Strong Start for Mothers and Newborns Initiative National Report


National Evidence Confirms Birth Centers Deliver Improved Health Outcomes at Lower Cost

by Diane W Shannon, MD, MPH for the American Association of Birth Centers

Health care is far more expensive in the U.S. than in other developed countries.[1] However, despite spending more, the U.S. ranks lower than many other countries in health outcomes, including those related to birth, such as preterm birth, low birth weight, maternal mortality, and infant mortality.[2] For example, the U.S. ranks last for infant mortality among the 27 most wealthy countries of the world.[3-5] Significant racial disparities exist in the U.S. regarding health outcomes for mothers and babies.[6] And maternal deaths have actually increased in the U.S. in recent years.[7]

Medicaid provides prenatal care for low-income women. This health care payment program is funded by the federal government through the Centers for Medicare and Medicaid Services (CMS), yet administered by state governments, with benefits varying by state.

The goal of the Strong Start initiative was to improve the quality of prenatal care for Medicaid recipients by providing additional services and to reduce costs during pregnancy, birth, and the infant’s first year of life. The initiative tested three different models for providing additional services, two that added education and support to typical services and a third that used a substantially different approach to prenatal and maternity care. A study by the Urban Institute compared the three models over a span of five years in terms of demographics, service use, and impact. (For more information on the Strong Start initiative and the study, see

Why are maternity outcomes worse in the U.S. than other developed countries?

A number of studies have shown that, in contrast with many other countries, the maternal mortality rate in the U.S. has gone up in recent years.[7] Possible reasons for the increase include:

  • More women with chronic diseases such as obesity and diabetes[8-9]
  • A cesarean birth (c-section) rate that is higher than ideal for balancing the need for medically necessary c-sections with the increased risks associated with the procedure (The current rate is 32 percent; experts believe the ideal rate is 19 percent.)[10-11]
  • Racial/ethnic health and economic disparities[12-13]
  • Reduced access to care; for example, the closure of hospitals in rural areas[14-15]

What was the Strong Start Initiative about?

The Center for Medicare and Medicaid Innovation (CMMI) was created as part of the Affordable Care Act (ACA, often referred to as “Obamacare”). Through the Strong Start for Mothers and Newborns Initiative, CMMI offered 27 awardees grants to provide enhanced prenatal care services in 211 care delivery sites across the country. The care delivery sites included Federally Qualified Health Centers (FQHCs), outpatient clinics associated with a hospital or health center, nationally certified birth centers, tribal health centers, local health departments, and physician groups.

model of strong start awardee sites
Source: CMS. Strong Start Findings At A Glance. Available at: Accessed December 5, 2018.

Who were the women in the initiative?

The Strong Start initiative included about 46,000 women from a variety of ethnic and racial groups. About 40 percent of women were black, 30 percent were Hispanic, and 26 percent were white. Three quarters of the women were between the ages of 20 and 34 years of age, which is considered the least risky age for pregnancy and childbirth. About 15 percent of participants were adolescents (age 19 and under).

These women faced several socioeconomic challenges: almost half were not employed or in school and only 15 percent had a college degree. More than one third of women reported experiencing barriers to obtaining prenatal care, such as lack of transportation.

About 28 percent screened positive for depression, which is twice the rate usually seen in pregnant women. In addition, many had chronic health problems, such as obesity, that increase the risks associated with childbirth. More than 20 percent had experienced a preterm birth in the past, which is a strong predictor of future preterm birth.

The sample of women who received care in birth centers was less racially and ethnically diverse than the total group of Strong Start participants, but more diverse than groups that participated in previous birth center studies.

What types of care were studied? How was the care in the Strong Start initiative different than typical care?

All sites that received the Strong Start grant provided additional services that included education, psychosocial support, and referrals for nonmedical services. These enhanced services were provided in three different models of care. The birth center model provided the additional services within the midwifery model, which is an approach to prenatal care and childbirth that is substantially different from typical care. The two other models provided the additional services within the context of typical prenatal and maternity care, one with group prenatal care and the other with health educators.

What is the midwifery model of care?

The midwifery model of care is based on the philosophy that birth is a natural part of life rather than a condition to be treated. The approach is holistic, wellness-based, and patient- and family-centered, using interventions only when medically necessary. Midwives provide extensive education and continuous, supportive care; for these reasons, midwifery care is generally more time-intensive than typical OB/GYN care.[16]

Which birth centers participated?

A total of 47 birth centers participated in the Strong Start initiative; all but one were funded through the grant awarded to AABC. Birth centers that participated in the AABC grant were located in 22 states across the country. 

How did the outcomes in birth centers compare to typical care?

The main question that the Strong Start initiative was designed to answer is, “What impact does the program have on gestational age, birth weight, rate of c-section, and cost for women and infants during pregnancy and the first year of life?” To answer this question, the researchers compared results for women in the Strong Start initiative to birth and cost outcomes for women enrolled in Medicaid who had similar risk profiles.

Compared with women with similar risks, women who received care in birth centers had better outcomes:

  • Preterm birth: 6.3 percent versus 8.5 percent (26 percent lower)
  • C-section rate: 17.5 percent versus 29 percent
  • Primary, or first-time, c-section rate: 8.7 percent versus 21.7 percent
  • Gestational age of baby: almost half a week longer
  • More weekend deliveries (which indicates fewer planned inductions or c-sections): 23.7 percent versus 19.8 percent
  • More vaginal births after c-section (VBACs): 24.2 percent versus 12.5 percent

Women who received prenatal care at birth centers had better outcomes, whether they gave birth at the birth center, chose to give birth at the hospital, or were transferred from the birth center and delivered at the hospital.

Birth Outcomes in Birth Center Participants and Matched Comparison Group


Birth Center Participants

Matched Comparison Group

Preterm birth rate 



Rate of low birth weight infants 



Average gestational age

39 weeks

38.6 weeks

Average birth weight

 3342 grams

3262 grams

C-section birth rate



Vaginal birth rate for women with a previous c-section



Weekend birth rate (indicating fewer scheduled inductions or c-sections)



Infant emergency department visits



Hospitalization among infants after birth



* Note that all comparisons were statistically significant at or below the 0.05 level.

Source: CMS Joint Information Bulletin. November 9, 2018. Available at:

How were disparities impacted by birth center care?

Strong Start data were analyzed by race and ethnicity to determine if enhanced prenatal care was associated with reductions in racial/ethnic disparities for key maternal and infant outcomes. Researchers found that birth center care was associated with reductions in racial/ethnic disparities.

For example, among AABC Strong Start participants, the rates of low birth weight ranged from 3 percent to 6 percent, all lower than the national average. Researchers found smaller disparities in health outcomes among racial/ethnic groups for AABC Strong Start participants than the general population.  The disparity in outcomes was most reduced for African American women, as shown in the table.  

 Racial/Ethnic Group    

   Low Birth Weight Rates Among
   AABC Strong Start Participants   

   National Low Birth Weight Rates

   African American









Sources: Centers for Medicare and Medicaid Services. Strong Start Final Evaluation. 2018;1:78; available at:; Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: Final data for 2016. NVSR. 2018;67 (1).  Hyattsville, MD.  National Center for Health Statistics; available at:

In addition, when comparing birth center care to one of the less intense models of care (Maternity Care Home), all racial/ethnic groups had significantly lower rates of low birth weight when cared for at birth centers than in the other, less intense, models of care. However, low birth weight rates showed a larger improvement (were reduced more) for African American women than for white and Hispanic women. 

How did the outcomes in birth centers compare to the two other care models?

Basically, the researchers found that the birth center model had better outcomes than the models that added enhanced services to typical prenatal and maternity care. According to the report authors, birth centers “succeeded in improving almost every outcome we measured.” Women cared for at birth centers had the lowest risk of preterm birth and low birth weight and the lowest c-section rate. The two less comprehensive models of care failed to achieve as much improvement in outcomes.

In addition, women cared for in birth centers were very satisfied with their care.  Ninety-six percent were very satisfied or extremely satisfied with their prenatal care, and 85 percent were very satisfied or extremely satisfied with their birth experience.

Source: Centers for Medicare and Medicaid Services. Strong Start Final Evaluation. 2018;1:250; available at:

Why are the findings about lower rates of preterm birth, low birth weight, and c-sections so important?

Preterm birth and low birth weight put babies at risk for complications.[4] C-sections increase the risk of complications for mothers and babies.[11] More c-sections, more intensive care for preterm and low birth weight infants, and treatment for associated complications increase the costs of births that involve preterm birth, low birth weight, or c-section.

How did the cost of care in birth centers compare to other models of care?

The cost of care in birth centers was lower than typical care by Medicaid providers. The average cost of birth at birth centers was $1,759 less (21 percent lower). The average total cost of care for women and infants for the first year after birth was $2,010 less (15 percent lower). Researchers believe the lower cost was due to fewer c-sections, fewer emergency department visits for infants, and a lower payment rate. (In some states Medicaid pays less for services provided by midwives in birth centers.)

What is the bottom line for women and families?

The midwifery model offers holistic, patient-centered care that has demonstrated better outcomes for mothers and babies. Prenatal care in birth centers has better outcomes than other sites of care, even if birth occurs in the hospital. Women who receive prenatal care at birth centers are very satisfied with their care.

What is the bottom line for health care providers?

The midwifery model, which emphasizes education, family-centered care, and a wellness approach to pregnancy and birth, is associated with improved outcomes and high satisfaction with prenatal care and birth. Many aspects of the midwifery model can be applied in other sites of care.

What is the bottom line for policymakers?

Slight alterations in the delivery of prenatal care failed to significantly improve outcomes for mothers and babies. System transformation, by spreading use of the midwifery model of care, is needed to achieve big gains in health for women and infants. The use of birth centers for prenatal care and birth should be supported and expanded. A critical step in expanding the use of birth centers is reducing the barriers to access, especially increasing payment for maternity services provided in birth centers. Addressing these barriers could allow more women covered by Medicaid to use birth centers, improving outcomes for these women and their babies, and reducing cost savings for the Medicaid program.

The findings of the Strong Start initiative are seismic and far-reaching. The study showed that maternal and infant outcomes can be improved, even among low-income women with a variety of life challenges. The initiative clearly demonstrated that birth centers and the midwifery model provide better outcomes for mothers and babies and reduce costs compared with typical care, and that women are highly satisfied with birth center care. Barriers to the use of birth centers need to be addressed and birth center use needs to be expanded to improve health outcomes for women and babies.

About the Author

Diane W. Shannon, MD, MPH is a physician-writer with expertise in writing about performance improvement in health care. Leaving clinical practice to focus on system-level solutions, she has been a freelance writer for 20 years, interviewing thought leaders and innovators across the country. Her topic areas of expertise include physician burnout, patient safety, and quality improvement. As the daughter of an influential nurse-midwife, Edith B. Wonnell, CNM, she is intimately familiar with the benefits of the midwifery model and the services provided by birth centers.

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