There per 1,000. (1) And while the

There is a tremendous
need to address the disproportionately high adverse birth outcomes for low
income African American teen mothers in the state of Maryland. In Maryland, a
black infant is 1.5 times more likely than a white infant to be born
prematurely; almost two times more likely to be at low birth weight (LBW);
three times more likely to be very low birth weight (VLBW); and 2.5 to three
times more likely to die in the first year of life. These statistics are
substantially most detrimental when you factor in the age (teens) and low
income of this population.

Background

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In the United States in
2015, a total of 229,715 babies were born to women aged 15–19 years of age, for
a birth rate of 22.3 per 1,000. (1) And while the teen birth rate
in Maryland has declined nearly 70 percent between 1991 and 2015, in 2015 there
were still 3,214 births to teens mothers in the state, of which, approximately
85 percent were to first time mothers. Teenage pregnancy is a critical matter associated
with high rates of adverse health outcomes, such as low birth weight, preterm
delivery, small for gestational age, and fetus/infant malformations. Further
analysis reveals that these poor pregnancy outcomes are substantially higher
for Black teen mothers than for Hispanic or White mothers. (2)  The
emotional and long-term burden of teen pregnancy on both the mother and infant
is high, and the financial burden is as well. In 2010 in Maryland, the public
cost of teen pregnancies/births totaled over $194 million with the majority of
the costs covered under Medicaid.  (3) While
Maryland is considered the most progressive state in the U.S. in terms of
Medicaid, access to health care remains a challenge. 

In 2016, Maryland’s uninsured rate was 5.6 percent. And according
to US Department of Health and Human Services, Agency for Healthcare Research
and Quality (AHRQ) 2016 statistics, Maryland was ranked #14 in health care
access nationally. (4) 

It has long been
recognized that African American infants are more than twice as likely as White
infants to die in their first year of life. In Maryland, a black infant is 1.5
times more likely than a white infant to be born prematurely; almost two times
more likely to be at low birth weight (LBW); three times more likely to be very
low birth weight (VLBW); and 2.5 to three times more likely to die in the first
year of life. (5) These statistics reinforce the need
for effective early intervention programs to reduce the risk factors
contributing to poor pregnancy outcomes such as preterm births and low birth
weight in this population.

Options

According to the Centers
for Disease Control and Prevention, increased access to prenatal services
reduces the risk of pregnancy and infant complications such as low birth
weight, preterm births, gestational diabetes and hypertension. It is
recommended that early prenatal care is critical for disadvantaged and
vulnerable populations. (6)

Option
#1 – In home prenatal visits such as Nurse-Family
Partnership (NFP) is an evidence-based, community health program that serves mothers
pregnant with their first child, most of whom are low-income, unmarried,
and teenagers. Each mother in the program is partnered with a registered nurse
early in her pregnancy and receives prenatal home visitations that continue
through her child’s second birthday. The nurses monitor the young mother’s
pregnancy and provide preventive health and prenatal assessments, assist mothers on how best to
breastfeed and care for their babies, help parents understand child
development milestones and behaviors, promoting parents’
use of praise and other positive parenting techniques, and work with mothers
to set goals for the future, continue their education, and find employment and
child care solutions. (8) Nurse-Family Partnership helps families —
and the communities they live in — become stronger while saving money for
state, local and federal governments.

Option
#2 – “Quick Start” is a community care coordinated prenatal
program designed to increase the number of women accessing prenatal care via local
health departments. Quick Start was created when public health workers discovered
that uninsured women were presenting to labor and delivery without previous
prenatal care and lacked access to Medicaid. (5) Quick Start is a
multidisciplinary (community health workers, nurses, social workers, and
others) multiagency (local community organizations, outreach centers, health
departments, and community health centers) initiative that reaches out to those
at greatest risk to provide access to critical prenatal care. Staffed by culturally
competent community health workers, Quick Start also serves as mediators for
at?risk pregnant women, the health department, and private healthcare providers.

 One strategy used for early entry into
prenatal care includes expediting Medical Assistance enrollment for the client
in local health departments (LHD) and local Department of Social Services (DSS)
sites. At time of enrollment, screening and referrals for prenatal
appointments, WIC nutrition, substance abuse treatment, and mental health
services are all confirmed. (11) See Table 1.

 

Recommendations

Of the two options
presented for reducing risk factors that contribute to poor pregnancy outcomes
for low income African American teen mothers living in Maryland, option #1 – in home prenatal visits such as Nurse-Family Partnership
(NFP), is the most economically feasible, politically appropriate, and
impactful solution to increasing access to quality prenatal care. The impact of
nurse home visitation programs on birth outcomes in young African American
women becoming more evident. One 2008 study in the Journal of the National
Medical Association concluded that prenatal home visitations, “appeared to be
protective against preterm delivery and could contribute to reducing racial
disparities in infant mortality,” and outcomes. (9) While other studies have
shown an 18 percent decrease in preterm deliveries, 21 percent increase in
infants that were breast fed, and 19 percent increase in immunizations for
mothers and children that have participated in the program. (10) The program
costs approximately $13,600 per woman over the three years of visits (in 2014).
(7) State and federal government cost savings average $26,898 per family served
or $2.90 per dollar invested, and total benefits to the community equal $60,428
per family served, or $6.40 per dollar invested in the program.

Because of more than 37
years of randomized, controlled trials, detailed performance measurement, and
national data collection and reporting for NFP, quality program replication is
possible. In addition to a reduction in almost all preterm births for families
enrolled in the program (over 30,000), positive unintended outcomes included:
48 percent reduction in child abuse and neglect; 56 percent reduction in
emergency room visits for accidents and poisonings; 59 percent reduction in
child arrests at age 15; and 67 percent reduction in behavioral and
intellectual problems at child age six.  

Since Medicaid revenue is an important source of
funding to sustain and grow prenatal home visitation programs in Maryland, we
recommend an “in-home visitation” coverage category in Medicaid and reimburse
for the full scope of the program’s services.