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The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a proven, cost-effective investment in strengthening families. As part of the United States Department of Agriculture's (USDA) 15 federal nutrition assistance programs for the past 40 years, WIC has grown to be the nation's leading public health nutrition program. WIC serves as an important first access point to health care and social service systems for many limited resource families, serving approximately half the births in the nation as well as locally. By providing nutrition education, breastfeeding promotion and foods in addition to referrals, WIC plays a crucial role in promoting lifetime health for women, infants and children. WIC helps achieve national public health goals such as reducing premature births and infant mortality, increasing breastfeeding, and reducing maternal and childhood overweight. Though individuals and families can self-refer into WIC, physicians and allied health professionals have the opportunity and are encouraged to promote awareness of WIC and refer families in their care.

A complete account of the US child care subsidy system requires an understanding of its implications for both parental and child well-being. Although the effects of child care subsidies on maternal employment and child development have been recently studied, many other dimensions of family well-being have received little attention. This paper attempts to fill this gap by examining the impact of child care subsidy receipt on maternal health and the quality of child-parent interactions. The empirical analyses use data from three nationally representative surveys, providing access to numerous measures of family well-being. In addition, we attempt to handle the possibility of non-random selection into subsidy receipt by using several identification strategies both within and across the surveys. Our results consistently indicate that child care subsidies are associated with worse maternal health and poorer interactions between parents and their children. In particular, subsidized mothers report lower levels of overall health and are more likely to show symptoms consistent with anxiety, depression, and parenting stress. Such mothers also reveal more psychological and physical aggression toward their children and are more likely to utilize spanking as a disciplinary tool. Together, these findings suggest that work-based public policies aimed at economically disadvantaged mothers may ultimately undermine family well-being., (Copyright © 2013 John Wiley & Sons, Ltd.)

Projection of current trends in maternal and neonatal mortality reduction shows that many countries will fall short of the UN Millennium Development Goal 4 and 5. Underutilization of maternal health services contributes to this poor progress toward reducing maternal and neonatal morbidity and mortality. Moreover, the quality of services continues to lag in many countries, with a negative effect on the health of women and their babies, including deterring women from seeking care. To enhance the use and provision of quality maternal care, countries and donors are increasingly using financial incentives. This paper introduces the JHPN Supplement, in which each paper reviews the evidence of the effectiveness of a specific financial incentive instrument with the aim of improving the use and quality of maternal healthcare and impact. The US Agency for International Development and the US National Institutes of Health convened a US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives on 24-25 April 2012 in Washington, DC. The Summit brought together leading global experts in finance, maternal health, and health systems from governments, academia, development organizations, and foundations to assess the evidence on whether financial incentives significantly and substantially increase provision, use and quality of maternal health services, and the contextual factors that impact the effectiveness of these incentives. Evidence review teams evaluated the multidisciplinary evidence of various financial mechanisms, including supply-side incentives (e.g. performance-based financing, user fees, and various insurance mechanisms) and demand-side incentives (e.g. conditional cash transfers, vouchers, user fee exemptions, and subsidies for care-seeking). At the Summit, the teams presented a synthesis of evidence and initial recommendations on practice, policy, and research for discussion. The Summit enabled structured feedback on recommendations which the teams included in their final papers appearing in this Supplement. Papers in this Supplement review the evidence for a specific financial incentive mechanism (e.g. pay for performance, conditional cash transfer) to improve the use and quality of maternal healthcare and makes recommendations for programmes and future research. While data on programmes using financial incentives for improved use and indications of the quality of maternal health services support specific conclusions and recommendations, including those for future research, data linking the use of financial incentives with improved health outcomes are minimal.

Objective: To estimate the U.S. maternal health burden from current breastfeeding rates both in terms of premature death as well as economic costs., Methods: Using literature on associations between lactation and maternal health, we modeled the health outcomes and costs expected for a U.S. cohort of 15-year-old females followed to age 70 years. In 2002, this cohort included 1.88 million individuals. Using Monte Carlo simulations, we compared the outcomes expected if 90% of mothers were able to breastfeed for at least 1 year after each birth with outcomes under the current 1-year breastfeeding rate of 23%. We modeled cases of breast cancer, premenopausal ovarian cancer, hypertension, type 2 diabetes mellitus, and myocardial infarction considering direct costs, indirect costs, and cost of premature death (before age 70 years) expressed in 2011 dollars., Results: If observed associations between breastfeeding duration and maternal health are causal, we estimate that current breastfeeding rates result in 4,981 excess cases of breast cancer, 53,847 cases of hypertension, and 13,946 cases of myocardial infarction compared with a cohort of 1.88 million U.S. women who optimally breastfed. Using a 3% discount rate, suboptimal breastfeeding incurs a total of $17.4 billion in cost to society resulting from premature death (95% confidence interval [CI] $4.38-24.68 billion), $733.7 million in direct costs (95% CI $612.9-859.7 million), and $126.1 million indirect morbidity costs (95% CI $99.00-153.22 million). We found a nonsignificant difference in number of deaths before age 70 years under current breastfeeding rates (4,396 additional premature deaths, 95% CI -810-7,918)., Conclusions: Suboptimal breastfeeding may increase U.S. maternal morbidity and health care costs. Thus, investigating whether the observed associations between suboptimal breastfeeding and adverse maternal health outcomes are causal should be a research priority.

We compare the experiences of women from three studies who were in different stages of participation in the U.S. welfare program, Temporary Assistance for Needy Families (TANF). The setting for the studies was a large Midwest urban county, targeted chain referral sampling was used, and the combined sample of the three studies was 106 women. The instruments were a semistructured interview guide, the HANES General Well-Being Schedule and a demographic data form. Quantitative data are augmented with qualitative interview data. The findings suggest barriers to self-sustaining employment include health challenges, limited education, socio-economic marginalization, and the welfare policy itself. Nurses are well positioned to advocate for women in poverty and mitigate the health challenges they face. The findings add to the limited evidence base on which the TANF policy is based and can be used to modify the policy to increase the success of the women who participate in it.

The goals of this study are to estimate federal maternal and child health (MCH) expenditures and identify their sources. This analysis is intended to provide a broad view of MCH funding appropriations and a basis for discussion of whether funds could be better utilized for the benefit of the population served. Data on federal maternal and child health expenditures for fiscal year (FY) 2006 were derived from examining federal legislation, department/agency budgets, and various web-based program documents posted by federal agencies. Based on selected criteria, we identified programs targeting children under 21 or pregnant/parenting women within the United States. The funding levels of agency programs for maternal and child health activities were determined and the programs briefly summarized. The identifiable funding for maternal and child health programs in FY 2006 approached $57.5 billion dollars. Funding sources for maternal and child health were concentrated within the U.S. Department of Health and Human Services, but spread across several different agencies within the department and in the Departments of Defense, Education, Agriculture, Housing and Urban Development, and the Environmental Protection Agency. Multiple agencies and offices often funded related activities, without evidence of a common underlying strategy. Federal maternal and child health funding mechanisms may lead to a fragmentation in maternal and child health activities. The funding and service delivery apparatus would benefit from an integrative MCH infrastructure approach to pediatric research, service delivery, and data collection/access that incorporates life-course and social/environmental determinants perspectives.

Welfare reform has had far-reaching consequences for unmarried women and their children, including effects on their health insurance status. Those who would be receiving cash assistance absent welfare reform may have lower rates of health insurance if they failed to enroll separately for Medicaid (whose rules did not tighten over this time period), or if the new employment they entered did not provide health insurance. Administrative difficulties involved in accessing Medicaid separately from cash welfare may also have been a factor in the short run. Our research uses data from a large and nationally representative household survey that tracks the same individuals over time, the Survey of Income and Program Participation, to examine the effect of welfare reform (AFDC waivers and TANF implementation) on the health insurance status of unmarried mothers with High School completion or less (the population whose health insurance we expect would be affected by the welfare reform, or the "treatment group") in the time period surrounding a particularly important life event, pregnancy. We look at the effects of these policies over the time period 1990--1999, as well as over the time period 1990--2003, to explore the short run vs. long run impact. Our "control group", those who should not be affected by welfare reform itself but are expected to be affected by other national or state events that are happening contemporaneously, consists of married mothers with High School completion or less; the insurance experience of these women is used to control for the other forces that might otherwise lead us to attribute too little or too large an effect to welfare reform. Given the importance of access to health care at all points in the period surrounding and during pregnancy, we look at how welfare reform has affected insurance status before conception, during pregnancy, and after the birth of the child. We find that the Aid to Families with Dependent Children (AFDC) waivers of the 1990s as well as Temporary Assistance for Needy Families implementation have decreased access to Medicaid health insurance, increased access to employer health insurance, and led to a decrease in overall insurance, depending on the point in pregnancy considered and the time period of the study, with the largest effects found in coverage after the birth of a child. These findings have particular implications for the increasing emphasis on preconception and interconception care as a strategy to improve women's and infant's health.

This article examines health insurance coverage among women of reproductive age and considers how national health insurance reform may affect access to high-quality, timely, and affordable preconception and interconception care. A focus on preconception and interconception care increasingly is understood as essential, not only to the health of women, but to that of infants as well, and thus, as a key part of a comprehensive infant health strategy. After a brief overview that examines the relationship between preconception and interconception health care and health insurance reform, the article examines the current state of health insurance coverage among women of childbearing age and the underlying causes of uninsurance and underinsurance in this population group. The article then sets forth a proposed health insurance reform taxonomy in the context of health and health care generally, and preconception and interconception health care in particular. It is the underlying assumption of this article that preconception and interconception care can serve as bellwethers of the extent to which health reform achieves preventive results. Such results include coverage reforms that not only put acute treatments within financial reach, but that also help finance interventions that can help to achieve population-wide preventive results, in this case, long-term improvement in the health of both women and children.

This special supplement of Women's Health Issues offers 2 types of articles related to the policy and finance context for improving preconception health and health care. These articles discuss the impact of finance and policy on preconception health and health care, as well as the strategies that are being used to overcome the challenge of implementing preconception care with limited resources and inadequate health coverage for women. Invited papers from authors with expertise in health policy and finance issues describe how women's health and preconception care fit into the larger debates on health reform and how the paradigm for women's health must change. Other invited papers discuss opportunities and challenges for using programs such as Medicaid, Title X Family Planning, Title V Maternal and Child Health Services Block Grant, Healthy Start, and Community Health Centers in improving preconception health and health care. Contributed articles on health services research in this supplement characterize the types of change occurring across the country. This paper also presents a framework for understanding the role of policy and finance in the larger Centers for Disease Control and Prevention Preconception Health and Health Care Initiative.

This study uses longitudinal data spanning 13 years from a study of 234 adolescent mothers to evaluate the effects of cumulative domestic violence on employment and welfare use before and after welfare reform. Domestic violence increased the odds of unemployment after welfare reform, but not before; domestic violence had no effect on welfare use during any time period. Psychological distress after welfare reform was associated with unemployment, but not with welfare outcomes. Thus, the authors found that the direct effect of domestic violence on unemployment is not mediated by concurrent level of psychological distress. The relationship of psychological distress to unemployment exists only for those with a history of domestic violence. Cumulative domestic violence can have negative effects on economic capacity many years after the violence occurs, suggesting that policymakers recognize the long-term nature of the impact of domestic violence on women's capacity to be economically self-reliant.

Objectives: To examine pre-pregnancy Medicaid coverage and initiation of prenatal care among women likely eligible for Medicaid coverage regardless of pregnancy., Methods: The Pregnancy Risk Assessment Monitoring System (PRAMS) was used to identify very low-income women with Medicaid payment for delivery. We then compared prenatal care initiation among women with (Non-GAP) and without (Medicaid GAP) pre-pregnancy Medicaid coverage., Results: Rates of first trimester prenatal care were 47.3% for women in the Medicaid GAP, 70.0% for women who were not. The adjusted odds ratio for being in the Medicaid GAP and delayed prenatal care was 2.7 (95% CI 1.2, 6.2), although this varied by race/ethnicity and education. The relationship was strongest among White and Hispanic women with less than a high school education: OR=13.8, (95% CI 3.0, 62.7) and OR=19.0 (95% CI 2.4, 149.2), respectively., Conclusions: Pre-pregnancy Medicaid coverage appears to be associated with early initiation of prenatal care. Almost a decade after welfare reform, it is essential to preserve the Medicaid expansions for pregnant women, foster Medicaid family planning waivers, and promote access to primary care and early prenatal care, particularly for very low-income women.

Objectives: We estimate the extent to which upward socioeconomic mobility limits the probability that Black and White women who spent their childhoods in or near poverty will give birth to a low-birthweight baby., Methods: Data from the National Longitudinal Survey of Youth 1979 and the 1970 US Census were used to complete a series of logistic regression models. We restricted multivariate analyses to female survey respondents who, at 14 years of age, were living in households in which the income-to-needs ratio did not exceed 200% of poverty., Results: For White women, the probability of giving birth to a low-birthweight baby decreases by 48% for every 1 unit increase in the natural logarithm of adult family income, once the effects of all other covariates are taken into account. For Black women, the relation between adult family income and the probability of low birthweight is also negative; however, this association fails to reach statistical significance., Conclusions: Upward socioeconomic mobility contributes to improved birth outcomes among infants born to White women who were poor as children, but the same does not hold true for their Black counterparts.

Objectives: Information regarding the type and scope of preconception care programs in the United States is scant. We evaluated State Title V measurement and indicator data and abstracts presented at the National Summit on Preconception Care (June 2005) in order to identify existing programs and innovative strategies for preconception health promotion., Methods: We used the web-based Title V Information System to identify state Performance Measures and Priority Needs pertaining to preconception health as reported for the 2005-2010 Needs Assessment Cycle. We also present a detailed summary of the abstracts presented at the National Summit on Preconception Care., Results: A total of 23 states reported a Priority Need that focused on preconception health and health care. Forty-two states and jurisdictions identified a Performance Measure associated with preconception health or a related indicator (e.g., folic acid, birth spacing, family planning, unintended pregnancy, and healthy weight). Nearly 60 abstracts pertaining to preconception care were presented at the National Summit and included topics such as research, programs, patient or provider toolkits, clinical practice strategies, and public policy., Conclusions: Strategies for improving preconception health have been incorporated into numerous programs throughout the United States. Widespread recognition of the benefits of preconception health promotion is evidenced by the number of states identifying related indicators.

Only a limited number of economic evaluations have addressed the costs and benefits of preconception care. In order to persuade health care providers, payers, or purchasers to become actively involved in promoting preconception care, it is important to demonstrate the value of doing so through development of a "business case". Perceived benefits in terms of organizational reputation and market share can be influential in forming a business case. In addition, it is standard to include an economic analysis of financial costs and benefits from the perspective of the provider practice, payer, or purchaser in a business case. The methods, data needs, and other issues involved with preparing an economic analysis of the likely financial return on investment in preconception care are presented here. This is accompanied by a review or case study of economic evaluations of preconception care for women with recognized diabetes. Although the data are not sufficient to draw firm conclusions, there are indications that such care may yield positive financial benefits to health care organizations through reduction in maternal and infant hospitalizations. More work is needed to establish how costs and economic benefits are distributed among different types of organizations. Also, the optimum methods of delivering preconception care for women with diabetes need to be evaluated. Similar assessments should also be conducted for other forms of preconception care, including comprehensive care.

Background: Research indicates that the double jeopardy of exposure to environmental hazards combined with place-based stressors is associated with maternal and child health (MCH) disparities., Objective and Discussion: Our aim is to present evidence that individual-level and place-based psychosocial stressors may compromise host resistance such that environmental pollutants would have adverse health effects at relatively lower doses, thus partially explaining MCH disparities, particularly poor birth outcomes. Allostatic load may be a physiologic mechanism behind the moderation of the toxic effect of environmental pollutants by social stressors. We propose a conceptual framework for holistic approaches to future MCH research that elucidates the interplay of psychosocial stressors and environmental hazards in order to better explain drivers of MCH disparities., Conclusion: Given the complexity of the link between environmental factors and MCH disparities, a holistic approach to future MCH research that seeks to untangle the double jeopardy of chronic stressors and environmental hazard exposures could help elucidate how the interplay of these factors shapes persistent racial and economic disparities in MCH.

Declines in the welfare caseload in the late 1990s brought significant change to the lives of many low-educated, single mothers. Many single mothers left welfare and entered the labor market and others found different ways to avoid going on public assistance. These changes may have affected the health and health behaviors of these women. To date, there has been little study of this issue. In this paper, we obtained estimates of the association between changes in the welfare caseload caused by welfare policy, and four health behaviors--smoking, drinking, diet, and exercise--and four self-reported measures of health--weight, days in poor mental health, days in poor physical health, and general health status. The results of our study reveal that recent declines in the welfare caseload were associated with less binge drinking, but otherwise welfare reform had little effect on health and health behaviors.

This research attempts to close an important gap in health economics regarding the efficacy of prenatal care and policies designed to improve access to that care, such as Medicaid. We argue that a key beneficiary-- the mother-- has been left completely out of the analysis. If prenatal care significantly improves the health of the mother, then concluding that prenatal care is 'ineffective' or that the Medicaid expansions are a 'failure' is premature. This paper seeks to rectify the oversight by estimating the impact of prenatal care on maternal health and the associated cost savings. We first set up a joint maternal-infant health production framework that informs our empirical analysis. Using data from the National Maternal and Infant Health Survey, we estimate the effects of prenatal care on several different measures of maternal health such as body weight status and excessive hospitalizations. Our results suggest that receiving timely and adequate prenatal care may increase the probability of maintaining a healthy weight after the birth and, perhaps for blacks, of avoiding a lengthy hospitalization after the delivery. Given the costs to society of obesity and hospitalization, these are benefits worth exploring before making conclusions about the effectiveness of prenatal care-- and Medicaid.

Some 5.9 million American mothers caring for young or school-aged children lack health insurance. Although nearly nine in ten uninsured mothers are members of working families, most lack access to affordable coverage through their job or a spouse's job. Most are ineligible for publicly subsidized coverage unless their incomes are far below the poverty line. The millions of uninsured mothers are at high risk of going without needed preventive and primary care. If they become seriously ill, their families can face the prospect of a financial crisis. The nation has made significant progress in extending health care coverage to children in low-income families through Medicaid and the State Children's Health Insurance Program (SCHIP), but no comparable effort has been made to insure the mothers of these children. A few states have started to address the problem by transforming their SCHIPs into family-based programs that also cover low-income parents. Bipartisan legislation under consideration, known as FamilyCare, would encourage this trend by providing more federal funding to states that could be used to extend health insurance to the parents of children already covered by publicly funded programs.

Objectives: This study analyzed changes in the financing of prenatal care and delivery, the use of prenatal care, and birth outcomes among foreign-born vs US-born Latino women following enactment of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in August 1996., Methods: We used a pre-post design with a comparison group. The sample consisted of resident Latinas in California, New York City, and Texas who delivered a live infant in 1995 or 1998., Results: The proportion of births to Latinas that initiated prenatal care in the first 4 months of pregnancy increased for all foreign-born Latinas in California, New York City, and Texas between 1995 and 1998 (P <.05). Except for non-Dominicans in New York City, there was no increase in the proportion of low- or very-low-birthweight births among foreign-born vs US-born Latinas in the 3 localities between 1995 and 1996., Conclusions: There is little evidence from vital statistics in California, New York City, and Texas that PRWORA had any substantive impact on the perinatal health and health care utilization of foreign-born relative to US-born Latinas.

Objectives: Welfare reform (Personal Responsibility and Work Opportunity Reconciliation Act of 1996) resulted in dramatic policy changes, including health-related requirements and the administrative separation of cash assistance from Medicaid. We were interested in determining if changes in welfare and health policies had had an impact on state MCH services and programs., Methods: We conducted a survey in fall 1999 of state MCH Title V directors. Trained interviewers administered the telephone survey over a 3-month period. MCH directors from all 50 states, Washington, DC, and Puerto Rico participated (n = 52; response rate = 100%)., Results: Among the most noteworthy findings is that similar proportions of respondents reported that welfare policy changes had either helped (46%) or hindered (42%) the agency's work, with most of the positive impact attributed to increased funding. MCH data linkages with welfare and other social programs were low. Despite welfare reform's emphasis on work, limited services and exemptions were available for mothers with CSHCN. Almost no efforts have been undertaken to specifically address the needs of substance abusers in the context of new welfare policies., Conclusions: Few MCH agencies have developed programs to address the special needs of women receiving TANF who either have health problems themselves or have children with health problems. Recommendations including increased MCH and family planning funding and improved coordination between TANF and MCH to facilitate linkages and services are put forth in light of reauthorization of PRWORA.

Objectives: Although there has been substantial policy interest in interventions to improve the neonatal outcomes of disadvantaged women, little attention has been paid to the health status of pregnant women themselves. We therefore examined whether the provision of health coverage to uninsured low-income pregnant women affects maternal health status or the use of cesarean section., Design: Natural experiment in Massachusetts., Patients: All in-hospital, single-gestation births in 1984 (N = 57,257) and 1987 (N = 64,346)., Intervention: Healthy Start is a statewide health coverage program for uninsured pregnant women. In 1985, it covered women with incomes below 185% of the federal poverty level., Main Outcome Measures: Rates of adverse maternal outcome (severe pregnancy-related hypertension, placental abruption, and a length of stay at least 1 day longer than infants' stay) and cesarean section for uninsured women, and for two concurrent control groups, women with Medicaid and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. We then examined the change in these interpayer differences in rates between 1984 and 1987 to measure the effect of Healthy Start., Main Results: In 1984, uninsured women had higher rates of adverse maternal health outcome than privately insured women (5.5% vs 5.1%, respectively; interpayer difference, 0.4%) and received fewer cesarean sections (17.2% vs 23.0%; interpayer difference, -5.8%). Between 1984 and 1987 there was no statistically significant change in the interpayer difference in adverse outcome relative to women with private insurance. However, the interpayer difference in cesarean sections between the uninsured and the privately insured was reduced by 2.3% (95% confidence interval [CI], +0.4% to +4.2%), although the uninsured continued to undergo fewer cesarean sections (22.4% vs 25.9%). Similar results were observed when the uninsured women were compared with women with Medicaid., Conclusions: The provision of health insurance alone to low-income pregnant women may not be associated with an improvement in maternal health. Expanded coverage was associated, however, with an increase in the rate of cesarean section.