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OCR for page 115
Chapter
4
Improving the Use of
Prenatal Care:
Program Experience
The previous chapters have discussed three aspects of access to prenatal
care patterns and trends in enrollment, research and anecdotal reports
regarding barriers to care, and the views of women themselves about why
they obtained insufficient prenatal services. This chapter pursues the
question further, from a different perspective. Here, the focus is on 31
programs that have tried to improve use of prenatal care.
The chapter begins with an overview of the Committee's method of
selecting programs for study and with discussion of two particularly
important aspects of trying to learn from program experience judging the
quality of available data and defining what constitutes evidence of
effectiveness. A five-part program classification scheme devised by the
Committee is then described, and the projects studied that emphasize each
approach are noted. The Committee's findings on the usefulness of the five
program types for improving participation in prenatal care are then
presented, and the chapter concludes with a summary of the implemen-
tation and operational problems reported to the Committee by many
program leaders.
SELECTION AND CLASSIFICATION OF PROGRAMS
The Committee and staff wrote and telephoned numerous groups and
knowledgeable experts, reviewed responses to a survey conducted by the
Healthy Mothers/Healthy Babies Coalition, and used other methods (see
115
OCR for page 116
~6
DILL ad: BRIG ~0~, ~C~G ~~
Appendix A) to idend~ programs mat might provide data on increasing
and sustaining participation in prenatal care. Because the Committee
Wanted is Landis to reRect the present conOgurabon of the heal care
Item and the maw recent changes in it the search emphasized programs
currents in operation or recent completed. A ~w programs that bee
been Beg described in Me literate were also included, men though some
of them are no longer in existence or bye changed ~gniRcant~ in recent
years.
From these maw sources, a master list of almost 200 project was
developed. Though the Committee beamed that the list was reasonably
complete at the time, it undoubted bad omissions. In particular,
ineffective programs were probably underrepresented because they are
rarer described in publ~bed, or men unpublished, articles
The Committee divided the programs into Me groups, according to
. .
t gear major amp flails:
1. reducing Me financial obstacles to care encountered by poor women
Tough Me prounion of insurance or other sources of patents
2. increasing the capacity of the prenatal care system robed on by maw
low-income ~'omen, Rich includes heakh department chnics, dbe network of
plate physicians To care far ~edicaid~enrolled and other lo-income
~omen, hospital ou~adent department, Community Heakh Center, and
similar setting;
3. improving institutional practices to make services more easily accessible
and acceptable ~ cbens:
4. identifying yeomen in need of prenatal care (caseOnding) Trough a aside
variety of medbods, including hotlines, community canvassing using outreach
worked or other paraprofessional personnel cross-agency reheals, and Me
. . ~ . .
prOVl~On OI 1ncent~es: ant
5. pr~iding social support to encourage continuation in prenatal care and,
more generaRy, to increase the probabUi~ of headed pregnancies and smooth
He transition into parenthood.
The latter two categories include the majority of activides generally
vised as "ou~eacb." In keeping with the Committees charge, a special
effort alas made to examine programs in those categories. Of course, h~v
programs employed only one approach, and some were -he compreben-
sKe: nonetheless, programs were dassiRed by Rabat appeared to be their
. . .
mam emphasis.
Bepresenutives of each of the almost 200 programs revere contacted by
telephone, mad, or both to learn about the programs actKides and to
ascertain Better they bad data that could be used to judge the programs
e~ct~eness in improving participation in prenatal care. Mere possible,
Eaten report Tom He programs were obtained, and in some instances
OCR for page 117
IMPROVING THE USE OF PRENATAL CARE
117
program directors were asked to develop summaries of their activities and
evaluation data for the Committee. These materials were used in selecting
a final group of programs for more detailed study. The main criteria used
in the selection process were the adequacy and quality of program data.
Consideration was also given to geographic variety, to having a mix of
urban and rural programs, and to including some statewide as well as
smaller scale programs. The selection process resulted in a final set of 31
programs chosen for detailed analysis. Appendix A describes all 31 and
includes evaluation data from each.
Only programs that were able to provide adequate descriptive and
quantitative materials to the Committee by March 1988 were included in
the final set of programs. Since that time, several additional programs have
come to the Committee's attention, indicating that an increasing number
of local communities and states are attempting to improve access to
prenatal care and to determine that effectiveness of these efforts. Space and
time limitations made it impossible to include these additional studies. The
Committee hopes that the federal government or a private organization
will continue the task begun here of collecting information on programs to
improve use of prenatal care and assessing their effectiveness.
It is important to emphasize at the outset that the Committee does not
view these 31 programs as model projects. Although many are innovative
and some quite successful, they were chosen primarily because their data
and experience were highly relevant to the Committee's task, not because
the Committee saw them as standards for the nation.
In selecting these 31, it was difficult to define what constituted adequate
data. The Committee had hoped to find several experimental programs
with control or comparison groups that had been used to evaluate
effectiveness. Unfortunately, few programs had been evaluated with any
methodological rigor, and thus a compromise position had to be adopted.
To be included in the Committee's review, a program did not have to have
conducted a randomized clinical trial to test impact; however, it did have
to be able to report such statistics as the number of women served and
their trimester of initiation of prenatal care, and it had to have made an
attempt to link changes in prenatal care utilization to program activities.
The presence of a comparison group of some sort was considered highly
desirable, even if only the before-and-after variety. Priority was given to
programs for which a formal evaluation had been conducted, particularly
if comparison groups were used.
The problems with such minimal criteria are obvious. For example, if a
prenatal care program was in existence before a concerted casefinding and
recruitment drive, the same number of women, or even more, might have
been served by the program eventually without the extra effort. Or the
women might have switched from a program that did not do active case-
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
finding to the one that did, resulting in no overall increase in the number
of women served in the community. In short, the absence of controls
makes it difficult to tell whether changes really occurred and, if so, whether
they were the result of a particular program.
A compromise position was also adopted concerning the source of
program data. The Committee had hoped that there would be a
substantial body of evidence available in peer-reviewed journals (or
accepted for publication) to help understand program experience in
improving use of prenatal care. Many programs that could shed light on
this issue, however, have not published their data, and Committee staff
often had to cajole program directors into releasing findings. While
several published articles are included in this review, many of the
descriptions are based on reports to funding agencies or documents
prepared for the Committee.
As with the issues of data quality and source, careful consideration was
also given to the concept of an effective program. For this review,
effectiveness was defined in terms of the month of pregnancy in which
prenatal care was begun or the number of prenatal visits or both. The
Committee recognizes that these process measures are not as important as
the outcome of pregnancy or other measures of maternal and infant
well-being. As discussed in the Introduction, however, this study was
limited to the narrow question of learning how best to improve use of
prenatal services, taking as a given that prenatal care improves pregnancy
outcome. As a consequence, programs that had assessed their impact using
only birth outcome measures (such as length of gestation, birthweight,
Apgar score, or infant mortality) were excluded from the final list of
programs studied. A number of projects reviewed reported data on both
use of prenatal care and pregnancy outcome; the Appendix, however,
presents only the utilization data.
THE PROGRAMS STUDIED
In this section, each of the five program types is described in greater
detail, and the 31 projects reviewed by the Committee are listed by
category. Descriptive summaries and evaluation data from each program
are in Appendix A.
Programs That Reduce Financial Barriers
Ample data suggest that financial barriers are a major reason why
women do not seek prenatal care early or complete the recommended
number of visits; this evidence was reviewed in earlier chapters. Despite
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IMPROVING THE USE OF PRENATAL CARE
119
the importance of financial barriers, the Committee identified very few
programs that deal with them directly. Many programs try to increase the
capacity of clinics frequented by low-income women, but only a few try to
provide poor women with funding for prenatal care that is simple for
patients to use and providers to receive and is honored in many private and
public settings.
Every program identified by the Committee that takes a direct approach
to reducing financial barriers is state-initiated.) Federal action has been
limited to recent modest increases in the Maternal and Child Health
Services Block Grant and gradual expansion of Medicaid's coverage of
pregnant women. Unfortunately, data for evaluating both state and federal
initiatives in this area are remarkably scant, as discussed later in this
chapter.
Only two programs reviewed by the Committee directly confront the
financial obstacles to prenatal care:
· the Healthy Start Program in Massachusetts, and
· the Prenatal-Postpartum Care Program in Michigan.
Programs That Increase System Capacity
Pregnant women who want to seek care early and keep their appoint-
ments have difficulty doing so if they live in areas with few private
practitioners or publicly financed facilities, or if local providers are
unwilling to accept Medicaid clients or to provide free or reduced-cost care
to uninsured women. In response, many states, counties, and cities have
tried to improve access to prenatal care by increasing the basic capacity of
the prenatal care system used by low-income women. Initiatives include
expanding existing clinic facilities, opening new ones, or paying private
providers to care for uninsured women. Such efforts frequently occur in
areas where services are plentiful for more affluent women, particularly
those with private insurance.
This approach to increasing the use of prenatal care has a long history.
The Maternity and Infant Care Projects, initiated by the federal govem-
ment in 1963, often involved opening clinics where none existed or
expanding existing facilities so they could accept more indigent patients.
Four more recent examples of this approach were examined by the
Committee:
· the Obstetrical Access Pilot Project in 13 counties in California;
· the Perinatal Program in Lea County, New Mexico;
· the Prenatal Care Assistance Program in New York State; and
· the Prevention of Low Birthweight Program in Onondaga County,
New York.
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
Programs That Improve Institutional Practices
Access to prenatal care may also be enhanced by revising the policies
and practices that shape the way services are provided. Reform of internal
operations is usually achieved when the leadership of a facility concludes
that it is important to make it easier for clients to obtain care or to stay in
care. Improvements might include expediting registration procedures,
providing interpreters, shortening the time spent in waiting rooms,
offering child care and transportation, and monitoring staff courtesy.
Several examples of this approach were examined:
· two Maternity and Infant Care Projects, one in Cleveland, Ohio, and
one in three North Carolina counties;
· an Improved Pregnancy Outcome Project in two counties in North
Carolina;
· an Improved Child Health Project in two areas of Mississippi;
· the Child Survival Project of the Columbia Presbyterian Medical
Center in New York City; and
· a perinatal system in Shelby County, Tennessee.
Programs That Conduct Casefinding
Casefinding encompasses a greater variety of activities than any of the
other four approaches defined by the Committee. It ranges from very
aggressive one-on-one recruiting in a neighborhood to the passive use of
newspapers and posters to attract women to a facility, and from traditional
referral networks to the newer concepts of hotlines and incentive pro-
grams.
Casefinding can be divided into four categories, roughly on the basis of
labor intensity. The most labor-intensive activities place women—often
called outreach workers—on the streets, in housing projects, in schools
and welfare offices, and in other places where pregnant women may be
found. These outreach workers talk with women who may be pregnant or
who may know women who are. Those not receiving care are referred to
an appropriate facility. In some cases, the outreach workers task stops at
that point; that is, she is responsible only for casefinding. More often, she
maintains contact with the pregnant woman and provides the forms of
social support described in the next section.
Hotlines, while reactive, are nevertheless quite labor-intensive, espe-
cially if their task extends beyond just answering questions. The hotlines
studied by the Committee do just that. They attempt in several ways to
ease the task of obtaining a prenatal appointment, to monitor follow-
through, to help women arrange for other health and social services, and
to encourage change at facilities that do not appear to be responding
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IMPROVING THE USE OF PRENATAL CARE
12
appropriately to the needs of the pregnant women referred to them by the
hotline.
A third form of casefinding involves referrals or agency networking. In
this approach, an organization offering prenatal services seeks referrals
from other agencies with different mandates, such as housing assistance.
The notion is that these other groups are likely to be in touch with
pregnant women and may therefore have an opportunity to convince them
of the importance of prenatal care, determine their care status, and refer
women not yet receiving care to a provider. Social service and WIC
agencies (that is, agencies administering the Special Supplemental Food
Program for Women, Infants, and Children) are especially likely to be in
touch with pregnant women and therefore be able to refer them for
prenatal care. Pregnancy testing facilities and settings providing pediatric
care are other potential sources of referral for prenatal care.
A fourth, relatively new form of casefinding is the use of incentives.
"Baby showers" open to the public are one example, and cash or gifts for
women who come to their first prenatal appointment or who keep their
appointments are others. Although European evidence on the effectiveness
of incentives is inconclusive,2 several programs in the United States are
experimenting with this approach.
Closely related to these four types of casefinding, and often supplement-
ing them directly, are public information efforts to announce specific
services or programs. Such activities may be sporadic or sustained over a
long period of time, and they include television and radio announcements
(free public service announcements or paid spots) and announcements or
educational materials in large-circulation newspapers and in neighborhood
newsletters, posters, pamphlets, church bulletins, and so forth. Although
their effectiveness as independent forms of casefinding may be limited,
common sense suggests that public information campaigns are key
elements of all serious efforts to improve use of prenatal care. Target
groups need to know of existing or new services, hotlines need to be
advertised, clinic telephone numbers must be widely disseminated, new
clinic hours must be announced, and new forms of financial assistance
must be communicated to potential recipients.
It is particularly difficult to evaluate the effectiveness of casefinding
activities because they are usually intertwined with such other program
components as provision of free or low-cost care to poor women. Many of
the casefinding projects reviewed by the Committee were able to quantify
where and how they found pregnant women and to show that the women
identified by the program were at high risk for insufficient prenatal care by
virtue of their demographic characteristics. Very few programs, however,
were able to assess whether their casefinding efforts lead to earlier
registration in prenatal care (or registration at all) among the women they
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122
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
found; those that could were included in the Committee's review, if at all
possible.
Ten examples of casefinding for prenatal care were studied:
· the Central Harlem Outreach Program in New York City;
· the Community Health Advocacy Program in New York City;
· the Better Babies Project in Washington, D.C.;
· the Maternity and Infant Outreach Project in Hartford, Connecticut;
· the Pregnancy Healthline in New York City;
· the 961-BABY hotline in Detroit, Michigan;
· the CHOICE hotline in Philadelphia, Pennsylvania;
· a free pregnancy testing program in Tulsa, Oklahoma;
· six studies that assess the role of WIC nutrition programs in
recruiting pregnant women into prenatal care; and
· a Baby Shower initiative in Michigan.
The first four programs have collected data on the effectiveness of a wide
variety of casefinding techniques, particularly the use of outreach workers
to identify pregnant women not already in care. The next three are
hotlines, and the remaining three programs find cases through cross-
program referrals and the provision of incentives.
Unfortunately, no programs of general public information and educa-
tion are included in this list. The Committee learned of many efforts
throughout the country to alert women to the need for prenatal care and
to specific services available in a particular area. However, none was able
to provide adequate information on the target populations being reached
or on the program's impact on use of prenatal care.
Programs That Provide Social Support
Many communities reach out to pregnant women through workers who:
communicate empathetically with their clients; educate women about
prenatal care, labor and delivery, and parenthood; provide referrals and
follow-up on such referrals to assure that needed services are actually
secured; and act as advocates for their clients in such other settings as
hospitals and welfare offices. These activities have been given many
names social support, case management, patient counseling and advo-
cacy, case coordination, and, when occurring outside a health care facility,
home visiting. The services may be offered by trained social workers,
public health nurses, neighborhood residents, or volunteers with various
amounts of on-thejob training. The interaction may occur in the home, at
a prenatal care or social service facility, in a school, or by telephone.
Social support is presumed to improve pregnancy outcomes indirectly
by helping pregnant women obtain quantitatively adequate prenatal care
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IMPROVING THE USE OF PRENATAL CARE
123
(i.e., assisting them in keeping their appointments). Social support is also
thought to improve pregnancy outcomes directly by interpreting and
reinforcing provider instructions, by reducing stress through counseling
and helping women become part of supportive social networks, and by
educating them about nutrition, substance abuse, medications, and other
topics.
Numerous projects offering intense social support have been imple-
mented in the past few years; the following were examined by the
Committee:
· the Resource Mothers Program in South Carolina (for teenagers only);
· six additional adolescent programs, reviewed as a group;
· the Prenatal/Early Infancy Project in Elmira, New York; and
· the Grannies Program in Bibb County, Georgia.
OBSERVATIONS ON PROGRAM EFFECTIVENESS
As the program summaries in Appendix A indicate, considerable time
and money are being spent on these programs, and the personal dedication
of their leaders is impressive. The question is whether they are working.
Are women seeking care who otherwise might not? Are they seeking it
earlier? Are they staying in care? When hundreds of women use a new
system of care, are they women who would have sought care under the old
system anyway, albeit with greater financial or other burdens? When
thousands of women call a hotline and are referred to providers, would
they not eventually have found providers themselves, perhaps after a more
difficult search?
The answer to these questions must take into account the fact that the
women who are easiest to bring into care are already in care. With each
new woman enrolled, it becomes more difficult to draw women from the
pool of the unenrolled. Clearly, the challenge faced by all these efforts to
improve utilization is formidable.
Equally clear is that data on which to judge program effectiveness are
rarely excellent and often inadequate. Most programs have no funds for
evaluation; when unrestricted dollars are available, service demands
usually take precedence. Even the few evaluated programs reviewed by the
Committee seldom used randomization techniques or other strong re-
search designs to assess program effects. Selection bias, in particular,
clouds most evaluations. Moreover, because many programs are complex,
it is often difficult to distinguish the impact of individual elements.
This is not to say, however, that no judgment can be made regarding
program effectiveness. The project data summarized in Appendix A, along
with numerous discussions with program staff (both in the 31 programs
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
reviewed and in many others), have led the Committee to conclude that
each of the five program types can succeed in bringing women into
prenatal care early and in maintaining their participation. With a consid-
erable commitment of resources, participation in prenatal care can be
improved, whether measured by month of registration or number of
prenatal visits. It is nonetheless true that the success of many programs is
modest, primarily because they are anomalies in a complicated, fragmented
"non-system" of maternity services characterized by pervasive financial
and institutional obstacles to care.
More specific conclusions can also be drawn about the five individual
program types. With regard to the first category—removing financial
barriers to care the Committee was struck by how few programs could be
identified that take this direct approach to improving participation in
prenatal care, despite the overriding importance of financial obstacles. As
noted earlier, most try to ease financial barriers by enlarging the clinic
system relied on by low-income pregnant women, rather than by enabling
them to use provider systems already in place, including physicians in
private practice. The Michigan initiative is unique in its legislative
guarantee of access, but the Massachusetts Healthy Start Program stancis
out as the one that has gone the furthest in removing financial barriers to
care. The financial eligibility criteria are very liberal, women can seek care
from the provider they choose (if willing to accept Healthy Start clients),
registration is simple, and there is no welfare stigma. The initial evaluation
suggests this is a promising approach to reaching high-risk women,
particularly the working poor without available cash or health insurance.
Existing ties to private providers and dislike of the welfare system may
make them unwilling to use a clinic and thus cause them to delay seeking
care or to seek it only sporadically. The Massachusetts program seems
especially well designed to overcome such problems.
The reluctance of most states to attack directly the financial barriers is
unfortunate; they are the primary factor in limiting use of prenatal care. It
is not surprising, however, given legislators' concern over the costs of
entitlement programs. Massachusetts' experience with a provider- and
consumer-acceptable and easily administered program may well lead other
states in this direction.
The program data also suggest that increasing the capacity of the
prenatal care systems relied on by low-income women can improve
utilization among this population. Three of the four programs studied by
the Committee in this category were able to provide data suggesting
improvements in use of prenatal care. It is noteworthy, though, that not all
were able to enlist the full cooperation and assistance of the private sector.
Although some physicians in private practice can be persuaded to care for
poor women through various administrative improvements in Medicaid
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IMPROVING THE USE OF PRENATAL CARE
125
and through other inducements, most capacity expansion is accomplished
through publicly financed facilities and with the leadership of the public
sector. The use of nurse-practitioners, certified nurse-midwives, and other
midIevel practitioners is often central to these programs. This emphasis
derives from their proven ability to work well with low-income, often
high-risk clients; the probability that program costs will be less if
physicians are not relied on exclusively; and the difficulty in some
communities of finding physicians willing to work in public clinics or with
low-income women.
With regard to the third program type revising internal procedures
and policies- the Committee found very persuasive data that such insti-
tutional modification can improve the use of prenatal care substantially.
The six programs reviewed underscore the importance of the way in
which prenatal care is actually organized and offered to individual
women how clients are treated, what the clinic or office procedures are,
and what the atmosphere of the setting is. This is by no means an
original observation it was presented in 1976 in Doctors and Dollars
Are Not Enough3 but the value of institutional self-examination has not
been taken to heart in many settings. All too many anecdotes describe
service policies and procedures that discourage use of prenatal care rather
than facilitate it. The startling results of modifications in the method of
determining Medicaid eligibility at Columbia Presbyterian Medical Center
show what can be accomplished by individuals who are willing to face the
possibility that"the enemy is us.',
Indeed, the Committee found great reluctance to change institutional
arrangements—to meddle with existing systems—as a way of increasing
participation in prenatal care. It is unclear whether this hesitation is the
result of negative experiences in dealing with large bureaucracies, prob-
lems in relationships between the nonphysicians who develop many of
these programs and the physicians who provide the care in them, or other
factors. Whatever the reason, the reluctance is clearly present. Complaints
from pregnant women about long waits in clinics, rude staff, and lack of
continuity of care are seldom addressed directly by the physicians in
charge; more often a new facility is opened or superficial changes in clinic
practices are made.
The 10 programs with data on casefinding for prenatal care the fourth
program type—presented the Committee with a wealth of data and
impressions, not the least of which was the enormous creativity shown by
many program leaders in devising ways to identify pregnant women and
draw them into care. Interest in these programs was dampened, however,
by a deep sense of unease that pervaded the Committee's assessment of
them. Given the multiple financial barriers to use of prenatal care, the
inadequate capacity of many existing services, and the inhospitable
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
institutional practices described repeatedly throughout this report, the
question continually arose: Casefinding for what? If care is not readily
available or suited to the target population, what can casefinding hope to
accomplish? How can it compensate for 6-week waits for an appointment,
inaccessible clinic sites, or providers unwilling to take Medicaid clients?
How can it correct the major obstacles to care that are embedded in the
inadequate financing of maternity care? These issues are developed more
fully in the report's conclusions and recommendations (Chapter 59. They
are noted briefly here, however, because they emerged so forcefully from
the Committee's assessment of the data on casefinding.
Nonetheless, the casefinding programs do offer some insights. Data from
projects that conduct casefinding with outreach workers and similar
personnel suggest that the number of clients recruited is often low, and
cost data from the Harlem program suggest that the cost per client enrolled
is very high. It is apparently not easy to identify pregnant women not
already in prenatal care, particularly among the highly mobile residents of
cities. Several program leaders emphasized that inner-city women are often
not at home; even when they are, they are unlikely to open their doors to
unknown neighborhood canvassers. They are also more likely to be
victims of such other problems as drugs, prostitution, and violence, which
make them unreceptive to the overtures of outreach workers. Pregnant
women in rural areas, frequently isolated from others and at a considerable
distance from a care facility, may be more responsive to outreach workers,
but distance and inadequate communication networks limit the success of
this casefinding method there as well. Nonetheless, outreach workers can
sometimes find the hardest-to-reach women. Anecdotal reports from both
Cleveland and Washington, D.C., suggest that periodic sweeps by outreach
workers through housing projects, for example, can uncover significant
numbers of pregnant women not in prenatal care. Whether these one-shot
efforts lead to enrollment in care is, unfortunately, not documented.
To improve their casefinding effectiveness, many projects ask newly
enrolled women how they found out about the program or who referred
them. Frequently, "word-of-mouth" or "friends" are cited. Other com-
monly reported referral sources include cards placed in subways and buses
with key telephone numbers, carefully crafted and placed radio spots, and,
to a lesser extent, television spots. Program directors generally report that
pamphlets, posters, and flyers are seldom cited as referral sources,
although they may help to reinforce messages communicated by other
means.
The hotlines give a particularly positive impression. They appear to be
meeting a real need and their success shows that the telephone has great
potential for casefinding. When hotlines do more than provide information
and referral, when they follow-up on referrals and try to solve their callers'
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IMPROVING THE USE OF PRENATAL CARE
127
problems, they can help to overcome major barriers to care. The Grannies
Program in Bibb County, Georgia, shows that even minimal telephone
contact can improve use of prenatal care. The value of telephone canvass-
ing as an alternative or adjunct to house-to-house canvassing (as con-
ducted by the Better Babies Project) has only begun to be explored.
Common sense suggests that this approach can have only a very small
yield, but it may find some women who could not be found any other way.
Of course, for women with no telephone, this casefinding method
promises little help, and it is probably true that some of the women at
greatest risk for inadequate prenatal care are too poor to afford a telephone.
The program data suggest that casefinding through cross-program
referrals can also improve participation in prenatal care. Close ties between
prenatal services and both pregnancy testing and WIC sites can lead to
earlier enrollment in prenatal care.
On the negative side, the Committee found little evidence that incen-
tives in kind or in cash brought women into care, although the amount of
data available in this area is extremely limited. Programs that use this
approach generally report that the women are appreciative, but program
staff do not think the incentives themselves are the primary factor in
initiating or maintaining care. The Committee learned that many programs
are experimenting with cash payments to encourage participation in
prenatal care. In a year or two, data may be available on the effectiveness
of this approach.
The final category of reviewed projects emphasizes social support,
principally as a means of encouraging women to continue care. Program
data indicate that this approach can indeed result in an increased number
of prenatal visits. Populations at greatest risk for inadequate prenatal care,
such as young teenagers and low-income minority women, often require
significant social and emotional support, information, advice, and caring.
Those providing such assistance are well positioner! to urge pregnant
women to seek and remain in care and to comply with the recommenda-
tions of their health care providers. Although most programs studied in
this category were for teenagers only, there is no reason to believe that the
efficacy of the approach is limited to this age group.
PROGRAM DESIGN AND MANAGEMENT
The Committee noted several design and management attributes com-
mon to projects that seemed to function well and were able to provide clear
descriptive and quantitative material on their activities:
~ Goals were clearly defined, well understood by everyone involved in
the program, and reasonable. For example, staff understood that outreach
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
services were only one of the steps needed to improve pregnancy outcome
and therefore had realistic expectations of what outreach could accom-
plish.
· Most program goals could be translated into a series of quantitative
measures, such as trends in first trimester registration for care, and systems
had been set up to track progress toward the goals.
· Similarly, program activities were carefully monitored, often through
computerized systems that provide basic management information and
data for program evaluation.
· The planning phase was considered important by funders and pro-
gram directors and had received adequate investments of time and money.
There was a shared appreciation of the need for careful definition of target
populations, needs assessment, development and refinement of manage-
ment information systems, and so on.
· Community residents and providers were involved in program design.
Significant time was devoted to establishing strong community ties, and a
high level of respect was accorded community leaders, staff from local
human services agencies, and local ways of reaching consensus and
effecting change.
· Involvement of the news media was encouraged to generate support,
to help communicate program goals and to convey specific messages, such
as the location of a new clinic site or a new source of payment for
maternity care.
· Basic concepts of product marketing had been incorporated where
appropriate. Program leaders understood that, in some sense, they were
selling prenatal care and should therefore draw selectively on the skills of
the advertising and marketing worlds.
· Particularly in community-based programs dealing with low-income
women, staff recognized the multiple burdens often facing clients and the
probability that such needs as employment and English-language training
were more important to them than prenatal care. Accordingly, close ties
with other social services were maintained, and caseworkers were respon-
sive to competing needs.
· In programs that employed community residents in such roles as
outreach worker or hotline operator, considerable resources were investecI
in recruitment, training, supervision, and support.
COMMON DIFFICULTIES IN PROGRAM IMPEEMENTATION AND MAINTENANCE
The Committee was struck by the amount of effort these disparate
programs involve, the degree of personal dedication required of their
leaders, and the difficulties many have had to overcome to make progress.
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The goal of early and continuous use of prenatal care by pregnant women
may seem straightforward and obviously sensible, but attaining it in the
United States at present is proving to be an arduous task. Many program
leaders described their struggles to implement and maintain programs. At
least 14 problem areas can be defined, and, although no single program
reported all of them, a discouraging number reported several. These are
listed below, grouped into several clusters.
Finding Financiat and Community Support
· Funds are rarely adequate to meet program goals, and persons who
must raise money annually find the constant application or lobbying
process exceedingly burdensome, adding worries about job security to the
usual pressures of running a program. Similarly, it is difficult to sustain
political and economic support for programs over many years. The
attention span of political bodies is short, which creates a continuing
problem of funding stability for projects that rely on public money. Several
, . ~ . . . . ~ .. . . . . . ..
program leaders noted that, although support tor"mothers and babies,,
receives a lot of lip service from public leaders, efforts to translate such
sentiments into ongoing legislative or fiscal support often encounter great
inertia. Private sector support may be somewhat less volatile, but private
foundations, in particular, are reluctant to invest in a single program for
many years. These problems in securing stable financing make it particu-
larly difficult to maintain a program or to institutionalize successful pilot
or demonstration programs.
· Projects that offer clinical prenatal services (as distinct from commu-
nity education, for example) can have difficulty securing funding for such
other program components as more intense supervision for high-risk
women, prescription drugs, certain diagnostic tests, public education,
casefinding, counseling, and follow-up services.
· The news media can help create and maintain broad community
support for a project and can help educate women about a particular
program or service. But sustaining media support can be difficult.
Moreover, even if the press is willing to cover a new initiative, interest
lessens as the program becomes routine, at least to outside observers.
One manager noted, "It's hard to have a press conference on an old idea."
Raising money for the media portion of a program is notoriously
difficult. Although television and radio spots may be comparatively easy
to fund early in a program, such support tends to fade as the months
progress. Programs that rely mainly on public funds report particular
difficulty in securing money for ongoing, high-intensity, creatively
packaged media campaigns about prenatal services and reproductive
health generally.
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
· The close relationship that many programs must maintain with area
clinics, hospitals, and health departments can make it difficult for them to
act aggressively on behalf of their clients in these settings. In particular, it
can be awkward for a program to seek funding from a hospital or health
department while simultaneously pointing out organizational obstacles to
care within these institutions and advocating change.
Recruiting and Keeping Personnel
· Program managers reported that outreach workers can be difficult to
recruit, train, supervise, and motivate and that only the most skilled and
persistent are likely to succeed. The threat of burnout is ever present and
requires specific attention and support. Program directors have found that
using outreach workers effectively requires major investments of time and
money and that both funders and program planners tend to underestimate
the challenge posed by using them. Similarly, other service systems often
have little understanding of outreach workers' roles in enhancing access to
health care and often do not work well with them.
· The tasks of outreach workers may be dangerous. It is common in
inner cities, for example, for outreach workers to canvass neighborhoods
or housing projects only in teams or with a security guard—or both. The
cost implications of such arrangements are obvious.
· Adequate money and time are seldom available for provider education
about cultural and other differences between themselves and clients that
may impede communication and compliance. Some programs report overt
resistance to such training among providers, both those in the program
and those in the community to whom program participants may be
referred.
· Some program clients are hard to engage, difficult to work with, and
occasionally abusive to the staff. One program manager noted: "It's hard to
make the doctors and nurses like and 'reach out' to some of these women."
Substance abusers in particular can put great stress on the staff.
Dealing with Bureaucracies
· Building an innovative program into an existing system is difficult and
fraught with potential turf battles. Competition for space and staff
positions, for computer time, for the attention of the broader organiza-
tion's leadership, and for community support creates serious tensions.
New programs face major bureaucratic obstacles in hiring staff; a position
for the new program may be approved but cannot be filled or hiring freezes
may paralyze progress altogether until ways of circumventing such
obstacles are found. Differences in responsibility, autonomy, perhaps also
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131
in pay between the new program's staff and others in roughly similar
positions in the existing bureaucracy can create suspicion and resent-
ment. Worries about job security among existing staff and the discom-
forts of organizational change can create a chilly environment for a new
program.
· Long-standing tensions between, for example, state and city health
authorities, health departments and local hospitals, and physicians and
nurse-midwives can interfere with programs that are trying to change the
prenatal care system. One program studied by the Committee has still not
been successful in employing nurse-midwives in its clinical services as
originally planned because of resistance by private physicians affiliated
with the major hospital in the community.
Planning and Sustaining Programs
· The start-up time of programs is often long, or at least should be long,
if adequate planning and training are to be accomplished. Yet, funders are
often impatient, wanting the program to begin quickly and show results
soon thereafter. Long start-up periods are reported by state-level programs
in particular, because they often need the tangible assistance and cooper-
ation of multiple bureaucracies (accounting, welfare, personnel, and so
on), many of which have no familiarity with maternal and child health
services.
· It is hard to maintain momentum in programs dependent on high-
energy founders, the charismatic people who generate fresh ideas and new
programs, overcoming numerous obstacles to progress. As leaders change
over time, a program's energy level often drops and the underlying
rationale and essential program features can be lost. Effectiveness can also
deteriorate when small, successful programs are expanded. For example,
one program that began small was accepted by providers because it
included a more efficient, accessible process for billing Medicaid; providers
were paid promptly, and billing problems were solved relatively easily.
When the program was expanded statewide, much of this billing system
was lost and provider participation along with it.
Other Problems
· The controversial issue of abortion can compromise support for
prenatal programs, particularly if such programs focus on reaching women
early in pregnancy. It was reported to the Committee that prenatal
programs can be suspected of encouraging abortion for some clients and
therefore have difficulty securing adequate support, particularly from
legislative bodies.
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
· Low-income clients often have great difficulty finding funds for labor
and delivery; consequently, program staff must spend considerable time
helping distressed clients locate financial aid. One nurse reported that a
large proportion of her time with pregnant women is spent on this single
issue, causing considerable anxiety to both herself and the client. Other
topics such as preparation for parenthood or infant feeding options are
sometimes shortchanged in the search for financial assistance with child-
birth expenses.
PROGRAM EVALUATION
The Committee also found that virtually all programs struggle with
evaluation- what to evaluate, how to build data collection into routine
program activities, how to enlist staff in the process of evaluation when
providing service is their primary focus, and, above all, how to find
adequate money, staff, and time to do high-quality evaluation studies.
Compounding such challenges is the fact that programs are often in a state
of flux. Patient populations, the number of geographic areas in which the
program operates, the nature of the services being offered- even the
forms—change frequently, making evaluation of impact difficult. Several
programs decided in mid course to study their effectiveness more system-
atically, but they were hampered by their late start and by the usual
resource constraints. Tensions between service goals and evaluation were
constantly evident; for example, leaders of the Resource Mothers program
reported difficulty in getting staff to adhere to certain data-gathering
routines or to such research methods as randomization. Perhaps most
troubling of all, some programs that believed they were evaluating their
activities properly were found, on closer examination, to be using inade-
quate evaluation designs, yielding data of limited value. The net result of
all these problems and constraints is that the quality of most program
evaluation reviewed by the Committee was poor and that considerable
energy was being wasted.
The challenge of evaluation is formidable not only for community-based
projects, but also for recent statewide efforts to reduce infant mortality and
enhance prenatal care. Illinois, California, Florida, and Connecticut, for
example, are deeply involved in efforts to improve perinatal care and infant
survival. However, the number and complexity of the interventions within
a given state, the diversity and number of settings providing the new
services, problems in collecting uniform data, the time and money required
to design statewide evaluation systems and to analyze the voluminous data
these systems generate- such problems often result in inadequate evalu-
ation or none whatever. Maternal and child health agencies within state
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133
health departments often have a leading role in these state initiatives, but
they seldom are provided with sufficient resources to evaluate the new
programs they are charged with operating.
SUMMARY
With typical American ingenuity and energy, a great variety of programs
has been organized in recent years to help women gain access to prenatal
care. A careful study of 31 such programs and a more limited review of
many more has led the Committee to conclude that, with adequate
investments of time, money, and commitment, rates of early registration in
prenatal care can be improved, as can rates of remaining in care. However,
many of these initiatives are only modestly successful because they are
anomalies in a complicated, fragmented maternity system with pervasive
financial and institutional obstacles to care. In studying these programs,
the Committee noted that management and evaluation vary in quality
across the programs; with regard to evaluation in particular, quality is
often poor.
The Committee was particularly impressed with the effectiveness of
programs that reduce fundamental financial or capacity barriers. Partici-
pation in care also can be improved through programs that try to change
policies at the service delivery site so that women will fee! welcomed into
care, or that act as advocates for women who have encountered problems.
Nevertheless, there are some women for whom a reduction in financial
barriers, an increase in service supply, and a modification in policies at the
service delivery level will still not be sufficient to bring them into prenatal
care early and regularly. For them, certain casefinding techniques seem
particularly useful, such as cross-program referrals and hotlines. Providing
intensive one-on-one social support can help to keep women in prenatal
care throughout their pregnancies.
In considering all five program types together, the Committee noted that
far more energy is going into outreach than into programs that reduce
fundamental financial and institutional barriers, despite their importance
(Chapter 29. If more programs focused squarely on eliminating basic
institutional barriers, it would easier to define who the truly "hard to
reach" pregnant women are and to target casefinding and social support
programs more effectively.
The effort that all these programs expend in achieving even small gains
is sobering. Launching new initiatives and sustaining momentum require
a tremendous commitment by program leaders and funders, and many
obstacles can be encountered along the way—unstable funding, bureau-
cratic in-fighting, private sector resistance, even physical danger. Indeed,
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
the job of drawing more pregnant women into care seems at present an
overwhelming, thankless task. As one program leader mused, "We're
trying to do the Lord's work and we keep finding devils."
REFERENCES AND NOTES
1. See, for example, Petschek MA and Adams-Taylor S. Prenatal Care Initiatives:
Moving Toward Universal Prenatal Care in the United States. New York: Center for
Population and Family Health, School of Public Health, Columbia University,
1986.
2. Beukens P. Determinants of prenatal care. In Perinatal Care Delivery Systems,
Kaminski M, Breart G. Beukens P. Huisjes HI, McIlwaine G. and Selbmann H. eds.
Oxford University Press, 1986, pp. 16-25.
3. Doctors and Dollars Are Not Enough. Washington, D.C.: Children's Defense Fund,
1976.
Representative terms from entire chapter:
pregnant women
