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CHAPTER 7 Ensuring Access to Prenatal Care An earlier chapter called for more emphasis on reducing risks associated with low birthweight before pregnancy occurs--a relatively new perspective in discussions of low birthweight prevention. ThiS chapter, by contr ast , takes up a long-stand i ng issue--ensur ing the availability of prenatal care to all pregnant women. The importance of ensuring access to prenatal care has been highlighted forcefully in recent years by various groups, including the Publ ic Health Service, through the Surgeon General of the United States. The 1980 report, Objectives for the Nation, set specific goals for reducing the number of women who receive inadequate prenatal care and for eliminating var Nations among groups in access to such services. * The commi ttee concurs with these statements. The weight of the evidence is that prenatal care reduces low birthweight among all women and that it conveys particular benefit to socioeconomically and medically high-risk women (Chapter 6) . Efforts to reduce ache nation' s incidence of low birthweight must include a commitment to enrolling all pregnant women in prenatal care, particularly because many of the women who r eceive inadequate prenatal care are those at greater than average risk of a low birth- weight delivery. Moreover, participation in a system of prenatal care is a prerequisite for undertaking many individual interventions that help reduce the risk of low birthweight, ranging from medically oriented procedures such as hoper tension management to counseling against smoking (Chapter 8). If prenatal care is to become available to all pregnant women, the population of women who receives inadequate or no prenatal care must be defined, circumstances analyzed to reveal why such women receive insufficient care, and then ways found to remove the barriers identi- fied. The balance of this chapter takes up these matters in three sections. The first presents data on prenatal care utilization, including recent trends. The second section describes some reasons *The Surgeon General's objective states: "By 1990, the proportion of women in any county or racial or ethnic groups who obtain no prenatal care dur ing the f irst tr imester of pregnancy should not exceed 10 percent . n 2 150

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151 why prenatal care is not sufficiently accessible and discusses ways to reduce the barriers. The chapter concludes with a proposal for a broad reaching commitment to making prenatal care fully available. Who Receives Inadequate Prenatal Care? The Advance Report on the 1981 nasality statistics3 states that prenatal care almost 24 percent of all births were to women who began after the first trimester of pregnancy. An additional 5 percent delayed care until the third tr imester or received no care . Blacks were more likely (9 percent) than whites (4 percent) to delay care until the third tr imester of pregnancy or to receive no care. Women between the ages of 25 and 34 were more likely (over 82 percent) to receive care in the first trimester than were younger women, especially those under 20 (15 years of age, 34.2 percent; 15-19 years of age, 53 percent). Mothers under 20 were also more than three times as likely to have received delayed or no care. The median number of visits by women receiving any prenatal care was 11.4 (whites, 11.7; blacks, 10.21. A report from the federal Division of Maternal and Child Health provides a further analysis by race and ethnic group of initiation of care.4 Data from 1980 show that 41 percent of Native Americans, 40 percent of Hispanics (based on 22 states only), 37 percent of blacks, and 21 percent of whites registered after the first trimester. All four groups showed increases in the 1978-1980 period in the percentage registering early. A comparison with data from 1970 shows that the overall percentage registering after the first trimester decreased by 26 percent (whites, 25 percent; blacks, 31 percent). The latest detailed analysis of receipt of prenatal care by the National Center for Health Statistics was conducted using 1969-1975 data. 5 In addition to race and age factors, it showed that women pregnant with their f irst child were less likely to receive care in the first trimester than those pregnant with their second child, but that for subsequent births the proportion starting care early decreased. Unmarried mothers, those who did not complete high school, and those living in nonmetropolitan areas received less care than those who were married, had more education, and lived in metropolitan areas. Time Trends The Advance Report on the 1980 nasality statistics stated that the proportion of births to mothers who began prenatal care in the first trimester of pregnancy continued to increase in 1980 , as it had over the past 11 years for which this information is available. 6 Unfor- tunately, the 1981 Advance Report noted that no change occurred in this indicator between 1980 and 1981, and that 1981 was the f irst year since 1969 in which no increase was found in the precentage of black mothers initiating care in the first trimester. 3 Unpublished nasality data

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152 for 1982 suggest that the erosion in early prenatal care starts is continuing. Also between 1980 and 1981, a smaller proportion of women between 15 and 29 received first trimester care, with teenagers showing the greatest decline. 3 Final federal statistics on patterns of prenatal care utilization are not available after 1981. In their absence, the committee reviewed reports from two advocacy groups and several state organizations to assess patterns of prenatal care use since 1981. These data must be interpreted with caution because of the br fief time per iod involved and because of normal year-to-year var Rations in such rates in small geographic areas. In January 1984, the Children's Defense Fund (CDF) released a report, American Children in Poverty, which found that over the past 3 years there had been a disturbing nationwide decrease in the percentage of women receiving prenatal care during the first 3 months of pregnancy and a rise In the percentage of women receiving late or no prenatal care. CDF listed 26 states (out of 33 reporting) that had inch eased percentages of late or no prenatal care in 1982 and 20 that documented decreased percentages of early care. Sixteen states (out of 20 with racial data} had an increase in late or no care among nonwhite women and a similar number had a decrease in first trimester care. Some states showed particularly sharp increases In late or no care among nonwhite women between 1978 and 1982, e.g., Florida, 63 percent; New York, 34 percent; and South Carolina, 29 percent.7 The Food Research and Action Center (FRAC) also released a report in January 1984, entitled The Widening Gap: The Incidence and Distribution of Infant Mortality and I.ow Birth Weight In the United States, 1978-1982.8 FRAC descr ibed increases between 1981 and 1982 in inadequate prenatal care {defined as care initiated In the third trimester, no care, or 0 to 5 visits) in seven states and several c ities and urban counties. The Kentucky Coalition for Maternal and Child Health and Kentucky Youth Advocates, Inc. , studied prenatal care and perinatal outcomes in '~;~^~ -of =-~. .~ I-; 9 my- =^~-~A that the rate of women per 1~000 births in 1979 to 32 in 1980, to 33 in 1981, and then to 55 in 1982. The Oregon Center for Health Statistics' analysis of inadequate prenatal care (no care, care begun in the third trimester, or less than five prenatal visits) showed that the marked improvement observed throughout the 1970s had been reversed.~ The increase in inadequate care was greatest among teenagers, unwed mothers, and blacks. The Children's Defense Fund in Ohio reported that the percentage of all women reporting third trimester or no care fluctuated only slightly from 1978 through 1981, but for nonwhite Others the percentages were substantially higher by 1981. ~ ~ The uniformity among the trends--the halting of declines in the proportion receiving inadequate care and the beginning of increases at the national, state, county, and c ity levels--strongly suggests that the number s reflect a real change in the use of prenatal care rather than a statistical artifact. The timing of the changes, coinciding with her eased unemployment, reductions in Medicaid eligibility and .L&~ "~& "~ - ~ "~= vow "~ - ~ &~! vow not receiving prenatal care had gone from 36

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153 benefits, and decreases in the number of public prenatal services point to a decrease in access to prenatal care, with the greatest impact on minor ities and other high-r~sk groups. The committee views with deep concern the possibility that the nation's progress in extending prenatal benefits to all women might be arrested or reversed. Seen in this context, the suggestions made in this chapter for enrolling more women in care are of heightened s Agnes 1cance . Why Do Some Women Obtain Inadequate Prenatal Care? There are several possible reasons why an individual woman does not enroll in prenatal care early or at all, but the literature that could help in understanding this problem is not extensive. From those studies and programs reviewed, however, the committee has def fined several types of barriers related to the poor utilization of prenatal care: f financial constraints, including inadequate insurance or public funds such as Medicaid to purchase adequate prenatal care; inadequate availability of maternity care providers, particularly providers willing to serve socially disadvantaged or high-risk pregnant women; insufficient prenatal services in some sites routinely used by high-risk populations such as Community Health Centers, hospital outpatient clinics, and health departments; experiences, attitudes, and beliefs among women that make them disinclined to seek prenatal care; transportation and child care services that are poor or absent; and inadequate systems to recruit hard-to-reach women into care. In the following sections, each of these tear r ier s is descr ibed and suggestions made for improvement. F inane ial Constraints The availability of funds to cover the costs of prenatal care, as well as hospitalization for labor and delivery, undoubtedly influences many women's decisions about seeking care. Direct evidence of the importance of financing was reported byChao et al. in a recent study of a group of poor, urban women who had obtained no prenatal care by the time of delivery. When asked why they had not received prenatal care, over half mentioned a money problem." 2 Similar f indings have been reported from a very different population in the rural Southwest. Berger studied a group of low-income pregnant women who had obtained virtually no prenatal care. Though some community physicians felt that factors such as cultural practices and lack of information explained the absence of care, it was

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154 found that 87 percent of the 400 women interviewed stated that the reason they had not obtained prenatal care was that they could not afford it.~3 Additional evidence of the impact of financial tear r iers on the receipt of prenatal care is indirect, based on associations between the care-seeking behavior of certain groups and the presence of insurance, personal funds, free or low price clinics, or Medicaid. The CDF and PRAC reports and those of several state organizations cited earlier explore these issues. Many of them stress decreases in Medicaid eligibility. Some descr ibe declines in private insurance coverage because of unemployment; others note increasingly restr ictive eligibility or increased cost-sharing requirements in health department clinics and Community Health Centers. These reports also cite hospital clinics or delivery services that are turning away women who can not pay for care. It seems reasonable to assume that such circumstances discourage women from seeking prenatal care early or at all. Easing such financial barriers can be approached from many perspectives. For example, ways could be explored to make pr ivate health insurance more affordable for those who currently have no coverage but do not qualify for Medicaid. The problem of the uninsured poor is especially relevant to the low birthweight problem because young adults in their childbearing years are particularly likely to be without health insurance and because minorities are disproportionately represented in the uninsured group. A 1977 survey supported by the National Center for Health Services Research found that 12 percent of the total population had no health insurance coverage of any type, public or private. For persons age 18 to 24, however, the proportion was close to 22 percent. Data from the 1980 National Medical Care Utilization and Expenditure Survey suggest that the situation has changed little, if at all, in the intervening years.is Health Interview Survey data from 1978 and 1980 also show that Hispanic and black people are more likely than whites to have no health insurance of any type. Twenty-six percent of Hispanics, 18 percent of blacks, and 9 percent of whites had no coverage." 6 Having private health insurance does not, however, guarantee that prenatal services are covered adequately. Insured individuals may still f ind that out-of-pocket expenses for maternity services are high. ThuS, removing financial tear r iers to prenatal care involves not only increasing the number of individuals covered by pr ivate health insurance, but also assuring that the maternity benefits of such policies are adequate. Another approach to lowering financial barriers to prenatal care is to increase support of public agencies that serve groups most likely to receive inadequate maternity services. Such an approach is developed more fully later in this chapter. In this section the committee has chosen to focus on the Medicaid program, the largest public program f inancing prenatal care. The significance of the Medicaid program for reducing low birthweight der ives f rom its capac ity to r educe f inane ial bar r ier s to car e generally and thereby increase the proportion of low-income women receiving prenatal care, which in turn is associated with improved

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155 pregnancy outcome. National Center for Health Statistics data show that the number of visits to physicians per year by the poor has increased since the passage of Title XIX of the Social Security Act in 1965 (the Medicaid program), and it is reasonable to assume that visits for prenatal care are among them. A1SO, the marked increase in those seeking first trimester care from 1967 to 1980, especially among blacks, who are more likely to be Medicaid recipients, suggests a probable cause and effect relationship.6 ~ 7 Specific studies supporting such a relationship include that of Norris and Williams, who found that between 1968 and 1978, Medi-Cal (the California Medicaid program) greatly increased access to early prenatal care. In 1968, Medi-Cal was the financing mechanism for 13 percent of California deliveries. BY 1978, the proportion had more than doubled to 27 percent. During the same period, the proportion of women receiving early prenatal care increased for all subpopulations surveyed (both Medi-Cal and non-Medi-Cal covered populations), but the increase was consistently larger for Medi-Cal births in all racial groups. ~ B Other data suggest that enrollment in Medicaid is associated with better pregnancy outcomes, though more often in terms of improved mortality rates than improved birthweight distributions. The same Norris and Williams study found that low-income women not covered by Medi-Cal had a greater risk of poor pregnancy outcome. They found that Among all three ethnic subpopulations studied [white, non-Spanish surname; white, Spanish surname; and black], the perinatal mortality rates for most birthweight groups were lower for Medi-Cal babies, especially in 1978. Decreases in birthweight specific mortality rates for all race-ethnicity groups were generally largest in the Medi-Cal group. (p. 11147.~8 Similarly, Schwartz and Poppen noted that women who received Medicaid had better pregnancy outcomes than similar women without it. They suggested that women with Medicaid coverage do not need to rely on free care or worry about the cost of care and thus have better access to care.~9 The program is also of great signif icance to the low birthweight problem because of the character istics of the recipients themselves . By the mere fact of their eligibility for Medicaid, they are at high risk for delivering a low birthweight infant. Medicaid-eligible pregnant women are typically poor and single and often have other r isk factors. For example, Missouri data on the character istics of Medicaid recipients who gave birth in 1980 show that 78 percent were unmarried, as compared with 18 percent of all Missour i mothers; that these Medicaid mothers were more likely to smoke dur ing pregnancy, to be underweight, to space births less than 18 months apart, and to have four or more children. Medicaid mothers living in Missouri had a 75 percent greater low birthweight rate than the state's overall low birthweight rate.20 While these data may not be generalizable to other states, they do highlight the high-risk characteristics of many Medicaid-eligible women. Another body of data indicates the cost-effectiveness of Medicaid maternity benefits. For example, expanding improved Medicaid benefits -

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156 to more low-income women was found to be cost-effective in the OB Access Project, which was conducted in 13 counties In California from 1979 to 1982. Cost savings were achieved by decreasing low birthweight (4.7 percent incidence of low birthweight in the study population versus 7.1 percent in a Medi-Cal comparison group) and by reducing associated costs of infant hospital care. Rorenbrot found that for every dollar Medi-Cal reimbursed for prenatal care, the state would save $1. 70 in reimbursements for newborn intensive care. She suggested that additional cost savings of unknown magnitude might be achieved f rom reduced need for Cr. ippled Children ' s Services, Developmentally Disabled Programs, and other high-risk infant follow-up services. Chapter 6 describes the content of care offered in the OB Access project and Chapter 10 discusses the cost-effectiveness of prenatal care in more detail. The committee does not mean to suggest that in all instances a simple, direct link can be shown between participation in Medicaid and reduced low birthwe~ght. Our assessment of available data, however, leads to the conclusion that: Medicaid increases participation in prenatal care by lowering financial barriers to such services. And because participation in prenatal care is associated with improved birthweight, efforts to expand and strengthen the Medicaid program should be part of a comprehensive program to reduce the nation's incidence of low birthweight. Decreasing the participation of pregnant women in the Medicaid program by such means as changing welfare or Medicaid eligibility criteria serves only to undermine the purpose of the program and, among other things, threatens appropriate use of prenatal care and increases costs for low birthweight infant care. Changes in the program should be dedicated to enrolling more, not fewer, indigent, eligible women in the program and to providing them with early and regular prenatal care of high quality. The committee did not undertake a detailed review of the 52 Medicaid programs in the United States or the many ways that have been suggested for revising the programs' maternity policies. It is apparent, though, that defining the population of Medicaid-el~gible pregnant women is a controversial topic both in Congress and in state governments. In that context, the committee recommends that: The Health Care Financing Administration (HCFA), in collaboration with the Division of Maternal and Child Health (DMCH), should establish a set of generous eligibility standards that maximize the possibility that poor women will qualify for Medicaid coverage and thus be able to obtain prenatal care. All Medicaid programs should be required to use such standards. In particular, eligibil- ity standards should provide Medicaid coverage for pregnant,

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157 indigent women, regardless of their family composition or the employment status of the chief breadwinner in the faunily unit. Medicaid policies and reimbursement rates also should reflect the high-risk nature of the Medicaid-eligible population. Pregnant women enrolled in the program often are at elevated risk of a poor pregnancy outcome, including low birthweight, and may need more frequent prenatal visits and care of a more specialized, intense nature than low-risk women. To reflect the hiqh-risk status of many Medicaid-eliaible pregnant women, the number of prenatal visits a Med~caid-eligible woman may have, and reimbursement rates should reflect the fact that such women of ten need more services and more specialized care than lower isk women. In Chapter 8, the committee urges that DMCH define a model of prenatal care for use in publicly f inanced facilities providing prenatal care. Building on that recommendation' the committee also urges that: program policies should not set a limit on HCFA should adopt the prenatal care model developed by DMCH as its standard of care for Medicaid recipients and should require its use in all Medicaid programs. HCFA and appropr late state agencies should monitor the adequacy of adherence to such a standard of care. Maternity Care Providers A second barrier is the lack of prenatal care providers. The problem of inadequate numbers of pr ivate physicians providing prenatal care in some areas is well documented. For example, as part of a 1983 needs assessment, the Oklahoma Depar tment of Health administered questionnaires and interviews to public health providers throughout the state. Respondents in 66 count) es reported "an ~ nsuff icient number of physicians who will provide any prenatal or delivery care. Almost one-third of the physicians who were providing maternity services were not taking new patients. Similarly, a survey of Kentucky obstetr icians and gynecologists found that in Lexington and Fayette counties none accepted Medicaid patients, even though these counties have the highest concentration of physicians in the state.9 Increasing the availability of prenatal care providers In var. ious locales is a complicated issue, in part because the participation of several provider groups must be considered in addition to obstetr ician- gynecologists, who perform about 80 percent of deliveries in the United States. In 1977, for example, family physicians and general prac- titioners performed almost 20 percent of all deliveries (6 percent and 12 percent, respectively); and certified nurse-midwives managed

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158 approximately 2 percent of deliveries, 2 3 socially disadvantaged women. Moreover, prenatal care (as distinct from deliveries) is managed nurse midwives, nurse practitioners, and public health Nonetheless, in this section only two of the provider groups are discussed: obstetrician- gynecologists, who offer the ma jor ity of prenatal services, and a combined group consisting of certified nurse-midwives and obstetr ical nurse practitioners, because they often care for socioeconomically disadvantaged women who are at elevated risk of low birthweight. many of which involved a substantial amount of by nurses. - . . Obstetrician-Gynecologists The major role played by obstetr ician-gyncologists in providing prenatal care is obvious. In recent years, however, several develop- ments in the obstetr ic community have restricted the capacity of the specialty to provide prenatal care to more pregnant women. Of special concern is the fact that the participation rate of obstetrician-gynecologists in the Medicaid program Is relatively low and may be decreasing. In California, for example, the number of obstetrician-gynecologists accepting Medicaid patients for maternity care dropped by 30 percent between 1974 and 1977 (from 65 percent to 46 percent).24 A 1983 Oklahoma report stated that one-third of Oklahoma physicians providing maternity care will not accept Medicaid as a method of payment. 2 2 It seems reasonable to assume that such poor participation in Medicaid results in an overall lack of available prenatal care. In one of the few detailed studies of Medicaid per t~cipatzon among obstetrician-gynecologists, Mitchell and Schurman studied a sample of more than 1,800 off~ce-based physicians to assess the factors influencing Medicaid participation decisions by physicians in three specialities: obstetrics-gynecology, pediatrics, and general surgery. They found that obstetr~cian-gynecologists had substantially smaller . . . Medicaid patient loads (8 percent) than either pediatricians or general surgeons {more than 13 percent). Moreover, almost 36 percent of the obstetr~cian-gynecologists saw no Medicaid patients whatsoever, in contrast to 23 percent of pediatricians and about 10 percent of general surgeons .2 5 Massachusetts Department of Public Welfare data from 1983 support these findings. Ten welfare service areas had no participating obstetrician-gynecologist for more than a thousand Medicaid women under 65, and 13 welfare service areas had only one obstetrician- g~lecologist.2 6 Mitchell and Schurman's study found that obstetrician- gynecologists, along with general surgeons, receive unusually low Medicaid reimbursement rates. Among the physicians they surveryed, they found that Medicaid often paid lens than 60 percent of the usual office visit fee. California, for example, reimbursed participating obstetrician-gynecologists in 1982 at only one-third of the private fee paid for normal prenatal care and delivery. These relatively low

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159 reimbursement rates account for some of the dif ferences found in physician participation rates, as documented in other studies.2 4 2 ~ Another reason for differentials in provider per citation is the fact that obstetricians are paid by Medicaid for a ~package" of services that usually includes 10 to 12 patient care visits, plus delivery and postpartum care. In many Medicaid programs, billing for all of these services cannot occur until after the delivery, so that by the time the physician is paid, 10 to 18 months may have elapsed, further reducing the reimbursement amount in real dollars because of inflation. Also, the fixed Medicaid fee for prenatal care does not allow for the large number of higher isk pregnancies in this population. These women often need more intensive care than low-risk women. Finally, in some states, the entire Medicaid fee goes to the health professional attending the delivery, whether or not that individual provided the ma jor Sty of the prenatal care. Thus, the incentives are directed more toward managing the deliver ies of Medicaid-eligible women than toward their prenatal care.2 ~ Consistent with such findings, Mitchell and Schurman reported that factors that appeared to increase physician participation in Medicaid included higher Medicaid fees, more efficient processing of Medicaid claims, and fewer benefit restrictions, such as pr for author ization and service limitations e In short, one reason that prenatal care is not fully accessible to poor populations is the relative lack of pr ivate obstetr ical services for women relying on Medicaid. To ease this problem the committee recommends that: HCFA should develop a ser. ies of demonstrat~on/evaluation projects aimed at increasing the participation of obstetriczan-gynecologists in Medicaid. Approaches should include reducing delays in reimbursement, increasing reimbursement rates, and increasing the namer of prenatal visits reimbursed by Medicaid. The results of these projects should be vigorously disseminated to policy leaders and others in a position to modify Medicaid policies. To the extent that provider attitudes are found to impede Medicaid participation, local and national professional societies, including the American College of Obstetricians and Gynecololgists, should undertake appropriate education to urge members to increase their Medicaid patient loads. The increased risk of a poor pregnancy outcome among high-risk women, discussed above, creates an additional disincentive to caring for these groups. Poor outcomes raise the possibility of a malpractice suit, and indeed, the threat of malpractice has emerged as a serious barrier to expanding obstetric care to women at risk of low birthweight and related problems. In response to increasing malpractice insurance premiums and other factors, obstetriczan-gynecologists are revising their practices. A 1983 survey of obstetrician-gynecolog~sts revealed that almost 18 percent of those surveyed had decreased their level of

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160 obstetric care to high-risk women, 10 percent had decreased the number of deliveries, and 9 percent no longer practiced obstetrics at all.29 Because prevention of low birthweight requires fully available prenatal care and, more important, specialized care for h~gh-risk women, these survey findings are of ma jor concern. Nurse-Midwives and Obstetrical Nurse Practitioners The committee also considered whether access to prenatal care could be extended by greater reliance on the use of nurse-midwives and nurse practitioners. Certified nurse-midwives (CNMS) are health professionals trained to manage the care of essentially normal women and their new- borns during pregnancy, childbirth, and the postpartum/neonatal period. They work in conjunction with physicians, with whom they consult and to whom they refer patients who develop complications or h~gh-risk medical conditions. Although nurse-midwives currently deliver only about 2 percent of the babies born in the United States, they are more active in many other industrialized nations. In Norway, almost 96 percent of pregnant women receive prenatal care and delivery services from midwives; in England, 70 percent do.30 Nurse practitioners (NPS), quite similar in most respects to nurse-midwives, do not manage intrapartum and immediate postpartum care; their training places greater emphasis on gynecology, but they also provide substantial amounts of prenatal care. The relevance of such providers to low b~rthweight prevention derives from the fact that CNMs and NPs have been shown to be particularly effective in managing the care of pregnant women who are at high risk because of social and economic factors.3t These women often have difficulty communicating effectively with authority figures and may need a great deal of education and support during pregnancy . CNMs and NPs are particularly well-suited to meet such needs. They tend to relate to their patients in a nonauthoritarian manner and to emphasize education, support, and patient satisfaction. Many anecdotal reports suggest that nurse-midwives and nurse practitioners spend more tome with their patients than do physicians and are more likely to include counseling and education in their interactions--components of care that are central to prevention of low birthweight (Chapter 8~. This general impression is confirmed by a 1981 study that analyzed the content and process of prenatal care provided by CONS and found significant time spent on teaching during each visit. The mean length of the prenatal visit with the CNM was 23.7 minutes.32 The 1975 National Ambulatory Medical Care Survey found that prenatal visits with office-based physicians tended to be brief (about 10 minutes) and usually did not include counseling. Thirty-two percent of the patients visits included no Snore than ~ minutes with the physician.33 One manifestation of the special skills of nurse-midwives and nurse practitioners is the finding of increased ~compliancen--i.e. keeping appointments and following specified treatments--among women served by nllrse-midw~ves. For example, in 1976, Slome et al. reported on a randomized clinical trial of nurse midwifery care as compared to care

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164 The committee believes, however, that while support of individual programs or service systems is important and clearly desirable, gaps in care probably will remain until a stronger commitment is made nationally to providing full access to prenatal care. This chapter concludes with a proposal along these lines. Women's Exper fences, Attitudes, and Beliefs Access to prenatal services depends not only on adequate providers, facilities, and funds. It is also affected by a woman's perceptions of whether such care is useful, supportive, and pleasant; by her genera' fund of knowledge about prenatal care; and by her cultural values and beliefs. In particular, a perceived lack of "caring" in prenatal care, especially as provided to poor and socially disadvantaged women, may be an important cause of late registration, poor continuation In care, unsuccessful communication with providers, and, consequently, heightened risk for a poor pregnancy outcome. This.has been confirmed by numerous studies of reasons given for not seeking prenatal care, including those of Her zog and Bernstein,40 the Perinatal Association of Mich~gan,4~ and Chao et al. Economic and health care system-related reasons are quoted often in these reports (which span two decades), but there is also considerable emphasis on reasons related to women's attitudes and beliefs. For example, women may fail to seek prenatal care ear ly because they lack information about the symptoms of pregnancy, the facilities that could assist them, or the importance of early care in averting the complications of pregnancy. The very young are particularly likely to fall into this category, as are the foreign born and those with limited formal education. Women who have experienced previous pregnancies may be unaware of their high-risk status or believe that they know enough and do not need early care or frequent visits. Additionally, some women may harbor fears about examinations, labor and delivery, and pregnancy generally to the extent that they avoid contact with health care providers. Some women may be aware of their need for prenatal care but be indifferent or resistant to seeking it. Often this Is related to previous unfortunate experiences with medical care. Several studies have noted frequent consumer dissatisfaction with prenatal services and the desire for more personal care.42~45 In a 1968 report on factors affecting perinatal mortality in England, Vaughan noted that Many mothers who delayed [prenatal care] had had previous pregnancies during which they had gained the impression that there is no value in prenatal care. They supported their arguments from their experience, with complaints of long waits, rushed examinations, and an impersonal approach which did not encourage them to ask questions or seek advice" (p. 144) .4 6 More recent studies from the United States reveal the same themes. A 1976 study based on interviews with almost 300 women who had recently delivered babies in hospitals in the Midwestern United States reported that only 69 percent were satisfied that their doctors understood their feelings during pregnancy, and only about 60 percent

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165 thought that their physicians' explanations of procedures and medications were satisfactory.4 7 Cultural, religious, or family beliefs also may impede acceptance For _ , . ~ , _ of prenatal care or compliance with provider recommendations. example, in discussion sessions held before the initiation of a federal information and education campaign to improve the outcome of pregnancy (the Healthy Mothers, Healthy Babies Coalition), women reported dietary patterns that made it difficult to follow selected nutritional guidelines. A more common cultural barrier to prenatal care is the view among some groups that women should receive prenatal care only from other women. Thus, some Hispanic, Southeast Asian, and Middle Eastern immigrants, accustomed to receiving health care from women practitioners, are reluctant to seek prenatal care from male physicians. A further cultural difference that impedes access to care is language incompatibility. The scarcity of health care providers who serve non-Engl~sh speaking clients in their own language presents a serious obstacle to many pregnant women. Inability to communicate with a health care practititioner effectively renders health care inaccessible. Women who are aware that their life styles are not conducive to a healthy pregnancy also may delay seeking care. These would include drug abusers, heavy smokers or drinkers, the obese, and those with poor eating habits. Delay also may be related to psychological factors, such as an unwanted pregnancy. A desire to conceal the pregnancy also may keep women from seeking care. This situation is found more often among very young or unmarried women and it may be related to denial or a wish not to be pregnant. Intrapsychic factors such as depression and denial also may be ma jor reasons for failure to seek out prenatal care, particularly among teenagers. 4 8 The strategies available to overcome such barriers to participation in prenatal care fall generally into two categories. The first, and most often discussed, is general education about prenatal care, provided in a variety of settings and through multiple media (Chapters 5 and 9~. The second strategy concerns the nature and atmosphere of prenatal care itself. A personal, caring environment has been a key ingredient of several prenatal care programs designed specifically to reduce low birthweight and infant mortality In high-risk groups, especially teenagers.4 9 Although programs differ, some common elements of a scaring environments can be def ined and should be incorporated into prenatal services to make them more accessible, particularly for socioeconomically disadvantaged women: . respect for patients--their questions, their problems, and their time; conveyance of the expectation that they can, with support and education, assume increasing responsibility for their own health and that of their babies; accessibility--institution of a system by which patients can always reach a provider who is known to them and who will respond to their concerns; this involves an increased capacity for telephone consultation;

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166 continuity of care--no more than two or three primary care providers for each woman; missed appointments should be followed up by a telephone call or home visit; restricted size (or decentralization into teams of limited size) so the woman does not have to deal with a large, impersonal bureaucracy--a program designed to be sensitive to local conditions and the schedules of the women themselves; responsiveness through individual education and commune cation to the concerns that are most salient to women in early pregnancy, such as first trimester nausea and other discomforts of pregnancy, and recognition of the need for emotional support and acceptance; flexibility that allows providers to help women obtain benefits other than prenatal care, such as we' fare and housing servi ces , and enrollment in the Special Supplemental Program for Women, Infants and Children (WIC) ; and under standing of cultural barriers such as language incompatibility and preferences for certain types of providers. Transportation and Child Care Difficulty in getting to a prenatal care facility, per titularly in rural areas, contributes to the problem of access. For the poor, distance appears to be a significant deterrent to seeking preventive care.s Where health care services exist but are difficult or impossible to reach because people lack adequate transportation, transportation services are a necessary component of care. Further, many women who would seek prenatal services have difficulty in arranging babysitting for other children at home and may put off getting care except in acute or emergency situations. Health care programs must intervene on behalf of their patients in circumstances such as these by providing transportation and child care services. For socially disadvantaged populations, these services should be viewed as important elements in overall maternity care. Increasing the Capacity for Outreach Sometimes health care programs must do more than provide an open door. They must take the initiative to find, educate, and help bring women in to receive care. Two principal strategies to do so are the use of outreach personnel and the forging of referral relationships among various service systems. Outreach Personnel Over the last two decades, many health and social service programs have used trained personnel, sees, tive to the needs and backgrounds of target populations, to recruit individuals into service programs. The tasks performed by these workers vary from setting to setting. In the

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167 field of maternity services, thei r activities generally include some of the following: identifying women requiring services and enrolling them in prenatal care; acting as an advocate for women to ensure access to needed services; and establishing links with other social services to address the hous ~ ng, nutr ition, income, and related needs of pregnant women. A recent report from the Harvard School of Public Health suggested that declining visits for prenatal care in a group of Boston neighbor- hood health centers could be attr ibuted in part to the decrease in outreach workers resulting from financial cutbacks.5~ The committee shares the belief that these workers are an effective way to improve access to care for difficult-to-reach populations. However, support for the role of outreach personnel stems mainly from anecdotal reports and program descr iptions. Little information exists, for example, on the comparative advantages of var ious case-f Ending approaches; the costs of different outreach systems and workers and their effectiveness; the types of personnel best suited to var ious program goals and target groups; the utility of adjuncts to typical outreach programs, such as financial incentives or links to other programs; and how to meet the security needs of outreach personnel In some settings. This partial 1 ist of unanswered quest ~ ons about such an impor tent topic leads the committee to urge that: Research and analys is should be supported on the nature and value of outreach to increase access to prenatal care. Efforts should be made to assemble and integrate existing information about outreach approaches and to identify additional research needs. Both costs and effectiveness should be considered. Outreach Through Program Links Bringing hard-to-reach women into care also can be accomplished by forging strong referral relationships between prenatal services and other programs that are in touch with potential clients. The Special Supplemental Food Program for Women, Infants and Children (WIC) Is a case in point. Several features of WIC facilitate increased prenatal care utilization. First, all WIC prenatal participants must document their pregnancy status, an act that encourages a formal prenatal visit and thereby increases the likelihood of early entry into a prenatal care network. Second, many WIC sites are located in neighborhood or county health centers--a fact that facilitates use of adjoining or coexisting prenatal clinics. And third, the WIC nutrition staff actively encourages prenatal care during nutritional counseling. Research on WIC's impact on enrollment in prenatal care is slim. Kotelchuck et al. showed that WIC prenatal participation is associated with increased prenatal care utilization. Based on birth certificate data in Massachusetts in 1978, they found that fewer WIC participants obtained inadequate prenatal care (measured by number of visits) than matched high-risk control group (3.8 percent versus 7 percent). This , ~

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168 was particularly true for teenage mothers in the WIC program, only 5.8 percent of whom obtained inadequate prenatal care, compared with 11 percent of the control group.52 In South Carolina, health department prenatal clinics and WIC clinics were integrated in 1981. WIC enrollment is now closely tied to prenatal services. Health department officials report that as a result of this change, the 21, 000 pregnant women enrolled in WIC, representing 40 percent of all South Carolina births. are more assured of receiving' prenatal care beginning at the time of certification for WIC. A trend over the last 2 years for pregnant women to enroll earlier in WIC has been paralleled by an increase in early starts in prenatal care. s 3 In sum, WIC appears to increase early enrollment in prenatal care by serving as a "recruiter. When WIC and prenatal care are closely tied, their mutual benefits may be enhanced. This particular set of findings illustrates the importance of program links as a source of outreach to clients in need of prenatal services. A System of Accountability and Responsibility The six preceding sections explore reasons why some women obtain inadequate prenatal care, but it is the committee's conclusion that problems of access also reflect the nation's patchwork, nonsystematic approach to making such services available. Although numerous programs have been developed in past years to extend prenatal care to more women, no institution bears responsibility for assuring that such services are genuinely available in some very fundamental, practical sense. That is, no local, state, or federal entity can be held accountable for inadequate care. Without such responsibility or accountability, it should not be surprising that gaps in care remain and that efforts to expand prenatal services often face enormous organizational and administrative difficulties. The federal government has long been on record as supporting prenatal care and urging that all women secure such care early in pregnancy. ThiS support must be accompanied by specific actions: providing funds to state and local agencies in amounts sufficient to remove financial barriers to prenatal care (through channels such as the Maternal and Child Health Services Block Grants, Medicaid, health departments, Community Health Centers, and related systems ); providing prompt, high-quality technical consultation to the states on clinical, administrative, and organizational problems that can impede the extension of prenatal services; defining a model of prenatal services for use in public facilities providing maternity care; and funding demonstration and evaluation programs, and supporting training and research related to these responsibilities. States should take a complementary reader ship role in extending prenatal services, backed by adequate federal money, support, and

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169 consultation. One way to do so is for each state to designate an organization--probably the state health department--as responsible e for ensuring that prenatal services are reasonably available and accessible in every community. Th is would involve the state in: assessing unmet needs--e.g., surveying existing prenatal services and identifying the localities and populations that have inadequate prenatal services; serving as a broker to contract with private providers to fill gaps In services; and in some instances, providing prenatal services directly through facilities such as Community Health Centers and health department clinics. In addition, the committee suggests that In each community a single organization be designated by the state as the "residual guarantor" of prenatal services. These organizations should be provided with sufficient funds to care for pregnant women who still remain outside of the prenatal care system. Local health departments could meet this responsibility in many ways: through contracts with private providers; through special programs; through arrangements with local hospitals, medical schools, and nurse-midwifery services; and through direct provision of care. In order to develop these concepts more fully, the committee recommends that: The Secretary of the Department of Health and Human Services should convene a task force charged with defining a system for making prenatal services fully available to all pregnant women. Such a group must include representa- tives from the Congress, the Public Health Service, the Health Care Financing Administration, state governments and health author ities, maternity care providers, and consumers . This task force should def ine concrete ways for both federal and state leaders to assume responsibility for the tasks outlined above. In so doing, the group should focus on four specific issues in the development of a workable system. First, the system must incorporate mechanisms at both federal and state levels to bring together the knowledge and general goals of maternal and child health programs with the Dollar powers of the Medicaid program. The clinical and health expertise of the one is rarely related to the financial power of the other. The committee did not define how such links might be made, but wishes to highlight this as a central issue. Second, existing experience with regionalization of perinatal services should be reviewed for lessons applicable to prenatal care. The regionalization of perinatal services has been shown to reduce neonatal mortality,5 4 and some aspects of the process probably could contribute to a decrease in low b, rthweight. In particular, regional~zation could help to:

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170 assess unmet needs, def ine available resources, and specify higher isk target populations; disseminate new data in an orderly way to practitioners; rationalize the system of health care services and facilties, and help to limit inappropr late dissemination of technology; monitor selected health indices and patterns of practice; and arrange ear ~ y referral/transport for higher isk women to a facility providing an appropriate level of obstetrical care. A third topic that the task force should address is the lack of adequate state and national data for assessing unmet need for prenatal services and available resources to meet these needs. Regionalized networks of perinatal care may provide a model for collecting such data. The Alan Guttmacher. Institute has developed a workable, well- respected system for estimating unmeet family planning needs; a similar effort should survey prenatal care. In so stating, the committee wishes to highlight the more general problem of inadequate data on a wide range of health indicators and health services. Lack of sufficient and timely data hamper efforts to emeOnitOr maternal and child health on a population basis and, in particular, to assess the impact of public programs such as Medicaid and various private initiatives on specific health outcomes. Efforts such as the Child Health Outcomes Project of the University of North Carolina are important in addressing this concern and in helping to increase available data. The professional societies concerned with maternal and child health (such as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists) also are involved in developing and refining various outcome measures that are useful in judging the impact of clinical and programmatic interventions. Additional observations on data systems are contained in Appendix D. Fourth, the task force should consider the long-term prospects for ensuring that prenatal care is financed adequately in times of cost containment. Preventive services' of which prenatal care is a prime example, often have been poor competitors for dollars. In part, this results from the fact that such services lie in the domain of low technology, labor-intensive services, and are often provided on an ambulatory basis. Such services traditionally have not been incor- norated into insurance plans and are considered to be services for _ e ~ _ Which individuals can and will pay from their own resources. For those unable to pay, preventive services are often supported by chronically underfunded municipal and county resources. In view of the general underfunding of such preventive services, the committee is concerned about the effects of current efforts at cost containment, which include the reimbursement of hospitals for publicly funded care on a per-case basis (diagnosis-related groups or DRGS); preferred provider options," under which care is payed for only if provided by approved providers; and "prepaid managed health care," which restricts the use of care by publicly funded patients to specific, limited provider systems that are paid prospectively. Each of these mechanisms has the potential to reduce costs and improve care, especially by increasing accountability among providers and improving

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171 continuity. However, in certain situations these alternatives also may have serious disadvantages, such as disruption of existing patient- provider relationships, decreased access to services in the name of cost-saving for h~gh-risk patients known to require such services, and changes in established referral patterns in regionalized systems. They also may threaten the roles traditionally played by health departments, nurse-midwives, Community Health Centers, and hospital outpatient departments. Thus, where such changes in the delivery of care are introduced, the committee urges that adequate resources be made available to monitor the access to and adequacy of care, particularly prenatal care, provided under the new arrangements. In sum, the committee believes that, in the long run, full access to prenatal care requires a fundamental assumption of responsibility by the public sector for mak ing such services available . In many instances, arrangements with private providers will be able to fill gaps in care; in others, governmental agencies may need to provide care directly. Federal leadership will be critical to this policy goal, but states also must attach high priority to prenatal care. At both levels, full support of the private sector and a greater commitment of public funds will be required. References and Notes 1. Select Panel for the Promotion of Child Health: Better Health for Our Children: A National Strategy. Vol. I, p. 192. DHHS No. (PHS) 79-55071. Public Health Service. Washington, D.C.: U.S. Government Printing Office, 1981. Public Health Service: Promoting Health/Preventing Disease: Objectives for the Nation, p. 18 . Washington, D.C .: U.S . Government Printing Office, Fall 1980. 3. National Center for Health Statistics: Advance Repor t of Final Natality Statistics, 1981. Monthly Vital Statistics Report, Vol. 32, No. 9 ( supplement) . DHHS No. (PHS) 84-1120 . Public Health Service. Washington, D.C.: U.S. Government Printing Office, December 198 3 . . Dive soon of Maternal and Child Health: Statistical Update on Progress, Pregnancy and Infant Health Objectives. Progress Review, Rockville, Md., March 29, 1983. 5. National Center for Health Statistics: Prenatal Care: united States 1969-1975. Prepared by S Taffel. Vital and Health Statistics, Series 21, No. 33. DHHS No. (PHS) 78-1911. Public Health Service. Washington, D.Ce UeSe Government Printing Office, September 1978. National Center for Health Statistics: Advance Report of Final Natality Statistics, 1980. Monthly Vital Statistics Report, Vol 31, No. 8 (supplement). DHHS No. (PHS} 83-1120. Public Health Service. Washington, D.C.: U.S. Government Printing Office, November 1982. 7. Children's Defense Fund: Washington, D.C., 1984. . ~ . American Children in Poverty.

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172 8. Food Research and Action Center: The Widening Gap: The Incidence and Distribution of Infant Mortality and Low Birthweight in the United States , 1978-1982 . Washington, D.C ., 1984 . 9. Kentucky Coalition for Maternal and Child Health, Kentucky Youth Advocates Inc.: Healthy Mothers and Babies: Pay Now or Pay Later . Lexington, Ky., ~ 983. 10. Oregon State Heal th Division: Prenatal Care In Oregon, 1982. Eugene, Oreg.: Center for Health Statistics, 1982 . 11. Lazarus W: Right From the Start: Improving Health Care for Ohio' s Pregnant Women and Their Children. Columbus, Ohio: Childrents Defense Fund-Ohio, 1983. 12. Chao S. Imaizumi S. Gorman S. and Lowenste~n R: Reasons for absence of prenatal care and its consequences. Unpublished paper. Department of Obstetrics and Gynecology, Harlem Hospital, New York, 1984. Berger LR: Public/private cooperation in rural maternal child health efforts: The Lea County, New Mexico Perinatal Program. Unpublished paper, 1983. 14. National Center for Health Services Research: Who are the uninsured? Data Review 11. Prepared by JA Rasper, D Walden, and G Wilensky. Hyattsville, Md.: National Center for Health Services Research, 1981. National Center for Health Statistics: Health care coverage and insurance premiums of families, United States, 1980. Prepared by M Dicker. National Medical Care Utilization and Expenditure Survey, Preliminary Data Report, No. 3. DENS No. (PHS) 83-20000. Public Health Service. Washington, D.C.: U.S. Government Printing Office, May 1983. 16. National Center for Health Statistics: Health insurance coverage and physician visits among Hispanic and non-Hispanic people. Prepared by FM Trevino and AJ Moss. In Health, United States, 1983, pp. 4548 . DHHS No. (PHS) 84 - 1232 . Public Health Service . Washington, D.C. : U.S. Government Printing Office, December 1983. National Center for Health Statistics: Vital Statistics of the United States, Vol. I, Natality. Individual years: 1967 through 1979. Public Health Service. Washington, D.C.: U.S. Government Printing Office. Norris ED and Williams RL: Per inatal outcomes among Medicaid recipients In California. Am. J. Pub. Health 74: 1112-~117, 1984. 19. Schwartz R and Poppen P: Measuring the Impact of CHCS on Pregnancy Outcomes: Final Report. Cambridge, Mass.: ABT Associates, 1982 . 20. Missouri Monthly Vital Statistics. Provisional Statistics from the Missouri Center for Health Statistics. Vol. 16, No. 9. Jefferson City, Mo.: Missouri Division of Health, November 1982. 21. Korenbrot CC: Risk reduction in pregnancies of low income women: Comprehensive prenatal care through the OB Access Project. Mobius 4:34-43, 1984. 22. Task Force on Per inatal Care in Oklahoma: Car ing for Pregnant Women and Their Infants in Oklahoma: A Needs Assessment, p. 54. Oklahoma City, Okla., 1983.

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173 23. American College of Obstetricians and Gynecologists and the Liaison Committee for Obstetrics and Gynecology: Manpower Planning in Obstetrics and Gynecology, 1977. Supported, in part, by MCH Grant MC R-170397. 24. California Department of Consumer Affairs: Pregnant Women and Newborn Infants in California: A Deepening Crisis in Health Care. March 26, 1982. Mitchell J and Schurman R: Access to OB-GYN services under Medicaid. Discussion paper. Chestnut Hill, Mass.: Center for Health Economics Research, June 30, 1982 . 26. Boston Globe: Many obstetricians refusing to take patients on Medicaid, pp. 1, 28 . December 4, 1983 . 27. Davidson S. Simon M, and Connelly J: Interstate variation in Medicaid coverage of newborns. Unpublished paper prepared for the American Academy of Pediatrics, 1984. 28. Committee to Study the Prevention of Low Birthweight: The role of Medicaid in deliver sing prenatal care to low income women. Unpublished paper prepared by MA McManus. Washington, D.C.: Institute of Medicine, November 1983 . 29. American College of Obstetricians and Gynecologists: Professional liability insurance and its effects: Report of a survey of ACOG ~ s membership. Unpublished report prepared by Porter, No~relli and Associates. Washington, D.C., August 31, 1983. 30. Judith Rooks, President, American College of Nurse-Midwives, Washington D.C. Personal communication, 1984. 31. Piechnik SL and Corbett MA: Adolescent pregnancy outcome: An exE>er fence with intervention. J. Nurse-Midwifery, in press . 3 2 . Lehrman E: Nurse-midwifery practice: A descr iptive study of prenatal care. J. Nurse-Midwifery 26: 27-41, 1981. 33. National Center for Health Statistics: Office Visits by Women: The National Ambulatory Medical Care Survey. Prepared by BE Cypress. Vital and Health Statistics, Ser ies 13, No. 45 . DENS No. (PHS) 80-1976. Public Health Service. Washington, DeCe UeSe Government Pr inting Off ice, March 1980 . 34. Slome C, Wetherbee H. Daly M, Christensen R. Meglen A, and Thiede H: Effectiveness of CAMS: A prospective evaluation study. Am. J. Obstet. Gynecol. 124:177-182, 1976. 35. Levy BS, Wilkinson FS, and Marine WM: Reducing neonatal mortality rates with nurse-midwives. Am. J . Obstet. Gynecol . 109: 50-58, 1971. 36. Adams C: Nurse-Midwifery In the United States: 1982. Washington, D.C.: American College of Nurse-Midwives, 1984. 37. Statewide Youth Advocacy, Inc.: Prenatal Care In Upstate New York, pp. 3-4. Rochester, N.Y.: Statewide Youth Advocacy, 1984. 38. Association of State and Territorial Health Officials Foundation: Public Health Agencies, 1982. Services and Activities, Vol. 2. Kensington , Md ., 1984 . 39. Data summarized by CA Miller for the committee based on data supplied by the Guilford County Health Department, N.C., by the Multnomah County Health Department, Oreg., and by the Commonwealth of Massachusetts.

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174 40 . Her zog E and Bernstein R: Health Services for Unmarried Mothers . Children's Bureau No. 425-1964. U.S. Department of Health, Education, and Welfare, Washington, D.C., 1964. 41. Perinatal Association of Michigan:- Barriers to Early Prenatal Care in Michigan. Pub. No. H-837-MDPH. Lansing, Mich., May 5, 1983. 42. Enkin M and Chalmers I: Effectiveness and satisfaction in antenatal care. In Effectiveness and Satisfaction in Antenatal Care, edited by M Enkin and I Chalmers, pp. 266-290. Philadelphia: Spastics International Medical Publications, 1982. 43. Garcia J: Women's views of antenatal care. In Effectiveness And Satisfaction in Antenatal Care, edited by ~ Enkin and I Chalmers, pp. 81-91. Philadelphia: Spastics International Medical Publications, 1982. 44. Ball ME, Chng PR, and MacG~llivray I: Is routine antenatal care worthwhile. Lancet II: 78-80, 1980. - 46. 45. Reid ME and McIlwaine GM: Consumer opinion of a hospital antenatal clinic. Soc. Sci. Med. 14A: 363-368, 1980 . Vaughan DH: Some social factors in per inatal mortality. Br . J. Prev. Soc. Med. 22 :138-145, 1968. 47. Light EIR, Solheim JS, and Hunter GW: Satisfaction with medical care dur ing pregnancy and delivery. Am. J . Obstet. Gynecol . 125: 827-831, 1976. 48. Joyce R. D~ffenbacker G. Green J. and Sorokin Y: Internal and external tear rzers to obtaining prenatal care. Social Work in Health Care 9:91-96, Winter 1983. 49. Georgetown University School of Nursing: 1983 Annual Report. Washington, D.C.: January 9, 1984. 50. Select Panel for the Promotion of Child Health: Children's health care: The myth of equal access. Prepared by D Dutton. In Better Health for Our Children: A National Strategy. Vol. IV, pp. 357-440. DEHS No. (PHS) 79-55071. Washington, D.C.: U.S. Government Printing Off ice, 1981. Feldman PH and Mosher BA: Preserving Essential Services: Effects of the MCH Block Grant on Five Inner City Boston Neighborhood Health Centers. Executive Sugary. Boston: Harvard School of Public Health, June 1984 . Rotelchuck M, Schwartz JB, Anderka MI, and Finison RS: WIC participation and pregnancy outcomes: Massachusetts statewide evaluation study. Am. J. Public Health 74 :1086-1092, 1984. Committee to Study the Prevention of Low Birthwe~ght: HOW to encourage disadvantaged women to enroll in prenatal care early and remain in care. Unpublished paper prepared by M Meglen. Washington, D.C.: Institute of Medicine, 1984. 54. McCormick MC, Shapiro S. and Starfield BE: The regionalization of perinatal services: Summary of the evaluation of a national demonstration program. JAMA, in press. Community of Caring: Georgetown University,