Journal of Community Health Vol. 17, No. 4, August 1992
EFFECTS OF A HOME V I S I T I N G PROGRAM ON PRENATAL CARE AND BIRTHWEIGHT: A CASE COMPARISON STUDY Marilyn L. Poland, PhD, RN; Paul T. Giblin, PhD; John B. Waller, Jr., DrPH; Janet Hankin, PhD ABSTRACT: Recent reports have stressed the importance of social support services to the health and well being of pregnant women and their newborns. T h e impact of paraprofessional support services on the amount of prenatal care received and birthweight was studied in a sample of 111 low-income women. Paraprofessionals were women who had been on public assistance and successfully attained health and human services for themselves and their infants. They were similar to the patients they served in educational background and ethnicity. A sixweek training program prepared them to counsel and assist pregnant women with health and social services, housing, food, transportation and other basic necessities. Women attending a publically-funded prenatal clinic were randomly assigned to a paraprofessional. A comparison group matched for ethnicity, parity and trimester entering prenatal care was also selected. Women followed by a paraprofessional had significantly more prenatal appointments (8.0 vs 6.5 visits) and infants with average higher birthweight (3125 grams) over the matched comparison group (3273 grams). While intensity of contact with a paraprofessional contributed significantly to the amount of prenatal care received by patients of paraprofessionals, the mechanism for improvement in birthweight is unknown.
INTRODUCTION Recent reports have stressed the importance of social support during pregnancy to amount of health care sought by the mother and to the physical health of her infant."2 Although there is no consensus on what is meant by support, in general, having friends, relatives and others who provide information, tangible assistance, and demonstrate Marilyn L. Poland is a Professor in the Department of Obstetrics and Gynecology; Paul T. Giblin is an Associate Professor in the Department of Pediatrics; John'B. Waller, Jr. is an Associate Professor and Chair of the Department of Community Medicine and Janet Hankin is an Associate Professor in the Department of Sociology, Wayne State University, Detroit, Michigan, U.S.A. Requests for reprints should be addressed to: Dr. Marilyn L. Poland, Department of Obstetrics and Gynecology, Hutzel, Hospital, Detroit, Michigan 48201. © 1992 Human Sciences Press, Inc.
221
222
JOURNAL OF COMMUNITY HEALTH
concern and caring, constitute elements of support? '4 T h e mechanism by which social support affects pregnancy outcome is not well understood, but is thought to attenuate the u n t o w a r d effects of social and physical stress ',~ and to communicate a sense of worth to the m o t h e r who can, in turn, focus these positive feelings on her fetus by adopting protective behaviors such as p r o p e r nutrition and receiving prenatal care. T h e practice of using indigenous paraprofessionals to provide support to pregnant women who lack a strong social network is not new. 6 In recent years, projects using "resource mothers" and public health nurses to provide support to p r e g n a n t adults and teens have a demonstrated effect on maternal behaviors. 7'8 However, a controlled trial of support services provided by paraprofessionals to w o m e n entering prenatal care early in pregnancy in the United Kingdom f o u n d no significant effects on pregnancy outcomes. 9 T h e authors suggest that future studies should include late registrants as well. This paper reports the effects of receiving support services from a paraprofessional worker (Maternal Child Health A d v o c a t e - - M C H A ) on participation in prenatal care and on birthweight in a r a n d o m l y assigned g r o u p of low income, primarily black w o m e n living in Detroit. We hypothesized at the outset of the study that p r e g n a n t w o m e n who were poor and enrolled in a publicly-funded prenatal clinic would keep more appointments and have babies with higher birthweights if they received support services from an indigenous paraprofessional. Further, based on findings reported by Giblin and Callard in 1980 of a h o m e visiting p r o g r a m to assist parenting of mothers at risk of foster care placement of their children, it was hypothesized that intensity of paraprofessional contacts would effect the degree of gain reported in prenatal visits and birthweight, l° METHODS
Six hundred fifty women who enrolled at the Hutzel Hospital's prenatal clinic were initially assigned to an advocate. These clients were part of a random sampling of 6,732 women who enrolled at the prenatal clinic from April 1986--March 1988 and delivered at that hospital. Prior to assignment, all women were assessed for trimester of pregnancy they entered care, parity, and sociodemographic characteristics. Clients signed a consent form approved by university and hospital Institutional Review Boards to participate in the random sampling and the advocate services. Of the 650 women, 227 could not be contacted after repeated attempts,
Marilyn L. Poland et al.
223
107 refused service, 169 discontinued service before delivery, and 147 remained with the advocate until delivery. From this latter group sample, 111 Detroit women who received three or more contacts from an advocate and had a singleton delivery during the first two years of our program were selected for study. We then selected a comparison sample of 111 women enrolled in Hutzel Hospital's prenatal clinic who did not receive advocate services matched with the advocate group on three variables: trimester they entered care, parity and race. Differences between the comparison group and those who refused or could not be contacted were examined for age, medical risk, Kessner Index, and birthweight. Women were randomly selected to receive in home supportive services by a MCHA. Advocates were women who had received public assistance and previously attended public health prenatal clinics and who successfully completed our 6-weeks training program. They were taught interviewing and counseling skills, assessments of growth and development and client needs, and how to refer to needed services. Advocates followed their clients over pregnancy and the first year of the infant's life under the supervision of a nurse or social worker. Advocates contacted their clients initially by phone or by home visit. Three attempts were made to contact each new client, including at least one home visit. A case management approach was used to assess client needs for tangible necessities such as housing, furniture, food, etc.; to assess for informational needs such as explanations about medical conditions, nutrition, health and social services, etc.; and to provide support and counseling for feelings of insecurity, depression, fear of medical procedures and other problems. Advocates also made referrals to health and human service agencies and accompanied their clients to appointments when necessary. A medical chart review was performed on the 111 patients and their matched comparison sample to identify medical risk indicators, amount of prenatal care received, and pregnancy outcomes including length of gestation and birthweight. A medical risk score was computed consisting of the total number of risk factors, including hypertension, diabetes, age < 14 or >35, parity >5, hematocrit
EFFECTS OF A HOME V I S I T I N G PROGRAM ON PRENATAL CARE AND BIRTHWEIGHT: A CASE COMPARISON STUDY Marilyn L. Poland, PhD, RN; Paul T. Giblin, PhD; John B. Waller, Jr., DrPH; Janet Hankin, PhD ABSTRACT: Recent reports have stressed the importance of social support services to the health and well being of pregnant women and their newborns. T h e impact of paraprofessional support services on the amount of prenatal care received and birthweight was studied in a sample of 111 low-income women. Paraprofessionals were women who had been on public assistance and successfully attained health and human services for themselves and their infants. They were similar to the patients they served in educational background and ethnicity. A sixweek training program prepared them to counsel and assist pregnant women with health and social services, housing, food, transportation and other basic necessities. Women attending a publically-funded prenatal clinic were randomly assigned to a paraprofessional. A comparison group matched for ethnicity, parity and trimester entering prenatal care was also selected. Women followed by a paraprofessional had significantly more prenatal appointments (8.0 vs 6.5 visits) and infants with average higher birthweight (3125 grams) over the matched comparison group (3273 grams). While intensity of contact with a paraprofessional contributed significantly to the amount of prenatal care received by patients of paraprofessionals, the mechanism for improvement in birthweight is unknown.
INTRODUCTION Recent reports have stressed the importance of social support during pregnancy to amount of health care sought by the mother and to the physical health of her infant."2 Although there is no consensus on what is meant by support, in general, having friends, relatives and others who provide information, tangible assistance, and demonstrate Marilyn L. Poland is a Professor in the Department of Obstetrics and Gynecology; Paul T. Giblin is an Associate Professor in the Department of Pediatrics; John'B. Waller, Jr. is an Associate Professor and Chair of the Department of Community Medicine and Janet Hankin is an Associate Professor in the Department of Sociology, Wayne State University, Detroit, Michigan, U.S.A. Requests for reprints should be addressed to: Dr. Marilyn L. Poland, Department of Obstetrics and Gynecology, Hutzel, Hospital, Detroit, Michigan 48201. © 1992 Human Sciences Press, Inc.
221
222
JOURNAL OF COMMUNITY HEALTH
concern and caring, constitute elements of support? '4 T h e mechanism by which social support affects pregnancy outcome is not well understood, but is thought to attenuate the u n t o w a r d effects of social and physical stress ',~ and to communicate a sense of worth to the m o t h e r who can, in turn, focus these positive feelings on her fetus by adopting protective behaviors such as p r o p e r nutrition and receiving prenatal care. T h e practice of using indigenous paraprofessionals to provide support to pregnant women who lack a strong social network is not new. 6 In recent years, projects using "resource mothers" and public health nurses to provide support to p r e g n a n t adults and teens have a demonstrated effect on maternal behaviors. 7'8 However, a controlled trial of support services provided by paraprofessionals to w o m e n entering prenatal care early in pregnancy in the United Kingdom f o u n d no significant effects on pregnancy outcomes. 9 T h e authors suggest that future studies should include late registrants as well. This paper reports the effects of receiving support services from a paraprofessional worker (Maternal Child Health A d v o c a t e - - M C H A ) on participation in prenatal care and on birthweight in a r a n d o m l y assigned g r o u p of low income, primarily black w o m e n living in Detroit. We hypothesized at the outset of the study that p r e g n a n t w o m e n who were poor and enrolled in a publicly-funded prenatal clinic would keep more appointments and have babies with higher birthweights if they received support services from an indigenous paraprofessional. Further, based on findings reported by Giblin and Callard in 1980 of a h o m e visiting p r o g r a m to assist parenting of mothers at risk of foster care placement of their children, it was hypothesized that intensity of paraprofessional contacts would effect the degree of gain reported in prenatal visits and birthweight, l° METHODS
Six hundred fifty women who enrolled at the Hutzel Hospital's prenatal clinic were initially assigned to an advocate. These clients were part of a random sampling of 6,732 women who enrolled at the prenatal clinic from April 1986--March 1988 and delivered at that hospital. Prior to assignment, all women were assessed for trimester of pregnancy they entered care, parity, and sociodemographic characteristics. Clients signed a consent form approved by university and hospital Institutional Review Boards to participate in the random sampling and the advocate services. Of the 650 women, 227 could not be contacted after repeated attempts,
Marilyn L. Poland et al.
223
107 refused service, 169 discontinued service before delivery, and 147 remained with the advocate until delivery. From this latter group sample, 111 Detroit women who received three or more contacts from an advocate and had a singleton delivery during the first two years of our program were selected for study. We then selected a comparison sample of 111 women enrolled in Hutzel Hospital's prenatal clinic who did not receive advocate services matched with the advocate group on three variables: trimester they entered care, parity and race. Differences between the comparison group and those who refused or could not be contacted were examined for age, medical risk, Kessner Index, and birthweight. Women were randomly selected to receive in home supportive services by a MCHA. Advocates were women who had received public assistance and previously attended public health prenatal clinics and who successfully completed our 6-weeks training program. They were taught interviewing and counseling skills, assessments of growth and development and client needs, and how to refer to needed services. Advocates followed their clients over pregnancy and the first year of the infant's life under the supervision of a nurse or social worker. Advocates contacted their clients initially by phone or by home visit. Three attempts were made to contact each new client, including at least one home visit. A case management approach was used to assess client needs for tangible necessities such as housing, furniture, food, etc.; to assess for informational needs such as explanations about medical conditions, nutrition, health and social services, etc.; and to provide support and counseling for feelings of insecurity, depression, fear of medical procedures and other problems. Advocates also made referrals to health and human service agencies and accompanied their clients to appointments when necessary. A medical chart review was performed on the 111 patients and their matched comparison sample to identify medical risk indicators, amount of prenatal care received, and pregnancy outcomes including length of gestation and birthweight. A medical risk score was computed consisting of the total number of risk factors, including hypertension, diabetes, age < 14 or >35, parity >5, hematocrit
