States Explore Text App to Reach Low-Income Pregnant Women
October 2017

Text4baby is a service that sends free, personalized text messages to expecting mothers three times a week, including nutrition and safe sleep tips, doctor visit and appointment reminders, breastfeeding advice, health insurance information, and urgent health alerts. Last year, AMCHP and a representative from Oklahoma’s Text4baby, a program designated as an Emerging Practice in AMCHP’s Innovation Station, provided technical assistance (TA) to states to institute or expand the service, which is operated by Zero to Three and Wellpass (formerly Voxiva).

Here is how Hawaii and Louisiana used that TA to move forward on their efforts to reach low-income pregnant women.

Hawaii Finds New Partners to Connect with Hard-to-Reach Population

Lisa Kimura
Executive Director
Healthy Mothers, Healthy Babies Coalition of Hawaii

There are over 23,000 pregnancies in Hawaii per year, and of these, 45.3 percent are unintended/unplanned. Hawaii’s Pregnancy Risk Assessment Monitoring System (PRAMS) data indicate that women who are more likely to have an unintended pregnancy either had Medicaid insurance or were uninsured before pregnancy. To proactively reach low-income pregnant women enrolled in Medicaid, the Healthy Mothers Healthy Babies Coalition applied for an AMCHP technical assistance grant to replicate Oklahoma’s automatic notification process to opt-in for Text4baby for women enrolled in Medicaid with their managed care organizations (MCO).

A key to success was that Hawaii’s state Medicaid agency offered full support for the project, facilitating personal introductions for us with each of the MCO health plans. Its enthusiastic support kicked off the project in a positive way.

The next significant “win” was when we presented the project to over 100 maternal and child health stakeholders statewide. We invited a representative from Oklahoma’s SoonerCare program to the annual Hawaii Maternal and Infant Health Collaborative to explain the components and outcomes of that organization’s experience with Text4baby, generating significant enthusiasm from potential partners. We followed up with each MCO individually and held personal meetings to discuss the logistics and details in greater depth.

We encountered several challenges in our meetings with the MCOs, including difficulty in effectively fielding answers to questions regarding pricing, legal considerations, and the availability of the Lifeline service in Hawaii (which is a subsidized phone program for qualified low-income individuals). Despite these challenges, we were able to connect interested parties to Voxiva (the technology company operating Text4baby) for answers.

Two of our MCOS are actively pursuing the program. We will continue to follow up with them to ensure a seamless integration, as well as to serve as a facilitator to continue to engage other MCOs.

Thanks to this process, we were able to engage with every one of our MCOs while simultaneously increasing awareness of the Text4baby program in a new and effective way. Given both the challenges and successes, we would advise future TA recipients to receive thorough cost and legal information from Voxiva before embarking on meetings with MCOs, as well as research Lifeline service providers in their states.

To continue moving forward, Healthy Mothers Healthy Babies intends to maintain consistent follow-up with the MCOs that showed significant interest in adopting the program. We will continue to promote the Text4baby program via social media and marketing materials to help engage partners to continue recommending the service to their clients and patients.


The state Bureau of Family Health, in partnership with Louisiana Medicaid, applied to AMCHP’S Text4baby Innovation Station project to develop a sustainable process for increasing Text4baby enrollment among Louisiana’s Medicaid recipients. Louisiana, as one of four states involved in a Centers for Medicare and Medicaid (CMS) pilot project around Text4baby, has been promoting the service since 2013, and this technical assistance (TA) provided us an opportunity to greatly increase Text4baby’s reach across the state by implementing an auto-enrollment process.

The TA we received from AMCHP was extremely valuable in an unexpected way: We learned that the Text4baby service is changing in a several critical ways, and those changes led us to decide against pursuing auto-enrollment.

We discovered that after this summer, the Text4baby data portal, which shows enrollment numbers by Zip code, will be available only through the purchase of the health messaging service WellPass. This information is essential to evaluating Louisiana’s statewide and regional efforts to increase Text4baby enrollment.

We also learned that the state-specific messaging and broadcast messaging features that Louisiana grew accustomed to during the CMS pilot would also only be available through WellPass. These features not only helped us deliver enrollees the best resources but helped us gain stakeholder support for Text4baby. Understanding these changes helped us see that implementing auto-enrollment would not be the best use of Louisiana Medicaid or the Bureau of Family Health resources.

While we decided not to pursue auto-enrollment, we will work with our Medicaid managed care organizations to optimize their existing promotion of Text4baby through their own health messaging services. We are looking forward to using the information we learned during this project to more thoughtfully and effectively allocate resources related to Text4baby promotion, outreach, enrollment, and evaluation in Louisiana.