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only a few basic indicators related to the timing and content of prenatal care and the birth outcome.

In general, large variations in outcomes exist across NICUs that cannot be explained by patient mix or other readily observable hospital characteristics, such as patient volume and level of care. Recent research has suggested a role for the organizational and management structures of NICUs in ensuring good patient outcomes (Pollack et al., 1993). More research on the determinants of high-quality care will be needed to be able to send patients to the best hospitals.

Recommendation V-2: Establish a quality agenda. Investigators, professional societies, state agencies, payors, and funding agencies should establish a quality agenda with the intent of maximizing outcomes with current technology for infants born preterm.

This agenda should:

  • Define quality across the full spectrum of providers who treat women delivering preterm and infants born preterm;

  • Identify efficacious interventions for preterm infants and identify the quality improvement efforts that are needed to incorporate these interventions into practice; and

  • Analyze variations in outcomes for preterm infants among institutions.

5. Investigate the Impact of the Health Care Delivery System on Preterm Birth

Policy makers have focused on expansion of access to prenatal care since the 1980s in an effort to improve birth outcomes in general, including a reduction in preterm birth rates. These efforts have primarily been achieved through the expansion of Medicaid eligibility for pregnant women at the state level. A direct link between the availability of increased insurance and the receipt of early prenatal care was demonstrated in a study of Medicaid expansion in Florida (Long and Marquis, 1998).

Alternately, states can increase access to prenatal care outside of the confines of Medicaid by expanding programs that target uninsured pregnant women to provide them with access to prenatal care through Maternal and Child Health block grants (Schlesinger and Kornesbusch, 1990). Coverage for prenatal care services has also been extended through expansion of the State Children’s Health Insurance Program (SCHIP) [Title XXI, Social Security Act, Pub. I, No. 74-271 (49 Stat 620) (1935)].

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