Carol C. Korenbrot

Preconception Care: A Systematic Review

Objectives: To perform a systematic review of published research trials of preconception care services to determine what evidence for effectiveness of care at improving the course of pregnancy or its outcomes has accumulated since the last major review in 1990. Methods: The review was conducted adapting the systematic methods developed by the Cochrane Collaboration to collect evidence from published clinical research literature with as little bias as possible. The review included literature published after January 1990, and posted on MEDLINE by July 1999. Results: Although more than 40 preconception risk conditions were searched and 470 articles were abstracted, only four problem areas and 19 research trials met the review criteria. New evidence of effectiveness was found for screening women who are seeking family planning for risk conditions; having sexually active women of reproductive age take dietary folate supplements; and providing women affected by certain metabolic conditions (diabetes and hyperphenylalanemia) with nutrition services. Conclusions: To help improve pregnancy outcomes MCH professionals need to promote the concept of readiness for pregnancy and help see that women are as healthy and appropriately nourished as possible before they become pregnant.

Management of term breech presentation

Abstract The management of 716 cases of singleton breech presentation occurring at 37 or more weeks of gestational age is reviewed. Beginning in 1980 a trial of external version was offered if the breech was identified before active labor. Only 433 (61%) breeches were identified before active labor. Of these, 171 (44%) underwent an attempt at external version and 83 (48%) were successful. The 623 cases remaining as breech presentation were stratified into three groups: (1) cesarean section without labor (379),(2) trial of labor with cesarean section (69), and (3) trial of labor with vaginal delivery (175). The criteria for allowing a trial of labor are detailed. Careful review of maternal and fetal variables indicates that a trial of labor in selected patients will result in vaginal delivery in 72% and that this can be achieved without an increase in fetal or maternal mortality or morbidity. Furthermore, successful external version followed by a trial of labor in selected cases is highly cost-effective.

Regulation of the primate fetal adrenal gland and testis in vitro and in vivo.

Abstract In vitro experiments with the separated fetal zone (FZ) and definitive zone (DZ) of the human fetal adrenal (10–20 weeks) demonstrated ACTH stimulation of cortisol and binding in the DZ. Dehydroepiandrosterone sulfate (DHAS), produced primarily in the FZ, was stimulated inconsistently by ACTH, but consistently by hCG. Thus, the DZ appears regulated by ACTH, and the FZ principally by hCG in the first half of gestation. To assess adrenal regulation in the primate during the second half of gestation, under more physiologic circumstances, studies were carried out in a chronic fetal rhesus monkey preparation in utero in which fetuses (130–145 d gestation) were catheterized, replaced in the uterus, and the pregnancy allowed to continue up to 14 days. Dexamethasone administered to the fetus suppressed DHAS, cortisol and ACTH. Seven fetuses were challenged with ACTH. An increase in cortisol production was only observed in two; no significant stimulation was seen in the others. The challenge with ACTH was given to two infant monkeys on the first day of life. Cortisol levels increased 10-fold after ACTH stimulation. The data suggest some intrauterine factor which blocks the response to ACTH. In studies of fetal monkey testicular regulation, in vitro and in vivo, specific hCG binding was demonstrated in testicular homogenates and hCG stimulated testosterone (T) production in testicular minces. In utero intra-arterial administration of hCG to fetuses resulted in a 4-fold increase in fetal serum T. Other fetuses were challenged with bolus infusions of 10 and 50 μg gonadotropin releasing hormone (GnRH). Only the higher dose resulted in fetal T stimulation. In newborn monkeys, the lower 10 μg dose of GnRH also caused an increase in serum T. Thus, the pituitary-adrenal and pituitary-gonadal axes appear functional in the third trimester in this species, and target gland sensitivity appears to increase after birth.

Birth weight outcomes in a teenage pregnancy case management project

While many comprehensive health care programs for pregnant adolescents are designed to improve the birth weights of the babies born, few provide statistical evidence that they were able to do so. In this study, information was gathered prospectively on 411 mothers in a Teenage Pregnancy and Parenting Program (TAPP) that coordinated medical, educational, and social services through individual case management and agency-level coordination, information on the mothers, their pregnancy, and services received. The low birth weight rate for TAPP participants was significantly lower than the rate for San Francisco teens prior to the establishment of the program (8.1% versus 12.0% p less than 0.05). The mean weights of babies born to teens in TAPP were significantly higher than those in San Francisco after controlling for differences in the race, infant gender, parity, and age (p less than 0.0001). Participation in the TAPP program prior to delivery was more strongly associated with better birth weight outcomes than was race, age, parity, or gender. Participation in the TAPP program was associated with significantly better birth weights independent of receiving a minimal number of prenatal medical visits adequate for the gestational age of the baby at birth. Our results provide evidence of better health outcomes for the babies of teens who had case management that included continuous individual counseling and coordination of health, education, psychosocial, and nutrition services.

A Performance Indicator of Psychosocial Services in Enhanced Prenatal Care of Medicaid-Eligible Women

Objective: Psychosocial services for low-income pregnant women vary widely in practice, and validated indicators of effective performance are lacking. The study presented here aims to determine whether a measure of provider compliance with a psychosocial service delivery guideline is associated with improved birth outcomes and therefore meets an important validity criterion of a performance indicator. Methods: Data on psychosocial services delivered to 3467 pregnant women came from 27 sites certified by the California Department of Health Services to provide enhanced perinatal services to Medicaid-eligible women. Multivariate regression analyses were used to test the association of adequate service delivery according to a performance guideline with birth outcomes and the dependence of the association on the credentials of the provider and the type of practice setting. Results: Women who received at least one psychosocial assessment each trimester of care according to the guideline were half as likely as women with inadequate services to have a low birthweight (OR = 0.49; CI 0.34, 0.71) or preterm birth (OR = 0.53; CI 0.40, 0.72) outcome. The effect did not depend on the credentials of the provider or the practice setting type. Conclusions: The indicator of the adequacy of psychosocial services according to a performance guideline appears to meet a fundamental criterion for a performance indicator, an association with improved outcomes. This indicator may be useful in monitoring performance of enhanced perinatal services for continuous quality improvement of services to low-income pregnant women.

Health Promotion and Psychosocial Services and Women’s Assessments of Interpersonal Prenatal Care in Medicaid Managed Care

Objectives: If prenatal health promotion and psychosocial support services are to remain accessible to Medicaid eligible women, evidence is needed as to whether the services improve care and benefit women in ways that matter to health plans. The aims of this study are to determine whether prenatal health promotion and psychosocial services are associated with better interpersonal care and greater satisfaction with care; and whether the effects on interpersonal care help explain satisfaction with care. Research Design: A telephone survey of 363 African American, Latina (US and nonUS-born) and White women receiving prenatal care in four Medicaid public health plans in California in 2001. Multivariate regression analyses were done with adjustments for potentially confounding variables. Measures: Independent variables included dichotomous variables for health promotion advice (five separate areas) and composite scales for psychosocial assessment (six areas combined). Dependent variables included satisfaction with care, and indices for interpersonal care (communication, decision-making, and interpersonal style). Results: Women who report receiving health promotion or psychosocial services also report receiving better interpersonal care and rate their satisfaction with care higher. Receiving either type of support service is associated with higher quality communication, decision-making and interpersonal style. The effects of the support services on satisfaction are, in turn, explained by the effects on interpersonal care. Conclusions: Prenatal health promotion and psychosocial services have associated benefits to enrollees that should matter to Medicaid health plans and their providers.

Association of acculturation with cesarean section among Latinas.

Objectives: Examine the association of acculturation and cesarean section after adjusting for clinical and non-clinical factors that could influence clinical discretion in performing the surgery. Methods: A sample of 2102 low-risk, low-income primarily Mexican Latinas in San Diego County was divided into two groups: primiparas and multiparas. For each parity group, logistic regression was used to assess the association of acculturation and cesarean section. Results: Among multiparous Latinas, the risk of cesarean section for highly acculturated women exceeded the risk for the less-acculturated women, but the result was reverse for primiparous women. The adjusted relative odds of cesarean section were twice as high [OR 2.1, 95%CI 1.1–4.1] for multiparous US-born Latinas relative to multiparous Spanish-speaking women born in Mexico. While for primiparous women this same comparison showed US-born Latinas to be approximately half as likely to have a cesarean delivery [OR 0.4, 95%CI 0.2–0.7]. Conclusions: In order to reduce the chances of unnecessary cesarean sections among Latinas, the role of acculturation in women who have and have not already given birth needs to be investigated further.

Rural American Indian Medicaid Health Care Services Use and Health Care Costs in California

OBJECTIVES We determined differences in Medicaid service use and health care costs in a rural Indian Health Service (IHS) user population of American Indians and Alaska Natives as compared with Whites. METHODS California Medicaid eligibility and claims files were linked to IHS user files to obtain a sample of Medicaid-eligible American Indian/Alaska Native users (n=7910). A random sample of Whites was matched for age, gender, aid category, length of eligibility, and county of residence (n=15075). We used generalized linear models to compare risk-adjusted use of resources-ambulatory visits, prescriptions, emergency room visits, hospitalizations, and costs-both adjusting and stratifying for dominant source of ambulatory visits. RESULTS American Indians/Alaska Natives had significantly lower use of Medicaid-paid ambulatory visits, prescriptions, emergency room visits, and hospitalizations and lower associated costs than Whites. Medicaid-paid total costs and use of services were lower for those who predominantly used Indian health program clinics, as well as for those who predominantly used other sources of ambulatory care. CONCLUSIONS Barriers to receiving Medicaid services and payments exist for American Indians/Alaska Natives in the rural IHS-user population. If American Indians/Alaska Natives are to have Medicaid resources comparable to those of Whites, these barriers must be reduced.

Funding of tribal health programs linked to lower rates of hospitalization for conditions sensitive to ambulatory care.

Objective:To determine first whether higher funding of Tribally Operated Health Programs (TOHP) is associated with reduced hospitalizations for ambulatory care sensitive conditions (HASC) of the American Indian/Alaska Natives (AIAN) who use them after adjusting for characteristics of TOHP service areas; and then whether improved ambulatory care with higher levels of funding mediates the association. Research Design:Records in the Indian Health Service (IHS) for California of an annual average 42,153 AIAN users of TOHP from 1998 to 2002 were linked with state hospital discharge records. We analyzed 3181 HASC for AIAN users of 20 TOHP in multilevel Poisson regression models to determine the association of HASC rates adjusted for individual age and gender with the Federal Disparity Index for IHS funding of TOHP. Results:Higher IHS funding of TOHP was associated with lower HASC rates for the AIAN who use them. For TOHP with less than 60% of health care costs funded, the HASC rate dropped 12% for every increase of 10% in funding. Even adjusting for characteristics of the service areas, the effect was only slightly reduced to a value of 9% to 11%. None of the available indicators of ambulatory care tested were found to mediate the effects. Conclusions:Our findings are consistent with a policy of IHS funding of all TOHP at a level of at least 60% of the health care costs of the AIAN who use the programs, instead of the current policy of 40%. Additional research is needed to understand what ambulatory care characteristics are improved by the funding.

Changes in Births to Foreign-born Women after Welfare and Immigration Policy Reforms in California

Objectives: To determine whether passage of welfare and immigration policies was followed in California by changes in births to foreign-born women in California with respect to total numbers, payer sources, prenatal care use, or health outcomes. Methods: Comparison of births to foreign-born and US-born women from 1990 to 1997 using adjusted odds ratios generated with multivariate logistic regression. Results: Policies passed in 1994 and 1996 were followed by decreases in adjusted odds of births to foreign-born women with prenatal Medicaid coverage, without a corresponding increase in uninsured foreign-born women. There was no decline in the use of prenatal care by foreign-born women, and no worsening of birth outcomes after passage of the reforms. Foreign-born women, however, remained more likely to have inadequate prenatal care than US-born women, and the improvement in outcomes that occurred for US-born women from 1994 to 1997 did not occur for foreign-born women. Conclusions: In spite of the fact that pregnant immigrant women remained eligible for Medicaid after passage of welfare and immigration policies in California, the volume of births to foreign-born women using Medicaid declined. The lack of a corresponding increase in births to uninsured foreign-born women appears to have prevented deterioration in the use of prenatal care or birth outcomes.