Click for next page ( 116


The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 115
Chapter 4 Improving the Use of Prenatal Care: Program Experience The previous chapters have discussed three aspects of access to prenatal care patterns and trends in enrollment, research and anecdotal reports regarding barriers to care, and the views of women themselves about why they obtained insufficient prenatal services. This chapter pursues the question further, from a different perspective. Here, the focus is on 31 programs that have tried to improve use of prenatal care. The chapter begins with an overview of the Committee's method of selecting programs for study and with discussion of two particularly important aspects of trying to learn from program experience judging the quality of available data and defining what constitutes evidence of effectiveness. A five-part program classification scheme devised by the Committee is then described, and the projects studied that emphasize each approach are noted. The Committee's findings on the usefulness of the five program types for improving participation in prenatal care are then presented, and the chapter concludes with a summary of the implemen- tation and operational problems reported to the Committee by many program leaders. SELECTION AND CLASSIFICATION OF PROGRAMS The Committee and staff wrote and telephoned numerous groups and knowledgeable experts, reviewed responses to a survey conducted by the Healthy Mothers/Healthy Babies Coalition, and used other methods (see 115

OCR for page 115
~6 DILL ad: BRIG ~0~, ~C~G ~~ Appendix A) to idend~ programs mat might provide data on increasing and sustaining participation in prenatal care. Because the Committee Wanted is Landis to reRect the present conOgurabon of the heal care Item and the maw recent changes in it the search emphasized programs currents in operation or recent completed. A ~w programs that bee been Beg described in Me literate were also included, men though some of them are no longer in existence or bye changed ~gniRcant~ in recent years. From these maw sources, a master list of almost 200 project was developed. Though the Committee beamed that the list was reasonably complete at the time, it undoubted bad omissions. In particular, ineffective programs were probably underrepresented because they are rarer described in publ~bed, or men unpublished, articles The Committee divided the programs into Me groups, according to . . t gear major amp flails: 1. reducing Me financial obstacles to care encountered by poor women Tough Me prounion of insurance or other sources of patents 2. increasing the capacity of the prenatal care system robed on by maw low-income ~'omen, Rich includes heakh department chnics, dbe network of plate physicians To care far ~edicaid~enrolled and other lo-income ~omen, hospital ou~adent department, Community Heakh Center, and similar setting; 3. improving institutional practices to make services more easily accessible and acceptable ~ cbens: 4. identifying yeomen in need of prenatal care (caseOnding) Trough a aside variety of medbods, including hotlines, community canvassing using outreach worked or other paraprofessional personnel cross-agency reheals, and Me . . ~ . . prOVl~On OI 1ncent~es: ant 5. pr~iding social support to encourage continuation in prenatal care and, more generaRy, to increase the probabUi~ of headed pregnancies and smooth He transition into parenthood. The latter two categories include the majority of activides generally vised as "ou~eacb." In keeping with the Committees charge, a special effort alas made to examine programs in those categories. Of course, h~v programs employed only one approach, and some were -he compreben- sKe: nonetheless, programs were dassiRed by Rabat appeared to be their . . . mam emphasis. Bepresenutives of each of the almost 200 programs revere contacted by telephone, mad, or both to learn about the programs actKides and to ascertain Better they bad data that could be used to judge the programs e~ct~eness in improving participation in prenatal care. Mere possible, Eaten report Tom He programs were obtained, and in some instances

OCR for page 115
IMPROVING THE USE OF PRENATAL CARE 117 program directors were asked to develop summaries of their activities and evaluation data for the Committee. These materials were used in selecting a final group of programs for more detailed study. The main criteria used in the selection process were the adequacy and quality of program data. Consideration was also given to geographic variety, to having a mix of urban and rural programs, and to including some statewide as well as smaller scale programs. The selection process resulted in a final set of 31 programs chosen for detailed analysis. Appendix A describes all 31 and includes evaluation data from each. Only programs that were able to provide adequate descriptive and quantitative materials to the Committee by March 1988 were included in the final set of programs. Since that time, several additional programs have come to the Committee's attention, indicating that an increasing number of local communities and states are attempting to improve access to prenatal care and to determine that effectiveness of these efforts. Space and time limitations made it impossible to include these additional studies. The Committee hopes that the federal government or a private organization will continue the task begun here of collecting information on programs to improve use of prenatal care and assessing their effectiveness. It is important to emphasize at the outset that the Committee does not view these 31 programs as model projects. Although many are innovative and some quite successful, they were chosen primarily because their data and experience were highly relevant to the Committee's task, not because the Committee saw them as standards for the nation. In selecting these 31, it was difficult to define what constituted adequate data. The Committee had hoped to find several experimental programs with control or comparison groups that had been used to evaluate effectiveness. Unfortunately, few programs had been evaluated with any methodological rigor, and thus a compromise position had to be adopted. To be included in the Committee's review, a program did not have to have conducted a randomized clinical trial to test impact; however, it did have to be able to report such statistics as the number of women served and their trimester of initiation of prenatal care, and it had to have made an attempt to link changes in prenatal care utilization to program activities. The presence of a comparison group of some sort was considered highly desirable, even if only the before-and-after variety. Priority was given to programs for which a formal evaluation had been conducted, particularly if comparison groups were used. The problems with such minimal criteria are obvious. For example, if a prenatal care program was in existence before a concerted casefinding and recruitment drive, the same number of women, or even more, might have been served by the program eventually without the extra effort. Or the women might have switched from a program that did not do active case-

OCR for page 115
118 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS finding to the one that did, resulting in no overall increase in the number of women served in the community. In short, the absence of controls makes it difficult to tell whether changes really occurred and, if so, whether they were the result of a particular program. A compromise position was also adopted concerning the source of program data. The Committee had hoped that there would be a substantial body of evidence available in peer-reviewed journals (or accepted for publication) to help understand program experience in improving use of prenatal care. Many programs that could shed light on this issue, however, have not published their data, and Committee staff often had to cajole program directors into releasing findings. While several published articles are included in this review, many of the descriptions are based on reports to funding agencies or documents prepared for the Committee. As with the issues of data quality and source, careful consideration was also given to the concept of an effective program. For this review, effectiveness was defined in terms of the month of pregnancy in which prenatal care was begun or the number of prenatal visits or both. The Committee recognizes that these process measures are not as important as the outcome of pregnancy or other measures of maternal and infant well-being. As discussed in the Introduction, however, this study was limited to the narrow question of learning how best to improve use of prenatal services, taking as a given that prenatal care improves pregnancy outcome. As a consequence, programs that had assessed their impact using only birth outcome measures (such as length of gestation, birthweight, Apgar score, or infant mortality) were excluded from the final list of programs studied. A number of projects reviewed reported data on both use of prenatal care and pregnancy outcome; the Appendix, however, presents only the utilization data. THE PROGRAMS STUDIED In this section, each of the five program types is described in greater detail, and the 31 projects reviewed by the Committee are listed by category. Descriptive summaries and evaluation data from each program are in Appendix A. Programs That Reduce Financial Barriers Ample data suggest that financial barriers are a major reason why women do not seek prenatal care early or complete the recommended number of visits; this evidence was reviewed in earlier chapters. Despite

OCR for page 115
IMPROVING THE USE OF PRENATAL CARE 119 the importance of financial barriers, the Committee identified very few programs that deal with them directly. Many programs try to increase the capacity of clinics frequented by low-income women, but only a few try to provide poor women with funding for prenatal care that is simple for patients to use and providers to receive and is honored in many private and public settings. Every program identified by the Committee that takes a direct approach to reducing financial barriers is state-initiated.) Federal action has been limited to recent modest increases in the Maternal and Child Health Services Block Grant and gradual expansion of Medicaid's coverage of pregnant women. Unfortunately, data for evaluating both state and federal initiatives in this area are remarkably scant, as discussed later in this chapter. Only two programs reviewed by the Committee directly confront the financial obstacles to prenatal care: the Healthy Start Program in Massachusetts, and the Prenatal-Postpartum Care Program in Michigan. Programs That Increase System Capacity Pregnant women who want to seek care early and keep their appoint- ments have difficulty doing so if they live in areas with few private practitioners or publicly financed facilities, or if local providers are unwilling to accept Medicaid clients or to provide free or reduced-cost care to uninsured women. In response, many states, counties, and cities have tried to improve access to prenatal care by increasing the basic capacity of the prenatal care system used by low-income women. Initiatives include expanding existing clinic facilities, opening new ones, or paying private providers to care for uninsured women. Such efforts frequently occur in areas where services are plentiful for more affluent women, particularly those with private insurance. This approach to increasing the use of prenatal care has a long history. The Maternity and Infant Care Projects, initiated by the federal govem- ment in 1963, often involved opening clinics where none existed or expanding existing facilities so they could accept more indigent patients. Four more recent examples of this approach were examined by the Committee: 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 York.

OCR for page 115
120 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS Programs That Improve Institutional Practices Access to prenatal care may also be enhanced by revising the policies and practices that shape the way services are provided. Reform of internal operations is usually achieved when the leadership of a facility concludes that it is important to make it easier for clients to obtain care or to stay in care. Improvements might include expediting registration procedures, providing interpreters, shortening the time spent in waiting rooms, offering child care and transportation, and monitoring staff courtesy. Several examples of this approach were examined: two Maternity and Infant Care Projects, one in Cleveland, Ohio, and one in three North Carolina counties; an Improved Pregnancy Outcome Project in two counties in North Carolina; an Improved Child Health Project in two areas of Mississippi; the Child Survival Project of the Columbia Presbyterian Medical Center in New York City; and a perinatal system in Shelby County, Tennessee. Programs That Conduct Casefinding Casefinding encompasses a greater variety of activities than any of the other four approaches defined by the Committee. It ranges from very aggressive one-on-one recruiting in a neighborhood to the passive use of newspapers and posters to attract women to a facility, and from traditional referral networks to the newer concepts of hotlines and incentive pro- grams. Casefinding can be divided into four categories, roughly on the basis of labor intensity. The most labor-intensive activities place womenoften called outreach workerson the streets, in housing projects, in schools and welfare offices, and in other places where pregnant women may be found. These outreach workers talk with women who may be pregnant or who may know women who are. Those not receiving care are referred to an appropriate facility. In some cases, the outreach workers task stops at that point; that is, she is responsible only for casefinding. More often, she maintains contact with the pregnant woman and provides the forms of social support described in the next section. Hotlines, while reactive, are nevertheless quite labor-intensive, espe- cially if their task extends beyond just answering questions. The hotlines studied by the Committee do just that. They attempt in several ways to ease the task of obtaining a prenatal appointment, to monitor follow- through, to help women arrange for other health and social services, and to encourage change at facilities that do not appear to be responding

OCR for page 115
IMPROVING THE USE OF PRENATAL CARE 12 appropriately to the needs of the pregnant women referred to them by the hotline. A third form of casefinding involves referrals or agency networking. In this approach, an organization offering prenatal services seeks referrals from other agencies with different mandates, such as housing assistance. The notion is that these other groups are likely to be in touch with pregnant women and may therefore have an opportunity to convince them of the importance of prenatal care, determine their care status, and refer women not yet receiving care to a provider. Social service and WIC agencies (that is, agencies administering the Special Supplemental Food Program for Women, Infants, and Children) are especially likely to be in touch with pregnant women and therefore be able to refer them for prenatal care. Pregnancy testing facilities and settings providing pediatric care are other potential sources of referral for prenatal care. A fourth, relatively new form of casefinding is the use of incentives. "Baby showers" open to the public are one example, and cash or gifts for women who come to their first prenatal appointment or who keep their appointments are others. Although European evidence on the effectiveness of incentives is inconclusive,2 several programs in the United States are experimenting with this approach. Closely related to these four types of casefinding, and often supplement- ing them directly, are public information efforts to announce specific services or programs. Such activities may be sporadic or sustained over a long period of time, and they include television and radio announcements (free public service announcements or paid spots) and announcements or educational materials in large-circulation newspapers and in neighborhood newsletters, posters, pamphlets, church bulletins, and so forth. Although their effectiveness as independent forms of casefinding may be limited, common sense suggests that public information campaigns are key elements of all serious efforts to improve use of prenatal care. Target groups need to know of existing or new services, hotlines need to be advertised, clinic telephone numbers must be widely disseminated, new clinic hours must be announced, and new forms of financial assistance must be communicated to potential recipients. It is particularly difficult to evaluate the effectiveness of casefinding activities because they are usually intertwined with such other program components as provision of free or low-cost care to poor women. Many of the casefinding projects reviewed by the Committee were able to quantify where and how they found pregnant women and to show that the women identified by the program were at high risk for insufficient prenatal care by virtue of their demographic characteristics. Very few programs, however, were able to assess whether their casefinding efforts lead to earlier registration in prenatal care (or registration at all) among the women they

OCR for page 115
122 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS found; those that could were included in the Committee's review, if at all possible. Ten examples of casefinding for prenatal care were studied: the Central Harlem Outreach Program in New York City; the Community Health Advocacy Program in New York City; the Better Babies Project in Washington, D.C.; the Maternity and Infant Outreach Project in Hartford, Connecticut; the Pregnancy Healthline in New York City; the 961-BABY hotline in Detroit, Michigan; the CHOICE hotline in Philadelphia, Pennsylvania; a free pregnancy testing program in Tulsa, Oklahoma; six studies that assess the role of WIC nutrition programs in recruiting pregnant women into prenatal care; and a Baby Shower initiative in Michigan. The first four programs have collected data on the effectiveness of a wide variety of casefinding techniques, particularly the use of outreach workers to identify pregnant women not already in care. The next three are hotlines, and the remaining three programs find cases through cross- program referrals and the provision of incentives. Unfortunately, no programs of general public information and educa- tion are included in this list. The Committee learned of many efforts throughout the country to alert women to the need for prenatal care and to specific services available in a particular area. However, none was able to provide adequate information on the target populations being reached or on the program's impact on use of prenatal care. Programs That Provide Social Support Many communities reach out to pregnant women through workers who: communicate empathetically with their clients; educate women about prenatal care, labor and delivery, and parenthood; provide referrals and follow-up on such referrals to assure that needed services are actually secured; and act as advocates for their clients in such other settings as hospitals and welfare offices. These activities have been given many names social support, case management, patient counseling and advo- cacy, case coordination, and, when occurring outside a health care facility, home visiting. The services may be offered by trained social workers, public health nurses, neighborhood residents, or volunteers with various amounts of on-thejob training. The interaction may occur in the home, at a prenatal care or social service facility, in a school, or by telephone. Social support is presumed to improve pregnancy outcomes indirectly by helping pregnant women obtain quantitatively adequate prenatal care

OCR for page 115
IMPROVING THE USE OF PRENATAL CARE 123 (i.e., assisting them in keeping their appointments). Social support is also thought to improve pregnancy outcomes directly by interpreting and reinforcing provider instructions, by reducing stress through counseling and helping women become part of supportive social networks, and by educating them about nutrition, substance abuse, medications, and other topics. Numerous projects offering intense social support have been imple- mented in the past few years; the following were examined by the Committee: the Resource Mothers Program in South Carolina (for teenagers only); six additional adolescent programs, reviewed as a group; the Prenatal/Early Infancy Project in Elmira, New York; and the Grannies Program in Bibb County, Georgia. OBSERVATIONS ON PROGRAM EFFECTIVENESS As the program summaries in Appendix A indicate, considerable time and money are being spent on these programs, and the personal dedication of their leaders is impressive. The question is whether they are working. Are women seeking care who otherwise might not? Are they seeking it earlier? Are they staying in care? When hundreds of women use a new system of care, are they women who would have sought care under the old system anyway, albeit with greater financial or other burdens? When thousands of women call a hotline and are referred to providers, would they not eventually have found providers themselves, perhaps after a more difficult search? The answer to these questions must take into account the fact that the women who are easiest to bring into care are already in care. With each new woman enrolled, it becomes more difficult to draw women from the pool of the unenrolled. Clearly, the challenge faced by all these efforts to improve utilization is formidable. Equally clear is that data on which to judge program effectiveness are rarely excellent and often inadequate. Most programs have no funds for evaluation; when unrestricted dollars are available, service demands usually take precedence. Even the few evaluated programs reviewed by the Committee seldom used randomization techniques or other strong re- search designs to assess program effects. Selection bias, in particular, clouds most evaluations. Moreover, because many programs are complex, it is often difficult to distinguish the impact of individual elements. This is not to say, however, that no judgment can be made regarding program effectiveness. The project data summarized in Appendix A, along with numerous discussions with program staff (both in the 31 programs

OCR for page 115
124 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS reviewed and in many others), have led the Committee to conclude that each of the five program types can succeed in bringing women into prenatal care early and in maintaining their participation. With a consid- erable commitment of resources, participation in prenatal care can be improved, whether measured by month of registration or number of prenatal visits. It is nonetheless true that the success of many programs is modest, primarily because they are anomalies in a complicated, fragmented "non-system" of maternity services characterized by pervasive financial and institutional obstacles to care. More specific conclusions can also be drawn about the five individual program types. With regard to the first categoryremoving financial barriers to care the Committee was struck by how few programs could be identified that take this direct approach to improving participation in prenatal care, despite the overriding importance of financial obstacles. As noted earlier, most try to ease financial barriers by enlarging the clinic system relied on by low-income pregnant women, rather than by enabling them to use provider systems already in place, including physicians in private practice. The Michigan initiative is unique in its legislative guarantee of access, but the Massachusetts Healthy Start Program stancis out as the one that has gone the furthest in removing financial barriers to care. The financial eligibility criteria are very liberal, women can seek care from the provider they choose (if willing to accept Healthy Start clients), registration is simple, and there is no welfare stigma. The initial evaluation suggests this is a promising approach to reaching high-risk women, particularly the working poor without available cash or health insurance. Existing ties to private providers and dislike of the welfare system may make them unwilling to use a clinic and thus cause them to delay seeking care or to seek it only sporadically. The Massachusetts program seems especially well designed to overcome such problems. The reluctance of most states to attack directly the financial barriers is unfortunate; they are the primary factor in limiting use of prenatal care. It is not surprising, however, given legislators' concern over the costs of entitlement programs. Massachusetts' experience with a provider- and consumer-acceptable and easily administered program may well lead other states in this direction. The program data also suggest that increasing the capacity of the prenatal care systems relied on by low-income women can improve utilization among this population. Three of the four programs studied by the Committee in this category were able to provide data suggesting improvements in use of prenatal care. It is noteworthy, though, that not all were able to enlist the full cooperation and assistance of the private sector. Although some physicians in private practice can be persuaded to care for poor women through various administrative improvements in Medicaid

OCR for page 115
IMPROVING THE USE OF PRENATAL CARE 125 and through other inducements, most capacity expansion is accomplished through publicly financed facilities and with the leadership of the public sector. The use of nurse-practitioners, certified nurse-midwives, and other midIevel practitioners is often central to these programs. This emphasis derives from their proven ability to work well with low-income, often high-risk clients; the probability that program costs will be less if physicians are not relied on exclusively; and the difficulty in some communities of finding physicians willing to work in public clinics or with low-income women. With regard to the third program type revising internal procedures and policies- the Committee found very persuasive data that such insti- tutional modification can improve the use of prenatal care substantially. The six programs reviewed underscore the importance of the way in which prenatal care is actually organized and offered to individual women how clients are treated, what the clinic or office procedures are, and what the atmosphere of the setting is. This is by no means an original observation it was presented in 1976 in Doctors and Dollars Are Not Enough3 but the value of institutional self-examination has not been taken to heart in many settings. All too many anecdotes describe service policies and procedures that discourage use of prenatal care rather than facilitate it. The startling results of modifications in the method of determining Medicaid eligibility at Columbia Presbyterian Medical Center show what can be accomplished by individuals who are willing to face the possibility that"the enemy is us.', Indeed, the Committee found great reluctance to change institutional arrangementsto meddle with existing systemsas a way of increasing participation in prenatal care. It is unclear whether this hesitation is the result of negative experiences in dealing with large bureaucracies, prob- lems in relationships between the nonphysicians who develop many of these programs and the physicians who provide the care in them, or other factors. Whatever the reason, the reluctance is clearly present. Complaints from pregnant women about long waits in clinics, rude staff, and lack of continuity of care are seldom addressed directly by the physicians in charge; more often a new facility is opened or superficial changes in clinic practices are made. The 10 programs with data on casefinding for prenatal care the fourth program typepresented the Committee with a wealth of data and impressions, not the least of which was the enormous creativity shown by many program leaders in devising ways to identify pregnant women and draw them into care. Interest in these programs was dampened, however, by a deep sense of unease that pervaded the Committee's assessment of them. Given the multiple financial barriers to use of prenatal care, the inadequate capacity of many existing services, and the inhospitable

OCR for page 115
26 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS institutional practices described repeatedly throughout this report, the question continually arose: Casefinding for what? If care is not readily available or suited to the target population, what can casefinding hope to accomplish? How can it compensate for 6-week waits for an appointment, inaccessible clinic sites, or providers unwilling to take Medicaid clients? How can it correct the major obstacles to care that are embedded in the inadequate financing of maternity care? These issues are developed more fully in the report's conclusions and recommendations (Chapter 59. They are noted briefly here, however, because they emerged so forcefully from the Committee's assessment of the data on casefinding. Nonetheless, the casefinding programs do offer some insights. Data from projects that conduct casefinding with outreach workers and similar personnel suggest that the number of clients recruited is often low, and cost data from the Harlem program suggest that the cost per client enrolled is very high. It is apparently not easy to identify pregnant women not already in prenatal care, particularly among the highly mobile residents of cities. Several program leaders emphasized that inner-city women are often not at home; even when they are, they are unlikely to open their doors to unknown neighborhood canvassers. They are also more likely to be victims of such other problems as drugs, prostitution, and violence, which make them unreceptive to the overtures of outreach workers. Pregnant women in rural areas, frequently isolated from others and at a considerable distance from a care facility, may be more responsive to outreach workers, but distance and inadequate communication networks limit the success of this casefinding method there as well. Nonetheless, outreach workers can sometimes find the hardest-to-reach women. Anecdotal reports from both Cleveland and Washington, D.C., suggest that periodic sweeps by outreach workers through housing projects, for example, can uncover significant numbers of pregnant women not in prenatal care. Whether these one-shot efforts lead to enrollment in care is, unfortunately, not documented. To improve their casefinding effectiveness, many projects ask newly enrolled women how they found out about the program or who referred them. Frequently, "word-of-mouth" or "friends" are cited. Other com- monly reported referral sources include cards placed in subways and buses with key telephone numbers, carefully crafted and placed radio spots, and, to a lesser extent, television spots. Program directors generally report that pamphlets, posters, and flyers are seldom cited as referral sources, although they may help to reinforce messages communicated by other means. The hotlines give a particularly positive impression. They appear to be meeting a real need and their success shows that the telephone has great potential for casefinding. When hotlines do more than provide information and referral, when they follow-up on referrals and try to solve their callers'

OCR for page 115
IMPROVING THE USE OF PRENATAL CARE 127 problems, they can help to overcome major barriers to care. The Grannies Program in Bibb County, Georgia, shows that even minimal telephone contact can improve use of prenatal care. The value of telephone canvass- ing as an alternative or adjunct to house-to-house canvassing (as con- ducted by the Better Babies Project) has only begun to be explored. Common sense suggests that this approach can have only a very small yield, but it may find some women who could not be found any other way. Of course, for women with no telephone, this casefinding method promises little help, and it is probably true that some of the women at greatest risk for inadequate prenatal care are too poor to afford a telephone. The program data suggest that casefinding through cross-program referrals can also improve participation in prenatal care. Close ties between prenatal services and both pregnancy testing and WIC sites can lead to earlier enrollment in prenatal care. On the negative side, the Committee found little evidence that incen- tives in kind or in cash brought women into care, although the amount of data available in this area is extremely limited. Programs that use this approach generally report that the women are appreciative, but program staff do not think the incentives themselves are the primary factor in initiating or maintaining care. The Committee learned that many programs are experimenting with cash payments to encourage participation in prenatal care. In a year or two, data may be available on the effectiveness of this approach. The final category of reviewed projects emphasizes social support, principally as a means of encouraging women to continue care. Program data indicate that this approach can indeed result in an increased number of prenatal visits. Populations at greatest risk for inadequate prenatal care, such as young teenagers and low-income minority women, often require significant social and emotional support, information, advice, and caring. Those providing such assistance are well positioner! to urge pregnant women to seek and remain in care and to comply with the recommenda- tions of their health care providers. Although most programs studied in this category were for teenagers only, there is no reason to believe that the efficacy of the approach is limited to this age group. PROGRAM DESIGN AND MANAGEMENT The Committee noted several design and management attributes com- mon to projects that seemed to function well and were able to provide clear descriptive and quantitative material on their activities: ~ Goals were clearly defined, well understood by everyone involved in the program, and reasonable. For example, staff understood that outreach

OCR for page 115
128 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS services were only one of the steps needed to improve pregnancy outcome and therefore had realistic expectations of what outreach could accom- plish. Most program goals could be translated into a series of quantitative measures, such as trends in first trimester registration for care, and systems had been set up to track progress toward the goals. Similarly, program activities were carefully monitored, often through computerized systems that provide basic management information and data for program evaluation. The planning phase was considered important by funders and pro- gram directors and had received adequate investments of time and money. There was a shared appreciation of the need for careful definition of target populations, needs assessment, development and refinement of manage- ment information systems, and so on. Community residents and providers were involved in program design. Significant time was devoted to establishing strong community ties, and a high level of respect was accorded community leaders, staff from local human services agencies, and local ways of reaching consensus and effecting change. Involvement of the news media was encouraged to generate support, to help communicate program goals and to convey specific messages, such as the location of a new clinic site or a new source of payment for maternity care. Basic concepts of product marketing had been incorporated where appropriate. Program leaders understood that, in some sense, they were selling prenatal care and should therefore draw selectively on the skills of the advertising and marketing worlds. Particularly in community-based programs dealing with low-income women, staff recognized the multiple burdens often facing clients and the probability that such needs as employment and English-language training were more important to them than prenatal care. Accordingly, close ties with other social services were maintained, and caseworkers were respon- sive to competing needs. In programs that employed community residents in such roles as outreach worker or hotline operator, considerable resources were investecI in recruitment, training, supervision, and support. COMMON DIFFICULTIES IN PROGRAM IMPEEMENTATION AND MAINTENANCE The Committee was struck by the amount of effort these disparate programs involve, the degree of personal dedication required of their leaders, and the difficulties many have had to overcome to make progress.

OCR for page 115
IMPROVING THE USE OF PRENATAL CARE 129 The goal of early and continuous use of prenatal care by pregnant women may seem straightforward and obviously sensible, but attaining it in the United States at present is proving to be an arduous task. Many program leaders described their struggles to implement and maintain programs. At least 14 problem areas can be defined, and, although no single program reported all of them, a discouraging number reported several. These are listed below, grouped into several clusters. Finding Financiat and Community Support Funds are rarely adequate to meet program goals, and persons who must raise money annually find the constant application or lobbying process exceedingly burdensome, adding worries about job security to the usual pressures of running a program. Similarly, it is difficult to sustain political and economic support for programs over many years. The attention span of political bodies is short, which creates a continuing problem of funding stability for projects that rely on public money. Several , . ~ . . . . ~ .. . . . . . .. program leaders noted that, although support tor"mothers and babies,, receives a lot of lip service from public leaders, efforts to translate such sentiments into ongoing legislative or fiscal support often encounter great inertia. Private sector support may be somewhat less volatile, but private foundations, in particular, are reluctant to invest in a single program for many years. These problems in securing stable financing make it particu- larly difficult to maintain a program or to institutionalize successful pilot or demonstration programs. Projects that offer clinical prenatal services (as distinct from commu- nity education, for example) can have difficulty securing funding for such other program components as more intense supervision for high-risk women, prescription drugs, certain diagnostic tests, public education, casefinding, counseling, and follow-up services. The news media can help create and maintain broad community support for a project and can help educate women about a particular program or service. But sustaining media support can be difficult. Moreover, even if the press is willing to cover a new initiative, interest lessens as the program becomes routine, at least to outside observers. One manager noted, "It's hard to have a press conference on an old idea." Raising money for the media portion of a program is notoriously difficult. Although television and radio spots may be comparatively easy to fund early in a program, such support tends to fade as the months progress. Programs that rely mainly on public funds report particular difficulty in securing money for ongoing, high-intensity, creatively packaged media campaigns about prenatal services and reproductive health generally.

OCR for page 115
130 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS The close relationship that many programs must maintain with area clinics, hospitals, and health departments can make it difficult for them to act aggressively on behalf of their clients in these settings. In particular, it can be awkward for a program to seek funding from a hospital or health department while simultaneously pointing out organizational obstacles to care within these institutions and advocating change. Recruiting and Keeping Personnel Program managers reported that outreach workers can be difficult to recruit, train, supervise, and motivate and that only the most skilled and persistent are likely to succeed. The threat of burnout is ever present and requires specific attention and support. Program directors have found that using outreach workers effectively requires major investments of time and money and that both funders and program planners tend to underestimate the challenge posed by using them. Similarly, other service systems often have little understanding of outreach workers' roles in enhancing access to health care and often do not work well with them. The tasks of outreach workers may be dangerous. It is common in inner cities, for example, for outreach workers to canvass neighborhoods or housing projects only in teams or with a security guardor both. The cost implications of such arrangements are obvious. Adequate money and time are seldom available for provider education about cultural and other differences between themselves and clients that may impede communication and compliance. Some programs report overt resistance to such training among providers, both those in the program and those in the community to whom program participants may be referred. Some program clients are hard to engage, difficult to work with, and occasionally abusive to the staff. One program manager noted: "It's hard to make the doctors and nurses like and 'reach out' to some of these women." Substance abusers in particular can put great stress on the staff. Dealing with Bureaucracies Building an innovative program into an existing system is difficult and fraught with potential turf battles. Competition for space and staff positions, for computer time, for the attention of the broader organiza- tion's leadership, and for community support creates serious tensions. New programs face major bureaucratic obstacles in hiring staff; a position for the new program may be approved but cannot be filled or hiring freezes may paralyze progress altogether until ways of circumventing such obstacles are found. Differences in responsibility, autonomy, perhaps also

OCR for page 115
IMPROVING THE USE OF PRENATAL CARE 131 in pay between the new program's staff and others in roughly similar positions in the existing bureaucracy can create suspicion and resent- ment. Worries about job security among existing staff and the discom- forts of organizational change can create a chilly environment for a new program. Long-standing tensions between, for example, state and city health authorities, health departments and local hospitals, and physicians and nurse-midwives can interfere with programs that are trying to change the prenatal care system. One program studied by the Committee has still not been successful in employing nurse-midwives in its clinical services as originally planned because of resistance by private physicians affiliated with the major hospital in the community. Planning and Sustaining Programs The start-up time of programs is often long, or at least should be long, if adequate planning and training are to be accomplished. Yet, funders are often impatient, wanting the program to begin quickly and show results soon thereafter. Long start-up periods are reported by state-level programs in particular, because they often need the tangible assistance and cooper- ation of multiple bureaucracies (accounting, welfare, personnel, and so on), many of which have no familiarity with maternal and child health services. It is hard to maintain momentum in programs dependent on high- energy founders, the charismatic people who generate fresh ideas and new programs, overcoming numerous obstacles to progress. As leaders change over time, a program's energy level often drops and the underlying rationale and essential program features can be lost. Effectiveness can also deteriorate when small, successful programs are expanded. For example, one program that began small was accepted by providers because it included a more efficient, accessible process for billing Medicaid; providers were paid promptly, and billing problems were solved relatively easily. When the program was expanded statewide, much of this billing system was lost and provider participation along with it. Other Problems The controversial issue of abortion can compromise support for prenatal programs, particularly if such programs focus on reaching women early in pregnancy. It was reported to the Committee that prenatal programs can be suspected of encouraging abortion for some clients and therefore have difficulty securing adequate support, particularly from legislative bodies.

OCR for page 115
132 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS Low-income clients often have great difficulty finding funds for labor and delivery; consequently, program staff must spend considerable time helping distressed clients locate financial aid. One nurse reported that a large proportion of her time with pregnant women is spent on this single issue, causing considerable anxiety to both herself and the client. Other topics such as preparation for parenthood or infant feeding options are sometimes shortchanged in the search for financial assistance with child- birth expenses. PROGRAM EVALUATION The Committee also found that virtually all programs struggle with evaluation- what to evaluate, how to build data collection into routine program activities, how to enlist staff in the process of evaluation when providing service is their primary focus, and, above all, how to find adequate money, staff, and time to do high-quality evaluation studies. Compounding such challenges is the fact that programs are often in a state of flux. Patient populations, the number of geographic areas in which the program operates, the nature of the services being offered- even the formschange frequently, making evaluation of impact difficult. Several programs decided in mid course to study their effectiveness more system- atically, but they were hampered by their late start and by the usual resource constraints. Tensions between service goals and evaluation were constantly evident; for example, leaders of the Resource Mothers program reported difficulty in getting staff to adhere to certain data-gathering routines or to such research methods as randomization. Perhaps most troubling of all, some programs that believed they were evaluating their activities properly were found, on closer examination, to be using inade- quate evaluation designs, yielding data of limited value. The net result of all these problems and constraints is that the quality of most program evaluation reviewed by the Committee was poor and that considerable energy was being wasted. The challenge of evaluation is formidable not only for community-based projects, but also for recent statewide efforts to reduce infant mortality and enhance prenatal care. Illinois, California, Florida, and Connecticut, for example, are deeply involved in efforts to improve perinatal care and infant survival. However, the number and complexity of the interventions within a given state, the diversity and number of settings providing the new services, problems in collecting uniform data, the time and money required to design statewide evaluation systems and to analyze the voluminous data these systems generate- such problems often result in inadequate evalu- ation or none whatever. Maternal and child health agencies within state

OCR for page 115
IMPROVING THE USE OF PRENATAL CARE 133 health departments often have a leading role in these state initiatives, but they seldom are provided with sufficient resources to evaluate the new programs they are charged with operating. SUMMARY With typical American ingenuity and energy, a great variety of programs has been organized in recent years to help women gain access to prenatal care. A careful study of 31 such programs and a more limited review of many more has led the Committee to conclude that, with adequate investments of time, money, and commitment, rates of early registration in prenatal care can be improved, as can rates of remaining in care. However, many of these initiatives are only modestly successful because they are anomalies in a complicated, fragmented maternity system with pervasive financial and institutional obstacles to care. In studying these programs, the Committee noted that management and evaluation vary in quality across the programs; with regard to evaluation in particular, quality is often poor. The Committee was particularly impressed with the effectiveness of programs that reduce fundamental financial or capacity barriers. Partici- pation in care also can be improved through programs that try to change policies at the service delivery site so that women will fee! welcomed into care, or that act as advocates for women who have encountered problems. Nevertheless, there are some women for whom a reduction in financial barriers, an increase in service supply, and a modification in policies at the service delivery level will still not be sufficient to bring them into prenatal care early and regularly. For them, certain casefinding techniques seem particularly useful, such as cross-program referrals and hotlines. Providing intensive one-on-one social support can help to keep women in prenatal care throughout their pregnancies. In considering all five program types together, the Committee noted that far more energy is going into outreach than into programs that reduce fundamental financial and institutional barriers, despite their importance (Chapter 29. If more programs focused squarely on eliminating basic institutional barriers, it would easier to define who the truly "hard to reach" pregnant women are and to target casefinding and social support programs more effectively. The effort that all these programs expend in achieving even small gains is sobering. Launching new initiatives and sustaining momentum require a tremendous commitment by program leaders and funders, and many obstacles can be encountered along the wayunstable funding, bureau- cratic in-fighting, private sector resistance, even physical danger. Indeed,

OCR for page 115
34 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS the job of drawing more pregnant women into care seems at present an overwhelming, thankless task. As one program leader mused, "We're trying to do the Lord's work and we keep finding devils." REFERENCES AND NOTES 1. See, for example, Petschek MA and Adams-Taylor S. Prenatal Care Initiatives: Moving Toward Universal Prenatal Care in the United States. New York: Center for Population and Family Health, School of Public Health, Columbia University, 1986. 2. Beukens P. Determinants of prenatal care. In Perinatal Care Delivery Systems, Kaminski M, Breart G. Beukens P. Huisjes HI, McIlwaine G. and Selbmann H. eds. Oxford University Press, 1986, pp. 16-25. 3. Doctors and Dollars Are Not Enough. Washington, D.C.: Children's Defense Fund, 1976.