Does one-size-fit-all for intensive prenatal care utilization?

1. Does one-size-fit-all for intensive prenatal care utilization? Martha S. Wingate, DrPH Department of Health Care Organization and Policy, University of Alabama at Birmingham

2. Acknowledgements • Thanks to Dr. Richard Shewchuk for his assistance with the cluster analysis and to Drs. Michael Kogan and Milton Kotelchuck for their review of earlier versions of this presentation

3. Introduction • Prenatal care is one of the most widely used preventive health care services in the U.S. • It is used for identifying and managing factors that may contribute to adverse pregnancy outcomes.

4. Introduction • The rate of adequate prenatal care changed from 30.4% in 1985-87 to 41.1% in 2000-02, a 35% increase. • In addition, rates of intensive prenatal care utilization have increased as well; from 4.4% in 1985-87 to 6.5% in 2000-02.

5. Introduction • There has been a change in maternal sociodemographic and medical characteristics among mothers in the U.S. • Each of these factors may result in more aggressive management of pregnancy. • Who are the women receiving intensive PNC?

6. Purpose • The primary purpose of this investigation is to determine whether women receiving intensive prenatal care are a homogenous group of women or subgroups/clusters that are defined by maternal characteristics. • If there are different subgroups, how does this relate to birth outcomes?

7. Methods • National Center for Health Statistics live birth-infant death cohort files from 2000-02 • Selected U.S. resident mothers with intensive prenatal care utilization, as measured by the R-GINDEX.

8. Methods • The R-GINDEX incorporates the month prenatal care began, the number of visits, and gestational age. • The intensive category for R-GINDEX includes women who had an excessively large number of prenatal care visits, that is, approximately 1 standard deviation beyond the mean recommended number of visits, given their gestational age at delivery and the month prenatal care began.

9. Methods • Latent class cluster analysis • Maternal sociodemographic and medical characteristics • Infant outcomes • Birth weight • Gestational age

10. Infant Outcomes

11. Results • 4 clusters were created, showing 4 distinct subgroups within the intensive PNCU category • These clusters were compared to those women receiving adequate prenatal care and the overall population

12. Table 1. Cluster Analysis: Maternal Profiling Indicators, Mothers Receiving Intensive Prenatal care in the United States, 2000-02

13. Results • Cluster 1: White, 31.1 yrs, married, highly educated, diabetes, hypertension • Cluster 2: Black, 26.2 yrs, married, average education, diabetes, hypertension, smokers(?) • Cluster 3: Black, 22.2 yrs, unmarried, lower education, primiparous, hypertension, smokers • Cluster 4: Hispanic, foreign-born, 28.7 yrs, urban, diabetes

14. Results • The rates of adverse birth outcomes were calculated for each of the 4 clusters. • These rates were then compared to the rates for the adequate care group and the overall population.

15. Table 2. Birth Outcomes by Cluster, Intensive Prenatal Care Utilization, U.S. Resident Mothers, 2000-02

16. Results • Higher rates of VLBW, MLBW, very preterm, moderately preterm among Clusters 1, 2, and 3 • Higher rate of HBW among Cluster 1 • Higher rate of postterm among all clusters when compared to adequate group • Higher rates of SGA among Clusters 2 and 3; slightly higher among Cluster 4

17. Discussion • There are distinct subgroups of women who receive intensive PNC. • These subgroups vary predominantly by race, age, maternal nativity, and risk behaviors (smoking). • Rates of diabetes and hypertension are higher among all groups when compared to the adequate care group and total population.

18. Discussion • There are some cluster variations by outcomes. • Rates of some adverse outcomes are comparable to or lower than those among the adequate care group and the total population.

19. Discussion • The limitations of the study include: • Secondary data • Limited information on maternal risk factors/behaviors • This preliminary analysis can be expanded to include issues such as: • Plurality • Hypertension (pregnancy vs. chronic) • C-section • Mortality outcomes

20. Discussion • Further examination of number of prenatal care visits and the month prenatal care began to explore the potential for further categorization among intensive care group. • When measuring quality of prenatal care, are there disparities between the clusters?

21. Discussion • Is the system driving the intensive care or is it the maternal characteristics (risk factors, etc.)? • Based on this preliminary analysis, it seems that the answer may vary. • What are the practice implications related to these preliminary findings? • Smoking and other risk behaviors • Preconception preventive care

22. So, does one-size-fit-all for intensive prenatal utilization?