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Maternal & Infant Health Care Quality

Nearly two out of every three adult women enrolled in Medicaid are in their reproductive years (ages 19-44), and Medicaid currently finances about 42% of all births in the United States.[1] The Centers for Medicare & Medicaid Services (CMS) can play a major role in improving the quality of maternity care, birth outcomes and in measuring how care is delivered to pregnant and postpartum women. The Maternal and Infant Health (MIH) Beneficiary Profile (PDF, 2.49 MB) provides an overview of the demographics, health status, health outcomes, risk factors, and health care utilization among reproductive age women, women with a recent live birth, and infants covered by Medicaid and CHIP. As the MIH Beneficiary Profile illustrates, CMS is in a unique position to improve perinatal outcomes and reduce disparities through quality improvement and measurement and supporting value based care.

Maternal and Infant Health Initiative

To improve access to and quality of care for pregnant and postpartum women and their infants, CMS launched the Maternal and Infant Health Initiative (MIHI) in July 2014. The MIHI was built on the foundation laid by CMS’s Expert Panel (PDF, 52.4 KB) on Improving Maternal and Infant Health Outcomes in Medicaid and Children's Health Insurance Program (CHIP) and the input of a wide range of stakeholders on recommended strategies. In light of recommendations from the Maternal and Infant Health Expert Panel, the MIHI initially focused on improving the rate and quality of postpartum visits, and increasing the use of effective methods of contraception among women in Medicaid and CHIP through a variety of technical assistance offerings for state Medicaid and CHIP Agencies including webinars, learning collaboratives, and issue briefs.

Five years into the MIHI and in light of increasing rates of maternal and infant mortality and morbidity, CMS identified a need to take stock of the progress of the MIHI and to chart a course for the next five years. To inform CMS in this process, another expert workgroup was convened comprised of new and returning members of the original Expert Panel, representing a variety of stakeholders including providers, health plans, quality collaboratives, state Medicaid agencies, and other federal partners. The workgroup helped to identify and prioritize three areas of focus where Medicaid and CHIP have a significant opportunity to influence change through technical assistance (TA):

  1. Increase the use and quality of postpartum care visits;
  2. Increase the use and quality of well-child visits; and
  3. Decrease the rates of cesarean section births in low-risk pregnancies, defined as nulliparous (first-time pregnancies), term (37 or more weeks gestation), singleton (one fetus), vertex (head facing down in the birth canal) or “NTSV births.”

The Expert Workgroup emphasized the need for a comprehensive life-course approach to maternal and infant health, one that recognizes the importance of the mother-infant dyad as well as the inter-connectedness of the focus areas and how they affect both maternal and infant health outcomes throughout the childbearing years as well as infancy and early childhood. Read the full report of the Expert Workgroup recommendations (PDF, 3.13 MB).

New Phase of Maternal and Infant Health Initiative

CMS is launching the next phase of the MIHI to support state Medicaid and CHIP agencies in their efforts to improve maternal and infant health. Over the course of 2021, CMS will roll out new technical assistance opportunities for states addressing the three focus areas recommended by the MIH Expert Workgroup and will include: (1) the Postpartum Care Learning Collaborative; (2) the Infant Well-Child Visits Learning Collaborative, and (3) the NTSV Learning Collaborative. Each learning collaborative will offer TA to state Medicaid and CHIP agencies and their partners using two strategies: (1) a webinar series open to all states, including a webinar that will address payment reform strategies to incentivize improvement, and (2) an affinity group for states interested in developing and implementing a quality improvement project.  In addition, the Center for Medicaid and CHIP Services (CMCS) will offer an on-demand Tobacco Cessation for Pregnant Women Webinar TA Series. In recognition of the Expert Workgroup’s emphasis on the mother-infant dyad and the need for a comprehensive approach, CMS will alternate TA offerings focusing on maternal health with TA offerings focusing on infant health approximately once every six months. And because the health of the mother directly affects the health of the infant, crossover opportunities to screen for maternal health during the course of pediatric office visits will be covered in the course of these Learning Collaboratives.

CMS will also be leveraging Transformed Medicaid Statistical Information System (T-MSIS) data, to the extent feasible, to ensure content in the new learning collaboratives is data-driven. CMS will also use T-MSIS data to aid participating states in tracking utilization of services, calculating quality measures, and pursuing value-based care.

As in all areas of healthcare, new challenges have arisen in MIH as a result of the current Covid-19 Public Health Emergency (PHE). One such challenge is the issue of forgone care. During the COVID-19 PHE, the rate of vaccination and primary and preventive care among Medicaid and CHIP beneficiaries has sharply declined. The MIHI will offer TA to address foregone care as it relates to utilization rates of postpartum care visits as well as infant well-child visits.

Improving Postpartum Care

More than half of pregnancy-related deaths occur in the postpartum period, and 12 percent occur after six weeks postpartum.[2] In Federal Fiscal Year (FFY) 2019 Core Set reporting, the percentage of women who had a postpartum care visit was only 61 percent.[3] Beginning in early 2021, the Postpartum Care Learning Collaborative webinar series will include presentations from experts in the field and by state Medicaid and CHIP programs on strategies for states to improve the use of postpartum care for high-risk women, access to postpartum contraceptive care, management of chronic diseases, improving the continuity of coverage for postpartum women, and implementing payment reform to incentivize changes in maternal health care practice. States interested in putting these strategies into practice in order to improve postpartum care will have the opportunity to participate in an action-oriented affinity group that will support the design and implementation of a postpartum care quality improvement (QI) project in their state.

Improving Well-Child Visits for Infants

The infant mortality rate for deliveries paid for by Medicaid in 2017 was 7.4 deaths per 1,000 live births, compared with 4.3 deaths for deliveries paid for by private insurance.[4] To promote infant health, the American Academy of Pediatrics and Bright Futures recommend nine well-care visits by the time children turn 15 months of age.[5] In FFY 2019 Core Set reporting, the percentage of children receiving six or more well-child visits in the first 15 months of life was only 64 percent.[6] In summer 2021, CMCS will launch the Infant Well-Child Visits Learning Collaborative. This learning collaborative will begin with a series of webinars focusing on best practices for improving attendance at, and the quality of, well-child visits. State Medicaid and CHIP programs will have the opportunity to express interest in participating in the action-oriented infant well-child visit affinity group to assist in developing and implementing QI projects, which will begin after the completion of the webinar series. CMCS will provide more information about the Infant Well-Child Visits Learning Collaborative in 2021.

Decreasing NTSV Cesarean Section Births

One factor associated with rising maternal morbidity is the increased use of cesarean sections. For births paid for by Medicaid in 2018, the overall cesarean rate was 31.7% and the cesarean rate among low risk pregnancies was 24.9%.[7] Cesarean section for women with low-risk pregnancies is an overused procedure that has not led to better outcomes for infants or women.[8],[9] In late 2021, CMCS plans to launch a learning collaborative focused on reducing cesarean section births among low-risk pregnancies to ensure women and their babies have healthy birth outcomes and avoid the increased risks to mothers postpartum and in subsequent pregnancies. This learning collaborative will include a series of webinars on effective strategies to lower the rates of NTSV cesarean births closer to the recommended rate in Healthy People 2030[10] as well as an affinity group for states interested in developing and implementing QI projects to reduce the rate of NTSV cesarean births. CMCS will provide more information about this Learning Collaborative in 2021.

Tobacco Cessation for Pregnant and Postpartum Women

Smoking during pregnancy can harm the health of both the mother and the infant. Women covered under Medicaid are three times more likely to smoke during the last trimester of pregnancy than privately insured women.[11] In early 2021, CMCS will offer the Tobacco Cessation for Pregnant Women Webinar TA Series. The webinar series will include several short, on-demand recorded programs featuring subject matter experts and descriptions of successful state strategies to help Medicaid and CHIP beneficiaries be smoke-free during pregnancy and after delivery. States will have the option for additional TA on this topic by request.

Questions?

Please contact the TA Mailbox at MACQualityImprovement@mathematica-mpr.com with any questions.

[1] National Center for Health Statistics. Key Birth Statistics (2018 data, released 2019).

[2] Petersen, E. E., N.L. Davis, D. Goodman, et al. “Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017.” Morbidity and Mortality Weekly Report, vol. 68, no. 18, 2019, pp. 423–429.

[3] 2020 Adult Chart Pack (PDF, 9.66 MB)

[4] Based on Mathematica’s analysis of data from the 2017 Period Linked Birth/Infant Death Public Use File, produced by the National Center for Health Statistics.

[5] Hagan, J.F., J.S. Shaw, and P.M. Duncan (eds.). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2017.

[6] 2019 Child Chart Pack (PDF, 23.83 MB)

[7] National Center for Health Statistics (NCHS). 2018 Natality Public Use File.

[8] Goer, H., A. Romano, and C. Sakala. “Vaginal or Cesarean Birth: What Is at Stake for Women and Babies?” New York: Childbirth Connections, 2012.

[9] Gregory, K.D., S. Jackson, L.M. Korst, and M. Friedman. “Cesarean versus Vaginal Delivery: Whose Risks? Whose Benefits?” American Journal of Perinatology, vol. 29, 2011, pp. 7–18.

[10] Healthy People 2030 sets data-driven national objectives to improve health and well-being over the next decade.

[11] Tong VT, Dietz PM, Morrow B, et al. “Trends in Smoking Before, During, and After Pregnancy -- Pregnancy Risk Assessment Monitoring System, United States, 40 Sites, 2000-2010.” Morbidity and Mortality Weekly Report Surveillance Summaries, vol. 62, no. 6, 2013, pp. 1-19.