The Effect of Passing an “Anti-immigrant” Ballot Proposition on the Use of Prenatal Care by Foreign-Born Mothers in California

This study examines whether the passage of California's Proposition 187, a proposition designed to restrict undocumented immigrants from using public services, had a negative effect on the use of prenatal care and birth outcomes. Comparisons of prenatal care use and birth outcomes before and after the passage of the proposition are made between low-education foreign-born and U.S.-born mothers using California's Birth Public Use files. Multivariate linear and logistic regressions were used to control for regional and maternal characteristics. We find a significant but small decline in the use of prenatal care by low-education foreign-born women after Proposition 187 passed; however, there was no detectable deterioration of birth outcomes. Whether future reductions in the availability of prenatal care would damage the health of children is unclear.     

Changes in Births to Foreign-born Women after Welfare and Immigration Policy Reforms in California

Objectives: To determine whether passage of welfare and immigration policies was followed in California by changes in births to foreign-born women in California with respect to total numbers, payer sources, prenatal care use, or health outcomes. Methods: Comparison of births to foreign-born and US-born women from 1990 to 1997 using adjusted odds ratios generated with multivariate logistic regression. Results: Policies passed in 1994 and 1996 were followed by decreases in adjusted odds of births to foreign-born women with prenatal Medicaid coverage, without a corresponding increase in uninsured foreign-born women. There was no decline in the use of prenatal care by foreign-born women, and no worsening of birth outcomes after passage of the reforms. Foreign-born women, however, remained more likely to have inadequate prenatal care than US-born women, and the improvement in outcomes that occurred for US-born women from 1994 to 1997 did not occur for foreign-born women. Conclusions: In spite of the fact that pregnant immigrant women remained eligible for Medicaid after passage of welfare and immigration policies in California, the volume of births to foreign-born women using Medicaid declined. The lack of a corresponding increase in births to uninsured foreign-born women appears to have prevented deterioration in the use of prenatal care or birth outcomes.     

Welfare Reform and the Perinatal Health and Health Care Use of Latino Women in California, New York City, and Texas

OBJECTIVES: This study analyzed changes in the financing of prenatal care and delivery, the use of prenatal care, and birth outcomes among foreign-born vs US-born Latino women following enactment of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in August 1996. METHODS: We used a pre-post design with a comparison group. The sample consisted of resident Latinas in California, New York City, and Texas who delivered a live infant in 1995 or 1998. RESULTS: The proportion of births to Latinas that initiated prenatal care in the first 4 months of pregnancy increased for all foreign-born Latinas in California, New York City, and Texas between 1995 and 1998 (P <.05). Except for non-Dominicans in New York City, there was no increase in the proportion of low- or very-low-birthweight births among foreign-born vs US-born Latinas in the 3 localities between 1995 and 1996. CONCLUSIONS: There is little evidence from vital statistics in California, New York City, and Texas that PRWORA had any substantive impact on the perinatal health and health care utilization of foreign-born relative to US-born Latinas.     

Perinatal Outcomes Among Foreign-Born and US-Born Chinese Americans, 1995–2000

This paper examines nativity differences in adverse perinatal outcomes of Chinese-American mothers. Singleton live births to US-resident Chinese women (150,620 foreign-born, 15,040 US-born) and a random sample of 150,620 non-Hispanic White mothers were selected from 1995 to 2000 national linked birth/infant death certificate files. Associations between maternal nativity status and adverse perinatal outcomes were assessed using multivariable logistic regressions. Compared to US-born Chinese mothers, foreign-born Chinese mothers were less likely to be unmarried, teen mothers, have a non-Hispanic White or other race partner, be rural residents, and more likely to be less educated, or utilize prenatal care inadequately. Controlling for these factors, foreign-born Chinese-American mothers had significantly lower risks for low birth weight, preterm birth, and small-for-gestational age, whereas risks for infant mortality, neonatal mortality, and post-neonatal mortality did not differ significantly from those of infants of US-born Chinese mothers. Chinese Americans exhibited clear nativity differentials for adverse birth outcomes.     

Pregnancy outcomes of US-born and foreign-born Japanese Americans.

OBJECTIVES: This study investigated the birth outcomes of Japanese Americans, focusing on the role of the mother's place of birth. METHODS: Single live births to US-resident Japanese American mothers (n = 37,941) were selected from the 1983 through 1987 US linked live birth-infant death files. RESULTS: US-born mothers were more likely than foreign-born mothers to be less than 18 years old and not married, to start prenatal care early, and to more adequately use prenatal care. Infants of foreign-born Japanese Americans had a slightly lower risk of low birthweight.No significant differences were found between nativity groups for very low birthweight or neonatal, postneonatal, and infant mortality. The mortality rates of infants of US-born (6.2) and foreign-born (5.4) Japanese American women were below the US Year 2000 objective but still exceeded Japan's 1990 rate (4.6). However, low-birthweight percentages of the US-born group (5.7%) and the foreign-born group (5.0%) were similar to that of Japan (5.5%). CONCLUSIONS: The infants of foreign-born Japanese-American women exhibited modestly better low-birthweight percentages than those of US-born Japanese Americans. This finding supports theories of the healthy immigrant.     

Foreign-born and US-born black women: differences in health behaviors and birth outcomes.

We studied health behaviors and birth outcome among 201 foreign-born and 616 US-born Black women receiving prenatal care at Boston City Hospital. Foreign-born women had better pre-pregnancy nutritional status and prenatal health behaviors, and their infants had greater intrauterine growth. Black women are not a homogeneous group; culture and ethnicity, in addition to other variables, must be considered in the study of their birth outcomes.     

Territorial differences in access to prenatal care and health at birth

We assess the impact of prenatal care on health at birth using birth certificates from the Czech Republic. We use a predictive machine learning algorithm to identify the observables affecting birth health outcomes. We control for those observables in our empirical analysis, which indicates that a more intense use of prenatal care is positively correlated with better health outcomes at birth. Exploiting the Czech adhesion to the EU in 2004, we construct an instrument to capture the geographical heterogeneous access to prenatal care across districts. Differently from the OLS results, the IV results do not capture any significant effect of prenatal care, leaving room for the hidden role of unobservable mothers’ characteristics when it comes to health behaviors during pregnancy.     

Use of Care, Outcomes and Costs of a Culturally-based Perinatal Program for Asian American and Pacific Islander Women in Hawaii

PURPOSE. This study examines whether psychosocial perinatal care services developed through community partnerships and cultural deference with attention to individual women's health issues, had an assocaited impact on use of prenatal care, birth outcomes and perinatal care costs for the three participating Asian Pacific Islander American ethinc groups. METHODS. The use of prenatal care visits and birth outcomes for women in the Malama program were compared to those for women of the same etnic groups in the community prior to the introduction of the program. Data on program participants from 1992 to 1994 were compared to birth certificate data on Hawaiian, Filipino and Japanese women from 1988 to 1991. Costs of providing Malama prenatal services were determined from data provided by cost accounting and encounter data systems for the program. SUMMARY OF IMPORTANT FINDINGS. The use of prenatal care visits and birth outcomes were significantly lower for Malama program participants than for women of the same ethnic groups prior to the introduction of the program. The costs of the prenatal program services were $846 to $920 per woman. The expected savings in medical costs per infant with the improved preterm birth rates were $680 per infant. Thus 75% to 80% of the costs of the services were likely to be saved in lower medical costs of the infants. MAJOR CONCLUSIONS. Programs that use community approaches and caring servies delivered in a cultural context, like the Malama model, have a potential for improving the use of prenatal care and birth outcomes at reasonable costs. RELEVANCE TO ASIAN PACIFIC ISLANDER AMERICAN POPULATIONS. The Malama approach to ascertaining cultural preferences for the content and delivery of care should prove useful in addressing public health goals of improved pregnancy outcomes for diverse groups of Asian Americans and Pacific Islanders. KEY WORDS. Asian Americans/Pacific Islanders, pregnancy, prenatal care, low birthweight, preterm birth, cultural competency, community partnerships, costs, cost effectiveness.     

The paternal component of the "healthy migrant" effect: fathers' natality and infants' low birth weight

This study examines the predictors of birth outcomes among women of European and African ancestry and considers the birthplace of the babies’ fathers (foreign born vs. native born) as a protective factor. This is a secondary data analysis of 146,431 singleton births among women of European and African ancestry, both native-born and foreign-born, in a 21 birth hospital region of Central New York State from 1996 to 2003. Foreign born fathers were found to have 15% fewer low birth weight infants than US-born fathers, after controlling for the race and birthplace of the mother, tobacco use and Medicaid. Although this secondary data analysis does not allow us to determine the social determinants of the better birth outcomes among infants of foreign born fathers, it does demonstrate that fathers matter and that foreign born fathers are associated with reduced low birth weight in their infants.     

Medicaid prenatal care: a comparison of use and outcomes in fee-for-service and managed care.

BACKGROUND. To control rising costs, state Medicaid agencies are enrolling recipients in managed care health plans (MCPs). We performed this study to assess this policy's impact on accessibility and outcomes of Medicaid-funded prenatal care. METHODS. We performed a retrospective, controlled study with three cohorts: a study group of 1106 Medicaid recipients enrolled in three MCPs, a matched comparison group of 4830 recipients receiving care in the fee-for-service (FFS) system, and a second matched comparison group of 4434 non-Medicaid enrollees of the same MCPs. Data on prenatal care use and birth outcomes were obtained through linkage of claims and discharge files with birth certificate files. RESULTS. Medicaid recipients enrolled in MCPs used prenatal care similarly to those in the FFS system and showed equal or modestly improved birth-weight distributions. However, Medicaid MCP enrollees showed poorer use of prenatal care and birth outcomes compared with non-Medicaid enrollees of the same plans. CONCLUSIONS. Enrollment in MCPs has a neutral or small beneficial effect on the prenatal care received by the Medicaid population. However, providing financial access and modifying the system of care for this population did not result in parity with the general population.     

Outcomes of enhanced prenatal services for Medicaid-eligible women in public and private settings.

OBJECTIVE: With changes in Medicaid, more low-income women are receiving prenatal care in private practice settings. The authors sought to determine whether private settings can provide the enhanced prenatal support services for low-income women that have been offered for decades in public settings. METHODS: The authors analyzed birth outcomes of Medicaid-eligible women receiving care from public and private providers certified to deliver enhanced prenatal care services, which included assessments of nutritional, psychosocial, and health educational risks and individualized counseling along with clinical care. Birth outcomes were compared by type of provider setting using multivariate logistic regression models to adjust for differences in risks and use of care. RESULTS: Among settings certified to deliver enhanced perinatal support services, private physicians'' offices had the best risk-adjusted birth outcomes and public health department clinics the worst, while public hospital clinics had outcomes no different from private physicians'' offices. Adjusted for prenatal care use, outcomes were still better for women seen in private physicians'' offices than for women seen in public health department clinics, community clinics, or private hospital clinics. CONCLUSIONS: The findings suggest that given a certification process, private providers can provide enhanced support services as effectively as providers in public practice settings.     

The tobacco industry, state politics, and tobacco education in California.

OBJECTIVES. Proposition 99 added 25 cents to the California state cigarette tax and mandated that 20% of the new revenues be spent on tobacco education and prevention programs. This paper examines the implementation of these programs and the tobacco industry's response to Proposition 99. METHODS. Political expenditure data for twelve tobacco firms and associations were gathered from California's Fair Political Practices Commission and secretary of state's Political Reform Division. Tobacco education expenditure data were collected from Governor's Budgets and the Department of Finance. RESULTS. Since Proposition 99 passed, tobacco industry political expenditures in California have risen 10-fold, from $790,050 in the 1985-1986 election to $7,615,091 in the 1991-1992 election. The tobacco industry is contributing more heavily to the California legislature than to Congress. A statistical analysis of data on campaign contributions indicates that California legislators' policy-making is influenced by campaign contributions from the tobacco industry. Since fiscal year 1989-1990, the state has ignored the voters' mandate and spent only 14.7% of the new revenues to tobacco education. Medical care programs received more money than permitted by the voters. CONCLUSIONS. The tobacco industry has become politically active in California following the passage of Proposition 99. One result may be that the state has underfunded tobacco education by $174.7 million through the 1993-1994 fiscal year. The estimated redirection of funds to medical care would essentially eliminate the tobacco education campaign by the year 2000.     

Measurement Error in Prenatal Care Utilization: Evidence of Attenuation Bias in the Estimation of Impact on Birth Weight

Objective: Errors in the measurement of the timing and number of prenatal care visits may produce downward bias in estimates of the impact of prenatal care use on birth outcomes. This paper examines the extent of attenuation bias from measurement error in the estimation of the effect of prenatal care use on birth weight. Methods: Data were analyzed from the 1980 National Natality Survey, a nationally representative sample of live births with information on prenatal care utilization from three sources: birth certificates, medical provider surveys, and maternal surveys. The extent of attenuation bias in estimates of the impact of different measures of prenatal care use on birth weight was examined by comparing estimates robust to measurement error (including instrumental variables) with ordinary least squares results. Results: There is considerable disagreement in measures of prenatal care across the three data sources, with correlations in the utilization measures computed from different sources around 0.5. The results also show evidence of attenuation bias from measurement error in estimates of the impact of prenatal care on birth weight for both White and Black mothers. Attenuation bias was least severe for information from the birth certificate report of prenatal care. Conclusions: Because of measurement error, previous studies may have underestimated the effect of prenatal care utilization on birth weight. Corrected estimates, however, do not suggest that prenatal care is a major predictor of birth weight. In addition, part of what previous analyses have interpreted as adverse selection bias may in fact be attenuation bias due to measurement error.     

Prenatal care utilization: its measurement and relationship to pregnancy outcome

This study proposes a redesigned measure of prenatal care utilization based on modifications made to a preexisting index of the adequacy of such care. Six prenatal care utilization groups were delineated: intensive, adequate, intermediate, inadequate, no-care, and missing/unknown. Using 430,349 cases from South Carolina and North Carolina vital records from 1978 to 1982 (live birth-infant death cohort files for white resident mothers), this proposed prenatal care utilization measure was examined by maternal sociomedical risk characteristics (age-parity, marital status, education, complications of pregnancy, and previous pregnancy terminations) and by pregnancy outcomes (birth weight, gestational age, and birth weight- and gestational age-specific neonatal mortality). The intensive prenatal care group had relatively more pregnancy complications but also the most preferred pregnancy outcomes. Appreciable differences in birth weight and gestational age distributions were observed among the prenatal care categories within maternal risk status groups. Increased utilization of prenatal care was associated with higher mean birth weight and gestational age. However, after controlling for maternal risk status, an appreciable variation in birth weight- and gestational age-specific neonatal mortality was not apparent across prenatal care groups.     

Effects of Prenatal Care on Child Health at Age 5

The broad goal of contemporary prenatal care is to promote the health of the mother, child, and family through the pregnancy, delivery, and the child’s development. Although the vast majority of mothers giving birth in developed countries receive prenatal care, past research has not found compelling evidence that early or adequate prenatal care has favorable effects on birth outcomes. It is possible that prenatal care confers health benefits to the child that do not become apparent until after the perinatal period. Using data from a national urban birth cohort study in the US, we estimate the effects of prenatal care on four markers of child health at age 5—maternal-reported health status, asthma diagnosis, overweight, and height. Prenatal care, defined a number of different ways, does not appear to have any effect on the outcomes examined. The findings are robust and suggest that routine health care encounters during the prenatal period could potentially be used more effectively to enhance children’s health trajectories. However, future research is needed to explore the effects of prenatal care on additional child health and developmental outcomes as well as the effects of preconceptional and maternal lifetime healthcare on child health.     

Barriers to Prenatal Care for Mexican and Mexican American Women

Despite the presumed health benefits, Latinas are less likely than women from other ethnic groups to receive adequate prenatal care during their pregnancy. However, it is unclear whether this trend is the result of political economic conditions that limit access of many Latinos in the United States to adequate health services in general, or of sociocultural conditions that restrict the use of such services even when they are made available. Furthermore, it is unclear whether these barriers pose a risk for adverse birth outcomes in this population. To address these issues, we conducted a two-phase study of the political economic and sociocultural barriers to use of prenatal care services among Mexican and Mexican American women living in San Diego, California, and their association with adverse birth outcomes in this population. A quantitative assessment of information abstracted from the medical records of 173 Latinas who had given birth at a university medical center found that absence of Medi-Cal benefits or other forms of health insurance was the only significant predictor of inadequate prenatal care during pregnancy. However, neither lack of insurance nor adequate prenatal care was associated with any adverse birth outcomes. A qualitative analysis of information obtained from interviews of 30 Latinas receiving prenatal care services at a medical clinic for the homeless and medically underserved residents of San Diego identified three major themes underlying the lack of adequate prenatal care: lack of trust in formal versus informal institutions, wanted versus unwanted pregnancies, and the importance of the social network.