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PRENATAL
ARE
Reaching Mothers,
Reaching infants
Sarah S. Brown, Editor
Committee to Study Outreach
for Prenatal Care
Division of Health Promotion and
Disease Prevention
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C. 1988
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NAnONALACADEMY PRESS 2101 Constitution Avenue, NVV Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of
the National Research Council, whose members are drawn from the councils of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The
members of the committee responsible for the report were chosen for their special competences
and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to the procedures
approved by a Report Review Committee consisting of members of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist
distinguished members of the appropriate professions in the examination of policy matters
pertaining to the health of the public. In this, the Insititute acts under both the Academy's 1863
congressional charter responsibility to be an adviser to the federal government and its own
initiative in identifying issues of medical care, research, and education.
This project has been supported by the Ford Foundation, the Carnegie Corporation of New
York, the March of Dimes Birth Defects Foundation, the Rockefeller Foundation, and the Division
of Maternal and Child Health within the U.S. Department of Health and Human Services (SPRANS
Grant No. MCJ-113852-02-HRSA).
Library of Congress Cataloging-in-Publication Data
Prenatal care: reaching mothers, reaching infants / Sarah S. Brown,
editor: Committee to Study Outreach for Prenatal Care, Division of
Health Promotion and Diseases Prevention, Institute of Medicine.
P cm.
Includes bibliographies and index.
ISBN 0-309-03892-8
1. Prenatal care. 2. Women's health services. I. Brown, Sarah
S. II. Institute of Medicine (U.S.). Committee to Study Outreach
for Prenatal Care
1DNLM: 1. Prenatal Care. WQ 175 P9257]
RG940.P74 1988
362.1'982—dcl9
DNLM/DLC
for Library of Congress
Cover Photograph:
CARRIE BORETZ/ARCHIVE
Printed in the United States of America
First Printing, October 1988
Second Printing, October 1989
88-28991
CIP
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COMMITTEE TO STUDY
OUTREACH FOR PRENATAL CARE
JOYCE C. LASHOF, Chairman, Committee to Study Outreach for
Prenatal Care, Institute of Medicine, and Dean and Professor, School
of Public Health, University of California, Berkeley, California
EZRA DAVIDSON, Professor and Chairman, Department of Obstetrics
and Gynecology, King Drew Medical Center, Los Angeles, California
STANLEY N. GRAVEN, Professor, College of Public Health, University
of South Florida, Tampa, Florida
BERNARD GAYER, Associate Professor, Department of Maternal and
Child Health, School of Public Health, Harvard University, Boston,
Massachusetts
MARGARET C. HEAGARTY, Professor of Pediatrics, College of
Physicians and Surgeons, Columbia University, and Director of
Pediatrics, Harlem Hospital Center, Columbia University, New York,
New York
SHEILA B. KAMERMAN, Professor of Social Policy and Planning,
School of Social Work, Columbia University, New York, New York
LORRAINE V. KLERMAN, Professor of Public Health, Department of
Epidemiology and Public Health, Yale University School of Medicine,
New Haven, Connecticut
GEORGE M. RYAN, Professor of Obstetrics and Gynecology, University
of Tennessee, Memphis, Tennessee
BARBARA T. SABOL, Secretary, Kansas Department of Health and
Environment, Topeka, Kansas
DAVID SMITH, Director, Brownsville Community Health Center,
Brownsville, Texas
Study Staff
SARAH S. BROWN, Study Director and Report Editor
AMY E. FINE, Senior Project Officer
ANNE B. HOCKETT, Research Associate
BLAIR B. POTTER, Editor
ENRIQUETA C. BOND, Director, Division of Health Promotion and
Disease Prevention
LINDA DEPUGH, Administrative Assistant
. . .
222
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Commissioned Papers
VIRGINIA CARTOOF, Cartoof Consulting, Dorchester, Massachusetts
RUTH R. FADEN, Professor, Department of Health Policy and
Management, School of Hygiene and Public Health, Johns Hopkins
University, Baltimore, Maryland
PAUL T. GIBLIN, Associate Professor, Department of Pediatrics,
Children's Hospital, Wayne State University, Detroit, Michigan
ROBERT HALPERN, Faculty, The Erikson Institute for Advanced Study
in Child Development, Chicago, Illinois
DANA HUGHES, Senior Health Specialist, Children's Defense Fund,
Washington, D.C.
KAY JOHNSON, Senior Health Specialist, Children's Defense Fund,
Washington, D.C.
MARGARET MCMANUS, McManus Health Policy, Inc., Washington,
D.C.
C. ARDEN MILLER, Professor, Department of Maternal and Child
Health, University of North Carolina at Chapel Hill, Chapel Hill,
North Carolina
MARYBETH PETSCHEK, Senior Staff Associate, Center for Population
and Family Health, Columbia University, New York, New York
PAUL PLACEK, Survey Statistician, Division of Vital Statistics, National
Center for Health Statistics, Hyattsville, Maryland
MARILYN POLAND, Associate Professor, Department of Obstetrics and
Gynecology, Wayne State University Medical School, Detroit,
Michigan
SARA ROSENBAUM, Director, Health Division, Children's Defense
Fund, Washington, D.C.
Contributed Paper
LORRAINE KLERMAN, Professor of Public Health, Department of
Epidemiology and Public Health, Yale University School of Medicine,
New Haven, Connecticut
iv
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Acknowledgments
This report represents the collaborative efforts of many individuals and
groups, especially the members of the supervising committee, who gave
generously of their time and wisdom. Joyce Lashof was an exceedingly
effective chairman, helping to engage all of the committee's members in
various aspects of the project. Lorraine Klerman, in particular, contributed
substantially to the report's development by taking a leadership role in
analyzing the materials that now appear in Chapters 3 and 4 and in
Appendix A, and Bernard Guyer was especially helpful in drafting Chapter
1. The report also reflects the insights and stimulation provided by a
number of commissioned papers, the authors of which appear at the
beginning of the report.
The contributions of staff members Amy Fine and Anne Hockett were
particularly important. Although neither was able to remain on the study
staff for the entire duration of the project, each had a major role in shaping
it. Blair Potter, the report editor, was very helpful in her careful attention
to countless details of both form and substance, and Linda DePugh
managed the immense task of typing this long report with grace and
humor.
An important part of the committee's work was its review of numerous
programs around the country that are trying to improve use of prenatal
care. Thirty-one such programs were studied in detail and are summarized
in Appendix A. To help develop the appendix, many program leaders
worked closely with the committee and staff; they reviewed numerous
drafts, answered endless questions, and seemed to have infinite patience
v
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Vl
ACKNOWIEDGMENTS
for explaining the "real world" of providing prenatal services. Special
thanks go to Richard Aubry, Lawrence Berger, Hannah Boulton, Vicki
Breitbart, Jeanne Brooks-Gunn, Elizabeth Campbell, Virginia Cartoof, Joan
Christison-Lagay, Deborah Coates, Lyn Headley, Cassandra Jackson, Ju-
dith Jones, Muriel Keyes, Athole Lennie,Joan Maxwell, Marie McCormick,
Marie Meglen, Katherine Messenger, David Olds, lanes Olszewski, Mary
Peoples, Linda Randolph, Jacqueline Scott, Donna Strobino, Lois Wan-
dersman, and Terri Wright.
Many other individuals played important roles in the committee's
deliberations by providing information, critical analysis, advice, and
reviews of draft materials. Sara Rosenbaum of the Children's Defense Fund
and her colleagues Dana Hughes and Kay Johnson were exceptionally
helpful and merit immense gratitude. Others who assisted the committee
include Robert Ball, Michael Bowling, Jan Chapin, Katherine Darabi, Sara
dePersio, Jack Hadley, Ian Hill, Marjorie Horn, Charles Johnson, Sarah
Johnson, Susan Kelly, Asta Kenney, Milt Kotelchuck, Mary Grace Kovar,
Tom McDonald, Diana Mertens, Arden Miller, Jeanette Miller, Elena
Nightingale, Gary Richwald, Anne Rosewater, Jeffrey Taylor, Beverly
Toomey, and Louise Warrick. Their assistance is much appreciated.
Funding for the study was provided by the Ford Foundation, the
Carnegie Corporation of New York, the March of Dimes Birth Defects
Foundation, the Rockefeller Foundation, and the Division of Maternal and
Child Health within the U.S. Department of Health and Human Services.
The support of these groups is gratefully acknowledged.
SARAH S. BROWN
Study Director
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Contents
SUMMARY / 1
INTRODUCTION / 17
1
WHO OBTAINS INSUFFICIENT
PRENATAL CARE? / 26
2
BARRIERS TO THE USE
OF PRENATAL CARE / 54
WOMEN'S PERCEPTIONS OF
BARRIERS TO CARE / 88
4
IMPROVING THE USE OF PRENATAL
CARE: PROGRAM EXPERIENCE / llS
. .
V11
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V111
covers
5
CONCLUSIONS AD ~COHMEND~IONS / 1
APPENDIX
A
SUNDAES OF THE 31 PRODS STUDIED / 163
TYPE 1: P~G~S 10 REDUCE FIN^C~ B~E~ / I64
Healthy Start Progra~assachuset~, 165
PrenataLPostparmm Care Progra~ichigan, 167
TYPE 2: PROGRAMS 10 INCOME ~S1EH C~^CI~ / ~9
Obstetrical Access Pilot Pr~ec~ali~rnia, 170
Perinatal Progra~a Count, New Mexico, 171
Prenatal Care Absence Progra~ew York State, 174
Pr~endon of Low Biu~eight Progra~nondaga County
New York, 176
TYPE ~ PROGRESS 10 I~P~ INSl~ulION~
P^ClICES / 178
Haterni~ and Infant Care Pr~ect~Obio and North
Cat, 1~
Improved Pregnancy Outcome Pr~ec~o Counties in
Norm CaroUns, 181
Improved Child HeaRb Pr~ec~o Yeas of Hiss~sippi, 181
Child Sundial Project, Columbi~resbyterian Medical
Cente~ew York City, 182
D~dopment of a Pednam1 System in Shelby Count,
Tennessee, 184
TYPE 4: PROGRAMS TO CONDUCT ENDING / 185
Central Hadem Ou~eacb Progra~e~ York City, 185
Community Realm Advocacy Program York City, 187
The Better Babies Pr~ec~shington1 D.C., 188
The Haterni~ and Infant Ou~eacb Pr~ec~art~rd,
Connecticut 191
Pregnancy Heal~lin~N~ York City, 192
The 961-B~ Telephone Information and Corral Service
Detroit, Michigan, 194
Concern for Heabb Options: In~rmadon, Care and Education
(CHOICE)~biladelpbi~ Pennsylvania, 195
The Free Pregnancy lesUng and Prenatal Care Advocate
Progra~ulsa, Oklahoma, 197
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CONTENTS
The Special Supplemental Food Program for Women, Infants,
and Children (WIC) Six Studies, 199
Baby Showers—Seven Counties in Michigan, 200
TYPE S: PROGRAMS THAT PROVIDE SOCIAL SUPPORT / 201
Resource Mother~Three Counties in South Carolina, 202
Comprehensive Service Programs for Pregnant Adolescent
A Summary of Six Programs, 203
The Prenatal and Infancy Home Visiting Program Elmira,
New York, 20S
The Grannies Program Bibb County, Georgia, 206
APPENDIX
B
PRENATAL CARE OUTREACH:
AN INTERNATIONAL PERSPECTIVE / 210
C. Arden Miller
APPENDIX
CTHE MEDICAL MALPRACTICE
CRISIS AND POOR WOMEN / 229
Sara Rosenbaum and Dana Hughes
INDEX / 245
IX
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