l0URNAL OF ADOLESCENT HEALTH 1991;12:583-584
LETTER TO THE EDITOR
I am writing in regard to the March 1991 article by Cartoof, Klerman, and Zazueta entitled The Effect of Source of Prenatal Care on Care-Seeking Behavior and Pregnancy Outcomes Among Adolescents (1). Their study related the environment with the outcomes of the pregnant adolescents attending each of four clinics. Although not included as a variable in the statistical analysis, it appears from Table 1 that nursemidwives staffed the two clinics that had the highest percentage of adolescents whlo began care in the first trimester, the highest number of prenatal visits per adolescent, the highest percentage judged to have adequate prenatal care, and infants with the highest mean birth weight and mean gestational age. Such a finding is in keeping with studies of the effectiveness of nurse-midwifery care in reducing prematurity and infant mortality and increasing birth weights and compliance with clinic visits (2-6). Although I appreciate the efforts of Cartoof, Klerman, and Zazueta to provide evidence regarding the importance of making a prenatal care site both attractive and inviting, I question their &inclusive definition of this environment. They did not separately analyze specific variables about a clinic that might make it attractive or inviting but instead included everything pertaining to clinic operations, such as characteristics of furniture, transportation, length of waiting time, availability of special services on site, decor of reception room, type of provider, provision for outreach, etc. I agree that all these things are important. However, this does not make each characteristic equally critical in the. successful provision of quality prenatal care as measured by the standard outcome variables of birth weight, gestational age, and Apgar scores, or even on the basis of patient satisfaction. The nurse-midwifery effectiveness studies largely took place in less-thanoptimal settings over which the nurse-midwives had no control, yet &nificant differences in outcomes resulted. I believe that the characteristics of a clinic reflect
the philosophy of the administrators and care providers responsible for that clinic. I applaud Cartoof, Klerman, and Zazueta for understanding and focusing upon the importance of the environment in the effective provision of prenatal care. Their “first cut” of identifying 26 characteristics of a clinic that n;dke it attractive or inviting is laudatory. Now these characteristics need to be analyzed separately or at least delineated into categories: those that describe the physical environment and those that pertain to thie services provided. At a minimum, regression analyses should be done on type of provider Zld the two categories of characteristics (physical and services provided) as independent variables. Helen Vavney Burst, C.N.M:, M.S.N., D.H.L. (Hon.) Yale University
References 1. Cartoof VG, Klerman LV, Zazueta V. The effect of source of prenatal care on care-seeking behavior and pregnancy outcomes among adolescents. Adolesc Health 1991;12:124-129. 2. Levy BS, Wilkinson FS, Marine WM. Reducing neonatal morAmer J Obstet Gynec tality rate with nurse-midwives. 1971;109:50-7. 3. Montgomery TA. A case for nurse-midwives. Amer J Obstkt Gynec 1969;105:309-13. 4. Meglen MC. A prototype of health services fur quality of life in a rural county. Bull Amer Coll Nrsc-Midw i972;XVIf:103-13. 5. Slome, C. et al. Effectiveness of certified nurse-midwives. .4mer 1 Obstet Gvnec 1976;124:177-82. 6. Piechnik S, Corbett MA. Reducing low birthweight among socio-economically high-risk adolescent pregnancies. ] NrseMidw 1985;30:88-98.
Authors’
response:
Although it is true that adolescents who had more positive outcomes were seen at clinics staffed by nurse-midwives, we believe that type of provider is only one of several variables that were responsible for improved outcomes. It is for this reason that provider type was included i.n the scale thsrt mea-
0 Society for Adolescent Medicine, 1991 Published by Elsevier science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
583 10~139xl91&3.50
LETTER TO THE EDITOR
I am writing in regard to the March 1991 article by Cartoof, Klerman, and Zazueta entitled The Effect of Source of Prenatal Care on Care-Seeking Behavior and Pregnancy Outcomes Among Adolescents (1). Their study related the environment with the outcomes of the pregnant adolescents attending each of four clinics. Although not included as a variable in the statistical analysis, it appears from Table 1 that nursemidwives staffed the two clinics that had the highest percentage of adolescents whlo began care in the first trimester, the highest number of prenatal visits per adolescent, the highest percentage judged to have adequate prenatal care, and infants with the highest mean birth weight and mean gestational age. Such a finding is in keeping with studies of the effectiveness of nurse-midwifery care in reducing prematurity and infant mortality and increasing birth weights and compliance with clinic visits (2-6). Although I appreciate the efforts of Cartoof, Klerman, and Zazueta to provide evidence regarding the importance of making a prenatal care site both attractive and inviting, I question their &inclusive definition of this environment. They did not separately analyze specific variables about a clinic that might make it attractive or inviting but instead included everything pertaining to clinic operations, such as characteristics of furniture, transportation, length of waiting time, availability of special services on site, decor of reception room, type of provider, provision for outreach, etc. I agree that all these things are important. However, this does not make each characteristic equally critical in the. successful provision of quality prenatal care as measured by the standard outcome variables of birth weight, gestational age, and Apgar scores, or even on the basis of patient satisfaction. The nurse-midwifery effectiveness studies largely took place in less-thanoptimal settings over which the nurse-midwives had no control, yet &nificant differences in outcomes resulted. I believe that the characteristics of a clinic reflect
the philosophy of the administrators and care providers responsible for that clinic. I applaud Cartoof, Klerman, and Zazueta for understanding and focusing upon the importance of the environment in the effective provision of prenatal care. Their “first cut” of identifying 26 characteristics of a clinic that n;dke it attractive or inviting is laudatory. Now these characteristics need to be analyzed separately or at least delineated into categories: those that describe the physical environment and those that pertain to thie services provided. At a minimum, regression analyses should be done on type of provider Zld the two categories of characteristics (physical and services provided) as independent variables. Helen Vavney Burst, C.N.M:, M.S.N., D.H.L. (Hon.) Yale University
References 1. Cartoof VG, Klerman LV, Zazueta V. The effect of source of prenatal care on care-seeking behavior and pregnancy outcomes among adolescents. Adolesc Health 1991;12:124-129. 2. Levy BS, Wilkinson FS, Marine WM. Reducing neonatal morAmer J Obstet Gynec tality rate with nurse-midwives. 1971;109:50-7. 3. Montgomery TA. A case for nurse-midwives. Amer J Obstkt Gynec 1969;105:309-13. 4. Meglen MC. A prototype of health services fur quality of life in a rural county. Bull Amer Coll Nrsc-Midw i972;XVIf:103-13. 5. Slome, C. et al. Effectiveness of certified nurse-midwives. .4mer 1 Obstet Gvnec 1976;124:177-82. 6. Piechnik S, Corbett MA. Reducing low birthweight among socio-economically high-risk adolescent pregnancies. ] NrseMidw 1985;30:88-98.
Authors’
response:
Although it is true that adolescents who had more positive outcomes were seen at clinics staffed by nurse-midwives, we believe that type of provider is only one of several variables that were responsible for improved outcomes. It is for this reason that provider type was included i.n the scale thsrt mea-
0 Society for Adolescent Medicine, 1991 Published by Elsevier science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
583 10~139xl91&3.50
