Prenatal Care Reaching Mothers, Reaching Infants (1988) / Chapter Skim
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5. Conclusions and Recommendations
5. Conclusions and Recommendations
Pages 135-162
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From page 135... ...
. Early deliberations, however, made it clear that outreach could not be studied in isolation and that the Committee's inquiries had to cover the larger maternity care system*
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From page 136... ...
Low-income women, women who are uninsured or underinsured, teenagers, inner-city and rural residents, certain minority group members, and other high-risk populations described earlier in this report are likely to experience significant problems in obtaining necessary maternity services. Securing prenatal services in particular can be especially difficult for these groups, as shown by the data in Chapters 1 and 2; moreover, there is evidence that utilization is actually declining among certain very high-risk groups.
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From page 137... ...
Slowly implemented, often small expansions in Medicaicl eligibility, brief bursts of publicity about infant mortality and the importance of prenatal care, efforts in a few communities to increase the number of clinics offering prenatal services these actions, while laudable, are too limited, sporadic, and uncoordinated to overcome the pervasive barriers to care detailed in this report. Rather, the current situation dictates more purposeful action: · We recommend that the President, members of Congress, and other national leaclers in both the public and private sectors commit themselves openly and unequivocably to designing a new maternity care system (or systems)
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From page 138... ...
Although the Committee was not asked to specify the elements of a new system or systems of maternity care, our work over the last 2 years has indicated the principles essential to significant improvement in the use of prenatal services. We presume that these same attributes would also improve the care women receive during childbirth and the postpartum period.
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From page 139... ...
for the Promotion of Child Health, ~ the American College of Obstetricians and Gynecologists2 and the American Academy of Pediatrics,3 and theforthcoming report of the Public Health Service's Expert Pane! on the Content of Prenatal Care;4 —address the liability pressures currently driving providers out of the practice of obstetrics;5 be administered separately from the welfare system; - rely on a wide array of providers, including both physicians and certified nurse-midwives, each of whom may practice in a variety of settings and systems; tee financed adequately; ensure that financing mechanisms support appropriate clinical practices; —include a large-scale, sustained program of public information and education about maternity care; —support education and training of providers to deepen their understanding both of the obstacles women can face in securing prenatal care and their perceptions of care once enrolled; include reliable, accurate means of collecting data on unmet maternity care needs and on the performance of the new system or systems, at local, state, and national levels; and specify a structure of accountability and responsibility under the control of a federal agency, with state agencies assuming leadership.
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From page 140... ...
It is also apparent that a deeper national commitment to family planning services and education should accompany major revisions in the maternity care system. Women with unintended pregnancies are particularly likely to delay seeking prenatal care and more than half of all pregnancies in the United States are unplanned (Chapter 2~.
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From page 141... ...
More specifically, we urge a stronger federal role in providing funds to state and local agencies in amounts sufficient to remove financial barriers to prenatal care (through such channels as the Maternal and Child Health Services Block Grant and other grant programs) and in providing prompt, high-quality technical consultation to the states on clinical, administrative, and organizational problems that can impede the extension of prenatal services.
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From page 142... ...
Surveys of pregnant women and of maternity care providers, and program experience over many years uniformly demonstrate the importance of economic circumstance especially the presence or absence of insurance—in predicting use of prenatal services. Although expansions of Medicaid and creative state initiatives have made some progress recently in lowering financial barriers to care, the pace of progress needs to accelerate, and remaining financial obstacles need to be removed.
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From page 143... ...
Private insurance companies themselves should take the initiative of offering comprehensive coverage of prenatal care as part of their basic insurance packages. In all these actions, attention should be focused on eliminating such gaps in coverage as waiting periods for prenatal benefits to begin, dependent coverage that fails to include prenatal services, limited insurance for part-time or seasonally employed individuals, and burdensome copayments and deductibles for maternity services (Chapter 21.7 INADEQUATE SYSTEM CAPACITY Urging all pregnant women to begin prenatal care early is a hollow message if prenatal clinics are nonexistent—or so backed up as to be
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From page 144... ...
Accordingly, as a companion initiative to reducing financial barriers: · We recommend that public and private leaclers designing policies to draw pregnant women into prenatal care make certain that prenatal services are plentiful enough in a community to enable all women to secure appointments within 2 weeks with providers close to their homes. Methods for achieving this objective will vary across states and communities, but several approaches will probably be required simultaneously.
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From page 145... ...
In reviewing initiatives to increase the early use of prenatal care, the Committee has been repeatedly impressed by the success of programs that emphasize internal institutional modification as a means of drawing more women into care and sustaining their participation. Therefore, in addition to addressing financial barriers and problems of limited capacity: · We recommend that those responsible for providing prenatal services periodically review and revise procedures to make certain that access is easy and prompt, bureaucratic requirements minimal, and the atmosphere welcoming.
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From page 146... ...
Several other, more general attributes of prenatal services can also help to increase use of care and we recommend that they be widely adopted: - services are easy tofnd in the telephone book, listed under several headings; - the telephone system in an individual setting is well organized and staged so that caZZers do not constantly reach a busy signal; reasonable efforts are made through various channels of public information to inform women of service hours and location, to advertise new maternity programs, and to alert women to services that complement prenatal care, such as the Special SuppZementaZ Food Program for Women, Infant, and Children (WIC) ; - there is a gap of 2 weeks or less between an initial caZZfor a prenatal care appointment and the appointment itself; - services are located near public transportation; where needed, transportation costs are subsidized or provided directly; a woman sees as few different providers as possible in the course of a pregnancy;
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From page 147... ...
PUBLIC INFORMATION AND EDUCATION Studies of women who received insufficient prenatal care reveal that an important contributing factor is a low value attached to this service (Chapter 31. Some women state quite directly that they did not think prenatal care was important or useful, some seem to fear it, some contend that other matters were more pressing than seeking out prenatal services, and some say care is important only if you feel sick.
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From page 148... ...
In addition to these messages about prenatal care and pregnancy, public information and education should emphasize basic concepts of family planning, given the strong association between whether a pregnancy is planned and onset of prenatal care (Chapter 21. Schools especially should help in conveying such information.
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From page 149... ...
This import referral opportunity—often missed- is discussed in more detail later. Finally, we wish to underscore the simple notion that prenatal services must be advertised to prospective clients.
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From page 150... ...
Faced with significant financial barriers, limited service capacity, inhospitable institutional practices, and a basic lack of public understanding about prenatal care, the response is often to hire outreach workers, or organize brief campaigns of posters in buses touting the importance of prenatal services, or arrange for compensatory social support rather than take on the more challenging task of repairing fundamental flaws. Repeatedly, outreach is organized to help women over and around major obstacles to care, but the obstacles themselves remain.
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From page 151... ...
Rather, outreach should be only one component of a well-designed, well-functioning system and should be targeted toward women who remain unserved despite easily accessible services. Outreach should only be funded when it is linked to a highly accessible system of prenatal services, or, at a minimum, when it is part of a comprehensive plan to strengthen the system, emphasizing the four areas previously described.
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From page 152... ...
strong referral ties between the prenatal program and a variety of other systems in which pregnant women at risk for insufficient care may be found: family planning clinics, schools, housing programs, VVIC agencies, welfare and unemployment offices, churches and community service groups, shelters for the homeless, the police and corrections systems, substance-abuse programs and treatment centers, and other health and social service networks; and S outreach workers who work in carefully defined target areas and seek clients among welI-defined target populations.
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From page 153... ...
The Committee also calls particular attention to casefinding through closer links between pregnancy testing and prenatal services. A major opportunity to enroll pregnant women in prenatal care promptly is missed each time a positive pregnancy test is not accompanied by an appointment for prenatal services, if appropriate.
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From page 154... ...
Accordingly: · We recommend that programs providing prenatal services to highrisk, often low-income groups include social support services to help maintain participation in care and arrange for additional services as needed. Home visiting is an important form of social support and should be available in programs caring for high-risk women.
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From page 155... ...
But the Committee strongly suggests that outreach should be aimed only at carefully defined high-risk groups and that it should be an adjunct to a well-functioning system that is easily accessible to the vast majority of pregnant women. MANAGEMENT AND EVALUATION The Committee's study of programs yielded several observations about management and evaluation (Chapter 41.
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From page 156... ...
should not be expected too soon. Issues to be considered in basic planning and needs assessment include in-depth reviews of existing maternity services, provider practices, and attitudes; public and private health insurance coverage in the target state or community; the views of local women regarding existing maternity services; careful definition of the target populations, of local barriers to prenatal care, of existing community services, and of relevant historical and political realities; market research and premarket testing of materials (where applicable)
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From page 157... ...
For example, in many communities only anecdotal information exists regarding the availability of prenatal services: whether certain clinics are overloaded, and if so, to what extent; the fees at area clinics; and so forth. Obtaining such basic information should be the first order of business in designing prenatal programs..
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From page 158... ...
The second topic suggests that early enrollment in prenatal services might increase if such care were more clearly directed to major issues in the first trimester of pregnancy. These include: the steps women can take
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From page 159... ...
A NOTE TO FUNDERS We conclude with some observations directed to those who fund prenatal services: public agencies, legislative bodies, and private foundations and voluntary groups. Many of these points have been covered elsewhere under various headings.
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From page 160... ...
First, the absence of ream and consistent funding of prenatal care programs for {ow-income groups often forces program directors to ask foundations or government for research and demonstration funds that in fact are used—out of necessity to subsidize basic program services. It is for this reason, perhaps, that the Committee found very little real innovation or research in the areas of delivery of prenatal care or outreach for low-income groups.
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From page 161... ...
A deeper commitment to family planning services and education should accompany improvements in the maternity care system. In the short term, we urge strengthening existing systems through which women secure prenatal services.
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From page 162... ...
7. Additional observations on private sector leadership in improving insurance coverage for maternity services are in National Commission to Prevent Infant Mortality.
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