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Intros ti n In 1985, approximately one-fourth of all infants in the Uniter! States were born to women who did not begin prenatal care in the first 3 months (or trimester) of pregnancy; a larger proportion almost one-thirdwere born to women who did not obtain the amount of care currently recommended by the American College of Obstetricians and Gynecolo- gists.i More than S percent were born to women who began care only in the third trimester of pregnancy or had no care at all. For certain groups, these percentages were even higher. For example, only 47 percent of black teenagers began care in the first trimester of pregnancy, and 14 percent obtained either no care or care only in the third trimester.2 Unfortunately, the steady increase during the 1970s in the proportion of women who begin prenatal care in the first trimester of pregnancy has ceased in the 1980s. And in 198S, for the sixth consecutive year, no progress was made in reducing the percentage of infants born to women who begin care only in the third trimester or not at all. For blacks, the size of this group actually appears to be increasing. In 1980, 8.8 percent of black infants were born to mothers who had third trimester or no prenatal care; by 1985, this number had grown to 10.3 percent.3 These disturbing trends present important challenges to public policy and to the health care system for several reasons. First, there is widespread agreement that prenatal care is an effective intervention, strongly and clearly associated with improved pregnancy outcomes. Because random- ized clinical trials are precluded on ethical grounds, incontrovertible scientific proof of this effectiveness is not available; nevertheless, exhaus- 17

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18 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS rive reviews of the literature and recent analyses continue to document the value of this basic health service.4 5 Declines in rates of maternal mortality, infant mortality, and low birthweight have been repeatedly associated with full participation in comprehensive prenatal care that is well connected to hospital-based services for labor and delivery and for neonatal care. Available evidence suggests that prenatal care is especially important for women at increased medical or social risk, or both. The importance of prenatal care also derives from its cost-effectiveness, particularly for low-income women. For example, in 198S, the Institute of Medicine calculated that each dollar spent on providing more adequate prenatal care to a cohort of low-income, poorly educated women could reduce total expenditures for direct medical care of their low birthweight infants by $3.38 during the first year of life.6 (The savings would result from a reduced rate of low birthweight.) Other investigators have com- puted different ratios, but virtually all find evidence of cost-effec- tiveness.7-~0 Finally, the importance of prenatal care is confirmed} by international comparisons. As discussed by C. Arden Miller in the paper he contributed to this volume and by others, many countries (particularly lapan and most Western European countries) provide prenatal care to pregnant women as a form of social investment. These countries, many of them with fewer resources than the United States, have developed relatively simple, welI-functioning maternity systems. Prenatal care, like health services generally, is made readily available with minimal barriers or preconditions in place, and it is closely connected to numerous social ant! financial supports for pregnant women and young families. Such services are seen as part of a broad social strategy to protect and support childbearing and to produce healthy future generations. As a result of this comprehensive approach, many European countries report that very high proportions of their pregnant women begin prenatal care early in pregnancy; they also report lower rates of infant mortality and low birthweight. i2 While the U.S. Surgeon General has set a goal of reducing the proportion of women who obtain no prenatal care cluring the first 3 months of pregnancy to 10 percent by 1990, the U.S. Department of Health and Human Services recently acknowledged that, "based on progress to date, it appears unlikely that this objective will be met."~3 This country's limited progress in extending prenatal care is only part of a larger problem of poor access to health services for low-income and minority populations. In the face of an increasingly competitive, profit- oriented medical care system, the United States has failed to find adequate ways to finance health care for the poor. In 1988, socioeconomic status remains a major determinant of both health status and use of medical services. Moreover, there is some evidence that access to health care may

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INTRODUCTION 19 be deteriorating for poor, minority, and uninsured Americans.14 l5 Igelhart has stated: The goal of providing quality medical care to the entire population of a vast country that prizes limited government, freedom, and individualism has remained elusive. Substantial resources have been committed to the task, and many citizens are prepared to allocate more' but the results thus far have been less than socially satisfying. To many millions of Americans, access to medical care remains uncertain or unobtainable, even though the United States spends more per capita for care than any other industrialized nations STUDY FOCUS Faced with evidence of prenatal care's value and cost-effectiveness, and with data revealing poor and declining use of this key service, in the summer of 1986 the Institute of Medicine convened an interdisciplinary committee, the Committee to Study Outreach for Prenatal Care, to study ways of drawing more women into prenatal care early in pregnancy and of sustaining their participation until delivery. The Committee was asked to develop recommendations for improving participation in prenatal care, particularly through "outreach." In keeping with conventional understand- ing, outreach was defined to include various ways of identifying pregnant women and linking them to prenatal care (casefinding) and services that offer support and assistance to help women remain in care once enrolled (social support). The special emphasis on outreach grew out of several considerations. First, an earlier Institute of Medicine committee had recommended that the nature and role of outreach in increasing access to prenatal care be studied. Concluding that the field was ill-defined, littIe-understood, and undervalued, the Committee urged that efforts be made to "assemble and integrate existing information about outreach approaches and to identify additional research needs."~7 Second, many community-based prenatal care programs rely heavily on outreach to improve access, believing that it is effective in bringing women into care and maintaining their participation. Despite its potential impor- tance, however, outreach is often discontinued"cut first', when health services face fiscal difficulties. The vulnerability of outreach is not surprising, given the unwillingness of most insurance systems to cover its costs, the scant and widely scattered data on its effectiveness, its relatively low status as a health service, and the low pay and training often provided to its practitioners. Finally, the Committee was asked to concentrate especially on outreach because it has attracted so little scholarship. It was hoped that assembling

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20 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS a wide variety of materials on prenatal outreach would increase the interest of health services researchers (and those who fund their work) in studying this neglected field. The Committee's work and this volume, however, were not confined to outreach for prenatal care. The Committee realized early in the study that this service cannot not be studied in isolation from the larger maternity care system* within which it occurs and that, as a consequence, the study's boundaries had to expand beyond outreach. At least four factors led to this broadened scope of study. First, many projects labelled as outreach are deeply involved in such problem-solving activities as helping women arrange financing for hospital-based childbirth- activities that are not included in conventional understandings of outreach. Second, the goals and content of outreach programs are so heavily influenced by the larger systems within which they operate that it would have been difficult, if not useless, to analyze them separately. Third, outreach is not the only way to accomplish the goals of~earlier registration and improved continuation in prenatal care; other approaches can have the same effect and thus merit study. (These other methods include reducing financial barriers to care, making certain that system capacity is adequate, and improving the policies and practices that shape prenatal services at the delivery site.) Fourth and finally, the larger maternity care system was considered because it makes little sense to stucly ways of drawing women into care if the system they enter cannot, or will not, be responsive to their needs. In this context, one issue deserves particular attention. Although the gap between prenatal services and hospitalization for labor and delivery might be considered well outside the jurisdiction of this Committee, it is too important to ignore in any policy analysis of maternity services. Every pregnant woman needs not only prenatal care, but also a safe, well- equipped setting in which to deliver her infant. Despite the clear need for such a continuum of care, there is ample evidence that the ties between prenatal and delivery services are often tenuously In some areas of the country, for example, women may receive prenatal care at Community Health Centers or health department clinics but deliver in hospitals without their prenatal records available, simply because of inadequate systems for transferring records among providers.~9 Moreover, obtaining prenatal services floes not lead automatically to admission at a hospital of choice for labor and delivery, because many institutions require large preadmission deposits or create other barriers to admission. (For example, in Brownsville, Texas, about 40 percent of women deliver out of hospital- *That is, the complicated network of publicly and privately financed services through which women obtain prenatal, labor and delivery, and postpartum care.

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INTRODUCTION 21 compared with a 1 percent rate nationally because the area's two for-profit hospitals require large preadmission deposits and have been reluctant to contract with the state for obstetrical care for low-income women.20 ~ Similarly, state programs that fund prenatal services often do not include funding for labor and delivery. A 1986 survey of 51 state maternal and child health agencies found that few state agencies have resources to help uninsured and other poor women pay for hospitalization for delivery. Only 23 states reported that they had funding for inpatient obstetrical care; 16 reported that existing funds were restricted to women who participated in designated maternity programs or were identified as high-risk prior to delivery. No state reported a program to fund hospital services for all uninsured pregnant women.2i These major flaws and gaps in the organization of maternity services provided additional impetus for the Committee's decision to enlarge its scope of study beyond the issue of outreach. One consequence of the expanded boundaries is that the Committee's conclusions and recommen- dations (Chapter S) are not limited to outreach, but also touch on issues of maternity care financing and organization. It is important to add that even with this larger scope of study, the report focuses on a limited topic. In particular, by concentrating on maternity care, other women's health services are largely overlooked, as are impor- tant issues of women's health status. For example, the poor coordination that often exists among family planning services, sexually transmitted disease services, general medical care and maternity services is addressed only briefly in this report. Although such limits are appropriate given the Committee's mandate, it is important to acknowledge them. Women need good health care whether pregnant or not, and plans to improve maternity services should always be developed within this broader context. STUDY METHOD The Committee surveyed existing or recently completed prenatal care programs in order to understand the range of approaches currently being used to increase participation in care, and to determine if data were available to judge their effect. The programs were divided by the Commit- tee into five broad categories, and one or more programs in each category was reviewed: 1. reducing the financial obstacles to care encountered by poor and uninsured women through provision of insurance or other sources of payment; 2. increasing the capacity of the prenatal care system relied on by many low-income women, which includes health department clinics, the network of

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22 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS private physicians who care for Medicaid-enrolled and other low-income women, hospital outpatient clinics, Community Health Centers, and similar settings; 3. improving institutional practices to make services more easily accessible and acceptable to clients; 4. conducting active casefinding through such methods as hotlines, com- munity canvassing via outreach workers or other paraprofessional personnel, cross-agency referrals, and the provision of incentives; 5. providing social support to encourage continuation in prenatal care and, more generally, to increase the probability of healthy pregnancies and smooth the transition into parenthood. The last two categories include the majority of activities generally consid- ered outreach. In keeping with its charge, the Committee made a special effort to examine programs in those categories. The objective of studying a given program was not merely to understand its approach to improving access, but also to determine which activities appeared effective, with what populations, and under what circumstances. The Committee posed the question: What is the evidence that the approach leads to earlier registration in prenatal care, to participation in care by women previously unserved, to improved continuation in care once begun, or any combination of these? The Committee also examined the environment in which programs had developed, the problems they faced, and the constraints on further expansion. An important part of the Committee's review of program data was a workshop held in May 1987 in which members talked in depth with the leaders of eight programs that use various means to improve participation in prenatal care. This opportunity to discuss in detail a number of issues that had emerged from written reports provided valuable insight into the history and current forces shaping such programs. In addition to reviewing project data, the Committee considered a variety of other information sources. It conducted a literature review, arranged for numerous commissioned and contributed papers, and had many informal conversations and correspondence with prenatal care providers, policymakers, and researchers. ORGANIZATION OF THE REPORT This volume begins with a brief summary that covers not only the body of the report, but also key themes in their introduction. Chapter 1 presents a demographic analysis of who does and does not obtain prenatal care and contains trends in utilization. Chapter 2 summarizes the literature on barriers to prenatal services. Chapter 3 synthesizes 17 studies of women's views about obstacles to care and discusses 12 recent multivariate analyses

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INTRODUCTION 23 of predictors of prenatal care use. Chapter 4 presents lessons learned from the Committee's review of 31 programs that attempt to draw women into care early in pregnancy and sustain their participation. Chapter 5 presents the Committee's conclusions and recommendations; these are directed toward those involved in national, state, and local health policy; those who provide maternity services; health services researchers; and leaders in the private sector, particularly those in foundations who fund maternity care programs and related research. Appendix A describes individually the 31 programs studied. Finally, two commissioned papers are included (Ap- pendixes B and C). One, by Sara Rosenbaum and Dana Hughes of the Chfldren's Defense Fund, delves into the causes and effects of the medical malpractice crisis on poor women's access to care. The other, by C. Arden Miller of the University of North Carolina, contrasts the maternity services available in 10 European countries with those in the United States. THE VALUE OF PRENATAL CARE: AN UNDERLYING ASSUMPTION A very important assumption underlying the entire volume is that prenatal care is a useful and cost-effective service. No effort was made by the Committee to document its benefits further or to defend its value. Nonetheless, the Committee acknowledges that there are many unanswered questions about what the specific components of prenatal services should be and that by focusing primarily on how to draw women into care, the report does not address the important issues of prenatal care's content and quality. The fact that most studies of prenatal services rely on quantitative measures of care, such as number of visits, rather than qualitative ones, increases the tendency in the maternal and child health field generally to overlook these other dimensions. Although the Committee's charge dictated the narrower focus, it is important to state clearly that the quality and content of prenatal services play a large role in their effectiveness, perhaps even more so than the number of visits or the month in which care was begun. In this context, it is useful to recognize that the term "prenatal care" describes an inexact constellation of procedures and interactions. To some people, the term suggests a minimum set of medical services offered by health care providers on a well-defined schedule, while to others it means those services plus an array of educational, social, and nutritional services provided in a culturally appropriate, flexible fashion. The absence of a clear, universal definition of what constitutes prenatal care is almost certainly at the root of much of the controversy about the content, costs, and effectiveness of this service. Many groups, including the Institute of Medicine, have called for additional research to specify the content of

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24 PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS prenatal care as currently offered and to assess the value of each of its components for different groups of women. A final resolution of the question of what is useful in prenatal care, whether defined narrowly or broadly, must await further understanding of the physiology of pregnancy, of threats to maternal and fetal health during pregnancy, and of the specific prenatal interventions needed to minimize these threats. Progress in this direction is promised by the work of the Public Health Service's Expert Pane! on the Content of Prenatal Care. Among other activities, that Panel has proposed a list of outcome variables by which the effectiveness of various aspects of prenatal care could be judged. The list is particularly valuable for its breadth. It suggests that the worth of prenatal care should not be determined solely on the basis of its effect on infant mortality or birthweightoutcomes that have dominated recent discus- sions of prenatal care but should consider instead a much broader array of measures. The Pane! has proposed that the impact of prenatal care be assessed in terms of maternal, infant, and family health, including, for example, maternal and fetal mortality, the developmental progress of preterm infants, family functioning, planning for future pregnancies, child abuse and neglect, and maternal stress.22 While awaiting the Panel's report and further consideration of the content of prenatal care, the Committee has elected to use a broad definition of prenatal care in this volume. Thus it has defined prenatal care to include the diagnosis of pregnancy; the medical, educational, social, and nutritional services needed to enhance the health and well-being of the woman and fetus during pregnancy; and the counseling and assistance required to plan for labor and delivery, postpartum care for the mother, and pediatric care for the newborn. REFERENCES AND NOTES American College of Obstetricians and Gynecologists. Standards for Obstetric- Gynecologic Services, 6th ed. Washington, D.C., 198S. 2. National Center for Health Statistics. Advance report of final nasality statistics, 1985. Monthly Vital Statistics Report, Vol. 36, No. 4 Suppl. DHHS Pub. No. (PHS)87- 1 120. Hyattsville, Md., 1987. 3. Ibid. 4. Committee to Study the Prevention of Low Birthweight. Preventing Low Birth- weight. Washington, D.C.: National Academy Press, 1985. 5. U.S. Congress, Office of Technology Assessment. Healthy Children: Investing in the Future. OTA-H-345. Washington, D.C.: Government Printing Office, 1988. 6. Committee to Study the Prevention of Low Birthweight. Op. cit., pp. 212-237. 7. Moore TR, Origel W. Key TC, and Resnik R. The perinatal and economic impact of prenatal care in a low-socioeconomic population. Am. J. Obstet. Gynecol. 154:29-33, 1986.

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INTRODUCTION 25 8. Corman H and Grossman M. Determinants of neonatal mortality rates in the U.S. A reduced form model. ]. Health Econ. 4:213-236, 1985. 9. Joyce TI, Corman H. and Grossman M. A cost-effectiveness analysis of strategies to reduce infant mortality. Paper presented at the National Conference on Prenatal Care: New Directions for Federal Policy, sponsored by the Bush Foundation. Washington, D.C., 1986. 10. U.S. Congress, Office of Technology Assessment. Op. cit. 11. International Hearings on Infant Mortality, held by the National Commission to Prevent Infant Mortality, United Nations, New York City, 1988. 12. Miller CA. Maternal Health and Infant Survival. Washington, D.C.: National Center for Clinical Infant Programs, 1987. 13. Once of Disease Prevention and Health Promotion. The 1990 Health Objectives for the Nation: A Midcourse Review. Washington, D.C.: U.S. Public Health Service, 1986, p. 51. 14. Freeman HE, Blendon RJ, Aiken LH, Sudman S. Mullinix C, and Corey CR. Americans report on their access to health care. Health Affairs 6(Spring):~18, 1987, p. 17. 15. Mundinger MO. Health service funding cuts and the declining health of the poor. N. Engl...~. Med. 313:44-17, 1985. 16. Igelhart J.: From the editor. Health Affairs 6(Spring):~-S, 1987, p. 4. 17. Committee to Study the Prevention of Low Birthweight. Op. cit., p. 167. 18. Klerman LV. The maternity care delivery system. Paper presented at the National Conference on Prenatal Care: New Directions for Federal Policy, sponsored by the Bush Foundation. Washington, D.C., 1986. 19. Mayor's Advisory Board on Maternal and Infant Health, District of Columbia. Personal communication, 1988. 20. David Smith, U.S. Public Health Service. Personal communication, 1987. 21. Rosenbaum S. Hughes DC, and Johnson K. Maternal and child health services for medically indigent children and pregnant women. Med. Care 26:315-332, 1988. 22. A final report of the Expert Panel on the Content of Prenatal Care is expected early in 1989.