and an impact analysis. In of work included the analysis of select program monitoring measures collected by CMMI to support the oversight of Strong Start implementation, as well as a technical assistance and data acquisition task that birth certificate and Medicaid data from states with Strong Start awards. worked to collect The purpose of this Year 5 final evaluation report is to present final synthesized findings from the Strong Start for Mothers & Newborns evaluation and summarize the evaluation’s research efforts and approaches. The remainder of this section offers background on the three enhanced models of care supported by Strong Start, provides a brief overview of the characteristics of the Strong Start awardees, and summarizes the evaluation desi gn and its research components. OVERVIEW OF STRONG S TART ENHANCED PRENATAL CARE MODELS to address perceived weaknesses in designed The Strong Start enhanced prenatal care models were “typical” prenatal care delivery models. d in practice is ternity care The vast majority of Medicaid ma such settings as private solo and/or group practices , Federally Qualified Health Centers, and hospital delivered through managed care outpatient department clinics. Furthermore, this care is generally arrangements, as prepaid managed care has become the dominant service delivery and financing model of Medicaid in most states. Criticisms of typical care often cited in the literature include that it is: overly medical in focus (paying less attention to psychosocial risks that contribute to poor birth • , such as poverty, unsafe housing, food insecurity, intimate partner violence, and outcomes mental health ); • may be quick intervene medically in normal to overly interventionist (in that providers s without medical C-section labor or conducting cing indu pregnancies and births, such as by ); indication • insufficiently focused on education (on such critical issues as nutrition, exercise, childbirth preparation, breastfeeding, and family planning); and, women will often be seen by many different health care lacking in continuity, (in that • pregnant providers over the course of their prenatal, delivery, and postpartum care, thus undermining the establishment of a each woman and strong trusting relationships between her provider). Described below are the three Strong Start “enhanced” prenatal care models, their core components, evidence of their effectiveness in the literature, and discussion of how they address the weaknesses in “typical” prenatal care identified above. BIRTH CENTER CARE Freestand ing Birth Centers are not just for giving birth — they are facilities that provide comprehensive prenatal, delivery, and postpartum care (and often well -woman gynecological care as well). They are almost always directed by midwives. Unless medical complicati ons arise , women enrolled in Birth -up care at a Birth Center. They may deliver their Centers receive their prenatal and postpartum follow infants either at the Birth Center attended by a midwife; at a hospital, where deliveries may be attended by midwives, physicians, or a mixed team; or, in some cases, at home attended by a midwife. Many Birth INTRODUCTION 3

22 Centers , nationally, are accredited by the Commission for the Accreditation of Birth Centers. Until recently not all states covered Birth Center care under Medicaid (Ranji et al. 2009). Although coverage of Birth Centers is currently required by the ACA, many Birth Centers still have difficulties with reimbursement because specific insurance carriers, particularly managed care organizations (MCOs), may not include Bir th Centers in their networks. States have different licensure requirements, and some states do not have any accredited birth centers. 4 Birth Centers, which follow the midwifery model of prenatal care, are characterized as providing substantial education and psychosocial support along with low rates of medical intervention, standing in direct contrast to the “typical” prenatal care model described above. For example, a study by Palmer et al. (2009) considered three sites of prenatal care : a Birth Center, a teaching hospital, and a safety net clinic. The study found that midwives at the Birth Center offered longer prenatal care visits than their counterparts in the other settings. Interventions such as pharmaceutically induced labor and continuous electronic f etal monitoring are generally not used at Birth Centers (Stapleton et al. 2013). For Strong Start, the Birth Center model was further enhanced by the addition of support provided by ir pregnancies “peer counselors ,” who met with women several times over the course of the . While research on the impact of Birth Centers is limited, there is substantial research on midwife 5 provided prenatal care in various settings , though results vary across studies. For example, across nine studies (including one review) of the impact of prenatal midwifery care on birth outcomes, three found a significant reduction in preterm birth rates and four found a significant increase in birth weight (Howell -enrolled on Medicaid et al. 2014; Sandall et al. 2015). However, none of these studies focused only women. Thus, the current evaluation contributes substantial information specifically concerning the infants. enrolled women and their impact of midwifery care in Birth Centers for Medicaid- GROUP PRENATAL CARE In place of brief, medical individual appointments with an obstetrical provider, Group ly -focused Prenatal Care offers pregnant women the opportunity to receive care in a group setting, meeting together as a cohort to have prenatal care appointments that include additional time for education and -known Group Prenatal Care support from their providers and other pregnant women. The most well CenteringPregnancy model is (Centering), which was formalized in 1998 through the Centering HealthCare Institute (CHI). Under Centering, groups of 8 to 12 pregnant women are brought together about 10 times beginning mid -pregnancy to have their prenatal care appointments, which also include facilitated group discussions about health, nutrition, childbirth preparation, stress reduction, family planning, parenting and personal relationships (among other topics). Strong Start awardees implementing Group Prenatal Care were not required to adopt a curriculum, but almost all explicitly used Centering or modeled their approach after Centering. 4 American College of Nurse Midwives, Care http://www.midwife.org/Our-Philosophy-of- 5 While birth centers universally offer the midwifery model, midwives in other se ttings may sometimes follow a medicalized or obstetric model. 4 INTRODUCTION

23 At the start of the Strong Start for Mothers and Newborns initiative, there was a paucity of on birth effects its research on the effectiveness of Group Prenatal Care. One literature review on outcomes identified 11 studies that report its impact on birth weight and/or gestational age (Howell et 6 al. 2014). Four of these studies found a statistically significant reduction in the rate of preterm birth and three showed a positive impact on birth weight. A more recent study in South Carolina compared to those of Medicaid women the outcomes of Medicaid enrollees participating in CenteringPregnancy receiving traditional, individual prenatal care. The study estimated that Centering participation reduced risk of premature birth by 36 percent compared with women who had traditional prenatal care and that, for every premature birth prevented, there was an average savings of $22,667 during the infant’s first year of life. In addition, participation in Centering reduced the incidence of low birthweight births by 44 percent, resulting in a cost savings of $29,627 during the infant’s first year of life. Finally, the study found that infants of Centering participants had a reduced risk of a NICU stay (28 percent), saving valuation further analyzes the impacts of $27,249 per avoided stay (Gareau et al. 2016). The current e Group Prenatal Care by considering a range of sites, states, and implementation approaches simultaneously. MATERNITY CARE HOMES their intended Maternity Care Homes are to improve continuity of care for pregnant women and infants during pregnancy, childbirth, and postpartum. The Maternity Care Home approach builds on the similar concept of the patient centered medical home (PCMH). The PCMH was first created for pediatric care in the late 1960s, has evolved and expanded to cover other forms of primary care, and has recently become a major focus of health care delivery system reforms in both the Medicaid and Medicare programs. According to Childbirth Connection, the various components of the Maternity ; (to improve continuity) y include a single clinician providing or coordinating care Care Home model ma -centeredness continuous quality improvement; patient (to focus more attention on pregnant women In November 2010, North and their questions and concerns); and timely access to care (Romano 2012). Carolina began to develop a list of core competencies for a Medicaid Maternity Care Home (North Carolina Department of Health and Human Services 2010). These competencies include providing all -risk, case management home and, for those identified as high eligible pregnant women with a medical services to help improve birth outcomes and continuity of care. This effort builds on a current program , which provides care coordination services to Baby Love called begun in the state in 1987, - Medicaid Under Strong Start, the most consistent feature of the eligible pregnant women (HCPHA, 2006). Maternity Care Home model was the addition of a care manager to organize and improve women’s access to care. latively new and not consistently implemented, there se the Maternity Care Home model is re Becau is little evaluation research documenting its effectiveness. Several studies in the 1990s showed the positive impacts of enhanced prenatal care initiatives that incorporated such services as case managem ent/care coordination, health and nutrition education, psychosocial counseling, and home visiting on birth outcomes, such as the probability of having a low birth weight infant (Heins et al. 1990). Baby Love lina’s Particularly relevant is an early evaluation of North Caro program suggesting that the ’s care coordination reduced low birthweight rates and Medicaid costs (Buescher and support program enhanced et al. 1991). However, a more recent comprehensive review of the literature on similar 6 Specific information related to the Strong Start design plan can be found in Annual Reports 1, 2, and 3. INTRODUCTION 5

24 prenatal care services for Medicaid women found mixed results across settings (Anum et al. 2010). The national data from the Strong Start evaluation builds on this base and furthers policymakers’ understanding of the impact of Maternity Care Home models on Medicaid birth outcomes. STRONG START AWARDEES AND SITES The 27 Strong Start awardees each provided enhanced services through one or more of the Strong Start models of care : two implemented Birth Center care, 15 implemented Group Prenatal Care, and 17 implemented the Maternity Care Home approach. Included in these counts are six awardees that 2, 2 2 percent of Strong Start’s provider sites implemented more than one model. As shown in Figure rovi ded services in a Birth Center Setting (47 sites), 2 0 sites), 7 percent offered Group Prenatal Care (6 p and 51 percent of Strong Start’s provider sites implemented Maternity Care Home (112 sites). 7 2: STRONG START SITES, BY MODEL (N=2 FIGURE 19) Birth  Center Group Prenatal Care   Maternity Care Home 27% Notes: As discussed in Table 1, this figure lists 2 19 site s; however, the number of unique sites throughout the Strong Start award pe riod is 21 0. The larger number encompasses multiple models offered at the same location. The Strong Start awardee sites were spread widely across 32 states, the District of Columbia, and 3. The Southeastern Puerto Rico. The geographic distribution of Strong Start sites is illustrated in Figure region of the US had the largest number of sites, an intentional result of CMMI’s desire to target areas Table with the highest rates of preterm birth. As seen in 1, the number of Strong Start provider sites per state/territory ranged from just one (in Puerto Rico) to 31 sites (in Illinois). izations and health care a wide variety of organ , comprised The Strong Start awardees organizations . providers and agencies based including hospital and health systems, health plans, and community- There was similar diversity among the Strong Start provider sites, but more than half were either ealth Centers (FQHCs) or outpatient clinics associated with a hospital or health Federally Qualified H 7 210 — These three numbers sum to 219, which is higher than the total number of unique sites because six awardees — implemented more than one of the three Strong Start models of enhanced prenatal care. 6 INTRODUCTION

25 center. The remaining sites included nationally certified Birth Centers, tribal health centers, local health 8 ith one exception, departments, and physician groups. It is important to note that, w CMMI did not directly contract with states or state Medicaid agencies in making its awards, which limited the initiative’s ability to require the submission of state data for evaluation purposes, use Medicaid policy to guide awardee implementation, or influence awardees’ decisions with regard to sustainability. UNITED STATES FIGURE 3: DISTRIBUTION OF STRONG START AWARDEES AND SITES ACROSS THE 0 oo 0 0 0 •• • 0 0 ~ 0 0 0 ' ~ 0 0 ~ ~ 'O • 0 0 • 0 = 0 0 e o 0 0 l o 0 0 • • 0 0 • 8 ~ • • • 0 • 0 • 0 • • ' "- • ~ o 0§ 0 ,. 0 0 0 - ,. 0 Model ron of St g S t art Awa r dees and Sit es 0 Awardee - Birth Ce nte r nter 0 Ce Bi rt h 0 t al Ca en up Pr - Gro na Pre Group tal Care re 0 Awardee ::-- Awardee me re Ho Ca ty - Materni Materni Ca ty re Home • • A ed Awardee - Mi x ed Mix • • Strong Start awardees initially received funding for a four-year period, intended to comprise a three -year intervention period for implementation and service delivery, and a fourth year to complete program and evaluation data collection. Most awardees ulti -cost extensions, mately received no allowing them to continue to enroll participants and provide services for part or all of the fourth year of the program and to continue data submission into a fifth year. Most Strong Start program enrollment –funded enhanced had ended by September 2016, and many awardees had also ceased Strong Start services by that point (see 1). Across awardees, end dates for enrollment ranged from August Table 2015 to December 2016. Accordingly, the final deliveries among Strong Start- enrolled women occurred between February 2016 and March 2017. All Strong Start programs, including the submission of all evaluation data, ended by June 2017. 8 The Oklahoma Health Care Authority the state agency responsible for administering Oklahoma’s Medicaid program, SoonerCare. INTRODUCTION 7

26 PARTICIPANTS BY AWARD EE SITES EVER ENROLLING 1: STRONG START TABLE Strong Start Number of Sites Status of Award State Awardee Name Model Final Deliveries Period Enrollment MCH GPC BC Access Community Health Aug us t 2013 - N/A September 2016 31 N/A MCH IL --------- Network (ACCESS) Jan uary 2016 Albert Einstei May 2013 – n Healthcare N/A 3 N/A GPC PA December 2016 Jul y Network (Einstein) 2016 American Association of Birth June 2013 - 1 N/A N/A BC 46 22 December 2016 Centers (AABC) Sep 2016 tember Feb ruary 2014 - December 2016 LA Amerigroup Corporation (Amerigroup) N/A 7 GPC N/A ust Aug 2016 - Apr Central Jersey Family Health 2013 il GPC December 2016 NJ N/A N/A 7 Jul y 2016 Consortium, Inc. (Central Jersey) - 2013 ember Nov Healthy Start Florida Association of FL N/A MCH N/A 8 October 2016 Jun e 2016 Coalitions (FASHC) Grady Memorial Hospital Corporation November/ Oct obe r 2013 - N/A 4 N/A GPC GA DBA Grady Health System (Grady) May 2016 December 2016 us Aug - t 2013 August 2016 N/A 7 N/A GPC TX (Harris) Harris County Hospital District 2016 Mar ch 2013 - Sep tember NV N/A GPC N/A HealthInsight of Nevada (HealthInsight) 3 February 2017 Jul y 2016 – July 2013 N/A 5 Johns Hopkins University (Hopkins) MD N/A MCH November 2016 Apr il 2016 Los Angeles County Department of obe Oct - r 2013 6 CA MCH N/A December 2016 N/A Health Services (LADHS) 2016 ust Aug Maricopa Special Health Care May 2013 - 5 N/A February 2017 N/A MCH AZ ember District (Maricopa) Dec 2016 – 2013 tember Sep Medical University of South April/May 2016 5 N/A N/A MCH SC Carolina (MUSC) December 2015 Sep tember 2013 – February 2016 MI Meridian Health Plan (Meridian) 1 N/A N/A MCH 2015 ember Dec Mississippi Primary Health Care Jun e 2013 – May 2016 N/A N/A MCH MS 8 2015 Association, Inc. (MPHCA) Sep tember ust Oklahoma Health Care – 2013 Aug January 2017 4 N/A , MCH GPC 4 OK 2 (OKHCA) Sep Authority tember 2016 Providence Health BC , MCH, July 2013 - DC January 2017 3 2 1 (Providence) ember Nov 2016 GPC Foundation – 2013 ust Aug Signature MO MCH N/A N/A 9 Medical Group (Signature) August 2016 Dec ember 2015 - May 2013 St. John Community Health Investment MI January 2017 1 4 N/A , MCH GPC 4 Corp. (St. John) 2016 ober Oct ober Oct – Texas Tech University Health Sciences 2014 2 1 N/A , GPC February 2017 TX MCH Oct Center (Texas Tech) ober 2016 June – 2013 United Neighborhood Health Services, 8 N/A N/A MCH TN March 2017 Jun e 2016 Inc. (United) - May 2013 University of Alabama at 2016 August 4 N/A N/A MCH AL Feb ruary 2016 Birmingham (UAB) ust - University of Kentucky Research Aug 2013 KY N/A GPC 7 N/A Se ptember 2016 ch 2016 Foundation (UKRF) Mar University of Puerto Rico Medical – 2013 ust Aug N/A September 2016 1 N/A GPC PR Sciences Campus (UPR) ruary 2016 Feb ober Oct - 2013 3 University of South Alabama (USA) N/A September 2016 , GPC MCH AL 7 2 May 2016 - 2013 tember University of Tennessee Health Sciences Sep 2 N/A GPC TN October 2016 N/A June 2016 Center (UTHSC) Virginia Commonwealth Ma y 2013 - VA GPC , MCH N/A 6 5 December 2016 5 University Sep tember 2016 (VCU) N/A TOTALS 47 6 0 112 Data on the number of sites is primarily from the evaluation’s four years of case study data collection and form Sources: submission information in the participant -level process evaluation data. The information is supplemented by additional eports documents provided to the case study team during the data collection period, and the program monitoring r awardees submit to CMMI. 8 INTRODUCTION

27 1 Notes: The American Association of Birth Centers was the only awardee operating in more than one state. During the Strong Start evaluation, AABC had active sites in Alaska, Arizona, California, Connecticut, Florida, Idaho, Illinois, Kansas, Maryland, Minnesota, Missouri, Nebraska, New Mexico, New York, North Carolina, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, West Virginia, and Wisconsin. 2 Two OKHCA sites implemented both MCH and GPC models. These sites are each counted once in the MCH column, and once in the GPC column. Therefore, the total number of sites overall is smaller than the totals reported in this table. 3 Two USA sites implemented both MCH and GPC models. These sites are each counted once in the MCH column, and once in the GPC column. Therefore, the total number of sites overall is smaller than the totals reported in this table. 4 One St. John site implemented both MCH and GPC models. This site is counted once in the MCH column, and once in the GPC column. Therefore, the total number of sites overall is smaller than the totals reported in this table. 5 Fo ur VCU sites implemented both MCH and GPC models. These sites are each counted once in the MCH column, and once in the GPC column. Therefore, the total number of sites overall is smaller than the totals reported in this table. For one of the four sites, case study interviewees gave conflicting reports of whether the site had implemented the MCH model; for this annual report (and in this table) that site is counted as having both the GPC and MCH model. -year award period, Initially, Strong Start had a goal of reaching up to 80,000 women over a three with awardee -specific enrollment goals generally between 1,500 and 3,000 women. However, because of implementation delays and early challenges with enrollment, in Year 2, most Strong Start awardees revised their enrollment targets downward (CMS/CMMI, 2014). Most new enrollment goals were between 1,000 and 2,000 women over the entire period of program operation (three to four years depending on whether the awardee received a no -cost extension for up to one year), wit h the total enrollment goal revised to approximately 58,000 women across all 27 awardees. In Years 3 and 4, with a total of 45,599 women ever s and Strong Start ended awardees worked toward revised goal 9 enrolled in the program, nearly 80 percent of the rev target enrollment. Figure 4 shows the total ised en . Maternity Care Home awardees accounting for the highest roll ment in Strong Start by model . dels enrollment numbers, with more than double the enrollment of either of the other mo ENROLLMENT, BY MODE 4: TOTAL STRONG START FIGURE 45,316) L (N= , 000 -.------------------------------ 30 26 , 007 , 25 --------------------- 000 000 , 20 +---------------------- 15 , 000 --------------------- 10,503 10 , 000 +------------- 000 5, ---- 0 +---- Care Center Care Maternity Home Prenatal Birth Group 9 This number represents the official enrollment total reported by CMMI program administrators. The total number of enrollees reported in Strong Start awardee quarterly monitoring reports is somewhat higher, however (46,353). Finally, the number of women for whom at least one participant Level Program Evaluation data form was submitted was 45,316. This final number, reflecting the total number of women who “participated in the evaluation,” is used in the remainder of this report. INTRODUCTION 9

28 The state and local context within which Strong Start awardees operated may have affected their operations and, potentially, their success. For example, Medicaid and CHIP eligibility and coverage policies vary considerably across the 32 states (and the District of Columbia and Puerto Rico) where Strong Start awardees were situated. States included those with some of the most and least generous 10 income eligibility li mits and benefits packages in the country. The upper Medicaid/CHIP income eligibility limit for pregnant women in April 2017 in the Strong Start states ranged from the minimum ouisiana and Oklahoma, to federally -required level of 138 percent of the federal poverty level (FPL) in L 324 percent of the FPL in the District of Columbia. Implementation of the ACA, which occurred prior to and during Strong Start program operations, changed the coverage landscape in every state. Starting in 2014, half of the Strong Start states (13 states and the District of Columbia) had elected to expand Medicaid coverage to all adults with incomes 11 12 up to 138 percent of poverty By July 2016, this total regardless of pregnancy or parenting status. had increased to 14 Strong Start states and DC. When Strong Start operations ceased in 2017, 16 states and DC had expanded their Medicaid programs under ACA authority. (For detailed information regarding each state’s income eligibility threshold by coverage authority, please see detailed fact sheets 13 provided by the Henry K. Kaiser Family Foundation , found in Appendix A . an example of which can be EVALUATION DESIGN The Strong Start evaluation employed a mixed -methods research design, comprised of case studies of -level process evaluation indicators, and a implementation, the collection and analysis of participant quantitative analysis of the impacts of Strong Start on birth outcomes and costs of care. The evaluation also employed a technical assistance component to acquire birth certificate and Medicaid data from states with Strong Start awards and/or support states in developing their capacity to link these data so th the analysis of certain evaluation included at the evaluation could assess program impacts. Finally, the program monitoring data collected from the Strong Start awardees by CMMI to support the oversight of awardee implementation. This section provides brief summaries of these research methods. EMENTATION CASE STUDIES OF IMPL team conducted case studies in each of the first four years of the evaluation. Case The evaluation studies provided an in -depth understanding of how Strong Start models were designed, im plemented, and evolved over time; documented barriers or challenges awardees encountered during ase implementation; and described perceived successes and factors that contributed to success. C studies included four components: document review, key informant interviews, focus groups with participating pregnant and postpartum women (as well as a small number of groups with similar nonparticipants), and structured observations of care and care settings. Because of resource limitations that precluded studying all service delivery sites, we collected case study data from all awardees and 10 — CHIP in just three of the Strong Start states Pregnant women themselves are eligible for Missouri, New Jersey, and Virginia. However, the following states have adopted the CHIP “unborn child” option, which permits states to consider a fetus a “target ed income child” for the purposes of CHIP cov low- erage: CA, IL, LA, MI, MN, MO, NE, NJ, OK, OR, TN, TX, VA, WI. 11 The ACA establishes a minimum income eligibility level of 133 percent of FPL for states that opt to expand Medicaid, and also ’s minimum income eligibility level for , this means that the ACA establishes a standard 5 percent income disregard. Taken together Medicaid expansion is 138 percent of FPL. 12 This includes states (e.g., Michigan and Pennsylvania) that have expanded Medicaid through a Section 1115 waiver. 13 chip/ https://www.kff.org/medicaid/fact- sheet/where-are -states- today -medicaid- and- 10 INTRODUCTION

29 ch of the four summarizes data collection for ea approximately one -third of sites they operated. Table 2 case study rounds, including when and how data were collected, the number of key informant interviews conducted and total number of key informants, the number of focus groups conducted and total number of focus group participants, and the number of structured observations performed. Appendix B describes Case Study methodology in more detail. TABLE 2: STRONG START CASE STUDY DATA COLLECTION, YEARS 1 -4 Focus Mode of Structured Focus Group Key Data Key Informant Evaluation 2 Observations † Data Participants † Groups Collection Informants Interviews Year 1 (N) Collection (N) (N) Period (N) (N) Mar. 2014 - Primarily in Year 1 488 36 65 266 409 person Nov. 2014 Mar. 2015 - Primarily by Year 2 2 18 2 152 207 phone Jun. 2015 - Nov. 2015 Primarily in 440 12 65 314 211 Year 3 person Jun. 2016 Oct. 2016 - Primarily by Year 4 0 1 110 144 5 May 2017 phone N/A 1074 133 951 48 TOTALS N/A 739 arly all the evaluation’s focus group participants were ne Notes: All columns marked with a dagger symbol (†) indicate that gnant and postpartum women enrolled in Strong Start (123 groups with a total of 892 women). In Year 1, the case pre study team conducted 10 focus groups with 59 pregnant and postpartum women not enrolled in the program, to collect -enhanced) models of prenatal care. These non- information on sites’ typical (non enrollee groups and participants are included in the totals for this table. 1 person AABC sites were visited in many In Years 1 and 3, nearly every awardee and . In Year 2 and Year 4 data collection was by phone with the exception of an in site visit with the University of Puerto Rico involving -person n interviews and focus groups; and in Y4 a small number of in- in- person interviews and one participant focus group perso for Virginia Commonwealth University and in- person interviews at site in North Carolina. the AABC 2 Structured observation numbers are approxima ted. OCESS EVALUATION LEVEL PR PARTICIPANT- The participant timely feedback to CMMI, the evaluation team, and gave -level process evaluation Strong Start awardees and sites on key indicators of enrollee demographics and risk factors, program performance, and interim participant outcomes. Using four data -gathering instruments, the evaluation etailed information on the participants’ demographic characteristics and risk profiles, service collected d . The instruments included an Intake Form, Third use, and outcomes of all Strong Start participants Trimester and Postpartum Surveys (all completed by participants, with or without assistance), and an Exit Form (which was completed by awardee staff based largely on medical record reviews). Copies of . Strong Start awardees were required to collect these forms are included in Appendix D e evaluation team on a -level data from all of their sites and transmit these data to th participant quarterly basis through a system that protected patients’ identifying and personal health information. identified and tracked risk factors for preterm birth among participants, complications Data experienced by participants during pregnancy, enhanced and routine services provided during -level pregnancy and postpartum, and birth processes and outcomes for women and infants. Individual data were summarized in quarterly reports. INTRODUCTION 11

30 Third Trimester Surveys, 27,109 Intake Forms, In total, the evaluation team received 42,988 Postpartum Surveys, and 44,485 3. Table Exit Forms. This information is summarized in 27,135 TABLE FORM SUBMISSION T 3: CUMULATIVE HROUGH YEAR 4 Total Total Third Number of Total Exit Total Intake Postpartum Trimester Awardees Evaluation Forms Forms Surveys Surveys Submitting Year Submitted Sub mitted Submitted Submitted Data N/A 343 568 3,666 22 Year 1 8,704 6,669 19,155 6,949 Year 2 26 27 20,387 Year 3 38,149 18,049 24,951 37,965 25,939 26,619 42,581 27 Year 4 27,109 42,988 44,485 27,135 27 TOTALS N AND DATA ACQUISITIO TECHNICAL ASSISTANCE The Technical Assistance and Data Acquisition team spent the first two evaluation years working with the Impacts team to plan the evaluation’s data collection approach ; reach out to Vital Records and Medicaid agencies in 20 states ; and begin submitting requests to obtain the birth certificate, Medicaid eligibility, and Medicaid claims/encounter data necessary for the impact analysis. During Year 3, the Impacts, Technical Assistance, and Data Acquisition teams worked closely together and with states to begin receiving vital records and Medicaid files. In Year 4, the teams continued to engage with state agencies to move the data submission process forward, as well as facilitate back -and -forth communications when the Impacts team needed follow up questions answered or required updated data files from states. This work continued into Year 5 as the Impacts team finalized its analysis. IMPACT ANALYSIS igned to assess whether and to what extent Strong Start models of care had The impact analysis was des an impact on three key outcomes: rates of preterm birth , rates of low birthweight births, and Medicaid/CHIP costs through pregnancy and the first year after birth. This analysis, wh ich relied on also assessed linked birth certificate and Medicaid data for births occurring in 2014, 2015, and 2016, whether these impacts varied among enhanced prenatal care models, awardees, sites (where feasible), and type of services offered and receiv ed. T he gold standard design for estimating program treatment effects is a randomized control trial. However, Strong Start was not designed to assign either awardees CMMI or participants to treatment and control groups through intentional randomization. Many experimental designs that use a difference -in -difference approach, but the evaluations rely on quasi- because . This is particular questions asked of this evaluation did not lend themselves to this strategy Strong Start layered enhancements upon existing models of prenatal care rather than implementing entirely new models of care, and therefore, there was no pre -period with which to compare . We therefore needed to take a n observational approach that compared outcomes for women participating in Strong Start and their infants to outcomes for non-participating Medicaid enrolled women with similar risk profiles and their infants. 12 INTRODUCTION

31 , in conjunction with a panel of twenty research methods and During Year 1, the evaluation team would focus on measuring the effects of maternity care experts, determined that the best approach 14 Strong Start in comparison to “typical ” Medicaid maternity care practices, which required the selection of comparison groups of women who did not receive services in Strong Start Birth Centers, Group Prenatal Care, or Maternity Care Homes. In Year 2, the evaluation team began to engage with states and refined the process for requesting matched birth certificate and Medicaid eligibility and claims data. During Year 3, there were two major tasks that the Impacts team finalized to move the data acquisition process forward: selecting comparison groups and establishing a decision rule for excluding a relatively small number of cases for which an accurate comparison group could not be drawn (for because women in Strong Start were served at a location where example, women in the -risk high all state were referred for prenatal care). After obtaining merged birth certificate and Medicaid data from states, a propensity score re -weighting method (described in more detail and justified as an appropriate matched comparison groups of is report) was used to select well of th Appendix R in evaluation strategy - men who delivered during the same period, who resided in roughly the same geographic aid wo Medic area as Strong Start participants, and who had similar risk characteristics. In Year 4, the Impacts team also linked Medicaid eligibility and birth certificate data for states that , assessed selection bias and did not link the data themselves, cleaned claims data for several states , and applied comparison group challenges to determine the appropriateness of various analyses preliminary propensity score reweighting models for four states to test the methods. In the Year 5, the final year of the evaluation, the team continued to collect, prepare, and analyze Medicaid and birth certificate data for remaining states and years; developed analytic claims files and finalized an app roach to analyzing costs data; prepared final estimates on the impact of Strong Start on birth outcomes and costs/utilization (from claims data); and implemented enhancements to the propensity score reweighting approach. ORGANIZATION OF THE YEAR 5 PROJECT SYNTHESIS -year Strong Start evaluation and This Year 5 Project Synthesis presents final findings from the five concentrates on synthesizing information gathered across the three evaluation components Project Synthesis presents cross-cutting throughout the course of the evaluation. Volume 1 of the findings across awardees and enhanced prenatal care models, while Volume II presents awardee - the following cross specific findings. In Volume 1, we present -cutting results: of implementation; • Case Studies Findings from the qualitative vel Process Evaluation des criptive findings; -Le Participant • Summaries of lessons learned from the effort; • Technical Assistance and Data Acquisition mpact Analysis base I d on merged birth certificate and Medicaid eligibility and • claims/encounter data; ng the PLPE data; and • Regression Adjusted Outcomes Analyses usi A series of • Summary of Findings base d on a synthesis of our findings across all components and all years of the evaluation. 14 lth department Typical Medicaid maternity care practices include private providers, community health centers, public hea clinics, and hospital outpatient departments that do not offer prenatal care through any of the Strong Start models. INTRODUCTION 13

32

33 Year 5 Results This volume presents findings from Year 5 of the evaluation. Case study findings come first, followed by -level program evaluation findings. We then present lessons learned from the Evaluation participant team’s effort to work with state agencies to acquire birth certificate and Medicaid data. The effects of -level impact Strong Start on maternal and infant outcomes and costs are assessed through model analyses based on merged birth certificate and Medicaid data, presented for the first time in this report. We conclude with a series of regression- adjusted outcome analyses using PLPE data. CASE STUDIES Our final case study analysis summarizes awardees’ experiences implementing the Strong Start program and is based on four rounds of comprehensive data collection from all 27 awardees and a selection of their provider sites. Specifically, this section presents common features and variations in of each awardee’s Strong Start awardees’ implementation approaches, classification of the intensity Strong Start intervention, awardees’ most significant implementation challenges and successes, factors awardees and sites identified as most critical for successful replication of their Strong Start models, and awardees’ plans for sustaining their Strong Start programs. DESCRIPTION OF THE S TRONG START MODELS Though each awardee took a unique approach to implementing its Strong Start enhanced care model, all shared some similar elements. Table 4 shows common features defining each of the three Strong Start models and how awardees’ implementation approaches varied. Just two awardees implemented the Birth operating all , AABC, ardee Center model, with a single aw but one of the 47 birth center sites that participated in Strong Start during the award period. All sites — 1) prenatal care provided by midwives across both awardees adopted the same two key components 15 following the midwifery mode l of care paired with 2) psychosocial support, health education, and [AABC’s 46 sites used a peer counselor referrals provided by a peer counselor or perinatal navigator. ity and Providence’s single Birth Center site used a perinatal navigator. For simplic , we use the single term “peer counselor” to refer to them.] Some variation existed, however, in the average number and eer counselors and enrollees and in the qualifications of the counselor. mode of encounters between p For instance, AABC did not use a standard definition of “peer,” though the awardee expected the peer counselor role to be distinct from the prenatal care provider. Some AABC peer counselors had no -created Strong Start training modules were selected for formal preparation beyond the ; they awardee characteristics that qualified them as peers of Strong Start participants, such as living in the same community, being young with small children, or having been a birth center prenatal patient. Most, 15 The midwifery model of care involves a holistic and wellness approach to pregnancy and birth. The approach combines medical -centered process care with comprehensive education about pregnancy, labor, delivery, and postpartum care using a patient - designed to empower women to take control of their health. Midwifery visits are generally at least 30 minutes (compared to 10 15 minu tes for a typical prenatal care visit with an OB/GYN) allowing more time to identify and addressing patients’ medical, psychosocial, or educational needs. http://www.midwife.org/Our-Philosophy-of- Care . YEAR 5 FINDINGS 15

34 however, had clinical or formal health education backgrounds as nurses, lactation consultants, doulas, or other certified health workers. TABLE 4: COMMON FEATURES DE FINING EACH STRONG START MODEL AND VARIA TIONS IN IMPLEMENTAT ION Model Type Birth Center Group Prenatal Care Maternity Care Home Addition of new staff to • • • Prenatal care in a group setting Midwifery model of provide care care Series of f -face acilitated, face -to • Common management/coordination hosocial support, sessions covering health Psy • c features and psychosocial support to health ed assessment, education, support ucation, and defining the eligible pregnant women referrals provided by Emphasis on building supportive • model a peer counselor or peer relationships perinatal navigator • • • are manager accessibility: C Use of CenteringPregnancy Peer counselor or atal navigator roach: most followed closely, some 24/7, others followed ap p n peri some used modified approach qualifications (e.g., clinic hours some professionally Group facilitator qualifications, anager qualifications m Care • • trained, others share both for the clinician facilitator (e.g., RN, LCSW, CHW) demographic features (e.g., CNM, FNP, OB/GYN) and Number of encounters • with participants) second facilitator who was from 1 to 8 ranged Number of • sometimes a prenatal care provider Mode of encounters: most • encounters ranged but often not (e.g., RN, social person at clinic, some by in- from 4 to 14 worker, community health worker) phone or in participant’s Variations in Mode of encounters: Number of facilitators ranged from • • home model rson at pe most in- 1 to 3 Number of care managers • implementation birth center, some by ber of group care sessions: Num • assigned to each patient: phone or in most used 10 (per Centering), with some use two -person teams, participant’s home range of 6 -12 sessions others assigned participant Some birth centers • Group size: most averaged 8 -12 to single care manager • offered childbirth 16 women, with range of 3- Additional program • education or other Composition of groups: most group • components such as prenatal classes free of charge by gestational age (per Centering), classes, free dental care, to Strong Start some group by demographic nutritional counseling, and participants or medical risk factors features skill-b uilding or (previously these collaboration opportunities classes required a fee) for prenatal care providers All Group Prenatal Care awardees provided prenatal care in a group setting via a series of -to facilitated, face -face sessions covering a broad range of issues, including health assessment, education, and support. These awardees also were uniform in their emphasis on building peer curriculum relationships. Many had common features because they followed CHI’s CenteringPregnancy and standards closely (e.g., providing 10 sessions, using co -faci litators, and creating cohorts based on 16 gestational age). But individual sites affiliated with about one -third of the awardees adopted an omewhat approach that departed s from Centering. UPR, for instance, provided 12 sessions, and one HealthInsight site provided only six. Several awardees grouped women based on demographic features or medical risk factors rather than (or in addition to) gestational age. Some examples include CJFHC’s and UTHSC’s groups for women with gestational diabetes, UKRF’s groups for Spanish Speakers or 16 CenteringPregnancy Under the approach, prenatal care cohorts (typically grouped by gestational age) meet ten times over a e -month period. Two trained facilitators lead each session, which are scheduled for two hours and take place in a privat seven space large enough to accommodate patient members and support people in the proscribed circular seating arrangement. off area in the corner of the Sessions begin with time for socialization while individual health assessments occur in a screened- -care activities like weighing themselves and taking their own blood pressure, which room. Gr oup members also participate in self they record in their own charts. The second half of the Centering session involves a facilitated discussion about a particula r topic. Centering materials available through the Centering Healthcare Institute include facilitator guides with suggested session content and activities, discussion aides, and notebooks that patients use throughout pregnancy. 16 YEAR 5 FINDINGS

35 women with opioid addition, VCU’s groups for teens or women with high-risk pregnancies, and UPR’s groups for women with HIV, Zika virus, or rheumatic diseases. Maternity Care Home awardees were the most varied in how they implemented St rong Start. All awardees added new staff to identify participant needs, coordinate care , and provide psychosocial support to eligible pregnant women. Though th ese individuals had a variety of titles, for simplicity we was their only shared use the single term “care manager” to refer to them. Having a care manager feature, however, and they adopted a range of approaches regarding care manager qualifications, the number and mode of encounters, and care manager assignments. For instance, most Maternity Care me models assigned a participant to a single care manager, but some used teams of two managers Ho with complementary skills. The ACCESS awardee paired a social worker with a registered nurse, while — anager and community health at Johns Hopkins, three teams each composed of a nurse care m worker — were embedded at Strong Start sites. Some Maternity Care Home awardees also had other program components beyond care management. MPHCA, for instance, provided free dental care and natal visits. USA provided a nutrition education session with a (at some sites) free childcare during pre registered dietician for some participants (including teens), primiparous women, or those entering care 17 either underweight or obese. s Similarities and Differences across the Strong Start Model Though the three Strong Start models had their own distinct and defining features, there were also similarities across the models. Each provided education related to a range of prenatal, childbirth, and o) nutrition, exercise, family planning, breastfeeding, postpartum issues including (but were not limited t normal and abnormal pregnancy symptoms, stress management, infant care and safety, what to expect during labor and delivery, smoking cessation, how to manage health conditions, oral hygiene, and rm birth prevention. In Maternity Care Homes and Birth Centers, education was generally prete delivered one -on-one as part of care manager or peer counselor encounters. In Group Prenatal Care, each session included shared learning via facilitated discussion on a specific topic. Participants across models highlighted health education as a major benefit of Strong Start during the evaluation’s focus groups. “I probably would skip a lot of my appointments, but the [care manager] is really positive and teaches me diff erent ways to think about things. We go over my diabetic stuff and she gives me different lists – Maternity Care Home participant and talks to me about how it could affect the baby’s heart.” “At the doctor’s office you sit and wait and wait and wait. At Centering you go in and are learning right – Group Prenatal Care participant away.” “I received a lot of handouts about healthy eating and I expressed to [the peer counselor] that I wasn’t easy suggestions for eating well because I am not really into vegetables. She gave me some incorporating vegetables that I had not really thought about. It made me feel like I was doing better.” – Birth Center participant 17 In the final evaluation year, the case study team conducted a small number of key informant interviews in support of the development of “special study” manuscripts on the Group Prenatal Care and Birth Center models. Findings from these interviews are summ arized in Appendix C . YEAR 5 FINDINGS 17

36 -medical services not provided during Across models, Strong Start staff made referrals to non prenatal visits. They often found participants were unaware of the resources available in their community or their eligibility for programs that could help them have a healthier pregnancy. In sed on the needs Maternity Care Homes and Birth Centers, referrals were direct and often ba assessment conducted with the evaluation’s Intake form. Common referrals were made to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Supplemental Nutrition h care, dental care, domestic violence services, smoking Assistance Program (SNAP), behavioral healt cessation classes, nutrition counseling, housing support, transportation services, childcare and services for other children in the family, and assistance with utility payments. Care managers and pee r usually followed up with participants about whether they accessed the referred service. counselors Group prenatal care awardees invited guest speakers to join topical discussions and provided materials/contact information for the speakers and other commu nity resources during sessions. Guest speakers commonly included pediatricians, social workers, doulas, domestic violence counselors, or WIC staff. Strong Start focus group participants recounted the many resources they had been rt. connected to via Strong Sta “[The care manager] tells you stuff no one else will, like babies’ doctors—I didn’t know you were supposed to look for them way ahead of time. She gives you resources for groups, or if you lost your job, – —things you don’t know exist.” employment opportunities, WIC information, food stamps, [etc.] Maternity Care Home participant —housing, food, “We had a social worker come in, and she could help us with anything we may need would help us with [and] things outside medical care. If we need it, we can reach out to her and she that.” – Group Prenatal Care participant – she told me about food banks in town when “I have a few needs [the peer counselor] helped out with my husband lost his job. She had it quicker than I could blink.” – Birth Center participant Finally, the three models shared an emphasis on psychosocial support through relationship -based care. For Group Prenatal Care awardees, this support was provided by group facilitators and by the other women participating in the group. Key informants reported that group members respected and learned from one another’s experiences and felt both supported by and accountable to one another. Focus group participants echoed this sentiment and valued the relationship they formed with their litator. prenatal care group faci “I missed one appointment... [The facilitator] called me to make sure everything was okay, and then like three people from my Centering group texted to make sure I was okay.” – Group Prenatal Care participant “One thing with the group is you need to share what you have, and sometimes it can be hard. But [the facilitator] makes it really comfortable. I really like her; we can talk about anything with her.” – Group Prenatal Care participant “The [facilitator] helped me with depression and a domestic violence situation. She’s not judging you. She’s not talking down to you.” – Group Prenatal Care participant YEAR 5 FINDINGS 18

37 For Maternity Care Home and Birth Center awardees, psychosocial support was provided by care managers or peer counselors. In some cases, these program staff members were licensed clinical social workers who provided counseling services. More often, however, psychosocial support was provided less formally and included regular check -ins with participants about how they were feeling, reminding them about or helping prepare for prenatal and other appointments, and reinforcing or further explaining information provided at appointments. Focus group participants spoke highly of this support, and sometimes said they felt more comfortable sharing concerns with Strong Start staff than with their prenatal care provider. “I didn’t have anything like this with my first pregnancy and I really just wanted support, especially from an outside source. Sometimes you don’t get that from your family.” – Maternity Care Home participant “I wouldn’t have told others about being bi -polar. I honestly feel like I can talk with [my care manager] about anything.” Maternity Care Home participant tter. That’s a “You can’t ignore stress. My blood pressure was down 20 points today... I felt so much be sign of the emotional support I’m getting and how it’s affecting my physical health.” – Birth Center participant Having a consistent Strong Start enhanced service provider was an important element of -based care across the three models. With few exceptions, the same Strong Start care relationship manager, peer counselor, or group facilitators served a participant throughout her pregnancy. Awardees agreed that this continuity allowed for increased understanding of patient needs and improved par ticipants’ trust while also promoting their willingness to share feelings, confidence to ask questions, and group bonding. A key informant from the AABC site in Sarasota Florida explained that participants’ ongoing relationships with the same peer counselors “opened pathways and doors to better communication, to find out more about their needs.” This shared program feature was also a significant departure from typical prenatal care where patients often saw a number of different key informant at LADHS (Maternity Care Home) remarked, “The care providers during pregnancy. A manager is the only one who follows the patient all the way through.” Comparisons between Strong Start and Sites’ Previous Approach to Prenatal Care Early in the evaluation period, the case study team assessed each awardee’s prenatal care model prior to implementing Strong Start. For most awardees and sites, Strong Start represented a considerable change from their previous model of prenatal care. With regard to Maternity Care Homes awardees rarely felt that their prior approach to prenatal care offered a robust set of psychosocial support and referral services for patients. Some sites affiliated with large tertiary care centers (e.g., MUSC, Texas -risk Tech, LADHS) reported good access to specialis ts and clinical referrals, and in some cases high populations like teens or women with substance use disorder also had consistent access to social workers. Some Maternity Care Home awardees described statewide or regionally -focused programs that provided care coordination and support to low -income or Medicaid -covered prenatal patients, YEAR 5 FINDINGS 19

38 18 19 or Healthy Start. such as Alabama’s Maternity Care Program And some sites, especially those affiliated with Federally -Qualified Health Centers (FQHCs) described establ ished relationships with community -based resources and co -located dental, behavioral health, or nutrition services. Overall, however, access to care coordination, referral networks, and social work services were limited or nonexistent prior to Strong Start. About half of the awardees that implemented Group Prenatal Care under Strong Start had previous experience with the model, and used their Strong Start funding to expand Group Prenatal Care or add . In some cases, (e.g., Harris, Providence) awardees service components like Community Health Workers had well -established group care programs they had operated for years while others’ prior experience was limited to pilot programs (e.g., Einstein, UKRF). Awardees not offering group care prior to Strong -one visits with OBs or -on lly provided a typical prenatal care model of consisting of brief one Start usua midwives, with limited time for patient education and discussion, and referrals to community -based -hoc basis only. services on an ad All Birth Center sites offered comprehensive maternity care provided by midwives prior to implementing Strong Start. The midwifery approach to care, an inherent feature of the Strong Start centers birth centers, involves a holistic and wellness approach to pregnancy and birth. Though birth view the midwifery model as enhanced care, it is not reimbursed as such (i.e., payment rates are the same or lower than rates for typical OB/GYN care). The birth centers also offered a variety of enhanced services and educational opportunities (e.g., lactation counseling, childbirth education classes, nutrition services, a lending library, and support groups). However, except for two AABC sites with established upport Community Health Worker (CHW) programs, none of the birth centers offered prenatal peer s or similar services before implementing Strong Start. Birth Centers’ connections to community -based resources and referral links varied—some had many well-established networks before Strong Start -net health care provider in their safety (especially sites that were also FQHCs or served as a Most Strong Start Birth Center sites did not target Medicaid community) while others did not. beneficiaries before they participated in the program, and Strong Start prompted some to make greater efforts to reach and offer care women enrolled in Medicaid. ng Start program staff and participants identified several common key differences In sum, Stro between Strong Start enhanced care and the prenatal care that awardees and sites previously provided. l prenatal care, Strong Start care: Compared to typica Involved a continuous Strong Start staff person (care manager, peer counselor, group • facilitator) , offering better care continuity throughout a woman’s pregnancy ; • Consistently identified patient needs via comprehensive prenatal intake; • Provided more education and psychosocial support; 18 ng histor s a lo a ha Alabam s ough it s thr nrollee d e nt Medicai regna or p t f l suppor sychosocia d p ion an oordinat e c ing car y of provid th materni s wi r work ontracto ry c ty ca istricts re d ty care aterni 4 m ’s 1 e state f th h o ac . I n e re Program ty Ca terni Ma , a prima Ahe ps te d either S , calle e Program he Maternit . T ort upp d s r enhance o delive s t vi der pro y Car ith gions w he re e in t Car OM r M ad o um of tw s a minim , require rt awards ta g S Stron o e s wit h a car e coordinator . T y into t entr s a r occur ncounte l e ncounter he initia fte he othe d t r delivery , b ut befor e t he mothe r ha s lef t the s an ervice l s r prenata d fo cai Medi d encounte r require r mus t occ ur a . http://www.usahealthsystem.com/momcare hosp ital 19 , Healt es a ed b y th e Healt h Resourc nd S ervice s Administrat ion (HRSA) Support hy Star t work s t o preve nt inf a nt mortalit y in 87 h d hig ge an l avera he nationa s t 5 time . t 1 m bir reter , p s of low birthweight th, rate leas t h infa nt mortalit y rate s a communitie s wit or resulting from conditions maternal mortality and maternal morbidity (serious medical aggravated by pregnancy and delivery). http s ://mchb.hrsa.gov/ maternal-child-health-initiatives /healthystart/ 20 YEAR 5 FINDINGS

39 • -up Connected patients to more resources, both Medicaid and non-medical, and included follow on referrals; allowed Allowed patients more time to ask questions and discuss concerns with providers, and • ; provider to get to know their patients better, particularly for Group Prenatal Care • -peer learning (for Group Prenatal Care); and, Included peer-to • Let patients use their time more productively, particularly in Group Prenatal Care where time was spent in a facilitated group discussion rather than in the waiting room prior to an individual appointment. TY INTERVENTION INTENSI One metric on which Strong Start interventions varied across awardees is the intensity of the es. To systematically describe the range of interventions implemented intervention provided to enrolle by awardees on this metric, we classified the intensity of the intervention provided for each Strong Start awardee. Definition of Intervention Intensity by Model The evaluation defines intensity based on the absolute level of enhanced prenatal care services received by women enrolled in Strong Start. This includes enhanced prenatal care services provided -Strong Start prenatal care enhancements in place before Strong through Strong Start as well as non Start implementation or provided to all women served by a site. To be included in our intensity do not include state classification, an enhancement needed to be specific to an awardee; therefore, we - eficiaries, such as MOMCare in Alabama. wide enhancements for pregnant Medicaid ben We measure -level. intensity at the awardee level, except for Birth Centers, for which intensity is measured at the site When intensity varies across an awardee's sites, an awardee is classified by the intensity level experienced by most women served by the awardee. We created three levels of intensity for each Strong Start model: low, medium, and high intensity. The definition for each classification was developed inductively based on patterns that emerged while reviewing case study memos for all awardees. Definitions are based on observable characteristics of interventions for which information was available consistently across awardees. Birth Center • Low Intensity: Interventions that do not include peer-counselor enco unters beyond visits with the midwife or that include fewer than four encounters Interventions with four encounters (the recommended minimum for both • Medium Intensity: birth center awardees) and no enhancements • High Intensity: Interventions with more than four encounters or additional enhancements YEAR 5 FINDINGS 21

40 Group Prenatal Care Low Intensity: • Interventions less than the Centering Healthcare Institute’s (CHI) curriculum CenteringPregnancy Interventions implementing Centering or an equivalent • Medium Intensity: • Interventions implementing Centering or an equivalent and additional services High Intensity: or content Maternity Care Home • Low Intensity: Interventions with fewer than four encounters with a care manager/coordinator Interventions with four or more encounters that only provide education and • Medium Intensity: referral services or fewer than four encounters that provide direct services Interventions with four or more encounters and provision of additional • High Intensity: services direct We used the definitions above to classify all Strong Start awardee and Birth Center sites into "low," "medium," and "high" designations within each model. Draft classifications were made based on review of case study memos and were discussed by the evaluation team internally and with CMMI. Team members then followed up on questions that arose during the discussion and checked case study memos and notes to resolve questions. Finally, awardee and sites were reclassified based on these reviews. Summary of Awardee Intervention Intensity Classifications We classified intervention intensity for 23 Birth Center sites for which case study data were available. Birth Center sites are classified at the site level rather than the awardee level because all but one in was the same awardee – AABC. These 23 sites represent 49 percent of all Birth Center sites in Strong 20 Start. Among these sites, we classified 9 percent as low intensity (2 sites), 61 percent as medium intensity (14 sites), and 30 percent as high intensity (7 sites). Low intensity site s only provided three encounters, or stated that midwives provided enhanced services during traditional visits. Some high intensity sites provided as many as ten to fourteen encounters, while others provided Group Prenatal approach in addition to Birth Center care with peer CenteringPregnancy Care using the counseling services. 20 using the following criteria: geographic variation (including state The case study team selected AABC sites for data collection (e.g., and urban/rural location), the number of participants enrolled in Strong Start, and type of midwives practicing at the center certified nurse -midwives vs. certified professional mid wives or certified midwives). YEAR 5 FINDINGS 22

41 Among the 14 awardees providing Group Prenatal Care, we classified 14 percent of interventions as low intensity (2 awardees), 50 percent as medium intensity (7 awardees), and 36 percent as high intensity (5 awardees). Low intensity awardees offered fewer than the ten Group Prenatal Care sessions that are standard in the Centering curriculum. The additional services and content provided by ement support similar to that provided in the high intensity awardees ranged from case manag Maternity Care Home model, to partnerships with local organizations to provide additional services and supports, to specialized groups targeting women with specific risk factors. Of the 17 Maternity Care Home awardees, we classified 24 percent as low intensity (4 awardees), 47 percent as medium intensity (8 awardees), and 29 percent as high intensity (5 awardees). Awardees with low intensity interventions often did not specify a standard number of encounters to be provided to all enrollees or reported fewer than four encounters. High intensity interventions provided enhancements ranging from additional encounters with the care manager to the direct provision of . counseling services through a clinical social worker Intervention intensity is only one metric by which awardees can be compared, and our classification system relies on intervention characteristics that were readily identifiable for each awardee. Thus, this classification system is unlikely to fully captu re differences between awardees, as those considered to be low intensity on this measure may be high performing in other ways. For example, this system is re managers and Strong Start enrollee unable to capture the strength of relationships built between ca s said among Maternity Care Home awardees, an aspect of the Strong Start program patient participants . Despite these limitations, classif was important to them ying intervention intensity provides an additional metric to inform our understanding of the Strong Start program and its impacts. This re the section to assess whether Impact Analysis classification of intervention intensity is used in the were differences in impact by the intensity of the intervention. STRONG START IMPLEME NTATION CHALLENGES AND SUCCESSES In this section, we summarize major implementation challenges and successes reported by Strong Start 21 urse of the demonstration period. awardees and sites over the co Most challenges and successes persisted throughout implementation and were experienced by multiple awardees within and across -in and high staff -related. Issues with low provider buy each model. Challenges were often inter turnover, for instance, contributed to slow enrollment and low program participation. Summary of Primary Implementation Challenges 5 shows primary implementation challenges reported by Strong Start awardees over four annual Table rounds of evaluation case studies. Challenges are included in the table if they were reported in multiple - . Top challenges included limited pre case study rounds and/or across multiple Strong Start models implementation planning; lack of stakeholder support; program enrollment and participation challenges; issues related to staffing, work flows, and scheduling; difficulties operationalizing whole - person approaches to care; data collection and reporting problems; and challenges stemming from 21 — as sites reporting rather than awardees — As in prior years, Birth Center findings are presented in a slightly different manner ion team selected a set of AABC since all but one of Strong Start’s Birth Center sites are operated by AABC. Each year the evaluat sites for inclusion in the case studies to ensure that data are collected from a similar number of sites implementing each model. YEAR 5 FINDINGS 23

42 in the Medicaid policies and state regulations. Each challenge is discussed in more detail following paragraphs . CHALLENGES REPORTED TABL E 5: PRIMARY DURING THE STRONG ST ART AWARD PERIOD, BY MODEL AND 1,2 EVALUATION YEAR Birth Center Group Prenatal Care Maternity Care Home Challenge Y1 Y2 Y3 Y4 Y1 Y2 Y3 Y4 Y1 Y2 Y3 Y4 Lack of pre - No Yes No Yes Yes No No Yes Yes No No Yes planning implementation Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Lack of stakeholder support Yes ------------ No No Yes Yes Yes Yes Yes No Yes Yes Yes Difficulty enrolling eligible women No No Yes Yes Yes Yes Yes Yes Yes No No No Poor attendance and program retention Yes Staffing issues Yes Yes No Yes Yes No Yes No Yes Yes Yes No Yes Yes No Yes No Yes Yes No No No Yes Work flow and scheduling problems Yes No No No Yes Yes Yes Yes No No No No Inadequate space Yes Difficulty addressing Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes psychosocial needs Yes No Onerous program data and reporting Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No No Yes No Yes No Yes Yes Yes Yes Yes Yes Medicaid policies and state regulations 1 one or more key informants from at least one awardee or birth center site reported the challenge in Notes: “Yes” indicates that the relevant year. Challenges are included in this table if they were reported in multiple case study rounds and/or across multiple St rong Start models. 2 In Years 1 through 3, key informants were asked to identify the most challenging aspect of Strong Start at that point in demonstration year the multi- reflect on however, key informants were asked to In Year 4, the demonstration period. period and identify the most challenging aspect of Strong Start during that entire period . Limited pre- implementation planning. In the first round of case studies, many awardees and sites voiced -implementation planning and concerns about limited pre general lack of program implementation guidance. Most felt their problems stemmed from a compressed award rollout period (dictated by CMMI) which did not include sufficient time to hire and train staff, develop procedures for enrollment, and set up data collection infrastructure before enrollment began. One key informant from LADHS characterized the Strong Start rollout by stating, “We didn’t have a planning period; it was just implementation.” In some were the primary cause of delays in cases, administrative processes of individual awardees -implementation planning. Some birth center sites felt implementation and limited time for pre challenged by the lack of structure and guidance from AABC on how to implement and operationalize the awardee’s peer counseling component. AABC’s preference, however, was to provide some peer counselor training materials but allow sites flexibility to adapt the program to their circumstances and d more patient population. Several Birth Center and Maternity Care Home key informants wante opportunities to engage with other sites to share best practices, noting that this could have aided their implementation efforts. Though a CMMI Learning and Diffusion contractor worked with the Strong Start awardees, it was not clear whether or how widely the Learning and Diffusion activities were promoted among sites, Finally, some awardees were frustrated that Strong Start funding did not cover start-up costs for program design and implementation, including outreach activities and certification cos ts (e.g., CHI certification for Group Prenatal Care). 24 YEAR 5 FINDINGS

43 -in was Many key informants felt that stakeholder buy Lack of provider and other stakeholder support. crucial for successful implementation and integration of new models of care into standard practice. executives and managers, prenatal care — ost agreed that support was necessary at multiple levels M providers, and front office staff. Initially, awardees and sites from all models reported difficulty achieving stakeholder support, but the challenges were more pronounced and persistent among Group Prenatal Care and Maternity Care Home awardees. Some Birth Center sites struggled to get midwives and other staff to screen and refer eligible patients for recruitment, but these problems were largely resolved by Year 3. In contrast, some Group Prenatal Care and Maternity Care Home sites continued to vie for support from staff and leadership throughout the demonstration period. Office staff members were sometimes resistant to adapting their daily routine to accommodate recruitment and scheduling for group sessions or care manager appointments. For providers, lack of support typically stemmed from reluctance to embrace a new approach to care delivery or work with new staff, including a perception that doing so would incr ease their workload or otherwise disrupt the clinic work flow. One key informant from ACCESS explained, “Some of our providers are used to working alone and don’t want anyone else to be involved.” Some providers (particularly in Group Prenatal Care settings) viewed Strong Start as competition and withheld support because they were concerned about losing patients to -in was also the new model and the subsequent negative impact on their practice revenue. Provider buy ed with teaching hospitals, where resident supervisors were difficult to achieve in some sites associat concerned that involvement in group care would be a distraction for residents’ core training and take too much time away from their direct care of women, and residents themselves simply did not have the bandwidth to familiarize themselves and embrace the new model of care. Finally, some providers at Group Prenatal Care sites simply did not believe in the group care model, and felt that individual prenatal visits were either preferred or necessary. . Identifying and enrolling eligible women in Strong Start was a Enrollment and participation challenges common challenge, especially in the first years of program implementation. In Year 1, several awardees struggled to set up new processes, hire staff, adjust clinic work flow, and familiarize providers and other stakeholders with the intervention. Such challenges slowed the pace of implementation and contributed to lower-than -expected enrollment for most sites. Enrollment challenges were so widespread that CMMI asked awardees to revise their enrollment targets in Year 2 and revised 22 program eligibility criteria so that more Medicaid and CHIP enrollees were eligible for Strong Start. Other barriers to enrollment included low Medicaid volume in general (especially among birth centers), internal communication issues related to identifying and referring eligible women to Strong Start, and ineffective outreach. Some enrollment challenges related to the target population itself: eligible women articipation in Strong Start, most commonly because they did not think they sometimes declined p needed the extra support or did not believe that the program was a good use of their time. For Maternity Care Home awardees, enrollment challenges were generally limited to Year 1. Birth centers 22 eks’ gestational age (some enrolled to be no more than 20 we women Initially Strong Start required the vast majority of the first factor being — have at least two risk factors for preterm birth exceptions allowed limited enrollment up to 28 weeks) and Medicaid or CHIP eligibility, plus an additional risk factor. In July 2014, the criteria for enrollment were modified by CMMI to a) ome remove the gestational age cutoff and b) eliminate the requirement for a second risk factor. Even after the modifications, s awardees still used a gestational age cutoff, and/or required at least one additional risk factor (besides Medicaid/CHIP eligibility) , eventually settling on a to qualify women for their Strong Start programs. CMMI continued to alter the gestational age cutoff policy that generally restricted Strong Start eligibility to women who were no more than 29 weeks’ gestation but allowed exceptions. YEAR 5 FINDINGS 25

44 and Group Prenatal Care awardees, on the other hand, experienced more persistent challenges throughout the award period (described later in this section). 1 HIGHLIGHT BOX A related challenge across models involved patient Challenges and Strategies Engaging Women Postpartum: agement and retention eng Recognizing the postpartum period as a particularly vulnerable time throughout the Strong Start for women when they may need lots of support and encouragement, intervention. Key informants Strong Start awardees placed emphasis on educating patients about identified several common barriers postpartum care and potential po stpartum issues (e.g., depression, family planning, or breastfeeding difficulties), making resources and that prevented enrollees from referrals available for postpartum support and services, and keeping participating fully in Strong Start. -up with patients after they delivered their in touch and following These included lack of babies. However , many awardees reported that despite their best transportation and childcare, time efforts, some participants disengaged from Strong Start after delivery and did not attend their postpartum check -up. Per key constraints or other priorities such informants, some women think that “they are done and don’t need to as school or employment, language ers just get too busy or experience barriers to care, come back,” oth barriers, and resistance to group and some might see a different provider. settings or sharing personal Strategies awardees developed to increase rates of postpartum information. Some awardees had visits included making reminder phone calls and offering incentives, difficulty maintaining contact w ith nts at the 6-week check-up. One such as baby photos or footpri Maternity Care Home awardee reported that care managers would participants because of transience visit Strong Start participants while they were still in the hospital and unreliable phone access, -delivery to personally schedule and encourage them to attend post especially Maternity Care Home -up. A Group Prenatal Care awardee hosted their postpartum check awardees who more often relied on “birthday parties” for the group members’ new babies as an incentive for women to attend a postpartum session. Many Birth -based contact. Postpartum phone Centers conducted several postpartum home visits with Strong engagement was often the most Start participants, checking up on both moms and babies. challenging for awardees (see Highlight Bo x 1). St In early implementation, many awardees and sites affing, work flow, scheduling, and space issues. e on establishing new experienced difficulties related to program staffing, including limited guidanc positions and responsibilities; difficulty hiring appropriate staff or redefining roles for existing staff; high staff turnover; limited training opportunities; and inadequate funding to compensate staff for overtime spent on activities such as collecting and reporting data, outreach, or developing program -based materials and resources (e.g., patient handouts, referral resources, relationships with community organizations). Additionally, many awardees had trouble integrating Strong Start services into existing patient care work flows. Early in their implementation period, some Birth Center and Maternity Care Home awardees reported difficulties figuring out how to best structure and seamlessly integrate peer counselor and care manager encounters into a site’s existing prenatal care patient flow to avoid additional burden for both providers and patients. A successful integration strategy for many sites was schedule care manager and peer counselor encounters immediately prior to or after patients’ to prenatal or postpartum appointments (additional strategies are described below in the Implementation Successes section). YEAR 5 FINDINGS 26

45 Work flow and scheduling issues were particularly prevalent among Group Prenatal Care awardees and extended beyond the early months of the program. Many sites struggled to identify the best times for group sessions or to coordinate the sessions with the clinic’s schedule of individual OB/GYN appointments. Lack of staff support for the model, lagging program enrollment and retention, or outdated electronic systems unable to accommodate group scheduling contributed to work flow a nd scheduling problems. Securing adequate, private, and comfortable space to hold group sessions was awardees. Most sites were ultimately able to also a significant issue for some Group Prenatal Care overcome space challenges through creative thinking about repurposing other spaces (e.g., waiting rooms or staff break rooms) , but space remained a chronic issue for some. Difficulty addressing patients’ psychosocial needs and barriers to care. As described above, each Strong Start model strove to address participants’ psychosocial needs through enhanced prenatal care ave services. Awardees used the evaluation’s Intake form to identify participant risks that might h otherwise gone undetected, such as food insecurity or domestic violence. However, uncovering these issues often led to realization that there were insufficient resources at care sites and in the community to address Strong Start participants’ needs. Awardees and sites most frequently identified access to and affordable housing as the most difficult mental health services, substance use disorder treatment, to obtain. Other common needs, as mentioned above, included childcare and transportation. While som e sites took steps to address childcare and transportation needs as part of their interventions, most found that they proved to be unsolvable barriers to Strong Start participation and prenatal care attendance. A key informant from ACCESS, a Maternity Care Home operating in the Chicago area, explained: “A big policy issues in Chicago is around transportation. We know that Medicaid offers funds for transportation, but the hoops that are involved [to access this transportation] are much bigger issues. The Chi cago transportation system looks big but has very limited functionality and hours in certain communities. Another challenge is that a transportation voucher may only cover the cost for the ic transportation, especially if she’s mother, and if she has two or three children to bring along on publ already pregnant, it can be really difficult.” Some awardees, particularly those implementing Group Prenatal Care and Maternity Care Homes, expressed frustration that Strong Start funds were not allowed to cover program expenses they deemed essential . For instance, they wanted to use their Strong Start award to pay for healthy snacks for group sessions or incentives (e.g., gift cards or baby supplies) to promote program enrollment and participation. One key informant from LADHS encouraged CMMI to not consider “food, water...a stroller and transportation not as incentive[s], but as a basic need” of program participants. Onerous data requirements . Most Strong Start awardees and sites reported challenges meeting the Strong Start program’s administrative demands and found the data collection and reporting requirements particularly burdensome. These requirements included (1) cooperative agreement -level data ant management and project progress reports for the CMMI program team and (2) particip collection for the Strong Start evaluation team, consisting of an intake form, third trimester prenatal survey, postpartum survey, and exit form. Awardees uniformly expressed frustration regarding the amount of data required, coupled with changing specifications of CMMI progress reporting and the gradual rollout of participant-level forms. Many struggled to efficiently incorporate Strong Start forms into patient encounters, allocate data collection and reporting responsibilities among staff, and adapt YEAR 5 FINDINGS 27

46 electronic medical record (EMR) systems to capture required elements and generate reports. Some AABC sites, for example, were simultaneously implementing and learning how to work with the collection system AABC adapted to collect -existing online data Perinatal Data Registry (PDR), a pre Strong Start patient-level data and transmit it to the central AABC awardee. Key informants sometimes reported that patients too were burdened by Strong Start data requirements, particularly when filling -page Intake Form, which some women found difficult to comprehend and others found out the multi too “invasive.” On the other hand, some Strong Start staff reported that information from the Intake nnoticed, and several awardees helped them identify patients’ needs that might have otherwise gone u used the evaluation’s data collection requirements to help structure Strong Start encounters. Medicaid . Finally, a number of awardees , particularly for Birth Center sites policies and state regulations and sites noted challenges related to state Medicaid policies and procedures. Especially in the program’s first year, when awardees across the board focused largely on increasing enrollment, some reported difficulties enrolling eligible women in Medicaid. Key informants from multiple states raised concerns about lengthy eligibility processing times — in the most extreme cases, Strong Start participants did not receive Medicaid coverage until several months after they had applied (and well into their pregnancies). Though in most states with Strong Start sites, Medicaid and CHIP programs had 23 policies providing expedited presumptive eligibility to pregnant women, awardees sometimes reported that providers were not willing to accept it and would not see a patient without full weeks or even months to obtain). In addition, some Medicaid/CHIP eligibility (which could take awardees reported challenges with continuous car e after the maternity period, noting that pregnancy - related Medicaid coverage typically expires at 60 days postpartum and in many states women do not have an affordable coverage option to which they can transition after that period ends. 2 HIGHLIGHT BOX For Birth Center s ites, Medicaid polic y challenges were more Unique Medicaid- Related Challenges for Birth Centers ext ensive (see Highlight Box 2 ). Th ey Some Strong Start Birth Center sites faced notable financial uded difficulties contracting with i l nc challenges related to low reimbursement from insurance carriers. Medicaid managed care Birth centers are typically reimbursed by Medicaid at rates that d organizations and Medicai are much lower than reimbursement for hospital-based births. A Birth Center site in Charleston South Carolina reported receiving reimbursement for birth center about $800 for prenatal care and an additional $800 facility fee for services too low to cover the actual birth services from the state’s Medicaid managed care program, cost of care. Some Birth Center sites when the actual cost of care was approximately $3,000. Because of also experienced significant delays in these financial considerations, Strong Start staff purposefully did not conduct any external outreach efforts for the program and as receipt of Medicaid payments. For of January 2017 (once its Strong Start participation had ended) the these reasons, a few Strong Start- birth center stopped enrolling Medicaid patients entirely. Though participating birth centers were red benefit freestanding birth center services are a mandatory cove under Medicaid, AABC and its sites reported that many Birth forced to limit the number of Centers cannot get contracts with the Medicaid MCOs that Medicaid patients they accepted to provide the bulk of Medicaid services to pregnant beneficiaries. remain financially viable. In addition, Birth Center sites in some states experienced significant challenges in establishing themselves as prenatal care providers because of scope of practice laws and licensing policies that made it difficult for birth centers and midwives to 23 d) Under presumptive eligibility, a state extends coverage to individuals temporarily (and reimburses providers for care provide while a full eligibility determination is made. https://www.kff.org/health -reform/state-indicator/presumptive-eligibility-in- -chip medicaid 28 YEAR 5 FINDINGS

47 practice. For instance, some states such as Florida have restrictive rules for advanced -practice nurses (including CNMs), placing limits on scope of practice and requiring physician oversight. Summary of Primary Implementation Successes Over the Demonstration Period Primary implementation successes reported by Strong Start awardees and sites are displayed in Table are included in this table if they were reported in multiple case study rounds and/or 6. Successes include developing across multiple Strong Start models. Strong Start implementation successes implementation; achieving stakeholder buy -in; increasing innovative systems to facilitate program participant enrollment and engagement; integrating Strong Start components into sites’ standard model of care; well -qualified and skilled Strong Start staff; and establishing collaborative relations hips with other organizations to address patients’ psychosocial needs and barriers to care. Many of these successes stemmed from the challenges discussed above, as Strong Start awardees and sites developed problems they experienced. effective strategies to address the implementation MODEL AND TABLE 6: PRIMARY SUCCESSES REPORTED D URING THE STRONG START AWARD PERIOD, BY 1,2 EVALUATION YEAR Birth Center Maternity Care Home Group Prenatal Care Success Y3 Y1 Y1 Y2 Y3 Y4 Y1 Y2 Y3 Y4 Y2 Y4 Yes Yes No No Yes ementation guidance and support Impl Yes No Yes No No Yes Yes Yes Yes No Yes No Yes Yes Yes No No Yes in - Achieving stakeholder buy No ------------ Yes No No Yes Yes Yes Yes Yes Yes Yes No Increasing enrollment and engagement Yes No Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Program design and integration Well qualified and skilled staff Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes - Yes Yes Yes No Yes No No Yes No No No Addressing patients’ psychosocial needs Yes 1 A “Yes” indicates that one or more key informants from at least one awardee or Birth Center site reported the success Notes: are included in this table if they were reported in multiple case study rounds and/or Successes in the relevant year. across multiple Strong Start models. 2 successful aspect of Strong Start at that point in In Years 1 through 3, key informants were asked to identify the most demonstration year multi- were asked to reflect on the the demonstration period. In Year 4, however, key informants period and identify t successful aspect of Strong Start during that entire period. he most Implementation guidance and support. In response to early implementation challenges, some awardees provided targeted support and technical assistance to their sites. For example, when Birth Center sites struggled with operationalizing the peer counseling component, AABC developed a “Quick Start” guide, which many informants referred to as a “cheat sheet,” that addressed how to enroll participants, provide peer support services, and report program data. Several awardees supported their sites by creating opportunities for sharing knowledge and best practices via meetings, conference calls, learning collaboratives, and regular newsletters. YEAR 5 FINDINGS 29

48 Achieving stakeholder buy-in . Getting broad-based support from organizational leadership, providers, and clinic staff was often identified as crucial to successful implementation of Strong Start. The most common effective strategies for increasing stakeholder support for interventions included identifying and nurturing a liaison or champion (most often a provider or administrator) to speak on behalf of Strong Start and educate other staff; hosting information sessions for providers and staff to introduce the program offer educate them about program processes and new protocols; and keeping the staff and executive leadership regularly informed about Strong Start activities and implementation progress (e.g., through newsletters, presentations at staff meetings). A care manager at FAHSC started bringing e brownies for the front desk staff member who sent her the most Strong Start participant homemad referrals each month. Several Group Prenatal Care awardees cultivated provider and office staff support by inviting stakeholders to observe a group session and experience the approach for themselves. Being able to establish firm stakeholder support for Strong Start played an important role in sustaining enhanced services after the award period ended. Increasing program enrollment and participant engagement. Virtually all awardees spent considerable time and effort refining recruitment strategies to boost Strong Start enrollment, particularly in the first half of the demonstration period when many struggled to meet program enrollment targets. Key -training multiple Strong Start and informants identified a number of best practices including cross office staff to recruit and enroll patients; centralizing all enrollment-related responsibilities; having peer counselors, group facilitators, and care managers directly involved in recruitment; training OB/GYNs and midwives to introduce the program and refer patients; and establishing referral processes with community organizations and social service agencies. -face recruitment and strong Many awardees and sites emphasized the importance of face -to communication skills. Key informants also shared their most effective messaging tactics, which included enrollment processes that involved presenting Strong Start as part of the site’s standard approach to benefits of participation (e.g., provider continuity, reductions in prenatal care and explaining the negative birth outcomes, psychosocial support), meaning that patients had to “opt out” if they did not want to participate. Some awardees reported better enrollment success when they explained that participating in Strong Start could benefit not only the pregnant woman herself, but other women as well. One key informant explained, “People are more likely to say ‘yes’ if they feel that they are part of something big or revolutionary that will help others.” Similarly, some Birth Center sites felt women were most receptive when Strong Start was described as a research project gathering data on the benefits of midwifery and birth center care. 30 YEAR 5 FINDINGS

49 HIGHLIGHT BOX 3 Strong Start sites used either an -out enrollment approach -in or opt opt Opt -In and Opt -Out Enrollment Approaches (see ). Though opt 3 -in Highlight Box Strong Start awardees and sites adopted one of two distinct e nrollment was a much more common enrollment approaches: approach, some awardees and sites Opt : eligible patients made an active choice -in enrollment • switched to opt-out during the award between enrolling in Strong Start or receiving typical period and found this was a more prenatal care. • O pt -out enrollment : eligible patients were automatically effecti ve enrollment strategy. Other enrolled in Strong Start unless they actively strategies include developing and declined participation. distributing Strong Start promotional Most awardees who chose an opt -in approach did so because it materials, playing a promotional video “felt” right to give women options . They believed women who in OB waiting rooms, using the EMR or actively chose to participate in Strong Start would be more other health system data to identify engaged in their care and committed to attending sessions and eligible women, and providing small encounters. Others including UPR, Einstein, Meridian, and -out enrollment from the start because they Signature used opt ntives from outside funding ince were interested in fundamentally transforming their prenatal care sources to increase enrollment. Some practice and maximizing enrollment. Some awardees tried both Group Prenatal Care awardees -in to opt enrollment approaches, usually transitioning from opt - out enrollment because the latter method was associated with showed eligible patients the group better uptake. A key inform ant at United noted, “Instead of asking meeting room or encouraged them to [of Strong Start] we said this is our people if they wanted to be part observe a session to entice them program. You are here for care and this is what you get.” enroll. to Successfully enrolling participants in Strong Start did not always translate to robust program attendance on an ongoing basis. Group Prenatal Care awardees especially found that it was sometimes -hour group sessions. They described several difficult for patients to commit to the fixed schedule of two ategies to boost session attendance, including providing participants with a written schedule of str group session dates as far in advance as possible; making reminder phone calls and sending texts in the -up with me mbers who missed sessions; and using days preceding each session; personal follow non- Strong Start-funded incentives (e.g., raffles for gift cards and baby gear) to keep participants motivated and engaged throughout the session cycle. Some Birth Centers and Maternity Care Home awardees also worked to keep participants engaged by making peer counseling and care manager encounters as convenient as possible. Some techniques included coordinating in-person encounters with prenatal and postpartum visits, using telephonic and text-based communication to facilitate more regular contact with participants, and making peer counselors and care managers available nearly 24/7. Some awardees also tasked CHWs or similar staff with targeted outreach and home visits to the -reach participants. hardest-to Awardees across models attempted to reduce common barriers to participation by arranging for or educating patients about Medicaid -covered transportation options, or providing transportation sites also either provided childcare or allowed women to bring the ir children to vouchers. Some individual prenatal care appointments or group sessions. All the Birth Center sites included in the case studies either allowed (and in some cases encouraged) women to bring children to their appointments or provided a play area for children in the waiting room. Allowing children in appointments seemed to enhance the care experience for many Birth Center patients, who described how midwives would include their children in prenatal exam activities such as using a Doppler monitor to find the fe tal Prenatal awardees generally discouraged participants from bringing Care Group heartbeat. Though YEAR 5 FINDINGS 31

50 children to appointments (as is stipulated by the CenteringPregnancy model) several suggested that they would rather have a woman attend with her children than skip the session because of lack of childcare. awardees sometimes discouraged participants from bringing children to Home Care aternity M appointments. These awardees tried to schedule in -person encounters during school hours, encouraged patients with young children to bring another adult to supervise the children, or made referrals to Early not clear how , though it was Head Start or to churches or local organizations that provide childcare services were available and affordable. often these . The extent to which awardees could seamlessly Program design and integration into standard care -existing model of care was often integrate Strong Start enhancements into their pre associated with successful implementation, particularly in sites that experienced initial resistance to new care rom providers and office staff. approaches f For Maternity Care Home and 4 HIGHLIGHT BOX Birth Center awardees and sites, Group Prenatal Care for Women with Opioid Addiction s uccessful integration often meant UKRF ’s PATHWAY (with “PATH” standing for Pe rinatal Assistance thoughtfully scheduling care manager were pregnant women who and Treatment Home) group enrolled and peer counselor encounters addicted to opioids and receiving suboxone treatment (most immediately prior to or after patients’ commonly, though methadone treatment is also used). One key “These informant described the value of PATHWAY by saying, tal or postpartum prena women have never had quality prenatal education. We treat them appointments; communicating by , they are like regular pregnant women, and the look on their face [s] phone or text as often as needed; so relieved this treatment and these services encourage them to making sure the educational continue pursuing healthcare. ” Generally, women in this prog ram felt more comfortable, respected, and cared for in comparison to component of Strong Start experiences during previous medical treatment or pregnancies. did not merely duplicate encounters One focus group participant in PATHWAY said, “Everyone is really what patients hear d from their nice here. This is the only place where everyone understands that you can be a drug addict and pregnant at the same time. [There is OB/GYNs or midwives; and no] shameful scorning. They are not judging you. That ’s a blessing establishing collaborative ” as far as I’ m concerned. relationships between providers and While provider support was difficult to establish for Group Strong Start staff to address patient Prenatal Care more generally at UKRF, it was easier to obtain for needs, such as through case specific groups such as PATHWAY. The awardee sustained conferencing. Some Group Prenatal PATHWAY using institutional funding, and the program grew Care awardees developed sessions considerably after the Strong Start award period ended. Since the institutional funding now supporting PATHWAY is more generous targeting specific populations (e.g., than Strong Start award funding, UKRF added a full-time therapist women with HIV, Spanish speakers) to the program, developed a postpartum component called Beyond to better meet the needs of a site and -step groups for Birth, and created therapy groups and 12 PATHWAY participants. its patients. When a Strong Start program was integrated into the pre - xisting model of care or provided a clear value -add by targeting a special population with unique e needs, providers more easily recognized and appreciated the benefits of the enhanced services and were thus more open to sustaining the enhancements. UKRF’s prenatal care groups for women with opioid addiction (called PATHWAY) is a good example of a sustained program like this, as described in Hi ghlight Box 4 . 32 YEAR 5 FINDINGS

51 Hiring and training competent, accomplished, and -Qualified and Skilled Strong Start Staff. Well and was a topic that committed staff had a significant impact on the overall success of the program figured prominently in evaluation interviews over the course of the demonstration period. For Maternity Care Home and Birth Center awardees and site, these staff included care managers and peer counselors whose salaries were typically paid for using Strong Start funds. For Group Prenatal Care awardees, these staff included group facilitators (e.g., OB/GYN physicians, RNs, and Advanced-Practice Nurses) who were trained using Strong Start funds but whose salaries were not generally a Strong Start expense. During the last round of case studies, key informants identified the staff attributes they felt were most important for successful program implementation (see 7). Table For all awardees and sites, the top attributes were ability to connect with patients (often described as having empathy or truly wanting to help people), being of a similar background as the target population, and prior experience work pregnant ing with patients or in an environment similar to the Strong Start site. Though professional qualifications were felt to be very important by most awardees attitude, and -building skills, a positive and sites, many also emphasized the importance of relationship relatable engaging personalities in addition to credentials. Some key informants even felt that interpersonal skills were more important than professional qualifications or an advanced degree. 1 7: MOST IMPORTANT STRONG START STAFF ATTRIBUTES FOR SUCCESSFUL PROGRAM IMPLEME NTATION TABLE Model Type - Most Commonly -Identified Strong Start Staff Attribute 1. Ability to connect with patients, has empathy 2. Relatable, shared All Awardees with target d population emographics 3. Sites & Prior experience working with pregnant patients like Strong Start provider site ience working in environment 4. Exper 1. Ability to connect with patients, has empathy Materni c ba Social work 2. ty Care kground training or Home Awardees 3. rior , f amiliar with community, p nowledge of community resources , k Passionate and dedicated patients pregnant ultural competence , and c experience working with Nurse - practitioner background or training - midwife or nurse 1. 2. Group Prenatal Prior king with pregnant wor experience patients Good liste ner and/or communicator , current on latest maternity care knowledge and training, and 3. Care Awardees bility to connect with patients, has empathy a Relatable, shared demographics with target population 1. Birth Center site provider to Strong Start similar environment Experience 2. ng in worki Awardees and Sites 3. Ability to connect with patients, has empathy Notes: The three most common attributes for all awardees and sites and within each model are included in this table. Five or r mo e awardees or sites reported the attributes listed for all awardees and sites. Two or more awardees or sites reported the attributes listed for each model. This analysis includes 17 Maternity Care Home awardees, 15 Group Prenatal Care awardees, and 12 Birth Center awardees or sites. Addressing patient’s psychosocial needs . Although addressing psychosocial needs, especially behavioral health and housing, remained challenging for most awardees and sites, many were successful in -based establishing new collaborative relationships with local health care providers, community in order to connect Strong Start participants to a range of organizations, and social service agencies supports and services. YEAR 5 FINDINGS 33

52 Some awardees collaborated with their state Medicaid agencies to expedite enrollment of eligi ble women or helped participants sign up for other benefits such as WIC or cash assistance. Others facilitated participants’ transportation to prenatal care appointments, provided referrals to dental care and behavioral health services, or assisted partici pants in obtaining food and baby supplies. Some Group -based Prenatal Care awardees leveraged their connections to other providers and community organizations to arrange for guest speakers at group sessions (e.g., pediatricians, home visiting program entatives, lactation consultants). repres Sustaining the Strong Start Programs Sustaining a program once the award period ended was perhaps the most significant indicator of 24 implementation success for Strong Start awardees. In the evaluation’s fourth annual report, we reported that slightly more than half of Strong Start awardees and Birth Center sites were fully or partially sustaining enhanced prenatal care models implemented under Strong Start (Hill et al, 2018). As shown in Table 8 , 9 of 17 Maternity Care Home and 7 of 13 Group Prenatal Care awardees had decided to continue their full programs at all or some sites. All Birth Center sites studied in evaluation Y4 were continuing their pre –Strong Start midwifery model of prenatal care, and most had also decided to continue peer counseling in some shape or form, although financial constraints meant that after Strong Start funding ended, services were less intensive. TABLE 8: SUSTAINABILITY OF THE STRONG START PRO GRAMS IN EVALUATION YEAR 4 Partial Model Sustained Full Model Sustained Not Continuing Prior Awardee Model of Care Sustaining Enhanced Model 1 w/out SS Additions Model Sites All SS Sites Some SS Sites Some All SS Sites SS 2 (n=17) 6 3 0 2 1 6 Maternity Care Home awardees ---- 0 Group Prenatal Care awardees (n=13) 4 3 1 5 0 N/A 3 Birth Center sites (n=11) 0 2 N/A 6 1 Notes: awardees and sites had enhanced prenatal care in place before Some they implemented Strong Start. In these cases, Strong Start services were layered on top of the preexisting enhancements, or the Strong Start award replaced expired funding to maintain enhanced prenatal care . For example, sites with established Group Prenatal Care programs that added community health worker services to group sessions, or Birth Center sites that added peer counseling services to complement their midwifery model of care. This column shows awardees and sites that will maintain the enhanced care models they had in place prior to Strong Start, but will not sustain the additional services that were layered on top of -Strong Start enhancements. their pre 2 Johns Hopkins University reported some sites sustaining full model and others sustaining a partial model and therefore is represented in both columns. All other MCH and GPC awardees reported uniform sustainability plans for the sites that were sustaining a SS model (e.g., all sites sustained either full or partial model). 24 May The fourth annual report was based on data collected during the final round of case s tudy interviews (October 2016 – snhancedprenatalcaremodels_evalrptyr4v1.pdf https://downloads.cms.gov/files/cmmi/strongstart- 2017). 34 YEAR 5 FINDINGS

53 HIGHLIGHT BOX 5 Awardees and sites reported that having a funding Sustaining Strong Start with Medicaid or Medicaid MCO Funding ource for enhanced prenatal s care services was the most Several awardees used Medicaid or Medicaid MCO funding to continue their Strong Start services: crucial component for sustainability. Most sustaining ACCESS Community Health Network in Illinois (Maternity Care Home) • awardees were partly or fully sustained care coordination services for pregnant patients through a combination of Medicaid MCO funds and private philanthropic funding. -funding sustained self • United Neighborhood Health Services (Maternity Care Home) sustained services (i.e., using internal and expanded its Strong Start intervention through a Medicaid value - practice or health system based payment reform pilot program that provides per member per d -centere month payments to clinics for implementation of the patient monies once the Strong Start medical home model. intervention period ended). A Virginia Commonwealth University (Group Prenatal Care and Maternity • few were relying on external Care Home) key informants reported that Virginia Medicaid now pays grants or philanthropic an enhanced reimbursement rate for Group Prenatal Care, which is helping the awardee sustain its Strong Start program. funding (sometimes in Amerigroup Corporation (), the only Medicaid MCO Group Prenatal Care • combination with self - awardee, received approval from the Louisiana Medicaid agency in funding), and a small group of 2015 to provide enhanced reimbursement for group care awardees reported receiving (approximately an additional $50 per participant per session) to providers in its MCO network. support or reimbursement from Medicaid or Medicaid a m Highlight Box naged care organizations (MCOs) to continue Strong Start services, as described in 5 . B in esides funding, key informants identified several other factors as critical to their ability to susta Strong Start services, with the most common being leadership and organizational support, and data showing Strong Start’s positive impact. KEY CONSIDERATIONS FOR REPLICATING STRONG START MODELS With very few exceptions, awardees believed the enhanced prenatal care models they implemented under Strong Start were worthy of replication. Based on their observations and interactions with Strong Start participants over the course of the intervention, awardees perceived that the program had including many positive effects for women and newborns, increased patient satisfaction with prenatal care; more trust in and engagement with the health care system; an increased sense of well -being; improved self -care and management of chronic conditions; greater food, housing , and financial security; and better awareness of community resources and how to access them. During the Year 4 case study interviews, we asked key informants to reflect on their experiences under Strong Start and identify factors they felt were most important to successful program replication, including those related to program design and implementation decisions, as well as to the environment in which their programs operated. Specifically, we prompted key informants to identify the most important program replicability factors related to: their prenatal care practice and providers; the patient population they served; the communities where sites were located; and, policies or regulations that influenced the care they could provide. YEAR 5 FINDINGS 35

54 Replicability Factors Related to Provider and Practice Sites The largest number factors that awardees and sites identified as important for replication were related to providers and practice sites. Table 9 displays these factors, across all awardees and sites and by model. Factors are assigned a high, medium, or low level of importance based on the proportion of awardees and sites that identified the factor during their Year 4 case study interviews. Given the large number of replication factors reported in this category, only factors that were rated a high or medium level of importance by all awardees and sites and within each model are discussed in more detail below (i.e., factors listed in the first seven rows of the table). (For Birth Center sites, these factors apply to ) midwifery model of care. funded under Strong Start, not the replication of the peer counseling services TABLE GRAM REPLICABILITY FACTORS RELAT ED TO PROVIDERS AND PRACTICE SITES 9: MOST IMPORTANT PRO Importance Based on Number of Awardees/Sites 2 Reporting Factor 1 Factor All Awardees/ Group Maternity Birth Center Sites Prenatal Care Care Home varied) High High High High Well - qualified, skilled Strong Start staff (specific attributes High Medium High Appropriate space for providing Strong Start services High High - Provider and administrative staff buy Medium Medium High in and support High Medium Medium Presence of program “champions” High Medium High Medium Medium continuity Strong Start staff Convenient provider site location Medium High Medium Medium Practice driven care - holistic, patient level commitment to - approach Medium Medium Medium Medium Medium Medium Low Medium Use of Electronic Medical Record (EMR) system Medium Education for providers and clinic staff about the model Medium Low Medium staff Medium Collaboration between providers, office staff, and Strong Start Medium Low Low Medium Medium Not reported Low Adequate training for Strong Start staff Sufficient patient volume Low Low Low Medium Medium Not reported Low Adequate staffing for the model Low Integrating Strong Start services into provider site work Low flow Low Low Low Care manager flexibility Low Not reported Not reported Low Consistent providers/low turnover at site Not reported Not reported Low Low 1 Notes: A replicability factor is included in the table if it was reported by at least 15% awardees and/or sites. 2 An assignment of “low” indicates that fewer than 25% of awardees or sites studied in Year 4 reported the factor; “medium” indicates that between 25% and 50% of awardees or sites reported the factor; and, “high” indicates that more than 50% awardees or sit es reported the factor. This analysis included 17 Maternity Care Home awardees, 15 Group Prenatal Care awardees, and 12 Birth Center awardees or sites. Three factors were mentioned by more than half of the awardees and Birth Center sites (and thus are assi gned a “high” level of importance): Well • -qualified and skilled Strong Start staff • Appropriate space for providing Strong Start services, and • Provider and administrative staff buy -in and support for the program. staff When discussing how a program like theirs could be successfully replicated, awardee and site qualifications and skills of the individuals they had selected to deliver Strong Start often mentioned various tion includes a discussion of services . The Strong Start Implementation Challenges and Successes sec staff attri butes, as having well -qualified and skilled Strong Start staff was also the most commonly - mentioned factor related to program success. Table 6 in the previous section shows the most important ng S tart staff attributes for successful program implementation, for all awardees and sites and by Stro model. Maternity care home awardees were most likely to report that staff ability to connect with nts (or having empathy) was important for successful replication, given the model’s focus on patie 36 YEAR 5 FINDINGS

55 Care awardees felt that having a background as a nurse midwife Prenatal psychosocial support. Group or nurse practitioner was important, reasoning that these advanced practice nurses were trained to value health education and discussion with patients and so were a “natural fit” for their model. Birth center awardees and sites were most likely to identify being relatable or having a shared background to patients as i mportant, since their intervention placed more value on peers as counselors. Notably, however, many Birth Center peer counselors had professional qualifications as well as (or instead of) sharing patient demographics. y those implementing Maternity Care Homes or Group Many awardees and sites, and especiall appropriate space for Strong Start service delivery Prenatal Care, felt that having was a key factor for successful program replication. They generally agreed that the space should be dedicated to Strong Start activities but not compromise the efficiency of the site’s prenatal care practice or disrupt the patient work flow. Other suggestions varied by model. Maternity Care Home awardees and Birth lor encounters sometimes delved into Centers emphasized privacy, since care manager or peer counse sensitive topics. Group prenatal care awardees focused on the size of the space (large enough for a group cohort plus support persons, and for group activities) and felt that it should be welcoming. Some -like” and inviting, peaceful space for providing Birth Centers noted the importance of a “home enhanced prenatal care. and give to -in buy When prenatal care providers and others who work in clinics and birth centers to a program like Strong Start, it has a much better chance at succeeding, even in the face of support significant implementation challenges. Provider support is critical, particularly for programs where the provider plays a role in recruitment or delivering the enhanced services. An Amerigroup (Group Care) key informant explained, “Your provider has to have the desire, especially at the Prenatal beginning, because it is more work to prepare for each group and get the dynamic of each group. It’s not your typical visit.” Most awardees and sites felt that buy -in n eeded to be “universal” and involve all elements of the practice for the program to be replicated most effectively. As a key informant from the Grady (Group Prenatal Care) awardee noted: “Most things are manageable if all the personnel are educated and treated respectfully about the program, so everyone owns it. The front desk person needs to own it, not treat it like second class care. so invaluable.” it’s They need to know where it comes from, and why 9 a Table Several other replicability factors included in re related to broad stakeholder support. For stance, more than half of Maternity Care Home and Group Prenatal Care awardees, and more than a in presence of program champions as an quarter of Birth Center awardees and sites, identified the important factor. Champions were valuable because they kept positive attention on Strong Start and could be effective messengers about the intervention’s purpose and progress, thus promoting support from others. They could also facilitate program operations, as one Group Prenatal Care awardee pointed out that an administrator champion had helped reserve space for groups and rearranged Awardees that had prior experience with the provider schedules to accommodate group sessions. -existing champions which made program enhanced prenatal care model sometimes had pre implementation much smoother. A key informant from UTHSC (Group Prenatal Care) noted: YEAR 5 FINDINGS 37

56 “The reason we were successful was the fact that we have been doing Centering since 2005, so we already knew the concept, we already had champions. If you don’t have a champion you’re just not going to make it. Even with a champion other people in the organization can set barriers...people who don’t [believe in] your vision or understand the process.” driven care -level commitment to a holistic, patient- practice When providers and leadership possess a approach, they may be more supportive of a program like Strong Start and more willing to dedicate th e time and resources to making it a success. Awardees and sites described this important replicability factor as a recognition that effective prenatal care comprises not only evidence -based medical care, but also care that identifies and addresses the psychosocial needs of women and their families. A key informant from Providence (which implemented all three models) explained: “One of the things our midwifery director and team is so invested in [is] the social aspect of our patients, because when you have p atients who have housing or other social risk factors that affect their lives, the baby in their belly is not their first priority.” Another key informant from Signature (Maternity Care Home) shared a similar sentiment when discussing how providers and Strong Start staff worked together to develop their comprehensive care approach. She said: “One of the things we do really well is [understand] that holistic lens. How does filling out a Medicaid application affect the pregnancy? How does that dental infection affect the pregnancy? How does not having a safe place to live affect the pregnancy? It all affects it.” Two replicability factors related to providers and practice sites that were identified by more than proportions of other awardees and sites) were half of Group Prenatal Care awardees (and smaller and Strong Start staff continuity As noted earlier in this section, having a convenient provider site location. — continuous enhanced service provider whether it is a care manager, peer counselor, or group facil itator—was a shared feature of all the models. However, Group Prenatal Care awardees were more likely to name this feature as important for program replicability, perhaps because of the increased amount of time facilitators spent with group participants (i.e., roughly 20 hours total for awardees using Centering’s ten 2 -hour session approach) when compared to the time care managers and peer counselors spent with participants in their caseload. Group prenatal care awardees felt that having the r for each session gave patients comfort and confidence, and facilitated group bonding same facilitato and cohesiveness. A key informant from Einstein (Group Prenatal Care) reported: “We see that groups are more successfully if they meet the centering provider the first time when the come in for their appointment, rather than meeting someone and then being sent on to Centering. We had better turnout with the same provider, and bonding with them and knowing them.” Regarding location, a number of Group Prenatal Care awardees struggled with session attendance. A conveniently located provider site that was near public transportation and/or within the community where most patients live helped ensure better attendance. Though awardees and sites across models s related to patient transportation barriers, Group Prenatal Care awardees could experienced challenge not employ ‘workarounds’ as easily as those implementing the other models. Maternity Care Home and Birth center sites could sometimes substitute home visits or phone -based com munication for in -person 38 YEAR 5 FINDINGS

57 care manager encounters when patients had difficulty getting to the provider site, but Group Care services were predicated on attendance at the group visit. Some Maternity Care Home awardees and Birth Center sites also identified provider site location as a replicability factor, but they emphasized the importance of choosing program sites that had a sufficient volume of low - -income and/or Medicaid covered patients so the program could enroll enough participants. A UNHS (Maternity Car e Home) key informant said: -income area, “In terms of the location of my clinic, our program works well because we are in a low -income... patients. They need extra support and they need to know where there is housing for low where they can find resources and Strong Start provides a lot of that type of support.” Replicability Factors Related to the Patient Population Awardees and sites also identified a number of patient-related factors they believed were important for entioned, by model. None of these shows the factors most commonly 10 Table program replication; -m factors were reported by more than half of awardees and sites. Only one factor was reported by more Awardees and sites than a quarter of all awardees and sites . engaged patients the presence of — implementing the Maternity Care Home and Birth Center models were most likely to identify an ugh key informants’ engaged patient population as important for successful program replication, tho opinions on this matter were sometimes mixed. For instance, one ACCESS (Maternity Care Home) key informant indicated that it can be “critical” that the patient is looking for help, noting that otherwise, “you can do everything possible, but they have something getting in the way of taking advantage of those opportunities.” But at ACCESS there was also tacit acknowledgement of the wide variation among patients, and another key informant suggested that “meeting patients where they are” is critical for building a rapport that facilitates patient engagement. A different Maternity Care Home awardee felt engagement was especially important if the target population includes patients with mental health or substance use disorders, as the intervention may not be very effective if these patients did not want to engage with enhanced service providers. TABLE 10: MOST IMPORTANT PROGRAM REPLICABILITY FACTORS RELATED TO THE PATIENT POPULATION 2 Importance Based on Number of A wardees/Sites Reporting Factor 1 Factor Maternity Care All Awardees/ Group Prenatal Birth Center Care Sites Home Engaged Patients Medium Medium Low Medium Low Low Low Strong visit attendance rates Not reported Low Low Site’s ability to address patient barriers to care Low Low - to - Targeted outreach to hard reach Low Not reported Low Low participants 1 A replicability factor is included in the table if it was reported by at least 10% awardees and/or sites. Notes: 2 An assignment of “low” indicates that fewer than 25% of awardees or sites studied in Year 4 reported the factor; “medium” indicates that between 25% and 50% of awardees or sites reported the factor; and, “high” indicates that more es reported the factor. This analysis included 17 Maternity Care Home awardees, 15 Group than 50% awardees or sit Prenatal Care awardees, and 12 Birth Center awardees or sites. Birth centers emphasized the importance of a patient population that is “proactive and motivated” to hav e a healthy pregnancy, which they felt contributed to program success. A key informant from AABC’s San Diego site added that patient engagement can be especially important for the midwifery model of care because patients must be open to building relationships with their midwives. YEAR 5 FINDINGS 39

58 Across the models, awardees and sites acknowledged that providers and Strong Start staff played an important role in engagement. Though a few tended to place the onus of responsibility squarely on the patient rather than consider how they might improve their own approach to care, most Strong Start programs recognized the ways they could stimulate patient engagement. They could, for instance, tailor recruitment messages so that patients understand the benefits of participating in the program; be approachable and supportive; and be well -equipped to help patients access resources to address the barriers to care that might make engagement challenging such as homelessness, substance use, and lack of transportation. are awardees were less likely to specifically mention an engaged patient Though Group Prenatal C population as key for replicability, some noted the importance of a related factor — . visit attendance rates because the discussion They described how the group dynamic suffers when session attendance is low, includes fewer individuals and is often less robust or interesting for participants. Some also emphasized the importance of an adequate group size for the model to be financially viable. Key informants from UTHSC (Group Prenatal Care) felt that attendance was important but also suggested ways to adjust the program to ensure success even with lower attendance rates. For instance, a site could create larger cohorts with the expectation that several participants will not show up, and le ave time for midwives to have individual appointments later in the day (after sessions end) with women who did not show up. Average group size for the Strong Start awardees was usually in the range of 8 -12 participants, but for some it was as low as 3 -5 pa rticipants. Awardees and sites representing each model felt that a site’s ability to address patient barriers to care was an important factor for successful program replication, and one that is related to both patient engagement and visit attendance rates. In particular, several mentioned that an intervention will be more successful if a site can assist patients with transportation problems. Strong Start awardees helped participants schedule rides with Medicaid -covered transportation vendors; encouraged car-pooling for Group Prenatal Care cohort members coming from the same neighborhoods; and in a few cases provided taxi, bus, or gas vouchers paid for under other programs (e.g., the St. John awardee funded taxis and Lyft rides through the health system’s breastfeeding support group program). Finally, a small number of Maternity Care Home and Group Prenatal Care awardees conducted targeted outreach For instance, VCU (Maternity Care to the hardest-to -reach program participants . Home and Group Prenatal Care) key informants suggested that for a program like Strong Start to accomplish its goals, patient isolation and lack of engagement in care should trigger additional outreach in housing projects to har -based services. VCU program staff conducted outreach and home d-to -reach participants. At UNHS (Maternity Care Home), Strong Start staff prioritized reminder calls for patients with high no-show rates and followed up immediately with additional phone calls and rescheduling opportunities if those patients missed prena tal appointments. 40 YEAR 5 FINDINGS

59 Replicability Factors Related to Community and Policies/Regulations Some awardees and sites identified factors associated with their particular communities, or policies and regulations as influencing the care they provided and being important for program replication. These Table 11. factors are displayed in TABLE ES/REGULATIONS 11: MOST IMPORTANT PROGRAM REPLICABILITY FACTORS RELATED TO COMMUNITY AND POLICI Importance Based on Number of Awardees/Sites Reporting 2 Factor 1 Factor Group Maternity Care All Awardees/ Birth Center Home Sites Prenatal Care Medium Low Sufficient funding for enhanced prenatal care services Medium Medium ---- Availability of community resources to meet program Low Medium Low Medium participants’ needs Low Low Low Low Strong connections to community resources [Birth Center Only] Relationship to medical High Not reported Not reported Low community [Birth Center Only] Affordable licensure and Not reported Low Not reported Low credentialing 1 A replicability factor is included in the table if it was reported by at least 10% awardees and/or sites. Notes: 2 An assignment of “low” indicates that fewer than 25% of awardees or sites studied in Year 4 reported the factor; “medium” indicates that between 25% and 50% of awardees or sites reported the factor; and, “high” indicates that more 17 Maternity Care Home awardees, 15 Group than 50% awardees or sites reported the factor. This analysis included Prenatal Care awardees, and 12 Birth Center awardees or sites. More than a quarter of all awardees and sites, especially those implementing Group Prenatal Care sufficient funding for enhanced prenatal care services was an and Birth Center models, felt that having important factor for replicability. This finding is not surprising given that funding was also identified as the most critical factor for sustaining Strong Start programs. Though some awardees included internal (organizational) monies or grants among the funding sources that would aid replicability, most felt the best source of funding for long-term program success was reimbursement from Medicaid or other health care payers. Funding recommendations varied by model: • Maternity care home awardees were least likely to identify funding as an important factor for replication, perhaps because care coordination services and case management are already In a 2016 survey the evaluation team conducted covered services for many Medicaid programs. with Medicaid officials in 20 Strong Start states, most officials indicated that care coordination or case management are covered services though some noted the services were provided through a specific program or limi ted to high -risk women, and others reported it was the MCOs’ role to provide them (Hill et al., 2018). Programs such as Strong Start, therefore, may need to contract with MCOs or become certified providers to qualify for Medicaid awardee was successful in obtaining funding to sustain its Strong reimbursement. The ACCESS Blue Cross/Blue Shield’s Medicaid managed care plan “Blue Community” Start services through In contrast, other Maternity Care Home awardees noted that few MCOs reimburse in Illinois. for care coordination or case management services and often provide the services in - instead. house Group prenatal care awardees felt more practices would offer the model if it were incentivized • through Medicaid/CHIP reimbursement policies. CJFHC key informants believed that if data showed improvements in birth outcomes, MCOs might consider a performance -based reimbursement approach that would motivate providers to implement the model. Amerigroup YEAR 5 FINDINGS 41

60 officials noted that group care programs carry certain costly elements, including training and CenteringPregnancy certification for those choosing the approach, establishing a room for group sessions, and (potentially) seeing fewer patients than can be seen through typical prenatal care. -party reimbursement, key informants expressed skepticism that Without enhanced third Group Prenatal Care could be financially viable. Amerigroup Louisiana health plan implemented an enhanced Group Prenatal Care reimbursement fee of $50 per member per visit for Medicaid providers during the Strong start award period, which encouraged some of the awardee’s sites to sustain the model. • For Birth Center sites, a primary challenge for replication of the peer counseling component is that, in most states, peer counseling services are not billable under Medicaid/CHIP. However, centers birth face broader challenges because Medicaid programs often pay lower fees for midwife services than they do for physician and hospital services. Low payments particularly impact birth center facility fees and midwife provider fees. The evaluation’s 2016 survey of Medicaid officials in Strong Start states found large payment differentials for uncomplicated vaginal deliveries at birth centers versus hospitals, with birth centers paid as little as 15 percent of hospital ra tes for the same delivery, and between obstetricians and midwives’ reimbursement, with midwives paid 70 to 92 percent of physician rates for the same service (Hill et al. 2018). Low reimbursement has been a recurrent theme in the evaluation’s case of Birth Centers, with some sites struggling to serve Medicaid beneficiaries because studies reimbursement does not cover the cost of providing care to these patients. Inability to get contracts with Medicaid MCOs is another significant barrier. A key informant from AABC explained, “It feels like MCOs want to deal with people they are used to dealing with, which is bigger hospitals and health networks.” to meet participants’ needs was identified as an important community resources The availability of replicability factor primarily by Maternity Care Home awardees whose interventions were usually centered on identifying participant needs and making referrals to outside resources. As was the case among other awardees, Maricopa care managers often made referrals to WIC, food banks, and behavioral health counseling. While establishing connections with community organizations and social service agencies required staff time and networking, a Maricopa key informant noted, “our facility can only do so much and we can’t provid e everything that patients may need.” Several key informants from LADHS noted it could be more difficult to implement the model in a resource -poor area or in a state lacking policies that encourage or require health systems to examine the psychosocial cont ext of a patient. At the same time, they agreed that patients could still benefit from a Maternity Care Home model even where outside resources were more limited. Two Group Prenatal Care awardees reported that a community with resources for low-income indi viduals was helpful when scheduling guest speakers, compiling handout materials for group sessions, and obtaining incentives (Strong Start funding could not be used for incentives). HealthInsight key informants, for instance, noted that the presence of loc al lactation consultants and organizations that provide necessities such as car seats and diaper bags helped them meet their program goals. While availability of resources was important, some awardees added that program staff must be ng connections to community resources. This involves forging relationships within skilled at making stro the community as well as keeping resource lists organized, updated, and verified (i.e., checking a resource out and confirming it is appropriate and accessible prior to making the referral). ACCESS YEAR 5 FINDINGS 42

61 (Maternity Care Home) considered its relationships with other community providers key to program success. ACCESS staff created what they called the “Purple Binder” for Strong Start, which was a -updated clearinghouse for resources available in specific pockets of the city of Chicago. An constantly ACCESS key informant explained: “If care managers run out of ideas [on how to help a patient], [the binder] helps us to identify resources in a specific neighborhood, and where other care managers or providers have referred patients. The Purple Binder is integrated into our EMR system...you can put in a patient zip code and a service they might need and see a list of things that are near them like food pantries or mental health services that ey might not be able to get at their health clinic.” th he two final factors included in are specific to the Birth Center model of care. More than 11 Table T h relationship with the broader medical alf of Birth Center awardees and sites identified a Birth Center’s for replicating the model. A Birth Center without good support from the community factor as a key medical community is in a riskier position because midwives and Birth Centers have a limited scope of practice, and collaborative relationships are critical to their ability to provide -quality care safe and high when complications arise. One key informant from the AABC awardee noted: With cooperation [between Birth Centers and the medical community] you are building trust, setting “ up procedures for communication so moms and babies are s afer, and outcomes will be better.” Another noted that when Birth Center midwives have hospital privileges and attend planned hospital births, collaborative relationships improve because hospital providers see midwives practicing, and “not just transferring their complicated cases.” In a brief Internet -based survey of AABC sites conducted as part of the Strong Start evaluation in December 2016, a majority of survey respondents (24 of 37) described their relationship with the medical community as cooperative and supportive. affordable licensure and credentialing Finally, are important for replication of the Birth Center model. A few sites noted that becoming licensed and/or credentialed is necessary for participating in the Medicaid program and contracting with MCOs, but the associated fees can be unaffordable, especially for independently-operated Birth Centers. A key informant from the AABC site in Grandin Florida explained that financial challenges are exacerbated for the Birth Center because the Medicaid M COs do not pay Birth Center facility fees, and some MCOs require credentialing by both AABC and licensing from the state. This site reported that it could no longer afford the former, resulting in health plans refusing to pay for services rendered to Medicaid beneficiaries. A related concern is that during the Strong Start award period, Birth Centers in Florida and South Carolina reported that their states were considering regulations that would place additional burdens on centers or make it more difficult for midwives to practice. DISCUSSION The evaluation’s Case Studies provide a rich profile of the three Strong Start models of prenatal care ir (Birth Centers, Group Prenatal Care, and Maternity Care Homes) by examining the interventions, the challenges they faced, and their perceived successes. While each model had distinct features, there were also similarities across the models. All provided education related to a range of prenatal, childbirth, and postpartum issues , made referrals to non -medical services not provided during prenatal YEAR 5 FINDINGS 43

62 These -based care. , and shared an emphasis on psychosocial support through relationship visits risk factors that most Strong Start innovative features were designed to address the myriad social participants faced. The program had a wide geographic reach, providing enhanced prenatal care in about half the U.S. states. Pregnant women served by Strong Start reported satisfaction with many features of the program. In 120 focus groups with nearly 900 pregnant and postpartum women, we heard that women valued the additional time and attention they received, including emotional support, education on a broad range of Program staff issues including family planning and breast feeding, and referrals to community services. expressed similar positive sentiments during interviews. Most felt Strong Start enhancements had increased trust satisfaction with prenatal care; substantial advantages for their patients, including more ; better management of -being sense of well an improved e system; in and engagement with the health car awareness of community and greater chronic conditions; greater food, housing, and financial security; resources and how to access them. f implementation challenges and Awardees’ Strong Start programs were shaped by a range o successes. Common challenges reported during the four rounds of case studies included limited pre - implementation planning; lack of stakeholder support; program enrollment and participation - challenges; issues related to staffing, work flows, and scheduling; difficulties operationalizing whole person approaches to care; data collection and reporting problems; and challenges stemming from Medicaid policies and state regulations. Awardees struggled to address the full scope of their clients’ mental health needs because of insufficient resources in the community to meet women’s needs for , substance abuse services treatment, transportation, affordable childcare, and housing. Primary awardee successes included developing innovative systems to facilitate program implementation; -in; increasing participant enrollment and engagement; cultivating and achieving stakeholder buy integrating Strong Start components into sites’ standard model of care; well -qualified and skilled Strong Start staff; and establishing collaborative relationships with other organizations to address patients’ psychosocial needs and barriers to care. During the final round of case study interviews, program staff reflected on their experiences under Strong Start. ery few exceptions, awardees believed the enhanced prenatal care models they With v implemented under Strong Start were worthy of replication and hoped that Medicaid would consider identif n asked to .- Whe including enhanced services as part of their standard prenatal care coverage y most commonly factors important to successful program well- mentioned replication, awardees the qualified and skilled Strong Start staff, , provider appropriate space for providing Strong Start services -in and and administrative staff buy , and support for the program , the presence of engaged patients having sufficient funding for e nhanced prenatal care services. 44 YEAR 5 FINDINGS

63 DINGS: LEVEL PROCESS EVALUATION FIN PARTICIPANT- ROFILES, A DESCRIPTIVE LOOK AT PARTICIPANT RISK P OMES SERVICE USE AND OUTC INTRODUCTION Throughout Strong Start implementation, the evaluation team collected extensive data from individual participants enrolled in the program. In addition to allowing us to describe a broad range of e data also provide information on visit type and characteristics of the enrolled population, thes frequency, as well as pregnancy conditions and outcomes. Data on many of the measures collected are not available elsewhere or were not available in a timely manner. In this section, we describe the data llection process and the content of the data, present an overview of the completeness of these data, co and discuss how these data have contributed to the evaluation. Following this, we present a detailed description of Strong Start enrollees, including their demographic characteristics and medical and social risk profiles. We then describe some of the routine and enhanced services received by enrollees. The section concludes with a description of pregnancy conditions and outcomes experienced by women Regression enrolled in Strong Start. Multivariate analyses using the PLPE data are presented later in the s ection. Adjusted Outcomes Analyses PL PE DATA COLLECTION The PLPE data collection effort was a collaboration between CMMI and the Urban Institute. CMMI developed and fielded the first participant-level data collection instrument (the Intake Form) prior to the evaluation contract being awarded, ensuring that intake data were captured by awardees who initiated services before the evaluation contract was awarded. Three additional instruments were designed, tested, and implemented by the evaluation team in 2013/2014. We developed a system for ees to collect and submit these data either electronically or by scannable form and provided award technical assistance as they integrated these systems into their work flow. -level data collection instruments are included in ull versions of the participant Appendix D F . A brief de scription of each form is presented below: • The Intake Form is a six-page form that addresses questions pertaining to the Intake Form. participant’s sociodemographic characteristics, pregnancy history, delivery intentions, and risk factors for premature birth. In addition, the form includes screening tools for depression, Appendix D for anxiety, intimate partner violence, substance abuse, and food security (see dditional information). Many measures on this form are consistent with those asked in the a MIHOPE Strong Start evaluation (Lee et al. 2016). Administration of the Intake Form was ultimately established as a condition of participant enrollment, resulting in a very robust response rate (95 percent). In most cases , these forms were self -administered by participants; but, -format, particularly Strong Start staff administered the form in interview in select cases, when interventions were phone-based. Forms were available in Spanish and English. As noted in a previous Strong Start Evaluation Annual Report, many awardees indicated that the Intake YEAR 5 FINDINGS 45

64 form was useful in assessing patient-risk and establishing a care plan, and several were planning to retain at least a modified version of the Intake Form in their practices (Hill et al. 2018). urveys. These are each two -page surveys designed to • Third Trimester Survey & Postpartum S capture information on select measures of health and well-being. The Third Trimester Survey collects information on smoking, marital status, intimate partner violence, delivery and postpartum intentions (delivery support, delivery expectations, intentions to breastfeed) and client satisfaction. The Postpartum Survey collects information on delivery experiences, delivery care. Select breastfeeding and family planning, as well as satisfaction with prenatal and measures were repeated from the Intake Form so that participants could be tracked over time. These short surveys were self -administered, and available in both Spanish and English. Awardees received guidance to distribute Third Trimester Surveys when wom en were between 28 and 32 weeks gestation and the Postpartum Survey at women’s postpartum visit. If participants did not return for a postpartum visit, awardees were asked to reach out to by phone within 10 weeks of delivery and administer the survey by ph one. Response rates for these two participant-level forms were overall low (approximately 60 percent for each form). This is likely attributable to several factors including: • The Third Trimester Survey was rolled out after some women had already delivered. • Approximately 21 percent of enrolled women dropped out of Strong Start prior to delivery. Exit forms indicate that women did not continue in Strong Start for a variety of reasons withdrawal including miscarriage or termination (approximately 3.6 percent), voluntary from the program (4.2 percent), move or relocation (2.9 percent), loss of Medicaid eligibility (0.6 percent), and loss to follow up (approximately 7.5 percent). ees Many women did not show up for a postpartum visit. In some, but not all cases, award • tried to reach participants on the phone, but found it challenging. In some cases, awardee staff were unable to contact participants by phone (their numbers changed or they did not answer calls). In other cases, awardee staff were focused on other tasks and found it challenging to allot the time necessary to track participants down. The Exit Form collects clinical and program data from the medical chart or the Strong • Exit Form. Start program record following discharge for all participants whether or not they completed the program. These data are used to quantify clinical pregnancy risks and clinical outcomes. Awardees were polled prior to development to determine what data would be routinely available. An initial version was piloted with four awardees in January 2014. Additional revisions were made in the spring of 2014 based on feedback from awardees and CMMI program and evaluation staff. Exit Forms were available in Spanish and English. Response rates -response exceeds 20 percent for for the Exit Form are high (98 percent), though item non certain measures. “crosswalk form” was created to link participant Study IDs To facilitate data management, a PLPE with their identifying information. The crosswalk is the source for personal identifiers including able. participant name, birthdate, address, infant name, infant date of birth, and Medicaid ID, if avail -filled Study IDs were provided to awardees and shared with the Crosswalks templates with pre evaluation team quarterly through a secure FTP site maintained by Urban Institute. Throughout the data collection period, the evaluation team provided awardees with ongoing support and technical assistance to mitigate data quality issues that arose and to provide requested 46 YEAR 5 FINDINGS

65 support. At the outset, the evaluation team held several training webinars and attended annual ance. Each awardee was assigned a liaison from the -person assist awardee meetings to provide in awardee evaluation team who was available to field questions throughout program implementation and . Periodically (or when necessary) senior members of the team also held phone calls with closeout to resolve data issues. Initial concern about burden associated with these data collection awardees requirements generally gave way to appreciation for the structure they provided to Strong Start encounters as well as the utility of the information being collected. The PLPE data have distinct advantages as an evaluation tool, particularly the ability to analyze at the individual -level. The process also made use of built -in validity checks. CMMI’s program team collected data in aggregate from awardees on a quarterly basis using Excel spreadsheets. Primary data elements included enrollment figures, overall demographics, insurance coverage, gestational age at enrollment, and outcomes. These served as a supplement to the PLPE data and helped to determine the denominator for the proportion of forms collected. Additional information on the Quarterly Program . Appendix F Monitoring Report collected by CMMI is available in DATA COMPLETENESS OF PLPE 5 Form submission rates for the PLPE data (presented by model in ) are robust, particularly for Figure In take and Exit Forms. Rates of missing data by measure vary greatly by awardee and are very high for a on the Intake Form (item non-response) small number of awardees. Rates of missing data for items range from 1 percent to 27 percent, with an average non -response rate of about five percent. Exit Form item non -response ranges from 3 percent to 29 percent, with an average of about 12 percent overall. Item non -resp onse also varies across measures on each form. PLPE data quality summaries by awardee -respo . In addition, item non Appendix G nse rates for each measure of interest overall are presented in nd by model can be found in . Appendix I Appendix H a , and by awardee in FIGURE RALL 5: PLPE FORM SUBMISSION, BY MODEL AND OVE 9% . 3% . 99 5% 98 98.2% . 9.5.0% 94 . 9% 93 . 9% 83 .. 9%  Intake Forms Rece ived Trimester  Third Surveys .  Postpa rt)u m . Surveys Exit Forn,  ,s. I Care a G ra:up P All A pp ro.aches renat Maternity Center Birth {n = 007) , (n=26 Home 503) 10 Care 6) (n=aS.80 !n=4S 31l6}, ., Denominators for form submission rates are based on the total number of women for whom we have any form. Notes: YEAR 5 FINDINGS 47

66 The PLPE data collection has resulted in a rich and comprehensive data set reflecting the entire program implementation period and nearly all program participants. Using these data, we have been able describe the demographic, social and medical risk factors of Strong Start participants as well as report preliminary outcomes associated with the initiative prior to this information being available through other means, or in lieu of other data (e.g., in states where administrative data files were not Impact Analysis section). Birth certificate and Medicaid claims data being used to obtainable for the a ssess the impact of the Strong Start initiative were not available until the last year of the evaluation. With the PLPE data we have been able to: Characterize the Strong Start population; • • Track intervention intensity and frequency; • ficate and Medicaid data reliability; Confirm/corroborate/evaluate birth certi Evaluate interim outcomes not reliably available elsewhere; • • Provide an early look at key outcomes prior to other data being available; and • ry Strong Start Control for risk factors not reliably available elsewhere when looking at prima outcomes (gestational age, birthweight and delivery method). METHODOLOGY Analyses presented below reflect all available data collected through August 31, 2017, which allowed for awardees to submit data following completion of program implementation. Any individual with at least one form was included in the final analytic dataset, resulting in a total N of 45,316 observations. This is slightly fewer than the CMMI Strong Start program team reports as the total number of women ever enrolled in Strong Start (N=45,999). There are several possible reasons for this discrepancy. In addition to the few cases where no forms were submitted for a woman enrolled in Strong Start, there were also observations removed from the PLPE dataset because the awardee failed to obtain proper consent from the individual, other cases where women were counted as enrolled, but received no Strong Start services and no forms were administered, and cases where the enrollee counts and the PLPE counts simply did not line up (see for additional information). Appendix F addition, we restricted the analyses presented below to women with singleton births. This In resulted in the exclusion of N=607 women from the dataset (20 Birth Center multiples, 123 Group aternity Care Home multiples). Multiples were excluded because 1) Prenatal Care multiples, and 464 M most Birth Centers will not treat women with multiple gestations, so including them in our analyses -results, and 2) data quality related to the birth outcomes of individuals reporting would bias by model multiple gestations was especially poor. 14. All reported rates exclude women with missing data The data were analyzed using STATA resulting from not having a form or item non -response. Rates also exclude women not included in the relevant universe (e.g., women who did not have a prior birth are not included in the denominator for women who have a prior preterm birth or prior low birthweight baby). Five measures also exclude women with outlier responses (mother’s age, BMI, gestational age, birthweight, and interpregnancy . Though and Appendix I Appendix H interval). Complete tables by model and by awardee are included in e findings exclude women with missing data, we do report the rate of missing data for each measure th as well as the share of women not included in the relev ant universe. Where significance is mentioned, it 001). < 0. -tests (p -sided t is estimated using two 48 YEAR 5 FINDINGS

67 STRONG START PARTICI PANT PROFILES In this section, we depict the risk profiles of Strong Start participants, beginning with their demographic characteristic s, followed by descriptions of the wide range of social and economic challenges participants face and, finally a summary of the medical risk factors they possess. Demographic Profile of Strong Start Participants As reported in prior Strong Start Annual Reports, Strong Start enrollees are disproportionately black and Hispanic compared with pregnant Medicaid beneficiaries overall. The overrepresentation of black women in the Strong Start population is notable, given evidence that black women of all income els are more likely to experience adverse pregnancy outcomes than comparable white or Hispanic lev pregnant women (Zhang et al. 2013; Martin et al. 2015). Forty percent of Strong Start enrollees are black, and 30 percent are Hispanic, while data from the Natio nal Health Insurance Survey (NHIS) indicate that 25 percent of pregnant Medicaid beneficiaries overall are black, and 20 percent are Hispanic. The disproportionate representation of black in Strong Start is likely driven in part by a concentration of awardees in the Southeastern United States. The large proportion of Hispanic women is likely driven by the Hispanic populations of states with large awardees, particularly Arizona, Texas, the territory of Puerto Rico, and the city of Los Angeles. Though Hispanic women are sometimes reported as being at higher risk for poor birth outcomes than are white women, when origin is considered, Puerto Rican women are at considerably higher risk, while women with origins in Mexico are not (Martin et al. 2018). Half of Hispanic women enrolled in Strong Start identify as Mexican (50 -quarter of Strong percent), and approximately 12 percent identify as Puerto Rican. Approximately one white Start participants identify as white, though the proportion of Birth Center enrollees who are exceeds 50 percent. Approximately 45 percent of women enrolled in Group Prenatal Care and Maternity Care Home awardees are black, but more Hispanic women are enrolled in Group Prenatal Care. Strong Start awardees enrolled very few Asian women, and as a result, they are grouped with “other/multiple races.” Racial breakdowns by model and overall are presented in . 6 Figure FIGURE AND OVERALL 6: PARTICIPANT RACE AND ETHNICITY, BY MODEL Other  Races t iple ul Race/M spank -Hi Non Black  is.panic Non-H  White  Hispanic Maternity Care A ll Approaches . Gro up Prenata l Birth Center {n=9 Care me {n=24 Ho 645) , :1l .],62) {n=4 ,804) {n=7 ,3 :1l 3) Women with missing data are excluded from these calculations. Rates of missing for race and ethnicity by model are as Notes: , 2.9 percent for Maternity Care Homes, and follows: 16.8 percent for Birth Centers, 7.1 percent for Group Prenatal Care 6.6 percent for All Approaches. Rates of missing by measure can also be found in Appendix H . YEAR 5 FINDINGS 49

68 The vast majority of Strong Start participants fall within what is considered the healthiest window -34 years of age (76 percent)— ed in the program. The at the time they enroll 20 for pregnancy and birth — mean age of Strong Start women having their first birth wa s 22.6, compared with a mean age of 26.6 for , few 7 Figure all U.S. women giving birth for the first time in 2016 (Martin et. al, 2018). As presented in were articipants trong Start p young teens (5 percent) which is consistent with other data that indicate S -19 years old) (Kost and Maddow-Zi met 2016). that most teen pregnancies occur to older teens (18 year Eighteen and 19- -olds ma de up about 10 percent of Strong Start participants. Approximately nine of advance percent of women were d maternal age (>=35 years of age), an age range during which risks increase for C -section, gestational diabetes and other adverse pregnancy conditions. FIGURE 7: MOTHER’S AGE AT INTAKE 18year:sof.age Les:sthan years of and 18  age 19 . rs yea 34 rough 20th  age of  35 years.and older N = 42,297. Notes: Rates are based on women for whom Intake Forms were submitted and who had nonmissing data for birth date on the crosswalk and date of entry into care on the Intake Form. Women with missing data are excluded from these 4 percent. Rate of missing by measure can calculations. The rate of missing for mother’s age at intake for all models is 5. Appendix H . also be found in As we have reported in the past, the share of Strong Start participants who were married was Figure ). Only 8 substantially lower than reported in other studies of low -income mothers (see quarter of all Strong Start participants reported being married. Published studies suggest that one - marriage rates among low -income mothers do range widely and have been decreasing in recent years, but Strong Start participants less likely to be married than the low end of the range reported in the were literature. Prior studies report marriage rates for low -income women ranging from 30 percent to 70 percent (Shattuck and Krieder 2013; Davis and Rackin 2014). Because being Brown et al. 2015; Gibson- unmarried was a risk factor that a small number of awardees initially used for determining Strong Start eligibility, we might expect that more unmarried women were enrolled in the early years of Strong Start. However, we find that marriage rates did not vary after the requirement for a risk in addition to Medicaid eligibility was removed in mid , however, report having -2014. Most Strong Start enrollees did a partner; in addition to those who e married, more than 32 percent of Strong Start participants wer living with a partner, and another 26 percent of participants were were in a relationship but not living with their partner. These patterns vary somewhat by model, with Birth Center participants being significantly more likely to be married (42 percent) than women in other models. Maternity Care Home enrollees were significantly more likely to be in a relationship but not living with their partners (30 50 YEAR 5 FINDINGS

69 001). Women enrolled in Group Prenatal Care were < 0. (p percent) than women in other models significantly more likely to report not being in a relationship compared to Birth Center participants (19 percent vs. 10 percent; 001) , but the difference between Group Prenatal Care and Maternity Care p < 0. Home participants is not significant. Relationship status and stability can contribute to healthy pregnancy and positive birth outcomes. Several studies have demonstrated that both the type and quality of a woman’s relationship can have bearing on maternal and infant outcomes around pregnancy, with women in stable partnerships experiencing more positive outcomes (Bloch et al. 2010; Fairley and Leyland 2006; Butler and Behrman 2007). Research also indicates that many low -income women who are partnered at the time of their child’s birth do have plans to marry but delay marriage because of financial instability (Cho et al. 2016). LL , BY MODEL AND OVERA 8: RELATIONSHIP STATUS OF STRONG START PARTICIPANTS AT INTAKE FIGURE 17.0% 18.4% 18.9% Re  Not in a ip lationsh Now Right  but lationship Re Ina % Together Not Living  Living with a Partner 32.3 % % 34.8 1% 3 1.  Married l up Gro All Prenata ro.aches pp Care Maternity A Center Birth Care ,(n ) 262 , 24 = Home 6) .91 =

70 ODEL OOL ATTENDANCE AT INTAKE FOR STRONG START PARTICIPANTS, BY M 9: EMPLOYMENT AND SCH FIGURE OVERALL AND 30.8% 35.3% 36.6% Not Employed,.  School in  Not ~ In Schoo Employed in and  Employed l Schoo Maternity ll A . Care pp Prenatal Group A roaches Center Birth Care , 3) 1. ,3 =24 (n Home 3011) =9 '{n ,H62) {n=40 (n =7,.248' l are as Missing data are excluded from these calculations. Rates of missing for employment and school status by mode Notes: follows: 17.5 percent for Birth Centers, 10.4 percent for Group Prenatal Care, 4.8 percent for Maternity Care Homes, Appendix and 8.6 percent across All Approaches. Rates of missing by measure can also be found in H. relatively low levels of educational attainment overall. had Furthermore, Strong Start enrollees More than 84 percent had a high school degree or less. Very few participants had a Bachelor’s degree have some college experience, which may be an (about six percent), but an additional 10 percent did Associate’s degree or vocational training. We did observe the statistically significant finding that more than three times as likely to have a college degree than women enrolled in Birth Center care were women enrolled in either of the other two models 001), though the vast majority of birth center (p < 0. ave a college degree. participants still did not h Participant rates of educational attainment are 10. Figure presented in 10: HIGHEST LEVEL OF EDUCATION COMPLETED BY STRONG START PARTICIPANTS, BY MODEL FIGURE AND OVERALL 9.3% 95% 9. 9% 5% . 12 4.5% --- 3.7% 5.8% ege Degree li Co Other  9% . 57 58.3% 's Degree  Bachelor 57.9% 575% Grad School u ate High  orGED l  Les:sthan High Schoo A pp ll Gro Care . Maternity l up Prenata roaches A Birth Center {n =7 =<3 9 ,11 22) ,668) Ho me ,11 ,353) 0 11) {n= Ca re (n =aB {n 23 Notes: Missing data are excluded from these calculations. Rates of missing for education level by model are as follows: 19.2 for Maternity Care Homes, and 12.5 percent for Birth Centers, 16.5 percent for Group Prenatal Care, 8.6 percent percent across All Approaches. Rates of missing by measure can also be found in Appendix H . 52 YEAR 5 FINDINGS

71 Education and employment patterns among participants could be related to the fact that many women enrolled in Strong Start already ha d children. Most women enrolled in Strong Start had a prior pregnancy (72 percent overall), and 61 percent ha d previously given birth. This is especially true among participants over 20, among whom 79 percent ha d a prior pregnancy and 68 percent reported having a prior birth. This observation is not surprising given the fact that some awardees initially targeted characteristics that would put them at increased risk of having a preterm baby, women with medical including some that specifically targeted women with prior preterm births. Women enrolled in Strong Start report ed struggling with a variety of other social and economic experiencing access barriers to challenges. Black and Hispanic women enrolled in Strong Start reported ntly significa were prenatal care at similar rates (37 and 36 percent respectively), while white women 001). less likely to report experiencing a barrier to accessing prenatal care (26 percent; p < 0. Many participants , though fewer that we might expect, specifically reported experiencing food insecurity (20 reported percent). M ore than a quarter of participants that it was difficult for them to get to their with the most commonly reported barriers Figure prenatal care appointments (34 percent, see 11), not having a car (60 percent of women who reported difficulties), not having enough money including in line with case are for a ride (20 percent), and work hours (17 percent). Barriers reported on the Intake study findings that consistently indicated, for instance, that transportation challenges pose substantial barriers to care for some women. Transportation barriers can range from not have access to a reliable vehicle, challenges with Medicaid transportation (e.g., inability to bring older children, inflexible id transportation schedules), and costs and access associated with public transportation. Medica FIGURE 11: NUMBERS OF BARRIER AND S TO PRENATAL CARE ACCESS REPORTED BY PARTICIPANTS, BY MODEL OVERALL Two Reported  or :s MoreAcces s Barrier Reported One  er i Barr A<:cess Reported  None renata P Care up Gro I Maternity ro.aches ll A pp . A Center ( n=42 ,:i60) 25 (n= Home ,398) 864 re t n=9 Ca ., ) ' 374 , n.d7 ( Notes: Missing data due to no intake form are excluded from these calculations; item nonresponse cannot be captured for this measure. Rates of missing for number of barrier to care by model are as follows: 16.1 percent for Birth Centers, 5.0 percent for Group Prenatal Care, 1.5 percent for Maternity Care Homes, and 5.2 percent across All Approaches. Rates of missing by measure can also be found in Appendix H . Ns include women with an intake form. Mental health frequently arose as an issue during Strong Start case study interviews. In the PLPE positive for depression and more than 35 that nearly 28 percent of women screened data, we observe 25 percent had some level of anxiety (mild, moderate or severe). Black participants were significantly 25 Anxiety was measured using the GAD- 7; scoring procedures are reported in Appendix E . YEAR 5 FINDINGS 53

72 more likely to screen positive for depression than white women (34 percent vs. 25 percent ; p < 0. 001), significantly less likely to screen p while Hispanic women were ositive for depressive symptoms than 001) .When we look at women who screened positive for either ; p < 0. white women (21 percent depression, or anxiety or both, we observe that a sizable share of women enrolled in the program struggle with both anxiety and depression (21.8 percent). have been reported in the literature Typical rates of depression among pregnant women in the U.S. 6 to 13 percent, and rely on a variety of scales to assess depression, to range from -9, including the PHQ S-D ( Venkatesh et al. 2016, Bennett et al. 2004; Melville et al. 2010; Katon et , and the CE the Edinburgh -analysis of antenatal al. 2011, Gavin et al. 2005). Though prenatal anxiety is understudied, a 2014 meta generalized anxiety disorder (GAD) found that between 0 and 10.5 percen t of pregnant women experience generalized anxiety (Goodman et al. 2014), less than a third of what was observed among Strong Start participants. High rates of depression and anxiety experienced by women in Strong Start (presented in 12 Figure ) may be a result of increased stress in the lives of women living in poverty, many o f whom are also experiencing an unintended or mistimed pregnancy. Approximately 70 percent of that they were not trying to become pregnant. Strong Start participants reported rior research has suggested that depression during pregnancy is associated with myriad poor birth P ntenatal anxiety has been outcomes, including preterm birth and low birth weight (Grote et al. 2010). A associated with shorter gestations and low birthweight, but the strongest evidence links anxiety during pregnancy with reduced capacity for women’s offspring to appropriately self-regulate, with cognitive and motor development delays and with challenges related to infant temperament during the first year of life (Beijers et al. 2010). Our data allow us to correlate depression and anxiety with birth outcomes, but we are unable to assess longer term consequences. NG START PARTICIPANTS EXHIBITING DEPRESSIVE SYMPTOMS, ANXIET FIGURE Y, OR BOTH AT 12: PROPORTION OF STRO OVERALL INTAKE, BY MODEL AND  Not Exhibiting Depressive or . AnxietySyrniptoms .50.7% .58.2%  Exhibiting Both Depressive .59.8% and Symptoms . Anxiety Anxiety  Exhibiting SymptomsOnly Depressive  Exhibiting Symptoms Only 5.3% 7.2% --.5 . 8% 5.8% Prenatal Care . Group Approaches Maternity All Center Birth me Ho 7.7.54) re {n = 22,30;8) ,(n=6 {n =36.706) {n= Ca ,644) Ns include women with nonmissing data for both depression and anxiety. Rates of missing for combined anxiety and Notes: depression by model are: 24.4 percent for Birth Centers, 25.3 percent for Group Prenatal Care, 12.7 percent for all approaches percent across Maternity Care Homes, and 17.9 . Rates of missing by measure can be found in Appendix H . 54 YEAR 5 FINDINGS

73 Strong Start Participants’ Medical Risk Profiles ed In addition to considerable economic and psychosocial needs, many Strong Start participants suffer from other chronic health conditions that can make pregnancy risky. In line with national trends that indicate that rates of overweight and obesity are increasing among women of reproductive age, particularly among women who are black, have a high school degree or less, and are multiparous (Meehan et al. 2014, Kim et al. 2007), we observe that well over half of women enrolled in Strong Start were overweight or obese at intake (26 percent are overweight and 36 percent are obese). Rates of ed 40 percent among women enrolled in the Maternity Care Home model, as presented obesity exceed in Figure 13 . The Maternity Care Home model also ha d a higher proportion of black women, who ge nerally had higher rates of obesity (42 percent) than Hispanic (35 percent) or white (30 percent) women. Higher maternal weight has been associated with incr eased risk of diabetes (prior to and during pregnancy), hypertension, C-section delivery, macrosomic infants, and (Leddy et other poor outcomes al. 2008; Bloomberg and Kallen 2009; Yu et al. 2013). not appear to track with rates of overweight and obesity among did ssociated chronic diseases A relatively low levels of . Specifically, participants had 13 Figure Strong Start participants, as presented in re -pregnancy diabetes (approximately 4 percent overall, 0.6 percent among Birth Center enrollees, p percent among Group Prenatal Care enrollees, and 4.0 percent among Maternity Care Home 6.8 Notably, some Group Prenatal Care awardees included groups that specifically targeted enrollees). women with diabetes, which may account for the slightly larger proportion of diabetic women enrolled were hypertension -pregnancy pre in this model. Rates of -pregnancy slightly higher than rates of pre diabetes (6 percent overall, 0.8 percent among Birth Center enrollees, 8.3 percent among Group Prenatal Care Enrollees, and 7.5 percent among Maternity Care Home enrollees). The Strong Start -income pregnant population in aggregate appears to be less likely than the overall population of low women t o have a pre -pregnancy diagnosis of hypertension, but has similar rates of diabetes, on average. This may be related to the fact that Strong Start participants are slightly younger than the mean age of mothers in the U.S. overall (25.6 percent vs. 28.7) (CDC 2018). One study reports that approximately 3 percent of low -income women of reproductive age (18-44) have diabetes and 12 percent are hypertensive (Robbins et al., 2013). -PREGNANCY DIAGNOSIS OF DIABETES, HYPERTENSION, AND OBESITY, BY MODEL AND OVERALL 13: PRE FIGURE Diabetes ,(Type :1. or  Type2) io  Hypertens n First Prenata l  Obese at >=30) . is it(BMI V Approadies li Al G ity 111 Mate renat.al p P roo Care er irtlh Ce 1111t . Appendix H Missing data are excluded from these calculations. Rates of missing by measure can be found in Notes: De nominators for diabetes are: BC=8,750, GPC=6,757, MCH=21,525, Total=37,032. Denominators for hypertension are: BC=8,752, GPC=8,059, MCH=22,046, Total=38,857. Denominators for obesity at first prenatal visit are: BC=8,474, GPC=7,052, MCH=20,908, Total=36,434. Denominators include women with nonmissing data for that outcome. YEAR 5 FINDINGS 55

74 As mentioned earlier, many women enrolled in Strong Start had previously been pregnant (72 th have also experienced percent) or given birth (61 percent). Many women who have had a prior bir Figure 14 ). More than 20 percent of women with a prior birth had prior poor birth outcomes (see the overall preterm rate in the U.S. is delivered preterm (before 37 completed weeks’ gestation) — . Given that having a prior preterm birth is one of the strongest predictors of around 10 percent subsequent preterm birth, this high proportion suggests that the Strong Start population is especially at risk for delivering a preterm infant. Although we might expect birthweight to track closely with prior preterm, rates of prior low birthweight (less than 2500g) are about half those of prior preterm birth (11 percent compared to 21 percent), which may indicate that many prior preterm births were late preterm, with infants at a normal birthweight, or could indicate a data quality issue. Many participants (28 percent), and especially women enrolled in Birth Center care (35 percent), report a short interpregnanc y interval between their Strong Start pregnancy and their prior birth (measured as less than 18 months). This could be related to the finding presented in previous evaluation reports that Birth Center participants were the least likely to be using a highly effective form of contraception postpartum -Barnet et al. 2018), as such women are more likely to experience an unintended (Hill et al. 2018; Cross However, had the highest rate of intended pregnancy (38 percent) as Birth Center enrollees pregnancy. ed to the overall rate among Strong Start participants (29 percent). Having at least 18 months compar between pregnancies can be important to the health of the mother and infant. Closely spaced nd increase risks for complications pregnancies do not allow sufficient time for a woman’s body to heal a such as placenta previa and placental abruption (see also Conde -Agudelo et al., 2006). Infants born after a short interpregnancy interval may be at increased risk for being born preterm, at low birthweight or small for g Agudelo et al., 2006, 2012; DeFranco et al., 2007). estational age (Conde- DEL AND OVERALL A PRIOR BIRTH, BY MO FIGURE 14: MEDICAL RISK FACTORS AMONG WOMEN WITH 34 6% .. J l% 28. 27 .:1. % 24.3% 23 . 9% (< Pl I Short :1  8 months sin ce pr ior bi rth} m B Preter rior P  irth  P rior Low B irthw eight Infant . Center Approaches rth ll A Care Maternity l up Prenata Gro Bi Care Home Missing data are excluded from these calculations. Rates of missing and not in universe by measure can be found in Notes: Appendix H . Denominators for previous preterm birth are: BC=5,588, GPC=5,150 346. 08, Total=26, , MCH=15,6 ators for Denominators for previous low birthweight are: BC=5,487, GPC=3,6 26, MCH=12,699, Total=21,812. Denomin short interpregnancy interval are: BC=4,052, GPC=3,664, MCH=12,235, Total=19,951. Denominators include women with a prior birth and nonmissing data for that outcome. 56 YEAR 5 FINDINGS

75 INTENSITY VISIT FREQUENCY AND As described earlier in this report, prenatal care enhancements offered to Strong Start participants varied by model and by awardee. Using PLPE data, we track both the type and frequency of specific can as kinds of visits. Below we quantify the routine prenatal care visits Strong Start participants received well as the enhanced encounters and services provided to them during their Strong Start pregnancies. Routine Prenatal Care Awardees were instructed to document routine prenatal care visits for participants, defined as “routine clinical prenatal care vis its with a physician, midwife, nurse practitioner, or similar care provider that occurred during the current pregnancy.” For routine Group Prenatal Care visits, awardees were instructed to “include Group Prenatal Care visits, such as Centering visits only.” Through the PLPE data we tracked the type and frequency of routine prenatal care visits participants received, presented in Table 12 . A s expected, the bulk of those who attended Group Prenatal Care sessions were enrolled in the Group Prenatal Care model. However, only 79.5 percent of women enrolled in Group Prenatal Care reportedly attended group visits. While it is likely that at least some of the remaining 20 perce nt dropped out of Strong Start prior to attending any sessions (48 percent of these women exited Strong Start prior to delivery), others may represent data quality issues or cases in which participation in Strong Start did not result in receipt of enhanced prenatal care services. Women who did attend Group Prenatal Care sessions had, on average , 5.7 group visits. small proportion of Birth Center and Maternity Care Home participants also attended group A visits (1.6 percent and 2.3 percent, respectively). We did learn through case study analyses that at a limited number of sites in these models, Group Prenatal Care was an option that existed before Strong Start implementation. For instance, one of the ACCESS’ Strong Start sites in Chicago offered Centering to some of its most high -risk clients, and several Birth Center sites utilized a Group Prenatal Care model as their standard of care. Maternity Care Home participants who attended group sessions attended roup Prenatal Care model of Strong Start (4.8 fewer sessions on average than those enrolled in the G visits), but Birth Center participants who attended Group Prenatal Care sessions attended an average of seven group visits. percent), and 90 Nearly all Birth Center participants received at least one individual care visit (99.7 percent of Maternity Care Home participants received at least one individual visit. Birth Center participants attended on average 9.3 individual visits and Maternity Care Home participants attended 8.8 individual visits, on average. The American Congress of Obstetricians and Gynecologists (ACOG) recommends that women without pregnancy complications schedule visits for every four weeks until 28 weeks gestation, then rdees did provide the every two weeks until they reach 36 weeks, then weekly thereafter. Some awa evaluation team with visit dates, while others did not, making it challenging to determine when visits occurred over the course of each participant’s pregnancy. While there is consensus about the importance of prenatal care, the ideal number of visits a woman should have during her pregnancy is ore visits (even among low less clear -risk women) are not consistently associated with improved . M outcomes (Buekens et al. 1993, Carter et al. 2016). Strong Start programs generally enrolled a higher YEAR 5 FINDINGS 57

76 adequate prenatal risk group of women, and more visits might signal higher risk pregnancies rather than care . , appropriately distributed throughout one’s pregnancy n effort to help women enroll early in pregnancy One feature of most Strong Start programs was a and keep their prenatal care appointmen ts, efforts lauded by both participants and staff. Based on awardees’ program monitoring reports, we found that the majority of Strong Start participants initiated care prior to 20 weeks (enrolling the vast majority of participants before 20 weeks was initially a program requirement, but that requirement was changed in 2014). Still, many sought care later than other pregnant populations, perhaps because their pregnancy was not intended, they were unsure if (Child ey had health coverage, or because they experienced barriers to accessing prenatal care th Trends 2015). Therefore, some women enrolled in Strong Start who did meet thresholds for an may have had these visits during a compressed time adequate number of routine prenatal care visits frame later in their pregnancies . ALL Y, BY MODEL AND OVER 12: STRONG START ROUTINE PRENATAL CARE VISIT TYPE AND FREQUENC TABLE Birth Maternity Group N or % Data Elements Total Care Home Prenatal Care Center Routine Prenatal Care (Individual Visits) 1.9 0.7 2 6. 0.1 % Missing Data Women with Non- 8,778 9,740 25,360 43,878 N Missing Data 88.1 90.0 72.8 99.7 % Received Individual Visits 5.3 9.3 8.3 8.8 Average Number of Individual Prenatal Visits Mean Routine Prenatal Care (Group Visits) 0.7 0.1 6. Missing Data 2 % 1.9 43,878 Women with Non- 25,360 9,740 8,778 N Missing Data 19.3 Received Group Visits % 1.6 79.5 2.3 Average Number of Group Prenatal Visits Mean 7.0 5.7 5.7 4.8 Enhanced Encounters and Services In addition to routine prenatal care visits, Birth Centers and Maternity Care Homes provided encounters with a care manager. Care managers (sometimes referred to as care coordinators or peer counselors by individual awardees) translated medical information for patients, navigated needed insurance approvals, made referrals for medical non -medical services, provided emotional support, and administered evaluation forms (Hill et al. 2018). Nearly all Birth Center enrollees (99.5 percent) and 93 percent of Maternity Care Home enrollees received at least one care coordination encounter during their pregnancy. While we understand from our case study analyses that the number of care coordinator encounters varied widely by awardee and even within awardees (see Hill et al. 2018), on average women met with their care coordinators approximately four times during their pregnancy or postpartum (3.2 times for Birth Centers and 4.6 times for Maternity Care Homes). Although not a central aspec t of Group Prenatal Care awardee interventions, 46 percent of group enrollees did receive a care coordinator encounter during their pregnancy, with an average number of 2.3 encounters. Given the high need for mental health care demonstrated among the population of Strong Start enrollees, some awardees focused on providing mental health services or referring women to outside services. As described above, mental health care access can be quite limited for Medicaid beneficiaries. This may be especially true fo r pregnant Medicaid beneficiaries, as some mental health providers are reluctant to treat depressed pregnant women in general, especially those who require medication YEAR 5 FINDINGS 58

77 management (Weinreb et al. 2014). As presented in Table 13, PLPE data indicate that less than six percent of participants received a mental health encounter during their pregnancies (though we know that more than a quarter of women screened positive for depression and/or anxiety). Women enrolled in Maternity Care Homes, however, were the most likely to have received a mental health encounter (8.8 percent). This could be because many Maternity Care Homes were part of an FQHC network or university -based healt h system, where specialty care referrals may be more streamlined or where mental health providers may be available on site. Mental health encounters were notably rare among Birth Center participants, with less than one percent of women reportedly receiving an encounter. Across models, if a mental health encounter was provided by a caregiver not associated with the site, this information may not have been known or reported. 13: ENHANCED ENCOUNTER TYPE AND FREQUENCY, BY MODEL AND TABLE OVERALL Maternity Group Birth N or % Total Data Elements Care Home Center Prenatal Care Care Coordinator Encounters Missing Data 31.8 12. 6 8. 0.6 % 4 N Women with Non 8,732 Missing Data - 39,155 7,081 23,342 46.1 93.0 % 86.0 Received Care Coordinator Encounters 99.5 4.0 4.6 2.3 3.2 Mean Average Number of Care Coordinator Encounters Mental Health Encounters 16. 2 5 18. 4 35. 5.2 % Missing Data Women with Non- 8,331 6,731 21,354 36,416 Missing Data N 5.9 8.8 3.4 0.7 % Received Mental Health Encounters 1.9 1.7 2.4 2.3 Average Number of Mental Health Encounters Mean INTERIM OUTCOMES The PLPE data allow us to track pregnancy conditions that developed during women’s time in Strong Start and assess variation across models and by participant characteristics. This benefit of the PLPE data is particularly important, as measures of pregnancy conditions are not readily available from other data sources, or available in a timely manner, and adverse conditions may contribute to poor pregnancy outcomes. In this sect ion, we describe the incidence of select pregnancy conditions among Strong Start 15 Figure participants that are directly related to maternal and infant outcomes, as displayed in . Later in adjusted analyses - Regression Adjusted Outcomes Analyses the report, in the section, we present risk for two – gestational diabetes and preeclampsia. se conditions of the Gestational Diabetes Slightly more than six percent of Strong Start participants developed gestational diabetes during their 26 pregnancies. This is higher than we have reported in years’ past, but lower than overall rates of gestational diabetes in a comparable population. For example, findings from a study using the Pregnancy Risk Assessment Monitoring System (PRAMS) data and birth certificates suggest that the incidence of gestational diabetes among women enrolled in Medicaid is nearly 10 percent (DeSisto, Kim, & Sharma, 2014). Low rates among Strong Start enrollees may be especially notable given that 26 ave developed gestational diabetes. When -pregnancy diabetes and h Some women in Strong Start are reported to have both pre -pregnancy diabetes (excluding 1,270 women), we find that 5.5 we limit the sample to Strong Start participants without pre percent of Strong Start participants developed gestational diabetes during their pregnancies. YEAR 5 FINDINGS 59

78 some awardees enrolled women specifically because they had gestational diabetes or were at risk of dev eloping gestational diabetes based on their medical history. We do not, however, know the gestational diabetes status of 18 percent of Strong Start women due to missing data. Women enrolled in Maternity Care Homes were significantly more likely to develop gestational diabetes than participants in the other two models (7.9 percent vs. 6.0 percent in Group Prenatal Care and 2.8 percent for Birth Centers ; p < 0. 001) . This could be related to the fact that Maternity Care associated with gestational diabetes. As shown isk factors Home awardees enrolled more women with r Table 14, rates of gestational diabetes are higher than average for Hispanic women, women age 35 in and older, and women who are obese. Maternity Care Home awardees enrolled more women who were 2 percent) and more women of advanced maternal age (9.5 percent) than the overweight or obese (66. other models. Birth centers a similar proportion of women who are >35 years old, but a smaller had proportion of women who are overweight or obese (50. 7 percent). We also observe that Hispanic other more likely to develop gestational diabetes than women of women enrolled in Strong Start were race/ethnicities — 8.7 percent of Hispanic women develop gestational diabetes compared with about 5 percent of white and black Strong Start participants. TABLE 14: RATES OF GESTATIONAL DIABETES BY PARTICIPANT CHARACTERISTICS Participant Characteristics Share that Developed Gestational Diabetes N or % Women with Non- 36,687 Missing Data N % All Participants 6.3 Race/Ethnicity Women with Non- Missing Data N 34,130 Hispanic 8.7 % % Non-Hispanic White 5.1 Non-Hispanic Black % 5.2 Other Race/Multiple Races 7.9 % Age N Women with Non- 34,564 Missing Data % 1.8 Less than 18 Years of Age 2.9 % 18 and 19 Years of Age 20 Through 34 Years of Age % 6.1 35 Years and Older 14.9 % BMI Women with Non- Missing Data N 32,911 2.3 Underweight (BMI < 18.5) % 2.6 Normal weight (=>18.5 BMI < 25) % Overweight (=>25 BMI < 30) % 5.9 Obese (=>30 BMI < 40) % 10.1 13.1 % Very obese (BMI >= 40) During case study interviews we heard that many Strong Start awardees focused on providing nutrition counseling, dietary guidance, linkages to WIC, and referrals to a nutritionist or diabetes -risk support group. Perhaps those efforts translated into reductions in gestational diabetes in this high population. Approximately one -quarter of partici pants received separate nutrition counseling sessions during their Strong Start pregnancy, according to the PLPE visit data. In addition, we know that the midwifery model of care practiced in Birth Centers emphasizes good nutrition and healthy activity during pregnancy and there are also sessions on this in the Centering pregnancy curriculum utilized by most Group Prenatal Care awardees. 60 YEAR 5 FINDINGS

79 Pregnancy -Induced Hypertension and Preeclampsia the lower gestational diabetes rates found among Strong Start participants , In contrast to pregnancy -related hypertension rates were higher than those reported in the literature for low -income — women, generally six percent compared to approximately three percent (Bateman et al., 2012). These rates vary by model, with women in Group Prenatal Care and Maternity Care Homes having much -induced hypertension and preeclampsia than women enrolled in the Birth higher rates of pregnancy Figure 15 . Center model. These results are presented in RELATED HYPERTENS ION AND PREECLAMPSIA, BY MODEL FIGURE 15: RATES OF GESTATIONAL DIABETES, PREGNANCY- AND OVERALL 8.1%  Pr , eeda m p,sl ia  lated m:y-Rel ,egna Pr Hypertens 'i. on  Gesta~ i ona 'l lliabetes er ,e car fy :i ,ern Mat . M Ii Approaches cent , , Prenata Group 'II Hom ,e Care Missing data are excluded from these calculations. Rates of missing and not in universe by measure can be found in Notes: Appendix H . Denominators for gestational diabetes are: BC=8,723, GPC=7,798, MCH=20,166, Total=36,687. -related hypertension are: BC=8,722, GPC=7,631, MCH=20,216, Total=36,569. enominators for pregnancy D Denominators for preeclampsia are: BC=8,722, GPC=7,767, MCH=20,070, Total=36,559. N s include women with nonmissing data for that outcome. -induced hypertension and preeclampsia among Strong Start participants High rates of pregnancy appear to be driven, at least in part, by race, which varies by model. We observe that 9.2 percent of -induced hypertension during their Strong Start pregnancy black women developed pregnancy compared with 3.7 percent of white women and 4.5 percent of Hispanic women. The literature shows that black women are at higher risk of hypertensive problems in general and specifically during pregnancy (Yoon et al. 2015, Ghosh et al. 2015). Higher rates of pregnancy -induced hypertension among black women also track with higher rates of preeclampsia: while the overall rate of preeclampsia among all Strong Start women is 4.9 percent, it is 6.6 percent for black women. The underlying causes , , therefore -induced hypertension are largely elusive and and mechanisms for preventing pregnancy pose a particular challenge to prenatal care providers. The incidence of preeclampsia has bee n on the rise in the U.S., however, and there is evidence that rising rates may be related to higher rates of obesity and related conditions such as hypertension and diabetes (Jeyabalan 2013). Though use of low -dose YEAR 5 FINDINGS 61

80 -eclampsia for those at risk, and is to reduce the risk of pre aspirin during pregnancy has been shown recommended practice by the U.S. Preventive Services Task Force, data collected through the case studied indicate that it was used inconsistently in Strong Start. Labor Induction -third of Strong Start participants (32 percent). The CDC reports about one for was induced Labor vidence (Martin et al. 2018), but e induction rates in 2016 were 20 percent for all U.S women in 2016 that birth certificate and hospital discharge records underreport the true rate of inductions suggests (Kjerulff & Attanasio 2017). A recent study looking at health plan data indicates the real rate of higher than 20 percent much induction is likely , peaking at 32.2 percent in 2005 and declining to 29.1 percent in 2007 et al. 2014), rates that are more consistent with what we observe in the Strong (Dublin Start population. According to PLPE data, most Strong Start women who were induced were induced with Pitocin (84 percent), but some deliveries may have been induced with prostaglandins by the artificial rupture of membranes (AROM), or by other means . Most induced Strong Start deliveries occurred between 39 and 41 weeks gestation (50.1 percent), but nearly a quarter (24.1 percent) were early term inductions (between 37 and 39 wee ks), and approximately 9 percent were induced preterm. Unfortunately, the nature of the PLPE data does not allow us to assess whether reported inductions were elective or medically necessary, but we can observe that approximately , 20 percent of women who were induced preterm had preeclampsia 47 percent had pregnancy related hypertension, and 12 percent had gestational diabetes . A national early term births has led to recent declines in non - movement to reduce the number of elective me , and many Strong Start awardees had induction being performed prior to 39 weeks dically indicated a reduction in early elective deliveries (both through induction and cesarean) as an operational goal. In fact, the largest changes in the induction rate in recent years have occurred among early-term births (Osterman and Martin 2014). In focus groups with participants, the evaluation team asked whether any provider or Strong Start staff had spoken with them about the importance of carrying their babies until at least 39 weeks, and if so, why. Consistently, we heard that this was a point that was emphasized, particularly in Birth Center and Group Prenatal Care, and that early elective inductions were generally discouraged. UTCOMES STRONG START BIRTH O Below we br iefly describe the primary maternal and infant outcomes we observe among Strong Start Regression participants in the PLPE data. Additional risk adjusted analyses are also presented in the Adjusted Outcome s Analyses ection. s Gestational Age enhanced care Preterm birth was a primary outcome that Strong Start sought to affect through funding eir pregnancies. In the U.S., women who are poor and support to Medicaid beneficiaries throughout th are at increased risk of experiencing preterm birth, as are black women regardless of socioeconomic status. As reported above, most women enrolled in Strong Start, all of whom had incomes low enough to YEAR 5 FINDINGS 62

81 them eligible for Medicaid and 40 percent of whom were also black, have had a prior birth, and make percent of participants with a prior birth had a preterm birth prior to Strong Start. 21.1 As we have reported in years past, the preterm birth rates among Strong Start participants are percent vs. 9.8 percent) ; reliable slightly higher than rates observed nationally for all women (11.1 national rates of preterm birth among Medicaid participants are not available. Also, as noted in earlier in the report, several Strong Start awardees were located in the Southeastern U.S. (Mississippi, Alabama, Georgia, Tennessee, Kentucky, South Carolina, Louisiana, and Florida), where rates of preterm birth are higher than the national average. In several of these states, preterm birth rates exceed 11 percent overall, regardless of insurance coverage (Martin et al. 2018). In Mississippi and Louisiana in 2016, overall preterm birth rates were 13.7 percent and 12.6 percent respectively. reterm birth rates do vary by model and are presented in P had . Birth Center participants 16 Figure th 11.9 e lowest rate of preterm delivery (4.5 percent), while percent of Group Prenatal Care participants and 12.95 percent of Maternity Care Home participants had a preterm birth. Most preterm births among Strong Start participants occurred after 34 weeks (late preterm). These rates (7.6 percent) are only slightly higher than those reported for all women by the CDC for 2016 (7.1 percent) (Martin et al. 2018). Rates of early preterm births (20 -33 weeks) are approximately one percentage point higher for Strong Start participants than for all U.S. birth in 2016 (3.5 percent vs. 2.8 percent). Notably, these be attributed to both a differences are smaller than those we have reported in past years can , which nationally in 2016 as well as the fact that, with the complete PLPE slight increase in preterm births dataset, preterm birth rates for the Strong Start population are lower than reported in previous years when all data had not yet been submitted. BY MODEL 16: INFANT ESTIMATED GESTATIONAL AGE (EGA) AT BIRTH AMONG WOMEN WITH A LIVE BIRTH, FIGURE AND OVERALL 2.0% . LS% 1.4% 1. , 3% D more (42weeks ) Postlierm or ,  Earlrylieim , lierm, or Laterlieim ) weeks 37-41 { 1 Preterm Late  ) (34-36weeks ) Ear lry Preterm ,(20-.33weelks  ---...__ 0% 1 .. ,, I Approaches G p Prenata l Mate roo 1111ity Care AI II rth Bi Genter (111 =7, (11 , Ho me 078) =32:,740) Care ) 6,433 = (11 , = •( ) ll ,,22.9 19 Notes: Missing data are excluded from these calculations. Rates of missing for EGA by model are as follows: 0.7 percent for percent for Maternity Care Homes, and percent for Group Prenatal Care, 5.8 5.4 Birth Centers, 1 7.0 percent across all approaches. Rates of missing and not in universe by measure can also be found in Appendix H . Ns include women with a liv e birth and nonmissing data for EGA. YEAR 5 FINDINGS 63

82 Black women enrolled in Strong Start were the most likely to deliver a preterm infant (13.4 percent), but this is lower than the rate of preterm birth for all black women in the U.S. (13.8) (Martin et nationally women white . White Strong Start participants had lower rates of preterm birth than al. 2018) 6 vs. 9.0). But, rates of preterm for Hispanic women enrolled in Strong Start were in 2016 (8. overall 2 percent vs. 9.5 percent). This may considerably higher than Hispanic women in the U.S. as a whole (11. versity of Puerto Rico where 21.4 percent of Strong Start — the Uni — be driven in part by one awardee pregnancies were delivered preterm. Puerto Rican women are generally more likely to have a preterm includin — birth; the CDC reports a preterm birth rate of 11.1 percent for Puerto Rican women overall g those living on the mainland and a 2016 March of Dimes analysis of NCHS data reports 11.4 percent — of women living in Puerto Rico had a preterm birth. In addition, UPR served as the only provider in Puerto Rico for high -risk women insured through Medicaid . When we exclude UPR from our calculations , the preterm birth rate among Hispanic women in the PLPE dataset decreases to 10.3 percent, which is more in line with the national average. Infant Birthweight Strong Start participants had higher rates of low birthweight than U.S. women overall: 9.1 percent vs. ; however, when we break down rates by race and ethnicity, 8.2 percent (Martin et al. 2018) we observe that black women enrolled in Strong Start were less likely to have a low birthweight infant that black women nationally (12.5 percent vs. 13.7 percent) and rates were nearly the same for white and Hispanic women in Strong Start and the U.S. as a whole (Martin et al. 2018). Low birthweight rates for Strong Start participants who are in the other/mixed race category are 8.7 percent, and we are missing 6.2 race/ethnicity for 5.8 percent of women for whom we have birthweight information — percent of whom had a very low birthweight infant. Only 6.8 percent of Strong Start infants were born macrosomic (> 4,000g) compared with 7.9 percent of U.S. infants born in 2016 (Martin et al. 2018) . Infant birthweight by model and overall is displayed i n 17 Figure . 17: INFANT BIRTHWEIGHT AMONG WOMEN WITH A LIVE BIRTH, BY MODEL AND OVERALL FIGURE >=40:D ( Macrosomia  ), grams hW  l Birt Normal eiglt ( 2,500-3,999 grams) 1,.5CD  l...olN Birth Weight { - 2 , } grams 499 Weight Very l...olN Birth  { <1,500 grams ) 1-5% L3% LB% 0..5% . All Apprwches ca-e Milltemity h Center Gn : q::1 Prenatal ) ( n=6,3l2 ) n=32 ( 173 , ca-e =7 ,1.W } Home (FF 1&672 (n } Missing data are excluded from these calculations. Rates of missing for birth weight by model are as follows: 2.1 percent Notes: percent for Group Prenatal Care, 8. 3 for Birth Centers, 14. percent across 3 percent for Maternity Care Homes, and 8. 0 All Approaches. Rates of missing and not in universe by measure can also be found in Appendix H . Ns include women w ith a live birth and nonmissing data for birth weight. 64 YEAR 5 FINDINGS

83 Delivery Method The C -sectio n rate for Strong Start participants is substantially lower than the U.S. rate overall for 2016 throughout the Strong Start (26.9 percent vs. 31.9 percent ), consistent with trends observed evaluation. Though none of the models exceeded the national rate, the overall rate for Strong Start continues to be driven primarily by very low rates of C-section among women enrolled in Birth Center care. Fewer than 13 percent of Birth Center participants had a C-section delivery in contrast to approximately 30 percent of Group Prenatal Care participants and Maternity Care Home participants. 18. These rates are presented in Figure ELIVERY, BY MODEL AND OVERALL FIGURE 18: DELIVERY METHOD AMONG STRONG START PARTICIPANTS WITH A D . 5% 9% 2 9. 30 D C- t ion Sec  V.ag na I De li very i . roaches Gm l!J p Care ernity t Ma A pp ll A t al Care Prena Center 1l 9,46'6 ) Home ,(n= n=33,4U {n=7.497) { ) {n=6.454 ) Notes: Missing data are excluded from these calculations. Rates of missing for delivery method by model are as follows: 0.7 percent 1 percent for Maternity Care Homes, and 6. are, 5.6 percent for Group Prenatal C 0 percent for Birth Centers, 12. Appendix across All Approaches. Rates of missing and not in universe by measure can also be found in H. Ns include en with a delivery and nonmissing data for delivery method. wom similar to those for the nation as a whole, though Trends in C-section by race and ethnicity were consistently lower when considered by race/ethnicity. In the Strong Start rates of C-section remain ed are U.S. overall, black women are the most likely to have a Cesarean delivery in 2016 (35.9 percent) and also the most likely Strong Start participants to deliver by C-section (30.7 percent). Hispanic women’s rates are lower (31.7 percent nationally vs. 26.2 percent in Strong Start), and white women are the least likely to have a C . vs. 23.5 percent in Strong Start) (Martin et al. 2018) nationally -section (30.9 percent -sections Low risk C — among women with a single ton ges tation, without a prior birth, and who – were slightly lower among Strong Start participants (24.1 percent) carried their babies to term -risk C (national rates also account for -section rate of 25.7 percent, nationally compared with a low vertex presentation, which we were not able to assess for Strong Start participants; which may create higher “low risk” rates in Strong Start than we would find if we were able to eliminate breech presentations) percent), compared with . They are especially low among Birth Center participants (16.7 — which are on par Group Prenatal Care (27.7 percent) and Maternity Care Home participants (25.3) with or slightly higher than the national estimate. Vaginal Birth after Cesarean (VBAC) rates are higher among Strong Start participants than nationally . As presented in Figure 19, nearly 20 percent of women with a prior C-section enrolled in Strong Start had a VBAC compared with 12.4 percent of women with a prior C-section nationally in 2016 (Martin et al. 2018). The Strong Start rate exceeds the Healthy sing VBAC deliveries to 18.3 percent, and is especially robust (though still People 2020 goal of increa within the recommended bounds) among Birth Center participants at 29.4 percent (ACOG 2017) . YEAR 5 FINDINGS 65

84 -SECTION, BY IOR C -SECTION AMONG WOMEN WITH A PR AT C -SECTION AND REPE R C 19: VAGINAL BIRTH AFTE FIGURE MODEL AND OVERALL Repeat  n C-Sectio 78.3% 80.7% . 5% 82 na l Bi rth After  Vag i VBAC) C-Section ,( up Prenata . Approaches ll A l Care Maternity Gro Center Bi rth (n443) Care Ho ,:i j ,929 n=4 ,( l60) n=3.426) n=1 ,( ,( me Missing data are excluded from these calculations. Rates of missing or not in universe for delivery method in this Notes: Group Prenatal Care, 86.6 percent for population are as follows: 96.1 percent for Birth Centers, 88.9 percent for Maternity Care Homes . Rates of missing by measure can also be found in , and 89.0 percent for All Approaches Appendix H. N s are based on women for whom Exit Forms were submitted and had nonmissing data for these measures. LIMITATIONS The PLPE data collected for this evaluation provided a unique opportunity to conduct timely analysis of aphic characteristics, risk factors, pregnancy conditions, and birth outcomes socioeconomic and demogr among Strong Start participants. However, as with most survey data, aspects of PLPE data quality may limit the accuracy and generalizability of the results. First, PLPE forms were not submitted for all Strong Start participants. Rates of submission were quite high for Intake Forms (95 percent) and Exit Forms (98 percent). These high submission rates ere much lower for reduce concerns about potential bias due to missing forms. Form submission rates w — of all women and 70 percent of women only 60 percent the Third Trimester and Postpartum Surveys , and thus we do not discuss the measures collected from who did not exit Strong Start prior to delivery these surveys in this section. Women who did not continue the Strong Start program, who attended care irregularly or not at all in their third trimester, or who did not attend a postpartum visit are most unlikely to have completed these two forms. However, because these forms were the only so urce of information on patient satisfaction, breastfeeding, and family planning, we do present targeted analyses . Because the low submission rates almost certainly created Appendix K and Appendix J of these rates in election bias, caution should be used when interpreting these results. s econd, while rates of form submission were quite high for Intake and Exit Forms, overall rates of S missing data due to item nonresponse on submitted forms are 5.2 percent for Intake Forms and 11.6 percent for Exit Forms. Again, if item nonresponse to form questions is systematic, our results may be biased. Where possible, we have defined measures using data from multiple sources (Intake Form, Exit Form, crosswalk file) to reduce the rates of missing data. For example, our measure of prior preterm birth uses the prior preterm birth questions on both the Intake Forms and Exit Forms, so women are only missing data if they do not have a response for either of these questions. Where possible, we also responses to other questions to reduce rates of missing. For example, women with use nonmissing 66 YEAR 5 FINDINGS

85 missing data for the prior pregnancy question are coded as having had a prior pregnancy if they reported any of the following: prior live birth, prior preterm birth, date of birth for prior pregnancy, risk factors for a prior pregnancy, prior low birth weight birth, prior miscarriage, prior termination, prior stillbirth, VBAC, repeat C-section, or receipt of 17P. Although these coding decisions helped us reduce rate s of missing data, they were not possible for all measures. We report the rates of missing data for be used when interpreting measures with high rates of hould each Appendix H variable in ; caution s mi ssing data. We also note that data quality also varied by awardee (see Appendix G ) and that the data. Therefore, these results may not be results presented in this section are limited to nonmissing Volume 2 of this report also presents PLPE representative of awardees with high rates of missing data. data for each awardee in greater detail as well as a discussion of awardee data quality. Finally, our reported rates of interim and birth outcomes by model should not be interpreted as estimates of the effects of each Strong Start intervention model . As ; they are descriptive statistics only discussed above, differences in outcomes may be attributable to differences in the characteristics of women enrolled in each model type, which were often substantial, with Birth Center participants having ants generally presenting the highest risks. lower risk levels overall and Maternity Care Home particip mental health status, BMI, risk factors from prior ed Risks with differences among models includ conditions developed during the Strong Start pregnancy . There may have also been pregnancies, and Impact Analysis unobserved differences. Estimates of the effects of Strong Start are presented in the se ction later in this report. In addition, we present multivariate analyses using the PLPE data in the ection. These compare effects by model, but do not estimate Regression Ad justed Outcomes Analyses s the effects of Strong Start relative to typical prenatal care. - Despite these limitations, there are important benefits to the collection and analysis of participant level data such as the PLPE data used in this evaluation. The PLPE data have allowed us to report on the characteristics of Strong Start participants throughout the evaluation and to report data on birth outcomes as they came available. Furthermore, the collection of PLPE data provided us with consistent data on Strong Start participants across all awardees, allowing us to offer descriptive statistics on all participants and their differences across models. And lastly, because awardees could rely on patient medical records to answer Exit Form questions, the PLPE data provide more complete and reliable data on women's medical histories than is available from survey sources or what is reported on the birth Furthermore, we were able to compare PLPE reported data with the vital records data certificate. e reliability of variables used in the Impact Analysis. collected from states to assess th DISCUSSION This chapter provides a rich description of the nearly 46,000 women who participated in Strong Start, that women derived from the Participant Level Process Evaluation (PLPE) data set. These data show enrolled in Strong Start experienced a multitude of social and economic challenges, confirming similar findings from the case studies. Strong Start participants were disproportionately black (40 percent) and Hispanic (30 percent) compared with M edicaid beneficiaries overall — characteristics associated with increased risk for poor birth outcomes (e.g., preterm birth) and certain pregnancy conditions (e.g., U.S. gestational diabetes). Strong Start mothers were also less likely than pregnant women in the generally to be married and had low levels of educational attainment. Many Strong Start participants experienced everyday struggles, including food insecurity, barriers to accessing prenatal care (most commonly not having a car or money to afford a ride), and poor mental health. Nearly 28 percent of YEAR 5 FINDINGS 67

86 women screened positive for depression — a rate more than two times the highest rate typically cited in and more than 35 percent had some level of anxiety. — the literature among pregnant women In addition to h igh levels of social and emotional need, many Strong Start participants had physical for poor birth outcomes. A majority of participants were health conditions that increased their risk overweight or obese, and many had a prior preterm birth. A majority of participants reported that their pregnancies were unplanned, and almost 30 percent of women reported a short interpregnancy interval (less than 18 months) between their Strong Start pregnancy and a prior birth. Participant risk factors varied, however, across Strong Start models. For example, the racial/ethnic composition of participants was quite different across models, with a majority of Birth Center participants being white, Group Prenatal Care serving a higher proportion of Hispanic women than the oth er models, and Maternity Care Homes serving a majority of black women (though there were also substantial variations by awardee within models; se . Mothers e Volume 2 for more information) receiving care in Birth Centers were about twice as likely to be married and college educated as women enrolled in the other two models, though even among Birth Center participants, the majority were unmarried and only 15 percent had a college degree . They also reported less depression and anxiety and had lower rates of obe sity. The highest rates of obesity and mental health needs were reported by Maternity Care Home mothers , who were often served at sites such as academic medical centers designed to serve higher risk women . The number of prenatal encounters women received also varied across the models. In terms of routine prenatal care visits, Birth Center participants received the most (average of 9.3 visits), while Group Prenatal Care participants received fewer individual visits (average of 5.3). However, Group Prenatal Care participants also participated in an average of 5.7 group care visits, giving them a higher average number of total prenatal care visits . The average for group visits, however, was well short of curri CenteringPregnancy the 10 visits prescribed by the employed by most awardees. Case study culum findings suggest that Birth Center midwifery visits lasted longer than typical Maternity Care Home (30 minutes or more vs. 15 minutes or less) , as did Group Prenatal Care sessions, which were visits -hour time blocks scheduled for transformative forms , suggesting that women enrolled in these two two of prenatal care spent more time with their health providers. Maternity Care Home participants, on the other hand, had more care coordinator encounte rs (where counseling, education, and referrals occurred) and mental health encounters than participants in either of the other models. These further enlighten the case study findings that variations in types of services received confirm and the intensity of services received. identified wide variations in services provided across models and The PLPE data also provide descriptive data on birth outcomes for participants. These do not compare Strong Start rates to those of women not participating in Strong Start (as is presented later in ), but give us a general sense of the trends. Furthermore, these data are for Impact Analysis section the impact analysis was able , not just those included in the states for which the cipants parti ll Strong Start a , and so provide a more comprehensive description of Strong Start birth outcomes. to obtain data P LPE data show that the overall rate of preterm birth among Strong Start participants was 11.1 among Maternity Care Home mothers, 12.9 . T he highest rate was observed by model , varying percent percent, who descriptively possessed higher social and medical needs. Given that the PLPE data provide a rich set of risk factors which can be used to adjust for differences across models, we performed chapter. regression analyses to further explore the differences. Results are presented in the next 68 YEAR 5 FINDINGS

87 REGRESSION ADJUSTED OUTCOMES ANALYSES Descriptive findings from the PLPE data indicate that many women enrolled in Strong Start had high could affect pregnancy conditions and birth levels of need (psychosocial and medical risk) that risk - we ran outcomes. To examine how each Strong Start model might influence participant outcomes, adjusted analyses that control led for a host of participant characteristics commonly associated with and health conditions developed during pregnancy (e.g., gestational diabetes and preeclampsia) poor ontrol for birth outcomes (preterm birth, low birthweight) participant . We also were able to c characteristics not commonly available in birth certificate or claims data that may affect health , particularly social and mental health risks such as outcomes food insecurity, depression, anxiety, and intimate partner violence. Read ers should keep in mind that these regression results consider Strong Start participants only. -Strong Start) comparison group in this analysis as there is in the Impacts There is no external (non Analysis presented later in this report results do not convey the impacts of . While these regression provide an opportunity to Strong Start enhanced prenatal care compared to typical care , they do models?” examine a different research question : “D o Strong Start participant outcomes vary across evel Process Evaluation -L Descriptive analyses of the PLPE data presented in the prior Participant sect ion suggest that there are differences in the risk profiles of women enrolled in each of the three ed enroll generally . Birth Centers the healthiest group of women with the fewest demographic models , while lation and social risks Maternity Care Home awardee s enrolled a popu with more medical substantial psychosocial needs ed to be higher . Group Prenatal Care participants appear and challenges lower risk on risk than Maternity Care Home and Birth Center participants on some measures, but others. These differences when o the importance of controlling for point t participant characteristics models. comparing birth outcomes across e estimate linear probability models In this chapter, w examine the relationship between each to Maternity Care Homes as the reference category Strong Start model and participant outcomes. We use because it has the largest number of Strong (the baseline group against which comparisons are made) Start enrollees and is the most similar to typical modes of prenatal care. All analyses are risk -adjusted to demographic, psychosocial, and medical control for factors and other characteristics as listed in risk the Table . Standard errors are clustered at the Strong Start site level to account for unobserved factors 15 likely shared by all participants at a site, such as seeing the same case manager or group prenatal care facilitator . Technical details of the models and descriptive statistics for the analytic samples are Appe presented in Appendix M , and full regression results can be found in ndix N . -ADJUSTED REG TABLE 15: MEASURES INCLUDED IN RISK RESSION MODELS Demographic and Location Psychosocial Risk Medical Risk and Time Socioeconomic Race/Ethnicity Prior Preterm Birth Strong Start • • Depression • • Site Region Anxiety Age • • Prior Low Birthweight Baby • • Year of Delivery -Section Prior C • • Education • Pregnancy Intention • Relationship Status • Interpregnancy Interval • History of Intimate Employment/Education • • Pre -Pregnancy Hypertension Partner Violence Participation -Pregnancy Diabetes Pre • Food Insecurity • • BMI at First Prenatal Visit Smoked Cigarettes at Intake • YEAR 5 FINDINGS 69

88 In the remainder of this section we present results for three sets of regressions : • In the first set, we look at differences in two pregnancy conditions (gestational diabetes and ) by Strong Start model. preeclampsia differences in Strong Start birth outcomes (gestational age, • In the second set, we consider . ) by Strong Start model birthweight, and delivery method (both C -Section and VBAC In the final set participant outcomes and depression relationship between , we analyze the • among all Strong Start participants. . these analyses and are described among Methods vary slightly as follows INTERMEDIATE OUTCOMES Our analytic sample for the risk -adjusted analyses of intermediate outcomes includes 32,593 women out of Strong Start participants with PLPE data. We exclude 28 percent of our total sample 45,316 cent) or because women had multiple gestations (e.g., because these women were missing data (27 per twins, 1 percent). The steps involved in constructing the analytic sample and summary statistics for the -squ . We performed chi Appendix M sample included in the regression are detailed in are and t-tests to re the 7,678 women excluded from the analysis because of missing outcome variables or missing compa final analytic sample within each model. The participants covariates to those who remained in the , but overall, it appears they may be at greater dropped do not follow clear or consistent patterns sociodemographic and psychosocial risk but lower medical risk due to prior adverse birth outcomes 27 than women included in the analysis. < 0. 01) between the Though there are significant differences (p women included and those dropped that indicate the findings presented in these regressions may not be representative of the full sample of Strong Start participants, the regressions still provide important insights about the women for whom we have data. Additionally, we conducted pairwise statistical tests to compare means across models and observed < 0.01). Consistent with that the populations enrolled in each Strong Start model do vary significantly (p el Process Evaluation the descriptive PLPE findings presented in the prior section (Participant -Lev Find ings: A Descriptive Look at Participant Risk Profiles, Service Use and Outcomes ), Birth Center Group Prenatal Care participants were participants were disproportionately white and disproportionately Hispanic. Whereas Group Prenatal Care and Maternity Care Home awardees had articipants similar rates of black participants in the full Strong Start population, Maternity Care Home p . Birth Center participants were more likely to were disproportionately black in the regression sample and their pregnancies were more often intended be married and between 20 and 34 years of age ; ntervals than participants in the other they were more likely to have short interpregnancy i however, two models. Group Prenatal Care participants were significantly more likely to be first-time mothers than participants in the other models, were more likely than participants in the other two models to be neither working nor in school, and had the highest rates of depression, anxiety, and food insecurity. 27 We find that disproportionately fewer Birth Center participants were dropped from the sample than expected given the share of enrollees overall. Not surprisingly, women who are dropped from the sample are more likely than excluded women to have missing data for covariates. Where covariates are reported, excluded women are more likely to be younger than 20 years old and nulliparous; be black; have a high school degree; be in school; and either not be in a relationship or be living apart from t heir . Excluded women are also more likely to be depressed, have anxiety, have an unintended pregnancy, and smoke partner cigarettes. While the overall excluded sample is more likely to be black, dropped Maternity Care Home participants are more y are also less likely to be depressed or have anxiety. While the overall dropped sample had similar rates of likely to be white; the ure. food insecurity to those included in the analysis, dropped Group Prenatal Care participants were more likely to be food insec 70 YEAR 5 FINDINGS

89 Maternity Care Home participants were significantly more likely to have had a prior preterm or low birthweight birth than women enrolled in Birth Centers or Group Prenatal Care. Because of these Table 26 , we made. In can be comparisons valid -adjusted before any be risk differences, outcomes must When rates are outcomes across models. -adjusted rates of intermediate present unadjusted and risk unadjusted (meaning they describe what was found in e ach model without accounting for women's chara ristics), as with the descriptive statistics in the Participant rocess Evaluation Findings: A -Level P cte ptive Look at Participant Risk Profiles, Service Use and Outcomes section Descri , we find that Maternity e p articipants had significantly higher unadjusted rates of gestational diabetes (8 percent) Care Hom than Group Prenatal Care participants ( ) and Birth Center participants (3 percent). Maternity 6 percent Care Home and Group Prenatal Care participants had the same rates of preeclampsia ), but (6 percent both these rates were significantly higher than the Birth Center preeclampsia rate of 2 percent. 15 Table listed in risk factors characteristics and , we find that After adjusting for the observed remain significantly women enrolled in Birth Center and Group Prenatal Care models less likely to develop gestational diabetes than women in Maternity Care Homes (by 4 percentage points, p < 0. 01 and by p < 0. respectively). Women enrolled in Birth 05 Center care are also 2 percentage points significantly less likely to develop preeclampsia than Maternity Care Home participants when controlling for specified covariates (2 percentage point difference ; p < 0. 01). These findings are presented in Table 16 . , FULL SAMPLE 16: DIFFERENCES IN INT ERMEDIATE OUTCOMES BY STRONG START MODEL TABLE Maternity Care Home Group Prenatal Care Birth Center Outcome Adjusted Unadjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference Gestational 0.08 -0.02* -0.03** 0.06 ** -0.04 ** -0.05 0.03 diabetes 0.00 Preeclampsia 0.00 0.06 0.06 ** 0.02 - ** 0.04 - 0.02 Notes: N = 32,593. Differences are from Maternity Care Home model. Cells that contain a caret (^) indicate marginal significance at the 0.1 level; cells that contain one asterisk ( *) indicate significance at the 0.05 level; and cells that contain **) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full two asterisks ( . Appendix N regression results are presented in Because Medical College of South Carolina (MUSC), the University of Alabama (UAB), and the the University of Puerto Rico (UPR) serve as the primary source of prenatal care for high risk Medicaid in their area and therefore serve a disproportionately higher risk population than the beneficiaries other Strong Start awardees, w a sample excluding participants enrolled e repeat the same analysis on observe similar by these awardees. When we exclude MUSC, UAB, and UPR from our samp le, we the magnitude of the difference in gestational diabetes between Group Prenatal Care results, though and Maternity Care Home participants increases by 1 percentage point while the difference in preeclampsia between Birth Center and Maternity Care Home participants decreases by 1 percentage point. Findings for the model excluding high -risk awardees in Table 17 . YEAR 5 FINDINGS 71

90 TABLE 17: DIFFERENCES IN INTERMEDIATE OUTCOMES BY STRONG START MOD EL, EXCLUDING MUSC, UAB, AND UPR Birth Center Group Prenatal Care Maternity Care Home Outcome Unadjusted Adjusted Unadjusted Adjusted Mean Mean Mean Difference Difference Difference Difference Gestational -0.04** -0.05** 0.03 0.08 -0.03* -0.02** 0.06 diabetes 0.04 - 0.02 Preeclampsia ** - 0.01 ** 0.06 0.01 ** 0.01 0.05 Notes: N = 29,902. Differences are from Maternity Care Home model. Cells that contain a caret (^) indicate marginal *) indicate significance at the 0.05 level; and cells that contain significance at the 0.1 level; cells that contain one asterisk ( isks ( **) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full two aster regression r Appendix N . esults are presented in Differences by Race Given well -documented racial disparities in birth outcomes in the U.S., we also conducted a set of sensitivity analyses that stratify our analytic sample by race/ethnicity (Blumenshine et al. 2010). These models estimate the ri -adjusted differences in outcomes between Birth Centers and Maternity Care sk Homes and between Group Prenatal Care and Maternity Care Home models separately for different are groups of women and allow us to assess whether the patterns we observed across models consistent for 1) white women, 2) black women, 3) Hispanic women, and 4) women with other or one percent). about — multiple races (including the very small proportion of Asian Strong Start enrollees nt difference in gestational diabetes for Group Our results from this analysis show that the significa is only observed among black women, who have a 3-percentage point lower participants Prenatal Care likelihood of developing gestational diabetes than black women in the Maternity Care Home model Birth Center differences , however, are lly consistent genera through 18 Table see < 0.01; (p 25 ). Table across racial/ethnic groups. ERMEDIATE OUTCOMES BY STRONG START MODEL , WHITE WOMEN 18: DIFFERENCES IN INT TABLE Maternity Care Home Birth Center Group Prenatal Care Outcome Unadjusted Adjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference Gestational -0.01 0.07 0.03 -0.04** -0.03** 0.06 -0.01 diabetes - 0.03 ** 0.05 0.02 - 0.02 - ** 0.04 - 0.01 Preeclampsia ** 0.02 Notes: N = 8,553. Differences are from Maternity Care Home model. Cells that contain a caret (^) indicate marginal significance *) indicate significance at the 0.05 level; and cells that contain two at the 0.1 level; cells that contain one asterisk ( ** isks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full aster regressio N. n results are presented in Appendix TABLE 19: DIFFERENCES IN INT ERMEDIATE OUTCOMES BY STRONG START MODEL, WHITE WOMEN EXCLUDING MUSC, UAB, AND UPR Maternity Care Home Birth Center Group Prenatal Care Outcome Unadjusted Adjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference Gestational -0.03** -0.04** 0.07 -0.01 0.03 -0.01 0.06 diabetes 0.02 - 0.02 * 0.03 - - ** -0.01 0.04 0.03 ** Preeclampsia 0.01 N = 8,170. Differences are from Maternity Care Home model. Cells that contain a caret (^) indicate marginal significance N otes: *) indicate significance at the 0.05 level; and cells that contain two at the 0.1 level; cells that contain one asterisk ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full ** isks ( aster regressi on results are presented in Appendix N . 72 YEAR 5 FINDINGS

91 , BLACK WOMEN ERMEDIATE OUTCOMES BY STRONG START MODEL 20: DIFFERENCES IN INT TABLE Maternity Care Home Group Prenatal Care Birth Center Outcome Unadjusted Adjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference Gestational -0.03** -0.04** 0.04 -0.02** -0.05** 0.06 0.01 diabetes 0.07 0.01 ** 0.02 0.08 ** 0.02 - Preeclampsia 0.02 - 0.05 ** Notes: N = 12,354. Differences are from Maternity Care Home model. Cells that contain a caret (^) indicate marginal *) indicate significance at the 0.05 level; and cells that contain significance at the 0.1 level; cells that contain one asterisk ( **) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full isks ( two aster regression resu . Appendix N lts are presented in TABLE 21: DIFFERENCES IN INT ERMEDIATE OUTCOMES BY STRONG START MODEL, BLACK WOMEN EXCLUDING MUSC, UAB, AND UPR Maternity Care Home Group Prenatal Care Birth Center Outcome Adjusted Unadjusted Unadjusted Adjusted Mean Mean Mean Difference Difference Difference Difference Gestational -0.02** 0.04 -0.04** -0.03** -0.05** 0.01 0.06 diabetes Preeclampsia 0.02 - 0.04 ** - 0.02 * 0.08 0.03 ** 0.02 0.06 Notes: N = 10,947. Differences are from Maternity Care Home model. Cells that contain a caret (^) indicate marginal *) indicate significance at the 0.05 level; and cells that contain significance at the 0.1 level; cells that contain one asterisk ( **) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full sks ( two asteri regression resu lts are presented in . Appendix N TABLE 22: DIFFERENCES IN INT ERMEDIATE OUTCOMES BY STRONG START MODEL , HISPANIC WOMEN Maternity Care Home Birth Center Group Prenatal Care Outcome Adjusted Unadjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference Gestational 0.00 -0.04** 0.09 -0.02** -0.07** 0.11 0.04 diabetes - 0.01 * 0.05 0.00 0.00 0.05 Preeclampsia 0.02 - 0.04 ** Notes: N = 10,194. Differences are from Maternity Care Home model. Cells that contain a caret (^) indicate marginal *) indicate significance at the 0.05 level; and cells that contain significance at the 0.1 level; cells that contain one asterisk ( sks ( **) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full two asteri regression resu lts are presented in . Appendix N 23: DIFFERENCES IN INT TABLE LUDING MUSC, , HISPANIC WOMEN EXC ERMEDIATE OUTCOMES BY STRONG START MODEL UAB, AND UPR Birth Center Group Prenatal Care Maternity Care Home Outcome Adjusted Adjusted Unadjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference Gestational 0.08 -0.02** 0.00 -0.03** 0.11 -0.07** 0.04 diabetes Preeclampsia 0.02 - 0.04 ** - 0.01 * 0.05 0.00 0.03 ^ 0.05 ^) indicate marginal significance N = 9,307. Differences are from Maternity Care Home model. Cells that contain a caret ( Notes: ) indicate significance at the 0.05 level; and cells that contain two level; cells that contain one asterisk (* at the 0.1 asterisks ( ** ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full regression resu lts are presented in Appendix N . YEAR 5 FINDINGS 73

92 TABLE 24: DIFFERENCES IN INT ERMEDIATE OUTCOMES BY STRONG START MODEL, OTHER WOMEN Birth Center Group Prenatal Care Maternity Care Home Outcome Adjusted Unadjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference Gestational -0.01 0.11 -0.06** -0.08** 0.03 0.07 -0.5* diabetes 0.00 Preeclampsia 0.02 - 0.03 * 0.04 - 0.01 - 0.02 0.05 Notes: N = 1,492. Differences are from Maternity Care Home model. Cells that contain a caret ( ^) indicate marginal significance at t he 0.1 level; cells that contain one asterisk ( *) indicat e significance at the 0.05 level; and cells that contain two ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full (** asterisks regression N. Appendix results are presented in TABLE ERMEDIATE OUTCOMES BY STRONG START MODEL, OTHER WOMEN EXCLUDING MUSC, 25: DIFFERENCES IN INT UAB, AND UPR Maternity Care Home Group Prenatal Care Birth Center Outcome Adjusted Unadjusted Unadjusted Adjusted Mean Mean Mean Difference Difference Difference Difference Gestational 0.03 -0.06** -0.08** 0.07 -0.05** -0.02 0.11 diabetes Preeclampsia 0.05 0.02 - 0.03 * 0.0 0.04 - 0.01 - 0.02 ^) indicate marginal significance N = 1,478. Differences are from Maternity Care Home model. Cells that contain a caret ( Notes: e significance at the 0.05 level; and cells that contain two he 0.1 level; cells that contain one asterisk ( at t *) indicat asterisks ( ** ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full . regression results are presented in Appendix N BIRTH OUTCOMES M ore women are missing data for the birth outcomes variables than the intermediate outcome , and thus variables Strong Start -45,316 the 28,332 women out of the analytic sample is smaller with participants with PLPE data. We exclude 3 7 percent of our total sample because these women were 6 percent ) or because women had multiple gestations (e.g., twins , 1 missing large amounts of data (3 ). The steps involved in constructing the analytic sample and summary statistics for the sample percent Appendix M . As with the intermediate outcomes sample, w e included in the regression are detailed in because of -square and t hi -tests to compare the 11,327 women excluded from the analysis ed c perform missing outcome variables or missing covariates to those who remained in the final analytic sample and again find that the dropped participants do not follow clear or consistent within each model pat terns but, overall, may be at greater sociodemographic and psychosocial risk but lower medical risk 28 due to prior adverse birth outcomes than women included in the analysis . We again conducted pairwise statistical tests to compare means across models and , despite dropping more women from the similar patterns to those described in the . section Intermediate Outcomes sample, observed 28 We find that slightly more Maternity Care Home participants are dropped from the sample than expected given the share of the enrollees overall, while disproportionately fewer Birth Center participants were dropped. Not surprisingly, women who are from the sample are more likely than excluded women to have missing data for covariates. Where covariates are dropped reported, excluded women are more likely to be 18 or 19 years old and nulliparous; less likely to be white, married, working, or in school; and more likely to be food insecure, to smoke, to have experienced intimate partner violence, to be depressed, and to have anxiety. While the overall dropped sample is less likely to be white, dropped Group Prenatal Care participants are less likely to be Hispan ic. Differences in education also vary by model, with dropped Birth Center participants reporting lower educational attainment than included women. Dropped Maternity Care Home participants appear to have higher educational attainment than included women. 74 YEAR 5 FINDINGS

93 , we present unadjusted and risk ted rates of birth outcomes across models. When -adjus 26 Table In rates are u 01) < 0. (p nadjusted, we find that Maternity Care Home participants had significantly higher unadjusted rates of preterm birth (13 percent) and low birthweight (11 percent) than Group Prenatal Care participants (11 percent and 10 percent, respectively) and Birth Center participants (4 percent for both preterm and low birthweight). Maternity Care Home and Group Prenatal Care participants had -section (31 percent and 30 percent, respectively), but both these rates were similar rates of C significantly higher than the Birth Center C-section rate of 13 percent. -adjus After tes specified in Table 15 , the risk covaria risks and other we control for ted differences that Birth Center participants are significantly less likely to have a preterm birth (a show 5- continue to < 0. per centage point lower rate than Maternity Care Home participants, p 01) , consistent with findings in evaluation reports (Hill et al. 2018). Birth Center participants are also less likely in prior Strong Start (4-percentage point difference, a low birthweight infant than Maternity Care Home enrollees to deliver and are less likely to have a Cesarean delivery than Maternity Care Home participants 01) p < 0. (7 29 difference, p < 0. percentage point 01) . e no In contrast to prior Strong Start annual reports, w longer observe significant differences between Group Prenatal Care participants and Maternity Care Home now that the participant level data set is complete . participants TH OUTCOMES BY STRONG START MODEL, 26: DIFFERENCES IN BIR TABLE FULL SAMPLE Group Prenatal Care Birth Center Maternity Care Home Outcome Unadjusted Adjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference - Preterm birth 0.04 - 0.08 ** - 0.05 ** 0.11 0.13 0.01 ** - 0.02 0.04 Low birth weight - ^ 0.01 - 0.11 0.01 0.10 ** 0.04 - ** 0.07 - 0.00 0.30 0.07 0.31 0.00 C - Section 0.13 - 0.18 ** - ** 1 0.29 VBAC 0.17 0.02 ** 0.04 0.21 * 0.10 ** 0.13 N = 28,332. Differences are from Maternity Care Home model. Cells that contain a caret ( Notes: ^) indicate marginal *) indicate significance at the 0.05 level; and cells that contain significance at the 0.1 level; cells that contain one asterisk ( **) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full two asterisks ( . Appendix N regression results are presented in 1 -Section, N=4,141 VBAC sample is limited to women with a prior C a sample excluding participants enrolled by the three e repeat the same analysis on Again, w awardees that served as the primary source of care for women with high risk pregnancies in their areas (MUSC, UAB, and UPR). When we exclude participants enrolled by these awardees, the adjusted difference between Birth Center and Maternity Care Home participants remains generally consistent our full sample with analysis, although both preterm birth and low birth weight estimates decrease by 1 serve that ob ). In contrast to the full sample analysis, however, we do percentage point (see Table 27 renatal Care participants have significantly lower rates of preterm birth and low birthweight Group P (each by 2 percentage points 01, respectively) than Maternity Care Home participants ; p<.05 and p < 0. . when MUSC, UAB and UPR participants are excluded 29 -section between Birth Center When we limit the C -section model to women without a prior birth, the difference in rate of C and Maternity Care Home participants increases to 9 percentage points (data not shown). YEAR 5 FINDINGS 75

94 TABLE 27: DIFFERENCES IN BIR TH OUTCOMES BY STRONG START MODEL, EXCLUDING MUSC, UAB, AND UPR Birth Center Group Prenatal Care Maternity Care Home Outcome Adjusted Unadjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference 0.07 ** - 0.04 Preterm birth 0.12 * 0.02 - ** 0.02 - ** 0.04 - 0.10 ** 0.03 - ** 0.06 0.04 Low birth weight 0.10 ** 0.02 - * 0.01 - 0.19 - ** 0.18 - 0.13 C-Section ** -0.02 0.03 - 0.28 ** 0.07 - 0.30 1 0.17 0.29 0.05 0.06** 0.22 0.13** 0.10* VBAC N = 25,792. Differences are from Maternity Care Home model. Cells that contain a caret ( Notes: ^) indicate marginal nce at the 0.1 level; cells that contain one asterisk ( *) indicate significance at the 0.05 level; and cells that contain significa two isks ( **) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full aster regression results are presented in . Appendix N 1 VBAC sample is limited to women with a prior C -Section, N=3,586 the full and limited samples and for both Birth Center and Group Prenatal Care models, For both reases the magnitude of the differences in outcomes from Maternity Care Home participants dec after adjusting for participant characteristics, considerably differences for the Group Prenatal Care and . The change after controls are introduced indicates that some of the model are no longer significant unadjusted difference between these groups is attributable to differences in women's observable characteristics across models, which put Birth Center (and in some cases, Group Prenatal Care participants) at lower risk of poor birth outcomes than Maternity Care Home participants. Still, after vable risk factors are controlled for, Birth Center participants remain significantly less likely to obser experience poor outcomes in both samples, and Group Prenatal Care participants are significantly less t when high -risk sites are excluded from likely to experience preterm birth or low birth weigh analysis. the (N Considering only the sample of women with a prior C-section and a current singleton pregnancy 30 = 4,141), we look at rates of vaginal birth after C-section (VBAC). The unadjusted rates of VBAC in is sample, by model, are 29 percent for Birth Center participants, 21 percent for Group Prenatal Care th participants, and 17 percent for Maternity Care Home participants (all significantly different from one another, see Appendix M ). After controls are included in the model, we find that Birth Center — participants remain significantly more likely to have a VBAC than Maternity Care Home participants 31 by 10 ). 26 Table (see 05) < 0. -percentage points (p The rate for Group Prenatal Care participants is not significantly different. Results do not change when we exclude MUSC, UAB, and UPR from the sample (see Table 27). Differences by Race As with our analysis of intermediate outcomes, we repeat these analyses stratifying by race/ethnicity to consider whether there are differences by model for women within each race/ethnicity category. Consistent with our main findings, unadjusted rates of preterm birth, low birthweight, and C-section are lower for Birth Center participants of all racial/ethnic categories than women of the same for ifferences between race/ethnicity who participated in Group Prenatal Care or Maternity Care Homes. D Group Prenatal Care and Maternity Care Home participants are more limited but do vary by race. 30 Women with a prior C- s those who were reported to have a VBAC or repeat C-section. section are defined a 31 The overall VBAC rate among Strong Start participants enrolled in Birth Centers substantially surpasses Healthy People 2020 goals. It should be noted that these goals are not set at top thresholds but are progressive goals that are set at thresholds thought -year period. The American College of Obstetricians and Gynecologists states that most women with a to be attainable over a 10 prior low -transverse cesarean are good candidates for attempted VBAC (see AGOG practice bulletin #184). 76 YEAR 5 FINDINGS

95 After adjusting for risk, we continue to see significant differences in these outcomes between Birth Center and Maternity Care Home participants, and th e size of these differences again varies by race/ethnicity. When comparing Group Prenatal Care participants and Maternity Care Home participants we find fewer significant differences after adjusting for risk, but significant differences by remain (see 35 Table through 28 Table ). /ethnicity race 28: DIFFERENCES IN BIRTH OUTCOMES BY STRONG START TABLE MODEL, WHITE WOMEN Group Prenatal Care Birth Center Maternity Care Home Outcome Adjusted Unadjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference ** - 0.04 Preterm birth 0.11 ** 0.05 - * 0.03 - 0.09 ** 0.06 - 0.08 ** 0.04 - ** 0.06 - 0.03 Low birth weight 0.09 ^ 0.02 - 0.01 - 0.08 0.31 0.10 - 0.20 ** - 0.08 ** C-Section 0.31 0.01 0.03 ) indicate marginal significance N = 7,453. Differences are from Maternity Care Home model. Cells that contain a caret (^ Notes: 0.1 level; cells that contain one asterisk (* ) indicate significance at the 0.05 level; and cells that contain two at the asterisks ( ** ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full regressio n results are presented in . Appendix N TABLE ODEL, WHITE WOMEN EXCLUDING MUSC, UAB, TH OUTCOMES BY STRON G START M 29: DIFFERENCES IN BIR UPR AND Maternity Care Home Group Prenatal Care Birth Center Outcome Adjusted Unadjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference -0.04** -0.06** 0.04 Preterm birth 0.10 -0.05** 0.09 -0.02 -0.03** -0.05** 0.03 Low birth weight 0.08 - 0.00 0.01 0.08 0.20 ** 0.08 - ** - 0.10 Section - C 0.31 0.01 0.03 0.30 Notes: N = 7,067. Differences are from Maternity Care Home model. Cells that contain a caret ( ) indicate marginal significance ^ te significance at the 0.05 level; and cells that contain two *) indica the 0.1 level; cells that contain one asterisk ( at ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full ** sks ( asteri regressio Appendix N n results are presented in . WOMEN TABLE 30: DIFFERENCES IN BIR TH OUTCOMES BY STRONG START MODEL, BLACK Birth Center Maternity Care Home Group Prenatal Care Outcome Unadjusted Adjusted Unadjusted Adjusted Mean Mean Mean Difference Difference Difference Difference 0.14 Preterm birth 0.05 - 0.08 ** - 0.05 ** 0.12 - 0.02 * - 0.02 * 0.13 0.11 - 0.02 ** - 0.03 - 0.05 ** Low birth weight 0.06 - 0.08 ** 0.18 Section - C - ** - 0.05 ** 0.30 - 0.02 0.14 * - 0.03 0.32 ) indicate marginal N = 11,043. Differences are from Maternity Care Home model. Cells that contain a caret ( Notes: ^ signif te significance at the 0.05 level; and cells that contain *) indica icance at the 0.1 level; cells that contain one asterisk ( **) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full sterisks ( two a regressio N. Appendix n results are presented in TABLE TH OUTCOMES BY STRONG START MODEL, BLACK WOMEN EXCLUDING MUS C, UAB, 31: DIFFERENCES IN BIR AND UPR Birth Center Group Prenatal Care Maternity Care Home Outcome Unadjusted Adjusted Unadjusted Adjusted Mean Mean Mean Difference Difference Difference Difference -0.01 ** 0.04 - 0.12 ** 0.13 -0.01 0.07 - 0.05 Preterm birth ^ 0.12 -0.02* Low birth weight 0.06 -0.06** -0.04** 0.11 -0.01 0.33 C - Section 0.18 - 0.14 ** - 0.06 ** 0.30 - 0.03 * - 0.03 * ^) indicate marginal significance Notes: N = 9,673. Differences are from Maternity Care Home model. Cells that contain a caret ( ) indicate significance at the 0.05 level; and cells that contain two at the 0.1 level; cells that contain one asterisk (* ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full ** asterisks ( n results are presented in Appendix N . regressio YEAR 5 FINDINGS 77

96 TABLE 32: DIFFERENCES IN BIR TH OUTCOMES BY STRON G START MODEL, HISPA NIC WOMEN Birth Center Group Prenatal Care Maternity Care Home Outcome Unadjusted Adjusted Adjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference Preterm birth 0.05 - 0.07 ** - 0.05 ** 0.11 - 0.01 0.00 0.12 ^ 0.04 0.02 ** 0.09 0.01 - 0.02 0.08 ** 0.04 - Low birth weight ** C-Section 0.13 - 0.14 ** - 0.04 * 0.31 0.03 0.27 0.04 tes: N = 8,619. Differences are from Maternity Care Home model. Cells that contain a caret ( ^) indicate marginal significance No at t he 0.1 level; cells that contain one asterisk (* ) indicate significance at the 0.05 level; and cells that contain two asterisks ( ** ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full on results are presented in . Appendix N regressi 33: DIFFERENCES IN BIR TH OUTCOMES BY STRON G START MODEL, HISPA NIC WOMEN EXCLUDING MUSC, UAB, TABLE UPR AND Birth Center Maternity Care Home Group Prenatal Care Outcome Unadjusted Adjusted Unadjusted Adjusted Mean Mean Mean Difference Difference Difference Difference Preterm birth 0.05 ** - 0.07 ** - 0.05 ** 0.07 - ** - 0.04 0.05 0.12 - Low birth weight 0.04 - 0.04 ** - 0.02 ** 0.05 - 0.02 ** 0.08 * 0.02 - C Section 0.13 - 0.14 ** - 0.05 * 0.24 - 0.03 ** - 0.01 0.27 ^) indicate marginal significance N = 7,849. Differences are from Maternity Care Home model. Cells that contain a caret ( Notes: at t ) indicate significance at the 0.05 level; and cells that contain two he 0.1 level; cells that contain one asterisk (* ** asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full on results are presented in . Appendix N regressi -ETHNICITY 34: DIFFERENCES IN BIR TH OUTCOMES BY STRONG START MODEL, WOMEN OF OTHER RACE TABLE Maternity Care Home Birth Center Group Prenatal Care Outcome Adjusted Adjusted Unadjusted Unadjusted Mean Mean Mean Difference Difference Difference Difference - * 0.04 - 0.05 Preterm birth 0.09 0.02 0.01 0.10 0.02 ^ Low birth weight - 0.06 ** - 0.03 0.13 0.04 0.03 0.04 0.09 0.26 ^ 0.04 ** 0.15 - 0.16 Section - C - 0.31 0.02 - 0.05 - Notes: ^) indicate marginal significance N = 1,217. Differences are from Maternity Care Home model. Cells that contain a caret ( at t he 0.1 level; cells that contain one asterisk (* ) indicate significance at the 0.05 level; and cells that contain two asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full ** regressi Appendix N . on results are presented in -ETHNICITY EXCLUDING OTHER RACE OF TABLE 35: DIFFERENCES IN BIR TH OUTCOMES BY STRONG START MODEL, WOMEN MUSC, UAB, AND UPR Birth Center Group Prenatal Care Maternity Care Home Outcome Unadjusted Adjusted Unadjusted Adjusted Mean Mean Mean Difference Difference Difference Difference 0.05 Preterm birth -0.02 * 0.04 0.09 0.02 01 0. 0.10 - -0.02 -0.06** 0.03 Low birth weight 0.09 0.04 0.04* 0.13 0.26 - 0.05 - 0.02 0.31 Section C 0.16 -0.15** -0.05^ - Notes: N = 1,203. Differences are from Maternity Care Home model. Cells that contain a caret ( ^) indicate marginal significance ) indicate significance at the 0.05 level; and cells that contain two he 0.1 level; cells that contain one asterisk (* at t asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full ** regressi . Appendix N on results are presented in White, black, and Hispanic women who participated in Birth Centers were all between 5 and 6 percentage points less likely to have a preterm birth than Maternity Care Home participants (p < 0. 01) . For Group Prenatal Care, however, only white women are in risk -adjusted regression analyses -risk awardees, the significantly less likely to have experienced a preterm birth. After excluding high decreased slightly. With the limited sample (excluding high risk awardees), risk -adjusted differences white, black and Hispanic Birth Center participants continued to have lower rates of preterm birth. In YEAR 5 FINDINGS 78

97 addition, with this limited sample we observe that both white and Hispanic participants enrolled in Group Prenatal Care experienced significantly lower rates of preterm birth, but black women did not. Race -specific analyses of low birthweight, on the other hand, reveal more variation. For example, while we found an overall differen ce of 4 percentage points in low birthweight between Birth Center -specific models, we observe and Maternity Care Home participants, when looking at the race < 0. differences are largest for black women (5 percentage points, p 01), followed by white women (4 01 < 0. 01). Additionally, < 0. , p ) and then Hispanic women (2 percentage points percentage points, p while we did not find an overall difference between Group Prenatal Care and Maternity Care Homes, < 0. (3 percentage points lower, p in low birthweight we do observe a significant difference 05) for black women. We also observe significant differences for black and Hispanic women when we exclude high- groups risk awardees (2 percentage points lower for both , p < 0. 05). ction we observe in the overall models between Birth -percentage point lower rate of C-se The 7 Center participants compared to Maternity Care home participants is largest among white women (8 percentage points, p <.01 ). Race -specific models reveal smaller effects for black women (5 percentage women (4 percentage points ) and Hispanic , p <.01 ts poin , p <.05) enrolled in Birth Center care Though we did not find an overall compared with the same groups enrolled in Maternity Care Homes. ternity Care Homes, when difference in rates of C-section between Group Prenatal Care and Ma a 3-percentage -risk awardees are excluded from the analyses, results reveal high point lower rate of C-section for black women in Group Prenatal Care . We do not observe differences for women < 0. (p 05) of other races. DEPRESSION ven the high rates of depression among the Strong Start population (reported in the Gi el -Lev Participant Proc ess Evaluation Findings: A Descriptive Look at Participant Risk Profiles, Service Use and Outcomes indications that depression is associated with a multitude of poor birth as noted earlier, section), and outcomes, including preterm birth and low birth weight, we conducted a series of bivariate and h preterm multivariate analyses to examine whether positive depression screening is associated wit birth, low birthweight, C-section deliveries, and postpartum breastfeeding initiation among all Strong Start participants. The analytic sample construction for these analyses (N = 23,980) differs slightly from . Due to missing data on depression (11 the models specified previously and is presented in Appendix M nt) than is analysis ) of Strong Start participants are excluded from th 47 percent , a larger share ( pe rce e again W -square and t-tests to compare the performed chi from the other two analyses. 21,447 women missing outcome variables or missing covariates because of to those who excluded from the analysis do not follow clear or sample participants remained in the final analytic dropped and again find that the -adjusted analyses may be at consistent patterns. Overall the women who were excluded from the risk greater sociodemographic and psychosocial risk than those included in the analysis , but they are also less likely to be high risk due to prior adverse birth outcomes nonmissing, ; when outcome variables are 32 they are worse than for the women included in the analytic sample. We conducted pairwise statistical 32 share We find that disproportionately fewer Birth Center participants were dropped from the sample than expected given the of the enrollees overall. Not surprisingly, women who are dropped from the sample are more likely than excluded women to have missing data for covariates. Where covariates are reported, excluded women are more likely to be black, less than 20 years old YEAR 5 FINDINGS 79

98 tests to compare means between women with and without depression and find that, overall, depressed women have higher risk of poor outcomes due to demographic characteristics, risk factors from prior 33 births, and risk factors from their current pregnancy. When comparing unadjusted differences, we find significant and positive relationships between depression and the likelihood of having a preterm birth, a low birthweight infant, and a C-section see ). We also find that depression is associated with being less likely to p < 0. delivery ( 01, 36 Table Table 15) initiate breastfeeding. However, after controlling for risk factors (specified in , the only nt di fference is that depression is associated with a one percentage point higher rate of preterm significa we observe a weaker association between depression and poor birth ). That 05, see Table < 0. (p birth 36 er adjusting for risk is not surprising. D epression is highly correlated with participant outcome s aft characteristics — including hist ory of IPV, food insecurity, controlled for in the regression models relationship status, pregnancy intention, among others. We again conducted analyses stratified by race/ethnicity and, after adjusting for the specified covariates, found only a one percentage point higher , and no other the analysis limited to black women rate of preterm birth among depressed women for 34 . differences for the other models TABLE 36: DIFFERENCES IN BIR TH OUTCOMES BY DEPRESSION STATUS, FULL SAMPLE Not Depressed Depressed Outcome Mean Mean Unadjusted Difference Adjusted Difference 0.13 Preterm birth ** 0.10 * 0.01 0.03 ------------- Low birth weight 0.02 ** 0.01 0.11 0.08 - C Section ** 0.03 0.29 0.00 0.26 1 0.04 0.00 0.82 ** - 0.78 Postpartum breastfeeding initiation Notes: N = 23,980. Differences are from Maternity Care Home model. Cells that contain one asterisk ( *) indicate significance at el; cells that contain two asterisks (**) indicate significance at the 0.05 level; and cells that contain three the 0.1 lev asterisks ( *** ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. Full regression resu Appendix N . lts are presented in 1 Postpartum breastfeeding initiation sample is further limited to women with a postpartum survey, N=16,428 LIMITATIONS These regression analyses do not tell us how Strong Start women fare compared with similar women not enrolled in Strong Start who received typical prenatal care through Medicaid; estimates of the impacts of Strong Start were presented in the Impact Analysis section of this report. Though these -enrolled women as a whole as the impacts are, it is still useful ot generalizable to Medicaid resul ts are n to understand how outcomes differ among Strong Start participants depending on their characteristics and the type of enhanced prenatal care they received. As noted above, t he analytic sample for these analyses excludes 28 percent of Strong Start participants in the intermediate outcomes models, 37 percent in the birth outcomes models, and 47 percent in the depression models. Further, where data are available, there is evidence that the excluded women may differ on some factors from those included in the sample, which mean s that the results and nulliparous; less likely to be married or working; and more likely to be food insecure, to smoke, to have experienced intimate partner violence, and to have an unintended pregnancy. 33 Depressed women are more likely to be black, have a high school degree or less education, to not be in a relationship, to not be working or in school, to be food insecure, to have an unintended pregnancy, to smoke, to have experienced intimate partner violence, to be overweight or obese, and to have had a prior poor birth outcome birth. 34 We also ran these analyses stratifying by model and only find marginally significant effects of 0.01 for MCH model women for . This could be attributable to the fact MCH also has 3 times the sample size of the other models. preterm birth 80 YEAR 5 FINDINGS

99 presented here may not be generalizable to Strong Start participants who were excluded from the have significant birth outcome analytic sample because of missing data. If the excluded women by model, the differences reported above may be biased. For example, if excluded Birth differences Center participants are more likely to have a poor birth outcome than those included in the analysis, while excluded Maternity Care Home participants are less likely to have a poor birth outcome than thos e included in the analysis, we may have overstated the differences in outcomes between these two Another consideration is that the rate of exclusion from the analytic sample varies by awardee, models. with between 28 percent and 88 percent of each awardee' s participants excluded. This may further bias our results if awardees with particularly good outcomes or particularly poor outcomes are more likely to be missing from the analysis and limit the generalizability of the findings to all Strong Start women. Each awardee’s data quality is discussed further in Volume 2. Finally, though we account for observable differences in risk by including a variety of controls in our , which is of particular concern if unobserved models, our findings are subject to omitted variable bias characteristics that are associated with our outcomes of interest vary systematically by model. These concerns, particularly selection bias in Group Prenatal Care awardees (where women were sometimes d care) and in the UAB and MUSC Maternity Care Home allowed to choose between group and standar awardees (which disproportionately served their states’ highest risk women), are described in detail in the Impact Analysis section. To address concerns about selection bias for our h igh -risk awardees, them analyses excluding separate , we conducted SC, UAB, and UPR . MU Although the differences in birth outcomes between Birth Center and Maternity Care Home participants decrease when we control for risk factors, Birth Center participants may be at lower risk — reasons that may for these outcomes for other reasons that we could not control for in our analysis also lead them to choose Birth Center care in the first place. If this is the case, differences observed to the models between models may be attributable to such unobserved characteristics rather than themselves. DISCUSSION results provided in the previous As noted in both the case study findings and the descriptive PLPE medical and emotional risk factors vary substantially across the three chapters, demographic, social, Strong Start models. Consequently, it is critical to take these variations into account when comparing -adjusted outcomes, using the rich birth outcomes across models. This chapter provided regression inclusive of awardees for and array of control variables available in the PLPE data for all awardees, the case studies showed that Maternity Care Homes which we do not have impact findings. Because provided services that were closer to typical Medicaid maternity care than the other two models, the regressions used Maternity Care Home women as the reference group. We ran analyses in two ways: 1) ng in Strong Start; and 2) excluding three awardees that served an including all awardees participati population (Medical College of South Carolina, University of Alabama, and -risk high extremely University of Puerto Rico), as including these mothers likely overstates the differences betwee n models. After adjusting for a range of risk factors, Birth Center participants continued to have significantly lower rates of preterm birth and low birthweight, suggesting that the midwifery model of care with additional peer counseling was likely more effective than care in Maternity Care Homes for preventing YEAR 5 FINDINGS 81

100 these outcomes. In addition, we observed large and significant effects on C-Section and Vaginal Birth After C-Section (VBAC) rates among Birth Center participants compared to women enrolled in nity Care Homes, even after controlling for risk. These results suggest that Birth Center care may Mater offer important lessons when tackling the national goal of reducing C-section rates (both primary and . repeat), which have skyrocketed in recent decades, while VBAC rates have sharply declined The differences observed between Group Prenatal Care and Maternity Care Home participants after controlling for observable risk factors are more modest. Group Prenatal Care participants did not -Section, and the differences in preterm delivery and low birth weight, have significantly lower rates of C while significant, were smaller than for Birth Centers and only observed in the limited sample (when awardees serving especially high -risk participants were excluded). Further examination of regression results by race and ethnicity revealed that the differences between Birth Centers and Maternity Care Homes were generally consistent across all outcomes, but with some variation in the size of the difference among racial and ethnic groups. However, in the case of Group Prenatal Care, we observed especially strong results among black and Hispanic women enrolled in the model compared with black and Hispanic women who received Maternity Care Home services, suggesting the features of Group Prenatal Care (including enhanced education, social support, self- efficacy, etc.) may be important ingredients in improving birth outcomes among minority women. The case study and PLPE results described the context in which Strong Start programs oper ated and the type of services they provided. Birth Centers provided a very different model of prenatal care was consistently provided by Holistic, individualized care than that provided in Maternity Care Homes. midwifery , and ies interventionist technolog ospitals and midwives in settings that were removed from h care was to bolster Birth Centers’ capacity to address the psychosocial enriched by peer counseling needs of pregnant Medicaid beneficiaries. These results suggest that Birth Centers succeeded more than Maternity Care Homes in achieving the outcomes that Strong Start aspired to. This was also true, but to a lesser extent, for Group Prenatal care awardees, though minority women appeared to ally benefit from care provided in a group setting. However, case study results and PLPE data especi show that the three models served very different populations, and it is possible that the comparisons were biased by selection into the different models of care. The impact analysis presented in the subsequent chapter used more rigorous econometric methods to attempt to adjust for selection bias, and compared Strong Start enrollees from all three models to Medicaid women who were not served by Strong Start. YEAR 5 FINDINGS 82

101 NICAL ASSISTANCE AND DATA ACQUISITION TECH INTRODUCTION The objective of the State Data Linkage Technical Assistance (TA) task of the Strong Start evaluation was to obtain linked birth certificate, Medicaid eligibility, and Medicaid claims and encounter data from states with Strong Start awardees. The data were used to support the impact analysis component of the evaluation, which assessed whether and to what extent Strong Start had an impact on birth outcomes and Medicaid costs through pregnancy and the first year after birth. The TA task was designed to “meet states where they are,” either by facilitating the transmission of these data to the Urban Institute so that they could be linked, or by assisting states as needed to conduct the data linkage themselves. Building on the progress made in prior years, during Year 5 of the Strong Start evaluation we continued to (1) nurture relationships with state officials in agencies responsible for Vital Records and Medicaid data; (2) complete, update or renew the various applications and agreements needed to secure approval to obtain the data, including progress reports to maintain data use agreements and IRB approval; and (3) facilitate the transfer of data from state agencies to Urban. AND RECEIPT SUMMARY OF PROGRESS: DATA APPROVAL 35 under Strong Start, and thus could not CMMI did not contract with states or state Medicaid agencies compel state officials to share their data with the evaluation. Still, states were overall quite supportive of the Strong Start evaluation and were willing to share data for the Impact Analysis. This positive response suggested that states were interested in participating in an evaluation that intended to examine the impacts of strategies to improve maternal and infant health outcomes. of Year 5, we had worked with both the Medicaid and Vital Records agencies in the 20 By the end states that we initially judged to have sufficient Strong Start enrollment to support a rigorous impact analysis and to merit the large investment in time and resources needed to obtain the necessary data. Ultimately, the technical assistance team received birth certificate, Medicaid eligibility, and claims data from nine states: Alabama, Arizona, District of Columbia, Florida, Louisiana, Missouri, New Jersey, In four states the Maryland, Mississippi, Nevada and Pennsylvania — — South Carolina, and Tennessee. evaluation team received birth certificates and Medicaid eligibility data, but not claims/encounter data, usually either because of time lags that occurred during negotiations surrounding the data acquisition process or because original data requests were too burdensome for the states. In two states – Georgia – we received requested data, but problems with the samples meant that we were unable and Michigan to include them in our impact analysis. Despite efforts to modify our data requests to ease burden on states, we were not able to collect any data in five states: California, Kentucky, Illinois, Texas, and Virginia. Finally, we pursued (though ultimately did not obtain) data from the Children’s Health Insurance Programs in two states, Tennessee and Texas, the only states that had large numbers of Strong Start enrollees insured through that program. 35 tate Medicaid program. The only exception was the award to the Oklahoma Healthcare Authority, which administers the s Given low enrollment in this award, however, the evaluation did not seek to obtain data from Oklahoma. YEAR 5 FINDINGS 83

102 Table 37 displays these states into the four groups defined as follows: • Group 1 : States from which all data were received, meaning that 2014, 2015, and 2016 birth /encounter data certificate data and Medicaid eligibility, and 2014 and 2015 Medicaid claims 36 were submitted to the Urban Institute for analysis. We obtained all data from Vital Records and Medicaid agencies in nine states: Alabama, Arizona, District of Columbia, Florida, ee. Louisiana, Missouri, New Jersey, South Carolina, and Tenness Group 2 : States from which all data were received (birth certificates, eligibility, and claims), but • 37 we could not analyze the data due to sample problems. This applies to Georgia and Michigan. : States from which we did not receive claims data, meaning that ONLY 2014, 2015, • Group 3 and 2016 birth certificate and Medicaid eligibility data were submitted to Urban for analysis. This applies to: Maryland, Mississippi, Nevada, and Pennsylvania. h we did not receive any data: California, Illinois, Kentucky, Texas, • : States from whic Group 4 and Virginia. also indicates that Urban performed the data linkage in five states, while state officials (or Table 37 a contractor to the state) did so in 12 states. Urban performed the linkage in Alabama, the District of Columbia, Florida, and Nevada. State officials performed the linkage in Louisiana, Missouri, Mississippi, New Jersey, Pennsylvania, South Carolina, and Tennessee. State contractors performed the linkage in Arizona and Maryland. TABLE 37: STATUS OF DATA ACQUISITION, BY STATE Group 4: Used Birth Group 3: Received/ eived Birth Group 2: Rec Group 1: Received/ Used Linkage Medicaid Eligibility , Certificate and Medicaid Certificate, Did Not Receive State Birth Certificate, Medicaid Responsibility 1 Eligibility Data ONLY and Claims Data: Limited Use Any Data and Claims Data Eligibility, Alabama Urban Yes No No No Arizona State Yes No No No Yes No No No A N/ California No Urban Yes No No District of Columbia No No No Urban Yes Florida Georgia No Urban No Yes No No No N/A Illinois No Yes N/A Kentucky No No No Yes No No No Yes Louisiana State Maryland No No Yes No State No No Yes No State Michigan Mississippi No No Yes No State State Missouri No Yes No No Nevada No Yes No No Urban No New Jersey State Yes No No Pennsylvania Yes No State No No South Carolina State No No No Yes State Yes No No No Tennessee A Texas N/ Yes No No No Virginia N/ No No No Yes A 1 Notes: States in Group 2 provided all data (birth certificates, eligibility, and claims) for all years, but the data were not used in the Impact Analysis due to sample problems. 36 Medicaid claims/encounter data were not requested for births occurring in 2016 because these data would not have been ready from states in time for inclusion in the evaluation. 37 We were unable to use these data because of significant numbers of missing individuals in the samples provided. In Michigan, approximately 25 percent of Strong Start participants matched to the birth certi ficate file were missing from the Medicaid eligibility and claims files. Those missing from the Medicaid files also had significantly worse birth outcomes compared to t hose who were matched (data not shown). In Georgia, we were unable to merge most Strong Start Participants to the Medicaid data. The state was unable to provide an updated file that corrected the issue in time for us to process and analyze the claims dat a. 84 YEAR 5 FINDINGS

103 SUMMARY OF TECHNICAL ASSISTANCE & DATA ACQUISITION PROCESS TIMELINE AND -year period, beginning in mid-2014 and concluding in the spring of 2018. The TA task spanned a four During those four years, the evaluation team engaged in numerous activities to develop and maintain productive relationships and agreements with state agencies and staff and ultimately secured Medicaid ). To start, the Urban team 37 Table and birth certificate data from 15 states for the impact analysis (see articipated in one in -person and numerous web -based data linkage workshops hosted by p -sponsored by the Center for Medicaid and CHIP Services (CMCS) and the AcademyHealth and co Centers for Disease Control (CDC) designed to support states working to link their Medicaid and Vital Records data in support of federal and state reporting initiatives and policy goals. In addition, we drew he Mother and Infant Home Visiting Program/Strong Start (MIHOPE) evaluation on the experiences of t to identify strategies for reaching out to and acquiring birth certificate and Medicaid data. Following these learning opportunities, Urban conducted initial outreach to Vital Records and Medicaid agencies in the eight MIHOPE/Strong Start states with data linkage experience and then, ove r time, expanded our reach to these agencies in 20 states. A lthough our experiences with each state agency were unique, we did undertake a core set of activities with each agency that included initial outreach and education about the Strong Start for Mothers and Newborns evaluation and our data request, identifying and completing the appropriate steps and materials to secure approval for the requested data, and ongoing communications to receive the requested data in the appropriate format. This section summarizes and describes our activities into five phases of data acquisition: Initial Outreach and Relationship Building with State Agency 1. 2. Preparing and Submitting Data Request Applications and/or IRB Applications to State Agency 3. Securing Approval and Finalizing Agreements with State Agency State Agency Data Preparation and Transfer of Initial Data File to Evaluator; and 4. 5. Review and Approval of All Data by Evaluator. Additional information on these phases is available in the first four Strong Start for Mothers and Newborns Evaluation Annual Reports, (Hill et al, 2015; Hill et al, 2016; Hill et al, 2017; and Hill et al, -Strong Start second annual report (Lee et al. 2015). 2018) and in the MIHOPE i Figure 20 llustrates these five phases of the data acquisition process in more detail, and the length of time needed to successfully complete each phase to ultimately receive the requested data. YEAR 5 FINDINGS 85

104 UISITION 20: PHASES OF DATA ACQ FIGURE Phase 2: Preparing & Phase 4: State Agency Phase 3: Securing Phase 5: Review & Phase 1: Initial Sub mitting Data D ata Preparation & pproval & Finalizing A A pproval of All Data by Outreach & Request and/or IRB Transfer of Initial Data Agreements with State Evaluator Relationship Building Applications to State to Evaluator Agency with State Agency Agency Took up to 18 months Took up 16 months Took up to 27 months Took up to 18 months Took up to 13 months Average = 6.5 months Average = 8 months Average = 6 months per state agency Average = 2.3 months Average = 4 months per state agency per state agency per state agency per state agency 16 states involved 18 states involved 16 states involved 20 states involved 18 states involved -Building with State Agencies (from less than 1 to Phase 1. Initial Outreach and Relationship • 18 months; average = 2.4 months per state agency; Number of states involved in this phase = 20) This phase involved several key steps, including: . • conducting background research on both the Vital Records and Medicaid agencies in each state, including identifying the most appropriate contacts and assessing the agencies’ prior experience sharing and/or linking data with outside organizations; • developing written materials for the state agencies to provide information on the project and how participation in the project could potentially benefit the state and its recipients; and tocol with specific questions to learn about the availability of • developing an interview pro data, the agencies’ processes for approving data requests, whether any fees would be incurred, whether they could accept a stipend to help defray the cost of their efforts, and with whom to communicate going forward. Overall, this preparation allowed us to complete this phase in a fairly short period of time, with the exception of a few states with which we struggled to connect with the appropriate officials at the state agencies. Phase 2. Preparing and Submitting Data Request Applications and/or IRB Applications to • State Agencies (from less than 1 to 13 months; average = 4 months per state agency; number Most state agencies – both Vital Records and Medic aid – of states involved in this phase = 18). required the team to complete an application to secure a Data Use Agreement (DUA), a Business Associate Agreement (BAA), and/or approval from the state’s Institutional Review 86 YEAR 5 FINDINGS

105 Board (IRB). Thus, this phase largely involved completing the applications and corresponding with staff at the state agencies to clarify questions and information requested as needed. In cases where it took longer than the average 4 months to submit an application, delays were due in part to state staff’s long internal discussions about whether or not to participate, clarification regarding the data request itself, and/or the involvement of an external agency or governing body that provided the application forms. Phase 3. Securing Approval and Finalizing Agreements with State Agencies (from 2 weeks to • 16 months; average = 6 months per state agency; number of states involved in this phase = Because state agencies had competing priorities and limited resources, this phase involved 18). maintaining regular and ongoing contact with state agencies regarding the approval process for a DUA, BAA, and/or IRB. During this phase, our collaboration with several states came to an end. For example, despite a signed agreement with Kentucky, the agency could not get past privacy and confidentiality concerns related to sharing claims data. In Texas, the delay between submitting our application and receiving approval was so long, that it was too late to receive and including any data in the impact analysis. Lastly, staff turnover and consequential pol icy changes regarding data requests also delayed approval in some states. • Phase 4. State Agency Data Preparation and Transfer of Initial Data Files to Evaluator (from 1 ase = to 27 months; average = 8 months per state agency; number of states involved in this ph To help facilitate the delivery of the requested data, this phase included several key steps: 16). • hosting calls to review data requests with the data analysts (to get ahead of potential challenges, calls were conducted prior to agencies beginning any work); • making adjustments to the data requests (e.g., changes to variables requested), providing additional guidance on how the linkage is conducted, and verifying the process for secure data transfer and timing for receiving the data; • requesting, receiving and reviewing a test files and asking for clarification from the agencies as needed, including questions about missing data; and • receiving the initial data files. While all of these interim steps proved helpful in securing the requested data, com peting priorities in many state agencies often took priority over our data requests. In addition, it took time for the data analysts to be “brought up to speed” on the request. • Phase 5. Review and Approval of All Data by Evaluator (from 1 to 18 months; average = 6.5 months per state agency; number of states involved in this phase = 16). Upon receipt of the initial data files, Urban reviewed the files for any outstanding questions/clarifications, and then requested revised, final files as needed. Again, due to competing priorities at state agencies, it was not uncommon for several months to pass before Urban received clarification on the data provided, allowing Urban to provide additional guidance as needed, and then receive the final file. In summary, the duration of the data acquisition process that resulted in data submitted to Urban varied considerably, with an average of 21 months per state agency, and a typical (median) span of 27 months per state agency. The range was approximately 9 to 37 months. YEAR 5 FINDINGS 87

106 LESSO NS LEARNED Over the four -year period, Urban identified a number of lessons learned regarding how best to collaborate with state agencies to access individual -level data in a timely and secure manner. These lessons reflect the nature and environment of state agencies, as well as the nature of our data request. four Additional information on our lessons learned is available in previous Strong Start for Mothers and -Strong Start Second Annual Report (Hill et al, and the MIHOPE Newborns Evaluation Annual Reports 38 ; Lee et al. 2015). 2015; Hill et al, 2016; Hill et al, 2017; and Hill et al, 2018 This section presents a -level summary of the lessons learned across all years of the evaluation. high 1. Figure As shown in s data. -size fits all” approach to securing approval to acces There is no “one 20, this process can take 7 months (on average) to develop and submit an application and This lengthy process results from many another 10 months (on average) to secure approval. factors, including: a. Each state’s organizational structure is different, inhibiting the use of a standardized approach to secure approval. Each state agency has its own process for approving data requests from outside organizations. These guidelines can also change mid -effort due to changes in organizational leadership who identify a need for different data sharing protocol. For example, upon submitting an approved DUA and Scope of Work to Urban Institute for signature, the leadership of the Texas Health and Human Services (HHSC, the Medicaid agency) changed and identified new protocols in the last six months of the evaluation for the agency to follow regarding data requests. b. State agencies States’ prior experiences sharing and linking data vary tremendously. generally fell into one of two categories with respect to prior experience in sharing and linking data. More experienced states, including those that participated in the MIHOPE existing and productive relationships between Vital Strong Start evaluation, tended to have Records and Medicaid agencies, and had prior experience sharing and/or linking data with outside entities for evaluation purposes. These states typically had established forms and process for handling da ta request applications and identified lead staff that handle such requests and/or performs data linkages. Less experienced states, in contrast, tended to require more education and support, including multiple meetings to answer questions and address concerns, particularly around data privacy and confidentiality. c. Personally Privacy and confidentiality concerns can slow progress in some states. identifiable information (PII) was needed to link the Medicaid and birth certificate data. required detailed information about Urban’s policies and procedures Thus, almost all states to protect the privacy and confidentiality of the individual level data. To secure approval, states required detail information regarding how Urban would ensure that (1) all data securely transferred to and stored at Urban’s office and (2) that individual women would be and infants could not be identified in any reports/materials developed by Urban as part of the evaluation. In addition, at least one state expressed concerns about sharing M edicaid claims data for pregnant women with HIV/AIDs, mental health, and/or substance abuse. While we were able to meet privacy and confidentiality requirements in most states, these 38 ort Strong Start Second Annual Rep The Mother and Infant Home Visiting Program Evaluation- , Cheaper, Faster, and Better: Are State Administrative Data the Answer? (January 2015). YEAR 5 FINDINGS 88

107 Illinois) (Hill et nd concerns proved insurmountable in three states (California, Kentucky, a al. 2018). Although we explored “workarounds” to satisfy these concerns, such as only providing aggregated data, we were ultimately unable to obtain data from either state. 2. Challenges receiving the requested data in a timely manner can occur even when clear guidance is provided. In some states, a number of factors contributed to state agencies sending incomplete and/or significantly delayed data. These factors included varied experiences in ir pulling and/or merging data (as described above), staff who face competing demands for the time and support with this voluntary effort, and staff turnover. Thus, once data sharing/use agreements were fully executed, it was necessary to build relationships with the state data analysts and IT staff that were directly involved in developing and transferring the data files. These staff members were likely not as familiar with the specifics of the data request and, thus, needed to be brought “up to speed.” In addition, states that were unaccustomed to sharing data with external entities could struggle with how to ensure HIPAA - and IRB -compliant data transfers. 3. Exercising patience and flexibility, and offering alternatives as needed, help s ease the burden on state official s. Over the course of the evaluation, many state agencies identified competing priorities (e.g., requests from the legislature) and limited resources (e.g., staff). Thus, it was critical to maintain ongoing communication with staff while also offering to work with them to luation when time constraints ease the burden, particularly in the last two years of the eva became a concern. For example, in some states, Urban offered to perform the data linkage on behalf of the states or to receive Medicaid eligibility data (needed to identify Medicaid ility in the vital records data), but not claims and participants and reasons for Medicaid eligib encounter data. However, it is important to recognize that no matter the extent of flexibility and patience, some state agencies were unable to share their data. Administrative data lags are routine and to be expected. 4. Beyond the lessons learned and challenges described above data lags existed in every state agency. More specifically, state agencies need time to clean and prepare administrative data for analysis, either internally for their state or externally for a research organization. The average length of time required to receive a full data set for Strong Start evaluation was 27 months per state agency, in part because of the typical lag time that exists between when the data collection year ends and when state agencies have completed their cleaning and compiling the data for public release. For example, in many states, final birth certificate data for a calendar year are not available — in particular, claims and until 9 months after the end of that year. Lags for Medicaid data encounter data— can be even longer (typically 18 months) — which, as noted above, is the reason that Urban did not request claims associated with 2016 births. SUMMARY OF BEST -PRACTICES FOR ACQUISITION OF STATE AGENCY DATA lesson learned via the technical assistance offered for the Strong Start program evaluation While a key -practices that can be considered and is that there is no “one size fits all” approach, there are best adapted to help other organizations secure state agency data for evaluation purposes. Table 38 su mmarizes the best -practices by phase. Each best-practice is described in more detail following the table. YEAR 5 FINDINGS 89

108 TABLE 38: SUMMARY OF BEST PR ACTICES TO FACILITATE DATA APPROVAL AND ACQUISTION FROM STAT E AGENCIES - Best -Practices Phases 1. st a Do your “homework” prior to contacting the agency. te Develop a clear agenda for initial meetings with specific “asks.” 2. Phase 1: Initial Outreach and 3. Provide resource materials for the state agency prior to and after the initial meeting. Relationship Building with State Offer a financial stipend to help offset the costs of sharing and linking data. 4. Agency Table Text Indent 5. Develop -level database to track contacts and progress. a state 6. Facilitate transfer of knowledge in the event of turnover at the state agency. ap Phase 2: Preparing and Submitting 1. Develop a “standard” set of plication questions and answers. Corre spond with state agency staff to clarify any questions/requests for information in the 2. Data Request and/or IRB application prior to submission. Applications to State Agency 1. Stay engaged du ring the review and approval process. Phase 3: Securing Approval and 2. Be flexible and patient. 3. Finalizing Data Use Agreements pared to implement alternative approaches to secure participation when time and Be pre other resources are constrained. with State Agency 4. As needed, employ strategies to exert increased pressure on agencies to get them to act. 1. Reiterate the specific data request, including transfer protocols, often and regularly to ensur e that all parties are on the same page and to minimize potential issues with the data pull and transfer, while also reassuring state agencies about the project’s various privacy se 4: State Agency Data Pha and security protections. paration and Transfer of Initial e Pr Develop relationships with data analysts and IT staff at the state agency to help ensure that 2. Data to Evaluator data are transferred securely and in the appropriate format. e requested th 3. Request test files to address any potential data issues prior to the state agency sending the complete file. Facilitate open and ongoing communication between the data analysts at the project team 1. Phase 5: Review and Approval of All Data by Evaluator and the state agency. Phase 1: Initial Outreach and Relationship Building with State Agency 1. Do background research prior to contacting the state agency. Prior to initiating any contact with a state agency, it is helpful to conduct background research to educate the project team about each state’s history, experience, and capacity related to sharing and linking data. This information can be used to group the states into tiers based on a specific characteristic (for example, data linkage experience), to help inform which states to contact first and/or to determine types of support the agency is expected to need throughout the process. Such preparation will help to facilitate a smoother and more productive initial meeting as well as subsequent meetings. 2. It is most efficient Develop a clear agenda for initial meetings with specific “asks.” – for both the evaluation team and the state agency – to have defined agendas and questions for initial meetings to ensure that contact information and roles for agency staff, as well as clear lines of accountability to the data request, are consistently collected. It is also helpful to develop a form to guide the conversation regarding the kinds of agreements and materials (DUA, MOU, IRB, SOW, etc.) that may be required and have the agency clarify what is required, by whom, and by when. It is also helpful to request a data dictionary as early as possible to guide the specific request and minimize “surprises” later on. . Prior to 3. Pr ovide resource materials for the state agency prior to and after the initial meeting and after the initial meeting, state agency directors and staff find it useful to refer to written evaluation and the potential benefits materials describing the purpose and goals of the program of the evaluation at both a national and state -level, if applicable (Hill et al. 2017). Such materials can also be used to help the project team make the case for sharing data and moving forward in the process. 90 YEAR 5 FINDINGS

109 . If project budget financial stipend to help offset the costs of sharing and linking data Offer a 4. and contract allow it, offer a financial stipend to states to help offset the time and resources needed to share (and link) the requested data. Some states may charge a fee for providing the data . F that ranged eight of the 21 states we initially worked with requested fees or this project, from $ 300 to just under $4 1, 000. Across those eight states, the average fee was $11,800 and the median fee was $5,324. Develop a state database to track contacts and progress 5. . When working with multiple states and state agencies, it is critical to develop and maintain a database or “tracker” to summarize cy. Such progress, meeting notes, next steps, and contact information for each state agen documentation can also be useful in the event of staff turnover at the state agency, which is not uncommon, particularly if working with a state agency over a prolonged period of time. 6. Facilitate transfer of knowledge in the event of turnover at the state agency. When a point of contact indicates s/he will be leaving the agency or moving to a different role within the agency, work with the outgoing point of contact to identify the new point of contact and set up a meeting with both individuals to discuss the data request process and smooth the transition. Phase 2: Preparing and Submitting Data Request and/or IRB Applications to State Agency Develop a “standard” set of application questions and answers. 1. Although each state agency ta request forms and/or IRB application, many of the questions will be the will have its own da same or similar across these forms. For example, common components across applications included descriptions of the research project, the specific data request (including years of data and variables), data security protocols, PHI and PII protections, and prior IRB approval. Therefore, it is efficient for the project team to develop a set of “Frequently Asked Questions” that assembles common facts, figures, variables, and answers to questions, allowing p Appendix O applications to be completed more quickly, efficiently, and consistently. ( rovides a st of the FAQs typically included in state data applications.) li Correspond with state agency staff to clarify any questions/requests for information in the 2. application prior to submitting data requests. It can be helpful to request additional meetings and/or send draft responses to questions to ensure that the information provided fulfills the - -run by reducing the likelihood of being asked to re request. This will save time in the long submit the application. Phase 3: Securing Approval and Finalizing Data Use Agreements with State Agency 1. Stay engaged during the review and approval process. State agency officials and staff are very busy with normal day -to -day program responsibilities; therefore, it is often necessary to send regular, friendly, reminders regarding the status of the application. Also, be prepared to provide additional clarification and documentation to your application. 2. It can take from several months to more than a year to receive approval Be flexible and patient. from a state agency. As a result, the project team may need to revise its request to decrease burden on state agencies to obtain approval as the project evolves and/or project staff change. 3. Be prepared to implement alternative approaches to secure participation when time and other resources are constrained. In the case of the Strong Start data request, modifications YEAR 5 FINDINGS 91

110 were made to eliminate the request for claims data when it was identified to be too burdensome to some agencies and/or the approval process was taking longer than anticipated. 4. Identify and employ strategies to exert increased pressure on agencies to get them to act. It may be important at times to “turn up the pressure” on the state agency by sharing updates -regarded agency leaders or decision -makers to ensure state resources are provided with highly and priorities are communicated to a legal and/or data analyst team. Sometimes it is beneficial to involve federal officials in such conversations, as well. Phase 4: State Agency Data Preparation and Transfer of Initial Data to Evaluator 1. Reiterate the specific data request often and regularly. Urban created and distributed documents that specifically laid out the requested birth certificate variables and/or the data needed to create the Medicaid eligibility, claims, and encounter variables for the Impact repeatedly communicated (via email staff endices X and Y). In addition, Urban Analysis (see App and phone) how best to transfer the data via secure FTP sites to ensure privacy and ll confidentiality. It is critical to share such information often and regularly to ensure that a parties are on the same page and to minimize potential issues with the data pull and transfer, while also reassuring state agencies about the project’s various privacy and security protections. 2. e state agency Develop relationships with data analysts and IT staff at th . Once agreements the evaluation both from — are fully executed, it is necessary to bring new staff into the process Impact analysis team and IT department) and the state Urban (e.g., staff from the contractor to ensure that the requested data are transferred agencies (e.g., data analysts and IT staff) — securely and in the appropriate format. At the same time, it is important to maintain existing relationships to help ensure that the state agency is working in a timely manner to prepare and the data. send 3. Request test files to address any potential data issues. It is helpful and efficient to request -identified data to identify any potential issues with the data prior to the “test files” with de state agency sending the complete file. Having a smaller test will save both the project team and the state agency time and minimize frustration for either or both parties. Phase 5: Review and Approval of All Data by Evaluator Facilitate open and ongoing communication between the data analysts on the eva 1. luation team and at the state agency . It is critical that the data analysts at both parties are engaged in ongoing communications to ensure that the project team fully understands the data and can verify that the data files are complete. Strong Start for Mothers and Newborns evaluation undertook the daunting task In conclusion, the of attempting to obtain and link birth certificate and Medicaid eligibility and claims/encounter data from 20 states, representing the largest effort of its kind by a CMS ed research organization. -support Ultimately, the persistent efforts of the Technical Assistance and Data Acquisition team were successful in obtaining these data from 15 of the 20 states with whom we worked , with data quality . Although the data acquisition process was time 13 states high enough for evaluation use from consuming, the data offered invaluable information for the analysis of Strong Start. We hope that the many important lessons learned can be helpful to other entities undertaking similar evaluation efforts. YEAR 5 FINDINGS 92

111 IMPACT ANALYSIS The impact analysis compares outcomes for women participating in Strong Start and their infants to outcomes for non-participating, Medicaid-enrolled women with similar risk profiles and their infants. itative methods to account for confounding factors that may drive This assessment relies on quant differences in outcomes and could otherwise be incorrectly attributed to Strong Start. The impact analysis aims to answer the following broad evaluation questions: • What are the combined impacts of the enhanced services supported by Strong Start and the care delivered in a Birth Center, Group Prenatal Care practice, or a Maternity Care Home 39 relative to typical Medicaid prenatal care on gestational age, birthweight, cost, utilization? and • Do impacts differ across the three Strong Start delivery models and across awardees? If so, how? • How does the implementation analysis explain the impact findings? Specifically, does the intensity of the intervention (such as the level and types of services off ered) lead to greater program impacts? This section first reviews the analytic approach and data sources associated with the impact using all valid data analysis, then discusses limitations to the methodology. After offering this context, ction presents results for each model (i.e., Birth Centers, Group Prenatal Care, and the se available, Homes) and Maternity Care also includes results for individual awardees if they had sufficient sample -level and site sizes. Full awardee in individual awardee chapters d in -level impact estimates are reporte Volume 2. ANALYTIC APPROACH AND DATA SOURCES To assess the impact of Strong Start and address the evaluation questions, we compared women receiving care in participating in Strong Start to a group of women with Medicaid coverage who were prenatal care practices in the same or similar geographic areas. For each typical (i.e. non -Strong Start) awardee or site with sufficient sample size, we used propensity score reweighting to develop a comparison group of women with similar risk profiles to those of women enrolled in Strong Start. We obtained: birth outcomes, process outcomes, demographic characteristics, and medical risk factors from • birth certificates; Medicaid eligibility of the mother and infant from state Medicaid eligibility files; and • • costs of care, utilization, and non -pregnancy -related diagnoses from Medicaid claims and data. encounter 39 erally The vast majority of typical Medicaid prenatal care is practiced in such settings as private solo and/or group practices, Fed Qualified Health Centers, hospital outpatient department clinics, and (to a smaller extent) public health department clinics . YEAR 5 FINDINGS 93

112 As described in the Technical Assistance and Data Acquisition s ection, we obtained birth rtificates and Medicaid eligibility data for 14 states and the District of Columbia and claims data for 9 ce states and the District of Columbia (see Table 15). Concerns about the quality of the link between Strong Start participants, birth certificates in Georgia and Michigan precluded the use data from these states in the impact analysis. For the analysis of birth outcomes, the sample includes awardees and sites a, Arizona, Florida, Louisiana, Maryland, Mississippi, Missouri, Nevada, New Alabam — in 12 states and the District of Columbia. While claims data Jersey, Pennsylvania, South Carolina, and Tennessee — — were initially requested from all states, only eight states lorida, Louisiana, Alabama, Arizona, F and the District of Columbia provided detailed Missouri, New Jersey, South Carolina, and Tennessee — 40 claims data within the time frame necessary for completing the analysis. In this section, we describe the analytic approach, including th e propensity score reweighting strategy, impact estimation methods, and comparison group selection. Next, we present detailed information on the key outcomes and matching variables for the propensity score approach. reweighting Analytic Approach analysis: impact three main steps to conducting the There were 1. Create propensity -score -based weights for the comparison group. 2. Confirm there are no remaining meaningful differences in control variables between Strong- Start participants and comparison observations after the weights have been applied. Estimate impacts as the difference in outcomes between Strong- 3. Start participants and propensity -score weighted comparison group observations. Propensity score reweighting yields statistically efficient estimates (Hirano, Imbens, and Ridder, that it perform s very well among alternative evidence 2003), and Monte Carlo simulation has shown -based methods propensity -score in terms of minimizing bias, but has lower variance than pairwise usso, DiNardo, and McCrary, 2014) (B our intent was to . Because matching across a range of scenarios awardee estimate treatment effects at the -levels (with many awardees and sites having only a - and site modest number of treated cases), we determined that a statistically efficient method that makes full use of available data would have the best chance of detect ing true treatment effects. Given the statistical efficiency of propensity score reweighting and evidence of its good performance relative to estimation method decided to alternatives, we use the propensity score reweighting approach as our 41 for the impact analysis . Appendix R provides a detailed discussion about the choice between rovides a more detailed description of the propensity score reweighting and matching and Appendix P p me thods. -specific data are developed first and then pooled to Awardee data and, in some cases, site produce model -level impacts. 40 Michigan also provided claims data, which could not be used because of the quality of the linkage between Strong Start participants, birth certificates, and eligibility records. 41 Selection of propensity score reweighting over matching methods is discussed in more detail in Appendix H of the Year 3 Annual Report. YEAR 5 FINDINGS 94

113 Computing Propensity Scores and Propensity Score- Adjusted Weights We created propensity scores by estimating logistic regressio ns in which the dependent variable indicates whether the woman is a Strong Start participant or in the comparison group. The regression s of the data section) including Table 40 control for a variety of factors (described in detail in 42 graphic characteristics, behavioral risk factors, medical risk factors, Medicaid eligibility type de mo , hospital characteristics, and, when available, diagnoses reported on the claims data. We construct with s, model these weights for the comparison group observations from the predicted probabilities of those more similar to Strong Start participants receiving larger weights. After weighting, comparison Table (see 40 group observations look very similar to participants in terms of the control variables in T able P. 1 in Appendix P). Estimating Impacts - levels, each of which is described in We produced impact es -, and model timates at the awardee -, site the following subsections. Awardee and Site- Specific Impacts After the propensity score reweighting, we estimated impacts by comparing mean outcomes for Strong Start participants and reweighted comparison group women. In the impact tables, we report differences for each outcome and the statistical significance of the differences. The differences represent the impacts of enrolling in Strong Start and receiving care at a specific awardee or Birth Center, Group Prenatal Care provider, or Maternity Care Home site relative to women of similar risk profiles served by typical Medicaid providers. Impacts by Strong Start Delivery Model To estimate impacts for each Strong Start model (i.e., Birth Center, Group Prenatal Care, and Maternity Care Home), we combined observations from awardees associated with each model in turn. Because comparison group cases are already weighed to be similar to Strong Start participants within each awardee’s data, they are also similar when the data for awardees are combined. The differences between women enrolled in Strong Start and women in the comparison group represent the impacts of enrolling in Strong Start in combination with having prenatal care delivered at a Birth Center, a Group Prenatal Care practice, or a Maternity Care Home compared to care received in typical Medicaid maternity care practices. 42 States have numerous mandated and optional pathways to Medicaid eligibility. YEAR 5 FINDINGS 95

114 Identifying the Comparison Group Identifying women who could serve as a comparison group for women enrolled in Strong Start was among the most challenging aspects of the evaluation. To estimate the impact of Strong Start in combination with one of the three delivery models of care (i.e., Birth Centers, Group Prenatal Care, or Maternity Care Homes), we had to identify women who received care in typical Medicaid maternity care practices, but were otherwise similar to Strong Start enrollees. The vast majority of typical Medicaid prenatal care is practiced in such settings as private solo and/or group practices, F ederally Qualified Health Centers, hospital outpatient department clinics, and (to a smaller extent) public health that it is riticisms of typical care cited in the literature department clinics. Common c medical in are on education, focused focus, interventionist, not sufficiently . In and does not offer provider continuity similar to ” practices also offer enhanced services “typical , some addition those funded by Strong Start offered throu or provide care through one of the three delivery models gh Strong Start. Ideally, a comparison group of women would be drawn from the same counties or parishes where Strong Start participants reside so that treatment and comparison group cases had been exposed to the same contextual factors. However, there were two scenarios that necessitated drawing the comparison group from a different county than that where Strong Start sites or participants located: were The demonstration, through a single site or multiple demonstration sites, “saturated” the 1. area. There wer 2. e some typical Medicaid maternity practices in the local area, but the Strong Start -risk pregnant women enrolled in Medicaid. site was the only source of care for high To determine which Strong Start awardees and sites fall under each of these categories, the impact analysis team reviewed case study memos and followed up with site visit teams to gather information prior to conducting any analyses. Appendix Q summarizes findings regarding whether valid comparison gro ups could be obtained from the local area surrounding each Strong Start site or whether matched comparison counties needed to be identified. we were able to pull the c omparison group from the same counties where Strong or 12 awardees, F Start participants reside d. For five awardees, we needed to find matched counties to select the comparison group for at least one of the sites associated with the awardee. For three of these awardees, s was due to scenario 1 (i.e., Strong Start saturation). Although qualitative data suggested that at thi least one of these awardees’ sites “saturated” the local area, a review of birth certificate and Medicaid -covered pregnant women in each county that were eligibility data found enough Medicaid enrolled not in Strong Start to conduct within -county analyses. For these awardees and sites, we estimated impacts county comparison groups, as this strategy best controlled for the local area context. using within- -county Ho wever, we assessed the consistency of these results with those obtained using an outside -of comparison group. For two of these awardees, we needed to find matched counties due to scenario 2 (i.e., Strong Start awardees being the only source for Medi caid high -risk care in the area). 96 YEAR 5 FINDINGS

115 To construct our within-county comparison groups, we geocoded Strong Start enrollment data and set that links birth identified the county of residence for women enrolled in Strong Start. Using the data certificates to Medic -covered pregnant aid eligibility files, we drew a comparison group of Medicaid 43 women for each awardee and site from the same counties in which Strong Start participants reside. ilar women who We applied propensity score reweighting to construct a group of observably sim enrolled in Medicaid but did not participate in Strong Start. for which there was a need to go outside the local area to find a comparison group, we For each case used a statistical matching technique, nearest neighbor matching using the Mahalanobis distance to find the most similar county within the same state, based on observable characteristics of measure, 44 the county. Matching variables included: ercent -rural continuum, personal income per capita, p urban in poverty, percent black, percent Hispanic, percent of children covered by Medicaid, number of doctors per capita, number of certified nurse midwives and certified midwives per capita, number of hospital Using beds per capita, percent of births with low birth weight. matching technique, we paired this treatment counties where Strong Start participants resided with the closest matched county in the state without Strong Start participants. With the comparison group drawn from Medicaid-covered as those we applied to births i n the counties identified through this process, we used the same methods within-county comparison groups. The statistical details of the county matching method can be found in 45 the Year 3 Annual Report. Data In this section, we describe key outcome and control variables constructed from birth certificate and contains detailed information on how we constructed the analytic files, Appendix S Medicaid data files. nc luding the linking process between Strong Start enrollment information, birth certificates, and i Medicaid eligibility and claims data, as well as the processes to create consistent variables across states. Appendix U pro contains an analysis of the quality of the linking process. Appendix T vides a description number and share of Strong Start awardees, sites, and participants included in the of the impact analysis. Outcome Variables (see es of outcomes in the impact analysis We assess three major categori Table 39 for : pe s cific variables) 1. birth outcomes process outcomes 2. mother and infant costs of care and utilization 3. 43 In order to reduce state burden in developing analytic files, we excluded comparison group women from counties in which less than 5 percent of the women enrolled in Strong Start resided, as long as over 90 percent of enrolled women were included. This the Year 3 led to a reduction in the Strong Start sample of about 5 percent. For a more detailed discussion of this issue, see Annual Report. 44 See Rubin, D.B. (1979). “Using Multivariate Matched Sampling and Regression Adjustment to Control Bias in Observational –328 74, 318 Journal of the American Statistical Association Studies.” 45 Hill, I., Benatar, S., Courtot, B., Dubay, L., Blavin, F., Garrett, B., ... Sinnarajah, B. (2017). Strong Start for Mothers and Newborns Evaluation: Year 3 Annual Report . Washington (DC): The Urban Institute. Retrieved from https://downloads.cms.gov/files/cmmi/strongstart- enhancedprenatalcare_evalrptyr3v1.pdf YEAR 5 FINDINGS 97

116 The first two categories come from birth certificates, and the third category comes from Medicaid 39 claims/encounter data, which was only available in eight states and the District of Columbia. Table describes the outcome. parameters of each TABLE 39: OUTCOME VARIABLES FOR THE IMPACT ANALY SIS Variable Specification Source Birth Outcomes Clinical gestational age Based on obstetrician's estimate in weeks Birth Certificate Clinical gestational age < 37 weeks Preterm birth Birth Certificate Very preterm birth Birth Certificate Clinical gestational age < 34 weeks Birth Certificate Infant weight at birth in grams Birth weight Low birth weight Infant birth weight < 2,500 grams Birth Certificate Infant birth weight < 1,500 grams Very low birth weight Birth Certificate Birth Certificate Apgar score at 5 minutes greater than or equal to 7 Apgar score Birth Process Outcomes Birth Certificate Infant delivered by C-section cesarean section Infant delivered vaginally after previous C VBAC Birth Certificate section delivery - Weekend delivery Birth Certificate Infant delivered on Saturday or Sunday Cost Outcomes Prenatal period expenditures Medicaid Claims prior to delivery month During 8 months Total expenditures during Includes mother and infant costs Medicaid Claims delivery period Total delivery and Medicaid Claims life Includes mother and infant costs during delivery period and first year of delivery expenditures - post Utilization Outcomes Number of ED visits in Medicaid Claims Number of ED visits 8 months before delivery month period prenatal Number of hospitalizations in Number of hospitalizations 8 months before delivery month Medicaid Claims prenatal period Medicaid Claims Number of days in NICU NICU days Number of ED visits for mother Medicaid Claims Number of ED visits for mother 11 months after delivery month delivery - post Number of hospitalizations for Medicaid Claims Number of hospitalizations for mother 11 months after delivery month mother post - delivery Number of ED visits for infant Number of ED visits for infant in first year of life Medicaid Claims delivery - post Number of hospitalizations for Number of hospitalizations for infant in first year of life Medicaid Claims -delivery infant post Birth outcomes from the birth certificate include gestational age, birthweight, and Apgar score. We variables categorical analyzed gestational age and birthweight as both continuous variables and as indicating preterm birth (or very preterm birth) or low birthweight (or very low birthweight), respectively. The Apgar score reflects the health of infants immediately after birth and is based on an infant’s heart rate, respiratory effort, muscle tone, reflex irritability, and color. We analyzed Apgar indicating whether the score is greater than or equal to 7 at 5 minutes after birth, scores as a variable 46 which reflects that the baby’s condition is good to excellent across these dimensions. 46 https://www.nejm.org/doi/pdf/10.1056/NEJM200102153440701 98 YEAR 5 FINDINGS

117 review of the birth certificate data for gestational age and birthweight, we observed outlier Upon values for ages and weights. To best approximate a sample of women with a live birth, we trimmed both variables using standard cut points from the field and the distribution of values in the data. For relied on ACOG definitions and excluded observations with gestational estimated gestational age, we ess than the periviable age of 20 weeks and those with gestational age above 45 weeks, which is age l 47 -term. nd post three weeks beyo and For birthweight, we excluded observations below 500 grams 48 above 6,800 grams. These exclusions represent no more than 2 percent of the sample in any state and also typically represent less than 1 percent. After removing these observations, we trimmed very low 49 and very high values of gestational age and birthweight to limit the influence of outlier cases. For example, in the Florida data, the small number of cases with gestational age of less than 29 weeks (the th st 1 percentile) were set to 29 weeks; cases with gestational age of more than 41 weeks (the 99 percentile) were set to 41 weeks. Process outcomes from the birth certificates include: • -section); whether the infant was delivered by cesarean section (C whether the mother had a vaginal birth after a previous cesarean section (VBAC); and • • whether the baby was delivered on a weekend, which is a proxy for the extent to which scheduled and/or elective inductions or C-sections are occurring. r data, we analyzed the impact of Strong Start In the states where we obtained claims and encounte on three cost measures and seven utilization measures that may drive costs. The cost measures include: expenditures in the 8 months prior to the delivery month; • expenditures for the mother and infant during the delivery period (i.e., the time between the • mother entering the hospital for delivery and the discharge of the infant); and • expenditures for the mother and infant during the delivery period and first year of life. , it is not always possible to disentangle the costs of the Appendix S As described in more detail in mother and infant during the delivery period. Thus, mother and infant costs are pooled for the delivery 50 period and for the year after the delivery. 47 -and-Publications/Committee-Opinions/Committee-on-Obstetric https://www.acog.org/Clinical- - Guidance -Consensus- Practice /Definition-of- Term -Pregnancy; https://www.acog.org/Clinical-Guidance- and-Publications/Obstetric- Care Series/Periviable-Birth 48 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658983/ ; https://www.ncbi.nlm.nih.gov/pubmed/18446176 th 49 st -coded to their 99 -coded to their 1 Using each state’s data separately, these variables are bottom percentile values and top percentile values. 50 In examining expenditure outcomes, the main focus is on total expenditures. However, we considered examining average expenditures, which divides total expenditures by the number of Medicaid eligibility months. The effects of Strong Start on t otal eligibility. expenditures capture the effects on average expenditures per eligibility month, as well as any effects on months of Effects of Strong Start on the number of months of eligibility were examined, and they were typically small and statistically insignificant. We concluded that any effects on total expenditure are mostly driven by effects on average expenditures per month not and do not report effects on average expenditure separately. In addition, because infant and mother costs are combined, it is clear which eligibility information to use in the denominator of an average expenditure per month variable. YEAR 5 FINDINGS 99

118 The utilization measures include the: number of emergency department (ED) visits in the 8 months prior to the delivery month; • delivery month; • number of hospitalizations in the 8 months prior to the • number of days in neonatal intensive care unit (NICU); • number of ED visits for the mother 11 months following the delivery month; number of hospitalizations for the mother 11 months following the delivery month; • number of ED visits for infant in the first year of life; and the • number of hospitalizations for the infant in the first year of life. • The cost measures are subject to extreme outlier values at both the high and low ends of the distribution. The utilization measures, which are limited to zero at the bottom, are subject to extreme outliers at the high end of the distribution. To reduce the undue influence of outlier values, very high 51 , and very high values for utilization measures are also trimmed. and very low values are trimmed Control Variables describes the control variables used in the propensity score reweighting process and whether 40 Table they were derived from birth certificates, Medicaid eligibility files, or Medicaid claims and encounter data. EWEIGHTING VARIABLES FOR IMPACT ANALYSIS 40: PROPENSITY SCORE R TABLE Variable Source Specification Demographic Factors Birth Certificate Age of mother in years Mother's age White, Non-Hispanic; Black, Non- Hispanic; Other, Non-Hispanic; Hispanic; Race Mother's race Birth Certificate Unknown < High School; High School Degree/GED; Some College; Associate's Degree; Bachelor's Mother's education Certificate Birth Degree or Higher; Missing Birth Certificate Marital status Married; Unmarried Birth Certificate Infant’s quarter of birth Quarter that infant was born Infant’s year of birth Year that infant was born Birth Certificate Mother’s county of residence Birth Certificate County Behavioral Risk Factors Smoking Mother's smoking habits in 3 months prior to pregnancy Birth Certificate Birth Certificate Trimester in which prenatal care began Prenatal care initiation Medical Risk Factors Birth Certificate Plurality Singleton; Twin; Triplet; Four or more Birth Certificate Number of previous live births Parity Birth Certificate Previous preterm birth Mother had a precious preterm birth Previous other poor Birth Certificate Mother had another previous poor outcome outcome pregnancy Interpregnancy interval Birth Certificate Months between date of last birth and beginning of current pregnancy Mother had diabetes prior to pregnancy -pregnancy diabetes Pre Birth Certificate -pregnancy hypertension Pre Mother had hypertension prior to pregnancy Birth Certificate - Mother’s BMI pre Birth Certificate Underweight; Normal Weight; Overweight; Obese pregnancy th 51 For all cost measures, the high outlier values are set to equal the value corresponding to the 99 percentile and low outlier st values are set to equal the value corresponding to the 1 percentile. For all utilization measures, the high outlier values are set to th equal the value corresponding to the 99 percentile. 100 YEAR 5 FINDINGS

119 Variable Specification Source Hospital Characteristics Hospital of delivery is in a Hospital Engagement Network (HEN) Birth Certificate HEN hospital Medicaid Eligibility income Hierarchy of eligibility in the 8 months before delivery: disabled; foster care; low - -related children; Children’s Health Insurance Program (CHIP); families; poverty Medicaid Basis of Medicaid eligibility Affordable Care Act Medicaid expansion; poverty -related pregnant women; medically Eligibility Files needy; Medicare; emergency Medicaid/CHIP for unborn children; family planning; other; not eligible; not in the eligibility file Medicaid Number of months eligible Number of months the mother was enrolled in Medicaid in the 12 months before delivery Eligibility Files Medicaid Infant not eligible Infant was not enrolled in Medicaid in the year after birth Eligibility Files Diagnostic Risk Factors pre - Diagnosis of Medicaid Claims Identified in the prenatal period diabetes pregnancy Diagnosis of pre - Identified in the prenatal period Medicaid Claims pregnancy hypertension Number of unique non- pregnancy -related mu lti -level Clinical Classification Software diagnosis categories identified in the prenatal periods . See Number of unique diagnoses https://www.hcup - Medicaid Claims us.ahrq.gov/toolssoftware/ccs/CCSUsersGuide.pdf . Clinical Classification Software diagnosis codes for Tuberculosis; HIV, hepatitis, any - neoplasms; endocrine; nutritional and metabolic disease; diseases of the blood and blood ors for unique Indicat forming organ s; mental illness; diseases of the nervous; circulatory; and digestive systems; -related non-pregnancy nephritis; acute and unspecified renal failure; chronic renal failure; urinary tract Medicaid Claims diagnoses in prenatal period infections; calculus of the urinary tract; hydronephrosis; other diseases of the bladder and defined conditions; diseases of the urethra; other and genitourinary symptoms and ill- skin; diseases of the musculoskeletal system; and congenital abnormalities The birth certificate variables used for reweighting include: demographic factors (characteristics of the mother, quarter and year of infant’s birth, and • county of residence for the mother); • behavioral risk factors of the mother; • medical risk factors of the mother; and • whether the delivery hospital participated in a Hospital Eng agement Network (HEN). We included the HEN variable in the propensity score reweighting model to try to account for the impact of hospitals’ participation in a HEN focused on reducing elective deliveries. These HENs were 52 implemented at approximately 3,700 hospitals over the same period as Strong Start. We used Medicaid eligibility files to create the following variables for reweighting: • Medicaid eligibility type in the 8 months before delivery • number of months mother is enrolled in Medicaid in the 12 months before delivery • whether the infant is enrolled in Medicaid in the year after delivery To determine the mother’s eligibility in the 8 months before delivery, and because many women have multiple types of eligibility over time, we created a hierarchy of el igibility types. We grouped the numerous eligibility categories contained in each state’s eligibility files, which vary considerably across states, into 12 broad categories of eligibility. 52 https://www.medicaid.gov/medicaid/quality-of-care/downloads/eed- brief.pdf YEAR 5 FINDINGS 101

120 For women who were eligible for more than one category in the 8 months prior to delivery, we used a hierarchy that first placed women in one of the following categories: disabled • • foster care • income families low- -related children poverty • Medicaid expansion Children’s Health Insurance Program (CHIP) • aid Expansion Affordable Care Act Medic • • poverty -related pregnant women • medically needy • Medicare - and Medicaid - enrolled emergency Medicaid/CHIP for unborn children • • family planning 53 • other To further control for health status, we estimated alternative model s that add diagnoses reported . We could only do this in the subset of on the claims data to the propensity score reweighting models states where Medicaid claims data are available. The addition of diagnosis variables from claims added significantly to the predictive power of the logistic regressions. We used Medicaid claims and encounter data to create the following variables for propensity score reweighting: • whether mother had diagnoses of pre -pregnancy diabetes or hypertension number of unique non-pregnanc -level Clinical Classification Software (CCS) • y-related multi 54 diagnosis categories that were identified in the prenatal period • whether any of a variety of non-pregnancy -related diagnoses based on CCS diagnosis are present on the claims file in the 8 months prior to delivery and are included in categories 55 the model In some cases, not all applicable control variables are included in all propensity score models: -pregnancy diabetes) Indicator variables with very low frequency (e.g., plurality and pre • may be pe rfect predictors of treatment status and cannot be included in the logistic regression models . in some samples The HEN variable is sometimes strongly aligned with Strong Start participation and is dropped • verlap in the distribution of propensity scores in cases in which its inclusion creates a lack of o for treated and comparison groups. • cases, with relatively small sample sizes, control variables with low frequency are In some dropped or merged with other categories. 53 Women only eligible for family planning and breast and cervical cancer programs are considered not -eligible as the benefits they are eligible for are quite limited. In some states, we combine the following categories that had small sample sizes within the edically needy. state: Foster care, CHIP and m 54 Clinical Classifications Software (CCS) is a method of clustering patient diagnoses and procedures into a manageable number of clinically meaningful categories. For a full description see: https://www.hcup -us.ahrq.gov/toolssoftware/ccs/CCSUsersGuide.pdf . 55 Diagnoses in CCS single level diagnosis category 11 –complications of pregnancy, childbirth, and the puerperium – and category 15 – certain conditions originating in the perinatal period – are excluded. 102 YEAR 5 FINDINGS

121 ESIGN LIMITATIONS OF THE D unded enhanced services through three evidence — -based prenatal care models Strong Start f Birth . The gold standard design for estimating Centers, Group Prenatal Care, and Maternity Care Homes Strong Start was not designed to program treatment effects is a randomized control trial. However, either awardees or assign participants to treatment and control groups through intentional -experimental designs that use a difference . Many CMMI evaluations rely on quasi randomization - -in difference approach, but the particular question asked regarding Strong Start does not lend itself to this . That is because the program layered enhancements upon existing models of care rather than strategy , and therefore, there was no pre -period with which to implementing entirely new models of care receiving and enhanced services of Strong Start funded effect combined In order to assess the pare. com in these relative to care received in practices that typically care for models three prenatal care care ides a complete Appendix V prov Medicaid covered women, an observational approach was necessary. di scussion of the analytic options considered to evaluate Strong Start. o assess the combined effect of Strong Start enhanced services provided in Birth Centers, Group T with Prenatal Care, and Maternity Care Homes, we have applied observational study methods to achieve a comparison group with similar observed characteristics as propensity score reweighting participants. A primary concern is whether the estimated effects capture the causal impact of Strong Start enrollment in combination with care in Birth Centers, Group Prenatal Care providers, or Maternity Care Homes relative to typical Medicaid maternity care practices. There are several sources of potential bias that could threaten the validity of the impact estimates. Selection Bias There are several ways that selection could bias the impact estimates. Selection happens at many points, including when women choose their site of care. Some women may prefer a certain type of provider. For example, they may want midwifery care and the option to deliver at a Birth Center, or they may or may not be interested in receiving Group Prenatal Care. Other women may want to receive care from a specific provider because of convenience or because they are familiar with the provider. hen sites add women to the Strong Start program based on pregnancy risk. Some Selection also occurs w Strong Start sites will select enrollees based on elevated risk, while others, particularly Birth Centers, factors that drive what type of might exclude some women with high medical risk. To the extent that the care women receive cannot be captured in the propensity score models and also affect birth outcomes, the impact estimates may be biased in one direction or the other. Selection also happens when women offered Strong Start enrollment decide whether to participate. Sites vary in terms of the procedures they used to enroll individuals in Strong Start, with some sites -in strategies. Sites that used opt- out procedures enrolled all women -out and others using opt using opt in Strong Start unless they expressly elected not to participate and “opted out." Sites that used opt-in procedures offered women the choice to enroll, and women had to “opt in” to participate in Strong Start. When women were asked whether they wanted to participate in Strong Start, some chose to enroll and some did not. To the extent that a large share of women in the opt -in sites declined to enroll in Strong Start on the basis of factors that were not captured in our propensity score models, our impact estimates could be biased. The same concern applies to a lesser extent to the opt-out sites. We reviewed the case study reports to determine the extent to which women who were given the option of YEAR 5 FINDINGS 103

122 enrollment in Strong Start participated (i.e., “opt in”). While some a wardees reported that acceptance of offers of enrollment was low at first, many reported that they changed their strategy to an opt- out policy, and others implemented different strategies to encourage women to participate. Overall, it seemed that most sites ultimately had relatively high acceptance among women who were offered enrollment in Strong Start. Other than the previously described issues, there are two special cases of selection bias that deserve discussion: awardees that serve a large proportion of high risk women from across the state • • awardees offering Group Prenatal Care The following sections outline specific issues and our strategies to address them. Selection Bias for Awardees Serving High -Risk Women Both the University of Alabama (UAB) and th e Medical University of South Carolina (MUSC) are academic medical centers located within larger metropolitan areas that are quite different from other communities in the state. Both attract publicly and privately insured high -risk women throughout their respective states and, for each, one of the Strong Start sites is the only source of care for high-risk 56 pregnant women on Medicaid in the local area and much of the state. Due to this combination of factors, there was concern, a priori, that neither simila r counties nor women in the state with risk profiles similar to those of Strong Start participants could be found to construct a valid comparison group for these awardees. As an alternative, for each of these awardees, we drew women for the comparison groups from the local area and from the best comparison county identified, and then tested the sensitivity of the results. In addition, rather than relying solely on birth certificates to assess risks, we estimated models that include diagnoses from the claims and encounter data to better control for health status than can be achieved using just the birth certificates. However, we found neither approach to be sufficient to adequately control for the pronounced selection bias for these awardees. -level estimates of ese awardees are not included in the Maternity Care Home model Consequently, th impacts. Awardee - and site -level analyses are presented in Volume 2; but the findings should not be interpreted as estimates of the program impacts. Selection Bias for Group Prenatal Care Maternity Care Home and Birth Center awardees had relatively high rates of acceptance among women offered enrollment in Strong Start. This was not always the case among Group Prenatal Care awardees. , generally care their site’s standard women a choice of Many Group Prenatal Care sites also offered short, one ; therefore, the decision to enroll in Group -on-one visits with a clinical prenatal care provider acceptance rate Prenatal Care could lead to selection bias. This is a particular concern in sites where the of Group Prenatal Care is less than 75 percent, as sites with lower rates of acceptance may be more Of the 7 awardees offering Group Prenatal Care in states where we are contaminated by bias. conducting impact analysis, 1 had acceptance ra tes of at least 75 percent in all sites; 3 had acceptance rates of less than 75 percent in all their sites; and 3 had acceptance rates of less than 75 percent in some 56 risk University of South Alabama (USA) is another location, other than UAB, where women in the state can go for high- maternity care. However, USA is different from UAB because their high-risk clinic is not a Strong Start site, although Strong Start women can be referred there if they become high- risk. At UAB, the high- risk clinic is one of the Strong Start sites. 104 YEAR 5 FINDINGS

123 -out approach and the extent to -in or opt for data on which sites used an opt Appendix W sites. See w hich enrollment in Group Prenatal Care was low. hen a Group Prenatal Care site had low Strong Start acceptance rate, women who enrolled in W Group Prenatal Care may have been systematically different than those who chose not to enroll. Moreover, it is not clear what the direction of the bias would be. To address this issue, only awardees or level estimates. percent are included in the model- sites deemed to have acceptance rates over 75 -level analyses that include all sites in the model, regardless of acceptance rates, are presented Awardee in Volume 2. However, these analyses should not be interpreted as impact estimates. ias Contamination B Ideally, our design would rely on comparing Strong Start enrollees to pregnant women receiving prenatal care services in typical Medicaid maternity practices. Achieving this goal would require that the comparison group exclude women who obtain prenatal care from providers delivering care through the Strong Start models and offering enhanced services similar to those offered through Strong Start. However, it was not possible to exclude such women using only birth certificate and Medicaid data. To the extent that women receiving intervention -like services or care end ed up in the comparison group, in an underestimation of Str ong there is uncontrolled “contamination bias” which may have resulted may offer overly conservative estimates to an unknown Start’s effects. Therefore, the impact estimates extent. Omitted Variable Bias Problems of data availability may result in omitted variable bias. While omitted variable bias could come y of sources, three issues are especially relevant for the impact analysis. from a variet First, birth certificates do not contain information on a variety of medical, behavioral, and social risks that may affect birth outcomes for low -income women. Moreover, the medica l and behavioral risks that are on the birth certificate are underreported. To better address the medical risk issue, we estimated alternative models that included a range of variables based on diagnoses codes in order to capture underlying health status. However, this was only feasible in the 9 states with claims data and is limited to births from 2014 and 2015. Second, we cannot identify the hospitals where women delivered their babies. To the extent that tice patterns for which we cannot control, we may cesarean section rates are driven by hospital prac falsely attribute differences in cesarean section rates to Strong Start. Finally, our expenditure analysis relies exclusively on payment information from claims and encounter data. Some states pay supplemental payments to managed care organizations and providers to account for high-risk patients or very sick infants, which are not accounted for in our analysis. To the e comparison extent that Strong Start women have better (worse) birth outcomes than women in th group, the absence of these supplemental payments may understate (overstate) any cost savings due to Strong Start. YEAR 5 FINDINGS 105

124 Omitted Awardee Bias The model level impact analyses were based on 14 awardees in 84 sites that served close to 15,000 Strong Start women. Overall 51.9 percent of awardees, 38.5 percent of sites, and 32.9 percent of participants were included in the impact analysis, which raises the question of whether the model level is evaluation set out to assess whether impact estimates reflect the overall impacts of Strong Start. Th Strong Start funded enhanced services provided in one of three delivery models could improve birth While not all outcomes and reduce costs relative to care Medicaid covered women typically receive. Strong Start awardees or sites were included in the analysis, we have no reason to believe that the effects estimated at the model level for Birth Centers, Group Prenatal Care, or Maternity homes are biased. This is because the main reason that awardees and sites were excluded is that they were located in a state for which we did not obtain birth certificate and Medicaid eligibility data. Our inability to obtain birth certificate and Medicaid eligibility data is unlikely related to the impact of Strong Start on unbiased. of interest. Consequently, we believe that our estimates are our outcomes In addition, the awardees included in this analysis represent a broad range of the types of organizations that participated in Strong Start (e.g., hospital and health systems, health plans, and community -based organizations) and provider sites (e.g., FQHCs, outpatient clinics, nationally certified – the inclusion of a diverse mix of Birth Centers, local health departments, and physician groups) awardee and site types in the impact analys is further reduces the risk that the reported model level This leads us to believe estimates are biased. our results would be robust to the inclusion of awardees in the other states. We were not able to estimate the impact of Strong Two exceptions are worth noting, however. Start in the two Maternity Care Homes where the Strong Start clinic served high risk women from across the state because we did not believe we could identify a credible comparison group. Similarly, we were not able to assess Group Prenat al Care practices that gave women a choice between standard care and Strong Start enrollment in Group Prenatal Care. While a small share of Group Prenatal Care sites is included in the model level analysis, the strategy we chose provided the best chance at estimating the unbiased effect of enrollment in Strong Start and receiving Group Prenatal Care. MODEL -LEVEL RESULTS level estimates of the effect of Strong Start enrollment on outcomes This section presents our model- separately for women receiving care in each of the three delivery models (i.e., Birth Centers, Group Prenatal Care, and Maternity Care Homes). For all estimates that follow, we report differences between Strong Start women and women in the comparison group that are statistically significant at the p<0.01 and p<0.05 levels and note those that are marginally statistically significant at the p<0.10 level. All standard errors in the model -level analysis are clustered at the county level. YEAR 5 FINDINGS 106

125 Birth Centers 41 ). These 21 sites represent 4 Table er sites (see -level analysis includes 21 Birth Cent The model 6 p ercent of all Birth Center sites that participated in Strong Start and served 40 percent of all Strong Start women receiving care in Birth Centers. The assessed differences reflect the effect on outcomes of Strong Start enrollment and receiving care in a Birth Center site in contrast to typical prenatal care. -L EVEL ANALYSIS 41: SITES IN BIRTH CENTER MODEL TABLE By State and Awardee Arizona: American Association of Birth Centers El Rio Birth and Women's Health Center District of Columbia: Providence Health Foundation of Providence Hospital Community of Hope’s Family Health and Birth Center Florida: American Association of Birth Centers Birth & Beyond The Birth Place Rosemary Birthing Home Breath of Life Women's Health & Birth Center Heart 2 Heart Birth Center Birthways Family Birth Center Tree of Life Birth & Gynecology Center Childbirth Options Birth and Wellness Center Agape Midwifery Services Tree of Life Birth & Gynecology Center - Orlando Maryland: American Association of Birth Centers (No Medicaid Claims) Special Beginnings Birth and Women's Center Missouri: American Association of Birth Centers New Birth Company Birth & Wellness Center Pennsylvania: American Association of Birth Centers (No Medicaid Claims) Reading Birth & Women's Center The Midwife Center for Birth & Women's Health South Carolina: American Association of Birth Centers Charleston Birth Place Tennessee: American Association of Birth Centers Women's Wellness & Maternity Center Lisa Ross Birth & Women's Center Infinity Birthing & Wellness Center YEAR 5 FINDINGS 107

126 Birth Outcomes Across most birth and process outcomes, women who enroll in Strong Start and receive care in Birth Centers have more positive outcomes than women in the comparison group (see 42). Infants born Table to women who enroll in Strong Start and receive care at a Birth Center have an average clinical estimate of gestation of 39.0 weeks, which is almost half a week (0.4 weeks) longer than that of infants born to women in the comparison group. Infants born to Strong Start-enrolled women are also 2.2 percentage points less likely to be preterm than infants born to comparison group women (6.3 percent versus percent). There were no significant differences in the share of infants 8.5 born very preterm between the two groups. TABLE 42: EFFECT OF STRONG START ON MATERNAL AND INFANT BIRTH OUTCOM ES, DIFFERENCES BETWEEN STRONG ISON GROUP, BIRTH CENTER MODEL -LEVEL ANALYSIS START AND COMPAR Altern ative e Altern ativ Specification 1: Main Model: cification 2: Spe Claims Sample, Main Model: - 2014 - 2016, Claims Sample, Main Model: Birth Certificate 2014 - 2016, - pari son Com Claims Controls, 20 Outcomes - 2014 - 16, Controls Only, Stro n Group g Start Difference † Difference † Difference † Reweighted (N=3,432) (N=1,853, (N=1,853, (N=325,647) N=114,409) N=114,409) Outco Birth mes Clinical gestational 38.6 0.4** 39.0 0.4** 0.4** (weeks) age Preterm birth rate 6.3% 8.5% -2.7** -2.5** -2.2** 1.7% 2.2% -0.4 -0.5^ -0.4 Very preterm birth rate 78.2** 3,342.8 3,263.8 79.0** Birthweight (grams) 71.9** -1.2^ -1.5* -1.5* 7.4% 5.9% Low birthweight rate Very low birthweight rate 1.1% -0.1 -0.2 -0.2 1.0% Rate of Apgar score greater -0.1 0.0 98.2% 98.2% -0.2 than or equal to 7 Process Outcomes C- section rate 17.5% -11.5** -11.7** -11.3** 29.0% 1 VBAC rate 12.5% 11.6** 11.5** 11.0** 24.2% Weekend delivery rate 23.7% 19.8% 4.0** 4.2** 4.1** Sources: Urban Institute analysis of merged birth certificate and Medicaid data. VBAC = vaginal -section. Claims sample excludes 2016 births, multiples births, and births with missing Notes: birth after C delivery claims. Reported sample sizes refer to the number of cases for which gestational age and birthweight are reported. Sample sizes for other outcomes may slightly vary due to differences in item non-response rates. Same sizes listed for the alternative specification models are for Strong Start and comparison group women, respectively. For cells that contain asterisks or carets, the Strong Start estimate differs significantly from the comparison group using ** ) indicate significance at the 0.01 level; cells that contain one asterisk two -tailed tests. Cells that contain two asterisks ( ^) indicate marginal significance at the 0.10 level. icate significance at the 0.05 level; and cells that contain a caret ( (*) ind All columns marked with a dagger -level analysis are clustered at the county level. All standard errors in the model ) indicate that the difference is a percentage point change in the rate between Strong Start and comparison symbol († women for all outcomes except for clinical gestational age and birthweight, for which the difference is measured in group respectively. weeks or grams, 1 Estimates are among women with a previous C -section. The sample sizes are 1,512 Strong Start women and 58,860 comparison group women. 108 YEAR 5 FINDINGS

127 Consistent with the lower rates of preterm births, infants born to women participating in Strong s more than Start and receiving care in a Birth Center on average weigh 3,343 grams, which is 79.0 gram infants born to women in the comparison group. Infants born to Strong Start women are also percentage points less likely to be of low birthweight compared to infants in the comparison group 1.5 ere are no significant differences between infants born percent versus 7.4 percent, respectively). Th (5.9 to women who enroll in Strong Start and infants born to women in the comparison group in the rate of very low birthweight and in the share with an Apgar score of seven or above. Rates of cesarean section are 11.5 percentage points lower for women who enroll in Strong Start and receive care in a Birth Center (17.5 percent) than for women in the comparison group (29.0 , regardless of whether they planned to birth at the birth center, hospital, or at home . Similarly, percent) rates of vaginal births after cesarean section (VBAC) are 11.6 percentage points higher for women who enroll in Strong Start (24.2 percent) compared to women in the comparison group (12.5 percent). Consistent with lower rates of planned inductions or cesarean sections relative to typical care, 23.7 percent of women who enroll in Strong Start have weekend deliveries compared to 19.8 percent of - t (two percen women in the comparison group. With no planned inductions or cesarean sections, 28.6 sevenths) of deliveries would occur on the weekend. a 42 Table lso shows that these birth outcome results are consistent across the alternative specifications. Alternative specification #1 limits the sample to observations for which claims data are available in 2014 and 2015. This specification holds the set of control variables the same as in the main nal controls for diagnoses that are model specification. Alternative specification #2 adds additio captured in the claims/encounter data. For all outcomes in the alternative specifications, the direction, magnitude, and significance levels are nearly identical to those in the main model specification , which makes us m ore confident that the results from the main analysis are not biased by unobserved conditions . health Expenditure and Utilization Outcomes 43 Table in Strong Start and ed and utilization findings for women who enroll ports expenditure re - 2015 claims sample. Birth Centers in Maryland and d care in Birth Centers for the 2014 receive Pennsylvania are excluded from this analysis because neither state could provide Medicaid c laims data. YEAR 5 FINDINGS 109

128 TABLE OMES, 43: EFFECT OF STRONG START ON MATERNAL AND INFANT EXPENDITURE AND UTILIZATION OUTC -LEVEL ANALYSIS NTER MODEL PARISON GROUP, BIRTH CE STRONG START AND COM DIFFERENCES BETWEEN Main Model: Main Model: - 2015 Main Model: 2014 - - 2015 2014 - Outcomes - 2015 2014 son Group Births, Compar i - Births, Strong Difference Reweighted (N=114,194) = a St rt (N=1,853) nd iture Outco mes (Means) Expe 1 Total expenditures during prenatal period $10 $2,203 $2,192 $6,527 Total expenditures during delivery period $8,286 -$1,759** 2 Total delivery and post -delivery expenditures $12,572 -$2,010** $10,562 Utilization Outcomes (Means) 0.03 1.16 1.19 Number of ED visits 8 months before delivery month Number of hospitalizations 8 months before delivery month 0.03 0.0 0.03 -0.24 0.95 0.71 Number of days in NICU -0.04 0.67 0.63 Number of ED visits for mother 11 months after delivery month Number of hospitalizations for mother 11 months after 0.01 0.04 0.04 delivery month -0.13** 0.99 0.86 Number of ED visits for infant in the first year of life 0.07 Number of hospitalizations for infant in the first year of life -0.01* 0.08 Sources: Urban Institute analysis of merged birth certificate and Medicaid data. ED = emergency department; NICU = neonatal intensive care unit. Reported sample sizes refer to the number of cases Notes: for which gestational age and birthweight are reported. Sample sizes for other outcomes may slightly vary due to differences in item non- resp onse rates. Same sizes listed for the alternative specification models are for Strong Start and comparison group women, respectively. For cells that contain asterisks or carets, the Strong Start estimate differs tailed tests. Cells that contain two asterisks (**) indicate significance significantly from the comparison group using two- ) t (^ hat contain one asterisk (*) indicate significance at the 0.05 level; and cells that contain a care at the 0.01 level; cells t level analysis are clustered at the l significance at the 0.10 le vel. All standard errors in the model- indicate margina county level. 1 During the 8 months before birth. 2 Includes expenditures during the delivery period; infant expenditures during the 11 months after the delivery month; and mother expenditures during the 11 months after the delivery month. Delivery expenditures for women who enrolled in Strong Start and received prenatal care at a Birth n Center and their infants are $6,527, on average, which is $1,759 less than expenditures for women i the comparison group and their infants. Total expenditures from delivery until the infant’s first birthday are $10,562 for women who enrolled in Strong Start at a Birth Center site and their infants, and $12,572 for women and infants in the comparison group, which is a difference of $2,010. There are no significant differences between the two groups in mean expenditures in the 8 months before the delivery period. 110 YEAR 5 FINDINGS

129 To better understand what may be driving observed expenditure differences, several additional potential cost drivers are examined: emergency department visits for mothers and infants, hospital 57 stays for mothers and infants, and NICU days. Infants born to women who enroll in Strong Start have on average 0.86 emergency department visits in the year after their births compared to 0.99 visits for infants born to women in the comparison group. Infants born to women enrolled in Strong Start also -0.01) compared to infants in the comparison group. There are have somewhat fewer hospitalizations ( no other statistically significant differences between the two groups in the other utilization outcomes in 43. Table Summary and Women who participate in Strong Start through Birth Centers have more positive birth outcomes women in the comparison group who receive care from typical improved care processes relative to Medicaid providers. Across the board, observed impacts are large and likely represent meaningful improvements in health and process outcomes that have been targeted by Healthy People 2020 and othe r public health efforts. Overall, our results suggest that receiving prenatal care in a Birth Center is igh -quality option for low -risk women served by the Medicaid program. an effective and h These i Lower achieved at a lower overall cost of care. mproved outcomes are costs are likely driven in part by improvements in care processes such as lower cesarean section rates and inc reased VBACs. However, little is known about the extent to which Medicaid programs and Medicaid managed care The small reductions organizations reimburse differentially for vaginal versus cesarean section births. or the infant in the first year of life likely contribute to lower in emergency room use and hospital visits f costs as well. In addition, midwives and birth centers are paid less for deliveries than physicians and wer costs. hospitals and this differential reimbursement surely accounts for some part of the lo Importantly, the case studies found that many birth centers felt that the Medicaid reimbursement rates Nonetheless, our results suggest that allowing prenatal care to be provided by midwives were too low. in birth centers is an efficient policy for Medicaid programs and managed care plans to consider. The main concern regarding the estimates of the impact of Strong Start for women receiving care in Birth Centers is that these women may be healthier or otherwise different from women who seek care seek prenatal care in a Birth Center are also in traditional settings. If the factors that lead women to related to positive health outcomes and we cannot control for these factors in our model because they are unobserved, our estimates may be biased upwards by selection. We try to address this issue by controlling for a wide variety of characteristics of women that may drive selection into or away from Birth Centers. In addition, using claims data, we controlled for a wide range of health conditions in an effort to better capture health status. Our results remain ed consistent with these controls in place, which provides strong support that our results are robust. 57 NICU days are only available for six of the nine states that provided Medicaid claims data. YEAR 5 FINDINGS 111

130 Group Prenatal Care ). These 11 sites Eleven Group Prenatal Care sites are included in the model -level analysis (see Table 44 a ccount for 18 percent of all Group Prenatal Care sites and 23 percent of Strong Start participants enrolled in Group Prenatal Care sites. For some Group Prenatal Care awardees, only a subset of sites is included in the model-level estimates. As previously discussed, excluded sites offered both traditional and Group Prenatal Care and had opt-in policies that resulted in low acceptance rates, which may The following described differences reflect the impact n. produce estimates that are biased by selectio on outcomes of enrollment in Strong Start and receiving care Group Prenatal Care compared to care. typical TABLE 44: SITES IN GROUP PRENATAL CARE MODEL -LEVEL ANALYSIS By State and Awardee District of Columbia: Providence Health Foundation of Providence Hospital (No Medicaid Claims) Providence Hospital Louisiana: Amerigroup Corporation Associates in Women's Health Baton Rouge Consortium New Jersey: Central Jersey Family Health JFK Medical Center / Family Practice Newark Community Health Center Nevada: HealthInsight of Nevada Renown Pregnancy Center Women's Specialty Care Women’s Health Associates of Southern Nevada Network (No Medicaid Claims) Pennsylvania: Albert Einstein Healthcare Einstein Medical Center Philadelphia Montgomery Hospital Medical Center Tennessee: University of Tennessee Medical Group The Med Hollywood Health Loop 112 YEAR 5 FINDINGS

131 Birth Outcomes presents the effects of enrollment in Strong Start on birth outcomes for awardees and sites 45 Table implementing the Group Prenatal Care model. Overall, there are a few positive differences in birth outcomes at the model level between women who enroll in Strong Start and receive Group Prenatal Care and women in the comparison group. STRONG EEN ES, DIFFERENCES BETW 45: EFFECT OF STRONG START ON MATERNAL AND INFANT BIRTH OUTCOM TABLE -LEVEL ANALYSIS CARE MODEL OUP, GROUP PRENATAL GR START AND COMPARISON Alt ernative Alternative Specifica tion 1: Specification 2: Ma n Main Model: Model: 2014 - i - Claims Sample, Main Model: Claims Sample, ison 2016, Compar 2014 16, - 20 - Birth Certificate 2016, 2014 - Outcomes - Claims Controls, Group Reweighted Str ong Start † Controls Only, Difference † Difference (N=176,822) (N=2,436) † Difference (N=529, N=39,618) (N=529, N=39,618) Birth Outcomes Clinical gestational 0.0 38.5 38.5 0.0 0.0 age (weeks) 10.4% 10.0% 0.4 1.6 1.5 Preterm birth rate Very preterm birth rate 2.5% 2.9% -0.4 -0.4 -0.3 3,141.8 3,149.4 -7.6 -3.1 -9.3 Birthweight (grams) 10.9% Low birthweight rate 0.2 0.4 0.5 10.4% 1.1% 0.2 0.1 -0.4^ 1.5% Very low birthweight rate Rate of Apgar score greater 98.2% -0.2 -0.2 0.6 97.6% than or equal to 7 Process Outcomes -0.5 0.2 1.1 29.5% 30.5% section rate C- 1 20.7% 3.1^ 17.7% 0.7 0.2 VBAC rate -0.2 25.5% Weekend delivery rate 23.4% 2.2* -0.3 Urban Institute analysis of merged birth certificate and Medicaid data. Sources: Notes: -section. Claims sample excludes 2016 births, multiples births, and births with missing VBAC = vaginal birth after C delivery claims. Reported sample sizes refer to the number of cases for which gestational age and birthweight are reported. Sample sizes for other outcomes may slightly vary due to differences in item non- response rates. Same sizes listed for the alternative specification models are for Strong Start and comparison group women, respectively. For cells contain asterisks or carets, the Strong Start estimate differs significantly from the comparison group using that ** two ) indicate significance at the 0.01 level; cells that contain one asterisk -tailed tests. Cells that contain two asterisks ( ^) indicat te significance at the 0.05 level; and cells that contain a caret ( (*) indica e marginal significance at the 0.10 level. All columns marked with a dagger -level analysis are clustered at the county level. All standard errors in the model ifference is a percentage point change in the rate between Strong Start and comparison symbol ( †) indicate that the d group women for all outcomes except for clinical gestational age and birthweight, for which the difference is measured in respectively. weeks or grams, 1 -section. The sample sizes are 362 Strong Start women and 28,671 e among women with a previous C Estimates ar comparison group women. There are no significant effects of enrollment in Strong Start at a Group Prenatal Care practice on the clinical estimate of gestation, rates of preterm or very preterm birth, average birthweight, rates of low birthweight, or having an Apgar score greater than or equal to seven. However, women participating in Strong Start’s Group Prenatal Care model are 0.4 percentage points less likely to have a very low birthweight infant than women in the comparison group. This difference is only marginally significant (p<0.10). YEAR 5 FINDINGS 113

132 For process outcomes, women participating in Strong Start and receiving care at a Group Prenatal Care site are more likely to have a VBAC than women in the comparison group (20.7 percent compared difference marginally significant , a to 17.7 percent) (p<0.10). In addition, 25.5 percent of women participating in Strong Start’s Group Prenatal Care model have a weekend delivery, which is percentage points higher than the rate for women in the comparison group. This suggests that 2.2 awardees implementing the Group Prenatal Care model may be less likely to plan inductions for Strong Start patients than for women in the comparison group ; however, there were no significant differences for the likelihood of having a cesarean section. These results are consistent in direction across the alternative models examined but the effect sizes are much smaller . While no significant differences in Apgar scores, VBAC, and weekend deliveries are different sample and not to the observed in the alternative models, this appears to be due to the addition of diagnostic controls from the claims data. Expenditure and Utilization Outcomes Table 46 presents the effects of enrollment in a Strong Start Group Prenatal Care model on 2015 claims sample. Group Prenatal Care awardees in expenditures and utilization for the 2014 - Pennsylvania and Nevada are excluded from the analysis because Medicaid claims could not be obtained for these states. OMES, 46: EFFECT OF STRONG START ON MATERNAL AND INFANT EXPENDITURE AND UTILIZATION OUTC TABLE DIFFERENCES BETWEEN STRONG START AND COMPARISON GR OUP, GROUP PRENATAL CARE MODEL -LEVEL ANALYSIS - Main Model: 2014 Main Model: Main Model: 2014 - 2015 - - 2015 Births, Strong - 2015 2014 Births, Comparison Group - Outcomes St a ) Reweighted (N=39,618) rt (N=529 Difference = = eans) re Outcomes ( M Expenditu 1 Total expenditures during prenatal period * -$427 $3,064 $2,637 during delivery period Total expenditures $11,645 $12,282 -$637 2 $17,464 $16,286 -$1,177 Total delive ry and post -delivery expenditures Utilization Outcomes (Means) Number of ED visits 8 months before delivery month 1.42 1.44 -0.02 Number of hospitalizations 8 months before delivery month 0.02 0.04 - 0.03 ** Number of days in NICU 0.86 1.09 -0.22 Number of ED visits for mother 11 months after delivery month 0.82 0.92 -0.10** Number of hospitalizations for mother 11 months after 0.05 0.03 -0.02^ delivery month 0.10 1.52 1.62 Number of ED visits for infant in the first year of life ^ 0.01 - 0.09 0.08 Number of hospitalizations for infant in the first year of life Urban Institute analysis of merged birth certificate and Medicaid data. Sources: Notes: ED = emergency department; NICU = neonatal intensive care unit. Reported sample sizes refer to the number of cases for which gestational age and birthweight are reported. Sample sizes for other outcomes may slightly vary due to response rates. Same sizes listed for the alternative specification models are for Strong Start and differences in item non- Strong Start estimate differs comparison group women, respectively. For cells that contain asterisks or carets, the ) indicate significance ** tailed tests. Cells that contain two asterisks ( significantly from the comparison group using two- ^) ain one asterisk ( *) indicate significance at the 0.05 level; and cells that contain a caret ( at the 0.01 level; cells that cont level analysis are clustered at the indicate marginal significance at the 0.10 level. All standard errors in the model- county level. 1 During the 8 months before birth. 2 Includes expenditures during the delivery period; infant expenditures during the 11 months after the delivery month; and mother expenditures during the 11 months after the delivery month. 114 YEAR 5 FINDINGS

133 effects of Strong Start on expenditures and utilization. positive some Overall, there are Expenditures in the 8 months before the delivery period for women who enroll in Strong Start and receive Group Prenatal Care are $2,637, on average, which is $427 less than the average for women in the comparison group. As can be seen in subsequent sections, this effect appears to be driven by large savings in prenatal care costs in New Jersey. There are no differences between women who enroll in Strong Start and receive Group Prenatal Care and women in the comparison group for delivery expenditures alone and for expenditures for delivery and the first year after birth for mother and combined. infant There are some relative reductions in hospitalizations and ED visits for Strong Start women have 0.03 fewer hospitalizations in the prenatal receiving Group Prenatal Care. Strong Start women period than women in the comparison group (0.02 versus 0.04 hospitalizations) and 0.10 fewer emergency department visits in the 11 months after the delivery month (0.8 2 versus 0.92). Relative to the comparison group, women enrolled in Strong Start also have 0.02 fewer hospitalizations in the 11 months after the month their infant was born, and infants born to women enrolled in the Strong Start Group Prenatal Care model have 0.01 fewer hospitalizations. However, these results are only marginally significant (p<0.10). There are no other significant differences in the use of services between mothers enrolled in Strong Start and receiving Group Prenatal Care and their infants and mothers in the comparison group and their infants. Summary affects birth practices Group Prenatal Care No evidence emerged that enrollment in Strong Start in outcomes. However, it does appear to increase the use of VBAC and weekend deliveries and low er use stays. emergency room and hospital Enrollment in Strong Start at a Group Prenatal Care setting is of also associated with a reduction in claims costs in the prenatal period due to a variety of factors , -group care. including lower hospitalization rates and lower reimbursement payments relative to non The chief methodological concern regarding the assessment of the impact of enrolling in Strong both typical prenatal care and Start and receiving Group Prenatal Care is that some awardees offer ed In these sites, only women choosing Group Prenatal Care could be enrolled in Strong Start group ca re. the so were concerned that our estimates may be biased by selection. To address this issue , we limit ed -out” enrollment -level analysis to awardees or sites within awardees that implemented “opt model policies and had opt -in rates that are greater than 75 percent. As a result, only 18 percent of all Strong Start Group Prenatal Care sites and 36 percent of the sites in the states included in the impact analysis were r epresented in the model -level analysis. While this is a small share of the total Group Prenatal Care sites, we believe that our strategy offers the best possibility of an unbiased estimate of the impact of Group Prenatal Care. Maternity Care Homes Fifty-tw o sites are included in the model -level analysis of Maternity Care Homes (see Table 47 ). These 5 percent of the Maternity Care Home sites and provide care to 33 percent of 47.3 2 sites represent women enrolled in Strong Start and receiving care at a Maternity Care Home. The following described differences reflect the effect on outcomes of Strong Start enrollment in a Maternity Care Home compared to typical care. YEAR 5 FINDINGS 115

134 TABLE 47: SITES IN MATERNITY CARE HOME MODEL -LEVEL ANALYSIS By State and Awardee Alabama: University of South Alabama ealth USA Center for Women's H USA OB/GYN Center Street Clinic Mostellar Medical Center Kendal Foster, MD Jean A. Sansarinq, PC - Mobile County Health Department The Women's Center Arizona: Maricopa Special Health Care District Maricopa Integrated Health System's Comprehensive Healthcare Center South Central Family Health Center 7th Avenue Family Health Center Maryvale Family Health Center Sunnyslope Family Health Center District of Columbia: Providence Health Foundation of Providence Hospital (No Medicaid Claims) MedStar Washington Hospital Center Howard University Hospital Mary’s Center Unity Health Care Florida: Florida Association of Healthy Start Coalitions - MLK Jr. Blvd. Tampa Tampa Obstetrics Exodus Clinic Tampa General Hospital Genesis Clinic Clearwater - Community Health Centers of Pinellas Community Health Centers of Pinellas - Pinellas Park Polk County Health Department — Bartow Tampa Obstetrics Exodus Clinic - Tampa Palms Tampa Obstetrics Exodus Clinic - North Lakeland 22nd Street - Tampa Obstetrics Exodus Clinic Maryland: Johns Hopkins University (No Medicaid Claims) East Baltimore Medical Center Johns Hopkins Outpatient Center Bayview Medical Center Wyman Park Center for Addiction and Pregnancy Missouri: Signature Medical Group Allied Associates in OB/GYN Bolivar OB/GYN Genesis OB/GYN OB/GYN Physicians The Healthcare Group for Women Women’s Health Partners Independence Women's Clinic Northland OB/GYN McCaffrey Mississippi: Mississippi Primary Health Care Association (No Medicaid Claims) Improvement (Jackson Hinds Comprehensive Health Center, Inc.) - Central MS Civic Delta Health Center, Inc. Family Health Care Clinic, Inc. Family Health Center G.A. Carmichael Family Health Center, Inc. Greater Meridian Health Clinic, Inc. Mallory (Arenia C) Community Health Center, Inc. Southeast Mississippi Rural Health Initiative, Inc. Tennessee: United Neighborhood Health Services Cayce Clinic Main Street Clinic Dickerson Road Clinic Madison Clinic Southside Clinic Unity Clinic Waverly Clinic 116 YEAR 5 FINDINGS

135 Birth Outcomes 48 Table presents the birth outcomes findings for Maternity Care Homes. There are no positive effects n birth outcomes and improvement in only one in Strong Start in a Maternity Care Home o nrollment of e process outcome (weekend delivery). ES, DIFFERENCES BETWEEN STRONG 48: EFFECT OF STRONG START ON MATERNAL AND INFANT BIRTH OUTCOM TABLE OUP, MATERNITY CARE HOME MODEL-LEVEL ANALYSIS START AND COMPARISON GR Alter tive na Alternative Main Model: Specification 1: Claims Main Model: Specification 2: Claims 2016, 2014 - Main Model: - Sample, Birth 2016, - 2014 - Sample, Claims Compar 2014 - 2016, ison Group Outcomes - Certificate Controls Strong Start Controls, Difference † † Difference Reweighted Difference † Only, (N=9,252) 147,143) (N =3,358, N = (N=372,905) = (N=3,358, N 147,143) = = h Outco Birt mes Clinical gestational -0.1^ -0.1* 0.0 38.3 38.3 age (weeks) 0.4 0.7 0.5 11.3% 11.9% Preterm birth rate preterm birth rate 0.3 0.4 0.4 3.4% 3.8% Very 3,129.7 Birthweight (grams) 3,145.5 -15.7* -15.6 -8.2 Low birthweight rate 11.7% 10.9% 0.8^ 0.7 0.4 0.3* Very low birthweight rate 2.0% 0.3* 0.2 1.8% Rate of Apgar score 96.4% 0.0 0.3 0.4^ 96.4% greater than or equal to 7 Process Outcomes C- section rate 30.9% 31.5% -0.7 0.0 -0.3 1 12.5% -0.3 -0.6 0.7 13.2% VBAC rate 1.1 Weekend delivery rate 20.7% 19.5% 1.1* 1.0 Sources: Urban Institute analysis of merged birth certificate and Medicaid data. -section. Claims sample excludes 2016 births, multiples births, and births with missing Notes: vaginal birth after C VBAC = delivery claims. Reported sample sizes refer to the number of cases for which gestational age and birthweight are reported. Sample sizes for other outcomes may slightly vary due to differences in item non- response rates. Same sizes listed for the alternative specification models are for Strong Start and comparison group women, respectively. For cells estimate differs significantly from the comparison group using that contain asterisks or carets, the Strong Start ) indicate significance at the 0.01 level; cells that contain one asterisk ** -tailed tests. Cells that contain two asterisks ( two cance at the 0.05 level; and cells that contain a caret ( ^) indicate marginal significance at the 0.10 level. (*) indicate signifi All columns marked with a dagger -level analysis are clustered at the county level. All standard errors in the model †) indicate that the difference is a percentage point change in the rate between Strong Start and comparison symbol ( group women for all outcomes except for clinical gestational age and birthweight, for which the difference is measured in weeks or grams, respectively. 1 ample sizes are 1,512 Strong Start women and 58,860 Estimates are among women with a previous C -section. The s comparison group women. There is no significant difference in preterm birth rates between Strong Start women receiving care in Maternity Care Homes and women in the comparison group. Women who enroll in S trong Start and receive care in maternity homes have infants that weigh 3,130 grams, on average, which is 15.7 grams less than infants born to mothers in the comparison group. Twelve percent of Strong Start infants have ntage points higher than the rate for infants in the comparison low birthweights, which is 0.8 perce owever, this result is only marginally significant (p<0.10). There are no effects of enrollment in ; h group Strong Start on rates of very low birthweight or having an Apgar score of seven or hi gher. There are no significant differences in the rate of cesarean section or VBAC between women who enroll in Strong Start and those in the comparison group, but women who enroll in Strong Start are 1.1 percentage points more likely to deliver on the weekend (20.7 percent) compared to women in the comparison group (19.5 percent). YEAR 5 FINDINGS 117

136 The main results are broadly consistent with the alternative specifications with two exceptions. -0.1 weeks) between Strong Start and clinical estimate of First, there is a small negative association ( gestation in the sample that has claims, but not in the sample that adds diagnosis controls in the claims aims data. Second, based on the cl -level analysis, it may be the case that the small, negative, and - significant effect on birthweight in grams and the marginally significant increase in the rate of low birthweight infants might not be significant in the main model and that Apgar scores may have controls. d if diagnoses are included as improve Expenditure and Utilization Outcomes Table 49 presents the results for expenditure and utilization outcomes for Maternity Care Homes in the - 2015 claims sample. Maternity Care Home awardees in Maryland and Mississippi are excluded 2014 because Medicaid claims and encounter data could not be obtained for these states. In general, women who enroll in Strong Start and receive care in Maternity Care Homes have higher expenditures and use more services than women and infants in the comparison group. 49: EFFECT OF STRONG START ON MATERNAL AND INFANT EXPENDITURE AND UTILIZATION OUTC TABLE OMES, -LEVEL ANALYSIS HOME MODEL OUP, MATERNITY CARE STRONG START AND COMPARISON GR DIFFERENCES BETWEEN Main Model: 2015 Main Model: 2014 - - Main Model: 2014 - 2015 - , t Bi i p C - on Group 2014 - 2015 Outcomes om ar hs r s Births, Strong = Difference Reweighted (N=147,143) S ) tart (N=3,358 = nditure Outco Expe mes (Means) 1 $2,527 - $15 $2,512 Total expenditures during prenatal period $546 $8,526 $9,071 Total expenditures during delivery period 2 Total delivery and post -delivery expenditures $12,968 $991 ^ $13,958 Utilization Outcomes (Means) -0.03 1.36 1.33 Number of ED visits 8 months before delivery month 0.06 Number of hospitalizations 8 months before delivery month 0.07 -0.01* Number of days in NICU 1.40 1.23 0.17 Number of ED visits for mother 11 months after delivery month 0.04 - 0.75 0.71 Number of hospitalizations for mother 11 months after 0.05 0.0 0.05 month delivery Number of ED visits for infant in the first year of life 1.33 1.24 0.09^ Number of hospitalizations for infant in the first year of life 0.12 0.10 0.01* Urban Institute analysis of merged birth certificate and Medicaid data. Sources: Notes: nsive care unit. Reported sample sizes refer to the number of cases ED = emergency department; NICU = neonatal inte for which gestational age and birthweight are reported. Sample sizes for other outcomes may slightly vary due to ve specification models are for Strong Start and differences in item non- response rates. Same sizes listed for the alternati comparison group women, respectively. For cells that contain asterisks or carets, the Strong Start estimate differs ** tailed tests. Cells that contain two asterisks ( significantly from the comparison group using two- ) indicate significance ) t (^ *) indicate significance at the 0.05 level; and cells that contain a care that contain one asterisk ( at the 0.01 level; cells lysis are clustered at the indicate marginal significance at the 0.10 level. All standard errors in the model- level ana county level. 1 During the 8 months before birth. 2 Includes expenditures during the delivery period; infant expenditures during the 11 months after the delivery month; and mother expenditures during the 11 months after the delivery month. There are no differences in expenditures for the prenatal or delivery periods between women enrolled in Strong Start Maternity Care Homes and women in the comparison group. However, total expenditures for the delivery and year after birth for th e mother and infant are $13,958 for women who enroll in Strong Start, which is $991 higher than expenditures for mothers and infants in the comparison group. This difference is only marginally significant (p<010). 118 YEAR 5 FINDINGS

137 Women who enroll in Strong Start and receive care in a Maternity Care Home have 0.01 fewer hospitalizations in the prenatal period than women in the comparison group (0.06 versus 0.07 hospitalizations). Women who enroll in Strong Start and receive care in a Maternity Care Home have department and hospital use in the post delivery period that is no different than women in emergency the comparison group. However, infants born to women who enroll in Strong Start visit the emergency department more often and have more hospitalizations than infants of women in the comparison group (1.33 versus 1.24 ED visits and 0.12 versus 0.10 hospitalizations). The difference for emergency room use. visits is only marginally significant (p<010). There are no significant differences in NICU Summary dence that enrollment in Strong Start in a Maternity Care Home improves birth There is no evi outcomes or reduces costs relative to typical care. In fact, this Strong Start model is associated with somewhat worse birth outcomes and higher claims costs only marginally re , but these results a significant and/or were inconsistent across our alternative models. There is a small increase in weekend a small reduction in deliveries, but no other improvements in process outcomes . There is also hospitalizations in the prenatal perio . d but no other effects on utilization Many Strong Start awardees, particularly in the Maternity Care Home model, intentionally targeted women at increased medical risk for poor outcomes or offered stronger encouragement to at-risk women to enroll. If we c annot perfectly account for differences in medical risk between Strong Start our propensity score model, the estimated effects of Strong Start women and the comparison group in similar results when we better controlled for health may be biased downwards. We did, however, obtain providing added confidence to our results. However, Maternity Care Homes using claims data, status are the delivery model that is closest to typical prenatal care , generally women received typical care . That there is generally no improvement in with care coordination and othe r services added on outcomes or costs suggests Strong Start enhanced services layered on top of typical care, the general e in positive model followed by Strong Start Maternity Care homes, are not sufficient to drive an increas outcomes for women served by the Medicaid program. S AWARDEE- LEVEL RESULT This section uses graphics to present awardee -level results for awardees included in the model level rth outcomes (rates of preterm, low to analyze the three key bi analysis and with sufficient sample size - birthweight, and cesarean section) and the three expenditure and utilization measures (expenditures in the prenatal period; total expenditures in the delivery period and year after birth for the mother and infant; and in , but impact estimates for all fant NICU days). Only key measures are presented here outcomes for awardees and sites with sufficient sample size can be found in individual awardee sections 58 in Volume 2. We present results for each Strong Start delivery mode l separately, and awardees are Case Studies section of this arrayed based on the intensity of their intervention (as described in the report). For all estimates that follow, differences between Strong Start women and women in the comparison group that are statistically significant (p<0.01 or p<0.05) are discussed and marginally significant effects noted (p<0.10). 58 For example, estimate for the Lisa Ross AABC site in Tennessee can be found in Volume 2. YEAR 5 FINDINGS 119

138 enters Birth C Birth Outcomes Figure 21 shows the effect of Strong Start enrollment and receiving care in Birth Centers on the rates of preterm birth, low birthweight, and ces arean section for awardees included in the model -level estimates and with sufficient sample size to support the analysis. AABC sites are pooled at the state 59 level, and the awardees are arrayed according to the intensity of the intervention. ES, DIFFERENCES BETWEEN STRONG 21: EFFECT OF STRONG START ON MATERNAL AND INFANT BIRTH OUTCOM FIGURE START AND COMPARISON GROUP, BIRTH CENTER AWARDEE -LEVEL ANALYSIS section Cesarean birthweight Low birth Preterm Intens ity -12 .3 -0.7 -2.2 FL-AABC Awardee B- • ------ -10.2 .9 -0 -1.3 Awardee -AABC TN -&- ----&- • ity High Intens -4.4 -3.3 -7.8 DC-Providence • • • Site Center Birth -10 -15 -10 -5 -5 -15 -10 -5 -15 0 0 0 intervention between Weighted and comparison groups difference Solid circles indicate that the difference is significant at the p<= 0.05 level. Notes: Two of the three birth center awardees show positive impacts of enrolling in Strong Start on preterm birth, with a 2.2 percentage point reduction in the rate for Strong Start women at the Florida AABC awardee and a 3.3 percentage point reduction in the rate for women at the Providence Health Foundation awardee’s Birth Center in DC. There is also variation in the effect of enrollment in Strong Providence Health Foundation awardee’s site have Start on low birthweight. Strong Start women at the a 4.4 percentage point lower rate of low birthweight than women in the comparison group; there is no effect on low birthweight for the pooled AABC sites in Florida and Tennessee . All awardees showed a 7.8 percentage point r rates of cesarean rates for women enrolled in Strong Start that range from lowe lower rate at Providence’s Birth Center site to a 12.3 percentage point lower rate for the pooled AABC no consistent High rather than medium i shows sites in Florida. f the Strong Start intervention ntensity o relationship with outcomes. 59 As described in an earlier section, for birth center awardees, Strong Start interventions that do not include peer -counselor encounters beyond visits with the midwife or that include fewer than four encounters are classified as low -intensity. -intensity interventions include four encounters and no additional enhancements, while interventions with more than Medium -intensity. four encounters or additional enhancements are classified as high 120 YEAR 5 FINDINGS

139 Expenditure and Utilization Outcomes Figure 22 shows the effect of Strong Start enrollment and receiving care at a Birth Center on prenatal and , total expenditures for delivery and the year after delivery for mother and infant, care expenditures NICU days. Awardees are arrayed by intensity of their intervention. OMES, 22: EFFECT OF STRONG START ON MATERNAL AND INFANT EXPENDITURE AND UTILIZATION OUTC FIGURE PARISON GROUP, BIRTH CENTER AWARDEE- LEVEL ANALYSIS STRONG START AND COM DIFFERENCES BETWEEN post-delivery and Delivery NICUdays expenditures care expenditures Medium Intensity -0.19 $54 $-j oo ~ FL-AABC Awardee \J 0 $18 00 0 $- TN-AABC Awardee 0 High Intensity $-219 $-398 DC-Providence r-... r-... '-.../ '--' Center Birth Site ' ' $250 0.00 -0.20 -0.40 ,000 $-500 $-250 $-2 ,000 $2 $0 $0 Weighted difference between intervention and comparison gro ups Solid circles indicate that the difference is significant at the p<= 0.05 level. Notes: There is only one statistically significant effect in this figure: for the AABC sites in Florida, women in -birth expenditures. The 0 lower delivery and year-after Strong Start and their infants have $2,50 intensity of the intervention does not appear to be related to the effect size for these outcomes. Group Prenatal Care Birth Outcomes rong Start on rates of preterm birth, low birthweight, and shows the effects of enrollment in St 23 Figure -level estimates and with sufficient sample size to cesarean sections for awardees included in the model 60 support the analysis. The awardees are arrayed by intensity of their intervention. Consisten t with the model -level findings, no awardees show significant differences between women who enroll in Strong Start and receive Group Prenatal Care and women in the comparison group in the rate of preterm and effect of enrollment in Strong Start Group Prenatal Care is low birthweight births. The only significant sites have cesarean section rates that that women enrolled in Central Jersey Family Health Consortium are 5.1 percentage points higher than women in the comparison group. There is no pattern of e ffect related to the intensity of the intervention. 60 -intensity if they are less than As mentioned previously, for group prenatal care awardees, interventions are classified as low curriculum. Interventions implementing CHI CenteringPregnancy full implementation of the Centering Healthcare Institute’s (CHI) CenteringPregnancy or an equivalent are classified as medium -intensity, and interventions implementing CHI CenteringPregnancy or an equivalent and additional services or content are classified as high-intensity. YEAR 5 FINDINGS 121

140 23: EFFECT OF STRONG START ON MATERNAL AND INFANT BIRTH OUTCOM FIGURE ES, DIFFERENCES BETWEEN STRONG START AND COMPARISON GROUP, GROUP PRENAT -LEVE AL CARE AWARDEE L ANALYSIS section Preterm Cesar hweight t bir Low t h bir e an s Low Inten ity -4.6 2.9 4 Si TN-Hollywood t e 0 0 0 ensity Int M edium -1.7 0.7 0 LA-Ame n W oma rigroup 's Sit e 0 0 -0.4 -1.3 0.1 ee NV-H IN Award -e- -e-- 0 6 0.8 0. 2 ee PA-Ein Aw stein ard -e-- 0 --e- Hi gh Int ity ens 0.4 1.7 .1 5 FHC rk Newa CJ NJ- -e- -e- + JFK Awardee • -5 -5 -5 0 10 10 5 0 5 10 5 0 Wei intervention ce between compar and i son group s differen ghted level. Notes: Solid circles indicate that the difference is significant at the p<= 0.05 Expenditure and Utilization Outcomes Figure 24 presents the awardee effects of Strong Start on expenditures in the prenatal period; total expenditures for delivery and the year after delivery for mother and infant; and NICU days for ient sample size to make estimates. awardees that are included in the model -level analysis and had suffic - For the two sites from the Central Jersey Family Health Consortium awardee included in the model level analysis, enrolling in Strong Start’s Group Prenatal Care model is associated with $717 lower -after -birth expenditures. However, the res and $1,581 lower delivery and year prenatal care expenditu alue<0.10). There are no other delivery and post -delivery costs are only marginally significant (p -v lower sign ificant effects for this awardee or any other Group Prenatal Care aw ardee. FIGURE 24: EFFECT OF STRONG START ON MATERNAL AND INFANT EXPENDITURE AND UTILIZATION OUTC OMES, STRONG START AND COMPARISON GROU -LEVEL ANALYSIS DIFFERENCES BETWEEN P, GROUP PRENATAL CARE AWARDEE el D ivery and post-delivery NIC care expenditures U days Prenata l exp enditures In te ns i ty Low $-248 $387 Ho llywood Sit e TN- 0 0 Me ntensity I dium $-273 $79 W oman's -Amer Si t e LA igroup 0 I High ntensity -0.22 $-7 17 r k C Newa FH CJ NJ- Award ee + JFK • 000 $-1,000 $-500 $0 0.00 -0.40 $500 -0.80 $0 $2 ,500 $5 , $-2,500 s ht ig ups ro g on We compari ion and en intervent e betwe differenc ed that the difference is significant at the p<= 0.05 level. Notes: Solid circles indicate 122 YEAR 5 FINDINGS

141 Maternity Care Homes Birth Outcomes -specific effects of enrollment in Strong Start on the rate of preterm birth, presents awardee 25 Figure low birthweight, and cesarean section for awardees included in the model -level estimates. Consistent level results, there are few with the model- positive effects at the awardee -level. Awardees are arrayed 61 by the intensity of their intervention. 25: EFFECT OF STRONG START ON MATERNAL AND INFANT BIRTH OUTCOM ES, DIFFERENCES BETWEEN STRONG FIGURE START AND COMPARISON GROU P, MATERNITY CARE HOM E AWARDEE-LEVEL ANALYSIS Low birthweight Preterm birth Cesarean section Intensity 0.7 -3.1 1.4 AL-USAAwardee --e--- 0 0 -6.2 -0.1 ·0.4 ardee Aw -Maricopa AZ 0 0 • Intensity M edium 2.4 1.2 0.1 Awardee -Providence DC -e- ~ 0 2.3 2.8 ·0.7 MD ee ard Aw -JHU 0 -+-- -+-- -0.2 ·0.5 0 MS-MP e Awarde HCA --e--- ~ ~ -0.5 -1.4 ·1. 1 TN-UNHS arde Aw e -e- --e--- 0 i Intens High ty 2.2 3.6 1.7 Aw FL-FAHSC ard ee 0 -+-- -0.5 -2.8 0.1 ---- MO re Awardee -Sig natu -B- ~ • .5 .5 .5 -10 0 - 10 0 ·1 5 0 5 0 5 and comparison nt interve between difference Wei11hted ion 11raups When diagnoses controls are employed, the is significant at the p<= 0.05 level. Notes: Solid circles indicate that the difference difference in the rate of preterm birth between Strong Start and comparison group women was not significant for the Florida Association of Health Start Coalition. Strong Start women at two awardees , the Florida Association of Healthy Start Coalitions and the 2 percentage points , have rates of preterm birth rates that are more than Johns Hopkins University However, when diagnoses controls from the claims higher than women in the comparison group. analyses are employed, for the Florida Association of Health Start Coalitions awardee the difference is Both the Florida Healthy Start a not shown). reduced and is not significantly different than zero (dat s of low birthweight for infants of higher rate Coalition and Johns Hopkins University awardees show women who enroll in Strong Start relative to infants of women in the comparison group. 61 -intensity if they include fewer As mentioned previously, for maternity care home awardees, interventions are classified as low than four encounters. Interventions with four or more encounters that only provide education and referral services or intensity. High-intensity interventions with fewer than f our encounters that provide direct services are classified as medium- interventions include four or more encounters and the provision of direct services. YEAR 5 FINDINGS 123

142 Lower rates of cesarean sections associated with Strong Start enrollment are found for three 62 awardees, with reductions ranging from 2.8 percentage points for women enrolled at the Signature Medical Group awardee to 6.2 percentage points for women enrolled at the Maricopa Special Health Care District awardee. Reductions in cesarean section rates are greatest among awardees with low - intensity interventions. Expenditure and Utilization Outcomes 26 -level estimates of the effect of Strong Start enrollment on expenditures in presents awardee Figure the prenatal period, expenditures for the delivery and year after birth, and NICU days. Overall, there fects at the awardee level. significant ef positive are few FIGURE OMES, 26: EFFECT OF STRONG START ON MATERNAL AND INFANT EXPENDITURE AND UTILIZATION OUTC EE-LEVEL ANALYSIS STRONG START AND COM PARISON GROUP, MATERNITY CARE HOME AWARD DIFFERENCES BETWEEN ivery and post - delivery l De ar c al at e expendit ur es NICUdays i tures expend sit ow Inten L y $3,003 0.23 $29 USA AL- Awardee 0 • $837 $320 0.02 AZ-Maricopa Awardee 0 0 • sity en Med ium Int $155 $-186 d Awar DC -Providence ee 0 0 7 $-30 $1,035 U TN- ee d Awar NHS 0 en y sit High Int ,232 $2 $388 0.58 d Awar HSC -F A FL ee • • -0.14 $-286 $-358 MO-Signature Awar d ee 0 -e- • $2 ,500 0.50 0.00 $-2,500 -0.50 $-400 $5 ,000 1.00 $0 $400 $0 intervention Weighted between and groups difference comparison Solid circles indicate that the difference is significant at the p<= 0.05 level. Notes: Enrollment in Strong Start is associated with higher prenatal care expenditures at the Maricopa Special Health Care District awardee site (marginally significant at p<0.10) d lower prenatal care an p<0.10) and Signature Medical expenditures at Providence Health Foundation (marginally significant at Group awardee sites. Strong Start enrollment at the Florida Healthy Start Coalition awardee was associated with expenditures that ar e $388 higher during the prenatal periods and $2,232 higher for and marginally significant at total delivery and the year after birth, with higher NICU use (0.58 days d effects on The University of South Alabama awardee also ha group. p<0.10) relative to the comparison total expenditures for delivery and the first year of life that are around $3,000 higher than those for women and infants in the comparison group. 62 10) -value<0. The estimated effect at the USA Awardee is only marginally significant (p . 124 YEAR 5 FINDINGS

143 DISCUSSION , after adjusting for maternal risk factors, birth outcomes varied The previous chapter showed that . However, one of the most basic research questions this evaluation across the Strong Start models is “What is the impact of Strong Start on infant gestational age, birth weight, rate of intended to answer Cesarean Section, and cost for women and infants during pregnancy and the first year of life?” Answering this question required an impact analysis with an external comparison group of women not sing linked birth certificate, Medicaid eligibility, and served by Strong Start. This impact analysis, u Medicaid claims/encounter data, compare d birth and cost outcomes for women participating in Strong Start enhanced prenatal care to outcomes for non-participating Medicaid- enrolled women with similar s of ropensity scor e reweighting to develop comparison group risk profiles. The analysis employed p women enrolled in Strong Start. Awardees he women with closely matched risk profiles to t 5 states in 1 of Strong Start on birth outcomes were included in the estimate of impact ; nine of these states provided d the impact of Strong Start on birth outcomes and costs ims data for the cost analysis. We estimate cla for Birth Centers, Group Prenatal Care providers, and Maternity Care Homes and at at the model level It is important to note that the size -level when sufficient sample e analysis. the awardee ed th support impact analysis could not examine outcomes for all Strong Start participants, as data could not be , 40 percent of Birth Center participants, 23 obtained from some states on a timely basis. As a result percent of Group Prenatal Care participants, and 23 percent of Maternity Care Home participants are included in this analysis. The impact analysis complements the results of the PLPE regression analysis of Strong Start outcomes presented in the previous chapter. With an analysis that a comparison group of includes women finds that Birth the impact analysis who did not participate in Strong Start, with similar risks ly more positive birth outcomes than women in d consistent Center participants ha comparison the s. of 39.0 Specifically, infants born to Birth Center participants ha group d an average gestational age weeks, almost half a w eek longer than that of infants born to comparison group women. Strong Start Birth Center infants were also 2.2 percentage points less likely to be preterm than comparison group men and non-Strong Start infants (6.3 percent vs. 8.5 percent). This difference between Birth Center wo between Birth Center and point difference 7-percentage women is substantially less than the Maternity Care Home Strong Start participants observed in the previous chapter, but the size of the difference is r study comparing Birth Center participants to Medicaid enrollees in the consistent with an earlie District of Columbia using similar methods (Benatar et al.). That the model level estimate was similar to what was found in the single District of Columbia study provides further supp ort for our contention that the results are robust and likely unbiased. Strong Start Birth Center infants were also 1.5 percentage points less likely to be born at low birthweight. Rates of C-section deliveries were 11.5 percentage points lower for Strong Start women who received care in a Birth Center (17.5 percent) than for women in the comparison group (29.0 percent). The differences in C -section rates were actually larger than those observed when Birth Center deliveries were compared to Maternity Care Home deliveries. Overall, our results suggest that receiving prenatal care in a Birth Center is an effective and high -quality option for medically low -risk women served by the Medicaid program. Because Birth Centers screened out most women at moderate to high medical risk, these results cannot be applied to such women. YEAR 5 FINDINGS 125

144 In the previous chapter we observed some differences in outcomes when Group Prenatal Care participants were compared to Maternity Care Home participants. However, these differences were served in the impact analysis when these participants were compared to non not ob -Strong Start There were no significant effects of Strong Start enrollment on gestation al age, rates of women. preterm birth, average birthweight, or Thus, rates of low birthweight. the findings from the regression analyses in the previous chapter showing differences between Group Prenatal Care and Maternity Care Homes were not generally confirmed when Group Prenatal care is compared to routine Medicaid 63 maternity care. However, we fo und one positive difference in birth outcomes for Strong Start Group Prenatal Care participants compared to women receiving typical Medicaid prenatal care. Women in are more likely to have a weekend delivery (25.5 percent) than women in the Group Prenatal Care comparison group (22.0 percent), suggesting that awardees may have been less likely to plan inductions This is consistent for Strong Start women than typical prenatal care providers were with their pa tients. with a similar finding for Birth Centers. It is possible that education provided in Group Prenatal Care encourage women visits or by peer counselors in Birth Centers some provider’s reject to not ask for and led preference for schedu . deliveries that enrollment in Strong Start Maternity Care from the impact analysis evidence no There is Homes improved birth outcomes . The fact that Maternity Care Homes provided such a diverse array of However, the in some places and not in others. services meant that outcomes might have improved examination of awardee -specific outcomes also showed no birth outcome improvements with two exceptions. C-Section rates were lower for two Maternity Care Homes. both lower If preterm delivery and birth weight rates are in Birth Centers, along with lower rates of C-Section, it seems likely that Medicaid costs for Birth Center enrollees would also be lower than those n Strong Indeed, the impact analysis found that Birth Center participants i in traditional prenatal care. Start had a lower cost to Medicaid . Delivery expenditures for women enrolled in Strong Start Birth Centers and their infants were $6,527 on average, which was $1,759 less (or 21 percent) than for women in the comparison group and their infants. Total expenditures for the mother and infant from delivery until the infant’s first birthday were $10,562 for women enrolled in Strong Start Birth Centers on average, which was $2,010 less (or 16 percent) than for women and infants in the comparison group. difference Lower costs appeared to be driven by -Section rates, and small reductions in the lower C s in number of infant emergency department visits and hospitalizations following delivery. Lower costs were also likely due to lower reimbursement rates for deliveries in Birth Centers relative to hospitals delivered at a Birth Center. T he case studies found given that 46 percent of Birth Center participants that many birth centers felt that Medicaid reimbursement rates were too low to incentivize extensive participation in Medicaid, and some found them too low to cover costs. Nonetheless, our results suggest prenatal care to be provided by midwives in birth centers is an that ensuring women have access to efficient policy for Medicaid programs and managed care p lans to consider. 63 Importantly, the impact analysis included only Group Prenatal Care Sites with high acceptance rates while the PLPE data included all sites. 126 YEAR 5 FINDINGS

145 It is not surprising that Group Prenatal Care enrollees did not have lower delivery and postnatal Medicaid costs than comparison group Medicaid women and infants, given that their outcomes were However, prenat al care expenditures were lower for Strong Start Group not significantly different. Expenditures in the Prenatal Care enrollees compared to women in typical Medicaid prenatal care. eight months prior to delivery for women enrolled in Strong Start Group Prenatal Care were $2,637 on ave rage , which was $427 less than the average for women in the comparison group. Since much of the care is provided in a group setting, and with equivalent outcomes to other Medicaid women, Group Prenatal Care may offer a lower cost alternative to traditional Medicaid prenatal care. Again, these findings apply only to those enrollees included in the impact analysis, a relatively small subset of all Still, the findings were substantially similar across the Group Prenatal Group Prenatal Care enrollees. Care awardees included in the impact analysis, lending credibility to the analysis. that enrollment in Strong Start Maternity Care There is no evidence from the impact analysis . This is consistent with the lack of Homes reduced costs relative to typical Medicaid prenatal care significant differences in birth outcomes between women served in Maternity Care Homes and other . Medicaid women Conclusion Strong Start funded three alternative enhanced prenatal care models to determine whether they could and reduce costs . In the case of one of the models, Birth Centers, we found mes lead to better outco — both in comparisons to outcomes for other Strong Start women and non- Strong consistent evidence that implementing a Birth Center model of care improved outcomes Start women with similar risks — and reduced costs for Medicaid maternity care. The evaluation’s case studies suggest that these improvements may grow from Birth Centers’ more holistic midwifery model of care that focuses more time on education and psychosocial support. Of the three models, this is the one that is most different from the typical care received by Medicaid covered women. Regardless, there are serious issues concerning the generalizability of these findings to other places and to more Medicaid women because currently Birth Centers serve primarily women at low medical risk, as evidenced by the PLPE data. Such a model would need to be vastly expanded beyond its current scope . Group Prenatal Care also showed some promise, particularly with lowering the cost of p renatal care . As is true of Birth Centers, Group Prenatal care offers a model of care that is qualitatively . However, the case studies found that the model can be challenging to care different from typical women. -enrolled implement for Medicaid respondents told us that it was difficult awardee ar, In particul -hour sessions, and the PLPE data bore this out, with for patients to commit to the fixed schedule of two women receiving 5.7 group visits on average compared to the standard 10 sessions in the transportation Centering . Many women curriculum missed group appointments because of Pregnancy issues and other barriers. The model that seems most easily generalizable to many different settings is the Maternity Care care manager onto a more typical model of obstetric Home , which generally layered the services of a care . However, the Strong Start evaluation, consistent with many (though not all) previous evaluations of enhanced are models that emphasize maternity care case management, such as Healthy Start in the 1990s (Devaney et al.), found that Maternity Care Homes did not lead to changes in birth outcomes in most places. This is perhaps due to the challenges both inside and outside the health care system that YEAR 5 FINDINGS 127

146 make it difficult to address the large array of intrac table social, physical, and mental health problems that faced high risk women served by Maternity Care Homes, and in general the highest risk women enrolled in Medicaid. s. While the Finally, our analytic approach is observational and therefore has potential limitation design faces challenges from selection, contamination, and omitted variable bias, we used a propensity score reweighting strategy to assure that women in the comparison group were similar to women enrolled in Strong Start along a wide variety of characteristics and limited our analysis to the awardee sites that represented a good experiment. We also analyzed a relative small share of all Strong Start enrollee sites, for the most part, because birth certificate and Medicaid data could not be obtained from the state in which they were located. We have no reason to believe that our results are biased by the exclusion of these awardees or sites, especially given the diverse nature of the awardee sites that are included in the analysis. Finally, the impact analysis was limited in the outcomes that were available on There are many other outcomes such as birth certificates and Medicaid claims and encounter data. satisfaction with care, initiation and continuation of breastfeeding, depression and anxiety family and planning that could not be examined by this evaluation, but for which our case studies and focus groups suggest may have improved as a result of Strong Start. 128 YEAR 5 FINDINGS

147 of Findings Summary e Strong Start for Mothers and Newborns initiative, which funded enhanced services through three Th evidence-based prenatal care models Birth Centers, Group Prenatal Care, and Maternity Care — aimed to improve maternal and infant outcomes for pregnancies covered by Medicaid and — Homes We synthesize five years of findings regarding the program’s implementation and impacts to CHIP. determine its effects on birth outcomes, health care delivery, and the cost of care. This final report from the evaluation presents results from the study’s qualitative and quantitative data collection and analysis, and a s ummary of key findings is presented in the following sections . RONG START? WHO WAS SERVED BY ST The Strong Start evaluation’s Participant Level Process Evaluation (PLPE ) collected detailed information on the demographic profiles and risk characteristics of every woman that was served under the initiative, as summarized below. provided enhanced prenatal care for a large and diverse group of women. Strong Start The Strong Start 46,000 women and their infants. for Mothers and Newborns initiative touched the lives of nearly According to the PLPE data collected by the evaluation, Strong Start participants were Medicaid pregnant disproportionately black (40 percent) and Hispanic (30 percent) compared with (who are 25 percent black and 20 percent Hispanic) (Kaiser Family Foundation, beneficiaries overall of awardees in 2016). The overrepresentation of black women was driven, in part, by the large number the southeaster n U.S. where there is a conce ntration of black residents , and is notable because overall black women across all income levels are more likely than white or Hispanic women to experience adverse pregnancy outcomes (Zhang et el. 2013; Martin et al 2015). The vast majority of Strong Start the healthiest age range for pregnancy — participants were between 20 and 34 years old (76 percent) — with a mean age of women having their first birth considerably younger than for women across the U.S. (22.6 vs. 26.6 years of age). Meanwhile, the share of Strong Start participants who were married (one - quarter) was substantially lower than reported in other studies of low -income mothers, though larger studies have shares did report either living with or having a partner. These factors are imp ortant as shown that both the type and quality of a woman’s relationship can have bearing on pregnancy and birth outcomes. Strong Start participants faced a large number of social and medical challenges that placed them at risk Women enrolled in Strong Start experienced a multitude of social of experiencing poor birth outcomes. and economic challenges. Nearly half were neither employed nor in school, more than a quarter had not experienced lege degree. A fifth col , and just 15 percent possessed a high school or a GED completed -third reported one or more barriers to accessing prenatal care (most food insecurity, and more than one commonly not having a car or money to afford a ride). Nearly 28 percent of Strong Start participants screened positive for depression a rate more than twice what is reported in the literature for pregnant — women generally — while more than 35 percent had some level of anxiety . (Bennett et al. 2004; Melville et al. 2010; Katon et al. 2011; Gavin et al. 2005). 12 SUMMARY OF FINDINGS 9

148 In addition to considerable psychosocial needs that placed Strong Start participants at risk of poor birth outcomes, many also suffered from chronic health conditions that can make pregnancy risky. In nd obesity among women of line with national trends that indicate increasing rates of overweight a more than a third of Strong Start participants were participant reproductive age, -level data show that majority of women in Strong Start had previously The 26 percent were overweight. obese and another many of these women had experienced a prior poor birth outcome. given birth (61 percent) and ore M than 20 percent had a prior preterm birth (before 37 completed weeks of gestation), the strongest predictor of subsequent preterm birth. Almost 30 percent of program participants reported a short interpregnancy interval (measured as less than 18 months) between their Strong Start pregnancy and their prior birth . C losely spaced pregnancies do not allow sufficient time for a woman’s body to heal, increase the risk of maternity complications , and also increase the risk that infants will be born preterm, at low birthweight, or small for gestational age. ? WHAT WERE THE STRONG START INTERVENTIONS The Strong Start enhanced prenatal care models were designed to address perceived weaknesses in in “typ ical” prenatal care delivery models. The vast majority of Medicaid maternity care is offered , Federally Qualified Health Centers, practices physician settings such as private solo and/or group hospital outpatient department clinics, and is delivered und er prepaid managed care arrangements. insufficient attention to , paying overly medical in focus Criticisms of typical care include that it is psychosocial risks that contribute to poor birth outcomes, such as poverty, unsafe housing, food may overly interventionist (in that insecurity, intimate partner violence, and mental health; providers rather than wait for natural induce labor or perform C-section deliveri — without medical indication es labor — at the first hint that waiting could endanger the health of mother or infant); insufficiently focused on education on such critical issues as nutrition, exercise, childbirth preparation, brea stfeeding, continuity , in that be seen by many, pregnant women will usually and family planning; and lacking in different health care providers over the course of their prenatal, delivery, and postpartum care, thus each an and strong, trusting relationships between wom undermining the establishment of a her provider. The evaluation’s case study component involved site visits to Strong Start awardees (and selected provider sites) in years one and three of the investigation, and telephone interviews with awardee and site staff in years two and four. Taken together, this qualitative data collection allowed the evaluation to differed from develop a nuanced understanding of the three Strong Start interventions , how they and how they were implemented, as highlighted . follows “typical” Medicaid prenatal care, as 130 SUMMARY OF FINDINGS

149 Birth Centers provided the midwifery model of care supplemented by peer counselors who provided support, health education, and referrals. Two Strong Start awardees implemented the Birth Center model and served approximately 20 percent of all Strong Start participants, who received their in 47 sites prenatal care at the Birth Center, regardless of where they gave birth. In the evaluation’s case studies, we found that all sites reflected two key components in their models: 1) prenatal care following the midwifery model, and 2) psychosocial support, health education, and referrals to additional resources provided by a “peer counselor.” The midwifery model of care, an inherent feature of birth centers, involves a holistic and wellness approach to pregnancy and birth that is usually more time -intensive than typical OB/GYN care. The peer counseling service added under Strong Start varied somewhat across sites i n terms of the number of contacts counselors had with women during pregnancy, whether those contacts were in person or by phone, and what qualifications counselors possessed. Most peer counselors were hired because they reflected the community and patient population served by Strong Start, and many also had clinical or health education backgrounds as nurses, social workers, lactation consultants, doulas, or other community health workers. engaged groups of women about 10 times over their pregnancies and provided in- Group Prenatal Care depth education during two -hour facilitated sessions. Fifteen awardees implemented Group Prenatal and served approximately 23 percent of Strong Start participants. All of these awardees 0 sites Care in 6 provided prenatal care in a group setting via a series of facilitated, face -face sessions covering a -to broad range of issues, including health assessment, education, and support. Group Prenatal Care awardees were also uniform in their emphasis on building strong peer relationships among enrolled pregnant women. The majority of awardees followed the Centering Healthcare Institute’s curriculum and standards closely (i.e., providing 10 sessions, using co-facilitators, CenteringPregnancy and creating cohorts of women with similar ges tational age). But individual sites affiliated with roughly one -third of awardees adopted approaches that significantly departed from Centering. One site conducted 12 sessions, while another held just six, for example. Several awardees grouped women based on demographic features or risk factors rather than (or in addition to) gestational age. Examples of this included sites that formed groups for women who were Spanish speakers, adolescents, or who had gestational diabetes, opioid addiction, HIV, Zika virus, or rheumatic diseases. Maternity Care Homes augmented typical prenatal care with the addition of “care managers” to Maternity Care Home facilitate coordination and provide psychosocial support services. s, which served 57 percent of S trong Start participants through 17 awardees and 112 sites, were the most varied in their . Their most consistent feature was the addition of approach and the intensity of their interventions “care managers” to provide care coordination and psychosocial support to enrolled pregnant women, in addition to the typical obstetrical care they received. Beyond this, Maternity Care Homes varied in the types of individuals who acted as care managers, the number and mode of encounters, and the types of services they provided. Most assigned women to a single care manager, but some used teams of two managers with complementary skills, such as a nurse (for clinical matters) and a social worker or community health worker (for psychosocial needs). Some awardees featured additional Strong Start components beyond care management, including providing dental care, childcare, and nutrition education classes during prenatal visits. SUMMARY OF FINDINGS 131

150 Intensive education , psychosocial support, and referrals to non- medical services were primary attributes of all Strong Start models. Though the three Strong Start models were distinct in their approaches to enhancing the scope and quality of prenatal care, we learned through the case studies that they also shared many similar features. Each went beyond an exclusively medical focus to provide a range of educational interventions designed to improve outcomes, addressing such topics as nutrition, exercise, family planning/birth spacing, breastfeeding, stress management, smoking cessation, oral hygiene, abnormal pregnancy symptoms, preterm birth prevention, childbirth preparation, and normal and infant care and safety, among others. In Birth Centers and Maternity Care Homes, education was generally delivered one-on-one as part of midwif e and peer counselor, or care manager encounters, respectively. In Group Prenatal Care, education occurred during group sessions and discussions. facilitated Furthermore, across models, Strong Start staff strived to make referrals (as possible) to non- medical services not provided during prenatal visits that could support healthy pregnancies. Participants, often not aware of what resources were available, were referred to services that food support programs like SNAP and WIC, behavioral health providers, dental commonly included care, domestic violence services, housing support, transportation services, childcare resources, and utility assistance programs, for example. At Birth Centers and Maternity Care Homes, referrals were peer counselor s and ve s, midwi , often based on the made directly by s (respectively) and care manager results of a needs assessment conducted with the evaluation’s Intake Form. Group Prenatal Care awardees, in contrast, often invited guest speakers to join group sessions who provided information urces, as well as supplemental materials with contact information. Guest about programs and reso speakers commonly included pediatricians, social workers, doulas, domestic violence counselors, lactation counselors, family planning counselors, and WIC staff. -based Finally, the three mod els shared an emphasis on psychosocial support through relationship care. For Group Prenatal Care awardees, this support was provided by group facilitators, but also— perhaps more importantly by the participants themselves. Case studies found that gro up members — respected and learned from each other’s experiences and felt both supported by and accountable to , the midwife and peer counselor provided psychosocial support; in one another. For Birth Centers care manager Maternity Care Homes, this role was filled by the . Peer counselors and care managers were sometimes licensed clinical social workers, expert at providing counseling. More often, however, they were less formally educated peers who took time to sit with women, check in on how their pregnancies were going, and provide a welcoming ear, or shoulder to lean on, if they were experiencing life difficulties. Awardees across all three models strove for continuity and consistency in Strong Start staff, as having women meet with the same group facilitator, peer counselor, or care manager throughout their pregnancies resulted in more trusting relationships. 132 SUMMARY OF FINDINGS

151 Strong Start awardees through worked hard to address a broad range of implementation challenges creativity, adaptability, and persistence. Across models, common implementation challenges included identifying and enrolling eligible women into Strong Start, integrating enhanced prenatal care services - and evaluation data burdens. Early in the into existing models of care, and handling program -related tration period, many awardees perceived that prenatal care providers did not support Strong demons Start because they made few referrals to the program. Some women resisted joining the initiative because they had given birth before and did not believe they needed extra help. Maternity Care Home care managers and Birth Center peer counselors often struggled to integrate Strong Start encounters into providers’ normal patient work flow, while Group Prenatal Care programs faced challenges establishing schedules for group care appointments within a traditional obstetrical office setting. Strong Start program and evaluation data collection requirements were significant and could take valuable time away from patient care. More intractable was the challenge that a wardees o ften struggled to address the full scope of their clients’ needs because most communities had insufficient resources to help with mental health, substance abuse, transportation, affordable childcare, and housing. women Over time, however, Strong Start awardees refined their approaches to care, often “hitting their stride” by the midpoint of the demonstration. Positive adaptations included: adopting “opt out” recruitment systems that automatically enrolled women into Strong Start unless they explicitly requested to not be involved; establishing clearer and more coordinated staff roles and responsibilities; adjusting enhanced service delivery practices to better fit the needs of patients and provider practices; building stronger relationships with obstetrical providers that enhanced both coordination of services and referrals; and hiring additional administrative staff to help with data collection and reporting. ES WITH WHAT DID WOMEN SAY A BOUT THEIR EXPERIENC STRONG START? Participant focus groups gave voic e to the experiences of pregnant and postpartum women who enrolled in Strong Start. As part of the evaluation’s case studies, we conducted 120 focus groups with nearly 900 pregnant and postpartum women during Years 1 and 3 of the evaluation (Hill et al, 2014; Hill et al, 2017). These groups, conducted in either English or Spanish as appropriate, explored a broad range of topics relating to their experiences and satisfaction with enhanced prenatal care under the program, and their feelings about Strong Start compared to experiences with more typical prenatal care under Medicaid with prior pregnancies. Key themes from what we learned and selected quotes are below. provided Women praised the additional time and attention received under Strong Start. “Here I get more time with [my midwife]. I definitely have more time to ask a question.” (Birth Center participant) Women valued the emotional support received from Strong Start providers. “[The peer counselor ] has an ability to relate to you on a personal level that is...very unique...feeling like you’re important, like your needs really matter.” (Birth Center Participant) SUMMARY OF FINDINGS 133

152 Intensive education on breastfeeding and family planning were highly valued. “My care coordinator motivated me to breastfeed my daughter. Breastfeeding didn’t work with [my] other two [children], but it’s working now.” (Maternity Care Home participant) “They ask you as soon as you come in what kind of birth control you are planning to use. They don’t force you or anything...they just want you to know about the options.” (Group Prenatal Care participant) Participants liked that partners were welcome to attend and participate in visits. “My partner gets to ask the questions he’s curious about. The participation is good for him...” (Birth Center participant) based services and resources. men appreciated the referrals they received for community- Wo “I didn’t have money for my lights, so [the care coordinator] got in touch with someone to help me with d diapers.” (Maternity Care that. She helped with getting a baby crib, car seat, clothes, an Home participant) Women felt more prepared for childbirth under Strong Start. “I felt a lot more prepared [with this pregnancy], not just because I knew what I was going through, but Centering group.” (Group Prenatal Care participant) because I felt I had more support through the Women’s experiences under Strong Start were more positive than with prior pregnancies. “With my OB/GYN, there was more alarm and anxiety that make me on edge. [At the birth center] I feel relaxed, comfor ted, [and] more personal.” (Birth Center participant) STRONG START WHAT OUTCOMES DID PARTICIPANTS EXPERIENCE? collect ed detailed , individual -level data for all Strong Start The evaluation’s PLPE component also on a wide range of measures, including breastfeeding, family planning, delivery intentions, participants service use, satisfaction, and birth outcomes. With regard to birth outcomes, descriptive analyses of highlight a number of the PLPE data important findings by model. For example, rates of preterm birth varied considerably across the three of Strong Start models, with women served by Birth Centers experiencing dramatically lower rates preterm birth (4.5 percent) than women served by either percent) or Group Prenatal Care sites (12 Maternity Care Homes ( 12.9 percent). Similarly, rates of low birthweight among Birth Center (3.6 percent) than for Group Prenatal Care and Maternity Care Home participants were much lower participants ( he rate of Cesarean section deliveries . Finally, t 10 percent and 10.5 percent, respectively) r Strong Start participants was, by far, lowest for women enrolled in Birth Centers (13 percent). In fo 134 SUMMARY OF FINDINGS

153 contrast, approximately 30 percent of Group Prenatal Care and Maternity Care Home participants C-s . ections had HOW DID OSS STRONG WOMEN’S OUTCOMES COMPARE ACR START MODELS? the Regression adjusted analysis using outcomes for all women who compared the data PLPE participated in Strong Start across the initiative’s three models. Comparisons were made by runni ng -adjusted analyses that controlled for a host of participant characteristics and risk medical and social , some of which were not available in data risk factors commonly associated with poor birth outcomes sources such as viral records (e.g., depression, food insecurity) . These results cannot convey the impacts of Strong Start enhanced prenatal care compared to typical Medicaid prenatal care (impact analysis is g Start Stron they can describe how mothers and infants in the three , but presented in the next section) awardees and models this analysis included outcomes for all fared relative to one another. Importantly, their participants, including those that were not included in the Impact analysis. Linear regression models used Maternity Care Homes as the ref erence category when comparing across models because this model had the largest number of Strong Start enrollees and was, arguably, the most similar to typical models of prenatal care. Regressions of participant data show that Birth Center participants experienced significantly better (overall) did outcomes than their counterparts in Maternity Care Homes, but Group Prenatal Care enrollees not. th Centers enrolled in Bir After demographic, medical, ad social risks were controlled for, women were five percentage points less likely to have a preterm birth than women enrolled in Maternity Care Homes. Birth Center participants were also four percentage points less like to deliver a low ly birthweight infant, and seven percentage points -section delivery than Maternity less likely to have a C Care Home enrollees. While overall, there were no significant differences in outcomes between women in Group Prenatal Care and their counterparts served by Maternity Care Homes, black Group Prenatal Care participants were three percentage points less likely to deliver a low birthweight baby, and white participants were five percentage points less likely to have a preterm birth . When awardees that served as the primary source of prenatal care for high risk Medicaid mothers were excluded from the analysis, both Birth Center and Group Prenatal Care enrollees had better outcomes than Maternity Care Home participants. Awardees at the Medical College of South Carolina, the University of and the University of Puerto Rico all served a disproportionately higher risk Alabama at Birmingham, population than other Strong Start awardees. When these awardees were removed from the model, better outcomes among Birth Center participants remained (though they shrunk by one percentage point), and Group Prenatal Care participants were observed as having significantly lower rates of preterm birth and low birthweight (by two percentage point each) compared to Maternity Care Home participants. SUMMARY OF FINDINGS 135

154 WHAT WERE THE IMPACT S OF STRONG START ON BIRTH CARE? OUTCOMES AND COST OF In the largest study of its type conducted to date, the evaluation used linked birth certificate, Medicaid eligibility, and Medicaid claims/encounter data to compare birth and cost outcomes for women Strong Start enhanced prenatal care to outcomes for comparable -participating non participating in Medicaid -enrolled women with similar risk profiles. To assess the initiative’s impacts, Strong Start participants were compared to women with Medicaid coverage who received care in “typical” prenatal with sites care practices in the same or similar geographic areas. For each awardee and for individual sufficient sample size, we used propensity score re -weighting to develop a comparison group of women rofiles to those of women enrolled in Strong Start. We included awardees with closely matched risk p 64 and sites in 13 states to estimate the impacts of Strong Start on birth outcomes, with nine of these states also included in the cost outcomes analysis. We estimated the impact of Strong Start on birth 65 outcomes and costs for Birth Centers, Group Prenatal Care providers, and at the model level — and at the awardee Maternity Care Homes -level only when sufficient samples supported — 66 this analysis. in Strong Start participants cared for Bir th Centers had significantly more positive birth outcomes than women in comparison groups who received care from typical Medicaid providers. Positive impacts of , regardless of whether women gave participation were observed for a large number of birth outcomes birth at the Birth Center or in a hospital, including gestational age, preterm birth rates, birthweight, rates of low birthweight, and rates of C-Section, weekend, and VBAC deliveries. Specifically, infants born to Birth Center participants had an average clinical estimate of gestation of 39.0 weeks, which was almost half a week longer than that of infants born to comparison group women. nfants Birth Center i were also 2.2 percentage points less likely to be preterm than comparison group infants (6.3 per cent vs. 8.5 percent). Consistent with the lower rates of preterm births, infants born to women participating in Strong Start Birth Centers weighed, on average, 3,343 grams, which was 79.0 grams more than infants born to comparison group women. These Strong Start infants were also 1.5 percentage points less likely to be born at low birthweight compared to infants in the comparison group (5.9 percent vs. 7.4 percent). -section deliveries were 11.5 percentage points lower for Strong Start women who received Rates of C Strong care in a Birth Center (17.5 percent) than for women in the comparison group (29.0 percent). Birth Centers were significantly more likely to have a weekend who enrolled in Start participants ), indicating lower (19.8 percent ) compared to women in the comparison group 23.7 percent delivery ( 67 -section incidence of planned inductions or C . Finally, rates of vaginal birth after C- section (VBAC) were 11.6 percentage points higher for women enrolled in Strong Start Birth Centers (24.2 percent) 64 As discussed in the Impact Analysis section, birth certificate and Medicaid data were received from two additional states – ates’ data were not included in our impact analysis because of various – but these st he total number to 15 states inging t br problems related to data quality and samples. 65 Reported differences are statistically significant at the p<0.01 and p<0.05 levels unless otherwise noted. 66 Because birth certificate and Medicaid data were not obtained from all states that had Strong Start awardees, model level ysis results (by definition) do not reflect the experiences of all Strong Start participants. Among Birth Centers, the impact anal included 21 provider sites, or 45 percent of all Birth Centers that participated in Strong Start and 39 percent of all Strong Start level analysis, accounting for 18 women receiving Birth Center care. Eleven Group Prenatal Care sites were included in the model- percent of all Group Prenatal Care sites and 23 percent of Strong Start participants enrolled in Group Prenatal Care. Finally, 52 33 Maternity Care Home sites were included in the impact analysis, representing 38 percent of all Maternity Care Home sites and percent of all Maternity Care Home enrollees in Strong Start. 67 With no planned inductions or cesarean sections, 28.6 percent (2/7ths) of deliveries would occur on the week end. 136 SUMMARY OF FINDINGS

155 In fact, the only two birth compared to women in typical Medicaid prenatal care (12.5 percent). outcomes for which no significant effects of Birth Center participation were found were rates of very low birthweight and Apgar scores. better birth outcomes lower cost. Birth Center participant at an overall s in Strong Start achieved Delivery expenditures for women enrolled in Strong Start Birth Centers and their infants were $6,527 mparison group and ) than for women in the co lower on average, which was $1,759 less (or 21 percent their infants. Total expenditures for the mother and infant from delivery until the infant’s first birthday were $10,562 for women enrolled in Strong Start Birth Centers on average, which was $2,010 less (or ) than for women and infants in the comparison group. Lower costs appeared to be lower 16 percent lower (such as approach to prenatal care and associated outcomes driven, in part, by changes in the rates of C-sections small reductions in the number of infant emergency department visits and ), and hospitalizations following delivery. Lower costs were also likely due to lower reimbursement rates for deliveries in Birth Centers relative to hospitals. compared to women Group Prenatal Care participants were more likely to have a weekend delivery Just over a quarter (25.5 percent) of w receiving typical Medicaid prenatal care. omen in Group Prenatal a weekend delivery, of Care had as compared to 22.0 percent women in the comparison group, suggesting that women in Group Prenatal Care were less likely to have scheduled inductions of C- sections . There were no significant effects of Strong Start enrollment on the clinical estimate of gestation, rates of preterm or very preterm birth, average birthweight, rates of low birthweight, or the f having an Apgar score greater than or equal to seven. probability o Prenatal care expenditures were lower for Strong Start Group Prenatal Care enrollees compared to Expenditures in the eight months prior to delivery for women women in typical Medicaid prenatal care. , $427 less than the average for enrolled in Strong Start Group Prenatal Care were $2,637 on average women in the comparison group. However, there were no significant differences between women enrolled in Group Prenatal Care and women in the comparison group for delivery expenditures or for may have This lower cost expenditures for delivery and the first year after birth for mother and infant. driven, in part, by been maternal hospitalizations during the prenatal a reduction in the number of period. Mothers who participated in Group Prenatal Care also had fewer emergency department visits in the 11 months after delivery relative to comparison group mothers. Maternity Care Home participan ts were also more likely to have a weekend delivery compared to women in typical Medicaid prenatal care, but there was no evidence that Strong Start Maternity Care Homes improved birth outcomes or reduced costs relative to typical Medicaid prenatal care. There was a small increase in weekend deliveries for women enrolled in Strong Start Maternity Care Homes, suggesting that awardees may have been less likely to plan inductions for Strong Start women than typical prenatal care providers were with their patients. However, we found no other positive effects of enrollment in a Start Maternity Care Home on birth outcomes or cost of care. More than the other Strong Start Strong models, there was considerable variation in effects across Maternity Care Home s, with some awardees or sites demonstrating some positive outcomes even though the pooled analysis di d not. Findings did not appear correlated with the intensity of the intervention. SUMMARY OF FINDINGS 137

156 WHAT LESSONS DID EVA LUATORS LEARN FROM C ONDUCTING THE STRONG START EVALUAT ION? The evaluation of the Strong Start for Mothers and Newborns initiative was c omplex and multi -faceted, and arguably “pushed the envelope” beyond many previous such studies in terms of its qualitative and quantitative data collection and analysis. Lessons learned by the evaluators that might be valuable to other future research efforts are summarized below. Maximizing the Value of Mixed Methods. The Strong Start for Mothers and Newborns evaluation was designed, from the outset, to employ mixed data collection and analysis methods. A rich qualitative case study component, spanning 739 key conducting four years of program operations all , involved informant interviews with a total of 1074 Strong Start providers and staff, and 123 focus groups with a total of 892 women participating in Strong Start. Qualitative data collection allowed us to develop a very detailed and nuanced understanding of how Strong Start was implemented, what challenges were faced, and what successes (and failures) were perceived by those implementing the initiative. Critically, focus groups amplified the voices of co nsumers, whose input could be compared with the views of informants. key , with Qua nt itative data collection was equally robust extensive individual -level data obtained from nearly all at intake, in the third trimester, postpartum, and program participants— upon women’s exit from Strong Start. These data allowed us to describe a broad range of characteristics of enrollees, on a timely, ongoing basis, and included and pregnancy conditions and outcomes services received, sewhere in the evaluation. some measures that were not available el birth certificate and Medicaid data from 13 states allowed valid Finally, the collection and linkage of the evaluation to design and execute a rigorous impact analysis of the birth outcomes and costs of care for women in Strong Start compared to the outcomes and costs for women who received typical Medicaid prenatal care. These analyses provi ded insights on how impacts differed across the three Strong Start delivery models – Birth Centers, Group Prenatal Care, and Maternity Care Homes . Overall, triangulating the findings from each source of data in our mixed methods approach Each data source for the evaluation strengthened our c onfidence in the robustness of our findings. informed the others. data were Case studies helped us understand what individual program participant on prenatal care education, telling us. For example, when we saw awardees placing particular emphasis we could look to the PLPE findings related to breastfeeding, family planning, or gestational diabetes for potential effect. We could also verify staff perceptions about services offered and accessed. Case study findings on enrollment processes helped the impacts team identify where selection bias problems might exist and adjust their models accordingly. Results from case studies also helped us interpret and refine findings from the impacts analyses and to analyze how the intensit y of the interventions may have -level program data on outcomes were affected outcomes. Individual generally reinforcing of the 68 outcomes found in the impact analysis. 68 Appendix X through Appendix DD present additional Strong Start evaluation data that were analyzed in support of the Appendix X presents data on Enhanced Prenatal Care Education; development of several “special study” manuscripts. Specifically, Appendix Y presents Characteristics of Birth Center Participants with a Home Birth or LPM as their Routine Prenatal Care 138 SUMMARY OF FINDINGS

157 Lessons Drawn from Acquiring State Birth Certificate and Medicaid Data. Technical The to obtain birth certificate, Medicaid task’s objective was ambitious: Assistance/Data Acquisition eligibility, and Medicaid claims and encounter data from st support of in ates with Strong Start awardees the Impact Analysis. As noted in the Introduction, CMMI did not contract with states or state Medicaid 69 agencies under Strong Start, and thus could not compel state officials to share their data with the evaluation. Still, in the end, the vast majority of both Vital Records and Medicaid officials expressed will ingness to share needed data, many were familiar and had prior experience with linking already these data sets, and all the impacts of understood the value and importance of linking the data to assess for Medicaid enrollees. prenatal innovations that could improve birth outcomes Applying for and obtaining state data required concerted, ongoing, and persistent work with Medicaid and Vital Records ma tely, we worked closely with 20 states that agencies that faced many competing demands. Ulti had sufficient Strong Start enrollment to support a rigorous analysis of impacts and to merit the large investment in time and resources needed to obtain the data. W hile privacy concerns and other challenges were ultimately insurmountable in five states, we succeeded in obtaining data from 15 other the largest study conducted to date that This is 13 of which provided data usable in the analysis. states, s on linking and analyzing birth certificate and Medicaid data. relie Maximizing the Potential of an Observational Impact Ana The gold standard design for lysis Design. estimating program treatment effects is a randomized control trial. However, Strong Start was not designed to assign either awardees or participants to treatment and control groups through intentional randomizatio n. Many CMMI evaluations rely on quasi -experimental designs that use a difference -difference approach, but the particular questions asked of this evaluation did not lend -in themselves to this strategy because Strong Start layered enhancements upon existing models of prenatal care rather than implementing entirely new models of care, or they used Strong Start funds to -period with which to compare . continue enhancements previously in effect. , there is no pre Therefore that compared outcomes for women As a result, w e needed to take a n observa tional approach -participating Medicaid enrolled participating in Strong Start and their infants to outcomes for non women with similar r isk profiles and their infants. The assessment incorporated the best available data and quantitative methods to account for possible confounding factors that may have driven differences that could have otherwise been linking birth incorrectly attributed to Strong Start. Strengths of the design were numerous , including ; certificate and Medicaid data in a rigorous manner that achieved high rates of matching across files states and constructing consistent birth outcome and cost variables from data obtained from numerous multiple agencies within each state; creating propensity score reweighted comparison groups of women ; and estimating the for every Strong Start awardee and site selected from the same or similar counties impacts of Strong Start for every awardee and site with sufficient numbers of women in the program while ing controll for a wide range of factors, including demographic characteristics, behavioral risk factors, medical risks, Medicaid eligibility category, hospital characteristics, and (when available) diagnoses identified on Medicaid claims. Appendix Z Provider; Appendix AA E data by AABC Site; LP presents P presents analysis of Gestational Diabetes Mellitus and presents dix CC Nutrit Appen presents analysis of Mental Health Services in Maternity Care Homes; Appendix BB ion Counseling; analy sis of Maternal and Infant Birth, Utilization, and Expenditure Outcomes Among Twin Pregnancies; and Appendix DD presents data on Substance Use Disorders Among Women Who Delivered Infants in 2014 -2015. 69 The only exception was the award to the Oklahoma Healthcare Authority, which administers the state Medicaid program. Given low enrollment in this award, however, the evaluation did not seek to obtain data from Oklahoma. SUMMARY OF FINDINGS 139

158 Fi nally, the evaluation went to great lengths to identify potential sources of selection bias (by model), contamination bias, and omitted variable bias to maximize the possibility that we estimated the causal impacts of Strong Start enrollment in combination with care in Birth Centers, Group Prenatal Care, or Maternity Care Homes relative to typical Medicaid prenatal care practices. 140 SUMMARY OF FINDINGS

159 Concludi ng Discussion of xplore w hether alternative m odels signed to e nd Newborn was de s Strong Start for Mothers a improving birth o utcomes fo r pregnant women co vered by renatal care “enhanced” p could succeed in odels – Birth C Medicaid an enters, G rou p d CHIP. The i Prenatal Ca re, a nd nitiative supported three m gh , different means) to go be yond typical – that each promised (throu medically - Maternity Care Hom es th address th e m any p sychosocial ri focused prenatal c are at Medicaid -enrolled w omen face and to sks e birth o tha utcomes . to p It was th e go al oor of the Ce nte r for Medicare a nd Medicaid t contribut w hether Strong Start could move th Innovation to e needle o n one of the m ost persistent and see d th paradoxical p .S. health ca re system: th at we spen w roblems more on maternity ca re tha n any ith e U world, yet w e nation in th ly e experience a mong t he w orst m aternal and inf ant o utcomes consistent compared t hy o s countries. ealt imilar ly w nd impacts o ch yea th r Strong Start evaluation w studying the i mplementation a as f The five- arged wi bi rth the th initiativ care delivery , e and costs. As di scussed throughout this fi nal outcomes, heal on sign employed a ri gorous m ixed -methods de e th at included case s tudies of implementation, report, w d an alysis o f detailed participant d ata, and an impact the c analysis. T his last co mponent ollection an — certificate a nd Medicaid data f rom 1 5 states considere making it the largest study of its linked birth d — to com pare out comes am ong w Strong S tart kind conducted to da omen, b y m odel, t o those of te edicaid -enroll ed closely m mothers w atched M re ceived typical p renatal care. Indeed, w ith th e ho evaluation now com te d demonstra an the fie plete , ld we can contribute im portant ne w findings t o the s g utility o link ing da ta evaluation source to , includin to a ssess birth o utcomes f a triangulated ap proach . and costs who First, we fi d nd that wome prenatal c ar e n in S trong Start’s B irth Ce nters experienced receive mproved birth o utcomes c ompared to th eir counterparts i n ty pica l significantly i care, regardless of be hey gave birth. Furthermore, these of tter outcomes w ere where t achieved at lower cost. Lower rates higher rates o and C-sec tion we re all observed, along with f VBAC birthweight, rth, low preterm bi and whil weekend e expenditures deliveries, r Strong Start women and their infants were 21 percent lower fo n th e compariso ese fi n group. Ou r confidence in th ndings is bolstered by than for those i very similar findings from r evaluation compone – risk a nt a djusted regression a nalyses o f participant da nothe ta – risks, nother after controlling for one a ound which f comparing Strong Start participants to when tha t, Birth C tter than did women care d for in Maternity Care Homes, enter participants fared significantly be for Medicaid prenatal . Our impact analysi to t s accounted ypical the l ow loser levels a model much c care Center participants by of medical ri creating comparison groups of similarly sk low -ri sk among Birth s The Birth Centers’ Strong Start model, holistic , women. individualized, which wa time intensive, more -fo and focused ducation than t raditional m edically on e cused prenatal care, made a significant outcomes o f the w omen they served. y difference in th e pregnanc T ar he s econd Strong Start mode l – Group P renatal C fferent from e – wa s a lso fu ndamentally di ppointments l ed groups o idwives) l f “typical” car e in t hat prenatal a often m asted two h ours, facilitators ( d in 8 to 10 women through clinical as sessmen t an s -d epth educationa l sessions on such topics a nutrition a nd exercise, breastfeeding, family planning, and childbirth p reparation, and pregnant women developed supportive re lationships a s th ey p roceede d togethe r through th eir pregnancies. Yet in th is N CONCLUDING DISCUSSIO 141

160 instance, the impact analysis found few significant improvements among Strong Start participants in ies were higher for weekend deliver relation to comparison gro up women. Rates of Group Prenatal Care suggests may have had fewer planned inductions and that Strong Start women participants, which to Medicaid . The model was also found to reduce prenatal care costs scheduled C-sections by about 15 percent. The evaluation’s cross -model comparison of outcomes using risk -adjusted regression models of Strong Start participants only suggested that Group Prenatal Care may have had beneficial effects for black women, who were significantly less likely to have a low birthweight baby than black women d for in Maternity Care Homes care , while white women were less likely to have a preterm birth . Our case studies and participant data help explain why we might not have observed greater quantitative group care strongly praised the omen receiving effects of the group model. Qualitative data show that w extra time, support, and education they received under Strong Start, saying that they were more prepared for childbirth and that they much preferred their experiences under Strong Start compared with prior pregnancies and traditional prenatal care. On the other hand , women attended on average just six of the 10 visits prescribed by the curriculum most commonly used by Group Prenatal Care awardees, , CenteringPregnancy m ost often because of problems women had securing transportation or childcare for their group appointments. Thus, most women enrolled in Strong Start Group Prenatal Care did not receive the full intervention as intended. Finally, Matern ity Care Homes, which most often added care managers to existing medical practices to facilitate coordination, support, and referrals to community services, did not produce either significant improvements in birth outcomes or reductions in cost. Though case studies found clear the evidence that Maternity Care Home participants appreciated and were very satisfied by the extra care they received from care managers under Strong Start, it seems clear that this relatively small to typical care was no enhancement t sufficient to meaningfully impact birth outcomes for participating . women who often faced high levels of both social and medical risk Beyond the evaluation’s impact and regression analyses, we observe other important positive results from Strong Start in the case study and participant-level data. For example, we learned from Strong Start staff and program participants in our focus groups that Strong Start helped women to understand the importance of carrying their pregnancies to term, breastfeeding their babies, eating family planning to safely space their pregnancies (especially ing exercise, us nutritious foods and getting by using long acting, reversible contraception methods and preparing s), , or LARC for childbirth. high levels of satisfaction with their Strong Start experience, Overwhelmingly, women expressed very especially in comparison to any received more , for which they had generally previous pregnancies . care typical the positive Even before this evaluation’s impact results were known, but surely influenced by experiences previously reported, a majority of Strong Start programs chose to sustain some or all of . The primary reason for sustaining was providers’ beliefs their enhanced services that they were improving the quality and scope of prenatal care, as well as the lives and health of women and infants they served. In our case study interviews, staff for more than half of Strong Start awardees reported that they were either fully or partially sustaining their enhanced prenatal care models after the end of as had been in the demonstration period. All Birth Centers were continuing the midwifery model of care peer place prior to and during Strong Start, and most had decided to continue (at least in part) the . A majority of both Group Prenatal Care and Maternity counseling services added under the initiative Care Home awardees were also sustaining their full Strong Start programs, including nine of 17 CONCLUDING 142 DISCUSSION

161 most Maternity Care Maternity Care Homes and seven of 13 Group Prenatal Care programs. Indeed, Home awardees were expanding their care management efforts to additional sites or populations. rograms, Finally, a considerable proportion of awardees, including some who were not sustaining their p reported that they had improved their standards of practice in delivering prenatal care in ways that be directly attributed to their experiences with Strong Start (e.g. by offering universal depression could . screening to prenatal patients) The r both for esults from the Strong Start evaluation hold a range of implications Medicaid and for -away is that if more pregnant more generally. For Medicaid, the clear take prenatal care practice experience beneficiaries accessed Birth Centers for their maternity care, on average they would likely significantly better birth outcomes and, as a result, the program could save money. Medicaid . Today, only a small Unfortunately, many barriers stand in the way of obtaining Birth Center care Birth Centers, and the Strong in can access maternity care fraction of pregnant Medicaid beneficiaries Start evaluation’s case studies identified many reasons can cause many Birth Centers to that, combined, limit the number of Medicaid beneficiaries they serve: payment m While managed care has b ecome the dominant service delivery and • odel f or Medicaid, contracting fficulty ave di often h ld us that they to Birth Center providers managed with Medicaid s). organizations (MCO care • Even when Birth Centers succeed in obtai ng contracts, reimbursemen t rates are often too low ni the to cover model. midwifery of the nature ntensive care, especially given the time-i of actual cost fee edicaid Tr ees aditional M -for-s ervice reimbursement for professional a nd facility f are a fra ction of what the progra m p ays o bstetricians a nd hospitals. The large savings in the first year, in addition to potential subsequent savings, would likely outweigh higher reimbursement. Th • ar payments Medicaid hen e financial strai e exacerbated w be can n of low payment rates delayed. Other Medicaid policies • eligibility also created challenges fo r Birth Centers, including lengthy women’s enrollment int delay can that rocesses il late unt o the program pregnant determination p in their pregnancies. More broadly, state regulations can limit the supply of Birth Centers available to all pregnant women. In some states, scope of practice laws and licensing policies make it difficult for Birth Centers and midwives to practice at all, which can further limit the availability of Birth Center care for pregnant ased me states require Birth Centers to have hospital-b of Medicaid status. So women, regardless t increases their physician medical directors, a role that does not appeal to many physicians because i malpractice exposure without providing sufficient additional income. prenatal c of development are an also hinder the edicaid policies c s M model enhanced Ex isting generally his evaluation’s telephone models. T Home y Care ernit renatal Care and Mat s Group P , such a revealed that, while program p in select states officials CHIP edicaid and M olicies generally ith survey w financi support o prenatal care, ly o re they ra al access t ffer explicit coverage of or incentives for prenatal c tates ements. S enhanc are flexibility e adopt Targeted Cas to tly retain the curren Management programs fo r pregnant women or Enhanced Prenatal Care s ervices through the Sta te a as Medicaid w when Plan Amendment process, but these op tions w er e more widel y use d by states fee-f or-s ervice p rogram prepaid be less viable in the progra m now do minated by and appear to managed care 2009) . The proprietary n ature o f Medicaid managed care h ealth plan (Hill et al, perate creates barriers to accessing information a bout how manag ed care organizations o information with rega rd to th eir provider networks, payments to providers, and the specific content of prenata l care services delivered under N CONCLUDING DISCUSSIO 143

162 bundled payment arrangements . The p roliferation o f managed ca re t hus m eans t hat state a nd federa l av ealth p lan a nd provider anges i nfluence ch officials h n h e fewer direct policy l evers to i service delivery. th clear evidence evaluation provides his In conclusion, t Birth Start’s in Strong care at prenatal significantly i care with t Centers – – succeeded in heir holistic model of mproving almost eve ry outcome easured, most importantly ra we m ection deliveries, rthweight, and C-s birth, low bi s of preterm te when were considered ag participants ainst a comparison group with similar risks. Improved outcomes, as well as reductions in health care u tilization, likely to re duced expenditures. It seems quite contributed in a ba could be that, if progress ddressing the rriers to Birth Center care made described above, likely -c overed pregnant women could experience positive more Medicaid ore infants bo rn to births, m t both the M edicaid program—a ealthy, and the federal and Medicaid mothers could start their lives h significant savings. state levels—c ould reap r Birth Centers provider under Medicaid care th come be to nrealistic fo It is u minant maternity e do Thus, e U.S. any time or in th soon , however. vast ings, where the aternity care sett more typical m majority of women of all incomes and insurance types still receive care, will continue to face the findings provide challeng e of improvin n and infants. The Strong Start evaluation’s g outcomes for wome is regard. Namely, the m be can mode l of care, which practiced be insights that may idwifery helpful in th by a ny provider in any s etting, offers lessons fo to structure prenatal care to improve outcomes r how poverty, relationship fo r women w ho fa ce instability, depression, and a host of other life-challenges. p care facilitators, midwives Across a anagers, grou ll Strong Start models, providers such care m , and education ere praised for spending more time with patients heal th and focusing on peer counselors w and psychosocial support services, areas often n ot addresse pical clinical visits. However, Strong d in ty ddressing the and staff de scribed the most Start providers difficulties they encountered in a also health tre r mental fo f participants, in particular needs pressing needs o atment, opioid and other substance use tre housing, healthy fo od, transportation, and personal safety (especially atment, stable n so often i were needs esources to m partner violence), because r gard to intimate with re itigate these in their nd risk social and medical of h levels hig x needs a he comple n t ive G communities. supply short ommunity resources, it is nrolled women -e d by Medicaid g many amon , accompanie inadequate c y small changes practice, such as t hose ad opted b care hat relativel unsurprising t y Maternity in clinical M outcomes. rth ot sufficient to improve bi Care Homes, were n oving forward, comprehensively th attending to e broader needs faced by low-i ncome women, inc luding m any social determinants of reductions i necessary health, will to achieve and other improved outcomes. No n preterm birth be particularly those ddress the myriad needs of Medicaid sufficiently a of ca model re can nrolled women, -e at higher risk, without broad communi ty support and robust social s upport systems. 144 CONCLUDING DISCUSSION

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173 Technical Appendices TECHNICAL APPENDICES 155

174

175 APPENDIX A: INTRODUC TION – MEDICAID AND CHIP ELIGIBILITY, BY STRONG START STATE TECHNICAL APPENDICES 157

176 TABLE A. 1: MEDICAID AND CHIP ELIGIBILITY POLICIES FOR CHILDBEARING WOMEN, BY STRONG ST ART STATE Income Eligibility (Percent Medicaid ACA Plans Medicaid Income Family Pregnant Women – of FP L) – I om e nc Eligibili t Parents of y – Planning Location – – Eligibility – CHIP Medicaid Marketplace Medicaid Dependent Children Program Other Adults (Title XXI) Type (Title XIX) Expansion Not Eligible 18% 146% Alabama N/A FFM Not Participating Yes -- -- 205% N/A 141% 138% No Alaska Not Participating FFM 161% Arizona FFM Participating No 138% 138% N/A California 214% N/A 138% 138% Yes Participating SBM N/A District of Columbia 324% 221% 215% No Participating SBM 1 Not Participating FFM 196% Florida Yes N/A 33% Not Eligible 225% Yes Not Eligible 37% N/A Georgia Not Participating FFM Not Participating SBM Not Eligible 138% Idaho N/A No 26% 213% N/A 138% 138% No Participating Partnership Illinois 2 FFM Not Participating No Not Eligible 38% N/A 171% Kansas 200% SBM Participating No N/A 138% 138% Kentucky -FP Yes Louisiana 138% N/A 138% 138% Not Participating FFM 138% Yes Participating SBM 264% N/A Maryland 138% 3 Partnership Participating Yes 138% 138% N/A 200% Michigan 4 Participating 138% 138% N/A 283% Minnesota Yes SBM N/A 199% Mississippi Not Eligible 27% Yes Not Participating FFM 5 FFM Participating Not 22% N/A Missouri 201% Yes Not Eligible 6 Nebraska 199% 63% Not Eligible No N/A FFM Not Participating 7 SBM Participating No 138% 138% N/A 165% Nevada New Jersey FFM 199% 205% 138% 138% No Participating 8 -FP Yes New Mexico 255% N/A 138% 138% SBM Participating N/A SBM Participating Yes 138% 138% 223% New York Not Participating FFM 201% N/A 44% Not Eligible Yes North Carolina 9 138% Oklahoma Not Eligible 44% N/A FFM Not Participating Yes 10 138% 138% N/A 190% Oregon -FP SBM Participating Yes 11 138% Participating Yes 138% 220% Pennsylvania FFM N/A 199% N/A 67% Not Eligible Yes South Carolina Not Participating FFM Not Eligible 99% 200% Tennessee N/A No Not Participating FFM 12 Not Participating FFM Not Eligible Texas 203% N/A 18% Yes 13 38% 148% Not Eligible 205% Virginia Yes FFM Not Participating Sources: Medicaid eligibility : http://www.kff.org/health -reform/state -indicator/medicaid- and-chip-income-eligibility-limits-for- pregnant- ; http://www.kff.org/health women -as -a- percent -of-the- federal -poverty -level/ -reform/state- federal -of-the- indicator/medicaid-income-eligibility-limits-for- -level/; Family Planning: percent -poverty -a- adults -as http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf ; Health Reform: http://www.kff.org/health - ; ator/state -activity-around-expanding- medicaid-under -the- affordable -care -act/ reform/state-indic -types/ marketplace http://www.kff.org/health -reform/state- indicator/state -health-insurance- 158 TECHNICAL APPENDICES

177 1 Notes: Florida will provide two years of family planning benefits to women losing coverage for any reason. 2 Kansas has received federal approval to conduct plan management activities to support certification of qualified health plans in FFMs. 3 Michigan has approved Section 1115 waivers for Medicaid expansions. 4 Minnesota received approval to implement a Basic Health Program (BHP) established by the ACA in December 2014 een 138 and 200% FPL to the BHP as of and transferred coverage for Medicaid enrollees with incomes betw 1, 2015. January 5 Missouri provides coverage to women with incomes up to 185% FPL. 6 received federal approval to conduct plan management activities to support certification of qualified Nebraska has health plans in F FMs. 7 Nevada is operating SBMs with federal support. 8 operating SBMs with federal support. is New Mexico 9 In Oklahoma, individuals without a qualifying employer with incomes up to 100% FPL are eligible for more limited subsidized insurance though the Insure Oklahoma Section 1115 waiver program. Individuals working for certain qualified employers with incomes at or below 200% FPL are eligible for premium assistance for employer - sponsored insurance. 10 Oregon is operating SBMs with federal support. 11 approved Section 1115 waivers for Medicaid expansions. In February 2015, Pennsylvania Penn sylvania has announced it will withdraw the Healthy Pennsylvania waiver to implement a traditional Medicaid expansion called Health Choices. The transition from Healthy Pennsylvania to Health Choices is planned to be completed by September 30, 2015. 12 funded program that provides family planning services to women at least 18 years of Texas operates an entirely state- age. Texas and Missouri provide coverage to women with incomes up to 185 percent FPL. 13 Virginia has received federal approval to conduct plan management activities to support certification of qualified health plans in FFMs. TECHNICAL APPENDICES 159

178

179 APPENDIX B: QUALITATIVE CASE STUDY - METHODOLOGY TECHNICAL APPENDICES 161

180 DATA COLLECTION The evaluation’s qualitative case studies involved four primary methods of data collection: design to inform the analytical framework used to describe program Document review • components, understand policy background, and consider potential implementation issues. Interviews with a variety of key informants (e.g., Strong Start awardee and site -level program • nt program implementation staff, prenatal care providers, and community partners) to docume and key features of the Strong Start interventions, perspectives on outcomes, and Strong -structured protocols related successes and challenges. Interviewers relied on semi Start– tailored to the type of respondent, and which allowed for both flexibility and thoroughness. • with pregnant and postpartum Strong Start enrollees (and, in the first evaluation Focus groups 70 year, a limited number of pregnant Medicaid/CHIP beneficiaries not enrolled in the program ) to obtain information about women’s experiences in Strong Start and how they compared to -structured moderator’s experiences with traditional prenatal care. Researchers used semi guides tailored to each type of group (e.g., pregnant or postpartum, enrolled in Strong Start or not). • Structured observations to collect data on the content and structure of enhanced prenatal services (e.g., how, when, and where services were delivered). This method was most often used to observe Group Prenatal Care sessions, and researchers used a standardized form to record their observations. The case study team collected data annually during the first four years of the Strong Start –14) and third (2015– evaluation. The first (2013 16) case study rounds included all five types of data collection: document re view, key informant interviews, focus groups, and structured observations. 17) case Most data collection was in person for these rounds. The second (2015) and fourth (2016– study rounds included document review and key informant interviews, and nearly all d ata collection was by phone. All researchers on the team completed training on data collection methods and instruments prior to each round of case studies. Following each case study, findings from all four methods of data collection were summarized in awar -site specific memos that were dee - and AABC shared with CMMI, the broader evaluation team, and the Strong Start awardees. NALYSIS CODING AND A The key informant interviews and focus groups were recorded and transcribed, and the resulting text files were ana lyzed using qualitative software NVivo version 10.0. Before uploading and coding the files, personally identifiable information was removed. Researchers used a comprehensive coding structure (included in this appendix, after the interview guide) to organize data based on interview and focus group guide themes, as well as key informant or group participant type, state, awardee and intervention model type, and implementation year. The structure was updated with each round of data interview and focus group topics were represented. All coders attended a collection to ensure that all uniform training session on NVivo and the Strong Start evaluation coding structure, and multiple 70 The case study team conducted 10 focus groups with a total of 59 pregnant and postpartum women who were not participating year. The primary purpose of these groups was to gather information on the standard models evaluation in Strong Start in the first care (without Strong Start enhancements) available at provider sites. As this was a research focus only for the first round of of participants were not repeated in later evaluation years. case study data, groups with non- 162 TECHNICAL APPENDICES

181 rounds of testing were conducted using several coders to obtain high inter -coder reliability. - and intra Using the coding structure, researchers queried the qualitative database to identify themes across models, key informant types, and data collection type, and key features present or absent in awardees’ -cutting analyses included Strong Start interventions. Qualitative findings have been reported via cross -specific) memos which in each evaluation annual report and in awardee-specific (and in some cases site 71 are summarized in annual reports from evaluation years . , and four two, three Stron tructure ualitative Coding S g Start Q Overarching (Whole D ocument) Codes: Data Collection Method • Key Informant Interview • Awardee Staff Site Staff (Program and Provider) • • -Strong Start Provider Non • Community Partner • Focus Group • Strong Start Participants Pregnant • • Postpartum • Strong Start Non -Participants Pregnant • • Postpartum State Model • Maternity Care Home Group Prenatal Care • Birth Center • Year • Year 1 • Year 2 ear 3 • Y • Year 4 71 Year Two: https://downloads.cms.gov/files/cmmi/strongstart- enhancedprenatalcare_evalrptyr2v1.pdf ; Year Three: ; Year Four: https://downloads.cms.gov/files/cmmi/strongstart- enhancedprenatalcare_evalrptyr3v1.pdf https://downloads.cms.gov/files/cmmi/strongstart- snhancedprenatalcaremodels_evalrptyr4v1.pdf TECHNICAL APPENDICES 163

182 Mode of Data Collection • In Person Phone • Substantive Text Codes Key Informant Interview (KII) Codes Background Provider Site Overview • Strong Start Program Implementation • Enhanced Services • Changes Needed to Implement Other Strong Start-Like Services • Strong Start Patient Population • Preterm Risk Factors and Eligibility Criteria • • Outreach • Enrollment • Retention C • onsistency in Implementation Across Sites • 17P • Depression • Provider Continuity • CenteringPregnancy Links to Aspirin Treatment to Treat Preeclampsia • Strong Start Program Outcomes • Preterm Birth • Low Birth Weight Breastfeeding • d Delivery Metho • Family Planning • • Health Care Costs Other Outcomes • Barriers to Care • Transportation • Childcare • Communication 164 TECHNICAL APPENDICES

183 Lessons Learned and Best Practices • Successes Challenges • • Recommendations for CMS and Evaluators Sustainability Replicability Opinion About • Replicability of Own Program • Practice Level Factors Provider Level Factors • Patient Level Factors • • Community of Policy Level Factors • Any Other Factors Medicaid/CHIP Policy Affordable Care Act Focus Group (FG) Codes Background Health Care Provider Choice arriers to Care B • T ransportation Childcare • Communication • Maternity Care Experience Enrollment • Strong Start Enhanced Services • Comparison to Previous Maternity Care Experiences B irth Experience Postpartum Experience • Breastfeeding • Family Planning Coverage Continuity • atisfaction S Recommendations TECHNICAL APPENDICES 165

184 GUIDES INTERVIEW STUDY CASE Year One Interview Guide Background and Overview 1. What is your position (at your organization) and what are your current responsibilities? What was your role, if any, in the decision to apply for Strong Start? [If involved]: 2. a. Who was most involved with or initiated the idea to apply to the Strong Start program? Is this person in a leadership (or very visible) role? b. Why did you decide to apply for Strong Start? How and where does Strong Start fit into the work your organization does? c. How were your sites selected? Access to Maternity Care -income women in the areas your sites How would you describe access to maternity care for low 3. operate? Have the number of places offering maternity care increased/decreased over time? a. b. What resources (if any) are available to help Medicaid/CHIP enrollees with access to maternity care? Are you familiar with Medicaid/CHIP policy in your state? [If yes] We’re aware of the following 4. Summarize background information on recent recent changes that might influe nce access to care: [ state policy changes such as: Medicaid expansion, eligibility requirements, enrollment or renewal processes, managed care options, benefits coverage. ] Are there any other changes to Medicaid/C HIP that we should know about? a. Is there community outreach about new coverage options in your area, like expanded Medicaid [if relevant] or the new Health Insurance Marketplaces? Overview of Awardee Patient Population and Sites What is the typical staffing model? 5. Let’s discuss the care typic ally provided before Strong Start. what other types of health care or other — which we’ll discuss next Besides maternity services — 6. services do the sites provide? Have any of your sites received - or are they actively pursuing—recognition as a patient — 7. centered medical home (PCMH) by the National Committee for Quality Assurance (NCQA) or a similar entity? Please describe. How would you describe the volume of pregnant patients at the sites 8. high or low? — a. About how many births do the sites see, annually? (Your best guesses are fine.) What proportion (roughly) of patients has a high-risk pregnancy? b. 9. Please describe the pregnant patient population at your sites, in terms of socioeconomic status, race/ethnicit y, health status, citizenship, age, and insurance coverage. TECHNICAL APPENDICES 166

185 10. At what stage of pregnancy do most patients first present themselves for a prenatal visit? a. If later than first trimester, why not sooner? pregnant patient population? 11. What challenges do the sites encounter in caring for their Were you tracking birth outcomes (preterm, low birth weight, etc.) prior to Strong Start? 12. 13. Putting Strong Start-related changes aside for the moment, in recent history have there been any major changes to the way your sites del iver maternity care? These can be internal or external changes. Strong Start Program Implementation How would you describe your Strong Start model of care? 14. a. What are the key components of the model? b. How often are enhanced service delivered, and in what setting? Which providers or other care team members are involved? c. [Additional questions if enhanced services include peer support]: How are peer supports selected and trained? What are their qualifications? d. e. [If there are multiple peer supports available] How a re peer support relationships determined? Please describe any efforts to “match” women with a specific peer for support. What materials or tools do peer supports have available for use during the encounter? How f. y? were these created? Are they used consistentl [Additional questions if enhanced services include or other Group Prenatal Care group activities]: How did you choose a curriculum? [Note that most but not all group care models have g. opted to use the Centering Healthcare Institute approach and curriculum.] h. [If using the Centering approach] How closely do your sites adhere to the Centering curriculum? For instance, have you added or eliminated any sessions? Have you made any other adaptations? our curriculum. How many sessions [If not using the Centering approach] Tell me about y i. are there and what is covered during each? Who facilitates the groups? j. [If more than one person facilitates a group] How do co-facilitators coordinate with each other and divvy up responsibilities? k. How are women assigned to groups? l. How many Strong Start participants are there per group, on average? m. — or moderate? high, low, is the average group attendance rate What [Additional questions if enhanced services include care coordination or referrals]: n. How are care coordinators or care navigators selected and trained? How do providers at your sites communicate or share information about Strong Start o. patient care with other providers, both health care and social service providers? How often does communication occur? Is there a desig nated ‘care team’ and who is on it? How does the electronic medical record (EMR) factor into communication, if at all? p. If your approach involves creating a care plan, how is it created and used? TECHNICAL APPENDICES 167

186 q. What follow -up steps — if any — do sites take to determine whether Strong Start participants access the services that are referred? How are linkages to community -based resources made? r. 15. What changes were required in order to implement Strong Start enhanced prenatal services? How would you describe the level of effort that these changes entailed? Please describe your implementation timeline. How long did it take between receiving the 16. Strong Start award and actually enrolling your first participant? a. Did it take more or less time than anticipated? Why? 17. How are sites reimbursed for the Strong Start services they provide? a. How do Strong Start payments compare to the Medicaid/CHIP reimbursements sites receive for providing prenatal care? How have sites responded to their new roles and responsibilities? 18. 19. tes operate, are you aware of any other providers offering enhanced In the area(s) where your si prenatal services like what is provided under Strong Start? Please describe. Are any of your sites providing enhanced prenatal services that are like the other Strong Start 20. models (but that aren’t being funded by Strong Start)? A moment ago, you described the demographics of the pregnant population your sites serve. Is 21. this also how you would describe your Strong Start population? Are there any key differences? a. b. Has the Strong Start program attracted new or different patients to your site? When determining eligibility for Strong Start, how is preterm birth risk assessed? 22. a. If a specific form or tool has been created, can you provide the case study team with a copy? b. Have you made any adjustments to the risk assessment process? Please describe? Which risks are most prevalent? c. Please describe how patients are enrolled in Strong Start, and any changes you have made to 23. your enrollment process (including reasons for the change). 24. What proportion (roughly) of eligible patients chooses to participate? What are your thoughts on why patients choose to (or choose not to) participate? What could help encourage reluctant patients to participate in Strong Start? a. Are you (or any of your sites) doing direct outreach to potential Strong Start enrollees? Please 25. describe. How successful have these outreach methods been, so far? a. Why do pregnant patients drop out from Strong Start before the intervention has been 26. completed? a. Strong Start? What could help keep patients enrolled in 27. Please describe any technical assistance you’ve received from external organizations while implementing Strong Start. a. Are you satisfied with the help you have had? TECHNICAL APPENDICES 168

187 Is Strong Start being implemented similarly across all the sites involved in your program? 28. a. What are the key differences in implementation across sites? b. What steps (if any) have you taken to ensure consistent implementation across sites? (Probes: trainings/re -trainings, site visits or frequent check -ins) How frequently do you communicate with your sites, and by what means? Do sites 29. communicate with each other, for instance about implementation challenges and best practices? Strong Start Program Outcomes What are your impressions of how the Strong Start enhanced services are affecting the physical 30. health of Strong Start enrollees? The psycho -social health of enrollees? What evidence have you collected or seen to date that the health of mothers and newborns is 31. better or worse? We are interested in anecdotes as well as any data you’ve collected or analyzed. 32. In your opinion, which of the Strong Start enhanced services provided by your sites have the greatest impact or potential impact on improving maternal and infant outcomes? Why? Do you expect (or have you seen) any other positive or nega 33. tive consequences, either for patients or for the sites themselves? Any unintended consequences? Please describe. Lessons Learned and Best Practices 34. What do you think has worked well in implementing Strong Start? a. Have you identified any particular features of your sites that have made implementation easier? What have been the key factors in your success? Do you have any advice for CMS if they decide to implement Strong Start with other health 35. care providers? a. What would you like CMS to do differently? Do you need more hands b. -on technical assistance or clearer guidance/instructions/rules? What learning sessions would you like to have? 36. Do you have any thoughts you’d like to share specifically about the evaluation? 37. Do you have any final thoughts about Strong Star t that you’d like to share? TECHNICAL APPENDICES 169

188 Year Two Interview Guide Changes and Updates Strong Start Implementation – 1. how would you say We’ll get into some more specific program areas in a moment, but first— Strong Start implementation has been going, overall? What would you say are some of the biggest “highlights” (or “lowlights”) from this last year that you’d like to share? Are you satisfied with your progress, or not? Why? a. ]? If your role or responsibilities have Fill in Is your role in the Strong Start program still [ 2. changed since we last spoke with you, please explain. Have there been any other changes to the way the Strong Start program is administered (e.g., 3. organizations affiliated with the award, personnel changes not already mentioned)? a. [If yes] What were the ch anges and what prompted them? What influence, if any, has it had on overall program operations? ] sites still participate in Strong Start? 4. Do [ Fill number Have any sites joined or exited the program? a. [If yes] What prompted this addition/exit? b. Summarize enhanced prenatal care services 5. ] under the Strong Start Do the sites still provide [ ] Have there been -specific variations in Strong Start services if necessary. Clarify site program? [ changes to the content or scope of sites’ Strong Start services? [If yes] a. What were the changes, and why did you make them? b. What has been the result of this change? 6. Have there been any particular changes to how sites provide breastfeeding support to Strong Start enrollees? How about family planning services — are there any notewor thy changes to how these services are incorporated (or not) into your Strong Start intervention? a. [If yes] Are you able to effectively track and follow -up on those referrals? Why or why not? Start marketing 7. Have you made any adjustments to your community outreach or Strong approach? [If yes] Why did you make this change? a. b. What has been the result of this change? How do you think your sites’ methods for identifying eligible patients are working? Please 8. explain. 9. Are you using the same eligibility criteria for Strong Start, and enrolling patients who show the ]? Fill with risk criteria following risk factors: [ [If criteria changed] Why did you make this change? Was it in response to changes in CMMI a. requirements issued in summer 2014? b. is change? What has been the result of th 170 TECHNICAL APPENDICES

189 Are you actively seeking out and enrolling patients in their third trimester of pregnancy? 10. [If yes] How (if at all) is the scope or content of Strong Start services different for patients a. o enroll earlier? who enroll in their third trimester, compared to those wh -out Do you still use an [ ] enrollment approach for Strong Start? Have you changed Fill opt -in/opt 11. the guidelines for sites in terms of how they can enroll patients in the program? s been the result? [If approach changed] Why did you make this change? What ha a. How do you think your sites’ methods for enrolling eligible patients are working? 12. a. Are you encouraging your sites to enroll patients with “pending” Medicaid or CHIP applications? b. Are sites using incentives to boost enrollment? How are these funded? How often do women decline (or opt out of) enrollment in Strong Start? What are the c. reasons? 13. How have sites done in terms of retaining Strong Start participants until the intervention is Has retention improved? completed? a. -up) Are there particular persistent reasons why participants drop out (or are lost to follow of Strong Start? Have you promoted any new retention strategies among your sites, in an effort to keep patients 14. enrolled and actively participating in Strong Start? Please describe. ve you used text messaging or social media to promote Strong Start, either as a recruitment Ha 15. tool or to engage and retain current enrollees? (Please describe) Has this approach been effective? ng Start enrollees? Do they 16. How would you describe the continuity of maternity care for Stro see a consistent set of providers throughout the prenatal, delivery, and postpartum periods? How does this affect patients’ overall care experience? a. [Questions for Maternity Care Home awardees/sites] Have there been any changes made to the roles and responsibilities of care coordinators in the 1. past year? What are care coordinators’ main responsibilities, currently? Have care coordinators’ caseloads grown with program enrollment? Are current caseloads 2. manageable? ]? Fill in dinators still have the following qualifications and credentials: [ Do your care coor 3. Do you think these are appropriate qualifications for a Strong Start care coordinator? Why or 4. why not? What other types of qualifications might be beneficial? [Questions for Group Prenatal Care awardees/sites] How many of your sites (if any) have been “approved” as Centering Healthcare Institute (CHI) 5. sites? How many of your sites (if any) are working towards approval? a. [If not approved or working towards it] What are the reasons behind sites’ decisions not to seek CHI approval? TECHNICAL APPENDICES 171

190 program deviate from CHI Group Prenatal Care [If not following CHI approach] How does your 6. protocols? Please describe the reasoning behind these deviations. patients of different coverage types (e.g., Do the sites’ Group Prenatal Care 7. cohorts include -insured and Medicaid-insured in one group)? What are the advantages and privately disadvantages of this approach? 8. What influence has the Group Prenatal Care schedule had on sites’ overall clinic schedule? For stance, have you observed any “downstream” effects of group scheduling, such as increased in -prenatal care services? appointment slots for gynecology or other non [Questions for Birth Center awardees/sites] [For AABC] AABC made a deliberate decision to provid 9. e Birth Centers with significant flexibility when implementing Strong Start’s peer counselor component, e.g., giving sites the option of hiring from within or not, allowing sites to determine the qualifications of their peer counselor. At this point in the award period, what do you think of that approach? Why? a. Does it matter whether a peer counselor or navigator is a true “peer” of Strong Start enrollees (e.g., sharing the same demographic or other characteristics)? What influence delivery? Please explain. does this have on service care Birth Center More generally, which risk factors would exclude a patient from 10. delivery? and/or Do you consider overweight (distinguished from obese) women ineligible for a. Birth Center care? abuse problems ineligible for Birth Center Do you consider women with substance b. care? What about women who smoke cigarettes? Strong Start Program Outcomes 11. What are your impressions of how the Strong Start enhanced services are affecting the physical health of Strong Start enrollees, both during pregnancy and after delivery? What about the psychosocial health of enrollees? Which maternal and newborn health outcomes do your Strong Start enhanced services a. have the greatest potential to influence? How are patients responding to the Strong Start enhanced services? 12. Have you observed differences in outcomes between Strong Start patients and similar women 13. not enrolled in Strong Start? -enrolled) patients? Please 14. Have you extended any Strong Start enhanced services to other (non describe. has Strong Start had on prenatal care providers? What effects— — positive or negative 15. 172 TECHNICAL APPENDICES

191 Lessons Learned, Best Practices, and Sustainability 16. At this point in program implementation, what top two or three elements of your Strong Start program would you say have had the biggest effect, in terms of improving care for pregnant Medicaid and CHIP beneficiaries? What parts of your program are you most proud of? a. What program area(s) could use the most improvement? 17. Based on what you know now, what might you have done differently? a. 18. Do y ou think Strong Start will be sustained after the award period is over? Why or why not? a. What plans have you made (if any) with regard to sustainability? Do you have any thoughts you’d like to share specifically about the evaluation? 19. a. How have you incorporat ed evaluation -related activities into your work? -level PLPE reports, case study b. Have you used any of the evaluation products (e.g., awardee memos) at all? Please explain. 20. Do you have any final thoughts about Strong Start that you’d like to share? TECHNICAL APPENDICES 173

192 Year Three Interview Guide Interviewee/Awardee Background ]? Please tell us about any changes in your position or Is your role here still [ 1. Fill in responsibilities. /Birth We understand that you are implementing the [ 2. Maternity Care Home/Group Prenatal Care fill number ] sites, and your Strong Start intervention includes [ Center ] approach in [ summarize in 2 or 3 sentences based on previous years’ memos ]. Is this right? a. Have there been any major changes to your intervention (e.g., adding/eliminating sites, adding or changing approach)? Please describe. Have there been any significant changes to your organization or to the management of the b. Strong Start award? Strong Start Program Outcomes 3. Which maternal and newborn outcomes do you think your Strong Start program has luenced? For instance, let’s discuss: inf - -level data time period], [Fill data point from participant [Fill participant Preterm Births: Through 4. level data] percent of Strong Start births were preterm (prior to 37 weeks). Does this sound right to you? a. satisfied with this rate? Why, or why not? Are you b. c. Do you think Strong Start services have influenced these rates? Which ones, and how? Are there other, non d. -Strong Start services you/your sites provide that might be influencing this outcome? Please explain. Low Birth Weight: Through [ 5. - -level data time period], [Fill data point from participant Fill participant level data ] percent of babies born to Strong Start participants had a low birth weight (<2500 grams). Does this sound right to you? a. rate? Why, or why not? b. Are you satisfied with this Do you think Strong Start services have influenced these rates? Which ones, and how? c. -Strong Start services you/your sites provide that might be influencing Are there other, non d. this outcome? Please explain. - -level data time period], [Fill data point from participant 6. ill participant [F Breastfeeding: Through percent of Strong Start participants were breastfeeding after delivery (according to level data] ] percent were not. [ ] percent who planned to breastfeed reported Fill postpartum data) and [ Fill that they were doing it. Does this sound right to you? a. Are you satisfied with this rate? Why, or why not? b. c. Are you satisfied with how breastfeeding outcomes compare to women’s intentions? Why or why not? 174 TECHNICAL APPENDICES

193 nfluenced these rates? Which ones, and how? Do you think Strong Start services have i d. -Strong Start services you/your sites provide that might be influencing Are there other, non e. this outcome? Please explain. Fill participant Delivery: Through [ 7. -level participant Fill data point from ], [ -level data time period data ] percent of your Strong Start births were vaginal and [ Of -section. percent were by C Fill] participants who said they planned a vaginal birth, [ ] percent had one. Fill a. Does this sound right to you? Are you satisfied with the rates of various delivery methods? Why or why not? b. c. Are you satisfied with how delivery outcomes compare to women’s intentions? Why or why not? d. Do you think Strong Start services have influenced these rates? Which ones, and how? e. Are there other, non -Strong Start services you/your sites provide that might be influencing this outcome? Please explain. 8. Fill participant Family planning: Through [ -level data time period ], [ Fill data point from participant - level data] percent of Strong Start participants had birth control counseling after delivery and [ ] percent did not. Fill Does this sound right to you? a. b. Are you satisfied with this rate? Why or why not? Do you think Strong Start services have influenced this rate? Which ones, and how? c. -Strong Start services you/your sites provide that might be influencing Are there other, non d. this outcome? Please explain. e. Do you think that birth control counseling or other family planning care has had an influence on the inter -pregnancy interval (birth spacing) for subsequent pregnancies Strong Start participants? Why or why not? among What aspects of your prenatal care approach may be reducing Medicaid costs (if any)? 9. Anecdotally, what are your views on the economics of your Strong Start approach? Are there 10. savings, or only costs? Is there a return on investment, and for whom? a. Do you have any data that supports your impressions? Program Enrollment and Outreach 11. Are you making progress toward meeting revised enrollment goals? Why or why not? As we begin our analysis of impacts, we want to explore the extent to which any selection bias 12. may exist surrounding your program’s enrollees. Specifically, can you tell us about patients who are offered the program but decline to enroll? a. How often does this happen (i.e., proportion of women who decline)? b. For what reasons do they decline? c. Does there seem to be any consistent ‘type’ of patient who is more likely to agree vs. decline to participate? why? 13. Are there patients who you are missing, who are eligible but not enrolled— TECHNICAL APPENDICES 175

194 14. [Keep if awardee’s data shows at le ast 10% are enrolled at 29 weeks gestation or later] Based on your quarterly program monitoring reports, through [ Fill participant -level data time period ], around [ Fill ] percent of participants have been enrolled in the third trimester. How does late entry into Strong Start influence the intervention and its ability to have an a. impact? Ideally, how would you handle enrollment processes to ensure more robust enrollment and a 15. healthy-sized program? Strong Start Program Services and Features 16. To what extent have you used social media in your Strong Start intervention? a. For example, have you used it to market Strong Start, link patients to one another (for support), remind women of appointments, etc.? What have been the advantages/disadvantages of social media for Strong Start? b. 17. Do your sites use an electronic medical record system? If so, to what extent has Strong Start service delivery been incorporated into this system? For instance, has it been used to identify eligible participants for enrollment, to identify a. eds or patterns among women enrolled in Strong Start, or as a way for Strong Start staff ne to communicate with providers? b. If it has not been used as tool for Strong Start, why not? What could be done to make the system more accessible? 18. you used incentives to modify behavior? We are interested in both How (if at all) have incentives for participants (to encourage enrollment and keep them engaged) as well as incentives for providers (for referrals to the program, for instance). Did the incentives achieve their a. purpose, or not? If not, why not? b. What resources were you able to use to support incentives? - -alpha We are trying to learn more about Strong Start sites’ use of 17P (17 19. hydroxyprogesterone caproate) to prevent preterm births. Does 17P administration play a role in your Strong Start intervention? Please describe. Based on your participant-level data, through a. -level data time period] around [Fill participant [ percent of participants with a history of preterm birth had received 17P treatment Fill] during their pregnancy. Does this reflect your experience? Please explain. b. Is Medicaid/CHIP reimbursement an issue? How about patient compliance? 20. We reviewed your participant-level data on family planning counseling earlier, and now we how family planning fits into Strong Start. Do you think that have a few more questions about If the Strong Start approach meets these needs more effectively than traditional prenatal care? so, how? At what point during prenatal or postpartum care is family planning discussed? a. b. (e.g., oral contraceptives, the birth control patch, injections Which methods are offered ], long [also called LARCs, including IUDs or -acting reversible contraception -Provera [Depo implants ], tubal ligation )? 176 TECHNICAL APPENDICES

195 How do patients select a method? c. Are certain methods encouraged or discouraged? If so, why? d. Have you observed any contraceptive access barriers? For instance, can LARCs be placed e. at hospital following delivery? Does Medicaid cover the full range of contraceptive options? Evaluation data have revealed that wo 21. men enrolled in Strong Start experience notably high rates of depression. Based on participant level data you’ve submitted, through - [Fill participant ], [Fill ] percent exhibited depressive symptoms at intake. level data time period a. Does this sound right to you? To what extent does your Strong Start intervention address depression? b. 22. We would like to learn more about the training, qualifications, and turnover among your Strong Start staff. Now with 2+ years of program experience, what have been the advantages a nd disadvantages to the staffing decisions you made? Has Strong Start staff had adequate training? What could improve? What works best? a. b. Is the mix of skills necessary to be successful at Strong Start service delivery easy or difficult to find in the workforce? What are the implications for replicating your approach in other communities? Do your Strong Start staff qualifications facilitate/hinder getting Medicaid reimbursement c. for enhanced prenatal care services? Has Strong Start staff turnover had an impact on enrollment or operations? How has this d. been addressed? e. -trained” to ensure turnover doesn’t impact the program work? Has your team “cross Model- Specific Questions -S [Maternity Care Home pecific Questions] How do referrals from care managers differ from the referrals a prenatal care provider might 23. give during a typical OB visit? Has the care manager had an impact on the practice/office functioning? On prenatal care 24. providers’ efficiency? 25. Does the care manager know (or do anything in particular to find out) if women use the services they are referred to? Do they have a system for monitoring and following up? How do care managers help prepare participants for discussions with their prenatal provider? 26. [Group Prenatal Care -S pecific Questions] y persistent challenges securing appropriate space for group sessions? 27. Have there been an 28. Do you allow children to attend group sessions if a woman does not have childcare options? )? 29. Are you using a specific Group Prenatal Care curriculum (e.g., CenteringPregnancy 30. [If awardee uses Centering approach] Does your model depart from CenteringPregnancy ? In what ways? Why? 31. [If awardee uses something other than Centering] How did you decide on a curriculum? TECHNICAL APPENDICES 177

196 [Birth Center-S pecific Questions] 32. How do the referrals, education, and support provided by peer counselors differ from the services midwives provide? Has the peer counselor influenced Birth Centers’ functioning? Midwives’ efficiency? 33. 34. Does the peer counselor know (or do anything in particular to find out) if women use the ices they are referred to? Do they have a system for monitoring and following up? serv 35. [For AABC] Do you track whether participants are using AABC’s Strong Start Facebook page? Any feedback or elements most utilized? 36. [For AABC] Do you track whether participants are using the AABC Maternity Care Guide? Any feedback or elements most utilized? 37. [For AABC] Are participants completing AABC’s Maternity Care Surveys? Tell us about any survey results you’ve received — what were they, and how have they been used? Barriers to Care Overcoming 38. To what extent has lack of transportation presented barriers to your clients seeking prenatal How have you specifically tried to address this challenge? Has it worked? care? 39. To what extent has lack of childcare presented barriers to your clients seeking prenatal care? How have you specifically tried to address this challenge? Has it worked? 40. Has communicating (keeping in touch) with Strong Start patients been a challenge? How have you specifically tried to address this challenge? ked? Has it wor Could the Strong Start intervention be adjusted to better address these barriers? 41. Provider Relations What role do obstetrical care providers play in your Strong Start program? 42. conduct the What kind of involvement and/or support is needed from them to successfully a. intervention? What concerns, if any, have providers had about implementing Strong Start? 43. 44. Have you developed any strategies to foster provider engagement? Please describe. a. How can providers be convinced that Strong Start services are valuable? How can providers be convinced to change practice patterns to incorporate enhanced b. prenatal care? To what extent have you involved medical residents in your Strong Start program? 45. How has that worked? a. Have you identified any successful ways to involve resid ents? b. Has involving residents presented any particular challenges? 178 TECHNICAL APPENDICES

197 Sustainability and Replicability Are you planning to sustain your Strong Start program? 46. a. Which aspect(s) are you particularly interested in sustaining? in planning for program sustainability. Tell us about any progress you’ve made 47. What funding avenues have you explored, or do you plan to explore? a. What kind of feedback are you getting? b. 48. To what extent have you explored Medicaid reimbursement (or enhancements to Medicaid reimbursement) to support Strong Start in the future? What current Medicaid policies either facilitate or hinder sustainability? 49. Are there policies or practices of Medicaid managed care organizations that present a. particular opportunities or barriers to sustainability? 50. Is su ccessful implementation contingent on women entering program at certain point in pregnancy? Please explain. What would sustainable intervention look like for someone who enters prenatal care late? a. Is it even feasible? Will sustaining the program be easier when you are no longer required to submit program and 51. evaluation data, after the award period is over? Please explain. Have program or evaluation data been useful in supporting program operations and 52. development? In obtaining funding to sustain Strong Star t-type services? 53. What Strong Start care elements or lessons can be applied to other types of care (beyond prenatal care) such as primary care, chronic disease management, and so on? Wrap -Up 54. What are the key differences between Strong Start- enhanced prenatal care and other “traditional” prenatal care being delivered in the area? If Strong Start is not sustained, what kind of care will pregnant women with Medicaid/CHIP get 55. in its absence? In other words, what are they losing? 56. How are you winding down Strong Start services? What is your schedule for completing the demonstration? Looking back at your experiences to date, what have been the most important lessons you’ve 57. learned about “what works” in improving prenatal care and birth outcomes? 58. Looking back, what h ave been the most persistent challenges you’ve faced in improving What have you succeeded in overcoming, and what prenatal care and birth outcomes? challenges have not been overcome? 59. Anything else? TECHNICAL APPENDICES 179

198 Year Four Interview Guide Current Status and Sustainability 1. First, please update us on the current status of your Strong Start award. a. When did/will enrollment end? If so, how many? b. Are any participants still receiving services? c. When [month/year] did/will the last Strong Start deliveries occur? d. When did/will you submit the last data you have for the evaluation (forms and surveys)? 2. Could you please update us on your plans for sustaining Strong Start after the award period is over? Last year, you told us [Summarize sustainability plans from Year 3 memo, in one or two sentences.] Which enhanced services will you sustain, if any? a. Which sites will offer the services? i. ii. Which population(s) will receive the services? Who will deliver the services? iii. iv. Are you making any [other] modifications to the way services are structured? data collection Are there any elements of Strong Start b. that you plan to continue? i. For example, using the Intake form as an initial risk assessment? [ ] How will you fund the services/additional data collection? If relevant c. 3. not planning to sustain Strong Start enhanced services or data collection, [If relevant ] If you are which factors have most influenced this decision? Or have you For example, lack of funding or lack of provider or administrator support? a. determined that Strong Start services were not effective? Replicability Beyond the sustainability of your own program, we’d like your thoughts on whether a Strong 4. Start program like yours could be replicated on a larger scale. First, do you think a program like be replicated? Why or w should yours hy not? 5. We’re interested in which factors you think are most important when it comes to successful program replication, based on your experiences implementing Strong Start at various sites. These factors could be related to the specific way you implemented your Strong Start intervention, or they might be related to the environment in which your sites are operating. As we explore these different factors, we’d like you to consider whether your program can be replicated in other parts of your state or the country, or in settings that are not like yours. , which factors make a difference in whether a program like a. practice level First, at the Strong Start succeeds? b. At the provider level , which factors make a difference? patient level c. At the , which factors make a difference? 180 TECHNICAL APPENDICES

199 community or policy level, which factors make a difference? Finally, at the d. e. Are there other factors we haven’t mentioned that you feel are important? Have you seen any evidence that enhanced prenatal care programs like Strong Start are 6. becoming more prevalent in your area? Please explain. Program Outcomes 7. Last year during our interviews with you and your Strong Start team, we spent a lot of time discussing specific program outcomes. Your team told us: [ Summarize perceptions of impacts on outcomes Does this still seem right to you? Do you have from Year 3 memo, in a few sentences.] anything to add about whether and how your Strong Start program has influenced maternal and newborn outcomes? [ If relevant ] Do you have any specific evidence of this imp a. act, or is it more of a gut feeling? If evidence indicated] [ i. What is the evidence? Can you share it with us? If relevant] Which parts of the program do you think are most responsible for the [ b. improvements in outcomes you just discussed? rvices have ceased If Strong Start se [ 8. ] Have you observed any changes in maternal and newborn outcomes among your Medicaid/CHIP patient population since you stopped offering Strong Start services? Please explain. Do you have any specific evidence of changes, or is it more of a gut feeling? a. What is the evidence? Can you share it with us? If evidence indicated] [ i. Do you think your Strong Start program has resulted in any cost 9. -savings? If so, where do you think those savings come from? How exactly did Strong Start services contribute to these savings? Program Features [For Maternity Care Home awardees/sites] Maternity Care Home Do 10. participants see the same prenatal care providers at each visit? Do the same providers that provide prenatal care also attend the deliveries of the parti cipants? Do they provide their postpartum care? a. If not, which providers attend deliveries? Which providers are responsible for postpartum care? i. Do patients have a prior relationship with these providers? When does the transfer of care occur? b. Do you think having provider continuity — meaning a consistent provider throughout pregnancy, delivery, and postpartum— makes a difference in patient outcomes or patient experience? c. Has Strong Start in any way influenced or improved provider continuity? TECHNICAL APPENDICES 181

200 11. A common feature of Strong Start Maternity Care Homes is adding a “care manager” to the traditional prenatal care approach, but we found that the qualifications of these “care managers” vary from one awardee to the next. Considering your experiences, which qualifications do you think are most important for a prenatal “care manager” to be effective? The Strong Start Maternity Care Home 12. awardees have taken different approaches to “care manager” encounters, both in how often these encounters occur and in whether they are in- per son or by some other means (e.g., telephone or text message). Our understanding is that Summarize encounters based on Y1- your “care managers” [ Y3 memos, in one to two sentences. erson, by phone, or -p Include average number or range of encounters and whether encounters were in text/email. ] In hindsight, would you make different decisions about how you structured the “care manager” encounters? Please explain. [For Group Prenatal Care awardees/sites] Do the same providers that participate in Group Prenatal Care sessions also attend the 13. deliveries of the group participants? Do they provide their postpartum care? If not, which providers attend deliveries for Group Prenatal Care a. members? Which providers are responsible for their postpartum care? i. Do group members have a prior relationship with these providers? When does the transfer of care occur? — b. meaning a consistent provider throughout Do you think having provider continuity pregnancy, delivery, and postpartum— makes a difference in patient outcomes or patient ience? exper s Strong Start in any way influenced or improved provider continuity? Ha c. ither before or during Strong Start, did you reach out to the Centering Healthcare Institute 14. E (CHI) for technical assistance or guidance on implementing Group Prenatal Care? If yes, please explain. a. Did you think this made a difference in your implementation success? Why/why not? CenteringPregnancy awardees have followed CHI’s 15. Group Prenatal Care Most Strong Start model to some degree. Considering your experiences, which aspects of the Centering model do you think are most important to “keep” when implementing , and which Group Prenatal Care ones can be modified and still allow for successful program implementation? [For Birth Center awardees/sites] 16. We are asking awardees and sites about provider continuity throughout prenatal, labor and delivery, and postpartum care. How would you describe continuity in the Birth Center model? Birth What role, if any, does provider continuity play in women’s decision to choose a. Center care? b. Has Strong Start in any way influenced or improved provider continuity? We found that the qualifications of peer counselors/navigators varied from one Birth Center 17. site to the next. Considering your experiences, which qualifications do you think are most important for a prenatal peer counselor to be effective? 182 TECHNICAL APPENDICES

201 Birth center sites have also taken different approaches to peer counselor/navigator 18. encounters, both in how often these encounters occur and in whether they are in-person or by some other means (e.g., telephone or text message). Our understanding is that your peer Summarize encounters based on Y1- counselor/navigator(s) [ Y3 memos, in one to two sentences. Include average number or range of encounters and whether encounters were in -person, by phone, or text/email. ] In hindsight, would you make different decisions about how you structured the peer counselor/navigator encounters? Please explain. [For all awardees/sites] - We’re trying to learn more about the use of aspirin treatment for women at risk for pre 19. eclampsia during pregnancy. What role, if any, does aspirin play in your prenatal care approach? Lessons 20. Looking back at the last three years, which part of your Strong Start program are you most proud of? What was the most challenging aspect of Strong Start implementation? 21. Were you able to overcome this challenge? If yes, how? If not, why? a. If you had to identify a single factor that had the biggest impact on how well your Strong Start 22. program worked, what would it be? Would you do anything differently? TECHNICAL APPENDICES 183

202

203 APPENDIX C: QUALITAT IVE CASE STUDY – CASE STUDY INTERVIEWS CONDUCTED IN YEAR 5 TECHNICAL APPENDICES 185

204 QUALITATIVE CASE STUDY: SUMMARY OF FINDI NGS FROM SOUTH CAROL INA MEDICAID INTERVIEW The Strong Start evaluation team interviewed representatives from the South Carolina (SC) Department of Health and Human Services (DHHS) in May 2018 as part of a special study of the barriers to Group Prenatal Care (GPC)/ Table nd solutions to overcome them. (CP) a CenteringPregnancy 1 summarizes the interview findings by topic. C. 1: SUMMARY OF FINDINGS FROM SOUTH CAROLINA MEDICAID INTERVIEW TABLE C. Interview Topic Summary of Findings 90 percent of Medicaid births and most obstetrical care are through managed care (MC) capitated - 85 A total of Billing and arrangements. SC uses a standard rate setting methodology, with a couple of nuances: births are not included in the risk payment for GPC calculation of the child bearing population, and every birth triggers a kick payment to the Medicaid managed care prior to enhanced organization (MCO) to address risk transfer; and there is a target mix of C -section vs. vaginal births that in the rate setting payment methodology. Until recently, GPC was not a covered benefit. If a GPC service was billed, it would not be reimbursed. Providers were just billing for traditional prenatal care. - “Phase 1”: Believing that the evidence around GPC was not sufficiently robust to obtain buy in from MCOs, SC created a financial incentive to steer members to GPC. SC issued payments through incentive authority rather than articula te GPC as part of the capitation rate; there was a quarterly pay -up, at a rate of 25% as a pass through. “Phase 2”: With the 2017 -through payments to providers Medicaid managed care Final Rule preventing states from increasing or adding direct pass contracted to MCOs, along with greater acceptance in the MCO community of the GPC model, adding GPC to the standard rate setting made the most sense. Building GPC into the rate protects integrity of the model and reimbursement Evolution of without being “heavy handed.” In other words, SC created a mechanism for GPC to be paid under the FFS system, even enhanced though small percentage of deliveries are through FFS. Adding GPC to the Policies and Procedures Manual as a FFS payment with the Final Rule (no longer a pass procedure meant that MCOs must cover it, and secured compliance through/incentive). The provider reimbursement component is based on the standard network agreement between MCO and provider office. Under the “Phase 1” incentive, they were getting $30/visit up to $150 (i.e., 5 visits); now $30/visit up to $300 (i.e., 10 visits). Also, one MCO (BCBS’ Blue Choice plan) initiated a retention bonus for their physicians of $175 for each patient verified as attending 5 group sessions. The actuaries used a utilization pattern that trended off current utilization and assumptions of likely trajectory based on trends and the availability and access to the GPC model that is spreading throughout the state, and the need to train Determining the additional sites, etc. Savings projections have not been incorporated in rates. The actuarial processes do not have any enhanced appreciation for future savings that can be derived from those costs, like smoking cessation, or immunizations, if it is payment outside the actuarial benefit window of 12 months. In the scheme of a $3 billion overall MCO spend, even though there is an appreciable amount of dollars related to GPC/savings, it doesn’t compare to the magnitude of other things. e federal match, SC developed an administrative contract between DHHS and Greenville Since Medicaid can draw down th Health System (GHS) as a consultant. This laid out the expectations of how SC would expand GPC throughout the state, at a Centering site. Representatives of GHS, the March of Dimes what rate, and how a practice would apply to become (MOD), the Centering Healthcare Institute (CHI) and the Birth Outcomes Initiative (BOI, a multi-stakeholder collaborative pplication, and GHS would provide the technical aimed at improving birth outcomes in South Carolina) reviewed a site’s a assistance to get it up and running. The contract included the startup costs for each practice, including the $35,000 - Promoting GPC 40,000 for a site to become certified by the Centering Healthcare Institute (CHI). Generating the interest was not that beyond the difficult, but convincing physicians that it would be better for patients was a bit harder, because they did not have a lot of enhanced data at that time. Clemson University is now under GHS contract to evaluate more data. payment 2016). Then in 2016 when the contract was renewed, emphasis was not Ten sites were included in the first 3 years (2013- on the number of new practices, but on providing additional TA to practices that were up and running and had staff turnover. There was funding for 5 new sites, and they have already received applications and approved all 5. They were also able to open the opportunity to more than just the practices that GHS could support, because of CHI interest in SC, and have also provided additional financial support for other practices to open in the state. At end of 2018, there will be about 24 practices with CP. . A lot of this work has been centered around the direct energies of Dr. Amy Crockett (GHS) and the networking of the BOI The University of South Carolina’s Institute for Families in Society conducted formalized studies of deliveries after GPC -2016, vs. routine prenatal care, and the state’s dashboard/analytics is tracking GPC, LARCS, and C -sections. In 2013 Uptake of GPC about 2,000 women enrolled in SC Medicaid were in GPC, of 30,000 births annually. This is viewed as close to their maximum potential, as practices that want to provide CP are already doing so. If others express interest, they would be referred to CHI for assistance. TECHNICAL APPENDICES 186

205 Interview Topic Summary of Findings When SC changed the program in 2016/2017 via FFS rates, and increased the coverage from 5 to 10 visits, they were Feedback recognizing what it takes for the physician. No physicians have said to the state that the reimbursement is not enough. regarding are “absolutely thrilled” at the convenience of 8-10 patients in a group at a time. Patients are happy also—they Providers nced enha get to talk as much as they want, get to socialize, and have a 6 -week postpartum get together where moms come back with payment babies. There is a lot of positive feedback on both sides, from providers and patients. SC is not planning any changes to the current FFS- based payment model for GPC, which is viewed as necessary for sustainability. CHI certification lasts for 3 or 5 years, a good period of time, and it is hoped the practices will want to be Sustainability recertified because they are happy with the results and the income they get from GPC. Medicaid, It is a “work in progress” to get physicians engaged, because the substantial cost savings are to the payer — MCOs, BCBS. They have seen a 36% reduction in preterm births, 44% reduction in low birth weight (LBW), and 28% Results reduction in NICU admissions. GPC has also shown positive results in terms of health disparities. Data for African disparities. ns is extremely positive for outcomes and does not show the usual America QUALITATIVE CASE STUDY: SUMMARY OF FINDINGS FROM DR. AMY CROCKETT INTERVIEW The Strong Start evaluation team interviewed Amy Crockett, MD, MSPH, a South Carolina (SC) Maternal- Fetal Medicine specialist and champion of SC Medicaid’s enhanced reimbursement for (CP) program in May 2018 as part of a special study of the barriers to Group CenteringPregnancy summarizes the interview findings Prenatal Care (GPC)/CP and solutions to overcome them. Table C. 2 c. by topi S FROM DR. AMY CROCK ETT INTERVIEW TABLE C. 2: SUMMARY OF FINDING Interview Topic Summary of Findings Dr. Crocket had a funding opportunity from the March of Dimes (MOD) to do GPC start - ups in 2008. She is also the 72 clinical lead for the Birth Outcomes Initiative (BOI) , and the Medical Director of Greenville Health Sys tem (GHS), a large -4 CP groups per month at outpatient group practice in Greenville, SC, serving medically underserved patients. There are 3 Background and that practice. involvement -to The first few years of MOD projects were funded for training and materials on an annual basis (“hand -mouth”). An in program evaluation found substantial reductions in preterm birth and racial disparity. In 2011, Dr. Crockett approached the South Carolina (SC) Medicaid Director with the findings, and he decided to do a Medicaid demonstration to expand access to C P. Built under the BOI, SC looked to leverage GHS’ experience to expand access to CP, with GHS providing training, technical P model, assistance (TA), and evaluation. SC Medicaid provides enhanced reimbursement to practices; SC requires the C and contracted with the Centering Healthcare Institute (CHI) because the model is evidence -based. In the first year, SC paid $200 per CP patient to the Medicaid managed care organization (MCO), with $150 meant to be passed to the xcel spreadsheets were initially used for payment requests. In the 2nd year, SC Medicaid helped practice. Basic E developed a code for the group visit: 99078 code, along with 99213 with TH modifiers. The 1st contract with GHS was for 3 years to start up new practices with C P. After 3 years, the state extended the program another 3 years to focus on sustainability, and 2018 is last year. GHS has applied for an extension to solidify the How the practices currently offering CP (e.g., there’s a lot of turnover and it is free for new providers/office staff to come to local program works trainings) and to continue the evaluation. It takes about 18 months from the time a practice is awarded the CP grant to the -9 months to deliver), and it takes time to -training, then training, then 6 1st Centering group’s deliveries (6 months pre ramp to volume. The outcome data lags behind. Currently 24 practices are engaged. Blue Choice (parent is BCBS) did its own evaluation and was impressed with savings; it offered enhanced reimbursement to practices for up to 10 visits ($300), plus a retention bonus of $150. In the $450 range, it seems to start to incentivize adoption. Commercial BCBS offers practices the same CP reimbursement program. BCBS and Medicaid cover 80% of state deliveries. 72 BOI is a multi- stakeholder collaborative aimed at improving birth outcomes in South Carolina. TECHNICAL APPENDICES 187

206 Interview Topic Summary of Findings GHS identifies and recruits practices. There are 3 major residency programs in SC. Dr. Crockett uses relationships with other providers to discuss CP, and raises CP at BOI, ACOG events, and grand rounds at all major teaching hospitals. There is a lot of skepticism about CP, and it is important to have a physician champion who can say, “I work in SC too and this is why CP is good for my patients.” Practices interested in applying for the enhanced payments are required to attend a bidders’ confere nce – a day -long seminar to help determine site readiness, hosted by CHI, that describes the CP model and its benefits, and asks if practice it. sure practices understand what is involved and are committed to en has space, enough volume, etc. They Identification and 40,000) and supplies, helping to address a major financial program pays for the CHI certification process ($35,000- The recruitment o f barrier to start up. It takes 18 months to “get anything back” – without the funding, it is cost prohibitive right now for a practices practice to implement CP and the program would not work. GHS provides statewide data to explain to practices’ administrators the background and importance of GPC, which helps some practices address internal resistance. GHS also conducts ongoing regional trainings, which is deemed critical to success. GHS manages the data, and gives practices report cards showing differences between CP and non- CP outcomes, which is “inspiring.” These are the most engaged practices, from providers to front desk staff. Giving them data they can see is encouraging and part of success. Pulling back the TA could jeopardize this. There are no specific criteria for member eligibility (following the CHI model, which does not specify criteria). At GHS, NPs/m idwives facilitate CP, so they include patients they are comfortable managing. Other practices have groups run by physicians, so they can see more types of patients – “it’s a mixed bag across the state.” Recruitment of women—convincing them that group care is a good thing to do—is a challenge. Each MCO sends publications when a member gets pregnant, but SC did not expand Medicaid under the Affordable Care Act; so, women are Identification and recruitment of enrolled in Medicaid only after they become pregnant, at which point they have 90 days to join a plan, making it generally patients too late to start CP when an MCO finally reaches them. The focus on recruitment is at the practice level, and each practice has its own strategies; e.g., through videos. The Communications Director at Medicaid has connections with the press and sends press releases when a practice opens a CP site. The local newspaper sends a photographer over so there is publicity ment are in local papers, leveraging state resources. However, recruitment remains a struggle and ideas for recruit discussed at consortium meetings each year. Percentage of A small percentage of Medicaid beneficiaries receive CP – “barely scratching the surface.” Problems come on the patient prenatal Medicaid side; the rigidity of the group model does not work well and there is a need to work through the model’s shortcomings. For example, GHS can only offer 2- 3 groups per month, and many patients are not able to attend. Even getting 30% of a beneficiaries included realistic. practice’s patients into group care may not be GPC leaders are “figuring it out as they go.” All physicians in SC know about CP, and agree patients like it but acknowledge What is needed the reasons they cannot do it. “We’ve made huge strides in 6 years, but don’t know where we’ll be in 3 years, and whether going forward support for infrastructure to support practices with ongoing training and evaluation .” there will be Public policies Solidifying the reimbursement modifier to ensure enhanced payment, and the adoption of enhanced payment for CP by all that could payers (Medicaid, commercial, Tricare) would help promote GPC. The payment level is important; at $450 -700/patient, mitigate the go (i.e., from acute care to CP). practices would look more closely. There is a need to switch where healthcare dollars barriers to GPC 188 TECHNICAL APPENDICES

207 QUALITATIVE CASE STUDY: SUMMARY OF FINDI NGS FROM CENTERING HEALTHCARE INSTITUTE INTERVIEW The Strong Start evaluation team interviewed officials from the Centering Healthcare Institute (CHI) in CenteringPregnancy cial study of the barriers to Group Prenatal Care (GPC)/ April 2018 as part of a spe (CP) and solutions to overcome them. Table C. 3 summarizes the interview findings by topic. LTHCARE INSTITUTE INTERVIEW S FROM CENTERING HEA 3: SUMMARY OF FINDING TABLE C. Interview Topic Summary of Findings - Buy all providers that will be doing GPC, leadership in from - in is primary for successful GPC. A practice needs to have buy -in from support/front line staff. Without buy to make the logistics happen, and early on, buy -in, it will make for a rocky ders need to be on board and actively most, if not all, provi — -driven model implementation. CP is fundamentally a provider providers cannot hold onto patients. Leadership support is — support CP. How patients are assigned has a huge impact needed. Budget line items are fundamental— GPC cannot just be supported by grant funding. Lack of buy -in stems from lack of education about GPC. When medical students have not heard of GPC until they are in Implementation practice, there is resistance to change. Education is needed to understand GPC and that it positively impacts their own barrier: lack of experience of care, patient exper ience of care and outcomes. Without that, it is a hard sell. GPC changes how providers buy -in engage with patients, and it is a big business practice change. There is a lot more support and interest from younger t es providers than from well- ablished providers. But there are also a lot of providers burning out and looking for new and better ways. GPC is a practice change journey. it requires a longer conversation with patients to describe what it — For support staff, getting CP set up is extra work offers. Support staff need to be part of clinic- wide education and movement from one -on-one care to CP. A new model requires new administrative processes. Incorporating GPC into residency programs is challenging because of schedules. The director needs to be able to change the schedules so residents can participate in the majority of group sessions. It takes a dedicated residency director to support that, and where you have that, it is really successful. All residency programs and CP integration methods are i.e., different. It works well when CP is the OB/GYN rotation for residents, and a CP trainer does training with residents — where CP has become institutionalized. Getting group facilitation to be part of the health care provider education and Implementation institutionalized for the new generation of healthcare workforce is needed for GPC to flourish and be sustained. Working barrier: enough. with residency programs around country is a strategy that can’t be overstated traditional/ Residents enjoy providing CP. It has worked successfully in places like Dartmouth Hitchcock (Dartmouth, NH), Einstein training programs (Philadelphia, PA), and Greater Lawrence Family Health (Lawrence, MA). Wake Forest trains residents through mock groups where other residents act as patients. Resi dents specifically choose to go these programs because of the CP offering. Training programs are also needed to continue educating other practice staff and new staff. Patients know what an individual group visit is, and do not understand group care, resulting in patient resistance to GPC. Educating and making patients feel comfortable about trying GPC fall on the provider team. Experience can be built, for -out model (whereby patients are example, by using group intake for the initial visits. Most successful sites use an opt Implementation declining to participate automatically assigned to GPC and may opt out). It allows for a binary, unforced choice, but with a barrier: patients -out. baseline of GPC. Patients gravitate toward what they are familiar with. Expose first, and then allow opt declining to Transportation and childcare are fundamental to attending sessions (an issue for individual appointments as well), and participate groups need to be scheduled when patients are available to attend them. When evening sessions are offered, they fill up faster because they don’t conflict with work and another parent is often available for childcare. It is a structural challeng e for practices (particularly those with labor contracts and set hours), with resistance fro m many providers. Implementation Through a grant from a charitable foundation, CHI has had the opportunity to “pressure test” whether practices are barrier: interested in CP when funding is not a barrier. There has been a highly positive response, indicating that practices are inadequate interested in CP when funding is available. CHI is looking at ways to reduce the costs through economies of scale, funding for targeting geographically to guide a community of local practices. start - up costs A commonly voiced concern is that GPC is not as profitable as traditional prenatal care, but there is no evidence to support Implementation , so it may appear that CP costs more, this. Clinics must take time and invest in things that are not needed in traditional care barrier: lack of nt even if productivity is better than or consistent with traditional care. In that regard, a financial incentive can be importa enhanced to a practice — higher reimbursement for better care makes the case for sustainability and encourages providers to get reimbursement more patients into CP. The “carrot” encourages them to build the CP practice. developed pathway and Knowing what the pitfalls can be and what a successful CP practice looks like, CHI has a well- implementation plan for providers. Whether providers trust and follow the start -up process in a slow and deliberate Successful manner can make or break whether a practice implements and sustains CP. It starts with a champion, and building an strategies to effective steer ing committee that can oversee and get reports on the successes and barriers. Normalizing CP requires mitigate barriers engaging leadership and including everyone who has a touch point with patients. TECHNICAL APPENDICES 189

208 Interview Topic Summary of Findings 8% of organizations do n About 7 ot renew their CP licenses with CHI annually. This is related to the large degree of - -4 years, and there is even more frequent turnover in healthcare. It is very rare have someone in leadership for more than 3 Challenges to turnover among other staff, which creates an ebb and flow for how normalized CP is within the organization. Also, the sustaining or practice needs to budget for training and extra items as part of their normal operating budget. The most successful sites expanding CP -out process as early as ormalizing CP through an opt make CP the standard of care (“This is how we do care here”), n possible. 12) and having patients attend the - Most important for achieving profitable GPC is getting adequate group numbers (10 Relative profitability for majority of sessions. Practices will struggle with this if they can only enroll 6- 7 women, and some women are absent from providers of GPC sessions. Then it is no longer cost effective. So, practices need to pay attention to enrollment, and perhaps over enroll to or no shows. Providers can also adapt the length of the visit; smaller groups can be done in 90 minutes rather vs. traditional account f than 2 hours. If a practice is creative and bold in enrolling women, profitability should not be an issue. prenatal care The vast majority of providers bill for GPC as they would for traditional care. In some states, they can add modifiers codes for certain components (e.g., education, breast feeding). South Carolina (SC) Medicaid is the most well documented example of a state making differential payments for GPC. The up to $300 total), and patient receive an additional payment per visit for women in CP (an additional $30 per providers , in Examples of an some cases, individual payment for each woman coming to 5 sessions (i.e., good attendance). This is the most additional differential common, and what other states are adopting as well. From a practice’s perspective, the enhanced payment is enough of an payments for GPC set of grantee sites, it has incentive to cover ongoing training and notebooks. Since SC started the program with its first not lost a single practice (no attrition). Montana Medicaid just rolled out a program. In New York, the “First 1000 days on Medicaid,” will replicate South Carolina in target areas of poor outcomes. There are also some differential payments by MCOs, such as CareSource and Anthem. Public policies Lawmakers become critical partners where public policy can affect funding and availability of GPC, and Medicaid payment that could structures. In Ohio, there a re Department of Health funds for programs that are targeting hard- hit areas, and support for mitigate barriers CP is part of that initiative. Changing policy takes time and is a longer -term strategy. to GPC NGS FROM QUALITATIVE CASE STUDY: SUMMARY OF FINDI BABY+CO. INTERVIEW 73 The in May 2018 as part of a special Strong Start evaluation team interviewed officials from Baby+Co. Table C. 4 study of access to midwifery and birth center care under state Medicaid programs. summarizes the interview findings by topic. 4: SUMMARY OF FINDINGS FROM BABY+CO. INTE RVIEW TABLE C. Interview Topic Summary of Findings In itial Baby+Co. birth center built “from scratch” in Arkansas, a state without a significant midwifery infrastructure and no standard birth center setup with significant attention paid other birth centers. Model morphe d and evolved but resembles primary investor for startup costs and infrastructure development. to financial sustainability. Baby+Co. used a and centers, which are all owned nd disseminated across model is centrally controlled a prenatal care Baby+Co. The The incor porates elements from all three Strong Start enhanced care approaches — a operated by Baby+Co. care model sta the group prenatal care component, ndard birth center approach which is very education heavy, and partnership with community programs to implement a maternity care home including educational offerings and community offerings . Baby+Co. does a lot of data collection—running a whole set week. of data every Background on centers are staffed by nurse-midwives (with support from nurses). Because the company operates largely in Baby+Co. Baby+Co. southern states [that have more restrictions related to other types of midwives] nurse -midwives were the only real option. midwives privileges in hospitals so women can get prenatal care at the birth center and get nurse- has worked to Baby+Co. (center or hospital) rth place of bi their then choose midwives don’t have privileges [at the hospital] then patients feel . If they must commit to their place of birth early in pregnancy, when it is not developmentally appropriate to ask somebody be born. will best prenatal care and then worry about where the baby to make that decision. We want women to have the The centers do not use birth assistants or doulas in any routinely- staffed way, but do use health coaches (who provide care coordination and navigation) and educators (who run t he curriculum). Professional qualifications of these individuals vary. 73 http://www.babyandcompany.com 190 TECHNICAL APPENDICES

209 Interview Topic Summary of Findings Baby+Co. has opened some birth centers (like the initial Arkansas center) from scratch and acquired other centers that Acquiring/ (like the Lisa Ross birth center in Knoxville, TN, which was part of the Strong Start demonstration). The already existed Developing New most important factors that influence the company’s decision to build or buy a new center are population size and then Baby+Co. reimbursement and economics . We look for a big enough population that there must be only a very small market Birth Centers penetration for the center to be full. And we look for high rates of commercial payment, because we have not had success working with Medicaid programs yet, and not for lack of e ffort. For commercial payers, we set up a case rate that includes both professional and facility aspects of what we do to make the -$9,000 per case. business model work, which requires a rate of $8,000 We have a tool, case builder, that gives them the list of codes to run internally to match against what we would bill them to help them see the savings. That’s a long process -9K rate is to say they only pay because there is little will or motivation on their side, and the initial reaction to the $8K doctors in hospitals $2500 (or similar). But that is not true, because their reference does not include the [hospital] facility fees and newborn care. Payers [do not take] that longitudinal aspect of care, they are not at a place yet where they can see avoided costs for [as examples] reducing the preterm birth rate or decreasing NICU admissions. They’re still trying to compare on a fee -for- are real. service, apples to apples, this code set to this code set. But the savings -insured target population. It has been very Baby+Co. has done active marketing and outreach to our commercially difficult to even get meetings on the books with the Medicaid managed care organizations (MCOs). The governor’s office terested but you must work with MCOs to actually get anywhere. And in Tennessee [as an example] birth may be very in centers have historically taken very low reimbursement rates so it is like pushing a boulder uphill to get past what the Challenges historical were. The Baby + Co. model certainly works. It works financially with great health outcomes but that may not be related to working sustainable if we do not find a way to work with the Medicaid programs. It is not a data problem, it is a political will issue. with Medicaid Nobody we have interacted with on the commercial or the Medicaid side does not understand that [the birth center program model] is good for people. They all understand that it is good for people. Ba b y+Co. could have accepted the very low rates that some birth centers [as in Tennessee example] had always taken from Medicaid, but we are trying to move the needle and say this is worth paying for and here is why. You are paying hospitals more than this and getting an inferior product, outcomes are not as good. But at the end of the day the people making the decision are the contract negotiators. Leadership may agree but things get stuck in the mechanics. And often the people who operate at that contract negotiation and implementation level, their personal bonus structure is set up against fee -for- ne items and they get penalized for increasing costs. If they increased the case rate for birth service li centers based on Baby+Co. negotiations, there could be negative repercussions related to their annual bonus. They have no incentive to make it happen and every incentive to stop it from happening. We do not have success stories about working with Medicaid programs. Those stories exist for commercial payers, but for Medicaid there is inertia in a variety of directions. The 2016 elections and uncertainty around the future of the Affordable Care Act put people into absolute stalemate, waiting to see how things were going to shake out. [Payers] have had bigger ac surgery. fish to fry, and are more worried about what is happening with payment for hip or knee replacements, or cardi There are tons of opportunities. The Medicaid programs have many good services aimed at moms and babies. But pulling all the disparate, siloed, pieces and parts together to make it work...t here is neither the political will nor the ability to change the granular systems that require a claim submitted and then paid. Some of the delivery system reforms related to risk and gain sharing could work well for birth centers. It is at the implementat ion level that things fall apart. [I often wish] births were paid for by Medicare so that I would have one set of Opportunities people to talk to instead of 50 different state Medicaid programs. There is a lot of interest in maternity- related delivery related to working -based reimbursement] and two things happened. One, births are considered reforms. Arkansas did a lot of work [on value with Medicaid inpatient services, so when you try to flip it and apply the reimbursement methodology to an “outpatient setting” which program birth centers are considered, there ’s no mechanism for it. Also, in almost all instances the primary accountable provider for the reimbursement arrangements had to be physician. And even though the birth centers all have medical directors, that person is never going to see the patient, yet the arrangements require the accountable provider to have seen the patient a certain number of times. There was no mechanism for midwives to be the primary accountable provider and there was no - hospital to be associated with a birth. mechanism for a non Patient recruitment is not very hard because health care is still very much a local thing and if you take good care of people that spreads in their communities. It also [helps] when place of birth can be determined later in pregnancy, for people who do not necessarily see themselves as the “birth center mom.” We did a lot of market research in various areas, typical marketing, focus groups and stuff, asking questions of women who were thinking about a hospital birth and those who were not and that sort of thing. And the myths and preconceptions around what happens in a birth center and what sort of Factors that could woman would go there exists broadly across women from different demographic backgrounds. facilitate birth In the existing environment, most birth centers who accept Medicaid patients are limited so their economics do not end up center upside down. It is a chicken and egg thing: if there was a sustainable Medicaid rate the demand would be there, but there is participation in no demand when centers set quotas or minimize exposure on the Medicaid side. Medicaid From a mechanism standpoint, the thing that would help birth centers grow the most would be some sort of front end population management payment because traditionally maternity care is paid for retrospectively. Birth centers find themselves in a debt hole all the time. A per member per month payment [similar to primary care case management] could really help birth centers grow because they wouldn’t be chasing the billing cycle all the time. TECHNICAL APPENDICES 191

210 Interview Topic Summary of Findings All the midwives have prescriptive privileges and we do use nitrous oxide in all the centers, but outside of that they offer pharmacological options. We have spent a bunch of time with a variety of startups around things like using mostly non- virtual reality for comfort in labor and some of the biomechanical options around biofeedback — these options are not Comfort and pain ready for primetime yet. relief options at We do use the occasional IM or IV narcotic but that is not standard. We typically we do not use those options because of Baby+Co. centers the side effects (nausea, vomiting). But all centers can provide narcotics, centers have DEA licenses and the providers all have the DEA numbers. The most common narcotic used would be morphine for therapeutic rest in early labor. They mirror the demographics in whatever the settings are, though in some cases (Cary, NC and Nashville, TN centers) there is a slightly higher proportion of non- white women in the birth center than in the cities where the centers are located. [Differences in] birth center recruitment is not about race and ethnicity as much as it is about exposure and education. We have women of all races and ethnicities who are typically all very well educated. We have fewer patients of Demographics at lower socioeconomic status. I wish there were a way for me for me to talk more specifically about the people we turn away Baby+Co. centers all the time because we do not have a way to pay for their care. We turn away Medicaid beneficiaries all day every day. It is not because they are not asking. They call, they come in for tours. We just cannot take care of them [because of the low reimbursement levels]. The risk criteria Baby+Co. uses are AABC standards . We fall right in the middle of the pack in terms of birth centers in -risk patients. We can do a lot of co-management because the midwives have hospital risk or low terms of caring for high- or pregnancy- privileges. So, for example, someone who has gestational diabetes induced hypertension, we’re typically able to co -manage them prenatally with a physician and then attend the birth at the hospital. They risk out of delivery at the birth center but they do not typically risk out of care with us. Currently th e Baby+Co. centers do not care for women with substance use disorders, though with birth centers’ focus on Patient risk levels patient engagement they would be a great platform for this. We have talked with some private funders who were - and co interested in addicted moms about setting about pilots. It would be great thing to do but we have not had a partner to help management with fund it. physicians A Boston-based OB/GYN recently gave a talk at ACNM and made a good point that was well -received by the audience, We was that just because your pregnancy is high risk doesn’t mean your labor and/or birth is going to be high risk. which -complicated pregnancies need to decouple those things more systematically so that women with medically end up do not for that The system is just not set up s there at birth. can still have their midwive and delivering with an MFM by default - there are not set up in an escalating way that when you get to the top escalate . reverse transfer, it is good ways to de 192 TECHNICAL APPENDICES

211 APPENDIX D: PARTICIPANT-LEVEL PROCESS EVALUATION – INSTRUMENTS TECHNICAL APPENDICES 193

212 Start Mothers and Newborns Initiative Patient Intake Form for ID Study Label: Instructions: mark your answer by placing a ~ in the appropriate box with a black pen. Please Incorrect® Correct© [D ~ or [ [x) ] or [@ ] or [ D x] X following Today's us i ng Enter Date, number format: MM/DD/YYYY. the ---'------''---- pregnancy? 1. We r e you on Medicaid when you became pregnant with this 1 D D No D Not Sure Yes you Did have 2. health insurance when you became pregnant with this pregnancy? other  Yes D No D Not Sure you 3. you in the WIC program right now (do Are get food for yourself from WIC)?  Yes  No origin? Spanish or Latina, Hispanic, 4a. What is your race? 4. Are you of (One be more categories may be selected) (One or more categories may or selected) D No , not of Hispanic, Latina, or Spanish origin White  American African D Yes, Mexican, Mexican American, Chicana or D Black Rican  American  Indian Yes, or Puerto Alaska Native D Yes, Cuban D Indian ian As origin D ish or ina, Lat Hispanic, another Yes, D Span Chinese D Filipino Japanese  Korean D etnamese Vi D  Asian Other Hawaiian D Native Guamanian Chamorro or D D Samoan D Other Pacific Isla nder than English at Do 5. home? you speak a language other D Yes  No ___ (Identify) _ o_ th_e_r language ~ . If yes, what is this language1 --  - S-pa_n_ is _h  194 TECHNICAL APPENDICES

213 live How (people 18 and older) adults in your home besides you? many 7. How many children (people 17 and younger) live in your home? chi 7a. are the ages (in years) of those What ldren? 2: Child 3: 4: Child Chi ld I : Child Child 6: 8: Chi Child 7: ld Child 5: than live children more in your home, please list their ages here: 7b . If 8 right if homeless or living in a shelter are now: D here 8. Check you have a job right now? 9. Do you  Yes No  what is your job? 9a. If yes, usually How hours (#) do you .b. work each week? . I I 9b many you in school right now? I Are 0.  Yes  No yes, . If in: are D College 0a I D Training you  School High GED  Other ease explain) D (p l are you: Ob. Full time D Part time If you ar e in school, D I A high school diploma D Do you Neither have: D I I . AGED  have a college you degree? 12. Do Yes  No  apply degrees have? (Please check all that you .) college what yes, do 12a. If (from a community college or other two year D program) Associate's Degree college 's Degree a four year college or university) D (from Bachelor other (please explain) , D Yes TECHNICAL APPENDICES 195

214 13 put a check next to any of these things that make it hard for YOU to come to appointments. . Please I do have a car D not to bus is hard to The to get o r train my appo i ntment  use I do not have enough money to pay for D to the appointment a ride D wo r k hours make it hard to come to appointments My trust I not always have someone I D to watch my older children do appointments to come  My spouse/partne r/boyfriend does not want me to D (Please list them below.) reason(s) Other . Other reason I: 13a . 13b reason 2: Other 13c . Other reason 3: 14. What is your relationship status now? spouse D Married, living w i th , not D Married spouse w ith living together a relationsh ip but not living In D D Not in a re lationship ri ght now Living D wi th a partner yea r ? 14a . If yes , have you been living together for more than one Yes   No 15 . Have you ever been divo rced?  Yes No  you ever been w idowed? D Yes 0 . Have 16 No If yes , yea r spouse died : 16a. . During the last 12 months , have you been to the dentist and had a dental check-up?  Yes  17  Not Su re No IS.We using birt h control when you became pregnant wi th t h is pregnancy? D Yes re you No  Sometimes D 19 Were you trying to . pregnant? become D Yes D No (c-sect Cesarean D baby 20. When you have this ion) , do you hope to have a:  Vaginal birth Unsure  . How many times have you been you did 21 babies 21 a. How many who were born alive? pregnancy? befo pregnant have re this D Yes D who 22. Did you eve r have a baby No was born too early (preterm or " preemie ," before 37 weeks)? your baby born 23 . If you have had a baby, when was last the following number format: MM/DD/YYYY)? (using I I ---------- 196 TECHNICAL APPENDICES

215 during following how you have been feeling address the past week (7 days). questions I of all or a or Occasionally a little or Some none or Rarely Most the the of of time time Question time the amount moderate I day) than (less days) (3-4 time of ( 1-2 days) (5-7 days) 24 felt depressed .1 I     an every was that felt effort thing I did . .1 25 D    - -- estless r was eep sl My . 26. D    happy. 27. 1 was D    28 . felt lonely .1 D    . People 29 re we un friendly . D    life. 1 enjoyed 30. D    31 . sad felt .1 D D   32 peop felt that .1 le disliked me . D    "going." 33 .1 could not get D D   - ( weeks I Over the last 2 problems? 14 days), how often have you been bothered by the follow ing Nearly every all Several Over half r Question Not at day the days days edge . . Feeling or , anxious, 34 nervous on D D D  35. stop or contro l worrying . Not be i ng able to D D D  different things . 36 . Worrying too much about     37 . Trouble relaxing . D D D  Being so it 's hard 38. sit still. that restless to D D D  irri easily annoyed or tab 39 le. . Becoming D D D  afraid awful if something as happen . Feeling 40 . might     41 . I f you checked off any pr oblems , how difficult have these made it for you to do you r work , take care of things at h ome , or along with othe r peop l el get D Not difficult at all D Somewhat difficult 0 Very difficult difficult  Ext remely TECHNICAL APPENDICES 197

216 can Sometimes arguments get out of control. hard. a woman might be afraid be Sometimes her partner, or she might get hurt. The next questions will ask about things like this that might have of to you. happened . H ave you ever been in a relationship where your partner has pushed or slapped you? 42 D Yes  No ever been in a relationship where your partner th r eatened you with violence? 43 . D Yes Have you  No 44. Have you ever been in a relationship where your partner has thrown , broken, or punched things? D Yes D No boyfriend If have a spouse, partner, or you right now, please answer the following questions. Agree Disagree Disagree Disagree a Agree Agree Question a little little somewhat strongly somewhat strongly feel me es My spouse/partner/boyfriend mak 45.       . unsafe even in my own home - - - the things he do es of me . feel .1 46 ashamed to       - - - 47. because boat the rock to not am try 1 l       id do . afra of what he might - - - .1 48 feel programmed am I rea to like ct a       way certain him. to - - - 49. r . keeps 1 feel me pr isone he like       - - - like feel c I me makes He 50. ontrol no have       , no protec tion . over my life, no power cigarettes mos smoke you do ks pac or on many how cigarettes, smoke do If you 51. days? t r ettes packs ciga r ettes ciga of not cigarettes I do smoke D Which best describes the 52 es about smoking inside your home now? . rul No one is allowed to smoke anywhe r e inside my home D Smok D ng is a llowed in some r ooms or at some times i Smok anywhere ng is permitted D ins i de my home i I am homeless or live in a shelter right now D Note: I Drink= 12 oz beer ( I regular can)= 12 oz cooler= 5 oz wine = I mixed drink ( 1.5 oz. hard liquor) 53. How drinks does it take to make you feel high? many do One 2 drinks D D than 2 drinks D I or not drink alcohol More 54 . Have people annoyed you by crit icizing your dr i nking? D Yes  No 55 . Have you felt you ought to cut down on your drinking? D Yes  No 198 TECHNICAL APPENDICES

217 nerves Have had a drink first thing in the morning to steady your ever or to get rid of a hangover? you D Yes D No 57.Did any of your parents have a problem with drug use? D Yes D No drug 58. partner have a problem with your use? Does  Yes  No 59.ln the past, have you had problems in your li fe because of drugs?  Yes  No = How true were each of these statements for you and your household during the past 12 months last year)? time (since this to worried whether {my/our} food would run out before {I/we} 60.1 money about buy more. got D Often true D Sometimes true D Never true 61. The food that {I/we} bought just didn't last, and {I/we} didn't have enough money to get more food. D true D Sometimes true D Never true Often 62.{l/we} couldn't afford to eat balanced meals. D Often true D Sometimes true D Never true skip mea 63.Since th is time last year, did {you/you or other adults in your household} ever cut the size of your meals or ls because wasn't money for food? D Yes D No there enough often this happen? How did 63a. every month D Some months D not every month D In only I or 2 months Almost but In the last 12 months, did you ever eat less than you felt you should because there wasn 't enough money for food? 64.   No Yes In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food? 65. D D No Yes L_ OFFICE USE ONLY FOR by: Completed D Patient on paper D With Assistance Patient electronically D Assistance D With D worker in person Healthcare Healthcare worker on the phone D D Other Number project was supported by Funding "The described CMS- ID 1-12-00 I from the Opportunity Centers for Medicare & Medicaid Services, Center for Medicare & Medicaid Innovation. The contents its of Intake Form do not necessarily represent the official views of HHS or any of this agencies. This project does not limit a fee-for-service Medicare, Medicaid, a CHIP patient's freedom to choose or provider." pa .rticular health care TECHNICAL APPENDICES 199

218 Strong for Mothers and Newborns Initiative Start Trimester Survey Third Study ID Label: 7 I pen. Please your answer by placing a Instructions: in the appropriate box with a black mark When appropriate, use ~ numbers I, 2, 3, etc.) (0, answer questions. to Correct© Incorrect® X] [D vu,] QL [ [x] ] or [@ ] or [ D X Your are voluntary and will be kept confidential. responses Date Date Due Today's Estimated ___ / ___ _ ___ / I I ---------- MM/DD/YYYY MM/DD/YYYY I. How many adults (people 18 and older) live in your home? (Do not count yourself.) How live children (people 17 and younger) many in your home? (Do not count yourself.) 2. 3. D answer to not Are you homeless or living in a shelter right now? D Yes Prefer No D you. 4. statement that best describes the (Select one answer.) choose Please pregnant. never smoked or I stopped smoking before I became D I have D I stopped smoking when I found out I was pregnant. smoking D cut down on my I have since I found out I was pregnant. pregnant. D I smoke about the same as before I found out I was not answer to D Prefer one 5. your relationship status now? (Select is answer.) What Married, living D spouse with D Married, not living w i th spouse D Living with a partner/boyfriend In D a relationship but not living together D Not in a relationship D Prefe r not to answer Unsure D D 6. Do you have a spouse, partner, or boyfriend right now? Yes D No - 200 TECHNICAL APPENDICES

219 questions. have boyfriend right now, please select one answer the following or partner, you a spouse, Prefer Disagree Agree a Agree Agree Disagree Disagree Question not to somewhat strongly a little strongly somewhat little answer 6a. My spouse/partner/boyfr iend unsafe feel even makes me my in        own home . 6b. ashamed I feel he things the of        r does me to . 6c . I ( cause r ock not to the boat try afraid troub le) because I am of        mi ght do . what he 6d. I feel li ke I am programmed to        him. react a to ce rtain way he ke li . I feel 6e r. prisone me keeps        me feel 6f. makes I have like He life, no power, no control over my        no protection. do 7. Where you plan to deliver this baby? Hospital Center Unsure D D Birth Home D D D No D Uns ur Do D Yes 8. you plan to have a support person with you during labor? e Othe member D ner/Boyfriend rt Spouse/Pa D Doula r family : apply that all select yes, If D 8a. (specify) else Someone D labor? Unsure plan you Do to D No D D Yes take something fo r pain du r ing 9. plan do , Epidural? you get yes to If an . 9a Unsure D Yes D D No D How Section (C-Section) D Unsure do you plan to deliver this baby? Cesarean I 0. D Vaginally suggested del ivery prio r to your due date? prenatal your 1 I . Have scheduling any of your providers care 1 re Unsu D D Yes D No in the first few weeks? 12. How do you plan to feed your baby D I haven't decided ly Both formula feed D and on feed Formula D only Breastfeed D breast are: 13. How would you rate your level of overall satisfaction with t he prenatal care you are rece i ving? Would you say you Moderately Very all satisfied Slightly satisfied at satisfied Not satisfied Extremely satisfied      TECHNICAL APPENDICES 201

220 Strong for Mothers and Newborns Start Postpartum Survey Initiative Study ID Label: 7 I Please pen. your answer by placing a ~ in the appropriate box with a black Instructions: When appropriate, use mark (0, numbers 2, 3, etc.) to answer questions. I, Incorrect® Correct© [D no] QL [ [x] ] X] [@ ] or [ D or X Your responses are voluntary and will be kept confidential. Today's Date Date Delivery ___ / ___ / ___ _ I I ---------- MM/DD/YYYY MM/DD/YYYY Where I. you deliver this baby? did D Hospital D Birth Center  Home D Other (please specify) D 2. you have a support person with you during labor? D Yes D No Did Unsure 2a. apply.) yes, please specify who supported If during labor. (Select all that you D D member family Other Spouse/Partner/Boyfriend Doula D D Someone else (specify) have you medicine during labor 3. Did any D you with pain? D Yes to No D Unsure help 3a. If yes, did you receive an Epidural? D Yes D No D Unsure Refused 4. How did you deliver this baby? D Vaginally D Cesarean Section (C-Section) D up labor Unsure D 5. Did a doctor, nurse, or midwife try to speed No your D using medicine? D Yes of to doctor, nurse, or midwife break your bag labor? water your start or speed up Did a 6. D Yes D No D Unsure 7. How satisfied were you with your delivery experience? (Select one.) Moderately Not all satisfied Slightly satisfied at satisfied Very satisfied Extremely satisfied      l l l l 202 TECHNICAL APPENDICES

221 the How your overall level of satisfaction with rate prenatal care you received? (Select one.) you would at all satisfied Not at all satisfied Not at all satisfied Not at all satisfied Not at all satisfied Not      r is your relationship status now? (Select one answer.) 9. What living D with Married, spouse living with not Married, D spouse D Living with a partner/boyfriend D but not living together In a relationship Not in a relationship D D Prefer not to answer - baby I 0. Did breastfeed or pump breast milk to feed your ever after delivery, even for a short period of time? you D Yes D No D Prefer not to answer ,__ or Oa. If yes , are you currently breastfeeding I feeding pumped breast milk to your new baby? D D Yes No D Refused - I I your new was born, did a doctor , nurse, or other health care worker talk with you about using birth .After baby control? Yes No D D Unsure D keep or spouse/partner/boyfriend do i ng anyth getting pregnant? g now to your from in you 12.Are D Yes D No D Unsure If yes, what kind(s) of birth control are you us in g to keep from 13. pregnant? (Select all that app ly.) getting D or rubber Condom Withdrawal or out D pulling or sterilization Vasectomy male D Control Pills  Birth (for example, Mirena/Paragard) IUD D Tubal ligation or female sterilization (Tubes Tied) D Spermicidal D foam/jelly/cream/film/suppository Hormonal or injection (lmplannon/Nexplanon) D implant D Injection (The Shot/Depo) Rhythm D safe period or D Breastfeeding D Something else (please specify) TECHNICAL APPENDICES 203

222 Start Mothers and Newborns for Data Form Exit Collection Study ID Label: black a your answer by pen. a IZl in the appropriate box with placing mark Please Instructions: For statements that ask for a number, please answer with a number only (e.g., 5). Do not include any text with or instead of the numbers ( e.g., five, five feet, 5, feet). Important: services, enhanced have D If you regarding submitted all Exit Form information electronically except details and skip box to the left the to Section VII of this form. please mark form, Note: For the purposes of this defined past and current pregnancies are as follows: that • Pregnancy: The pregnancy or pregnancies Past occurred prior to this Strong Start pregnancy. Start . occurred • Current Pregnancy: The pregnancy during which most recent enrollment in Strong Information Participant 14.Today's date I I ---------- MM/DD/YYYY participant enrolled 15. Strong Start Date in I I ---------- MM/DD/YYYY (EDD) Estimated Date of Delivery Participant's 16. I I ---------- MM/DD/YYYY 17. Did the participant stop receiving Strong Start services prior to delivery? D Yes  No 17a. If yes, please services. the reason she stopped receiving Strong Start select program  Loss of Medicaid/CHIP eligibility the from withdrawal Voluntary D D Elective pregnancy termination Move/Relocation D Lost D Miscarr to D abortion iage/Spontaneous follow-up specify) Other D (please I. Past Pregnancy History and Complications Strong this pregnancy)? Start 18. Did the participant have any past pregnancies (pregnancies that occurred prior to question (If yes, continue to Sa.) Yes D 12.) question to skip (If no, No  . 18a If yes , how many prior did participant the have? pregnancies TECHNICAL APPENDICES 204

223 l 1nstructions: place a [gJ in the appropriate box to indicate if the participant had risk factors from past pregnancies. Please of the number times the risk factor occurred. previous outcomes, For indicate birth factors (pregnancies) past pregnancy Risk from the Please if participant 19. any of indicate following risk factors during a previous pregnancy: had  Preeclampsia or pregnancy-induced hypertension D Gestational diabetes incompetence D Cervical Placental abnormalities D the fetus Congenital D of abnormalities None D D Not known D Other risk factor(s): of number yes, If Not outcome(s) Previous birth No Yes occurrences Known 20. Previous preterm weeks, weeks~36 birth(s) Estimated (20 6 days    [EGA]) Age Gestational had 20a. If "Not previous preterm birth(s), please specify the reason(s). If unknown, indicate participant known." Other reason(s): D . Previous than 2,500 grams less birth(s) 21    miscarriage(s) (< 20 weeks EGA) 22. Previous    23 elective termination(s) . Previous    . Previous weeks (fetal death ~ 20 24 EGA) stillbirth(s)    II. General Medical Risk Factors Instructions: Please place a [gJ in the appropriate box to indicate if the participant had any of the risk factors prior to her current pregnancy. risk factors prior to current pregnancy Not No Yes Known Participant I diabetes 25. Type    II diabetes 26. Type    27 . Hypertension    TECHNICAL APPENDICES 205

224 During Current Pregnancy Factors Risk Please enter the mother 's height and weight in the approp ri ate boxes. Respond in only one type of Instructions: (e.g. centimeters OR inches; kilograms OR pounds). , measurement Height Inches in Height OR Centimeters in Height st prenatal vis it 28 . Height of mother at fi r Pounds in Weight OR Kilograms Weight in Weight of 29 . Weight it at mother prenatal first vis . 30 Weight at mother of prenatal visit last Instructions: Place a current her ng had pregnancy. IZI in the appropriate box to indicate if the participant i a risk factor dur Yes Not current pregnancy No Known during factors Risk pregnancy tract 6 months of infect ion(s) during last Urinary 31. D D D incompetence . Cervical 32 D D D previa Placenta 33. D D D Placental 34. abruption D D D diabetes . Gestational 35 D D D Pregnancy-related hypertens ion 36. D D D . Preeclampsia 37 D D D 38 . Syphilis D D D (HIV) immunodeficiency virus 39 . Human D D D 40. of the fetus Congenital abnormalities D D D 41. Other risk factor(s): D D D 206 TECHNICAL APPENDICES

225 Delivery Information Pregnancy - Current la place ~ in the appropriate box to Please the p a ce and method of delivery for the participant. Instructions: indicate of delivery Place the . Please type of facility where the participant's delivery occurred. indicate 42 Hospital  Birth center  Home birth  Other  of delivery Method of . Please indicate the method delivery. 43 (Check all that apply for this pregnancy.) D Vaginal Cesarean sect ion (C-section) D If vaginal: Was it a vaginal birth after Cesarean (VBAC)? 43a. known Not  No   Yes C-section: If known Not D No 43b . Was it a repeat C-sect ion? D Yes  Was known C-section? it a scheduled Not 43c. D No D D Yes a Instructions: Please place IZI following in the app ropriate box to indicate whether the participant received the prior during labor. treatments to or to or during labor Not Treatment Known prior No Yes delivery r impending fo steroids preterm .Antenatal 44    preterm 17 h ( e.g., 17P , P 45 or . Progesterone injections to prevent birt    17-OHP; hydroxyprogesterone caproate) 46 . Vaginal birth to preterm prevent progesterone    4 7 . T ocolytics preterm prevent to birth    . 48 participant 's labor induced? Was the    48a. participant If used? , was induced was Pitocin    48b . If participant had previous pr eterm birth(s), please specify the reason(s). If unknown , indicate "Not known." D Not known : reason(s) Other D TECHNICAL APPENDICES 207

226 Delivery Outcomes - Current Pregnancy In identified Instructions: Please complete the tables below by entering numbers to indicate number of fetuses born. and the all second table, please report the weight of born infants . -- Number Number ofi etuses identified and born - . 49 ified? How many fetuses were i dent 50 . How many infants we r e live born? 51. How many infants were still born? rams or What was the infant weight at birth (g pounds or ounces)? 52. births, the w record multiple If Note: r each baby. newborn fo eight - Ounces and Pounds OR Grams - - 52a. #I Baby lbs. oz. ---- ' - multiple 2 Baby# (if 52b. births) lbs. oz . ---- ' - Baby #3 births) multiple (if 52c. lbs. oz. ---- ' - 52d. #4 Baby (if multiple births) , lbs . oz . -- ------ ---- ---- Pregnancy - Care Postpartum Current VI. Information on Routine Prenatal and indicate who place an ~ in the appropriate box to Please Instructions: provided routine obstetric care to the participant . provider Routine prenatal service routine provided one.) 53. Please indicate who (Select obstetric care to the participant. Obstetrician D Licensed Professional Midwife D D i Nurse Practit oner Midwife Midw Nurse ife/Certified D Certified Medicine Physician Family D Other D 208 TECHNICAL APPENDICES

227 below. st of all routine clinical p renata l AND postpartum fo llow up vis i ts in the ta b le dates List li the Please 5 • the that occurred dur i ng in current pregnancy4 rout e visits all of dates Dates Individual of Dates 55. Postpartum of Group and Prenatal and Postpartum Prenatal 54. Follow-Up (MM/DD/YYYY) Visits (MM/DD/YYYY) Follow-Up Vis its I. Visit I I I I - -=== =------I --1-------' ==- - 2. Visit I I I / --- ---- Visit 3. I I I I =------I == -= - Visit 4. I I I I - -=== =--------1 --1--------= - ==- Visit 5. I I I I - -=== =------I - - ==- -I-------= 6. Visit I I / I - -=== =--------1 -I-------= ==- - 7. Visit I / I I =--------1 == -= - Visit 8. I I I -'/ ==- -I-------= Visit 9. I I I I - - -=== =------I = =- - 4------ -= Vis it 10. I I / I - -=== =--------1 4------ - ==- -= 11. Vis it I I / =-- -----1 /_ == - 12. it Vis I I I I - -=== =--------1 =----' = -= 1----- Vis . 13 it I I I I - =------I -=== - -= =-- -1----- = - Vis it 14 . I I I / - -=== =--------1 -1----- - =-- = -= Vis it 15. I / I I it . 16 Vis I I I I -=== - =------I - ==- 4------ -= Vis . 17 it / I I I - -=== =------I - -= ==- - 4------ Vis it 18 . / I I I 4------ ...::c. = =- - -= == =--------1 - Vis it 19 . I I I I . Vis it 20 I I I I --- - =------I -= == it dates l of tota if vis number are not available. O r, indicate visits ls 41 Tota N umber of ind ividua l visits per t r imester: 42a. Num ber of group visits per t rim ester: a. Trimester: Fir st Trimester: First T ri mester: Trimester: Second Second 1 ------ T hir d Trimester: Third Trimester : ------ 5 For individua l visits : in clu de rou tine cl in ical prenatal visits ' th a ph w i ic ian , midw if e, nurse pr ac ti tio ner or simi lar care provider that occurred dur ing the cur re nt pregnancy. ys visits For group or : Inc lu de group prenatal care vis its, suc h as cente ri ng visits on ly. Do no t i ncl ude special i st visits re lated t o the pregn anc y or other med i ca l reasons p education, n. nh anced " se rvi ces suc h as grou io pe er counse li ng, or smoki ng cessat "e TECHNICAL APPENDICES 209

228 Number Encounters for Enhanced Services of an Please an ~ in the appropriate box to in dicate whether Instructions: participant received place enhanced service. the the occurred. that encounters enter of number each received, service enhanced For Note: An enhanced encounter or service is a face-to-face o r phone encounter that is not part of routine clinical to prenatal These visits do not need .re. be funded by Strong Start ca Select "No" if the select did not receive the service because it was not needed or the service is not offered. A/so participant participant ll a for ided "No" if the prov receives the service as part of routine prenatal care. For example, if care coo rdination is not individua routine prenatal care visits, and does during involve meeting with a separate patients l, select "No." Select . encounter additional if the service involves an " only "Yes a care coord Do not double count services . For example, if the care ly ina tor visit includes health education, select on study work visit . We will understand from our case coordinator and your operational plan what is encompassed in those visits. number If Not the indicate yes, encounters Yes No Enhanced enhanced of Known encounters encounters with a social 56 . Care coordinator encounters ( e.g.,    ity worker) health or commun worker, case , nurse manager 57 hea encounters . Mental care lth    Doula 58. encounters    been all where enhanced services were If have encounters counted in question 43 to 45, provided question to continue Otherwise, skip 46. to question 51. Not number services not counted the Enhanced If yes, indicate Yes No enhanced encounters in questions 43 - 45 of Known education centering) (not 59 . Health    60 . Home visits    61. ( Self-care not centering)    62. Nutr ition counseling    services 63 . Substance abuse    for non-medical services 64 . Referrals outs ide of Strong the    Start program for 65 . Referrals high medical services risk    , please services high-risk referral(s). of type 65a. If referred for indicate lmonolog D D Maternal Fetal Specialist D Pu diologist i st logist Endocrino D Car Other D 65b. had: the participant encounters If known, please indicate the number of hi gh-risk Exit Form. Thank you for completing the 210 TECHNICAL APPENDICES

229 APPENDIX E: PARTICIPANT-LEVEL PROCESS EVALUATION – MEASURES: SCORING PROCEDURES TECHNICAL APPENDICES 211

230 CES-D Depression (CES — The shortened version of the Center for Epidemiological Studies -D) scale used on Strong Start for Mothers and Newborn Intake Form, which can be found at - , is a four https://downloads.cms.gov/files/cmmi/strongstart-enhancedprenatalcare_evalrptyr3v1.pdf 74 category response form with 10 items developed by Andresen and colleagues [1994]). Each item has a frequency over the past week the respondent has felt a value of 0 to 3, which corresponds to the particular way: • 0 = Rarely or none of the time (less than 1 day) • 1 = Some or a little of the time (1 –2 days) • 2 = Occasionally or moderate amount of time (3– 4 days) 3 = Most of the time (5 –7 days) • “positive mood” items (items d [“I was happy”] and g [“I enjoyed life”]) are reverse scored. The The score is then the sum of all item scores, resulting in a range of 0 to 30. The threshold for characterizing individuals as having depressive symptoms varies ac ross studies, with typical cutoffs of 8, 9, or 10. For Strong Start for Mothers and Newborns, individuals who score 8 or higher on the CES-D 10 are characterized as exhibiting depressive symptoms. GAD-7 GAD -item screener to identify Anxiety Severity developed in 2006 by Spitzer et al., and -7 is a seven publicly available here: - http://www.phqscreeners.com/sites/g/files/g10016261/f/201412/GAD 7_English.pdf . of the screener are calculated by assigning scores in the following manner: Results 0 = Not at all • 1 = Several days • 2 = More than half the days • . 3 = Nearly every day • ints GAD -7 total score for the seven items ranges from 0 to 21. Scores of 5, 10, and 15 represent cutpo for mild, moderate, and severe anxiety, respectively. When using the GAD-7 to screen for anxiety referred for further disorders, it is recommended that individuals with a score of 10 or greater be evaluation. FOOD SUFFICIENCY 75 The -item scale that can have distinguished different levels of food security. We are using a USDA six sum of Participants with a raw score 0– 1 are considered to be experiencing food insecurity. 74 10 in a Björgvinss on, T., Kertz, S.J., Bigda -Peyton, J.S., McCoy, K.L., Aderka, I.M. (2013). Psychometric properties of the CES -D- psychiatric sample. Assessment, 20, 429 -436. 75 https://www.ers.usda.go v/media/8282/short2012.pdf 212 TECHNICAL APPENDICES

231 F BATTERY (WEB) WOMEN’S EXPERIENCE O -item WEB). The Strong Start Intake Form includes a six-item scale (short form of the 10 The scoring includes the following steps: • 6 (1 for strongly disagree, 6 for strongly agree) Score each item from 1– –36, with higher scores meaning higher psychological vulnerability This creates a range from 6 • (i.e., more battered). To dichotomize the scores, women who score 12 or lower are not battered. • SLAPPED THREATENED AND THROW (ST aT) simple, sensitive, self-administered questionnaire for STaT is a three -question screener designed to be a identifying if a woman has a history of being subject to intimate partner violence (IPV). The three questions are: • Have you ever been in a relationship where your partner has pushed or slapped you? e? Have you ever been in a relationship where your partner threatened you with violenc • • Have you ever been in a relationship where your partner has thrown, broken, or punched things? Answering yes to one question results in a score of 1, with a maximum score of 3 possible. All participants who scored 1 or greater were coded as having had a history of IPV. TECHNICAL APPENDICES 213

232

233 APPENDIX F: PARTICIPANT-LEVEL PROCESS EVALUATION – PROGRAM MONITORING PROGRESS REPORT QUARTERLY TECHNICAL APPENDICES 215

234 Separate from the Participant-Level Process Evaluation (PLPE) data collection effort, developed by the Evaluation Team, CMMI’s Strong Start program team had developed a quarterly program monitoring data collection effort, seeking aggregated counts of enrollment, deliveries and a handful of other y in the evaluation, awardees expressed measures prior to the evaluation team being hired. Earl frustration that some of the data being requested through the monitoring reports and via the PLPE data were duplicative. Additionally, awardees indicated that the data request format— Excel spreadsheets that varied from quarter to quarter— was burdensome. After the evaluation contract began, the evaluation and program teams attempted to implement a more streamlined program monitoring reporting system. Urban Institute and our subcontractor, Briljent, with input from CMMI, created a web -based program monitoring tool that saved data from the prior quarter to ease data reporting and amending. We worked with CMMI to ensure all measures were collected in the manner they preferred and developed tools for reporting the quarterly results by awardee and by model. Some features of the system developed included: • Data collection forms that could be pre -populated with prior quarter data to reduce the amount of entry required of awardees and ensure data consistency; o ensure that all pertinent data are entered before the user can continue to Navigation control t • the next step; Survey design features to improve data quality and accuracy; • • Survey tracking on a real -time, ongoing basis, allowing us to remind users that have not completed the survey that the deadline is approaching; Data ready for immediate review; • • Automate communication and reporting. This process was implemented for one quarter (Quarter 4 2013), but the data was reported in a format that the program team couldn’t use on their own (e.g. to construct graphs) without re -entering the data into a different format. The CMMI program team thus decided that they’d prefer to return to -spreadsheet reporting system. the original Excel Because of the time it took to establish the systems and the fact that awardees ultimately reported monitoring and evaluation data to separate systems for most of the program’s duration, there is some inconsistency across awardees in the accuracy and format of certain data elements. In particular, totals reported by some awardees in program monitoring reports the program team enrollment received and reviewed are of concern. In a few cases, there was a substantial discrepancy between the that s report were enrolled number of individuals with PLPE data and the number of individuals awardee . For consistency sake, we have relied on the the program and evaluation teams were not able to resolve number of individuals with PLPE data (at least one form) to represent the universe of Strong Start enrollees. This approach h as been confirmed during conversations with enrollees, who have indicated that having at least one PLPE form submitted offers the most accurate enrollment count. 216 TECHNICAL APPENDICES

235 APPENDIX G: PARTICIPANT-LEVEL PROCESS EVALUATION – DATA QUALITY SUMMARY TECHNICAL APPENDICES 217

236 DATA QUALITY TABLES There are two kinds of missing PLPE data: 1) data missing due to a missing form, and 2) data missing due to item nonresponse on a form that was submitted. Table G. 1 present information on how much PLPE data were miss ing, by awardee, to provide an overall sense of data quality. Form submission rates are an d Table G. 2 presented in the P section articipant -Level Process Evaluation Findings: A Descriptive Look at Participant Risk Profiles, Service Use and Outcomes ; here, we present re sents the proportion of items on forms submitted to the evaluation team that were missing. For example, among Table G. p 1 mation on item nonresponse. infor Inta ke Forms submitted by awardees, MUSC had the fewest items left blank (0.9 percent), and University of Tennessee Medical Group had the highest rates of missing presents an overall assessment of missing data combining information about items missing because a form was not submitted with 2 items (27.4 percent). Table G. ite ms missing because the information on a submitted form was left blank, for a complete picture of missing data regardless of why it is missing. TABLE G. 1: AVERAGE RATE OF IT EM NONRESPONSE, BY FORM AND AWARDEE Nonresponse Rate, Postpartum Nonresponse Rate, Exit Nonresponse Rate, Intake Nonresponse Rate, Third Awardee Form Measures (%) Form Measures (%) Form Measures (%) Trimester Form Measures (%) Access Community Health Network 3.9 1.3 7.4 3.9 Healthcare Network 5.3 5.5 3.0 9.1 Albert Einstein 4.5 11.8 2.6 American Association of Birth Centers (AABC) 1.1 Amerigroup Corporation 22.3 5.3 20.8 10.3 6.4 2.9 6.3 4.9 Central Jersey Family Health Consortium 18.5 1.0 14.3 2.1 Florida Association of Health Start Coalitions 3.3 Grady Memorial Hospital Corporation 2.6 0.5 17.2 Harris County Hospital District 1.7 3.3 0.2 22.8 HealthInsight of Nevada 6.1 5.7 6.8 3.4 Johns Hopkins University 2.0 8.9 19.1 1.0 Los Angeles County Department of Health Services 8.5 1.0 1.4 3.1 0.7 0.4 1.5 Maricopa Special Health Care District 5.9 0.9 Medical University of South Carolina 17.9 11.3 0.5 Meridian Health Plan 1.4 27.8 0.4 0.3 Mississippi Primary Health Care Association 11.5 9.6 1.8 6.8 Oklahoma Health Care Authority 27.6 0.9 3.7 4.1 4.2 Providence Health Foundation of Providence Hospital 5.3 4.6 11.3 2.1 1.4 16.5 13.7 Signature Medical Group St. John Community Health Investment Corp. 1.5 21.7 2.0 19.2 1.1 20.3 7.1 Texas Tech University Health Sciences Center 0.7 United Neighborhood Health Services 1.5 2.0 5.5 4.1 19.4 8.5 1.5 University of Alabama at Birmingham 0.2 1.0 University of Kentucky Research Foundation 5.3 12.8 1.3 1.3 3.3 12.4 6.0 University of Puerto Rico Medical Sciences Campus 2 1. 8 4. 4.8 Alabama University of South 12.2 27.4 University of Tennessee Medical Group 65.3 53.9 28.7 23.1 4.8 6.7 14.5 Virginia Commonwealth University 8.4 All Awardees 5.2 11. 6 2.7 Appendix K . Rate of item nonresponse is limited to received forms. d Notes: Rates are based on the variables included in Appendix I an 218 TECHNICAL APPENDICES

237 TABLE G. 2: AVERAGE COMBINED MISSING RATE, BY FORM AND AWARDEE Combined Missing Rate, Combined Missing Rate, Combined Missing Rate, Combined Missing Rate, Third Awardee Trimester Form Measures (%) Exit Form Measures (%) Intake Form Measures (%) Postpartum Form Measures (%) 34.6 29.7 7.4 4.2 Access Community Health Network 26.8 11.1 74.8 90.2 Albert Einstein Healthcare Network 46.8 39.6 11.9 19.4 American Association of Birth Centers (AABC) 56.9 Amerigroup Corporation 11.2 22.7 46.2 Central Jersey Family Health Consortium 13.2 11.9 43.9 55.3 Florida Association of Health Start Coalitions 34.2 44.6 2.1 14.3 Grady Memorial Hospital Corporation 6.7 18.2 38.9 75.6 3.3 30.6 26.4 5.7 Harris County Hospital District 43.2 56.1 HealthInsight of Nevada 8.0 51.2 31.3 8.9 2.2 Johns Hopkins University 35.2 67.8 60.3 8.5 3.2 Los Angeles County Department of Health Services 5.9 51.5 20.0 Maricopa Special Health Care District 68.2 0.9 Medical University of South Carolina 11.3 34.2 20.6 36.0 Meridian Health Plan 35.1 1.8 28.8 52.9 10.3 13.0 Mississippi Primary Health Care Association 51.5 38.9 63.4 65.3 Oklahoma Health Care Authority 5.2 24.4 20.2 12.5 4.2 Providence Health Foundation of Providence Hospital 57.0 51.2 18.3 16.7 Signature Medical Group 63.7 43.7 24.5 23.0 St. John Community Health Investment Corp. 10.1 20.8 41.0 48.1 Texas Tech University Health Sciences Center 57.1 5.6 United Neighborhood Health Services 50.8 4.3 36.7 48.4 8.5 1.5 University of Alabama at Birmingham University of Kentucky Research Foundation 46.6 58.9 5.3 12.8 56.7 38.8 12.4 8.1 University of Puerto Rico Medical Sciences Campus 4.8 41.3 56.3 University of South Alabama 5. 0 67.7 56.1 31.3 28.2 University of Tennessee Medical Group Commonwealth University 31.4 58.4 7.0 14.7 Virginia 10.3 All Awardees 13. 4 4 2.9 48. 5 . Combined missing rate includes missing data due to missing form or item nonresponse. Appendix K Notes: R ates are based on the variables included in Appendix I and TECHNICAL APPENDICES 219

238

239 APPENDIX H: PARTICIPANT-LEVEL PROCESS EVALUATION – MAIN FINDINGS, BY MODEL TECHNICAL APPENDICES 221

240 MAIN FINDINGS BY MOD EL AND OVERALL The following tables present all of the main findings from the PLPE dataset, by model and overall. Rates of missing data reported in these tables include data that are missing because a form was not submitted and data that are missing because the measure was left blank on a submitted form (item nonresponse). Data, particularly on the exit form, are often missing for women who are reported to have left Strong – these women are included in our sample and represent about 23 percent of Start prior to delivery participants. In case where the relevant population represents a subgroup of participants (e.g., women with a prior birth are the only group that could have had a prior preterm birth), we restrict the N to only those women in the universe. Women with nonmis sing data (and if relevant, in the universe) are the denominator used for calculating all percentages presented in the tables below. Cells representing -). Table H. 1 fewer than 11 women are censored using a dash ( includes all Strong Start participants for e have any PLPE forms. All subsequent tables are limited to women with a single gestation who m w (excluding N=607 women with multiple gestations), results for women with a multiple gestation are . Appendix S presented in TABLE H. 1: FORM SUBMISSION Birth Group Prenatal Maternity N or % Data Elements Total Care Center Care Home N 8,806 10,5 03 26,0 07 45,316 Strong Start Participants with PLPE Data Intake Forms Received N 7,392 10,020 25,687 43,099 Intake Form Submission Rate % 83.9 95.0 98.5 94.9 5,489 N 6, 15,578 27,109 042 Third -Trimester Surveys Received - 59.8 62.3 % Third Trimester Survey Submission Rate 59.9 57.5 Postpartum Surveys Received 5,157 5,991 15,987 27,135 N 57.0 59.9 61.5 58.6 % Postpartum Survey Submission Rate Exit Forms Received 8,798 9,863 25,824 44,485 N 98.2 3 99. 93.9 99.9 % Form Submission Rate Exit TABLE H. 2: DEMOGRAPHICS Birth Group Prenatal Maternity N or % Data Elements Total Care Center Care Home Mother's Age at Intake Missing Data 16.2 % 1.6 5.4 5.5 Missing Data 7,364 N 9,805 - Non Women with 25,128 42,297 Less than 18 Years of Age 5.4 5.6 6.9 2.7 % 9.7 12.7 6.5 % 18 and 19 Years of Age 9.8 72.9 75.1 75.8 20 Through 34 Years of Age % 81.7 35 Years and Older % 9.1 9.0 9.5 7.6 Race and Ethnicity 2.9 7.1 16.8 % Missing Data 6.6 Women with Non N 7,313 9,645 24,804 41,762 Missing Data - Hispanic % 25.4 37.1 28.0 29.7 25.6 22.5 12.7 53.2 % Non-Hispanic White 45.0 16.1 % Hispanic Black - Non 44.8 39.8 4.9 4.7 5.4 % Other Race/Multiple Races 5.1 Ethnicity (Among Hispanic Women) 13.3 11.3 12.8 19.6 % Missing Data Not in Universe % 59.3 52.6 61.5 59.0 N Missing Data - Women with Non 3,583 12,388 6,951 1,854 Mexican, Mexican American, Chicana % 52.6 36.3 55.8 49.7 12.4 Puerto Rican % 12.5 29.9 3.3 1.1 Cuban % 1.3 1.1 1.0 222 TECHNICAL APPENDICES

241 Maternity Group Prenatal Birth N or % Data Elements Total Center Care Care Home Other Hispanic, Latina, or Spanish Origin % 30.7 31.8 38.8 35.6 % 1.3 1.0 0.9 2.9 Multiple Hispanic, Latina, or Spanish Origins Living in Shelter or Homeless at Intake 5.2 1.5 5.0 16.1 % Missing Data Women with Non- N 7,374 9,864 25,160 42,398 Missing Data 1.8 1.2 % Yes 1.5 1.5 Employment and School Status at Intake 8.6 4.8 10.4 17.5 % Missing Data 40,862 Women with Non- Missing Data N 7,248 9,301 24,313 Employed, Not in School % 36.6 30.8 35.3 34.5 11.5 In School, Not Employed % 8.7 12.6 11.9 5.7 5.4 5.5 5.5 Employed and in School % 48.5 47.4 51.0 48.9 % Neither Employed nor in School Education Level at Intake % Missing Data 19.2 16.5 8.6 12.5 23,353 39,122 Women with Non - Missing Data N 7,101 8,668 Less than High School % 15.4 27.8 29.1 26.4 58.3 57.9 57.9 High School Graduate or GED % 57.5 4.6 5.2 8.2 % Associate's Degree 5.4 Bachelor's Degree % 14.5 4.5 3.7 5.8 4.5 Other College Degree % 4.3 4.2 4.7 Relationship Status at Intake 5.0 Missing Data % 17.2 14.1 9.5 40,455 24,262 8,916 7,277 N Missing Data Non- Women with Married 42.1 20.4 20.8 24.5 % 32.3 34.8 33.2 % Living with a Partner 31.1 29.7 26.1 25.9 14.7 % In a Relationship but Not Living Together 10.0 18.9 18.4 17.0 % Not in a Relationship Right Now Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in Notes: universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or an outlier value (mother's age). Not in universe indicates a -) A dash ( includes women who whom a measure does not apply, and is defined separately for each measure. censored cell due to small sample size (N<11). TABLE H. 3: PSYCHOSOCIAL Birth Group Prenatal Maternity N or % Data Elements Total Care Care Home Center Insured When Became Pregnant 6.6 % Missing Data 17.0 6.8 3.4 Women with Non N 7,291 9,696 24,677 41,664 Missing Data - 59.7 Yes % 51.8 51.8 56.5 % 42.3 44.6 39.8 No 37.4 Unsure % 3.5 5.9 2.8 3.7 Type of Insurance (Among Women Who Were Insured When They Became Pregnant) Missing Data % 17.0 6.6 3.4 6.8 40.5 38.9 45.0 40.0 % Not in Universe 5,026 14,735 23,539 Women with Non - Missing Data N 3,778 % Medicaid 75.3 79.9 72.6 61.1 17.2 13.5 18.6 30.0 % Other 7.4 6.6 8.8 8.9 % Both Medicaid and Other Health Insurance Smokes Cigarettes at Intake 15.1 Missing Data % 23.9 24.3 8.4 37,946 Women with Non - Missing Data N 6,687 7,859 23,400 Yes % 10.7 10.1 13.2 12.1 Food Insecure at Intake 14.3 Missing Data % 20.4 19.2 10.1 Women with Non - Missing Data N 6,996 8,383 22,953 38,332 TECHNICAL APPENDICES 223

242 Birth Group Prenatal Maternity N or % Data Elements Total Center Care Care Home Yes % 19.1 24.4 19.2 20.3 WIC at Intake -------------------- 5.5 9.6 18.4 9.0 Missing Data % 7,165 9,387 24,145 40,697 Women with Non- Missing Data N 42.2 Yes % 57.2 46.4 48.1 1 Exhibiting Depressive Symptoms at Intake 23.9 11.6 23.5 % Missing Data 16.8 N - Women with Non Missing Data 37,190 22,573 7,896 6,721 Yes 26.0 24.7 34.0 27.5 % 2 Exhibiting Anxiety Symptoms at Intake 7.8 16.5 19.3 Missing Data 12.1 % Women with Non - Missing Data N 7,090 8,664 23,549 39,303 64.5 65.5 59.0 67.9 % None 20.2 23.8 21.4 % 21.2 Mild 6.8 % Moderate 8.6 8.5 10.3 5.1 5.3 3.0 % Severe 4.8 Incomplete Score but Showing Symptoms of 0.9 % 1.0 0.7 1.7 Anxiety 3 History of Intimate Partner Violence 10.4 Missing Data % 17.5 14.0 6.4 40,075 Women with Non - Missing Data N 7,247 8,931 23,897 19.8 20.7 17.4 Yes % 19.4 Experiencing Intimate Partner Violence at Intake (Among Women With a Completed Score or Who Report Being in 4 a Relationship) Missing Data % 11.8 7.7 16.3 18.3 Not in Universe 7.8 7.4 6.8 % 3.7 Women with Non - Missing Data N 6,849 7,881 21,691 36,421 Yes 2.5 2.6 3.2 % 2.3 Experiencing Prenatal Care Access Barrier % Missing Data 5.2 5.0 16.1 1.5 42,398 Missing Data 7,374 - Women with Non 9,864 N 25,160 None Reported % 72.3 61.3 66.5 66.3 28.1 21.1 % Reported One Access Barrier 24.7 24.9 6.6 10.6 8.8 8.9 Reported Two or More Access Barriers % 5 Women Who Reported Any Barrier) Types of Barriers Reported (Among 59.7 60.0 65.0 48.3 % No Car Public Transportation Challenges 13.0 14.1 13.5 % 12.1 Not Enough Money for a Ride 19.9 20.8 19.9 16.1 % 15.4 17.2 Difficult % It Work Hours Make 24.6 17.1 Childcare Challenges % 19.8 9.8 7.9 10.1 Partner Objections 0.7 0.7 0.7 % 0.6 19.0 16.4 Other % 15.6 11.2 Notes: Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn or item nonresponse. Not in universe includes women for whom a measure indicates a censored cell due to small sample size -) does not apply, and is defined separately for each measure. A dash ( . Appendix E All scales are defined in (N<11). 1 D 10 scale. Measured by CES- 2 -7 scale. Measured by GAD 3 Measured by STaT scale. 4 Measured by WEB scale. 5 Women could report multiple barriers. 4: PREGNANCY HISTORY AND INTENTIONS TABLE H. Group Prenatal Birth Maternity Care N or % Total Data Elements Center Care Home Prior Pregnancy 2.2 0.0 0.8 0.5 Missing Data % 224 TECHNICAL APPENDICES

243 Birth Group Prenatal Maternity Care Data Elements N or % Total Home Care Center 8,785 N Missing Data Women with Non 44,368 25,427 10,156 - 73.8 % Yes 72.1 72.8 68.8 Pregnancy History Among Women with a Prior Pregnancy 27.3 27.6 29.6 26.1 % Not in Universe (No Prior Pregnancy) Prior Miscarriage (<20 weeks EGA) % Missing Data 12.2 21.9 11.6 2.4 15,615 26,923 Women with Non - Missing Data N 6,276 5,032 % 33.4 35.8 26.4 33.0 Yes Prior Elective Termination % 2.3 21.8 11.8 12.3 Missing Data Women with Non 26,883 15,554 5,038 6,291 N Missing Data - 20.1 16.5 Yes 19.0 19.6 % Prior Still Birth (Fetal Death >= 20 Weeks EGA) 23.3 23.3 31.3 13.9 % Missing Data Missing Data 12,614 4,051 5,267 N 21,932 Women with Non- % Yes 3.1 4.2 2.3 0.9 Prior Preeclampsia 40.5 32.3 % Missing Data 41.0 43.1 14,275 Women with Non- Missing Data N 3,651 3,050 7,574 Yes 11.7 17.9 13.7 6.5 % Prior Gestational Diabetes % Missing Data 33.3 42.7 45.4 42.4 13,413 6,986 2,867 3,560 N Missing Data - Women with Non % Yes 4.1 6.1 11.0 8.1 Prior Cervical Incompetence Missing Data % 34.9 43.8 47.4 44.1 Women with Non - Missing Data N 12,654 6,467 2,759 3,428 Yes 3.8 2.6 0.4 2.4 % Prior Placenta Abnormalities Missing Data % 34.5 43.9 44.3 47.8 3,457 6,371 12,576 N Missing Data - 2,748 Women with Non Yes 1.9 1.9 2.3 1.2 % Prior Congenital Abnormalities of the Fetus Missing Data 44.0 47.5 43.9 34.2 % 12,677 6,449 2,741 3,487 N Missing Data Women with Non- % 2.1 2.0 3.5 2.8 Yes All measures except for prior pregnancy are among women with a prior pregnancy. Women with multiple gestations Notes: results. Rates of missing data and not in universe are reported based on the (N=607) have been excluded from these share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. Not in universe includes women who did not have a prior pregnanc a censored cell due to small sample size (N<11). -) indicates A dash ( y. TABLE H. 5: PRIOR BIRTH OUTCOMES Maternity Care Birth Group Prenatal Total Data Elements N or % Center Care Home Prior Birth (Among Women with a Prior Pregnancy) 1.0 0.6 1.5 1.7 % Missing Data 26.2 32.4 27.5 28.4 Not in Universe % 6,337 6,857 18,350 31,544 Women with Non - Missing Data N 85.4 86.9 78.6 88.3 % Yes Prior Birth Outcomes Among Women with a Prior Birth Pregnancy Interval with Current Pregnancy Since Last Birth - Inter Missing Data % 23.5 18.9 15.2 17.7 37.7 Not in Universe % 30.4 45.8 36.9 19,951 Women with Non - Missing Data N 4,052 3,664 12,235 < 18 months % 34.6 24.3 27.1 28.1 >= 18 months % 65.4 75.7 72.9 71.9 TECHNICAL APPENDICES 225

244 Birth Group Prenatal Maternity Care Data Elements N or % Total Care Center Home < 37 Weeks) Prior Preterm Birth (=>20 Weeks - 2.5 1.4 1.4 0.1 % Missing Data 47.8 36.3 % Not in Universe 37.5 39.7 Women with Non- N 5,588 5,150 15,608 Missing Data 26,346 Yes 13.2 21.3 23.9 21.1 % Prior Low Birthweight Infant (< 2,500 Grams) 20.8 12.6 13.1 Missing Data % 1.3 36.3 38.7 % 44.3 Not in Universe 37.2 5,487 21,812 12,699 3,626 N Missing Data Women with Non- Yes 1.3 11.4 15.6 12.4 % All measures except for prior birth are among women with a prior birth. Women with multiple gestations (N=607) have Notes: been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; a response of don’t know, unsure, not known, prefer not to answer; or an outlier value (interpregnancy interval). Not in universe includes women for whom a measure does not apply, and is defined separately for each a censored cell due to small sample size (N<11). -) indicates A dash ( measure. 6: PRE TABLE H. CAL CONDITIONS -PREGNANCY MEDI are Maternity C Group Prenatal Birth Data Elements N or % Total Center Care Home Pregnancy Intention % 14.5 6.6 10.8 Missing Data 18.6 8,871 7,155 N Missing Data - Women with Non 39,878 23,852 29.4 27.1 28.2 38.4 % Trying to Become Pregnant Not Trying to Become Pregnant, Not 59.6 57.9 % 48.3 60.8 Contraception Using Not Trying to Become Pregnant, Sometimes 3.6 4.1 6.5 % 3.7 Using Contraception Not Trying to Become Pregnant, % 6.8 7.4 9.6 8.6 Contraception Using - Diabetes Pre - Pregnancy 15.7 17.2 34.9 0.4 % Missing Data - Women with Non Missing Data 37,032 21,525 6,757 8,750 N Yes 6.8 4.0 3.7 0.6 % Hypertension Pre - Pregnancy - Missing Data 13.7 22.4 0.4 % 13.1 Women with Non N 8,059 22,046 38,857 8,752 Missing Data - 7.5 0.8 % Yes 8.3 6.1 Mother's BMI at First Prenatal Visit Missing Data % 3.6 32.1 18.1 18.5 36,434 20,908 7,052 8,474 N Missing Data - Women with Non 3.3 2.8 3.7 4.2 % Underweight (BMI < 18.5) 34.9 31.0 33.9 45.2 % Normal Weight (=>18.5 BMI <25) Overweight (=>25 BMI <30) 27.3 25.8 26.0 % 25.6 % 27.6 29.9 27.3 Obese (=>30 BMI < 40) 20.8 Very 7.5 8.5 10.5 4.3 % Obese (BMI >= 40) Notes: Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be mi ssing due to a or missing form from which a measure is drawn; item nonresponse; a response of don’t know, unsure, not known, prefer not to answer; or an outlier value (BMI of mother at first prenatal visit). Not in universe includes women for whom a a censored cell due to small -) indicates . A dash ( measur e does not apply, and is defined separately for each measure sample size (N<11). 226 TECHNICAL APPENDICES

245 NS DEVELOPED DURING TABLE H. 7: PREGNANCY CONDITIO STRONG START Birth Maternity Group Prenatal Total Data Elements N or % Care Center Care Home Preeclampsia % 0.7 21.4 18.2 Missing Data 25.2 8,722 N Women with Non- 7,767 36,559 20,070 Missing Data 4.9 6.0 1.5 % Yes 5.8 - Related Hypertension Pregnancy - 20.9 % 18.2 0.7 Missing Data 26.5 36,569 7,631 8,722 N Missing Data - Non 20,216 Women with 8.1 1.4 Yes % 6.0 7.2 Gestational Diabetes 17.9 Missing Data % 0.7 24.9 21.1 Women with Non - Missing Data N 8,723 7,798 20,166 36,687 2.8 Yes 6.0 7.9 6.3 % Cervical Incompetence 22.4 20.6 32.7 0.8 % Missing Data Women with Non Missing Data N 8,719 6,984 19,813 35,516 - 0.9 1.3 2.0 - % Yes Placenta Previa 0.8 22.2 26.2 % Missing Data 18.9 Women with Non- Missing Data N 8,719 7,656 19,871 36,246 1.1 Yes % 0.3 0.9 1.6 Placental Abruption 0.8 Missing Data 26.7 23.3 19.7 % 7,610 8,720 N Missing Data Women with Non- 19,584 35,914 % 0.4 0.5 0.8 Yes 0.6 Congenital Abnormalities of the Fetus % Missing Data 0.6 20.5 22.3 32.8 Women with Non - 35,565 Missing Data N 8,737 6,974 19,854 1.8 2.1 1.5 1.2 % Yes UTI(s) During Last 6 months of Pregnancy 23.1 19.9 Missing Data % 0.8 28.0 35,825 Women with Non Missing Data N 8,717 7,473 19,635 - 13.2 17.3 11.8 5.2 % Yes Notes: left Strong Start prior to This table is among all women, but we note that 23 percent of women are reported to have delivery. Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data are from reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form . A which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer dash ( indicates a censored cell due to small sample size (N<11). -) PREGNANCY 8: TREATMENTS DURING TABLE H. Maternity Group Prenatal Birth Total Data Elements N or % Center Care Home Care Vaginal Progesterone 40.0 6.6 33.5 40.1 % Missing Data 15,309 29,743 6,230 8,204 N Missing Data - Women with Non % Yes 0.2 1.1 0.6 0.8 Women with a Prior Preterm Birth) 17P (Progesterone Injections, Among 5.1 5.4 Missing Data % 0.8 10.0 84.8 83.7 91.5 % Not in Universe 85.8 Women with Non 3,919 2,585 654 680 N Missing Data - 15.0 Yes % 2.6 10.9 19.2 Antenatal Steroids Missing Data % 1.3 43.5 46.0 36.7 28,321 Women with Non - Missing Data N 8,673 5,862 13,786 Yes % 0.4 2.4 4.1 2.6 TECHNICAL APPENDICES 227

246 Birth Group Prenatal Maternity N or % Data Elements Total Care Home Care Center Tocolytics 49.1 43.7 1.5 % Missing Data 38.5 Women with Non - Missing Data N 8,654 5,848 13,013 27,515 Yes % 0.3 1.1 1.8 1.2 Notes: This table is among all women, but we note that 23 percent of women are reported to have left Strong Start prior to delivery. Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not with PLPE data. Data may be missing due to a in universe are reported based on the share of Strong Start participants missing form from which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. Not in universe includes women who whom a measure does not apply, and is define d separately for each a censored cell due to small sample size (N<11). -) indicates A dash ( measure. TABLE H. 9: PRENATAL CARE Maternity Group Prenatal Birth N or % Data Elements Total Care Home Center Care Routine Prenatal Care Provider Missing Data % 0.6 20.4 16.4 14.2 Women with Non Missing Data N 8,730 8,264 21,355 38,349 - Obstetrician 64.5 29.5 4.7 % 43.3 5.4 1.0 Licensed Professional Midwife 18.8 % 2.3 5.7 26.5 - % Nurse Practitioner 8.9 37.5 18.3 35.2 Certified Nurse Midwife/Certified Midwife % 74.6 Family Medicine Physician % 1.7 2.5 1.4 1.7 5.4 1.6 9.1 0.1 % Other Provider Routine Prenatal Care (Individual Visits) 1.9 0.7 6.2 0.1 Missing Data % 9,740 8,778 N Missing Data 43,878 25,360 Women with Non- Received Individual Visits 99.7 72.8 90.0 88.1 % 8.3 8.8 5.3 9.3 Average number of Individual Prenatal Visits Mean Routine Prenatal Care (Group Visits) 1.9 Missing Data 0.7 6.2 0.1 % 25,360 43,878 9,740 8,778 - N Missing Data Women with Non 1.6 % Received Group Visits 2.3 79.5 19.3 5.7 4.8 5.7 7.0 Mean Average Number of Group Prenatal Visits Care Coordinator Encounters 8.6 12.4 31.8 0.6 % Missing Data 39,155 23,342 8,732 N Missing Data Women with Non- 7,081 Received Care Coordinator % 99.5 46.1 93.0 86.0 Encounters 4.6 Average Number of Care Coordinator Encounters Mean 3.2 2.3 4.0 Mental Health Encounters 5.2 % 18.5 Missing Data 35.2 16.4 Women with Non- 21,354 6,731 8,331 N Missing Data 36,416 0.7 % Received Mental Health Encounters 5.9 3.4 8.8 Average Number of Mental Health Encounters Mean 1.9 1.7 2.4 2.3 Doula Encounters 15.7 36.1 89.3 % Missing Data 34.9 6,635 939 N Missing Data Women with Non- 29,116 21,542 3.4 75.0 % Received Doula Encounters 1.2 0.6 2.4 2.7 1.0 2.2 Mean Doula Encounters Average Number of Health Education Missing Data % 98.0 38.9 33.9 47.7 23,392 Women with Non- Missing Data N 172 6,347 16,873 26.1 Received Health Education, Not Centering % 16.9 13.4 30.9 2.4 2.5 Average Number of Health Education Sessions Mean 1.5 1.4 Home Visits 38.2 Missing Data % 62.9 42.9 27.8 27,628 18,445 5,925 3,258 Women with Non- Missing Data N 228 TECHNICAL APPENDICES

247 Birth Maternity Group Prenatal Data Elements N or % Total Center Care Care Home 2.5 12.3 7.7 55.6 % Received Home Visits 1.6 1.5 1.4 1.4 Average Number of Home Visits Mean Self - Care, not Centering - Missing Data % 49.4 36.8 51.8 98.2 21,560 Women with Non- Missing Data N 157 5,257 16,146 9.5 9.8 8.8 - % Care, Not Centering - Received Self - Care Sessions Mean 3.5 3.9 1.2 - Average Number of Self Nutrition Counseling 7.2 % Missing Data 27.9 30.7 38.7 Women with Non- Missing Data N 8,151 6,361 17,701 32,213 Received Nutrition Counseling % 0.3 28.6 32.7 23.7 2.0 2.1 1.5 Average Number of Nutrition Counseling Sessions Mean 1.0 Substance Abuse Services 28.1 Missing Data % 7.2 37.3 31.6 32,133 Women with Non- Missing Data N 8,152 6,511 17,470 2.3 3.2 Received Substance Abuse Services % - 2.6 2.4 2.2 4.0 - Mean Average Number of Substance Abuse Services Referrals for High Risk Medical Services 37.8 17.1 19.6 5.3 % Missing Data 35,942 21,163 8,322 N Missing Data Women with Non- 6,457 25.8 24.5 0.3 % Received Referrals for High Risk Medical Services 19.7 Average Number of Referrals for High Risk 1.6 1.7 1.8 Mean 1.6 Medical Services Types of Referrals for High Risk Medical Services (Among Women with Services) 52.0 Maternal Fetal Specialist % 52.4 70.7 46.7 Pulmonologist % - 1.5 1.4 1.3 4.8 Endocrinologist % - 4.1 5.1 % - 6.4 6.9 Cardiologist 6.8 54.6 60.8 32.8 - % Other This table is among all women, but we note that 23 percent of women are reported to have left Strong Start prior to Notes: delivery. Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from All which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. reported means are among women with a visit or encounter. It is unlikely the women enrolled in Maternity Care Home or Group Prenatal Care were cared for by a Licensed Profession Midwife though this was reported for 1% and 2.3%, -care” directed to indicate women conducted “self -care” if they weighed themselves, respectively. Awardees were “self took their own blood pressure, etc., outside of the context of Group Prenatal Care . A dash ( -) indicates a censored cell due to small sample size (N<11). 10: DELIVERY INFORMATION TABLE H. Birth Maternity Group Prenatal Data Elements N or % Total Center Care Care Home - Induction of Labor (Among Women Who Delivered, Excluding Planned C sections) 19.5 23.3 25.3 1.4 % Missing Data 25.4 26.2 21.6 27.5 % Not in Universe 24,650 12,897 5,511 6,242 N Missing Data - Women with Non 32.1 35.5 37.4 20.5 Yes % Induction of Labor with Pitocin (Among Women Who Were Induced) 3.5 Missing Data % 0.3 7.8 2.9 Not in Universe % 85.3 74.0 81.4 80.4 7,188 Women with Non - Missing Data N 1,263 1,894 4,031 84.4 Yes % 56.1 89.9 90.7 Delivery) Place of Delivery (Among Women with a Missing Data % 4.6 11.5 7.3 7.7 19.2 Not in Universe % 25.8 15.8 18.2 Women with Non - Missing Data N 6,114 7,551 19,027 32,692 TECHNICAL APPENDICES 229

248 Birth Group Prenatal Maternity N or % Data Elements Total Center Care Care Home Hospital % 51.8 99.4 99.5 90.6 % - 0.1 8.2 Birth center 43.4 Home birth % 4.3 - 0.2 0.9 0.2 Other % 0.5 0.4 0.3 Delivery Method (Among ALL Women with a Delivery) % Missing Data 0.7 12.0 5.6 6.1 % Not in Universe 15.8 19.2 18.2 25.8 Women with Non Missing Data N 6,454 7,497 19,466 - 33,417 % Vaginal Only 73.1 70.1 87.1 69.5 % Section Only C- 29.9 12.9 26.9 30.5 1 Delivery Method (Among LOW RISK Women with a Delivery) Missing Data % 0.4 8.7 2.3 3.4 Not in Universe % 74.1 61.4 73.0 70.5 6,298 Women with Non- Missing Data N 2,239 3,100 11,637 Vaginal 72.9 74.7 75.9 % 83.3 25.3 % C - Section 16.7 27.1 24.1 - - Section) - Section (Among Women with a C - Scheduled C 4.7 6.3 7.4 % Missing Data 12.5 Not in Universe % 90.5 72.2 76.1 78.0 Missing Data N 429 1,586 4,495 6,510 Women with Non- 34.3 38.1 45.6 43.0 Yes % Section) - - VBAC (Among Women with a Prior C 1.9 0.7 6.2 0.1 % Data Missing 96.0 87.1 85.9 82.7 % Not in Universe Missing Data Women with Non- 4,929 3,426 1,160 343 N 19.3 17.5 21.7 29.4 % Yes Women with multiple All measures are among women with a delivery. Notes: gestations (N=607) ha ve been excluded from ar d ase d b reporte e e univers in and not t with s participant ong Star Str of e shar the on thes a ing dat miss of s Rate . results e m ite ; drawn is e measur h a whic fr om m miss to a ue ing d miss be y ma a Dat . data E PLP ing for response a or ; nonresponse prefer includes know, unsure, a not measure known, does don’t not women who whom of universe in Not to answer. not (-) size A dash censored measure. to small sample each a for (N<11). defined separately indicates and is cell due , apply 1 women with nulliparous, singleton, term births. defined as is Low risk 11: BIRTH OUTCOMES TABLE H. Maternity Group Prenatal Birth Data Elements N or % Total Center Care Care Home 1 Outcomes of Strong Start Pregnancy 14.9 17.9 20.7 23.2 % Missing Data Missing Data - with Non Women 8,227 6,745 21,734 N 36,706 97.6 95.5 96.2 % 94.4 Live Birth 0.9 0.3 % Stillbirth 0.7 0.8 Termination % 0.5 0.6 0.2 0.3 3.3 4.1 1.3 3.2 % Miscarriage Estimated Gestational Age (EGA, Among Women with Live Births) 5.8 % 0.7 Missing Data 7.0 15.4 Not in Universe % 26.1 16.4 18.9 19.8 6,433 7,078 19,229 32,740 N Missing Data - Women with Non 3.5 Very Preterm (20 =< EGA < 34) % 1.0 3.5 4.3 7.6 Preterm (34 =< EGA < 37) % 3.5 8.4 8.6 86.7 87.4 Term (37 =< EGA < 42) % 93.4 85.7 1.5 1.3 1.4 2.0 % -Term (42+) Post Birth Weight (Among Women with Live Births) 2.1 % Missing Data 8.3 8.0 14.3 Not in Universe % 26.1 16.4 18.9 19.8 6,312 18,672 7,189 32,173 Women with Non- Missing Data N 230 TECHNICAL APPENDICES

249 Birth Group Prenatal Maternity Data Elements N or % Total Care Home Care Center 0.5 % Very Low Birthweight (<1500g) 1.8 1.3 1.5 8.7 3.1 % Low Birthweight (=>1500g < 2500g) 8.7 7.6 84.9 85.5 % Normal Birthweight (=>2500 < 4000g) 84.2 83.4 % 10.9 5.2 6.0 6.8 Macrosomic Birthweight (=>4000g) (N=607) have been excluded from All measures are among women with a delivery. Women with multiple gestations Notes: these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or an outlier value (estimated gestational age and birth weight). Not in universe includes women who whom a measure does not apply, and is defined separately for each measure -) indicates a censored cell due to small sample size (N<11). . A dash ( 1 For the measure Outcomes of Strong Start Pregnancy, 11 percent of the missing data is attributable to a missing exit remaining form. Among the 89 percent of data missing due to item nonresponse, 67 percent of participants were rior to delivery and 17 percent are missing information on whether they left Strong reported to have left Strong Start p Start. Remaining sources of missing data include women missing responses for all of the following variables: number of live births delivered, estimated gestational age, baby date of birth, and infant birth weight. TECHNICAL APPENDICES 231

250

251 APPENDIX I: PARTICIPANT-LEVEL PROCESS EVALUATION – MAIN FINDINGS, BY AWARDEE TECHNICAL APPENDICES 233

252 TABLE I. 1: PLPE FORM SUBMISSION ial ty Health Total N or % th Alabama University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority Sou Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Spec Investment Corp. Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care District Providence Hospital Research Foundation Meridian Health Plan Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Communi Texas Tech University Health Strong Start Participants with 45,316 1,629 732 N 2,676 1,429 8,426 976 1,238 1,343 709 1,264 857 1,629 3,142 959 820 1,812 2,628 869 3,458 1,802 247 1,094 1,174 1,322 696 928 1,457 PLPE Data 1,626 726 42,988 Intake Forms Received N 2,668 1,122 7,012 967 1,153 1,343 685 1,214 841 1,627 3,139 782 820 1,804 2,589 859 3,457 1,747 194 1,061 1,171 1,322 696 908 1,455 --- -------------------- 94.9 99.8 99.2 99.9 97.8 Intake Form Submission Rate % 99.7 78.5 83.2 99.1 93.1 100.0 96.6 96.0 98.1 99.9 99.9 81.5 100.0 99.6 98.5 98.8 100.0 96.9 78.5 97.0 99.7 100.0 100.0 -- ----- -- ----- Third - Trimester 873 599 27,109 755 381 684 595 657 716 144 905 N 1,917 404 5,178 577 731 898 452 933 545 1,136 1,280 472 544 1,167 1,322 326 2,918 Received Surveys -- ----- -- ----- Third Trimester Survey 64.5 54.7 59.8 46.3 97.8 59.9 51.7 % 71.6 28.3 61.5 59.1 59.0 66.9 63.8 73.8 63.6 69.7 40.7 49.2 66.3 64.4 50.3 37.5 84.4 50.2 58.3 60.1 50.7 - --- -- ----- Submission Rate 27,135 1,494 714 814 414 293 1,094 528 575 137 812 2,799 Postpartum Surveys Received N 1,855 270 4,863 638 632 992 177 1,166 406 1,367 1,055 309 798 1,182 1,417 334 ----- --- - -- Postpartum Survey 91.7 97.5 55.9 44.6 42.1 82.8 45.0 52.6 55.5 45.1 80.9 38.4 53.9 65.2 97.3 32.2 33.6 83.9 47.4 92.2 25.0 73.9 51.1 65.4 57.7 18.9 69.3 % 59.9 Submission Rate ----- -- ----- -- 1,152 958 8,418 1,350 2,675 N Exit Forms Received 771 959 3,416 1,770 240 1,795 1,089 1,173 1,322 696 928 1,457 713 1,625 44,485 3,142 1,629 467 1,264 702 1,343 820 2,611 ----- -- --- - 94.5 99.9 98.2 93.1 100.0 99.0 100.0 54.5 100.0 100.0 100.0 100.0 99.1 99.4 88.7 98.8 98.2 97.2 99.5 99.9 100.0 100.0 100.0 100.0 97.4 99.8 98.2 Exit Form Submission Rate % 100.0 -- ----- -- ----- TABLE I. 2: DEMOGRAPHICS ----------------------------- otal T N or % l University of Start Coalitions University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Tech University Health Maricopa Special Investment Corp. Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medica Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady University of Tennessee Healthy Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Mother s Age at Intake ' 0.1 0.4 1.9 4.0 4.7 0.0 7.1 1.5 16.9 23.0 0.3 % Missing Data 5.4 0.4 1.5 0.1 2.1 1.0 0.0 0.3 4.6 20.7 3.5 0.1 1.3 1.6 0.4 0.0 18.6 3417 Women with Non - Missing Data N 2623 1280 1087 6986 931 1142 1305 670 1208 835 1602 3099 773 788 1779 2525 843 1716 191 1025 42297 1603 719 1431 882 682 1155 ----------------------------- 5.4 5.7 13.9 8.5 7.4 5.3 6.4 5.3 5.7 - 4.3 5.6 6.6 8.0 2.7 1.8 11.8 2.6 7.4 6.1 8.0 7.8 7.1 3.9 3.7 2.6 6.4 6.5 % Less than 18 Years of Age -- -- - ---- - -- 6.3 10.1 9.9 11.9 17.8 9.6 16.9 11.5 5.7 13.7 6.6 9.9 12.2 10.4 8.3 10.9 8.4 11.5 9.0 10.2 12.8 10.3 12.4 18.4 11.2 9.8 9.3 18 and 19 Years of Age 12.9 % - -- - ---- -- -- 82.1 74.4 75.0 82.9 68.2 73.6 73.1 71.1 68.8 71.0 74.5 77.9 80.3 81.9 76.1 75.6 78.6 79.6 75.5 74.2 76.6 75.2 68.0 73.5 64.8 73.6 75.8 70.8 % 20 Through 34 Years of Age -- - -- -- ---- - 35 Years and Older 9.0 % 13.4 4.6 9.2 5.9 8.2 6.5 3.4 13.6 5.9 7.9 18.1 6.3 9.5 4.5 4.8 8.5 10.6 6.3 9.9 7.3 11.5 6.8 6.7 14.3 5.6 2.9 9.5 - -- -- -- - ---- Race and Ethnicity ----------------------------- Missing Data % 1.7 22.6 17.5 1.4 8.8 0.3 3.6 4.3 4.0 0.4 0.8 19.2 0.5 1.0 3.8 1.9 2.1 4.8 20.7 7.6 1.9 0.2 1.6 3.9 0.8 8.5 5.9 6.6 668 1421 866 678 41762 1278 1136 992 191 1514 Women with Non -Missing Data N 2586 1093 6938 932 1121 1301 678 1204 817 1602 3077 768 784 1769 2469 838 3347 1694 ----------------------------- 29.7 23.1 Hispanic % 51.7 16.7 26.4 7.2 49.1 22.4 4.3 83.5 40.1 8.1 64.7 64.7 4.2 3.4 1.2 42.1 28.0 3.4 - 59.6 52.1 2.6 33.5 98.3 1.8 - ----------------------------- 25.6 15.0 1.8 35.0 1.4 50.1 19.6 11.3 23.0 5.8 Non -Hispanic White % 4.9 8.9 56.0 17.1 9.7 30.1 4.3 2.3 23.3 13.0 5.2 13.3 25.0 83.7 13.1 17.8 1.2 77.9 - -- -- ---- - -- 72.7 12.2 68.0 12.5 89.5 15.4 67.6 8.7 84.8 11.3 41.3 % -Hispanic Black Non 34.3 69.4 18.9 18.5 72.6 24.4 13.5 - 59.5 96.7 52.1 39.8 14.4 77.5 42.0 36.9 88.8 - -- -- ---- - -- 2.7 5.6 4.3 3.0 5.4 6.5 2.1 % Other Race/Multiple Races 9.8 - 3.7 - 3.8 - 2.3 3.0 4.9 - 3.3 3.2 31.4 1.0 1.5 1.4 3.1 11.7 6.4 12.2 - -- - -- -- ---- - Ethnicity (Among Hispanic Wom en) ----------------------------- 20.9 13.3 8.3 8.5 Missing Data % 10.2 31.2 20.2 12.6 19.2 7.7 9.1 5.6 8.3 2.0 5.6 23.7 0.5 1.7 40.3 11.4 9.9 5.7 22.8 15.0 5.0 0.5 3.5 4.3 234 TECHNICAL APPENDICES

253 Total N or % l University of Start Coalitions University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Tech University Health Maricopa Special Investment Corp. Oklahoma Health Providence Health Health Consortium Access Community Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medica Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady University of Tennessee Healthy Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas 96.9 Not in Universe % 39.0 55.9 58.1 80.3 36.0 70.0 86.8 14.5 53.1 90.0 30.2 24.0 95.3 94.9 58.6 47.3 62.8 91.1 75.9 30.0 43.9 63.6 1.2 77.3 90.4 69.9 59.0 591 592 33 227 851 26 - 350 12388 Women with Non -Missing Data N 1338 182 1831 67 550 291 29 1005 328 129 1991 497 33 61 29 353 936 57 - Mexican, Mexican American, % 10.1 85.0 14.8 53.1 22.4 49.7 20.9 - 50.0 - 71.8 69.7 54.2 25.0 - - 16.9 65.7 48.3 72.1 63.6 87.7 67.0 22.5 71.0 65.0 41.4 16.5 Chicana 63.7 12.3 Puerto 2.5 - 15.8 39.9 - - - 17.8 - - - - - - 2.1 - - - - - - 96.1 - - 9.4 12.4 % Rican - 1.1 - - - - - - - - - - - - - - - - - - 1.1 - 14.4 - - 1.3 - - % Cuban Other Hispanic, Latina, or 10.8 % 35.6 67.4 - - 2.7 25.6 - 44.4 74.3 - 82.5 86.9 31.7 - 23.0 - 31.6 56.6 24.1 33.7 - 21.6 64.2 65.7 30.4 15.9 10.3 Spanish Origin Multiple Hispanic, Latina, or 1.4 - 2. - - - - 9 - - - - - - - - - - 0.7 - - - - 7.6 - 1.3 - - - % Spanish Origins ntake r Homeless at I o Living in Shelter 1.6 18.6 0.3 3.1 20.7 3.1 0.0 1.2 1.5 0.4 0.0 0.0 0.1 0.1 3 4.0 3.4 0.0 6.8 0.8 16.8 21.3 0. 0. 0.1 0.8 5.2 2.1 0.2 0 % Missing Data Women with Non - Missing Data N 2623 1111 6996 937 1145 1305 679 1208 837 1606 3099 773 788 1779 2527 844 3418 1724 191 1041 1155 1280 689 882 1431 724 1606 42398 1.1 Yes % 1.1 1.8 0.9 - 1.4 2.5 1.6 - 1.3 1.2 - 1.4 - 1.5 3.4 3.2 1.2 - - 1.9 0.9 5.8 3.4 1.2 - 1.3 1.5 Employment and School Status at Inta ke 2.5 2.5 7.7 21.6 14.3 2.0 4.6 9.9 1.3 0.3 19.7 2.0 0.9 6.3 5.3 5.8 1.2 10.7 12.1 18.2 23.7 1.6 % Missing Data 9.1 2.8 8.6 0.7 11.0 13.5 1593 797 1191 662 1289 1098 831 6876 1077 2588 N -Missing Data Women with Non 1271 189 1524 3349 815 2312 1764 786 763 3041 672 819 1393 650 1392 40862 991 1129 % 33.3 20.6 35.0 24.4 27.5 32.0 33.8 36.5 24.9 45.3 35.6 35.6 35.6 33.7 37.2 28.7 36.2 32.9 30.5 21.2 33.7 34.1 34.8 40.4 36.9 36.6 34.9 34.5 Employed, Not in School School, Not Employed In 11.7 11.5 18.6 14.0 15.8 10.6 10.3 8.4 8.7 12.7 7.7 14.9 9.2 16.0 10.9 9.9 15.7 10.5 13.4 10.5 10.2 17.1 13.7 9.4 12.2 8.2 12.3 11.5 % 6.6 8.6 2.1 4.1 5.1 6.6 4.8 5.2 4.6 4.5 6.7 5.8 6.4 - 4.6 4.5 5.8 5.7 4.4 5.6 4.8 4.6 5.5 6.9 Employed and in School % 4.6 5.7 7.9 6.0 49.8 % 49.1 48.5 50.4 56.0 45.4 55.4 56.3 51.8 53.2 50.2 57.1 40.6 43.7 48.5 43.9 50.7 47.7 50.7 46.7 48.6 54.8 66.6 40.6 45.6 39.5 49.2 44.3 Neither Employed nor in School Education Level at Intake 8.5 4.5 19.6 32.9 0.7 18.7 10.9 22.0 21.1 7.8 11.7 15.3 1.5 0.9 21.7 1.8 1.4 8.3 7.5 7.4 2.9 15.3 19.9 25.4 5.1 % Missing Data 21.5 12.5 23.4 1232 668 1368 724 462 1271 941 957 188 1403 3154 754 2173 1760 781 744 3045 1585 780 1164 651 1267 965 800 6734 1054 2497 N -Missing Data Women with Non 39122 34.9 36.1 26.4 26.3 28.0 28.9 9.9 - 25.5 38.6 30.7 25.0 13.8 28.2 35.9 20.7 24.7 24.6 43.4 30.3 31.8 34.6 65.5 25.5 17.7 21.6 15.0 21.7 % Less than High School 32.2 61.8 57.9 59.0 68.9 59.2 49.7 82.9 65.8 48.5 52.9 65.4 64.7 58.8 49.5 68.7 64.5 60.8 45.7 52.8 61.2 55.9 61.9 51.8 63.6 57.5 68.6 50.9 % Graduate or GED High School 3.3 5.4 5.3 1.8 6.4 15.5 6.7 3.4 1.9 3.0 - 5.9 4.3 5.4 5.8 5.0 5.1 3.6 4.4 2.5 - 5.5 5.1 7.5 4.9 8.4 4.1 5.3 % Associate's Degree 5.9 5.8 - 1.9 8.7 6.3 2.1 3.5 2.5 - 6.8 5.2 5.2 2.1 3.4 4.0 1.5 6.6 2.8 3.1 - 4.3 1.6 7.7 5.6 14.8 2.8 3.2 % Bachelor's Degree 4.4 Other College Degree 4.5 3.5 - 3.5 16.2 4.1 3.2 7.5 10.9 - 8.8 3.6 4.0 2.7 2.4 5.5 5.8 5.9 1.6 3.1 1.1 2.8 6.6 5.4 4.3 4.3 2.8 % Relationship Status at Intake 13.1 17.8 20.7 13.5 2.5 3.6 15.3 0.9 0.3 19.5 0.7 1.6 6.2 4.6 9.5 16.7 51.8 4.1 6.0 1.6 0.9 1.6 5.1 6.3 26.3 9 0.5 11.5 % 1. Missing Data 40455 1088 1298 659 1200 798 1583 3080 765 786 1771 2173 823 3332 1539 191 1019 1140 1268 678 847 1374 352 Women with Non N 1340 2580 - 1040 6910 821 Missing Data 24.5 25.6 8.2 16.0 21.6 29.8 13.0 29.6 23.9 9.4 27.7 17.9 34.9 11.5 26.2 16.8 14.9 27.1 12.8 18.3 29.1 12.4 15.1 23.9 14.0 43.7 11.1 22.8 % Married Living with a Partner 32.3 % 32.5 33.0 33.6 40.1 28.5 35.4 31.0 35.8 43.5 35.0 35.5 37.0 26.3 30.3 19.9 33.8 28.3 35.9 27.2 34.1 34.5 24.4 38.1 46.5 27.7 26.7 28.1 In a Relationship but Not 33.1 30.0 28.8 28.9 13.6 19.7 29.8 27.5 30.8 41.1 27.6 43.1 17.3 32.4 21.6 23.0 19.2 21.5 38.6 18.9 17.7 31.1 43.2 24.3 26.1 34.0 28.6 % 18.2 Together Living 9.1 21.9 16.1 % Not in a Relationship Right Now 17.0 22.0 21.9 25.1 14.2 13.3 24.0 14.4 22.8 40.3 14.8 21.4 14.1 25.5 15.9 15.8 17.3 9.9 22.5 18.5 17.0 23.5 19.5 18.8 17.1 Notes: Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or an outlier value (mother's age). Not in universe includes women who whom a measure does not app ly, and is defined separately for each measure . A dash ( -) indicates a censored cell due to small sample size (N<11). TECHNICAL APPENDICES 235

254 TABLE I. 3: PSYCHOSOCIAL t p. Tennessee Total N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Cor Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care Distric Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady University of Healthy Start Coalitions Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Insured When Became Pregnant 0.2 6.8 0.8 1.3 4.7 0.9 1.1 2.1 4.2 22.0 15.7 0.8 1.6 3.7 0.6 0.8 19.3 0.8 1.4 3.6 4.5 4.0 1.7 8.2 7.7 17.7 23.2 1.4 % Missing Data 41,664 724 1,414 859 683 1,266 1,134 1,029 188 1,500 3,390 840 2,471 1,776 782 767 3,076 1,586 820 1,202 675 1,283 1,128 872 6,916 1,085 2,592 N -Missing Data Women with Non 1,606 51.7 84.7 54.2 72.0 33.6 35.1 87.2 44.9 82.2 37.1 52.3 51.7 59.3 71.8 63.9 70.5 64.1 13.1 45.3 63.2 39.9 51.9 50.2 57.9 65.2 % Yes 56.5 38.1 97.5 31.8 No 34.4 46.2 39.0 54.9 34.8 50.1 86.0 31.5 24.1 33.8 27.9 39.4 48.1 45.1 58.2 15.1 51.3 12.8 63.9 64.6 27.3 42.2 13.5 40.1 2.5 46.0 39.8 % % Unsure 7.7 3.6 9.1 5.2 1.9 4.6 0.9 4.4 5.4 2.3 - - - 2.6 4.6 2.7 3.9 - - 1.9 - 3.7 1.7 8.2 - 15.9 3.7 3.0 Type of Insurance (Among Women Who Were Insured When They Became Pregnant) 4.0 Missing Data % 1.4 23.2 17.7 7.7 8.2 1.7 4.5 3.6 1.4 0.8 19.3 0.8 0.6 3.7 1.6 0.8 15.7 22.0 4.2 2.1 1.1 0.9 4.7 1.3 0.8 0.2 6.8 40.5 Not in Universe % 34.3 32.4 41.0 44.3 55.2 36.2 52.5 83.1 34.5 29.1 35.8 22.7 40.4 48.0 45.9 61.8 17.6 46.5 10.0 62.2 65.0 27.7 45.4 14.5 47.7 2.5 61.8 23,539 Women with Non -Missing Data N 1,690 628 3,471 453 450 811 306 157 526 1,118 1,967 551 464 919 1,292 312 2,787 673 164 361 381 911 370 728 731 706 612 62.9 Medicaid % 86.3 56.1 59.5 64.9 79.3 65.0 65.6 78.1 82.3 91.0 91.5 90.5 90.6 64.5 48.1 85.4 41.5 79.3 63.2 52.2 86.6 66.8 84.6 69.4 93.2 71.9 75.3 6.7 % Other 17.2 19.1 - 19.3 8.7 24.3 8.7 35.4 30.7 - 55.0 5.6 45.2 25.3 7.2 5.4 6.7 5.8 11.5 11.2 28.0 26.5 11.7 22.9 27.8 31.9 33.3 Both Medicaid and Other Health % 6.9 10.7 8.6 9.3 12.2 9.0 8.5 - 10.6 6.2 3.3 - 4.1 7.4 2.2 10.2 6.7 9.0 3.6 14.6 6.1 12.3 4.7 8.9 6.7 11.4 5.5 9.0 Insurance Smokes Cigarettes at Intake 29.7 % 5.2 35.9 24.4 18.5 19.9 1.0 12.9 9.4 13.9 8.3 4.1 19.3 Missing Data 0.1 1.5 8.2 7.6 12.9 24.1 8.5 2.7 0.5 0.0 13.2 6.4 81.4 32.1 15.1 Women with Non 37,946 1,092 136 1,341 782 689 1,274 1,127 983 183 1,550 3,158 784 1,803 1,760 787 767 2,975 1,474 733 1,140 612 1,292 984 770 6,353 905 2,492 N -Missing Data 23.8 Yes 7.9 14.9 10.6 9.7 3.9 17.0 5.7 - 9.3 17.3 4.4 9.8 12.7 % 19.0 11.2 6.6 20.4 8.2 11.5 12.1 14.0 14.0 20.7 10.9 19.6 32.4 3.2 Food Insecure at Intake % 16.5 1.9 11.8 6.0 12.7 1.7 9.9 23.6 0.9 14.3 3.7 16.4 6.0 6.3 30.0 22.8 14.8 7.5 52.1 13.1 10.9 7.1 2.3 26.2 Missing Data 5.2 33.8 21.1 18.4 1,245 803 640 1,250 1,071 915 186 1,245 3,202 803 2,145 1,720 781 726 2,794 1,581 743 1,183 620 1,280 1,026 771 6,635 935 2,494 N Women with Non 350 -Missing Data 38,332 1,188 % Yes 24.0 20.3 30.3 17.4 21.3 27.3 30.9 28.1 11.0 23.2 28.0 12.9 27.0 22.3 16.5 3.6 16.6 7.4 17.8 15.4 32.2 13.8 23.1 22.9 24.3 23.6 17.9 28.6 WIC at Intake Missing Data 9.0 12.2 11.4 2.8 3.9 1.5 1.9 6.0 5.6 23.2 21.8 3.0 3.0 7.3 1.6 0.9 19.7 1.9 2.5 5.8 4.9 4.0 2.5 9.8 12.1 19.0 22.9 3.2 % -Missing Data 40,697 1,413 647 1,393 866 679 1,256 1,089 1,014 185 1,392 3,315 828 2,378 1,759 781 763 3,043 1,568 802 1,196 675 1,273 1,108 831 6,808 1,088 2,547 N Women with Non 48.1 Yes 65.8 25.6 87.3 62.0 56.0 24.1 47.0 79.5 56.0 33.3 46.9 55.5 66.0 65.3 44.4 50.6 51.5 48.9 60.2 64.7 47.4 53.2 47.4 42.8 43.8 31.8 % 53.7 1 Exhibiting Depressive Symptoms at Intake 36.2 Missing Data % 7.8 35.8 24.1 24.4 26.0 2.6 14.1 6.5 17.6 2.1 1.9 22.8 1.8 5.6 19.8 13.3 11.8 28.3 22.8 25.1 7.7 6.0 11.2 24.1 10.5 53.7 16.8 1,027 338 1,282 684 612 1,203 1,069 804 186 1,275 3,016 740 2,057 1,687 774 733 3,042 1,574 701 1,176 604 1,271 909 714 6,381 906 2,425 N -Missing Data Women with Non 37,190 Yes - 34.8 40.2 38.7 51.8 13.8 - - 24.6 30.6 21.4 35.2 - 12.0 - 21.4 32.4 35.8 12.8 36.4 32.4 30.5 40.9 23.8 44.4 22.8 % 27.5 40.1 2 Exhibiting Anxiety Symptoms at Intake 0.9 9.3 4.5 6.3 0.8 15.3 16.1 20.0 27.0 3.0 % 12.1 28.8 50.1 4.3 9.4 7.1 1.9 4.1 17.5 21.6 27.9 3.8 Missing Data 4.4 15.9 2.7 0.6 20.4 2.0 2,159 1,739 783 756 3,041 1,593 772 1,202 659 1,295 1,041 793 6,724 1,031 2,550 N 39,303 1,146 364 1,371 816 640 1,256 1,111 886 189 1,282 3,288 816 Women with Non -Missing Data 64.0 55.2 54.3 86.2 51.9 53.4 59.2 49.9 68.8 48.1 69.4 % 55.2 64.5 60.5 55.9 57.0 41.8 81.0 64.1 42.3 64.5 62.8 69.0 54.9 87.3 80.5 84.8 67.5 None 21.2 26.0 27.2 22.9 Mild % 18.0 25.4 20.9 27.9 24.5 26.3 27.8 8.8 25.0 26.0 19.7 9.9 14.9 7.0 24.6 19.4 22.5 18.7 36.5 19.9 12.4 36.1 26.1 24.2 2.8 2.0 Moderate % 8.0 14.5 6.6 14.1 9.1 12.3 14.0 3.9 11.8 11.3 7.5 11.7 2.2 11.9 7.5 8.9 10.2 14.3 7.6 3.3 14.3 9.5 8.9 9.8 7.7 8.6 236 TECHNICAL APPENDICES

255 t p. Tennessee Total N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Cor Oklahoma Health Providence Health Health Consortium Access Community Mississippi Primary Los Angeles County Health Care Distric Providence Hospital Research Foundation Meridian Health Plan Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health 2.6 2.2 5.2 7.1 7.1 1.1 4.7 7.7 4.3 6.1 2.8 9.6 3.8 % Severe 3.2 4.8 5.1 - 6.2 5.9 6.1 6.1 2.6 6.4 5.3 - 4.6 3.6 7.5 Incomplete Score but Showing % 1.0 1.9 - 0.7 2.4 0.9 2.0 2.9 - 1.7 - 1.8 - - - - - 1.1 - 1.3 - - 2.0 - 1.6 - 2.1 - Symptoms of Anxiety 3 History of Intimate Partner Violence 14.4 4.4 0.4 4.5 4.1 2.0 48.4 23.6 10.4 5.5 0.5 2.3 19.5 0.5 1.5 10.5 1.9 2.1 Missing Data % 2.1 25.6 18.2 13.0 10.7 5.1 4.8 4.2 27.4 22.0 Women with Non 40,075 -Missing Data N 2,576 1,050 6,876 822 1,098 1,238 669 1,205 804 1,600 3,032 765 784 1,761 2,296 838 3,348 1,291 188 919 1,107 1,275 658 864 1,405 377 1,229 19.4 11.1 16.2 15.6 26.0 27.6 14.9 19.9 24.5 23.7 16.9 20.6 17.4 15.1 15.9 22.5 26.4 14.8 22.5 17.3 13.8 35.1 16.2 15.2 20.4 17.6 17.8 % Yes 10.2 4 Experiencing Intimate Partner Violence at Intake (Among Women With a Completed Score or Who Report Being in a Relationship) 7.5 12.0 1.6 7.1 14.8 21.6 26.2 4.3 4.3 16.0 2.8 0.6 19.9 2.3 0.7 9.3 4.8 5.5 7.0 16.1 14.8 19.0 26.1 3.6 % Missing Data 2.6 49.9 20.8 11.8 0.4 6.3 7.2 6.5 10.2 8.4 16.3 19.9 9.8 7.2 6.0 3.7 7.4 5.7 7.5 1.8 4.2 8.7 11.4 5.4 13.8 9.8 5.8 3.5 6.2 9.1 % 6.8 12.8 Not in Universe 1,068 363 1,306 728 580 1,129 979 740 141 1,139 3,028 766 2,061 1,605 738 2,977 1,529 713 1,053 626 1,034 911 750 6,515 957 2,295 N -Missing Data Women with Non 690 36,421 Yes % 3.6 3.7 2.2 3.3 4.0 2.8 2.6 1.3 2.7 2.4 3.3 0.4 1.8 0.1 3.0 1.7 3.4 2.9 6.4 1.2 1.1 2.1 6.0 4.5 2.1 1.9 3.1 2.6 Experiencing Prenatal Care Access Barrier Missing Data % 0.3 21.3 16.8 0.8 6.8 0.0 3.4 4.0 1.6 0.1 0.1 18.6 0.0 0.4 1.5 1.2 0.0 3.1 20.7 3.1 0.3 0.0 0.0 2.1 0.1 0.8 0.2 5.2 Women with Non 42,398 1,606 724 1,431 882 689 1,280 1,155 1,041 191 1,724 3,418 844 2,527 1,779 788 773 3,099 1,606 837 1,208 679 1,305 1,145 937 6,996 1,111 2,623 N -Missing Data 66.3 None Reported 66.0 51.0 73.5 68.2 56.9 58.9 59.8 68.5 52.3 61.6 50.5 56.8 69.5 81.2 70.0 71.6 55.2 77.6 52.4 71.9 79.6 83.6 54.0 56.1 66.4 78.0 70.0 % 24.9 18.8 17.1 26.8 29.5 31.9 15.3 17.5 22.8 25.7 11.1 28.8 24.6 17.9 15.9 42.8 41.2 25.0 31.3 27.7 28.1 25.4 33.4 26.4 20.8 32.4 20.9 % Reported One Access Barrier 24.3 Reported Two or More Access 4.8 6.8 14.4 14.1 1.1 2.9 5.4 22.0 11.3 16.0 4.1 5.3 0.9 8.9 - 8.3 13.4 16.4 3.8 12.1 15.7 9.6 5.4 5.7 16.6 13.1 % 14.6 11.2 Barriers 5 Types of Barriers Reported (Among Women Who Reported Any Barrier) 73.2 69.5 70.3 49.6 65.6 47.5 62.5 79.9 87.9 95.8 25.7 72.0 66.9 76.6 62.3 65.9 66.7 53.0 46.1 65.8 66.5 % No Car 82.4 59.6 59.7 62.3 63.0 69.8 47.8 7.9 15.2 9.5 - 6.4 6.1 33.0 12.7 22.2 9.6 3.4 - 39.6 - 11.4 24.8 18.3 7.1 18.3 16.8 13.4 9.7 11.1 12.1 18.6 % Public Transportation Challenges 13.5 16.8 10.1 - 7.2 23.3 23.6 10.5 24.9 31.2 14.4 8.1 13.4 25.7 28.7 % Not Enough Money for a Ride 27.9 14.7 16.8 12.1 29.1 58.1 34.1 21.5 7.6 11.9 18.6 28.9 18.1 12.6 25.9 19.9 It - 14.5 11.9 18.3 6.7 17.7 Work Hours Make - 9.7 18.8 - 23.0 21.0 26.7 17.4 - - 16.0 10.0 16.8 6.3 21.2 16.6 22.5 26.5 25.3 22.2 17.6 % Difficult 17.2 9.7 17.5 8.5 3.9 8.1 - 7.1 - 4.1 12.1 7.7 11.1 14.2 8.3 - 10.4 10.1 21.0 11.9 11.3 % Childcare Challenges 10.5 6.8 11.7 - - 12.6 15.4 12.7 - - - - - - - - 4.9 - - - - - - - - - - - - - - 0.7 - - % Partner Objections - 0.7 6.2 23.7 16.0 12.1 19.6 3.6 10.4 13.7 9.3 16.7 - 57.2 12.2 9.5 12.3 6.9 12.8 16.5 8.5 12.0 % Other 13.9 4.4 16.4 7.3 17.6 8.7 16.3 20.8 Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start Notes: participants with PLPE data. whom a measure does not apply, and is defined separately for each or Data may be missing due to a missing form from which a measure is drawn or item nonresponse. Not in universe includes women f . Appendix E ensored cell due to small sample size (N<11). All scales are defined in a c -) indicates A dash ( measure. 1 Measured by CES- D 10 scale. 2 Measured by GAD -7 scale. 3 Measured by STaT scale. 4 Measured by WEB scale. 5 Women could report multiple barriers. TECHNICAL APPENDICES 237

256 TABLE I. 4: PREGNANCY HISTORY AND INTENTIONS uthority ght of Nevada Total ty of Kentucky N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care A South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health Providence Health Health Consortium Access Community Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood Universi Association DBA Grady University of Tennessee Healthy Start Coalitions Health Care Association HealthInsi American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Prior Pregnancy 0.1 0.4 0.0 1.5 0.7 0.0 1.1 0.0 5.9 0.0 0.1 Missing Data 0.0 0.4 0.5 2.0 0.1 0.8 7.9 0.6 0.0 0.0 0.3 0.0 0.0 0.7 10.0 0.8 % 0.0 Missing Data N 2,628 1,406 8,407 931 1,221 1,305 695 1,258 801 1,608 3,100 950 788 1,779 2,553 837 3,414 1,765 222 1,068 1,158 1,280 687 901 1,433 725 1,448 44,368 Women with Non - % 75.5 73.7 63.5 59.0 70.5 59.4 72.3 60.4 78.9 66.4 68.0 77.9 73.6 70.0 67.7 74.6 72.0 81.5 77.5 73.2 71.5 66.1 71.1 66.5 99.2 71.1 72.1 Yes 78.0 Pregnancy History Among Women with a Prior Pregnancy Not in Universe (No Prior % 22.0 22.4 26.3 36.8 37.8 29.5 40.5 27.7 20.1 21.1 33.7 32.0 22.1 26.2 30.0 29.3 24.9 28.0 22.8 22.8 26.7 28.5 34.1 28.9 33.5 - 35.7 27.6 Pregnancy) Prior Miscarriage (<20 weeks EGA) % 3.8 14.0 1.5 21.1 11.8 2.6 22.5 7.3 53.6 4.5 6.4 2.5 2.5 Missing Data 32.7 47.9 11.9 8.1 26.6 3.7 9.4 2.1 0.1 32.0 3.1 60.7 15.4 12.2 31.8 - Missing Data N 1,952 899 6,075 398 619 886 260 818 224 Women with Non 1,196 1,861 622 594 750 957 195 2,161 1,136 122 789 740 888 453 353 908 280 787 26,923 Yes % 33.5 25.4 32.9 30.2 32.5 39.4 31.2 33.9 29.9 36.0 39.0 34.9 39.2 34.7 33.6 30.8 33.5 36.2 39.3 35.5 33.2 43.5 - 26.9 36.1 7.9 27.6 33.4 Prior Elective Termination % 3.8 13.7 1.5 21.6 11.7 2.8 22.3 7.4 53.1 3.5 6.3 2.1 2.8 31.8 34.7 48.8 11.5 8.2 27.8 3.8 10.2 2.2 0.1 31.5 3.5 59.7 15.7 12.3 Missing Data - Missing Data N 1,950 903 6,075 393 620 884 261 817 228 1,213 1,863 626 592 749 906 187 2,174 1,135 119 788 731 887 453 357 903 287 782 26,883 Women with Non 11.1 20.5 42.9 15.1 12.2 34.5 20.2 26.8 4.0 26.3 45.1 30.1 13.1 Yes 13.8 8.3 - 29.9 13.3 33.6 4.2 9.3 10.4 - - 9.5 13.6 22.8 19.0 % Prior Still Birth (Fetal Death >= 20 Weeks EGA) % 19.0 40.2 12.3 26.3 29.0 15.6 32.0 10.0 60.0 36.3 23.7 10.1 10.0 37.4 36.9 50.0 30.0 16.4 44.4 6.6 15.9 9.2 1.5 32.1 9.3 64.7 26.5 23.3 Missing Data -Missing Data N 1,550 528 5,162 348 408 717 193 784 169 685 1,323 550 535 649 849 177 1,543 989 79 758 665 797 444 352 820 251 607 21,932 Women with Non Yes % 1.2 4.4 0.8 - 3.7 4.3 - - - 5.7 6.2 2.5 10.7 2.8 5.7 - 2.9 2.1 - 7.8 2.7 7.4 - - 3.9 - 2.1 3.1 Prior Preeclampsia % 66.2 32.2 31.5 34.7 33.7 26.4 37.0 16.4 59.5 43.8 43.7 24.9 53.9 44.7 50.5 58.4 26.2 63.2 65.1 43.8 50.0 24.4 63.6 55.2 24.4 86.3 26.3 40.5 Missing Data Missing Data 500 N 310 641 3,549 269 350 575 158 704 174 565 702 409 189 520 - 105 1,671 156 29 359 270 603 16 144 603 93 611 14,275 Women with Non 44.2 15.3 6.2 9.7 4.3 25.2 15.8 7.1 - 23.5 14.7 11.2 50.3 9.6 13.4 11.4 7.8 55.8 - 23.4 16.7 17.9 - 38.9 19.4 18.3 10.3 13.7 Yes % Prior Gestational Diabetes % 67.5 38.0 32.4 36.3 34.2 31.0 39.3 16.5 59.6 49.1 43.5 26.7 62.4 45.1 Missing Data 52.1 58.4 28.2 65.4 66.4 43.9 51.5 30.4 61.4 59.3 30.3 88.2 28.5 42.4 Women with Non Missing Data N 277 560 3,473 254 344 516 142 702 173 479 708 392 122 512 459 105 1,605 117 26 357 253 526 31 107 519 79 575 13,413 - 8.2 37.5 3.0 4.1 4.3 - 16.7 - 6.7 - 9.8 15.4 7.4 23.0 Yes 5.9 11.4 4.0 41.0 - 22.7 11.1 5.7 67.7 18.7 6.0 - 5.0 8.1 % Prior Cervical Incompetence % 70.2 38.2 34.0 36.5 34.7 36.9 40.5 20.3 60.0 50.6 46.1 29.8 60.3 Missing Data 52.4 59.7 29.8 67.1 66.0 49.6 53.5 30.8 64.4 60.5 32.0 88.6 28.2 44.1 47.4 Women with Non - Missing Data N 204 556 3,339 252 337 439 133 655 169 455 628 363 139 471 452 94 1,550 87 27 296 229 521 - 96 495 76 581 12,654 Yes 15.2 2.3 - - - - - - - 5.1 4.6 - 32.4 - 4.2 - - 20.7 - 6.8 - 4.6 - - - - 6.0 2.6 % Prior Placenta Abnormalities % 70.9 38.9 33.6 36.2 34.9 37.0 40.5 20.0 59.8 51.4 46.3 29.6 63.3 47.0 52.7 59.7 29.8 66.8 67.2 51.0 53.7 32.5 62.6 61.0 32.0 88.6 29.3 44.3 Missing Data 478 Women with Non N 186 547 3,372 255 335 437 133 658 171 443 622 365 115 Missing Data 446 94 1,550 91 24 281 227 499 23 91 495 76 562 12,576 - Yes % 7.0 - 1.2 4.7 - - - - - 2.5 3.7 - 18.3 - 2.9 - - 24.2 - - - - 56.5 - - - - 1.9 Prior Congenital Abnormalities of the Fetus 52.8 70.0 38.6 33.2 36.4 34.5 35.8 40.4 20.0 60.2 51.3 46.0 29.5 61.5 46.8 Missing Data % 59.6 29.9 67.1 67.2 50.9 53.5 31.9 64.0 60.9 31.1 88.6 29.8 44.0 Women with Non -Missing Data N 210 551 3,402 253 340 453 134 659 168 444 630 366 129 482 443 95 1,547 87 24 282 229 507 13 92 507 76 554 12,677 21.8 Yes % 17.6 - 2.1 - - 5.3 - - - 2.7 4.9 - 27.1 2.5 - - - - - - - 100.0 - 3.7 - - 2.8 Notes: All measures except for prior pregnancy are among women with a prior pregnancy. Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. Not in universe includes women who did not have a prior pregnanc y. A dash ( -) indicates a censored cell due to small sample size (N<11). 238 TECHNICAL APPENDICES

257 TABLE I. 5: PRIOR BIRTH OUTCOMES t p. Total N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Cor Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care Distric Providence Hospital Research Foundation Meridian Health Plan Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Prior Birth (Among Women with a Prior Pregnancy) % 0.8 1.0 1.7 0.8 3.8 0.0 1.4 0.5 2.5 0.1 0.6 2.0 0.1 0.3 1.2 0.5 0.8 1.0 1.2 0.5 0.5 0.0 0.0 Missing Data 0.8 0.3 0.5 0.5 3.3 22.1 26.7 30.3 33.4 25.5 28.6 24.9 22.9 26.8 28.5 34.1 28.9 33.5 - 35.8 28.4 Not in Universe % 22.0 24.6 26.3 37.5 41.1 29.5 41.1 27.7 42.0 21.1 33.7 32.0 2,031 1,267 2,040 627 613 1,305 1,756 565 2,521 1,254 178 823 842 915 454 634 948 719 1,025 31,544 473 904 404 920 677 583 6,048 1,018 N -Missing Data Women with Non 89.9 47.6 Yes % 88.5 87.4 88.5 84.2 70.0 87.2 69.1 86.4 78.4 84.0 74.5 90.4 90.9 89.7 90.8 88.3 85.4 89.2 83.1 91.3 89.9 85.5 85.4 85.7 86.1 87.4 Women with a Prior Birth Prior Birth Outcomes Among - Inter - Pregnancy Interval with Current Pregnancy Since Last Birth 20.6 11.8 15.0 20.3 5.7 6.5 20.3 22.1 12.2 22.7 15.7 10.2 3.2 17.6 9.9 24.0 33.1 23.0 % Missing Data 17.7 10.8 47.4 11.4 11.5 14.4 8.3 6.7 19.8 31.5 37.1 34.2 29.3 33.6 51.0 33.8 54.9 36.9 38.5 56.8 47.4 30.1 29.1 31.5 % Not in Universe 37.7 45.4 52.5 40.5 37.7 43.5 38.4 34.4 28.7 28.6 35.7 37.0 40.4 58.0 534 1,196 N -Missing Data Women with Non 760 19,951 705 - 690 457 290 682 682 553 96 777 1,750 381 1,093 1,075 506 438 833 868 191 597 223 315 403 3,855 < 18 months 23.6 24.7 35.2 21.8 17.1 33.3 24.7 17.6 33.5 23.0 18.4 30.8 27.1 31.6 32.1 24.4 19.5 37.6 25.0 36.7 22.4 26.7 27.9 29.5 32.6 - 24.8 28.1 % 71.9 75.2 - 67.4 70.5 72.1 73.3 77.6 63.3 75.0 62.4 80.5 67.9 68.4 72.9 69.2 81.6 77.0 66.5 82.4 75.3 66.7 82.9 78.2 64.8 75.3 76.4 % >= 18 months 75.6 - Prior Preterm Birth (=>20 Weeks - = < 37 Weeks) 1.3 0.0 0.5 0.6 0.2 1.1 0.1 1.4 0.1 0.3 0.2 0.0 0.5 8.0 1.2 0.4 2.0 0.8 0.7 0.4 0.0 0.0 1.7 0.1 18.5 6.7 1.4 Missing Data % 0.2 39.7 45.4 52.6 40.5 38.5 43.5 38.4 34.6 30.1 38.6 37.0 37.0 41.3 37.8 34.5 29.3 40.3 51.0 33.8 55.2 37.9 60.2 38.5 61.2 48.0 36.3 36.8 31.6 % Not in Universe ---------------------------­ 1,794 5,351 26,346 771 211 851 539 389 788 752 744 146 1,084 2,140 491 1,389 1,161 557 565 1,509 1,062 369 780 272 800 470 486 875 N -Missing Data Women with Non - -- - -- ---- ---- 12.7 15.1 28.1 15.1 21.4 13.2 25.3 22.6 % Yes 21.1 17.3 26.1 36.5 36.2 24.2 40.1 18.4 29.7 32.9 16.8 15.4 17.9 28.9 14.8 38.2 20.0 23.7 24.9 17.1 ---------------------------­ Prior Low Birthweight Infant (< 2,500 Grams) ------ --------------------- 10.0 11.6 12.6 13.7 23.2 4.9 27.9 54.1 2.8 11.2 9.5 46.5 27.6 29.5 9.9 6.2 8.7 8.1 51.9 3.5 15.9 6.0 10.6 19.3 0.2 11.8 8.3 % Missing Data 53.5 38.7 45.3 51.5 40.5 38.5 43.5 38.4 34.5 29.8 36.5 36.4 36.3 35.6 37.4 34.1 29.3 40.3 51.0 33.8 28.3 37.9 59.6 38.5 56.6 47.3 36.3 34.3 31.6 % Not in Universe ---------------------------­ Women with Non -Missing Data N 21,812 660 185 782 303 16 752 628 652 24 953 1,783 153 899 650 479 508 1,249 933 168 1,580 762 5,340 316 404 724 172 737 - -- - -- ---- ---- 16.5 6.4 19.8 14.0 12.6 - 13.6 12.9 12.8 35.1 8.2 20.2 - 10.0 8.8 - 16.4 11.5 24.2 100.0 - 23.0 16.2 11.4 11.4 % 17.2 16.1 1.1 Yes ---- ---- -- - -- - Notes: All measures except for prior birth are among women with a prior birth. Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are ---- -- - ---- -- - a missing form from which a measure is drawn; item nonresponse; a response of don’t know, reported based on the share of Strong Start participants with PLPE data. Data may be missing due to . whom a measure does not apply, and is defined separately for each measure unsure, not known, prefer not to answer; or an outlier value (interpregnancy interval). Not in universe includes women for A dash ( -) indicates a censored cell due to small sample size (N<11). TECHNICAL APPENDICES 239

258 TABLE I. 6: PRE- PREGNANCY MEDI CAL CONDITIONS Total N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health althInsight of Nevada Providence Health Health Consortium Access Community Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association He American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Pregnancy Intention 7.6 4.8 6.3 1.0 11.4 12.9 19.1 25.8 1.8 % Missing Data 1.3 0.9 19.2 2.1 3.2 17.2 3.9 3.3 23.7 22.8 6.7 1.7 1.3 3.6 6.9 4.5 49.2 21.6 10.8 1,368 664 1,263 1,138 1,002 186 1,357 3,305 821 2,124 1,763 781 768 3,037 1,556 786 1,197 659 1,292 1,089 823 6,799 1,047 2,582 N -Missing Data Women with Non 371 39,878 1,261 839 24.1 31.8 23.7 20.3 41.2 27.0 24.9 42.4 26.6 13.8 24.7 12.8 38.0 29.4 25.1 18.3 27.4 35.5 18.3 36.7 29.3 17.5 12.9 22.0 29.4 Trying to Become Pregnant 31.3 23.0 % 39.3 Not Trying to Become Pregnant, 65.7 70.4 63.0 57.8 69.9 52.4 64.8 70.6 80.1 69.8 57.9 % 55.3 65.4 47.2 64.6 57.6 65.0 68.7 41.9 61.6 63.8 42.9 64.8 77.0 61.4 59.2 48.5 59.0 Not Using Contraception Not Trying to Become Pregnant, 4.1 6.8 2.2 4.6 8.1 3.8 5.1 2.4 % 3.2 5.3 3.3 4.1 1.0 - 4.3 - - 1.4 - - - - 3.8 3.7 11.3 3.5 2.8 - Contraception Sometimes Using Not Trying to Become Pregnant, 7.2 - 7.6 5.1 10.1 10.4 6.2 8.8 10.2 8.7 7.8 9.9 16.8 10.4 6.4 8.1 11.4 8.8 6.4 8.9 6.4 9.1 7.4 6.8 7.4 8.1 % 7.5 8.6 Using Contraception - Pregnancy Diabetes Pre - 0.5 24.8 14.6 52.8 4.7 9.3 4.1 3.8 41.0 34.0 64.1 9.3 17.0 34.9 12.6 0.3 9.5 1.4 98.5 1.2 4.3 50.5 % 17.2 Missing Data 0.1 10.7 33.1 9.1 99.3 - 1,262 1,048 939 157 1,477 3,100 307 1,694 1,054 758 911 2,813 1,533 402 1,074 529 1,298 1,117 632 8,399 1,261 2,623 -Missing Data Women with Non N 37,032 12 361 1,371 890 - Yes 0.6 1.9 - 3.2 38.2 - - 2.0 4.6 - 7.1 2.1 3.0 2.0 1.4 2.2 - 14.8 2.6 7.9 - 13.5 2.8 16.3 100.0 3.7 % 4.7 - Pregnancy - Hypertension Pre % 0.5 10.7 0.1 33.1 9.1 0.6 24.2 14.6 52.9 4.4 9.4 4.1 4.2 41.0 31.9 63.6 9.1 16.1 34.4 8.9 9.2 1.2 0.6 0.9 4.5 Missing Data 34.4 13.1 53.4 38,857 1,056 1,369 893 685 1,265 1,052 978 158 1,493 3,108 311 1,748 1,055 755 911 2,810 1,538 401 1,074 533 1,297 1,117 632 8,400 1,261 2,617 N -Missing Data Women with Non 340 4.1 6.1 5.4 7.0 0.8 6.0 3.0 7.4 46.0 - 3.7 8.5 5.7 5.5 17.6 Yes 13.8 3.9 3.5 2.7 12.7 8.9 5.7 13.1 - 14.8 11.2 12.9 6.5 % First Prenatal Visit Mother's BMI at Missing Data % 18.5 94.2 44.7 1.0 19.9 38.6 0.6 1.1 7.9 61.0 21.1 14.4 70.1 32.2 53.8 11.9 2.9 13.5 4.8 56.3 0.7 31.3 2.4 7.9 35.6 3.5 24.2 1.6 Women with Non 36,434 93 404 1,419 722 423 1,272 1,145 989 94 1,403 2,927 255 1,740 826 694 922 2,683 1,531 372 1,249 483 1,274 1,132 609 8,115 1,071 2,587 N -Missing Data Underweight (BMI < 18.5) % 2.4 3.5 4.3 5.6 2.8 4.0 5.0 1.8 4.8 2.5 2.5 3.3 2.3 2.8 2.5 5.1 1.9 3.0 - 2.8 3.2 3.4 3.3 6.2 3.6 - - 3.3 35.5 Normal Weight (=>18.5 BMI <25) % 26.2 32.1 45.5 33.2 35.4 35.1 34.2 33.5 39.2 31.4 29.6 37.2 23.6 31.5 27.2 32.9 33.5 39.3 37.2 30.2 34.5 31.7 32.6 34.5 28.7 31.2 34.9 Overweight (=>25 BMI <30) % 25.4 25.1 25.6 23.8 31.6 24.5 26.1 32.8 25.5 23.7 30.9 25.2 22.8 25.4 23.2 23.9 28.8 25.4 16.0 24.9 29.7 22.6 28.8 22.9 20.1 25.5 21.5 26.0 27.3 Obese (=>30 BMI < 40) % 33.0 29.7 20.6 28.9 24.6 26.4 25.5 27.1 24.7 29.2 30.3 28.1 33.4 29.8 32.9 27.8 27.9 23.7 28.7 33.3 26.2 29.5 28.6 27.6 33.7 30.4 25.8 6.6 12.9 6.4 8.8 16.0 8.6 7.9 10.2 14.3 10.5 17.9 6.3 6.7 8.5 - 13.2 5.6 4.8 9.3 10.0 5.5 8.5 4.0 9.6 12.9 % 10.9 (BMI >= 40) 14.0 8.9 Very Obese Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Notes: Data may be missing due to a missing form from which a measure is drawn; item nonresponse; a response of don’t know, unsure, not known, prefer not to answer; or an outlier value (BMI of mother at a censored cell due to small sample size (N<11). -) indicates . A dash ( easure first prenatal visit). Not in universe includes women for whom a measure does not apply, and is defined separately for each m 240 TECHNICAL APPENDICES

259 TABLE I. 7: PREGNANCY CONDITIO STRONG START NS DEVELOPED DURING ial ty Health Total N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Spec Investment Corp. Oklahoma Health Providence Health Health Consortium Access Community Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Communi Texas Tech University Health Preeclampsia 27.0 13.2 43.6 6.0 36.7 16.6 69.3 34.4 12.8 0.3 22.3 27.0 0.8 % 34.0 10.1 34.2 32.8 7.4 3.5 0.6 19.9 53.0 27.5 18.2 9.6 56.2 23.1 13.7 Missing Data 625 343 36,559 1,166 1,148 896 665 1,185 778 966 159 1,299 2,983 262 1,623 1,007 684 2,384 1,453 373 1,086 513 1,227 1,025 620 8,382 1,097 2,610 N -Missing Data Women with Non 4.9 % 3.8 6.7 1.5 7.6 3.8 3.6 11.9 8.6 - 5.8 7.7 10.2 Yes 2.1 3.4 - 3.1 5.0 10.7 7.0 3.5 12.9 2.3 4.6 13.0 9.9 5.1 7.9 Related Hypertension - Pregnancy - 15.5 5.8 26.9 13.7 56.1 9.0 22.7 32.0 13.6 43.7 34.1 69.0 12.7 26.5 34.0 9.5 32.4 7.3 3.5 17.1 19.7 52.7 27.5 18.2 % Missing Data 0.6 22.5 0.3 34.5 36,569 1,166 345 1,151 747 665 1,186 783 972 159 1,308 2,986 265 1,691 1,006 681 646 2,399 1,463 374 1,086 514 1,229 1,039 619 8,382 1,094 2,613 N -Missing Data Women with Non 4.1 5.6 % Yes 15.8 4.1 7.5 13.9 6.3 11.1 3.5 9.4 17.7 4.5 8.4 8.9 1.3 8.7 3.0 5.1 15.7 10.5 4.7 6.2 2.1 5.5 6.8 16.2 6.9 6.0 Gestational Diabetes Missing Data % 21.2 0.3 34.3 15.1 5.7 27.0 14.1 56.3 9.8 22.1 25.1 13.2 43.5 37.6 69.2 12.6 27.3 41.1 13.0 32.1 4.9 3.5 0.6 19.8 52.1 27.5 17.9 0.7 372 Women with Non -Missing Data N 2,612 1,112 8,382 621 1,043 1,231 513 1,081 1,450 2,416 712 684 1,009 1,601 263 2,987 1,293 142 934 786 1,217 665 896 1,149 350 1,166 36,687 7.9 % 4.3 - 8.8 2.8 2.9 5.0 8.6 10.8 3.5 10.3 4.8 7.4 12.7 6.3 6.3 6.0 5.3 5.7 4.0 5.7 9.9 15.6 6.6 7.3 5.0 8.9 5.3 Yes Cervical Incompetence 20.6 34.9 28.2 12.8 69.8 39.3 43.6 13.3 23.3 22.2 9.0 56.2 13.7 27.0 6.2 15.5 34.2 0.3 20.9 0.6 % Missing Data 20.1 100.0 3.4 62.8 10.9 53.7 27.5 17.0 35,516 1,166 338 748 - 1,236 431 957 157 1,278 2,982 258 1,557 1,008 683 729 2,413 1,463 373 1,086 513 1,224 1,038 622 8,381 1,117 2,613 N -Missing Data Women with Non 1,145 Yes 3.3 1.5 - - - 1.4 - - - 1.4 2.2 - 7.5 % 1.1 - 0.5 1.6 - 4.9 - 2.4 - - - - - 1.3 - Placenta Previa 20.5 % 0.7 0.3 34.5 15.2 5.7 27.2 13.7 56.1 9.0 22.5 15.7 13.7 43.7 39.0 70.0 13.0 28.2 34.4 11.1 61.1 5.2 3.5 17.0 20.0 53.6 27.5 18.9 Missing Data Women with Non -Missing Data N 2,611 1,122 8,381 619 1,042 1,230 512 1,086 374 1,463 2,403 801 680 1,006 1,565 256 2,976 1,278 158 955 1,214 665 748 1,146 339 1,166 36,246 450 - 3.1 - - - - - - 1.1 Yes % 1.1 - 0.2 - 1.6 3.3 - - - 1.0 2.5 - 3.7 5.2 1.0 - 1.1 2.3 - Placental Abruption 20.2 17.0 3.5 7.2 64.9 12.1 34.4 28.1 12.9 69.8 39.3 43.7 13.7 35.2 22.9 9.2 56.3 27.0 6.1 16.3 34.6 0.3 22.3 0.7 % Missing Data 13.7 19.7 27.5 53.8 Women with Non 1,166 337 1,144 748 665 1,188 406 944 158 1,279 2,977 258 1,557 1,006 680 616 2,392 1,460 372 1,086 513 1,225 1,029 618 8,382 1,097 2,611 N -Missing Data 35,914 - - 0.6 - - 1.0 - - 1.2 - 2.8 - 1.0 0.5 - - 1.5 - - - - - - - - - 0.4 0.6 % Yes Congenital Abnormalities of the Fetus 52.6 21.6 17.1 100.0 3.7 57.5 12.6 38.6 27.2 13.2 69.2 37.6 43.8 9.8 20.3 24.4 9.2 13.8 26.6 6.4 14.7 34.7 0.1 22.2 0.8 % Missing Data 56.3 20.5 27.5 35,565 Women with Non -Missing Data N 2,608 1,099 8,399 617 1,048 1,221 516 1,084 372 1,460 2,346 757 711 1,005 1,600 263 2,969 1,296 148 939 492 1,233 - 747 1,123 346 1,166 - - 2.6 1.8 Yes % 0.9 - 1.2 2.3 2.5 2.7 - - - 2.9 3.6 3.2 4.9 - 0.7 - 0.5 1.9 - 6.8 - 2.0 - 5.8 UTI(s) During Last 6 months of Pregnancy 27.5 56.2 24.5 17.0 20.6 6.6 36.7 9.9 61.4 28.9 21.6 70.4 44.5 13.6 25.9 23.7 8.7 56.3 13.7 26.9 10.3 15.5 19.9 Missing Data % 0.5 21.2 0.3 34.4 35.5 35,825 1,166 320 1,082 748 547 1,195 733 968 93 1,265 2,679 253 1,655 991 681 704 2,366 1,468 372 1,086 514 1,171 1,038 620 8,382 1,112 2,616 N -Missing Data Women with Non Yes 9.1 4.1 20.7 3.5 % 20.3 10.5 5.1 13.9 23.9 6.8 28.4 3.0 4.3 16.5 19.7 26.8 21.0 12.2 25.0 4.7 7.7 10.0 37.6 43.4 8.2 14.4 12.2 13.2 Notes: This table is among all women, but we note that 23 percent of women are reported to have left Strong Start prior to delivery. Women with multiple gestations (N=607) have been excluded from these ata may be missing due to a missing form from which a measure is drawn; item results. Rates of missing data are reported based on the share of Strong Start participants with PLPE data. D nonresponse; or a response of don’t know, unsure, not known, prefer not to answer . A dash ( -) indicates a censored cell due to small sample size (N<11). TECHNICAL APPENDICES 241

260 TABLE I. 8: TREATMENTS DURING PREGNANCY t Corp. Total N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care Distric Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Vaginal Progesterone 91.0 37.6 25.1 54.7 22.9 % 58.9 11.1 39.7 24.7 8.6 52.3 67.4 75.8 48.6 27.3 42.3 Missing Data 6.7 54.4 8.2 48.5 25.0 25.8 68.1 44.4 33.5 38.2 5.7 21.1 584 29,743 894 233 1,064 676 355 1,175 528 1,002 139 1,293 1,756 207 837 852 720 715 1,869 1,429 350 942 439 117 970 7,930 640 2,027 N -Missing Data Women with Non - Yes 1.7 - 0.2 - - - - - - 1.9 0.8 - 6.7 - - % 0.9 - - - - - - - - - 0.8 - 17P (Progesterone Injections, Among Women with a Prior Preterm Birth) Missing Data 3.4 12.0 0.7 5.6 7.8 3.6 3.7 1.3 47.0 1.8 3.7 2.9 1.4 % 10.8 18.1 6.2 4.6 7.5 1.8 6.6 1.8 11.3 6.3 5.2 7.1 3.0 5.4 5.6 92.1 93.2 82.8 87.8 87.2 91.5 79.4 84.6 % Not in Universe 88.5 83.6 49.9 88.1 73.0 89.5 83.8 79.0 89.2 88.1 78.0 79.0 88.0 75.3 86.4 78.4 78.3 90.1 91.5 85.8 88 3,919 20 236 138 16 293 62 207 35 129 155 24 137 88 202 85 243 235 26 83 22 178 54 68 656 122 317 N -Missing Data Women with Non 15.9 8.5 24.0 21.3 2.0 22.1 - 29.8 - - - 20.9 28.8 - 45.0 % - - 11.6 16.3 - - - 24.2 - - Yes - - 15.0 Antenatal Steroids 26.9 36.7 54.5 76.0 67.4 25.8 67.6 52.4 9.3 25.3 39.8 11.9 59.0 25.1 37.7 35.4 21.5 38.3 0.1 55.8 99.9 % Missing Data 43.9 25.0 100.0 8.5 54.3 6.7 41.5 238 902 1,064 676 - 1,171 529 1,002 141 1,301 1,555 205 831 851 715 710 1,867 1,417 349 942 438 843 965 583 8,400 624 - N -Missing Data Women with Non 28,321 - 4.2 5.2 - 10.9 - - 20.6 1.7 1.5 - - 1.5 8.4 3.5 4.9 5.7 - - - 4.0 - 4.1 0.3 4.0 - % Yes 3.2 2.6 Tocolytics 91.7 25.1 8.4 54.3 6.6 41.9 27.4 54.8 75.4 67.7 52.4 9.0 25.3 40.2 12.5 59.0 25.1 37.6 100.0 22.1 38.9 0.3 56.0 99.9 % Missing Data 25.6 67.8 43.8 38.5 27,515 905 235 1,066 675 - 1,172 529 1,003 140 1,291 1,545 210 828 850 717 710 1,854 1,407 349 942 439 108 958 577 8,381 621 3 N -Missing Data Women with Non -----­ --------------------- % - 2.3 0.2 - - 13.9 - - - 1.7 2.0 3.0 5.3 - - - - - 10.7 - - 1.8 - - 2.4 - 2.8 1.2 Yes ---- --- - -- -- -- Notes: This table is among all women, but we note that 23 percent of women are reported to have left Strong Start prior to delivery. Women with multiple gestations (N=607) have been excluded from these -- -- ---- - -- --- results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE dat ssing due to a missing form from which a measure is a. Data may be mi who whom a measure does not apply, and is defined separately for drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. Not in universe includes women indicates each measure. A dash ( -) a censored cell due to small sample size (N<11). 242 TECHNICAL APPENDICES

261 TABLE I. 9: PRENATAL CARE of Total N or % University Birmingham University of Birth Centers Foundation Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services ersity of Puerto Rico Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care District Providence Hospital Research Foundation Meridian Health Plan Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady University of Tennessee Healthy Start Coalitions Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group Univ Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Routine Prenatal Care Provider 45.8 0.9 20.3 9.1 59.8 7.0 0.2 43.6 8.6 1.8 Missing Data % 16.7 0.4 63.3 6.8 21.6 73.0 33.9 8.1 0.5 6.0 0.9 4.6 19.2 2.4 47.9 15.3 14.2 1.9 N Women with Non -Missing Data 2,624 1,290 8,371 625 1,130 1,293 560 1,144 342 1,495 1,751 933 773 968 2,137 313 3,188 1,394 65 1,069 1,089 1,268 657 728 1,399 380 1,363 38,349 43.3 30.9 30.5 53.8 100.0 74.7 1.1 50.4 99.9 29.2 100.0 35.2 52.7 94.4 96.3 48.4 49.9 Obstetrician % 62.7 2.2 4.9 65.8 15.8 88.4 - 2.2 16.4 70.0 60.1 5.4 Licensed Professional Midwife % - - 19.6 - 1.3 - - - - - 0.7 - - - - - 1.7 - - - - - - - - 7.1 20.4 Nurse Practitioner % - 88.4 - 20.6 - 10.0 18.8 16.7 41.5 11.2 7.4 3.0 - - 1.4 31.9 0.4 - - - 23.1 - - - 26.7 22.1 28.6 8.9 Certified Nurse 35.2 % 25.0 - 73.8 12.2 64.9 1.6 81.3 79.6 40.6 16.9 26.4 46.2 34.4 3.5 1.5 12.8 61.4 - - - 1.8 - 25.3 - 19.1 38.7 19.7 Midwife/Certified Midwife 1.7 - - - - - - 24.3 - - - 1.2 - - - - - - - - - - - 17.6 - 1.6 - - % Family Medicine Physician - 5.4 Other Provider % 12.3 9.2 0.1 - - - - - - 1.8 5.3 - 16.7 - 2.6 - - - 70.8 - - 98.8 - - - - Routine Prenatal Care (Individual Visits) 45.8 0.0 0.0 0.0 0.0 1.0 0.7 11.5 1.2 1.8 2.9 0.5 % 0.1 0.0 0.0 0.0 0.0 2.6 0.2 1.9 Missing Data 5.6 0.1 1.9 7.0 0.0 0.0 1.0 0.0 43,878 1,605 711 1,433 901 689 1,280 1,157 1,069 234 1,747 3,377 756 2,549 1,770 788 950 3,102 1,608 461 1,258 696 1,305 1,143 927 8,400 1,333 2,629 N -Missing Data Women with Non - 98.0 82.0 - 99.1 98.4 93.2 45.7 90.2 96.3 36.1 59.4 88.7 99.7 86.2 98.4 65.7 99.3 80.9 99.2 98.6 71.8 99.8 83.3 99.6 % Received Individual Visits 89.5 85.6 88.1 Average number of Individual 7.7 - 8.2 3.2 - 11.1 5.7 11.2 7.6 10.3 7.2 6.8 9.3 10.7 10.5 8.2 7.4 8.8 5.2 5.9 4.5 10.1 6.1 4.7 9.3 4.4 8.7 Mean 8.3 Prenatal Visits Routine Prenatal Care (Group Visits) % 0.1 1.9 7.0 0.0 1.0 0.0 45.8 0.0 0.0 0.0 0.0 1.0 0.7 11.5 1.2 1.8 2.9 0.5 0.1 0.0 0.0 0.0 0.0 2.6 0.2 1.9 Missing Data 5.6 0.0 N 1,605 711 1,433 901 689 1,280 1,157 1,069 234 1,747 3,377 756 2,549 1,770 -Missing Data 788 Women with Non 950 3,102 1,608 461 1,258 696 1,305 1,143 927 8,400 1,333 2,629 43,878 1.4 19.3 - 9.6 83.4 83.5 Received Group Visits % - - 5.0 - - 3.1 16.8 0.7 74.2 7.7 - - - 83.1 95.9 81.3 - 97.7 73.1 1.6 95.3 2.6 Average Number of Group 4.5 3.5 7.0 5.9 5.5 - 5.5 7.0 5.5 - - - 4.5 6.0 6.0 4.4 6.6 - - 11.8 - - 7.5 7.4 5.3 - 4.8 5.7 Mean Prenatal Visits Care Coordinator Encounters Missing Data 35.2 54.7 1.7 17.2 100.0 0.2 0.5 5.8 42.3 10.8 3.2 71.0 8.8 40.6 0.0 0.1 3.9 3.0 53.2 1.8 25.2 0.0 10.1 34.6 0.5 26.1 0.2 % 12.4 1,042 331 1,409 746 - 1,277 1,152 1,012 139 1,587 3,311 248 2,339 1,062 788 949 2,982 1,559 398 1,235 526 1,305 1,105 618 8,367 1,043 2,625 N -Missing Data Women with Non 39,155 Received Care 52.0 76.0 95.1 100.0 100.0 99.9 97.8 16.6 86.8 20.7 100.0 70.3 11.0 99.5 50.0 100.0 % 86.0 31.8 20.8 75.9 6.4 - 99.6 96.2 96.0 91.4 91.9 96.1 Encounters Coordinator Number of Care Average Mean 2.0 3.2 2.1 1.1 - 1.7 4.0 3.6 4.0 3.3 4.9 5.9 2.8 2.8 10.3 6.8 3.7 6.0 1.7 2.8 1.6 7.3 1.4 1.3 3.1 1.8 5.2 4.0 Coordinator Encounters Mental Health Encounters 18.5 36.7 55.3 2.9 17.2 Missing Data % 0.4 37.7 5.1 35.7 16.9 1.5 26.7 1.8 53.2 10.7 16.3 2.1 16.0 44.9 13.1 74.9 5.2 11.8 44.4 98.9 3.0 1.8 100.0 12 134 1,569 3,240 214 2,231 985 662 930 2,595 1,436 398 1,235 515 1,286 1,021 608 7,983 880 2,619 N -Missing Data Women with Non - 1,257 36,416 1,019 326 1,392 746 1,123 Received Mental 8.3 5.5 0.2 3.3 7.8 - - 3.7 - 9.1 10.5 - 16.3 % 1.3 8.4 3.9 46.3 - - 4.8 9.5 - - - - 9.3 5.4 5.9 Health Encounters Average Number of Mental 2.3 2.7 - Mean 1.8 1.2 - 2.3 1.1 - - 2.4 - 4.3 3.1 - 3.0 2.3 1.3 1.6 3.2 2.1 - - 1.7 1.6 - - - Health Encounters Doula Encounters 98.6 46.1 11.2 6.2 74.0 14.1 44.6 14.6 2.3 9.7 1.4 10.8 10.6 53.1 35.3 92.6 50.2 0.8 2.0 % 26.7 34.9 37.2 53.7 2.7 17.9 100.0 1.8 3.3 Missing Data Women with Non -Missing Data N 2,610 703 618 611 1,096 1,287 515 1,233 399 1,438 2,800 928 673 990 2,203 222 3,206 1,579 130 15 1,120 1,257 - 740 1,394 338 1,011 29,116 TECHNICAL APPENDICES 243

262 of Total N or % University Birmingham University of Birth Centers Foundation Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services ersity of Puerto Rico Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady University of Tennessee Healthy Start Coalitions Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group Univ Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Received Doula Encounters % 0.7 3.6 100.0 3.4 - - - - - - - - - - 8.5 4.3 - 2.7 - - - - - - - - - 4.1 Average Number of Mean 3.2 1.0 - 2.4 4.2 - - - - - - - - - 2.2 - 1.0 2.4 - - - - - - - - - - Encounters Doula Health Education 100.0 52.0 11.6 96.7 1.7 53.5 9.5 40.5 1.8 72.8 88.2 14.6 76.7 42.8 16.4 53.9 75.0 2.0 35.6 100.0 16.9 2.7 55.2 12.0 47.7 Missing Data 0.6 46.3 % 91.9 23,392 1,416 327 1,395 749 - 824 1,135 268 111 1,487 1,956 199 2,192 211 214 933 1,845 1,456 396 1,236 23 106 1,086 454 - 758 2,615 N -Missing Data Women with Non Received Health Education, 23.1 2.0 - 4.2 53.6 - - 7.0 21.7 1.0 5.9 - 51.9 42.7 62.3 32.7 63.7 39.9 47.7 98.5 4.8 81.8 - - - 5.8 2.9 26.1 % Centering Not Average Number of Health 2.5 3.4 - - - Mean 3.4 1.5 - 1.7 1.3 - - 1.2 3.1 1.4 2.1 - 1.1 2.4 4.0 1.8 2.1 3.9 1.7 4.2 1.3 - 2.4 Sessions Education Home Visits 17.0 100.0 36.0 1.5 74.7 53.9 16.5 43.2 75.9 16.0 50.8 73.2 1.8 10.1 8.8 53.5 1.7 96.7 91.9 36.0 53.8 63.3 54.2 0.5 % 38.2 12.0 54.8 2.8 Missing Data 206 Women with Non -Missing Data N 2,616 647 3,082 437 787 106 23 1,237 396 1,466 2,788 933 211 879 2,156 1,942 1,486 111 272 1,141 819 - 748 1,393 330 1,416 27,628 % Received Home Visits 3.7 3.7 58.7 3.2 12.3 1.6 3.6 - - - - 2.0 98.5 - 18.7 - 22.3 12.2 31.2 27.5 - - 7.6 - - - - 8.4 1.5 Average Number of Home Visits 1.3 1.4 1.0 1.2 - - - - 1.7 - - 1.5 1.8 1.2 4.8 - 1.6 - 1.3 1.0 - - - - 1.7 - 1.2 Mean Care, not Centering Self - - 75.6 51.8 % 0.5 53.9 100.0 52.9 14.8 91.9 96.9 1.7 53.7 9.1 33.7 1.8 Missing Data 88.1 19.8 77.5 44.3 16.5 53.1 98.8 1.6 36.1 100.0 16.9 2.7 55.8 100.0 2,616 651 - 445 -Missing Data 1,047 106 22 1,237 394 1,461 2,056 933 Women with Non 192 213 2,057 192 1,903 1,485 113 13 1,139 818 - 749 1,395 323 - 21,560 N -Care, Received Self - 9.5 - - - - - - 1.1 - 44.2 42.3 9.4 14.6 28.6 39.0 - - - - 13.5 - - - 37.4 - - - % Not Centering Average Number of - 3.5 - - - 2.7 - - - - 1.1 - - - - - Mean - - - 2.2 - 3.9 2.3 2.6 4.9 9.2 2.4 - Self -Care Sessions Nutrition Counseling 52.8 2.1 96.6 91.8 10.9 52.0 5.1 45.3 0.6 % Missing Data 55.2 1.5 12.0 27.9 17.2 100.0 35.6 1.8 98.6 53.9 16.6 42.8 76.6 13.7 50.9 75.4 1.8 28.7 8.6 -Missing Data Women with Non 32,213 1,416 327 1,412 746 - 824 1,137 15 111 1,484 1,957 200 2,215 877 194 933 2,213 1,469 402 1,232 24 107 1,095 454 7,983 772 2,614 N Received Nutrition Counseling 23.7 24.2 17.1 63.2 10.7 - 53.6 3.9 - 21.6 25.1 71.5 27.0 74.0 13.5 38.7 - 17.4 16.1 27.9 4.2 - - 84.1 21.1 - 34.3 - % Average Number of Nutrition Mean - 2.4 1.1 1.1 - 1.3 1.4 - 1.0 1.8 2.0 3.4 3.2 2.1 1.1 - 2.1 2.9 3.2 1.2 - - 1.6 1.3 - 1.1 - 2.0 Sessions Counseling Substance Abuse Services 51.7 % 12.0 54.9 2.4 17.1 75.5 35.9 2.2 99.1 55.2 17.1 44.0 77.3 16.8 28.1 75.0 1.8 29.1 9.2 53.8 1.8 96.9 91.9 17.8 52.6 5.1 39.5 1.9 Missing Data Women with Non 32,133 -Missing Data N 2,581 854 7,983 448 1,010 106 22 1,235 393 1,460 2,198 933 197 864 2,136 194 1,914 1,475 108 - 1,132 820 169 747 1,399 329 1,416 Received Substance 3.4 - - - % - 5.4 - - - - - - 8.1 5.1 2.1 - 6.1 10.1 5.0 - 2.4 7.1 - - - 8.2 24.3 2.3 Services Abuse Average Number of Substance - - - - 2.4 - Mean - 2.8 - - - - - - 2.0 3.4 2.5 - 13.3 2.3 1.4 - 2.6 1.5 - - - 2.1 Abuse Services Referrals for High Risk Medical Services 6.2 19.6 % 0.6 44.3 5.1 32.9 13.3 8.4 26.5 14.8 53.6 8.8 11.0 2.0 Missing Data 44.3 16.7 73.8 6.0 15.5 57.7 98.4 8.2 2.2 100.0 17.4 2.5 55.2 49.8 - 1,252 1,063 17 102 1,503 3,213 224 2,138 996 739 931 2,761 1,466 395 1,072 517 1,196 1,066 634 7,983 786 2,613 N -Missing Data Women with Non 35,942 807 327 1,397 744 Received Referrals for High Risk 15.0 19.7 4.0 % 47.6 26.3 - 41.5 43.2 8.5 - 21.7 8.4 28.4 47.4 17.7 44.8 23.2 8.2 12.1 11.1 8.6 - - 11.1 32.0 - 27.0 37.4 Medical Services Average Number of Referrals for 1.6 4.9 2.0 1.1 1.5 - Mean 2.5 2.5 - 1.9 1.4 1.1 - 1.1 1.6 2.0 1.8 1.2 1.3 1.8 1.5 1.5 1.5 1.1 - - 1.1 1.4 High Risk Medical Services 244 TECHNICAL APPENDICES

263 of Total N or % University Birmingham University of Birth Centers Foundation Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services ersity of Puerto Rico Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health Providence Health Health Consortium Access Community Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady University of Tennessee Healthy Start Coalitions Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group Univ Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Types of Referrals for High Risk Medical Services (Among Women with Services) - 99.2 48.9 - 23.8 10.6 80.9 - - 92.1 59.3 56.5 75.4 63.0 86.7 82.5 55.6 22.0 96.9 52.0 - 36.7 74.7 97.6 - 82.4 5.4 76.5 % Maternal Fetal Specialist - - - - - - % Pulmonologist - - - 4.4 - - 4.5 - - - - - - - - - - - - - - 1.4 --------------------- ------- - 5.8 4.8 - - - 23.6 - - - - - - 4.2 - - 14.4 5.1 - 7.3 - - - - 14.3 - - Endocrinologist % - - - --- --- - ---- 10.3 Cardiologist 3.6 5.5 - - 4.6 14.3 - - - 21.7 6.8 - 8.2 % - - 10.7 - - - - 5.9 - 18.5 2.9 - 5.9 6.8 - - --- --- - ---- 21.6 25.4 - 21.9 74.7 71.2 - 39.8 43.8 4.8 - 17.5 95.4 % Other 22.2 - 40.7 54.6 - - 76.7 - 22.6 88.1 - 24.2 30.6 3.9 - ------- --------------------- Notes: This table is among all women, but we note that 23 percent of women are reported to have left Strong Start prior to delivery. Women with multiple gestations (N=607) have been excluded from these ------- --------------------- based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item results. Rates of missing data are reported a censored cell due to small nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. All reported means are among women with a visit or encounter . A dash ( -) indicates sample size (N<11). ON TABLE I. 10: DELIVERY INFORMATI th m Total N or % University Birmingha University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Heal Providence Health Health Consortium Access Community Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady University of Tennessee Healthy Start Coalitions Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health -sections) Induction of Labor (Among Women Who Delivered, Excluding Planned C - 19.5 19.4 26.2 1.6 20.4 78.8 3.2 28.9 1.9 17.8 11.4 36.8 60.0 52.1 48.0 1.9 6.4 7.7 6.6 48.1 7.2 20.9 55.6 18.7 18.9 0.9 27.8 6.2 % Missing Data Not in Universe 33.0 26.5 28.0 26.0 18.8 29.0 19.8 15.7 15.3 16.7 43.6 33.4 18.3 13.0 24.4 15.1 21.0 26.4 26.1 16.5 34.0 15.5 21.2 22.1 32.2 40.0 15.8 25.4 % 24,650 1,042 247 948 518 0 1,040 429 877 135 1,107 1,444 213 602 697 629 572 1,509 1,234 312 969 417 201 768 520 5,977 645 1,598 N -Missing Data Women with Non 34.4 22.8 58.2 69.2 36.6 34.0 20.7 27.9 24.3 % Yes 48.4 32.1 24.4 43.7 33.8 41.1 - 41.7 27.7 27.5 30.4 51.9 19.7 35.2 21.3 34.0 37.8 30.9 53.9 Induction of Labor with Pitocin (Among Women Who Were Induced) 0.2 0.0 0.0 3.9 0.7 3.7 5.0 4.5 14.4 2.4 3.1 7.4 0.2 0.8 0.4 46.9 4.1 2.0 5.4 7.7 2.2 0.1 7.7 2.5 % Missing Data 3.5 4.5 2.9 0.0 76.4 80.4 84.0 82.6 77.7 Not in Universe 100.0 66.1 89.6 77.1 80.1 65.9 90.5 79.7 94.3 85.8 69.8 81.4 73.8 73.6 45.8 55.2 70.3 89.3 70.1 79.4 85.2 81.7 85.2 % ·--------------------------- Women with Non 7,188 -Missing Data N 324 150 1,237 174 272 68 195 512 62 418 788 175 180 199 84 50 173 518 39 238 75 434 0 211 320 106 186 -- ---- --- -- - 84.4 86.3 99.5 - 100.0 85.3 92.9 89.7 96.7 93.1 70.4 Yes % 95.1 44.0 55.4 96.6 91.9 92.6 96.4 93.9 98.4 93.3 90.9 52.0 89.4 91.0 89.3 92.0 97.2 -- - -- --- ·--- Delivery (Among Women with a Delivery) Place of ·--------------------------- 0.5 1.9 0.0 2.3 2.1 0.6 13.3 7.7 14.6 9.0 Missing Data % 0.6 8.0 4.6 15.9 8.4 1.3 10.5 4.4 46.4 1.4 2.7 1.5 0.4 41.6 8.1 47.3 3.2 7.6 27.9 8.3 18.3 15.4 16.1 15.8 36.8 23.2 6.0 21.2 6.1 Not in Universe % 22.4 18.1 26.3 20.0 11.5 21.8 15.4 9.9 11.0 6.8 34.8 29.7 4.6 5.4 17.4 11.6 19.2 ·--------------------------- 362 1,078 521 1,004 985 606 5,804 1,043 2,027 N -Missing Data Women with Non 32,692 1,119 395 1,093 830 543 1,173 811 979 165 1,369 2,759 351 1,910 947 749 654 1,939 1,476 - -- -- --- ---- 99.9 100.0 99.8 90.6 99.6 100.0 99.5 99.5 99.4 97.6 99.4 Hospital % 99.9 97.1 49.5 100.0 99.9 99.5 99.8 99.4 99.7 99.5 99.3 100.0 99.6 99.4 99.8 98.6 99.1 -- - -- ·--- --- 0.5 - - - - - - - - - - - - - 45.5 - - % Birth center - 8.2 - - - - - - - - - ·--------------------------­ ------- -------------------- TECHNICAL APPENDICES 245

264 th m Total N or % University Birmingha University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Heal Providence Health Health Consortium Access Community Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health - % Home birth 4.5 - - - - - - - - - - - - - - - - - - - - - - - - 0.9 - 0.5 - - - - - - - - - - - - - - - - - - - - - - - - 0.3 Other % - 2.7 (Among Women with a Delivery) Delivery Method 7.7 12.3 49.1 4.6 3.8 14.9 4.5 2.6 2.7 2.5 2.7 0.6 16.2 5.1 6.1 Missing Data % 0.9 0.6 16.2 10.2 4.5 11.0 4.5 46.8 2.4 2.9 2.1 0.5 10.3 15.8 19.2 Not in Universe % 22.4 18.1 26.3 20.0 11.5 21.8 15.4 9.9 11.0 6.8 34.8 29.7 4.6 5.4 17.4 11.6 16.1 15.4 18.3 8.3 27.9 6.1 21.2 6.0 23.2 36.8 6,147 Women with Non -Missing Data N 2,019 1,010 603 963 962 518 1,077 359 1,460 1,933 648 748 1,553 1,804 336 2,712 1,438 161 937 805 1,168 526 823 1,092 343 1,272 33,417 87.6 75.2 69.7 67.9 52.5 69.4 72.3 72.7 80.5 68.9 71.2 74.7 69.0 65.0 67.3 63.8 81.0 65.1 66.0 70.2 77.4 73.6 64.7 67.0 70.5 71.3 69.1 % Vaginal Only 73.1 29.8 34.0 34.9 19.0 36.2 32.7 35.0 31.0 25.3 28.8 31.1 19.5 27.3 27.7 30.6 47.5 32.1 30.3 24.8 26.9 12.4 28.7 30.9 29.5 % -Section Only C 33.0 35.3 26.4 22.6 1 Delivery Method (Among Low Risk Women with a Delivery) 8.7 0.4 7.2 0.3 % Missing Data 3.4 2.9 7.6 9.5 1.2 5.1 1.9 46.1 0.9 1.6 0.8 0.1 3.0 4.5 24.0 2.1 2.5 7.5 1.3 1.0 0.6 0.9 0.7 0.1 70.5 66.4 69.9 73.6 70.9 69.5 69.6 79.6 74.9 75.9 71.6 70.6 60.7 72.2 70.1 76.9 74.7 72.0 70.4 33.6 71.6 52.5 73.4 47.6 62.8 74.2 78.4 % Not in Universe 70.8 11,637 495 151 377 256 204 381 224 40 461 933 131 598 480 181 232 818 462 173 333 298 331 537 280 2,133 311 561 N -Missing Data Women with Non 256 Vaginal Only 71.3 76.5 83.8 71.1 67.6 69.2 74.2 76.0 69.9 68.2 71.3 83.6 70.7 73.1 70.9 75.6 79.2 76.8 72.5 88.3 76.3 81.1 69.6 65.2 77.2 % 75.9 74.8 77.6 28.9 25.8 24.1 C -Section Only % 28.7 23.5 16.2 22.4 32.4 30.8 25.2 24.0 30.1 31.8 28.7 16.4 29.3 26.9 29.1 24.4 20.8 23.2 27.5 11.7 23.7 18.9 30.4 34.8 22.8 - - Scheduled C - Section (Among Women with a C -Section) Missing Data % 1.1 8.4 4.5 4.6 10.3 10.4 2.8 1.4 47.8 3.2 1.1 0.5 7.4 19.8 7.7 0.6 8.4 23.4 0.5 8.5 1.4 4.1 3.2 9.9 16.3 13.3 17.8 1.6 80.7 41.6 69.2 78.3 87.1 65.6 70.6 74.7 76.3 78.7 74.9 76.3 82.5 80.9 74.8 76.6 56.6 75.6 83.2 80.2 78.0 % Not in Universe 76.2 73.9 90.8 79.3 67.1 73.9 79.5 -Missing Data N 595 251 394 153 277 Women with Non 6,510 - 67 342 315 - 316 122 173 47 389 387 63 309 207 258 118 639 445 90 225 124 204 43.0 29.7 41.9 65.2 58.3 47.6 42.9 50.4 40.4 50.9 58.2 38.3 - Yes 37.7 34.3 - 43.0 32.4 46.6 32.5 40.0 37.3 35.0 47.0 47.2 % 35.7 25.0 46.0 - Section) Women with a Prior C- VBAC (Among Missing Data 0.0 5.6 0.1 1.9 7.0 0.0 1.0 0.0 45.8 0.0 0.0 0.0 0.0 1.0 0.7 11.5 1.2 1.8 2.9 0.5 0.1 0.0 0.0 0.0 0.0 2.6 0.2 1.9 % Not in Universe 84.3 87.4 82.2 81.3 83.5 88.5 83.1 87.4 89.9 76.5 90.7 87.9 81.9 49.1 88.9 92.0 85.6 83.4 88.5 96.2 80.4 85.0 % 87.1 87.4 92.1 75.7 88.1 84.8 186 38 261 352 46 306 163 185 88 376 291 43 140 49 188 118 91 315 198 393 N -Missing Data Women with Non 201 4,929 198 39 218 145 219 82 % Yes 24.7 27.3 19.8 11.9 9.6 22.4 35.0 - 17.2 19.7 35.2 16.8 11.7 8.8 - 23.6 9.6 - 32.3 16.6 23.4 15.9 17.4 9.6 - 30.3 19.3 18.3 Notes: All measures are among women with a delivery. Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer . A dash ( a censored cell due to small sample size (N<11). -) indicates not to answer. Not in universe includes women who whom a measure does not apply, and is defined separately for each measure 1 Low risk is defined as women with nulliparous, singleton, term births. 246 TECHNICAL APPENDICES

265 TABLE I. 11: BIRTH OUTCOMES rict Health ingham Total N or % University Birm University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital Dist Maricopa Special Investment Corp. Oklahoma Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care District Providence Hospital Research Foundation Meridian Health Plan Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Outcomes of Strong Start Pregnancy 28.1 25.5 3.7 5.4 15.1 20.6 14.3 14.3 20.3 7.0 20.3 5.7 19.9 4.4 15.6 38.4 12.6 17.9 Missing Data % 22.5 23.8 21.2 16.9 17.6 18.2 15.8 9.3 56.2 1.2 Women with Non -Missing Data N 2,185 1,095 6,407 745 1,013 1,068 592 1,141 373 1,589 2,229 708 759 1,690 2,179 678 2,929 1,525 192 999 923 1,207 552 861 1,210 450 1,407 36,706 % 95.5 95.0 98.0 90.1 95.2 98.4 97.1 90.0 97.1 98.4 96.1 96.0 96.5 95.6 98.9 97.2 93.6 89.8 93.8 98.4 99.1 98.1 94.9 98.2 98.4 96.3 97.7 92.2 Live Birth - - - 0.5 - 0.9 - 1.8 - 1.0 0.7 - - - - - - 0.3 - 1.2 % Stillbirth - 2.5 - 3.1 - - 1.0 - % 1.1 - 0.2 - - - - - - 1.3 2.2 - - - - - 0.7 - - - - - - - - - - 0.5 Termination - 3.3 8.8 1.6 - - 8.8 1.9 - 3.3 2.8 3.1 3.5 1.0 - 5.5 7.0 4.3 - - - 3.5 - - 3.2 1.3 5.5 % Miscarriage 3.3 Estimated Gestational Age (EGA, Among Women with Live Births) 18.1 10.3 9.7 1.5 1.3 5.2 9.9 16.4 5.2 7.0 8.7 2.6 4.0 2.7 3.0 4.8 3.4 21.2 17.0 7.0 Missing Data 1.4 1.6 48.3 13.7 15.9 0.6 14.2 1.5 % 16.7 19.8 Not in Universe % 23.4 18.6 26.5 20.5 12.0 22.3 16.4 10.1 11.0 7.3 35.5 30.2 6.3 5.5 18.2 11.9 16.6 15.9 18.7 9.2 28.2 8.4 21.2 9.0 23.9 37.0 6,127 949 1,976 N -Missing Data Women with Non 601 32,740 1,067 305 1,041 777 522 1,138 786 947 175 1,372 2,674 612 1,846 1,595 728 649 1,700 1,326 346 1,111 461 996 913 Very Preterm (20 =< EGA < 34) 3.9 5.1 1.0 4.2 2.2 5.2 3.0 2.0 - 4.8 4.7 3.5 7.0 3.7 5.7 4.6 1.6 2.1 8.6 3.2 3.9 8.0 2.3 5.7 5.0 6.9 3.6 3.5 % 9.9 15.7 6.7 12.2 9.8 7.8 10.9 7.0 5.4 6.4 10.6 6.1 11.8 7.6 11.2 8.7 5.5 6.5 6.3 8.6 4.9 8.0 3.4 9.5 8.6 % Preterm (34 =< EGA < 37) 7.6 8.1 15.7 Term (37 =< EGA < 42) 85.3 75.1 84.6 77.3 89.8 79.0 82.3 86.8 80.0 90.7 91.6 84.8 82.3 89.1 81.0 87.2 82.5 85.4 91.9 90.7 90.2 85.0 91.3 86.9 93.5 83.8 86.8 % 87.4 1.6 1.7 1.5 3.1 - - - - - 3.9 2.2 - - 1.3 4.2 1.4 1.1 - 1.7 1.1 - - - 1.1 1.5 - 2.0 0.6 % -Term (42+) Post Birth Weight (Among Women with Live Births) 7.1 24.9 0.7 3.0 4.8 3.2 3.7 3.1 15.4 9.1 5.6 52.7 16.4 19.9 0.9 3.9 5.3 2.7 47.5 4.5 3.3 14.8 16.5 2.0 13.0 2.2 % Missing Data 13.4 8.3 19.8 Not in Universe % 23.4 18.6 26.5 20.5 12.0 22.3 16.4 10.1 11.0 7.3 35.5 30.2 6.3 5.5 18.2 11.9 16.6 15.9 18.7 9.2 28.2 8.4 21.2 9.0 23.9 37.0 16.7 32,173 Women with Non -Missing Data N 1,957 965 6,006 595 899 971 494 1,074 353 1,448 1,838 626 731 1,332 1,678 302 2,661 1,335 159 942 789 1,131 510 793 1,080 278 1,226 2.4 1.5 2.0 - 1.5 Very Low Birthweight (<1500g) % 2.0 1.5 0.5 - - 2.5 - - - 2.1 1.8 - 3.8 1.0 1.8 - 0.9 - - 1.6 1.5 4.1 - Low Birthweight 10.7 6.1 7.2 4.3 8.3 6.2 14.1 7.3 7.1 10.8 7.9 4.7 7.9 9.9 5.6 9.6 3.0 % 10.6 7.6 8.2 12.9 9.3 15.6 8.6 14.8 6.1 5.8 11.4 (=>1500g < 2500g) Normal Birthweight 78.4 82.0 77.9 83.5 75.6 83.9 87.5 83.6 86.3 85.9 88.1 84.3 84.8 77.7 87.2 84.4 81.1 89.5 87.6 87.9 80.5 87.9 84.9 85.4 83.6 83.4 % 84.2 83.8 (=>2500 < 4000g) Macrosomic Birthweight 6.4 5.8 % 6.3 4.4 11.1 4.0 5.9 7.1 2.6 6.9 - 6.0 6.7 4.6 4.4 8.0 2.5 6.6 5.9 7.0 - 5.1 8.5 5.6 6.9 4.4 6.3 6.8 (=>4000g) Notes: All measures are among women with a delivery. Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or an outlier value (estimated gestational age and birth a censored cell due to small sample size (N<11). indicates weight). Not in universe includes women who whom a measure does not apply, and is defined separately for each measure . A dash ( -) TECHNICAL APPENDICES 247

266

267 APPENDIX J: PARTICIPANT-LEVEL PROCESS EVALUATION – THIRD TRIMESTER AND BY MODEL POSTPARTUM FINDINGS, TECHNICAL APPENDICES 249

268 FINDINGS FROM THE THIRD TRIMESTER AND PO STPARTUM SURVEYS The information presented in the tables below comes from items collected on the Third Trimester and Postpartum Surveys. We have separated these from the main PLPE findings because of high rates of missing data, limiting the generalizability of thes e results. High rates of missing data from the Third Trimester and Postpartum Surveys may be attributable to women who are reported to have left Strong Start prior to delivery, women who had sporadic prenatal care attendance, and women who were not able to be reached postpartum. Details on the quality of these data and awardee data collection processes are reported in Volume 2. Despite having weaker data quality than the Intake and Exit forms , the Third Trimester and Postpartum Surveys are the only source of certain measures of interest, including satisfaction with care (prenatal and delivery care), breastfeeding initiation, and postpartum e J. 1 We th pregnancy prevention. Tabl erefore report these findings below. through Table J. 3 arize findings from these two forms among Strong Start enrollees with a single gestation for summ whom we have data. Rates of missing data, by measure, are presented as well. Cells representing fewer All subsequent tables are limited to women with a single -). than 11 women are censored using a dash ( gestation (excluding N=607 women with multiple gestations), results for women with a multiple gestation are pr Appendix S esented in . TABLE J. 1: SATISFACTION Group Birth Maternity Data Elements N or % Total Center Care Home Prenatal Care Satisfaction with Prenatal Care 52.0 48.7 64.9 46.4 Missing Data % Women with Non- 4,712 3,648 13,095 21,455 N Missing Data 0.6 0.6 1.0 - % Not at All Satisfied % Slightly Satisfied 1.0 1.3 0.4 1.0 Moderately Satisfied 7.8 4.4 3.3 % 6.2 25.6 % Very Satisfied 35.6 46.1 39.8 70.6 58.1 44.2 52.3 Extremely Satisfied % Satisfaction with Delivery Experience 52.1 48.7 65.2 46.5 % Missing Data 3,615 4,698 N Missing Data Women with Non- 21,427 13,114 % 2.0 3.1 2.3 2.4 Not at All Satisfied Slightly Satisfied % 3.0 4.0 2.9 3.1 12.1 12.8 11.6 Moderately Satisfied % 10.4 Very Satisfied 42.6 46.6 42.1 29.1 % Extremely Satisfied % 55.7 38.7 35.4 40.4 Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data are reported Notes: based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a a censored cell due to small sample size (N<11). -) indicates . A dash ( measure is drawn or item nonresponse 250 TECHNICAL APPENDICES

269 TABLE J. 2: BREASTFEEDING Maternity Group Birth Data Elements Total N or % Care Home Prenatal Care Center Breastfeeding Intention at Third Trimester 42.4 41.1 48.4 38.8 % Missing Data 15,042 Missing Data 25,769 5,351 5,376 N Women with Non- 80.4 % 50.3 40.5 Breastfeed Only 47.5 Formula Feed Only % 4.0 10.1 15.3 11.9 Both Breast and Formula Feed % 10.8 31.9 32.5 27.8 10.1 I Haven't Decided % 4.8 10.5 11.8 Breastfeeding Initiation After Delivery 48.8 Missing Data % 46.6 57.4 46.1 4,694 4,418 13,780 22,892 Women with Non- Missing Data N 76.6 77.3 72.6 Yes % 91.5 No % 7.6 14.9 23.8 18.8 8.5 Prefer Not to Answer 4.0 3.6 % 0.8 Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data are reported Notes: based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a a censored cell due to small sample size (N<11). -) indicates . A dash ( measure is drawn or item nonresponse TABLE J. 3: FAMILY PLANNING Birth Maternity Group N or % Data Elements Total Center Care Home Prenatal Care Received Birth Control Counseling after Delivery 57.8 % 47.2 Missing Data 46.6 49.3 Women with Non- Missing Data N 4,642 4,384 13,636 22,662 82.2 77.0 % Yes 77.5 80.3 14.2 14.0 20.0 % No 15.3 3.6 8.4 3.0 % Unsure 4.4 Reported Doing Something to Keep From Getting Pregnant Postpartum ” “ 46.4 49.2 58.0 47.1 % Missing Data Women with Non- Missing Data N 4,645 4,356 13,701 22,702 84.2 % Yes 75.5 74.0 70.8 No 17.7 13.2 % 19.1 21.5 4.5 11.5 2.6 % Unsure 5.4 Reported Using Birth Control Postpartum (Among All Women Who Report Doing Something to Keep from Getting Pregnant) 38.6 40.2 42.9 41.5 % Missing Data 21.5 21.7 27.4 14.0 % Not in Universe 17,136 10,138 3,086 3,912 N Missing Data Non- Women with Female Sterilization % 3.2 12.6 12.1 10.2 1.4 Male Sterilization % 3.6 0.7 0.7 LARC - Implant % 2.8 11.4 10.9 9.2 TECHNICAL APPENDICES 251

270 Birth Group Maternity Data Elements N or % Total Center Prenatal Care Care Home LARC - IUD % 10.8 11.9 12.3 11.9 Pills 8.6 11.9 13.0 11.8 % 20.2 16.2 5.9 % 16.2 Injection 19.8 17.9 13.9 26.6 % Condoms 5.3 3.1 2.9 12.8 % Breastfeeding Rhythm or Safe Period 0.5 0.2 0.8 2.6 % 2.6 Withdrawal or Pulling Out 1.8 1.7 1.2 % Spermicide % - - - - Other Method 8.1 9.5 10.9 16.7 % 2.7 3.0 3.8 % Method Not Indicated 2.2 Notes: Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a for missing form from which a measure is drawn or item nonresponse. Not in universe includes women whom a measure . A dash ( -) indicates a censored cell due to small sample size does not apply, and is defined separately for each measure (N<11). 252 TECHNICAL APPENDICES

271 APPENDIX K: PARTICIPANT-LEVEL PROCESS EVALUATION – THIRD TRIMESTER AND BY AWARDEE POSTPARTUM FINDINGS, TECHNICAL APPENDICES 253

272 TABLE K. 1: SATISFACTION es tem Total N or % University Birmingham University of Birth Centers Foundation of Harris County Health Sys Data Elements Medical Group Department of South Carolina Albert Einstein Care Authority South Alabama Health Servic Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady University of Tennessee Healthy Start Coalitions Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Health Satisfaction with Prenatal Care % 35.4 91.7 47.4 61.4 55.7 48.6 75.7 35.3 55.1 38.6 67.8 68.6 24.1 35.1 54.8 67.0 29.2 57.3 66.8 48.9 Missing Data 58.2 44.5 60.5 55.8 57.8 80.7 77.4 52.0 Women with Non 364 141 605 398 272 711 484 549 80 759 2,421 282 1,160 1,160 598 298 999 987 382 814 171 671 544 365 4,425 117 1,698 N -Missing Data 21,455 ---------------------------­ Not at All Satisfied - - - - - - - - - - 1.2 - - - - - 0.7 - - - - - - 2.8 - - 3.6 0.6 % ---------------------------­ - - - 1.5 - 2.4 - - 1.0 - - - - - 3.0 2.0 - - - 1.5 - - 0.4 - 0.6 % Slightly Satisfied 1.0 5.2 - ---------------------------­ 3.3 6.0 4.8 1.4 30.2 6.2 7.9 8.1 19.3 12.5 1.3 6.4 3.2 8.0 7.8 6.9 4.0 11.6 5.9 3.3 1.8 4.4 4.1 6.3 4.2 2.2 6.0 5.6 % Moderately Satisfied ---------------------------­ Very Satisfied % 51.5 45.3 24.7 22.7 50.9 35.6 31.0 37.2 31.2 39.9 49.4 18.5 53.2 35.3 48.4 34.4 59.2 25.2 40.0 49.7 53.5 43.9 47.1 26.6 39.2 28.4 29.1 39.8 ---------------------------­ 53.9 37.4 Extremely Satisfied % 41.8 47.9 71.6 75.1 43.2 56.3 63.7 57.6 67.0 51.7 34.7 76.8 38.1 55.5 42.8 61.0 32.7 72.9 42.5 27.3 45.3 47.1 63.1 70.2 31.9 52.3 ---------------------------­ Satisfaction with Delivery Experience ---------------------------- 57.7 47.5 66.7 55.6 48.5 75.8 35.5 55.3 38.4 67.7 68.3 24.1 35.0 54.8 67.0 29.0 57.5 66.8 48.6 58.3 44.7 61.1 55.5 Missing Data % 91.8 80.8 75.5 52.1 35.7 268 708 483 552 80 756 2,429 282 1,161 1,162 598 301 1,001 991 380 170 672 546 315 4,411 116 1,692 N -Missing Data Women with Non 21,427 394 140 606 401 812 ---------------------------­ 3.1 - 1.9 - - 3.0 - - - 2.3 3.8 - - 0.9 1.2 - Not at All Satisfied 2.1 - - 2.7 - 4.5 - 9.5 3.3 - 9.4 2.4 % ---------------------------­ % 3.6 - 2.9 - 2.7 5.2 - 2.6 - 4.2 5.7 - - Slightly Satisfied 1.4 - 3.1 - - 3.1 - 3.5 4.9 10.2 3.1 - 6.6 3.1 1.5 ---------------------------­ 12.1 % 14.2 15.5 10.3 6.3 16.1 13.5 15.9 9.7 7.6 11.4 13.9 8.6 Moderately Satisfied 11.4 10.9 7.4 12.1 6.1 - 23.4 11.2 13.8 6.3 15.7 9.7 8.6 32.7 12.0 ---------------------------­ 25.4 42.1 Very Satisfied % 50.3 44.8 28.2 25.7 55.9 39.4 36.5 46.9 38.7 39.1 48.7 32.2 50.0 37.3 49.1 31.9 61.3 30.8 32.5 47.1 54.5 41.4 57.8 30.7 39.1 57.1 ---------------------------­ 41.3 61.2 21.4 56.4 37.5 49.0 34.9 57.1 28.0 43.0 52.1 39.9 41.2 38.8 23.6 65.7 56.6 36.2 28.8 % Extremely Satisfied 40.4 25.9 29.3 44.7 36.7 33.9 27.6 32.5 23.7 ---------------------------­ Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data are reported based on the share of Notes: Strong Start participants with PLPE data. Data may be ---------------------------- a censored cell due to small sample size (N<11). -) indicates . A dash ( missing due to a missing form from which a measure is drawn or item nonresponse TABLE K. 2: BREASTFEEDING Health Total h Carolina N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of Sout Albert Einstein Care Authority South Alabama y Memorial Hospital Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health Providence Health Health Consortium Access Community Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady University of Tennessee Healthy Start Coalitions Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grad Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University Breastfeeding Intention at Third Trimester 17.3 63.9 50.8 51.6 35.9 33.4 51.4 40.0 60.7 31.3 40.2 26.5 38.7 42.4 54.6 56.0 34.5 43.9 45.6 39.6 74.6 29.2 % Missing Data 41.0 38.2 45.9 48.4 43.2 50.9 730 Women with Non -Missing Data N 1,862 359 5,078 514 690 855 431 925 509 1,105 1,219 462 525 1,145 1,243 308 2,826 874 137 644 570 661 373 557 846 321 25,769 --------------------------­ 39.4 50.3 72.5 36.8 70.8 8.3 61.3 31.8 28.3 20.0 50.6 53.9 30.4 31.9 55.6 Breastfeed Only % 35.1 42.9 82.3 36.8 56.2 43.7 47.6 52.5 50.7 23.3 64.5 57.1 55.2 --- ----­ --- --- --- - 29.9 16.5 17.5 10.8 9.9 24.6 11.9 10.2 13.9 22.5 16.3 Formula Feed Only % 12.9 14.8 3.7 21.2 3.0 15.2 5.1 4.3 5.7 25.7 4.8 11.0 9.7 19.2 25.4 4.9 8.8 --------------------------­ 30.8 26.4 27.8 Both Breast and Formula Feed % 40.6 30.4 9.7 36.8 30.9 29.5 38.3 40.9 22.8 35.3 25.1 25.5 25.5 11.5 40.7 16.6 40.2 13.7 29.2 19.6 47.0 40.4 26.0 31.4 40.5 --------------------------­ APPENDICES TECHNICAL 254 ---------------------------

273 Health Total h Carolina N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Department of Sout Albert Einstein Care Authority South Alabama y Memorial Hospital Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care District Providence Hospital Research Foundation Meridian Health Plan Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grad Johns Hopkins University Medical Sciences Campus St. John Community Health Texas Tech University 3.0 14.1 7.8 25.6 7.9 9.5 6.3 5.7 15.7 20.8 2.3 9.0 11.6 9.9 5.3 4.4 12.0 11.3 % I Haven't Decided 13.9 8.4 4.7 6.7 6.2 7.7 9.6 16.2 31.9 10.1 Breastfeeding Initiation After Delivery ------ -------------------- Missing Data % 34.0 91.9 47.5 59.4 48.8 9.4 80.4 59.7 56.9 57.8 37.7 57.4 47.7 67.2 57.6 22.8 66.7 54.5 35.2 24.7 68.1 67.6 38.7 57.2 35.1 76.0 47.7 56.5 -Missing Data 682 169 817 364 985 1,004 303 593 1,158 1,168 284 2,641 22,892 1,458 143 578 388 291 797 493 Women with Non N 1,735 114 4,413 562 384 79 535 754 --------------------------­ % 76.5 82.5 91.8 70.8 89.2 75.8 88.2 93.1 89.6 59.6 91.1 79.2 74.5 74.1 44.6 88.7 82.1 77.3 77.2 73.7 80.3 70.3 72.5 74.7 63.8 69.9 51.6 77.3 Yes --- - --- --- --- ----­ 10.9 24.7 35.6 29.4 20.0 18.8 14.0 22.4 26.2 17.8 29.7 - 22.8 37.3 25.9 25.5 20.8 8.6 8.0 6.6 10.7 24.0 9.9 28.9 7.4 16.7 22.7 % No 40.0 --------------------------­ Prefer Not to Answer 0.7 - 0.9 - - - - - - 28.4 4.0 - - - - - - - - 27.5 - - - - - 3.9 - 18.1 % --------------------------­ Notes: Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data are reported based on the share of Strong Start participants wit h PLPE data. Data may be --------------------------- nsored cell due to small sample size (N<11). a ce -) indicates . A dash ( missing due to a missing form from which a measure is drawn or item nonresponse TABLE K. 3: FAMILY PLANNING Total artment of N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Dep South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation edical Sciences Campus Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University M St. John Community Health Texas Tech University Health Received Birth Control Counseling after Delivery 38.9 57.5 35.2 76.2 49.1 57.1 60.0 48.1 92.0 35.9 % Missing Data 49.3 9.4 81.6 59.7 57.4 57.8 38.4 58.1 48.3 67.2 57.3 23.6 67.0 54.1 35.3 24.0 68.5 68.7 Women with Non 22,662 N 1,685 113 4,361 378 527 664 167 815 362 982 971 299 599 1,157 1,177 282 2,612 759 79 555 485 789 291 384 577 134 1,458 -Missing Data --------------------------­ 98.2 69.2 97.0 96.0 57.6 86.6 96.2 77.7 84.1 88.6 93.0 71.6 82.6 79.7 71.0 80.3 81.6 90.4 95.4 77.1 86.6 90.4 84.3 66.8 91.5 76.2 80.5 78.7 % Yes --------------------------­ 7.8 14.0 31.1 7.1 20.7 17.7 18.2 % No 2.5 - 15.3 - 3.6 40.9 3.4 15.1 15.3 - 6.6 24.2 13.5 12.1 27.9 - 18.1 8.7 4.2 18.8 12.5 --------------------------­ 4.1 4.4 - - Unsure % 3.1 - 3.1 - 2.1 1.7 - - 28.3 - - - - 1.1 8.2 3.9 4.2 - - - 7.2 - 13.4 - --------------------------­ Reported Doing Something to Keep From Getting Pregnant Postpartum --------------------------- % Missing Data 92.0 48.1 59.5 58.3 48.4 76.4 35.2 59.3 38.9 68.5 67.9 23.7 34.8 53.7 67.2 23.6 57.8 67.6 47.8 57.5 39.5 57.8 58.3 59.9 80.4 9.4 49.2 34.8 143 22,702 Women with Non -Missing Data N 1,716 113 4,365 383 513 674 166 815 346 983 976 305 601 1,166 1,188 280 2,613 751 78 561 492 775 291 376 574 1,458 --------------------------­ 91.0 90.4 61.5 88.0 56.4 64.6 81.1 51.3 87.2 96.4 86.4 76.6 70.3 87.3 86.1 59.8 86.4 83.7 79.6 75.8 % Yes 75.8 74.3 76.6 70.2 88.7 93.7 56.2 75.5 --------------------------­ 11.0 21.0 17.7 19.1 13.6 10.4 38.2 11.6 10.8 28.5 18.8 7.4 13.1 - % 48.1 11.2 27.5 37.8 10.7 34.6 7.8 18.3 25.3 - 27.9 10.1 - 6.0 No --------------------------­ 1.5 37.7 5.4 Unsure % 3.2 - 2.7 3.1 - 2.4 - - 4.6 - - - 1.8 - 7.7 7.9 5.8 - - - 5.9 - 23.4 - - --------------------------­ Reported Using Birth Control Postpartum (Among All Women Who Report Doing Something to Keep from Getting Pregnant) --------------------------- 55.4 47.5 44.4 55.0 19.2 62.4 46.3 34.7 2.7 67.8 66.4 15.9 52.8 7.8 75.4 26.2 49.0 34.0 42.3 81.0 30.4 % 40.2 8.4 2.5 44.2 55.3 57.8 17.3 Missing Data 40.6 21.5 Not in Universe % 20.1 12.6 14.2 31.0 26.0 29.3 4.0 46.7 16.1 28.4 6.4 1.3 30.8 31.8 16.2 16.4 37.7 7.8 35.7 5.3 12.3 37.7 9.9 15.4 20.2 79.2 --------------------------­ 820 17,136 Women with Non -Missing Data N 1,301 90 3,655 331 307 580 145 573 265 895 843 294 524 598 964 181 1,475 661 48 507 373 576 223 264 509 134 --------------------------­ 9.1 22.4 13.5 11.9 10.0 14.4 7.0 6.8 18.3 - 11.4 4.9 11.5 3.2 - 16.8 % 4.3 19.9 - Female Sterilization 10.2 11.5 12.7 10.6 22.3 17.0 15.3 5.3 14.4 --------------------------­ 2 55 T E CH N I C A L A P P E ND I CE S ---------------------------

274 Total artment of N or % University Birmingham University of Birth Centers Foundation of Harris County Health System Data Elements Medical Group Dep South Carolina Albert Einstein Care Authority South Alabama Health Services Health Services Sciences Center Health Network Health Network Hospital District Maricopa Special Investment Corp. Oklahoma Health Providence Health Access Community Health Consortium Mississippi Primary Los Angeles County Health Care District Providence Hospital Meridian Health Plan Research Foundation edical Sciences Campus Medical University of Central Jersey Family Florida Association of United Neighborhood University of Kentucky Association DBA Grady Healthy Start Coalitions University of Tennessee Health Care Association HealthInsight of Nevada American Association of Virginia Commonwealth University of Alabama at Amerigroup Corporation Signature Medical Group University of Puerto Rico Grady Memorial Hospital Johns Hopkins University M St. John Community Health Texas Tech University Health 1.4 - - - - - - - - - 3.5 - - Male Sterilization % - - 3.9 - - - - - - - - - - 2.3 - - 13.0 9.9 11.5 7.2 15.6 - 8.9 2.8 - 10.8 % - Implant LARC 6.1 2.2 9.7 9.0 14.5 13.3 17.1 23.0 4.5 19.4 13.1 2.9 4.2 9.2 12.2 23.9 5.9 --------------------------­ 4.2 17.0 10.1 14.2 22.8 15.2 - 16.0 11.0 - 15.4 % - IUD LARC 12.2 2.5 9.0 8.0 8.2 18.0 18.1 20.7 6.0 9.6 19.3 8.8 8.1 11.9 18.2 9.0 3.5 --------------------------­ 15.6 - 20.3 8.7 - 7.2 % Pills 22.7 14.2 14.4 7.3 9.5 10.2 13.0 9.7 10.6 10.6 - 17.6 13.0 11.8 14.9 13.4 20.4 6.4 11.2 11.6 20.2 13.9 --------------------------­ 16.0 29.2 5.9 4.6 15.6 15.0 % Injection 11.6 39.1 12.5 18.5 23.3 29.3 9.0 18.5 21.1 15.0 15.9 22.1 14.0 16.2 23.9 20.1 18.7 - 6.7 45.3 19.6 8.8 --------------------------­ 6.9 - 16.2 27.2 32.2 8.1 % Condoms 8.8 19.6 4.8 2.5 24.5 7.5 19.5 13.7 28.7 13.8 22.8 12.8 34.9 17.9 10.1 10.4 23.6 35.2 18.8 5.7 12.4 19.8 --------------------------­ - - 8.5 12.5 - 4.4 % Breastfeeding - - 11.5 - 6.8 - - - 5.3 - - - 8.1 5.3 - - - - - - - 8.0 --------------------------­ - - - 2.7 - - % Rhythm or Safe Period - - - - - - - - - - - - - 0.8 - - - - - - - - --------------------------­ - - - 2.7 - 7.8 % Withdrawal or Pulling Out - - - - 1.8 - - - - - - - - 1.8 - - - - - - - - --------------------------­ - - - - - - % Spermicide - - - - - - - - - - - - - - - - - - - - - - --------------------------­ - 5.1 17.0 13.3 10.7 % Other Method 14.4 5.6 11.7 32.8 4.2 9.2 5.8 7.9 4.2 10.2 10.8 - 19.7 7.2 10.9 3.4 - 11.6 12.5 9.0 2.3 9.4 6.7 --------------------------­ - 1.9 - - 3.7 - 2.8 % Method Not Indicated 6.2 - 2.7 3.0 - 2.4 5.3 - - 3.2 - - - 2.0 - - - 3.2 1.2 4.5 - --------------------------­ Notes: Women with multiple gestations (N=607) have been excluded from these results. Rates of missing data and not in universe are r the share of Strong Start participants with PLPE data. eported based on --------------------------- Data may be missing due to a missing form from which a measure is drawn or item nonresponse. Not in universe includes women w ho whom a measure does not apply, and is defined separately for each measure. A dash ( a censored cell due to small sample size (N<11). indicates -) 256 TECHNICAL APPENDICES

275 APPENDIX L: PARTICIPANT-LEVEL PROCESS ES MULTIPL EVALUATION – TECHNICAL APPENDICES 257

276 MAIN FINDINGS FOR MULTIPLES The following tables present all of the main findings from the PLPE dataset for the 607 women with multiple gestations. Rates of missing data reported in these tables include data that are missing because a form was not submitted and data that are missing because the measure was left blank on a submitted form (item nonresponse). In case where the relevant population represents a subgroup of participants (e.g., women with a prior birth are the only group that could have had a prior preterm birth), we restrict th e N to only those women in the universe. Women with nonmissing data (and if relevant, in the universe) are the denominator used for calculating all percentages presented in the tables below. Cells are not reported separate by representing fewer than 11 women are censored using a dash (-). Results model due to small sample sizes: Birth Center awardees had 20 participants with multiple gestations, Group Prenatal Care awardees had 123 participants with multiple gestations, and Maternity Care 464 participants with multiple gestations. Home awardees had TABLE L. CHARACTERISTICS AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS 1: DEMOGRAPHIC Data Elements N or % Total Mother's Age at Intake 3.3 Missing Data % Missing Data N 587 Non- Women with % 2.9 Less than 18 Years of Age 5.1 18 and 19 Years of Age % 20 Through 34 Years of Age % 81.1 35 Years and Older % 10.9 Race and Ethnicity % Missing Data 4.3 N 581 Women with Non- Missing Data 23.8 % Hispanic 19.4 % White Non-Hispanic Non-Hispanic Black 54.4 % Other Race/Multiple Races % 2.4 Ethnicity (Among Hispanic Women) Missing Data 13.8 % Not in Universe % 63.4 Women with Non- 138 N Missing Data 42.0 % Mexican, Mexican American, Chicana Puerto Rican 18.8 % Cuban % - Other Hispanic, Latina, or Spanish Origin % 34.8 - Multiple Hispanic, Latina, or Spanish Origins % Living in Shelter or Homeless at Intake 2.8 % Missing Data 590 N Missing Data Women with Non- 2.2 Yes % Employment and School Status at Intake 5.8 % Missing Data Women with Non- 572 N Missing Data Employed, Not in School 38.3 % In School, Not Employed 8.9 % 3.7 % Employed and in School Neither Employed nor in School % 49.1 258 TECHNICAL APPENDICES

277 Data Elements N or % Total Education Level at Intake Missing Data % 10.2 Women with Non- Missing Data N 545 Less than High School % 21.7 62.8 % High School Graduate or GED % Associate's Degree 5.7 Bachelor's Degree % 5.0 Other College Degree 5.0 % Relationship Status at Intake Missing Data 5.3 % - N 575 Missing Data Women with Non Married % 19.8 29.9 % Living with a Partner In a Relationship but Not Living Together % 30.8 19.5 % Not in a Relationship Right Now Sample is limited to women with multiple gestations (N=607). Rates of missing data and not in universe are reported Notes: based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or an outlier value (mother's age). Not in universe includes women who whom a measure does not apply, and is defined separately for each measure -) indicates a censored cell due to small . A dash ( sample size (N<11). TABLE L. 2: PSYCHOSOCIAL CHARACTERISTICS AMONG STRONG START PARTICIPANTS WIT H MULTIPLE GESTATION S Total N or % Data Elements Insured When Became Pregnant Missing Data % 4.3 Women with Non- Missing Data N 581 Yes 58.2 % 36.5 % No Unsure 5.3 % Type of Insurance (Among Women Who Were Insured When They Became Pregnant) Missing Data 4.3 % Not in Universe 40.0 % Missing Data N 338 Women with Non- Medicaid % 74.9 17.2 Other % Both Medicaid and Other Health Insurance 8.0 % Smokes Cigarettes at Intake Missing Data % 13.2 Women with Non- Missing Data N 527 13.5 Yes % Food Insecure at Intake 9.1 % Missing Data 552 N Missing Data Women with Non- 23.4 % Yes WIC at Intake Missing Data % 6.3 Women with Non- Missing Data N 569 50.6 Yes % 1 Exhibiting Depressive Symptoms at Intake Missing Data % 15.0 516 N Women with Non - Missing Data % 28.3 Yes 2 E xhibiting Anxiety Symptoms at Intake Missing Data % 9.2 259 TECHNICAL APPENDICES

278 Data Elements Total N or % Women with Non - Missing Data N 551 None 59.9 % % Mild 22.9 9.6 % Moderate Severe 6.4 % - % Incomplete Score but Showing Symptoms of Anxiety 3 Intimate Partner Violence History of Missing Data % 5.6 Women with Non- Missing Data N 573 Yes % 17.3 Experiencing Intimate Partner Violence at Intake (Among Women With a Completed Score or Who Report Being in 4 a Relationship) Missing Data % 8.6 9.9 % Universe Not in 495 N Missing Data Women with Non- - Yes % Experiencing Prenatal Care Access Barrier % 2.8 Missing Data 590 N Missing Data Women with Non- None Reported 67.5 % Reported One Access Barrier % 21.0 11.5 Reported Two or More Access Barriers % 5 Types of Barriers Reported (Among Women Who Reported Any Barrier) 59.9 % No Car 20.3 Public Transportation Challenges % 26.6 % Not Enough Money for a Ride Work Hours Make It Difficult % 17.7 Childcare Challenges 16.1 % % - Partner Objections Other % 15.1 Sample is limited to women with multiple gestations (N=607). Rates of missing data and not in universe are reported Notes: based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn or item nonresponse. Not in universe includes women for whom a measure does not apply, and is -) indicates a censored cell due to small sample size (N<11 ). All scales are defined separately for each measure. A dash ( . ndix E defined in Appe 1 D 10 scale. Measured by CES- 2 -7 scale. Measured by GAD 3 Measured by STaT scale. 4 Measured by WEB scale. 5 Women could report multiple barriers. TABLE L. 3: PREGNANCY HISTORY AND INTENTIONS AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS Total Data Elements N or % Prior Pregnancy 0.2 % Missing Data Women with Non- Missing Data N 606 82.2 Yes % Pregnancy History Among Women with a Prior Pregnancy 18.0 Not in Universe (No Prior Pregnancy) % Prior Miscarriage (<20 weeks EGA) 12.9 Missing Data % Missing Data 420 N Women with Non - Yes % 31.9 Prior Elective Termination 13.0 % Missing Data 260 TECHNICAL APPENDICES

279 Data Elements N or % Total Women with Non - Missing Data N 419 19.1 % Yes Prior Still Birth (Fetal Death >= 20 Weeks EGA) Missing Data % 25.7 Women with Non- 342 N Missing Data Yes 3.5 % Prior Preeclampsia 46.6 Missing Data % Missing Data Women with Non- N 215 Yes % 22.3 Prior Gestational Diabetes Missing Data % 52.9 Women with Non- 177 Missing Data N Yes % - Prior Cervical Incompetence Missing Data % 53.5 Women with Non- 173 N Missing Data - % Yes Prior Placenta Abnormalities % 54.0 Missing Data Missing - Women with Non N Data 170 Yes % - Prior Congenital Abnormalities of the Fetus % 54.0 Missing Data 170 N Missing Data Women with Non- - % Yes Notes: All measures except for prior pregnancy are among women with a prior pregnancy. Sample is limited to women with multiple gestations (N=607). Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. Not in universe includes women who did not have a prior pregnanc A dash ( -) indicates a censored cell due to small sample size (N<11). y. STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS 4: PRIOR BIRTH OUTCOMES AMONG TABLE L. N or % Data Elements Total Prior Birth (Among Women with a Prior Pregnancy) Missing Data % 0.5 Not in Universe % 18.0 Missing Data Women with Non- 495 N Yes % 90.7 Prior Birth Outcomes Among Women with a Prior Birth - Inter Pregnancy Interval with Current Pregnancy Since Last Birth % Missing Data 15.8 Not in Universe % 25.4 N 357 - Women with Non Missing Data 25.5 % < 18 months >= 18 months 74.5 % Prior Preterm Birth (=>20 Weeks - - < 37 Weeks) Mis 1.5 % sing Data 26.0 % Not in Universe N Missing Data Women with Non- 440 25.0 Yes % Prior Low Birthweight Infant (< 2,500 Grams) Missing Data 15.2 % 26.0 % Not in Universe TECHNICAL APPENDICES 261

280 Data Elements N or % Total 357 N Missing Data - Women with Non Yes % 14.3 Notes: All measures except for prior birth are among women with a prior birth. Sample is limited to women with multiple gestations (N=607). Rates of missing data and not in universe are reported based on the share of Strong Start to a missing form from which a measure is drawn; item participants with PLPE data. Data may be missing due nonresponse; a response of don’t know, unsure, not known, prefer not to answer; or an outlier value (interpregnancy fined separately for each interval). Not in universe includes women for whom a measure does not apply, and is de a censored cell due to small sample size (N<11). measure. A dash ( -) indicates TABLE L. -PREGNANCY MEDI 5: PRE CAL CONDITIONS AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS Total N or % Data Elements Pregnancy Intention Missing Data 6.6 % Women with Non- Missing Data N 567 27.0 Trying to Become Pregnant % Not Trying to Become Pregnant, Not Using Contraception % 60.8 % Not Trying to Become Pregnant, Sometimes Using Contraception 3.9 % 8.3 Trying to Become Pregnant, Using Contraception Not Pr Diabetes Pre- egnancy - 15.2 % Missing Data 515 N Missing Data Women with Non- Yes % 2.5 - Hypertension Pre - Pregnancy % 10.9 Missing Data Women with Non- Missing Data N 541 9.8 % Yes at First Prenatal Visit Mother's BMI % 17.3 Missing Data 502 N Missing Data Women with Non- Underweight (BMI < 18.5) % - Normal Weight (=>18.5 BMI <25) 27.9 % Overweight (=>25 BMI <30) 25.1 % % 40) 30.7 Obese (=>30 BMI < Very Obese (BMI >= 40) 14.9 % Sample is limited to women with multiple gestations (N=607). Rates of missing data and not in universe are reported Notes: based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; a response of don’t know, unsure, not known, prefer not to answer; or an outlier value (BMI of mother at first prenatal visit). Not in universe includes women for whom a measure does not apply, and is defined separately for each measure. A dash ( -) indicates a censored cell due to small sample size (N<11). NS DEVELOPED DURING 6: PREGNANCY CONDITIO TABLE L. STRONG START AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS Total N or % Data Elements Preeclampsia 13.7 Missing Data % Women with Non- Missing Data N 524 Yes % 12.2 -Related Hypertension Pregnancy - Mis 13.5 % sing Data Women with Non- Missing Data N 525 Yes % 9.1 Gestational Diabetes 13.3 Missing Data % Women with Non- Missing Data N 526 % Yes 7.0 TECHNICAL 262 APPENDICES

281 Data Elements N or % Total Cervical Incompetence % Missing Data 17.5 Missing Data Women with Non- 501 N Yes % 3.2 Placenta Previa Missing Data % 16.0 Women with Non- Missing Data N 510 Yes % - Placental Abruption Missing Data % 15.8 Women with Non - Missing Data 511 N - % Yes Congenital Abnormalities of the Fetus Missing Data % 17.1 Women with Non- Missing Data N 503 Yes % 3.8 UTI(s) During Last 6 months of Pregnancy 15.8 % Missing Data 511 Missing Data Women with Non- N 13.7 % Yes of women are reported to have left Strong Start prior to percent 16 This table is among all women, but we note that Notes: delivery. Sample is limited to women with multiple gestations (N=607). Rates of missing data are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer a -) indicates . A dash ( censored cell due to small sample size (N< 11). 7: TREATMENTS DURING PREGNANCY AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS TABLE L. Data Elements N or % Total Vaginal Progesterone 28.8 Missing Data % N 432 Missing Data - Women with Non Yes 3.2 % (Progesterone Injections, Among Women with a Prior Preterm Birth) 17P 4.6 % Missing Data Not in Universe 81.9 % Women with Non- 82 N Missing Data Yes % - Antenatal Steroids Missing Data % 33.1 Women with Non- Missing Data 406 N 20.9 Yes % Tocolytics Missing Data % 35.9 N Missing Data Women with Non - 389 10.5 % Yes This table is among all women, but we note that Notes: percent of women are reported to have left Strong Start prior to 16 delivery. Sample is limited to women with multiple gestations (N=607). Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. Not -) in universe includes women who whom a measure does not apply, and is defined separately for each measure . A dash ( indicates a censored cell due to small sample size (N<11). TECHNICAL APPENDICES 263

282 TABLE L. 8: PRENATAL CARE AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS Data Elements Total N or % Routine Prenatal Care Provider % 8.2 Missing Data Women with Non- Missing Data N 557 68.0 Obstetrician % % - Licensed Professional Midwife Nurse Practitioner % 6.8 Certified Nurse Midwife/Certified Midwife % 10.6 - Family Medicine Physician % Other Provider 13.5 % Routine Prenatal Care (Individual Visits) % Missing Data 0.0 607 N Missing Data - Women with Non Received Individual Visits % 89.6 Average number of Individual Prenatal Visits Mean 8.2 Routine Prenatal Care (Group Visits) Missing Data 0.0 % 607 N Missing Data Women with Non- 20.4 % Received Group Visits 5.0 Mean Average Number of Group Prenatal Visits Care Coordinator Encounters Missing Data 8.9 % Women with Non - Missing Data N 553 Received Care Coordinator Encounters % 80.1 4.6 Mean Average Number of Care Coordinator Encounters Mental Health Encounters Missing Data 14.5 % 519 N Missing Data Women with Non- 7.5 Received Mental % Health Encounters Average Number of Mental Health Encounters Mean 1.9 Doula Encounters 17.1 Missing Data % Women with Non - Missing Data N 503 Received Doula Encounters - % - Mean Average Number of Doula Encounters Health Education Missing 37.4 % Data N 380 Missing Data Women with Non- Received Health Education, Not Centering % 35.0 2.4 Average Number of Health Education Sessions Mean Home Visits 32.8 Missing Data % Missing Data - N Women with Non 408 8.6 % Received Home Visits Average Number of Home Visits Mean 1.6 are, not Centering - Self -C M 41.5 % issing Data Women with Non- Missing Data N 355 15.2 Received Self -Care, Not Centering % 4.0 Average Number of Self - Care Sessions Mean Nutrition Counseling 30.6 Missing Data % N Women with Non - Missing Data 421 APPENDICES TECHNICAL 264

283 Data Elements N or % Total 39.0 % Received Nutrition Counseling Average Number of Nutrition Counseling Sessions Mean 2.0 Substance Abuse Services Missing Data % 31.6 415 N Missing Data Women with Non- 4.6 % Received Substance Abuse Services Average Number of Substance Abuse Services - Mean Referrals for High Risk Medical Services Missing Data % 16.6 N Missing Data 506 Women with Non- Received Referrals for High Risk Medical Services % 44.7 Average Number of Referrals for High Risk Medical Services 1.7 Mean Types of Referrals for High Risk Medical Services (Among Women with Services) Maternal Fetal Specialist % 66.4 - Pulmonologist % - % Endocrinologist Cardiologist 7.0 % 47.2 Other % of women are reported to have left Strong Start prior to percent that 16 This table is among all women, but we note Notes: delivery. Sample is limited to women with multiple gestations (N=607). Rates of missing data are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is All reported means are drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. y Care Home or Group Prenatal among women with a visit or encounter. It is unlikely the women enrolled in Maternit Care were cared for by a Licensed Profession Midwife though this was reported for 1% and 2.3%, respectively. Awardees -care” if they weighed themselves, took their own care” directed to indicate women conducted “self were “self- blood pressure, etc., outside of the context of Group Prenatal Care a censored cell due to small sample size -) indicates . A dash ( (N<11). 9: DELIVERY INFORMATI ON AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS TABLE L. Data Elements N or % Total Induction of Labor (Among Women Who Delivered, Excluding Planned C -sections) - 21.1 % issing Data M Not in Universe % 23.6 Missing Data 336 N Women with Non- % Yes 27.4 Induced) Induction of Labor with Pitocin (Among Women Who Were Missing Data 1.8 % 84.8 Not in Universe % N Missing Data Women with Non- 81 90.1 % Yes Place of Delivery (Among Women with a Delivery) % Missing Data 4.6 Not in Universe % 4.8 Missing Data Women with Non- 550 N Hospital % 99.8 % Birth center - Home birth - % - Other % Delivery Method (Among ALL Women with a Delivery) Missing Data % 3.3 4.8 % Not in Universe Women with Non- Missing Data N 558 Vaginal Only % 38.4 61.7 % Section Only C- TECHNICAL APPENDICES 265

284 Data Elements N or % Total - - Scheduled C - Section (Among Women with a C - Section) Missing Data % 13.1 43.3 Not in Universe % Women with Non - Missing Data N 264 Yes % 43.2 VBAC (Among Women with a Prior C -Se ction) - 0.0 % ing Data Mis s 41.2 % Not in Universe 114 N Missing Data Women with Non- % 12.3 Yes Notes: All measures are among women with a delivery. Sample is limited to women with multiple gestations (N=607). Rates of missing data and not in universe are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn; item nonresponse; or a response of don’t know, unsure, not known, prefer not to answer. Not in universe includes women who whom a measure does not apply, and is defined 1 a Low risk is defined as women with nulliparous, singleton, term births . A dash indicates (-) separately for each measure. (N<11). size censored cell due to small sample AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS TABLE L. 10: BIRTH OUTCOMES Total N or % Da ta Elements Outcomes of Strong Start Pregnancy 4.0 % Missing Data Women with Non- 583 Missing Data N 80.3 % s Live Birth Only 3.4 Only Stillbirths % 15.4 % Both Live Births and Stillbirths % s Termination Only - Miscarriage Only - % s Estimated Gestational Age (EGA, Among Women with Live Births) Missing Data % 6.8 8.1 % Not in Universe N Women with Non- 517 Missing Data 25.1 Very Preterm (20 =< EGA < 34) % 35.4 % Preterm (34 =< EGA < 37) Term (37 =< EGA < 42) 39.1 % Post (42+) % - -Term 1 Birth Weight (Among Women with Live Births) % Missing Data 7.4 Not in Universe % 6.4 523 Women with Non- Missing Data N 14.3 Any Very Low Birthweight (<1500g) % Any Low Birthweight (=>1500g < 2500g) % 57.6 Any Normal Birthweight (=>2500 < 4000g) % 50.5 Any Macrosomic Birthweight (=>4000g) % - All measures are among women with a delivery. Sample is limited to women with multiple gestations (N=607). Rates of Notes: tart participants with PLPE data. Data may missing data and not in universe are reported based on the share of Strong S be missing due to a missing form from which a measure is drawn; item nonresponse; or an outlier value (estimated and is defined gestational age and birth weight). Not in universe includes women who whom a measure does not apply, -) indicates A dash ( separately for each measure. a censored cell due to small sample size (N<11). 1 Birth Weight sums to more than 100 percent because women can have babies with different birth weights in a delivery. single 266 TECHNICAL APPENDICES

285 FINDINGS FROM T HE THIRD TRIMESTER AND POSTPARTUM SURVEY S The information presented in the tables below comes from items collected on the Third Trimester and Postpartum Surveys. We have separated these from the main PLPE findings because of high rates of , limiting the generalizability of , including women who left Strong Start prior to delivery missing data these results. However, the Third Trimester and Postpartum Surveys are the only source of certain measures of interest, including satisfaction with care (prenatal and delivery care), breastfeeding initiation, and postpartum pregnancy prevention. TABLE L. 11: SATISFACTION AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS Data Elements N or % Total Satisfaction with Prenatal Care 45.6 Missing Data % Women with Non- N 330 Missing Data - % Not at All Satisfied - Slightly Satisfied % Moderately Satisfied % 6.7 Very Satisfied % 45.8 Extremely Satisfied % 45.2 Satisfaction with Delivery Experience % 45.6 Missing Data Missing Data 330 N - Non Women with % Not at All Satisfied 4.5 Slightly Satisfied - % Moderately Satisfied % 10.3 43.0 % Very Satisfied Extremely Satisfied % 39.1 Notes: Sample is limited to women with multiple gestations (N=607). Rates of missing data are reported based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn or . A dash ( item nonresponse -) indicates a censored cell due to small sample size (N<11). 12: BREASTFEEDING AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS TABLE L. Data Elements N or % Total Breastfeeding Intention at Third Trimester Missing Data % 45.1 333 N Missing Data Women with Non- % 33.9 Breastfeed Only 18.3 % Formula Feed Only % Both Breast and Formula Feed 35.7 12.0 % I Haven't Decided Breastfeeding Initiation After Delivery Missing Data % 43.8 Women with Non- Missing Data N 341 % 66.9 Yes 27.9 % No 5.3 % Prefer Not to Answer Sample is limited to women with multiple gestations (N=607). Rates of missing data are reported based on the share of Notes: Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn or nsored cell due to small sample size (N<11). a ce indicates item nonresponse . A dash ( -) TECHNICAL APPENDICES 267

286 13: FAMILY PLANNING AMONG STRONG START PARTICIPANTS WITH MULTIPLE GESTATIONS TABLE L. Total N or % Data Elements Received Birth Control Counseling after Delivery % 43.7 Missing Data N 342 Women with Non- Missing Data % Yes 81.3 % No 14.9 Unsure % 3.8 ” “ Reported “Doing Something to Keep From Getting Pregnant” Postpartum Missing Data 44.0 % Women with Non 340 N Missing Data - 72.9 Yes % No % 20.3 % Unsure 6.8 Control Postpartum (Among All Women Who Report Doing Something to Keep from Getting Reported Using Birth Pregnant) 35.3 % Missing Data Not in Universe 23.9 % Women with Non- Missing Data N 248 % Female Sterilization 26.2 - % Male Sterilization % - Implant LARC 8.9 - IUD LARC % 4.8 % 9.7 Pills 19.4 Injection % % Condoms 9.7 5.2 % Breastfeeding - % Rhythm or Safe Period Withdrawal or Pulling Out - % % - Spermicide 11.7 % Other Method % Method Not Indicated - Sample is limited to women with multiple gestations (N=607). Rates of missing data and not in universe are reported Notes: based on the share of Strong Start participants with PLPE data. Data may be missing due to a missing form from which a measure is drawn or item nonresponse. Not in universe includes women who whom a measure does not apply, and is defined separately for each measure. a censored cell due to small sample size (N<11). indicates -) A dash ( 268 TECHNICAL APPENDICES

287 OUTCOMES – ADJUSTED REGRESSION- APPENDIX M: REGRESSION SAMPLE AN TICS D DESCRIPTIVE STATIS TECHNICAL APPENDICES 269

288 INTERMEDIATE OUTCOME S ANALYSIS TABLE M. 1: CONSTRUCTION OF TH E ANALYTIC SAMPLE FO R INTERMEDIATE OUTCOMES ANALYSIS # of Remaining Logic for Dropping Observations # Excluded Observations - 45,316 Starting Sample: Number of Strong Start participants with PLPE data Dropping participants without an exit form 831 44,485 Dropping participants without an intake form 42,186 2,299 Dropping participants with a miscarriage or elective termination 1,330 40,856 40,271 585 Dropping participants with multiples Dropping participants missing an intermediate outcome variable 6,912 33,359 (gestational diabetes or preeclampsia) covariates 32,593 766 Dropping participants missing any Final analytic sample 32,593 - Notes: -) indicates the reference category for a variable. A dash ( 2: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE OUTCOMES ANALY TABLE M. TIC SAMPLE Model Measure Maternity Care Homes Group Prenatal Care Centers Birth 7,047 7,076 18,470 Sample Size ~ Means Outcomes 0.06 *** 0.03 Gestational Diabetes 0.08 ^^^ *** Preeclampsia 0.02 *** ^^^ 0.06 0.06 Demographic Characteristics Race/Ethnicity *** ^^^ 0.13 White 0.21 0.53 *** 0.29 *** 0.42 ^^^ *** 0.25 Hispanic *** ^^^ 0.41 *** 0.45 Black 0.16 ^^^ *** 0.05 0.04 0.04 Other Age 0.03 *** ^^^ 0.06 * 0.06 Less than 18 Years Old ^^^ 0.12 *** 18 to 19 Years of Age 0.10 *** 0.07 20 to 34 Years of Age 0.75 ** 0.74 ^^^ *** 0.82 0.09 0.09 *** 0.08 ^ Older 35 Years of Age or Education *** 0.25 ^^^ *** 0.28 0.15 Less than High School 0.51 ^^^ ** 0.55 High School Graduate / GED *** 0.54 *** Bachelor's Degree 0.14 0.03 ** 0.04 ^^^ 0.09 0.12 Other Degree *** ^^^ 0.09 *** Education Unknown 0.11 ^^^ *** 0.04 0.06 Relationship Status *** Married 0.42 0.20 0.20 *** 0.31 0.33 *** ^^^ 0.33 Living with a Partner 0.14 In a Relationship, Not Living Together *** 0.28 0.24 ^^^ *** 0.18 Not in a Relationship 0.10 *** ^^^ 0.17 0.03 *** 0.06 ^^^ *** 0.01 Relationship Status Unknown Employment/School 0.29 *** ^^^ *** 0.36 Working, Not in School 0.34 0.12 0.12 ^ *** 0.09 In School, Not Working 0.05 ^^ 0.05 Working and in School 0.05 Neither Working nor in School 0.46 *** 0.50 ^^^ *** 0.48 0.02 0.03 *** 0.04 ^^^ *** Status Unknown Work/School Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 0.36 ^^^ 0.47 *** 0.37 Prior Preterm Birth 0.09 *** ^^^ 0.11 *** 0.15 TECHNICAL 270 APPENDICES

289 Model Measure Maternity Care Homes Group Prenatal Care Centers Birth No Prior Preterm Birth 0.55 ^^^ 0.42 *** 0.48 *** ~ Prior Low Birth Weight No Prior Birth 0.36 ^^^ 0.47 *** 0.37 *** Prior Low Birth Weight Birth 0.01 *** ^^^ 0.05 0.09 0.47 *** 0.36 ^^^ *** 0.62 No Prior Low Birth Weight Birth 0.01 Prior Low Birth Weight Unknown *** 0.07 *** 0.12 ^^^ Prior C Section - 0.36 ^^^ 0.47 *** 0.37 No Prior Birth ^^^ *** 0.16 0.14 0.04 Section - Prior C *** *** 0.59 Section - Prior C No *** 0.46 0.39 ^^^ Interpregnancy Interval 0.47 0.36 ^^^ No Prior Birth *** 0.37 0.13 Short Interpregnancy Interval 0.19 *** ^^^ 0.10 *** 0.36 Normal Interpregnancy Interval ^^^ 0.32 *** 0.36 *** Interpregnancy Interval Unknown 0.09 *** ^^^ 0.12 0.13 Risk Factors from Current Pregnancy Depression Not Depressed at Intake 0.67 *** 0.57 ^^^ *** 0.69 0.24 ^^^ 0.27 Depressed at Intake *** *** 0.22 0.09 0.17 Depression Unknown 0.09 * ^^^ *** Anxiety ^^^ 0.62 *** 0.56 *** 0.66 No Anxiety at Intake 0.35 *** 0.31 *** 0.33 Anxiety at Intake ^^^ *** Anxiety Unknown 0.04 ^^^ 0.08 *** 0.06 Food Insecurity Not Food Insecure at Intake 0.74 *** 0.68 ^^^ *** 0.77 Food Insecure at Intake ^^^ 0.18 0.21 *** 0.18 0.08 Food Insecurity Score Unknown 0.05 *** ^^^ 0.11 *** Pregnancy Intent 0.28 ^^^ *** 0.37 Intended Pregnancy 0.26 *** 0.61 Unintended Pregnancy *** 0.70 ^^^ *** 0.67 0.04 *** 0.05 ^^^ 0.02 Pregnancy Intent Unknown *** - Pregnancy Hypertension Pre 0.86 0.99 *** ^^^ 0.91 *** No Pre- Pregnancy Hypertension Hypertension Pregnancy - Pre *** 0.08 ^^^ *** 0.07 0.01 *** *** 0.06 0.00 Pregnancy Hypertension Unknown - Pre ^^^ 0.02 Pre Pregnancy Diabetes - 0.74 *** *** No Pre - Pregnancy Diabetes ^^^ 0.92 0.99 0.06 ^^^ *** 0.00 Pregnancy Diabetes *** Pre 0.04 - 0.04 *** 0.21 ^^^ 0.00 Pregnancy Diabetes Unknown - Pre *** BMI At First Prenatal Visit 0.04 Underweight (<18.5 BMI) 0.03 ** 0.03 ^^^ *** ^^^ Normal Weight (18.5 -<25 BMI) 0.44 *** 0.28 0.27 0.22 0.24 <30 BMI) 0.25 *** ^^^ Overweight (25- ** ^^^ *** 0.20 <40 BMI) - Obese (30 0.22 0.27 *** ^^^ 0.10 *** 0.06 *** 0.04 (>=40 BMI) Very Obese *** 0.03 BMI Unknown ^^^ 0.19 *** 0.09 Smoking * ^^ 0.76 *** 0.82 Did not Smoke at Intake 0.81 *** 0.12 Smoked at Intake 0.10 *** ^^^ 0.08 0.06 0.09 *** 0.16 *** Smoking Status Unknown Intimate Partner Violence 0.78 **^^^ 0.78 No History of Intimate Partner Violence 0.77 ** ^^^ 0.19 *** 0.16 *** 0.20 History of Intimate Partner Violence History of Intimate Partner *** 0.06 ^^^ *** 0.02 0.04 Violence Unknown Year *** 2013 and 2014 0.20 ^^^ 0.24 *** 0.22 2015 0.31 *** ^^^ 0.39 *** 0.35 TECHNICAL APPENDICES 271

290 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes *** 0.31 0.25 ^^^ *** 0.27 2016 and 2017 Region 0.11 ^^^ *** 0.22 Northeast 0.12 0.00 0.25 ^^^ 0.03 Midwest *** *** *** 0.08 South *** ^^^ 0.00 0.26 0.60 *** West 0.68 *** ^^^ 0.70 data. Significance calculated using pairwise comparison of means test. Sample limited to women with Notes: One nonmissing * ** ce at the 0.05 level; and three ) indicates significan ) indicates significance at the 0.1 level; two asterisks ( asterisk ( ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret *** asterisks ) indicates significance at the 0.1 level; two carets ( ( ^ ^^ ^^^ ) ) indicates significance at the 0.05 level; and three carets ( indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. 3: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE OUTCOMES ANALY TIC SAMPLE EXCLUDING MUSC, UAB, TABLE M. AND UPR Model Measure Birth Centers Maternity Care Homes Group Prenatal Care 16,623 6,203 7,076 Sample Size ~ Outcomes Means ^^^ 0.06 *** Gestational Diabetes 0.03 *** 0.08 0.05 Preeclampsia 0.02 *** ^^^ 0.06 *** Demographic Characteristics Race/Ethnicity ^^^ 0.21 *** 0.14 *** 0.53 White 0.25 0.32 Hispanic *** ^^^ 0.35 *** Black 0.16 *** ^^^ 0.46 *** 0.42 0.05 ** 0.05 Other 0.05 Age Less Than 18 Years Old *** 0.06 0.06 0.03 ^^^ of Age 0.07 ^^^ *** 0.12 0.10 18 To 19 Years *** 20 To 34 Years of Age ^^^ *** 0.75 0.75 0.82 0.10 *** 0.07 ** ^^^ 0.09 Older or Age 35 Years of Education ** 0.28 0.27 *** ^^^ 0.15 Less Than High School High School Graduate / GED 0.53 0.52 *** ^^^ 0.55 Bachelor's Degree 0.14 ^^^ *** 0.04 0.03 *** Other Degree 0.12 ^^^ 0.07 *** 0.09 ^^^ 0.07 0.04 *** 0.10 *** Education Unknown Relationship Status 0.21 0.20 *** 0.42 Married ^^^ Living With a Partner 0.33 ** 0.32 0.31 0.14 In a Relationship, Not Living Together 0.27 *** 0.25 *** ^^^ *** 0.17 Not in a Re lationship 0.10 ^^^ 0.18 *** ^^^ 0.01 Relationship Status Unknown 0.06 *** 0.03 Employment/School Working, Not in School 0.34 0.36 *** 0.30 *** ^^^ 0.12 In School, Not Working *** 0.11 0.09 and Working In School 0.05 0.05 ^^ 0.05 nor in School *** Neither Working 0.46 0.48 ^^^ *** 0.50 0.04 *** ^^^ 0.02 Status Unknown Work/School 0.03 * Risk Factors from Prior Birth Prior Preterm Birt h *** 0.48 * ^ 0.36 Birth No Prior 0.38 *** 0.14 0.10 Prior Preterm Birth 0.09 ^^^ *** 0.48 0.42 *** ^^^ 0.55 No Prior Preterm Birth *** Prior Low Birth Weight *** 0.48 * ^^^ 0.36 No Prior Birth 0.38 ^^^ 0.05 0.08 *** *** Prior Low Birth Weight Birth 0.01 0.62 No Prior Low Birth Weight Birth ^^^ *** 0.37 *** 0.48 0.07 Prior Low Birth Weight Unknown 0.01 ^^^ *** 0.11 *** TECHNICAL 2 72 APPENDICES

291 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Prior C - Section 0.48 * ^^^ 0.36 No Prior Birth 0.38 *** 0.13 *** 0.16 *** ^^^ 0.04 -Section Prior C *** 0.46 Prior C- Section 0.59 *** 0.40 No ^^^ Interval Interpregnancy *** No Prior Birth ^^^ * 0.48 0.36 0.38 0.13 *** 0.09 *** 0.19 Short Interpregnancy Interval ^^^ 0.31 0.36 *** ^^^ 0.36 Normal Interpregnancy Interval Interpregnancy Interval Unknown ^^^ *** 0.12 *** 0.14 0.09 Current Pregnancy Risk Factors from Depression ** ^^^ 0.69 Intake Not Depressed 0.67 at *** 0.58 0.26 0.23 Depressed at Intake 0.22 ^^^ *** De pression Unknown 0.09 ^^^ *** 0.16 0.10 *** Anxiet y at Intake 0.66 ^^^ *** 0.57 No Anxiety *** 0.62 0.31 ^^^ 0.35 *** 0.32 Anxiety at Intake 0.06 *** 0.08 *** ^^^ 0.04 Anxiety Unknown Food Insecurity 0.68 0.74 *** *** ^^^ 0.77 Intake at Not Food Insecure 0.20 0.17 at Intake 0.18 ^^^ Food Insecure *** *** 0.09 *** 0.11 ^^^ 0.05 Food Insecurity Score Unknown Pregnancy Intent Intended Pregnancy 0.37 ^^^ *** 0.28 0.27 0.67 ^^^ 0.61 Unintended Pregnancy *** *** 0.69 0.04 *** 0.05 *** ^^^ 0.02 Pregnancy Intent Unknown Pregnancy Hypertension Pre - 0.91 No Pre - Pregnancy Hypertension 0.99 ^^^ *** 0.86 *** 0.07 *** ^^^ Pregnancy Hypertension - Pre 0.01 0.06 *** ^^^ 0.07 0.02 Pre - Pregnancy Hypertension Unknown 0.00 *** *** Pre - Pregnancy Diabetes No Pre - Pregnancy Diabetes 0.99 ^^^ *** 0.72 *** 0.92 Pre -Pregnancy Diabetes 0.00 ^^^ *** 0.05 *** 0.03 *** 0.04 ^^^ 0.00 e-Pregnancy Diabetes Unknown Pr 0.23 *** BMI At First Prenatal Visit Underweight (<18.5 BMI) 0.03 *** ^^^ 0.04 0.03 *** - 0.27 <25 BMI) Normal Weight (18.5 0.28 0.44 ^^^ 0.25 <30 BMI) Overweight (25 - 0.24 0.23 ** ^^^ Obese (30 <40 BMI) 0.20 ^^^ *** 0.22 - *** 0.27 (>=40 BMI) 0.04 ^^^ *** 0.09 *** 0.06 Very Obese 0.03 0.10 BMI Unknown ^^^ *** 0.19 *** Smoking Did Not Smoke at Intake 0.81 0.74 0.82 *** Sm 0.10 ^^^ *** 0.09 at Intake oked *** 0.11 Smoking Status Unknown *** 0.07 0.09 *** 0.16 Intimate Partner Violence 0.77 0.78 ** ^^^ 0.78 Intimate Partner Violence of No History 0.16 0.19 *** *** ^^^ 0.20 Intimate Partner Violence of History 0.05 *** 0.06 *** ^^^ 0.02 Unknown History of Intimate Partner Violence Year *** 0.25 0.21 2013 and 2014 0.20 ^^^ ^^ 2015 0.31 *** 0.37 *** 0.35 2016 and 2017 0.27 ^^^ *** 0.25 *** 0.32 273 TECHNICAL APPENDICES

292 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Region ^^^ *** 0.12 0.12 Northeast 0.22 ^^^ *** 0.28 *** 0.00 0.03 Midwest 0.28 *** 0.08 0.00 South *** ^^^ *** ^^^ 0.68 West 0.66 *** 0.55 data and excludes participants at the Medical College of South Carolina, the nonmissing Sample limited to women with Notes: University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately enrolled high-risk women. Significance calculated using pairwise comparison of means test. *) indicates One asterisk ( ***) indicate ) indicates significance at the 0.05 level; and three asterisks ( ** significance at the 0.1 level; two asterisks ( Homes. ignificance at the 0.01 level for the difference in means from Maternity Care ^) indicates significance One caret ( s ) indicates significance at the 0.05 level; and three carets ( at the 0.1 level; two carets ( ^^ ^^^ ) indicates significance at the 0.01 level f or the difference in means from Group Prenatal Care. MEN TIC SAMPLE, WHITE WO 4: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE OUTCOMES ANALY TABLE M. Model Measure Maternity Care Homes Group Prenatal Care Birth Centers Sample Size 3,782 882 3,889 Outcomes Means Gestational Diabetes *** 0.06 0.07 0.03 ^^^ Preeclampsia 0.01 ^^ 0.03 *** *** 0.05 Demographic Characteristics Age ^^^ *** 0.05 * 0.04 Less than 18 Years Old 0.02 ^^^ 0.13 ** 0.10 18 to 19 Years of Age 0.06 *** 0.76 *** ^^^ 0.82 20 to 34 Years of Age 0.79 ** 35 Years of Age or Older *** 0.06 0.07 ^^^ 0.10 Education 0.10 0.11 *** *** Less than High School 0.22 0.58 0.55 0.56 High School Graduate / GED Bachelor's Degree 0.18 ^^^ *** 0.07 0.05 Other Degree 0.14 ^^^ *** 0.09 0.10 0.02 0.08 *** 0.15 *** ^^^ Education Unknown Relationship Status ** 0.29 ^^^ 0.48 Married 0.25 *** ^^^ 0.38 0.37 Living with a Partner *** 0.33 0.16 *** 0.20 *** ^^^ 0.10 In a Relationship, Not Living Together Not in a Relationship *** 0.12 0.12 ^^^ 0.08 Relationship Status Unknown 0.01 ^^^ *** 0.04 0.05 Employment/School Working, Not in School 0.39 ^^^ *** 0.33 0.34 * 0.09 0.10 *** In School, Not Working 0.07 ^^^ 0.04 ** 0.05 Working and in School 0.05 0.48 0.49 0.48 Neither Working nor in School Status Unknown Work/School *** 0.03 *** 0.05 0.02 Risk Factors from Prior Birth Prior Preterm Birth 0.39 0.54 ** *** ^^^ 0.36 No Prior Birth 0.14 *** *** ^ 0.08 term Birth Prior Pre 0.10 *** ^^^ *** 0.47 0.56 No Prior Preterm Birth 0.36 Prior Low Birth Weight *** 0.39 0.54 ** ^^^ 0.36 No Prior Birth 0.08 *** 0.03 *** ^^^ 0.01 Prior Low Birth Weight Birth 0.49 No Prior Low Birth Weight Birth 0.63 ^^^ *** 0.21 *** *** 0.04 ^^^ 0.00 Prior Low Birth Weight Unknown 0.22 *** Section - Prior C 0.54 ** ^^^ 0.36 No Prior Birth 0.39 *** ^^^ 0.16 *** Prior C-Section 0.04 *** 0.11 *** 0.45 0.35 *** No Prior C -Section 0.60 ^^^ 274 TECHNICAL APPENDICES

293 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Interpregnancy Interval *** 0.54 ** ^^^ 0.36 No Prior Birth 0.39 *** 0.16 0.11 *** ^^^ 0.21 Short Interpregnancy Interval ^^^ 0.27 0.34 *** Norm al Interpregnancy Interval 0.34 0.11 Interpregnancy Interval Unknown *** 0.09 ** 0.08 Current Pregnancy Risk Factors from Depression 0.71 0.57 *** ^^^ Not Depressed at Intake 0.66 *** 0.22 *** 0.21 0.32 ^^^ Depressed at Intake 0.07 Depression Unknown ^^^ *** 0.11 0.13 Anxiet y ^^^ No Anxiety at Intake 0.59 *** 0.48 *** 0.66 ^^^ Anxiety at Intake *** 0.31 0.31 0.45 Unknown 0.07 *** ^^^ 0.04 Anxiety *** 0.10 Food Insecurity 0.75 Not Food Insecure at Intake 0.79 ^^^ *** 0.67 *** *** 0.14 Food Insecure at Intake 0.17 ^^^ *** 0.24 0.11 *** 0.09 *** ^^^ 0.04 Food Insecurity Score Unknown Pregnancy Intent Intended *** Pregnancy 0.39 ^^^ 0.31 0.23 *** 0.59 0.69 ** 0.65 *** ^^^ Unintended Pregnancy 0.02 Pregnancy Intent Unknown 0.04 *** 0.08 ^^^ *** - Pre Pregnancy Hypertension No Pre- Pregnancy Hypertension 0.99 ^^^ 0.92 0.92 *** Pre 0.05 *** 0.03 *** ^^^ 0.01 Pregnancy Hypertension - *** - Pregnancy Hypertension Unknown Pre 0.00 ^^^ *** 0.05 0.03 Pre - Pregnancy Diabetes No Pre 0.50 *** ^^^ 1.00 Pregnancy Diabetes - *** 0.93 0.02 * 0.03 - Pregnancy Diabetes 0.00 ^^^ *** Pre 0.00 0.48 *** ^^^ *** Pre - 0.04 Pregnancy Diabetes Unknown Prenatal Visit BMI At First 0.03 0.04 *** Underweight (<18.5 BMI) 0.04 *** Normal Weight (18.5 0.32 0.26 *** ^^^ 0.48 -<25 BMI) 0.17 ^^^ 0.23 *** <30 BMI) 0.23 ight (25- Overwe Obese (30 0.24 *** 0.20 *** 0.18 <40 BMI) - (>=40 BMI) Very Obese 0.03 *** 0.04 *** 0.09 ^^^ *** 0.10 0.03 BMI Unknown 0.29 *** Smoking 0.67 *** 0.58 *** ^^^ 0.78 Did not Smoke at Intake Smoked at Intake 0.28 0.30 *** ^^^ 0.14 Smoking Status Unknown 0.05 *** 0.08 ^^^ *** 0.12 Intimate Partner Violence 0.76 No History of Intimate Partner Violence 0.66 0.66 *** ^^^ 0.22 0.29 *** ^^^ History of Intimate Partner Violence *** 0.24 History of Intimate Partner 0.05 *** ^^^ 0.02 0.09 *** Violence Unknown Year 0.19 0.28 *** ^^^ 0.29 2013 and 2014 *** ^^^ 0.32 2015 0.38 0.39 0.24 *** ^^^ 0.27 2016 and 2017 ** 0.20 Region Northeast 0.22 ^^^ *** *** 0.09 0.13 Midwest *** 0.20 *** ^^^ 0.03 0.00 0.06 0.49 South ^^^ *** 0.00 *** 0.71 0.46 0.67 West *** *** ^^ Notes: Sample limited to white women with nonmissing data. Significance calculated using pairwise comparison of means test. tes significance at the 0.05 level; and three ** One asterisk ( ) indica *) indicates significance at the 0.1 level; two asterisks ( asterisks (***) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret (^ ) in dicates significance at the 0.1 level; two carets ( ^^ ) indicates significance at the 0.05 level; and three carets ( ^^^ ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TECHNICAL APPENDICES 275

294 TABLE M. 5: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE OUTCOMES ANALYTIC SAMPLE, WHITE WOMEN EXCLUDING MUSC, UAB, AND UPR Model Measure Maternity Care Homes Group Prenatal Care Birth Centers Sample Size 3,782 870 3,518 ~ Outcomes Means 0.07 Gestational Diabetes 0.03 0.06 ^^^ *** 0.03 ^^ 0.01 Preeclampsia 0.04 *** *** Demographic Characteristics Age 0.04 Less than 18 Years Old 0.02 ^^^ 0.05 *** 0.06 18 to 19 Years of Age ^^^ 0.13 ** 0.10 *** ^^^ 0.76 0.82 ** 0.79 20 to 34 Years of Age *** ^^^ 0.10 35 Years of Age or Older 0.06 0.06 *** Education 0.10 Less than High School 0.22 0.11 *** *** ** 0.58 0.56 High School Graduate / GED 0.54 0.05 * 0.07 ^^^ 0.18 Bachelor's Degree *** 0.09 0.10 ^^^ 0.14 Other Degree *** 0.15 0.09 Education Unknown 0.02 ^^^ *** *** Status Relationship 0.25 ** 0.29 ^^^ 0.48 Married *** 0.33 0.37 0.39 ^^^ Living with a Partner *** In a Relationship, Not Living Together ^^^ 0.16 0.10 0.20 *** *** 0.13 a Relationship 0.08 ^^^ 0.12 Not in *** 0.01 Relationship Status Unknown ^^^ 0.04 ** 0.06 *** Employment/School Working, Not in School 0.39 0.33 0.35 ^^^ *** In School, Not Working 0.07 ^^^ 0.10 0.09 *** 0.05 Working and in School 0.04 * 0.05 0.49 0.47 Neither Working nor in School 0.48 Status Unknown Work/School 0.05 0.03 *** 0.02 *** from Prior Birth Risk Factors Prior Preterm Birth *** ** 0.39 0.55 0.36 No Prior Birth ^^^ *** 0.08 Prior Preterm Birth 0.13 *** 0.10 0.36 0.48 *** *** ^^^ 0.56 No Prior Preterm Birth Prior Low Birth Weight ** 0.55 *** No Prior Birth 0.36 ^^^ 0.39 *** 0.07 Prior Low Birth Weight Birth 0.01 ^^^ *** 0.03 0.63 *** 0.50 *** 0.21 ^^^ No Prior Low Birth Weight Birth 0.00 Prior Low Birth Weight Unknown 0.04 ^^^ *** 0.22 *** Prior C - Section 0.36 No Prior Birth 0.55 ** ^^^ *** 0.39 Prior C-Section *** 0.11 *** ^^^ 0.04 0.16 0.45 *** 0.60 No P ^^^ *** Section C- 0.35 rior Interpregnancy Interval No Prior Birth 0.36 ^^^ ** 0.55 *** 0.39 0.16 0.10 *** ^^^ Short Interpregnancy Interval *** 0.21 0.26 ^^^ 0.34 Normal Interpregnancy Interval 0.33 *** 0.08 *** 0.09 *** 0.12 Interpregnancy Interval Unknown Risk Factors from Current Pregnancy Depression *** Not Depressed at Intake 0.71 0.66 0.57 *** ^^^ 0.20 *** 0.22 essed at Intake Depr 0.32 *** ^^^ Dep 0.07 *** ^^^ ression Unknown 0.11 ** 0.14 Anxiety No Anxiety at Intake 0.66 ^^^ *** 0.48 *** 0.60 Anxiety at Intake 0.31 ^^^ 0.46 *** 0.29 *** Anxiety Unknown 0.04 ^^^ *** 0.07 0.11 APPENDICES 276 TECHNICAL

295 Model Measure Group Prenatal Care Birth Centers Maternity Care Homes Food Insecurity *** 0.74 0.67 *** ^^^ 0.79 Not Food Insecure at Intake ^^^ 0.13 *** 0.24 *** 0.17 Food Insecure at Intake 0.13 *** Food Insecur 0.09 *** ^^^ 0.04 ity Score Unknown Pregnancy Intent ^^^ 0.31 Intended Pregnancy 0.39 *** *** 0.24 Unintended Pregnancy *** ^^^ 0.59 0.65 0.68 Pregnancy Intent Unknown 0.09 ^^ 0.02 *** 0.04 *** Pregnancy Hypertension Pre - ^^^ *** 0.91 0.93 No Pre - Pregnancy Hypertension 0.99 * 0.03 *** ^^^ 0.01 Pregnancy Hypertension - Pre 0.05 0.00 0.03 Pre - Pregnancy Hypertension Unknown *** ^^^ *** 0.05 Pre - Pregnancy Diabete s No Pre- Pregnancy Diabetes 1.00 ^^^ *** 0.49 *** 0.93 0.03 0.02 Pre - Pregnancy Diabetes 0.00 ^^^ *** Pre 0.04 *** 0.49 *** ^^^ 0.00 Pregnancy Diabetes Unknown - BMI At First Prenatal Visit *** 0.03 0.04 Underweight (<18.5 BMI) 0.04 *** 0.32 0.26 Normal Weight (18.5 ^^^ 0.48 <25 BMI) - *** Overweight (25 - <30 BMI) ^^^ 0.18 *** 0.23 0.23 *** 0.23 0.19 *** 0.18 <40 BMI) - Obese (30 *** 0.08 Very Obese (>=40 BMI) 0.03 *** 0.04 0.11 0.03 0.29 *** ^^^ *** BMI Unknown Smoking Did not Smoke at Intake 0.78 ^^^ *** 0.58 *** 0.67 Smoked at Intake ** 0.30 *** ^^^ 0.14 0.27 Smoking Status Unknown 0.06 *** 0.12 *** ^^^ 0.08 Intimate Partner Violence 0.76 0.66 0.66 *** ^^^ No History of Intimate Partner Violence *** History of Intimate Partner Violence 0.22 ^^^ ** 0.29 0.24 History of Intimate Partner 0.10 0.02 ^^^ *** 0.06 *** Violence Unknown Year 2013 and 2014 0.19 ^^^ *** 0.28 0.29 *** 2015 0.32 ^^^ 0.39 0.38 0.24 ** 0.20 *** ^^^ 0.27 2016 and 2017 Region Northeast 0.22 ^^^ *** 0.13 ** 0.10 ** * Midwest 0.03 ^^^ 0.20 0.00 *** ^^^ *** 0.06 0.55 0.00 *** South 0.67 West 0.71 *** *** 0.40 ^^ Notes: Sample limited to white women with nonmissing data and excludes participants at the Medical College of South Carolina, the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately * ) indicates enrolled high- One asterisk ( risk women. Significance calculated using pairwise comparison of means test. *** ** significanc ) indicate ) indicates significance at the 0.05 level; and three asterisks ( e at the 0.1 level; two asterisks ( ^ ) indicates significance significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret ( ^^ ^^^ the ) indicates significance at ) indicates significance at the 0.05 level; and three carets ( at the 0.1 level; two carets ( l for the difference in means from Group Prenatal Care. 0.01 leve TABLE M. 6: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE O UTCOMES ANALYTIC SAM PLE, BLACK WOMEN Model Measure Maternity Care Homes Group Prenatal Care Birth Centers 1,113 8,363 2,878 Sample Size Means Outcomes ^^^ Gestational Diabetes 0.01 *** 0.04 *** 0.06 0.07 Preeclampsia 0.02 ^^^ *** 0.08 *** Demographic Characteristics Age 0.06 ** Less than 18 Years Old 0.04 ^^^ *** 0.07 TECHNICAL APPENDICES 277

296 Model Measure Group Prenatal Care Maternity Care Homes Birth Centers 18 to 19 Years of Age 0.08 ^^^ ** 0.13 *** 0.10 0.81 ^^^ 0.75 0.76 20 to 34 Years of Age *** 0.07 *** 0.05 ^^ 0.07 35 Years of Age or Older Education 0.24 * *** ^^^ 0.18 0.22 Less than High School High School Graduate / GED 0.59 0.61 0.61 Bachelor's Degree 0.11 ^^^ *** 0.03 ** 0.04 0.09 Other Degree * 0.07 ** ^^^ 0.10 0.06 *** 0.04 Education Unknown 0.02 ^^^ *** Relationship Status 0.10 ** 0.09 *** ^^^ Married 0.25 0.24 Living with a Partner 0.25 0.26 *** 0.33 *** ^^^ 0.27 In a Relationship, Not Living Together 0.38 Not in a Relationship 0.25 ** 0.23 *** 0.21 Relationship Status Unknown 0.03 *** 0.09 ** ^^^ 0.02 Employment/School Working, Not in School 0.34 0.33 0.34 0.14 In School, Not Working 0.14 0.14 0.06 0.06 0.05 Working and in School 0.43 0.43 0.45 Neither Working nor in School 0.01 Work/School ^^^ ** 0.04 *** 0.02 Status Unknown Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth ^^^ 0.51 0.38 *** 0.40 0.10 Prior Preterm Birth 0.11 *** *** 0.17 0.50 0.45 No Prior Preterm Birth ^^^ *** 0.38 *** Prior Low Birth Weight 0.38 No Prior Birth ^^^ 0.51 *** 0.40 0.06 Prior Low Birth Weight Birth 0.02 ^^^ *** 0.10 *** 0.44 *** 0.36 *** ^^^ 0.52 Birth Weight Birth No Prior Low Prior Low Birth Weight Unknown 0.08 0.07 ** 0.06 Section Prior C - No Prior Birth *** 0.51 ^^^ 0.38 0.40 0.06 0.13 *** ^^^ - Prior C Section 0.17 *** 0.45 No Prior C Section 0.54 ^^^ *** 0.36 *** - Interpregnancy Interval 0.38 0.51 No Prior Birth 0.40 ^^^ *** *** Short Interpregnancy Interval 0.17 ^^^ *** 0.10 0.13 ^^^ 0.38 *** 0.26 0.34 Normal Interpregnancy Interval *** Interpregnancy Interval Unknown 0.11 *** 0.13 * ^^^ 0.09 Risk Factors from Current Pregnancy Depression Not 0.50 ^^^ 0.61 Depressed at Intake *** 0.62 Depressed at Intake * 0.30 0.31 0.29 0.08 Depression Unknown 0.10 ^^^ 0.19 *** Anxiety No Anxiety at Intake 0.59 ^^^ 0.48 *** 0.57 0.39 ^^^ 0.38 Anxiety at Intake *** 0.42 Anxiety Unknown 0.04 *** 0.10 ^^^ 0.03 Insecurity Food 0.66 *** 0.68 Not Food Insecure at Intake 0.74 *** ^^^ 0.20 0.21 *** 0.26 Food Insecure at Intake 0.06 *** 0.14 ^^^ 0.06 Food Insecurity Score Unknown Pregnancy Intent 0.25 Intended Pregnancy ^^^ *** 0.18 0.17 Unintended Pregnancy 0.73 ^ *** 0.75 *** 0.80 *** Pregnancy Intent Unknown 0.03 ^^^ 0.07 0.03 TECHNICAL 278 APPENDICES

297 Model Measure Maternity Care Homes Group Prenatal Care Birth Centers - Pre Pregnancy Hypertension Pregnancy Hypertension *** 0.78 *** ^^^ 0.97 0.88 - No Pre Pre 0.10 *** 0.13 *** ^^^ 0.02 Pregnancy Hypertension - -Pregnancy Hypertension Unknown 0.09 Pre 0.01 ^^^ ** *** 0.03 Pre - Pregnancy Diabetes No Pre 0.73 *** ^^^ 0.98 Pregnancy Diabetes - *** 0.92 0.03 -Pregnancy Diabetes 0.01 ^^^ *** 0.08 Pre *** Pre - Pregnancy Diabetes Unknown ^^^ *** 0.19 *** 0.05 0.02 BMI At First Prenatal Visit Underweight (<18.5 BMI) 0.03 0.03 0.03 0.26 Normal Weight (18.5 - <25 BMI) 0.40 ^^^ *** 0.27 - Overweight (25 <30 BMI) 0.25 ^^^ *** 0.19 ** 0.21 0.23 <40 BMI) *** 0.23 *** 0.28 - Obese (30 Very Obese 0.08 *** 0.12 *** 0.07 (>=40 BMI) 0.21 BMI Unknown *** 0.10 0.02 ^^^ *** Smoking *** Did not Smoke at Intake 0.82 ^^^ 0.70 0.81 0.08 ** 0.08 *** 0.11 Smoked at Intake 0.08 Smoking Status Unknown 0.10 ^^^ 0.22 *** Intimate Partner Violence No History of Intimate Partner Violence 0.79 0.80 0.78 * ^^^ 0.21 History of Intimate Partner Violence 0.17 *** 0.14 *** History of Intimate Partner Violence Unknown 0.02 ^^^ ** 0.08 *** 0.03 Year 2013 and 2014 0.19 *** 0.21 *** 0.25 2015 *** ^^^ 0.31 0.37 0.37 0.28 2016 and 2017 0.27 0.28 Region 0.14 *** Northeast 0.24 ^^^ *** 0.11 *** 0.00 Midwest 0.02 ^^^ *** 0.31 *** 0.16 South 0.11 ^^^ *** 0.00 West *** 0.65 *** ^^^ 0.82 0.78 nonmissing Sample limited to black women with Notes: data. Significance calculated using pairwise comparison of means test. significance at the 0.05 level; and three ** * ) indicates significance at the 0.1 level; two asterisks ( ) indicates One asterisk ( ) indicate asterisks ( significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret *** ^^^) ^^ ^ ) indicates significance at the 0.05 level; and three carets ( ) indicates significance at the 0.1 level; two carets ( ( indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TABLE M. MEN EXCLUDING TIC SAMPLE, BLACK WO 7: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE OUTCOMES ANALY MUSC, UAB, AND UPR Model Measure Maternity Care Homes Group Prenatal Care Birth Centers 6,959 Sample Size 1,113 2,875 Means Outcomes *** 0.06 0.01 0.04 *** Gestational Diabetes ^^^ 0.02 ^^^ *** 0.08 Preeclampsia *** 0.06 Characteristics Demographic Age *** 0.07 Less than 18 Years Old 0.04 ^^^ 0.07 0.10 *** 0.13 ** ^^^ 0.08 18 to 19 Years of Age ^^^ 0.81 0.76 0.75 *** 20 to 34 Years of Age 0.07 *** 0.05 ^^ 0.07 35 Years of Age or Older Education ^^^ 0.18 Less than High School 0.23 *** 0.22 0.59 High School Graduate / GED 0.60 0.61 Bachelor's Degree *** 0.11 ^^^ 0.04 * 0.03 Other Degree 0.10 ^^^ 0.07 *** 0.09 TECHNICAL APPENDICES 279

298 Model Measure Maternity Care Homes Group Prenatal Care Birth Centers *** ^^^ 0.05 Education Unknown 0.02 * 06 0. Relationship Status *** ^^^ 0.09 ** Married 0.11 0.25 0.25 0.25 Living with a Partner 0.25 *** In 0.27 ^^^ 0.33 0.36 a Relationship, Not Living Together *** *** 0.21 Not in a Relationship 0.25 ** 0.23 *** 0.02 ^^^ Relationship Status Unknown 0. 09 *** 0.04 Employment/School 0.33 0.34 Working, Not in School 0.34 0.15 0.14 0.14 In School, Not Working 0.06 0.05 Working and in School 0.06 0.43 0.43 0.45 Neither Working nor in School Status Unknown Work/School ** 0.04 ** ^^^ 0.01 0.03 Risk Factors from Prior Birth Prior Preterm Birth 0.40 No Prior Birth 0.38 *** 0.51 ^^^ *** *** 0.11 0.16 0.10 Prior Preterm Birth 0.46 0.38 ** ^^^ 0.50 No Prior Preterm Birth *** Prior Low Birth Weight 0.38 *** 0.51 ^^^ 0.40 No Prior Birth *** 0.02 Prior Low Birth Weight Birth ^^^ 0. 06 *** 0.08 0.45 No Prior Low Birth Weight Birth 0.52 ^^^ *** 0.36 *** Prior Low Birth Weight 0.06 *** 0.07 ** 0.09 Unknown -Section Prior C 0.40 ^^^ 0.51 0.38 No Prior Birth *** *** Section 0.06 0.16 *** 0.13 Prior C ^^^ - *** 0.45 Section 0.54 ^^^ *** 36 0. No Prior C- Interpregnancy Interval 0.40 No Prior Birth 0.38 *** 0.51 ^^^ *** ^^^ 0.13 *** 0.10 0.17 Interval Short Interpregnancy ** 0.37 *** 0.26 Normal Interpregnancy Interval 0.34 ^^^ 0.09 Interpregnancy Interval Unknown ^^^ ** 0.13 *** 0.11 Current Pregnancy Risk Factors from n Depressio 0.61 Not Depressed at Intake 0.62 *** 0.50 ^^^ 0.31 0.29 Depressed at 0.29 *** Intake 0.09 0.10 ^^^ 0.19 Depression Unknown *** Anxiety 0.48 No Anxiety at Intake 0.57 *** ^^^ 0.59 Anxiety at Intake 0.38 ^^^ 0.42 0.39 *** Anxiety Unknown 0.04 ^^^ 0.10 *** 0.03 Food Insecurity *** Not Food Insecure at Intake 0.68 0.66 *** 0.74 *** Food Insecure at Intake 0.26 ^^^ 0. 21 0.19 *** 0.14 ^^^ 0.06 Food Insecurity Score Unknown 0.07 Pregnancy Intent *** Intended Pregnancy 0.25 0. 18 ^^^ 0.18 *** Unintended Pregnancy *** ^ 0.73 0.79 0.75 0.03 *** 0.07 ^^^ 0.03 Pregnancy Intent Unknown n Pregnancy Hypertensio - Pre *** 0.89 - No Pre *** 0.78 ^^^ 0.97 Pregnancy Hypertension *** 0.08 *** Pre - Pregnancy Hypertension 0.02 ^^^ 0.13 ^^^ 0.01 Pregnancy Hypertension Unknown - Pre 0.03 *** 0.09 ** - Pre Pregnancy Diabetes *** Pregnancy Diabetes No Pre - 0.98 ^^^ 0.73 *** 0.92 Pre - Pregnancy Diabetes 0.01 ^^^ *** 0.08 *** 0.03 0.06 *** 0.19 Pre - Pregnancy Diabetes Unknown 0.02 ^^^ *** 280 TECHNICAL APPENDICES

299 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.03 0.03 0.03 Normal Weight (18.5 ^^^ 0.26 0.26 *** 0.40 <25 BMI) - Overweight (25- <30 BMI) 0.21 0.25 ^^^ *** 0.19 ** - <40 BMI) 0.23 *** 0.23 *** 0.27 Obese (30 *** Very Obese (>=40 BMI) 0.07 0.11 *** 0.08 *** 0.02 ^^^ *** 0.21 BMI Unknown 0.12 Smoking ^^^ 0.82 Did not Smoke at Intake 0.80 *** 0.70 Smoked at Intake 0.11 ** 0.08 *** 0.08 *** Smoking Status Unknown 0.10 0.10 0.22 ^^^ Intimate Partner Violence 0.78 No History of Intimate Partner Violence 0.79 0.80 ^^^ *** 0.14 *** 0.21 History of Intimate Partner Violence 0.17 0.03 *** 0.08 *** ^^^ 0.02 Unknown History of Intimate Partner Violence Year 0.19 0.23 0.21 *** 2013 and 2014 0.31 0.37 *** ^^^ 2015 0.36 0.29 2016 and 2017 0.28 * 0.27 Region 0.24 Northeast 0.13 0.14 *** ^^^ *** Midwest *** 0.31 0.02 0.00 ^^^ 0.11 South 0.19 *** 0.00 *** ^^^ 0.74 West ^^^ 0.65 *** 0.82 *** data and excludes participants at the Medical College of South Carolina, nonmissing ple limited to black women with Sam Notes: the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately risk women. Significance calculated using pairwise comparison of means test. One asterisk ( enrolled high- ) indicates * ) indicate ) indicates significance at the 0.05 level; and three asterisks ( at the 0.1 level; two asterisks ( ** *** significance significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret ( ) indicates significance ^ at the 0.1 level; two carets ( the ) indicates significance at ^^^ ) indicates significance at the 0.05 level; and three carets ( ^^ 0.01 level for the difference in means from Group Prenatal Care. 8: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE OUTCOMES ANALY TABLE M. WOMEN TIC SAMPLE, HISPANIC Model Measure Group Prenatal Care Birth Centers Maternity Care Homes 1,800 Sample Size 2,972 5,422 Outcomes Means 0.11 Gestational Diabetes 0.04 ^^^ *** 0.09 *** *** ^^^ 0.02 0.05 0.05 Preeclampsia Demographic Characteristics Age 0.05 0.06 Less than 18 Years Old *** ^^^ 0.03 * ^^^ * 0.10 ** 0.08 18 to 19 Years of Age 0.07 ** 0.71 0.73 *** ^^^ 20 to 34 Years of Age 0.82 ^^^ 0.09 0.14 *** 0.12 35 Years of Age or Older *** Education *** ^^^ 0.23 Less than High School 0.40 *** 0.32 ^^^ 0.52 High School Graduate / GED *** *** 0.43 0.38 0.03 Bachelor's Degree 0.07 ^^^ *** *** 0.02 0.09 ^^ *** 0.11 *** 0.07 Other Degree 0.08 Education Unknown 0.09 *** ^^^ 0.15 Relationship Status 0.38 0.28 0.27 *** Married ^^^ Living with a Partner 0.37 ** 0.39 0.37 *** 0.17 In a Relationship, Not Living Together 0.15 *** 0.22 *** 0.11 Not in a Relationship 0.08 ^^^ *** 0.14 0.03 *** Relationship Status Unknown 0.01 ^^^ 0.01 281 TECHNICAL APPENDICES

300 Model Measure Maternity Care Homes Group Prenatal Care Birth Centers Employment/School ^^^ Working, Not in School 0.35 *** 0.25 * 0.33 ** 10 0. 0.09 0.08 In School, Not Working ** 0.03 ^^^ 0.04 Working and in School 0.05 0.49 *** 0.58 *** ^^^ 0.52 Neither Working nor in School ^^^ 0.05 *** Work/School 0.02 Status Unknown 0.02 Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 0.34 *** 0.40 ^^^ 0.33 0.13 0.12 ^^^ 0.10 Prior Preterm Birth *** 0.57 No Prior Preterm Birth *** 0.48 *** 0.53 ^^^ Prior Low Birth Weight No Prior Birth 0.33 ^^^ *** 0.34 0.40 0.04 *** ^^^ 0.01 rior Low Birth Weight Birth P 0.07 *** 0.52 *** No Prior Low Birth Weight Birth 0.66 ^^^ *** 0.42 0.15 Prior Low Birth Weight Unknown 0.00 ^^^ *** *** 0.07 Prior C - Section No Prior Birth 0.33 ^^^ 0.40 *** 0.34 - 0.05 Prior C Section ^^^ 0.16 0.16 *** No Prior C 0.50 Section 0.62 *** 0.45 - ^^^ *** Interpregnancy Interval 0.34 *** 0.40 ^^^ 0.33 No Prior Birth 0.10 Short Interpregnancy Interval 0.11 *** ^^^ 0.17 0.36 ** 0.39 *** 0.40 Normal Interpregnancy Interval *** 0.11 0.19 Interval Unknown 0.10 Interpregnancy *** Risk Factors from Current Pregnancy Depression 0.74 0.63 *** *** ^^^ 0.70 Not Depressed at Intake 0.18 Depressed at Intake *** 0.20 ^ 0.17 0.12 ^^^ Depression Unknown 0.17 *** 0.09 *** Anxiety *** 0.67 0.69 No Anxiety at Intake 0.71 0.26 0.25 Anxiety at Intake 0.24 *** 0.08 ^^^ 0.05 0.04 Anxiety Unknown Food Insecurity *** 0.72 ^^^ Not Food Insecure at Intake 0.76 0.75 0.15 *** 0.19 ^^^ 0.17 Food Insecure at Intake ** 0.08 0.09 0.09 Food Insecurity Score Unknown Pregnancy Intent 0.42 Intended Pregnancy ^^^ *** 0.36 ** 0.39 ^^^ 0.59 0.60 ** 0.56 Unintended Pregnancy 0.02 Pregnancy Intent Unknown *** 0.04 ^^^ 0.02 Pre Pregnancy Hypertension - 0.99 *** 0.92 *** 0.94 Pregnancy Hypertension No Pre- ^^^ Hypertension Pregnancy 0.04 * - Pre ^^^ *** 0.01 0.05 Pregnancy Hypertension Unknown - Pre 0.01 *** *** ^^^ 0.00 0.03 - Pregnancy Diabetes Pre 0.82 *** ^^^ 1.00 No Pre 0.93 *** Pregnancy Diabetes - - *** Pregnancy Diabetes Pre 0.04 0.00 ^^^ 0.04 *** 0.13 *** ^^^ 0.00 Pre Pregnancy Diabetes Unknown - 0.03 BMI at First Prenatal Visit 0.03 Underweight (<18.5 BMI) *** 0.03 *** 0.02 * 0.27 Normal Weight (18.5 0.37 ^^^ *** 0.28 -<25 BMI) 0.30 <30 BMI) Overweight (25- 0.28 0.27 ** ^^ 0.23 - 0.30 *** 0.23 *** <40 BMI) Obese (30 Very Obese 0.07 *** 0.05 *** 0.04 (>=40 BMI) 0.06 *** 0.14 BMI Unknown 0.03 ^^^ *** Smoking *** Did not Smoke at Intake 0.87 *** 0.87 0.94 TECHNICAL 282 APPENDICES

301 Model Measure Group Prenatal Care Birth Centers Maternity Care Homes 0.02 0.03 0.02 Smoked at Intake * Smoking Status Unknown *** 0.11 *** 0.10 0.03 Intimate Partner Violence 0.80 0.82 ** No History of Intimate Partner Violence 0.83 *** 0.14 ** *** History of Intimate Partner Violence 0.15 0.17 History of Intimate Partner 0.03 *** ^^^ 0.02 0.04 Violence Unknown Year *** 0.26 *** 0.14 2013 and 2014 0.21 ^^^ 0.32 2015 0.30 *** 0.41 * ^^^ 0.24 *** 2016 and 2017 0.28 ^^ *** 0.40 Region *** *** 0.09 Northeast 0.13 0.22 ^^^ ^^^ Midwest 0.02 0.00 *** 0.20 *** *** South 0.10 ^^^ *** 0.00 0.25 ^^^ 0.62 West *** 0.76 *** 0.42 data. Significance calculated using pairwise comparison of means Notes: Sample limited to Hispanic women with nonmissing * ** ignificance at the 0.05 level; and One asterisk ( ) indicates significance at the 0.1 level; two asterisks ( ) indicates s test. three asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One *** caret ( ) indicates significance at the 0.05 level; and three carets ^^ ^ ) indicates significance at the 0.1 level; two carets ( ^^^ ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. ( 9: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE OUTCOMES ANALY TABLE M. WOMEN TIC SAMPLE, HISPANIC EXCLUDING MUSC, UAB, AND UPR Model Measure Group Prenatal Care Birth Centers Maternity Care Homes 1,800 2,413 5,364 Sample Size Means Outcomes 0.08 0.11 *** *** ^^^ 0.04 Gestational Diabetes 0.05 0.05 Preeclampsia ^^^ *** 0.02 Demographic Characteristics Age Less than 18 Years Old 0.03 *** 0.05 *** 0.06 ^^ 0.09 ^^^ 0.07 18 to 19 Years of Age 0.08 * 0.75 *** 0.71 20 to 34 Years of Age 0.82 ^^^ *** 0.09 ^^ *** 0.11 *** 0.15 35 Years of Age or Older Education *** ^^^ 0.23 Less than High School 0.40 0.41 0.37 0.52 ^^^ *** 0.42 *** High School Graduate / GED 0.02 0.07 Bachelor's Degree ^^^ *** 0.02 Other Degree 0.09 ^^^ *** 0.05 0.07 * 0.09 0.15 *** 0.08 ^^^ Education Unknown Relationship Status Married 0.38 0.29 0.28 ^^^ *** 0.37 0.37 0.37 Living with a Partner In a Relationship, Not Living Together 0.17 *** 0.15 *** 0.22 *** 0.08 tionship Not in a Rela 0.14 *** ^^^ 0.11 *** ^^^ 0.03 Relationship Status Unknown 0.01 0.01 Employment/School 0.33 ^^^ 0.26 Working, Not in School 0.35 *** * 0.08 ** 0.10 In School, Not Working *** 0.07 *** 0.03 Working and in School 0.05 ^^^ 0.05 *** 0.61 *** Neither Working nor in School ^^^ 0.52 0.49 0.02 *** 0.04 ^^^ 0.02 Status Unknown Work/School Risk Factors from Prior Birth Prior Preterm Birth ^^^ No Prior Birth 0.33 0.40 *** 0.34 0.13 *** 0.08 *** rm Birth 0.10 Prior Prete No Prior Preterm Birth 0.57 ^^^ *** 0.52 0.53 283 TECHNICAL APPENDICES

302 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Prior Low Birth Weight 0.33 No Prior Birth 0.40 ^^^ 0.34 *** Prior Low Birth Weight Birth 0.01 ^^^ *** 0.05 *** 0.07 *** No Prior Low Birth Weight Birth 0.66 ^^^ *** 0.45 0.52 0.10 Prior Low Birth Weight Unknown *** 0.00 ^^^ *** 0.07 - Section Prior C 0.34 0.40 No Prior Birth 0.33 ^^^ *** - 0.16 0.13 *** ^^^ 0.05 Section *** Prior C No Prior C - Section 0.62 ^^^ 0.50 * 0.48 *** Interpregnancy Interval ^^^ No Prior Birth 0.33 *** 0.34 0.40 Short Interpregnancy Interval 0.17 ^^^ *** 0.08 *** 0.11 *** 0.40 *** 0.40 Normal Interpregnancy Interval 0.36 0.10 0.19 *** 0.12 *** erpregnancy Interval Unknown Int ^ Risk Factors from Current Pregnancy Depressio n Not Depressed at Intake 0.70 *** 0.70 *** 0.74 Depressed at Intake 0.18 ^ 0.16 0.17 0.09 *** 0.12 Depression Unknown 0.14 *** ^^ Anxiety ^^^ 0.74 ** 0.71 Anxiety at Intake 0.69 No 0.19 Anxiety at Intake 0.26 ^^^ * 0.24 *** Anxiety Unknown ^^^ 0.08 *** 0.04 0.05 Food I nsecurity 0.75 0.76 ^ 0.73 Not Food Insecure at Intake * 0.17 Food Insecure at Intake 0.17 0.15 Food Insecurity Score Unknown 0.09 0.09 ** 0.08 Pregnancy Intent Intended Pregnancy 0.39 0.42 0.40 ** 0.59 Unintended Pregnancy 0.56 ** ** 0.56 ^^^ 0.02 Pregnancy Intent Unknown 0.02 *** 0.04 Pregnancy Hypertension - Pre Pregnancy Hypertension No Pre- 0.94 *** ^^^ 0.95 0.99 0.04 *** 0.02 *** ^ 0.01 Hypertension -Pregnancy Pre Pregnancy Hypertension Unknown 0.04 0.01 *** *** ^^^ 0.00 Pre - Pre - Pregnancy Diabetes 0.93 - No Pre ^^^ 1.00 Pregnancy Diabetes *** 0.81 *** *** 0.00 Pre - 0.05 0.01 Pregnancy Diabetes *** ^^^ *** *** 0.18 0.03 - Pre 0.00 Pregnancy Diabetes Unknown BMI at First Prenatal Visit 0.02 *** ^^^ 0.02 Underweight (<18.5 BMI) 0.03 * 0.27 0.37 <25 BMI) - Normal Weight (18.5 0.29 *** ^^^ 0.28 0.30 <30 BMI) Overweight (25- 0.30 ** ** Ob ese (30 -<40 BMI) 0.23 *** 0.30 *** 0.24 0.07 *** 0.04 (>=40 BMI) Very Obese 0.04 *** *** 0.11 *** 0.06 ^^^ BMI Unknown 0.03 Smokin g 0.88 Did not Smoke at Intake 0.87 0.94 *** *** ** 0.03 Smoked at Intake 0.02 0.02 *** 0.10 *** Smoking Status Unknown 0.10 0.03 Intimate Partner Violence *** 0.83 Partner Violence No History of Intimate 0.80 * 0.82 History of Intimate Partner Violence *** 0.14 ** 0.15 0.17 History of Intimate Partner *** 0.03 * ^^^ 0.02 0.04 Violence Unknown Year 0.14 0.29 0.21 *** *** ^^^ 2013 and 2014 0.30 0.32 *** 2015 ^^^ * 0.36 *** 2016 and 2017 0.28 ^^ *** 0.25 0.41 TECHNICAL 284 APPENDICES

303 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Region *** Northeast 0.22 ^^^ 0.13 *** 0.10 *** ^^^ 0.28 Midwest 0.02 *** 0.00 *** ^^^ 0.10 South 0.25 0.00 *** 0.41 ^^ *** 0.66 0.62 West *** data and excludes participants at the Medical College of South Notes: Sample limited to Hispanic women with nonmissing Carolina, the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately enrolled high-risk women. Significance calculated using pairwise comparison of means test. One ** * icance at the 0.05 level; and three ) indicates significance at the 0.1 level; two asterisks ( asterisk ( ) indicates signif asterisks Homes. ) indicate significance at the 0.01 level for the difference in means from Maternity Care One caret *** ( ^^ ) indicates significance at the 0.1 level; two carets ( ( ^ ) indicates significance at the 0.05 level; and three carets ( ) ^^^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. 10: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE OUTCOMES ANALYTIC SAMPLE, WOMEN WI TABLE M. TH OTHER/MULTIPLE RACE/ ETHNICITY Model Measure Maternity Care Homes Group Prenatal Care Birth Centers Sample Size 315 796 381 Means Outcomes 0.07 0.11 Gestational Diabetes 0.03 *** ^ ** 0.05 ** 0.02 Preeclampsia 0.04 Demographic Characteristics Age 0.02 ^^^ 0.07 *** 0.04 Less than 18 Years Old ^^^ 0.13 0.04 18 to 19 Years of Age *** 0.07 * *** ^^^ 0.85 20 to 34 Years of Age 0.76 0.73 *** Age or Older 0.09 0.13 ** 0.08 35 Years of Education ^^ 0.16 0.12 Less than High School 0.18 * 0.51 0.53 High School Graduate / GED 0.50 Bachelor's Degree 0.15 ^^^ 0.08 ** 0.13 ^ 0.17 Other Degree 0.12 0.15 *** 0.03 0.05 Education Unknown ^^^ 0.11 Status Relationship 0.25 ^^^ 0.39 Married 0.40 *** ** 0.27 Living with a Partner 0.37 *** 0.34 In a Relationship, Not Living Together 0.13 ^^^ ** 0.19 0.22 0.14 ^ 0.09 Not in a Relationship 0.13 0.02 ^^^ 0.05 *** 0.02 Relationship Status Unknown Employment/School 0.32 Working, Not in School 0.34 0.34 0.11 0.10 In School, Not Working ^ 0.15 ** Working and in School 0.10 ^^ ** 0.06 0.06 0.43 * 0.44 Neither Working nor in School * 0.49 0.03 0.03 0.02 Status Unknown Work/School Risk Factors from Prior Birth Preterm Birth Prior 0.42 No Prior Birth ** 0.55 ^^^ 0.47 0.09 0.07 Prior Preterm Birth 0.10 0.38 0.48 No Prior Preterm Birth 0.44 * ^^ Prior Low Birth Weight 0.42 ^^^ 0.55 No Prior Birth 0.47 ** 0.07 *** Prior Low Birth Weight Birth 0.00 *** 0.02 0.41 *** 0.30 No Prior Low Birth Weight Birth 0.57 ^^^ *** ^^^ 0.05 *** 0.12 *** Prior Low Birth Weight Unknown 0.01 Section Prior C - ** 0.55 ^^^ 0.42 No Prior Birth 0.47 0.14 *** 0.04 Section ^^^ * 0.10 Prior C - TECHNICAL APPENDICES 285

304 Model Measure Maternity Care Homes Group Prenatal Care Birth Centers No Prior C- 0.39 0.34 *** ^^^ 0.54 Section Interpregnancy Interval ** 0.55 0.42 No Prior Birth 0.47 ^^^ 0.12 ** ^^ 0.18 Short Interpregnancy Interval 0.13 Normal Interpregnancy Interval 0.34 ^^ * 0.25 0.29 Interpregnancy Interval Unknown 0.11 0.08 0.06 *** Risk Factors from Current Pregnancy Depression 0.70 Intake 0.68 0.58 *** ^^^ Not Depressed at Depressed at Intake 0.23 * 0.29 0.24 0.06 Depression Unknown ^^^ 0.13 ** 0.08 Anxiety No Anxiety at Intake 0.65 ^^^ 0.50 0.62 *** *** Anxiety at Intake ^^^ 0.43 0.33 0.33 Anxiety Unknown 0.02 * 0.07 0.05 ^^^ Food Insecurity 0.72 *** 0.61 *** ^^^ 0.80 Not Food Insecure at Intake 0.28 0.18 *** 0.19 ^^^ Food Insecure at Intake *** ^^^ 0.03 Food Insecurity Score Unknown 0.08 ** 0.12 Pregnancy Intent ** 0.35 Intended Pregnancy *** 0.41 0.29 Unintended Pregnancy *** 0.64 ** 0.62 0.56 0.03 ^^ 0.03 Pregnancy Intent Unknown 0.06 ** Pre -Pregnancy Hypertension ^^^ *** No Pre 0.87 *** - 0.92 Pregnancy Hypertension 1.00 Pregnancy Hypertension 0.00 ^^^ Pre *** - 0.05 0.05 0.03 0.08 Pre -Pregnancy Hypertension Unknown 0.00 ^^^ *** *** Pre - Pregnancy Diabetes *** *** ^^^ 0.99 Pregnancy Diabetes - No Pre 0.69 0.91 - Pre 0.03 * 0.01 Pregnancy Diabetes 0.03 0.00 *** 0.28 *** 0.06 - ^^^ Pre Pregnancy Diabetes Unknown BMI at First Prenatal Visit 0.04 0.04 0.05 Underweight (<18.5 BMI) ^^^ Normal Weight (18.5 0.46 - 0.30 *** 0.34 <25 BMI) Overweight (25 0.26 - <30 BMI) 0.23 0.19 ** * 0.19 - Obese (30 0.15 0.18 <40 BMI) 0.06 ** 0.04 (>=40 BMI) Very Obese 0.08 0.09 0.26 *** ^^^ BMI Unknown 0.04 *** Smoking 0.74 *** ^^ 0.80 Did not Smoke at Intake 0.87 *** 0.08 0.11 ^ 0.07 Smoked at Intake 0.04 0.15 *** Smoking Status Unknown 0.12 *** Intimate Partner Violence No History of Intimate Partner Violence 0.70 * 0.71 0.75 0.20 History of Intimate Partner Violence 0.28 ^ *** 0.23 0.05 0.07 *** History of Intimate Partner Violence Unknown 0.01 ^^^ Year 2013 and 2014 0.20 0.13 *** 0.28 ^^^ *** *** 0.30 2015 0.33 ^^ 0.41 0.25 0.41 *** 2016 and 2017 0.20 *** TECHNICAL APPENDICES 286

305 Model Measure Birth Centers Maternity Care Homes Group Prenatal Care Region ** Northeast 0.22 ^^^ ** 0.11 0.16 *** Midwest ** 0.29 0.03 0.00 ^^^ *** 0.00 *** 0.14 South 0.08 ^^^ 0.57 0.54 West 0.52 nonmissing limited to women with other/mixed race/ethnicity and Sample Notes: data. Significance calculated using pairwise ) indicates signif ) indicates significance at the 0.1 level; two asterisks ( comparison of means test. One asterisk ( * ** icance *** significance at the 0.01 level for the difference in means from ) indicate ( vel; and three asterisks at the 0.05 le ^^ ^ Maternity Care Homes. One caret ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the ignificance at the 0.01 level for the difference in means from Group ( hree carets ) indicates s ^^^ 0.05 level; and t Prenatal Care . TH 11: DESCRIPTIVE STATISTICS FOR THE INTERMEDIATE OUTCOMES ANALYTIC SAMPLE, WOMEN WI TABLE M. ETHNICITY EXCLUDING MUSC, UAB, AND OTHER/MULTIPLE RACE/ UPR Model Measure Maternity Care Homes Birth Centers Group Prenatal Care 381 Sample Size 782 315 Means Outcomes *** *** ^ 0.03 0.07 0.11 Gestational Diabetes Preeclampsia ** 0.04 0.05 0.02 Demographic Characteristics Age 0.04 0.07 ^^^ 0.02 18 Years Old Less than *** *** 0.13 ^^^ 0.04 18 to 19 Years of Age 0.07 * 0.76 0.73 *** ^^^ 0.85 20 to 34 Years of Age *** 0.08 ** 0.09 35 Years of Age or Older 0.13 Education 0.12 0.18 * ^^ 0.16 Less than High School 0.50 High School Graduate / GED 0.53 0.51 Bachelor's Degree ** 0.08 ^^^ 0.13 0.15 ^ Other Degree 0.17 0.12 0.15 Education Unknown 0.05 *** 0.03 0.11 ^^^ Relationship Status 0.40 *** 0.25 ^^^ 0.39 Married 0.27 *** Living with a Partner 0.37 ** 0.34 ** 0.13 In a Relationship, Not Living Together ^^^ 0.19 0.22 ^ 0.12 0.14 Not in a Relationship 0.09 Relationship Status Unknown 0.02 0.02 ^^^ 0.05 *** Employment/School Working, Not in School 0.34 0.31 0.34 ** 0.15 ^ 0.10 0.11 In School, Not Working ** ^^ 0.10 Working and in School 0.06 0.06 0.49 * 0.43 * 0.44 Neither Working nor in School 0.03 Work/School Status Unknown 0.02 0.03 Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 0.42 ^^^ 0.55 ** 0.47 0.09 Prior Preterm Birth 0.10 0.07 0.44 No Prior Preterm Birth 0.48 ^^ 0.38 * Prior Low Birth Weight 0.47 No Prior Birth 0.42 ^^^ 0.55 ** 0.06 Prior Low Birth Weight Birth 0.00 *** 0.02 *** 0.42 No Prior Low Birth Weight Birth 0.57 ^^^ *** 0.30 *** 0.05 Prior Low Birth Weight Unknown 0.01 ^^^ *** 0.12 *** Prior C - Section 0.47 No Prior Birth 0.42 ^^^ 0.55 ** 0.14 * Prior C - Section 0.04 ^^^ *** 0.10 TECHNICAL APPENDICES 287

306 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes 0.39 No Prior C- Section 0.54 ^^^ *** 0.34 Interpregnancy Interval 0.47 ** 0.55 ^^^ 0.42 No Prior Birth Short Interpregnancy Interval ^^ ** 0.12 0.18 0.13 ^^ 0.34 Normal Interpregnancy Interval 0.29 0.25 * *** Interpregnancy Interval Unknown 0.11 0.08 0.06 Risk Factors from Current Pregnancy Depression Not Depressed at Intake 0.70 0.68 *** 0.58 ^^^ Depressed at Intake * 0.23 0.24 0.29 ** 0.09 Depression Unknown 0.06 ^^^ 0.13 Anxiety 0.65 Intake No Anxiety at 0.62 *** 0.50 ^^^ Anxiety at Intake 0.33 *** 0.43 ^^^ 0.33 0.02 Anxiety Unknown ^^^ * 0.07 0.05 Food Insecurity ^^^ *** 0.61 *** 0.80 Not Food Insecure at Intake 0.73 0.28 ^^^ 0.18 Food Insecure at Intake *** 0.19 0.12 Food Insecurity Score Unknown 0.03 ^^^ *** * 0.08 Pregnancy Intent 0.29 ** Intended Pregnancy 0.41 0.35 *** 0.56 0.64 ** 0.62 *** Unintended Pregnancy 0.03 0.03 ^^ 0.06 ** Pregnancy Intent Unknown Pre -Pregnancy Hypertension 0.87 *** ^^^ 1.00 Pregnancy Hypertension 0.92 *** No Pre - *** 0.05 0.05 Pre - Pregnancy Hypertension 0.00 ^^^ *** ^^^ 0.00 -Pregnancy Hypertension Unknown Pre 0.03 *** 0.08 Pre - Pregnancy Diabetes - 0.69 0.91 *** No Pre *** Pregnancy Diabetes 0.99 ^^^ - Pre 0.03 Pregnancy Diabetes 0.01 * 0.03 0.06 *** 0.28 *** ^^^ 0.00 Pregnancy Diabetes Unknown - Pre BMI at First Prenatal Visit 0.04 0.05 0.04 Underweight (<18.5 BMI) 0.46 Normal Weight (18.5 ^^^ 0.34 0.30 *** <25 BMI) - - ** 0.19 0.23 <30 BMI) 0.26 Overweight (25 0.20 0.15 0.18 - Obese (30 <40 BMI) * 0.06 (>=40 BMI) 0.04 ** 0.07 Very Obese 0.26 0.09 *** ^^^ BMI Unknown *** 0.04 Smoking Did not Smoke at Intake 0.87 0.80 ^^ *** 0.74 *** 08 0. 0.11 ^ 0.07 Smoked at Intake Smoking Status Unknown *** 0.15 *** 0.12 0.04 Intimate Partner Violence 0.70 0.71 No History of Intimate Partner Violence 0.75 0.20 0.23 *** ^ 0.28 History of Intimate Partner Violence 0.01 0.05 0.07 *** ^^^ Unknown History of Intimate Partner Violence Year 2013 and 2014 0.20 ^^^ 0.13 *** 0.28 *** 2015 0.33 ^^ 0.41 *** 0.29 *** 2016 and 2017 0.25 *** 0.20 0.41 TECHNICAL 288 APPENDICES

307 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Region 0.22 0.11 Northeast ^^^ ** ** 0.17 Midwest 0.03 ^^^ ** 0.29 *** 0.00 0.14 *** 0.00 *** ^^^ 0.08 South West 0.57 0.54 0.51 * data and excludes participants at the Medical nonmissing ple limited to women with other/mixed race/ethnicity and Sam Notes: College of South Carolina, the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately enrolled high- risk women. Significance calculated using pairwise co mparison of means test. * ** significance at the 0.05 level; and three ) indicates ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret *** ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ( ) ^^^ ^^ ^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. BIRTH OUTCOMES AN ALYSIS TABLE M. 12: CONSTRUCTION OF TH E ANALYTIC SAMPLE FO R BIRTH OUTCOMES ANA LYSIS # of Remaining Logic for Dropping Observations # Excluded Observations Starting Sample: Number of Strong Start participants with PLPE data 45,316 - Dropping participants without an exit form 831 44,485 Dropping participants without an intake form 42,186 2,299 Dropping participants with a miscarriage or elective termination 40,856 1,330 585 40,271 Dropping participants with multiples Dropping participants missing an outcome variable (preterm, birthweight, or 28,944 11,327 delivery method) 612 28,332 Dropping participants missing any covariates - 28,332 Final analytic sample Among the 11,327 dropped due to missing outcome data: 53.9% dropped out of SS; 34.9% did not drop out of SS; Notes: and11.2% do not have data on SS drop out. TABLE M. 13: DESCRIPTIVE STATISTICS FOR THE BIRTH O UTCOMES ANALYTIC SAM PLE Model Measure Group Prenatal Care Maternity Care Homes Birth Centers Sample Size 16,930 5,978 5,424 Means Outcomes ^^^ *** 0.11 *** 0.13 Preterm Birth 0.04 0.10 * 0.11 Low Birth Weight ^^^ 0.04 *** 0.30 Section 0.13 ^^^ *** - 0.31 C Demographic Characteristics Race/Ethnicity *** 0.23 *** ^^^ 0.54 White 0.12 ^^^ 0.28 Hispanic *** 0.43 0.25 *** 0.15 Black ^^^ 0.41 *** *** 0.46 0.04 *** ^^ 0.04 ** Other 0.05 Age ^^^ 0.02 *** 0.07 *** 0.06 Less than 18 Years Old 0.06 *** 18 to 19 Years of Age 0.11 *** ^^^ 0.10 ^^^ 0.74 *** 0.83 *** 0.75 20 to 34 Years of Age 0.09 ** Older 0.09 0.08 35 Years of Age or Education *** ^^^ *** 0.28 Less than High School 0.26 0.14 0.50 0.55 0.54 ^^^ *** High School Graduate / GED 0.03 *** 0.04 *** ^^^ 0.15 Bachelor's Degree 0.08 *** ** Other Degree 0.09 ^^^ 0.13 ^^^ 0.06 *** 0.11 Education Unknown 0.03 *** TECHNICAL APPENDICES 289

308 Model Measure Care Homes Maternity Group Prenatal Care Birth Centers Relationship Status ^^^ Married 0.44 0.20 *** 0.20 0.34 0.33 0.30 *** Living with a Partner *** *** 0.24 *** 0.29 0.13 ^^^ In a Relationship, Not Living Together ^^^ *** 0.17 * 0.18 Not in a Relationship 0.09 0.03 *** 0.05 *** ^^^ 0.01 Relationship Status Unknown Employment/School 0.34 Working, Not in School 0.38 ^^^ *** 0.30 *** In School, Not Working 0.08 ^^^ 0.12 0.12 *** 0.06 Working and in School ^ * 0.05 0.05 0.50 Neither Working nor in School ^^^ *** 0.46 0.47 0.04 *** ^^^ 0.02 Status Unknown Work/School 0.03 *** Risk Factors from Prior Birth Prior Preterm Birth 0.36 No Prior Birth 0.36 0.46 ^^^ *** ^^^ 0.11 *** 0.08 *** Prior Preterm Birth 0.15 No Prior Preterm Birth 0.56 ^^^ *** 0.43 *** 0.48 Prior Low Birth Weight No Prior Birth 0.36 0.36 ^^^ 0.46 *** *** ^^^ 0.01 Birth Weight Birth 0.09 *** Prior Low 0.05 No Prior Low Birth Weight Birth 0.62 ^^^ *** 0.37 *** 0.46 0.09 ^^^ 0.01 Prior Low Birth Weight Unknown *** *** 0.12 Section - Prior C ^^^ 0.46 0.36 0.36 No Prior Birth *** Prior C - Section 0.05 ^^^ *** 0.15 *** 0.17 *** No Prior C - Section 0.59 ^^^ 0.39 *** 0.46 Interpregnancy Interval No Prior Birth 0.36 *** 0.46 ^^^ 0.36 *** ^^^ 0.20 Short Interpregnancy Interval 0.14 *** 0.10 *** Normal Interpregnancy Interval 0.32 ^^^ 0.36 * 0.37 0.08 ^^^ *** Interpregnancy Interval Unknown 0.11 0.13 ** Current Pregnancy Risk Factors from Depression 0.57 0.67 *** ^^^ 0.71 Not Depressed at Intake *** 0.23 *** ^^^ *** 0.21 Depressed at Intake 0.27 0.10 Depression Unknown 0.08 ^^^ *** 0.16 *** Anxiety *** ^^^ 0.67 0.57 0.62 No Anxiety at Intake *** 0.29 0.32 *** 0.36 Anxiety at Intake ^^^ *** ^^^ Anxiety Unknown 0.06 *** 0.04 0.07 *** Food Insecurity *** Not Food Insecure at Intake ^^^ *** 0.75 0.78 0.69 *** 0.17 Food Insecure at Intake 0.17 ^^^ 0.21 0.10 *** 0.05 Food Insecurity Score Unknown ^^^ 0.08 *** Pregnancy Intent *** ^^^ 0.38 *** 0.28 Intended Pregnancy 0.26 Unintended Pregnancy ^^^ 0.71 0.59 *** 0.67 *** Pregnancy Intent Unknown 0.02 0.04 0.04 *** ^^^ - Pregnancy Hypertension Pre ^^^ 0.99 Pregnancy Hypertension - No Pre 0.84 ** 0.83 *** 0.08 0.07 Pre ^^^ *** *** 0.01 Hypertension Pregnancy - 0.09 *** ^^^ 0.00 Pregnancy Hypertension Unknown - Pre 0.09 - Pregnancy Diabetes Pre *** No Pre- 0.99 ^^^ *** 0.72 Pregnancy Diabetes 0.86 *** 0.00 Pregnancy Diabetes - Pre 0.06 *** 0.03 ^^^ 0.00 Pregnancy Diabetes Unknown - Pre 0.22 *** 0.11 *** ^^^ BMI at First Prenatal Visit ^^ Underweight (<18.5 BMI) 0.04 *** 0.03 *** 0.02 *** 0.28 ^^^ Normal Weight (18.5 - <25 BMI) 0.45 0.27 APPENDICES TECHNICAL 290

309 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes - ^^ 0.23 0.23 *** 0.25 <30 BMI) Overweight (25 0.26 *** 0.22 ^^^ 0.20 <40 BMI) - Obese (30 *** Very Obese (>=40 BMI) 0.04 *** *** 0.06 ^^^ 0.09 *** 0.12 BMI Unknown 0.03 ^^^ *** 0.18 Smoking *** 0.82 0.77 ^^^ 0.83 Did not Smoke at Intake *** 0.08 0.12 0.08 Smoked at Intake *** 0.15 *** 0.06 Smoking Status Unknown 0.10 ^^^ *** Intimate Partner Violence No History of Intimate Partner Violence 0.79 0.79 0.78 History of Intimate Partner Violence 0.20 ^^^ *** 0.17 ** 0.18 0.04 History of Intimate Partner 0.05 0.02 ^^^ *** Unknown Violence Year ^^^ 0.29 *** 0.25 2013 and 2014 0.25 0.40 2015 *** ^^^ 0.44 ** 0.42 *** 0.34 2016 and 2017 0.35 ^^^ 0.27 Region 0.00 *** 0.24 *** Northeast 0.03 ^^^ Midwest 0.09 ^^^ *** 0.00 *** 0.26 0.66 *** 0.71 *** 0.62 ^^^ South 0.12 0.22 *** 0.05 West *** ^^^ data. Significance calculated using pairwise comparison of means test. One Notes: Sample limited to women with nonmissing * ** icance at the 0.05 level; and three ) indicates significance at the 0.1 level; two asterisks ( ) indicates signif asterisk ( ) indicate ( asterisks significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret *** ) indicates significance at the 0.05 level; and three carets ( ) indicates significance at the 0.1 level; two carets ( ^ ^^ ^^^ ( ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. E -SECTION SAMPL 14: DESCRIPTIVE STATISTICS FOR THE NULLIPAROUS C TABLE M. Model Measure Group Prenatal Care Maternity Care Homes Birth Centers 2,758 6,134 1,942 Sample Size Outcomes Means *** 0.28 0.27 C - Section 0.17 ^^^ Demographic Characteristics Race/Ethnicity 0.14 White 0.54 ^^^ *** *** 0.23 *** 0.22 0.25 ^^^ Hispanic ** 0.36 ** Black 0.18 ^^^ *** 0.45 0.47 ^ Other 0.06 *** 0.05 0.05 Age 0.14 *** 0.13 ^^^ 0.06 Less than 18 Years Old ^^^ 0.13 0.20 0.20 *** 18 to 19 Years of Age ^^^ 0.63 0.76 0.65 *** 20 to 34 Years of Age 0.03 *** ^^^ 0.05 35 Years of Age or Older 0.03 Education 0.14 Less than High School *** 0.27 0.24 *** ^^^ High School Graduate / GED 0.55 *** ^ 0.54 0.52 ^^^ Bachelor's Degree 0.17 *** 0.04 0.04 0.12 ^^^ *** 0.09 0.08 Other Degree 0.02 *** ^^^ 0.11 0.06 *** Education Unknown Relationship Status 0.11 ^^^ *** Married 0.12 0.28 Living with a Partner 0.28 * 0.30 *** ^^^ 0.39 0.36 In a Relationship, Not Living Together 0.30 *** ^^^ 0.19 *** 0.21 *** 0.21 ^^^ Not in a Relationship 0.13 *** 0.03 Relationship Status Unknown 0.01 ^^^ *** 0.06 Employment/School 0.30 *** 0.31 Working, Not in School 0.44 ^^^ TECHNICAL APPENDICES 291

310 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes *** In School, Not Working 0.13 ^^^ 0.19 0.21 *** 0.09 ^^ 0.07 0.08 Working and in School ^^^ 0.38 Neither Working nor in School 0.33 *** 0.41 *** *** ^^^ 0.01 Status Unknown Work/School 0.02 0.04 *** Risk Factors from Prior Birth Prior Preterm Birth 1.00 ^^^ *** 1.00 *** 1.00 No Prior Birth Prior Preterm Birth 0.00 ^^^ *** 0.00 0.00 *** *** 0.00 No Prior Preterm Birth 0.00 *** 0.00 ^^^ Prior Low Birth Weight 1.00 ^^^ No Prior Birth *** 1.00 *** 1.00 0.00 Prior Low Birth Weight Birth *** *** 0.00 ^^^ 0.00 0.00 *** 0.00 *** ^^^ No Prior Low Birth Weight Birth 0.00 0.00 *** 0.00 *** 0.00 Prior Low Birth Weight Unknown ^^^ Prior C - Section 1.00 ^^^ *** 1.00 1.00 No Prior Birth *** 0.00 ^^^ *** Prior C - 0.00 *** 0.00 Section No Prior C - 0.00 ^^^ Section *** 0.00 *** 0.00 Interpregnancy Interval *** No Prior Birth 1.00 1.00 *** 1.00 ^^^ *** 0.00 0.00 Short Interpregnancy Interval 0.00 ^^^ *** Normal Interpregnancy Interval 0.00 ^^^ *** 0.00 *** 0.00 0.00 Interpregnancy Interval Unknown *** 0.00 *** ^^^ 0.00 Risk Factors from Current Pregnancy Depression 0.58 ^^^ 0.71 Not Depressed at Intake 0.70 *** ^^^ 0.22 Depressed at Intake 0.21 0.27 *** Depression Unknown 0.16 *** 0.09 0.08 ^^^ Anxiety *** 0.53 ^^^ 0.64 No Anxiety at Intake 0.63 0.39 Anxiety at Intake *** ^^^ 0.32 0.33 *** 0.05 Anxiety Unknown 0.03 ^^^ *** 0.08 Food Insecurity ^^^ 0.77 *** 0.77 Not Food Insecure at Intake 0.69 0.22 Food Insecure at Intake 0.19 ^^^ *** *** 0.16 0.04 *** 0.09 0.07 Food Insecurity Score Unknown ^^^ *** Pregnancy Intent 0.25 ** 0.23 ^^^ 0.33 Intended Pregnancy *** 0.70 *** 0.74 Unintended Pregnancy ^^^ 0.65 *** Pregnancy Intent Unknown 0.02 ^^^ ** 0.05 0.03 *** Pre - Pregnancy Hypertension Pregnancy Hypertension 0.99 ^^^ 0.83 *** 0.86 No Pre *** - Pre 0.07 *** 0.05 -Pregnancy Hypertension 0.00 ^^^ *** -Pregnancy Hypertension Unknown 0.09 ** 0.11 0.00 ^^^ Pre *** Pregnancy Diabetes - Pre Diabetes Pregnancy 0.86 *** 0.71 *** ^^^ - No Pre 0.99 *** ^^^ 0.01 Pregnancy Diabetes - Pre 0.03 *** 0.05 ^^^ Pre 0.00 0.23 *** *** 0.11 Pregnancy Diabetes Unknown - BMI at First Prenatal Visit 0.04 0.04 *** ^ Underweight (<18.5 BMI) 0.06 0.33 *** Normal Weight (18.5 - <25 BMI) 0.51 0.34 ^^^ <30 BMI) 0.22 0.22 0.22 - Overweight (25 *** Obese (30 0.21 *** -<40 BMI) 0.19 ^^ 0.16 0.05 *** 0.07 ^^^ 0.03 Very Obese (>=40 BMI) *** *** 0.03 BMI Unknown 0.13 0.17 ^^^ *** Smoking 0.78 ^^^ 0.84 *** Did not Smoke at Intake 0.85 0.09 *** *** Smoked at Intake 0.07 0.07 0.06 ^^^ *** *** 0.15 0.09 Smoking Status Unknown TECHNICAL 292 APPENDICES

311 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Intimate Partner Violence 0.82 0.80 *** ^ No History of Intimate Partner Violence 0.79 *** 0.14 History of Intimate Partner Violence 0.20 ^^^ 0.14 History of Intimate Partner *** ^^^ 0.01 0.04 0.05 *** Violence Unknown Year 2013 and 2014 0.26 ^^^ 0.30 *** 0.25 *** 2015 0.42 0.41 0.44 ^ ^^^ ** 0.25 *** 0.35 2016 and 2017 0.32 Region ^^^ 0.25 0.00 0.04 *** Northeast *** 0.00 0.24 *** ^^^ Midwest 0.08 *** *** ^^^ * 0.63 0.61 South 0.68 ^^^ West 0.15 *** 0.06 *** 0.25 Sample limited to nulliparous women with nonmissing data. Significance calculated using pairwise comparison of means Notes: * es significance at the 0.05 level; and ) indicat test. One asterisk ( ) indicates significance at the 0.1 level; two asterisks ( ** three asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One *** dicates significance at the 0.1 level; two carets ( ^ ) in caret ( ^^ ) indicates significance at the 0.05 level; and three carets ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. ^^^ ( LE TABLE M. 15: DESCRIPTIVE STATISTICS FOR THE VBAC SAMP Model Measure Maternity Care Homes Group Prenatal Care Birth Centers 2,933 916 292 Sample Size Outcomes Means *** 0.21 ^^^ 0.29 0.17 *** VBAC Demographic Characteristics Race/Ethnicity 0.47 White *** ^^^ *** 0.09 0.20 0.28 *** ^^^ 0.28 Hispanic 0.49 0.48 Black 0.20 ^^^ *** 0.39 *** Other 0.04 0.03 0.05 Age ^^^ 0.02 *** 0.01 Less than 18 Years Old 0.00 0.01 0.03 0.03 18 to 19 Years of Age 20 to 34 Years of Age ^^^ 0.81 0.81 *** 0.88 ** 0.14 0.16 35 Years of Age or Older 0.10 Education 0.28 *** 0.23 *** ^^ 0.15 Less than High School High School Graduate / GED 0.61 ^^^ *** 0.49 * 0.52 ^^ *** 0.05 ** 0.03 Bachelor's Degree 0.08 Other Degree 0.10 0.12 0.10 Education Unknown ^^^ 0.06 *** 0.12 0.05 Relationship Status Married 0.25 0.26 *** 0.41 ^^^ 0.37 0.34 Living with a Partner 0.32 *** *** 0.17 *** ^^ 0.24 0.11 In a Relationship, Not Living Together ^ 0.12 Not in a Relationship 0.16 0.16 ** 0.03 ^ 0.03 0.01 Relationship Status Unknown Employment/School 0.29 0.38 0.36 School Working, Not in ^^ *** In School, Not Working 0.07 0.06 0.05 0.04 Working and in School 0.03 0.03 0.50 *** 0.58 ^ 0.52 Neither Working nor in School 0.01 Status Unknown 0.04 Work/School * ^^ 0.03 Risk Factors from Prior Birth Prior Preterm Birth *** 0.00 No Prior Birth 0.00 ^^^ *** 0.00 Prior Preterm Birth 0.18 ^^^ *** 0.27 0.29 TECHNICAL APPENDICES 293

312 Model Measure Maternity Care Homes Group Prenatal Care Birth Centers 0.71 0.73 *** ^^^ No Prior Preterm Birth 0.82 ~ Prior Low Birth Weight 0. 00 *** 0. ^^^ No Prior Birth *** 00 0. 00 0. ^^^ *** *** 0. 0. 11 Prior Low Birth Weight Birth 02 18 No Prior Low Birth Weight Birth 0.95 ^^^ *** 0.69 0.71 *** 0.12 ^^^ Prior Low Birth Weight Unknown 0.03 *** 0.21 - Section Prior C No Prior Birth 0.00 ^^^ *** 0.00 *** 0.00 1.00 Section - Prior C ^^^ 1.00 *** 1.00 *** - 0.00 No Prior C *** Section 0.00 ^^^ *** 0.00 Interpregnancy Interval *** No Prior Birth 0.00 0.00 *** 0.00 ^^^ 19 0. ** ^^ 24 0. Short Interpregnancy Interval 0.19 Normal Interpregnancy Interval 0.60 0.59 0.60 0.21 0.17 0.20 Interpregnancy Interval Unknown Current Pregnancy Risk Factors from Depression 0.65 *** 0.54 ^^^ 0.66 Depressed at Intake Not 0.26 ** 0.30 ^ Depressed at Intake 0.24 ^^^ 0.09 Depression Unknown 0.09 *** 0.16 Anxiety 0.61 No Anxiety at Intake 0.60 ** 0.56 * 0. 34 Anxiety at Intake 0. 38 0.35 0.06 0.06 0.04 Anxiety Unknown Food Insecurity 0.73 ^^ 0.66 *** 0.74 Not Food Insecure at Intake Food Insecure at Intake 0.22 0.19 0.18 *** Food Insecurity Score Unknown 0.08 0.08 *** ^^ 0.11 Pregnancy Intent *** 0.26 0.37 0.26 Intended Pregnancy ^^^ 0.71 0.63 0.70 ** ^^ Unintended Pregnancy 0.00 ^^ *** 0.03 0.04 Intent Unknown Pregnancy Pregnancy Hypertension - Pre 0.84 82 0. *** ^^^ 99 Pregnancy Hypertension No Pre- 0. - *** 0.13 0.12 Pregnancy Hypertension 0.01 ^^^ Pre - Pregnancy Hypertension Unknown 0.00 ^^^ *** 0.05 0.04 Pre Pregnancy Diabetes Pre - 1.00 ^^^ *** 0.73 *** 0.87 No Pre - Pregnancy Diabetes 0.08 Pre - 0.07 *** ^^^ Pregnancy Diabetes 0.00 *** 0.19 *** ^^^ 0.00 Pre - 0.06 Pregnancy Diabetes Unknown BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.02 0.02 0.01 20 27 ^^ *** 0. 0. 0.18 -<25 BMI) Normal Weight (18.5 <30 BMI) 29 22 Overweight (25- 26 ** ** 0. 0. 0. 0.34 - 0.31 Obese (30 0.28 <40 BMI) *** *** *** 0.11 0.17 Very Obese 0.09 (>=40 BMI) 0.03 ^^^ *** 0.14 *** 0.08 BMI Unknown Smoking 0.80 Did not Smoke at Intake 0.77 0.74 *** 0.15 Smoked at Intake *** 0.11 0.13 *** 0.05 *** 0.15 ^^^ 0.10 Smoking Status Unknown Intimate Partner Violence 0. 80 * 0. 77 0.75 No History of Intimate Partner Violence History of Intimate Partner Violence 0.18 0.21 0.19 History of Intimate Partner 0.04 0.02 04 0. ** Violence Unknown Year 0.25 2013 and 2014 0.28 0.25 *** ^^^ 0. ** 0. 0. 48 2015 35 41 TECHNICAL APPENDICES 294

313 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes 0.37 0.33 *** 0.27 ^^^ 2016 and 2017 Region 0.04 Northeast ^^^ *** 0.24 *** 0.00 0.24 0.00 *** ^^^ 0.09 Midwest *** 0.72 0.63 *** 0.72 *** South 0.14 0.13 West 0.04 *** ^^^ Notes: VBAC = vaginal birth after C -Section. Sample limited to women with a prior C -Section with nonmissing data. Significance * calculated using pairwise comparison of means test. One asterisk ( ) indicates significance at the 0.1 level; two asterisks significance at the 0.01 level for the significance at the 0.05 level; and three asterisks ( ) indicate ** *** es ( ) indicat ) ^^ ^ ) indicates significance at the 0.1 level; two carets ( difference in means from Maternity Care Homes. One caret ( ) indicates significance at the 0.01 level for the difference in indicates significance at the 0.05 level; and three carets ( ^^^ means from Group Prenatal Care. 16: DESCRIPTIVE STATISTICS FOR THE BIRTH O TABLE M. UTCOMES ANALYTIC SAM PLE, EXCLUDING MUSC, UAB, A ND UPR Model Measure Maternity Care Homes Group Prenatal Care Birth Centers Sample Size 5,253 15,115 5,424 ~ Outcomes Means *** Preterm Birth ^^^ *** 0.10 0.04 0.12 ^^^ 0.09 ** 0.10 0.04 Low Birth Weight *** *** - C Section 0.13 ^^^ 0.28 *** 0.30 Characteristics Demographic Race/Ethnicity 0.13 0.54 White 0.23 *** ^^^ *** Hispanic 0.25 *** ^^^ 0.36 *** 0.30 *** Black *** 0.42 ^^^ 0.15 0.46 ** Other 0.04 *** 0.05 0.05 Age 0.06 ^^^ *** 0.02 0.06 Less Than 18 Years Old ** f Age 18 To 19 Years o *** ^^^ 0.12 *** 0.10 0.06 0.75 0.74 ^^^ *** 0.83 of 20 To 34 Years Age Age of 35 Years 0.10 0.07 ^^^ 0.09 Older or *** Education ^^^ 0.28 0.28 *** Less Than High School 0.14 High School Graduate / Ged 0.55 *** ^^^ 0.51 ** 0.53 0.04 *** ^^^ Bachelor's Degree 0.03 0.15 *** ^^^ 0.07 Other Degree 0.13 *** 0.09 *** ^^^ 0.10 0.03 *** 0.07 Education Unknown Relationship Status 0.20 Married ^^^ 0.44 0.21 *** 0.33 Partner a ** 0.31 * 0.32 Living With In a Relationship, Not Living Together ^^^ 0.25 *** 0.27 *** 0.13 Not in a 0.18 0.18 *** 0.09 tionship Rela ^^^ 0.05 *** 0.03 Relationship Status Unknown *** ^^^ 0.01 Employment/School 0.34 0.38 Not in School Working, *** 0.31 ^^^ *** In School, Not Working *** ^^^ 0.11 0.12 0.08 0.05 0.05 ^ * 0.06 In School and Working Neither Working nor in School 0.47 ^^^ 0.50 *** 0.46 0.03 ^^^ *** 0.02 Status Unknown Work/School 0.03 Risk Factors from Prior Birth Prior Preterm Birth ^^^ 0.47 *** No Prior Birth 0.36 0.36 ^^^ 0.14 *** *** 0.08 Prior Preterm Birth 0.10 No Prior Preterm Birth ^^^ 0.43 *** 0.50 *** 0.56 Birth Weight Prior Low 0.36 *** 0.47 ^^^ 0.36 No Prior Birth Prior Low Birth Weight Birth 0.07 0.01 *** ^^^ 0.05 *** *** 0.38 0.46 No Prior Low Birth Weight Birth 0.62 *** ^^^ TECHNICAL APPENDICES 295

314 Model Measure Maternity Care Homes Group Prenatal Care Birth Centers 0.10 *** ^^^ 0.01 Prior Low Birth Weight Unknown 0.10 ~ Prior C Section - 0.36 *** 0.47 ^^^ 0.36 No Prior Birth 0.17 *** 0.14 *** ^^^ -Section Prior C 0.05 No Prior C Section 0.59 ^^^ *** - *** 0.47 0.39 Interpregnancy Interval No Prior Birth 0.36 ^^^ 0.47 *** 0.36 0.14 *** ^^^ 0.20 Short Interpregnancy Interval 0.10 *** 0.36 ^^^ 0.32 *** 0.37 Normal Interpregnancy Interval *** 0.13 0.12 *** ^^^ 0.08 Interpregnancy Interval Unknown Current Pregnancy Risk Factors from Depression Not Depressed 0.68 *** 0.59 *** ^^^ 0.71 at Intake 0.26 Depressed at Intake 0.21 ^^^ * *** 0.22 Depression Unknown 0.08 ^^^ *** 0.15 *** 0.10 Anxiety *** 0.63 *** 0.58 ^^^ 0.67 Intake at No Anxiety Intake *** 0.35 0.31 Anxiety at 0.29 ^^^ ** 0.07 ^^^ 0.04 *** 0.06 *** Anxiety Unknown Food Insecurity 0.75 0.78 Intake at Not Food Insecure *** *** ^^^ 0.69 0.17 ^^^ at * 0.21 *** 0.16 Food Insecure Intake 0.10 *** 0.08 Food Insecurity Score Unknown ^^^ 0.05 *** Pregnancy Intent *** ^^^ 0.38 Intended Pregnancy 0.27 ** 0.28 ** Unintended Pregnancy 0.59 0.69 0.67 ^^^ *** 0.04 Pregnancy Intent Unknown 0.02 ^^^ *** 0.04 Pregnancy Hypertension - Pre *** ^^^ 0.99 Hypertension Pregnancy - No Pre 0.84 ** 0.83 0.06 *** 0.07 *** ^^^ 0.01 Pregnancy Hypertension - Pre Pre 0.00 ^^^ *** 0.10 0.10 Pregnancy Hypertension Unknown - Pre - Pregnancy Diabetes Pregnancy Diabetes No Pre- 0.85 *** 0.70 *** ^^^ 0.99 0.03 *** 0.04 *** ^^^ 0.00 -Pregnancy Diabetes Pre Pre *** ^^^ 0.00 Pregnancy Diabetes Unknown - 0.12 0.25 *** BMI At First Prenatal Visit * 0.02 0.03 ^^^ 0.04 Underweight (<18.5 BMI) *** 0.28 *** ^^^ 0.45 ) 0.27 <25 BMI - Normal Weight (18.5 *** <30 BMI) - 0.23 Overweight (25 0.24 0.25 Obese (30 0.26 *** 0.22 *** ^^^ 0.20 BMI) <40 - Very Obese ) 0.04 ^^^ *** 0.06 0.09 *** (>=40 BMI *** BMI 0.13 Unknown 0.03 ^^^ *** 0.18 Smoking 0.82 ^^^ at Intake 0.76 Did Not Smoke 0.83 *** Smoked 0.08 *** 0.11 Intake at 0.08 *** 0.10 Smoking Status Unknown ^^^ 0.07 *** 0.15 *** Intimate Partner Violence 0.78 Intimate Partner Violence 0.79 0.78 No History of 0.20 Intimate Partner Violence of History *** 0.18 0.17 ^^^ History of Intimate Partner 0.02 0.05 ^^^ *** 0. 05 Violence Unknown Year *** 0.30 2013 and 2014 0.25 ^^^ *** 0.23 0.43 ^^^ 0.40 * 2015 0.41 ^^^ 0.35 2016 and 2017 0.35 *** 0.28 TECHNICAL APPENDICES 296

315 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Region *** 0.27 *** ^^^ 0.03 Northeast 0.00 0.09 0.29 Midwest ^^^ *** 0.00 *** South 0.66 *** 0.67 *** 0.57 0.22 ^^^ *** West 0.06 *** 0.14 nonmissing Sample limited to women with Notes: data and excludes participants at the Medical College of South Carolina, the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately ) indicates One asterisk ( risk women. Significance calculated using pairwise comparison of means test. enrolled high- * significance at ** *** ) indicate ) indicates significance at the 0.05 level; and three asterisks ( the 0.1 level; two asterisks ( ^ significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret ( ) indicates significance ^^^ ^^ ) indicates significance at the 0.05 level; and three carets ( at the 0.1 level; two carets ( ) indicates significance at the the difference in means from Group Prenatal Care. 0.01 level for LE, EXCLUDING MUSC, UAB, AND UPR -SECTION SAMP 17: DESCRIPTIVE STATISTICS FOR THE NULLIPIAROUS C TABLE M. Model Measure Group Prenatal Care Birth Centers Maternity Care Homes Sample Size 1,942 2,468 5,502 Outcomes Means *** ^^^ 0.27 0.27 - C Section 0.17 Demographic Characteristics Race/Ethnicity ^^^ 0.15 0.24 White 0.54 *** *** 0.22 *** 0.29 0.27 Hispanic ^^^ Black 0.44 0.50 ^^^ *** *** 0.18 Other 0.05 0.06 ** 0.06 Age 0.12 ^^^ 0.06 0.14 *** ** Less than 18 Years Old 0.20 0.20 ^^^ *** 0.13 18 to 19 Years of Age 0.63 20 to 34 Years of Age 0.76 ^^^ 0.65 ** *** 0.05 35 Years of Age or Older 0.02 ^^^ *** 0.03 Education 0.14 Less than High School *** 0.28 ** 0.26 ^^^ 0.54 0.54 0.54 High School Graduate / GED 0.04 *** ^^^ 0.17 0.04 Bachelor's Degree ** Other Degree 0.12 0.07 *** ^^^ 0.08 0.06 Education Unknown 0.02 *** ^^^ 0.10 *** Relationship Status 0.12 0.12 *** 0.28 ^^^ Married *** ^^^ 0.30 0.29 0.39 Living with a Partner *** 0.31 ^^^ *** 0.19 In a Relationship, Not Living Together 0.35 *** ^^^ 0.22 0.21 Relationship 0.13 Not in a 0.03 *** *** ^^^ 0.06 Relationship Status Unknown 0.01 Employment/School 0.30 0.44 0.31 ^^^ Working, Not in School *** 0.13 *** In School, Not Working *** 0.21 0.18 ^^^ 0.08 ^ 0.09 Working and in School 0.07 Neither Working nor in School 0.41 *** ^^^ 0.33 *** 0.38 Work/School Status Unknown 0.01 ^^^ *** * 0.03 0.03 Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 1.00 *** ^^^ *** 1.00 1.00 Prior Preterm Birth 0.00 *** 0.00 *** ^^^ 0.00 0.00 *** 0.00 No Prior Preterm Birth 0.00 *** ^^^ Prior Low Birth Weight 1.00 *** 1.00 *** ^^^ No Prior Birth 1.00 *** 0.00 0.00 ^^^ *** Prior Low Birth Weight Birth 0.00 *** 0.00 ^^^ *** No Prior Low Birth Weight Birth 0.00 0.00 ^^^ *** 0.00 *** 0.00 0.00 Prior Low Birth Weight Unknown TECHNICAL APPENDICES 297

316 Model Measure Maternity Care Homes Group Prenatal Care Birth Centers - Prior C Section ^^^ No Prior Birth 1.00 *** 1.00 *** 1.00 -Section 0.00 0.00 *** ^^^ 0.00 *** Prior C *** 0.00 0.00 *** Section No Prior C- 0.00 ^^^ Interpregnancy Interval 1.00 ^^^ *** 1.00 No Prior Birth 1.00 *** Short Interpregnancy Interval 0.00 *** ^^^ 0.00 *** 0.00 0.00 *** 0.00 ^^^ *** 0.00 Normal Interpregnancy Interval 0.00 *** *** 0.00 Interpregnancy Interval Unknown ^^^ 0.00 Current Pregnancy Risk Factors from Depression 0.71 0.71 Not Depressed at Intake *** ^^^ 0.59 0.20 *** 0.27 ^^^ 0.22 Depressed at Intake pression Unknown De 0.08 ** ^^^ 0.15 *** 0.09 Anxiety 0.54 *** 0.64 0.64 ^^^ No Anxiety at Intake *** 0.39 ^^^ * 0.33 0.31 Anxiety at Intake 0.07 *** *** ^^^ 0.03 Anxiety Unknown 0.05 Food Insecurity 0.69 *** 0.77 Not Food Insecure at Intake 0.77 ^^^ *** 0.15 0.19 Insecure at Intake Food *** 0.22 ^^^ *** ^^^ *** 0.10 0.04 Food Insecurity Score Unknown 0.08 Pregnancy Intent ^^^ *** 0.33 Intended Pregnancy 0.24 0.25 Unintended Pregnancy 0.72 ^^^ 0.70 *** 0.65 ** 0.04 *** 0.05 ^^^ *** 0.02 Pregnancy Intent Unknown Pregnancy Hypertension - Pre *** 0.99 Pregnancy Hypertension - No Pre *** 0.82 0.86 ^^^ ^^^ - Pre Pregnancy Hypertension 0.00 *** 0.06 0.04 *** Pregnancy Hypertension Unknown 0.00 *** Pre 0.10 - ^^^ 0.12 *** Pregnancy Diabetes - Pre 0.86 No Pre 0.69 ^^^ *** *** 0.99 Pregnancy Diabetes - 0.01 *** ^^^ Pre 0.05 *** 0.02 -Pregnancy Diabetes -Pregnancy Diabetes Unknown 0.26 *** *** ^^^ 0.12 0.00 Pre BMI at First Prenatal Visit 0.06 *** Underweight (<18.5 BMI) ^^^ 0.04 0.04 <25 BMI) 0.51 *** ^^^ 0.32 - Normal Weight (18.5 0.34 0.22 0.23 0.22 <30 BMI) - (25 Overweight ^^ ** 0.21 - Obese (30 <40 BMI) 0.16 *** 0.19 Very Obese ^^^ 0.06 *** *** 0.03 (>=40 BMI) 0.05 0.18 BMI Unknown 0.03 *** ^^^ 0.14 *** Smoking 0.77 ^^^ 0.84 Did not Smoke at Intake *** 0.85 Smoked at Intake 0.08 0.07 0.07 ** Smoking *** 0.09 ^^^ 0.16 *** 0.07 Status Unknown Intimate Partner Violence 0.82 * 0.80 0.79 No History of Intimate Partner Violence *** 0.14 0.14 History of Intimate Partner Violence 0.20 *** ^^^ History of Intimate Partner 0.06 ^^^ *** *** 0.01 0.04 Violence Unknown Year 0.23 *** ^^^ *** 0.31 2013 and 2014 0.26 0.43 0.41 0.42 2015 0.32 0.36 *** 2016 and 2017 0.26 ^^^ *** TECHNICAL APPENDICES 298

317 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Region Northeast ^^^ 0.28 *** 0.04 *** 0.00 ^^^ *** 0.08 Midwest 0.27 *** 0.00 0.56 0.65 *** *** 0.63 South West *** 0.07 ^^^ *** 0.25 0.17 nonmissing Sample limited to nulliparous women with Notes: data and excludes participants at the Medical College of South Carolina, the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately enrolled high-ri Significance calculated using pairwise comparison of means test. One women. sk * ** s significance at the 0.05 level; and three ) indicate ) indicates significance at the 0.1 level; two asterisks ( asterisk ( asterisks *** ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret ) indicates significance at the 0.05 level; and three carets ( ) indicates significance at the 0.1 level; two carets ( ( ) ^^^ ^^ ^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TABLE M. 18: DESCRIPTIVE STATISTICS FOR THE VBAC SAMPLE, EXCLUDING MUSC, UAB, AND UPR Model Measure Group Prenatal Care Maternity Care Homes Birth Centers Sample Size 292 726 2,568 Outcomes Means VBAC 0.29 *** ^^^ 0.22 *** 0.17 Demographic Characteristics Race/Ethnicity *** 0.47 *** ^^^ White 0.11 0.20 ** Hispanic 0.28 ^^ 0.36 0.32 0.44 0.20 Black *** ^^^ 0.49 ** 0.04 Other 0.05 0.04 Age 0.01 0.02 ^^^ 0.00 Less than 18 Years Old *** 0.03 0.03 0.01 18 to 19 Years of Age 0.81 0.82 ^^ *** 0.88 20 to 34 Years of Age 0.13 * 0.16 35 Years of Age or Older 0.10 ** Education *** 0.28 0.15 0.26 ^^^ Less than High School 0.61 High School Graduate / GED 0.51 *** 0.51 ^^^ 0.03 ^^^ *** 0.08 Bachelor's Degree 0.04 0.10 0.08 * 0.11 Other Degree 0.07 0.05 Education Unknown ^^^ *** 0.10 Relationship Status 0.26 0.41 *** ^^^ 0.28 Married 0.33 Living with a Partner 0.34 0.33 0.22 *** 0.18 ^^ *** In a Relationship, Not Living Together 0.11 Not in a Relationship * ^^ 0.17 0.16 0.12 ^ * 0.01 Relationship Status Unknown 0.03 0.04 Employment/School 0.38 *** Working, Not in School 0.30 ^ 0.36 In School, Not Working 0.07 0.05 0.06 0.03 0.03 Working and in School 0.04 Neither Working nor in School 0.52 ^ 0.59 *** 0.49 ^ 0.03 ** Work/School Status Unknown 0.01 0.04 Risk Factors from Prior Birth Prior Preterm Birth 0.00 ^^^ *** 0.00 No Prior Birth *** 0.00 0.24 ^ *** 0.27 Prior Preterm Birth 0.18 0.82 ^ 0.76 *** No Prior Preterm Birth 0.73 Low Birth Weight Prior No Prior Birth 0.00 *** ^^^ 0.00 *** 0.00 * ^^^ 0.16 0.13 Prior Low Birth Weight Birth 0.02 *** * ^^^ 0.69 0.72 *** No Prior Low Birth Weight Birth 0.95 Prior Low Birth Weight Unknown *** ^^^ 0.12 0.18 *** 0.03 TECHNICAL APPENDICES 299

318 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Prior C - Section 0.00 ^^^ No Prior Birth 0.00 *** *** 0.00 *** -Section 1.00 *** ^^^ 1.00 Prior C 1.00 * 0. No Prior C- ** Section 00 0.00 *** ^^^ 0.00 Interpregnancy Interval 0.00 0.00 No Prior Birth ^^^ 0.00 *** *** 0.19 ** 0.24 0.18 Short Interpregnancy Interval ^^ 0.59 0.58 Normal Interpregnancy Interval 0.59 0.17 0.24 ^^ * Interpregnancy Interval Unknown 0.22 Current Pregnancy Risk Factors from Depression 0.65 Not Depressed at Intake 0.66 ^^^ 0.56 *** 0.29 0.24 Depressed at Intake ** 0.25 Depression Unknown 0.09 ^^^ 0.15 *** 0.10 Anxiety 0.58 Anxiety at Intake No 0.61 0.60 Anxiety at Intake 0.35 0.35 0.33 0.07 0.07 0.04 Anxiety Unknown ^ Food Insecurity Not Food Insecure at Intake 0.73 ^ 0.68 *** 0.74 ** 0.17 0.21 0.19 Food Insecure at Intake 0.11 ^ 0.08 Food Insecurity Score Unknown 0.09 * Pregnancy Intent 0.28 Intended Pregnancy 0.37 ^^^ 0.27 *** 0.70 0.68 0.63 Unintended Pregnancy * ^^ 0.00 *** 0.04 0.04 ^^ Pregnancy Intent Unknown Pregnancy Hypertension Pre - 0.85 0.99 - *** Pregnancy Hypertension ^^^ 0.83 No Pre 0.11 0.11 Pre ^^^ *** 0.01 Pregnancy Hypertension - 0.04 Pre - Pregnancy Hypertension Unknown 0.00 *** ^^^ 0.06 * Pregnancy Diabetes - Pre 0.87 *** 0.70 ^^^ *** 1.00 Pregnancy Diabetes No Pre - ^^^ 0.06 0.06 *** -Pregnancy Diabetes 0.00 Pre *** 0.07 *** 0.24 ^^^ 0.00 -Pregnancy Diabetes Unknown Pre BMI at First Prenatal Visit 0.01 Underweight (<18.5 BMI) 0.01 0.02 ^^^ 0.19 0.18 Normal Weight (18.5 - <25 BMI) 0.27 *** Overweight (25 0.23 ** 0.27 ** 0.29 <30 BMI) - 0.34 *** 0.26 Obese (30 - 0.31 <40 BMI) Very Obese 0.11 *** 0.16 *** (>=40 BMI) 0.09 ^^^ 0.16 *** 0.08 *** 0.03 Unknown BMI Smoking Did not Smoke at Intake 0.77 ^ 0.72 *** 0.80 Sm oked at Intake 0.13 0.14 0.12 0.10 Smoking Status Unknown 0.16 *** 0.06 ^^^ ** Intimate Partner Violence No History of Intimate Partner Violence 0.80 * 0.76 0.75 0.18 0.20 History of Intimate Partner Violence 0.20 History of Intimate Partner ** 0.04 0.05 0.02 ^ Violence Unknown Year 0.28 2013 and 2014 0.24 * 0.27 2015 0.41 0.35 * ^^ 0.43 0.36 ^^ 0.30 *** 0.37 2016 and 2017 300 TECHNICAL APPENDICES

319 Model Measure Maternity Care Homes Group Prenatal Care Birth Centers Region 0.31 0.00 *** ^^^ *** 0.04 Northeast *** 0.27 0.09 *** ^^^ 0.00 Midwest South 0.72 *** ^^ 0.64 *** 0.58 0.15 West 0.14 ^^^ *** 0.05 Notes: -Section. Sample limited to women with a prior C -Section and nonmissing data and excludes VBAC = vaginal birth after C participants at the Medical College of South Carolina, the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately enrolled high- women. Significance calculated using risk * es ** ) indicat ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( mparison of means test. pairwise co significance at the 0.05 level; and three asterisks ) indicate significance at the 0.01 level for the difference in means *** ( ^ ^^ ) indicates significance at ) indicates significance at the 0.1 level; two carets ( One caret ( Homes. from Maternity Care the 0.05 level; and three carets ( ) indicates significance at the 0.01 level for the difference in means from Group ^^^ Prenatal Care. PLE, WHITE WOMEN TABLE M. 19: DESCRIPTIVE STATISTICS FOR THE BIRTH O UTCOMES ANALYTIC SAM Model Measure Group Prenatal Care Birth Centers Maternity Care Homes 2,921 703 3,829 Sample Size ~ Means Outcomes 0.11 0.09 ^^^ *** 0.04 Preterm Birth ** Low *** 0.03 ^^^ Birth Weight 0.08 0.09 0.31 C-Section 0.10 *** ^^^ 0.31 Demographic Characteristics Age Less than 18 Years Old 0.02 ^^^ 0.05 ** 0.04 *** 0.10 18 to 19 Years of Age 0.05 *** ^^^ 0.14 *** ^^^ 20 to 34 Years of Age 0.80 *** 0.74 *** 0.83 35 Years of 0.06 0.07 Age or Older 0.10 *** ^^^ Education 0.21 *** 0.12 ^^ *** 0.09 Less than High School 0.57 0.56 High School Graduate / GED 0.56 0.05 ** 0.07 ^^^ 0.20 Bachelor's Degree *** 0.10 ^^^ *** 0.14 Other Degree 0.10 Education Unknown 0.02 0.08 *** *** 0.14 ^^^ Relationship Status 0.29 *** 0.52 Married ^^^ 0.25 * 0.37 ^^^ *** 0.36 0.32 Living with a Partner In a Relationship, Not Living Together 0.09 *** ^^^ 0.18 * 0.21 Not in a Relationship 0.07 ^^^ 0.12 0.13 *** 0.05 Relationship Status Unknown 0.01 0.04 ^^^ *** Employment/School 0.40 Working, Not in School 0.34 0.33 ^^^ *** In School, Not Working ^^^ 0.10 0.09 0.07 *** 0.06 * 0.04 ** 0.05 Working and in School 0.49 Neither Working nor in School 0.46 * 0.48 Status Unknown 0.02 *** 0.03 *** 0.05 Work/School Factors from Prior Birth Risk Prior Preterm Birth 0.36 ^^^ 0.55 *** 0.38 No Prior Birth 0.07 0.14 *** 0.09 *** Prior Preterm Birth No Prior Preterm Birth 0.48 *** *** ^^^ 0.57 0.36 Prior Low Birth Weight 0.36 No Prior Birth ^^^ 0.55 0.38 *** 0.07 0.01 *** ^^ 0.03 Weight Birth Prior Low Birth *** *** 0.22 ^^^ *** No Prior Low Birth Weight Birth 0.64 0.43 ^^^ *** 0.20 0.12 *** Prior Low Birth Weight Unknown 0.00 Section Prior C - 0.38 0.55 ^^^ *** No Prior Birth 0.36 Prior C - Section 0.05 *** ^^^ 0.12 *** 0.15 301 TECHNICAL APPENDICES

320 Model Measure Maternity Care Homes Group Prenatal Care Birth Centers 0.47 *** 0.33 ^^^ *** 0.60 Section - C No Prior ~ Interpregnancy Interval 0.38 No Prior Birth 0.55 ^^^ 0.36 *** 0.17 *** 0.10 ^^^ *** 0.22 Short Interpregnancy Interval 0.34 ^^^ Normal Interpregnancy Interval *** 0.35 0.26 Interpregnancy Interval Unknown 0.08 *** 0.09 0.11 Current Pregnancy Risk Factors from Depression Not Depressed at Intake *** 0.68 0.74 ^^^ 0.56 *** Depressed at Intake ^^^ 0.33 *** 0.20 0.20 0.11 ^^^ *** * 0.06 0.13 Depression Unknown Anxiety 0.48 ^^^ 0.62 *** No Anxiety at Intake 0.68 *** Anxiety at Intake 0.29 ^^^ 0.28 0.46 *** Anxiety Unknown *** ^ 0.05 0.03 0.10 *** Food Insecurity ^^^ 0.81 Not Food Insecure at Intake *** *** 0.69 0.76 0.16 *** ^^^ 0.25 *** Food Insecure at Intake 0.13 *** ^^ 0.06 *** 0.11 Food Insecurity Score Unknown 0.03 Pregnancy Intent *** 0.41 Intended Pregnancy 0.24 *** 0.30 ^^^ 0.66 *** Unintended Pregnancy 0.57 0.69 ^^^ Pregnancy Intent Unknown *** 0.03 *** 0.02 0.07 -Pregnancy Hypertension Pre - No Pre 0.79 *** 0.91 ^^^ *** 0.99 Pregnancy Hypertension 0.05 Pre - Pregnancy Hypertension 0.01 *** ^^^ 0.04 * Pre - Pregnancy Hypertension Unknown 0.00 *** ^^^ 0.05 *** 0.16 Pre Pregnancy Diabetes - - 0.79 Pregnancy Diabetes 1.00 *** ^^^ 0.53 *** No Pre Pre 0.02 0.03 ^^^ *** 0.00 Pregnancy Diabetes - - ^^^ 0.45 *** 0.17 0.00 Pregnancy Diabetes Unknown Pre *** First Prenatal Visit BMI at ** Underweight (<18.5 BMI) 0.04 *** 0.04 0.02 0.28 ^^^ -<25 BMI) Normal Weight (18.5 *** 0.50 0.28 Overweight (25 <30 BMI) 0.23 ** ^^^ - 0.18 0.20 - <40 BMI) 0.17 0.21 Obese (30 *** ^ 0.20 Very Obese (>=40 BMI) 0.03 *** ^^ 0.05 *** 0.07 0.25 ^^^ *** 0.21 *** BMI Unknown 0.03 Smoking Did not Smoke at Intake 0.81 *** ^^^ 0.62 *** 0.68 0.28 ^^^ Smoked at Intake 0.11 *** 0.27 0.10 *** 0.08 0.05 *** Smoking Status Unknown Intimate Partner Violence 69 No History of Intimate Partner Violence 0.78 *** ^^^ 0.66 0. 0.23 *** History of Intimate Partner Violence 0.21 ** ^^^ 0.30 History of Intimate Partner 0.04 *** 0.09 *** ^^ 0.02 Unknown Violence Year 0.28 * 0.32 ^^^ *** 0.25 2013 and 2014 ^^ *** 2015 0.48 0.41 0.45 0.23 ^^^ *** 2016 and 2017 0.35 0.24 APPENDICES TECHNICAL 302

321 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Region *** 0.21 0.00 Northeast 0.04 *** ^^^ *** 0.53 Midwest 0.06 *** ^^^ 0.00 *** South 0.43 0.68 *** 0.66 0.04 ^^^ *** 0.24 *** West 0.10 Sample limited to white women with data. Significance calculated using pairwise comparison of means test. nonmissing Notes: significance at the 0.05 level; and three ** * ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( ) indicates asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret *** ( dicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ( ) ) in ^^^ ^^ ^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TABLE M. , WHITE WOMEN EXCLUDING MUSC, OMES ANALYTIC SAMPLE S FOR THE BIRTH OUTC ESCRIPTIVE STATISTIC 20: D UAB, AND UPR Model Measure Group Prenatal Care Maternity Care Homes Birth Centers Sample Size 2,921 693 3,453 Means Outcomes Preterm Birth 0.04 0.09 0.10 ^^^ *** Low Birth Weight 0.08 ^^^ 0.03 0.08 *** 0.10 Section C 0.30 0.31 ^^^ - *** Demographic Characteristics Age ^^^ 0.05 Less Than 18 Years Old * 0.04 0.02 *** *** ^^^ of Age 0.05 0.10 0.14 18 To 19 Years *** 0.80 20 To 34 Years 0.83 ^^^ 0.74 *** Age of *** 35 Years 0.10 Age ^^^ 0.06 0.06 of Older or *** Education Less Than High School 0.09 ^^ 0.12 *** 0.21 *** 0.56 High School Graduate / Ged 0.57 0.56 ^^^ 0.20 Bachelor's Degree 0.07 ** 0.04 *** Other Degree ^^^ 0.09 0.10 0.14 *** 0.08 0.14 ^^^ 0.02 Education Unknown *** *** Relationship Status 0.24 0.28 ** 0.52 Married ^^^ *** 0.32 0.36 Partner a Living With 0.37 ^^^ *** * 0.21 ^^^ , Not Living Together In a Relationship 0.09 0.18 *** 0.13 Not in a Relationship 0.07 0.12 ^^^ *** * 0.04 0.05 Relationship Status Unknown 0.01 *** ^^^ Employment/School 0.33 Not in School ^^^ Working, 0.35 0.40 *** *** ^^^ 0.07 0.10 0.09 In School, Not Working and In School 0.04 * 0.06 Working 0.05 * Neither Working nor in School 0.49 0.46 0.47 0.02 0.05 *** *** 0.02 Status Unknown Work/School from Prior Birth Risk Factors Prior Preterm Birth ^^^ * 0.36 No Prior Birth 0.55 0.38 *** Prior Preterm Birth *** 0.09 ** 0.12 0.07 *** 0.36 0.57 ^^^ *** No Prior Preterm Birth 0.50 Prior Low Birth Weight 0.55 0.36 *^^^ *** No Prior Birth 0.38 0.06 ior Low Birth Weight Birth 0.01 *** ^^^ *** 0.03 Pr ^^^ *** 0.64 *** 0.43 0.22 No Prior Low Birth Weight Birth ^^^ *** 0.00 Prior Low Birth Weight Unknown 0.13 *** 0.20 Prior C - Section *** ^^^ * 0.55 No Prior Birth 0.36 0.38 *** 0.15 *** 0.12 ^^^ Prior C - Section 0.05 *** 0.33 0.47 No Prior C - Section 0.60 *** ^^^ TECHNICAL APPENDICES 303

322 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Interpregnancy Interval No Prior Birth ^^^ * 0.36 *** 0.38 0.55 *** ^^^ 0.10 *** 0.17 Short Interpregnancy Interval 0.22 ^^^ 0.26 0.35 Normal Interpregnancy Interval 0.34 *** *** 0.09 Interpregnancy Interval Unknown 0.08 0.11 Risk Factors from Current Pregnancy Depression Intake Not Depressed at 0.74 *** ^^^ 0.56 *** 0.68 *** 0.18 Depressed Intake 0.20 at ** ^^^ 0.33 0.06 Depression Unknown *** ^^^ 0.11 ** 0.14 Anxiety at No Anxiety 0.48 0.62 *** ^^^ *** 0.68 Intake 0.27 at Intake Anxiety 0.29 *^^^ 0.47 *** ^ 0.05 *** 0.11 *** 0.03 Anxiety Unknown Food Insecurity ^^^ Not Food Insecure at Intake 0.81 *** 0.69 *** 0.76 0.12 ^^^ *** 0.16 Intake at Food Insecure 0.25 *** 0.03 *** ^^ 0.06 *** 0.12 Food Insecurity Score Unknown Intent Pregnancy *** 0.24 *** Intended Pregnancy 0.30 0.41 ^^^ ^^^ 0.67 0.67 *** 0.57 Unintended Pregnancy *** 0.02 0.08 *** 0.03 Pregnancy Intent Unknown Pre - Pregnancy Hypertension *** ^^^ 0.91 *** 0.78 No Pre- Pregnancy Hypertension 0.99 0.04 0.04 *** 0.01 Pregnancy Hypertension ^^^ - Pre Pre ^^^ *** 0.00 Pregnancy Hypertension Unknown - 0.18 *** 0.05 Pregnancy Diabetes Pre - No Pre - 0.53 0.78 Pregnancy Diabetes 1.00 *** *** ^^^ ^^^ - 0.02 Pregnancy Diabetes 0.00 *** Pre 0.02 0.45 ^^^ *** 0.19 0.00 Pregnancy Diabetes Unknown - Pre *** BMI At First Prenatal Visit *** 0.04 0.02 ** Underweight (<18.5 BMI) 0.04 0.50 ) -<25 BMI 0.28 0.28 ^^^ Normal Weight (18.5 *** ^^ 0.18 0.20 <30 BMI) ** Overweight (25- 0.23 Obese (30 - <40 BMI) 0.17 *** 0.20 0.20 0.05 0.07 ** Very Obese (>=40 BMI ) 0.03 *** ^^ 0.25 ^^^ *** 0.03 Unknown 0.22 * BMI Smoking at Intake 0.81 *** ^^^ 0.62 Did Not Smoke 0.68 *** 0.26 0.28 ^^^ *** 0.11 Intake Smoked at Smoking Status Unknown *** 0.10 *** 0.06 0.08 Intimate Partner Violence 0.66 of No History 0.68 ^^^ *** 0.78 Intimate Partner Violence of 0.30 *** History Intimate Partner Violence 0.22 0.21 ^^^ History of Intimate Partner ^^ *** 0.10 0.04 0.02 *** Violence Unknown Year ** 0.32 ^^^ ** 0.25 2013 and 2014 0.27 *** * 0.45 0.41 2015 ^^ 0.49 0.23 2016 and 2017 0.35 *** ^^^ 0.24 APPENDICES TECHNICAL 304

323 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Region ^^^ 0.22 0.00 *** Northeast 0.04 *** *** 0.59 0.06 Midwest ^^^ 0.00 *** 0.37 South 0.66 *** 0.68 *** West 0.24 *** ^^^ 0.10 *** 0.04 Notes: nonmissing data and excludes participants at the Medical College of South Carolina, Sample limited to white women with the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately risk women. Significance calculated using pairwise comparison of means test. One asterisk ( ) indicates enrolled high- * significanc * *** * ) indicate ) indicates significance at the 0.05 level; and three asterisks ( e at the 0.1 level; two asterisks ( significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret ( ) indicates significance ^ ^^ ^^^ the ) indicates significance at the 0.05 level; and three carets ( at the 0.1 level; two carets ( ) indicates significance at for the difference in means from Group Prenatal Care. 0.01 level UTCOMES ANALYTIC SAM TABLE M. 21: DESCRIPTIVE STATISTICS FOR THE BIRTH O PLE, BLACK WOMEN Model Measure Birth Centers Group Prenatal Care Maternity Care Homes 840 Sample Size 2,424 7,779 ~ Means Outcomes ^^^ 0.14 ** 0.12 *** 0.05 Preterm Birth *** 0.06 *** 0.13 Birth Weight Low ^^^ 0.11 0.18 C - Section 0.32 *** ^^^ 0.30 ** Demographic Characteristics Age 0.08 0.07 ** ^^^ *** 0.04 Less Than 18 Years Old 18 To 19 Years of Age 0.07 ^^^ 0.13 *** *** 0.10 20 To 34 Years 0.75 ^^^ *** 0.83 Age of 0.76 Age of *** 35 Years 0.07 0.05 ^ 0.06 Older or Education * 0.17 Less Than High School *** ^^^ 0.22 0.24 0.61 0.61 0.58 High School Graduate / Ged *** 0.03 0.13 Bachelor's Degree *** ^^^ 0.04 ** 0.08 0.07 0.10 Other Degree ^^^ *** 0.04 Education Unknown 0.06 ^^^ *** 0.02 Relationship Status * ^^^ *** 0.26 0.09 Married 0.10 ** 0.24 Living With a Partner 0.26 0.26 In a Relationship, Not Living Together 0.37 0.27 *** ^^^ *** 0.34 Relationship Not in a ** 0.23 0.25 *** 0.20 *** 0.03 Relationship Status Unknown ** ^^^ 0.08 0.01 Employment/School Working, 0.35 0.34 0.36 Not in School In School, Not Working 0.14 0.14 0.14 Working In School 0.05 0.06 0.06 and 0.43 0.43 0.42 Neither Working nor in School Work/School * ^^^ 0.03 * 0.03 0.02 Status Unknown Risk Factors from Prior Birth Prior Preterm Birth *** 0.37 0.51 *^^^ No Prior Birth 0.40 Prior Preterm Birth *** 0.18 0.09 0.11 *** 0.38 No Prior Preterm Birth *** ^^^ *** 0.51 0.45 Prior Low Birth Weight 0.40 0.37 *** 0.51 ^^^ * No Prior Birth *** 0.10 0.02 *** ^^^ 0.06 Prior Low Birth Weight Birth *** 0.36 ^^^ *** 0.43 0.50 No Prior Low Birth Weight Birth 0.10 *** Prior Low Birth Weight Unknown 0.07 ** 0.08 Section Prior C - *** 0.51 *^^^ 0.40 0.37 No Prior Birth Prior C -Section 0.07 *** ^^^ 0.15 *** 0.18 ^^^ *** *** 0.35 No Prior C - Section 0.53 0.45 305 TECHNICAL APPENDICES

324 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Interpregnancy Interval *** 0.37 ^^^ * 0.40 No Prior Birth 0.51 0.17 0.14 Short Interpregnancy Interval *** 0.10 ^^^ ** *** Normal Interpregnancy Interval 0.39 0.27 0.36 *^^^ *** ^^^ 0.10 Interpregnancy Interval Unknown 0.07 *** 0.12 Current Pregnancy Risk Factors from Depression 0.62 Not Depressed at 0.61 ^^^ *** 0.50 Intake Depressed at 0.29 *** 0.32 0.30 Intake 0.17 *** Depression Unknown 0.08 ^^^ 0.09 Anxiety *** 0.57 0.60 No Anxiety at Intake ^^^ 0.48 0.37 at Intake Anxiety 0.39 *** 0.44 ^^^ 0.04 Anxiety Unknown ^^^ 0.04 0.08 *** Food Insecurity *** 0.68 Intake at Not Food Insecure *** 0.75 0.66 ^^^ Intake at Food Insecure *** 0.27 0.19 ** 0.22 0.06 *** 0.12 ^^^ 0.05 Food Insecurity Score Unknown Pregnancy Intent 0.17 Intended Pregnancy 0.26 *** ^^^ 0.18 0.80 Unintended Pregnancy 0.72 *** ^^ 0.76 *** 0.03 Pregnancy Intent Unknown 0.02 ^^^ 0.05 *** Pregnancy Hypertension Pre - No Pre- Pregnancy Hypertension 0.98 *** ^^^ 0.74 0.82 *** *** ^^^ 0.13 *** 0.10 Pre Pregnancy Hypertension - 0.01 *** ^^^ 0.13 0.01 Pregnancy Hypertension Unknown 0.09 *** - Pre Pregnancy Diabetes - Pre 0.69 No Pre ^^^ Pregnancy Diabetes *** 0.86 0.98 *** - 0.08 *** 0.01 Pre - Pregnancy Diabetes 0.03 *** ^^^ 0.01 Pregnancy Diabetes Unknown - Pre 0.11 *** 0.23 ^^^ *** BMI At First Prenatal Visit 0.03 Underweight (<18.5 BMI) 0.03 0.03 0.26 0.26 ^^^ *** 0.39 ) -<25 Normal Weight (18.5 BMI 0.25 *** 0.20 ^^^ Overweight (25- <30 BMI) 0.20 <40 BMI) 0.23 0.27 ** 0.23 *** - Obese (30 0.12 *** 0.08 *** 0.07 ) BMI Very Obese (>=40 Unknown 0.12 *** 0.21 ^^^ *** BMI 0.03 Smoking ^^^ 0.72 *** 0.82 Did Not Smoke at Intake 0.82 0.08 *** Smoked at Intake 0.08 0.11 *** 0.08 Smoking Status Unknown 0.10 ** ^^^ 0.20 *** Intimate Partner Violence History of Intimate *** ^^ 0.80 Partner Violence 0.76 0.81 No 0.14 ^^^ History of Intimate Partner Violence 0.22 0.16 *** *** History of Intimate Partner *** 0.03 ^^^ 0.06 ** 0.01 Unknown Violence Year *** 0.29 2013 and 2014 0.25 ** 0.26 0.42 0.43 0.40 2015 2016 and 2017 0.30 0.31 ^^ *** 0.35 Region 0.00 Northeast *** ^^^ 0.30 *** 0.02 ^^^ *** 0.16 0.00 Midwest *** 0.12 0.80 0.66 *** 0.80 South ^^^ 0.04 West 0.05 0.04 data. Significance calculated using pairwise comparison of means test. Notes: Sample limited to black women with nonmissing * ** cates significance at the 0.05 level; and three ) indi ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( asterisks ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret *** ( ) ) indicates significance at the 0.1 level; two carets ( ^^^ ^^ ^ ( ) indicates significance at the 0.05 level; and three carets ( indicates significance at the 0.01 level for the difference in means from Group Prenatal Care . 306 TECHNICAL APPENDICES

325 TABLE M. 22: DESCRIPTIVE STATISTICS FOR THE BIRTH O UTCOMES ANALYTIC SAM PLE, BLACK WOMEN EXCLUDING MUSC, UAB, AND UPR Model Measure Group Prenatal Care Birth Centers Maternity Care Homes 2,421 840 Size Sample 6,412 ~ Means Outcomes ^^^ 0.12 0.13 Preterm Birth 0.05 *** 0.06 Low Birth Weight *** ^^^ 0.11 * 0.12 0.18 0.33 ^^^ *** ** 0.30 C - Section Demographic Characteristics Age ^^^ 0.07 0.08 *** Less Than 18 Years Old 0.04 *** 0.07 ^^^ 0.13 Years of Age *** 18 To 19 0.11 *** 0.75 0.75 ^^^ 0.83 20 To 34 Years of Age 35 Years of Age or Older 0.06 ^ 0.05 *** 0.07 Education Less Than High School 0.17 *** ^^^ 0.24 0.22 High School Graduate / Ged 0.61 0.60 0.58 Bachelor's Degree 0.13 ^^^ 0.04 ** 0.03 *** ^^^ * Other Degree * 0.08 0.07 0.10 0.05 ^^^ *** 0.02 Education Unknown 0.05 Relationship Status * 0.11 0.09 ^^^ *** 0.26 Married 0.26 0.26 Living With a Partner 0.24 * 0.36 0.34 ^^^ *** 0.27 In a Relationship, Not Living Together Not in a Relationship 0.23 *** 0.20 *** 0.26 0.01 Relationship Status Unknown *** ^^^ 0.08 *** 0.04 Employment/School Not in School 0.36 0.35 0.34 Working, In School, Not Working 0.14 0.14 0.15 Working and In School 0.05 0.06 0.06 0.42 0.43 0.43 nor in School Neither Working 0.03 0.03 Work/School Status Unknown 0.02 ** ^^ Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth ^^^ 0.51 *** 0.40 0.38 0.16 *** *** 0.09 0.11 Prior Preterm Birth 0.38 0.46 No Prior Preterm Birth ** ^^^ *** 0.51 Prior Low Birth Weight 0.51 0.38 No 0.40 ^^^ Prior Birth *** Prior Low Birth Weight Birth 0.08 *** 0.06 ^^^ *** 0.02 ^^^ *** 0.50 No Prior Low Birth Weight Birth 0.43 *** 0.36 0.11 0.08 *** 0.07 Prior Low Birth Weight Unknown *** Prior C Section - *** 0.38 0.40 ^^^ 0.51 No Prior Birth *** 0.18 Prior C *** 0.15 ^^^ 0.07 -Section *** *** ^^^ 0.35 0.53 Section - No Prior C 0.45 Interpregnancy Interval 0.40 ^^^ 0.51 *** No Prior Birth 0.38 Short Interpregnancy Interval 0.13 *** 0.10 ^^^ 0.17 ** 0.36 Normal Interpregnancy Interval 0.38 *** 0.27 ^^^ ^^^ 0.12 * 0.11 Interpregnancy Interval Unknown *** 0.07 Current Pregnancy Risk Factors from Depression 0.62 *** 0.50 ^^^ 0.61 Not Depressed at Intake Depressed at Intake *** 0.32 0.30 0.28 Depression Unknown 0.09 0.09 ^^^ 0.18 *** Anxiety 0.57 No Anxiety at Intake 0.60 ^^^ 0.48 *** 0.44 ^^^ 0.37 *** Anxiety at Intake 0.38 307 TECHNICAL APPENDICES

326 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes *** Anxiety Unknown 0.04 ^^^ 0.08 0.04 ~ Food Insecurity 0.74 *** 0.67 Not Food Insecure at Intake 0.68 *** *** Food Insecure at Intake 0.27 ^^^ 0.22 *** 0.19 *** 0.12 0.07 * 0.05 Food Insecurity Score Unknown ^^^ Pregnancy Intent ^^^ Intended Pregnancy 0.26 *** 0.17 0.18 0.79 *** 0.76 ^^ *** 0.72 Unintended Pregnancy 0.05 Pregnancy Intent Unknown * *** 0.02 ^^^ 0.04 - Pre Pregnancy Hypertension 0.81 0.74 ^^^ *** 0.98 Pregnancy Hypertension - No Pre *** ^^^ *** 0.01 Pregnancy Hypertension Pre 0.08 *** 0.13 - 0.01 -Pregnancy Hypertension Unknown Pre 0.10 *** 0.13 ^^^ *** Pre -Pregnancy Diabetes No Pre 0.69 ^^^ *** 0.98 Pregnancy Diabetes *** 0.84 - 0.01 ** ^^^ Pregnancy Diabetes 0.08 *** 0.02 Pre - Pre - 0.13 Pregnancy 0.23 ^^^ *** 0.01 Diabetes Unknown *** BMI At First Prenatal Visit * 0.02 0.03 Underweight (<18.5 BMI) 0.03 ) 0.39 *** ^^^ 0.26 0.26 - Normal Weight (18.5 <25 BMI 0.20 0.20 Overweight (25 - <30 BMI) 0.25 *** ^^^ *** 0.27 Obese (30 - <40 BMI) 0.23 ** 0.23 Very Obese (>=40 BMI ) 0.07 *** 0.08 0.11 *** *** 0.13 BMI 0.03 *** 0.21 Unknown ^^^ Smoking 0.72 *** 0.80 0.82 Did Not Smoke at Intake ^^^ *** 0.08 *** 0.08 Smoked at Intake 0.11 *** 0.20 ^^^ 0.10 Smoking Status Unknown 0.09 Intimate Partner Violence Partner Violence 0.76 ^^ 0.80 0.81 No *** History of Intimate History of Intimate 0.22 *** ^^^ 0.14 ** 0.16 Partner Violence History of Intimate Partner *** 0.01 *** ^^^ 0.06 0.04 Violence Unknown Year 0.26 2013 and 2014 0.25 0.27 2015 0.40 0.42 0.43 0.31 0.31 ^^ ** 0.35 2017 2016 and Region 0.30 *** 0.00 *** 0.02 Northeast ^^^ Midwest 0.19 *** 0.00 ^^^ *** 0.12 0.76 South 0.66 *** 0.80 ^^^ *** 0.05 * 0.04 West 0.05 nonmissing data and excludes participants at the Medical College of South Carolina, Notes: Sample limited to black women with the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately mparison of means test. One asterisk ( ) indicates risk women. Significance calculated using pairwise co enrolled high- * ** significance a t the 0.1 level; two asterisks ( ) indicates significance at the 0.05 level; and three asterisks ( ) indicate *** ^ ) indicates significance significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret ( ^^ ^^^ at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ( ) indicates significance at the or the difference in means from Group Prenatal Care. 0.01 level f PLE, HISPANIC WOMEN UTCOMES ANALYTIC SAM 23: DESCRIPTIVE STATISTICS FOR THE BIRTH O TABLE M. Model Measure Birth Centers Maternity Care Homes Group Prenatal Care Sample Size 1,371 2,583 4,665 Outcomes Means 0.12 Preterm Birth 0.05 *** ^^^ 0.11 ^^^ 0.08 * 0.09 Low Birth Weight 0.04 *** *** C - Section 0.13 *** ^^^ 0.31 0.27 APPENDICES TECHNICAL 308

327 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Demographic Characteristics Age Less Than 18 Years Old 0.06 0.06 ^^^ 0.02 *** 0.06 18 To 19 Years of Age 0.10 0.09 ** ^^^ Years of Age *** ^^^ 0.72 0.71 0.82 20 To 34 ^^^ ** 0.12 35 Years of Age 0.14 or Older 0.09 *** Education ^^^ *** 0.23 Less Than High School *** 0.34 0.41 High School Graduate / Ged ^^^ 0.38 *** 0.41 *** 0.53 Bachelor's Degree 0.08 *** 0.02 *** 0.03 ^^^ *** 0.10 Other Degree 0.07 *** 0.11 0.09 Education Unknown ^^^ 0.15 *** ** 0.07 Relationship Status 0.27 * 0.39 Married *** ^^^ 0.29 ** 0.39 0.38 Living With a Partner 0.37 0.21 *** 0.17 ^^ *** 0.14 , Not Living Together In a Relationship Not in a Relationship *** ^^^ 0.14 *** 0.11 0.07 0.01 ^^^ 0.03 *** 0.01 Relationship Status Unknown Employment/School Not in School Working, 0.33 ^^^ 0.24 *** 0.35 In School, Not Working 0.08 * ^ 0.10 0.10 0.05 ** ^^^ 0.04 Working and In School 0.04 0.50 *** 0.58 Neither Working nor in School 0.52 ^^^ 0.05 0.02 Status Unknown Work/School *** 0.02 ^^^ Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 0.39 *** 0.33 ^^^ 0.32 0.09 *** ^^^ Prior Preterm Birth 0.13 0.13 ^^^ 0.54 *** 0.59 0.49 No Prior Preterm Birth *** Prior Low Birth Weight *** 0.33 0.39 No Prior Birth 0.32 ^^^ 0.01 *** ^^^ 0.04 *** 0.07 Prior Low Birth Weight Birth No Prior Low Birth Weight Birth *** ^^^ 0.67 0.53 *** 0.43 0.14 ^^^ *** 0.00 Prior Low Birth Weight Unknown 0.07 *** Section - Prior C ^^^ 0.33 No Prior Birth 0.32 0.39 *** 0.18 0.17 ^^^ *** 0.06 Section - Prior C *** No 0.62 *** ^^^ 0.44 Section 0.50 Prior C - Interpregnancy Interval 0.39 0.32 No Prior Birth *** 0.33 ^^^ 0.10 ** 0.11 Short Interpregnancy Interval 0.18 ^^^ *** 0.40 * 0.38 Normal Interpregnancy Interval 0.41 * 0.10 ^ 0.11 *** 0.18 *** Interpregnancy Interval Unknown Risk Factors from Current Pregnancy Depression 0.64 ^^^ * 0.72 Not Depressed at Intake 0.75 *** 0.17 Depressed at Intake *** 0.20 ^^^ 0.16 0.11 0.09 Depression Unknown ^^^ 0.15 *** *** Anxiety 0.71 0.72 No ^ 0.68 Anxiety at Intake *** Anxiety at Intake 0.25 0.25 0.24 0.07 0.05 Anxiety Unknown 0.04 *** ^^^ Food Insecurity ^^^ 0.78 Insecure at Intake Not Food 0.76 *** 0.72 0.19 ^^^ * 0.14 Insecure at Intake Food 0.16 *** 0.08 0.09 Food Insecurity Score Unknown 0.08 Pregnancy Intent Intended Pregnancy 0.42 ^^^ 0.37 * 0.39 0.59 0.57 Unintended Pregnancy 0.60 ^^ TECHNICAL APPENDICES 309

328 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes 0.02 ^^ 0.03 0.02 Pregnancy Intent Unknown *** Pregnancy Hypertension Pre - Pregnancy Hypertension 0.90 ^^^ *** 0.99 No Pre- *** 0.93 Pre -Pregnancy Hypertension 0.01 *** ^^^ 0.05 0.04 Pregnancy Hypertension Unknown 0.00 *** - 0.02 0.05 *** ^^^ Pre - Pre Pregnancy Diabetes *** ^^^ *** 0.81 1.00 Pregnancy Diabetes - No Pre 0.91 0.05 0.04 Pre ^^^ *** - 0.00 Pregnancy Diabetes ^^^ 0.04 0.15 Pre - Pregnancy Diabetes Unknown *** *** 0.00 BMI At First Prenatal Visit 0.04 ** 0.02 Underweight (<18.5 BMI) *** ^ 0.03 *** ^^^ <25 ) 0.38 0.29 - ** 0.26 BMI Normal Weight (18.5 0.29 0.28 Overweight (25- <30 BMI) 0.28 30 0.23 Obese (30 -<40 BMI) *** 0.24 *** 0. *** 0.07 *** 0.05 ^^ Very Obese (>=40 BMI ) 0.03 ^^^ *** 0.07 *** 0.12 BMI Unknown 0.02 Smoking 0.94 Did Not Smoke at Intake 0.87 *** 0.87 *** 0.03 Smoked at Intake * 0.02 ** 0.02 *** Smoking Status Unknown 0.11 *** 0.11 0.03 Intimate Partner Violence 0.81 ** 0.82 Partner Violence 0.83 No History of Intimate 0.15 0.15 0.16 History of Intimate Partner Violence History of Intimate Partner 0.02 *** ^^ 0.03 0.03 Violence Unknown Year 0.30 *** 0.16 0.26 2013 and 2014 *** ^^ 2015 0.38 ^^^ 0.45 0.37 *** 0.47 *** 0.25 ^^^ *** 0.35 2016 and 2017 Region *** 0.02 *** Northeast ^^^ 0.00 0.19 ^^^ 0.12 Midwest *** 0.23 *** 0.00 *** South 0.77 *** 0.46 ^^^ 0.60 0.05 *** ^^^ *** 0.26 West 0.30 Sample limited to Hispanic women with nonmissing data. Significance calculated using pairwise comparison of means Notes: ** and ignificance at the 0.05 level; test. One asterisk ( ) indicates s * ) indicates significance at the 0.1 level; two asterisks ( *** three asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One ^^ ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ^ caret ( ( ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. ^^^ TABLE M. 24: DESCRIPTIVE STATISTICS FOR THE BIRTH O UTCOMES ANALYTIC SAM PLE, HISPANIC WOM EN EXCLUDING MUSC, UAB, AND UPR Model Measure Birth Centers Group Prenatal Care Maternity Care Homes 4,607 1,371 Size Sample 1,871 Means Outcomes ^ 0.05 Preterm Birth 0.12 *** 0.07 *** 0.05 Low Birth Weight 0.08 *** ^ *** 0.04 ^^^ 0.24 *** 0.27 Section C 0.13 *** - Demographic Characteristics Age *** ^^^ 0.05 0.06 Less Than 18 Years Old 0.02 0.06 ^^^ 0.09 0.09 ** 18 To 19 Years of Age ** 0.82 0.71 *** Years of Age 20 To 34 ^^^ 0.74 Years of Age or Older *** 0.11 ^^ *** 0.09 0.14 35 Education 0.41 * Less Than High School 0.23 *** ^^^ 0.43 0.41 *** 0.37 High School Graduate / Ged 0.53 *** ^^^ 0.01 Bachelor's Degree 0.08 *** ^^^ 0.02 APPENDICES TECHNICAL 310

329 Model Measure Group Prenatal Care Birth Centers Maternity Care Homes 0.10 0.07 ** 0.05 ^^^ *** Other Degree ~ 0.13 ^^^ ** 0.07 Education Unknown 0.09 *** Relationship Status ^^^ Married *** 0.30 0.29 0.39 Living With a Partner 0.38 0.37 0.38 ^ *** 0.21 *** 0.14 , Not Living Together 0.17 In a Relationship 0.07 0.14 *** 0.11 ^^^ *** Relationship Not in a 0.01 ^^ 0.02 * 0.01 Relationship Status Unknown Employment/School 0.35 *** 0.25 ^^^ 0.33 Not in School Working, 0.10 In School, Not Working 0.08 * 0.08 ** ^^^ 0.03 * Working and In School 0.05 * 0.04 Neither Working nor in School 0.52 ^^^ 0.61 *** 0.50 ^^^ 0.02 0.02 0.04 Work/School *** Status Unknown Risk Factors from Prior Birth Prior Preterm Birth 0.33 *** 0.38 ^^^ 0.32 No Prior Birth 0.09 Prior Preterm Birth *** 0.09 *** 0.13 ^^^ *** 0.59 No Prior Preterm Birth 0.54 0.53 Prior Low Birth Weight 0.33 No Prior Birth 0.32 ^^^ *** 0.38 0.07 ^^^ *** *** 0.05 0.01 Prior Low Birth Weight Birth 0.67 No Prior Low Birth Weight Birth 0.47 0.53 *** ^^^ *** *** 0.07 Prior Low Birth Weight Unknown *** ^^^ 0.00 0.10 -Section Prior C 0.38 ^^^ 0.32 Birth No Prior 0.33 *** 0.06 *** ^^^ 0.14 *** 0.18 - Prior C Section 0.50 0.48 ^^^ *** 0.62 - No Prior C Section Interpregnancy Interval 0.38 *** ^^^ 0.33 0.32 No Prior Birth ^^^ *** 0.11 *** 0.08 Short Interpregnancy Interval 0.18 Normal Interpregnancy 0.38 ** 0.41 * Interval 0.41 ^^ 0.12 *** 0.10 0.18 Interpregnancy Interval Unknown *** Risk Factors from Current Pregnancy Depression ** 0.72 Not Depressed at Intake *** 0.71 0.75 0.17 0.16 0.16 Depressed at Intake Depression Unknown 0.09 0.11 *** 0.13 *** Anxiety ** 0.72 No Anxiety at Intake 0.71 ^^ 0.75 ^^^ 0.19 *** 0.24 Anxiety at Intake 0.25 Anxiety Unknown 0.05 *** 0.07 ^^^ 0.04 Food Insecurity * 0.74 ^^ 0.78 Insecure at Intake Not Food 0.76 ^^ 0.17 0.16 0.14 Food * Insecure at Intake 0.09 0.08 Unknown Food Insecurity Score 0.08 Pregnancy Intent 0.42 0.41 0.40 Intended Pregnancy Unintended Pregnancy 0.57 0.56 0.58 0.02 Pregnancy Intent Unknown 0.02 ** 0.03 ^^ Pre - Pregnancy Hypertension 0.93 * 0.92 ^^^ *** 0.99 Pregnancy Hypertension - No Pre -Pregnancy *** 0.01 *** 0.01 Hypertension 0.04 Pre 0.03 *** 0.00 -Pregnancy Hypertension Unknown Pre 0.07 *** ^^^ Pre -Pregnancy Diabetes 1.00 ^^^ *** *** 0.79 0.91 Pregnancy Diabetes - No Pre Pregnancy Diabetes 0.04 *** 0.01 *** Pre - 0.00 0.04 *** 0.20 Pre - Pregnancy Diabetes Unknown 0.00 *** ^^^ TECHNICAL APPENDICES 311

330 Model Measure Group Prenatal Care Maternity Care Homes Birth Centers BMI At First Prenatal Visit Underweight (<18.5 BMI) 0.04 *** ^^^ 0.02 0.02 BMI ^^^ *** 0.38 ) 0.26 * 0.28 -<25 Normal Weight (18.5 0.28 0.29 0.32 *** <30 BMI) Overweight (25- Obese (30 *** 0.30 0.23 <40 BMI) - *** 0.24 0.07 *** 0.04 *** 0.03 ) BMI Very Obese (>=40 0.07 *** BMI Unknown 0.02 *** ^^^ 0.10 Smoking Did Not Smoke at Intake 0.87 *** 0.88 *** 0.94 0.02 0.02 *** 0.01 * Smoked at Intake 0.03 Smoking Status Unknown 0.11 *** 0.11 *** Intimate Partner Violence ** 0.83 Partner Violence History of Intimate No 0.82 0.81 History of Intimate Partner Violence 0.15 0.16 0.15 History of Intimate Partner 0.02 *** ^^^ 0.03 0.04 Violence Unknown Year *** 0.34 ^^^ *** 0.26 2013 and 2014 0.16 0.38 2015 0.37 *** 0.41 0.47 2016 and 2017 *** 0.35 0.26 *** ^^^ Region 0.00 *** 0.26 ^^^ *** 0.02 Northeast 0.12 Midwest *** 0.00 ^^^ *** 0.24 ^^^ South 0.46 *** 0.68 *** 0.60 West 0.31 *** 0.26 *** ^^^ 0.06 Sample limited to Hispanic women with Notes: data and excludes participants at the Medical College of South nonmissing Carolina, the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately enrolled high-risk women. Significance calculated using pairwise comparison of means test. One ** * s significance at the 0.05 level; and three ) indicate ) indicates significance at the 0.1 level; two asterisks ( asterisk ( asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret *** ^ ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ( ) ^^ ^^^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TABLE M. 25: DESCRIPTIVE STATISTICS FOR THE BIRTH O UTCOMES ANALYTIC SAM PLE, WOMEN WITH OTHE R/MIXED RACE/ETHNICITY Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Sample Size 292 268 657 Outcomes Means ** 0.05 ^^ Preterm Birth 0.10 0.09 0.09 * 0.13 ^^^ Low Birth Weight *** 0.03 0.31 C - Section 0.16 *** ^^^ 0.26 Demographic Characteristics Age ^^ 0.03 Less Than 18 Years Old 0.03 *** 0.07 0.11 ^^^ 0.07 ** 0.04 Years of Age 18 To 19 ** 0.83 ^^^ 0.74 0.77 ** 20 To 34 Years of Age ** 0.13 35 Years of Age or Older 0.10 0.08 Education ^^^ Less Than High School 0.20 * 0.11 0.16 0.52 0.48 0.53 High School Graduate / Ged 0.12 0.10 ^^ 0.15 Bachelor's Degree 0.14 0.17 ^ 0.12 Other Degree 0.04 Education Unknown 0.05 *** 0.10 ^^^ Relationship Status Married *** 0.26 0.42 ^^^ 0.41 *** 0.26 Living With a Partner 0.34 ** 0.35 0.18 In a Relationship, Not Living Together 0.13 ** ^^ 0.19 * ^ 0.15 Not in a Relationship 0.09 0.13 APPENDICES TECHNICAL 312

331 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes 0.02 0.05 ^ 0.02 Relationship Status Unknown ** ~ Employment/School Not in School 0.34 0.32 0.34 Working, 0.14 0.10 0.11 In School, Not Working Working and In School 0.10 *** ^^ 0.05 0.05 ** Neither Working nor in School 0.43 0.45 0.51 Status Unknown 0.02 0.02 0.02 Work/School Birth Risk Factors from Prior Prior Preterm Birth No Prior Birth *** 0.44 0.55 ^^^ 0.43 ** 0.10 Prior Preterm Birth 0.09 0.06 0.40 * 0.46 No Prior Preterm Birth 0.48 ^^ Prior Low Birth Weight 0. 55 0. *** 44 No Prior Birth 0. 43 ^^^ 0.07 Prior Low Birth Weight Birth *** 0.02 *** 0.00 *** 0.42 No Prior Low Birth Weight Birth *** ^^^ 0.29 0.56 0.01 *** ^^^ 0.14 *** 0.07 Prior Low Birth Weight Unknown Prior C - Section 0.44 0.55 No Prior Birth 0.43 ^^^ *** 0.12 ^^ *** 0.05 Section - Prior C 0.16 * ^^^ *** 0.52 Section - No Prior C 0.40 * 0.33 Interpregnancy Interval 0. ^^^ 43 0. No Prior Birth 44 0. *** 55 ** ^^^ 0. 0. Short Interpregnancy Interval 19 11 0.13 0.26 0.32 0.32 Normal Interpregnancy Interval 0.08 Interpregnancy Interval Unknown * 0.12 0.06 *** Risk Factors from Current Pregnancy Depression 0.69 Not Depressed at Intake 0.70 ^^^ 0.59 *** 0.24 0.22 Depressed at Intake ** 0.29 0.09 Depression Unknown 0.12 ^^^ 0.06 Anxiety 0. *** 50 0. ^^^ No Anxiety at Intake 0. 64 66 ^^^ 0. 0. 0. *** 43 Anxiety at Intake 31 32 Anxiety Unknown 0.02 0.05 0.07 ^^ * Food Insecurity Insecure at Intake 0.80 ** ^^^ 0.63 *** 0.74 Not Food Insecure at Intake 0.17 ^^^ 0.26 ** 0.19 Food 0.07 ** 0.10 ^^^ Food Insecurity Score Unknown ** 0.03 Pregnancy Intent Intended Pregnancy * 0.30 *** 0.42 0.35 0.62 Unintended Pregnancy 0.64 ** ** 0.55 ^ 0. 06 * 0. 04 Pregnancy Intent Unknown 0. 03 Pre -Pregnancy Hypertension 0.89 No Pre - 0.85 ^^^ *** 1.00 Pregnancy Hypertension * 0.05 0.06 ^^^ *** 0.00 Pregnancy Hypertension Pre - Pre - 0.00 *** ^^^ 0.10 ** 0.06 Pregnancy Hypertension Unknown Pre - Pregnancy Diabetes 0.87 0.67 ^^^ *** 0.99 Pregnancy Diabetes - No Pre *** Pregnancy Diabetes 0.02 0.03 0.01 - Pre Pre Pregnancy Diabetes Unknown 0.00 *** ^^^ 0.30 *** 0.10 - BMI At First Prenatal Visit 0.05 Underweight (<18.5 BMI) 0.04 0.05 0. 0. ^^^ *** 29 44 ) BMI -<25 Normal Weight (18.5 0.31 0.27 0.20 0.25 <30 BMI) - Overweight (25 ** <40 BMI) - 0.15 Obese (30 0.19 0.17 Very Obese (>=40 0.07 ** 0.07 0.04 BMI ) 0.12 *** 0.24 BMI Unknown 0.05 *** ^^^ TECHNICAL APPENDICES 313

332 Model Measure Maternity Care Homes Birth Centers Group Prenatal Care Smoking ^^^ Did Not Smoke at Intake 0.82 ** 0.72 *** 0.87 0.11 ^^ 0.06 Smoked at Intake 0.09 Smoking Status Unknown 0.04 *** 0.16 *** 0.13 Intimate Partner Violence Partner Violence 0.71 * 0.71 * 0.77 No History of Intimate 0.23 0.18 History of Intimate Partner Violence 0.27 *** History of Intimate Partner 0.02 ** 0.05 0.06 ^^^ Violence Unknown Year ^^ *** 0.25 0.34 0.16 *** 2013 and 2014 2015 0.36 *** 0.46 * 0.42 0.48 2016 and 2017 ^^^ 0.33 0.21 *** *** Region 0.00 *** 0.26 ^^^ ** 0.03 Northeast *** 0.00 0.07 Midwest ^^^ *** 0.15 0.59 0.56 South 0.53 West 0.37 ** ^^^ 0.15 *** 0.29 data. Significance calculated using pairwise nonmissing Sample limited to women with other/mixed race/ethnicity with Notes: ) indica ) indicates significance at the 0.1 level; two asterisks ( comparison of means test. One asterisk ( * tes significance ** *** at the 0.05 level; and three asterisks ( ) indicate significance at the 0.01 level for the difference in means from ^ ^^ ) indicates significance at the ) indicates significance at the 0.1 level; two carets ( Maternity Care Homes. One caret ( ^^^ vel; and three carets ( ) indica 0.05 le tes significance at the 0.01 level for the difference in means from Group atal Care. Pren PLE, WOMEN WITH OTHE R/MIXED 26: DESCRIPTIVE STATISTICS FOR THE BIRTH O TABLE M. UTCOMES ANALYTIC SAM TY EXCLUDING MUSC, UAB, AND UPR RACE/ETHNICI Model Measure Maternity Care Homes Group Prenatal Care Birth Centers Sample Size 292 268 643 Outcomes Means 0.09 ^^ 0.10 0.05 Preterm Birth ** 0.03 Low Birth Weight ** 0.13 0.09 ^^^ *** Section 0.16 *** 0.26 0.31 C - ^^^ Demographic Characteristics Age 0.03 ^^ Less Than 18 Years Old 0.07 0.03 *** 0.11 ^^^ * 0.04 Years of Age 18 To 19 0.07 ** ^^^ 0.83 Years of Age ** 0.76 20 To 34 0.74 35 0.08 ** 0.14 Years of Age or Older * 0.10 Education 0.16 0.20 *^^^ 0.11 Less Than High School High School Graduate / Ged 0.53 0.48 0.52 ^^ Bachelor's Degree 0.15 0.10 0.13 0.17 ^ 0.12 Other Degree 0.14 *** 0.05 ^^^ Education Unknown 0.04 0.10 Relationship Status *** 0.26 ^^^ 0.42 Married 0.41 *** 0.35 ** 0.34 Living With a Partner 0.26 , Not Living Together In a Relationship 0.18 0.19 ^^ * 0.13 0.15 ^ 0.09 Not in a Relationship 0.13 0.02 Relationship Status Unknown 0.02 ^ 0.05 ** Employment/School 0.32 Working, Not in School 0.34 0.34 0.10 In School, Not Working 0.11 0.14 0.05 0.05 Working and In School 0.10 *** ^^ 0.51 Neither Working nor in School 0.43 ** 0.45 0.02 0.02 0.02 Status Unknown Work/School 314 TECHNICAL APPENDICES

333 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes Risk Factors from Prior Birth Prior Preterm Birth ^^^ No Prior Birth 0.44 *** 0.55 0.43 ** 0.06 0.09 rior Preterm Birth 0.10 P 0.48 No Prior Preterm Birth * 0.46 0.40 ^^ Prior Low Birth Weight ^^^ 0.44 No Prior Birth 0.43 0.55 *** Prior Low Birth Weight Birth 0.00 *** 0.02 *** 0.07 ^^^ No Prior Low Birth Weight Birth 0.56 0.29 *** *** 0.42 ^^^ 0.14 0.07 *** *** 0.01 Prior Low Birth Weight Unknown Prior C Section - ^^^ 0.55 *** 0.44 0.43 No Prior Birth *** ^^ -Section 0.05 0.16 * 0.12 Prior C ^^^ No Prior C- 0.52 *** Section 0.33 0.40 ** Interpregnancy Interval ^^^ 0.43 No Prior Birth 0.44 0.55 *** ^^^ 0.19 ** Short Interpregnancy Interval 0.11 0.13 Normal Interpregnancy Interval 0.31 0.32 0.26 0.12 Interpregnancy Interval Unknown * 0.08 *** 0.06 Risk Factors from Current Pregnancy Depression ^^^ 0.59 0.70 Not Depressed at Intake 0.69 *** 0.22 ** 0.29 Depressed at Intake 0.24 ^^^ 0.12 0. 0.06 * Depression Unknown 09 Anxiety ^^^ 0.50 No Anxiety at Intake 0.66 *** 0.64 ^^^ 0.31 *** 0.43 Anxiety at 0.32 Intake Anxiety Unknown 0.02 * ^^ 0.07 0.05 Food Insecurity ^^^ 0.63 * 0.80 Insecure at Intake 0.74 *** Not Food ^^^ 0.19 Insecure at Intake 0.17 Food 0.26 *** ^^^ 0.03 Food Insecurity Score Unknown 0.07 * ** 0.10 Pregnancy Intent 0.30 Intended Pregnancy * *** 0.42 0.35 *** 0.54 ** 0.62 0.64 Unintended Pregnancy Pregnancy Intent Unknown 0.03 ^ 0.06 * 0.04 Pregnancy Hypertension - Pre ^^^ - No Pre 0.85 ** *** 1.00 0.89 Pregnancy Hypertension ^^^ 0.00 Pre - *** 0.05 0.06 Pregnancy Hypertension ^^^ Pre 0.10 0.06 *** 0.00 ** Pregnancy Hypertension Unknown - Pre Pregnancy Diabetes - ^^^ 0.67 *** 0.87 No Pre - Pregnancy Diabetes 0.99 *** Pre -Pregnancy Diabetes 0.01 0.03 0.02 ^^^ -Pregnancy Diabetes Unknown Pre *** 0.00 *** 0.10 0.30 BMI At First Prenatal Visit 0.05 0.04 0.05 Underweight (<18.5 BMI) ^^^ *** <25 0.29 0.31 Normal Weight (18.5 - ) 0.44 BMI Overweight (25 0.27 ** 0.20 0.25 <30 BMI) - <40 BMI) 0.19 0.15 0.17 - Obese (30 * 0.07 0.07 Very Obese (>=40 BMI ) 0.04 ^^^ BMI 0.12 0.24 *** *** 0.05 Unknown Smoking ^^^ ** 0.72 *** 0.87 0.82 Did Not Smoke at Intake S moked at Intake 0.06 ^^ 0.11 0.09 0.13 0.04 *** *** 0.16 Smoking Status Unknown Intimate Partner Violence * 0.71 No History of Intimate Partner Violence 0.71 0.76 History of Intimate Partner Violence 0.27 *** 0.23 0.19 TECHNICAL APPENDICES 315

334 Model Measure Birth Centers Group Prenatal Care Maternity Care Homes History of Intimate Partner ** 0.05 ^^^ 0.02 0.06 Unknown Violence Year 2013 and 2014 0.25 *** 0.16 *** 0.34 ^^ 2015 0.36 * 0.46 *** 0.42 2016 and 2017 0.49 *** 0.21 ^^^ *** 0.33 Region ** 0.03 Northeast 0.00 *** 0.26 ^^^ 0.07 0.00 *** 0.16 *** Midwest ^^^ 0.53 0.59 0.55 South 0.15 ** ^^^ West *** 0.30 0.37 data and excludes participants at the Medical Notes: Sample limited to women with other/mixed race/ethnicity with nonmissing College of South Carolina, the University of Alabama, Birmingham, and the University of Puerto Rico because these awardees disproportionately enrolled high- risk women. Significance calculated using pairwise co mparison of means test. ** * cates significance at the 0.05 level; and three ) indi ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret *** asterisks ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ( ) ^^^ ^^ ^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TABLE M. H PLPE DATA INCLUDED IN THE BIRTH OUTCOMES ANALYTIC 27: SHARE OF STRONG START PARTICIPANTS WIT SAMPLE, BY AWARDEE Share in Count in Total Number Awardee Regression Regression of Enrollees Sample Sample 2,676 Access Community Health Network 1,897 70.9% Albert Einstein Healthcare Network 1,429 675 47.2% American Association of Birth Centers (AABC) 8,426 5,139 61.0% Amerigroup Corporation 976 467 47.8% Central Jersey Family Health Consortium 1,238 759 61.3% 915 1,343 Health Start Coalitions Florida Association of 68.1% 410 57.8% Grady Memorial Hospital Corporation 709 79.9% 1,010 1,264 Harris County Hospital District 325 HealthInsight of Nevada 857 37.9% Johns Hopkins University 1,629 1,276 78.3% Los Angeles County Department of Health Services 3,142 1,576 50.2% 50.4% Maricopa Special Health Care District 959 483 Medical University of South Carolina 820 718 87.6% 1,252 Meridian Health Plan 69.1% 1,812 Mississippi Primary Health Care Association 2,628 1,378 52.4% 30.5% 265 869 Health Care Authority Oklahoma 72.3% Providence Health Foundation of Providence Hospital 3,458 2,499 65.9% 1,188 Signature Medical Group 1,802 247 St. John Community Health Investment Corp. 48.6% 120 829 1,094 Texas Tech University Health Sciences Center 75.8% 63.6% 747 1,174 United Neighborhood Health Services 83.0% 1,097 1,322 University of Alabama at Birmingham University of Kentucky Research Foundation 696 483 69.4% 78.1% University of Puerto Rico Medical Sciences Campus 928 725 % University of South Alabama 1, 457 1,020 70.0 205 732 University of Tennessee Medical Group 28.0% Virginia Commonwealth University 1,629 874 53.7% % 28,332 All Awardees 45,316 62.5 -section. Regression sample is the sample included in regression models for preterm birth, low birth weight, and C Notes: 316 TECHNICAL APPENDICES

335 DEPRESSION ANALYSIS E ANALYTIC SAMPLE FOR DEPRESSION ANALYSIS 28: CONSTRUCTION OF TH TABLE M. # # of Remaining Logic for Dropping Observations Observations Excluded 316 45, - Sample: Number of Strong Start participants with PLPE data Starting 44,485 831 Dropping participants without an exit form 42,186 2,299 Dropping participants without an intake form 40,856 1,330 Dropping participants with a miscarriage or elective termination Dropping participants with multiples 40,271 585 35,325 4,946 Dropping participants missing depression variable Dropping participants missing an outcome variable (preterm, birthweight, or 25,748 9,577 method) delivery 23,980 Dropping participants missing any covariates 1,768 23,980 - Final analytic sample ION ANALYTIC SAMPLE 29: DESCRIPTIVE STATISTICS FOR THE DEPRESS TABLE M. Depression Status Measure Depressed Not Depressed 6,237 Sample Size 17,743 Outcomes Means 0.13 0.10 Preterm Birth *** Low Birth Weight 0.11 *** 0.08 C-Section 0.29 *** 0.26 Demographic Characteristics Race/Ethnicity *** 0.28 0.23 White *** 0.23 0.33 Hispanic *** 0.49 Black 0.35 Other 0.04 0.04 Age 0.05 *** 0.06 Less than 18 Years Old 0.09 18 to 19 Years of Age 0.09 20 to 34 Years of Age 0.77 0.76 0.09 35 Years of Age or Older 0.08 * Education 0.25 * 0.26 Less than High School High School Graduate / Ged 0.54 *** 0.57 *** Bachelor's Degree 0.07 0.04 0.09 0.10 Other Degree 0.04 Unknown Education 0.04 Relationship Status Married 0.17 *** 0.28 *** 0.33 Living with a Partner 0.30 In a Relationship, Not Living Together 0.28 *** 0.25 0.14 *** 0.25 Not in a Relationship Employment/School *** Working, Not in School 0.36 0.33 0.11 In School, 0.12 Not Working 0.05 Working and in School 0.05 Neither Working nor in School 0.51 *** 0.48 Risk Factors from Prior Birth Prior Preterm Birth ** 0.37 No Prior Birth 0.39 0.12 Prior Preterm Birth 0.16 *** 0.49 *** 0.47 No Prior Preterm Birth Low Birth Weight Prior ** 0.37 No Prior Birth 0.39 0.06 *** 0.08 Prior Low Birth Weight Birth TECHNICAL APPENDICES 317

336 Depression Status Measure Not Depressed Depressed 0.47 0.46 No Prior Low Birth Weight Birth ~ Prior Low Birth Weight Unknown 0.09 0.08 Prior C - Section No Prior Birth 0.37 ** 0.39 Prior C - Section 0.14 0.16 *** - Section 0.47 0.47 Prior C No Interpregnancy Interval No Prior Birth 0.37 ** 0.39 Short Interpregnancy Interval 0.15 0.14 Normal Interpregnancy Interval 0.36 0.37 0.10 0.11 Interpregnancy Interval Unknown Risk Factors from Current Pregnancy Insecurity Food 0.83 *** Not Food Insecure at Intake 0.61 0.13 0.35 Food Insecure at Intake *** Food Insecurity Score Unknown 0.04 0.04 Pregnancy Intent Intended Pregnancy *** 0.32 0.22 Unintended Pregnancy *** 0.78 0.68 Pregnancy Hypertension - Pre No Pre - 0.87 * 0.87 Pregnancy Hypertension *** 0.07 Pre 0.05 - Pregnancy Hypertension 0.07 Pre ** 0.06 -Pregnancy Hypertension Unknown Pre -Pregnancy Diabetes *** No Pre - Pregnancy Diabetes 0.85 0.87 - Pre Pregnancy Diabetes 0.04 ** 0.03 0.10 - Pre Pregnancy Diabetes Unknown *** 0.11 BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.03 0.03 <25 BMI) - Normal Weight (18.5 0.31 0.31 *** - <30 BMI) 0.22 Overweight (25 0.24 0.24 0.25 <40 BMI) - Obese (30 *** 0.07 Very Obese (>=40 BMI) 0.09 0.11 0.10 BMI Unknown Smoking 0.76 *** 0.86 Did not Smoke at Intake 0.08 *** 0.16 Smoked at Intake Smoking Status Unknown 0.06 *** 0.08 Intimate Partner Violence *** 0.86 No History of Intimate Partner Violence 0.66 *** History of Intimate Partner Violence 0.14 0.34 Year 2013 and 2014 0.27 0.25 *** 2015 0.42 0.42 0.31 2016 and 2017 *** 0.33 Model Maternity Care Home 0.59 ** 0.61 Birth Center 0.17 *** 0.21 0.18 0.24 *** Group Prenatal Care Region Northeast *** 0.05 0.06 0.62 *** 0.70 Midwest 0.19 South 0.13 *** West 0.10 0.15 *** nonmissing Notes: Sample limited to women with data. Significance calculated using pairwise comparison of means test. One * icates significance at the 0.05 level; and t hree ** ) ind ) indicates significance at the 0.1 level; two asterisks ( asterisk ( significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret ) indicate ( asterisks *** ^^^ ^ ^^ ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ( ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. 318 TECHNICAL APPENDICES

337 TABLE M. 30: DESCRIPTIVE STATISTICS FOR THE DEPRESS ION ANALYTIC SAMPLE, BIRTH CENTER MODEL Depression Status Measure Depressed Not Depressed 1,072 3,696 Sample Size -------- Outcomes Means ---------------- Preterm Birth 0.05 0.04 0.04 0.03 Low Birth Weight - 0.12 0.13 C Section Demographic Characteristics Race/Ethnicity White 0.51 *** 0.56 Hispanic 0.20 *** 0.26 Black 0.13 *** 0.22 Other 0.06 0.05 Age Less than 18 Years Old 0.03 0.02 ** 0.05 18 to 19 Years of Age 0.07 * 0.81 20 to 34 Years of Age 0.84 0.09 0.08 35 Years of Age or Older Education 0.18 *** 0.12 Less than High School 0.55 0.58 High School Graduate / Ged Bachelor's Degree 0.11 *** 0.17 0.11 Other Degree 0.13 Education Unknown 0.02 0.03 Relationship Status Married 0.32 *** 0.49 0.33 Living with a Partner 0.32 0.12 In a Relationship, Not Living Together 0.18 *** 0.17 Not in a Relationship *** 0.07 Employment/School 0.36 Working, Not in School * 0.39 In School, Not Working 0.08 0.09 0.06 Working and in School 0.05 0.48 Neither Working nor in School 0.48 Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 0.37 0.36 0.07 *** 0.11 Prior Preterm Birth 0.57 *** 0.52 Birth No Prior Preterm Prior Low Birth Weight No Prior Birth 0.37 0.36 Prior Low Birth Weight Birth 0.01 * 0.01 No Prior Low Birth Weight Birth 0.63 0.59 ** 0.01 *** 0.02 Prior Low Birth Weight Unknown Prior C - Section 0.36 No Prior Birth 0.37 0.06 Prior Section - C 0.05 0.57 0.59 No Prior C - Section Interpregnancy Interval 0.37 0.36 No Prior Birth Short Interpregnancy Interval 0.19 * 0.21 0.37 0.36 Normal Interpregnancy Interval Interpregnancy Interval Unknown 0.07 0.07 Current Pregnancy Risk Factors from Food Insecurity 0.61 Not Food Insecure at Intake 0.84 *** 0.12 *** Food Insecure at Intake 0.36 0.03 0.03 Food Insecurity Score Unknown Pregnancy Intent 0.43 *** 0.28 Intended Pregnancy TECHNICAL APPENDICES 319

338 Depression Status Measure Depressed Depressed Not 0.72 *** 0.57 Unintended Pregnancy Pregnancy Hypertension Pre - No Pre- Pregnancy Hypertension 0.99 0.99 -Pregnancy Hypertension Pre 0.01 0.01 Pre 0.00 0.00 Pregnancy Hypertension Unknown - Pregnancy Diabetes Pre - Pregnancy Diabetes - No Pre 0.99 0.99 Pre - Pregnancy Diabetes 0.00 0.01 Pre Pregnancy Diabetes Unknown 0.00 0.00 - BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.04 0.04 <25 BMI) Normal Weight (18.5 - 0.45 0.45 Overweight (25- <30 BMI) 0.23 0.25 Obese (30 -<40 BMI) 0.20 0.19 0.03 ** 0.05 Very Obese (>=40 BMI) 0.03 0.03 Unknown BMI Smoking Did not Smoke at Intake 0.85 *** 0.78 Smoked at Intake 0.13 0.06 *** Smoking Status Unknown 0.08 0.09 Intimate Partner Violence 0.84 *** No History of Intimate Partner Violence 0.65 *** 0.16 History of Intimate Partner Violence 0.35 Year 0.25 0.25 2013 and 2014 0.40 2015 0.41 0.35 0.34 2016 and 2017 Region 0.03 0.04 Northeast Midwest ** 0.68 0.65 0.08 South 0.09 0.23 ** 0.19 West data participating in the Birth Center model. Significance calculated using nonmissing Notes: Sample limited to women with es ** * pairwise comparison of means test. ) indicat ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( significance at the 0.05 level; and three asterisks ) indicate significance at the 0.01 level for the difference in means *** ( ^ ^^ ) indicates significance at ) indicates significance at the 0.1 level; two carets ( One caret ( from Maternity Care Homes. the 0.05 level; and three carets ( ) indicates significance a t the 0.01 level for the difference in means from Group ^^^ Prenatal Care. ION ANALYTIC SAMPLE, GROUP PRENATAL CARE 31: DESCRIPTIVE STATISTICS FOR THE DEPRESS TABLE M. MODEL Depression Status Measure Depressed Not Depressed Size 3,212 1,467 Sample -------- Means Outcomes ---------------- 0.10 0.12 Preterm Birth *** Low Birth Weight 0.09 ** 0.11 C - 0.30 0.31 Section Demographic Characteristics Race/Ethnicity White 0.12 *** 0.15 *** 0.48 Hispanic 0.32 0.35 *** 0.48 Black Other 0.05 0.05 Age 0.06 Less than 18 Years Old 0.07 ** 0.11 0.12 18 to 19 Years of Age 0.74 0.75 20 to 34 Years of Age 0.07 0.09 ** 35 Years of Age or Older 320 TECHNICAL APPENDICES

339 Depression Status Measure Depressed Not Depressed Education *** 0.22 Less than High School 0.30 High School Graduate / Ged 0. 56 *** 0. 50 0.04 Bachelor's Degree 0.04 0.10 Other Degree 0.09 0.07 0.07 Education Unknown Relationship Status 0.13 *** 0.24 Married 0.36 * Living with a Partner 0.33 *** 0.24 In a Relationship, Not Living Together 0.29 Not in a Relationship 0.15 *** 0.25 Employment/School Working, Not in School 0.31 0.32 11 13 In School, Not Working 0. * 0. 0.05 Working and in School 0.05 Neither Working nor in School 0.52 0.52 Risk Factors from Prior Birth Prior Preterm Birth 0.46 No Prior Birth 0.46 Prior Preterm Birth 0.14 0.10 *** *** 0.40 No Prior Preterm Birth 0.44 Prior Low Birth Weight 0.46 No Prior Birth 0.46 Prior Low Birth Weight Birth 0.05 0.05 No Prior Low Birth Weight Birth *** 0.33 0.40 *** 0.10 Prior Low Birth Weight Unknown 0.16 Section Prior C - No Prior Birth 0.46 0.46 Section 0.14 ** - Prior C 0.17 No Prior C 0.40 * 0.37 Section - Interpregnancy Interval 0.46 No Prior Birth 0.46 0.11 0.10 Short Interpregnancy Interval Normal Interpregnancy Interval 0.32 0.34 0.10 0.10 Interpregnancy Interval Unknown Risk Factors from Current Pregnancy Food Insecurity 0.80 0.57 Not Food Insecure at Intake *** 0.15 *** 0.37 Food Insecure at Intake 0.05 Food Insecurity Score Unknown 0.05 Pregnancy Intent Intended Pregnancy 0.33 0.22 *** *** Unintended Pregnancy 0. 0. 78 67 Pre -Pregnancy Hypertension - Pre No 0.86 *** 0.81 Pregnancy Hypertension *** Pregnancy Hypertension - Pre 0.07 0.10 0.08 0.09 Pregnancy Hypertension Unknown - Pre - Pre Pregnancy Diabetes 0.68 No Pre - 0.75 *** Pregnancy Diabetes Pre - 0.06 0.06 Pregnancy Diabetes Unknown 0.20 - Pregnancy Diabetes Pre *** 0.26 BMI at First Prenatal Visit 0.03 0.03 Underweight (<18.5 BMI) -<25 BMI) Normal Weight (18.5 0.29 0.28 - 0.25 *** 0.20 Overweight (25 <30 BMI) Obese (30 - <40 BMI) 0.23 0.24 0.07 Very Obese (>=40 BMI) 0.06 0.19 BMI Unknown *** 0.14 TECHNICAL APPENDICES 321

340 Depression Status Measure Not Depressed Depressed Smoking 0.82 *** 0.73 Did not Smoke at Intake 0.14 Smoked at Intake 0.06 *** 0.13 Smoking Status Unknown 0.12 Intimate Partner Violence 0.87 0.70 No History of Intimate Partner Violence *** *** 0.13 0.30 History of Intimate Partner Violence Year 2013 and 2014 0.30 0.29 2015 0.45 0.44 2016 and 2017 0.26 0.26 Region 0.25 ** 0.22 Northeast 0.73 0.69 Midwest *** South 0.00 *** 0.00 West 0.06 0.05 Significance calculated Notes: Sample limited to women with nonmissing data participating in the Group Prenatal Care model. * ** One asterisk ( ) ) indicates significance at the 0.1 level; two asterisks ( using pairwise comparison of means test. *** s significance at the 0.05 level; and three asterisks ( ) indicate significance at the 0.01 level for the difference in indicate ^^ means from Maternity Care Homes. One caret ( ) indicates significance at the 0.1 level; two carets ( ) indicates ^ ) indicates significance at the 0.01 level for the difference in means ^^^ significance at the 0.05 level; and three carets ( from Group Prenatal Care. TABLE M. MODEL MATERNITY CARE HOME ION ANALYTIC SAMPLE, 32: DESCRIPTIVE STATISTICS FOR THE DEPRESS Depression Status Measure Depressed Not Depressed Sample Size 10,835 3,698 -------- Outcomes Means ---------------- Birth Preterm 0.12 *** 0.15 Low Birth Weight *** 0.10 0.13 C - Section 0.32 0.30 *** Demographic Characteristics Race/Ethnicity White *** 0.23 0.19 0.31 Hispanic 0.20 *** Black 0.58 *** 0.42 Other 0.04 0.04 Age 0.05 * 0.06 Less than 18 Years Old of Age 18 to 19 Years 0.09 * 0.10 0.75 20 to 34 Years of Age 0.76 0.09 0.09 35 Years of Age or Older Education Less than High School 0.28 ** 0.30 High School Graduate / Ged 0.55 0.57 0.04 *** 0.02 Bachelor's Degree 0.09 0.08 Other Degree 0.04 Education Unknown *** 0.03 Relationship Status 0.22 *** 0.14 Married Living with a Partner 0.28 *** 0.33 0.29 In a Relationship, Not Living Together 0.31 ** 0.27 Not in a Relationship 0.16 *** Employment/School 0.32 *** 0.36 Working, Not in School 0.12 0.12 In School, Not Working 0.04 ** 0.05 Working and in School 0.47 0.51 *** Neither Working nor in School 322 TECHNICAL APPENDICES

341 Depression Status Measure Depressed Not Depressed Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 0.33 *** 0.38 *** 0.19 0.14 Prior Preterm Birth No Prior Preterm Birth 0.48 0.48 Prior Low Birth Weight 0.33 0.38 No Prior Birth *** 0.08 *** 0.11 Prior Low Birth Weight Birth *** 0.44 No Prior Low Birth Weight Birth 0.48 *** 0.08 Prior Low Birth Weight Unknown 0.10 Prior C - Section No Prior Birth 0.33 *** 0.38 0.19 *** 0.17 Prior C -Section ** Section No Prior 0.47 C- 0.45 Interpregnancy Interval 0.33 No Prior Birth *** 0.38 0.13 ** Short Interpregnancy Interval 0.15 0.37 *** 0.40 Normal Interpregnancy Interval 0.11 0.12 Interpregnancy Interval Unknown Risk Factors from Current Pregnancy Food Insecurity 0.62 Not Food Insecure at Intake 0.84 *** Food Insecure at Intake 0.12 *** 0.34 0.04 0.04 Food Insecurity Score Unknown Pregnancy Intent 0.29 *** Intended Pregnancy 0.21 Unintended Pregnancy 0.79 *** 0.71 Pre Pregnancy Hypertension - Pregnancy Hypertension 0.84 - Pre No 0.85 Pre 0.08 Pregnancy Hypertension 0.07 ** - 0.07 *** 0.09 - Pre Pregnancy Hypertension Unknown - Pre Pregnancy Diabetes 0.87 0.87 No Pre- Pregnancy Diabetes 0.04 Pre 0.03 -Pregnancy Diabetes Pre 0.10 ** 0.09 Pregnancy Diabetes Unknown - BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.03 0.02 Normal Weight (18.5 - <25 BMI) 0.28 0.27 Overweight (25 - <30 BMI) 0.23 0.23 Obese (30 0.26 0.27 - <40 BMI) *** 0.11 Very Obese (>=40 BMI) 0.09 *** BMI Unknown 0.13 0.09 Smoking Did not Smoke at Intake 0.86 0.77 *** *** Smoked at Intake 0.18 0.10 0.05 Smoking Status Unknown 0.03 *** Intimate Partner Violence No History of Intimate Partner Violence 0.86 *** 0.65 0.14 *** 0.35 History of Intimate Partner Violence Year 0.23 0.27 2013 and 2014 *** 0.43 2015 0.42 0.31 2016 and 2017 *** 0.34 TECHNICAL APPENDICES 323

342 Depression Status Measure Depressed Not Depressed Region 0.00 *** Northeast 0.00 *** Midwest 0.71 0.57 0.28 South 0.20 *** 0.15 *** 0.09 West data participating in the Maternity Care Home model. Significance calculated nonmissing Sample limited to women with Notes: ** * ) indicates significance at the 0.1 level; two asterisks ( ) using pairwise comparison of means test. One asterisk ( significance at the 0.01 level for the difference in ) indicate s ( s significance at the 0.05 level; and three asterisk *** indicate means from Maternity Care Homes. One caret ( ) indicates significance at the 0.1 level; two carets ( ) indicates ^^ ^ significance at the 0.05 level; and three carets ( ) indicates significance at the 0.01 level for the difference in means ^^^ from Group Prenatal Care. TABLE M. 33: DESCRIPTIVE STATISTICS FOR THE DEPRESS ION ANALYTIC SAMPLE, WHITE WOMEN Depression Status Measure Not Depressed Depressed 1,463 4,928 Sample Size Means Outcomes *** 0.10 Preterm Birth 0.07 0.06 *** 0.08 Low Birth Weight 0.25 Section - C 0.22 ** Demographic Characteristics Age Less than 18 Years Old 0.04 *** 0.03 18 to 19 Years of Age 0.09 0.08 20 to 34 Years of Age 0.79 ** 0.81 0.08 35 Years of Age or Older 0.08 Education *** 0.19 Less than High School 0.15 High School Graduate / Ged 0.59 0.58 Bachelor's Degree 0.12 *** 0.08 Other Degree 0.12 0.11 0.02 Education Unknown 0.03 Relationship Status Married 0.40 0.28 *** 0.36 0.36 Living with a Partner In a Relationship, Not Living Together 0.16 0.19 *** Not in a Relationship 0.17 *** 0.09 Employment/School *** 0.32 Working, Not in School 0.39 0.08 0.08 In School, Not Working 0.04 0.05 Working and in School 0.56 *** Neither Working nor in School 0.48 Risk Factors from Prior Birth Prior Preterm Birth 0.39 No Prior Birth 0.39 0.15 Prior Preterm Birth 0.10 *** No Prior Preterm Birth 0.46 *** 0.51 Prior Low Birth Weight 0.39 No Prior Birth 0.39 *** 0.06 Prior Low Birth Weight Birth 0.03 0.48 0.49 No Prior Low Birth Weight Birth Prior Low Birth Weight Unknown 0.07 *** 0.09 -Section Prior C No Prior Birth 0.39 0.39 0.13 0.10 Prior C - Section *** - 0.48 ** Section No Prior C 0.51 Interpregnancy Interval 0.39 0.39 No Prior Birth 0.19 0.18 Short Interpregnancy Interval 324 TECHNICAL APPENDICES

343 Depression Status Measure Depressed Not Depressed 0.34 0.35 Normal Interpregnancy Interval 0.09 Interpregnancy Interval Unknown *** 0.07 Current Pregnancy Risk Factors from Food Insecurity Not Food Insecure at Intake 0.63 *** 0.87 Food Insecure at Intake 0.10 0.34 *** Food Insecurity Score Unknown 0.03 0.03 Pregnancy Intent 0.25 0.35 Intended Pregnancy *** Unintended Pregnancy 0.75 *** 0.65 Pregnancy Hypertension Pre - No Pre - Pregnancy Hypertension 0.92 *** 0.87 0.03 Pre -Pregnancy Hypertension 0.03 -Pregnancy Hypertension Unknown Pre 0.05 *** 0.10 Pregnancy Diabetes Pre - 0.85 No Pre - Pregnancy Diabetes 0.86 *** 0.02 Pre - Pregnancy Diabetes 0.03 0.11 ** 0.14 - Pregnancy Diabetes Unknown Pre BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.03 0.03 Normal Weight (18.5 - <25 BMI) 0.38 0.37 0.23 ** 0.20 Overweight (25 <30 BMI) - 0.19 0.19 -<40 BMI) Obese (30 0.05 Very Obese (>=40 BMI) 0.07 ** 0.16 0.10 BMI Unknown *** Smoking *** Did not Smoke at Intake 0.64 0.77 Smoked at Intake 0.31 *** 0.18 0.05 0.05 Smoking Status Unknown Intimate Partner Violence No History of Intimate Partner Violence *** 0.82 0.57 0.18 0.43 History of Intimate Partner Violence *** Year 0.28 2013 and 2014 0.27 2015 0.42 *** 0.46 2016 and 2017 0.30 *** 0.26 Model 0.51 ** Maternity Care Home 0.48 0.42 *** 0.37 Birth Center 0.15 Group Prenatal Care 0.08 *** Region *** 0.03 Northeast 0.05 *** Midwest 0.66 0.51 *** 0.33 South 0.18 West 0.13 * 0.12 data. Significance calculated using pairwise comparison of means test. nonmissing Sample limited to white women with Notes: ** ignificance at the 0.05 level; and three ) indicates s One asterisk ( ) indicates significance at the 0.1 level; two asterisks ( * *** asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ( ) ^^^ ^^ ^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TABLE M. BLACK WOMEN ION ANALYTIC SAMPLE, 34: DESCRIPTIVE STATISTICS FOR THE DEPRESS Depression Status Measure Not Depressed Depressed Sample Size 3,084 6,207 -------- Outcomes Means ---------------- Preterm Birth 0.14 *** 0.12 0.12 Low Birth Weight 0.13 * C - Section 0.32 0.30 TECHNICAL APPENDICES 325

344 Depression Status Measure Depressed Not Depressed Demographic Characteristics Age Less than 18 Years Old 0.06 0.07 0.11 0.11 18 to 19 Years of Age 0.77 0.76 20 to 34 Years of Age 35 Years of Age or Older 0.06 0.07 Education 0.21 Less than *** High School 0.26 High School Graduate / Ged 0.62 0.62 0.05 *** 0.03 Bachelor's Degree Other Degree 0.07 *** 0.09 0.03 0.02 Education Unknown * Relationship Status 0.13 Married 0.08 *** Living with a Partner 0.24 0.26 ** 0.39 *** 0.36 Living Together In a Relationship, Not Not in a Relationship *** 0.22 0.32 Employment/School Working, Not in School 0.33 *** 0.37 0.15 In School, Not Working 0.14 0.05 *** 0.07 Working and in School Neither Working nor in School 0.42 *** 0.48 Risk Factors from Prior Birth Prior Preterm Birth 0.41 No Prior Birth 0.39 *** *** Prior Preterm Birth 0.18 0.15 0.44 0.44 No Prior Preterm Birth Prior Low Birth Weight 0.41 *** 0.39 No Prior Birth 0.09 Prior Low Birth Weight Birth 0.08 * 0.43 0.42 No Prior Low Birth Weight Birth 0.09 0.09 Prior Low Birth Weight Unknown Section - Prior C 41 * ** 0. 0.39 No Prior Birth 0.16 Prior C - Section 0.18 - Section 0.44 0.42 No Prior C Interpregnancy Interval *** No Prior Birth 0.39 0.41 0.14 0.14 Short Interpregnancy Interval ** 0.38 Normal Interpregnancy Interval 0.36 0.10 Interpregnancy Interval Unknown 0.09 Risk Factors from Current Pregnancy Food Insecurity 0.61 *** 0.82 Not Food Insecure at Intake 0.14 Food Insecure at Intake *** 0.35 0.04 0.04 Food Insecurity Score Unknown Pregnancy Intent Intended Pregnancy 0.17 0.19 * Unintended Pregnancy 0.83 0.81 * Pre - Pregnancy Hypertension 0.82 Pregnancy Hypertension - No Pre 0.81 Pre - 0.09 0.10 Pregnancy Hypertension -Pregnancy Hypertension Unknown 0.09 0.09 Pre -Pregnancy Pre Diabetes *** No Pre - Pregnancy Diabetes 0.82 0.85 0.04 0.04 Pregnancy Diabetes - Pre Pre *** 0.14 - Pregnancy Diabetes Unknown 0.11 BMI at First Prenatal Visit 0.03 Underweight (<18.5 BMI) 0.02 TECHNICAL APPENDICES 326

345 Depression Status Measure Depressed Not Depressed - <25 BMI) 0.28 0.28 Normal Weight (18.5 Overweight (25 - <30 BMI) 0.20 0.21 -<40 BMI) 0.27 0.26 Obese (30 Very Obese (>=40 BMI) 0.10 0.11 BMI Unknown 0.12 0.12 Smoking *** 0.85 0.77 Did not Smoke at Intake 0.08 *** Smoked at Intake 0.15 0.08 * 0.09 Smoking Status Unknown Intimate Partner Violence No History of 0.70 Intimate Partner Violence *** 0.89 0.11 History of Intimate Partner Violence 0.30 *** Year 2013 and 2014 0.27 0.28 2015 0.43 0.43 0.30 0.29 2016 and 2017 Model *** Maternity Care Home 0.74 0.69 Birth Center 0.08 0.08 0.18 *** Group Prenatal Care 0.23 Region 0.07 Northeast 0.06 0.77 * 0.78 Midwest South *** 0.13 0.11 West 0.04 0.05 data. Significance calculated using pairwise comparison of means test. nonmissing Sample limited to black women with Notes: tes significance at the 0.05 level; and three * One asterisk ( ** ) indica ) indicates significance at the 0.1 level; two asterisks ( One caret significance at the 0.01 level for the difference in means from Maternity Care Homes. ) indicate ( asterisks *** ( ^^^ ) ) indicates significance at the 0.05 level; and three carets ( ^^ ^ dicates significance at the 0.1 level; two carets ( ) in indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TABLE M. 35: D ESCRIPTIVE STATISTIC S FOR THE DEPRESSION ANALYTIC SAMPLE, HISPANIC WOMEN Depression Status Measure Depressed Not Depressed 1,420 Sample Size 5,839 -------- Outcomes Means ---------------- 0.11 0.12 Preterm Birth 0.07 Low Birth Weight 0.08 * 0.28 * 0.26 C - Section Demographic Characteristics Age Less than 18 Years Old 0.06 * 0.05 0.09 0.08 18 to 19 Years of Age 20 to 34 Years of Age 0.74 * 0.72 0.13 35 Years of Age or Older 0.14 Education 0.34 Less than High School 0.39 *** 0.43 0.44 High School Graduate / GED Degree 0.03 0.03 Bachelor's 0.08 Other Degree 0.11 *** Education Unknown 0.08 0.08 Relationship Status *** Married 0.32 0.22 0.39 Living with a Partner *** 0.35 In a Relationship, Not Living Together 0.23 *** 0.19 *** 0.19 Not in a Relationship 0.10 Employment/School Working, Not in School 0.33 0.32 0.09 0.10 In School, Not Working TECHNICAL APPENDICES 327

346 Depression Status Measure Depressed Not Depressed Working and in School 0.05 0.04 ~ Neither Working nor in School 0.51 ** 0.54 Risk Factors from Prior Birth Prior Preterm Birth 0.31 ** 0.35 No Prior Birth Prior Preterm Birth *** 0.11 0.15 0.54 No Prior Preterm Birth 0.53 Prior Low Birth Weight 0.35 ** 0.31 No Prior Birth * 0.05 Prior Low Birth Weight Birth 0.06 0.53 No Prior Low Birth Weight Birth 0.52 Prior Low Birth Weight Unknown 0.10 *** 0.07 Prior C - Section 0.35 ** 0.31 Prior Birth No 0.15 Section - Prior C 0.18 *** 0.50 - 0.51 Section No Prior C Interpregnancy Interval 0.35 ** 0.31 No Prior Birth 0.12 0.13 Short Interpregnancy Interval Normal Interpregnancy Interval 0.39 0.41 Interpregnancy Interval Unknown 0.15 0.14 Risk Factors from Current Pregnancy Food Insecurity 0.82 *** Not Food Insecure at Intake 0.59 *** 0.35 Food Insecure at Intake 0.13 Food Insecurity Score Unknown 0.05 0.05 Pregnancy Intent Intended Pregnancy 0.28 *** 0.43 Unintended Pregnancy 0.72 *** 0.57 - Pregnancy Hypertension Pre 0.94 No Pre - Pregnancy Hypertension 0.93 0.05 Pregnancy Hypertension - * 0.03 Pre -Pregnancy Hypertension Unknown Pre 0.03 0.03 - Pregnancy Diabetes Pre No Pre - Pregnancy Diabetes 0.90 0.91 Diabetes Pregnancy - Pre 0.04 0.04 0.05 0.06 - Pre Pregnancy Diabetes Unknown BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.03 ** 0.02 Normal Weight (18.5 - <25 BMI) 0.30 0.29 - <30 BMI) *** 0.30 0.26 Overweight (25 0.27 <40 BMI) Obese (30 - 0.27 Very Obese (>=40 BMI) 0.06 0.06 BMI Unknown 0.08 ** 0.06 Smoking 0.93 *** 0.87 Did not Smoke at Intake Smoked at Intake *** 0.02 0.05 *** Smoking Status Unknown 0.05 0.08 Intimate Partner Violence 0.69 *** 0.87 No History of Intimate Partner Violence 0.13 *** 0.31 Partner Violence History of Intimate Year 0.21 *** 0.25 2013 and 2014 2015 0.41 0.39 0.40 2016 and 2017 0.33 *** Model Maternity Care Home 0.51 *** 0.57 0.16 Birth Center 0.15 Group Prenatal Care *** 0.33 0.27 APPENDICES 328 TECHNICAL

347 Depression Status Measure Depressed Not Depressed Region *** 0.04 0.08 Northeast 0.56 Midwest ** 0.59 South ** 0.16 0.13 *** 0.24 0.20 West Notes: Sample limited to Hispanic women with nonmissing data. Significance calculated using pairwise comparison of means ** es significance at the 0.05 level; and * test. ) indicat ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( three asterisks ( ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One *** caret ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ^^ ^ ( ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. ^^^ WOMEN WITH OTHER/MI XED TABLE M. ION ANALYTIC SAMPLE, 36: DESCRIPTIVE STATISTICS FOR THE DEPRESS /ETHNICITY RACE Depression Status Measure Depressed Not Depressed 270 Sample Size 769 -------- Outcomes Means ---------------- 0.08 Preterm Birth 0.11 ** Low Birth Weight * 0.08 0.12 C 0.28 0.23 Section - Demographic Characteristics Age Less than 18 Years Old 0.05 0.03 0.06 Years of Age 18 to 19 0.08 20 to 34 Years of Age 0.81 0.77 35 Years of Age or Older 0.08 * 0.11 Education 0.15 Less than High School 0.20 * High School Graduate / GED 0.55 0.52 0.15 0.08 *** Bachelor's Degree 0.14 0.16 Other Degree 0.03 Education Unknown 0.02 Relationship Status 0.27 *** 0.41 Married 0.35 * Living with a Partner 0.30 0.17 * 0.21 In a Relationship, Not Living Together 0.17 Not in a Relationship ** 0.12 Employment/School 0.35 0.31 Working, Not in School 0.10 0.14 In School, Not Working 0.07 0.05 Working and in School Neither Working nor in School 0.50 0.48 Risk Factors from Prior Birth Prior Preterm Birth 0.40 No Prior Birth 0.48 ** 0.06 0.16 Prior Preterm Birth *** 0.46 0.44 No Prior Preterm Birth Prior Low Birth Weight ** 0.40 Birth No Prior 0.48 Prior Low Birth Weight Birth 0.08 *** 0.03 0.42 0.44 No Prior Low Birth Weight Birth 0.07 Prior Low Birth Weight Unknown 0.07 Prior C -Section ** 0.48 No Prior Birth 0.40 0.12 0.14 Prior C - Section 0.40 No Prior C * - 0.46 Section Interpregnancy Interval No Prior Birth 0.40 ** 0.48 0.19 0.13 ** Short Interpregnancy Interval TECHNICAL APPENDICES 329

348 Depression Status Measure Not Depressed Depressed 0.31 0.31 Normal Interpregnancy Interval Interpregnancy Interval Unknown 0.08 0.10 Risk Factors from Current Pregnancy Food Insecurity Not Food Insecure at Intake 0.60 *** 0.81 0.15 *** 0.36 Food Insecure at Intake 0.04 0.04 Food Insecurity Score Unknown Pregnancy Intent 0.32 Intended Pregnancy 0.41 *** Unintended Pregnancy *** 0.59 0.68 - Pregnancy Hypertension Pre No Pre - Pregnancy Hypertension 0.90 0.91 0.04 -Pregnancy Hypertension Pre 0.05 0.07 Pre -Pregnancy Hypertension Unknown 0.05 Pregnancy Diabetes Pre - Pregnancy Diabetes No Pre 0.86 0.89 - - 0.01 0.02 Pre Pregnancy Diabetes 0.09 Pre - Pregnancy Diabetes Unknown 0.13 ** BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.05 0.04 0.32 <25 BMI) - Normal Weight (18.5 0.36 - <30 BMI) 0.24 0.25 Overweight (25 Obese (30 -<40 BMI) 0.23 ** 0.17 0.06 Very Obese (>=40 BMI) 0.07 0.10 0.11 BMI Unknown Smoking 0.86 *** 0.73 Did not Smoke at Intake Intake Smoked at 0.06 *** 0.18 Smoking Status Unknown 0.09 0.08 Intimate Partner Violence No History of Intimate Partner Violence 0.84 *** 0.58 History of Intimate Partner Violence 0.42 *** 0.16 Year 2013 and 2014 0.26 0.22 0.38 0.40 2015 2016 and 2017 0.36 0.38 Model Maternity Care Home 0.50 * 0.56 0.25 0.25 Birth Center Group Prenatal Care 0.19 ** 0.25 Region 0.06 Northeast 0.07 *** 0.50 0.63 Midwest 0.10 0.11 South 0.33 *** 0.19 West Notes: Sample limited to women with other/mixed race/ethnicity and nonmissing data. Significance calculated using pairwise s significance ** * comparison of means test. One asterisk ( ) indicates significance at the 0.1 level; two asterisks ( ) indicate ) indicate significance at the 0.01 level for the difference in means from ( at the 0.05 level; and three asterisks *** Maternity Care Homes. One caret ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the ^ ^^ te 0.05 level; ) indica and three carets ( s significance at the 0.01 level for the difference in means from Group ^^^ Prenatal Care. ION BREASTFEEDING ANALYTIC SAMPLE 37: DESCRIPTIVE STATISTICS FOR THE DEPRESS TABLE M. Depression Status Measure Depressed Not Depressed 12,332 Sample Size 7,096 Means Outcomes 0.82 *** 0.78 Breastfeeding Initiation 330 TECHNICAL APPENDICES

349 Depression Status Measure Not Depressed Depressed Demographic Characteristics Race/Ethnicity White 0.24 *** 0.29 Hispanic 0.23 *** 0.33 Black 0.48 *** 0.35 Other 0.05 0.04 ge A *** Less than 18 Years Old 0.06 0.04 0.09 18 to 19 Years of Age 0.09 20 to 34 Years of 0.77 0.76 Age 0.09 35 Years of Age or Older 0.09 Education Less than High School 0.26 0.24 0.54 *** 0.57 High School Graduate / GED 0.08 0.05 Bachelor's Degree *** 0.10 0.10 Other Degree Education Unknown 0.03 0.04 Relationship Status *** Married 0.30 0.18 0.33 0.30 *** Living with a Partner *** 0.28 0.24 In a Relationship, Not Living Together 0.13 *** 0.24 Not in a Relationship Employment/School *** 0.34 Working, Not in School 0.36 In School, Not Working 0.12 0.11 * 0.05 Working and in School 0.05 0.47 ** 0.49 Neither Working nor in School Risk Factors from Prior Birth Prior Preterm Birth ** 0.39 0.37 No Prior Birth 0.11 *** 0.15 Prior Preterm Birth No Prior Preterm Birth 0.48 ** 0.50 Prior Low Birth Weight ** 39 No Prior Birth 0. 37 0. *** 0.06 Prior Low Birth Weight Birth 0.08 No Prior Low Birth Weight Birth 0.48 0.48 0.07 0.07 Prior Low Birth Weight Unknown Prior C - Section 0.39 ** No Prior Birth 0.37 Prior C 0.16 *** 0.14 Section - 0.47 No Prior C - 0.46 Section Interpregnancy Interval 0.39 ** 0.37 No Prior Birth Short Interpregnancy Interval 0.14 0.14 Normal Interpregnancy Interval 0.39 * 0.37 0.10 0.10 Interpregnancy Interval Unknown Risk Factors from Current Pregnancy Food Insecurity Not Food Insecure at Intake 0.62 *** 0.83 0.35 Food Insecure at Intake 0.13 *** Food Insecurity Score Unknown 0.03 * 0.04 Pregnancy Intent 0.34 Intended Pregnancy 0.23 *** Unintended Pregnancy 0.77 *** 0.66 Pre -Pregnancy Hypertension 0.88 No Pre - Pregnancy Hypertension 0.89 Hypertension ** 0.06 Pregnancy Pre - 0.05 Pre - Pregnancy Hypertension Unknown 0.05 *** 0.06 331 TECHNICAL APPENDICES

350 Depression Status Measure Depressed Not Depressed Pregnancy Diabetes - Pre ** - Pregnancy Diabetes No Pre 0.87 0.88 Pre -Pregnancy Diabetes 0.03 0.03 0.09 Pre -Pregnancy Diabetes Unknown ** 0.10 BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.03 0.03 0.31 0.31 <25 BMI) - Normal Weight (18.5 0.24 *** <30 BMI) - Overweight (25 0.22 <40 BMI) 0.25 Obese (30 0.24 - 0.07 *** 0.09 Very Obese (>=40 BMI) 0.11 * 0.10 BMI Unknown Smoking 0.86 0.77 *** Did not Smoke at Intake Smoked at Intake 0.16 *** 0.08 0.06 *** 0.07 Smoking Status Unknown Intimate Partner Violence 0.86 *** 0.66 No History of Intimate Partner Violence *** 0.14 History of Intimate Partner Violence 0.34 Year 2013 and 2014 0.25 0.24 2015 0.42 0.43 2016 and 2017 0.32 ** 0.34 Model Maternity Care Home 0.61 0.62 Birth Center 0.21 *** 0.23 Group Prenatal Care 0.18 *** 0.15 Region Northeast 0.03 *** 0.04 *** 0.71 0.62 Midwest 0.21 *** 0.15 South West 0.10 *** 0.14 One data. Significance calculated using pairwise comparison of means test. nonmissing Sample limited to women with Notes: s significance at the 0.05 level; and three ** ) indicate * ) indicates significance at the 0.1 level; two asterisks ( asterisk ( One caret significance at the 0.01 level for the difference in means from Maternity Care Homes. ) indicate ( asterisks *** ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three carets ( ) ^^^ ^^ ^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TABLE M. CENTER MODEL ION BREASTFEEDING ANALYTIC SAMPLE, BIRTH 38: DESCRIPTIVE STATISTICS FOR THE DEPRESS Depression Status Measure Depressed Not Depressed 2,849 Sample Size 841 Outcomes Means 0.91 Breastfeeding Initiation ** 0.93 Demographic Characteristics Race/Ethnicity White 0.56 *** 0.51 0.25 *** 0.20 Hispanic Black *** 0.13 0.22 0.06 0.07 Other Age Less than 18 Years Old 0.03 0.02 ** 0.07 0.05 18 to 19 Years of Age 20 to 34 Years of 0.84 ** 0.81 Age 0.09 0.09 35 Years of Age or Older Education Less than High School 0.17 *** 0.12 High School Graduate / Ged 0.54 0.57 *** 0.18 Bachelor's Degree 0.12 0.14 0.12 Other Degree 332 TECHNICAL APPENDICES

351 Depression Status Measure Depressed Not Depressed 0.03 0.02 Education Unknown ~ Relationship Status 0.32 *** 0.50 Married Living with a Partner 0.34 0.32 0.17 In a Relationship, Not Living Together 0.12 *** Not in a Relationship *** 0.17 0.06 Employment/School 0.36 Working, Not in School ** 0.40 0.08 0.10 In School, Not Working 0.06 0.07 Working and in School 0.46 Neither Working nor in School 0.47 Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 0.38 0.36 Prior Preterm Birth 0.10 *** 0.07 No Prior Preterm Birth 0.53 0.57 ** Prior Low Birth Weight 0.38 0.36 No Prior Birth ** Prior Low Birth 0.01 0.01 Weight Birth 0.58 * 0.62 No Prior Low Birth Weight Birth Prior Low Birth Weight Unknown 0.03 *** 0.01 - Section Prior C No Prior Birth 0.36 0.38 -Section 0.06 0.05 Prior C No Prior C - Section 0.56 0.59 Interpregnancy Interval 0.36 No Prior Birth 0.38 ** Short Interpregnancy Interval 0.21 0.17 0.38 Normal Interpregnancy Interval 0.36 0.06 Interpregnancy Interval Unknown 0.07 Risk Factors from Current Pregnancy Food Insecurity *** Not Food Insecure at Intake 0.62 0.84 0.35 Intake Food Insecure at 0.13 *** Food Insecurity Score Unknown 0.03 0.02 Pregnancy Intent *** 0.44 Intended Pregnancy 0.29 0.56 Unintended Pregnancy 0.71 *** Pre - Pregnancy Hypertension Pregnancy Hypertension No Pre - 0.99 0.99 0.01 Pregnancy Hypertension - Pre 0.01 Pregnancy Hypertension Unknown - Pre 0.00 0.00 Pre Pregnancy Diabetes - 1.00 1.00 No Pre- Pregnancy Diabetes Pre - Pregnancy Diabetes 0.00 0.00 0.00 Pregnancy Diabetes Unknown Pre 0.00 - BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.03 0.04 0.46 Normal Weight (18.5 - <25 BMI) 0.46 Overweight (25 - <30 BMI) 0.23 0.25 0.20 <40 BMI) - Obese (30 0.19 0.03 0.04 Very Obese (>=40 BMI) 0.03 BMI Unknown 0.03 Smoking 0.86 Did not Smoke at Intake 0.79 *** 0.12 0.06 Smoked at Intake *** Smoking Status Unknown 0.09 0.09 Intimate Partner Violence 0.84 *** 0.65 No History of Intimate Partner Violence TECHNICAL APPENDICES 333

352 Depression Status Measure Depressed Not Depressed History of Intimate Partner Violence 0.35 *** 0.16 -------- Year ---------------- 2013 and 2014 0.26 0.24 2015 0.41 0.39 2016 and 2017 0.34 0.36 Region 0.03 0.03 Northeast 0.62 ** 0.67 Midwest South 0.09 0.10 0.21 West 0.25 *** data participating in the Birth Center model. Significance calculated using nonmissing Sample limited to women with Notes: tes * pairwise comparison of means test. ) indica ** ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( significance at the 0.05 level; and three asterisks ) indicate significance at the 0.01 level for the difference in means *** ( ^^ ^ dicates significance at the 0.1 level; two carets ( ) in One caret ( from Maternity Care Homes. ) indicates significance at the 0.05 level; and three carets ( ^^^ ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TIC SAMPLE, GROUP PRENATAL BREASTFEEDING ANALY S FOR THE DEPRESSION ESCRIPTIVE STATISTIC 39: D TABLE M. CARE MODEL Depression Status Measure Not Depressed Depressed Sample Size 1,847 756 Outcomes Means Breastfeeding Initiation 0.85 0.84 Demographic Characteristics Race/Ethnicity 0.17 *** 0.12 White 0.53 Hispanic 0.31 *** 0.31 *** 0.47 Black 0.04 0.06 Other Age Less than 18 Years Old 0.08 *** 0.06 0.10 0.11 18 to 19 Years of Age 0.74 20 to 34 Years of Age 0.73 0.10 0.07 35 Years of Age or Older ** Education *** 0.32 Less than High School 0.23 *** 0.56 0.49 High School Graduate / GED Bachelor's Degree 0.05 0.05 0.09 0.10 Other Degree 0.05 Education Unknown 0.05 Relationship Status 0.14 Married *** 0.26 Living with a Partner 0.37 ** 0.33 In a Relationship, Not Living Together 0.23 0.29 *** 0.24 Not in a Relationship *** 0.15 Employment/School Working, Not in School 0.32 0.31 0.10 *** 0.14 In School, Not Working 0.05 0.04 Working and in School 0.52 0.50 Neither Working nor in School Risk Factors from Prior Birth Prior Preterm Birth 0.49 No Prior Birth 0.46 0.10 ** 0.12 Prior Preterm Birth No Prior Preterm Birth 0.39 ** 0.44 Prior Low Birth Weight 0.46 No Prior Birth 0.49 0.05 0.05 Prior Low Birth Weight Birth 334 TECHNICAL APPENDICES

353 Depression Status Measure Depressed Not Depressed No Prior Low Birth Weight Birth 0.31 *** 0.41 ~ Prior Low Birth Weight Unknown 0.15 *** 0.08 - Section Prior C No Prior Birth 0.46 0.49 - ** 0.17 Section 0.14 Prior C No Prior C Section - 0.40 0.35 *** Interpregnancy Interval No Prior Birth 0.46 0.49 Short Interpregnancy Interval 0.11 * 0.09 0.35 Normal Interpregnancy Interval 0.30 ** 0.10 0.10 Interpregnancy Interval Unknown Current Pregnancy Risk Factors from Food Insecurity Not Food Insecure at Intake *** 0.81 0.59 0.15 *** 0.37 Food Insecure at Intake Food Insecurity Score Unknown 0.04 0.04 Pregnancy Intent 0.35 Intended Pregnancy 0.22 *** *** Unintended Pregnancy 0.78 0.65 Pre Pregnancy Hypertension - No Pre 0.84 0.81 ** Pregnancy Hypertension - 0.05 Pre - Pregnancy Hypertension ** 0.07 0.12 0.11 Pre -Pregnancy Hypertension Unknown -Pregnancy Diabetes Pre No Pre - Pregnancy Diabetes 0.63 *** 0.73 Pregnancy Diabetes Pre 0.04 0.04 - *** 0.32 Pregnancy Diabetes Unknown - Pre 0.22 BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.04 0.04 0.29 0.28 <25 BMI) - Normal Weight (18.5 0.19 *** 0.25 Overweight (25 - <30 BMI) 0.23 0.22 <40 BMI) - Obese (30 0.05 Very Obese (>=40 BMI) 0.06 0.14 *** 0.21 BMI Unknown Smoking 0.84 Did not Smoke at Intake 0.73 *** *** 0.04 Smoked at Intake 0.13 Smoking Status Unknown 0.14 0.12 Violence Intimate Partner *** No History of Intimate Partner Violence 0.70 0.87 *** History of Intimate Partner Violence 0.30 0.13 Year 2013 and 2014 0.28 0.30 2015 0.47 0.47 0.23 2016 and 2017 0.25 Region 0.14 0.16 Northeast ** 0.79 Midwest 0.75 0.00 *** 0.00 South 0.10 West 0.07 ** Sample limited to women with Notes: data participating in the Group Prenatal Care model. Significance calculated nonmissing ** * One asterisk ( ) indicates significance at the 0.1 level; two asterisks using pairwise comparison of means test. ( ) significance at the 0.01 level for the difference in ates significance at the 0.05 level; and three asterisks ( ) indicate *** indic ^ ^^ ) indicates ) indicates significance at the 0.1 level; two carets ( One caret ( means from Maternity Care Homes. ^^^ signif icance at the 0.05 level; and three carets ( ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TECHNICAL APPENDICES 335

354 TABLE M. 40: DESCRIPTIVE STATISTICS FOR THE DEPRESS ION BREASTFEEDING ANALYTIC SAMPLE, MATERNITY CARE HOME MODEL Depression Status Measure Depressed Not Depressed Sample Size 7.636 2,499 ~ Outcomes Means *** Breastfeeding Initiation 0.73 0.77 Demographic Characteristics Race/Ethnicity 0.22 *** White 0.18 0.21 Hispanic 0.31 *** Black 0.57 *** 0.43 0.04 0.04 Other Age Less than 18 Years Old 0.06 0.05 0.10 0.09 18 to 19 Years of Age 20 to 34 Years of Age 0.76 0.76 0.09 0.10 35 Years of Age or Older Education Less than High School 0.27 * 0.29 0.56 High School Graduate / GED 0.57 0.04 *** 0.02 Bachelor's Degree 0.09 Other Degree 0.09 0.04 Education Unknown 0.03 *** Relationship Status Married 0.14 *** 0.23 0.33 *** 0.28 Living with a Partner In a Relationship, Not Living Together 0.29 0.31 0.15 *** 0.27 Not in a Relationship Employment/School ** Working, Not in School 0.34 0.36 0.12 0.12 In School, Not Working Working and in School 0.05 * 0.05 *** 0.50 Neither Working nor in School 0.46 Risk Factors from Prior Birth Prior Preterm Birth 0.34 *** 0.38 No Prior Birth *** 0.18 Preterm Birth Prior 0.14 No Prior Preterm Birth 0.48 0.49 Prior Low Birth Weight No Prior Birth 0.34 *** 0.38 0.11 0.08 *** Prior Low Birth Weight Birth 0.44 No Prior Low Birth Weight Birth 0.50 *** 0.06 Prior Low Birth Weight Unknown *** 0.10 Prior C - Section No Prior Birth 0.34 *** 0.38 0.20 *** Section 0.17 Prior C - 0.47 No Prior C - Section 0.45 Interpregnancy Interval *** 0.34 No Prior Birth 0.38 Short Interpregnancy Interval 0.13 0.14 Normal Interpregnancy Interval 0.41 0.38 *** Interpregnancy 0.11 0.11 Interval Unknown Risk Factors from Current Pregnancy Food Insecurity 0.83 *** 0.62 Not Food Insecure at Intake 0.34 Food Insecure at Intake 0.13 *** Food Insecurity Score Unknown * 0.04 0.03 Pregnancy Intent Intended Pregnancy 0.22 0.30 *** 336 TECHNICAL APPENDICES

355 Depression Status Measure Depressed Not Depressed 0.70 *** 0.78 Unintended Pregnancy Pregnancy Hypertension Pre - *** 0.88 Pregnancy Hypertension No Pre- 0.85 0.07 0.07 -Pregnancy Hypertension Pre Pre - 0.08 Pregnancy Hypertension Unknown 0.05 *** - Pre Pregnancy Diabetes *** 0.88 No Pre 0.90 Pregnancy Diabetes - Pre - 0.03 Pregnancy Diabetes 0.03 *** 0.09 0.07 Pregnancy Diabetes Unknown - Pre BMI at First Prenatal Visit Underweight (<18.5 BMI) 0.02 0.02 Normal Weight (18.5 - <25 BMI) 0.28 0.27 <30 BMI) 0.23 Overweight (25- 0.23 -<40 BMI) Obese (30 0.26 0.28 * *** Very Obese (>=40 BMI) 0.09 0.11 BMI Unknown 0.08 *** 0.13 Smoking Did not Smoke at Intake 0.78 *** 0.87 Smoked at Intake 0.18 0.10 *** *** 0.04 0.03 Smoking Status Unknown Intimate Partner Violence 0.87 No History of Intimate Partner Violence 0.66 *** *** 0.34 History of Intimate Partner Violence 0.13 Year 0.22 2013 and 2014 0.23 0.43 0.42 2015 0.36 0.34 2016 and 2017 Region *** 0.00 Northeast 0.00 0.71 *** 0.59 Midwest 0.31 *** 0.22 South West 0.06 0.11 *** data participating in the Maternity Care Home model. Significance calculated nonmissing Sample limited to women with Notes: ** * ) ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( using pairwise comparison of means test. ignificance at the 0.05 level; and three asterisks ( ) indicate significance at the 0.01 level for the difference in *** indicates s ) indicates dicates significance at the 0.1 level; two carets ( ) in One caret ( means from Maternity Care Homes. ^ ^^ ) indicates significance at the 0.01 level for the difference in means significance at the 0.05 level; and three carets ( ^^^ from Group Prenatal Care. TIC SAMPLE, WHITE WOMEN S FOR THE DEPRESSION ESCRIPTIVE STATISTIC BREASTFEEDING ANALY TABLE M. 41: D Depression Status Measure Depressed Not Depressed 3,515 1,003 Sample Size Outcomes Means 0.85 0.82 Breastfeeding Initiation *** Demographic Characteristics Age 0.02 *** 0.04 than 18 Years Old Less 0.08 0.09 18 to 19 Years of Age 0.82 20 to 34 Years of Age 0.79 * 0.08 0.08 35 Years of Age or Older Education *** 0.18 0.14 Less than High School High School Graduate / GED 0.58 0.58 0.14 *** Bachelor's Degree 0.09 0.12 Other Degree 0.12 Education Unknown 0.02 0.02 Relationship Status Married 0.29 0.42 *** TECHNICAL APPENDICES 337

356 Depression Status Measure Not Depressed Depressed 0.37 Living with a Partner 0.36 0.15 In a Relationship, Not Living Together *** 0.18 Not in a Relationship 0.16 *** 0.08 Employment/School Working, Not in *** 0.40 School 0.33 0.08 0.08 In School, Not Working Working and in School 0.05 0.05 0.54 Neither Working nor in School 0.47 *** Risk Factors from Prior Birth Prior Preterm Birth 0.39 0.39 No Prior Birth Prior Preterm Birth 0.14 *** 0.10 No Prior Preterm Birth 0.48 ** 0.51 Prior Low Birth Weight 0.39 0.39 No Prior Birth *** 0.05 Prior Low Birth Weight Birth 0.03 No Prior Low Birth Weight Birth 0.49 0.51 0.08 *** 0.05 Prior Low Birth Weight Unknown Prior C - Section No Prior Birth 0.39 0.39 *** Prior Section 0.13 C 0.09 - * 0.49 Section - No Prior C 0.52 Interpregnancy Interval 0.39 No Prior Birth 0.39 Short Interpregnancy Interval 0.17 0.19 0.35 Normal Interpregnancy Interval 0.35 0.07 Interpregnancy Interval Unknown 0.09 ** Current Pregnancy Risk Factors from Food Insecurity Not Food Insecure at Intake 0.65 *** 0.87 0.32 Food Insecure at Intake 0.10 *** 0.03 0.03 Food Insecurity Score Unknown Pregnancy Intent Intended Pregnancy 0.26 *** 0.37 Unintended Pregnancy 0.74 0.63 *** - Pre Pregnancy Hypertension - No Pre 0.87 *** 0.93 Pregnancy Hypertension 0.03 Pre - Pregnancy Hypertension 0.03 0.04 *** 0.10 Pre - Pregnancy Hypertension Unknown Pre - Pregnancy Diabetes No Pre * - Pregnancy Diabetes 0.86 0.88 - Pre 0.02 * 0.03 Pregnancy Diabetes Pre *** 0.12 0.09 -Pregnancy Diabetes Unknown BMI at First Prenatal Visit 0.03 0.03 Underweight (<18.5 BMI) Normal Weight (18.5 0.37 <25 BMI) - 0.39 - <30 BMI) 0.22 0.20 Overweight (25 Obese (30 - <40 BMI) 0.20 0.19 0.05 0.06 Very Obese (>=40 BMI) BMI 0.10 *** 0.15 Unknown Smoking 0.79 *** 0.67 Did not Smoke at Intake 0.17 *** 0.28 Smoked at Intake S moking Status Unknown 0.05 0.06 Intimate Partner Violence 0.82 *** 0.57 No History of Intimate Partner Violence 0.18 0.43 History of Intimate Partner Violence *** Year 0.27 2013 and 2014 0.28 338 TECHNICAL APPENDICES

357 Depression Status Measure Depressed Not Depressed 2015 0.42 * 0.45 2016 and 2017 0.31 ** 0.28 Model * 0.48 Maternity Care Home 0.45 * 0.46 Birth Center 0.42 0.06 *** 0.13 Group Prenatal Care Region * 0.02 Northeast 0.03 *** 0.50 0.65 Midwest 0.33 *** South 0.18 0.14 0.13 West Sample limited to white women with Notes: data. Significance calculated using pairwise comparison of means test. nonmissing ** es significance at the 0.05 level; and three ) indicates significance at the 0.1 level; two asterisks ( * ) indicat One asterisk ( ( asterisks ) indicate significance at the 0.01 level for the difference in means from Maternity Care Homes. One caret *** ( ) indicates significance at the 0.1 level; two carets ( ) indicates significance at the 0.05 level; and three car ets ( ) ^^^ ^^ ^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. ALYTIC SAMPLE, BLACK WOMEN 42: DESCRIPTIVE STATISTICS FOR THE DEPRESS TABLE M. ION BREASTFEEDING AN Depression Status Measure Depressed Not Depressed 1,970 Sample Size 4,255 Outcomes Means 0.71 0.71 Breastfeeding Initiation Demographic Characteristics Age 0.06 Less than 18 Years Old 0.07 0.10 18 to 19 Years of Age 0.10 0.76 0.77 20 to 34 Years of Age 0.07 0.07 Older 35 Years of Age or Education *** 0.26 Less than High School 0.20 High School Graduate / GED 0.62 0.62 Bachelor's Degree 0.05 *** 0.03 0.08 ** 0.10 Other Degree 0.03 0.02 Education Unknown Relationship Status Married 0.09 *** 0.14 0.26 0.24 Living with a Partner 0.39 *** 0.35 In a Relationship, Not Living Together 0.32 0.21 *** Not in a Relationship Employment/School 0.37 Working, Not in School 0.33 *** 0.15 0.14 In School, Not Working *** 0.05 Working and in School 0.07 *** 0.48 Neither Working nor in School 0.41 Risk Factors from Prior Birth Prior Preterm Birth *** 0.38 No Prior Birth 0.42 0.14 Prior Preterm Birth 0.17 *** No Prior Preterm Birth 0.44 0.44 Prior Low Birth Weight 0.42 No Prior Birth 0.38 *** 0.09 0.10 Prior Low Birth Weight Birth 0.41 No Prior Low Birth Weight Birth 0.44 ** Prior Low Birth Weight Unknown 0.08 0.08 Section Prior C - *** 0.38 0.42 No Prior Birth 0.18 ** 0.16 Prior C -Section 0.43 Section 0.42 No Prior C - TECHNICAL APPENDICES 339

358 Depression Status Measure Not Depressed Depressed Interpregnancy Interval 0.42 0.38 No Prior Birth *** Short Interpregnancy Interval 0.13 0.13 0.40 ** 0.37 Normal Interpregnancy Interval Interpregnancy Interval Unknown 0.09 0.08 Current Pregnancy Risk Factors from Food Insecurity *** 0.60 Not Food Insecure at Intake 0.82 Food Insecure at Intake 0.36 0.15 *** 0.04 0.03 Food Insecurity Score Unknown Pregnancy Intent 0.20 Intended Pregnancy 0.18 0.80 Unintended Pregnancy 0.82 -Pregnancy Hypertension Pre 0.84 Pregnancy Hypertension - No Pre 0.85 0.09 0.09 Pregnancy Hypertension - Pre Pregnancy Hypertension - Pre * 0.07 0.06 Unknown - Pregnancy Diabetes Pre - 0.86 * 0.85 Pregnancy Diabetes No Pre Pre - Pregnancy Diabetes 0.03 0.03 Pre 0.10 ** 0.12 Pregnancy Diabetes Unknown - BMI at First Prenatal Visit 0.03 Underweight (<18.5 BMI) 0.03 -<25 BMI) Normal Weight (18.5 0.28 0.28 Overweight (25 0.21 0.21 <30 BMI) - - Obese (30 0.26 0.26 <40 BMI) 0.10 0.12 Very Obese (>=40 BMI) 0.11 BMI Unknown 0.12 Smoking 0.78 *** 0.86 Did not Smoke at Intake *** 0.15 Smoked at Intake 0.07 0.06 0.07 Smoking Status Unknown Intimate Partner Violence 0.70 No History of Intimate Partner Violence 0.89 *** History of Intimate Partner Violence 0.11 0.30 *** Year 2013 and 2014 0.24 0.24 0.43 0.44 2015 0.33 2016 and 2017 0.32 Model 0.78 *** 0.72 Maternity Care Home 0.09 0.10 Birth Center *** 0.13 Group Prenatal Care 0.18 Region Northeast 0.03 0.02 Midwest 0.81 0.80 South 0.14 0.13 0.04 West 0.04 nonmissing Sample limited to black women with Notes: data. Significance calculated using pairwise comparison of means test. ** cates significance at the 0.05 level; and three ) indicates significance at the 0.1 level; two asterisks ( One asterisk ( * ) indi *** One caret significance at the 0.01 level for the difference in means from Maternity Care Homes. ) indicate ( asterisks ^^^ ) indicates significance at the 0.05 level; and three carets ( ^ dicates significance at the 0.1 level; two carets ( ) in ( ) ^^ indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. 340 TECHNICAL APPENDICES

359 TABLE M. 43: D ESCRIPTIVE STATISTIC S FOR THE DEPRESSION BREASTFEEDING ANALYTIC SAMPLE, HISPANIC WOMEN Depression Status Measure Depressed Not Depressed Sample Size 929 4,044 Means Outcomes 0.90 0.88 Breastfeeding Initiation * Demographic Characteristics Age 0.05 Less 0.06 than 18 Years Old 0.08 18 to 19 Years of Age 0.08 0.74 0.73 20 to 34 Years of Age 35 Years of Age or Older 0.13 0.13 Education 0.34 *** 0.39 Less than High School 0.43 * High School Graduate / GED 0.46 Bachelor's Degree 0.03 0.04 0.08 ** 0.10 Degree Other Education Unknown 0.08 0.07 Relationship Status Married *** 0.34 0.24 0.39 * 0.36 Living with a Partner 0.22 *** 0.18 In a Relationship, Not Living Together 0.09 0.18 Not in a Relationship *** Employment/School ** 0.33 Working, Not in School 0.36 0.10 0.09 In School, Not Working Working and in School 0.06 ** 0.04 0.54 *** 0.48 Neither Working nor in School Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 0.32 0.35 0.10 Prior Preterm Birth 0.12 No Prior Preterm 0.56 0.55 Birth Prior Low Birth Weight 0.35 No Prior Birth 0.32 Prior Low Birth Weight Birth 0.05 0.06 0.54 0.54 No Prior Low Birth Weight Birth 0.08 Prior Low Birth Weight Unknown *** 0.06 Section - Prior C No Prior Birth 0.32 0.35 Prior C 0.17 0.15 -Section 0.51 No Prior C - Section 0.51 Interpregnancy Interval No Prior Birth 0.32 0.35 0.12 0.11 Short Interpregnancy Interval 0.40 0.39 Normal Interpregnancy Interval Interpregnancy Interval Unknown 0.15 0.15 Risk Factors from Current Pregnancy Food Insecurity *** 0.61 Not Food Insecure at Intake 0.81 Food Insecure at Intake 0.35 *** 0.13 Food Insecurity Score Unknown 0.05 0.05 Pregnancy Intent 0.30 Intended Pregnancy 0.44 *** *** 0.56 0.70 Unintended Pregnancy Pre - Pregnancy Hypertension Pregnancy Hypertension 0.93 * No Pre - 0.94 0.04 Pregnancy Hypertension - Pre 0.03 - Pre Pregnancy Hypertension Unknown 0.03 0.03 Pre - Pregnancy Diabetes ** Pregnancy Diabetes No Pre- 0.90 0.93 TECHNICAL APPENDICES 341

360 Depression Status Measure Depressed Not Depressed 0.03 0.04 Pregnancy Diabetes - Pre Pregnancy Diabetes Unknown - 0.04 ** 0.06 Pre BMI at First Prenatal Visit 0.02 Underweight (<18.5 BMI) 0.03 <25 BMI) - Normal Weight (18.5 0.29 0.31 0.30 *** 0.25 <30 BMI) - Overweight (25 Obese (30 0.27 0.29 <40 BMI) - Very Obese (>=40 BMI) 0.06 0.06 BMI Unknown 0.06 0.06 Smoking 0.93 0.88 *** Did not Smoke at Intake 0.04 Smoked at Intake 0.01 *** 0.05 *** 0.08 Smoking Status Unknown Intimate Partner Violence 0.87 *** 0.70 No History of Intimate Partner Violence History of Intimate Partner Violence 0.13 *** 0.30 Year 2013 and 2014 0.25 *** 0.20 0.40 * 0.43 2015 0.40 *** 0.32 2016 and 2017 Model 0.57 0.58 Maternity Care Home 0.18 0.18 Birth Center 0.24 Group Prenatal Care 0.25 Region Northeast ** 0.03 0.05 0.56 * 0.59 Midwest 0.20 0.18 South West * 0.21 0.18 Notes: Sample limited to Hispanic women with nonmissing data. Significance calculated using pairwise comparison of means * s significance at the 0.05 level; and ** ) indicates significance at the 0.1 level; two asterisks ( ) indicate One asterisk ( test. ) indicate ( three asterisks *** significance at the 0.01 level for the difference in means from Maternity Care Homes. One ^ ) indicates significance at the 0.05 level; and three carets ) indicates significance at the 0.1 level; two carets ( caret ( ^^ ^^^ ( ) indicates significance at the 0.01 level for the difference in means from Group Prenatal Care. TABLE M. /OTHER WOMEN ION BREASTFEEDING ANALYTIC SAMPLE, MIXED 44: DESCRIPTIVE STATISTICS FOR THE DEPRESS Depression Status Measure Depressed Not Depressed Sample Size 194 518 Means Outcomes Breastfeeding Initiation 0.86 0.90 Demographic Characteristics Age Less than 18 Years Old 0.05 0.03 18 to 19 Years of Age 0.07 0.08 20 to 34 Years of Age 0.80 0.81 0.09 0.09 35 Years of Age or Older Education Less than High School 0.13 * 0.18 High School Graduate / GED 0.54 0.57 0.07 Bachelor's Degree 0.15 *** 0.15 0.15 Other Degree Education Unknown 0.03 0.02 Relationship Status *** 0.42 Married 0.27 0.29 Living with a Partner 0.34 In a 0.16 ** Relationship, Not Living Together 0.23 Not in a Relationship 0.13 0.15 342 TECHNICAL APPENDICES

361 Depression Status Measure Depressed Not Depressed Employment/School Working, Not in School 0.32 0.36 16 In School, Not Working 0. ** 0. 10 0. * 0. 05 08 Working and in School Neither Working nor in School 0.47 0.45 Risk Factors from Prior Birth Prior Preterm Birth No Prior Birth 0.43 0.47 0.07 *** Prior Preterm Birth 0.13 0.43 No Prior Preterm Birth 0.46 Prior Low Birth Weight 0.47 0.43 No Prior Birth ** 07 0. Prior Low Birth Weight Birth 0. 03 No Prior Low Birth Weight Birth 0.44 0.43 0.06 0.07 Prior Low Birth Weight Unknown Prior C - Section 0.47 0.43 No Prior Birth Prior C Section 0.12 0.12 - No Prior C 0.41 0.45 Section - Interpregnancy Interval 0.43 0.47 No Prior Birth Short Interpregnancy Interval 0.11 ** 0.18 Normal Interpregnancy Interval 0.29 0.34 0.07 0.10 Interpregnancy Interval Unknown Risk Factors from Current Pregnancy Food Insecurity 0.80 *** 0.63 Not Food Insecure at Intake Food Insecure at Intake 0.35 *** 0.17 0.03 0.02 Food Insecurity Score Unknown Pregnancy Intent 0.34 0.42 ** Intended Pregnancy Unintended Pregnancy 0.66 ** 0.58 Pregnancy Hypertension - Pre 0.92 Pregnancy Hypertension 0.91 No Pre- - Pregnancy Hypertension 0.03 0.03 Pre 0.05 0.06 Pregnancy Hypertension Unknown - Pre - Diabetes Pregnancy Pre 0.89 0.86 Pregnancy Diabetes - No Pre 0.02 0.01 Pregnancy Diabetes - Pre Pregnancy Diabetes Unknown Pre - 0.13 0.09 BMI at First Prenatal Visit 0.05 0.05 Underweight (<18.5 BMI) 0.36 0.31 -<25 BMI) Normal Weight (18.5 Overweight (25- 0.24 0.24 <30 BMI) <40 BMI) * 0.17 0.23 - Obese (30 Very Obese (>=40 BMI) 0.07 0.06 BMI Unknown 0.11 0.11 Smoking 0.75 *** 0.86 Did not Smoke at Intake Smoked at Intake 0.16 *** 0.06 Smoking Status Unknown 0.09 0.08 Intimate Partner Violence *** 59 0. Partner Violence No History of Intimate 0. 83 0. *** 0. History of Intimate Partner Violence 17 41 Year 2013 and 2014 0.22 0.22 2015 0.39 0.41 2016 and 2017 0.38 0.39 TECHNICAL APPENDICES 343

362 Depression Status Measure Depressed Not Depressed Model Maternity Care Home 0.48 0.54 Birth Center 0.31 0.30 ** 0.15 Group Prenatal Care 0.22 Region 0.03 0.05 Northeast 0.66 *** 0.54 Midwest 0.12 0.12 South West 0.16 *** 0.30 Sample limited to women with other/mixed race/ethnicity with nonmissing data. Significance calculated using pairwise Notes: ** es significance ) indicat comparison of means test. One asterisk ( ) indicates significance at the 0.1 level; two asterisks ( * ( at the 0.05 level; and three asterisks ) indicate significance at the 0.01 level for the difference in means from *** ) indicates significance at the dicates significance at the 0.1 level; two carets ( ) in One caret ( Maternity Care Homes. ^ ^^ 0.05 lev es significance at the 0.01 level for the difference in means from Group el; and three carets ( ) indicat ^^^ Prenat al Care. EPRESSION CORRELATES TABLE M. NALYTIC SAMPLE FOR D 45: CONSTRUCTION OF THE A ANALYSIS # of Remaining # Excluded Logic for Dropping Observations Observations - Starting Sample: Number of Strong Start participants with PLPE data 45,316 exit form 831 44,485 Dropping participants without an 42,186 Dropping participants without an intake form 2,299 40,856 1,330 Dropping participants with a miscarriage or elective termination 40,271 585 Dropping participants with multiples 35,325 4,946 variable Dropping participants missing depression 32,409 2,916 Dropping participants missing any covariates Final analytic sample - 32,409 ION CORRELATES SAMPL 46: DESCRIPTIVE STATISTICS FOR THE DEPRESS TABLE M. E Depression Status Measure Depressed Depressed Not Sample Size 8,747 23,662 -- Demographic Characteristics ---------------- Race/Ethnicity *** 0.24 White 0.27 0.22 *** Hispanic 0.32 Black 0.35 *** 0.49 0.05 0.05 Other Age 0.06 0.05 *** Less than 18 Years Old 0.10 *** 0.09 18 to 19 Years of Age *** 0.77 of Age 20 to 34 Years 0.75 0.09 0.08 35 Years of Age or Older Education Less than High School 0.26 0.25 *** High School Graduate / GED 0.55 *** 0.57 0.04 *** 0.06 Bachelor's Degree ** 0.10 Other Degree 0.09 Education Unknown 0.04 0.04 Relationship Status 0.27 *** 0.17 Married Living with a Partner *** 0.33 0.29 0.25 *** In a Relationship, Not Living Together 0.29 0.14 Not in a Relationship 0.25 *** Employment/School *** 0.31 Working, Not in School 0.35 0.11 In School, Not Working 0.12 ** School Working and in 0.06 0.05 344 TECHNICAL APPENDICES

363 Depression Status Measure Depressed Not Depressed Neither Working nor in School 0.51 *** 0.48 -- Risk Factors from Prior Birth ---------------- Prior Preterm Birth No Prior Birth 0.39 0.40 ** *** 0.12 Prior Preterm Birth 0.16 0.45 0.48 No Prior Preterm Birth *** Prior Low Birth Weight ** 0.39 0.40 No Prior Birth Prior Low Birth Weight Birth 0.07 *** 0.05 0.44 ** 0.43 No Prior Low Birth Weight Birth *** 0.11 Prior Low Birth Weight Unknown 0.10 Section - Prior C 0.40 ** 0.39 No Prior Birth - 0.11 0.13 *** Section Prior C 0.48 0.48 Section - No Prior C Interpregnancy Interval 0.40 ** 0.39 No Prior Birth Short Interpregnancy Interval 0.14 0.14 Normal Interpregnancy Interval 0.35 * 0.36 0.11 Interpregnancy Interval Unknown 0.11 Current Pregnancy Risk Factors from Food Insecurity 0.82 Not Food Insecure at Intake 0.60 *** Food Insecure at Intake 0.36 *** 0.13 0.04 0.04 Food Insecurity Score Unknown Pregnancy Intent 0.32 0.22 *** Intended Pregnancy Unintended Pregnancy *** 0.68 0.78 Pre - Pregnancy Hypertension Pregnancy Hypertension - No Pre *** 0.85 0.83 Pre *** 0.06 Pregnancy Hypertension - 0.05 - 0.10 Pregnancy Hypertension Unknown Pre 0.10 Pre - Pregnancy Diabetes - 0.84 Pregnancy Diabetes *** 0.81 No Pre Pre - Pregnancy Diabetes 0.03 * 0.03 - Pre 0.13 *** 0.16 Pregnancy Diabetes Unknown BMI at First Prenatal Visit 0.03 0.03 Underweight (<18.5 BMI) Normal Weight (18.5 - <25 BMI) 0.29 0.30 <30 BMI) 0.23 *** Overweight (25 - 0.21 Obese (30 - <40 BMI) 0.24 0.23 0.07 Very Obese (>=40 BMI) 0.08 *** BMI Unknown 0.15 0.15 Smoking 0.75 *** 0.85 Did not Smoke at Intake *** 0.09 Smoked at Intake 0.17 Smoking Status Unknown 0.08 *** 0.06 Intimate Partner Violence *** 0.66 No History of Intimate Partner Violence 0.85 0.34 *** 0.15 History of Intimate Partner Violence Anxiety 0.18 *** No Anxiety at Intake 0.24 0.80 Intake 0.21 *** Anxiety at 0.20 Unknown Anxiety at Intake 0.79 *** Year ** 0.21 0.22 2013 and 2014 ** 0.34 2015 0.33 *** 0.24 0.27 2016 and 2017 TECHNICAL APPENDICES 345

364 Depression Status Measure Depressed Not Depressed Model 0.18 Maternity Care Home 0.21 *** Birth Center 0.59 *** 0.62 0.20 *** 0.17 Group Prenatal Care Region 0.07 Northeast 0.04 *** *** 0.69 Midwest 0.60 0.19 *** 0.12 South 0.17 West 0.12 *** Sample limited to women with nonmissing Notes: data. Significance of the difference in means from women who are not * ) indicates significance at the 0.1 level; two calculated using pairwise comparison of means test. One asterisk ( depressed ** *** significance at the 0.01 level. sterisks ( ) indicate significance at the 0.05 level; and three asterisks ( ) indicate a APPENDICES 346 TECHNICAL

365 – ADJUSTED OUTCOMES APPENDIX N: REGRESSI ON- FULL REGRESSION RESULTS TECHNICAL APPENDICES 347

366 INTERMEDIATE OUTCOME S ANALYSIS TABLE N. 1: FULL INTERMEDIATE OUTCOMES REGRESSION RESULTS Gestational Diabetes Measure Preeclampsia Model - Maternity Care Home - Birth Center -0.04*** -0.02*** - 0.00 Group Prenatal Care -0.02** Race Non - Hispanic W