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OCR for page 135
Chapter
Conclusions ant!
Recommenclations
At the outset, the focus of this study was outreach for prenatal care. The
Committee's charge was to determine which outreach techniques most
effectively draw women into care early in pregnancy and maintain their
participation until delivery. For this study, outreach was defined to include
various ways of identifying pregnant women and linking them to prenatal
care (casefinding) and services that offer support and assistance to help
women remain in care once enrolled (social support).
Early deliberations, however, made it clear that outreach could not be
studied in isolation and that the Committee's inquiries had to cover the
larger maternity care system* within which outreach occurs. At least four
considerations led to this expanded scope of study. First, many projects
conventionally labeled outreach (that is, programs of casefinding or social
support or both) were found, on closer examination, to be actively
involved in such problem-solving activities as trying to help women
arrange financing for an in-hospital delivery activities that are not
included in conventional understandings of outreach. Second, the goals
and content of outreach programs are so heavily influenced by the larger
systems within which they operate that it would have been difficult, if not
useless, to analyze them apart from their surrounding environment. Third,
a variety of approaches other than outreach can accomplish the goals of
earlier registration in prenatal care and improved continuation in care.
*That is, the complicated network of publicly and privately financed services through which
women obtain prenatal, labor and delivery, and postpartum care.
135
OCR for page 136
136
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
These activities include reducing financial barriers to care, making certain
that system capacity is adequate, and improving the policies and practices
that shape prenatal services at the delivery site. Finally, the Committee
reviewed the larger maternity care system because it makes little sense to
study ways to draw women into care if the system they enter cannot, or
will not, be responsive to their needs. Because of this expanded scope of
study, many of the recommendations contained in this chapter are directed
at the maternity care system as a whole rather than only its outreach
component, although specific recommendations on outreach are pre-
sented.
REVISING THE NATION S MATERNITY CARE SYSTEM:
A LONG-TERM GOAL
The data and program experience reviewed by the Committee reveal a
maternity care system that is fundamentally flawed, fragmented, and
overly complex. Unlike many European nations, the United States has no
direct, straightforward system for making maternity services easily acces-
sible. Although well-insured, affluent women can be reasonably certain of
receiving appropriate health care during pregnancy and childbirth, many
other women cannot share this expectation. Low-income women, women
who are uninsured or underinsured, teenagers, inner-city and rural
residents, certain minority group members, and other high-risk popula-
tions described earlier in this report are likely to experience significant
problems in obtaining necessary maternity services.
Securing prenatal services in particular can be especially difficult for
these groups, as shown by the data in Chapters 1 and 2; moreover, there
is evidence that utilization is actually declining among certain very
high-risk groups. Recent efforts to expand eligibility for Medicaid and
numerous state and local initiatives to strengthen maternity services may
improve use of prenatal care somewhat, but given the modest scale of most
initiatives and the magnitude of the problem, major inequities in the use
of prenatal services are likely to remain. These data are deeply troubling in
light of the value and cost-effectiveness of prenatal care.
Achieving major improvements in the maternity care system, particu-
larly in the use of prenatal care, will be neither quick nor easy. Significant
improvement must begin with a fundamental recognition that pregnancy
and childbearing are profoundly important events requiring carefully
formulated social policies and supports.
· We recommend that the nation adopt as a new social norm the
principle that all pregnant women not only the affluent" should be
provided access to prenatal, labor and delivery, and postpartum services
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CONCLUSIONS AND RECOMMENDATIONS
137
appropriate to their need. Actions in all sectors of society, and clear
leaclership from the public sector especially, will be required for this
principle to become a clear, explicit, and widely shared value.*
A consensus of this nature means that maternity services must be viewed
not as a consumer good, available only to women with certain financial and
personal assets, but as an essential part of the country's social and health
services, comparable to public education easily available, valued, and
used by virtually all women. The merit of such social policy is amply
supported by data on the effectiveness—including the cost-effectiveness
of prenatal care (see the Introduction). It is also consistent with basic
civility and compassion, with the concept of adequate investment in future
generations, and with the need to provide special care during a particularly
vulnerable phase of life pregnancy and childbirth. All subsequent rec-
ommendations in this report are subsumed under this one. We suggest it
as a standard against which to measure a wide array of policy sugges-
tions—ours and others'.
Attaining this goal requires major reform in the way maternity services
are organized, financed, and provided in this country, particularly for
low-income and other high-risk groups. Continuing to make marginal
changes in existing programs is unlikely to meet the standard of universal
participation that we advocate. Slowly implemented, often small expan-
sions in Medicaicl eligibility, brief bursts of publicity about infant mortality
and the importance of prenatal care, efforts in a few communities to
increase the number of clinics offering prenatal services these actions,
while laudable, are too limited, sporadic, and uncoordinated to overcome
the pervasive barriers to care detailed in this report. Rather, the current
situation dictates more purposeful action:
· We recommend that the President, members of Congress, and other
national leaclers in both the public and private sectors commit them-
selves openly and unequivocably to designing a new maternity care
system (or systems) dedicated to drawing all women into prenatal care
and providing them with an appropriate array of health and social
services throughout pregnancy, childbirth ant! the postpartum period.
Although a new system might build on existing arrangements, long-term
solutions require fundamental reforms, not incremental changes in
. .
exlstmg programs.
Several ways of designing a new system are feasible, once the political
will to create one has been mustered. For example, Congress could appoint
*Throughout this chapter, major recommendations are bulleted (a) and in bold face; subsidiary
recommendations and suggestions that develop a recommendation further are in italics.
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138
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
a commission of experts knowledgeable about the maternity care system
and public policy; a group of experts within the U.S. Department of Health
and Human Services could be assembled; Congress could itself develop
alternative proposals using existing data and opinions, drawing on the
expertise of established congressional committees and such resources as
the Office of Technology Assessment and the Congressional Budget Office;
or an independent group could be asked for advice.
In making this recommendation, the Committee emphasizes that a
commitment to enact major reforms must precede the establishment of any
commission or other mechanism.* Too often, studies are funded or panels
appointed without such a commitment: as a consequence. change mar be
postponed or fad! to take place altogether.
We urge that the group chosen to work out the specifics of a new system be
a technical, expert body charged only with defining the components and
costs of a new maternity system, not with describing current problems yet
again or with developing the political momentum needed to accomplish
major changes.
Once the components of the system have been defined, action to implement
the recommendations must follow; otherwise, the effort will be futile and may
actually be destructive, by raising false hopes among those in need.
In recommending a new maternity system, the Committee recognizes
that problems of access to maternity care are only part of the larger
problem of access to health services generally. It may well be that
far-reaching reforms in the overall health care system will overtake the
efforts recommended here to improve access to maternity care. For
example, the increasing pressures of the AIDS epidemic alone may lead to
significant changes in the health care system. Nonetheless, the focus here
is on maternity care, as dictated by the Committee's mandate.
Although the Committee was not asked to specify the elements of a new
system or systems of maternity care, our work over the last 2 years has
indicated the principles essential to significant improvement in the use of
prenatal services. We presume that these same attributes would also
improve the care women receive during childbirth and the postpartum
period. We urge that the new system:
*This sequence was followed in the early 1980s when the Social Security system was threatened
with financial difficulties. Both the President and the Congress recognized that corrective action
needed to be taken and appointed the National Commission on Social Security Reform (the
"Greenspan Commission") to develop a plan for solving the system's financial problems. The
Commission recommended a series of measures in January 1983 and Congress adopted them later
that year.
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CONCLUSIONS AND RECOMMENDATIONS
139
accommodate the maternity care needs of all women, not only women in
privileged economic or geographic subgroups;
embrace the full continuum of maternity services (prenatal, labor and
delivery, and postpartum care), erasing the gap that currently exists between
systems that provide andfinance prenatal care and those that support carefor
childbirth;
be closely coordinated with other health services used by women,
improving the quality and accessibility of these related services as much as
possible;
—over a uniform, comprehensive package of maternity services that can
accommodate variations in individual needs, as suggested by the Select Pane!
for the Promotion of Child Health, ~ the American College of Obstetricians and
Gynecologists2 and the American Academy of Pediatrics,3 and theforthcoming
report of the Public Health Service's Expert Pane! on the Content of Prenatal
Care;4
—address the liability pressures currently driving providers out of the
practice of obstetrics;5
be administered separately from the welfare system;
- rely on a wide array of providers, including both physicians and certified
nurse-midwives, each of whom may practice in a variety of settings and
systems;
tee financed adequately;
ensure that financing mechanisms support appropriate clinical practices;
—include a large-scale, sustained program of public information and
education about maternity care;
—support education and training of providers to deepen their understanding
both of the obstacles women can face in securing prenatal care and their
perceptions of care once enrolled;
include reliable, accurate means of collecting data on unmet maternity
care needs and on the performance of the new system or systems, at local,
state, and national levels; and
specify a structure of accountability and responsibility under the control
of a federal agency, with state agencies assuming leadership.
Many of these issues, such as the urgent need to address liability
pressures, are taken up again and in more detail in later sections presenting
the Committee's short-term recommendations. Here, we wish to empha-
size two in particular. First, the separation of maternity care financing from
the welfare system is emerging as a key element of initiatives to improve
use of prenatal care among poor women, as demonstrated by recent
Medicaid reforms (Chapter 29. Although Medicaicl and welfare obviously
need to be coordinated, the links between the two programs have had the
unfortunate effect of attaching a welfare "stigma" to a health care financing
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140
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
program. Therefore, the notion of separating the programs administra-
tively is important. Second, we emphasize the need for national standards
of maternity care. Increased communications, rapid dissemination of new
information and technologies, and increased use of national standards in
malpractice suits make it ever more unreasonable for maternity care to
differ widely among geographic or socioeconomic groups, although care
must always accommodate variations in individual need.
It is also apparent that a deeper national commitment to family planning
services and education should accompany major revisions in the maternity
care system. Women with unintended pregnancies are particularly likely to
delay seeking prenatal care and more than half of all pregnancies in the
United States are unplanned (Chapter 2~. Therefore, reducing rates of
unplanned pregnancy could lead to lower rates of late entry into prenatal
care. The Committee recognizes that progress in this direction is compli-
cated and that a large literature exists on both the antecedents of
unintended pregnancy and ways to reduce it. Nonetheless, a firm commit-
ment to extencting family planning services is an obvious, essential first
step, particularly for those populations most at risk of unintended
pregnancy (and, subsequently, poor participation in prenatal care)-
low-income women, teenagers, and minorities. Such services should be
easily available in numerous settings, should be provided for free or at very
low cost, and should be carefully linked to prenatal services (as discussed
in more detail below). High-quality, widely disseminated public informa-
tion and education about family planning is also important and should be
coordinated with messages about prenatal care. In fact, it might be possible
to develop information and education campaigns around broad issues of
reproductive responsibility and health, encompassing both family plan-
ning and prenatal care.
DEVELOPING A COMPREHENSIVE, MULTIFACTED PROGRAM:
A SHORT TERM GOAL
While consensus grows on the need for a major restructuring of the
maternity care system in the United States, and while the specifics of a new
approach are being defined, several more immediate steps should be taken
to increase participation in prenatal care. Although some of them are quite
far-reaching, they all derive from and are based on the existing maternity
care system. As such, they differ fundamentally from our recommendation
in the preceding section, which argues for a more profound and complete
reorganization of this health care field.
· We recommend that more immediate efforts to increase participation
in prenatal care emphasize four goals: eliminating financial barriers to
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CONCLUSIONS AND RECOMMENDATIONS
141
care, making certain that the capacity of the system is adequate,
improving the policies and practices that shape prenatal services at the
site where they are provided, and increasing public information about
prenatal care.
The Committee has concluded that these four reforms promise
significant improvement in the use of prenatal care. The first of the
four eliminating financial barriers is undoubtedly the most impor-
tant. Indeed, we believe that if this single barrier were removed, many of
the other problems noted throughout this report would decrease
appreciably. Ample data indicate, however, that it is not only financial
problems that keep women out of care. Other problems can impede
access as well and also require attention. Thus, removing financial
barriers should be viewed as a necessary but not entirely sufficient-
step in improving the use of prenatal care.
We urge that leadership for this comprehensive approach come from the
federal government. Individual states and communities should not have to
both develop and fund programs to improve access to care, even though
some states have been particularly innovative in doing so—by offering
health insurance to those with inadequate or absent coverage, for example,
or by constructing new programs to supplement Medicaid and federal
funds for maternal and child health. Leaving the entire task of program
innovation and support up to the states is certainly consistent with
political trends in the 1980s, but the federal government should nonethe-
less play a stronger role.
· We recommend that the federal government provide increased lead-
ership, financial support, and incentives to help states and communities
meet the four goals we advocate. In a parallel effort, states should accept
the responsibility for ensuring that prenatal care is genuinely available to
all pregnant women in the state, relying on federal assistance as needed
in meeting this responsibility.
More specifically, we urge a stronger federal role in providing funds to
state and local agencies in amounts sufficient to remove financial barriers
to prenatal care (through such channels as the Maternal and Child Health
Services Block Grant and other grant programs) and in providing prompt,
high-quality technical consultation to the states on clinical, administrative,
and organizational problems that can impede the extension of prenatal
services. The federal government should also take more leadership in
defining a mode! of prenatal services for use in public facilities providing
maternity care; and supporting related training and research.
States should assume direct responsibility for ensuring that all women
within the state have full access to prenatal services. Backed by adequate
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42
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
federal funds, support, and consultation, the states should invest generous
amounts of time and money in extending this basic health service. This
would involve states more deeply in assessing unmet needs by surveying
existing prenatal services and identifying the localities and populations for
which they are inadequate; contracting with various providers to fill gaps
in services; and in some instances, providing prenatal services directly,
through such facilities as health department clinics. In addition, the
Committee suggests that each state pass legislation making the maternal
and child health agency of the state health department responsible for
ensuring that prenatal services are reasonably available and accessible in
every community.
FINANCIAL BARRIERS
Removing financial barriers to care is the cornerstone of the compre-
hensive program we recommend. Surveys of pregnant women and of
maternity care providers, and program experience over many years
uniformly demonstrate the importance of economic circumstance espe-
cially the presence or absence of insurance—in predicting use of prenatal
services. Although expansions of Medicaid and creative state initiatives
have made some progress recently in lowering financial barriers to care,
the pace of progress needs to accelerate, and remaining financial obstacles
need to be removed. Accordingly, as a critical first step:
· We recommend that top priority be given to eliminating financial
barriers to prenatal care.
This broad recommendation has specific implications for all the major
networks, public and private, that underwrite prenatal care. For the
Medicaid program:
We recommend that the federal government require all states to provide
Medicaid coverage of prenatal care for pregnant women with incomes up to
185 percent of the federal poverty level,* to be followed by eligibility
expansions beyond 185 percent to cover more uninsured or underinsured
women.
Detailed discussions of how states and the federal government can
accomplish this and other expansions in Medicaid eligibility for pregnant
women and other groups are contained in Medicaid Options: State Oppor-
tunities and Strategies for Expanding Eligibility, prepared by the American
Hospital Association.6
*This is currently only an option for states (Chapter 2).
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CONCLUSIONS AND RECOMMENDATIONS
143
For the various federal grant programs (particularly the Maternal and
Child Health Services Block Grant and the programs funding Community
Health Centers, Rural Health Centers, and Migrant Health Centers) and for
state and local health departments:
We recommend that federal and state authorities provide these service
systems with su.fficientfunds to o.fferfree or reduced-cost prenatal care without
delay to aZZ pregnant women requesting it in these settings.
Meeting this broad objective will require, among other things, more
sophisticated measurement of unmet need in the areas served by these
publicly financed clinics.
For private insurance, where coverage of prenatal care can be inadequate:
We recommend that Congress and state governments act to expand and
strengthen private insurance coverage of maternity services.
This goal could be reached in various ways. For example, Congress could
mandate that all employers covered by the Fair Labor Standards Act
provide a defined package of maternity services to employees and their
dependents. Congress could also repeal the exemption contained in the
Pregnancy Discrimination Act allowing employers of fewer than 15
persons to provide no pregnancy coverage. Congress could also modify the
Employee Retirement Income Security Act (ERISA) in order to permit
states to require that self-funded employer health plans provide maternity
benefits; more than half of employer-provided health insurance plans are
self-funded and as such are exempt from state insurance regulation
through ERISA.
We also urge purchasers of private insurance to pressfor improved coverage
of prenatal care through labor union negotiations, switching to more comprehen-
sive plans, and similar consumer-based actions. Private insurance companies
themselves should take the initiative of offering comprehensive coverage of
prenatal care as part of their basic insurance packages.
In all these actions, attention should be focused on eliminating such
gaps in coverage as waiting periods for prenatal benefits to begin,
dependent coverage that fails to include prenatal services, limited insur-
ance for part-time or seasonally employed individuals, and burdensome
copayments and deductibles for maternity services (Chapter 21.7
INADEQUATE SYSTEM CAPACITY
Urging all pregnant women to begin prenatal care early is a hollow
message if prenatal clinics are nonexistent—or so backed up as to be
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
nonexistent in practical terror if private providers are lacking or
unwilling to accept low-income patients. Yet the Committee uncovered
considerable evidence that capacity is inadequate in various communities,
particularly for poor women (Chapter 2~. Accordingly, as a companion
initiative to reducing financial barriers:
· We recommend that public and private leaclers designing policies to
draw pregnant women into prenatal care make certain that prenatal
services are plentiful enough in a community to enable all women to
secure appointments within 2 weeks with providers close to their homes.
Methods for achieving this objective will vary across states and com-
munities, but several approaches will probably be required simultaneously.
We recommend:
more careful assessment at the community level of existing service
capacity and of the areas and groups for whom capacity is inadequate; state
leadership in this area is particuZarZy appropriate, as noted above;
more generous financing of clinic systems, in particular, to allow them to
meet demand, also noted above;
resolution of the malpractice crisis in obstetrics;
increased Medicaid reimbursement for maternity care offered by private
providers in order to increase the number of physicians who accept Medicaid
patients;
restoration of the National Health Service Corps and equivalent state
programs to help develop an adequate pool of providers for medically
underserved areas;
expansion of the variety of settings in which prenatal care is offered;
school-based health clinics in particular can help bring prenatal care to
adolescents;
increased use of certified nurse-midwives (CNMs) and obstetrical nurse-
practitioners; state laws and physicians themselves shouts support hospital
privileges for CNMs and collaboration between physicians and nurse-mid-
wives or nurse-practitioners; eventually, large interstate variations in the laws
governing the use of such midZeve! practitioners should be eliminated; and
leadership by the professional societies of obstetric care providers to
increase the involvement of private physicians in the care of indigent
women. (For example, private sector leaders should work coliaborativeZy
with Medicaid officials and leaders of maternal and child health agencies to
raise reimbursement levels for maternity care, to solve administrative
problems in the Medicaid program, and to develop proposals for providing
physicians with incentives to serve poor women. National professional
organizations snooze urge local ones to focus on problems of underserved
women).
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CONCLUSIONS AND RECOMMENDATIONS
145
The last point is particularly important. Raising Medicaid fees and
addressing the malpractice problem in obstetrics are undoubtedly neces-
sary to enhance private sector involvement in indigent care, but leadership
from the professional societies is also critical. The work of the Commit-
tee on Underserved Women of the American College of Obstetricians
and Gynecologists is a useful step in this regard. Other national, state,
and local organizations of obstetric care providers should establish
. .
slm1 ar groups.
With regard to the specific issue of malpractice, the Committee urges
public and private groups with expertise in this area to develop without
delay a range of possible solutions to the current situation, perhaps
experimenting with various approaches in different states. One interesting
proposal is to provide sufficient funds to public agencies for them to absorb
the costs of malpractice insurance for providers (MDs, CNMs, and others)
who care for significant numbers of indigent women.
INSTITUTIONAL ORGANIZATION, PRACTICES, AND ATMOSPHERE
However well-organized the maternity care system appears at the state
or national level, a pregnant woman experiences and judges it in her
individual community, in a specific clinic or office, and with a particular
provider. In reviewing initiatives to increase the early use of prenatal care,
the Committee has been repeatedly impressed by the success of programs
that emphasize internal institutional modification as a means of drawing
more women into care and sustaining their participation. Therefore, in
addition to addressing financial barriers and problems of limited capacity:
· We recommend that those responsible for providing prenatal services
periodically review and revise procedures to make certain that access
is easy and prompt, bureaucratic requirements minimal, and the
atmosphere welcoming. Equally important, services should be pro-
vided to encourage women to continue care; follow-up of missed
appointments should be routine, and additional social supports should
be available where needed.
In this context, the Medicaid program requires special emphasis.
However generous the eligibility expansions described earlier, little is
gained if the task of applying for and maintaining Medicaid coverage is so
difficult, complicated, and time-consuming that prompt, continuous par-
ticipation in prenatal care is virtually impossible for all but the most
socially organized and determined women. Accorclingly:
We recommend that states shorten and simplify the process of obtaining
Medicaid coverage for prenatal services and that, once a woman is enrolled,
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PRENATAL CARE: REACHING MOTHER, ACHING INFANTS
2. television and, in particular, radio spots to announce specific
services, coordinated with posters displayed in the mass transit system;
3. efforts to encourage current program participants to recruit
additional participants from their friends, neighbors, ant! relatives;
4. strong referral ties between the prenatal program and a variety of
other systems in which pregnant women at risk for insufficient care may
be found: family planning clinics, schools, housing programs, VVIC
agencies, welfare and unemployment offices, churches and community
service groups, shelters for the homeless, the police and corrections
systems, substance-abuse programs and treatment centers, and other
health and social service networks; and
S. outreach workers who work in carefully defined target areas and
seek clients among welI-defined target populations.
Whatever the method used, casefinding should be directed toward high-
risk groups and areas. This requires that program leaders pinpoint the
sociodemographic characteristics and geographic locations of women who
obtain insufficient prenatal care.
The materials in Chapter 1 can help to define target groups, although the
data discussed there are primarily national- states and communities need
more detailed information on their own populations. Chapter 2 also
presents information that can help to define target groups. Data from both
chapters suggest that several populations are likely candidates for targeted
casefinding (as they are for focused campaigns of public information): very
young teenagers, low-income multiparous teenagers, women over 35 with
several children, substance-abusing women and homeless women, recent
immigrants, certain high-risk minority groups, and very low-income
women in both inner-city and rural areas.
The fifth method highlighted above, use of outreach workers, requires
comment. Much of the program data assembled by the Committee suggest
that the effectiveness of these workers is limited. We suspect, though, that
when such workers are used only in a carefully targeted way in very
low-income housing projects, for example, or other areas with high
concentrations of women at risk for inadequate prenatal care, their
effectiveness may be greater than some of the program data suggest. The
personal touch they offer to women whose lives are often in chaos may be
just what is needed, and the poorest inner cities and rural areas of America
may need more of them. We emphasize again, though, the importance of
their work being focused on areas of greatest need only, given the expense,
labor-intensity, and occasional dangers of the job.
A final note on outreach workers. It is not uncommon for communities
to have outreach workers from several different agencies working in a
single area. Representatives from child abuse and neglect services, pediat-
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CONCLUSIONS AND RECOMMENDATIONS
153
rics, social services, sanitation, housing, and rat and poison control can all
be knocking on the same doors. The potential for fear, suspicion, and lack
of efficiency that such a scenario suggests {cads us to a simple suggestion:
We recommend that communities experiment with multipurpose outreach
workers in an effort to increase efficiency, enhance the receptivity of neigh-
borhood residents, and, perhaps, increase the effectiveness of such workers.
Evaluation should accompany welI-designed trials of this approach and, if they
are found useful, results should be widely disseminated.
We recognize a historical cycle here. Over the years, single-purpose and
multipurpose outreach move in and out of style. In the early days of the
War on Poverty, for example, the multiservice mode! was ascendant; in the
1980s it is rare. Our sense is that the pendulum has swung too far in the
single-purpose direction and that a change is in order.
The Committee also calls particular attention to casefinding through
closer links between pregnancy testing and prenatal services. A major
opportunity to enroll pregnant women in prenatal care promptly is missed
each time a positive pregnancy test is not accompanied by an appointment
for prenatal services, if appropriate. Similarly, a negative pregnancy test
signals that referral to family planning or even infertility services may be
in order.
We recommend that pregnancy-testing services and prenatal care programs
develop stronger referral ties, including the ability to make appointments for
prenatal care at the pregnancy testing site. Missed prenatal appointments
require vigorous follow-up.
In this context, we also urge that, given teenagers' poor use of prenatal
care (especially teenagers who already have one or more children), schools
include the availability of pregnancy testing in their health services and
make special efforts to help pregnant teenagers obtain prenatal care. Health
clinics based in schools are increasingly common and provide a natural
setting for this function.
Similarly, pediatricians, family practitioners, and others caring for
families with young children can help in the task of casefinding. In
Chapter l, the strong association between higher birth order and poor use
of prenatal care was noted; young, poor, multiparous women in particular
form an exceedingly high-risk group. This finding supports an additional
suggestion:
We recommend that health care providers in touch with women who have
young children—particularly Zow-income teenagers with young children
periodically raise the topics offamity planning and child spacing. If additional
children are planned or already on the way, the topic of prenatal care should
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54
PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
be raised. Specific information on where and how to obtain prenatal care
should be easily available in these settings.
We also urge that careful thought be given to the mechanics of linking
prenatal services more directly to pregnancy testing and pediatric services.
In particular, referral systems must ensure that patient confidentiality and
sensitivity are respected. To help develop and disseminate information
about this method of casefinding, it would be useful to describe and
evaluate alternative approaches.
On a more general level, we also emphasize that casefinding by
whatever method—can be time-consuming, expensive, and difficult to
conduct. For example, high-risk groups who remain outside the maternity
care system may resist efforts to draw them into care and be difficult to
engage; casefinding through outreach workers requires a significant
investment in recruitment, training, support, and supervision; developing
appealing placards for subways and buses often requires careful graphic
design, market research and premarket-testing, and extensive negotiations
with local transit authorities. Yet it is our impression that in planning and
raising funds for prenatal care programs, the casefinding function is often
shortchanged.
We recommend that those responsible for planning and funding prenatal
programs recognize explicitly that casefinding is not simple and may be costly.
Program planning and budgeting should provide adequate, realistic supportfor
casefinding.
SOCIAL SUPPORT
Ample data show that with the care and attention of a single person or
two (a patient advocate, a case manager, a granny, or whatever), high-risk
women can be helped to obtain adequate prenatal care and to secure the
many ancillary services they need (see Appendix A).
Were the four recommendations for improving the maternity system
implemented, the need for social support might decrease, because women
would not need as much help arranging for care. Even in a well-
functioning system of prenatal services, however, Group C (see Figure 5.1)
would remain, requiring concentrated support and assistance. Accord-
ingly:
· We recommend that programs providing prenatal services to high-
risk, often low-income groups include social support services to help
maintain participation in care and arrange for additional services as
needed. Home visiting is an important form of social support and should
be available in programs caring for high-risk women.
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CONCLUSIONS AND RECOMMENDATIONS
155
Sometimes the primary obstetric care provider fills this social support
role; sometimes the task is delegated to others. Whatever the arrangement,
this function needs to be adequately financed (and, in particular, reim-
bursed through public and private insurance), as it, like casefinding, can be
time-consuming and therefore expensive.
However, having made this general point, we are reluctant to urge that
"case management," as it is currently being used in the administration of
the Medicaid program, be widely applied. As a recent survey of state
Medicaid directors noted, "Case management lacks a precise conceptual or
operational definition. In the absence of a definition, case management
typically describes a range of activities that can vary from routine,
minimally professional referral services, to primary nursing, to compre-
hensive care plan development, oversight, and monitoring."8 This situa-
tion leads to an additional suggestion:
We recommend that the federal government, in partnership with states,
providers, consumers, and public and private insurers, develop clear standards
and performance criterinfor thefunction of case management. These standards
and criteria must be unequivocally oriented toward women's health and social
needs. Once developed, they should be adopted in a wide range of prenatal settings,
particularly those caring for significant numbers of high-risk women, and al!
payment systems should support such care.
In concluding these sections on casefinding and social support, the
Committee again stresses that they do not substitute for the basic system
repairs outlined earlier. Program leaders and policymakers concerned with
increasing use of prenatal care should concentrate first and foremost on
financial and institutional issues and should not be seduced into thinking
that more limited measures such as hotlines or outreach workers will solve
the problem. Instituting an outreach program may appear less difficult and
expensive than fundamental system reform; it may also have considerable
public relations value. But the Committee strongly suggests that outreach
should be aimed only at carefully defined high-risk groups and that it
should be an adjunct to a well-functioning system that is easily accessible
to the vast majority of pregnant women.
MANAGEMENT AND EVALUATION
The Committee's study of programs yielded several observations about
management and evaluation (Chapter 41. On the basis of these findings:
· We recommend that programs to improve participation in prenatal
care invest generously in planning and assessment of needs. Doing so
will require a deeper appreciation, among funders in particular, of the
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
time needed for responsible, intelligent program design and planning.
Substantial improvements in the use of prenatal care (or in other
measures of outcome such as low birthweight or infant mortality) should
not be expected too soon.
Issues to be considered in basic planning and needs assessment include
in-depth reviews of existing maternity services, provider practices, and
attitudes; public and private health insurance coverage in the target state
or community; the views of local women regarding existing maternity
services; careful definition of the target populations, of local barriers to
prenatal care, of existing community services, and of relevant historical
and political realities; market research and premarket testing of materials
(where applicable); design and testing of management information systems
or other mechanisms for providing basic program data (who is being
served, how staff and other resources are being used, program changes
over time, and so on); and consideration of whether a formal evaluation
should be included, and, if so, what type.
Far too many of the programs reviewed by the Committee were deficient
in conducting these basic functions, even programs receiving public funds
and in existence for many years. Many programs came into existence quite
quickly—often because of the sudden availability of money or opportu-
ni~and were in business before a number of important preliminary
steps could be taken. Funders, policymakers, and particularly politicians
need to understand that these programs like human services generally—
cannot be organized in a hurried, slipshod manner; information needed for
planning takes time to gather and analyze.
The Committee noted a reluctance to view investments in prenatal care
programs as long-term commitments whose impact should not be antici-
pated too soon. Developing new statewide networks of clinics, changing
community views about the value of a service such as prenatal care,
encouraging more private physicians to care for low-income patients,
convincing a community that a certain care facility is now receptive to
immigrant women, or developing trust in a particular community worker
are all difficult tasks that take generous amounts of time. We were
distressed by the number of programs that felt under pressure to show
"results,' (such as a dramatic increase in first-trimester enrollment in
prenatal care or a marked decrease in low birthweight) in a year or so,
sometimes less. Common sense alone suggests that many of the types of
programs outlined in the Appendix take several years to develop into
smoothly functioning services and sometimes longer to show results, if
any. Moreover, no single approach (such as a media campaign or a modest
expansion in Medicaid eligibility) should be under pressure to correct such
complicated problems as infant mortality or Tow birthweight.
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CONCLUSIONS AND RECOMMENDATIONS
With regard to program evaluation:
157
· We recommend that early in a program's course its directors decicle
whether it is to be primarily a service program (with data collected
mainly to help in program development and monitoring) or whether it is
also to test an idea in the field. The latter type requires ample funding if
the evaluation is to be sound; it also requires sophisticated systems for
data collection and experts in program evaluation resources that must
be built into the program from the outset.
This recommendation carries the implicit message that although all
programs should be carefully managed, not all should be evaluated.
Meaningful evaluation is often expensive, drawing resources from other
activities that may be more urgent; moreover, it requires control or
comparison groups, which many operating programs cannot establish. It
requires significant technical skill and expertise, as well as adequate
investments in research design, computer software, and data entry and
analysis.
For programs that choose to include a strong evaluation component,
specific consideration should be given to qualitative versus quantitative
approaches and to the possibility of randomized trials and alternative
designs that attempt to overcome selection bias. We also note that a higher
quality of effort is needed than that exhibited by most of the programs.
reviewed. Indeed, the Committee found that significant amounts of time
and money are being wasted on evaluation studies that are so flawed
methodologically as to be almost useless.
RESEARCH
The Committee found a number of topics that merit research. Before
listing them, however, we assert that no further research should be
conducted to show the importance of financial and institutional barriers in
the poor use of prenatal care. More than enough data documenting these
relationships exist, even if public policy addressing these problems is
inadequate. We do urge, however, that any community designing pro-
grams to increase early use of prenatal care carefully assess the extent of
financial barriers, inadequate system capacity, and inhospitable institu-
tional practices. For example, in many communities only anecdotal
information exists regarding the availability of prenatal services: whether
certain clinics are overloaded, and if so, to what extent; the fees at area
clinics; and so forth. Obtaining such basic information should be the first
order of business in designing prenatal programs..
We are reluctant to recommend extensive research on the relative
effectiveness of various casefinding activities, i.e., assessing the client-yield
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
of community workers versus hotlines or financial incentives. These
activities are usually so intertwined with other variables in the system that
methodologically sound studies of their impact would be virtually impos-
sible to design. Moreover, given the major role that financial and institu-
tional barriers play in determining use of prenatal care, it seems almost
diversionary to study outreach techniques rather than to improve the basic
prenatal care system. With this context in mind:
· We recommend that in communities where financial! and institutional
obstacles to care have been significantly lowered, research be undertaken
on several topics:
1. Why do some pregnant women register late—or not at all for
prenatal care even when financial and institutional barriers are ostensi-
bly absent? In particular, what are the emotional and attitudinal factors
that limit participation in care?
2. How can the content of prenatal care be revised to encourage
women to seek such care early in pregnancy?
3. What casefinding techniques are most helpful in identifying very
high-risk groups (such as low-income multiparous teenagers) and link-
ing them to prenatal services?
4. What are the costs associated with various forms of casefinding
and social support?
S. What are the most effective ways to forge links between physi-
cians in private practice and community agencies providing the ancillary
health and social services that high-risk women often need?
6. How is access to maternity services being affected by such recent
developments as the decreased ability of hospitals to finance care for
indigent patients through cost-shifting, the increase in corporate own-
ership of hospitals, the gradual expansion of the DRG (diagnosis-related
groups) system beyond the Medicare program, and the increasing profit
orientation of the health care sector generally?
With regard to the first topic, it would be helpful if researchers could use
similar theoretical frameworks and lists of barriers when interviewing
women. As Chapter 3 shows, many questionnaires have been developed,
but their diversity hampers efforts to synthesize findings. One particular
issue that research of this type might probe is why some women who are
clearly pleased to be pregnant seek pregnancy confirmation early but then
do not arrange for prenatal care, even in areas where the maternity care
system is functioning well.
The second topic suggests that early enrollment in prenatal services
might increase if such care were more clearly directed to major issues in
the first trimester of pregnancy. These include: the steps women can take
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CONCLUSIONS AND RECOMMENDATIONS
159
to protect the health and development of the fetus (such as avoiding
x-rays, alcohol and other drugs); the discomforts of early pregnancy (such
as nausea, worries about "getting fat," and changing personal relationships
occasioned by the pregnancy); and the ambivalence or negative feelings
that some women experience when first learning they are pregnant. If
prenatal care gave more emphasis to these first trimester issues, and if
women better understood that prenatal care was helpful and important
from conception onward, use of this health service might well increase.
The third topic should include such questions as: (l) What is the
relative effectiveness of such case-finding techniques as community can-
vassing via outreach workers, telephone canvassing, hotlines, public
service announcements, and/or provision of various incentives? Do some
approaches work better in some settings and for some target groups? (2)
How can referral [inks between prenatal care and other services in which
high-risk women participate best be developed and maintained? (3) What
institutional homes (health departments, social services agencies, free-
standing institutions) are best suited to various outreach activities?
The fourth topic—costs—merits emphasis. With very few exceptions-
the Central Harlem Outreach Program of New York City being the shining
example the programs reviewed by the Committee had little or no data
linking program costs to client outcomes. To compete for future support
and to provide more accountability, such data need to be collected.
The fifth topic addresses the problem of private practitioners being
isolated from many community-based agencies that provide the supple-
mentary services some of their patients need, such as WIC and substance
abuse treatment. Research in this area should proceed with the full
involvement of private practitioners so that conclusions will be acceptable
to them and relevant to their practices.
Our sixth and final suggestion for research simply acknowledges that
fact that current changes in the health care system may be decreasing
access to prenatal care. If so, such influences need to be carefully described
and quantified, and policymakers should be alerted to the findings of such
investigations.
A NOTE TO FUNDERS
We conclude with some observations directed to those who fund
prenatal services: public agencies, legislative bodies, and private founda-
tions and voluntary groups. Many of these points have been covered
elsewhere under various headings. We collect and reiterate them here for
emphasis.
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
Over the years, private and public institutions have funded a variety of
demonstration and research programs in the general area of prenatal care
for low-income groups. The Committee has reviewed many of these
programs and has concluded that at least three problems cloud the
relationship between these programs and their sponsors.
First, the absence of ream and consistent funding of prenatal care
programs for {ow-income groups often forces program directors to ask
foundations or government for research and demonstration funds that in
fact are used—out of necessity to subsidize basic program services. It is
for this reason, perhaps, that the Committee found very little real
innovation or research in the areas of delivery of prenatal care or outreach
for low-income groups. In the Committee's view, fostering high-quality
research on complicated issues of access to care will require government,
foundations, and program directors to give up the fiction of subsidizing
direct services through research grants.
Second, the Committee found that many research and demonstration
An. . . ~ 1 ~ ~ - ~ 1 ~ · . . ~ 1 -
programs are funded by foundations and government for 2 or 3 years.
These short funding cycles have at least two negative consequences. First,
they require program leaders to spend large amounts of time searching for
funds, responding rapidly to competitive grant announcements, preparing
numerous funding applications, lobbying state legislatures and other
public groups for support, and so on. Coupled with often burdensome
reporting requirements, the struggle to maintain funding has become
debilitating and frustrating. Second, the short cycles carry the implicit
message that programs must implement, evaluate, and show results
within 2 or 3 years. Program directors are aware that their funding may
depend upon their ability to provide these results quickly. Such a
process suggests a lack of understanding of the basic facts of organiza-
tional sociology. To implement and institutionalize change in any
organization or client population requires considerable time. The Com-
mittee suggests that genuine innovation and evaluation cannot be
accomplished in much less than S years and that to expect valid results
in less time is naive.
Third, although both government and foundations have regularly
funded demonstration projects in the area of prenatal care for poor
women, often with considerable public fanfare, support of successful
programs over many years is less evident. The Committee suggests that
foundations and government might more usefully serve this area of health
care by working together, in a deliberate and planned fashion, to ensure
that programs whose value and effectiveness have been proven are
maintained "when the grant runs out.', A conscious plan for moving
innovation into the mainstream would allow those responsible for health
care to use their energies in more constructive and innovative ways. It
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CONCLUSIONS AND RECOMMENDATIONS
161
would also enable useful programs to continue when the next social
priority comes along claiming attention and funds.
SUMMARY
In the long run, the best prospects for improving use of prenatal care-
and reversing current declines—lie in reorganizing the nation's maternity
care system. Although a new system may include some elements of the
existing one, the Committee specifically recommends against the current
practice of making incremental changes in programs already in place;
instead it argues for fundamental reform. Several ways are available for
designing the specific components of a new system, but no such work
should proceed until the nation's leaders first make a commitment to enact
substantial changes. A deeper commitment to family planning services and
education should accompany improvements in the maternity care system.
In the short term, we urge strengthening existing systems through
which women secure prenatal services. This includes simultaneous actions
to remove financial barriers to care, make certain that basic system
capacity is adequate for all women, improve the policies and practices that
shape prenatal services at the delivery site, and increase public information
and education about prenatal care. Federal leadership of this four-part
program is essential, supplemented by state action to ensure the availabil-
ity of prenatal services to all residents.
Even if all four system changes were implemented, there would still be
some women without sufficient care because of extreme social isolation,
youth, fear or denial, drug addiction, cultural factors, or other reasons. For
these women, there is a clear need for casefinding and social support to
locate and enroll them in prenatal services and to encourage continuation
in care once it is begun. These outreach services, built onto a well-
designed, highly accessible system of prenatal services, can help draw the
most hard-to-reach women into care.
Unfortunately, though, outreach is often undertaken without first
making certain that the basic maternity care system is accessible and
responsive to women's needs. Too often, communities organize outreach
to help women over and around major obstacles to care rather than
removing the obstacles themselves. Thus, the Committee specifically urges
that outreach be funded only when linked to a well-functioning system of
prenatal services or, at a minimum, when it is part of a comprehensive plan
that emphasizes four areas noted above. To fund outreach in isolation and
hope that it alone will accomplish major improvements in the use of
prenatal services is naive and wasteful.
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PRENATAL CARE: REACHING MOTHERS, REACHING INFANTS
In support of this general view, the Committee also makes a number of
recommendations regarding program management, evaluation, and re-
search. The Committee concludes that not all programs should have to
muster the funds and expertise to conduct meaningful evaluation. For
those that choose to do so, a higher quality of effort is needed than that
exhibited by most of the programs reviewed. With regard to research, the
Committee specifically urges that no more research be conducted to
demonstrate the importance of financial and other institutional barriers to
care. We do, however, suggest six specific research topics and recommend
that the current practice of securing funds for services under the guise of
research cease.
REFERENCES AND NOTES
1. Select Panel for the Promotion of Health. Better Health for Our Children: A National
Strategy, Vol. 1. DHHS Pub. No. (PHS) 79-55071. Washington, D.C.: Government
Printing Office, 1981.
2. American College of Obstetricians and Gynecologists. Standards of Obstetric-
Gynecologic Services, 6th ed. Washington, D.C., 1985.
3. American Academy of Pediatrics and American College of Obstetricians and
Gynecologists. Guidelines for Perinatal Care. Washington, D.C., 1983.
4. A final report of the Expert Panel on the Content of Prenatal Care is expected early
in 1989.
5. The Institute of Medicine has a study under way at present on the effects of medical
liability on the delivery of maternal and child health care. A final report is expected
in early 1989.
6. American Hospital Association. Medicaid Options: State Opportunities and Strate-
gies for Expanding Eligibility. Chicago, 1987.
7. Additional observations on private sector leadership in improving insurance
coverage for maternity services are in National Commission to Prevent Infant
Mortality. The Private Sector's Role in Reducing Infant Mortality. Washington, D.C.,
1988.
8. Luehrs I. Issue Brief: Case Management as an Optional Medicaid Service. Washing-
ton, D.C.: Health Policy Studies, National Governors' Association, September 1986,
p. 3.
Representative terms from entire chapter:
prenatal services
