The cost of doing nothing: Preventable premature births for at-risk women

: Background: The effects of poverty in the United States are growing, and the impacts are most severe for the already vulnerable populations. This analysis looks at the cost of doing nothing for at-risk pregnant women in one county in NE Ohio. Most of these women are living at or below the poverty level, lack safe, affordable, and stable housing, and often do not receive recommended levels of prenatal care. This examination uses data from Mahoning County, Ohio, where one program has provided wrap-around support for any at-risk pregnant mother since 2016. Objective: Examine the cost/savings of providing wrap-around support services to at-risk pregnant women. Methods: Data was provided by the Mahoning County Pathway HUB (MCPH) regarding all births since its 2016 inception. Data was extracted from the Ohio Department of Health, the CDC, and other sources regarding the cost of births and specifically premature births. These sources of data were analyzed using causal-comparative methods, in order to understand the frequency of premature births, with, and without the support services provided by the MCPH. Conclusion: The results of these causal-comparative analyses suggest that the cost of doing nothing for at-risk pregnant women is substantial for all stakeholders. Results demonstrate a savings of 2.45 million dollars for the five years included in the analysis. Because most of the services provided by the MCPH are billable to public health insurance, this model of supporting pregnant mothers who are at risk is important. The cost of doing nothing can lead to a lifetime of avoidable suffering and financial hardship for the women and infants who are born premature. The results from the MCPH suggest that this model of support and service delivery is making a difference, based on the lower-than-expected pre-term births over their tenure of operation


Introduction
Ohio is grappling with a persistent issue of infant mortality.Factors contributing to infant mortality, such as poverty [1] , chronic stress [2,3] , lack of access to prenatal and postnatal care [3,4] , maternal health issues [5,6] , substance abuse [7,8] , low birth weight [9,10] , and premature births [11,12] , are challenging to address in the short term [13,14] .Mitigation efforts focus on the prenatal-to-birth health of mothers and infants.At the same time, data reveals that at least 45% of infant deaths in Ohio occur after the first month of life.
Data from the Ohio Department of Medicaid [15] indicates Mahoning County's infant mortality rate is 9.1/1000 through 2021.According to this report, this is an increase of 12.1% from 2019 to 2020.Overall, the pre-term rate was 19.4% in Mahoning County, representing an increase of 18.2% from 2020 to 2021.This pre-term rate is 4% higher than the state average for Ohio.Consistently, the rate of Caucasian infant deaths and pre-term births is decreasing.At the same time, there continues to be a rise in infant mortality for minority infants of non-Hispanic black women.This ranks Ohio eighth in the nation for its infant mortality rate, with "black infants are 2.7 times more likely to die before their first birthday than white infants" [16] .Specifically, this report indicates that the infant mortality rate for white infants is 5.4/1000, while for black infants, it is a staggering 14.2/1000.One of the core objectives outlined in Healthy People 2030 [17] is to reduce the overall infant mortality rate.Promoting healthy behaviors and addressing maternal health before and between pregnancies aim to improve birth outcomes and reduce the risk of adverse events for mothers and infants.This comprehensive approach recognizes the interconnectedness of maternal and infant health.It highlights the potential for long-term impact through comprehensive strategic interventions such as those organized by the Ohio Commission on Minority Health [18] .Consistent with the focus of the CDC goals, the OCMH has led the charge to reduce the factors that impede the likelihood of a healthy pregnancy, healthy birth outcomes, and first birthday celebrations for all infants.
The OCMH seeks to accomplish this through the funding of pathway HUBs to support healthy pregnancies and births for at-risk, low-income, minority women across the state of Ohio.Mahoning Valley Pathway HUB (MVPH) has been providing services to these groups since 2016.This model of support utilizes CHWs from the same neighborhoods as the enrollees.CHWs effectively support mothers throughout pregnancy and delivery [19] .As a pathway HUB, the MVPH provides wrap-around support and navigation of all life needs through an extensive list of pathway services.Each enrollee is assigned a community health worker (CHW) who supports her in navigating twenty identified pathways, including education on all topics related to pregnancy and child care, Social Service Referral, Medical Referral, Pregnancy, Postpartum, Housing, Medical Home, Family Planning, Adult Learning, Tobacco Cessation, Medication Assessment, Health Insurance, Behavioral Health, Employment, Immunization Screening, Medication Management, Lead Screening, Developmental Referral, Developmental Screening, and Immunization Referral.A description of the pathways is in Appendix.This evolving list of pathway services is based on the Pathways Community HUB model developed by Redding and Redding [20] and Redding et al. [21] .Since its inception, the MVPH has served more than five hundred mothers and infants.
Little-known research has empirically investigated these supports' savings when provided to minority families [22] .The only known study by Larwin et al. demonstrated that this model can have a fiscally positive impact on overall costs.Further, Larwin and Larwin [23] demonstrated that participation in a pathway HUB resulted in significantly fewer pre-term births overall for enrollees with one or more previous pre-term or adverse birth outcomes.The number of repeat pre-term births was 86% lower than was expected.medical costs is a first step to understanding the overall savings to all stakeholders when a child is born to an at-risk minority woman in NE Ohio.

Method
This premature birth analysis relied on Waitzman et al.'s [26] March of Dimes report on state-level costs, showing the differential cost for premature births beyond those incurred for full-term births.Table 1 provides that the national average differential cost of prematurity is $64,816; Ohio's cost is $62,389, based on Waitzman et al. [26] .Waitzman et al. [26] included indirect costs resulting from lost labor market productivity and heightened morbidity over a lifetime, as well as direct medical costs, early intervention, and special education services.This differential cost of prematurity is used to estimate the cost savings within the HUB relative to the local community, the state of Ohio, and the United States.The HUB's prematurity rate for black infants was lower than the national average, the state average, and the overall Mahoning County average in each year from 2017 to 2021.The first year of the MCPH was not included in the analysis, as the MVPH was building its capacity to serve at-risk pregnant women during the first months of that first year.

Results
The analysis for understanding savings focuses on the premature births of minority infants, specifically black infants.The percentage of premature births among black infants in Mahoning County and surrounding areas is provided in Table 2.  [27] .
Table 2 indicates that improved birth outcomes within the MVPH were realized from 2017 through 2021.However, a more direct measure is a comparison of outcomes within the HUB to those in the county who are not receiving the HUB's services.
Therefore, the cost of doing nothing for at-risk mothers is best captured by the prematurity rates for black infants of mothers who are attempting to navigate their pregnancy without the available support provided by the MVPH.
The estimates of the expected reductions in pre-term births due to HUB participation were computed using the difference in pre-term birth rates in the HUB versus the rest of Mahoning County.These results are provided in Table 3.Based on the values provided in Table 3, the prematurity rates were calculated for those receiving HUB services and those who are not receiving HUB services.These results are provided in 4. As indicated in Table 4, the computed differences are substantial.As demonstrated below, the cost of doing nothing for these at-risk mothers represents substantial costs for all stakeholders.In the absence of the HUB, how many more infants would have likely been born prematurely?The reduction in premature births because of the MVPH is presented in Table 5.As indicated in Table 5, without access to the MVPH's wrap-around services, 36 infants would likely have been born prematurely in Mahoning County over the past five years.To examine the financial benefit resulting from this reduction in prematurity, Waitzman et al.'s [26] differential cost of maturity in Ohio is used to estimate the savings.In 2016, a premature birth was $62,389 more expensive than a fullterm birth in Ohio.Price index data was used to determine the inflation factors to bring 2016 data forward.Table 6 provides the additional costs of premature birth when applying the health care inflation factor.Applying the yearly prematurity costs presented in Table 6 to the expected reduction in premature births yields the expected savings.These results are provided in Table 7. to the MVPH's wrap-around services to at-risk pregnant mothers.Without MVPH services, these savings represent the cost of doing nothing for these mothers and their infants.

Conclusion
The absence of prenatal care can significantly impact the health outcomes of both the mother and the child.Research indicates that inadequate or no prenatal care, as experienced by women in poverty and minority mothers, is associated with higher rates of pre-term birth, low birth weight, and infant mortality [2][3][4]28] , lack of access to prenatal and postnatal care [2,[4][5][6][7][8]11,12] . Addtionally, failure to receive prenatal care may result in undetected medical conditions, such as gestational diabetes or hypertensive disorders, as well as untreated stress, that negatively influence birth outcomes.
Women missing prenatal care do not have opportunities for education and counseling on proper nutrition, substance use, maternal behaviors, and other factors that can contribute to healthier pregnancies, such as those provided by the MVPH.As indicated in this analysis, the absence of MVPH wrap-around support and interventions is related to a substantially increased risk of adverse birth outcomes, specifically premature births, the strongest predictor of infant mortality [26] .Premature birth, according to Waitzman et al. [26] creates a lifetime of morbidities for the child, such as asthma, learning disabilities, cerebral palsy, and vision and hearing impairments.These health issues are estimated to cost at least three times more for a child with one of these disabilities than that of a child born without them [28] .The 2.45 million dollars in potential savings estimated here is only a small estimate of how much can be saved by providing more women with the prenatal support they need to ensure their infant grows into a healthy and productive citizen.In light of the results of this case study, doing nothing for at-risk mothers no longer be an option.

Figure 1
Figure1illustrates the proportion of pre-term births for the participants in the MVPH and for those women who were not enrolled in the MVPH (Non-MVPH).
Note: 1 CDC; 2 ODH; * Preliminary data (Centers for Disease Control and Prevention, National Center for Health Statistics.National Vital Statistics System, Natality on CDC WONDER Online Database.Data are from the Natality Records 2016-2022, as compiled from data provided by the fifty-seven vital statistics jurisdictions through the Vital Statistics Cooperative Program

Table 3 .
Premature births by a group.
* indicates Mahoning County mothers not using the services of the MVPH.
* indicates Mahoning County mothers not using the services of the MVPH.

Table 5 .
Reduction in premature births based on the MPVH's data.

Table 6 .
PPI commodity data for Health care services, not seasonally adjusted (WPU51).

Table 7 .
Expected savings from the reduction of premature births.

Table 7 ,
an expected $2.45 million reduction in costs over five years is expected due