Facilitators and Barriers to Healthy Pregnancy Spacing among Medicaid Beneficiaries: Findings from the National Strong Start Initiative

Closely spaced, unintended pregnancies are common among Medicaid beneficiaries and create avoidable risks for women and infants, including preterm birth. The Strong Start for Mothers and Newborns Initiative, a program of the Center for Medicare and Medicaid Innovation, intended to prevent preterm birth through psychosocially based enhanced prenatal care in maternity care homes, group prenatal care, and birth centers. Comprehensive care offers the opportunity for education and family planning to promote healthy pregnancy spacing. As of March 30, 2016, there were 42,138 women enrolled in Strong Start and 23,377 women had given birth. Individual-level data were collected through three participant survey instruments and a medical chart review, and approximately one-half of women who had delivered (n = 10,374) had nonmissing responses on a postpartum survey that asked about postpartum family planning. Qualitative case studies were conducted annually for the first 3 years of the program and included 629 interviews with staff and 122 focus groups with 887 Strong Start participants. Most programs tried to promote healthy pregnancy spacing through family planning education and provision with some success. Group care sites in particular established protocols for patient-centered family planning education and decision making. Despite program efforts, however, barriers to uptake remained. These included state and institutional policies, provider knowledge and bias, lack of protocols for timing and content of education, and participant issues such as transportation or cultural preferences. The Strong Start initiative introduced a number of successful strategies for increasing women's knowledge regarding healthy pregnancy spacing and access to family planning. Multiple barriers can impact postpartum Medicaid participants' capacity to plan and space pregnancies, and addressing such issues holistically is an important strategy for facilitating healthy interpregnancy intervals.