Prenatal care and pregnancy outcome in an HMO and general population: a multivariate cohort analysis.

We studied the use of prenatal care and pregnancy outcome in 4,148 deliveries among members of a well-established health maintenance organization (HMO) and 19,116 births among the 1973-1974 White birth cohort in the Portland, Oregon area. Mothers in the HMO were almost one year older on the average, slightly better educated, and less frequently unmarried, but had virtually identical past pregnancy histories when compared with the general population cohort. HMO members began prenatal care one month later and had three fewer visits than the general population (p less than .01); 78 per cent of the general population and only 64 per cent of HMO members began prenatal care in the first trimester (p less than .01). With maternal risk held constant, low birthweight, neonatal mortality, and infant mortality were 1.5 to 5 times greater with late, less frequent prenatal care than with early, frequent care. Multivariate analysis demonstrated a positive relationship between prenatal care and birthweight. Although this relationship was independent of risk factors recorded on birth certificates, it is not necessarily a causal relationship. Unadjusted prematurity, neonatal and infant mortality rates did not differ between the HMO and general populations. Multivariate analyses indicated that, independent of all maternal risk factors, HMO membership was associated with an increase of 30 grams in the predicted birthweight (P less than .01), but had no effect on mortality. The data suggest that, in Portland, Oregon, pregnancy outcome for HMO members is comparable to that of the general population.     

Clinical obstetric outcomes related to continuity in prenatal care.

BACKGROUND: Continuity of care has long been considered a benefit to patients of family physicians, but quantifying these benefits has been problematic. Previous studies focused on patient preferences and relationship issues, whereas evidence regarding clinical endpoints has been lacking. This study reports differences in obstetric and neonatal outcomes related to continuity in prenatal care. METHODS: Using an historical prospective design, data were collected on 494 maternal-fetal dyads in two groups. One (named GAP, n = 40) received a high degree of continuity in their prenatal care, and one (named NHC, n = 454) received relatively little. Analyses were performed to determine not only the outcome differences between the groups, but also to what factor(s) these differences were attributable. RESULTS: The continuity in prenatal care group had better outcomes in neonatal morbidity, birth weight, maternal weight gain, and both Apgar scores. None of these differences was directly attributable to continuity. Rather, continuity in prenatal care was associated with the observed increase in the number of prenatal visits, which in turn was shown to be a significant factor in the greater birth weights and maternal weight gain. None of the factors examined appears to explain the difference in neonatal morbidity. CONCLUSIONS: Women who receive prenatal care from a single physician are likely to receive more prenatal care, which is correlated with greater maternal weight gains and greater fetal birth weights.     

Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care

BackgroundThe Safety Program for Perinatal Care (SPPC) seeks to improve safety on labor and delivery (L&D) units through three mutually reinforcing components: (1) fostering a culture of teamwork and communication, (2) applying safety science principles to care processes; and (3) in situ simulation. The objective of this study was to describe the SPPC implementation experience and evaluate the short-term impact on unit patient safety culture, processes, and adverse events.MethodsWe supported SPPC implementation by L&D units with a program toolkit, trainings, and technical assistance. We evaluated the program using a pre-post, mixed-methods design. Implementing units reported uptake of program components, submitted hospital discharge data on maternal and neonatal adverse events, and participated in semi-structured interviews. We measured changes in safety and quality using the Modified Adverse Outcome Index (MAOI) and other perinatal care indicators.ResultsForty-three L&D units submitted data representing 97,740 deliveries over 10 months of follow-up. Twenty-six units implemented all three program components. L&D staff reported improvements in teamwork, communication, and unit safety culture that facilitated applying safety science principles to clinical care. The MAOI decreased from 5.03% to 4.65% (absolute change -0.38% [95% CI, -0.88% to 0.12%]). Statistically significant decreases in indicators for obstetric trauma without instruments and primary cesarean delivery were observed. A statistically significant increase in neonatal birth trauma was observed, but the overall rate of unexpected newborn complications was unchanged.ConclusionsThe SPPC had a favorable impact on unit patient safety culture and processes, but short-term impact on maternal and neonatal adverse events was mixed.     

A cost-effectiveness analysis of three staffing models for the delivery of low-risk prenatal care.

BACKGROUND. Health care costs are increasing at more than twice the rate of inflation, thus, public officials are seeking safe and economic methods to deliver quality prenatal care to poor pregnant women. This study was undertaken to determine the relationship between the cost and effectiveness of three prenatal clinic staffing models: physician based, mixed staffing, and clinical nurse specialist with physicians available for consultation. METHODS. Maternal and neonatal physiological outcome data were obtained from the hospital clinical records of 156 women attending these clinics. The women were then interviewed concerning their satisfaction with their prenatal care clinic. The financial officer from each clinic provided data on the clinic staffing costs and hours of service. RESULTS. There were no differences in outcomes for the maternal-neonatal physiological variables, although newborn admission to the Neonatal Intensive Care Unit (NICU) approached significance among the clinics. The clinic staffed by clinical nurse specialists had the greatest client satisfaction and the lowest cost per visit. CONCLUSIONS. The use of clinical nurse specialists might substantially reduce the cost of providing prenatal care while maintaining quality, and might thereby save valuable resources.     

Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma

BACKGROUND: We assessed the role and importance of continuity of care in predicting the perceptions of the physician-patient relationship held by patients with asthma. METHODS: We analyzed the 1997 statewide probability survey of adult Kentucky Medicaid recipients. The participants included 1726 respondents with 2 or more visits to a physician's office, clinic, or emergency department in the previous 12 months. Of these, 404 reported having asthma. The respondents used 5-point single-item scales to rate continuity of care, provider communication, and patient influence over treatment. RESULTS: Multivariate linear regression analyses were used to assess the contribution of continuity of care to provider communication and patient influence in the presence of control variables. Those variables included age, sex, education, race, number of visits, general health, health improvement, and life satisfaction. For persons with asthma, continuity of care was the only variable that significantly contributed to the provider communication model (P = .01) and the only variable other than life satisfaction that contributed to the patient influence model (P < .05 for each). For patients who did not have asthma, continuity of care was one of several variables contributing significantly (P < .05) to the provider communication and patient influence models. CONCLUSIONS: Particularly for patients with asthma, continuity of care was linked to patient evaluations of their interaction with the physician. Because of this, changes in health care systems that promote discontinuity with individual physicians may be particularly disruptive for patients with chronic diseases.     

A competency based approach to comprehensive pregnancy care.

This paper assesses the quality and cost of a pregnancy care program based on explicit and achieved patient competencies. By using the USPHS Content of Prenatal Care (1989), key psychosocial/education elements of perinatal care were identified. The goal was a process of patient education that is competency based, integrated, and outcome oriented. Psychosocial assessment, patient education tools, criterion-based length of postpartum stay, and home nursing follow-up were implemented as part of a Comprehensive Pregnancy Program (CPP). Case-control and cohort survey methodology were used to evaluate outcome. There was a significant decrease in hospital length of stay for mothers and newborns after implementation of the CPP. Post-discharge maternal emergency room visits and/or readmits did not increase. Differences in newborn emergency room visits and/or readmits were non-significant. There was a marked reduction in hospital costs for mothers and newborns. Patient satisfaction remained high. Core competencies forming the basis of educational and assessment programs allow the focus of care to be optimal outcome, and provide a useful template against which to measure prenatal, intrapartum, and postpartum care.     

Improving surveillance for maternal and perinatal health in 2 districts of rural Tanzania

OBJECTIVES: As part of a community-based reproductive health project in rural Tanzania, a maternal and perinatal health care surveillance system was established to monitor pregnancy outcomes. This report presents preliminary results. METHODS: Village health workers were trained to collect data during health education visits to pregnant and postpartum women. Maternal and fetal or infant survival or deaths were tracked on a community monitoring board. RESULTS: Among 904 pregnancies, the fetoneonatal mortality rate was 69.4 deaths per 1000 live births and fetal deaths; 4 maternal deaths occurred. Intrapartum and early neonatal deaths of infants with birthweights of 1500 g or greater represented a large proportion of deaths. CONCLUSIONS: These preliminary results will be used to prioritize project interventions, including increasing access to skilled delivery care.     

Prenatal Care Utilization and the Implementation of Prophylaxis to Prevent Perinatal HIV-1 Transmission

OBJECTIVES: To describe prenatal care utilization among women with HIV-1 in 4 US states, and to determine whether the adequacy of prenatal care utilization is associated with the implementation of prenatal, intrapartum, and postnatal HIV antiretroviral therapy (ARV). METHODS: Three-hundred three women completed a prenatal interview. Prenatal, labor and delivery, and infant medical records were reviewed. RESULTS: Thirty-nine percent of women did not receive adequate prenatal care; nearly one quarter of women did not begin care within the recommended timeframe, and approximately one-fifth of women received fewer than the recommended number of prenatal care visits from the time of entry into care until delivery. Those classified as less than adequate in terms of receipt of recommended visits were at increased risk for not receiving ARV during the prenatal care period and during labor and delivery, and were more likely to have had an infant subsequently diagnosed with HIV infection. CONCLUSION: Although women with HIV require adequate prenatal care for their own health as well as to improve perinatal outcomes, many are at risk for not receiving this care. Lower adherence to prenatal care appointments is an important risk factor for not receiving full HIV prophylactic regimens.     

孕期综合管理对产妇分娩方式及母婴结局的影响

目的探讨孕期综合管理对产妇分娩方式及母婴结局的影响。方法选择在广元市妇幼保健院分娩的240例初产妇,在产科门诊进行孕期综合管理的120例为观察组,同期行孕期常规检查的120例为对照组,比较两组产妇妊娠期并发症、产前负性情绪、分娩方式及母婴结局情况。结果观察组产妇妊娠期并发症发生率、产前负性情绪低于对照组(P0.05);观察组自然分娩率高于对照组,围生儿不良结局(巨大儿、早产儿、低体重儿)发生率低于对照组(P0.05)。结论孕期综合管理有利于母婴健康,提高了自然分娩率,是一种有效的产科管理方式。     

Mexican-Americans' use of prenatal care and its relationship to maternal risk factors and pregnancy outcome.

We evaluate the adequacy of prenatal care use and the association of use to a series of maternal risk factors and pregnancy outcomes, such as low birthweight, preterm delivery, and macrosomia in both Mexican-Americans and non-Hispanic whites in Arizona. The data came from all live-birth certificates from 1986 and 1987 for a total of 101,202 (26,826 Mexican-Americans). We evaluated the adequacy of prenatal care using a redesigned index that accounts for three factors: the month when prenatal care began, the number of prenatal care visits, and the duration of pregnancy. From this index we identified six prenatal care groups: intensive, adequate, intermediate, inadequate, no-care, and missing/unknown. Overall, we observed ethnic differences in patterns of prenatal care use, social profiles, and medical risk factors. Non-Hispanic whites, compared to Mexican-Americans, showed a greater risk for low birthweight and preterm delivery in those groups receiving poor prenatal care versus those who received adequate care. Within Mexican-Americans the risk of low birthweight was not the same for all subgroups. A higher overall prevalence of preterm delivery and macrosomia in comparison to low birthweight occurred in Mexican-Americans. We discuss the implications of the results for the identification, interpretation, evaluation, and public health significance of perinatal health problems of Mexican-Americans.     

Ready or Not—Intrapartum Prevention of Perinatal HIV Transmission in Illinois

Objectives: The overall readiness of Illinois birthing hospitals to comply with the 2003 Illinois HIV Perinatal Prevention Act and prevent perinatal HIV transmission, and the hospital characteristics that predict readiness were examined. Methods: Nurse Managers of all 137 Illinois birthing hospitals were surveyed regarding current labor and delivery (L&D) practices for HIV status identification, documentation, testing and zidovudine (AZT) availability in March 2004. Bivariate and multivariable regression analysis was performed. Results: All 137 hospitals returned the surveys. Almost forty seven percent of Illinois birthing hospitals had adequate maternal HIV status documentation on arrival in L&D, 72.3% documented prenatal HIV results in the L&D chart, 65.7% documented prenatal HIV in the newborn chart, 38.7% ordered HIV tests on L&D if no prenatal HIV status was available, and 61.3% had AZT available. Only 17 hospitals (12.4%) met requirements for overall readiness to prevent perinatal HIV transmission. Sixteen hospitals (11.6%) met a minimal level of readiness (prenatal HIV status documentation and AZT availability). Conclusions: Despite passage of legislation to increase perinatal HIV testing and reduce transmission, Illinois birthing hospitals had an overall low level of readiness to implement the intrapartum interventions that are an essential part of eradicating pediatric HIV infection. Perinatal reduction protocols and implementation guidelines would improve the overall readiness of Illinois birthing hospitals to prevent perinatal HIV transmission.     

Comparison of anticoagulation clinic patient outcomes with outcomes from traditional care in a family medicine clinic

BACKGROUND: Giving patients oral anticoagulation therapy in an ambulatory clinic setting is associated with substantial risk of adverse outcomes leading to emergency department visits and unplanned inpatient admissions. This article describes an effectiveness study conducted in a well-characterized family practice setting that compares anticoagulation outcomes in patients managed by a traditional care model with outcomes obtained with an anticoagulation clinic model. METHODS: All study patients received continuous anticoagulation care at the Family Medicine of Southwest Washington (FMSW) clinic during the 1-year study period. The method was retrospective and used linked record review, including outpatient, inpatient, and emergency department records. Patients were divided into two groups as naturally observed: those treated in the clinic by traditional care compared with those treated in an anticoagulation clinic model. Data analyses compared the two groups in terms of patient demographics, anticoagulation control, and inpatient admissions and emergency department visits that were related to clotting or bleeding events. RESULTS: There were no differences in demographic variables between the anticoagulation clinic and traditional care groups. There was a statistically significant difference in anticoagulation control as measured by international normalized ratio (INR) values. The anticoagulation clinic group had fewer INR values outside the target range, +/- 0.1, than the traditional care group (40.4% vs 47.3% P = .022). The anticoagulation clinic group also had significantly fewer INR tests drawn more than 6 weeks apart than the traditional care group (3.7% vs 8.1% P = .01). There was no statistically significant difference in emergency department visit rates caused by adverse events. Inpatient admission rates for the anticoagulation clinic and traditional care groups were not statistically different; however, they were clinically different (4.7 vs 19.7 admissions per 100 patient years of therapy P = .15). CONCLUSIONS: More anticoagulation patients treated by the anticoagulation clinic model at FMSW received an INR test at least every 6 weeks than those treated by the traditional care model, and more of their INR results were within target range +/- 0.1 when compared with the traditional care model.     

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 impact of maternal health improvement on perinatal survival: cost-effective alternatives

Each year, an estimated half million women die from complications related to child birth either during pregnancy, delivery or within 42 days afterwards. When pregnant women have complications, their infants are at greater risk of becoming ill, permanently disabled or dying. For every maternal death, there are at least 20 infant deaths: stillbirths, neonatal or postneonatal deaths. Altogether, an estimated 7 million infants each year die perinatally (stillborn or deaths within the first week of life). Low cost, feasible, and effective intervention strategies include: a) improved family planning and abortion services; b) obstetric care at delivery; and, c) prenatal services. Two hypothetical populations of one million (a low mortality and a high mortality country) are used to illustrate maternal and perinatal program strategies and priorities. In countries with high fertility, major reductions in maternal and infant deaths result both from reductions in the number of pregnancies through family planning and from improved obstetric care. Where fertility is already low, reductions result almost entirely from improved obstetric and prenatal care. The investments required are relatively low, while the potential gains are great. The cost to avert each death in a high mortality population is estimated between $800 and $1,500 or as low as $0.50 per capita per year. The priorities for programs targeting maternal and perinatal health depend on demographic, ecologic and economic factors, and should include the promotion of good health, not merely the avoidance of death. More operational research is required on various aspects of maternal and perinatal health; in particular, on the cost-effectiveness of different service components.     

Understanding High Utilization of Unscheduled Care in Pregnant Women of Low Socioeconomic Status

BackgroundPregnant high utilizers of unscheduled care may be at particular risk for poor perinatal outcomes, but the drivers of this association have not been explored from the patient perspective.PurposeWe sought to understand maternal preference for unscheduled hospital-based obstetric care to inform interventions and improve value of publicly funded care during pregnancy.MethodsWe conducted a comparative qualitative analysis of in-depth semistructured interviews. Low-income pregnant women presenting to an inner city hospital-based obstetric triage unit were purposively sampled, categorized as either high or low utilizers of unscheduled care, and interviewed about challenges faced in obtaining pregnancy care and reasons for choosing between unscheduled versus scheduled care delivery.ResultsDemographically, high utilizers were similar to low utilizers, but were more likely to report adverse childhood experiences (p = .01). All 40 participants reported resource constraints and perceived hospital-based unscheduled obstetric care to be more accessible than outpatient prenatal care. Beyond this, high (n = 20) and low (n = 20) utilizer narratives differed significantly. Two distinct high utilizer profiles emerged. Some high utilizers repetitively used unscheduled hospital-based services owing to psychosocial determinants. Other high utilizing participants were driven by severe experiences of illness insufficiently addressed by outpatient prenatal care. Low utilizer narratives demonstrated high self-efficacy and social support compared with high utilizers.ConclusionsLow-value, unscheduled, hospital-based care utilization by pregnant women of low socioeconomic status was driven by unmet clinical and psychosocial need.Implications for Policy and/or PracticeTailored community-focused innovations that use unscheduled visits as signals of risk may improve value of both outpatient and inpatient maternity care and better address adverse perinatal outcomes in vulnerable subgroups.     

中国南北方部分地区1994-2000年孕产妇系统保健状况及其变化

目的 了解中国南北方部分地区1994—2000年的孕产妇系统保健状况及其变化。方法 数据来自“中美预防出生缺陷和残疾合作项目”中13个县（市）的围产保健监测数据库。研究对象为19942000年在上述项目县（市）分娩了孕满20周单胎活产儿的368589名妇女。结果 从19942000年，南北方地区产前检查率一直高于99．0％，第一次产前检查时的平均孕周从1994年13．1周提前至2000年的10．7N，早孕检查率从65．5％升至79．4％，产前检查次数≥5次的比例从34．1％升至71．8％，住院分娩率从913％升至98．8％，家庭分娩率从5．6％降至0．6％，产后访视次数≥3次的比例从80．5％升至951％。除早孕检查率外，同期比较，北方地区的其他各率均低于南方地区，且北方地区的城乡差别大于南方地区。结论 中国南北方地区的孕产妇系统保健状况得到了极大的改善，但南北地区之间、北方城乡之间存在明显的差别。     

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.     

Prenatal care,low birth weight and prematurity in São Paulo State,Brazil, 2000

OBJECTIVE: The historical evolution of infant mortality rate and neonatal mortality according to birth weight and term of delivery in the state of S o Paulo are presented to assess the role of the number of prenatal visits and others factors for determining mortality. METHODS: Based on data available from the Seade Institute of Vital Statistics, four variables (maternal age, marital status, education, and childbirth order) were analyzed and divided into two categories according to the relative risk of low birth weight and/or preterm prevalence. Sixteen specific groups were created from crossing the four variables into two categories. Low birth weight and/or preterm prevalence per number of prenatal visits and the relative risk were calculated for all sixteen groups. RESULTS: For all sixteen groups, the higher the number of prenatal visits the lower the prevalence of low birth weight and/or prematurity. Additionally, there was an overall reduction of the difference of low birth weight and/or preterm prevalence among the 16 groups from 14% to 4% with an increase from 0-3 to 7 visits or more. CONCLUSIONS: Due to the current infant mortality composition in the state of Sao Paulo, increasing the number of prenatal visits and accessibility of women at risk would probably lead to a reduction in intrauterine growth retardation, prematurity, low birth weight and deaths associated to conditions originated in the perinatal period.     

Performance failure of an evidence-based upper respiratory infection clinical guideline.

BACKGROUND: We evaluated an upper respiratory infection (URI) clinical guideline to determine if it would favorably affect the quality and cost of care in a health maintenance organization. METHODS: Patients with URI symptoms contacting 4 primary care practices before and after guideline implementation were compared to ascertain what proportion of all patients with respiratory symptoms were eligible for treatment in accordance with the URI guideline; what proportion of eligible patients were managed without an office visit; and what proportion of eligible patients were treated with antibiotics, before and after guideline implementation. RESULTS: A total of 3163 patients with respiratory symptoms were identified. Of these, 59% (n = 1880) had disqualifying symptoms or comorbid conditions for URI guideline care, and 28% (n = 1290) received disqualifying diagnoses on the day of first contact, leaving 13% (n = 408) who received a diagnosis of URI and were eligible for care in accordance with the guideline. Among this group of patients, the proportion who received guideline-recommended initial telephone care was 45% preguideline and 47% postguideline (chi2 = 0.40; P = .82). Likelihood of a subsequent office visit increased from pre- to postguideline (chi2 = 17.1; P <.01), although the majority of patients had no further diagnoses other than URI. Antibiotic use for the initial URI diagnosis declined from 24% preguideline to 16% postguideline (chi2 = 3.97; P = .046), but antibiotic use during 21-day follow-up did not change (F = 0.46, P = .66). The mean cost of initial care was $37.80 preguideline and $36.20 postguideline (P >.05). CONCLUSIONS: Only 13% of primary care patients with respiratory symptoms were eligible for URI guideline care. Among eligible patients, use of the guideline failed to decrease clinic visits, decrease antibiotic use during a 21-day period, or reduce cost of care to the health plan.