Expanding developmental and behavioral services for newborns in primary care: program design, delivery, and evaluation framework

BACKGROUND: Healthy Steps (HS) for Young Children strengthens the healthcare system as a source of developmental and behavioral support for parents. This series of papers presents a study of HS as implemented within a large health maintenance organization that tested the benefit of beginning intervention services during pregnancy with an extension program called "PrePare" (PP). METHODS: The design was a quasi-experimental comparison of intervention families with families receiving usual care. Within the intervention, families were assigned randomly to begin receiving Healthy Steps services prenatally (PP+HS) or shortly after birth (HS). We used a systems model, PRECEDE/PROCEED, for planning, implementation, and process evaluation. Outcomes examined when the infants were aged 3 months included changes in family social support and capacity for parenting, parenting behaviors, and satisfaction and loyalty to the health plan. RESULTS: The sample of 439 families was distributed as follows: usual care (n=136), prenatal initiation of services (PP+HS; n=151), and postnatal Healthy Steps (HS; n=152). Information about program implementation, including provider satisfaction, is provided for the early phases of the study (through age 3 months). The intervention was delivered with fidelity and with minimal disruption to the practice styles of pregnancy providers, most of whom considered the program valuable to their patients. Relative to families in the comparison group, families in the intervention group received more usual care services and more intervention-specific services. CONCLUSIONS: The pregnancy and newborn phases of the intervention were embedded successfully within the existing healthcare delivery system. The program was considered valuable for parents by providers and parents. Participating families received more services and a greater variety of services than families in usual care. Whether these differences result in beneficial outcomes for families or the health plan are topics of the subsequent papers.     

Developmental services in primary care for low-income children: Clinicians’ perceptions of the healthy steps for young children program

Difficulties with providing quality primary health care for low-income Americans have been well documented. Few studies have addressed the challenges faced by pediatric clinicians serving low-income families or whether practice-based interventions improve clinicians’ ability to provide quality preventive health services. We investigated if, over time, the Healthy Steps for Young Children program affected the practices and perceptions of clinicians in pediatric primary care practices serving low-income families compared to practices serving more affluent families. Self-administered questionnaires were completed at baseline (N=104) and at 30 months (N=91) by clinicians at 20 pediatric practices participating in the Healthy Steps program. Practices were divided into three groups: those serving families with low, middle, and high incomes. Barriers to providing care, provision of preventive developmental services, and perceptions of care were assessed at baseline and at 30 months after introducing the program. Across all income groups and over time, clinicians were more likely to report the provision of preventive developmental health services. Clinicians in low-income practices reported increased problems with both reimbursement and time barriers; clinicians in high-income practices reported increased problems with reim-bursement. At 30 months, clinicians serving low-income families reported the greatest positive changes in their perceptions about the quality of care provided by their practices. They also were more likely to strongly agree that they gave support to families and to be very satisfied with the ability of their clinical staff to meet the developmental needs of children. We found that Healthy Steps was successful in universally increasing developmental services despite the reported practice barriers for both low- and high-income practices. The Healthy Steps program enabled low-income practices to achieve similar levels of clinician satisfaction as middle- and high-income practices despite having reported lower levels at the beginning months of the program. The Healthy Steps for Young Children Program is a program of the Commonwealth Fund, local funders, and health care providers across the nation. It is cosponsored by the American Academy of Pediatrics. Funding for the Healthy Steps National Evaluation is being provided by the Commonwealth Fund, the Robert Wood Johnson Foundation, the Atlantic Philanthropic Foundation, and local funders. The views presented here are those of the authors and not necessarily those of the funders, their directors, officers, or staff.     

Narrowing the income gaps in preventive care for young children: Families in healthy steps

Persistent unmet preventive and developmental health care needs of children in low-income families are a national concern. Recently, there have been efforts to promote developmental services as part of primary care for all young children. However, there is limited research to determine whether the neediest families are well in universal interventions. In our study, we assessed if disparities persist in utilization of developmental services, well child care, and satisfaction with care among low-, middle-, and high-income families participating in Healthy Steps for Young Children. Healthy Steps is a national experiment that incorporated developmental services into primary care for children from birth to 3 years of age. In the United States, 15 pediatric practices participated in this prospective study. At birth, 2,963 children were enrolled between September 1996 and November 1998 and followed through 33 months of age. The utilization of developmental services, satisfaction with care, and receipt of age-appropriate well child visits were measured at 30–33 months and adjusted for demographic and economic covariates. We found that the adjusted odds of low-income families did not differ from high-income families in receipt of four or more Healthy Steps services, a home visit, or discussing five or more child rearing topics. Low- and middle-income families had reduced adjusted odds of receiving a developmental assessment and books to read. The adjusted odds of low- and middle-income families did not differ from high-income families in being very satisfied with care provided or receiving age-appropriate well child visits. A universal practice-based intervention such as Healthy Steps has the potential to reduce income disparities in the utilization of preventive services, timely well child care, and satisfaction with care.     

A randomized trial of a serialized self-help smoking cessation program for pregnant women in an HMO.

We report the results of a population-based randomized clinical trial that tested the effectiveness of a prenatal self-help smoking cessation program. The intervention consisted predominantly of printed materials received through the mail. The population (n = 242) consisted of a socioeconomically and ethnically diverse group of pregnant women enrolled in a large health maintenance organization (HMO) who reported they were smoking at the time of their first prenatal visit. Biochemical confirmation of continuous abstinence achieved prior to the 20th completed week of pregnancy and lasting through delivery revealed 22.2 per cent of the women in the eight-week serialized program quit versus 8.6 per cent of controls with usual care. The adjusted odds ratio was 2.80 (95 per cent CI = 1.17, 6.69). We conclude that a low-cost prenatal self-help intervention can significantly affect the public health problem of smoking during pregnancy and its associated risks for maternal and child health.     

Schwangerenvorsorge in Deutschland

Prenatal care in Germany is based on a nationwide standardized program of care for pregnant women. Besides support and health counseling, it comprises prevention or early detection of diseases or unfavorable circumstances with risks for mother and child. Prenatal care is regulated by law and structured by directives and standard procedures in maternity guidelines (Mutterschafts-Richtlinien). This includes information and counseling of future mothers on offers of psychosocial and medical assistance in normal pregnancies as well as in unplanned or unwanted pregnancies. Further aspects are clinical examinations and risk determinations for genetic variations or direct genetic analysis. During pregnancy, medical history, clinical examination, and blood testing are part of the sophisticated program, which includes at least three standardized sonographic examinations at 10, 20, and 30 weeks of gestation. The maternity passport allows a pregnant woman to carry the most relevant information on her pregnancy and her personal risks with her. For 45 years now, women in Germany are used to carrying their Mutterpass. Societal changes have influenced the central goals of maternity care: In the beginning, the mortality of mother and child had to be reduced. Today, maternal morbidity and impaired development of the child are the center of interest, with expansion to familial satisfaction. The reduction in the mortality and morbidity of both the mother and the child during pregnancy, delivery, and postpartum can be attributed to prenatal care. Thus, investment in a program of nationwide structured prenatal care seems to be worthwhile—despite the lack of evidence concerning its effectiveness.     

Organisational variation, satisfaction, and women's time investment in prenatal care

This study measured the amount of time women spent obtaining prenatal care, and related that time spent to satisfaction with care. Women with Medicaid coverage (n = 364) were interviewed about several parameters related to their most recent prenatal visit: (1) how long it took them to get to the visit; (2) how long they waited upon arrival; and (3) how much time they spent with practitioners during the visit. Women were asked questions regarding satisfaction with the most recent visit, and with their care in general. They received care from four sources: private practitioners, community health centres (CHCs), hospital clinics and health department clinics. Women's satisfaction with care decreased as time spent with practitioners decreased, relative to time spent travelling and waiting. Those obtaining care from CHCs were more likely to have shorter waiting times and longer visit times than women obtaining care from other sources. Women spent approximately 3 h during pregnancy in face-to-face contact with practitioners. Satisfaction with care is closely associated with women's relative time investment in obtaining care. Both satisfaction and time investment parameters vary widely by source of prenatal care.     

Using incentives to motivate women to seek prenatal care: an effective outreach strategy

Expanded Medicaid eligibility and case-managed care have contributed to improved birth outcomes and reduced Medicaid expenditures in Alabama. In 1990, 26.5 percent of all women delayed entry to care until the fourth month of pregnancy or later. Additionally, more than 1,000 women in the state received no care at all. In many of these cases, women perceived prenatal care as unimportant or unnecessary until later in pregnancy. As a result, the Alabama Medicaid Agency developed Healthy Beginnings, an incentive and awareness program which utilizes coupons to motivate women to seek prenatal care. Pregnant women can receive the coupon book (worth about $300) simply by dialing a toll-free number. To take advantage of the free gifts and discounts, expectant mothers must visit a private physician or health clinic and have their coupons validated monthly. The project was initiated in August, 1990, and already there is clear evidence that the use of incentives represents a viable outreach strategy to motivate poor and uninsured women to seek care. In the program's first year, more than 20,000 women received the coupons, of which 78 percent were Medicaid recipients, uninsured or in a presumptive (Medicaid) eligibility period. Focus group studies, field visits and a survey were used to evaluate the effectiveness of the new program. Preliminary data analysis has revealed that the incentive program may be a significant factor in motivating women to seek early and continuous prenatal care.     

Impacts of the 10 Steps to Healthy Feeding in Infants: a randomized field trial

This study assesses the impact of an intervention known as the Ten Steps to Healthy Feeding: A Nutritional Guide for Children under Two on nutritional conditions and infant health in low-income families. Two hundred newborns were randomized to the intervention group and three hundred to the control group. Parents of the intervention group received nutritional orientation during the child's first year of life. Both groups received visits at 6 and 12 months and routine follow-up by their pediatricians. The results (n = 397) showed that the intervention was associated with a higher proportion of exclusive breastfeeding at 4 months (RR = 1.58; 95%CI: 1.21-2.06) and 6 months (RR = 2.34; 95%CI: 1.37-3.99) and breastfeeding at 12 months (RR = 1.26; 95%CI: 1.02-1.55) and a lower proportion of children with diarrhea (RR = 0.68; 95%CI: 0.51-0.90), respiratory problems (RR = 0.63; 95%CI: 0.46-0.85), use of medication (RR = 0.56; 95%CI: 0.34-0.91), and dental caries (RR = 0.56; 95%CI: 0.32-0.96) in the 12-16 month bracket. The intervention had no effect on the occurrence of anemia, hospitalization, or nutritional status. The results suggest that the nutritional orientation program led to positive changes in infant feeding practices and health conditions, but that it was insufficient to prevent iron deficiency anemia.     

Pregnancy and medical cost outcomes of a self-help prenatal smoking cessation program in a HMO

The results of a randomized clinical trial of a prenatal self-help smoking cessation program are reported in terms of the pregnancy and cost outcomes. The study population were the socioeconomically and ethnically diverse members of a large health maintenance organization (HMO) who reported that they were smoking at the time of their first prenatal visit. The intervention consisted predominantly of printed materials received through the mail. Compared with the usual care control group, women assigned to the self-help program were more likely to achieve cessation for the majority of their pregnancy (22.2 percent versus 8.6 percent), gave birth to infants weighing on average 57 grams more, and were 45 percent less likely to deliver a low birth weight infant. An economic evaluation of the self-help program was conducted from the perspective of the sponsoring HMO. Based upon the expenditures associated with the neonates' initial hospital episode, the intervention had a benefit-cost ratio of 2.8:1. These findings provide strong evidence to support widespread incorporation of smoking cessation interventions as a standard component of prenatal care.     

Integrating smoking cessation into routine public prenatal care: the Smoking Cessation in Pregnancy project.

OBJECTIVES. In 1986, the state health departments of Colorado, Maryland, and Missouri conducted a federally-funded demonstration project to increase smoking cessation among pregnant women receiving prenatal care and services from the Women, Infants, and Children (WIC) program in public clinics. METHODS. Low-intensity interventions were designed to be integrated into routine prenatal care. Clinics were randomly assigned to intervention or control status; pregnant smokers filled out questionnaires and gave urine specimens at enrollment, in the eighth month of pregnancy, and postpartum. Urine cotinine concentrations were determined at CDC by enzyme-linked immunosorbent assay and were used to verify self-reported smoking status. RESULTS. At the eighth month of pregnancy, self-reported quitting was higher for intervention clinics than control clinics in all three states. However, the cotinine-verified quit rates were not significantly different. CONCLUSIONS. Biochemical verification of self-reported quitting is essential to the evaluation of smoking cessation interventions. Achieving changes in smoking behavior in pregnant women with low-intensity interventions is difficult.     

Initiation of and Barriers to Prenatal Care Use Among Low-Income Women in San Antonio,Texas

Healthy People 2010 goals set a target of 90% of mothers starting prenatal care in the first trimester of pregnancy. While there are questions about the value of prenatal care (PNC), there is much observational evidence of the benefits of PNC including reduction in maternal, fetal, perinatal, and infant deaths. The objective of this study was to understand barriers to PNC as well as factors that impact early initiation of care among low-income women in San Antonio, Texas. A survey study was conducted among low-income women seeking care at selected public health clinics in San Antonio. Interviews were conducted with 444 women. Study results show that women with social barriers, those who were less educated, who were living alone (i.e. without an adult partner or spouse), or who had not planned their pregnancies were more likely to initiate PNC late in their pregnancies. It was also observed that women who enrolled in the WIC program were more likely to initiate PNC early in their pregnancies. Women who initiated PNC late in pregnancy had the highest odds of reporting service-related barriers to receiving care. However, financial and personal barriers created no significant obstacles to women initiating PNC. The majority of women in this study reported that they were aware of the importance of PNC, knew where to go for care during pregnancy, and were able to pay for care through financial assistance, yet some did not initiate early prenatal care. This clearly establishes that the decision making process regarding PNC is complex. It is important that programs consider the complexity of the decision-making process and the priorities women set during pregnancy in planning interventions, particularly those that target low-income women. This could increase the likelihood that these women will seek PNC early in their pregnancies.     

An Assessment of the Use and Impact of Ancillary Prenatal Care Services to Medicaid Women in Managed Care

Objectives: Managed care plans under Medicaid are becoming a usual source of care for low-income pregnant women. This study describes an ancillary prenatal care service intervention developed by one managed care organization (MCO) for Medicaid-enrolled women, assesses the extent to which the intervention services were used, and appraises the influence of the intervention on prenatal care participation. Method: There were 226 intervention and 258 control women with a single live birth delivered between 28 and 44 weeks gestation who (1) were enrolled in the MCO's Medicaid program, (2) were high-risk based on a prenatal risk assessment, and (3) started prenatal care prior to 26 weeks gestation. Less than adequate and intensive prenatal care utilization were chosen as intervention outcomes measures. Results: Family planning, a 2-month postpartum baby visit, a maternal postpartum visit, and a WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) referral were among the most self-selected intervention services for this population; home health aide and breast-feeding support were the least requested services. Over 90% of those needing family planning or breast-feeding services received the services, while over 20% of the intervention group refused child care, food assistance and family violence referrals, and home health aide and smoking cessation services. The intervention group had a significantly lower risk of less than adequate utilization of prenatal care (OR = .32; 95% CI: 0.17–0.60) and was more likely to have an intensive number of prenatal care visits (OR = 1.61; 95% CI: 1.05–2.48). Conclusions: The ability of managed care organizations to provide ongoing prenatal care to Medicaid populations in a cost-effective manner depends partly on their development of packages of prenatal services that foster positive preventive health care utilization behaviors and good pregnancy outcomes. The results of this project suggest that the intervention was beneficial in the area of improving utilization of prenatal care.     

An evaluation of a Medicaid managed maternity program: the impact of comprehensive care coordination on utilization and pregnancy outcomes

The purpose of this study is to evaluate the effectiveness of the implementation of a Medicaid managed maternity care program in a public health department service population, analyzing race-specific models of WIC participation and risk of small-for-gestational age of term. There were 13,095 singleton deliveries during the period 1987-1990 to women with prenatal care in this managed maternity care program. The research design entailed comparison of the intervention group (those receiving regular prenatal care plus comprehensive care coordination in 1989-90) with an historical comparison group of women who received only regular prenatal care in the two years (1987-88). For the intervention groups, black women were 1.7 times and white women 2.1 times more likely to participate in WIC than their comparison groups. The impact of care coordination on term-SGA births indicates a protective odds ratio of 0.851 for black women. Results for white women were not significant. These findings suggest that care coordination is associated with an increase in WIC participation and with lower risk of term-SGA births for black women but not for white women. The overall results add to growing evidence regarding the efficacy of comprehensive care coordination in improving specific pregnancy outcomes and inform our understanding of the evaluation of a comprehensive approach in preventive, community-based intervention.     

Piecing together the crazy quilt of prenatal care

The failure to provide adequate prenatal care for low-income pregnant women in the United States and the effects of this failure on infant mortality are well known. Many studies have identified institutional barriers against access to care as a major cause. To overcome these barriers, Public Health District V, South Central Idaho, has created a comprehensive prenatal health care model that has almost tripled participation in its program during the first year of implementation and increased it again significantly during the second year. This decentralized pregnancy program has succeeded in getting all of the physicians offering obstetrical care in the district to serve low-income pregnant clients on a rotating basis. The new program provides pregnancy testing as well as financial screening services. Also, it has combined support services into one-stop-shopping clinics that include an innovative expansion of the Women, Infants and Children (WIC) Program of the U. S. Department of Agriculture. WIC food vouchers help attract clients into the prenatal care system and keep them coming. Enrichment of the duties of the public health nurse provides case coordination that pulls together the patchwork of medical and support services for the pregnant client.     

Prenatal care among Puerto Ricans on the United States mainland

Recent public health initiatives in the USA identify the improvement of maternal and infant health outcomes among ethnic minorities as a national priority. Prenatal care is emphasized in these initiatives as a crucial intervention for reducing the risks of adverse outcomes. We investigate the barriers to prenatal care and the adequacy of prenatal care among mainland Puerto Ricans using data from a follow-back survey of a representative sample of mothers. The results show that barriers to prenatal care and the adequacy of prenatal care cannot be reduced solely to financial problems or problems associated with migration. Rather, attention to the social and the psychological circumstances surrounding the pregnancy (e.g. pregnancy wantedness) is required.     

玉林社区围产保健现况的调查分析

目的 为了解围产保健服务的需求和现状，探讨提高服务质量、满足需求的先进服务模式和有效方法。方法 于2001年3月按分层整群的抽样方法抽取玉林社区1/10户家庭中在4年内有妊娠史的妇女，共86人，进行入户问卷调查。结果 调查显示：本社区孕妇产前检查的覆盖率为93.9%；围产保健手册建册率为76.1%。产前检查的覆盖率、检查次数及被调查妇女接爱孕期保健的程度与建立围产保健手册呈正相关；产后访视率为52.9%；产前检查服务的满意率为61.0%；产后访视满意率为50.0%。被调查妇女希望改善候诊条件、开设周末门诊并改进医务人员的服务态度。在产后访视方面提出增加访视次数、提早首访时间的建议。结论 玉林社区产前保健已获得较满意的覆盖率，但产后访视率和对服务的满意率尚需进一步提高。应利用社区卫生服务者这一新型服务模式的优势，增强围产保健服务及信息的连续性，进一步提高产后访视率；应加强围产保健档案的科学化、系统化管理，以提高围产保健的依从性。还应在围产保健方面加大健康教育的宣传力度、提高围产保健人员的技术水平和服务意识，为社区居民提供“以人为本”，便捷、质优的围产保健服务。     

Physical Violence by Partner during Pregnancy and Use of Prenatal Care in Rural India

The role of physical violence during pregnancy on receipt of prenatal care is poorly understood, particularly for South Asian countries that have high levels of both fertility and domestic violence. Data from the 1998/1999 Indian National Family Health Survey and a 2002/2003 follow-up survey that re-interviewed women in four states were analyzed, examining the association between physical violence during pregnancy and the uptake of prenatal care. Women who experienced physical violence during pregnancy were less likely to receive prenatal care, less likely to receive a home-visit from a health worker for a prenatal check-up, less likely to receive at least three prenatal care visits, and less likely to initiate prenatal care early in the pregnancy. This study highlighted the constraining effect that the experience of physical domestic violence during pregnancy had on the uptake of prenatal care for women in rural India. Maternal health services must recognize the unique needs of women experiencing violence from their intimate partners.Key words: Domestic violence, Pregnancy, Prenatal care, India     

对孕期保健的影响因素调查

摘要l目的探讨不同因素对孕期保健的影响,为社区干预提出相关对策。方法采用回顾性分析的方法对2012年1月-12月在东莞市企石镇医院住院分娩的1021例孕产妇的保健情况进行统计分析。结果孕产妇实施孕期保健者893例,覆盖率为87．4％,保健次数以4～8次最多。不同年龄、户籍、婚姻状况、孕产史的孕期保健次数比较,差异均有统计学意义（P〈0．01）。年龄21～35岁、本市户籍、已婚、怀孕次数2～3次、流产次数少的孕妇,产前检查覆盖率较高。结论年龄、户籍、婚姻状况及孕产史对孕期保健有显著影响。加强对未参加孕期保健孕妇的指导工作,对提高孕妇的自我保健意识、避免不良妊娠、有效降低孕产妇死亡率和新生儿出生缺陷发生率有重要意义。