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Mother and Child Mother and Child: A Multi-Determinant Model for Maternal and Infant Health Outcomes in Urban, Low-Income Communities and the Effectiveness of Prenatal Care and Other Interventions 169 9 MOTHER AND CHILD: A MULTI-DETERMINANT MODEL FOR MATERNAL AND INFANT HEALTH OUTCOMES IN URBAN, LOW-INCOME COMMUNITIES AND THE EFFECTIVENESS OF PRENATAL CARE AND OTHER INTERVENTIONS Matthew W. Wolfe Research examining the outcomes of prenatal care has largely been restricted to medical interventions. Focusing on low-in- come women in urban communities, this paper fi rst describes a broadened set of expectations of prenatal care and other inter- ventions. It proposes a more holistic framework for analyzing policy choices by examining the numerous determinants that affect maternal and child health outcomes. Then, it examines policy options through these determinants. INTRODUCTION What we currently have in place is not a health care system but a disease care system. We have created a medical complex that is pretty darn good at diagnosing disease, managing disease, and sometimes curing disease, but not nearly so good at preventing disease—and Matthew W. Wolfe is a joint degree candidate in Law and Public Policy at Duke Uni- versity School of Law and the Terry Sanford Institute, Duke University (matthew. [email protected]). 7 170 Matthew W. Wolfe sometimes it’s only too good at creating disease. —Dr. Ronald David, Wiener Center for Social Policy at the Kennedy School of Government Pregnancy, in economic terms, provides an opportunity for increased assets to a community as well as a demand for increased support from a community. A developed society responds to this demand and attains the assets primarily through prenatal care, a health-based intervention to assist the mother in carrying and delivering a healthy child. The goal of prenatal care, then, seems to be maximizing the health outcomes, however defi ned, of the mother and child. To put the objective more poetically, our society has committed to assisting the development of new lives. This vision of pregnancy and childbirth is far from a reality in the United States, where infants are more likely to be born with low-birth weight than those born in almost any other developed country (Reichman & Teitler 2005, 151). Every year about 70,000 women, roughly 2 percent of pregnant women, receive no prenatal care (Taylor et al. 2005, 125). Minorities lack prenatal care disproportionately: 66 percent of those who receive no prenatal care are black or Hispanic, even though 65 percent of the pregnant population is white (ibid.). Yet, prenatal care exemplifi es the merits of preventative care. To the extent that proper care and education is given to the mother and diagnostics per- formed to anticipate any complications in the pregnancy to ensure greater predictability of labor, delivery, and the infant’s antenatal care, prenatal services are extremely worthwhile from a simple cost-benefi t analysis. Historically, prenatal care’s role has evolved from an obstetric intervention to a public health intervention that serves as a platform to other services (Agency for Healthcare Research and Quality 2000, 5). Because prenatal care is somewhat nebulous, it is increasingly diffi cult for researchers to recognize what characteristics are having a positive impact on the desired outcomes in their studies. Generally, the use of prenatal care services has had a positive effect on the birth outcomes of infants (Gortmaker 1979; Institute of Medicine 1985; McLaughlin et al. 1992). Prenatal care has also proven apt in mitigating high-risk pregnancies (Sokol, Woolf, and Rosen 1980; Quick, Greenlick, and Roghmann 1981; Poland, Ager, and Sokol 1991). Moreover, a lack of prenatal care correlates to increased risks of premature births, low birth weight, neonatal and infant mortality, and maternal mortality (Showstack, Budetti, and Minkler 1984; Fisher, LoGerfo, and Daling 1985; Koonin et al. 1991). Mother and Child: A Multi-Determinant Model for Maternal and Infant Health Outcomes in Urban, Low-Income Communities and the Effectiveness of Prenatal Care and Other Interventions 171 While the number of women not receiving any care has dropped and the number of mothers commencing prenatal care in the fi rst trimester has increased (U.S. Department of Health and Human Services, Health Resources and Services Administration 2005), a proportionate improvement in birth outcomes has not been evinced. Therefore, many question the effi cacy of prenatal care for its inability to reduce premature births and low birth weight (Strong 2000). Prenatal care still fails to address some of the most persistent causes of poor health outcomes for both the infant and the mother. For example, a 1998 Patient Outcomes Research Team study revealed that eleven traditional interventions had no or only marginal effects on preterm birth rates or survival rates of low birth weight babies (Goldenberg 2002). The interventions were prenatal care, risk screening, nutrition counseling, bed rest, hydration, home uterine activity monitor- ing, and caloric, protein, and/or iron supplementation. One explanation is that combining “complicated” and “normal” preg- nancies makes prenatal care seem ineffective (Conway and Deb 2005). The data from the National Maternal and Infant Health Survey (NMIHS) demonstrates prenatal care’s effectiveness in reducing premature births and low birth weight in “normal” pregnancies. Since the purpose of this paper is to examine determinants of all birth outcomes, the exclusion of “complicated” pregnancies is inadequate. Further, the outcomes measured should not be limited to birth out- comes. Rather, evidence suggests the benefi ts of prenatal care for women’s general health during pregnancy and postpartum (Haas et al. 2004, 48-9). Utilization of prenatal care services predicts the continuation of healthcare services after giving birth for both the mother and for the child (York, Tulman, and Brown 2000, 39). One way of increasing the scope of prenatal care is to pursue a life-course perspective in which pregnancy is not an isolated event but instead a pos- sibility during the childbearing age of a women’s life (Misra, Guyer, and Allston 2003). In this context, one can better analyze what prenatal care must address and what outcomes it should pursue. In addition, this model looks at prenatal care as only one of many forms of policy interventions. Prenatal care has an enormous impact on not only the immediate maternal health and the infant characteristics such as gestational age and infant birth rate, but also on the child’s quality of life, including edu- cational and economic outcomes (Herzig et al. 2005, 1). Additionally, access to quality prenatal care also has the potential of improving quality of life for the mother by serving as an entry point to adequate medical care and other related social services that might alter the trajectory of the mother’s life path. 172 Matthew W. Wolfe Because of its prominence, prenatal care warrants much study. Strangely, much of the evaluation is done through review processes that focus on maternal, child, infant, and fetal mortality (Hutchins, Grason, and Handler 2004, 259). These retrospective approaches take only the most extreme cases and ignore the more subtle and subversive products of the inadequacy of maternal and child health services. Thus, by focusing on fatalities, these reviews ignore the populations whose health is adversely affected or not signifi cantly improved through pregnancy. Despite this limitation, much research concerns itself with the character- istics required to provide adequate prenatal care. Additionally, researchers have isolated several pre-pregnancy factors that have an enormous impact on the maternal and infant health outcomes. Yet, largely absent from the discussion is what policy interventions, in addressing these pre-pregnancy determinants, would most readily improve the maternal and infant health outcomes. Also buried in the clash over competing ideas of service provision and behavioral interventions is the notion that prenatal care can serve as an opportunity for women and the society in which they live. In this way, prenatal care can help to undo past harms, alter risky behaviors, build capacity for better health, broadly defi ned, and create bridges between women and the community. Thus, pregnancy has the potential to serve as an opportunity to ensure a healthier child and mother (Herzig et al. 2005, 1). Given the current state of research on prenatal care and the policy envi- ronment on the subject, this paper seeks to perform fi ve interrelated tasks: (1) describe the population of urban, low-income women of childbearing age and their relationship with pregnancy and childbirth, (2) outline the desired outcomes in this policy arena, (3) explore all of the major deter- minants, prior to and during pregnancy, of maternal and infant health outcomes, (4) survey the main policy interventions currently available, and (5) propose a more expansive and ambitious model for evaluating prenatal care outcomes and analyzing policy choices. IDENTIFICATION OF THE POPULATION The horrible part is the disparity. The places where kids do well, they do very, very well. And places not doing well, they do very, very badly. —Anne Roberts, executive director of the Oklahoma Institute for Child Advocacy Mother and Child: A Multi-Determinant Model for Maternal and Infant Health Outcomes in Urban, Low-Income Communities and the Effectiveness of Prenatal Care and Other Interventions 173 As advocated at a conference held by the Agency for Healthcare Research and Quality in the summer of 2002, research must explore the effective- ness of prenatal care on different populations. While studies have analyzed the varying role of prenatal care in women of specifi c subgroups that have below average maternal and child outcomes, they tend to focus on specifi c interventions or determinants. This paper is unique in applying a multi- determinant framework to the population of urban, low-income women of childbearing age in the United States.
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