The federal Strong Start for Mothers and Newborns initiative supported alternative approaches to prenatal care, enhancing service delivery through the use of birth centers, group prenatal care, and maternity care homes. Using propensity score reweighting to control for medical and social risks, we evaluated the impacts of Strong Start's models on birth outcomes and costs by comparing the experiences of Strong Start enrollees to those of Medicaid-covered women who received typical prenatal care. We found that women who received prenatal care in birth centers had lower rates of preterm and low-birthweight infants, lower rates of cesarean section, and higher rates of vaginal birth after cesarean than did the women in the comparison groups. Improved outcomes were achieved at lower costs. There were few improvements in outcomes for participants who received group prenatal care, although their costs were lower in the prenatal period, and no improvements in outcomes for participants in maternity care homes.

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Birth center services must be covered under Medicaid per federal mandate, but reimbursement and other policy barriers prevent birth centers from serving more Medicaid patients. r Midwifery care provided through birth centers improves maternal and infant outcomes and lowers costs for Medicaid beneficiaries. Birth centers offer an array of birth options and have resources to care for patients with medical and psychosocial risks. r Addressing the barriers identified in this study would promote birth centers' participation in Medicaid, leading to better outcomes for Medicaid-covered mothers and newborns and significant savings for the Medicaid program. Context: Midwifery care, particularly when offered through birth centers, has shown promise in both improving pregnancy outcomes and containing costs. The national evaluation of Strong Start for Mothers and Newborns II, an initiative that tested enhanced prenatal care models for Medicaid beneficiaries, found that women receiving prenatal care at Strong Start birth centers experienced superior birth outcomes compared to matched and adjusted counterparts in typical Medicaid care. We use qualitative evaluation data to investigate birth

Background: Medicaid pays for approximately half of United States births, yet little research has explored Medicaid beneficiaries' perspectives on their maternity care. Typical maternity care in the United States has been criticized as too medically focused while insufficiently addressing psychosocial risks and patient education. Enhanced care strives for a more holistic approach. Methods: The perspectives of participants in the Strong Start for Mothers and Newborns II initiative, which provided enhanced prenatal care to women covered by Medicaid or the Children's Health Insurance Program (CHIP) during pregnancy through Birth Centers, Group Prenatal Care, and Maternity Care Homes, are evaluated. Strong Start intended to improve care quality and birth outcomes while lowering costs. We analyzed data from 133 focus groups with 951 pregnant or postpartum women who participated in Strong Start from 2013 to 2017. Results: The majority of focus group participants said that Strong Start's enhanced care offered numerous important benefits over typical maternity care, including considerably more focus on women's psychosocial risk factors and need for education. They praised increased support; nutrition, breastfeeding, and family planning education; community referrals; longer time with practitioners; and involvement of partners in their care. Maternity Care Home participants, however, occasionally voiced concerns over lack of practitioner continuity and short clinical appointments, whereas Group Prenatal Care participants sometimes said they could not attend visits because of lack of childcare. Conclusions: Medicaid and CHIP beneficiaries reported positive experiences with Strong Start care. If more Medicaid practitioners could adopt aspects of the prenatal care approaches that women praised most, it is likely that women's risk factors could be more effectively addressed and their overall care experiences could be improved. K E Y W O R D S enhanced care, Medicaid, prenatal care, Strong Start | 245 HILL et aL.

Introduction Group prenatal care combines clinical care with peer support and education. Research has indicated neutral or positive results for group care when compared with traditional individual prenatal visits. A national initiative, Strong Start II, was implemented to determine if specific prenatal care interventions such as group prenatal care can reduce the rate of preterm birth, improve health outcomes, and lower costs. This study explored barriers to implementation and sustainability and strategies for overcoming barriers and sustaining the model. Methods Results from prenatal care provider‐level qualitative case studies for the independent evaluation of Strong Start were examined. Case studies for sites implementing group prenatal care were based on a total of 313 interviews with 441 Strong Start key informants (eg, prenatal care providers, project staff, and health administrators involved in group care) and 53 focus groups with 428 Strong Start participants from 2013 to 2016. Supplemental interviews with 25 additional stakeholders were also conducted. Case study data were queried using content analysis followed by a grounded theory‐based analysis of these findings. Results Barriers to implementation existed at patient, provider, administrator, system, and funding levels and included inflexible appointment times, lack of childcare, lack of appropriate meeting space, new scheduling and training needs, meeting requirements of graduate medical education programs, prenatal care provider and administrator reluctance to adopt new practices, and Medicaid payment policies. Sites newly implementing group prenatal care had varying degrees of success sustaining their programs. Both new and established sites identified provider champions and opt‐out enrollment approaches as critical for maintaining buy‐in. Discussion Successful implementation of group prenatal care depends on systematic strategies at the practice, payer, provider, patient, and policy levels to implement, reimburse for, and sustain the model. Strategies for overcoming barriers can assist practices in offering this transformative approach, including practices with graduate medical education programs or those serving women with clinical, demographic, or psychosocial risk factors for preterm birth.