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Prenatal Care: Reaching Mothers, Reaching Infants (1988)

Chapter: Appendix A: Summaries of the 31 Programs Studied

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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Page 202
Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Page 203
Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Page 205
Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Page 206
Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Suggested Citation:"Appendix A: Summaries of the 31 Programs Studied." Institute of Medicine. 1988. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: The National Academies Press. doi: 10.17226/731.
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Appendix A Summaries of the 31 Programs Studiect To identify programs that might provide data on increasing and sustaining adequate use of prenatal care, the Committee and staff: · reviewed survey data assembled in Spring 1985 by the national Healthy Mothers/Healthy Babies coalition; · sent letters in August 1986 and March 1987 to all directors of state maternal and child health agencies, requesting assistance in identifying data on the relative effectiveness of various outreach activities in their states; · contacted organizations active in maternal and child health, including advocacy groups (such as the Children's Defense Fund), foundations (such as the Ford Foundation), and professional societies (such as the American College of Obstetricians and Gynecologists); · queried other organizations known to be conducting research in prenatal care, including the Alan Guttmacher Institute, the Office of Technology Assessment, the American Hospital Association, the Centers for Disease Control, and the General Accounting Office; · commissioned an update of the report on statewide prenatal care initiatives issued in 1986 by the Center for Population and Family Health, Columbia University School of Public Health; · commissioned a paper reviewing comprehensive service programs for pregnant teenagers funded by the Office of Adolescent Family Life Programs within the U.S. Department of Health and Human Services; · ran an advertisement in The Nation's Health (newspaper of the American Public Health Association) requesting program leads; and 163

164 APPENDIX A · discussed the project with members of the public health and medical care communities, and reviewed journals and reports in which relevant material might be published. From these sources, a master list of almost 200 programs was compiled. Each program was contacted directly by telephone or mall or both to learn more about its activities and to ascertain whether it had adequate data to judge its effectiveness in improving participation in prenatal care. Written reports from projects were reviewed, and in some instances program directors were asked to work with Committee staff to develop summaries of programmatic activities and data. Out of these approximately 200 programs, 31 were selected for more intensive study and are described in this appendix. The criteria used in the selection process are discussed in Chapter 4. An important part of the program review was a workshop held in May 1987 during which the Committee talked in depth with the leaders of eight programs using varied means of improving use of prenatal care. These informal conversations provided valuable insight into the history and context of these and other programs. Program directors, particularly directors of projects not already de- scribed in the published literature, were closely involved in drafting the summaries that follow. They emphasize each program's origins, its prin- cipal activities, and evidence that it has influenced registration or contin- uation in prenatal care. Most note the year of each program's initiation, key factors in its inception, funding sources, and whether the program is still under way. Unfortunately, very few projects were able to supply the committee with data on program costs in relation to impact (that is, cost-benefit data of some type); consequently, most of the summaries do not include such information. As wfl} be evident, the program descriptions vary in length, depth, and intensity of data. This reflects the diversity of the programs, wide variations in their ability to provide clear descriptions of their activities, and differences in the amount of relevant information they could supply. Chapter 4 describes the five categories developed by the Committee to group the many programs reviewed briefly and the 31 studied in detail. As noted there, programs were classified on the basis of their major emphasis. TYPE 1: PROGRAMS TO REDUCE FINANCIAL BARRIERS The Committee studied two programs that take a direct approach to reducing financial barriers to care: the Healthy Start Program in Massa- chusetts and the Prenatal-Postpartum Care Program in Michigan.

APPENDIX A Heatthy Start Program Massachusetts t 165 Massachusetts initiated its Healthy Start Program in December 198S. The genesis of the program was similar to that of many others reviewed by the Committee: a rise in infant mortality rates followed by the appointment of a Blue Ribbon Task Force and implementation of at least some of the Task Force's recommendations. The scope of the Massachusetts program, however, is broader than that of many of the other programs reviewed. Most programs start small, involving a limited number of providers, one city, or a few counties. The Massachusetts program started statewide and was designed to include all willing providers. Healthy Start, a joint effort of the state health and welfare departments, offers financing for a full range of maternity services for any pregnant woman who lives in Massachusetts, is not currently enrolled in Medicaid, has no private health insurance, and has a family income at or below 200 percent (originally, 185 percent) of the federally defined poverty level.* Healthy Start funds can also be used to underwrite the initial care of women who are potentially eligible for Medicaid. Once such a woman has begun prenatal care through the Healthy Start program, her financial status is reviewed carefully; if she is found to be Medicaid-eligible in fact, that financing source (rather than Healthy Start) eventually covers her prenatal care costs. The program is noteworthy for emphasizing expansion of the range of sites, including private providers, where low-income women can receive services, rather than taking the usual route of enlarging the capacity of existing settings where low-income women have traditionally received care. A pregnant woman enrolled in Healthy Start decides where she wishes to receive care, and as long as that provider is enrolled in the program, she may receive care there. Healthy Start staff believe that the program's focus on freedom of choice is one of its most important elements. Women who cannot or do not want to travel Tong distances, who have a good relationship with a current provider, or who do not want to use a particular facility have no reason to delay seeking care, because they can make the arrangements they prefer, provided that their chosen caregiver participates in the program. After completing a very simple registration process, all obstetrician-gy- necologists, family practitioners, pediatricians, medical specialists and other health care providers, health centers, hospitals, laboratories, and *As this report is being written, Massachusetts has raised its Medicaid income eligibility ceiling to 185 percent of the federal poverty level. This expansion will result in about 80 percent of Healthy Start clients being transferred to the Medicaid program. The state has also passed landmark legislation that significantly expands the availability of health insurance to all state residents.

166 APPENDIX A pharmacies are eligible for reimbursement for services provided to Healthy Start participants. The registration procedure is intentionally less cumber- some than that required to become certified as a Medicaid provider. Registration has also been made easy for the woman. She may apply through her care provider or by calling a statewide toll-free number (1-800-531-BABY). The application form can be completed at home and mailed in, thus avoiding any "welfare taint" that can accompany applying for Medicaid. Healthy Start covers all "medical care necessary to maintain health during pregnancy" plus one pediatric visit. Although the program does not require a particular type or "package" of care, women who call the project's 800 number for a referral are sent, when possible, to comprehensive services in their communities. Healthy Start originally reimbursed for hospital labor and delivery costs as well, but these expenses have recently been shifted to the Hospital Free Care Pool. Providers are reimbursed at the Medicaid rate for physicians and community health centers and at the non-Medicaid Public Assistance Rate for hospitals. The average cost per program participant has been $1,100 for prenatal care and $2,200 for hospitalization. The estimated cost of Healthy Start in the 1987 fiscal year was $20.3 million. A preliminary evaluation of Healthy Start has been conducted using program records, hospital discharge data, birth certificates, focus group discussions, and informal interviews with program staff.2 One major finding is that the program has been successful in enrolling providers. As of February 1988, all hospital-based prenatal clinics, all health centers with prenatal care services, and more than 2,000 physicians and nurse-mid- wives, including 476 obstetricians (some of whom were not certified as Medicaid providers) had agreed to serve Healthy Start clients. The program enrolled 65 percent of all uninsured pregnant women and estimates that it enrolled 85 percent of the women eligible for the program on the basis of income. Forty percent of Healthy Start participants used private providers. The program's penetration has been particularly high among minorities, teenagers, the unmarried, and those with less than a high school educa- tion. Another major component of the evaluation is a comparison between Healthy Start participants and those insured under other programs or uninsured. Covering the period of July through December 1986, this analysis was made possible by the inclusion on Massachusetts birth certificates of source of payment for prenatal care. More than 40,000 birth certificates were analyzed and over 2,000 were of babies born to Healthy Start participants. In general, the evaluation showed that Healthy Start was more successful in helping women to maintain participation in care once begun than to initiate care early. Controlling for demographic differences

APPENDIX A 167 in the composition of the various groups defined by payer status, Healthy Start participants were found to be more likely than those on Medicaid to initiate care in the first 4 months of pregnancy, but less likely to do so than those with private or other government insurance or the uninsured. Participants were also found more likely than all groups except those with private insurance or whose insurance status was unknown to have utilized care adequately, defined as 80 percent or more of the visits recommended by the American College of Obstetricians and Gynecologists (see Chapter 1), adjusted for the timing of initiation of care. The largest difference in rates of remaining in care was among the highest risk groups: blacks, teenagers, and the unmarried. These differences, suggesting that Healthy Start participants received more quantitatively adequate prenatal care, are sup- ported by comparisons of pregnancy outcomes flow birthweight and prematurity) across payor groups, which also show Healthy Start having a positive impact. The evaluators attribute the the program's success in improving pregnancy outcomes to its emphasis on enhancing the conti- nuity and content of care, greater participation among program enrollees in programs such as WIC, and decreased maternal strain because the program reduces worries about paying for maternity care. Prenatat-Postpartum Care Program Michigan3 In 1981, Michigan recorded an increase in its rate of infant mortality, a development that many experts in the state linked to the recession during the early 1980s and the resultant loss of health insurance by many families and individuals. To address this increase, the governor established a Director's Special Task Force on Prenatal Care. In 1984, this group released its findings and recommendations in Prenatal Care: A Healthy Beginning for Michigan's Children. The major recommendation of the report was that the state establish a program to finance prenatal care for women who were ineligible for Medicaid and had no private health insurance that is, the uninsured, many of whom worked in jobs that provided no health insurance or were married to men who had lost their jobs or health insurance during the recession. Receptive to this recommendation, the state legislature passed a bill in 1984 that established the Prenatal-Postpartum Care (PPC) Program and in 1986 declared prenatal and postpartum care a "basic health service" in state law. As such, these services are to be made available and accessible to all state residents in need of the services without regard for place of residence, marital status, sex, age, race, or inability to pay. In fiscal year (FY) 1984-198S, about $2.5 million was allocated to begin phasing in the PPC program; for FY 1985-1986 and FY 1986-1987, $5 million dollars was provided. By 1988, the appropriation had grown to $S.9 million.

168 APPENDIX A The program began enrolling clients around January 1, 1985. It covers women at or below 18S percent of the federal poverty level who are not enrolled in the Medicaid program. In addition, as in Massachusetts, funds may be used to underwrite the cost of early prenatal care for women who may become Medicaid recipients later in their pregnancies. Once Medicaid eligibility is established, Medicaid funds are used instead of PPC monies. Services covered include medical care during pregnancy (using ACOG standards) and one postpartum visit. Also included are outreach and referral to prenatal care, nutritional and psychosocial assessments, vita- mins, routine laboratory procedures, patient education, and referral for high-risk prenatal services; limited reimbursement is available for special tests, procedures, and medications. It is important to note that the PPC program primarily reimburses for a basic package of low-risk services. Women at high risk of poor pregnancy outcomes require additional nursing, nutrition, and social work services. These ancillary services have historically been available in some geographic areas through the state health department's Maternity and Infant Care (MIC) Projects and its Infant Health Improvement Projects (IHIP). Health departments in these areas use PPC and either MIC or IHIP funds to provide a more compre- hensive set of prenatal services. PPC does not guarantee availability of care in a woman's county of residence or by a woman's provider of choice; it does not pay for inpatient care, nor does it pay for most special services that a high-risk pregnancy might require. The program originally did not include payment to physicians for labor and delivery services; however, such payment was added January 1, 1988. The PPC program is administered through the Michigan Department of Public Health and its 48 local health departments. Local health depart- ments either contract with area providers "private physicians, hospital clinics, health maintenance organizations (HMOs) or others] or, less often, provide the services themselves. Participating prividers must agree to offer the specified services and to accept Medicaid patients (to ensure continuity of care for those PPC women who become eligible for Medicaid during the pregnancy). Providers are reimbursed on a global fee basis, now including labor and delivery services, as noted above. During the first full program year, 1985, 32 of the state's local health departments adopted the PPC program. By October 1986, 47 had. It is not known how many providers statewide have contracted with these local departments to provide care or what proportion were private physicians, hospital clinics, HMOs, or others. However, a recent survey conducted by a regional arm of the Michigan Healthy Mothers, Healthy Babies Coalition found that in 27 counties composing roughly one-third of the state, 33 percent of all prenatal providers accept Medicaid patients, and 26 percent accept both Medicaid and PPC. Leaders of the PPC Program report that

APPENDIX A 169 some local health departments have been very successful in drawing individual providers into the program; others have had more trouble, particularly in areas with a limited number of settings offering prenatal care. In these areas, local health departments have tried to enlarge basic system capacity or to develope alternative provider systems, such as nurse-midwifery clinics. In 1986 the state health department and state Medicaid agency gave funds to several local health departments to address problems in system capacity, particularly those caused by the growing liability crisis. These grants could be used either to underwrite a portion of the physician's liability premium for each PPC or Medicaid client served or to establish nurse-midwifery clinics in areas with few or no providers. One county established such a clinic. All local agencies reported that under- writing liability premiums helDed keen Droviders participating in the - r -A r r ~ 1 ~ program. Data on the use of prenatal care by program enrollees are available for 198S and 1986. In 1985 about 2,500 women participated in PPC; 47 percent began prenatal care in the first trimester of care and 18 percent began in the third. In 1986 enrollment grew to 6,000 women; S5 percent began care in the first trimester, and 10 percent began in the third. In 1987 enrollment grew to 8,350 women. Data are not yet available on this group's patterns of care. Although there are no baseline data against which to evaluate these statistics, the program appears to have increased marginally the percentage of women seeking care early in pregnancy. Program leaders report that, between 1985 and 1986, many program procedures were smoothed and administrative problems eased. The program became better known among social service workers and health professionals generally. News of the program spread by word-of-mouth, and the various techniques used to publicize the program became more extensive and better organized (the baby showers program and the 961-BABY hotline, described later in this appendix, both included PPC as one of their referral listings). In particular, the number of local health departments participating in PPC increased significantly between 198S and 1986. TYPE 2: PROGRAMS TO INCREASE SYSTEM CAPACITY Four programs were studied that improve use of prenatal care by expanding the capacity of the clinic systems relied on by low-income women for their prenatal care. The four are: 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

170 APPENDIX A York. The first two in particular emphasized developing services for poor women where few had existed for this population before. Obstetucat Access Pilot Project- Californian The Obstetrical Access Pilot Project (OB Access) was developed in the late 1970s in California to address the fact that, despite the enactment of Medi-Cal (the California Medicaid program), serious gaps existed in the availability and extent of perinatal services for low-income women, particularly in certain geographic areas and ethnic groups. The proportion of California obstetricians who accepted Medi-Cal patients actually de- clined from 65 percent in 1974 to 46 percent in 1977. Patients and communities complained that many low-income women, both those eligible for Medi-Cal and others were experiencing severe problems in finding physicians with formal training and experience in obstetrics. Also, an increasing number of physicians were complaining about their inability to provide adequate care at the prevailing Medi-Cal reimbursement rates. In 1977, an emergency statute was enacted to revise physician reimburse- ment and stimulate Medi-Cal provider participation in primary and maternity care. By 1979, however, it was clear that the initiative was not having the desired effects, and a formal legislative resolution was passed so stating. In the wake of this incident, the OB Access Pilot Project emerged (1) to provide better access to comprehensive and early obstetric services for Medi-Cal eligible mothers in areas where there were no obstetricians or where providers declined to participate in Medi-Cal and (2) as a conse- quence of improving access, to reduce the incidence of Tow birthweight and the associated incidence of perinatal morbidity and mortality. OB Access was a pilot program to test the feasibility and impact of providing reimbursement for a comprehensive package of perinatal services under Medi-Cal. The project operated for 3 years (1979-1982) and registered almost 7,000 women. OB Access' comprehensive care included psychosocial and nutritional assessments, perinatal education (hearth, labor, delivery, and parenting education), and an initial outpatient well-baby examination, in addition to routine antepartum, intrapartum, and postpartum care (11 recommended examinations), prenatal vitamins, and routine laboratory tests (generally blood and urine analyses). The assessments determined what, if any, psychosocial, nutritional, or educational risks were present; when prob- lems were detected, counseling was provided and referrals to other services were made as needed. Formal birth education classes were also provided. Following an application and review process, seven community clinics and four county health departments (one in collaboration with a university

APPENDIX A 17 hospital) were selected as OB Access providers. These were located in obstetrically underserved areas and appeared to be able to provide the amount and range of services specified. All the sites used a variety of methods to inform pregnant women of their programs. These included public service announcements on radio and television, newspaper articles, informational brochures, community meetings, and the casefinding efforts of welfare workers. The evaluators commented, however, that "the most effective method appeared to be word-of-mouth from patients who were satisfied with the care that they were receiving." A fulI-scale evaluation of OB Access was conducted. With regard to initiation of care, evaluators found in the OB Access counties a reduction in the weighted average percent of inadequate care among pregnancies terminating in a live birth, from 10.1S percent in 1978 to 5.49 percent in 1982, a 45.9 percent decrease. (Inadequate care was defined as care begun in the third trimester, no care, or unknown care.) During the same period in the entire state, the percentage with inadequate care dropped from 10.0 percent to 6.60 percent, a 34.0 percent decrease; the reasons for this statewide decrease have not been defined. A second analysis compared the percentage of OB Access participants who received care in the first trimester with a matched group of Medi-Cal women. The results were negative, that is, the percentage of women who began care in the first trimester was higher in the Medi-Cal group. The evaluation also suggested that the project had reduced the rate of low birthweight among program participants, which in turn formed the basis for benefit-cost analyses. It was estimated that every new dollar spent on OB Access services would save between $1.70 and $2.60, principally through reduced expenditures for neonatal intensive care. These estimates did not include any additional state administrative costs or start-up costs. The cost-effectiveness data in particular convinced the California legis- lature to extend the program. In 1984, a bill was passed establishing the Comprehensive Perinatal Services Program, which requires that OB Access services be made available to all pregnant women enrolled in Medi-Cal. A closely related program currently in operation is the Community-Based Perinatal Services (CBPS) Program, which provides comprehensive peri- natal care (prenatal care in particular) to Tow-income women (that is, women whose incomes fall below 200 percent of the federal poverty level). In 1986, CBPS served about 30,000 women. Perinatat Program Lea County, New Mexico5 One of the programs funded under the Robert Wood Johnson Founda- tion's Rural Infant Care Program was in Lea County, New Mexico, a relatively wealthy county that nevertheless had an infant death rate in 1980

172 APPENDIX A of 19.8, 80 percent higher than the state average and among the highest county rates in the nation. Problems obtaining prenatal care, delivery services, and assistance with infants' medical problems were described in the application for funding prepared by the University of New Mexico School of Medicine (Depart- ment of Pediatrics). It was the horror story found only too often in underserved areas. Many physicians required patients to pay in advance for prenatal care, even if they had insurance. This meant that a woman had to find $600 to $800 before she was accepted for her first visit. The local health department provided no prenatal care, nor did its nurses make home visits. The local hospital was operated by a for-profit chain and had no outpatient prenatal clinics. The result of these limitations was that approximately 20 percent of the women who (lelivered in the local hospital were walk-ins, defined as women who came to the emergency room for delivery having had five or fewer prenatal visits or no prenatal care at all. Others chose to go to Texas for prenatal care or labor and delivery, or both, claiming that these services cost less and were more easily accessible there. A survey of barriers to prenatal care in Lea County showed that, among 92 women who had received little or no care during a recent pregnancy, financial barriers were the explanation most commonly given. Foundation funding made it possible for the medical school, working with the community, to develop ways to reduce infant mortality and increase access to prenatal care. A proposal to have the local health department operate prenatal clinics was turned down by the local physi- cians. According to the physician who coordinated the foundation grant, the local physicians argued that a county as wealthy as theirs would have few medically indigent families. They believed that those women who did not receive adequate prenatal care probably lacked motivation or educa- tion or both, and that other factors not associated with financial need accounted for the poor enrollment in prenatal care. A health department clinic, therefore, might compete with the private sector, attracting women who could afford private care but chose instead to use a "government giveaway program." Furthermore, local physicians were adamantly op- posed to having a nurse-practitioner or other nonphysician provide prenatal care, as some had suggested. An alternative plan was suggested by the community physicians and implemented in December 1980. Two women were employed to identify pregnant women in need of prenatal care (casefinding), to provide transportation, translation, and follow-up services for the women and their infants, and to serve as community health educators. Potential program participants identified by these community workers were then interviewed by a community coordinator to establish financial eligibility, to identify medical and social issues that required referrals, and to function as a

APPENDIX A 173 liaison among the various program components. More than half of the physicians with obstetrical privileges at the local hospital agreed to care for eligible women in their offices on a sliding fee schedule, or without charge, if necessary. Medically indigent women were assigned to these physicians on a rotating basis for both prenatal care and delivery. The health `department did pregnancy testing and routine laboratory work and distributed prenatal vitamins and iron. The March of Dimes and the Levi Strauss Company provided funds for supplementary services and prescrip- tion drugs. Additional funding was also provided by the state's Crippled Children's Services agency to finance the program and to support program evaluation. It soon became apparent to the private physicians in the area that the unmet need for prenatal care among indigent women was significant and beyond their capacity or willingness to accommodate. It was not uncom- mon, for example, for women referred to private physicians by the community coordinator to report a 3- to 4-month waiting time for a first prenatal appointment, because the private physicians limited the number of indigent patients they would accommodate. Accordingly, about a year and a half after the community workers were initially funded, the health department was encouraged by the private physicians to hire a family nurse-practitioner to offer prenatal services at two field health offices run by the county health department. The nurse-practitioner referred high-risk women to the private physicians for prenatal care; county funds were made available to pay for such specialized care. In addition, the obstetrical staff at the local hospital voted to require physicians who agreed to care for high-risk indigent women with payment provided by the county to serve periodically as attending physicians in the health department prenatal clinics. This new service was soon saturated with women seeking care who had formerly remained outside the maternity system, thereby lessening the need for direct casefinding, except in some areas, such as trailer parks, occupied by exceedingly poor, socially isolated families. Direct measures of the impact of these initiatives on, for example, trimester of registration in prenatal care are not available; however, the program reported that by 1984 the percentage of walk-ins at the local hospital (virtually the only hospital available for maternity care in the county) had fallen to 5 percent from the 1979 figure of 20 percent. Program staff believe that the availability of providers willing to accept some low-income women and the institution of new clinic services were probably the keys to this apparent change in prenatal care use, not the casefinding activities. As the program director noted, "Word of mouth makes complicated identification of patients unnecessary." Increasing social support through home visits from the outreach workers and other

174 APPENDIX A community changes probably also contributed to the apparent improve- ment in prenatal care use. A crude cost-benefit analysis of the program was conducted. The analysis assumed that the program would provide prenatal care to 100 high-risk women per year in the county and that the cesarean section rate would be 20 percent. Annual savings from improved prenatal and intrapartum care were calculated to be one infant's life and $310,000 through reduced rates of low birthweight and maternal complications. With such figures in hand, along with those on the declining number of women arriving at the local hospital in labor having had little or no prenatal care (and evidence of a decline in the area's infant mortality rate), program leaders were able to convince both the county administrators and the private physicians of the success of the program and the need to continue and expand it. Support for the program has also grown because expenditures from the county indigency fund to cover the high costs of maternal and infant complications have decreased, probably due in part to the increased use of prenatal care by the area's poor, high-risk women. At present, a nurse-practitioner funded by the state continues to provide prenatal care to poor women in the local health department, referring high-risk women to private physicians in the community. The county provides funding not only for the private care of high-risk women, but also for a fulI-time perinatal coordinator working in the community. Funds are no longer available for the casefinding and patient-advocacy services of the community workers, and these activities have therefore been `discontinued. Prenatal Care Assistance Program—New York Stated New York's Prenatal Care Assistance Program (PCAP), originally the Prenatal Care and Nutrition Program, resulted from pressures generated by a formal petition requesting that prenatal care be declared a public health service to be provided by the state. A report of the Children's Defense Fund showing that New York State led the nation in the percentage of nonwhite women receiving late or no prenatal care furthered! the cause. In April 1984, the state legislature appropriated $7.S million for outreach, educa- tion, prenatal care, and nutritional services for pregnant women who were not eligible for Medicaid, had no private health insurance, and whose family income was at or below 18S percent of the federally defined poverty level. Applications for participation in the program were sought from public and private not-for-profit health care providers serving areas of the state believed to be at high risk because of their socioeconomic indicators and high rates of infant mortality and low birthweight. Forty-three providers were selected in January 198S; by July 1987, the number had grown to 88

APPENDIX A 175 projects, located in all S boroughs of New York City and 44 of the 57 upstate counties. The PCAP has three major components. The Primary Prenatal Services component reimburses providers for prenatal and postpartum visits, diagnostic procedures, and physician or nurse-midwife deliveries. Re- quired services include risk assessment, health education, nutrition serv- ices, psychosocial services, after-hours and emergency counseling and care, referral of high-risk patients, referral for pediatric care, and follow-up of missed visits and referrals. The Outreach and Education Services component includes dissemination of information on the importance of prenatal care, education to eliminate perceived barriers, recruitment, linkages with other community services, and follow-up of clients who miss appointments. These services are supported by grants to providers for staff and other costs. The third component is Prenatal Care Development. The state health department is attempting to develop services in areas without them and to expand services in areas with limited capacity. Thus, funds are available to support construction or renovation of service sites, purchase of equipment, and short-term costs of medical service personnel. The state hopes that by June 1988 these funds will ensure that 98 percent of its population will reside within 20 miles of a PCAP service site. Initiatives for 1987-1988 include a statewide media campaign, a community outreach worker program in selected areas, placement of health education staff in each regional office, a pilot home visitation program in four rural areas, an increase in the prenatal care and delivery service fee, and an in-depth evaluation of the PCAP by an outside consultant. In the fiscal year beginning~uly 1986, more than 21,600 women were served by 88 projects in over 120 service sites. The state expects to serve more than half of the 49,000 women eligible for the program in 1987-1988. The average cost per client in the 1986-1987 fiscal year was $639. A report on over 16,000 clients who entered care during 1985 and 1986, over 7,000 of whom had completed care, indicated that the PCAP was reaching racial and ethnic minorities (nonwhite women made up 51.1 percent of clients and Hispanics of all races totaled 47.1 percent), teenagers (19.3 percent of clients), and women at high risk (approxi- mately 2S percent met demographic and medical risk criteria). The PCAP population was not initiating care early, however: less than 25 percent enrolled in the first trimester, and more than 18 percent delayed care until the third trimester. Nonetheless, the PCAP clients apparently "made up" for their late initiation of care, because they averaged just under nine visits. The legislature has made available almost $26 million for fiscal year 1987-1988. Approximately $19 million is for the services component,

176 APPENDIX A more than $3 million for the outreach and education component, and more than $4 million for the development component. Prevention of Low Birthweight Program— Onondaga County, New York7 Another example of a program focused heavily on basic system capacity is the Onondaga County Prevention of Low Birthweight Program, one of 14 related efforts in the state financed in large part by New York's Maternal and Child Health Block Grant. The program was developed with state encouragement and is being led jointly by the Onondaga County Health Department and the Department of Obstetrics and Gynecology of the State University of New York's Health Science Center. It began in dune 1984 and was built in part on the area's successful effort to regionalize its perinatal services, with the assistance and leadership of the Robert Wood Johnson Foundation. Despite the many accomplishments of the regionalization process—in particular, striking reductions in infant mortality it became apparent in the late 1970s and early 1980s that two residual problems required attention. First, the proportion of infants who were born at low birthweight was remaining relatively constant rather than declining. Second, a small but persistent proportion of pregnant women was receiving late (third trimester) or no prenatal care. A public health nursing survey revealed that, although late registration had some motivational and socioeconomic roots, inadequate capacity of the prenatal care system kept out even those indigent pregnant women who applied for early care. Onondaga County statistics showed that in 1982 76 percent of pregnant women in the county obtained prenatal care in the private sector, primarily through private physicians and an HMO (health maintenance organiza- tion). According to data from the local university and health department, women who used the private sector initiated care early (94 percent in the first trimester) and faced only a 1- to 2-week lag between an appointment request and the first prenatal visit. Patients using the area's four clinics (two hospital clinics, one school-based clinic, and one neighborhood health center), however, initiated care later, due in part to a 4- to 8-week lag between an appointment request and the first visit. State vital statistics for 1981 showed that 84.6 percent of all Onondaga County residents registered in the first trimester of their pregnancy, whereas the correspond- ing percentage for black clients, who were more likely to use a clinic, was only 56.4 percent. An analysis of the prenatal patients registered in the clinics in August 1983 revealed that only 24 percent had been registered in their first trimester. In addition, data for 1981 from the special Supple- mental Food Program for Women, Infants, and Children (WIC) showed

APPENDIX A 177 that only 14 percent of recipients entered WIC in the first trimester, rejecting the delay of entry into medical care. Thirty-three census tracts in the central city of Syracuse were identified as contributing disproportionately to the county's high rates of low birthweight and late registration in prenatal care. A variety of efforts was made to encourage pregnant women in this target area to begin prenatal care early in pregnancy. For example, television spots directed at the target population were developed and aired; these stressed the benefits of early prenatal care and its role in reducing low birthweight. Public awareness efforts noted the possible availability of financial support for prenatal care and encouraged women to seek care regardless of their financial status. The county health department also intensified its emphasis on the importance of prenatal care in its communication with other agencies and clients in the target area. Training sessions were held for clinic personnel serving large numbers of women from the target area; these explained ways to make clients feel more welcome and to arrange clinic procedures so that clients hac] shorter, more pleasant encounters. The major emphasis, however, was on increasing the number of prenatal appointment slots, particularly for new patients. Two strategies were pursued. First, existing sites in the target area providing a large proportion of services to clinic patients (such as the Syracuse Community Health Center and the Health Science Center's Maternity Center) were provided with additional nurse-practitioner staff so that patient Toad could be increased. Second, three new satellite pregnancy diagnosis and triage sites were established in census tracts having especially high rates of low birthweight and low use of prenatal care. These new sites offer the full range of services usually provided at a first prenatal visit, including a history, physical examination, laboratory tests, and risk assessment. When appropriate, application for Medicaid and WIC is begun. A pregnant woman typically makes only one visit to a satellite site and is then referred elsewhere for ongoing care (primarily to the four clinics), depending on her risk status, place of residence, preferences, and similar factors. Staff spend significant amounts of time helping patients secure other needed services; in particular, patients are helped to get prompt appointments for continuing prenatal care at the facilities to which they have been referred. The satellite clinics offer appointments within a week or two of a request (at present, because of the popularity of these satellites, waiting times for appointments are lengthening), and the appointments are free two attributes not shared by any other public facilities in the targeted area. Each satellite clinic operates a half-day a week and is staffed by a nurse-practitioner with physician backup, a public health nurse, and a community health aide. These individuals work in the preexisting clinics

178 APPENDIX A during the rest of the week, thereby increasing the clinics' capacity. Anecdotal reports suggest that these teams are especially eEective in developing good rapport with the clients, in scheduling adequate time for visits, and in referring clients successfully for ongoing care. Two different data sets suggest that these improvements in the capacity of the prenatal care system have increased the proportion of pregnant women in the high-risk, target census tracts who begin prenatal care in the first trimester. The first data set spans July 1984 to July 1987 and is composed of 1,290 women residing in the target area who were subse- quently identified as being at high risk for a low birthweight delivery. For this group, the average lag time between the call for a first prenatal care appointment and the appointment itself was 4.6 weeks during the first year of the program (1984), declining to 1.9 in 1987. A second measure of impact is derived from comparisons of trimester of registration for prenatal care for all births in the target area versus all other births in the county (so-called nontarget area births). A trend analysis shows a highly statistically significant increase in the percentage of births to first-trimester registrants residing in the target area- from 71.5 percent in 1983 (before the program began in 1984) to 76.4 percent in 1986, compared to an increase of only 1 percent in the nontargeted census tracts during the same period. This general trend was apparent for white women, nonwhite women, women age 17 and under, and women age 20 and over. For 18- and 19-year-olds, the difference was larger. In 1983, 52.8 percent began prenatal care in the first trimester; in 1986, 66 percent did so, a statistically significant change. In the nontargeted area, the figure remained essentially stable at about 60 percent. The impact in the targeted census tracts was great enough to increase the county's total of first-trimester registration in prenatal care from 81.6 percent in 1983 to 85.S percent in 1986. Unfortunately, during these same years there was no reduction in the percentages of women receiving late or no prenatal care, suggesting that expanding the capacity of prenatal services cannot, by itself, solve the problem of nonparticipation. At present, the project is focusing its efforts on drawing this hard-to-reach population into care. TYPE 3: PROGRAMS TO IMPROVE INSTITUTIONAL PRACTICES In this section are summaries of six programs that try to draw more women into prenatal care by improving the nature and organization of services themselves: two Maternity and Infant Care (MIC) Projects, one in Cleveland, Ohio, and the other in three North Carolina counties; an Improved Pregnancy Outcome (IPO) Project in two counties in North

APPENDIX A 179 Carolina; an Improved Child Health Project (ICHP) in two areas of Mississippi; the Child Survival Project of the Presbyterian Medical Center in the city of New York; and the development of a perinatal system in Shelby County, Tennessee. Maternity and Infant Care Projects- Ohioan and North Carolina9 The Maternity and Infant Care (MIC) Projects began in 1963 as a demonstration program administered by the federal Children's Bureau (whose health programs are now within the Bureau of Maternal and Child Health). The data produced by the projects funded in the 1960s suggested that accessible, high-quality maternity care could reduce the rate of infant mortality. In 1974 every state was required to have at least one such project, and responsibility for the projects was shifted to the states. According to a 1975 federal publication, MIC Projects not only provided medical care to pregnant women and their infants, but also provided social services, nutritional counseling, patient education, home visits by a project nurse, special services to pregnant adolescents, transportation, and child care. The projects were also to emphasize the importance of"humanizing the clinics." The description of this approach is, unfortunately, just as pertinent today as it was 12 years ago: The most important task that each project must accomplish to reach the community is to overcome the unfavorable impression that many people have about what they can expect in the way of meaningful help from a public clinic. The women who come to the project for assistance must be sure that they will not be faced with long waits in dingy hallways on uncomfortable benches, and that they will not be rushed through treatment in assembly line fashioned Examples of humanizing include seeing the same obstetrician and public health nurse at each visit, avoiding across-the-desk interviews by using round tables, having interpreters available, and, in Atlanta, having "all new personnel ... register as new obstetric patients on their first day of employment and 'go through the clinic.' This experience increases their awareness of what a patient's average day involves and underlines the importance of treating patients with respect and courtesy." The MIC Project at the Cleveland Metropolitan Hospital—still in operation—used many of these approaches during a period in which prenatal care utilization was studied. It operated five satellite clinics and provided social service assessments and interventions, health education, nutritional counseling, home visits, special services for adolescents, and follow-up of missed appointments. The project tried in particular to improve the nature of the services from the clients' perspective. A patient advocacy group was formed to act as an ombudsman. A "Friends of the MIC" group was formed, with three

180 APPENDIX A subcommittees: Finders, who found clothes, bassinets, and other items needed by patients; Go-Getters, who provided transportation; and Rock- ers, who played with and rocked young children in clinics while their mothers made their prenatal visits. Training for staff was provided, to increase their sensitivity to patient needs and to possible cultural barriers between staff and clients; continuity of care was increased; and small changes in procedures were made to demonstrate a caring attitude toward patients (for example, securing parking spaces near the hospital for pregnant clinic patients). The project also mounted an intensive promo- tional campaign aimed at encouraging early entry into prenatal care. The campaign was staffed by 12 community workers and included door-to- door canvassing; explicit encouragement of word-of-mouth referrals (en- rolled clients were asked to bring in pregnant friends and relatives); Koffee Klatches in housing projects and elsewhere, during which the MIC Project was explained; and free pregnancy testing with immediate referral of those testing positive to prenatal care. A formal evaluation of program impact on various measures of outcome was conducted by comparing more than 3,000 mothers who received MIC care in 1976 and 1977 with approximately half that number who received care and delivered at the same hospital but who were ineligible for MIC care because they resided outside the target area. The MIC and comparison groups were similar on numerous sociodemo- graphic measures, but the MIC group had higher levels of medical and obstetric risk. The rates of early registration for care were significantly higher in the MIC group (MIC: first trimester, 47.6 percent; first half of pregnancy, 69.0 percent; non-MIC: first trimester, 34.0 percent; first half of pregnancy, 56.5 percent). Project staff report that many of these service improvements were not sustained beyond the 1970s. The 12 community workers, for example, were decreased to 4 by 1979. In recent years, rates of early registration in prenatal care have reportedly decreased. The MIC Project in North Carolina operated in three rural counties. Its services included active casefinding, transportation, public health nursing, nutrition and social services, health education, and follow-up of missed appointments. Participants between 1970 and 1977 were com- pared to similar residents in three other counties during the same period. The two sets of women were quite comparable, but there were some significant differences, including higher risk for inadequate prenatal care in the MIC group. Compared to the control group, the MIC population was more heavily nonwhite, unmarried, and less educated. Nonetheless, the MIC group exhibited a smaller proportion of women with inadequate care (Kessner index definition) than did the comparison group. Moreover, when five risk factors were held constant

APPENDIX A 18 in the analysis (the three already mentioned plus two measures of obstetric risk), a larger proportion of the MIC group than of the comparison group received quantitatively adequate care (Kessner index definition). Improved Pregnancy Outcome Project Two Counties in North Carolinai2 The federal Improved Pregnancy Outcome (IPO) Project began in 1976. States with high rates of infant mortality received funds to "improve maternal care and pregnancy outcomes." States were given considerable freedom to design their IPO programs, though improving organizational arrangements was emphasized at the federal level. For its IPO Project, North Carolina chose a two-county project site that was disproportionately rural and poor, with excessive rates of perinatal and infant mortality. Prenatal and maternity resources in the area were extremely limited. Funds were used to increase maternity services by having certified nurse-mid- wives provide maternity care, with obstetric backup, and to expand health department services to include social services, health education, and nutrition counseling. The program also featured casefinding and transpor- tation, directed particularly at teenagers and others at high risk. The project was evaluated by comparing the experience of IPO regis- trants to that of all women in the IPO counties (including the registrants) and to women in several neighboring counties judged to be roughly comparable in health care resources and in both socioeconomic and perinatal status. Evaluation was confined to black women. In 1972-1976, before the project began, about 27 percent of black women in the IPO counties and 19.5 percent of black women in the comparison counties received quantitatively adequate prenatal care (defined by a modified version of the Kessner index). By 1979-1981, during which time the project was operating and the evaluation data collected, 49.6 of black women in the IPO counties and 41.2 percent of IPO registrants received adequate care versus 30.3 percent of black women in the comparison counties. Improved Child Health Project Two Areas of Mississippii3 The federal Improved Child Health Projects (ICHP) were initiated in 1978 to improve pregnancy outcomes and followed the same pattern as the IPO Projects, although a portion of the funds was to be used for in-hospital care. In Mississippi, two projects were funded (ICHP #1 and ICHP #2), each of which covered several counties. In general, the funds were used to add staff to health departments and to provide transportation, social

182 APPENDIX A services, tracking, and casefinding services. High-risk referral centers were also established. The project was evaluated using several comparison groups. The results were mixed. In one set of ICHP counties, the percentage of all women with quantitatively adequate care (using a modified Kessner index definition) increased 14.6 percent between 1975-1978 and 1979-1981, while in the comparison counties it increased by only 9.2 percent. In a second set of ICHP counties, the percentage of all women with adequate care increased 3.5 percent over the same interval but increased even more—8.7 percent- in the control counties. The evaluators believe this is because the first group of counties used a community-planning approach involving both public and private providers, while the second group of counties had problems in implemental tion, resulting in, among other things, less success in reaching target populations. Child Survival Project, Columbia-Presbyterian Medical Center- New York Cityi~ Columbia-Presbyterian Medical Center (CPMC) serves the Washington Heights neighborhood of New York City, an area with a large Hispanic population and high rates of poverty and teenage pregnancy. Many residents in 1982 were newly arrived immigrants, including an unknown number who were in the United States illegally. Lack of knowledge about the health care system, lack of English-language skills, and significant financial constraints posed serious obstacles to the use of health services generally, and timely prenatal care in particular. Data from the New York City Department of Health revealed that in 1982 28 percent of women in the community received late or no prenatal care. A grant from the Child Survival/Fair Start Program of the Ford Foundation to the Center for Population and Family Health of the Columbia University School of Public Health financed a program from 1982 to 1985 to reduce the percentage of community women receiving inadequate prenatal care. Other program goals included improving infant feeding practices (specifically, encouraging breast-feeding) and bolstering the use of health care services during the first years of life. The program pursued a complex blend of activities within the Medical Center and within the community as well, trying in particular to strengthen links between the two. Within the community, for example, the program used volunteers and existing networks to call attention to issues of maternal and child health and to disseminate information to pregnant women and new mothers on such topics as the elements of well-baby care and where to go for checkups. In general, the program leaders found that the institutional changes they accomplished within the hospital were more ~ ~ , , . ~ . . . .

APPENDIX A 183 easily measured and probably more successful than the more diffuse efforts in the community. Two of the hospital-based activities are summarized here: an effort to shorten the time between confirmation of pregnancy and first prenatal visit, and making the Medicaid certification process less complex. To speed entry into prenatal care, the Child Survival Team arranged for a nurse-midwife and a bilingual health advocate to be placed in the hospital's pregnancy screening clinic. The nurse-midwife counseled all women about the need for prenatal care and healthful behavior during pregnancy and also screened and referred women at high risk for poor pregnancy outcomes. In addition, the obstetrics department agreed to designate all women age 18 and under or who first visited the clinic in their third trimester as high risk and thus immediately eligible for prenatal care, regardless of ability to pay. The health advocate guided patients through the process of making an appointment for prenatal services, which was especially difficult for women who spoke little or no English. In addition, the appointment system for financial screening, laboratory services, and the initial visit was centralized, and the number of appointments for financial screening and prenatal care was increased. With regard to Medicaid, it was clear that the certification process was a major block to care, since an appointment for an initial prenatal visit could not be made until the pregnant woman actually had a Medicaid card. The process was made particularly difficult because the city's Medicaid application form had not been translated into Spanish. In addition, the Medicaid Eligibility Unit at the hospital had been limited to inpatient care. Agreement was reached to hire a bilingual staff member to work in the outpatient obstetric clinic. This worker saw women the same day they had a positive pregnancy test, assisted them in completing the Medicaid application form and in obtaining the necessary documentation, made appointments at the city Medicaid office, and helped resolve problems that arose in the application process. Efforts to get the application form translated into Spanish were successful. Additional changes included the employment of a liaison person to hand carry the completed Medicaid applications to the Medicaid office, correct mistakes, and obtain a Medicaid number. The hospital also agreed to allow prenatal appoint- ments to be made for women who had been notified in writing that their Medicaid application had been accepted but who had not yet received their Medicaid card. And finally, a reduced-rate prenatal package, payable in installments, was introduced for women ineligible for Medicaid. These several institutional reforms reduced the delay in obtaining a first prenatal appointment from up to 90 days after the positive pregnancy test to about 2 weeks. According to the program's leaders, the improvements in

184 APPENDIX A bureaucratic process, coupled with such other program elements as the placement of a bilingual health advocate in the prenatal clinics and the community-level health education initiatives alluded to earlier, led to increased patient understanding of and satisfaction with prenatal care. Most of the system improvements have remained in place. The team leader traces the project's success to the involvement of the bureaucracy in the process of change and the ability of the Child Survival team to show that not only did community women benefit from the program, but so did the medical center. The overall costs of the changes to the hospital, especially additional staff, were substantially reduced by the increased volume of visits and more timely Medicaid reimbursements, since more women were found eligible for Medicaid and began making visits earlier. However, detailed cost computations are not available. Development of a Perinatal System in Shelby County, Tennesseei5 In 1977 the Department of Obstetrics and Gynecology at the University of Tennessee established a Division of Ambulatory and Community Medicine and recruited two faculty members whose charge was to convert fragmented services in Memphis and Shelby County into a smoothly functioning system of perinatal services for women relying on care provided in publicly financed settings. At the time, prenatal care for these women was fragmented among health department clinics, hospital clinics, and grant-funded neighborhood health centers, and there were 6- to 8-week delays for a first prenatal appointment at the county hospital clinic. Although all deliveries occurred at the county hospital, there was little communication of patient information among the various facilities, no standardized prenatal record, and deteriorating attitudes toward patients among personnel at the clinic. As a result of these problems and others, the infant mortality rate within the area was over 20 deaths per 1,000 live births, and many patients who had not received care or for whom no record of care was available came to the county hospital for delivery. The providers, including the medical faculty and the staffs of the county hospital and the health department, developed a plan to integrate the facilities into a coordinated perinatal care system. The initial risk assess- ment at the county hospital clinic was continued, but all Tow-risk patients were referred to the health department clinics for ongoing care; a standard prenatal record was adopted; an improved appointment system was instituted; and obstetrical faculty were assigned to all prenatal clinics in the county hospital, with the goal of changing the attitudes and behavior of the providers in those settings. In order to improve the quality of care, the number of health department clinics was reduced from 12 to 6, allowing

APPENDIX A 185 each clinic to be staffed by specially trained nurses, and a 1-month training program and protocol were developed for the health department nurses who provided prenatal care. These programs were subsequently expanded to include three adjoining rural counties under the asupices of the Robert Wood Johnson Foundation's Rural Infant Care Program. From 1980 to 1985, the percentage of women delivering at the county hospital who initiated care in the first trimester increased from 16 to 23 percent, and the percentage with no prenatal care decreased from 26 to 14 percent. According to the project director, other results included a reduction in the time between initial call and first appointment from 6 weeks to S days at the county hospital clinic, an increase in the percentage of patients enrolled in the system whose records were available at time of delivery (from 40 to 9S percent), improved skills among the nurses in health department clinics, and improved attitudes among providers in the county hospital clinic. TYPE 4: PROGRAMS THAT CONDUCT CASEFINDING Ten examples of casefinding for prenatal care were studied by the Committee. The Central Harlem Outreach Program and the Community Health Advocacy Program of New York City have collected data on the casefinding electiveness of outreach workers. The Better Babies Project of Washington, 13.C., and the Maternity and Infant Outreach Project of Hartford, Connecticut, employ a wide variety of casefinding techniques, including outreach workers. Three hotlines were studied—the Pregnancy HealthTine in New York City, 961-BABY in Detroit, and CHOICE in Philadelphia. Two examples of casefinding through referrals among pro- grams were assessed a Tulsa, Oklahoma, project that provided free pregnancy testing coupled with volunteer advocates linking pregnant women to prenatal care, and a set of studies that examine the role of WIC nutrition programs in recruiting pregnant women into prenatal care. Finally, the Committee reviewed a recent baby shower project in Michi- gan, a type of incentive-oriented effort to recruit women into prenatal care. Central Harlem Outreach Program—New York cityi6 The Central Harlem Outreach Program operated between August 1, 1982, and September 30, 1983. It was financed by the Commonwealth Fund to develop and test strategies that might decrease perinatal and early childhood morbidity in a group of urban, low-iIlcome mothers and infants. Central Harlem is home to a group of economically deprived black families whose rates of inadequate prenatal care, adolescent pregnancy, low

186 APPENDIX A birthweight, and infant mortality are significantly higher than those of the city as a whole. The program had three components: an outreach program designed to identify pregnant women early in their pregnancies and enroll them in care in the Harlem Hospital system; a travel allowance for enrolled women during pregnancy and their infant's first year to encourage compliance with prenatal and child care; and a group of community workers— "maternal advocates" to provide basic health information and social support during pregnancy and the first year postpartum. Only the first component will be described. Four outreach workers (ORWs) were employed to locate pregnant women not in prenatal care and recruit them into the Harlem Hospital system. All were community residents, had extensive social networks, were unemployed, and seemed comfortable on the street. They were supervised by a social worker who was also a community resident. The ORWs met twice a week with the supervisor to discuss strategies for finding pregnant women. The ORWs were paid a small commission ($10) for each pregnant woman they found who entered the Harlem Hospital system. In addition, the ORWs received a salary, but it was less than that of comparable workers in the hospital. The ORWs reported using a variety of strategies. They began by advertising the program. They designed flyers and placed them where women would see them. They spent most of their time in welfare offices and clinic settings, but they also did door-to-door canvassing in apartment buildings and approached women on the streets. Casefinding in apartment buildings and housing projects yielded few contacts, because fear of crime has led to mistrust of door-to-door canvassers. The outreach program was carefully evaluated. In 1 year, three full-time- equivalent ORWs (there was some attrition) made approximately 7,400 contacts, an estimated 20 contacts per day. They located 2SS pregnant women, of whom 104 were not receiving prenatal care. Only half of these enrolled in a Harlem Hospital facility. Women who enrolled as a result of outreach contact started care slightly earlier than those who did not (at 15.8 versus 17.0 weeks). They were more likely to be 20 or older, to live with a husband or boyfriend, and to have experienced a prior adverse outcome of pregnancy. The outreach component of the program cost approximately $44,000, including all of the ORWs and one-third of the supervisor's salaries, incentive payments to the ORWs, and miscellaneous expenses. Thus, the cost was $6 per contact; $1SS per pregnant woman located; $440 per potential enrollee; and $846 per actual enrollee. The program staff were not convinced that this was a cost-effective way to encourage enrollment in the Harlem Hospital system of prenatal care.

APPENDIX A Community Health Advocacy Program New York Cityl7 187 Before its efforts within the Presbyterian Medical Center (see the description of the Child Survival Project, above), the Center for Population and Family Health implemented a community-based project to link high-risk women and adolescents to prenatal and other reproductive health services. This Community Health Advocacy Program was supported by federal and state agencies and a consortium of private foundations and was designed to train bilingual (Spanish and English) community resi- dents, called health advocates, to provide preventive health education, referral, and counseling services in homes and other community sites. Social area analysis was used to identify those census tracts in the Washington Heights community that had had high rates of poor birth outcomes over the preceding several years. The program focused on finding individuals in the target area who do not often use preventive services without special encouragement or assistance and linking them to services at the Columbia-Presbyterian Medical Center and other health care sites in the city. The program stressed contraception, prenatal care, and general concepts of reproductive health. Volunteers were used to supplement the casefinding and health education work of the salaried health advocates. Over an 18-month period (April 1981 to September 1982), 979 men and women became registered clients of the program; that is, they allowed an advocate to discuss health and social services needs with them, received referrals, general counseling, and advocacy support as appropriate, and agreed to be contacted again for follow-up. Of the 979 clients, 72 women (7 percent) were either pregnant or possibly pregnant. Of the 72, 32 were already receiving pregnancy-related services; thus, only 40 of all individ- uals contacted (4 percent) were in need of prenatal care. All of these women were referred to prenatal services by the health advocate, but 13 did not go to the site to which they were referred. Larger numbers of women, especially teenagers and older women, were located who needed other reproductive health services, but follow-up data suggest that more than half the referrals for such services were unsuccessful. Follow-up information on over 60 percent of the referrals, however, was not available. The program leader has suggested several reasons that might account for the limited impact. First, the project's evaluation design prevented the program from expanding beyond an initial 10-block area, even though it soon became clear that the number of persons in need of services who could be contacted by an advocate was very low. Second, although most of the community residents were from the Dominican Republic, many of the health advocates and volunteers that assisted in the door-to-door canvass- ing were from other ethnic groups, raising issues of cultural incompati-

188 APPENDIX A bility. In particular, a large proportion of community residents were newly arrived immigrants (an unknown proportion of whom were in the United States illegally) who might have been suspicious of representatives from a formal institution. A high rate of staff and volunteer turnover limited the ability of the program to sustain a consistent image in the target areas, and over time many volunteers left for paying jobs, particularly those who were more highly skilled. (Some approaches to recruiting, training, and maintaining volunteers, however, were found to be useful and have been described thoughtfully in a final program summary submitted to funders.) This underlying instability was compounded by the fact that the target com- munities were themselves highly mobile; Sit percent of program clients had been in the community less than S years, and moves within the neighbor- hood were frequent. Security problems increased program costs, since staff would work only in pairs and canvassing had to be limited to daylight hours. It also became apparent that other concerns, such as jobs, housing, and instruction in English, were of much greater importance to neighborhood residents than preventive health care. In response to this finding, the project made several modifications in its approach. For example, the stab developed a series of pamphlets on health maintenance that were used in English-as-a-second-language classes in the community as a part of the Child Survival Project described earlier. The Better Babies Project- Washington, D.C. i8 The Better Babies Project (REP) is an intervention program that is attempting to reduce the incidence of low birthweight by 20 percent in nine contiguous census tracts in the District of Columbia; the population in this area is largely black and poor. Begun in 1986, the project is to be completed in 1990, after which point its impact on low birthweight will be assessed. Several comparison groups have been defined, and a sophisti- cated evaluation is planned with the assistance of the National Institute of Child Health and Human Development. BBP employs many methods to locate pregnant women in the target area and enroll them in the program. Once in the program, women are linked to prenatal services, if they are not already in care (most are); their risks for low birthweight are assessed; and an individual treatment plan is developed and carried out to address those risks. Most enrollees—known as participants—are in monthly, often weekly, contact with the program. BBP includes a casefinding staff of 10 and a drop-in center. Eight Service Coordinators, under the supervision of two Service Supervisors, are responsible for casefinding, using neighborhood canvassing and other

APPENDIX A 189 techniques, and for providing health education and friendly support at the drop-in center and in participants' homes. Multiple types of canvassing are used. Service Coordinators are assigned areas and given logs, maps, and lists of addresses to improve their efficiency. In each area, they stop women, men, and children on the street to tell them about BBP, asking women to come to the drop-in center if they are pregnant and asking everyone to pass the message to friends who are pregnant. Carrying bright yellow canvas bags with large BBP emblems, they systematically knock on household doors and talk to anyone who responds, selectively leaving buttons, key chains, or refrigerator magnets as reminders. A BBP pamphlet or flyer is slid under the door when there is no answer and is handed selectively to people met at home or on the street. As safety measures, the Service Coordinators usually work in pairs, occasionally attend the police roll call, and carry boat sirens to use in an emergency. Service Coordinators also visit local businesses and bring the message of the importance of prenatal care to owners and salespeople, always including a request to refer pregnant women to BBP. By special arrange- ment, recruiting also takes place in the waiting rooms of several public and private clinics. BBP has attempted telephone canvassing, but did not find it very productive. Some poor households do not have phones. When the caller does reach a low-income household, the number of women recruited is low, since pregnancy is not that common, even when pregnancy among friends is included. BBP staff note, however, that telephone canvassing is often the only way to reach women who do not leave their homes and will not answer the door. The phone is also used regularly to canvass former participants and staff members' personal networks in the community. Service Coordinators spend approximately 20 percent of their time in casefinding and the remainder in offering specific interventions (such as help in smoking reduction) in participants' homes or the drop-in center and in providing friendly support. Third-party referrals are also sought by staff. Service Supervisors maintain contact with WIC and welfare offices, EPSDT (the Early and Periodic Screening, Diagnosis and Treatment Program of Medicaid) staff, school personnel, clergy, social service agencies, day care centers, women's groups, soup kitchens, battered women's shelters, and private physicians. The program has two public service radio announcements that are aired occasionally. Staff also participate periodically in local radio talk shows. The drop-in center, which functions primarily as a base for social support and intervention activities, also assists in casefinding. Its visibility reminds pregnant women of the need for care and provides a place where they can receive help in selecting a source of prenatal care and obtaining an appointment. The center offers free pregnancy testing; women who have positive tests are guided immediately to a prenatal care provider, as

190 APPENDIX A appropriate. Women using the center for group activities, snacks and light meals, or rest often inform the staff of pregnancies among relatives and friends. BBP uses cash and other participation incentives. A $10 monthly stipend is offered to women who keep their prenatal appointments. A woman can receive a maximum of between $SO and $100, depending on how early in her pregnancy she enrolls. The money is intended to help defray costs associated with prenatal care, such as transportation to appointments, medications, and child care. Moreover, anyone who successfully refers a pregnant woman to BBP receives $5 for the referral. The BBP staff believes that the financial incentive is not viewed bY Participants as being as important as the friendly support trom the Service Coordinators and the availability of the drop-in center in enrolling women and sustaining their participation. Data will not be available until late 1991 on the impact of the program on low birthweight. Preliminary data are available, however, on the characteristics of women enrolled in the program between January 1, 1986, and March 31, 1987, and on the yield of specific casefinding efforts. Of 520 · . . .1 ~ . '1 r ~ J ~ 1 ~ . ~ ~ . women contacted and believed to be eligible tor enrollment (that is, believed to be less than 32 weeks pregnant and a resident of the target area), 66 percent were already in prenatal care, 30 percent were not, and 4 percent were not certain they were pregnant. Of the women enrolled in the program, 64 percent were between 0 and 20 weeks pregnant; 78 percent entered prenatal care between O and 21 weeks. Those not in care at the time of initial contact were earlier in their pregnancies than those already in care. Referrals came from a wide variety of sources: 30 percent from neighborhood and door-to-door canvassing, 22 percent from friends and relatives, IS percent from clinics and hospitals, and 12 percent from other participants; 10 percent were walk-ins with no specific referral source. Telephone surveys and the media advertisements yielded about 3 percent of referrals. The rest were from a variety of sources, including one referral from the District's Commissioner of Public Health. Information is also available on the source of referral for participants who are pregnant and already in prenatal care versus those who are pregnant but not yet in care. As expected, clinics and hospitals generate more program participants who are in care than not, but otherwise the relative yield of various referral sources is about the same for both groups. In 1986, 44 percent of enrolled women already in care were referred by a friend, relative, or other participant or were walk-ins with no referral source; 17 percent were referred by a clinic or hospital; 31 percent came from neighborhood canvassing; and the rest came from other sources. For pregnant women not in care, referral sources were 47 percent from a

APPENDIX A 191 friend, relative, or other participant or were walk-ins; 5 percent were from a clinic or hospital; 36 percent from neighborhood canvassing; and the rest were from other sources. The Maternity and Infant Outreach Project Hartford, Connecticuti9 The Hartford Action Plan on Infant Health was developed in the early 1980s in response to the city's very high rate of infant mortality. It was spearheaded by a consortium of corporate leaders, including representa- tives of banks and insurance companies. The Maternity and Infant Outreach Project (MIOP) is one of the Action Plan's components and was built on the experience of the city's Improved Pregnancy Outcome Project and longstanding Maternity and Infant Care Project. Like the Better Babies Project in Washington, MIOP does not provide prenatal care directly, but rather offers services that supplement medical care. These services include social support, counseling on nutrition, help in securing welfare and housing assistance, and assistance with substance abuse problems, often through home visiting. Program participants are followed through the first 6 months of the baby's life. Seven neighborhoods with high rates of infant mortality were targeted when MIOP began in July 1985. As of December 31, 1987, 1,057 women have been enrolled in the program, which is housed in the Hartford City Health Department and is funded by both private and public donors. The seven neighborhoods were divided into three areas, and a team composed of a health educator and two neighbor- hood health workers was assigned to each area. The workers try to recruit pregnant women into care and to provide social support. MIOP has collected data on referral sources and on the yield of its casefinding activities. About 40 percent of MIOP clients are referred to the program by community clinics and by the obstetric clinics in the three Hartford hospitals. These women are already in prenatal care but are referred to MIOP because the clinic providers judge them to be at high risk of a poor pregnancy outcome or difficulties postpartum, or both. Defined risk factors include social isolation, being 16 or younger, a history of social or emotional problems, and a previous preterm delivery. Seventeen percent are referred by family planning clinics, and 36 percent are referred through such MIOP casefinding activities as street and door-to-door canvassing, group discussions in community settings, media announce- ments, and the efforts of neighborhood Baby Watch volunteers. Street and door-to-door canvassing was the most successful of these casefinding methods, yielding 16 percent of program participants. Self-referral or other clients accounted for 12 percent of referral sources. Media spots, Baby Watch volunteers, and referrals from other neighborhood organizations each yielded very few participants.

192 APPENDIX A MIOP has specifically examined the methods most successful in locating pregnant women not already in prenatal care and has concluded that family planning clinics are key referral sources. Forty-three percent of MIOP participants who were in their first trimester of pregnancy but not in care were first identified through the health department's family planning clinic. Street canvassing and door-to-door inquiries yielded 25 percent of this group; self-referral accounted for 10 percent. More than half (54 percent) of MIOP clients not in care who were in the second trimester of pregnancy were referred by the family planning clinic, and 23 percent were identified via street canvassing and door-to-door work. For women in the third trimester, the family planning clinic remained the most successful referral source. In light of these data, increased efforts are being made to recruit clients through family planning systems. The project director reports that threats of violence and general security concerns are forcing them to decrease street and door-to-door canvassing, even though these methods, too, seem effective. The program costs approximately $430,000 per year. The community workers receive about $17,000 annually. No evaluation of the project has been completed that relates costs to the number of clients found by the casefinding work. MIOP does not know whether its casefinding and advocacy are leading to earlier registration and continuation in prenatal care. Although first- trimester registration rates increased in five of the seven targeted neigh- borhoods between 1985 and 1986 (from 48.8 percent to 52.3 percent; MIOP began in July 1985), comparison data from other neighborhoods have not been analyzed, and specially constituted comparison groups have not been defined. Pregnancy Heatthline New York City20 The Pregnancy Healthline (PHL) is an ongoing project of the New York City Health Department, part of a mayoral initiative to decrease both infant mortality and the percentage of women who receive late or no prenatal care. The Healthline number is answered by a PHL staff member from 9:00 a.m. to 5:00 p.m., Monday through Friday. After 5:00 p.m. and on weekends and city holidays, a recorded message instructs callers to leave a number at which their call can be returned. All PHL staff are female. Their education varies from a high school degree through master's training. Several are bilingual, and two are trilingual. All are trained in women's health issues. The PHL goes beyond the usual question-answering and referral func- tions of a hotline. In particular, it is able to schedule prenatal appointments during the initial call to the hotline. Over 70 facilities give PHL blocks of

APPENDIX A 193 appointments into which hotline staff can schedule callers, saving them a second phone call. PHL only negotiates appointment blocks with facilities that can provide appointments within 2 weeks. Before making an appoint- ment, PHL staff obtains financial information. If a woman is eligible for Medicaid, she is sent to a facility that can do Medicaid eligibility on site. Staff members also conduct a rudimentary risk assessment in order to refer women to the most appropriate facility or to obtain additional help for them. Staff members contact the prenatal care facilities weekly to give them appointment information and to determine which PHL-referred women did not keep appointments the previous week (33 percent in 19861. The PHL staff attempts to contact these women (successfully in about 40 percent of the cases) to determine why the appointments were not kept and to assist women in overcoming obstacles to obtaining care. Many have sought care on their own at other sites; some had miscarriages or abortions. For a few, PHL staff make another prenatal appointment. In addition, the staff attempts to contact 30 percent of women who keep their appointments, stratified by risk status, to determine whether they have continued in care, to assess satisfaction with care, and, if they have delivered, to learn the outcome of the pregnancy. This process also uncovers problems which the staff tries to overcome by becoming client advocates in the health care system. The Healthline uses a variety of techniques to make its services known. It was launched with a mass media campaign that included television and radio spots, subway cards, posters, flyers, and wallet cards. The program has also advertised in local and citywide newspapers, as well as in telephone directories for particular boroughs and for New York's Spanish- speaking population. PHL staff have established relationships with other agencies that work with similar populations, presented them with infor- mation on the Healthline, and cooperated with them on direct mailings that display the phone number prominently. PHL announcements have been included in welfare check and Medicaid mailings. It is also advertised through the Women's Health Program (another part of the mayoral infant mortality reduction initiative), which employs health educators who offer educational sessions in the target areas and promote the Healthline. In addition, the project sends a newsletter to women who keep their appoint- ments. PHL tests its media ideas using focus groups, and it has found that subway ads in particular increase the number of calls. Radio spots and telephone directory listings have been found useful, more so than television spots. The PHL phone number has also appeared in media campaigns developed by other groups, including the New York chapter of the March of Dimes, the Mayor's Office of Adolescent Pregnancy and Parenting Services, and the New York State Family Planning Media Consortium.

194 APPENDIX A From its inception in February 1985 through the end of September 1987, PHL received over S1,000 calls. In the last 9-month period for which data have been analyzed January through September 1987), more than 20,000 calls were received. More than half of the calls (63 percent) were pregnancy-related, and another large group concerned family planning, abortion, and various gynecological problems. Sociodemographic data on the callers suggest that they are at high risk for low use of prenatal care. Sixteen percent of the callers were under 18 years old; 9 percent had health insurance, about 16 percent were on Medicaid, and 76 percent had no health insurance at all. Between February 1985 and lanuary 1986, over half the callers, especially women without the proper immigration papers and the working poor, cited financial problems as barriers to care, and over 10 percent had difficulty securing care due to a recent move. Some of these were homeless women who had been placed in welfare hotels in unfamiliar neighbor- hoods. The staff rated 18.4 percent of the women as being at medical risk, 21 percent at social risk, and ~ percent as both. The 961-BABY Telephone Information and Referral Service Detroit, Michigan2i 961-BABY is a 24-hour telephone information and referral service. It was established in 1984 by the Detroit-Wayne County Infant Health Promo- tion Coalition, which is composed of 42 agencies. Telephones are an- swered by professional counselors who are trained to manage crisis situations as well as to provide information about health and social services. Callers are given the names, locations, and telephone numbers of appropriate agencies; appointments are not made. 961-BABY refers women only to prenatal facilities that can provide psychosocial and nutritional services, health education, postpartum care, family planning, and well- baby care. The facility must be able to offer care within 10 business days of an annointment request and not ask initialiv about source of naYment - -try -I - a ~ ~ r _ '' ~ ~ . r. ~ ·1' 1' .1 ~ . 11 .1 1 1 . _ tor care. (callers are asKeo it they Will allow tne stall to call tnem cacK to determine whether they followed through on the referral and whether they were satisfied with the care that they received. Like New York's Pregnancy Healthline, 961-BABY staff act as advocates for callers in securing appointments, applying for public assistance and Medicaid, and other needs. The hotline director routinely discusses with the leaders of major prenatal care providers in the area ways to improve services and to resolve the problems that hotline callers report. Project staff believe such advocacy is a critical element of a service directed at individuals likely to remain outside existing networks of health and social services.

APPENDIX A 195 Initially, 961-BABY depended upon public service announcements and other free publicity to advertise its presence. Commercial advertising, including television and radio spot announcements and billboards, was used for half of 1986, with positive results. Television was the most important source of information about the service for the callers, followed by radio and friends and relatives. Since its inception, 961-BABY has received over 23,000 calls, 7,S00 in 1987 alone. Each year the volume of calls grows. Forty-six percent of the calls in 1987 were related to prenatal care. Sociodemographic data suggest that the hotline is being used by women at risk of insufficient prenatal care. Almost a fifth of the callers who sought information about prenatal care in 1987 were under 18 years old, over three-quarters were black, and four-fifths were unmarried. Half called while they were still in their first trimester. The number of women calling who were Detroit residents represented about 13 percent of births in Detroit. Recently, an attempt was made to contact a random sample of callers 4 to 6 weeks after their call to the hodine to determine whether they followed through on advice and information offered by answering staff. Only 36 percent could be located, suggesting that a substantial portion of the callers are highly mobile, which is also indicated by the demographic characteristics of callers. Of the women located, about three-fourths agreed to be interviewed by telephone. Of these, 80 percent reported that they had called to make a prenatal appointment within 1 week of the 961-BABY referral. Fifty-~ree percent kept that appointment; the 47 percent who did not gave a variety of reasons for not doing so. The most common were that the clinic to which they were referred was not convenient in hours or location and that the person answering the phone was rude or unfriendly. Most of these women, however, eventually secured prenatal care elsewhere. Ninety-two percent were satisfied with the help they received from the hotline counselors. Concern for Health Options: Information, Care and Education (CHOICE) Philadelphia, Pennsylvania22 CHOICE is a private, nonprofit organization in Philadelphia that conducts a variety of educational and advocacy activities on aspects of women's reproductive health. One of its functions is the operation of the CHOICE hotline, which provides counseling and referrals for family planning, prenatal care, pregnancy options, and other women's health issues. Like both of the hotlines described earlier, CHOICE uses info~a- tion gained from callers to identify problems in the maternity care system and to act on behalf of individual women and for system improvements generally. A recent focus, for example, was the elimination of preadmission deposits for labor and delivery services at area hospitals.

196 APPENDIX A Many activities are used to advertise the hotline, to convey various messages about reproductive health, and to inform women of Philadel- phia's Maternal and Infant Care (MIC) Projects. These activities include newspaper ads and articles, subway and bus cards, listings in the white and yellow pages, public service announcements on radio and television, the distribution of consumer brochures in English and Spanish, brochures and posters for teenagers, and wallet cards. CHOICE staff appear at health fairs and on talk shows, arrange celebrity participation in various events promoting the program, make presentations at area workshops and training sessions, and support a teen theatre group. Information about the service is also sent regularly to school nurses and counselors, family planning counselors at pregnancy testing sites, and to other providers. Special informational efforts have been targeted at the Hispanic population. From July 1, 1986, through June 30, 1987, the hotline received more than 24,000 calls. Half of these were for pregnancy testing and counseling referrals and about a quarter concerned family planning, sexually trans- mitted diseases, and other reproductive health issues. Among the remain- ing quarter were some 1,827 calls from women who knew they were pregnant, lived in Philadelphia, and wanted help in finding a prenatal care provider. Descriptive information on these maternity care callers suggests that the hotline reached the intended audience of low-income and teenage women. Almost 40 percent of the calls were from teenagers. Of those who knew their insurance status, more than two-thirds had none and more than a fifth had Medicaid. Forty-one percent of the women who knew their pregnancy status were in the first trimester. However, only 2 percent of the calls were from Hispanic women, despite the special efforts to advertise the hotline to the Hispanic community. Over time, the hotline appears to be attracting more uninsured and teenage callers. They are also further along in pregnancy than callers several years ago, which may have some relationship to new constraints on the public financing of abortions in the state. A recent evaluation revealed that about two-thirds of the women referred to MIC projects for prenatal care actually enrolled at the sites to which they were referred. Word-of-mouth was the most frequently cited source of information about the hotline, followed by the various public information activities noted above. The third most common source of referral to the hotline was hospitals, clinics, and agencies. Callers who knew about CHOICE through the various public information activities were reached earlier in their pregnancies than those who cited other referral sources. The staff has concluded that public information activities about the hotline were the single most effective method of reaching teenagers, uninsured women, and women in their first trimester of pregnancy all of whom were target

APPENDIX A 197 groups. Staff has also concluded that reaching women at high risk of insufficient prenatal care requires a clear, simple, and direct message in promotional materials. The Free Pregnancy Testing and Prenatal Care Advocate Program Tulsa, Okiahoma23 Low rates of prenatal care use and high rates of low birthweight prompted a major community effort in Tulsa County, Oklahoma, to improve pregnancy outcomes. A key element was promoting entry into prenatal care in the first trimester by providing free pregnancy tests, supplemented by volunteer patient advocates to facilitate entry into prenatal care. The project was sponsored by the Community Service Council of greater Tulsa. The free pregnancy testing service was offered once a week at four area clinics over a 14-week period in 1987 and was advertised on local radio stations in order to reach community groups known to be at high risk of late registration in prenatal care low-income women, black women, and teenagers, particularly black teenagers. The advertisements referred listen- ers to HELPLINE, a 24-hour telephone information and referral service, for specifics of where and when the free tests were available. In addition, the tests were also advertised through the newspaper and through flyers `distributed in areas where women in the target groups might see them, such as housing projects. The clinics providing the tests were also asked to let callers know of the free service. Volunteer patient advocates did the actual pregnancy testing and counseling and consulted with all women about the importance of prenatal care and about reproductive health generally. A woman testing positive who chose to seek prenatal care at one of five designated sites providing obstetric services was asked by an advocate to participate in a special project by allowing the advocate to help her arrange for prenatal care and obtain other services she might need (such as Medicaid). During the 14 weeks of the project, 1,252 women obtained free tests at the four pregnancy testing sites. Seventy-eight percent of these women were asked how they found out about the service. Forty-three percent mentioned the radio advertisements, 25 percent the clinics themselves, 13 percent friends, and the rest a host of other sources. As a result of the radio advertisements, calls to HELPLINE for pregnancy testing and many other reproductive health services increased significantly. For example, during the project interval, 85 calls per month were made to HELPLINE for birth control and pregnancy testing services versus 7 per month over the same period a year earlier.

198 APPENDIX A Data from the most popular of the four testing sites (one that performed 62 percent of the 1,2S2 tests) suggest that the free pregnancy testing brought more women in for testing than before the service was available. From April through July 1986, the year before the project, this site administered 795 pregnancy tests. Over those same 4 months in 1987, which include the 14-week program, 1,239 tests were completed, 774 of which were free and done as part of the special program. This represents a S6 percent increase in testing volume over the previous year. Similar data from the other three sites are not available, but program leaders report increases in these settings. Representation of black women and young women in the test population was greater than their representation in the Tulsa County childbearing population, suggesting that the targeting of the project may have been successful. However, because a demographic profile of women obtaining pregnancy tests at the four sites before the project is not available, it is not possible to determine whether the special program drew in greater numbers of women from the target groups. A preliminary evaluation of the program has tried to assess whether the free pregnancy testing coupled with clinic-based patient advocates led to earlier registration in prenatal care, particularly among women in the target groups. Of the 1,2S2 tests administered over the 14 weeks of the project, results were recorded for 1,107; of these, 406 were positive. Of these 406 women, 236 (S8 percent) chose not to enroll in the patient advocate program, usually due to a desire to obtain prenatal care from a private doctor or at a site other than the five participating in the special study. Of the 170 women actually enrolling in the patient advocate program, S3 withdrew from the project because of moving, miscarriage, switching to a care provider not in the project, or other reasons; 117 women continued in the project. A demographic comparison of the women who withdrew from the project and those who remained showed that the groups were quite similar in age distribution but that those who remained in the project were more likely to be white. About So percent of the women who continued in the project obtained prenatal care in the first 12 weeks of pregnancy. Fifty-two percent of white women and 49 percent of black women obtained early care; among women under the age of 20, 49 percent obtained care in the first trimester. Although no control group was constituted for a formal evaluation, program leaders did compare the prenatal registration patterns of the 117 women in the project to a group of 499 women who received prenatal care at one of the five participating sites, a local university-affiliated women's clinic (OU-TMC). This group was seen for prenatal care just before the special project was initiated and was judged to be roughly comparable to the project group in terms of education and income—perhaps slightly better off than the project group on both measures. The age distribution of

HINDS ~ 199 He Ho groups was about He same, but the OU3HC group bad about bag He proportion of black women Hat the project group did (16 percent versus 30 percents Based on this difference, women in the OU3HC group would be expected to register earDer in prenatal care than women in He patient suffocate group. Nonetheless, 51 percent of the special intervention group registered far prenatal care in He brat trimester, compared to 29 percent in He OU)HC group. Hong Ibid women, He percentages were 51 versus 30: among black ~omen, 47 versus 26: and among teenagers, 47 versus 28 percent. ~~ougb selEselechon issues and Misdone about the comparabih~ of the groups loom large in this project ~ reasonable conclusion is that this Bee pregnancy testing service coupled Aim social support probably contributed to earDer registration in prenatal care. Tulsa area officials share this generally postage view of He program and bee provided far a years conOnuadon, ~~ougb He program teas been raised. For example, at present, paid stag bee replaced volunteers as patient advocates. The Speci~I SKI Food Prom ~men, 1 ~~d Children HO 3~ SfuJic~ One of the o~ect~es of the SAC program ~ to ensure Hat pregnant women recede adequate prenatal care. SAC agencies are rewired to check that pregnant women are obtaining care and to refer Hem if Hey are not: in a paraDel Euro prenatal chnics oRen stem Hat linking pregnant women to SAC services ~ one of their Unctions. Consequently, in communizes Obese SAC ~ Hatable, women might be expected to seek prenatal care Barber by virtue of close reheal links. Similarly, women Ho obtain prenatal care at bcHides Hat also house the TIC program might be expected to keep more of Bed prenatal appointment if the appointment mere scheduled on the days they could obtain TIC vouchers. (A recent Department of Realm and Human Services pubUcabon, leaving ACE ~C Coo~inchon, provides numerous suggestions far improving He relationship between these Ho agencies: ~ also includes case report of eight sate programs. Several studies bee explored the relationship between participation in TIC and use of prenatal care. The largest is ~sb's historical study, rabid, beginning in 1972 Nab He Commodity Supplemented Food Program and extending through 1980, linked He proportion of eligible pregnant~omen sewed each year by He TIC program in individual counties ('~C penetration") to levels of prenatal care far the same county and year.25 A sutisUcal~ signiRcant relationship was Lund between TIC program penetration and bow hcst-~imester regis~adon and bigher numbers of void. The beneR~ were greatest among women with less education Sub

200 APPENDIX A concluded that the WIC program is an inducement to and a vehicle for achieving greater use of prenatal care. More recent studies have confirmed this conclusion. Among Massachu- setts women who delivered in 1978, those who participated in WIC, as compared to a non-WIC group matched by age, race, parity, education, and marital status, had a higher number of prenatal visits (11.8 versus 10.8) and started care earlier (2.7 versus 2.9 months).26 These results were all statistically significant, although they may not be programmatically meaningful. There was a large difference, however, in the percentage with inadequate care, as measured by the Kessner index (3.9 percent in the WIC group versus 7.0 percent in the non-WIC group). Schramm conducted two studies of Missouri women who delivered in the early 1980s. The first study was of women enrolled in Medicaid who delivered in 1980.27 In this analysis, with no variables controlled, women on WIC were less likely to have had inadequate prenatal care (defined by a combination of frequency of visits and number of weeks pregnant) than those not on WIC (39.1 percent versus 41.S percent). In a 1982 replica- tion, the percentage of WIC participants receiving inadequate prenatal care had been reduced to 35.4, while the percentage of non-WIC had increased to 44.8. Schramm suggested that the increased difference might reflect an improvement in referral patterns among WIC providers or changes in the types of mothers participating.28 Stockbauer also published two studies of Missouri births, but the analyses were not limited to women enrolled in Medicaid and were adjusted for race and education. In a study of 1980 births, the percentage of mothers obtaining inadequate prenatal care was higher in the WIC than in the non-WIC group (32.8 versus 29.59.29 However, in a 1982 replication that controlled for a larger number of variables, the percentage receiving inadequate prenatal care was lower in the WIC group overall (30.4 percent versus 31.7 percent), significantly lower among blacks (32.1 percent versus 37.9 percent), but slightly higher among whites (29.S percent versus 28.4 percent).30 Baby Showers Seven Counties in Michigan3i The Detroit-Wayne County Infant Health Promotion Coalition not only organized the 961-BABY hotline described above, but also sponsored a series of community baby showers. These events were directed at identi- fying pregnant women early in pregnancy, enrolling them in a compre- hensive prenatal care program, and sustaining their enrollment. They were also designed to identify women with infants in need of pediatric care and related social services.

APPENDIX A 201 In essence, the showers were casefinding and health education sessions that were open to the public and that included prepared presentations, small group discussions, and opportunities to make appointments on the spot for selected maternity, pediatric, and social services. In addition, various gifts, door prizes, and other incentives were offered throughout the day in order to create a baby shower atmosphere, encourage attendance, and underline the health education messages. In each county, the showers were publicized in advance by such efforts as door-to-door canvassing, direct mailings, posters, public health nurses' spreading the word, local McDonalds and grocery stores handing out shower invitations, billboards, car signs, "Mother's Day" sermons in target area churches, school presen- tations, and poster contests. Eight showers were given in seven counties from October to December 1985. Attendance at the baby showers varied from 287 in Detroit to 34 in one county, for a total of 689. Approximately half the participants were black and more than a third were teenagers. Almost 70 percent of attendees were pregnant (478), but only 3 percent (21 women) were not receiving prenatal care already. Nonetheless, 74 prenatal appointments were made at the baby showers—a few for the women not in care, but most for those who stated they were already in care but who, in the opinion of the shower sponsors, required additional supervision. An additional 148 appoint- ments were made for a variety of other services, including pediatric care, WIC, family planning, and social services. No information is available on the percentage of appointments actually kept. Although the showers may have provided health education and social support, as well as facilitating the use of some services, their value as a casefinding too! for pregnant women not already in care was clearly limited. Anecdotal reports from similar efforts in California suggest greater casefinding success from this type of activity. The director estimates that the eight showers cost about $32,000 in the aggregate, not counting the substantial in-kind contributions of the sponsoring agencies and volunteers. One major value of the showers may be that they increased the involvement of various church and community groups in issues of infant mortality and maternal health. This consciousness-raising function for the middle-cIass organizers of the events included a new appreciation of the problems faced by low-income women in securing prenatal and pediatric health care. TYPE 5: PROGRAMS THAT PROVIDE SOCIAE SUPPORT Many projects offering intense social support to improve pregnancy outcome have been implemented in recent years. In this section, several

202 APPENDIX A are described beginning with the Resource Mothers Program in South Carolina, which focuses exclusively on adolescents. Following this is a summary of six additional comprehensive programs for pregnant adoles- cents. The section concludes with a description of the Prenatal and Infancy Home Visiting Program in Elmira, New York, and a brief note on the Grannies Program in Bibb County, Georgia. Resource Mothers Three Counties in South Carolina32 The Resource Mothers (RM) Program began in 1981 as a component of the Robert Wood Johnson Foundation's Rural Infant Care Program. It was originally confined to a three-county area, the Pee-Dee, which is very poor and rural, with few adequate health facilities and a postneonatal mortality rate (deaths that occur between 28 days and 12 months of age) in 1980 that was the highest of all 200 Health Service Areas in the United States. The RM Program is for teenagers under 18 who are pregnant with their first child. The project emphasizes social support, health education and information, and general assistance offered by a Resource Mother. Teen- agers are referred to the program by schools, health departments, private physicians, service agencies, civic and church groups, and peers. The Resource Mothers themselves are all mothers (many were pregnant as teenagers), high school graduates, and residents of the target counties. According to the project director, they are chosen on the basis of"personal warmth, successful personal parenting experiences, knowledge of commu- nity resources, demonstrated ability to accept responsibility, evidence of natural leadership, ability to use written and spoken language effectively, and subtle interpersonal skills." Resource Mothers participate in a 6-week training course. In addition, there are biweekly continuing education sessions and patient reviews with a social worker supervisor. The average caseload for a Resource Mother is 30 to 35 pregnant and postpartum teenagers. Resource Mothers visit the participating teenagers at home or in other settings during pregnancy, in the hospital at the time of delivery, and during the first year postpartum. Visits are scheduled more often if there is a crisis. Although the visits are very structured, with a well-defined approach and specific content to be covered at each session, the Resource Mothers are encouraged to get to know the air! and her family very well— to become involved. They make sure that appointments are kept, providing transportation if necessary, and that recommendations from physicians and others are followed. The program has been the subject of several evaluations, many of them focusing on reductions in low birthweight and improvements in infant development, since those are major goals of the program. The Committee,

APPENDIX A 203 however, reviewed only those studies that examined use of prenatal care. One retrospective analysis compared a sample of RM women with matched controls drawn from the same counties. Women in both groups had a first, live birth (single) during the 1981-1985 interval. Using birth certificate records, controls were selected from women under 19 who had no known previous pregnancy; matching variables were year of delivery, county of residence, and race and sex of the child. Adequate controls were found for 519 of 575 RM cases. Of the RM clients, 17.S percent evidenced inadequate prenatal care (fewer than five visits or care begun after the sixth month o pregnancy) versus 24.S percent of the controls; the RM women averaged 8.6 prenatal visits versus 7.9 for the controls.33 Because of concern that selection bias limited the validity of these observed differences, a second retrospective analysis was conducted in which the controls were drawn from different counties that were nonethe- less sociodemographically comparable to the Pee Dee area in which the RM Program operated. The study matched 565 women who had participated in the RM Program between 1981 and 1985 with women from nearby rural counties who also had first, live births (single) and no previous pregnan- cies; variables matched were year of delivery, maternal age, and child's race and sex. Of RM patients, 18.3 percent had received inadequate prenatal care versus 3S.9 percent of the controls.34 The program still operates in the Pee Dee and has been expanded to other areas of the state as well. At present, some 16 Resource Mothers are at work in 20 counties, financed primarily by federal funds. Although state funds have been sought, few have been provided. Program leaders claim that state officials seem favorably impressed by the project, but thus far competing demands for public dollars have been too strong to allow RM much state support.33 Comprehensive Service Programs for Pregnant Adotescents- A Summary of Six Programs35 36 Because the needs of pregnant adolescents are so great, many commu- nities have developed comprehensive programs to meet them. Such programs usually include, at a minimum, educational, social, and medical services in one facility or by referral. These types of programs have been encouraged and sometimes funded by the federal Office of Adolescent Pregnancy Programs. As with most of the services described in this appendix, few comprehensive adolescent programs use only one method to draw teenagers into prenatal care and sustain their partici- pation. The three most commonly employed by the six programs described in this section are improving institutional arrangements, casefinding, and social support. The six projects summarized are the

204 APPENDIX A Teen Mother and Child Program at the University of Utah School of Medicine; Youth Health Services in Elkins, West Virginia; the Teenage Pregnancy and Parenting Project in San Francisco: the adolescent program of the Visiting Nurse Association of Manchester and Southern New Hampshire; the Ethnic Adolescent Family Life Project in Provi- dence, Rhode Island; and Johns Hopkins Hospital's Adolescent Preg- nancy Program in Baltimore. Improving Institutional Arrangements Adolescents frequently have difficulty using health services designed for older women. Hours may conflict with school, the site may be clifficult to reach without a car, education may be minimal, and provider attitudes may be negative. All of the six programs address such issues by holding separate clinic sessions for teenagers, emphasizing continuity of providers, holding special group educational sessions, and so on. Some programs use vans to pick up clients at home and take them to sessions. A program serving rural adolescents provides transportation to and from the program site, the prenatal clinic, the WIC office, and other agencies. An inner-city program has developed a prenatal clinic in a school, providing medical care, prenatal education classes, and counseling and referral. Two programs have nurse-practitioners providing routine prenatal care because of their special skills in working with this age group. Other programs use nurse-practitioners for educational sessions and support during labor. One program provides in-home nursing care to adolescents between medical appointments. The visiting nurses provide routine health assessments, counseling, and prenatal and parenting education. Casefinding Programs for adolescents rely heavily on referrals from current and former clients. Clients are educates! to the need for such referrals. In one program, if an adolescent is missed—that is, not identified at an appropriate time—the staff asks currently enrolled clients how they could have found her earlier. Schools are an obvious source of referrals for adolescents. One program stations workers in two inner-city high schools 1 day a week. Students who have been identified as pregnant by a teacher or school nurse or who are suspected of being pregnant are seen by the worker during school time and helped to register for care. Pregnancy testing sites are also used to locate pregnant adolescents. One program continually reminds private physicians of its presence in order to obtain referrals. Another has a counselor visit adolescents who have been referred but who have not made contact with the program. Social Support Many programs assign single individual (one program calls her a each teenage participant to a "continuous counselor") who

APPENDIX A 205 coordinates and integrates the many services typically required by preg- nant teenagers. While such counselors have traditionally been social workers, they may also be nurses, nutritionists, or other staff members. One program director said, "We have to rid ourselves of the medical model in serving teens. Teens need to be treated as whole persons. We can't have one practitioner counseling them in the clinic and another going out to make home visits. Everybody does everything here." These case supervi- sors provide counseling, education, referrals, advocacy, and follow-up, addressing the entire constellation of client needs. They must be able to become a "significant other" for young women who lack support from family members; in some programs they are expected to be available during nonworking hours, visit homes in inner-city neighborhoods, and provide support during labor. Bilingual case supervisors are often recruited by programs serving linguistic minorities. Evaluation The six programs have all studied the results of their activities by comparing program participants to other, similar groups on various measures of pregnancy outcome and use of prenatal care; none, however, has used randomization to overcome the possibility of selection bias. Five of the six programs demonstrated earlier entry into prenatal care, more prenatal visits, or both in comparison to a control group of adolescents. Only one program (the Ethnic Adolescent Family Life Project) found that the special program group entered prenatal care later and had fewer visits than the comparison group. The Prenatal and Infancy Home Visiting Program— Elmira, New Yorh37 This research and demonstration project was carried out between 1978 and the early 1980s in the target community of Elmira, which is semirural and located in the Appalachian region. In 1980 its economic conditions were rated the worst of all U.S. Standard Metropolitan Statistical Areas; its rates of child abuse and neglect were the highest in the state; and its infant mortality rate during the 1975-1977 interval, prior to the study, was 15.2 per 1,000 live births. The program was designed to prevent a wide range of health and developmental problems in children through prenatal and postpartum home visiting by nurses. A sophisticated research and evaluation plan was built into the program at the outset. Pregnant women were recruited into the program if they had no previous live births and one or more of the following additional risk characteristics: under 19 years old, single, and low socioeconomic status. Other women expecting their first babies who asked to participate were also admitted.

206 APPENDIX A Four hundred women were enrolled, stratified by marital status, race, and geographical region within the county, and assigned at random to one of four groups: (T1) assessment of the infant but no services; (T2) services limited to infant assessment and transportation assistance; (T3) home visiting during pregnancy only, plus transportation assistance and infant assessment; and (T4) same as (T3), but visiting continued through the first 2 years of the child's life. Nurses visited families about once every 2 weeks during the pregnancy, for an average of nine visits, each of which lasted over an hour. The visits had three basic objectives: parent education, the enhancement of women's informal support systems, and the linkage of women with commu- nity services. The nurses were taught to emphasize the strengths of the women and their families. (In assessing program results, the few nonwhite women in the program and women with maternal or fetal conditions that might lead to preterm birth were eliminated from the analyses.) There was no difference between the groups visited by nurses (T3 and T4) and those not (T1 and T2) in number of prenatal care visits made by the pregnant women: both sets averaged about lO.S visits, reflecting in part the fact that prenatal services were easily available through nine area obstetricians and a free antepartum clinic sponsored by the health department. There were, however, differences between the groups visited by nurses and those not visited on several other prenatal factors. For example, the visited women were aware of more community services, attended childbirth classes more frequently, received more WIC vouchers, talked more with service providers and members of their informal networks about the stresses of pregnancy and family life, indicated that their babies' fathers showed a greater interest in their pregnancies, and were accompanied more frequently in labor. Smokers who were visited reduced their smoking more than those who were not. The program is still operating, but as the years proceed and staff change, its original clarity of purpose and energy have diminished. Supported at first with federal research dollars, it is now funded by state monies and administered through the local health department. The Grannies Program Bibb County, Georgia38 The Grannies Program provides social support via the telephone. Women who come to the Bibb County health department prenatal clinic are assigned a Granny, who calls them twice a month before their babies are born and once a month for 12 months afterward. Grannies are paid by the hour and work out of their homes. They are supervised by a part-time program coordinator. The Grannies remind patients of their clinic appoint- ments, suggest ways to obtain assistance when needed, and provide education and support.

APPENDIX A 207 The rate of broken appointments at the clinic has fallen from about 34 percent to 10 percent since the program has been in operation. Other measures of impact, such as trimester of registration, are not available. REFERENCES AND NOTES 1. Descriptive material and data provided by the Division of Family Health Services, Massachusetts Department of Public Health; Katherine Messenger and Hannah Boulton, Massachusetts Department of Public Health. Personal communication, 1987-1988. 2. Azzara CV, Kotelchuch M, Anderka MT, Clark KS, and Robanske D. A Preliminary Healthy Start Evaluation: Interim Report for the Massachusetts Legislature. Boston: Division of Family Health Services, Department of Public Health, March 1988. 3. Descriptive material and data provided by the Michigan Department of Public Health; Janet Olszewski, Michigan Department of Public Health. Personal com- munication, 1988. 4. Maternal and Child Health Branch. Final Evaluation of the Obstetrical Access Pilot Project, July 1979-June 1982. Sacramento: California Department of Health Services, 1984; Korenbrot CC. Risk reduction in pregnancies of low-income women: Comprehensive prenatal care through the OB Access Project. Mobius 4:34-43, 1984; Lennie JA, KlunlR, and Hausner T. Low-birthweight rate reduced by the Obstetrical Access Project. Health Care Financing Rev. 8:83~86, 1987; Athole Lennie and Lyn Headley, California Department of Health Services. Personal communication, 1987-1988 S. Berger LR. Public/private cooperation in rural maternal child health efforts: The Lea county perinatal program. Tex. Med. 80:54-57, September 1984; Canfield E. The Select Panel Report a follow-up. Paper presented at the American Public Health Association annual meeting, Los Angeles, 1981; Russell RE. The first report on the Lea County survey of women who have delivered babies while residents of Lea County during 197~1981. Unpublished paper, 1982; Spice B. Program reduces infant death rate. Albuquerque Jounal, January 5, 1987; Lawrence Berger, Lovelace Medical Foundation. Personal communication, 1987-1988. 6. Description of Prenatal Care Assistance Program, New York State Department of Health, December 30, 1987; PCAP client characteristics, services, and pregnancy outcomes, New York State Department of Health, September 21, 1987; Linda Randolph, New York State Department of Health. Personal communication, 1987-1988. 7. Division of Maternal-Fetal Medicine, State University of New York and Onondaga County Health Department. Prevention of low birthweight program in Onondaga County. Proposal for funding to Department of Health, State of New York, 1983; Richard Aubry, Health Science Center, State University of New York. Personal communication, 1987-1988. 8. Sokol RI, Wolf RB, Rosen MG, and Weingarden K. Risk, antepartum care, and outcome: Impact of a Maternity and Infant Care Project. Obstet. Gynecol. 56:150-156, 1980; Elizabeth Campbell, Cleveland Metropolitan General Hospital. Personal communication, 1987. 9. Peoples MD and Siegel E. Measuring the impact of programs for mothers and infants on prenatal care and low birth weight: The value of refined analysis. Med. Care 21:58~605, 1983.

208 APPENDIX A 10. Health Services Administration, Bureau of Community Health Services. The Maternity and Infant Care Projects: Reducing Risks for Mothers and Babies. DHEW Pub. No. (HSAj7S-5012. Rockville, Md., 1975, p. IS. 11. Ibid., p. 16. 12. Peoples MD, Grimson RC, and Daughtry GL. Evaluation of the effects of the Carolina Improved Pregnancy Outcome Project: Implications for state-level deci- sion making. Am. I. Public Health 74:549-554, 1984. 13. Strobino DM, Chase GA, Kim Y], Crawley BE, Salim OH, and Baruffi G. The impact of the Mississippi improved child health project on prenatal care and low birthweight. Am. I. Public Health 76:274-278, 1986. 14. lones]E, Tiezzi L, and Williams-KayeJ. Notes from the field: Overcoming barriers to Medicaid eligibility. Am. I. Public Health 76:1247, 1986; Jones]E, Tiezzi L, and Williams-Kaye I. Financial access: Key to early prenatal care. Paper presented at the American Public Health Association annual meeting, Washington, D.C., 1985; Judith Jones, National Resource Center for Children in Poverty, Columbia University. Personal communication, 1987-1988. IS. Rural infant deaths decline with aid of UT Memphis project. The Record (University of Tennessee Health Science Center), February 1987; Ryan GM. Papers presented at the Orange County Obstetric and Gynecological Congress, Costa Mesa, Calif., April 3, 1987, and at the Boston Obstetrical Society, March 23, 1981; George Ryan, Department of Obstetrics and Gynecology, University of Tennessee. Personal communication, 1987-1988. 16. Brooks-Gunn I, McCormick MC, Gunn RW, Shorter T. Wallace CY and Haegarty MC. Locating low-income pregnant women: The process of outreach. Medical Care, in press.; McCormick MC, Brooks-Gunn J. Shorter T. Holmes TH, Wallace CY, and Haegarty MC. Outreach as casefinding: Its effect on enrollment in prenatal care. Medical Care, in press; Margaret Haegarty, Harlem Hospital Center. Personal communication, 1987. 17. Jones I. Community health advocate program: Final report to The Ford Foundation, April 1981-September 1982; Judith [ones, National Resource Center for Children in Poverty, Columbia University. Personal communication, 1987-1988. 18. Deborah Coates and Joan Maxwell, The Better Babies Project. Personal commu- nication, 1987-1988. 19. Christison-Lagay J. The maternity and infant outreach project of the Hartford Action Plan on Infant Health. Unpublished report, 1986; Joan Christison-Lagay, Hartford City Health Department. Personal communication, 1987-1988. 20. Breitbart V and Zeitel L. Hotline As a Means to Improve Access to Prenatal Care in New York City. New York: Bureau of Maternity Services and Family Planning, New York City Department of Health, 1986; Vicki Breithart, Bureau of Maternity Services and Family Planning, New York City Department of Health. Personal communication, 1987-1988. 21. Wright TD. Evaluation of 961-BABY: A telephone information and referral service. Paper presented at the American Public Health Association annual meeting, Las Vegas, 1986; Terri Wright, Detroit/Wayne County Infant Health Promotion Coalition. Personal communication, 1987. 22. CHOICE. Hotline data report July 1, 1985-June 30, 1986, submitted to the Philadelphia Department of Public Health; Muriel Keyes, CHOICE. Personal communication, 1987-1988. 23. Jackson CI, Renner S and Lapolla M. The Use of Free Pregnancy Testing to Encourage Early Entry into Prenatal Care. Tulsa: Oklahoma Medical Research

APPENDIX A 209 Foundation, Center for Health Policy Research, 1987; Cassandra Jackson, Center for Health Policy Research. Personal communication, 1987-1988. 24. Improving MCH/VVIC Coordination Final Report and Guide to Good Practices. Submitted by Professional Management Associates, Inc. to the Office of the Assistant Secretary of Planning and Evaluation, Department of Health and Human Services. Contract No. HHS-100-84-0069, Washington, D.C., August 1986. 25. Rush D. Evaluation of the Special Supplemental Food Program for Women, Infants and Children (WIC). Vol. I: Summary. Submitted by Research Triangle Institute to the Office of Analysis and Evaluation, Food and Nutrition Service, Department of Agriculture. Contract No. 53-3198-9-87, Washington, D.C., January 1986. 26. Kotelchuck M, Schwartz IB, Anderka MT, and Finison KS. WIC participation and pregnancy outcomes: Massachusetts statewide evaluation project. Am. ]. Public Health 74:1086-1092, 1984. 27. Schram WE. WIC participation and its relationship to newborn Medicaid costs in Missouri: A cost-benefit analysis. Am. I. Public Health 75:851-857, 1985. 28. Schram WE. Prenatal participation in WIC related to Medicaid costs for Missis- sippi newborns: 1982 update. Public Health Reps. 101:607-615, 1986. 29. Stockbauer IW. Evaluation of the Missouri WIC program: Prenatal component. I. Am. Dieter. Assoc. 86:61-67, 1986. 30. Stockbauer IW. WIC prenatal participation and its relation to pregnancy outcomes in Missouri: A second look. Am. I. Public Health 77:813-818, 1987. 31. Wright TD and O'Meara M. Community Baby Shower Summary Report: Regional Outreach Campaign, Fall 1985. Detriot: Detroit/Wayne County Infant Health Promotion Coalition, 1986; Terri Wright, Detroit/Wayne County Infant Health Promotion Coalition. Personal communication, 1987. 32. Lois Wandersman and Marie Meglen, South Carolina Department of Health and Environmental Control. Personal communication, 1987-1988. 33. Meglen MC and Wandersman LP. Perinatal impact of South Carolina's Resource Mothers Program. Unpublished paper, 1987. Reins HE Nance NW and Fer~uson lE. Social succors in improving nerinatal 34. 7 _ ~ 7 _ ~ _ To -— ~ - 1 1 1 ~ ~ outcome: The Resource Mothers Program. Obstet. Gynecol. 70:26~266, 1987. 35. Cartoof VG. Increasing adolescents' access to prenatal care: A case study of six programs. Paper prepared for the Committee on Outreach for Prenatal Care, Institute of Medicine, Washington, D.C. 1987: 36. Elster AB, Lamb ME, Tavare J. and Ralston CW. The medical and psychosocial impact of comprehensive care on adolescent pregnancy and parenthood..~. Am. Med. Assoc. 258:1187-1192, 1987. 37. Olds DL, Henderson CR, Tatelbaum, R and Chamberlin R. Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics 77: 16-28, 1986; David Olds, Department of Pediatrics, University of Rochester. Personal communication, 1988. 38. Jacqueline Scott, Bibb County Health Department. Personal communication, 1987.

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Prenatal care programs have proven effective in improving birth outcomes and preventing low birthweight. Yet over one-fourth of all pregnant women in the United States do not begin prenatal care in the first 3 months of pregnancy, and for some groups—such as black teenagers—participation in prenatal care is declining. To find out why, the authors studied 30 prenatal care programs and analyzed surveys of mothers who did not seek prenatal care. This new book reports their findings and offers specific recommendations for improving the nation's maternity system and increasing the use of prenatal care programs.

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