Pregnancy and birth outcome improvements for American Indians in the Healthy Start Project of the Inter-Tribal Council of Michigan, 1998-2008: An 11-year cohort study

Objectives: American Indians living in Michigan experience disproportionately high rates of infant mortality. This cohort study evaluated the impact of a Healthy Start (HS) program administered by the Inter-Tribal Council of Michigan (ITCM) to improve pregnancy and birth outcomes during 1998-2008. Methods: Women who voluntarily enrolled in ITCM's HS program ("exposed") were compared with non-enrolled ("unexposed") for various outcomes, including low birth weight, preterm birth, and adequacy of prenatal care. To identify exposed and unexposed women and their children, Michigan vital records data were linked with HS enrollment records to identify participants and non-participants among all American Indian births. Logistic regression was used to compare participants and non-participants for the odds of low birth weight, preterm birth, and inadequate prenatal care. Results: Although unstratified analysis showed no differences between participants and non-participants, after controlling for identified confounders stratified analyses demonstrated that participants from rural and low-income counties had decreased odds of low birth weight, short gestational age, and inadequate prenatal care. In contrast, participants from higher income counties had higher odds of low birth weight and short gestational age. Conclusions: Results suggest that in areas where participants and non-participants are at similar risk for poor outcomes, HS is reducing barriers and improving neonatal health. In other areas where participants experience more risk factors as compared to non-participants, participants continue to have similar or worse outcomes than non-participants. The complex interplay among need, access, and benefit makes analyses difficult, and suggests the need for more in-depth and focused studies.