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Appendix A Summaries of the 31 Programs Studiect To identify programs that might provide data on increasing and sustaining adequate use of prenatal care, the Committee and staff: reviewed survey data assembled in Spring 1985 by the national Healthy Mothers/Healthy Babies coalition; sent letters in August 1986 and March 1987 to all directors of state maternal and child health agencies, requesting assistance in identifying data on the relative effectiveness of various outreach activities in their states; contacted organizations active in maternal and child health, including advocacy groups (such as the Children's Defense Fund), foundations (such as the Ford Foundation), and professional societies (such as the American College of Obstetricians and Gynecologists); queried other organizations known to be conducting research in prenatal care, including the Alan Guttmacher Institute, the Office of Technology Assessment, the American Hospital Association, the Centers for Disease Control, and the General Accounting Office; commissioned an update of the report on statewide prenatal care initiatives issued in 1986 by the Center for Population and Family Health, Columbia University School of Public Health; commissioned a paper reviewing comprehensive service programs for pregnant teenagers funded by the Office of Adolescent Family Life Programs within the U.S. Department of Health and Human Services; ran an advertisement in The Nation's Health (newspaper of the American Public Health Association) requesting program leads; and 163

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164 APPENDIX A discussed the project with members of the public health and medical care communities, and reviewed journals and reports in which relevant material might be published. From these sources, a master list of almost 200 programs was compiled. Each program was contacted directly by telephone or mall or both to learn more about its activities and to ascertain whether it had adequate data to judge its effectiveness in improving participation in prenatal care. Written reports from projects were reviewed, and in some instances program directors were asked to work with Committee staff to develop summaries of programmatic activities and data. Out of these approximately 200 programs, 31 were selected for more intensive study and are described in this appendix. The criteria used in the selection process are discussed in Chapter 4. An important part of the program review was a workshop held in May 1987 during which the Committee talked in depth with the leaders of eight programs using varied means of improving use of prenatal care. These informal conversations provided valuable insight into the history and context of these and other programs. Program directors, particularly directors of projects not already de- scribed in the published literature, were closely involved in drafting the summaries that follow. They emphasize each program's origins, its prin- cipal activities, and evidence that it has influenced registration or contin- uation in prenatal care. Most note the year of each program's initiation, key factors in its inception, funding sources, and whether the program is still under way. Unfortunately, very few projects were able to supply the committee with data on program costs in relation to impact (that is, cost-benefit data of some type); consequently, most of the summaries do not include such information. As wfl} be evident, the program descriptions vary in length, depth, and intensity of data. This reflects the diversity of the programs, wide variations in their ability to provide clear descriptions of their activities, and differences in the amount of relevant information they could supply. Chapter 4 describes the five categories developed by the Committee to group the many programs reviewed briefly and the 31 studied in detail. As noted there, programs were classified on the basis of their major emphasis. TYPE 1: PROGRAMS TO REDUCE FINANCIAL BARRIERS The Committee studied two programs that take a direct approach to reducing financial barriers to care: the Healthy Start Program in Massa- chusetts and the Prenatal-Postpartum Care Program in Michigan.

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APPENDIX A Heatthy Start Program Massachusetts t 165 Massachusetts initiated its Healthy Start Program in December 198S. The genesis of the program was similar to that of many others reviewed by the Committee: a rise in infant mortality rates followed by the appointment of a Blue Ribbon Task Force and implementation of at least some of the Task Force's recommendations. The scope of the Massachusetts program, however, is broader than that of many of the other programs reviewed. Most programs start small, involving a limited number of providers, one city, or a few counties. The Massachusetts program started statewide and was designed to include all willing providers. Healthy Start, a joint effort of the state health and welfare departments, offers financing for a full range of maternity services for any pregnant woman who lives in Massachusetts, is not currently enrolled in Medicaid, has no private health insurance, and has a family income at or below 200 percent (originally, 185 percent) of the federally defined poverty level.* Healthy Start funds can also be used to underwrite the initial care of women who are potentially eligible for Medicaid. Once such a woman has begun prenatal care through the Healthy Start program, her financial status is reviewed carefully; if she is found to be Medicaid-eligible in fact, that financing source (rather than Healthy Start) eventually covers her prenatal care costs. The program is noteworthy for emphasizing expansion of the range of sites, including private providers, where low-income women can receive services, rather than taking the usual route of enlarging the capacity of existing settings where low-income women have traditionally received care. A pregnant woman enrolled in Healthy Start decides where she wishes to receive care, and as long as that provider is enrolled in the program, she may receive care there. Healthy Start staff believe that the program's focus on freedom of choice is one of its most important elements. Women who cannot or do not want to travel Tong distances, who have a good relationship with a current provider, or who do not want to use a particular facility have no reason to delay seeking care, because they can make the arrangements they prefer, provided that their chosen caregiver participates in the program. After completing a very simple registration process, all obstetrician-gy- necologists, family practitioners, pediatricians, medical specialists and other health care providers, health centers, hospitals, laboratories, and *As this report is being written, Massachusetts has raised its Medicaid income eligibility ceiling to 185 percent of the federal poverty level. This expansion will result in about 80 percent of Healthy Start clients being transferred to the Medicaid program. The state has also passed landmark legislation that significantly expands the availability of health insurance to all state residents.

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166 APPENDIX A pharmacies are eligible for reimbursement for services provided to Healthy Start participants. The registration procedure is intentionally less cumber- some than that required to become certified as a Medicaid provider. Registration has also been made easy for the woman. She may apply through her care provider or by calling a statewide toll-free number (1-800-531-BABY). The application form can be completed at home and mailed in, thus avoiding any "welfare taint" that can accompany applying for Medicaid. Healthy Start covers all "medical care necessary to maintain health during pregnancy" plus one pediatric visit. Although the program does not require a particular type or "package" of care, women who call the project's 800 number for a referral are sent, when possible, to comprehensive services in their communities. Healthy Start originally reimbursed for hospital labor and delivery costs as well, but these expenses have recently been shifted to the Hospital Free Care Pool. Providers are reimbursed at the Medicaid rate for physicians and community health centers and at the non-Medicaid Public Assistance Rate for hospitals. The average cost per program participant has been $1,100 for prenatal care and $2,200 for hospitalization. The estimated cost of Healthy Start in the 1987 fiscal year was $20.3 million. A preliminary evaluation of Healthy Start has been conducted using program records, hospital discharge data, birth certificates, focus group discussions, and informal interviews with program staff.2 One major finding is that the program has been successful in enrolling providers. As of February 1988, all hospital-based prenatal clinics, all health centers with prenatal care services, and more than 2,000 physicians and nurse-mid- wives, including 476 obstetricians (some of whom were not certified as Medicaid providers) had agreed to serve Healthy Start clients. The program enrolled 65 percent of all uninsured pregnant women and estimates that it enrolled 85 percent of the women eligible for the program on the basis of income. Forty percent of Healthy Start participants used private providers. The program's penetration has been particularly high among minorities, teenagers, the unmarried, and those with less than a high school educa- tion. Another major component of the evaluation is a comparison between Healthy Start participants and those insured under other programs or uninsured. Covering the period of July through December 1986, this analysis was made possible by the inclusion on Massachusetts birth certificates of source of payment for prenatal care. More than 40,000 birth certificates were analyzed and over 2,000 were of babies born to Healthy Start participants. In general, the evaluation showed that Healthy Start was more successful in helping women to maintain participation in care once begun than to initiate care early. Controlling for demographic differences

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APPENDIX A 167 in the composition of the various groups defined by payer status, Healthy Start participants were found to be more likely than those on Medicaid to initiate care in the first 4 months of pregnancy, but less likely to do so than those with private or other government insurance or the uninsured. Participants were also found more likely than all groups except those with private insurance or whose insurance status was unknown to have utilized care adequately, defined as 80 percent or more of the visits recommended by the American College of Obstetricians and Gynecologists (see Chapter 1), adjusted for the timing of initiation of care. The largest difference in rates of remaining in care was among the highest risk groups: blacks, teenagers, and the unmarried. These differences, suggesting that Healthy Start participants received more quantitatively adequate prenatal care, are sup- ported by comparisons of pregnancy outcomes flow birthweight and prematurity) across payor groups, which also show Healthy Start having a positive impact. The evaluators attribute the the program's success in improving pregnancy outcomes to its emphasis on enhancing the conti- nuity and content of care, greater participation among program enrollees in programs such as WIC, and decreased maternal strain because the program reduces worries about paying for maternity care. Prenatat-Postpartum Care Program Michigan3 In 1981, Michigan recorded an increase in its rate of infant mortality, a development that many experts in the state linked to the recession during the early 1980s and the resultant loss of health insurance by many families and individuals. To address this increase, the governor established a Director's Special Task Force on Prenatal Care. In 1984, this group released its findings and recommendations in Prenatal Care: A Healthy Beginning for Michigan's Children. The major recommendation of the report was that the state establish a program to finance prenatal care for women who were ineligible for Medicaid and had no private health insurance that is, the uninsured, many of whom worked in jobs that provided no health insurance or were married to men who had lost their jobs or health insurance during the recession. Receptive to this recommendation, the state legislature passed a bill in 1984 that established the Prenatal-Postpartum Care (PPC) Program and in 1986 declared prenatal and postpartum care a "basic health service" in state law. As such, these services are to be made available and accessible to all state residents in need of the services without regard for place of residence, marital status, sex, age, race, or inability to pay. In fiscal year (FY) 1984-198S, about $2.5 million was allocated to begin phasing in the PPC program; for FY 1985-1986 and FY 1986-1987, $5 million dollars was provided. By 1988, the appropriation had grown to $S.9 million.

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168 APPENDIX A The program began enrolling clients around January 1, 1985. It covers women at or below 18S percent of the federal poverty level who are not enrolled in the Medicaid program. In addition, as in Massachusetts, funds may be used to underwrite the cost of early prenatal care for women who may become Medicaid recipients later in their pregnancies. Once Medicaid eligibility is established, Medicaid funds are used instead of PPC monies. Services covered include medical care during pregnancy (using ACOG standards) and one postpartum visit. Also included are outreach and referral to prenatal care, nutritional and psychosocial assessments, vita- mins, routine laboratory procedures, patient education, and referral for high-risk prenatal services; limited reimbursement is available for special tests, procedures, and medications. It is important to note that the PPC program primarily reimburses for a basic package of low-risk services. Women at high risk of poor pregnancy outcomes require additional nursing, nutrition, and social work services. These ancillary services have historically been available in some geographic areas through the state health department's Maternity and Infant Care (MIC) Projects and its Infant Health Improvement Projects (IHIP). Health departments in these areas use PPC and either MIC or IHIP funds to provide a more compre- hensive set of prenatal services. PPC does not guarantee availability of care in a woman's county of residence or by a woman's provider of choice; it does not pay for inpatient care, nor does it pay for most special services that a high-risk pregnancy might require. The program originally did not include payment to physicians for labor and delivery services; however, such payment was added January 1, 1988. The PPC program is administered through the Michigan Department of Public Health and its 48 local health departments. Local health depart- ments either contract with area providers "private physicians, hospital clinics, health maintenance organizations (HMOs) or others] or, less often, provide the services themselves. Participating prividers must agree to offer the specified services and to accept Medicaid patients (to ensure continuity of care for those PPC women who become eligible for Medicaid during the pregnancy). Providers are reimbursed on a global fee basis, now including labor and delivery services, as noted above. During the first full program year, 1985, 32 of the state's local health departments adopted the PPC program. By October 1986, 47 had. It is not known how many providers statewide have contracted with these local departments to provide care or what proportion were private physicians, hospital clinics, HMOs, or others. However, a recent survey conducted by a regional arm of the Michigan Healthy Mothers, Healthy Babies Coalition found that in 27 counties composing roughly one-third of the state, 33 percent of all prenatal providers accept Medicaid patients, and 26 percent accept both Medicaid and PPC. Leaders of the PPC Program report that

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APPENDIX A 169 some local health departments have been very successful in drawing individual providers into the program; others have had more trouble, particularly in areas with a limited number of settings offering prenatal care. In these areas, local health departments have tried to enlarge basic system capacity or to develope alternative provider systems, such as nurse-midwifery clinics. In 1986 the state health department and state Medicaid agency gave funds to several local health departments to address problems in system capacity, particularly those caused by the growing liability crisis. These grants could be used either to underwrite a portion of the physician's liability premium for each PPC or Medicaid client served or to establish nurse-midwifery clinics in areas with few or no providers. One county established such a clinic. All local agencies reported that under- writing liability premiums helDed keen Droviders participating in the - r -A r r ~ 1 ~ program. Data on the use of prenatal care by program enrollees are available for 198S and 1986. In 1985 about 2,500 women participated in PPC; 47 percent began prenatal care in the first trimester of care and 18 percent began in the third. In 1986 enrollment grew to 6,000 women; S5 percent began care in the first trimester, and 10 percent began in the third. In 1987 enrollment grew to 8,350 women. Data are not yet available on this group's patterns of care. Although there are no baseline data against which to evaluate these statistics, the program appears to have increased marginally the percentage of women seeking care early in pregnancy. Program leaders report that, between 1985 and 1986, many program procedures were smoothed and administrative problems eased. The program became better known among social service workers and health professionals generally. News of the program spread by word-of-mouth, and the various techniques used to publicize the program became more extensive and better organized (the baby showers program and the 961-BABY hotline, described later in this appendix, both included PPC as one of their referral listings). In particular, the number of local health departments participating in PPC increased significantly between 198S and 1986. TYPE 2: PROGRAMS TO INCREASE SYSTEM CAPACITY Four programs were studied that improve use of prenatal care by expanding the capacity of the clinic systems relied on by low-income women for their prenatal care. The four are: the Obstetrical Access Pilot Project in 13 counties in California; the Perinatal Program in Lea County, New Mexico; the Prenatal Care Assistance Program in New York State; and the Prevention of Low Birthweight Program in Onondaga County, New

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170 APPENDIX A York. The first two in particular emphasized developing services for poor women where few had existed for this population before. Obstetucat Access Pilot Project- Californian The Obstetrical Access Pilot Project (OB Access) was developed in the late 1970s in California to address the fact that, despite the enactment of Medi-Cal (the California Medicaid program), serious gaps existed in the availability and extent of perinatal services for low-income women, particularly in certain geographic areas and ethnic groups. The proportion of California obstetricians who accepted Medi-Cal patients actually de- clined from 65 percent in 1974 to 46 percent in 1977. Patients and communities complained that many low-income women, both those eligible for Medi-Cal and others were experiencing severe problems in finding physicians with formal training and experience in obstetrics. Also, an increasing number of physicians were complaining about their inability to provide adequate care at the prevailing Medi-Cal reimbursement rates. In 1977, an emergency statute was enacted to revise physician reimburse- ment and stimulate Medi-Cal provider participation in primary and maternity care. By 1979, however, it was clear that the initiative was not having the desired effects, and a formal legislative resolution was passed so stating. In the wake of this incident, the OB Access Pilot Project emerged (1) to provide better access to comprehensive and early obstetric services for Medi-Cal eligible mothers in areas where there were no obstetricians or where providers declined to participate in Medi-Cal and (2) as a conse- quence of improving access, to reduce the incidence of Tow birthweight and the associated incidence of perinatal morbidity and mortality. OB Access was a pilot program to test the feasibility and impact of providing reimbursement for a comprehensive package of perinatal services under Medi-Cal. The project operated for 3 years (1979-1982) and registered almost 7,000 women. OB Access' comprehensive care included psychosocial and nutritional assessments, perinatal education (hearth, labor, delivery, and parenting education), and an initial outpatient well-baby examination, in addition to routine antepartum, intrapartum, and postpartum care (11 recommended examinations), prenatal vitamins, and routine laboratory tests (generally blood and urine analyses). The assessments determined what, if any, psychosocial, nutritional, or educational risks were present; when prob- lems were detected, counseling was provided and referrals to other services were made as needed. Formal birth education classes were also provided. Following an application and review process, seven community clinics and four county health departments (one in collaboration with a university

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APPENDIX A 17 hospital) were selected as OB Access providers. These were located in obstetrically underserved areas and appeared to be able to provide the amount and range of services specified. All the sites used a variety of methods to inform pregnant women of their programs. These included public service announcements on radio and television, newspaper articles, informational brochures, community meetings, and the casefinding efforts of welfare workers. The evaluators commented, however, that "the most effective method appeared to be word-of-mouth from patients who were satisfied with the care that they were receiving." A fulI-scale evaluation of OB Access was conducted. With regard to initiation of care, evaluators found in the OB Access counties a reduction in the weighted average percent of inadequate care among pregnancies terminating in a live birth, from 10.1S percent in 1978 to 5.49 percent in 1982, a 45.9 percent decrease. (Inadequate care was defined as care begun in the third trimester, no care, or unknown care.) During the same period in the entire state, the percentage with inadequate care dropped from 10.0 percent to 6.60 percent, a 34.0 percent decrease; the reasons for this statewide decrease have not been defined. A second analysis compared the percentage of OB Access participants who received care in the first trimester with a matched group of Medi-Cal women. The results were negative, that is, the percentage of women who began care in the first trimester was higher in the Medi-Cal group. The evaluation also suggested that the project had reduced the rate of low birthweight among program participants, which in turn formed the basis for benefit-cost analyses. It was estimated that every new dollar spent on OB Access services would save between $1.70 and $2.60, principally through reduced expenditures for neonatal intensive care. These estimates did not include any additional state administrative costs or start-up costs. The cost-effectiveness data in particular convinced the California legis- lature to extend the program. In 1984, a bill was passed establishing the Comprehensive Perinatal Services Program, which requires that OB Access services be made available to all pregnant women enrolled in Medi-Cal. A closely related program currently in operation is the Community-Based Perinatal Services (CBPS) Program, which provides comprehensive peri- natal care (prenatal care in particular) to Tow-income women (that is, women whose incomes fall below 200 percent of the federal poverty level). In 1986, CBPS served about 30,000 women. Perinatat Program Lea County, New Mexico5 One of the programs funded under the Robert Wood Johnson Founda- tion's Rural Infant Care Program was in Lea County, New Mexico, a relatively wealthy county that nevertheless had an infant death rate in 1980

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172 APPENDIX A of 19.8, 80 percent higher than the state average and among the highest county rates in the nation. Problems obtaining prenatal care, delivery services, and assistance with infants' medical problems were described in the application for funding prepared by the University of New Mexico School of Medicine (Depart- ment of Pediatrics). It was the horror story found only too often in underserved areas. Many physicians required patients to pay in advance for prenatal care, even if they had insurance. This meant that a woman had to find $600 to $800 before she was accepted for her first visit. The local health department provided no prenatal care, nor did its nurses make home visits. The local hospital was operated by a for-profit chain and had no outpatient prenatal clinics. The result of these limitations was that approximately 20 percent of the women who (lelivered in the local hospital were walk-ins, defined as women who came to the emergency room for delivery having had five or fewer prenatal visits or no prenatal care at all. Others chose to go to Texas for prenatal care or labor and delivery, or both, claiming that these services cost less and were more easily accessible there. A survey of barriers to prenatal care in Lea County showed that, among 92 women who had received little or no care during a recent pregnancy, financial barriers were the explanation most commonly given. Foundation funding made it possible for the medical school, working with the community, to develop ways to reduce infant mortality and increase access to prenatal care. A proposal to have the local health department operate prenatal clinics was turned down by the local physi- cians. According to the physician who coordinated the foundation grant, the local physicians argued that a county as wealthy as theirs would have few medically indigent families. They believed that those women who did not receive adequate prenatal care probably lacked motivation or educa- tion or both, and that other factors not associated with financial need accounted for the poor enrollment in prenatal care. A health department clinic, therefore, might compete with the private sector, attracting women who could afford private care but chose instead to use a "government giveaway program." Furthermore, local physicians were adamantly op- posed to having a nurse-practitioner or other nonphysician provide prenatal care, as some had suggested. An alternative plan was suggested by the community physicians and implemented in December 1980. Two women were employed to identify pregnant women in need of prenatal care (casefinding), to provide transportation, translation, and follow-up services for the women and their infants, and to serve as community health educators. Potential program participants identified by these community workers were then interviewed by a community coordinator to establish financial eligibility, to identify medical and social issues that required referrals, and to function as a

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APPENDIX A 173 liaison among the various program components. More than half of the physicians with obstetrical privileges at the local hospital agreed to care for eligible women in their offices on a sliding fee schedule, or without charge, if necessary. Medically indigent women were assigned to these physicians on a rotating basis for both prenatal care and delivery. The health `department did pregnancy testing and routine laboratory work and distributed prenatal vitamins and iron. The March of Dimes and the Levi Strauss Company provided funds for supplementary services and prescrip- tion drugs. Additional funding was also provided by the state's Crippled Children's Services agency to finance the program and to support program evaluation. It soon became apparent to the private physicians in the area that the unmet need for prenatal care among indigent women was significant and beyond their capacity or willingness to accommodate. It was not uncom- mon, for example, for women referred to private physicians by the community coordinator to report a 3- to 4-month waiting time for a first prenatal appointment, because the private physicians limited the number of indigent patients they would accommodate. Accordingly, about a year and a half after the community workers were initially funded, the health department was encouraged by the private physicians to hire a family nurse-practitioner to offer prenatal services at two field health offices run by the county health department. The nurse-practitioner referred high-risk women to the private physicians for prenatal care; county funds were made available to pay for such specialized care. In addition, the obstetrical staff at the local hospital voted to require physicians who agreed to care for high-risk indigent women with payment provided by the county to serve periodically as attending physicians in the health department prenatal clinics. This new service was soon saturated with women seeking care who had formerly remained outside the maternity system, thereby lessening the need for direct casefinding, except in some areas, such as trailer parks, occupied by exceedingly poor, socially isolated families. Direct measures of the impact of these initiatives on, for example, trimester of registration in prenatal care are not available; however, the program reported that by 1984 the percentage of walk-ins at the local hospital (virtually the only hospital available for maternity care in the county) had fallen to 5 percent from the 1979 figure of 20 percent. Program staff believe that the availability of providers willing to accept some low-income women and the institution of new clinic services were probably the keys to this apparent change in prenatal care use, not the casefinding activities. As the program director noted, "Word of mouth makes complicated identification of patients unnecessary." Increasing social support through home visits from the outreach workers and other

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HINDS ~ 199 He Ho groups was about He same, but the OU3HC group bad about bag He proportion of black women Hat the project group did (16 percent versus 30 percents Based on this difference, women in the OU3HC group would be expected to register earDer in prenatal care than women in He patient suffocate group. Nonetheless, 51 percent of the special intervention group registered far prenatal care in He brat trimester, compared to 29 percent in He OU)HC group. Hong Ibid women, He percentages were 51 versus 30: among black ~omen, 47 versus 26: and among teenagers, 47 versus 28 percent. ~~ougb selEselechon issues and Misdone about the comparabih~ of the groups loom large in this project ~ reasonable conclusion is that this Bee pregnancy testing service coupled Aim social support probably contributed to earDer registration in prenatal care. Tulsa area officials share this generally postage view of He program and bee provided far a years conOnuadon, ~~ougb He program teas been raised. For example, at present, paid stag bee replaced volunteers as patient advocates. The Speci~I SKI Food Prom ~men, 1 ~~d Children HO 3~ SfuJic~ One of the o~ect~es of the SAC program ~ to ensure Hat pregnant women recede adequate prenatal care. SAC agencies are rewired to check that pregnant women are obtaining care and to refer Hem if Hey are not: in a paraDel Euro prenatal chnics oRen stem Hat linking pregnant women to SAC services ~ one of their Unctions. Consequently, in communizes Obese SAC ~ Hatable, women might be expected to seek prenatal care Barber by virtue of close reheal links. Similarly, women Ho obtain prenatal care at bcHides Hat also house the TIC program might be expected to keep more of Bed prenatal appointment if the appointment mere scheduled on the days they could obtain TIC vouchers. (A recent Department of Realm and Human Services pubUcabon, leaving ACE ~C Coo~inchon, provides numerous suggestions far improving He relationship between these Ho agencies: ~ also includes case report of eight sate programs. Several studies bee explored the relationship between participation in TIC and use of prenatal care. The largest is ~sb's historical study, rabid, beginning in 1972 Nab He Commodity Supplemented Food Program and extending through 1980, linked He proportion of eligible pregnant~omen sewed each year by He TIC program in individual counties ('~C penetration") to levels of prenatal care far the same county and year.25 A sutisUcal~ signiRcant relationship was Lund between TIC program penetration and bow hcst-~imester regis~adon and bigher numbers of void. The beneR~ were greatest among women with less education Sub

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200 APPENDIX A concluded that the WIC program is an inducement to and a vehicle for achieving greater use of prenatal care. More recent studies have confirmed this conclusion. Among Massachu- setts women who delivered in 1978, those who participated in WIC, as compared to a non-WIC group matched by age, race, parity, education, and marital status, had a higher number of prenatal visits (11.8 versus 10.8) and started care earlier (2.7 versus 2.9 months).26 These results were all statistically significant, although they may not be programmatically meaningful. There was a large difference, however, in the percentage with inadequate care, as measured by the Kessner index (3.9 percent in the WIC group versus 7.0 percent in the non-WIC group). Schramm conducted two studies of Missouri women who delivered in the early 1980s. The first study was of women enrolled in Medicaid who delivered in 1980.27 In this analysis, with no variables controlled, women on WIC were less likely to have had inadequate prenatal care (defined by a combination of frequency of visits and number of weeks pregnant) than those not on WIC (39.1 percent versus 41.S percent). In a 1982 replica- tion, the percentage of WIC participants receiving inadequate prenatal care had been reduced to 35.4, while the percentage of non-WIC had increased to 44.8. Schramm suggested that the increased difference might reflect an improvement in referral patterns among WIC providers or changes in the types of mothers participating.28 Stockbauer also published two studies of Missouri births, but the analyses were not limited to women enrolled in Medicaid and were adjusted for race and education. In a study of 1980 births, the percentage of mothers obtaining inadequate prenatal care was higher in the WIC than in the non-WIC group (32.8 versus 29.59.29 However, in a 1982 replication that controlled for a larger number of variables, the percentage receiving inadequate prenatal care was lower in the WIC group overall (30.4 percent versus 31.7 percent), significantly lower among blacks (32.1 percent versus 37.9 percent), but slightly higher among whites (29.S percent versus 28.4 percent).30 Baby Showers Seven Counties in Michigan3i The Detroit-Wayne County Infant Health Promotion Coalition not only organized the 961-BABY hotline described above, but also sponsored a series of community baby showers. These events were directed at identi- fying pregnant women early in pregnancy, enrolling them in a compre- hensive prenatal care program, and sustaining their enrollment. They were also designed to identify women with infants in need of pediatric care and related social services.

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APPENDIX A 201 In essence, the showers were casefinding and health education sessions that were open to the public and that included prepared presentations, small group discussions, and opportunities to make appointments on the spot for selected maternity, pediatric, and social services. In addition, various gifts, door prizes, and other incentives were offered throughout the day in order to create a baby shower atmosphere, encourage attendance, and underline the health education messages. In each county, the showers were publicized in advance by such efforts as door-to-door canvassing, direct mailings, posters, public health nurses' spreading the word, local McDonalds and grocery stores handing out shower invitations, billboards, car signs, "Mother's Day" sermons in target area churches, school presen- tations, and poster contests. Eight showers were given in seven counties from October to December 1985. Attendance at the baby showers varied from 287 in Detroit to 34 in one county, for a total of 689. Approximately half the participants were black and more than a third were teenagers. Almost 70 percent of attendees were pregnant (478), but only 3 percent (21 women) were not receiving prenatal care already. Nonetheless, 74 prenatal appointments were made at the baby showersa few for the women not in care, but most for those who stated they were already in care but who, in the opinion of the shower sponsors, required additional supervision. An additional 148 appoint- ments were made for a variety of other services, including pediatric care, WIC, family planning, and social services. No information is available on the percentage of appointments actually kept. Although the showers may have provided health education and social support, as well as facilitating the use of some services, their value as a casefinding too! for pregnant women not already in care was clearly limited. Anecdotal reports from similar efforts in California suggest greater casefinding success from this type of activity. The director estimates that the eight showers cost about $32,000 in the aggregate, not counting the substantial in-kind contributions of the sponsoring agencies and volunteers. One major value of the showers may be that they increased the involvement of various church and community groups in issues of infant mortality and maternal health. This consciousness-raising function for the middle-cIass organizers of the events included a new appreciation of the problems faced by low-income women in securing prenatal and pediatric health care. TYPE 5: PROGRAMS THAT PROVIDE SOCIAE SUPPORT Many projects offering intense social support to improve pregnancy outcome have been implemented in recent years. In this section, several

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202 APPENDIX A are described beginning with the Resource Mothers Program in South Carolina, which focuses exclusively on adolescents. Following this is a summary of six additional comprehensive programs for pregnant adoles- cents. The section concludes with a description of the Prenatal and Infancy Home Visiting Program in Elmira, New York, and a brief note on the Grannies Program in Bibb County, Georgia. Resource Mothers Three Counties in South Carolina32 The Resource Mothers (RM) Program began in 1981 as a component of the Robert Wood Johnson Foundation's Rural Infant Care Program. It was originally confined to a three-county area, the Pee-Dee, which is very poor and rural, with few adequate health facilities and a postneonatal mortality rate (deaths that occur between 28 days and 12 months of age) in 1980 that was the highest of all 200 Health Service Areas in the United States. The RM Program is for teenagers under 18 who are pregnant with their first child. The project emphasizes social support, health education and information, and general assistance offered by a Resource Mother. Teen- agers are referred to the program by schools, health departments, private physicians, service agencies, civic and church groups, and peers. The Resource Mothers themselves are all mothers (many were pregnant as teenagers), high school graduates, and residents of the target counties. According to the project director, they are chosen on the basis of"personal warmth, successful personal parenting experiences, knowledge of commu- nity resources, demonstrated ability to accept responsibility, evidence of natural leadership, ability to use written and spoken language effectively, and subtle interpersonal skills." Resource Mothers participate in a 6-week training course. In addition, there are biweekly continuing education sessions and patient reviews with a social worker supervisor. The average caseload for a Resource Mother is 30 to 35 pregnant and postpartum teenagers. Resource Mothers visit the participating teenagers at home or in other settings during pregnancy, in the hospital at the time of delivery, and during the first year postpartum. Visits are scheduled more often if there is a crisis. Although the visits are very structured, with a well-defined approach and specific content to be covered at each session, the Resource Mothers are encouraged to get to know the air! and her family very well to become involved. They make sure that appointments are kept, providing transportation if necessary, and that recommendations from physicians and others are followed. The program has been the subject of several evaluations, many of them focusing on reductions in low birthweight and improvements in infant development, since those are major goals of the program. The Committee,

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APPENDIX A 203 however, reviewed only those studies that examined use of prenatal care. One retrospective analysis compared a sample of RM women with matched controls drawn from the same counties. Women in both groups had a first, live birth (single) during the 1981-1985 interval. Using birth certificate records, controls were selected from women under 19 who had no known previous pregnancy; matching variables were year of delivery, county of residence, and race and sex of the child. Adequate controls were found for 519 of 575 RM cases. Of the RM clients, 17.S percent evidenced inadequate prenatal care (fewer than five visits or care begun after the sixth month o pregnancy) versus 24.S percent of the controls; the RM women averaged 8.6 prenatal visits versus 7.9 for the controls.33 Because of concern that selection bias limited the validity of these observed differences, a second retrospective analysis was conducted in which the controls were drawn from different counties that were nonethe- less sociodemographically comparable to the Pee Dee area in which the RM Program operated. The study matched 565 women who had participated in the RM Program between 1981 and 1985 with women from nearby rural counties who also had first, live births (single) and no previous pregnan- cies; variables matched were year of delivery, maternal age, and child's race and sex. Of RM patients, 18.3 percent had received inadequate prenatal care versus 3S.9 percent of the controls.34 The program still operates in the Pee Dee and has been expanded to other areas of the state as well. At present, some 16 Resource Mothers are at work in 20 counties, financed primarily by federal funds. Although state funds have been sought, few have been provided. Program leaders claim that state officials seem favorably impressed by the project, but thus far competing demands for public dollars have been too strong to allow RM much state support.33 Comprehensive Service Programs for Pregnant Adotescents- A Summary of Six Programs35 36 Because the needs of pregnant adolescents are so great, many commu- nities have developed comprehensive programs to meet them. Such programs usually include, at a minimum, educational, social, and medical services in one facility or by referral. These types of programs have been encouraged and sometimes funded by the federal Office of Adolescent Pregnancy Programs. As with most of the services described in this appendix, few comprehensive adolescent programs use only one method to draw teenagers into prenatal care and sustain their partici- pation. The three most commonly employed by the six programs described in this section are improving institutional arrangements, casefinding, and social support. The six projects summarized are the

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204 APPENDIX A Teen Mother and Child Program at the University of Utah School of Medicine; Youth Health Services in Elkins, West Virginia; the Teenage Pregnancy and Parenting Project in San Francisco: the adolescent program of the Visiting Nurse Association of Manchester and Southern New Hampshire; the Ethnic Adolescent Family Life Project in Provi- dence, Rhode Island; and Johns Hopkins Hospital's Adolescent Preg- nancy Program in Baltimore. Improving Institutional Arrangements Adolescents frequently have difficulty using health services designed for older women. Hours may conflict with school, the site may be clifficult to reach without a car, education may be minimal, and provider attitudes may be negative. All of the six programs address such issues by holding separate clinic sessions for teenagers, emphasizing continuity of providers, holding special group educational sessions, and so on. Some programs use vans to pick up clients at home and take them to sessions. A program serving rural adolescents provides transportation to and from the program site, the prenatal clinic, the WIC office, and other agencies. An inner-city program has developed a prenatal clinic in a school, providing medical care, prenatal education classes, and counseling and referral. Two programs have nurse-practitioners providing routine prenatal care because of their special skills in working with this age group. Other programs use nurse-practitioners for educational sessions and support during labor. One program provides in-home nursing care to adolescents between medical appointments. The visiting nurses provide routine health assessments, counseling, and prenatal and parenting education. Casefinding Programs for adolescents rely heavily on referrals from current and former clients. Clients are educates! to the need for such referrals. In one program, if an adolescent is missedthat is, not identified at an appropriate timethe staff asks currently enrolled clients how they could have found her earlier. Schools are an obvious source of referrals for adolescents. One program stations workers in two inner-city high schools 1 day a week. Students who have been identified as pregnant by a teacher or school nurse or who are suspected of being pregnant are seen by the worker during school time and helped to register for care. Pregnancy testing sites are also used to locate pregnant adolescents. One program continually reminds private physicians of its presence in order to obtain referrals. Another has a counselor visit adolescents who have been referred but who have not made contact with the program. Social Support Many programs assign single individual (one program calls her a each teenage participant to a "continuous counselor") who

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APPENDIX A 205 coordinates and integrates the many services typically required by preg- nant teenagers. While such counselors have traditionally been social workers, they may also be nurses, nutritionists, or other staff members. One program director said, "We have to rid ourselves of the medical model in serving teens. Teens need to be treated as whole persons. We can't have one practitioner counseling them in the clinic and another going out to make home visits. Everybody does everything here." These case supervi- sors provide counseling, education, referrals, advocacy, and follow-up, addressing the entire constellation of client needs. They must be able to become a "significant other" for young women who lack support from family members; in some programs they are expected to be available during nonworking hours, visit homes in inner-city neighborhoods, and provide support during labor. Bilingual case supervisors are often recruited by programs serving linguistic minorities. Evaluation The six programs have all studied the results of their activities by comparing program participants to other, similar groups on various measures of pregnancy outcome and use of prenatal care; none, however, has used randomization to overcome the possibility of selection bias. Five of the six programs demonstrated earlier entry into prenatal care, more prenatal visits, or both in comparison to a control group of adolescents. Only one program (the Ethnic Adolescent Family Life Project) found that the special program group entered prenatal care later and had fewer visits than the comparison group. The Prenatal and Infancy Home Visiting Program Elmira, New Yorh37 This research and demonstration project was carried out between 1978 and the early 1980s in the target community of Elmira, which is semirural and located in the Appalachian region. In 1980 its economic conditions were rated the worst of all U.S. Standard Metropolitan Statistical Areas; its rates of child abuse and neglect were the highest in the state; and its infant mortality rate during the 1975-1977 interval, prior to the study, was 15.2 per 1,000 live births. The program was designed to prevent a wide range of health and developmental problems in children through prenatal and postpartum home visiting by nurses. A sophisticated research and evaluation plan was built into the program at the outset. Pregnant women were recruited into the program if they had no previous live births and one or more of the following additional risk characteristics: under 19 years old, single, and low socioeconomic status. Other women expecting their first babies who asked to participate were also admitted.

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206 APPENDIX A Four hundred women were enrolled, stratified by marital status, race, and geographical region within the county, and assigned at random to one of four groups: (T1) assessment of the infant but no services; (T2) services limited to infant assessment and transportation assistance; (T3) home visiting during pregnancy only, plus transportation assistance and infant assessment; and (T4) same as (T3), but visiting continued through the first 2 years of the child's life. Nurses visited families about once every 2 weeks during the pregnancy, for an average of nine visits, each of which lasted over an hour. The visits had three basic objectives: parent education, the enhancement of women's informal support systems, and the linkage of women with commu- nity services. The nurses were taught to emphasize the strengths of the women and their families. (In assessing program results, the few nonwhite women in the program and women with maternal or fetal conditions that might lead to preterm birth were eliminated from the analyses.) There was no difference between the groups visited by nurses (T3 and T4) and those not (T1 and T2) in number of prenatal care visits made by the pregnant women: both sets averaged about lO.S visits, reflecting in part the fact that prenatal services were easily available through nine area obstetricians and a free antepartum clinic sponsored by the health department. There were, however, differences between the groups visited by nurses and those not visited on several other prenatal factors. For example, the visited women were aware of more community services, attended childbirth classes more frequently, received more WIC vouchers, talked more with service providers and members of their informal networks about the stresses of pregnancy and family life, indicated that their babies' fathers showed a greater interest in their pregnancies, and were accompanied more frequently in labor. Smokers who were visited reduced their smoking more than those who were not. The program is still operating, but as the years proceed and staff change, its original clarity of purpose and energy have diminished. Supported at first with federal research dollars, it is now funded by state monies and administered through the local health department. The Grannies Program Bibb County, Georgia38 The Grannies Program provides social support via the telephone. Women who come to the Bibb County health department prenatal clinic are assigned a Granny, who calls them twice a month before their babies are born and once a month for 12 months afterward. Grannies are paid by the hour and work out of their homes. They are supervised by a part-time program coordinator. The Grannies remind patients of their clinic appoint- ments, suggest ways to obtain assistance when needed, and provide education and support.

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APPENDIX A 207 The rate of broken appointments at the clinic has fallen from about 34 percent to 10 percent since the program has been in operation. Other measures of impact, such as trimester of registration, are not available. REFERENCES AND NOTES 1. Descriptive material and data provided by the Division of Family Health Services, Massachusetts Department of Public Health; Katherine Messenger and Hannah Boulton, Massachusetts Department of Public Health. Personal communication, 1987-1988. 2. Azzara CV, Kotelchuch M, Anderka MT, Clark KS, and Robanske D. A Preliminary Healthy Start Evaluation: Interim Report for the Massachusetts Legislature. Boston: Division of Family Health Services, Department of Public Health, March 1988. 3. Descriptive material and data provided by the Michigan Department of Public Health; Janet Olszewski, Michigan Department of Public Health. Personal com- munication, 1988. 4. Maternal and Child Health Branch. Final Evaluation of the Obstetrical Access Pilot Project, July 1979-June 1982. Sacramento: California Department of Health Services, 1984; Korenbrot CC. Risk reduction in pregnancies of low-income women: Comprehensive prenatal care through the OB Access Project. Mobius 4:34-43, 1984; Lennie JA, KlunlR, and Hausner T. Low-birthweight rate reduced by the Obstetrical Access Project. Health Care Financing Rev. 8:83~86, 1987; Athole Lennie and Lyn Headley, California Department of Health Services. Personal communication, 1987-1988 S. Berger LR. Public/private cooperation in rural maternal child health efforts: The Lea county perinatal program. Tex. Med. 80:54-57, September 1984; Canfield E. The Select Panel Report a follow-up. Paper presented at the American Public Health Association annual meeting, Los Angeles, 1981; Russell RE. The first report on the Lea County survey of women who have delivered babies while residents of Lea County during 197~1981. Unpublished paper, 1982; Spice B. Program reduces infant death rate. Albuquerque Jounal, January 5, 1987; Lawrence Berger, Lovelace Medical Foundation. Personal communication, 1987-1988. 6. Description of Prenatal Care Assistance Program, New York State Department of Health, December 30, 1987; PCAP client characteristics, services, and pregnancy outcomes, New York State Department of Health, September 21, 1987; Linda Randolph, New York State Department of Health. Personal communication, 1987-1988. 7. Division of Maternal-Fetal Medicine, State University of New York and Onondaga County Health Department. Prevention of low birthweight program in Onondaga County. Proposal for funding to Department of Health, State of New York, 1983; Richard Aubry, Health Science Center, State University of New York. Personal communication, 1987-1988. 8. Sokol RI, Wolf RB, Rosen MG, and Weingarden K. Risk, antepartum care, and outcome: Impact of a Maternity and Infant Care Project. Obstet. Gynecol. 56:150-156, 1980; Elizabeth Campbell, Cleveland Metropolitan General Hospital. Personal communication, 1987. 9. Peoples MD and Siegel E. Measuring the impact of programs for mothers and infants on prenatal care and low birth weight: The value of refined analysis. Med. Care 21:58~605, 1983.

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208 APPENDIX A 10. Health Services Administration, Bureau of Community Health Services. The Maternity and Infant Care Projects: Reducing Risks for Mothers and Babies. DHEW Pub. No. (HSAj7S-5012. Rockville, Md., 1975, p. IS. 11. Ibid., p. 16. 12. Peoples MD, Grimson RC, and Daughtry GL. Evaluation of the effects of the Carolina Improved Pregnancy Outcome Project: Implications for state-level deci- sion making. Am. I. Public Health 74:549-554, 1984. 13. Strobino DM, Chase GA, Kim Y], Crawley BE, Salim OH, and Baruffi G. The impact of the Mississippi improved child health project on prenatal care and low birthweight. Am. I. Public Health 76:274-278, 1986. 14. lones]E, Tiezzi L, and Williams-KayeJ. Notes from the field: Overcoming barriers to Medicaid eligibility. Am. I. Public Health 76:1247, 1986; Jones]E, Tiezzi L, and Williams-Kaye I. Financial access: Key to early prenatal care. Paper presented at the American Public Health Association annual meeting, Washington, D.C., 1985; Judith Jones, National Resource Center for Children in Poverty, Columbia University. Personal communication, 1987-1988. IS. Rural infant deaths decline with aid of UT Memphis project. The Record (University of Tennessee Health Science Center), February 1987; Ryan GM. Papers presented at the Orange County Obstetric and Gynecological Congress, Costa Mesa, Calif., April 3, 1987, and at the Boston Obstetrical Society, March 23, 1981; George Ryan, Department of Obstetrics and Gynecology, University of Tennessee. Personal communication, 1987-1988. 16. Brooks-Gunn I, McCormick MC, Gunn RW, Shorter T. Wallace CY and Haegarty MC. Locating low-income pregnant women: The process of outreach. Medical Care, in press.; McCormick MC, Brooks-Gunn J. Shorter T. Holmes TH, Wallace CY, and Haegarty MC. Outreach as casefinding: Its effect on enrollment in prenatal care. Medical Care, in press; Margaret Haegarty, Harlem Hospital Center. Personal communication, 1987. 17. Jones I. Community health advocate program: Final report to The Ford Foundation, April 1981-September 1982; Judith [ones, National Resource Center for Children in Poverty, Columbia University. Personal communication, 1987-1988. 18. Deborah Coates and Joan Maxwell, The Better Babies Project. Personal commu- nication, 1987-1988. 19. Christison-Lagay J. The maternity and infant outreach project of the Hartford Action Plan on Infant Health. Unpublished report, 1986; Joan Christison-Lagay, Hartford City Health Department. Personal communication, 1987-1988. 20. Breitbart V and Zeitel L. Hotline As a Means to Improve Access to Prenatal Care in New York City. New York: Bureau of Maternity Services and Family Planning, New York City Department of Health, 1986; Vicki Breithart, Bureau of Maternity Services and Family Planning, New York City Department of Health. Personal communication, 1987-1988. 21. Wright TD. Evaluation of 961-BABY: A telephone information and referral service. Paper presented at the American Public Health Association annual meeting, Las Vegas, 1986; Terri Wright, Detroit/Wayne County Infant Health Promotion Coalition. Personal communication, 1987. 22. CHOICE. Hotline data report July 1, 1985-June 30, 1986, submitted to the Philadelphia Department of Public Health; Muriel Keyes, CHOICE. Personal communication, 1987-1988. 23. Jackson CI, Renner S and Lapolla M. The Use of Free Pregnancy Testing to Encourage Early Entry into Prenatal Care. Tulsa: Oklahoma Medical Research

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APPENDIX A 209 Foundation, Center for Health Policy Research, 1987; Cassandra Jackson, Center for Health Policy Research. Personal communication, 1987-1988. 24. Improving MCH/VVIC Coordination Final Report and Guide to Good Practices. Submitted by Professional Management Associates, Inc. to the Office of the Assistant Secretary of Planning and Evaluation, Department of Health and Human Services. Contract No. HHS-100-84-0069, Washington, D.C., August 1986. 25. Rush D. Evaluation of the Special Supplemental Food Program for Women, Infants and Children (WIC). Vol. I: Summary. Submitted by Research Triangle Institute to the Office of Analysis and Evaluation, Food and Nutrition Service, Department of Agriculture. Contract No. 53-3198-9-87, Washington, D.C., January 1986. 26. Kotelchuck M, Schwartz IB, Anderka MT, and Finison KS. WIC participation and pregnancy outcomes: Massachusetts statewide evaluation project. Am. ]. Public Health 74:1086-1092, 1984. 27. Schram WE. WIC participation and its relationship to newborn Medicaid costs in Missouri: A cost-benefit analysis. Am. I. Public Health 75:851-857, 1985. 28. Schram WE. Prenatal participation in WIC related to Medicaid costs for Missis- sippi newborns: 1982 update. Public Health Reps. 101:607-615, 1986. 29. Stockbauer IW. Evaluation of the Missouri WIC program: Prenatal component. I. Am. Dieter. Assoc. 86:61-67, 1986. 30. Stockbauer IW. WIC prenatal participation and its relation to pregnancy outcomes in Missouri: A second look. Am. I. Public Health 77:813-818, 1987. 31. Wright TD and O'Meara M. Community Baby Shower Summary Report: Regional Outreach Campaign, Fall 1985. Detriot: Detroit/Wayne County Infant Health Promotion Coalition, 1986; Terri Wright, Detroit/Wayne County Infant Health Promotion Coalition. Personal communication, 1987. 32. Lois Wandersman and Marie Meglen, South Carolina Department of Health and Environmental Control. Personal communication, 1987-1988. 33. Meglen MC and Wandersman LP. Perinatal impact of South Carolina's Resource Mothers Program. Unpublished paper, 1987. Reins HE Nance NW and Fer~uson lE. Social succors in improving nerinatal 34. 7 _ ~ 7 _ ~ _ To - ~ - 1 1 1 ~ ~ outcome: The Resource Mothers Program. Obstet. Gynecol. 70:26~266, 1987. 35. Cartoof VG. Increasing adolescents' access to prenatal care: A case study of six programs. Paper prepared for the Committee on Outreach for Prenatal Care, Institute of Medicine, Washington, D.C. 1987: 36. Elster AB, Lamb ME, Tavare J. and Ralston CW. The medical and psychosocial impact of comprehensive care on adolescent pregnancy and parenthood..~. Am. Med. Assoc. 258:1187-1192, 1987. 37. Olds DL, Henderson CR, Tatelbaum, R and Chamberlin R. Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics 77: 16-28, 1986; David Olds, Department of Pediatrics, University of Rochester. Personal communication, 1988. 38. Jacqueline Scott, Bibb County Health Department. Personal communication, 1987.