The association between care management and neonatal outcomes: the role of a Medicaid-managed pregnancy medical home in North Carolina

Background

Preterm birth is a significant clinical and public health issue in the United States. Rates of preterm birth have remained unchanged, and racial disparities persist. Although a causal pathway has not yet been defined, it is likely that a multitude of clinical and social risk factors contribute to a pregnant person’s risk. State-based public health and provider programmatic partnerships have the potential to improve care during pregnancy and reduce complications, such as preterm birth. In North Carolina, a state-based Medicaid-managed Pregnancy Medical Home Program screens pregnant individuals for psychosocial and medical risk factors and utilizes community-based care management, to offer support to those at highest risk.

Objective

This study aimed to examine the association between care-management and birth outcomes (low birthweight and preterm birth rates) among high-risk non-Hispanic White and Black pregnant people enrolled in the North Carolina Pregnancy Medical Home.

Study Design

This was a quasi-experimental study of people in the Medicaid-managed North Carolina Pregnancy Medical Home who had singleton pregnancies and who enrolled in the program between January 2016 and December 2017. Black and White pregnant people were included in the analysis if they had singleton pregnancies, were enrolled in the Pregnancy Medical Home, and for whom there were data regarding care management involvement. Preterm birth and low birthweight were chosen as the outcomes of interest. Two different methodologies were used to test the effect of care management on outcomes: Method 1 evaluated the effect of intensive care management (≥5 face-to-face visits from a care manager) and Method 2 evaluated the effect of the implementation of a specific risk-stratification system. Chi-squared and multivariate logistic regressions were performed as appropriate.

Results

From January 1, 2016 to December 31, 2017, a total of 3564 singleton pregnancies occurred among non-Hispanic Black and White pregnant Medicaid beneficiaries, who were a part of the Pregnancy Medical Home in North Carolina. White pregnant people comprised 57% and Black pregnant people comprised 43% of the sample. In the Method 1 analysis, intensive care management was significantly associated with reductions in preterm birth and low birthweight among Black and White pregnant people whereas in the Method 2 analysis, the implementation of a risk-stratification score only resulted in a significant reduction among Black pregnant people. In multivariable logistic modeling, race, number of prenatal visits, and intensive care management were all significantly associated with the outcomes of interest.

Conclusion

Care management is associated with reductions in preterm birth and low birthweight in the Medicaid-managed Pregnancy Medical Home in North Carolina. This study contributes to a growing body of literature on the role of state-based initiatives in reducing perinatal morbidity. These results are significant as it demonstrates the importance of care coordination and management, in identifying and providing resources for high-risk pregnant people. In the United States, where pregnancy-related outcomes are poor, programs that address the multitude of economic, social, and clinical complexities are becoming increasingly crucial and necessary.

Introduction

In the United States, 1 of every 10 neonates is born preterm.¹ Although a topic of extensive basic science, clinical, and public health inquiry and initiatives, rates of preterm birth have not significantly declined in the last 3 decades, and the United States continues to have the highest rate among high-income nations.^2,3 Moreover, racial and ethnic differences in preterm birth rates are unacceptably disparate with Black mothers nearly 50% more likely to have a preterm birth as compared with their White counterparts.¹ The etiologies of preterm birth and other neonatal outcomes, such as low birthweight, include various clinical and social determinants, including age, medical and obstetrical comorbidities, the incidence of multiple gestations, substance use, adverse environments, and racism.^4,5 One definitive causal pathway remains elusive as there are likely multiple complex contributing factors.

AJOG at a Glance

To evaluate whether care management in a high-risk population is associated with reductions in adverse neonatal outcomes.

Intensive care management, defined by ≥5 face-to-face visits during pregnancy, is associated with reductions in preterm birth and low birthweight rates. Although the rate reduction was greater among births to Black than White pregnant women, considerable disparities persist.

Pregnancy medical homes and care-management programs can offer additional resources to support people whose pregnancies are both clinically and socially complex.

The effects of preterm birth cannot be understated. Neonates born before 37 weeks gestation or with low birthweight have higher rates of death and disability, including respiratory difficulties, cerebral palsy, and developmental delay.⁶ From a societal perspective, the estimated cost of preterm birth in the United States is over $26 billion, not including costs associated with long term health outcomes, caregiver duties, or educational and other support services.⁵ Unfortunately, the complexities surrounding preterm birth are similarly reflected in many other aspects of maternal and newborn care, such as access to care, severe maternal morbidity, and maternal mortality.

In an effort to improve care during pregnancy and reduce the morbidity of complications, such as preterm birth, several states have started to design interventions during pregnancy.^7,8 In North Carolina, the state-based Medicaid-managed Pregnancy Medical Home Program has been a unique opportunity to address adverse outcomes in high-risk pregnant people.⁹ Established in 2011, the program is a public-private partnership between Community Care of North Carolina, the North Carolina Division of Public Health, and the Division of Health Benefits (Medicaid) with the goal of improving the quality of perinatal care for Medicaid beneficiaries. Medicaid enrollees are screened for psychosocial and medical risk factors at their first prenatal visit and offered targeted care management throughout pregnancy. Thus, the community-based care managers team with the prenatal care providers to address clinical and social needs to promote optimal birth outcomes.

There are limited data on the impact of the Pregnancy Medical Home on maternal or neonatal outcomes, particularly in relation to the efficacy of care management in high-risk pregnancies. The objective of this research is to measure the association between care management in pregnancy and adverse neonatal outcomes, specifically preterm birth and low birthweight and whether there is a differential impact by race. This analysis is significant as it is among the first of its kind to demonstrate how state-based Medicaid innovation can influence health outcomes and the quality of care that is provided to high-risk pregnant people.