Practice Variation and the Risk of Low Birth Weight in a Public Prenatal Care Program
ABSTRACT Use of antepartum tests of fetal well-being is widespread even though effectiveness in preventing fetal damage or stillbirth has not been established. The study objective was to examine whether aggressive use of these tests might contribute to increased rates of other birth outcomes, including low birth weight (LBW).
A total of 3,235 low-income women receiving care from 28 clinic sites were studied. All women were eligible for Medi-Cal benefits. Clinic sites were classified as aggressive, moderate, or low users of antepartum tests. The relations between patient risk factors, clinic testing style, LBW, and other pregnancy outcomes were examined using multiple logistic regression.
After adjustment for risk factors, patients seen by aggressive testers had a risk of LBW higher than patients receiving care from moderate testers (odds ratio = 1.65; P < 0.01). Rates of LBW within patients receiving care from moderate and low testers did not differ (P = 0.22). Patients seen by aggressive testers also had higher rates of preterm delivery, cesarean delivery, and provided more expensive care.
Although antepartum testing is intended to prevent fetal distress, extremely aggressive use of antepartum testing may have unfavorable effects on LBW and other pregnancy outcomes. More attention should be paid to variation in obstetric practices in evaluations of the costs and effectiveness of public prenatal care programs.
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- "Herman et al. (1996) Retrospective cohort Enhanced care study, but not randomized. Helfand and Zimmer- Gembeck (1997) Retrospective cohort Examined specific component of prenatal care. Homan and Korenbrot (1998) Retrospective cohort Enhanced care study, but not randomized. "
ABSTRACT: Abstract For morethan two decades, prenatal care has been a cornerstone of our nation?s strategy for preventing low birthweight (LBW). The enrollment of all pregnant women in prenatal care was promoted by the seminal 1985 Institute of Medicine report Preventing Low Birthweight (IOM, 1985a), following a comprehensive review of the literature by a select IOM committee on the effectiveness of prenatal care for preventing LBW. Because LBW contributes significantly to racial-ethnic disparities in infant mortality and morbidity, increasing access to prenatal care for all women has also become established as the key population-based public health intervention to address racial-ethnic disparities in perinatal outcomes. The purpose of this chapter is to review evidence on the overall effectiveness of prenatal care in preventing LBW and reducing racial-ethnic disparities in LBW.11/2010: pages 151-179;
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ABSTRACT: A retrospective, observational study of 3073 low income African American, Latina, and White women receiving comprehensive prenatal care at 26 provider sites was completed. The purpose of the study was to test three hypotheses. First, after adjustment for biomedical complications, the presence of maternal behavioral and psychosocial factors would be associated with an increased rate of low birthweight infants. Second, increased time spent in psychosocial services would negate the relationship between maternal psychosocial factors and low birthweight. Third, after adjusting for biomedical, behavioral, and psychosocial factors, rates of low birthweight would no longer differ by race. Maternal smoking (over five cigarettes per week), maternal low weight for height and/or weight gain, negative mood (depression, anxiety, and/or hostility) and rejection of the pregnancy were found to be related to an increased rate of low birthweight birth (< 2500 g). Receiving more than 45 min of psychosocial services was related to a reduced rate of low birthweight birth for all women regardless of risk profile. The rate of low birthweight remained higher in African American women after adjusting for all significant maternal biomedical, behavioral, and psychosocial risk and intervention factors. Further analyses revealed that the strength and direction of the relationship between time spent in psychosocial services and low birthweight remained after controlling for the number of prenatal care visits, the time spent in nutrition or health educational services, and gestational age. Also, the time spent in psychosocial services was related to a reduced rate of low birthweight even after excluding time spent in psychosocial services in the third trimester of pregnancy or excluding women who received their first psychosocial assessment in the third trimester from the analysis. Although definitive evidence from randomized trials of psychosocial services is lacking, receiving over 45 min of psychosocial services was related to a reduced risk of low birthweight for all women in this study. Therefore, general psychosocial services appears to be an important component of prenatal care for all low income women.Social Science & Medicine 07/1996; 43(2):187-97. DOI:10.1016/0277-9536(95)00361-4 · 2.56 Impact Factor
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ABSTRACT: This study examines the contribution of the adequacy of nutrition, psychosocial, and health education support service delivery in explaining variation in birth outcomes among Medicaid-eligible women, their provider sites, and practice settings. Logistic regression models for low birthweight and preterm birth outcomes are first fitted with medical record data on maternal risks and use of prenatal visits for more than 3,485 women receiving care at 27 ambulatory sites, correcting for clustering of women within sites. The change in variation explained by these models with the addition of the adequacy of support services indicates that providing at least one nutrition, psychosocial, and health education service session each trimester of care contributes significantly to explaining better birth outcomes when compared with providing fewer sessions. When the expected outcome rates calculated with the estimated effects in the models are compared with their observed rates across provider sites and setting types, however, adequacy of service delivery does not help to explain differences in outcomes at individual sites or types of settings. Although repeated support service sessions during prenatal care improve the chances of avoiding poor birth outcomes in low income women, further adjustments for other differences between women or service delivery are needed to explain variation in outcomes at different sites and practice settings.Medical Care 03/1998; 36(2):190-201. DOI:10.1097/00005650-199802000-00008 · 2.94 Impact Factor