DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
Joint Informational Bulletin 
DATE:  November 9, 2018 
FROM:  Adam Boehler 
Deputy Administrator and Director 
Center for Medicare and Medicaid Innovation 
Mary C. Mayhew 
Deputy Administrator and Director  
Center for Medicaid & CHIP Services 
SUBJECT:    Strong Start for Mothers and Newborns initiative (Strong Start) 
This informational bulletin describes the improved outcomes and substantial savings associated 
with Birth Center care as reported in the final Strong Start for Mothers and Newborns (Strong 
Start) evaluation. Strong Start was a Center for Medicare and Medicaid Innovation initiative for 
pregnant women enrolled in Medicaid or the Childrens Health Insurance program (CHIP). The 
initiative intended to test psychosocial approaches to reducing preterm birth, improving overall 
pregnancy outcomes for mothers and infants, and reducing costs to Medicaid and CHIP during 
pregnancy and the year following birth.  
From 2013-2017, model participants received care in one of three models: Maternity Care 
Homes, Group Prenatal Care, or Birth Centers, and found significantly improved outcomes 
among the Birth Center participants. 
tate Medicaid programs can 
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associated with multiple cesareans, improved outcomes observed among Birth Center 
participants may offer health benefits and cost savings that are realized long past the infants first 
year. 
Background 
Rates of preterm birth and low birth weight are high in the United States, especially among births 
to Medicaid beneficiaries. Research consistently shows that infants born preterm (before 37 
completed weeks of gestation) have higher mortality risks and may endure a lifetime of 
developmental and health problems when compared to infants born at term.  The Center for 
Medicare and Medicaid Innovations Strong Start initiative tested three models of prenatal care 
to find successful ways to improve birth outcomes among Medicaid beneficiaries. Strong Start 
was designed to test which prenatal care models might improve maternal-infant health and 
reduce costs to Medicaid through pregnancy and the infants first year.    Informational Bulletin  Page 2 
 
Strong Start made 27 awards to organizations that operated more than 200 provider sites in 32 
states, Washington, D.C., and Puerto Rico.  From 2013-2017, the program provided enhanced 
prenatal care services to almost 46,000 women through three approaches:  
  Maternity Care Homes, which offered standard clinical care enhanced with a consistent 
care coordinator and sometimes additional health education or other services; 
  Group Care, which offered clinical care in a group setting, followed by extended health 
education and peer support; and  
  Birth Centers, which offered the midwives model of care, a time-intensive holistic 
approach, supplemented with peer counseling for additional education, referrals, and 
support. 
 
Strong Start programs adjusted to meet needs of participants, who commonly faced issues such 
as unstable housing, unemployment, depression and anxiety, food insecurity, barriers to care 
(e.g. transportation), and a lack of social support.   
Results showed particular promise in the Birth Center model. Birth Centers, which were all 
freestanding facilities that were members of the American Association of Birth Centers (AABC), 
employ certified nurse midwives and other state-licensed midwives who practice the midwifery 
model of care. These facilities follow standards for Birth Centers established by AABC 
(https://www.birthcenters.org/page/Standards). The midwifery model, a holistic and patient-
centered model, is distinct from the medical model that is usually employed by both physicians 
and midwives in typical clinical settings. Best practices associated with the Birth Centers 
midwifery model include prenatal care appointments that generally last at least 30 minutes, far 
longer than typical maternity care appointments, which usually last 15 minutes or less. These 
prenatal care appointments include extensive education on nutrition, exercise, childbirth 
preparation, breastfeeding, infant care and self-care. Most Birth Centers offer multiple 
postpartum visits, often including at least one home visit. .During the Strong Start initiative, 
many Birth Centers offered classes on topics such as childbirth and breastfeeding free of charge 
to Medicaid patients. In addition, Strong Start Birth Centers employed peer counselors, who 
offered additional support and referrals prenatally and postpartum. Although the addition of peer 
counseling did not appear to impact outcomes, patients reported positive care experiences with 
the peer counselors, and many Birth Centers used their own funds to sustain them at the end of 
the Strong Start program. 
The evaluation compared participants in Strong Start to other women enrolled in Medicaid, with 
similar demographic characteristics and medical risks (identified in birth certificates and 
Medicaid claims), and who lived in the same counties but received care in non-Strong Start 
practices. Regardless of where they gave birth (birth center or hospital) Birth Center participants 
had costs that were $2,010 lower on average from birth through the first year for each mother-
infant dyad.  Birth Center participants had preterm birth rates that were 25% lower than those of 
comparators, along With better birth outcomes in other multiple areas, described in Table 1: 
 
 
    Informational Bulletin  Page 3 
 
Table 1: Birth outcomes in Birth Center Participants and Comparison Group 
 
Outcome  Birth Center  Risk-matched  Statistically 
Participants  Comparison Group  significant 
difference?  
preterm birth rate  6.3%  8.5%  Yes (p < .01) 
 
rate of low birth  5.9%  7.4%  Yes (p < .05) 
weight infants 
average gestational  39 weeks  38.6 weeks  Yes (p < .01) 
age 
average birth weight  3, 342 grams  3,263 grams  Yes (p < .01) 
Cesarean delivery  17.5%  29%  Yes (p < .01) 
rate 
vaginal birth rate for  24.2%  12.5%  Yes (p < .01) 
women with a 
previous Cesarean  
weekend delivery rate  23.7%  19.8%  Yes (p < .01) 
(indicates fewer 
scheduled inductions 
or Cesareans) 
infant emergency  0.86  0.99  Yes (p < .01) 
department visits 
post-birth  0.07  0.08  Yes (p < .05) 
hospitalizations 
among infants 
 
All findings were robust to alternative specifications. Lower costs for Birth Center participants 
were likely driven by lower cesarean rates and shorter birth facility (birth center or hospital) 
stays, with added savings from reduced infant emergency department and hospital utilization in 
the year following birth. 
A comparison of participants in the three models allowed controls for psychosocial risks (e.g 
intimate partner violence, depression, food insecurity) in addition to medical risks and 
demographics. This comparison showed that relative to similar Maternity Care Home 
participants, Birth Center participants had lower rates of preterm birth, low birth weight infants, 
and cesarean sections. All findings were statistically significant at p < .01. Birth Centers also 
showed a higher VBAC rate (p< .05). 
Interviews with Birth Center staff and providers and with Medicaid officials in 20 states 
indicated that, in many cases, Birth Centers face barriers to serving Medicaid beneficiaries. State 
Medicaid officials in many states reported paying lower rates to midwives than to physicians for 
the same services (reported rates ranged from 70-92%).  Birth Center facility fees for 
uncomplicated vaginal birth were also reported to be less than those paid to hospitals in many  Informational Bulletin  Page 4 
 
states, with reported rates from 15% to 70% lower.  Many Birth Centers reported having 
difficulties in contracting with Managed Care Organizations (MCOs) providing Medicaid 
coverage because of inadequate reimbursement, state licensure requirements connected to 
inclusion in the contract, burdensome paperwork, or lack of interest on the part of the MCO.  
Laws regulating the scope of practice for midwives and licensure of Birth Centers differ among 
states. Regulations, such as those requiring a hospital-affiliated physician to serve as a Birth 
Center's medical director or requiring that midwives practice under direct supervision of 
physicians, can make it difficult to establish and operate a Birth Center.  
For states wishing to use these results to consider changes or enhancements to their prenatal care 
benefits and networks, a summary of federally mandated and optional coverage for midwifery 
and birth center care for Medicaid and CHIP programs is summarized below. 
 
Medicaid and CHIP Coverage of Midwives 
Nurse-midwife Services are a mandatory benefit described in regulations at 42 CFR 440.165. 
These are services furnished by a nurse midwife within the scope of practice authorized by state 
law or regulation and, in the case of inpatient or outpatient hospital services or clinic services, 
are furnished by or under the direction of a nurse-midwife to the extent permitted by the facility. 
These services are reimbursed without regard to whether the nurse-midwife is under the 
supervision of, or associated with, a physician or other healthcare provider, unless such 
supervision is required by state law or regulations.  Furthermore, to the extent nurse-midwives 
are authorized to practice independently under state law or regulation, Federal regulations at 42 
CFR 441.21 require that the plan must provide that the nurse-midwife may enter into an 
independent provider agreement, without regard to whether the nurse-midwife is under the 
supervision of, or associated with, a physician or other health care provider. In CHIP, nurse 
midwife services are an optional benefit that may be provided as child health assistance as a 
component of nursing care services as described in regulations at 42 CFR 457.402(o). 
Licensed midwives are another type of practitioner that may be covered in the Medicaid program 
based upon regulations for Other Licensed Practitioner Services at 42 CFR 440.60. This optional 
benefit allows coverage of midwives who are not registered professional nurses, but are 
otherwise licensed by the state to furnish midwifery services. Additionally, there may be other 
Medicaid benefits a state may use to cover services should a practitioner possess other state 
established qualifications. There is also flexibility to provide coverage of licensed midwives in 
CHIP if they are recognized to practice under state law and meet the additional requirements at 
42 CFR 457.402(x).  Decisions regarding the inclusion of other licensed practitioners in the 
Medicaid benefit are left up to states, and CMS is not making any specific recommendations 
about the inclusion of a particular provider type in the State Plan. 
  Informational Bulletin  Page 5 
 
Medicaid Coverage of Freestanding Birth Center Services  
Section 2301 of the Affordable Care Act requires states that recognize freestanding birth centers 
in their state to provide coverage and separate payments under Medicaid for freestanding birth 
center facility services and services rendered by certain professionals providing services in a 
freestanding birth center, to the extent the state licenses or otherwise recognizes such providers 
under state law. This authority gives specific reference to birth attendant services, which is 
interpreted to mean any non-licensed practitioner (such as lactation consultants, doulas, etc.) 
recognized by the state to provide prenatal, labor, and delivery or postpartum care in a 
freestanding birth center.  In general and specifically for freestanding birth centers, states have 
considerable discretion in setting provider payment rates that are reasonable, economic and 
efficient, and sufficient to encourage provider participation in the program.  CMS issued a State 
Health Officials letter (SHO#16-006) on April 26, 2016 clarifying (in part) how freestanding 
birth centers are incorporated in managed care contracts. Unlike Medicaid, coverage of free 
standing birth centers under CHIP is not required, but states may provide coverage of services 
provided in these facilities to the extent the state licenses or otherwise recognizes such providers 
under state law. 
Full results of the Strong Start evaluation, including a state-by-state assessment of outcomes, are 
available in the final evaluation report, which can be accessed at 
https://innovation.cms.gov/initiatives/strong-start/