Impact of a Population-based Systems Approach on Evidence-based Care for Medicaid-insured Pregnant and Postpartum Women: A Quasi-Experimental Study

Introduction. Evidence-based enhanced prenatal/postnatal care (EPC) programs for Medicaid-insured women have significant positive effects on care and health outcomes. However, EPC enrollment rates are typically low, enrolling less than 30% of eligible women. This study investigated the effects of a population-based systems approach on timely EPC participation and other health care utilization. Methods: This quasi-experimental, population-based, difference-in-difference study used linked birth certificates, Medicaid claims, and EPC data from complete statewide Medicaid birth cohorts retrieved from 2009-2017 and analyzed in 2019-20. System strategies included cross-agency leadership, clinical-community linked practices, Community Health Worker care, mental health coordination, and patient empowerment. Outcomes included EPC participation and early enrollment, prenatal care adequacy, emergency department contact, and postpartum care. Results: Prenatal EPC (7.4 absolute percentage points; 95% CI: 6.3-8.5) and first trimester EPC, (12.4; 95% CI: 10.2-14.5) increased among women served by practices that co-located EPC resources, relative to the comparator group. First trimester EPC improved in the county (17.9; 95% CI: 15.7 - 20.0); ED decreased in the practices ( - 11.1; 95% CI: -12.3- -9.9) and postpartum care improved (7.1; 95% CI: 6-8.2) in the county. EPC participation for Black women served by the practices improved (4.4; 95% CI: 2.2-6.6), as well as early EPC (12.3; 95% CI: 9.0-15.6) and postpartum visits (10.4; 95% CI: 8.3-12.4). Conclusions: A population systems approach improved EPC participation and service utilization for Medicaid-insured women in a county population, for those in practices that co-located EPC resources, and for Black women.