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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 362.1'982dcl9 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 ShowersSeven 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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