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Non-Medicaid enhanced prenatal care programs for African-American women

Health Care: Maternal and Infant Health
Benefit-cost estimates updated May 2017.  Literature review updated December 2016.
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Non-Medicaid enhanced prenatal care programs for African-American women provide psychosocial support and health education regarding risk reduction. Some programs also include case management and nutritional counseling. Services are provided by paraprofessionals or nurses. Participants typically receive the program for five months, including prenatal and postpartum services. All women in treatment and comparison groups receive clinical prenatal care (treatment as usual).
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $561 Benefits minus costs $2,763
Participants $279 Benefit to cost ratio $5.66
Others $442 Chance the program will produce
Indirect $2,074 benefits greater than the costs 69 %
Total benefits $3,355
Net program cost ($592)
Benefits minus cost $2,763
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Health care associated with Cesarean sections $82 $3 $82 $41 $209
Health care associated with low birthweight births ($2) $0 ($2) ($1) ($6)
Subtotals $80 $3 $80 $40 $203
From secondary participant
Infant mortality $118 $261 $0 $2,149 $2,528
Health care associated with low birthweight births ($20) ($1) ($20) ($10) ($50)
Health care associated with NICU admissions $382 $16 $382 $192 $970
Subtotals $481 $276 $362 $2,331 $3,449
Adjustment for deadweight cost of program $0 $0 $0 ($297) ($297)
Totals $561 $279 $442 $2,074 $3,355
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $1,967 2014 Present value of net program costs (in 2016 dollars) ($592)
Comparison costs $1,383 2014 Cost range (+ or -) 15 %
Per-participant program cost estimates are based on average costs for included studies. We estimate provider hours, apply the mean hourly wage estimate for Washington State reported by the Bureau of Labor Statistics (September 2016) for the appropriate provider, and increase wages by a factor of 1.441 to account for the cost of employee benefits. Studies averaged ten provider hours, and providers varied (paraprofessionals or nurses). Both groups receive treatment as usual. The costs of treatment as usual are the average costs of usual prenatal care in Washington State (Washington State Department of Health, September 2016).
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

***We report this outcome twice: once for mothers (designated as the primary participant) and once for infants (designated as the secondary participant). We do this because the outcome is associated with costs and benefits for both mothers and infants, and the amount of the cost or benefit is different for mothers than it is for infants.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Cesarean sections Primary 1 311 -0.158 0.136 23 0.000 0.000 24 -0.158 0.248
Low birthweight births*** Primary 4 1432 0.015 0.086 23 0.000 0.000 24 -0.031 0.759
Preterm birth (< 37 weeks)*** Primary 1 311 -0.192 0.151 23 0.000 0.000 24 -0.192 0.203
Very low birthweight birth (< 1500g)*** Primary 1 669 -0.199 0.142 23 0.000 0.000 24 -0.199 0.161
Low birthweight births*** Secondary 4 1432 0.015 0.086 1 0.000 0.000 2 -0.031 0.759
NICU admission Secondary 1 311 -0.234 0.149 1 0.000 0.000 2 -0.234 0.115
Preterm birth (< 37 weeks)*** Secondary 1 311 -0.192 0.151 1 0.000 0.000 2 -0.192 0.203
Very low birthweight birth (< 1500g)*** Secondary 1 669 -0.199 0.142 1 0.000 0.000 2 -0.199 0.161

Citations Used in the Meta-Analysis

Herman, A.A., Berendes, H.W., Yu, K.F., Cooper, L.C., Overpeck, M.D., Rhoads, G., . . . Coates, D.L. (1996). Evaluation of the effectiveness of a community-based enriched model prenatal intervention project in the District of Columbia. Health Services Research, 31(5), 609-21.

Klerman, L.V., Ramey, S.L., Goldenberg, R.L., Marbury, S., Hou, J., & Cliver, S.P. (2001). A randomized trial of augmented prenatal care for multiple-risk, Medicaid-eligible African American women. American Journal of Public Health, 91(1), 105-11.

Norbeck, J.S., DeJoseph, J.F., & Smith, R.T. (1996). A randomized trial of an empirically-derived social support intervention to prevent low birthweight among African American women. Social Science & Medicine, 43(6), 947-954.

Peoples, M.D., Grimson, R.C., & Daughtry, G.L. (1984). Evaluation of the effects of the North Carolina Improved Pregnancy Outcome Project: implications for state-level decision-making. American Journal of Public Health, 74(6), 549-54.

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov