Prenatal Care Reaching Mothers, Reaching Infants (1988) / Chapter Skim
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Appendix A: Summaries of the 31 Programs Studied
Appendix A: Summaries of the 31 Programs Studied
Pages 163-209
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From page 163... ...
, and professional societies (such as the American College of Obstetricians and Gynecologists) ; · queried other organizations known to be conducting research in prenatal care, including the Alan Guttmacher Institute, the Office of Technology Assessment, the American Hospital Association, the Centers for Disease Control, and the General Accounting Office; · commissioned an update of the report on statewide prenatal care initiatives issued in 1986 by the Center for Population and Family Health, Columbia University School of Public Health; · commissioned a paper reviewing comprehensive service programs for pregnant teenagers funded by the Office of Adolescent Family Life Programs within the U.S.
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From page 164... ...
As noted there, programs were classified on the basis of their major emphasis. TYPE 1: PROGRAMS TO REDUCE FINANCIAL BARRIERS The Committee studied two programs that take a direct approach to reducing financial barriers to care: the Healthy Start Program in Massachusetts and the Prenatal-Postpartum Care Program in Michigan.
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From page 165... ...
The Massachusetts program started statewide and was designed to include all willing providers. Healthy Start, a joint effort of the state health and welfare departments, offers financing for a full range of maternity services for any pregnant woman who lives in Massachusetts, is not currently enrolled in Medicaid, has no private health insurance, and has a family income at or below 200 percent (originally, 185 percent)
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From page 166... ...
had agreed to serve Healthy Start clients. The program enrolled 65 percent of all uninsured pregnant women and estimates that it enrolled 85 percent of the women eligible for the program on the basis of income.
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From page 167... ...
These differences, suggesting that Healthy Start participants received more quantitatively adequate prenatal care, are supported by comparisons of pregnancy outcomes flow birthweight and prematurity) across payor groups, which also show Healthy Start having a positive impact.
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From page 168... ...
The PPC program is administered through the Michigan Department of Public Health and its 48 local health departments. Local health departments either contract with area providers "private physicians, hospital clinics, health maintenance organizations (HMOs)
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From page 169... ...
TYPE 2: PROGRAMS TO INCREASE SYSTEM CAPACITY Four programs were studied that improve use of prenatal care by expanding the capacity of the clinic systems relied on by low-income women for their prenatal care. The four are: the Obstetrical Access Pilot Project in 13 counties in California; the Perinatal Program in Lea County, New Mexico; the Prenatal Care Assistance Program in New York State; and the Prevention of Low Birthweight Program in Onondaga County, New
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From page 170... ...
Formal birth education classes were also provided. Following an application and review process, seven community clinics and four county health departments (one in collaboration with a university
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From page 171... ...
The cost-effectiveness data in particular convinced the California legislature to extend the program. In 1984, a bill was passed establishing the Comprehensive Perinatal Services Program, which requires that OB Access services be made available to all pregnant women enrolled in Medi-Cal.
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From page 172... ...
The local health department provided no prenatal care, nor did its nurses make home visits. The local hospital was operated by a for-profit chain and had no outpatient prenatal clinics.
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From page 173... ...
Accordingly, about a year and a half after the community workers were initially funded, the health department was encouraged by the private physicians to hire a family nurse-practitioner to offer prenatal services at two field health offices run by the county health department. The nurse-practitioner referred high-risk women to the private physicians for prenatal care; county funds were made available to pay for such specialized care.
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From page 174... ...
In April 1984, the state legislature appropriated $7.S million for outreach, education, prenatal care, and nutritional services for pregnant women who were not eligible for Medicaid, had no private health insurance, and whose family income was at or below 18S percent of the federally defined poverty level. Applications for participation in the program were sought from public and private not-for-profit health care providers serving areas of the state believed to be at high risk because of their socioeconomic indicators and high rates of infant mortality and low birthweight.
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From page 175... ...
The Primary Prenatal Services component reimburses providers for prenatal and postpartum visits, diagnostic procedures, and physician or nurse-midwife deliveries. Required services include risk assessment, health education, nutrition services, psychosocial services, after-hours and emergency counseling and care, referral of high-risk patients, referral for pediatric care, and follow-up of missed visits and referrals.
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From page 176... ...
A public health nursing survey revealed that, although late registration had some motivational and socioeconomic roots, inadequate capacity of the prenatal care system kept out even those indigent pregnant women who applied for early care. Onondaga County statistics showed that in 1982 76 percent of pregnant women in the county obtained prenatal care in the private sector, primarily through private physicians and an HMO (health maintenance organization)
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From page 177... ...
A variety of efforts was made to encourage pregnant women in this target area to begin prenatal care early in pregnancy. For example, television spots directed at the target population were developed and aired; these stressed the benefits of early prenatal care and its role in reducing low birthweight.
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From page 178... ...
Two different data sets suggest that these improvements in the capacity of the prenatal care system have increased the proportion of pregnant women in the high-risk, target census tracts who begin prenatal care in the first trimester. The first data set spans July 1984 to July 1987 and is composed of 1,290 women residing in the target area who were subsequently identified as being at high risk for a low birthweight delivery.
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From page 179... ...
In 1974 every state was required to have at least one such project, and responsibility for the projects was shifted to the states. According to a 1975 federal publication, MIC Projects not only provided medical care to pregnant women and their infants, but also provided social services, nutritional counseling, patient education, home visits by a project nurse, special services to pregnant adolescents, transportation, and child care.
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From page 180... ...
The MIC Project in North Carolina operated in three rural counties. Its services included active casefinding, transportation, public health nursing, nutrition and social services, health education, and follow-up of missed appointments.
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From page 181... ...
Funds were used to increase maternity services by having certified nurse-midwives provide maternity care, with obstetric backup, and to expand health department services to include social services, health education, and nutrition counseling. The program also featured casefinding and transportation, directed particularly at teenagers and others at high risk.
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From page 182... ...
Data from the New York City Department of Health revealed that in 1982 28 percent of women in the community received late or no prenatal care. A grant from the Child Survival/Fair Start Program of the Ford Foundation to the Center for Population and Family Health of the Columbia University School of Public Health financed a program from 1982 to 1985 to reduce the percentage of community women receiving inadequate prenatal care.
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From page 183... ...
To speed entry into prenatal care, the Child Survival Team arranged for a nurse-midwife and a bilingual health advocate to be placed in the hospital's pregnancy screening clinic. The nurse-midwife counseled all women about the need for prenatal care and healthful behavior during pregnancy and also screened and referred women at high risk for poor pregnancy outcomes.
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From page 184... ...
As a result of these problems and others, the infant mortality rate within the area was over 20 deaths per 1,000 live births, and many patients who had not received care or for whom no record of care was available came to the county hospital for delivery. The providers, including the medical faculty and the staffs of the county hospital and the health department, developed a plan to integrate the facilities into a coordinated perinatal care system.
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From page 185... ...
Three hotlines were studied—the Pregnancy HealthTine in New York City, 961-BABY in Detroit, and CHOICE in Philadelphia. Two examples of casefinding through referrals among programs were assessed a Tulsa, Oklahoma, project that provided free pregnancy testing coupled with volunteer advocates linking pregnant women to prenatal care, and a set of studies that examine the role of WIC nutrition programs in recruiting pregnant women into prenatal care.
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From page 186... ...
were employed to locate pregnant women not in prenatal care and recruit them into the Harlem Hospital system. All were community residents, had extensive social networks, were unemployed, and seemed comfortable on the street.
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From page 187... ...
This Community Health Advocacy Program was supported by federal and state agencies and a consortium of private foundations and was designed to train bilingual (Spanish and English) community residents, called health advocates, to provide preventive health education, referral, and counseling services in homes and other community sites.
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From page 188... ...
Several comparison groups have been defined, and a sophisticated evaluation is planned with the assistance of the National Institute of Child Health and Human Development. BBP employs many methods to locate pregnant women in the target area and enroll them in the program.
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From page 189... ...
Its visibility reminds pregnant women of the need for care and provides a place where they can receive help in selecting a source of prenatal care and obtaining an appointment. The center offers free pregnancy testing; women who have positive tests are guided immediately to a prenatal care provider, as
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From page 190... ...
In 1986, 44 percent of enrolled women already in care were referred by a friend, relative, or other participant or were walk-ins with no referral source; 17 percent were referred by a clinic or hospital; 31 percent came from neighborhood canvassing; and the rest came from other sources. For pregnant women not in care, referral sources were 47 percent from a
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From page 191... ...
Seven neighborhoods with high rates of infant mortality were targeted when MIOP began in July 1985. As of December 31, 1987, 1,057 women have been enrolled in the program, which is housed in the Hartford City Health Department and is funded by both private and public donors.
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From page 192... ...
Pregnancy Heatthline New York City20 The Pregnancy Healthline (PHL) is an ongoing project of the New York City Health Department, part of a mayoral initiative to decrease both infant mortality and the percentage of women who receive late or no prenatal care.
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From page 193... ...
The PHL phone number has also appeared in media campaigns developed by other groups, including the New York chapter of the March of Dimes, the Mayor's Office of Adolescent Pregnancy and Parenting Services, and the New York State Family Planning Media Consortium.
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From page 194... ...
961-BABY refers women only to prenatal facilities that can provide psychosocial and nutritional services, health education, postpartum care, family planning, and wellbaby care. The facility must be able to offer care within 10 business days of an annointment request and not ask initialiv about source of naYment - -try -I - a ~ ~ r _ '' ~ ~ .
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From page 195... ...
One of its functions is the operation of the CHOICE hotline, which provides counseling and referrals for family planning, prenatal care, pregnancy options, and other women's health issues. Like both of the hotlines described earlier, CHOICE uses info~ation gained from callers to identify problems in the maternity care system and to act on behalf of individual women and for system improvements generally.
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From page 196... ...
From July 1, 1986, through June 30, 1987, the hotline received more than 24,000 calls. Half of these were for pregnancy testing and counseling referrals and about a quarter concerned family planning, sexually transmitted diseases, and other reproductive health issues.
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From page 197... ...
The Free Pregnancy Testing and Prenatal Care Advocate Program Tulsa, Okiahoma23 Low rates of prenatal care use and high rates of low birthweight prompted a major community effort in Tulsa County, Oklahoma, to improve pregnancy outcomes. A key element was promoting entry into prenatal care in the first trimester by providing free pregnancy tests, supplemented by volunteer patient advocates to facilitate entry into prenatal care.
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From page 198... ...
A preliminary evaluation of the program has tried to assess whether the free pregnancy testing coupled with clinic-based patient advocates led to earlier registration in prenatal care, particularly among women in the target groups. Of the 1,2S2 tests administered over the 14 weeks of the project, results were recorded for 1,107; of these, 406 were positive.
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From page 199... ...
For example, at present, paid stag bee replaced volunteers as patient advocates. The Speci~I SKI Food Prom ~men, 1 ~~d Children HO 3~ SfuJic~ One of the o~ect~es of the SAC program ~ to ensure Hat pregnant women recede adequate prenatal care.
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From page 200... ...
.30 Baby Showers Seven Counties in Michigan3i The Detroit-Wayne County Infant Health Promotion Coalition not only organized the 961-BABY hotline described above, but also sponsored a series of community baby showers. These events were directed at identifying pregnant women early in pregnancy, enrolling them in a comprehensive prenatal care program, and sustaining their enrollment.
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From page 201... ...
Although the showers may have provided health education and social support, as well as facilitating the use of some services, their value as a casefinding too! for pregnant women not already in care was clearly limited.
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From page 202... ...
The project emphasizes social support, health education and information, and general assistance offered by a Resource Mother. Teenagers are referred to the program by schools, health departments, private physicians, service agencies, civic and church groups, and peers.
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From page 203... ...
Of the RM clients, 17.S percent evidenced inadequate prenatal care (fewer than five visits or care begun after the sixth month o pregnancy) versus 24.S percent of the controls; the RM women averaged 8.6 prenatal visits versus 7.9 for the controls.33 Because of concern that selection bias limited the validity of these observed differences, a second retrospective analysis was conducted in which the controls were drawn from different counties that were nonetheless sociodemographically comparable to the Pee Dee area in which the RM Program operated.
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From page 204... ...
Pregnancy testing sites are also used to locate pregnant adolescents. One program continually reminds private physicians of its presence in order to obtain referrals.
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From page 205... ...
A sophisticated research and evaluation plan was built into the program at the outset. Pregnant women were recruited into the program if they had no previous live births and one or more of the following additional risk characteristics: under 19 years old, single, and low socioeconomic status.
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From page 206... ...
in number of prenatal care visits made by the pregnant women: both sets averaged about lO.S visits, reflecting in part the fact that prenatal services were easily available through nine area obstetricians and a free antepartum clinic sponsored by the health department. There were, however, differences between the groups visited by nurses and those not visited on several other prenatal factors.
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From page 207... ...
7. Division of Maternal-Fetal Medicine, State University of New York and Onondaga County Health Department.
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From page 208... ...
The maternity and infant outreach project of the Hartford Action Plan on Infant Health. Unpublished report, 1986; Joan Christison-Lagay, Hartford City Health Department.
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From page 209... ...
38. Jacqueline Scott, Bibb County Health Department.
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