Prenatal Care Reaching Mothers, Reaching Infants (1988) / Chapter Skim
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4. Improving the Use of Prenatal Care: Program Experience
4. Improving the Use of Prenatal Care: Program Experience
Pages 115-134
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From page 115... ...
A five-part program classification scheme devised by the Committee is then described, and the projects studied that emphasize each approach are noted. The Committee's findings on the usefulness of the five program types for improving participation in prenatal care are then presented, and the chapter concludes with a summary of the implementation and operational problems reported to the Committee by many program leaders.
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From page 116... ...
reducing Me financial obstacles to care encountered by poor women Tough Me prounion of insurance or other sources of patents 2. increasing the capacity of the prenatal care system robed on by maw low-income ~'omen, Rich includes heakh department chnics, dbe network of plate physicians To care far ~edicaid~enrolled and other lo-income ~omen, hospital ou~adent department, Community Heakh Center, and similar setting; 3.
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From page 117... ...
Unfortunately, few programs had been evaluated with any methodological rigor, and thus a compromise position had to be adopted. To be included in the Committee's review, a program did not have to have conducted a randomized clinical trial to test impact; however, it did have to be able to report such statistics as the number of women served and their trimester of initiation of prenatal care, and it had to have made an attempt to link changes in prenatal care utilization to program activities.
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From page 118... ...
As discussed in the Introduction, however, this study was limited to the narrow question of learning how best to improve use of prenatal services, taking as a given that prenatal care improves pregnancy outcome. As a consequence, programs that had assessed their impact using only birth outcome measures (such as length of gestation, birthweight, Apgar score, or infant mortality)
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From page 119... ...
Every program identified by the Committee that takes a direct approach to reducing financial barriers is state-initiated.) Federal action has been limited to recent modest increases in the Maternal and Child Health Services Block Grant and gradual expansion of Medicaid's coverage of pregnant women.
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From page 120... ...
Improvements might include expediting registration procedures, providing interpreters, shortening the time spent in waiting rooms, offering child care and transportation, and monitoring staff courtesy. Several examples of this approach were examined: · two Maternity and Infant Care Projects, one in Cleveland, Ohio, and one in three North Carolina counties; · an Improved Pregnancy Outcome Project in two counties in North Carolina; · an Improved Child Health Project in two areas of Mississippi; · the Child Survival Project of the Columbia Presbyterian Medical Center in New York City; and · a perinatal system in Shelby County, Tennessee.
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From page 121... ...
In this approach, an organization offering prenatal services seeks referrals from other agencies with different mandates, such as housing assistance. The notion is that these other groups are likely to be in touch with pregnant women and may therefore have an opportunity to convince them of the importance of prenatal care, determine their care status, and refer women not yet receiving care to a provider.
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From page 122... ...
The interaction may occur in the home, at a prenatal care or social service facility, in a school, or by telephone. Social support is presumed to improve pregnancy outcomes indirectly by helping pregnant women obtain quantitatively adequate prenatal care
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From page 123... ...
Numerous projects offering intense social support have been implemented in the past few years; the following were examined by the Committee: · the Resource Mothers Program in South Carolina (for teenagers only) ; · six additional adolescent programs, reviewed as a group; · the Prenatal/Early Infancy Project in Elmira, New York; and · the Grannies Program in Bibb County, Georgia.
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From page 124... ...
As noted earlier, most try to ease financial barriers by enlarging the clinic system relied on by low-income pregnant women, rather than by enabling them to use provider systems already in place, including physicians in private practice. The Michigan initiative is unique in its legislative guarantee of access, but the Massachusetts Healthy Start Program stancis out as the one that has gone the furthest in removing financial barriers to care.
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From page 125... ...
Complaints from pregnant women about long waits in clinics, rude staff, and lack of continuity of care are seldom addressed directly by the physicians in charge; more often a new facility is opened or superficial changes in clinic practices are made. The 10 programs with data on casefinding for prenatal care the fourth program type—presented the Committee with a wealth of data and impressions, not the least of which was the enormous creativity shown by many program leaders in devising ways to identify pregnant women and draw them into care.
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From page 126... ...
Nonetheless, outreach workers can sometimes find the hardest-to-reach women. Anecdotal reports from both Cleveland and Washington, D.C., suggest that periodic sweeps by outreach workers through housing projects, for example, can uncover significant numbers of pregnant women not in prenatal care.
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From page 127... ...
The final category of reviewed projects emphasizes social support, principally as a means of encouraging women to continue care. Program data indicate that this approach can indeed result in an increased number of prenatal visits.
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From page 128... ...
Significant time was devoted to establishing strong community ties, and a high level of respect was accorded community leaders, staff from local human services agencies, and local ways of reaching consensus and effecting change. · Involvement of the news media was encouraged to generate support, to help communicate program goals and to convey specific messages, such as the location of a new clinic site or a new source of payment for maternity care.
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From page 129... ...
Finding Financiat and Community Support · Funds are rarely adequate to meet program goals, and persons who must raise money annually find the constant application or lobbying process exceedingly burdensome, adding worries about job security to the usual pressures of running a program. Similarly, it is difficult to sustain political and economic support for programs over many years.
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From page 130... ...
Program directors have found that using outreach workers effectively requires major investments of time and money and that both funders and program planners tend to underestimate the challenge posed by using them. Similarly, other service systems often have little understanding of outreach workers' roles in enhancing access to health care and often do not work well with them.
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From page 131... ...
· Long-standing tensions between, for example, state and city health authorities, health departments and local hospitals, and physicians and nurse-midwives can interfere with programs that are trying to change the prenatal care system. One program studied by the Committee has still not been successful in employing nurse-midwives in its clinical services as originally planned because of resistance by private physicians affiliated with the major hospital in the community.
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From page 132... ...
However, the number and complexity of the interventions within a given state, the diversity and number of settings providing the new services, problems in collecting uniform data, the time and money required to design statewide evaluation systems and to analyze the voluminous data these systems generate- such problems often result in inadequate evaluation or none whatever. Maternal and child health agencies within state
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From page 133... ...
If more programs focused squarely on eliminating basic institutional barriers, it would easier to define who the truly "hard to reach" pregnant women are and to target casefinding and social support programs more effectively. The effort that all these programs expend in achieving even small gains is sobering.
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From page 134... ...
See, for example, Petschek MA and Adams-Taylor S Prenatal Care Initiatives: Moving Toward Universal Prenatal Care in the United States.
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