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.     

Group Prenatal Care Attendance: Determinants and Relationship with Care Satisfaction

Objectives Group prenatal care results in improved birth outcomes in randomized controlled trials, and better attendance at group prenatal care visits is associated with stronger clinical effects. This paper’s objectives are to identify determinants of group prenatal care attendance, and to examine the association between proportion of prenatal care received in a group context and satisfaction with care. Methods We conducted a secondary data analysis of pregnant adolescents (n = 547) receiving group prenatal care in New York City (2008–2012). Multivariable linear regression models were used to test associations between patient characteristics and percent of group care sessions attended, and between the proportion of prenatal care visits that occurred in a group context and care satisfaction. Results Sixty-seven groups were established. Group sizes ranged from 3 to 15 women (mean = 8.16, SD = 3.08); 87 % of groups enrolled at least five women. Women enrolled in group prenatal care supplemented group sessions with individual care visits. However, the percent of women who attended each group session was relatively consistent, ranging from 56 to 63 %. Being born outside of the United States was significantly associated with higher group session attendance rates [B(SE) = 11.46 (3.46), p = 0.001], and women who received a higher proportion of care in groups reported higher levels of care satisfaction [B(SE) = 0.11 (0.02), p < 0.001]. Conclusions Future research should explore alternative implementation structures to improve pregnant women’s ability to receive as much prenatal care as possible in a group setting, as well as value-based reimbursement models and other incentives to encourage more widespread adoption of group prenatal care.     

Behavioral, health, and cost outcomes of an HMO-based prenatal health education program

This report presents the results of an evaluation of a prenatal health education program conducted within a health maintenance organization (HMO) setting. Specifically, the behavioral, birth, and treatment-cost outcomes for 57 women in an experimental group who received individual nutrition counseling and a home-correspondence smoking cessation program were evaluated against the outcomes for 72 women in a control group who received standard prenatal care. In comparison with the controls, a greater percentage of women in the experimental group quit smoking during pregnancy (49.1 percent versus 37.5 percent). Of those who smoked throughout their pregnancy, women in the experimental group had a greater reduction in their mean rate of daily smoking. A significantly greater percentage of experimental group women adjusted their diets during the prenatal period (91 percent versus 68 percent), and particular success was achieved in increased consumption of dairy products and vegetables, decreased consumption of coffee, and adequate weight gain during pregnancy. Analysis of birth outcome data revealed that infants born to the experimental group had a significantly higher mean birth weight than infants born to the controls (121.34 oz versus 113.64 oz). The experimental group also had fewer low birth weight infants (7.0 percent versus 9.7 percent for controls). Hospital treatment cost savings associated with the reduced incidence of low birth weight infants among experimental group women yielded an overall benefit-cost ratio for the prenatal program of approximately 2:1.     

WIC participation and pregnancy outcomes: Massachusetts Statewide Evaluation Project.

The effects of WIC prenatal participation were examined using data from the Massachusetts Birth and Death Registry. The birth outcomes of 4,126 pregnant women who participated in the WIC program and gave birth in 1978 were compared to those of 4,126 women individually matched on maternal age, race, parity, education, and marital status who did not participate in WIC. WIC prenatal participants are at greater demographic risk for poor pregnancy outcomes compare to all women in the same community. WIC participation is associated with improved pregnancy outcomes, including, a decrease in low birthweight (LBW) incidence (6.9 per cent vs 8.7 per cent) and neonatal mortality (12 vs 35 deaths), an increase in gestational age (40.0 vs 39.7 weeks), and a reduction in inadequate prenatal care (3.8 per cent vs 7.0 per cent). Stratification by demographic subpopulations indicates that subpopulations at higher risk (teenage, unmarried, and Hispanic origin women) have more enhanced pregnancy outcomes associated with WIC participation. Stratification by duration of participation indicates that increased participation is associated with enhanced pregnancy outcomes. While these findings suggest that birth outcome differences are a function of WIC participation, other factors which might distinguish between the two groups could also serve as the basis for alternative explanations.     

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.     

Cluster Randomized Controlled Trial of Group Prenatal Care: Perinatal Outcomes Among Adolescents in New York City Health Centers

Objectives. We compared an evidence-based model of group prenatal care to traditional individual prenatal care on birth, neonatal, and reproductive health outcomes.Methods. We performed a multisite cluster randomized controlled trial in 14 health centers in New York City (2008–2012). We analyzed 1148 pregnant women aged 14 to 21 years, at less than 24 weeks of gestation, and not at high obstetrical risk. We assessed outcomes via medical records and surveys.Results. In intention-to-treat analyses, women at intervention sites were significantly less likely to have infants small for gestational age (< 10th percentile; 11.0% vs 15.8%; odds ratio = 0.66; 95% confidence interval = 0.44, 0.99). In as-treated analyses, women with more group visits had better outcomes, including small for gestational age, gestational age, birth weight, days in neonatal intensive care unit, rapid repeat pregnancy, condom use, and unprotected sex (P = .030 to < .001). There were no associated risks.Conclusions. CenteringPregnancy Plus group prenatal care resulted in more favorable birth, neonatal, and reproductive outcomes. Successful translation of clinical innovations to enhance care, improve outcomes, and reduce cost requires strategies that facilitate patient adherence and support organizational change.Bundling health care services—integrating prevention and treatment—is a strategy to meet “triple aim” goals: enhanced health care quality, improved health outcomes, and lower cost.1,2 The institutional benefits of bundling health care include reduced infrastructure and cost, the opportunity to provide additional services, and collaborative partnerships. Patient benefits include integrated services and reduced barriers to care.Pregnancy is an important window of opportunity, with frequent health care contact. Nonetheless, adverse birth outcomes remain leading causes of US infant morbidity and mortality3 and are concentrated among disadvantaged groups.4 Pregnant adolescents also have higher rates of sexually transmitted infection (STI) than do their nonpregnant counterparts and those who are nulliparous.5 Taken together, adolescent women from socially disadvantaged groups face adverse reproductive and sexual health disparities.Yet, bundled preventive interventions are not as common as are those that address individual risk factors.6 Regarding pregnancy, interventions among pregnant adolescents target either reproductive or sexual health, both with limited effectiveness. Clinical interventions such as progesterone administration and cervical cerclage prevent preterm birth in singleton gestations with previous preterm birth or short cervix.7 However, one half of women who deliver preterm have no known risks.8 An independent review of prenatal care models found only 1 randomized controlled trial (RCT) that demonstrated improved health outcomes.9 This study, from our research team, compared CenteringPregnancy group prenatal care to standard individual prenatal care. Our previous research documented that women randomized to group prenatal care had a 33% lower rate of preterm delivery.10 We also documented improved outcomes among women randomized to group prenatal care that bundled reproductive health promotion (CenteringPregnancy Plus): greater than 50% reduction in rapid repeat pregnancy among all women and incident STI among adolescents.11Translating evidence to routine health care practice is a National Institutes of Health priority.12 It is important to determine whether clinical interventions with demonstrated efficacy can be implemented to produce clinical benefits comparable to those observed during efficacy studies. First developed in 1968 to improve well-child care, group care consists of the same components of individual care visits coupled with education and skills building and takes place in a group of patients.13 Previous research across a range of health conditions suggests many clinical and psychosocial benefits, including improved patient self-management, adherence, satisfaction, and clinical outcomes.14 More time between patients and health care providers results in more patient-centered care.We conducted a multisite cluster RCT to assess the clinical effectiveness of group prenatal care bundled with reproductive health promotion compared with the clinical effectiveness of standard individual prenatal care. Cluster randomized trials can evaluate changes in service provision under conditions of actual use and are characterized by their multilevel nature15: in this case, pregnant women clustered into prenatal care settings. We hypothesized that women at clinical sites randomly assigned to deliver group prenatal care would have better reproductive and sexual health outcomes than those of women at sites randomized to individual care and that greater exposure to group prenatal care would be associated with better outcomes. Specifically, a priori outcomes included gestational age at delivery, infant birth weight, and small for gestational age as well as incident STI, rapid repeat pregnancy, and behavioral risk factors (e.g., condom use). We also included admission to and days in the neonatal intensive care unit (NICU).     

Improved Outcomes for Hispanic Women with Gestational Diabetes Using the Centering Pregnancy<Superscript>©</Superscript> Group Prenatal Care Model

Objective To determine the impact of Centering Pregnancy^©-based group prenatal care for Hispanic gravid diabetics on pregnancy outcomes and postpartum follow-up care compared to those receiving traditional prenatal care. Methods A cohort study was performed including 460 women diagnosed with gestational diabetes mellitus (GDM) who received traditional or Centering Pregnancy^© prenatal care. The primary outcome measured was completion of postpartum glucose tolerance testing. Secondary outcomes included postpartum visit attendance, birth outcomes, breastfeeding, and initiation of a family planning method. Results 203 women received Centering Pregnancy^© group prenatal care and 257 received traditional individual prenatal care. Women receiving Centering Pregnancy^© prenatal care were more likely to complete postpartum glucose tolerance testing than those receiving traditional prenatal care, (83.6 vs. 60.7 %, respectively; p < 0.001), had a higher rate of breastfeeding initiation (91.0 vs. 69.4 %; p < 0.001), had higher rates of strictly breastfeeding at their postpartum visit (63.1 vs. 46.3 %; p = 0.04), were less likely to need medical drug therapy compared to traditional prenatal care (30.2 vs. 42.1 %; p = 0.009), and were less likely to undergo inductions of labor (34.5 vs. 46.2 %; p = 0.014). When only Hispanic women were compared, women in the Centering group continued to have higher rates of breastfeeding and completion of postpartum diabetes screening. Conclusion for Practice Hispanic women with GDM who participate in Centering Pregnancy^© group prenatal care may have improved outcomes.     

Group Prenatal Care Results in Medicaid Savings with Better Outcomes: A Propensity Score Analysis of CenteringPregnancy Participation in South Carolina

Objectives This study was undertaken to determine the cost savings of prevention of adverse birth outcomes for Medicaid women participating in the CenteringPregnancy group prenatal care program at a pilot program in South Carolina. Methods A retrospective five-year cohort study of Medicaid women was assessed for differences in birth outcomes among women involved in CenteringPregnancy group prenatal care (n = 1262) and those receiving individual prenatal care (n = 5066). The study outcomes examined were premature birth and the related outcomes of low birthweight (LBW) and neonatal intensive care unit (NICU) visits. Because women were not assigned to the CenteringPregnancy group, a propensity score analysis ensured that the inference of the estimated difference in birth outcomes between the treatment groups was adjusted for nonrandom assignment based on age, race, Clinical Risk Group, and plan type. A series of generalized linear models were run to estimate the difference between the proportions of individuals with adverse birth outcomes, or the risk differences, for CenteringPregnancy group prenatal care participation. Estimated risk differences, the coefficient on the CenteringPregnancy group indicator variable from identity-link binomial variance generalized linear models, were then used to calculate potential cost savings due to participation in the CenteringPregnancy group. Results This study estimated that CenteringPregnancy participation reduced the risk of premature birth (36 %, P < 0.05). For every premature birth prevented, there was an average savings of $22,667 in health expenditures. Participation in CenteringPregnancy reduced the incidence of delivering an infant that was LBW (44 %, P < 0.05, $29,627). Additionally, infants of CenteringPregnancy participants had a reduced risk of a NICU stay (28 %, P < 0.05, $27,249). After considering the state investment of $1.7 million, there was an estimated return on investment of nearly $2.3 million. Conclusions Cost savings were achieved with better outcomes due to the participation in CenteringPregnancy among low-risk Medicaid beneficiaries.     

PrePare: a program of enhanced prenatal services within health-maintenance organization settings

This paper presents the conceptual framework and implementation strategies of a relationship-focused behavioral intervention for pregnant women and their families. The program, PrePare ('Prenatal Parenting'), was designed as a prenatal precursor to the pediatric health care model, Healthy Steps. PrePare includes preventive intervention elements that address parents' universal concerns about pregnancy and parenthood, as well as specific activities to support optimum pregnancy health and reduce high-risk behaviors. As described here, the program is embedded within a large not-for-profit health-maintenance organization (HMO). Delivery of the prenatal component is carried out by Healthy Steps interventionists through three home visits and telephone follow-up during mothers' second and third trimesters of pregnancy. An evaluation of program outcomes is underway. The design compares three groups of families, those who receive PrePare followed by Healthy Steps, Healthy Steps alone and a usual HMO-practice comparison. It is hypothesized that initiating expanded services during the prenatal period will lead to increases in reported patient satisfaction, provider satisfaction and organizational efficiency within the health care delivery system.     

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.     

Program Management of High-Risk Pregnancy

In spite of technological advances in healthcare, poor maternal and infant birth outcomes remain at unacceptably high levels in Western countries. Therefore, governmental and healthcare institutions, particularly in North America, have implemented various models of expanded prenatal-care programs focused on improving birth outcomes of high-risk pregnant women. This article presents an overview of recent studies that evaluated the quality and cost (if available) of programs (case management, home care, nurse specialist care, or augmented prenatal care) for the management of high-risk pregnancy. The findings suggest that enhanced prenatal programs (particularly with expert nurses) improve birth outcomes while controlling costs. These enhanced programs provide early and continuing psychosocial assessment, psychosocial interventions to mediate the effects of the risk factors, and health promotion education.     

Improved birth outcomes among HIV-infected women with enhanced Medicaid prenatal care

OBJECTIVES: This study evaluated the impact of enhanced prenatal care on the birth outcomes of HIV-infected women. METHODS: Medicaid claims files linked to vital statistics were analyzed for 1723 HIV-infected women delivering a live-born singleton from January 1993 to October 1995. Prenatal care program visits were indicated by rate codes. Logistic models controlling for demographic, substance use, and health care variables were used to assess the program's effect on preterm birth (less than 37 weeks) and low birthweight (less than 2500 g). RESULTS: Of the women included in the study, 75.3% participated in the prenatal care program. Adjusted program care odds were 0.58 (95% confidence interval [CI] = 0.42, 0.81) for preterm birth and 0.37 (95% CI = 0.24, 0.58) for low-birthweight deliveries in women without a usual source of prenatal care. Women with a usual source had lower odds of low-birthweight deliveries if they had more than 9 program visits. The effect of program participation persisted in sensitivity analyses that adjusted for an unmeasured confounder. CONCLUSIONS: A statewide prenatal care Medicaid program demonstrates significant reductions in the risk of adverse birth outcomes for HIV-infected women.     

Evaluation of the effectiveness of a community-based enriched model prenatal intervention project in the District of Columbia.

OBJECTIVE: To evaluate an enriched prenatal intervention program designed to reduce the risk of low birth weight. STUDY SETTING: Freestanding community-based prenatal intervention project located in a poor inner-city community, serving mostly African American women. STUDY DESIGN: All women less than 29 weeks pregnant were eligible to participate. They were compared to women who lived in neighborhoods with similar rates of poverty. DATA COLLECTION: The birth certificate was the source of data on maternal age, education, marital status, timing and frequency of prenatal care attendance, parity, gravidity, prior pregnancy terminations, fetal and child deaths, and birth weight. PRINCIPAL FINDINGS: Thirty-eight percent of the women who delivered live-born infants in the study area participated in the program. There were no differences in low- and very low birthweight rates in the study and comparison groups. In a secondary analysis comparing participants and nonparticipants in the study census tracts, participants were at higher risk for low and very low birth weight, and they adhered more closely to the schedule of prenatal visits than nonparticipants. Low- and very low birthweight rates were lower among participants than among nonparticipants and comparison women. CONCLUSION: The Better Babies Project did not have an effect on the overall low- and very low birthweight rates in the study census tracts. This was probably due to the low participation rates and the high population mobility.     

First- and Second-Trimester WIC Participation Is Associated with Lower Rates of Breastfeeding and Early Introduction of Cow's Milk during Infancy

Background

Existing literature suggests prenatal participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may reduce breastfeeding among low-income mothers. However, little is known about whether the timing of WIC entrance during pregnancy influences infant feeding decisions.

Objective

This study assesses the association between the timing of prenatal participation in WIC and various infant feeding practices, including breastfeeding initiation, breastfeeding for at least 4 months, exclusive breastfeeding, formula feeding, and early introduction of cow's milk and solid food.

Design

Cross-sectional survey matching of birth certificate data to mothers' interviews 9 months after the child's birth. Mothers provided information on participation in the WIC program, infant feeding practices, and sociodemographic characteristics.

Subjects

A nationally representative sample of 4,450 births in 2001 from the Early Childhood Longitudinal Survey-Birth Cohort.

Analyses

Multivariate logistic regression techniques (using STATA 9.0 SE, Stata Company, College Station, TX) estimated the relationship between the timing of prenatal WIC participation and infant feeding practices.

Results

Entry into the WIC program during the first or second trimester of pregnancy is associated with reduced likelihood of initiation of breastfeeding and early cow's milk introduction; and entry during the first trimester is associated with reduced duration of breastfeeding. WIC participation at any trimester is positively related to formula feeding.

Conclusions

Prenatal WIC participation is associated with a greater likelihood of providing babies infant formula rather than breastmilk after birth. Findings also indicate that there are critical prenatal periods for educating women about the health risks of early cow's milk introduction. Given the health implications of feeding infants cow's milk too early, WIC may be successful in educating women on the health risks of introducing complementary foods early, even if direct counseling on cow's milk is not provided.     

Weighing costs and benefits of adequate prenatal care for 12,023 births in Missouri's Medicaid program, 1988.

Numerous studies have shown that the receipt of adequate prenatal care is associated with improvements in pregnancy outcome, particularly a reduction in the risk of low birth weight. Since medical costs for these low birth weight infants are several times higher than for normal birth weight infants, one would expect that medical costs for newborns would be lower for babies whose mothers have had adequate prenatal care than for those with inadequate prenatal care. Explored in this paper is whether the reduction in Medicaid costs for newborn and post-partum maternal care is greater than the increase in prenatal costs for a Medicaid population. The analysis used a file of 12,023 Missouri Medicaid records linked with the corresponding 1988 birth certificates. A modified version of the Kessner index was used to define the adequacy of prenatal care. Prenatal care costs were $233 higher for pregnancies with adequate prenatal care than for those in which prenatal care was inadequate. Newborn and post-partum costs starting within 60 days after the birth were $347 lower for the adequate prenatal care pregnancies, resulting in a savings of $1.49 for each extra $1 spent on prenatal care. Among the other factors studied in determining this benefit to cost ratio were global billing, Supplemental Food Program for Women, Infants, and Children (WIC), and participation in Medicaid under the expanded eligibility provisions that were effective in Missouri in 1988.     

Is Timing of Enrollment Associated with Birth Outcomes? Findings from a Healthy Start Program in Kansas

Objective The Sedgwick County Healthy Babies Healthy Start (HBHS) program provides community-based services (including care coordination, interconception care and home visiting) aimed at reducing racial/ethnic disparities in poor birth outcomes. The purpose of this study is to assess the effectiveness of the Sedgwick County HBHS program by comparing the birth outcomes of program participants who enrolled prenatally and those who did not participate while pregnant. Methods In this retrospective cohort study, we used data drawn from the Sedgwick County HBHS program. The sample included 280 clients who were enrolled in the Sedgwick County HBHS program between September 2014 and December 2015. We performed logistic regression analyses to assess the associations between enrollee type (prenatal enrollee vs. interconceptional enrollee) and birth outcomes (low birth weight, preterm birth). Results The majority of the sample consisted of racial/ethnic minority women (32.1% non-Hispanic black, 31.8% Hispanic). After adjusting for covariates, women who enrolled in the Sedgwick County HBHS program prenatally were less likely than women who were not enrolled during pregnancy to have a preterm birth (OR 0.19, [CI 08, 0.43]) and deliver a low birth weight infant (OR 0.31, [CI 0.10, 0.97]). Conclusions for Practice Women, particularly minority women, who participate in the HBHS program experienced better birth outcomes than women who did not participate in the program during pregnancy. However, findings also suggest that interconceptional enrollees may stand to benefit from continued participation in the program.     

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.     

Husbands and maternal health matters in rural Guatemala: wives' reports on their spouses' involvement in pregnancy and birth

This paper explores the content, prevalence, and determinants of husbands' involvement in two aspects of their wives' maternal health: (1) providing advice and care during pregnancy and (2) attending birth. Using primarily women's reports of their spouses' involvement taken from qualitative and survey data from a sample of rural Guatemalan households, I find that husband participation is relatively high compared to some expectations and that the dynamics of male involvement differ between the two aspects. The analysis of receiving advice or care from husbands during pregnancy, an analysis done only among women who experienced a complication during pregnancy, suggests that the type of prenatal care sought and the quality of the familial and marital relationships are important factors. On the other hand, husbands' attendance at birth seems driven more by men's availability and access to birth. Together, the data show that "male involvement" is not a singular behavior and point to ways to conceptualize its complexity.     

First-birth outcomes and timing of second births: a statewide case management program for adolescent mothers

This study examines a case management intervention for first-time pregnant and parenting adolescents. It compares a sample of 1,260 first-time adolescent mothers in the Adolescent Parenting Program (APP) in North Carolina with 1,260 first-time adolescent mothers who did not participate in the program (non-APP). Using birth certificate data, logistic regression and survival analyses were used to compare prenatal care use, birth outcomes, and subsequent births, adjusting for age, race, marital status, and tobacco use during pregnancy. The groups had similar rates of prenatal care use. Participation in APP, however, was associated with an increased likelihood of normal birthweight (more than 2,500 grams [5.5 pounds]) and full-term birth (at or more than 37 weeks). Adolescents ages 12 to 16 in the APP group also delayed second births significantly longer than the non-APP group. Study implications point to case management and direct services provided by social workers and health service professionals as instrumental to helping adolescent mothers achieve favorable birth outcomes and postpone subsequent births during adolescence.