AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 9, NUMBER 4 July 1992
EDITORIAL PRENATAL CARE REVISITED: DOES IT MAKE A DIFFERENCE? Katherine D. LaGuardia, M.D., M.P.H.
American Journal of Perinatology.8 A total birth cohort of
infants born in South Dakota between 1983 and 1985 was analyzed for the relationship of prenatal care to neonatal intensive care unit (NICU) admission and its associated costs. The study is important for several reasons: (1) It adds substantial support to the cost-benefit argument for prenatal care in reducing NICU utilization and costs; (2) it sheds light on some of the fundamental issues under discussion at the national level on how to improve access to prenatal care; and (3) it demonstrates the power of epidemiologic research in influencing health policy at the legislative level. The cost-benefit argument for prenatal care has been well-documented by health economists. In 1985, the IOM calculated that each dollar spent on providing more adequate prenatal care to a cohort of low-income women could reduce medical expenditures on the care of their low birthweight infants by $3.38 in the first year of life.4 This savings would result from a reduced rate of low birthweight associated with increased prenatal care. Other studies use different cost-benefit ratios but all demonstrate cost-effectiveness. Wilson et al show that if all women in
South Dakota had received adequate prenatal care during the study period, the NICU admission rate would have been reduced by 44% and the average hospital bill would have decreased by 32%. Even after providing Medicaid coverage for all women during pregnancy, a savings is still obtained. Why has this cost-benefit argument taken so long to penetrate the legislative deliberations on health policy? New York State has begun to respond to the costbenefit argument and now has one of the most progressive Medicaid entitlement programs for pregnant women in the country. The Prenatal Care Assistance Program provides presumptive eligibility and enrollment up to 185% of the federal poverty level. It remains to be seen, however, whether this is sufficient incentive for women to enter prenatal care in the timely manner required to achieve a reduction in medical expenditures following birth. In fact, if one examines national trends in prenatal care utilization over the past decade, some disturbing trends emerge. Between 1970 and 1979, the United States witnessed a steady decrease in the percentage of all women receiving late or no prenatal care, with a greater decline among blacks than among whites. In the 1980s, these favorable trends were reversed. From 1980 to 1985, the receipt of late or no prenatal care increased 10% for all races, 9% for whites, and 17% for blacks.8 This brought the rate of inadequate prenatal care in 1985 to 4.7% for whites and 10.3% for blacks.3 Wilson et al reveal striking data about the Native American population in South Dakota. A significantly greater proportion of Native Americans compared with whites in the birth cohort had late or no prenatal care (39% versus 7%). This is a disturbing and powerful statement about access to care among a largely low income, minority community in a rural state. It raises questions about the most effective strategies to employ to encourage timely prenatal care among women in diverse cultural and geographic settings. The IOM has identified six major barriers to receipt of timely prenatal care and they are applicable across the diverse settings in the United States: financial constraints; limited availability of maternity care providers; insufficient prenatal services; experiences, attitudes, and beliefs that discourage women from seeking prenatal care; inadequate transportation and
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
The relationship between prenatal care and birth outcome has been the subject of much health policy concern and debate.1"3 There is abundant evidence that links inadequate prenatal care to prematurity, low birthweight, and infant mortality.4^6 Yet, this evidence remains associative and not incontrovertible. The data thus far are necessary to demonstrate that prenatal care is a condition for good birth outcome but are not sufficient to prove causality. The critical ingredient in the prenatal care package remains elusive. In fact, as the Institute of Medicine (IOM) acknowledges, the term "prenatal care" describes an inexact constellation of procedures and interactions.7 Its definition focuses more on number of visits than on the content or quality of these visits. The presumed direct relationship between amount of prenatal care and birth outcome is, nevertheless, widely accepted as one of the most important assumptions underlying maternal-child health research and policy formulation. It is this assumption that forms the basis for the important study contributed by Wilson et al in this issue of the
Department of Obstetrics and Gynecology and Public Health, The New York Hospital-Cornell Medical Center, New York, New York Reprint requests: Dr. LaGuardia, Department of Obstetrics and Gynecology and Public Health, The New York Hospital-Cornell Medical Center, 525 East 68th St., New York, NY 10021 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
309
AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 9, NUMBER 4
310
REFERENCES
1. Institute of Medicine: Prenatal Care, National Academy Press, Washington, DC, 1988 2. Public Health Service: Promoting Health/Preventing Disease: Objectives for the Nation. Washington, DC: US Department of Health and Human Services, Public Health Service, 1980 3. Miller CA, Fine A, Adams-Taylor S: Monitoring Children's Health, Key Indicators, 2nd ed. Washington, DC: American Public Health Association, 1989 4. Institute of Medicine: Preventing Low Birthweight. Washington, DC: National Academy Press, 1985, pp 132-149 5. Moore TR, et al: The perinatal and economic impact of prenatal care in a low socioeconomic population. Am J Obstet Gynec 154:29-33, 1986 6. Children's Defense Fund: Maternal and Child Health Data Book, The Health of America's Children. Washington, DC 1986 7. Institute of Medicine: Prenatal Care. Washington, DC: National Academy Press, 1988, p 23 8. National Center for Health Statistics: Advance report of final natality statistics, 1985. Monthly Vital Statistics Report 36(4). Supplement DHHS Pub No (PHS) 87-1120. Washington, DC: NCHS, 1987
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
child care services; and inadequate recruitment of hardto-reach populations.4 In the case of South Dakota, one is struck by a set of issues that are not particularly pertinent to the inner city setting. Why do Native American women have such poor prenatal care utilization patterns? It is known that community and migrant health centers play a major role in the provision of prenatal care in rural states, yet how many clinics exist per county? What is the average travel time to these clinics? What mode of travel does a woman in poverty use? With whom will she leave her children? How will she negotiate the Medicaid enrollment system? Finally, does she even believe that the care she'll receive is important? The six barriers to care outlined by the IOM are not easy to overcome, but insurance entitlement may be the least significant to a pregnant woman with four children on a reservation 60 miles from the nearest health center. The authors are to be congratulated on the impact of their study on the South Dakota State Legislature, who responded by relaxing its Medicaid eligibility income requirements. However, this is only the beginning and it will clearly take more to have an impact on NICU admissions.
July 1992
EDITORIAL PRENATAL CARE REVISITED: DOES IT MAKE A DIFFERENCE? Katherine D. LaGuardia, M.D., M.P.H.
American Journal of Perinatology.8 A total birth cohort of
infants born in South Dakota between 1983 and 1985 was analyzed for the relationship of prenatal care to neonatal intensive care unit (NICU) admission and its associated costs. The study is important for several reasons: (1) It adds substantial support to the cost-benefit argument for prenatal care in reducing NICU utilization and costs; (2) it sheds light on some of the fundamental issues under discussion at the national level on how to improve access to prenatal care; and (3) it demonstrates the power of epidemiologic research in influencing health policy at the legislative level. The cost-benefit argument for prenatal care has been well-documented by health economists. In 1985, the IOM calculated that each dollar spent on providing more adequate prenatal care to a cohort of low-income women could reduce medical expenditures on the care of their low birthweight infants by $3.38 in the first year of life.4 This savings would result from a reduced rate of low birthweight associated with increased prenatal care. Other studies use different cost-benefit ratios but all demonstrate cost-effectiveness. Wilson et al show that if all women in
South Dakota had received adequate prenatal care during the study period, the NICU admission rate would have been reduced by 44% and the average hospital bill would have decreased by 32%. Even after providing Medicaid coverage for all women during pregnancy, a savings is still obtained. Why has this cost-benefit argument taken so long to penetrate the legislative deliberations on health policy? New York State has begun to respond to the costbenefit argument and now has one of the most progressive Medicaid entitlement programs for pregnant women in the country. The Prenatal Care Assistance Program provides presumptive eligibility and enrollment up to 185% of the federal poverty level. It remains to be seen, however, whether this is sufficient incentive for women to enter prenatal care in the timely manner required to achieve a reduction in medical expenditures following birth. In fact, if one examines national trends in prenatal care utilization over the past decade, some disturbing trends emerge. Between 1970 and 1979, the United States witnessed a steady decrease in the percentage of all women receiving late or no prenatal care, with a greater decline among blacks than among whites. In the 1980s, these favorable trends were reversed. From 1980 to 1985, the receipt of late or no prenatal care increased 10% for all races, 9% for whites, and 17% for blacks.8 This brought the rate of inadequate prenatal care in 1985 to 4.7% for whites and 10.3% for blacks.3 Wilson et al reveal striking data about the Native American population in South Dakota. A significantly greater proportion of Native Americans compared with whites in the birth cohort had late or no prenatal care (39% versus 7%). This is a disturbing and powerful statement about access to care among a largely low income, minority community in a rural state. It raises questions about the most effective strategies to employ to encourage timely prenatal care among women in diverse cultural and geographic settings. The IOM has identified six major barriers to receipt of timely prenatal care and they are applicable across the diverse settings in the United States: financial constraints; limited availability of maternity care providers; insufficient prenatal services; experiences, attitudes, and beliefs that discourage women from seeking prenatal care; inadequate transportation and
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
The relationship between prenatal care and birth outcome has been the subject of much health policy concern and debate.1"3 There is abundant evidence that links inadequate prenatal care to prematurity, low birthweight, and infant mortality.4^6 Yet, this evidence remains associative and not incontrovertible. The data thus far are necessary to demonstrate that prenatal care is a condition for good birth outcome but are not sufficient to prove causality. The critical ingredient in the prenatal care package remains elusive. In fact, as the Institute of Medicine (IOM) acknowledges, the term "prenatal care" describes an inexact constellation of procedures and interactions.7 Its definition focuses more on number of visits than on the content or quality of these visits. The presumed direct relationship between amount of prenatal care and birth outcome is, nevertheless, widely accepted as one of the most important assumptions underlying maternal-child health research and policy formulation. It is this assumption that forms the basis for the important study contributed by Wilson et al in this issue of the
Department of Obstetrics and Gynecology and Public Health, The New York Hospital-Cornell Medical Center, New York, New York Reprint requests: Dr. LaGuardia, Department of Obstetrics and Gynecology and Public Health, The New York Hospital-Cornell Medical Center, 525 East 68th St., New York, NY 10021 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
309
AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 9, NUMBER 4
310
REFERENCES
1. Institute of Medicine: Prenatal Care, National Academy Press, Washington, DC, 1988 2. Public Health Service: Promoting Health/Preventing Disease: Objectives for the Nation. Washington, DC: US Department of Health and Human Services, Public Health Service, 1980 3. Miller CA, Fine A, Adams-Taylor S: Monitoring Children's Health, Key Indicators, 2nd ed. Washington, DC: American Public Health Association, 1989 4. Institute of Medicine: Preventing Low Birthweight. Washington, DC: National Academy Press, 1985, pp 132-149 5. Moore TR, et al: The perinatal and economic impact of prenatal care in a low socioeconomic population. Am J Obstet Gynec 154:29-33, 1986 6. Children's Defense Fund: Maternal and Child Health Data Book, The Health of America's Children. Washington, DC 1986 7. Institute of Medicine: Prenatal Care. Washington, DC: National Academy Press, 1988, p 23 8. National Center for Health Statistics: Advance report of final natality statistics, 1985. Monthly Vital Statistics Report 36(4). Supplement DHHS Pub No (PHS) 87-1120. Washington, DC: NCHS, 1987
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
child care services; and inadequate recruitment of hardto-reach populations.4 In the case of South Dakota, one is struck by a set of issues that are not particularly pertinent to the inner city setting. Why do Native American women have such poor prenatal care utilization patterns? It is known that community and migrant health centers play a major role in the provision of prenatal care in rural states, yet how many clinics exist per county? What is the average travel time to these clinics? What mode of travel does a woman in poverty use? With whom will she leave her children? How will she negotiate the Medicaid enrollment system? Finally, does she even believe that the care she'll receive is important? The six barriers to care outlined by the IOM are not easy to overcome, but insurance entitlement may be the least significant to a pregnant woman with four children on a reservation 60 miles from the nearest health center. The authors are to be congratulated on the impact of their study on the South Dakota State Legislature, who responded by relaxing its Medicaid eligibility income requirements. However, this is only the beginning and it will clearly take more to have an impact on NICU admissions.
July 1992
