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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 timing—the
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 ticket—a
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.
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APPENDIX B
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Representative terms from entire chapter:
federal republic
