evaluation of california's statewide implementation of enhanced

Evaluation of California's Statewide Implementationof Enhanced Perinatal Services as Medicaid BenefitsCAROL C. KORENBROT, PhDAYESHA GILL, PhDZOE CLAYSON, ScDELIZABETH PATTERSON, MPH

Dr. Korenbrot is an Associate Adjunct Professor at theUniversity of California, San Francisco, School of Medicine,Institute for Health Policy Studies (IHPS), and the Department ofObstetrics, Gynecology and Reproductive Sciences. During theresearch project, Dr. Gill was the Project Statistician, Dr. Claysonwas the Project Director, and Ms. Patterson the Research Assistant.Dr. Clayson is currently a Research Associate at IHPS.The study was funded jointly by Ford Foundation Grant

880-0630 and the Maternal and Child Health Bureau of the PublicHealth Service's SPRANS Grant MCJ-067-010 with additionalsupport from Packard Foundation Grant 89-1745 and Sierra HealthFoundation Grant 89-P007.

Jeanne Buhl, Beverly Gamer, Rosie Lopez, Emily Ravenscroft,and Michael Costic of Associated Record Technician Services,Inc., abstracted medical charts used in this study.

Tearsheet requests to Carol C. Korenbrot, IHPS, 1388 SutterStreet, 11th Floor, San Francisco, CA 94109; tel. 415-476-3094;FAX 415-476-0705.

Synopsis ....................................

The authors evaluated enhanced perinatal servicesdeveloped by public health specialists that were

implemented statewide through specially certifiedMedicaid providers to find out whether they were aseffective as those services originally tested in thepublic health agency's pilot project, and moreeffective than services from regular Medicaidproviders. Multivariate logistic regression analysesyielded adjusted odds ratios of use of care and healthoutcome measures for the statewide services com-pared with both the pilot project and routineMedicaid care.

Although women receiving the enhanced servicesimplemented statewide did not return for prenatalvisits as well as those in the pilot project, they didbetter than women with routine Medicaid providers.Women who kept at least the eight prenatal visitsrecommended by the Public Health Service in 1989had risks of low weight births no different from thosein the pilot project and significantly better than thosefor women with at least eight visits with routineMedicaid providers (adjusted odds ratio 0.70 with a95 percent confidence interval from 0.54 to 0.91).Thus, there is evidence for the efficacy of theservices, but additional improvement could be real-ized through improving the use of care.

IMPLEMENTATION OF HEALTH SERVICES is a largelyuncharted area in establishing health policy and notmerely administrative routine (1). Statewide imple-mentation of enhanced perinatal services for low-income women was done so rapidly in Michigan in1984 and 1985 that a number of programmatic set-backs occurred (2). Implementing services developedby public health agencies through State MedicaidPrograms can be particularly difficult. State MedicaidPrograms have not had impressive records in gettingwomen to use prenatal care or improving birth weightoutcomes (3-5). After completion of the ObstetricalAccess Demonstration Project by the Maternal andChild Health Branch (6,7), the California Departmentof Health Services took 5 years (1984 to 1989) toimplement the enhanced perinatal services in itsstatewide Comprehensive Perinatal Service Program(CPSP) (8). The services were implemented throughits Medicaid Program (Medi-Cal) in collaborationwith the Maternal and Child Health Branch.

Evaluation of the public health agency pilot projectdemonstrated that recipients of enhanced services didnot start prenatal care earlier, but they did return formore prenatal visits and had significantly better birthweight outcomes than women in routine Medicaidcare (6,7). Because of the changes that were made inservice delivery during the implementation process,we undertook the following study to determinewhether the CPSP implemented statewide was aseffective as its pilot project in improved use ofprenatal care and in birth weight outcomes. Further-more, because the effectiveness of the pilot projecthad been shown by comparisons with the routineMedicaid care prevailing at the time that the pilotproject was conducted, this study also comparesCPSP with routine Medicaid care when the programwas implemented. The results of the study provideinsight as to the importance of continuing to monitoreffectiveness of public health services that aretranslated into Medicaid benefits.

March-April 1995, Vol. 110, No. 2 125

Table 1. Percentage distribution of provider settings for theComprehensive Perinatal Service Program (CPSP) and the

Obstetrical Access Demonstration Project (OB Access)

CPSP OB Access

Provider settings Number Percent Number Percent

Community clinics ........ 8 29 7 64Health departments ....... 6 21 2 18Private physicians' offices.. 6 21 1 9Public hospital clinics ..... 5 18 0 0Private hospital clinics .... 3 11 1 9

Totals ................ 28 100 11 100

NOTE: The distribution of provider settings for Medi-Cal is not known. See"Methods, comparisons of provider and patient samples" for the reasons.

Methods

Prenatal services. Three types of prenatal servicesare compared in this study. The enhanced perinatalservices provided through the OB Access pilotproject, enhanced perinatal services provided throughthe statewide CPSP, and routine perinatal servicesprovided by obstetric providers generally participatingin Medicaid (see box). Enhanced or comprehensiveperinatal services in OB Access and CPSP are thosederived from the maternal and infant care projects ofthe Maternal and Child Health Bureau of the U.S.Public Health Service (6). They were designed toprovide an array of support services through anapproach to care that integrated nutrition, socialwork, and health education with regular clinicalperinatal services. Thus while routine perinatalservices provided by obstetric providers generallyparticipating in Medicaid includes obstetrical riskassessments and standard obstetrical care and may ormay not include nutrition services as prescribed, inthe enhanced service programs every woman wasscheduled for risk assessments for nutrition, healtheducation, and psychosocial ills. An individual careplan was required, outlining the coordinated supportservices that the woman was to receive in each areaof risk. Subsequent support services included individ-ual counseling and group classes, as well as referraland followup to specialized support services notavailable at the site. In the California enhanced careservices, the risk assessments could be administeredevery trimester of care in all three areas, and prenatalvitamin and mineral supplements were to be pre-scribed for every woman.

Although the major components of the enhancedservices tested in the pilot project and the statewideprogram were similar, a number of differences weredocumented in the administration of the services andthe types of participating provider settings (see box

and table 1) (8). Compared with the pilot project (5),(a) MCH State staff operated the programmatic func-tions and Medicaid operated claims processinginstead of MCH doing both; (b) oversight of servicedelivery was shifted from State specialists to locallyappointed county coordinators with varying back-grounds, roles, and training; (c) proportionately moreprivate physicians and public hospital clinics andfewer community and public health departmentclinics participated; (d) the use of nurse midwivesdelivering support services decreased; and (e) the useof health workers who had experience, but little or nospecial training in support service risk assessments orcounseling, increased.The ways of reimbursing service providers also

differed among the pilot project, the statewideprogram, and routine Medicaid providers and couldaffect the use or outcomes of care. Although in thepilot project all services were fee-for-service, inCPSP routine perinatal services were covered by theglobal fee paid generally to obstetric providersparticipating in Medicaid, and support services werefee-for-service. In addition, CPSP providers weregiven financial incentives for desirable providerbehavior that had been obtained in the pilot projectthrough the annual site visits for contract approval.

Extra payments of $50 were made for each patientwhose care began in the first trimester to rewardproviders for not delaying the scheduling of the firstprenatal care visit. A care coordination fee of $111was paid if all of the four first risk assessments(clinical, psychosocial, nutrition, and health educa-tion) were completed within the first month of care.And a payment of $100 was made if a patientreceived 10 or more prenatal care visits. All of theseincentives were designed to increase the chances thatproviders would encourage women to seek prenatalcare early and often and receive appropriate care fora wide range of risks that could improve birthoutcomes. As in the pilot project, a provider stood toearn more for providing enhanced services than justproviding routine Medicaid care.

CPSP provider sample. All certified providers ofCPSP who responded to a survey in 1990 (174 of 231providers) indicating they had billed CPSP forservices already provided by April 1989 and providedcare to at least 50 Medicaid-eligible women a year(89 sites), were included in a sampling procedure (8).The study was limited to the two metropolitanregions in the State and two corresponding non-metropolitan regions comprising more than half of theState of California to control data collection costs.The 57 qualifying sites in the four regions were

126 Public Health Reports

Medi-Cal

RoutineRoutineOptionalOptionalRareRareRareRareRareOptionalOptional

CPSP

RoutineRoutineRequiredOptionalRequiredOptionalRequiredOptionalRequiredRequiredRequired

OB Access

RoutineRoutineRequiredOptionalRequiredOptionalRequiredOptionalRequiredRequiredRequired

Comparison of Prenatal Services under Medi-Cal, the Comprehensive Perinatal ServiceProgram (CPSP), and the Obstetrical Access Demonstration Project (OB Access)

Type of servicesand facets of administration

ServicesObstetric risk assessmentsObstetric careNutrition risk assessmentsNutrition counselingPsychosocial risk assessmentsPsychosocial counselingHealth education risk assessmentsHealth education counselingCoordinated care planGroup classesVitamin and mineral supplements

AdministrationProgram contentClaims processingService delivery oversight

MD, CNMNA

NOTE: The words in boldface are the status of services paid for on a fee-for-service basis; these are audited by anoversight agency indicated in "service delivery oversight" under Administration.NA = not applicable; MD = physician (family practitioner, obstetrician, pediatrician); CNM = Certified Nurse

Midwife.

Obstetric providersSupport service providers

NAMedi-CalMedi-Calaudit

MCHMedi-CalCountygeneralists

MD > CNMMoregeneralists

MCHMCHStateMCHspecialistsCNM > MDMorespecialists

stratified by region and type of provider setting(private physician, private hospital clinic, communityclinic, public hospital clinic, and public healthdepartment clinic, table 1). A random sample of twoof each type of setting was selected. Because not allregions had two of each provider setting typecertified and providing services at the time, in all 29sites met the criteria (table 1). No sites refused toparticipate, but recovery of medical charts provedimpossible at one site.

CPSP patient sample. The CPSP sample is com-posed of all Medicaid-eligible women (incomes lessthan 200 percent of the Federal poverty level andallowable assets not in excess of about $3,000) whoreceived one or more support service assessmen.ts (8).At each study site, the birth log was used to identifyall Medicaid eligible women with births between June30, 1989, and December 31, 1990. The medicalcharts of all women thus identified were requested

and, when a woman was found to have had at leastone clinical visit, one CPSP support service riskassessment, and a singleton birth within the pre-scribed time, her medical chart, risk assessments, andindividual care plan were all abstracted. Every chartmeeting the three criteria was abstracted sequentiallyuntil 140 charts were abstracted. The final samplesize for study was 3,662 women.

Comparison of provider and patient samples. All11 participating providers (5 in metropolitan, 6 innonmetropolitan areas) in the OB Access pilot projectwere included (table 1). Their practice settings wereprivate physician's practice 1; private hospital clinic1; community clinics 7; and public health departmentclinics 2 (7). The patient sample of 5,370 in the pilotproject included women with family incomes nogreater than 200 percent of the Federal poverty level,who completed OB Access care and had single livebirths (7).


No information on the prenatal providers for theMedicaid comparison group was available becausebirth certificate data were used to identify women forthe Medicaid comparison group. Live births forwhom Medicaid was the primary payor source forprenatal care were identified from a data item on theconfidential portion of California birth certificatesthat was reported for 99.6 percent of births in 1989and 1990. Medicaid prenatal care providers wereidentified from this item. No further information wasavailable on them.A random sample of women with Medicaid as the

indicated prenatal payor source (but not CPSP) wasselected from the California 1989 and 1990 live birthtapes in the same proportions from each year asbirths in the CPSP sample. The total Medicaid birthswere stratified by year, and a sampling ratio thatprovided a population three times the CPSP samplefor each year was determined (N=10,836 singletonlive births).

Although CPSP can also be indicated as theprimary payor for prenatal care on the State birthcertificate, it is greatly underreported. To eliminate asmany CPSP patients as possible from the Medicaidsample, those Medicaid CPSP patients included inour CPSP sample were deleted from the Medicaidcomparison sample. An unknown number of CPSPpatients not in our CPSP sample and thus notidentified may remain in the Medicaid randomsample. The effect of their inclusion would be tolower the apparent strength of any beneficial effectsof the CPSP in comparisons to usual "Medicaid"care.

CPSP chart abstraction. Data were abstracted by sixaccredited medical record technicians who were hiredspecifically for the study and carefully trainedtogether (8). Their abstracted data were regularlycollected and examined for completeness, errors, andinconsistencies so that corrections could be madebefore the technician left the study site.

Analysis of prenatal care utilization. Three aspectsof the use of prenatal care were analyzed: late onsetof care, poor continuity of care, and making less thana minimal number of visits. The onset of care wascategorized as late if the first prenatal care visitoccurred after the fourth month of gestation. Thecontinuity of care was coded as poor if the proportionof visits actually kept was less than 80 percent of thenumber expected for the gestational period from theonset of care to birth, given the American College ofObstetricians and Gynecologists (ACOG) schedule ofvisits for an uncomplicated, low-risk term pregnancy

(9,10). The minimal number of comprehensive carevisits used for the third measure of prenatal care usewas the eight visits recommended by the PublicHealth Service Expert Panel for an uncomplicatedpregnancy of a woman who has not had a preconcep-tion visit (11). The likelihood of women in CPSP tounderutilize prenatal care by any of the threemeasures was compared with that for women in theOB Access pilot project and women in regularMedicaid care in separate multivariate logistic regres-sion models. The indicator of the comparative use ofprenatal care was the adjusted odds ratio for eachmeasure. All models were adjusted for other possibleexplanatory variables of prenatal care use common toall three data sets (maternal age, race-ethnicity,previous live births, and marital status). Beforemodeling, the interactions of all explanatory variablesin the model were tested, and those of age and paritywere sufficiently large to require the use ofinteraction variables for adjustment; women 20 to 34years of age with no previous births were used as thereference group.

Analysis of low birth weight. The birth weightoutcome analyzed was low weight (less than 2,500grams) for singleton live births. The likelihood of lowbirth weight in CPSP was compared with that in theOB Access pilot project and with regular Medicaidcare in separate multivariate logistic regressionmodels. The low birth weight odds ratios wereadjusted in the manner described previously forprenatal care utilization, except that the sex of babywas added as an explanatory variable. The firstadjusted low birth weight odds ratios obtained werefor all women (regardless of the number of visits).Then the adjusted low birth weight odds ratios forwomen who obtained at least the minimal recom-mended number of visits were tested by furtheradjusting each model for onset and continuity ofthose visits. Finally, the dependence of the adjustedlow birth weight odds ratios on support services withand without adjustment for onset and continuity ofcare was analyzed.

Results

Characteristics of the women. The characteristics ofthe samples are presented so that the comparability ofthe populations can be examined before statisticaladjustments are made. The total study samples foreach of the three groups were generally similar insociodemographic characteristics that have beenshown to affect the use of care or birth weightoutcomes (table 2). There tended to be proportion-

128 Public H"lth Reports

ately more whites (non-Latinas) in the CPSP sample(32 percent), than in Medicaid (27 percent) or OBAccess (26 percent), but in general both groups hadpredominantly white, Latina women (46 percent, 51percent and 50 percent respectively). In all threesamples, African American women formed the nextlargest ethnic group (11 percent, 13 percent, and 10percent respectively).CPSP with 40 percent and Medicaid with 45 per-

cent had much lower proportions of married womenthan OB Access with 62 percent. No statistical testsof significance for these differences are reported, bothbecause the regression analyses adjust for differencesand to avoid the problems of multiple testing.

Use of prenatal care. Direct comparison of CPSPwith the OB Access pilot project indicated thatwomen in CPSP were just as likely to start prenatalcare early as in the pilot project, but they were lesslikely to return for prenatal visits once care began.Compared with routine Medicaid care, women withCPSP services were less likely to start care early, butmore likely to return for prenatal visits once carebegan. Thus the services implemented statewide wereno different than the pilot project in its associatedeffects on the start of prenatal care, but worse thanroutine Medicaid care; the statewide program wasworse than the pilot project in its effects on the returnfor subsequent prenatal care visits, but better thanroutine Medicaid care.

Onset of care. There was no difference betweenCPSP and OB Access women in the relative odds thatwomen started prenatal care in the first 4 months ofgestation [adjusted odds ratio (OR) 0.99, confidenceinterval (CI) 0.90, 1.09] (table 3). Compared withMedicaid, however, participation in CPSP wasassociated with a later start in prenatal care (adjustedOR 1.31; CI 1.20, 1.42).

Continuity of care. Participation in CPSP wasassociated with decreased continuity of prenatal carevisits when compared with OB Access, but increasedcontinuity when compared with Medicaid. When thecontinuity of prenatal care is measured by the percentof ACOG-recommended prenatal visits for an uncom-plicated pregnancy that women keep, continuity ofcare was significantly better in CPSP than inMedicaid in general (adjusted OR 0.49; CI 0.45,0.54), but significantly worse than in the OB Accesspilot project (adjusted OR 1.74; CI 1.54, 1.95) (table3). About three-quarters (78 percent) of the CPSPwomen return for more than four-fifths of recom-mended visits, compared with 63 percent of womenin regular Medicaid care.

Table 2. Comparison of the demographic characteristics ofthe Comprehensive Perinatal Service Program (CPSP),Medi-Cal, and the Obstetrical Access Demonstration

Program (OB Access) study samples1 (percentages)

Medi-Cal CPSP OB AccessCharacteristic (N = 10,836) (N = 3,648) (N = 5,336)

Race:White, non-Latina ....... 27 32 26White, Latina ......... 51 46 50African American ....... 13 11 10Other . ........... 9 10 10Missing . .......... 0 2 3

Age (years):Younger than age 20.... 21 26 2320-34 ............. 73 69 7234 and older ......... 6 5 5Missing . .......... 0 0 0

Parity:Nulliparous .......... 38 43 43Parous ............ 62 56 57Missing . .......... 0 1 1

Marital status:Married ............ 45 40 62Unmarried ........... 55 59 35Missing . .......... 0 1 3

Mother's education:Less than 12 years ..... 54 (54) 57 (60) 45 (58)12 years ........... 33 (34) 28 (30) 20 (25)More than 12 years..... 12 (12) 10 (10) 13 (16)Missing ................. 2 ... 6 ... 22 ...

'Excluding participants who had fetal deaths.NOTE: Percentages in parentheses are calculated after excluding missing

values because of the large proportion of women with missing values in theOB Access Demonstration Project.

Threshold levels of care. Women with CPSPproviders were less likely than women in the OBAccess pilot project to have returned for at least theminimal number of prenatal care visits recommendedby the Public Health Service's Expert Panel (11) butmore likely than women with traditional Medicaidproviders. In CPSP, the proportion of women whoreceived above the minimal amount of prenatal carewas significantly lower than in OB Access (adjustedOR 1.74; CI 1.56, 1.93), but significantly higher thanin Medicaid (adjusted OR 0.77; CI 0.71, 0.84) (table3). About three-quarters (72 percent) of the CPSPwomen returned for at least eight comprehensive carevisits, compared with 66 percent for Medicaid and 83percent for OB Access.

Low birth weight outcomes. Birth weight outcomesfor women in CPSP depended on whether or notwomen attended at least the minimal number of visitsrecommended for an uncomplicated pregnancy. Forwomen who kept at least the minimal eightrecommended visits, the CPSP services were associ-ated with risks of low weight births no different fromthose for the OB Access pilot project, but better thanthose for routine Medicaid services. When the low


Table 3. Effects of the Comprehensive Perinatal Service Program (CPSP) associated with utilization of care measures

CPSP compared with Medi-Cal CPSP compared with OB Access

Adjusted' 95 percent Adjusted' 95 percentDepdendent variables odds ratio confidence interval odds ratio confidence interval

Late onset of care (5-9 months gestation) .............. 1.31 1.20, 1.42 0.99 0.90, 1.09Discontinuity of care (less than 80 percent of expected

visits made) ......................................... 0.49 0.45, 0.54 1.74 1.54, 1.95Below minimum amount of care (less than 8 visits) ..... 0.77 0.71, 0.84 1.74 1.56, 1.93

'Models are adjusted for age, parity, marital status, and ethnicity of women. NOTE: Medi-Cal = California's Medicaid Program; OB Access = ObstetricalAccess Demonstration Project.

Table 4. Effects of the Comprehensive Perinatal Service Program (CPSP) associated with low birth weight outcome in groups ofwomen with differences in prenatal care utilization

CPSP compared with Medi-Cal CPSP compared with OB Access

Dependent variable: Adjusted' 95 percent Adjusted' 95 percentinfant's low birth weight for groups of women odds ratio confidence interval odds ratio confidence interval

All women (both levels of visits) ........................ 0.90 0.75, 1.08 1.07 0.87, 1.328 visits or more ....................................... 0.70 0.54, 0.91 0.94 0.70, 1.27Less than 8 visits ............... ...................... 1.25 0.97, 1.61 0.89 0.66, 1.208 visits or more adjusted for onset of care and

continuity of care .................................... 0.70 0.53, 0.92 0.97 0.72, 1.31Less than 8 visits, adjusted for onset of care and

continuity of care .................................... 1.03 0.79, 1.35 0.95 0.68, 1.32

'Adjusted as in table 2 plus infant's sex; the models for the last 2 groups ofwomen also were adjusted for onset and continuity of care.

birth weight rates for CPSP (5.3 percent) werecompared with those in either the pilot project (5.0percent) or routine Medicaid (5.8 percent), thedifferences were not significant (P > 0.05). Evenadjustments for differences in sociodemographiccharacteristics and sex of the baby between groupsdid not yield a statistical difference in low birthweight rates between CPSP and the OB Accessproject (adjusted OR 1.07; CI 0.87, 1.32), or CPSPand routine Medicaid prenatal care (adjusted OR0.90; CI 0.75, 1.08) (table 4).Women in CPSP with at least the eight visits

recommended by the Public Health Service, however,had significantly better outcomes than women whoreceived at least eight obstetrical visits in routineMedicaid care. Unadjusted low birth weight rateswere significantly lower for women in CPSP whoreceived eight visits (3.1 percent) when comparedwith those in Medicaid who received at least eightprenatal visits (4.3 percent; P < 0.05; see chart). TheCPSP low birth weight rate of 3.1 percent for womenwith at least eight visits was identical to that for suchwomen in OB Access. When these rates wereadjusted for sociodemographic differences in thegroups, the low birth weight rate for care in CPSPwas significantly better than for Medicaid prenatal

NOTE: Medi-Cal = California's Medicaid Program; OB Access = ObstetricalAccess Demonstration Project.

care (adjusted OR 0.70; CI 0.54, 0.91) (table 4) andnot different than in OB Access (adjusted OR 0.94;CI 0.70, 1.27) (table 4). When the regression modelfor those with at least minimal amounts of care isfurther adjusted for prenatal care (onset of care andcontinuity of care), the low birth weight risks are stillsignificantly lower in CPSP than in Medicaid(adjusted OR 0.70; CI 0.53, 0.92) (table 4). Therewas no significant difference in low birth weight ratesbetween women in CPSP who had less than eightvisits and their counterparts in either Medicaid or OBAccess (table 4).

Discussion

Providing prenatal care to low-income women thatboth motivates them to return for visits and isassociated with improved birth outcomes is a criticalobjective of public health. Perinatal care ordinarilyprovided to Medicaid-eligible women in California,as in other States, has generally been associated withlow levels of use of care and poor birth weightoutcomes compared with both uninsured and privatelyinsured women (3-5). Enhanced perinatal serviceslike those in the OB Access Demonstration Projectthat grew out of Maternal and Child Health Services,


however, were associated with increased use ofprenatal care visits and significantly better low birthweight rates (6,7). It is thus important that, in spite ofchanges made in the services pilot tested in the OBAccess project when CPSP was implemented state-wide, the program was associated with onset ofprenatal care no later, and birth weight outcomes noworse, than in the pilot project. Even though theindicators for the use of care during pregnancyrevealed lower use than in the pilot project, they werestill higher than those in routine Medicaid care.

Birth weight outcomes, furthermore, were signifi-cantly better for the newborn infants of those womenwho received at least the eight comprehensive carevisits recommended by the Public Health ServiceExpert Panel (11). The birth weight effect remainedeven after adjustments in the analysis for gestationalage at onset of care and gestational age at birth(9,10). Limitations in the data precluded studying theassociation of the support services which form thebasis of the enhanced services with the improvedoutcomes. But more of the women who attended atleast the minimal number of recommended visits alsohad more support services as indicated by multiplerisk assessments in more than one support servicearea of nutrition, social work, or health education (62percent compared with 36 percent of women withless than eight visits, P < 0.001).

There are still opportunities for improvement in theeffectiveness of the CPSP services implementedstatewide, particularly in promoting the use ofprenatal care (12). Women receiving the servicesimplemented statewide did not start care as early asthose who receive routine Medicaid care, and theydid not attend as many visits once they started care asdid women in the pilot project. Improving servicedelivery within CPSP to be more like that of the pilotproject, therefore, could be expected to improve theamount of return visits.

Nevertheless, measures in addition to those alreadytried in either the pilot project or the statewideprogram are needed to improve the early start ofprenatal care, since neither set of services had womenstarting prenatal care as early as women generally didin routine Medicaid care. The Medicaid eligibilityprocess could have contributed to the delay in startingCPSP care if fewer women using CPSP providerswere eligible for Medicaid when they becamepregnant. In California, a large proportion of women(44 percent) covered by the State Medicaid Programdo not become eligible until they are pregnant (4,13).However, the Medicaid eligibility process is not thelikely reason for the later onset of care for women inCPSP or the OB Access pilot project, since there was

Percentage of low birth weight infants (unadjusted rates) of womenin three study groups

1O.OT

-

0

4)04._c

0

a8-

8.04OB Access 0CPSP UMedi-Cal ED

6.04

4.04

2.04

0.0. II

8 or more

NOTE: The diffemrnc between the Modi-Cal women and the OB Access and CPSPgroups was statstcally signiflcant at the P<0.03 level.

a 'presumptive eligibility process' for women in thepilot project whereby a woman was presumed eligibleif her stated family income was below the allowablelimits. Thus it appears that a major source of delay ofprenatal care may still have to do with the knowledgeand attitudes of women toward the pregnancy, pro-viders, or preventive medical care itself (14,15).

Improvements are also needed in motivating morewomen to participate in even the minimal number ofrecommended prenatal visits. In CPSP services, 72percent of Medicaid eligible women obtained at leasteight visits compared with 66 percent of womenwhose primary payer source for prenatal care wasMedicaid. Although the difference was statisticallysignificant (P < 0.01), more than one-fourth of thewomen with enhanced services received less than theminimal recommended number of visits duringpregnancy. The newborns of these women were morethan twice as likely to be low birth weight than thechildren of women who had at least the minimalnumber of visits. Although some of this added risk isbecause of early preterm births to women withassociated insufficient time for eight routine visits,not all of the added risk can be explained this way(16). Many in this group of women who apparentlywere not sufficiently motivated by CPSP to come forenough care to benefit from it.

In multivariate logistic regression analyses notincluded in this paper, we found that CPSP womenmost likely to receive less than basic levels of carewere African Americans, Latinas, and unmarriedwomen. Women in metropolitan areas were lesslikely to receive minimal levels of care than womenin nonmetropolitan areas. CPSP women receivingcare at health departments were significantly more


likely to get basic levels of care than CPSP womenwith other provider types (physicians' offices, com-munity clinics, public or private hospitals).The primary limitations of the study lie in the lack

of randomization of the pregnant women to thedifferent systems of care compared. The lack ofrandom assignment of women to prenatal care groupsin effectiveness studies always raises the possibilityof self-selection biases contributing to the outcomes.However, Medicaid-eligible women do not selectCPSP providers or services. Once women havestarted care with a CPSP provider, they can refusethe initial support service assessments and therebyexclude themselves from CPSP care at a site, butthere is no marketing of the program or of CPSPproviders to Medicaid eligible women, nor is there anenrollment process for CPSP. The enhanced servicesare the standard of care for Medicaid-eligible womenwith the specially certified CPSP providers.We could not compare the differences in

established risks of low birth weight because we werelimited to birth certificate data for women in routineMedicaid care. We were at least able to establish,however, that in our CPSP sample the sameproportion (37 percent) of women had identified highrisks and returned for more than 110 percent of thevisits recommended for an uncomplicated pregnancyas women in the Medicaid sample (37 percent). Inrandomized clinical trials of similarly enhancedprenatal services, others have reported better birthweight outcomes in nulliparous, but not parouswomen (17).The use of birth certificate data for the routine

Medicaid care in comparisons with medical chart datafor CPSP is an additional limitation of the study.Recording of birth certificate data on the month ofonset of prenatal visits and the number of prenatalvisits is rarely done with access to a completemedical record of ambulatory care, as was done toobtain information for both the CPSP and OB Accesscare groups. We were able to estimate biases in birth

certificate data for this study by examining birthcertificate records of infants born to women in theCPSP group that had been removed from theMedicaid random sample. We found that, while thelater onset of care in CPSP might be attributed tobiases in birth certificate data, the improved use ofvisits in CPSP was less likely to be attributable tothis potential source of error.

For the 104 CPSP women whose infants' birthcertificates were removed from Medicaid sample, 36percent were found by medical charts to have startedcare after the fourth month of pregnancy, whereasonly 29 percent were found to have done so by theirbirth certificate data. In the entire study, 35 percentof CPSP women were found by medical charts tohave started care after the fourth month of pregnancy,and 29 percent of the Medicaid random sample werefound to have done so by their birth certificate data.When the threshold measure of prenatal care use is

compared for the two types of data sources, 27percent of women were found to have kept less thanthe minimal eight visits by medical chart audit butonly 20 percent by birth certificate data. For thewhole CPSP sample, however, 28 percent of womenkept less than eight visits, as did 34 percent ofwomen in routine Medicaid prenatal care. Thus whilebiases in birth certificate data reporting do appear toexplain differences in the onset of care between bothCPSP and its pilot project when compared withroutine Medicaid care, they do not appear to explaindifferences found for the use of care between thegroups.

This study has demonstrated that the transfer ofenhanced perinatal services from the jurisdiction ofdirect services of maternal and child health agenciesto Medicaid benefits, even on a statewide basis, neednot necessarily lead to a deterioration in the use ofservices and outcomes if done carefully. BesidesCalifornia, New York is also undertaking such atransition of multidisciplinary services, and otherStates can be expected to do so also. However, it isimportant to note that a number of functions were nottransferred from the Maternal and Child HealthBranch when CPSP was implemented as a Medicaidbenefits program. In the State of California, theagency certifies providers, oversees provider servicedelivery, and trains support personnel involved indelivery of services. In addition, Medi-Cal providedenhanced reimbursement for the support services andpackaged a variety of financial incentives forperforming all initial risk assessments within the firstmonth of care, starting prenatal visits in the firsttrimester, and providing at least 10 visits. Thus therewere a number of safeguards in the implementation


process to assure a certain level of accountability forthe enhanced services.

During the implementation it became clear that thedifferences between the pilot project and the state-wide implementation of the services stemmed fromthe fundamental contrast in purposes of the pilotproject and statewide program: the pilot was con-cerned with providing the highest quality of servicespossible at a limited number of sites, but thestatewide efforts are aimed at providing the highestquality possible at the most sites possible. Admin-istrators of the OB Access project were able to focuson the content and delivery of the services, whileCPSP struggles with competing goals of expandingprovider participation and maximizing the chancesthat they will provide the quality of care intendedunder the program.

Problems arise in implementation because admin-istrative measures designed to assure the quality, suchas the application process for certification, areperceived by providers as burdensome bureaucraticinterference. On the other hand, measures to expandprovider participation, such as reducing paperworkand increasing flexibility in staffing credentials, arefeared by officials and advocates for low-incomewomen and children because they could erode theexpertise in the services, particularly support services,delivered. The balancing of these two competinggoals becomes the key to how effective the servicesare in the end.

Evaluating effectiveness of health care services inpractice has become a high priority of Federalagencies in recent years, particularly for publiclyfunded care like that of Medicaid financed care (18).The limitations of randomized controlled trials forestablishing effectiveness of care have recentlybecome widely recognized (19). While effectivenessstudies, such as this one, have limitations, they areuseful because they do not eliminate the types ofpatients usually treated in the real world of clinicalpractice, as frequently occurs in randomized trials.This study indicates the importance of continuing tomonitor health service use and effectiveness evenwhen the services have been tested previously in apilot project. The study revealed that the use of theservices and their associated outcomes are goodenough to justify continuation of the program, butimportant aspects of the service delivery andoutcomes should be improved.

References ..................................

1. Goggins, M. L.: Policy design and the politics of implemen-tation: the case of child health care in the American states.

University of Tennessee Press, Knoxville, 1987.2. Miller, C. L., Margolis, L. H., Schwethelm, B., and Smith,

S.: Barriers to implementation of a prenatal care program forlow income women. Am J Public Health 79: 62-64 (1989).

3. Schwethelm, B., Margolis, L. H., Miller, C., and Smith, S.:Risk status and pregnancy outcome among Medicaidrecipients. Am J Prev Med 5: 157-163 (1989).

4. Howell, E. M., and Ellwood, M. R.: Medicaid and pregnancy:issues in expanding eligibility. Fam Plann Perspect 23: 123-127 (1991).

5. Braveman, P., et al.: Access to prenatal care following majorMedicaid eligibility expansions. JAMA 269: 1285-1289,Mar. 10, 1993.

6. Lennie, J. A., Klun, J. R., and Hausner, T.: Low birth weightrate reduced by the Obstetrical Access Project. Health CareFinanc Rev 8: 83-86 (1987).

7. California Department of Health Services. Final report of theOB Access pilot project. Maternal and Child Health Branch,Sacramento, 1984.

8. Korenbrot, C. C., Gill, A., Clayson, Z., and Patterson, E.:Evaluation of the implementation of the ComprehensivePerinatal Service Program: final report. Maternal and ChildHealth Bureau, Public Health Service, Rockville, MD, 1993.

9. American College of Obstetricians and Gynecologists:Standards for obstetric-gynecologic services. Ed. 7. Wash-ington, DC, 1989.

10. Kotelchuck, M.: An evaluation of the Kessner Adequacy ofPrenatal Care Index and a proposed Adequacy of PrenatalCare Utilization Index. Am J Public Health 84: 1414-1428(1994).

11. Public Health Service: Caring for our future: the content ofprenatal care. A report of the Public Health Service ExpertPanel. U.S. Government Printing Office, Washington, DC,1989.

12. Klerman L.: Epilogue: a public health perspective on "caringfor our future." In New perspectives on prenatal care, editedby I. R. Merkatz and J. E. Thompson. Elsevier, New York,1990, pp. 633-642.

13. California Department of Health Services: Medicaid fundeddeliveries, 1990. Medical Care Statistics Section, Sacramento,1991.

14. U.S. General Accounting Office: Prenatal care: Medicaidrecipients and uninsured women obtain insufficient care.GAO/HRD-87-137; Washington, DC, 1987.

15. Institute of Medicine: Prenatal care: reaching mothers,reaching infants. National Academy Press, Washington, DC,1988.

16. Gordis, L., Kleinman, J. C., Mullen, P. D., and Paneth, N:Criteria for evaluating evidence regarding the effectiveness ofprenatal interventions. In New perspectives on prenatal care,edited by I. R. Merkatz and J. E. Thompson. Elsevier Press,New York, 1990, pp. 31-39.

17. McLaughlin, J. F., et al.: Randomized trial of comprehensiveprenatal care for low-income women: effect on infant birthweight. Pediatrics 89: 128-132 (1992).

18. Raskin, I. E., and Maklan, C. W.: Medical treatmenteffectiveness research: a view from inside the Agency forHealth Care Policy and Research. AHCPR Publication No.91-0025, Public Health Service, Washington, DC, 1991.

19. Cotton P.: Determining more good than harm is not easy.[Editorial]. JAMA 270: 153-158, July 14, 1993.


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