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Appendix B Prenatal Care Outreach: An International Perspective C. Arden Miller Infant mortality rates are generally lower in Western Europe than in the United States, a circumstance that has attracted comment from health policy analysts for several decades. The trend during this time has been toward continued lowering of rates among all industrialized nations, yet the United States' relative rank has dropped (Children's Defense Fund, 19879. Recent adverse trends in several U.S. indicators of maternal and infant health (Miller et al., 1986; Children's Defense Fund, 1987) have sharpened interest in how countries with the lowest rates achieve them (National Center for Health Statistics, 1985b). An opportunity to review perinatal supports, services, and financing in Europe came in 1982, with the completion of a 23-nation survey con- ducted by the Perinatal Study Group convened by the World Health Organization Regional Office for Europe (EURO). The lS-member group represented 10 countries and 10 different professional disciplines (eco- nomics, epidemiology, health administration, midwifery, nursing, obstet- rics, pediatrics, psychology, sociology, and statistics). The results of the survey were summarized in two works (Regional Office for Europe, l9SS; This paper is condensed from a larger work, entitled Pennatal Care in Europe: Implications for U.S. Policy, published by the National Center for Clinical Infant Programs, Washington, D.C., 1987. The work was supported by a Fulbright Grant and the Ford Foundation, and was facilitated by Marsden Wagner, Regional Officer for Maternal and Child Health, World Health Organization, Regional Office for Europe, Copenhagen. C. Arden Miller is Professor, Department of Maternal and Child Health, School of Public Health, University of North Carolina, Chapel Hill. 210

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APPENDIX B 2 Phaff, 19861. Although the information is useful and important, much of it is descriptive and cannot be linked to individual countries. Identification of models that might be of special interest in U.S. policy formulation is clouded by the aggregation of survey findings among countries with diverse social and political traditions and with a wide range of accomplish- ment in perinatal care. In 1986, Marsden Wagner, Regional Officer for Maternal and Child Health for EURO, granted me permission to review the raw responses to the 1982 survey. He also arranged for the national files at EURO to be opened for inspection and made available the proofs of the World Health Organization's (WHO's) seventh annual report on the world health situation (WorId Health Organization, 19861. That work contains WHO's most recent statistical tabulations of health status for each country as well as narratives on the health care system of each. Other useful sources of information are the periodic reports from UNICEF (1987) and the World Bank (1986~. In addition, I visited academics, health officials, researchers, and clinic providers in Denmark, Federal Republic of Germany, Nether- lands, Belgium, and the United Kingdom. Experts from each of these countries were asked to review the ensuing report, and I have incorporated their suggestions for revision. These advisers were especially helpful in directing my attention to reports on relevant research in Europe. Although extensive writings on perinatal care in Western Europe were reviewed, their scope does not embrace the full range of available literature- and none of the literature printed in languages other than English. STUDY COUNTRIES The Perinatal Study Group characterized each country's health care system as monopolistic, pluralistic, or intermediate, and categorized survey responses accordingly. Monopolistic systems of health care were identified as those in which " ... pregnancy and birth care is offered exclusively through institutions such as health centers and maternity outpatient and inpatient departments. In these institutions all personnel are employed by the state" (Regional Office for Europe, 198S, pp. 7~. In pluralistic systems, " . . . care during pregnancy and birth is provided by midwives and doctors in private practice and, to a lesser extent, through institutions. The woman is relatively free to choose the type of care she wants" (Regional Office for Europe, 1985, p. 81. Intermediate systems have features of both. Countries that were characterized as having monopolistic systems of health care were excluded from this analysis because their experience is unlikely to have much relevance for U.S. policy. On this basis Finland and

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212 APPENDIX B Sweden were excluded, even though both have an outstanding record of maternity care and are frequently cited in international comparisons of maternal and child health services (Wallace, 1975; National Center for Health Statistics, 198Sa). Nearly all prenatal care in these countries is rendered in public clinics, and women must deliver in a hospital that is determined by place of residence, circumstances that are not likely to come about in the United States. Designation of the United Kingdom's system as an intermediate one deserves comment. Although the National Health Service has been in operation since 1948, pregnant women may choose place of delivery, a small private sector of physician providers persists, and private health insurance coverage is growing in importance. In addition, the physician providers, although they contract with the National Health Service, are not government employees. Inclusion of Spain and Ireland in the study group is noteworthy because they are less affluent than the other nations in the study. Both have undertaken important health service reforms in recent years and have achieved impressive new records for infant survival. Countries with populations of less than one million and countries with infant mortality rates higher than that of the United States were also excluded. Ten countries remained for analysis (see Table 11. TABLE 1 Rates of Infant Mortality and Low Birthright in the Study Countries, 1982a Infant Mortality Low Birthweight Country Rateb RateC Belgium 10.10 5 Denmark 7.71 6& France 9.40 5 Federal Republic of Germany 10.20 5 Ireland 10.10 4 Netherlands 8.40 ~ Norway 7.90 4 Spain 9.60 NA Switzerland 7.60 5 United Kingdom 10.00 7 aThe infant mortality rate is the number of deaths per 1,000 births. The low birthweight rate is the number of newborns weighing 2,500 grams or less per 1,000 live births. Data are usually for 1982. World Health Organization, 1986. CUNICEF, 1987. Other sources report a rate of four for Denmark (World Health Organization, 19861.

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APPENDIX B 213 ADEQUACY OF DATA Research on prenatal care in the United States focuses on timingthe stage of pregnancy at which the first visit occurs and the number of subsequent visit~because those data are readily available on birth certificates. Scant data are available on the content of prenatal visits (Institute of Medicine, 19859. Insofar as criteria for the adequacy of care have been developed, they are framed in terms of the number of visits in the various stages of pregnancy (Kessner, 19739. Cost and cost-effec- tiveness attract attention (Institute of Medicine, 198S). Comparable data are not generally available for Europe. Data are available on the number of prenatal visits to various providers, but information on the timing of the first prenatal visit is conspicuously lacking. All advisers insist, without recourse to confirming data, that attracting women to the first prenatal visit is not a problem because many perinatal benefits are contingent on confirming the pregnancy and regis- tering it with the appropriate official agencies, tasks undertaken at the first visit. The focus in improving prenatal care is on women who do not return after the first visit. Blonde! (1987) reports that in the study countries less than 2 percent of women who deliver have had no prenatal care. Standards of perinatal care are established for all countries and are expressed in terms of entitlement to health services and social supports. The number of visits, examinations, laboratory tests, screening procedures, home visits, income transfers, and other benefits are specified for every country. In some countries (for example, Norway), the number and content of prenatal visits take the form of government-sanctioned recom- mendations rather than legal regulations. The survey inquired about the existence of national standards and asked for certain particulars about them. A full reporting of standards was not requested and was usually not provided. The EURO survey inquired about the use of prenatal screening proce- dures (blood testing, toxoplasmosis, rubella, tetanus, syphilis, amniocen- tesis, and ultrasound), and those results have been reported (Regional Office for Europe, 198S). A study committee working on behalf of the European Economic Community has conducted a survey of teaching hospitals on the recom- mended content of prenatal visits. Complete results are not yet available, but variation among nations is said to be exceedingly great (P. Buekens, personal communication, 19869. For example, in France and Germany the cervix is routinely examined during prenatal visits; in the United Kingdom (and the United States) such examinations are done only for special indications. The pros and cons of these two approaches have not been evaluated.

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214 APPENDIX B Adequate data on the cost of prenatal care and its various components are not available. Even when the aggregate costs of the entire perinatal sequence are reported, comparisons are suspect; some reports appear to include income ~ supplements that are associated with childbearing, whereas others appear to confine themselves to medical costs. To the extent that data are available on cost, they focus on the use of hospitals. Many countries have attempted to reduce hospital expenses by relying on home care and outpatient visits. These strategies are considered to be less expensive than hospital care, but careful cost-benefit analyses are not generally available. An exception is the Netherlands, where the expense of the extensive postnatal home visiting program has come under review. That review appears to ask only about the possible disadvantages that might result if home visiting, lasting up to 8 hours a day for 10 days (averaging 64 hours for every delivery in 1986), were reduced to 7 days. Several reports emphasize that either home care or outpatient care is less expensive than keeping new mothers and their babies in the hospital more than 36 hours after birth (in the absence of medical indications to the contrary). Responses to the survey were enormously instructive but diverse in style. Some queries that asked for data were completed with a narrative. Others that requested a narrative were answered with a word or a copy of a multipage published report. In the analysis that follows, I have attempted to adhere to a quantitative treatment, but descriptions and undocumented generalizations are given when they contribute to an understanding of well-established practice as represented in the survey responses. Research and precise documentation of perinatal care in Europe are actively pursued but, understandably, not with the same urgency as in the United States. CHARACTERISTICS OF STUDY COUNTRIES Several factors affecting prenatal care in the 10 study countries deserve consideration. Demographics Comparisons of the human services offered in the United States and in European countries are sometimes discounted on the basis of the belief that the heterogeneity of the U.S. population complicates delivery of care more here than in Europe. That reasoning is weakened if one regards the considerable migration into Western Europe since World War II of persons from the Middle East, North Africa, and various former colonies.

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APPENDIX B 215 For example, foreign-born persons make up 10.6 percent of the population of France, 16.7 percent of Switzerland, and 8.8 percent of the United Kingdom (Demographic Yearbook, 1983). Proportions are much higher in some cities. In Amsterdam, 18.2 percent of the population is foreign-born (Doornbos and Nordbeck, 1985), and the proportion for Brussels was 23.9 percent in 1981 (Buekens, personal communicator, 19861. The large contribution of nonindigenous populations to the problems of childbear- ing is most strikingly revealed by data on the country of origin of children under five in Amsterdam in 1981: 44.5 percent were born to nonindige- nous families, most commonly Surinamese or Moroccan (Doornbos and Nordbeck, 19851. Many reports (Blonde! et al., 1985; Doornbos and Norbeck, 198S; Kaminski et al., 1987) indicate that pregnancy-related use of services and outcomes of pregnancy are less favorable for immigrant women than for indigenous women, but the gaps are neither great nor consistent. In Amsterdam, 70 percent of Dutch women and 50 percent of immigrant women went for prenatal care within the first 16 weeks of pregnancy; subsequently, the immigrant women made more frequent visits. In Munich, women of non-Germanic origin (about 20 percent of deliveries) used public health services at the same rate as German women (Doornbos and Nordbeck, 1985~. The quality of prenatal care for each of several national subgroups was judged to be similar for all patients delivered of babies at a large London hospital (cited by Buekens, 1987~. Both in Amsterdam and in Munich, outcomes of pregnancy were less favorable for immigrant women. A letter from Buekens ( 1987) presents similar findings for Belgium in 1983, citing a perinatal mortality rate of 10.7 for Belgium women and higher rates for foreign-born women living in Belgium (Turkish, 17.8; North African, 14.81. Not all studies demonstrate such a difference. In Sweden (not included among the study countries) non-Nordic immigrant families were shown to use health services extensively and to have pregnancy outcomes that were comparable to, if not more favorable than, those of Swedes (Smedby and Ericson, 19799. Doornbos and Nordbeck (1985) cite a study in West Germany demonstrating that perinatal mortality rates among Turkish immigrants were similar to those among the German population of the same socioeconomic status. These data are not presented with the intent of establishing that circumstances for immigrant families in Europe are in every way parallel to those for indigenous minority families in the United States. Almost certainly a different set of problems pertains, but both situations involve overcoming barriers associated with sociocultural differences. Some spe- cial measures have been taken in Europe to overcome these differences; in the Netherlands, for example, health care providers and their patients who

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216 APPENDIX B encounter a language barrier can obtain instantaneous, on-site translations over the telephone. None of the survey responses or other descriptions identified well-organized educational campaigns or other outreach efforts specifically directed toward immigrants. All countries in the study except for the United Kingdom have lower rates of low birthweight than the United States (Table 1~. When the U.S. rates are disaggregated by race, the rate for whites (S.6) is still substantially higher than the lowest European rates (4.0) (National Center for Health Statistics, 19879. These differences cannot be explained entirely on the basis of different rates of teenage childbearing. When corrections are made for other known variables, the contribution of maternal age to low birthweight is small (Institute of Medicine, 19851. Population density is high in most of the countries, but the exceptions are important. Norway's population is widely scattered among many isolated communities. The average number of prenatal visits varies between 10 and 14 in all parts of the country. Pregnant women who live in remote areas are reimbursed for travel expenses and subsistence for 10 days in order to be near a hospital when delivery is expected. The urban population of the study countries ranges from a low of 57 percent for Ireland to a high of 96 percent for Belgium. Four countries (France, Norway, Ireland, and Switzerland) have a less urbanized popu- lation than the United States (UNICEF, 19879. Teenage ChiZd:bearing The most important demographic difference between the United States and the 10 European nations is the age-specific fertility rate. Rates of teenage pregnancy, abortion, and childbearing are substantially lower in Europe ~ Jones et al., 198S). The rate of childbearing among IS- to 19-year-olds in the 1980s was roughly three times higher in the United States than in European countries (Table 2~. That difference holds for both black and white populations, and it would be even greater if abortion did not interrupt nearly half the teenage pregnancies in the United States. This entire issue and its implications for infant survival have been carefully reviewed at the Alan Guttmacher Institute Oones et al., 1985~. Findings suggest that the age of onset of sexual activity does not vary greatly among these countries, but access to contraception is more limited and fewer children participate in organized programs of sex education in the United States. A dramatic decline in rates of teenage childbearing in Europe took place during the 1970s, while the U.S. rate remained high (Table 29. That decline occurred in the context of extensively expanded medical and social benefits for pregnant women, including income supplements to help with , , .

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APPENDIX B TABLE 2 Rate of Teenage Childbearinga in the United States and the Study Countries 217 Country 1970s 1980s Belgium 31 19 Denmark 32 11 France 27 IS Federal Republic of Germany 36 10 Ireland 16 18 Netherlands 23 7 Norway 45 20 Spain 22 27b Switzerland 22 8 United Kingdom 41 28 United States 64' ~ 5lc alive births per 1,000 women age 1~19. bData for 1979. 'Demographic Yearbook, 1973 and 1983. Data for 1969. SOURCE: EURO files, 1986. the expense of child rearing. Clearly, the expanded benefits did not induce teenagers to increase their fertility. Household Income The per-capita gross national product (GNP) in the United States and in Western Europe is high, but income alone does not account for low rates of infant mortality. A threefold difference in per capita GNP separates the European countries with the lowest values from those with the highest (Ireland and Spain with values of $5,230 and $5,640, respectively, and Switzerland with $17,4301. Household income in the United States is higher than that in six study nations with better records of infant survival (WorId Health Organization, 1986~. The distribution of proportional shares of household income between the highest and lowest quintiles is interesting (Table 31. The gap between rich and poor is greater in the United States than in any other country except France, for which recent data are not available. Redistribution of household income to reduce poverty might bring about many benefits, including a reduction in infant mortality rates. But the record clearly indicates that household wealth far below the U.S. average and income distributions nearly as disparate as those in the United States (in France, Denmark, and Spain, for example) are compatible with

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218 APPENDIX B highly favorable rates of infant survival. Without in any way minimizing the urgency of lowering poverty rates, especially in households with children, one can make a compelling case that selective, direct approaches for improving outcomes of pregnancy are feasible within the present income structure of the United States. The recent records in Ireland and Spain are especially compelling in this regard. Barcelona, known to have extensive barrios of poverty and congestion, has an infant mortality rate of eight (EURO files, 19869. National Finances No country in the study spends as high a proportion of its GNP on health care as the United States (10.7 percent). Countries that emphasize insurance systems to reimburse private physician providers on a fee-for- service basis tend to spend more (Belgium, 9.1 percent; France, S.0; Federal Republic of Germany, 9.3; Switzerland, 7.1) than countries that compensate providers at a negotiated, fixed per-capita rate (Denmark, 5.5 percent; United Kingdom, 6.1; Norway, 7.1; NetherIands, S.8) or those that make extensive use of public clinics (Spain, 4.3 percent; Ireland, 7.~; and, in some areas, the United Kingdom and Norway) (WorId Health Organization, 1986~. The predominant health care provider systems and their means of financing vary greatly among the European countries, but they have been consistent in pursuing vigorously policies to reduce hospitalization other than for childbearing (WorId Health Organization, 19861. They have also TABLE 3 Difference Between Highest and Lowest Quintiles in Proportional Share of Total Household Income in the United States and the Study Countries, 1979-1982 Country Difference Belgium Netherlands Switzerland Federal Republic of Germany Ireland (1973) Norway United Kingdom Spain Denmark United States France (1975) 26.1 27.9 31.4 31.6 32.2 32.2 32.7 33.1 33.2 34.6 40.3 SOURCE: Adapted from World Health Organization, 1986.

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APPENDIX B 219 emphasized organized community services with decentralized administra- tions and uniform national standards for preventive measures. Increasing responsibility for health services has been placed on local governmental jurisdictions as the role of central government has been strengthened for standard setting, monitoring, and overall financing. Even in Switzerland, probably the most privatized system of health care among the 10 study countries, national standards for perinatal service are defined and their implementation subsidized by government grants to the insurance com- pan~es. Health Care Financing and Delivery Financing systems for health care are strikingly different among the countries and bear no consistent relationship to differences in prevailing health care provider systems. Insurance and social security schemes predominate, premium payments being made both by employers and by workers, as wage deductions. Insurance may be government run or controlled (Netherlands, Spain, Belgium), predominantly private (Switzer- land), or a combination of public and private (Federal Republic of Germany, France). In four countries, all of which rely predominantly on office-based practitioners for primary care, financing comes entirely or in large part from general tax revenues (Denmark, United Kingdom, Ireland, Norway). This diversity should not obscure a theme common to all the countries. No matter what the financing system, even when private intermediaries participate extensively, the central government has defined the services that are to be provided and, in the case of maternity care, has removed all barriers to those services. The full range of perinatal services is provided without charge to women of all socioeconomic levels, with only a few minor fees that are readily waived in the event of need. MATERNITY-REEATED SERVICES The survey inquired about public education programs and the use of communications media to inform women about the desirability and availability of prenatal care. Survey responses for all countries indicated that such activities go on, often under the auspices of volunteer organiza- tions or public interest professional groups. The activities are described as occasional, random, and not aggressively organized. On the other hand, several reports emphasize the highly organized programs of education about sexuality and human reproduction that are conducted in European schools (Jones et al., 1985~. Presumably those programs incorporate

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220 APPENDIX B instruction about the importance of prenatal care, but that assumption was not investigated. In several countries (Belgium, France, Federal Republic of Germany, Norway, and Switzeriand) the usual procedure is for a pregnant woman to seek prenatal care from the general practitioner or obstetrician of her choice. In Denmark and the United Kingdom every person is registered with a general practitioner who serves as a gatekeeper to other services. In the United Kingdom that practitioner ordinarily continues prenatal care for uncompli- cated pregnancies, arranging for a visit with the midwife and consultations, as needed, with obstetricians at the hospital where the woman is booked for delivery. In Denmark a precise schedule is followed, including two visits to an obstetrician, five to a midwife (who is a public employee), and three to the general practitioner. Public clinics are an option for care in Norway. In the Netherlands a woman first sees a general practitioner and then decides to continue that care or be transferred to a privately practicing midwife, who would also deliver the baby. An obstetrician is seen only for complicated pregnancies. In Ireland and Spain women may seek care from an obstetrician or general practitioner of their choice, but recently emphasis has been placed on the use of multidisciplinary primary care public clinics. The general practitioner's role has declined except as a participant in those clinics. Specialists, such as obstetricians, are generally hospital-based and render their consultations in hospital outpatient de- partments. Midwives are extensively involved in European maternity care. Their work is ordinarily confined to hospitals and multidisciplinary clinics except in the Netherlands, where they are independent, office-based practitioners. In Denmark midwives are government employees and work out of public offices or clinics; they participate in a schedule of routine prenatal care that includes visits to a general practitioner and to an obstetrician. A 1984 government report in Norway recommends 12 prenatal visits for uncomplicated pregnancies, half of them to a midwife and half to a general practitioner. In most countries, midwives attend uncomplicated deliveries for women who have received routine prenatal care from office-based general practitioners. Public Clinics Public clinics are sometimes regarded as an alternative to office-based physician practice. In Norway, for example, each municipality is required to maintain at least one public, multidisciplinary health center, even though care by office-based medical practitioners may be readily available. Multidisciplinary public clinics have been developed in selected locales of other countries to enhance services for hard-to-reach populations (Bel-

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APPENDIX B 221 glum, United Kingdom). Several countries have either phased out public clinics or have elected not to develop them, in the belief that access to physicians' offices is both assured and universally utilized (Denmark, Netherlands, Federal Republic of Germany, Switzerland, and France). Only two countries in the study (Ireland and Spain) have dramatically increased the number of public clinics recently, relying on them to provide multidisciplinary primary medical care (including perinatal care) and a number of social support services. Both of these countries were faced with the need to improve health conditions without major increase in expen- ditures, and in both countries these goals have been impressively realized. Number of Prenatal Visits The officially required or recommended number of prenatal visits for an uncomplicated pregnancy varies enormously (4 to 129. The average number of visits actually made closely approximates or exceeds the recommendations (Table 41. The survey responses did not provide data on the range of visits from which the averages were calculated. The survey inquired about instructional classes for pregnant women. Many volunteer organizations, agencies, and clinics offer such classes, and they are reported to be well utilized, but they are not regularly institu- tionalized into standards of prenatal care. TABLE 4 Prenatal Visits in the Study Countries, 1981-1982 Country Number Recommended Average Actual or Legally Required Number Belgium (French-speaking sector) 7 Denmark 10 Federal Republic of Germany 10 France 7 Ireland 6 Netherlands Norway Spainb Switzerland United Kingdom aVandenbussche et al., 1985. Some characteristics of antenatal care in 13 European countries. Brit. J. Obstet. Gynaecol. 92:1297. bI. Alvarez, personal communication, 1987. SOURCE: EURO survey, 1982, adapted from Blondel, B., 1987. 9.4a 8 ND 5.9 10 urban S rural 12-14 10 (39% of women) 6 s 10-12 (Scotland) 12 12-14 10 3-4 12-13

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222 APPENDIX B Home Visiting Home visiting is a feature of nearly every country's maternity care and is practiced more consistently after delivery than before (Table 5~. For uncomplicated pregnancies, prenatal home visiting is extensively used to inquire about missed appointments in an effort to resolve any contributing problems. Home visitors are sometimes midwives, but they are more often nurses with special training for home visiting. No country makes use of health aides or neighborhood workers as home visitors except possibly the Netherlands, where an extensive postnatal homemaking service supple- ments routine postnatal visits by the midwife or general practitioner who rendered prenatal care. TABLE 5 Home Visiting in the Study Countries, 1982a PRENATAL VISITS Always at least once Belgium (unevenly implemented) Denmark (unevenly implemented) Netherlands Only for complicated pregnancies or to check on clinic nonattenders Belgium Federal Republic of Germany (not an extensive program) France Irelandb Norway Switzerland United Kingdomb POSTNATAL VISITS Always at least once Belgium Denmark Ireland Netherlands (daily visits for up to 8 hours through tenth day postpartum) Norway Switzerland United Kingdom (daily visits by a midwife or health visitor for 10 days) Only for special indications Federal Republic of Germany France aSpain is currently implementing a program for prenatal and postnatal home visiting. Services are not yet widely available (I. Alvarez, personal communication, 1987~. Well-developed program for nonattenders. SOURCE: EURO survey, 1982.

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APPENDIX B 223 Postnatal home visiting in the Netherlands is a central theme of maternity care. Every woman is visited at home by either the midwife or the general practitioner. In addition, a specially trained maternity home helper stays with the mother and infant for up to 8 hours a day until the tenth day after birth. The visitor helps with infant care, shopping, housekeeping, meal preparation, and care of older siblings. In 1986 each newborn and mother received an average of 64 hours of postnatal home visiting (H. P. Verbrugge, personal communication, 19879. For this service the family pays only a token fee. In all countries, postnatal home visiting is seen as a means for counseling about infant care, for follow-up on the mother's health, for advice on family planning, for initial or follow-up neonatal screening procedures, and for setting up additional appointments for the infant and mother. Incentives to Participate in Prenatal Care In two countries (France and Federal Republic of Germany) financial benefits, payable at the time of delivery, have been withheld from women who did not make a specified number of prenatal visits. In West Germany this practice has been discontinued, and the benefits are now rendered without reference to prenatal visitation; only France continues the practice of offering a financial bonus for women who have made at least three prenatal visits. Prenatal attendance in France, particularly among Algerian immigrant women, improved markedly during the 1970s. Between 1972 and 1981 the proportion of pregnant women with fewer than four prenatal visits fell from 15.3 percent to 3.9 percent (Maxwell, 19841. The influence of financial incentives on this trend is problematic. Buekens has examined evidence that attempts to evaluate the effectiveness of financial incentives and found the evidence inconclusive (Buekens, 19879. The French system places incentives in an explicit context with some punitive implications. Another way of considering incentives is to regard the full range of benefits and supports associated with childbearing as incentives to seek prenatal care. These include transportation, early booking for delivery at a location of the woman's choice, paid leave from employment, birthing bonus, family allowances, home visitors, preference in housing, and children's allowances to help with the costs of child rearing. All of these are powerful incentives to register the pregnancy and impending delivery with the appropriate agencies, procedures ordinarily accomplished at the first prenatal visit. In all European countries in the study, the incentives for participating in prenatal care are strong and the barriers are virtually nonexistent. Rather than ask why pregnant women participate so early and so consistently, one might instead ask, Why wouldn't they?

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224 APPENDIX B TABLE 6 Home Deliveries as a Percentage of All Deliveries in Study Countries, 1979-1982a Country Percent Belgium (1984) Denmark Federal Republic of Germany France Netherlands Spaina United Kingdom aPrecise data are not available for other counmes beyond notations that home deliveries are rare or uncom- mon. bI. Alvarez, personal communication, 1987. SOURCE: EURO survey, 1982. 0.4 0.5 1.0 0.5 35.4 0.s 1.4 Home Deliveries The proportion of home deliveries has declined everywhere and remains high only in the Netherlands, where it represents officially supported policy (Table 6~. The Dutch insurance system will not compensate for an obstetrician's services or for a hospital delivery without a specific medical indication from an authorized list. New perinatal guidelines in Denmark encourage home deliveries, and they are increasing in some parts of the country. Hospital Deliveries Precise data on the duration of hospital stays for childbearing were not available. Evidence suggests that stays are longer in Europe than in the United States and that, when the stay is less than S days, the postnatal home visits are increased in frequency and duration. The Netherlands provides for deliveries that are neither fully hospital- based nor fully home-based. A polyclinic delivery allows a woman and her attending midwife to arrange for delivery on hospital premises, stay for up to 36 hours, and then return home for the usual pattern of home visiting. The delivery is not recorded as a hospital admission, and hospitals are not compensated on that basis. About one-third of the nation's deliveries conform to this pattern. Caesarean sections are performed at consistently lower rates in Europe (S to 13 percent in 1983) than in the United States, where in 1985 the rate was 23 percent (Placek, 1986; Notzon et al., 19871. The trend is upward in all countries.

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APPENDIX B 225 Continuity of Care Continuity of care in the sense that one provider attends the same patient throughout the prenatal, intrapartum, and postnatal periods is not a prominent feature in any of the countries. Because a pregnant woman may receive prenatal care in more than one setting (practitioner's office and specialist's clinic at the hospital), be delivered by yet another provider (hospital-based midwife), and be visited postnatally by someone else, com- munications among the various providers are very important. Communica- tions are facilitated by having the woman carry her own record, or part of it. MATERNITY RELATED BENEFITS Every country provides paid maternity leave and sets protective limits on the working circumstances of pregnant women. Usual practice in most countries is to transfer women to nonstrenuous jobs as soon as pregnancy is confirmed. Night work for pregnant women is forbidden in the Netherlands, Belgium, Switzerland, and Federal Republic of Germany, although exceptions may be made in certain job categories or with the woman's consent. The law in several countries specifies that wages will continue during absences for prenatal visits or classes. The duration of maternity leave varies from a total of 9 weeks (Ireland) to 29 weeks (United Kingdom) (Table 7~. In most countries the leave is obligatory. In Switzerland, Norway, and Belgium the woman may elect to work until delivery and add the allowable prenatal leave to the postnatal leave. Similar postnatal extensions are permissible in the event of premature delivery. In Norway the father may take up to 12 weeks' paid postnatal leave if he is the principal care giver; the Federal Republic of Germany allows either parent to take postnatal leave. The amount of pay during maternity leave varies from 100 percent of the mother's salary (usually to a maximum level) in Belgium, Federal Republic of Germany, Norway, and the Netherlands, to 90 percent of her salary in Denmark and France, and 75 percent in Spain. Ireland, the United Kingdom, and Switzerland provide a fixed payment, regardless of salary (EURO survey, 1982; Ierodiaconou, 1986~. The source of funds for paid maternity leave varies considerably. It is more often from social security or health insurance than directly from the employer, a circumstance that may protect against discrimination in the employment of women of childbearing age. Leave can often be extended on an unpaid basis without loss of job or job-related benefits. Such extensions are possible in France and the Federal Republic of Germany for 1 to 3 years. In Belgium the period of unpaid

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226 TABLE 7 Duration of Paid Maternity Leave in Study Countries 1982, 1986 APPENDIX B Leave (weeks) Country Prenatal Postnatal Belgium 6 8 Denmark 4 14a Federal Republic of Germany 6 24 France 6 8 Ireland 6 3a Netherlands 6 6 Norway 12 6 Spainb 6 8 Switzerland ~ ~ United Kingdom 11 29 aLeave is extended for premature delivery. bI. Alvarez, personal communication, 1987. SOURCES: EURO survey, 1982; Ierodiaconou, E. 1986. leave is extended to the end of the fifth month for mothers who breast-feed. All countries provide that additional paid sick leave may be given, if medically authorized. Payment during nursing breaks is ordinarily assured, ranging from two half-hour periods to two full-hour periods each day (France and Norway). Maternity grants or bonuses, without means testing, are paid at the time of childbearing in all countries except Denmark. The payments are intended to assist with the cost of supplies and equipment for the new baby. Switzerland pays an additional bonus to mothers who breast-feed their babies. In all countries family allowances are paid for each child on a monthly basis, ordinarily until adulthood or completion of education. The amount of the monthly allowance varies with the number of children. Some special maternity-related considerations are noteworthy. Belgium allows pregnant women first-cIass rail travel on a second-cIass ticketa way of assuring a seat for pregnant women in a population of commuters. Additional considerations are given to single mothers in most countries. Priorities for day care and for public housing are well established for working mothers or for large families. CONCLUSIONS Review of pregnancy-related supports and services in 10 Western European countries with outstanding records of infant survival and low

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APPENDIX B 227 birthweight suggest that participation in early and continuous prenatal care can be achieved by: establishing easily understood and readily available provider systems; removing all barriers, especially economic ones, to the full range of services embraced by those systems; and linking prenatal care to comprehensive social and financial benefits that enable pregnant women and new mothers to protect their own well-being and to nurture their infants. Inadequate scholarship exists to measure the relative importance of the several components of comprehensive Perinatal care. Most of the countries surveyed have established impressive programs of outreach featuring home visiting, which is designed primarily to prolong and enrich prenatal care rather than recruit women into care. Women appear to be attracted to prenatal care in order to avail themselves of the substantial medical and social benefits that attach to pregnancy and childbearing. Nothing in this analysis suggests that special endeavors or v ~ , ~ ~ 1 . , ~ ~ ~ ~ ~ . . .~1 . . . .. Outreach in the absence ot the above provisions will improve participation of pregnant women in prenatal care or improve outcomes of pregnancy. REFERENCES Blondel, B. 1987. Antenatal care in the European community countries over the last 20 years. In Perinatal Care Delivery Systems: Description and Evaluation in European Community Countries, M. Kaminski et al., eds. London: Oxford University Press. Blondel, B., D. Pusch, and E. Schmidt. 1985. Some characteristics of antenatal care in 13 European countries. Brit. l. Obstet. Gynaecol. 9:56~568. Buekens, P. 1987. Determinants of prenatal care. In Perinatal Care Delivery Systems: Description and Evaluation in European Community Countries, M. Kaminski et al., eds. London: Oxford University Press. Children's Defense Fund. 1987. The Health of America's Children. Washington, D.C., p.7. Demographic Yearbook. 1973 and 1983. New York: United Nations. Doornbos, J. P. R., and Hal. Nordbeck. 1985. Perinatal Mortality. Obstetric Risk Factors in a Community of Mixed Ethnic Origin in Amsterdam. Amsterdam: B. V. Dordrecht. Ierodiaconou, E. 1986. Maternity protection in 22 European countries. In Perinatal Health Services in Europe, J. M. L. Phaff, ed. Dover, N. H.: Croom Helm. Institute of Medicine, 1985. Preventing Low Birthweight. Washington, D.C.: National Academy Press. Jones, E. F., J. D. Forrest, N. Goldman, S. K. Henshaw, R. Lincoln, ]. I. Rosoff, C. F. Westoff, and D. Wulf. 1985. Teenage pregnancy in developed countries: Determi- nants and policy implications. Fam. Plan. Perspect. 17:53 63. Kaminiski, M., G. Breart, P. Buekens, H. I. Huisjes, G. McIlwaine, and H. K. Selbmann, eds. 1987. Perinatal Care Delivery Systems: Description and Evaluation in European Community Countries. London: Oxford University Press.

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228 APPENDIX B Kessner, D. M. 1973. Infant Death: An Analysis by Maternal Risk and Health Care. Washington, D.C.: Institute of Medicine. Maxwell, I. 1984. Prenatal care and infant mortality: The French experience. Unpub- lished manuscript. Miller, C. A., A. Fine, and S. Adams-Taylor. 1986. Monitoring Children's Health: Key Indicators. Washington, D.C.: American Public Health Association. . National Center for Health Statistics. 1985a. Health United States, 1985. Hyattsville, Md.: U.S. Department of Health and Human Services. National Center for Health Statistics. 1985b. Proceedings of the International Collab- orative Effort on Perinatal and Infant Mortality, Vol. 1. Hyattsville, Md.: U.S. Department of Health and Human Services. National Center for Health Statistics. 1987. Vital Statistics for the United States, 1985. Vol. 1, Natality. DHHS Publ. No. (PHS)87-1119. Washington, D.C.: Government Printing Office. Notzon, F. C., P. I. Placek, and S. M. Taffel. 1987. Comparisons of National Cesarean Section Rates. N. Eng. I. Med. 316:38~389. Phaff, I. M. L., ed. 1986. Perinatal Health Services in Europe. Dover, N. H.: Croom Helm. Placek, P. I. 1986. Commentary: Caesarean rate still rising. Stat. Bull. 67~3~:9. Regional Office for Europe. 1985. Having a Baby in Europe. Copenhagen: World Health Organization. Smedby, B., and A. Ericson. 1979. Perinatal mortality among children of immigrant women in Sweden. Acta Paedeatr. Scand. Suppl. 275~69~:41-47. UNICEF. 1987. The State of the World's Children 1987. Oxford: UNICEF. Vandenbussche, P., E. Wollast, and P. Buekens. 1985. Some characteristics of antenatal care in 13 European countries. Brit. I. Obstet. Gyr~aecol. 92:1297. Wallace, H. M. 1975. Health Care of Mothers and Children in National Health Services. Cambridge, Mass.: Ballinger. World Bank. 1986. World Development Report. Oxford: World Bank. World Health Organization. 1986. Evaluation of the Strategy for Health for All by the Year 2000, 7th Report on the World Health Situation. Vol. S. European Regional Office. Copenhagen: WHO.