Community Health Workers: Improving Home Visiting Engagement of High-Risk Birthing People in Segregated Neighborhoods.

CONTEXT: Racial and ethnic disparities in perinatal health remain a public health crisis. Despite improved outcomes from home visiting (HV) participation during pregnancy, most eligible individuals of color do not engage. Neighborhood segregation, a manifestation of structural racism, may impose constraints on engaging eligible individuals in HV. OBJECTIVE: To examine whether race, ethnicity, and/or language-concordant community health workers (CHWs) increased HV engagement for birthing people in segregated neighborhoods. DESIGN: Program evaluation using administrative linked data from birth records, Medicaid claims, and HV program participation. Strong Beginnings (SB), a program with HV provided by CHWs working with nurses and social workers, was compared with the Maternal Infant Health Program (MIHP), a state Medicaid-sponsored HV program without CHW involvement. Data were analyzed using χ 2 tests and Poisson regressions. PARTICIPANTS: A total of 4560 individuals with a Medicaid-eligible birth between 2016 and 2019, including 1172 from SB and 3388 from the MIHP. MAIN OUTCOME MEASURES: Penetration (percentage of participants in HV among all Medicaid-eligible individuals across quintiles of neighborhood segregation) and dosage (the total number of home visits from both CHWs and nurses/social workers, and then restricted to those from nurses/social workers). RESULTS: SB penetrated more segregated neighborhoods than the MIHP (58.4% vs 48.3%; P < .001). SB participants received a higher dosage of home visits (mean [SD]: 11.9 [6.1]) than MIHP participants (mean [SD]: 4.4 [2.8], P < .001). Importantly, CHWs did not replace but moderately increased home visits from nurses and social workers (51.1% vs 35.2% with ≥5 intervention visits, P < .001), especially in more segregated neighborhoods. POLICY IMPLICATION: Community-informed HV models intentionally designed for people facing disparities may help facilitate program outreach to segregated neighborhoods with concentrated deprivation and reduce racial and ethnic disparities. CONCLUSIONS: An HV program provided by CHWs working with nurses and social workers was associated with an increase in penetration and dosage in segregated neighborhoods, compared with HV without CHW involvement. This underscores the value of CHWs partnering with licensed professional workers in improving HV engagement in disadvantaged communities.

Neighborhood Deprivation and Severe Maternal Morbidity in a Medicaid Population.

INTRODUCTION: Few studies have examined whether neighborhood deprivation is associated with severe maternal morbidity (SMM) in already socioeconomically disadvantaged populations. Little is known about to what extent neighborhood deprivation accounts for Black-White disparities in SMM. This study investigated these questions among a statewide Medicaid-insured population, a low-income population with heightened risk of SMM. METHODS: Data were from Michigan statewide linked birth records and Medicaid claims between 01/01/2016 and 12/31/2019, and were analyzed between 2022 and 2023. Neighborhood deprivation was measured with the Area Deprivation Index at census block group and categorized as low, medium, or high deprivation. Multilevel logistic models were used to examine the association between neighborhood deprivation and SMM. Fairlie nonlinear decomposition was conducted to quantify the contribution of neighborhood deprivation to SMM racial disparity. RESULTS: People in the most deprived neighborhoods had higher odds of SMM than those in the least deprived neighborhoods (aOR [95% CI]: 1.27 [1.15, 1.40]). Such association was observed in Black (aOR [95% CI]: 1.34 [1.07, 1.67]) and White (aOR [95% CI]: 1.26 [1.12, 1.42]) racial subgroups. Decomposition showed that of 57.5 (cases per 10,000) explained disparity in SMM, neighborhood deprivation accounted for 23.1 (cases per 10,000; 95% CI: 16.3, 30.0) or two-fifths (40.2%) of the Black-White disparity. Analysis on SMM excluding blood transfusion showed consistent but weaker results. CONCLUSIONS: Neighborhood deprivation may be used as an effective tool to identify at-risk individuals within a low-income population. Community-engaged interventions aiming at improving neighborhood conditions may be helpful to reduce both SMM prevalence and racial inequity in SMM.

Community Health Worker Home Visiting, Birth Outcomes, Maternal Care, and Disparities Among Birthing Individuals With Medicaid Insurance.

Importance: Home visiting is recommended to address maternal and infant health disparities but is underused with mixed impacts on birth outcomes. Community health workers, working with nurses and social workers in a combined model, may be a strategy to reach high-risk individuals, improve care and outcomes, and address inequities. Objective: To assess the association of participation in a home visiting program provided by community health workers working with nurses and social workers (Strong Beginnings) with adverse birth outcomes and maternal care vs usual care among birthing individuals with Medicaid. Design, Setting, and Participants: This retrospective, population-based, propensity score matching cohort study used an administrative linked database, including birth records and Medicaid claims, linked to program participation. The Strong Beginnings program exposure took place in 1 county that includes the second largest metropolitan area in Michigan. Study participants included primarily non-Hispanic Black and Hispanic Strong Beginnings participants and all mother-infant dyads with a Medicaid-insured birth in the other Michigan counties (2016 through 2019) as potential matching nonparticipants. The data were analyzed between 2021 and 2023. Exposure: Participation in Strong Beginnings or usual care. Main Outcomes and Measures: Preterm birth (less than 37 weeks' gestation at birth), very preterm birth (less than 32 weeks' gestation), low birth weight (less than 2500 g at birth), very low birth weight (less than 1500 g), adequate prenatal care, and postnatal care (3 weeks and 60 days). Results: A total of 125 252 linked Medicaid-eligible mother-infant dyads (mean age [SD], 26.6 [5.6] years; 27.1% non-Hispanic Black) were included in the analytical sample (1086 in Strong Beginnings [mean age (SD), 25.5 (5.8) years]; 124 166 in usual prenatal care [mean age (SD), 26.6 (5.5) years]). Of the participants, 144 of 1086 (13.3%) in the SB group and 14 984 of 124 166 (12.1%) in the usual care group had a preterm birth. Compared with usual prenatal care, participation in the Strong Beginnings program was significantly associated with reduced risk of preterm birth (-2.2%; 95% CI, -4.1 to -0.3), very preterm birth (-1.2%; 95% CI, -2.0 to -0.4), very low birth weight (-0.8%; 95% CI, -1.3 to -0.3), and more prevalent adequate prenatal care (3.1%; 95% CI, 0.6-5.6), postpartum care in the first 3 weeks after birth (21%; 95% CI, 8.5-33.5]), and the first 60 days after birth (23.8%; 95% CI, 9.7-37.9]). Conclusions and Relevance: Participation in a home visiting program provided by community health workers working with nurses and social workers, compared with usual care, was associated with reduced risk for adverse birth outcomes, improved prenatal and postnatal care, and reductions in disparities, among birthing individuals with Medicaid. The risk reductions in adverse birth outcomes were greater among Black individuals.

Study protocol: The Maternal Health Multilevel Intervention for Racial Equity (Maternal Health MIRACLE) Project.

PURPOSE: To test the effectiveness and cost-effectiveness of a multilevel intervention for population-level African American (AA) severe maternal morbidity and mortality. BACKGROUND: Severe maternal morbidity and mortality in the U.S. disproportionately affect AA women. Inequities occur at many levels, including community, provider, and health system levels. DESIGN: Intervention. Throughout the two intervention counties, we will expand access to enhanced prenatal care services using telehealth and flexible scheduling (community level), provide actionable maternal health-focused anti-racism training (provider level), and implement equity-focused community care maternal safety bundles (health system level). Partnership. Interventions were developed/co-developed by intervention county partners, including AA women, enhanced prenatal care staff, and health providers. For equity, 46% of project direct cost dollars go to our partners. Most study investigators are female (75%) and/or AA (38%). Partners are overwhelmingly AA women. Sample, measures, analyses. We use a quasi-experimental difference-in-differences with propensity scores approach to compare pre (2016-2019) to post (2022-2025) changes in outcomes for Medicaid-insured women in intervention counties to similar women in the other Michigan, USA, counties. The sample includes all Medicaid-insured deliveries in Michigan during these years (n ~ 540,000), with women observed during pregnancy, at birth, and up to 1 year postpartum. Measures are taken from a linked dataset that includes Medicaid claims and vital records. CONCLUSION: This study is among the first to examine effects of any multilevel intervention on AA severe maternal morbidity and mortality. It features a rigorous quasi-experimental design, multilevel multi-partner county-wide interventions developed by community partners, and assessment of intervention effects using population-level data.

The Impact of a Population-Based System of Care Intervention on Enhanced Prenatal Care and Service Utilization Among Medicaid-Insured Pregnant Women.

INTRODUCTION: Enhanced prenatal/postnatal care home visiting programs for Medicaid-insured women have significant positive impacts on care and health outcomes. However, enhanced prenatal care participation rates are typically low, enrolling <30% of eligible women. This study investigates the impacts of a population-based systems approach on timely enhanced prenatal care participation and other healthcare utilization. METHODS: This quasi-experimental, population-based, difference-in-differences study used linked birth certificates, Medicaid claims, and enhanced prenatal care data from complete statewide Medicaid birth cohorts (2009 to 2015), and was analyzed in 2019-2020. The population-based system intervention included cross-agency leadership and work groups, delivery system redesign with clinical-community linkages, increased enhanced prenatal care-Community Health Worker care, and patient empowerment. Outcomes included enhanced prenatal care participation and early participation, prenatal care adequacy, emergency department contact, and postpartum care. RESULTS: Enhanced prenatal care (7.4 percentage points, 95% CI=6.3, 8.5) and first trimester enhanced prenatal care (12.4 percentage points, 95% CI=10.2, 14.5) increased among women served by practices with established clincial-community linkages, relative to that among the comparator group. First trimester enhanced prenatal care improved in the county (17.9, 95% CI=15.7, 20.0), emergency department contact decreased in the practices (-11.1, 95% CI= -12.3, -9.9), and postpartum care improved in the county (7.1, 95% CI=6.0, 8.2). Enhanced prenatal care participation for Black women served by the practices improved (4.4, 95% CI=2.2, 6.6) as well as early enhanced prenatal care (12.3, 95% CI=9.0, 15.6) and use of postpartum care (10.4, 95% CI=8.3, 12.4). CONCLUSIONS: A population systems approach improved selected enhanced prenatal care participation and service utilization for Medicaid-insured women in a county population, those in practices with established clinical-community linkages, and Black women.

Determining County-Level Counterfactuals for Evaluation of Population Health Interventions: A Novel Application of K-Means Cluster Analysis.

OBJECTIVES: Evaluating population health initiatives at the community level necessitates valid counterfactual communities, which includes having similar population composition, health care access, and health determinants. Estimating appropriate county counterfactuals is challenging in states with large intercounty variation. We describe an application of K-means cluster analysis for determining county-level counterfactuals in an evaluation of an intervention, a county perinatal system of care for Medicaid-insured pregnant women. METHODS: We described counties by using indicators from the American Community Survey, Area Health Resources Files, University of Wisconsin Population Health Institute County Health Rankings, and vital records for Michigan Medicaid-insured births for 2009, the year the intervention began (or the closest available year). We ran analyses of 1000 iterations with random starting cluster values for each of a range of number of clusters from 3 to 10 with commonly used variability and reliability measures to identify the optimal number of clusters. RESULTS: The use of unstandardized features resulted in the grouping of 1 county with the intervention county in all solutions for all iterations and the frequent grouping of 2 additional counties with the intervention county. Standardized features led to no solution, and other distance measures gave mixed results. However, no county was ideal for all subpopulation analyses. PRACTICE IMPLICATIONS: Although the K-means method was successful at identifying comparison counties, differences between the intervention county and comparison counties remained. This limitation may be specific to the intervention county and the constraints of a within-state study. This method could be more useful when applied to other counties in and outside Michigan.

Clinical-Community Linkages: The Impact of Standard Care Processes that Engage Medicaid-Eligible Pregnant Women in Home Visiting.

BACKGROUND: To better address physical, emotional, and social needs of Medicaid-insured pregnant women, a Federally Qualified Health Center and a hospital-based obstetrics and gynecology residency practice collaborated with their agency-based state Medicaid-sponsored home visiting program, the Maternal Infant Health Program (MIHP). In partnership, both practice sites created patient standards of care to identify and engage eligible pregnant women into underutilized home visiting services for enhanced prenatal care coordination. The purpose of this study was to describe how each practice operationalized clinical-community linkage strategies that best suited their setting and to determine if efforts resulted in improved MIHP participation and other service use. METHODS: Using linked administrative data, a quasi-experimental pre-post difference-in-difference design was used to examine changes in MIHP participation, adequate prenatal care, emergency department use, and postpartum care among patients in each practice compared with the same birth cohorts between 2010 and 2015 in the rest of the state. RESULTS: When compared with similar women from the rest of the state, the Federally Qualified Health Center observed a 9.1 absolute percentage points (APP; 95% confidence interval [CI], 8.1-10.1) increase in MIHP participation and 12.5 APP (95% CI, 10.4-14.6) increase in early first trimester enrollment. The obstetrics and gynecology residency practice experienced increases of 4.4 APP (95% CI, 3.3-5.6) in overall MIHP participation and 12.5 APP (95% CI, 10.3-14.7) in first trimester enrollment. Significant improvements in adequate prenatal care, emergency department use, and postpartum visit completion were also observed. CONCLUSIONS: Clinical-community linkages can significantly improve participation of Medicaid-insured women in an evidence-based home visiting program and other prenatal services. This work is important because health providers are looking for ways to create clinical-community linkages.

Defining the Role of the Community Health Worker within a Federal Healthy Start Care Coordination Team.

Introduction Federal and state policies often require utilization of evidence-based home visiting programs. Measurement of specified interventions is important for tracking program implementation and achieving program outcomes. Thus, the Strong Beginnings program worked to define community health worker (CHW) interventions, a core service of the program to improve maternal and child health. Methods A workgroup consisting of CHWs, supervisors and other program staff was created in order to develop and define specific CHW interventions within a nurse or social worker care team. Basic interventions were first compared to the nurse or social worker care coordinator home visiting interventions by risk topic. The evaluator then grouped each CHW intervention into categories per risk domain using thematic analysis and assigned a CHW core function or role based on literature review findings. The workgroup confirmed the results. The workgroup then continued discussions to further enhance CHW interventions per risk domain once the general structure was created. Results The workgroup identified seven core functions and 28 maternal and child health risk topics to be addressed by the CHW. The process resulted in a detailed document of program interventions that the CHWs use to guide care. Conclusions The process helped CHWs feel more valued with their role in team care. The specified interventions will help others understand the CHW role within the care team, ensure consistent interventions are delivered across program partners, provide a foundation to better understand how specific CHW contributions are related to health outcomes, and support program sustainability.

Understanding Perspectives of African American Medicaid-Insured Women on the Process of Perinatal Care: An Opportunity for Systems Improvement.

Objectives To address disparities in adverse birth outcomes, communities are challenged to improve the quality of health services and foster systems integration. The purpose of this study was to explore the perspectives of Medicaid-insured women about their experiences of perinatal care (PNC) across a continuum of clinical and community-based services. Methods Three focus groups (N = 21) were conducted and thematic analysis methods were used to identify basic and global themes about experiences of care. Women were recruited through a  local Federal Healthy Start (HS) program in Michigan  that targets services to African American women. Results Four basic themes were identified: (1) Pursuit of PNC; (2) Experiences of traditional PNC; (3) Enhanced prenatal and postnatal care; and (4) Women's health: A missed opportunity. Two global themes were also identified: (1) Communication with providers, and (2) Perceived socio-economic and racial bias. Many women experienced difficulties engaging in early care, getting more help, and understanding and communicating with their providers, with some reporting socio-economic and racial bias in care. Delays in PNC limited early access to HS and enhanced prenatal care (EPC) programs with little evidence of supportive transitions to primary care. Notably, women's narratives revealed few connections among clinical and community-based services. Conclusions The process of participating in PNC and community-based programs is challenging for women, especially for those with multiple health problems and living in difficult life circumstances. PNC, HS and other EPC programs could partner to streamline processes, improve the content and process of care, and enhance engagement in services.

A statewide Medicaid enhanced prenatal care program: impact on birth outcomes.

IMPORTANCE: Policy makers and practitioners need rigorous evaluations of state-based Medicaid enhanced prenatal care programs that provide home visiting to guide improvements and inform future investments. Effects on adverse birth outcomes are of particular interest. OBJECTIVE: To test if participation in the Michigan statewide enhanced prenatal care program, the Maternal Infant Health Program (MIHP), accounting for program timing and dosage, reduced risk for low birth weight (LBW) and preterm birth, particularly among black women who are at greater risk for adverse outcomes. DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental cohort study. Data, including birth records, Medicaid claims, and monthly program participation, were extracted from the Michigan Department of Community Health warehouse. Participants included all 60 653 pregnant women who had a Medicaid-insured singleton birth between January 1 and December 31, 2010, in Michigan. The MIHP participants were propensity score-matched with nonparticipants based on demographics, previous pregnancies, socioeconomic status, and chronic disease. EXPOSURE: An enhanced prenatal care program. MAIN OUTCOMES AND MEASURES: Low birth weight, very low birth weight (VLBW), preterm birth, and very preterm birth. RESULTS: In the propensity score-matched models, black women who enrolled and were screened in the MIHP by the end of the second trimester had lower odds of VLBW (odds ratio [OR], 0.76; 95% CI, 0.59-0.97) and very preterm births (OR, 0.68; 95% CI, 0.54-0.85) than matched nonparticipants. Black MIHP participants who enrolled and were screened in the program by the second trimester and had at least 3 additional prenatal MIHP contacts had lower odds of LBW (OR, 0.76; 95% CI, 0.65-0.89), VLBW (0.42; 0.30-0.61), preterm birth (0.71; 0.61-0.83), and very preterm birth (0.41; 0.30-0.57) compared with matched nonparticipants. The MIHP participants of other races and ethnicities who enrolled and were screened in the program by the second trimester and had at least 3 additional prenatal MIHP contacts had lower odds of LBW (OR, 0.78; 95% CI, 0.66-0.93), VLBW (0.38; 0.22-0.66), preterm birth (0.77; 0.66-0.89), and very preterm birth (0.63; 0.43-0.91) compared with matched nonparticipants. CONCLUSIONS AND RELEVANCE: Participation in MIHP reduced the risk for adverse birth outcomes in a diverse, disadvantaged population. The study adds to the evidence base for enhanced prenatal care home visiting programs and informs state and federal investments.

Physician awareness of enhanced prenatal services for medicaid-insured pregnant women.

CONTEXT: Medicaid enhanced prenatal service (EPS) programs, including care coordination, were developed to improve birth outcomes for low-income pregnant women. In Michigan, less than a third of eligible pregnant women are enrolled in services. Physician or medical clinics provide referrals to community-based EPS. OBJECTIVE: The objective of this study was to examine physician knowledge and perceptions of EPS. DESIGN: A cross-sectional survey of obstetric providers was conducted in 2009. A questionnaire was created to assess understanding of the EPS program. SETTING: The study was conducted in an urban Michigan community. PARTICIPANTS: Participants included a convenience sample (N = 56) of community Obstetrics and Gynecology attending physicians and resident physicians within a single, large health system. MAIN OUTCOME MEASURES: Outcome measures included knowledge of the program and patient participation, referral practices, perceptions of the program, value for patients and providers, appropriateness of physicians to provide program referrals, and barriers to referring. RESULTS: Findings indicated that most physicians (84%) had little familiarity with EPS, 60% did not personally refer to EPS, 54% did not know whether other office staff referred to EPS, and 65% were unaware whether their patients received EPS. Yet, more than 90% of physicians reported that EPS would benefit their patients and believed that it was appropriate for them to refer all their eligible patients. CONCLUSION: Further efforts should be made to better understand how physicians and EPS providers could function together on behalf of patients. Statewide Medicaid-sponsored EPS programs could serve as a valuable patient and physician resource for psychosocial risk screening, care management, education, and referral support if better utilized.

Moving toward evidence-based federal Healthy Start program evaluations: accounting for bias in birth outcomes studies.

We used administrative and screening data from 2009 to 2010 to determine if Healthy Start (HS), an enhanced prenatal services program, is reaching the most vulnerable African American women in Kent County, Michigan. Women in HS are at higher risk of key predictors of birth outcomes compared with other women. To advance toward evidence-based HS program evaluations in the absence of randomized controlled trials, future studies using comparison groups need to appropriately establish baseline equivalence on a variety of risk factors related to birth outcomes.

Medicaid home visitation and maternal and infant healthcare utilization.

BACKGROUND: The Michigan Maternal and Infant Health Program (MIHP) is a population-based home-visitation program providing care coordination, referrals, and visits based on a plan of care. MIHP is available to all Medicaid-eligible pregnant women and infants aged ≤1 year in Michigan. PURPOSE: To assess the effects of MIHP participation on maternal and infant healthcare utilization. METHODS: Propensity-score matching methods were used to assess differences in healthcare utilization between MIHP participants and nonparticipants using 2009-2010 Medicaid claims and administrative data obtained from the Michigan Department of Community Health. Data were analyzed between October 2011 and March 2013. RESULTS: MIHP participants had higher odds of receiving any prenatal care compared to matched women not participating in MIHP (OR=2.94, 95% CI=2.43, 3.60) and higher odds of receiving adequate prenatal care (OR=1.06, 95% CI=1.01, 1.11). MIHP participants had higher odds of receiving an appropriately timed postnatal visit (OR=1.50, 95% CI=1.43, 1.57). Infants participating in MIHP had higher odds of receiving any well-child visits over the first year of life (OR=1.70, 95% CI=1.51, 1.93) and higher odds of receiving the appropriate number of well-child visits over their first year of life (OR=1.47, 95% CI=1.35, 1.60) compared to matched nonparticipant infants. CONCLUSIONS: The results from Michigan provide strong evidence for the effectiveness of a Medicaid-sponsored population-based home-visitation program in improving maternal prenatal and postnatal care and infant care. This evidence is important to consider as the federal healthcare reform is implemented and states are making decisions on the expansion of the Medicaid program.

Maternal perceptions of help from home visits by nurse-community health worker teams.

We used data from a home visiting trial to examine low-income women's perceptions of services received from nurses (the community care [CC] group) and from a nurse-community health worker (CHW) team. More mothers in the nurse-CHW group than in the CC group reported receiving help in all of the categories assessed. For both groups, assistance with health education ranked highest among the types of assistance received. A higher percentage of women in the nurse-CHW group than the CC group reported that they received psychosocial help.

Psychological and physical abuse among pregnant women in a Medicaid-sponsored prenatal program.

OBJECTIVES: To document psychological and physical abuse during pregnancy among women enrolled in enhanced prenatal services (EPS); explore the associations between maternal risk factors and type of abuse; and examine the relationship between abuse and EPS participation. DESIGN AND SAMPLE: Cross-sectional study utilizing screening data collected between 2005 and 2008. Convenience sample of Medicaid-insured pregnant women enrolled in EPS selected from urban and rural providers. MEASURES: A prenatal screening tool that included measures such as Cohen's Perceived Stress Scale-4, Patient Health Questionnaire-2, and Abuse Assessment Screen was used. RESULTS: Logistic regressions showed that high perceived stress and lack of father support were associated with all types of abuse and abuse history. Women with risk factors, such as a positive depression screen (odds ratio [OR]=2.36), were associated with psychological abuse but not with physical abuse during pregnancy. Less than a 12th-grade education was associated with physical abuse (OR=1.64) but not psychological abuse during pregnancy. The amount or the timing of EPS participation was not significantly associated with abuse history or abuse during pregnancy. CONCLUSIONS: Risk factors, such as high perceived stress and lack of father support, may alert nurses to further explore abuse during pregnancy. Additional research is needed for understanding the relationship between abuse and EPS participation.

Who participates in state sponsored Medicaid enhanced prenatal services?

Medicaid insures an estimated 43% of all births in Michigan and provides additional funding for enhanced prenatal services (EPS). The objectives of this study are to report on the (1) use of statewide administrative data to examine risk characteristics and EPS enrollment of Medicaid-insured pregnant women in Michigan; and (2) presence and extent of a broad range of risk factors in a sample of EPS participants in Michigan, using a newly developed two-tier, risk screener and assessment tool. This study uses Vital Records, Medicaid and other data to describe EPS participation by maternal risks in the statewide population of Medicaid-insured pregnant women (54,582 in the fiscal year 2005). The screener study data is a convenience sample of 2,203 women screened between February 2005 and October 2007. The administrative data indicates that 26% of Medicaid-eligible pregnant women had EPS contact. Most women with health behavior risks, such as smoking and drug use, had no contact with EPS (68-72%). Approximately 58% of all Medicaid-insured women had zero to two co-occurring risks, while 42% had three or more of the analyzed risks. Among screened women who smoke, 9% smoked more than a pack a day. Approximately 34% of women with a depression screen scored in the moderately or severely depressed range. The results of this study suggest great opportunity for EPS enhancement by improving the capacity to identify and engage women with modifiable risks, match interventions to specific health problems, and deliver services at an intensity warranted by the risk level.

Smoking among pregnant women with Medicaid insurance: are mental health factors related?

Smoking during pregnancy is the single most modifiable risk factor for poor birth outcomes, yet it remains prevalent among low-income women. This study examined factors associated with continued smoking and quitting among pregnant women. A total of 2,203 Medicaid-eligible pregnant women were screened at their first enhanced prenatal services visit for risk factors including demographics, health behaviors (smoking, alcohol and drug use), mental health (history of mental health disorders, current depressive symptoms), and stress. Smoking status was divided into non-smokers, quitters (quit smoking since learning of pregnancy), and continuing smokers. Descriptive statistics and logistic regression models were used to describe the sample and analyze relationships between smoking status and other characteristics. Overall, 57% were non-smokers, 17% quitters, and 26% continuing smokers. Approximately 18% had severe depressive symptoms, 53% had a high stress score, and 33% had a history of mental health problems. Younger women had lower odds of continued smoking as compared to both non-smokers (OR = 0.48, p < 0.01) and quitters (OR = 0.56, p < 0.05). Older women with less than a 12th grade education had higher odds of continued smoking (OR = 2.17, p < 0.01) and quitting (OR = 1.62, p < 0.05) as compared to non-smokers. Alcohol use (OR = 2.81, p < 0.05) and drug use before pregnancy (OR = 5.32, p < 0.01) predicted continued smoking compared to non-smoking. Women with a mental health history (OR = 1.81, p < 0.01) and high stress scores (OR = 1.39, p < 0.05) had higher odds of continued smoking compared to non-smokers. Mental health history, stress, demographics, current alcohol and past drug use are strongly related to continued smoking in this population.