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COMPREHENSIVE COMMUNITY-BASED PERINATAL CASE MANAGEMENT:
A PANACEA FOR IMPROVED OUTCOMES

BY
Donna Ellyn Clark Scheideberg

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Family and Child Ecology

1995

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ABSTRACT

COMPREHENSIVE COMMUNITY-BASED PERINATAL CASE MANAGEMENT:
A PANACEA FOR IMPROVED OUTCOMES

BY
Donna Ellyn Clark Scheideberg

This dissertation examined the effect of comprehensive,
community-based, perinatal case management on perinatal
outcomes and family stability. The study was conducted to
test the hypotheses that comprehensive, community-based,
perinatal case management improves perinatal outcomes of
birth weight, APGAR scores, and gestational age at delivery,
and that it has a positive effect on family stability
factors for the psychosocially at-risk perinatal client.
Survey data were gathered for the case managed women who
were matched by age, fecundancy, and marital status to women
who had received either comprehensive perinatal care or
standard obstetrical care in a tri-county are of northern
New York state and delivered between October 1991 and May
1993.

Women who received either comprehensive care or case
management perinatal care had perinatal outcomes that were
similar to women who received standard obstetrical care.
Low birth weight and macrosomia indicators were found to be

well below national averages and well below those of the

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standard obstetrical care group.

There was found to be no support for the second
hypotheses. Strong evidence indicated, however, that
domestic violence, child abuse/neglect, and decreased
education and employment opportunities contribute to the
continuing high-risk status of the case managed client.
Pregnancy recidivism was also found higher in case managed

clients.

Copyright by
DONNA ELLYN CLARK SCHEIDEBERG

1995

DEDICATION

To Paul for his nurturing,
love, and support

To Ashley and Ian for their kisses
and hugs when things got tough

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ACKNOWLEDGEMENTS

The completion of this dissertation could not take
place without acknowledging the many people that assisted in
its birth. The gestational period was long and the
dissertation arrived post-mature but healthy with the
support of the wonderful people of Watertown, New York.
Linda Knight ARNP, Dr. Paul Kruger, Nancy Marsalis, and
Joanne Dwyer, all of the Maternal Health Center, provided
continuous input, support, and listened to my many woes and
worries. The competent, compassionate, caring that they
provided to their clients showed over and over as I gathered
data from patient records.

I would also like to thank the staffs of the House of
the Good Samaritan (especially the obstetrical nursing staff
and the medical records staff) and OB-GYN Associates of
Northern New York in helping me access patient records and
directing my questions to the appropriate source. The
College of Nursing at the University of Kentucky, especially
Dean Carolyn Williams, Dr. Margaret Grier, Dr. Gwendolen
Lee, Renate Sward, and Sally Rogers, I thank for their
guidance and encouragement over the past twelve months. I

need to thank especially the time commitment the College of

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Nursing provided for the completion of this dissertation.

I would like to thank all my dissertation committee
members for their guidance and perseverance over the years
of struggle to complete this study. Initially I would like
to thank Dr. Lillian Phenice, Chairperson, Dr. Verna
Hildebrand, and Dr. Linda Nelson of the Department of Family
and Child Ecology, and Dr. Barbara Given of the College of
Nursing. Due to retirement and other time commitments, my
committee changed towards the end of the long road. I would
like to thank Dr. Robert Griffore of the Department of
Family and Child Ecology and Dr. Herbert Whittier of the
Department of Family Practice and Anthropology for
graciously accepting the challenge of assisting me in the
final stages. A special thanks to Drs. John and Verna
Hildebrand who befriended my family in Okinawa, Japan and
helped to pave the way to Michigan State University.

A healthy conception and birth cannot occur alone. My
partner in this dissertation was my spouse, Paul
Scheideberg, without whom this dissertation would not have
been completed. His continual support--both emotionally and
financially (in large amounts of both) provided the impetus
to continue through the trials and tribulations of
dissertation research. I thank him for the hours of
nagging, the dollars expended, the love bestowed, and the

many years of dishes and vacuuming that he willingly gave.

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I also thank my children and apologize to them for the
time commitment that this dissertation required. Their hugs
and kisses helped to make this possible. Finally I would
like to thank my parents, although deceased, for teaching me

to challenge myself and to continually strive for a higher

goal.

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TABLE OF CONTENTS

List of Tables .................................... xi
List of Figures .................................. xiii
Chapter 1: Introduction ........................... 1
Chapter 2: Review of the Literature ............... 7
Factors that Influence Perinatal Outcomes ..... 7
Prenatal Care Programs ........................ 26
Chapter 3: A Review of Conceptual Frameworks ...... 38
Family Ecosystem Framework .................... 39
Neuman's System Model ......................... 55
Case Management Synthesis ..................... 70
Chapter 4: Statement of the Problem ............... 83
Purpose ....................................... 83
Hypotheses .................................... 83
Conceptual Definitions ........................ 88
Case Management in the North Country .......... 92
Chapter 5: Methodology ........................... 102
Subjects ..................................... 102
Instruments .................................. 106
Procedures ................................... 111
Statistical Analysis ........................ 114
Chapter 6: Results ............................... 116
Overview of Demographic and Obstetrical
Characteristics .............................. 116
Perinatal Risk Assessment .................... 126
Birth Outcomes ............................... 129
Family Stability ............................. 145
Chapter 7: Conclusions ........................... 160
Discussion of Findings ....................... 160
Limitations .................................. 167
Implications ................................. 169
Summary ...................................... 171

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Appendices

A: Letters .................................. 173
B: Risk Assessment Tools .................... 180
C: Instrument ............................... 182
Bibliography ...................................... 19S

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LIST OF TABLES

Behavioral risks And risk of Delivering

Low Birth Weight Infants ..................... 22
Low Birth Weight and Pregnancy Recidivism

Rates ........................................ 34
Tri-County Population Demographics ........... 94

Community Service Referrals of the North
Country Prenatal/Perinatal Council, Inc ...... 97

Case Management Organizations of the North

Country Prenatal/Perinatal Council, Inc ...... 98
Identified Perinatal Risk Factors ........... 107
Summary of Demographic Characteristics ...... 117
Summary of Obstetrical Characteristics ...... 121
Antepartal Complications .................... 123
Intrapartal Complications ................... 125

Perinatal Risk Assessments by Prenatal Care
Group ....................................... 128

Gestational Weeks by Prenatal Risk Status
and Prenatal Care Group ..................... 131

Gestational Age by Prenatal Care Type
Using ANOVA ................................. 132

Birth Weight by Risk Status and Prenatal
Care Group .................................. 133

ANOVA of Birth Weight by Prenatal Care
Group ....................................... 135

Comparison of One and Five Minute APGAR
Means and Standard Deviations ............... 139

xi

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18

19

20

21

22

23

24

25

ANOVA of One Minute and Five Minutes APGAR
Scores by Prenatal Care Group ............... 140

Multivariate Tests of Significance for

Birth Outcome and Prenatal Care Grouping....142
Multivariate Tests of Significance for

Birth Outcome, Prenatal Care Grouping, and
Risk Status ................................. 143
Frequency Distribution of Family Outcome
Factors ..................................... 147
Family Outcome Factors Using Chi-Square ..... 149
Frequency Distribution of Infant Outcomes...151
Infant Outcome Factors Using Chi-Square ..... 154
Client Outcome Factors Using Chi-Square ..... 156
Frequency Distribution of Client Outcomes...157

xii

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LIST OF FIGURES

The Human Ecosystem: A Model ................ 41
The Family Ecosystem ......................... 42
The Human Ecosystem .......................... 49
Neuman System Model .......................... 57

Community-Based Case Management:
A Schema ..................................... 73

Conceptual Model: Comprehensive,
Community-Based, Perinatal Case
Management ................................... 75

The Human Environed Unit:

Model Synthesis .............................. 78
Human Environed Unit: Variables
and Factors Under Study ...................... 89

North Country Prenatal/Perinatal
Council, Inc. Tri-County Area Map ........... 92

Case Management Model of the North

Country Prenatal/Perinatal Council, Inc ...... 95
Map of the Central New York Health
Systems Region .............................. 104

Perinatal Risk Assessments by Prenatal
Care Type ................................... 126

Percent of Low, Average, and Macrosomic
Infants by Prenatal Care Group .............. 136

Low Birth Weight Status by Prenatal
Care Group and Risk Status .................. 137

Macrosomia by Prenatal Care Group and
Risk Status ................................. 137

xiii

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CHAPTER 1

INTRODUCTION

Improved perinatal outcome is, and has been, a goal for
health care providers in the United States for decades. In
1960 the United States ranked twenty-sixth in world
standings for infant mortality and morbidity (World Bank,
1980). Thirty years later despite medical and technological
advances, the United States still only ranks twenty-second
in infant mortality (Copeland, 1992).

The purpose of this dissertation is to determine how
comprehensive, community-based, perinatal case management
affects the perinatal and family outcomes of psychosocially
at-risk clients. Poor perinatal outcomes (low birth weight,
prematurity, birth defects, and infant mortality and
morbidity) are a result of a myriad of factors--poor access
to health care, poor nutritional status, low socioeconomic
status, lack of adequate housing, noncompliance to medical
care, adolescence, and multiparity. Various disciplines
have sought programs and developed services hoping to
decrease poor outcomes:

. Nursing developed school based health care clinics and

family life education.

. Medicine brought expanded hours and easier access to
care.

. Social work developed school based infant day care
centers.

. The federal Health Care Finance Agency developed

expanded Medicaid and insurance coverage for pregnant
women and young children.

. Home economists in cooperative extension developed
parenting and nurturing programs for adolescent
expectant mothers.

- Multidisciplinary teams developed comprehensive care
programs for pregnant women utilizing nutritionists,
social workers, nurse-midwives, public health nurses,
and perinatologists.

All these initiatives have had limited successes. Reasons

for this may include competition for scarce resources,

limited impact areas, or provision of only secondary
interventions.

The statistics surrounding perinatal outcome are
staggering:

. Twenty percent of all newborns are born with health
problems; 10% with serious medical problems (Lincoln &
Johnson, 1987).

. The number of premature births has risen steadily
since 1981. In 1989, premature births accounted for

10.6% of the total births (Steven & O'Connell, 1992).

. In 1988, 1 in 14 babies born in the United States
were of low birth weight (Fink, Yano, & Goya, 1992).

. Two-thirds of all neonatal deaths are due to low birth
weight (Watkins, 1988).

. Infants born to teenaged mothers are three times more
likely to die in their first 28 days of life (Ringdahl,
1992).

. The Black infant mortality rate in 1992 was 17.6/1000
as compared to the overall infant mortality rate of
8.9/1000 (Wegman, 1993).

In 1985 the Consolidated Omnibus Reconciliation Act

(PL. 99-272) was enacted. This law assisted the further

development of one-stop shopping services (multiple services

located at one site that cover a variety of health and human
services) and opened the door for multidisciplinary case
management services for perinatal clients. The central
theme of case management is the interaction between the
client and the case manager/case management organization to

(1) assess the client's lines of defense/resistance to

stressors, (2) to assess the degree of reaction and

reconstitution to develop mutually agreed upon and accepted
goals and (3) to provide through service and/or referral
intervention modalities to restore or maintain homeostasis
of the family ecosystem. Although the central theme is

identified, the conceptualization of case management varies:

 

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A process of ensuring that the services provided are
appropriate for the client's needs (Ryndes, 1989).
Planning and defining services that are coordinated
among all service providers with effective client
involvement and input (Cervera & Videka-Sherman,
1989).

A mechanism for coordinating community-based services
(Sevick, 1989).

The responsibility for the oversight of the woman's
care (Curry, 1987).

A system of patient care delivery that focuses on the
achievement of outcomes within effective and
appropriate time frames and resources (Swansburg,
1990).

Identification and "linkage" of patient to needed
services, monitoring patient needs, and participation
and when necessary, advocacy on behalf of

the patient with service providers (Wissow, Worshow,
Box & Baker, 1988).

A set of logical steps and a process of interactions
with service networks that assure a patient receives
needed services in a supportive, efficient, and cost-
effective manner (McKenzie, Trokelson, & Hall,

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8. A health care delivery process whose goals are to
provide quality health care, decrease fragmentation,
enhance the quality of life and contain costs (ANA
Publication #NS 32).

9. A systematic process of assessment, planning, service
coordination and/or referral, and monitoring through
which the multiple—service needs of clients are met
(Pittman, 1989).

With the mandate under the 1985 Consolidated Omnibus
Reconciliation Act, the charge for one-stop shopping (the
consolidation of health care, Medicaid coverage, WIC
participation, and a variety of human services at one site)
for prenatal care services based on the National Commission
to Prevent Infant Mortality's 1988 report Death before life:
The tragedy of infant mortality (Building on the Basics,
1990), and Health Care Reform, it is clear that the
comprehensive multidisciplinary approach will be the model
for prenatal care programs developed in the United States
for the remainder of this decade; however the effectiveness
of this strategy for reducing risks and thus improving
pregnancy outcomes and, in turn, family stability, has not

been fully documented.

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Information obtained from this study will allow health
and human service care providers an expanded format to
assist with meeting the needs of the community, meeting the
goals of decreasing infant mortality, strengthening family
bonds, and reducing wastage of dollars spent in duplication

of services.

CHAPTER 2

REVIEW OF THE LITERATURE

In 1979 Healehy Peeple, a report from the Surgeon

General, established a goal to reduce infant mortality to
fewer than 9 deaths per 1000 births (Platt, 1989). In 1978
the infant mortality rate was 13.8/1000. Thirteen years
later, in 1991, that goal was met with the rate at 8.9/1000,
however the United States ranked 24th in worldwide infant
mortality standings, a decline from 20th in 1980 (Infant
Mortality, 1993; Wegman, 1993). Despite technological and
medical advances in maternal-fetal care, poor perinatal
outcomes with resultant neonatal and child morbidity and
mortality continues to perplex scientists and health care

providers.

n r' t m 8
There has been a myriad of studies conducted on factors
that may affect perinatal outcomes. Increasing access to
prenatal care was considered the number one factor in
reducing infant mortality and morbidity over the past two
decades. Therefore, the majority of research centers on

barriers to care. The Institute of Medicine (IOM)

 

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identified the major barriers as (Curry, 1987):

1. Limited availability of providers of prenatal care.

2. Insufficient prenatal care services in sites serving
high-risk populations.

3. Experiences, attitudes, and beliefs among women that

disincline them to seek or maintain prenatal care.

4. Lack of transportation and shortage of child care
services.

5. Inadequate systems to recruit hard to reach women into
care.

Interventions successful in improving pregnancy
outcomes, although limited in scope and application,
include:

1. Initial and ongoing risk assessments.

2. Adequate prenatal care.

3. Nutritional counseling
4. Health education
5. Social support services.

Each of these interventions is reviewed in relation to

identified barriers and perinatal and family outcomes.

 

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Risk Assessments

There are various tools to determine risk status of
pregnant women. The Institute of Medicine in 1985 found no
consensus on a risk assessment tool that was both a reliable
and sensitive method for pregnant women in various
populations (Mawn & Bradley, 1993). Although each tool
varies in scope and complexity most address three major
areas: socio—demographic characteristics, lifestyle
factors, and medical/health status.

There is consensus on medical/health status risks and
pregnancy outcomes. Women with chronic conditions of
diabetes, hypertension, and cardiac or renal diseases are at
risk for less than optimal pregnancy outcomes. There is
also some consensus, although not unanimous, on other
medical conditions: chronic and acute anemia, thyroid
diseases, and collagen diseases. Obstetrical problems of
grand multiparity (greater than five pregnancies), abdominal
surgery during pregnancy, bleeding during pregnancy, uterine
anomalies, pyelonephritis, and previous delivery of a low
birth weight infant (weight under 2500 grams) are considered
high risk factors for poor perinatal outcomes. Health care
providers are well equipped to treat these medical and

obstetrical conditions and thus decrease the risks.

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Socio—demographic risk factors for pregnant women
include age less than 18 or greater than 35, single status,
poor economic status, minority race or ethnic group, less
than a high school education, and communication barriers.

In 1989 the number of low birth weight infants was
7.0/1000--the highest rate the United States has seen since
1978. If a woman was a teenager that rate was higher
(13.4). The same was true is she was 40 years of age or
older (10.5) (Stevens & O'Connell, 1992).

In 1988, 66% of births to teenagers were to single
mothers (LeHew, 1992) compared to only 15% in 1950 (Davis,
R., 1989). In 1989 births to teens increased to its highest
level in 15 years. Births to teens aged 15-17 was 36.5/1000
while those to teens aged 18-19 was 86/1000 (Stevens &
O'Connell, 1992). Infants born to mothers aged 17 or
younger are three times more likely to die in their first
twenty-eight days of life (Ringdahl, 1992). Post-neonatal
mortality rates are approximately twice as high for infants
of teens than for older women (McAnarney & Hendee, 1989a).
Teenaged pregnancies result not only in poor infant
outcomes, but are linked to high unemployment, poverty, and
lack of educational attainment for the parents. The child
born to teenaged parents is also at risk for lower
intellectual and academic achievement, social and behavioral

problems and becoming teen parents themselves (LeHew, 1992).

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Births to unmarried women hit a new high in 1990 with
1,165,384 babies born to single mothers. This breaks down
to 20% of all White births, 37% of all Hispanic births, and
67% of all Black births for an overall 28% single parent
birth rate compared to a 3.9% rate in 1950 (Beck, 1993).

Poverty "by itself does not contribute to poor outcomes
but is associated with...cultural, institutional, financial
and personal barriers to care that do convey high risk"
(Culpepper & Jack, 1993). In 1985, 75% of families
maintained by a woman under 25 years of age were living in
poverty (McAnarney & Hendee, 1989a). Fifty percent of all
women receiving government assistance had their first child
when they were teens (Ringdahl, 1992). Infant mortality
rates among low income children are twice that for non-low
income children (Rosenbaum, Hughes, Butler, & Howard, 1988).
Haas, Udvarhelyi, Morris, and Epstein (1993) found no change
in the incidence of poor birth outcomes in their study of
health coverage for poor uninsured pregnant women in
Massachusetts from 1984-1987. Piper, Ray, and Griffin
(1990) investigated financial coverage and adverse birth
outcomes in their 1984-1987 study in Tennessee on Medicaid
changes. They also found no improvement in birth outcomes.

The maternal mortality rates for Black and non-White
women are four times higher than for White women (Rosenbaum
et a1., 1988). Infant mortality rates are also higher for

non-White infants born in the United States. One-fourth of

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all the Black infants born in the United States are to
single teens (Davis, R., 1989). In 1992 the Black infant
mortality rate was 17.6/1000 as compared to the overall
infant mortality rate of 8.9/1000 (Wegman, 1993).
Schoendorf, Hogue, Kleinman, and Rowley (1992) studied the
infant mortality rates of college educated parents in 1983-
1985. They found that infants of Black college educated
parents were twice as likely as infants of White college
educated parents to have low birth weight and the risk of
very low birth weight (1500 grams or less) was three times
higher.

More than one million pregnancies occur to teens
annually. These teen mothers are less likely to finish high
school which contributes to their inability to achieve
economic independence. Parenthood before age 18 reduces
high school completion rates by 50% for women and 25% for
men (Ambler & Dull, 1987). Studies have shown however, that
living with their children (for Whites) and marrying the
mother (for Blacks) increases the odds that teen males will
finish high school (Davis, 3., 1989).

The major life style factors that are associated with
premature birth, intrauterine growth retardation, and infant
mortality are substance use/abuse, poor nutrition, and short
interpregnancy interval (less than twelve months between
pregnancies). The relationship of smoking to low birth

weight was established in 1957 by Simpson (Floyd, Rimer,

R; Roy: VIC,
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Giovino, Mullen, & Sullivan, 1993). Smoking continues to be
a major contributor to poor perinatal outcomes. Among the
3.9 million women delivering annually 25% smoke (Huddleston,
1992; Windsor, Li, Lowe, Perkins, Erschoof, & Glynn, 1993).
Approximately 5% of all prenatal deaths and 14% of all low
birth weight deliveries in the US can be attributed to
smoking (Culpepper & Jack, 1993). Smoking accounts for
20-30% of the low birth weight rate and 10% of the infant
mortality rates in the U.S. (Windsor et al., 1993). Smoking
reduces birth weight by an average of 150—250 grams and
doubles the risk of low birth weight (Willis & Fullerton,
1991). Land and Stockbauer (1993) analyzed smoking among
pregnant Black teens in Missouri from 1978-1990. They found
that the overall Black teen smoking rate decreased 28.6%
while the Black pregnant teen smoking rate decreased 15%.
They also found that the incidence of low birth weight
infants among Black teens decreased 13.6% over the same
period. McDonald, Armstrong, and Sloan (1992) in their
study of Montreal single new parents found smoking accounted
for 39% of low birth weight for gestational age, 35% of low
birth weight infants, and 11% of premature births.

Alcohol consumption and its effects on embryonic
development are well known. Current findings on alcohol
consumption and low birth weight are somewhat startling.
McDonald et al. (1992) found in their Montreal study of just

completed pregnancies that light consumption of alcohol had

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14

a small but significant reduction in risk relative to total
abstainers.

Consumption of cocaine contributes to a high incidence
of premature labor and birth and thus low birth weight
infants. Infants of cocaine users were three times more
likely to have low birth weight (Willis & Fullerton, 1991).
A retrospective population-based study in New York City
1988-1990 (Racine, Joyce, & Anderson, 1993) found that
receipt of prenatal care among cocaine users was associated
with significant improvements in birth weight.

Women who have short interpregnancy intervals are at
high risk for delivery of a low birth weight infant. A
multicenter study of 55,000 women from 1959—1966 found that
short interpregnancy intervals occurred in women who were
young, had less education, and were light weight (Klebanoff,
1988). Other researchers found that teens were likely to
have a second pregnancy within two years of their first

delivery (O'Sullivan & Jacobsen, 1992).

Prenatal_gare
"Prenatal care is defined as services provided to
all patients (mother, fetus, newborn) (1) from the time
of conception to the onset of labor, (2) during labor

and delivery, and (3) for an extended period after

delivery" (Dexelgnment. 1992, p. 4).

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The components of prenatal care include early and continuing

risk assessments, health promotion, and medical and

psychological interventions with follow-up. The objectives

for prenatal care based on the Report of the public health

service expert panel on the content of prenatal care,

October 1988 are (Culpepper & Jack, 1993):

1. For the pregnant woman:

a.

To increase well-being before, during, and after

pregnancy and to improve self-image and self-care.

b. To reduce maternal morality and morbidity, fetal
loss, and unnecessary pregnancy interventions.

c. To reduce the risk to her health prior to
subsequent pregnancies and beyond childbearing
years.

d. To promote the development of parental skills.

2. For the fetus and infant:

a. To increase well-being.

b. To reduce premature birth, intrauterine growth
retardation, congenital anomalies, and failure to
thrive.

c. To promote healthy growth and development,
immunizations, and health supervision.

d. To reduce neurological, developmental, and other

morbidity.

16

e. To reduce child abuse and neglect, injuries,
preventable acute and chronic illness, and the
need for extended hospitalization after birth.

3. For the family during pregnancy and the infant's

first year of life:

a. To promote family development and positive
parent-infant interaction.

b. To reduce unintended pregnancies.

'c. To identify for treatment behavior disorders
leading to child neglect and family violence.

Prenatal care utilization is influenced by financial

resources, system capacity, and cultural and personal
attitudes and beliefs. A 1983 study (Hutchins, 1985) for
the National Governor's Association found that women living
in poverty in the United States were three times more likely
to receive no prenatal care than women living in non-poverty
areas. The perception of cost barriers was the most
important variable in determining adequacy of prenatal care
received by teenagers in a study by Cartwright, McLaughlin,
Martinez, Caul, Hogan, Reed, & Swafford (1993). Harvey and
Fober (1993) in their study of rural Oregon women 1988-1990
found that despite the establishment of a program to provide
;prenatal care to low income women who could not afford it,
the most common reasons cited for inadequate prenatal care

‘were financial obstacles (70% had difficulty in paying for

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17

prenatal care and 55% had difficulty with medical insurance
coverage).

In the early 1980s states were able to appropriate new
state dollars to pay for prenatal services for women up to
185% of poverty who were previously ineligible for Medicaid.
Goldfarb, Hillman, Eisenberg, Kelly, Cohen, and Dellheim
(1991) studied the impact of a financial-based (cost-
containment) Medicaid program called HealthPASS had on the
adequacy of prenatal care and birth outcomes among
enrollees. They found no significant differences between
HealthPASS and Medicaid enrollees on either services or
outcomes. The GAO (U.S. Government Accounting Office)
report of 1987 on Medicaid recipients and uninsured women
(Platt, 1989) found that 63% of the women interviewed cited
lack of money to pay for prenatal care as the primary reason
for inadequate prenatal care. Family income, travel time,
plannedness of the pregnancy, and type of financial
coverage were significant predictors of when prenatal care
was initiated in McDonald and Coburn's (1988) study of Maine
women in 1983.

Available data suggest that prenatal care is cost-
effective. For every dollar spent on prenatal care, $2-
$3.33 is saved in neonatal intensive care for low birth
weight infants alone. The indirect cost of preventable low
birth weight and infant mortality has been estimated between

6-12 billion dollars annually in lost productivity (Platt,

 

 

 

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1989; Fink et al., 1992; Children's Defense Fund, 1991).

Thirty-four percent of pregnant women (approximately
1.3 million annually) receive inadequate prenatal care.
Inadequate care is defined as care started after the first
trimester, only one prenatal visit between gestational weeks
22-29, or less than 4 total visits (Lincoln & Johnson,
1987). Based on the 1987 GAO report, 81% of privately
insured women began prenatal care in the first trimester and
made nine or more prenatal visits compared with 36% of women
with Medicaid coverage and 32% of women with no health
insurance (Platt, 1989). In 1985, the National Center for
Health Statistics reported that only 45% of teenagers enter
prenatal care during the first trimester and 5% receive no
prenatal care at all (Cartwright et al., 1993). Women who
do not obtain adequate prenatal care double the risk of
having a low birth weight infant. These women are also at
risk for inadequate weight gain and delivering an infant
prematurely (Lincoln & Johnson, 1987). Showstack, Burdetti,
and Minkler (1984) used multiple regression to analyze birth
outcomes and prenatal care. They found an increase of
approximately 200 grams in infant birth weight when adequate
prenatal care was received.

Inadequate prenatal care is not only linked to
financial resources but to availability of health care
‘providers. In the early 19808, 44% of US physicians

providing obstetrical services did not accept Medicaid

 

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19

patients (Harvey & Fober, 1993). Expanded Medicaid and
increased payments to health care providers has brought the
participating physician rate to approximately 60% (Copeland,
1992). Unfortunately this still leaves a large portion of
pregnant women without physician providers who will accept
Medicaid. Pregnant women must travel quite long distances
in many areas of the U.S. to receive prenatal care. In
1987, 799 counties throughout the U.S. had documented
200,000 births where no prenatal care was available
(Copeland, 1992). Transportation difficulties have been
cited as a major barrier to obtaining adequate prenatal care
in several research studies (Harvey & Fober, 1993; Kugler,
Yeash, & Rumbaugh, 1993; Cartwright et al., 1993). Arizona,
the first state to enroll all Medicaid clients in a managed
care program, provides primary health care, no copayment for
prenatal care, and reimbursement for transportation to a
health care provider. This program, however, was not
effective in ensuring adequate prenatal care usage. The
researchers found that transportation problems (limited
access to bus services), other children in the family, lack
of social support, and lack of knowledge of Medicaid
coverage were the major barriers cited by the recipients

(Moore and Hepworth, 1994).

20

Cultural or personal factors that are significant
predictors of obtaining adequate care include (Harvey &
Fober, 1993):

1. Poor understanding or low value of the importance of
prenatal care.
2. Ambivalence about the pregnancy.
3. Stress
Cartwright et a1. (1993) study of teenagers' perceptions of
barriers to prenatal care found that the degree of support
after cost barriers was the most important barrier. Kugler
et a1. (1993) found a negative correlation between optimal
prenatal care utilization and dysfunctional family scores in
their research of 368 military pregnancy families in 1989.
Poland, Giblin, Waller, and Bayer (1991) found that 14.4% of
their study population of low income mothers in Detroit
cited prenatal care as unimportant (lack of knowledge of
importance of prenatal care) as a reason for missing

prenatal care appointments.

H ! .!.
Nutrition and its role in birth outcomes have been
studied thoroughly over the past few decades. Research was

instrumental in the initiation of the federal nutrition
program, Women, Infants, and Children (WIC), for pregnant
and lactating women and their children through age five.

‘Research findings were also instrumental in initiating SNAP,

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21

Supplemental Nutrition Assistance Program, which allows more
pregnant women to enroll in state funded forms of WIC.
Buescher, Larson, Nelson, and Lenihan (1993) studied the
impact of prenatal WIC on low birth weight and Medicaid
costs for newborn care for 1988. Their findings were
significant. White participants had 22% lower low birth
weight and 44% lower very low birth weight infants while
Black participants had 31% lower low birth weight and 57%
lower very low birth weight infants than non-WIC
participants. The cost-benefit analysis showed that for
every dollar spent on WIC services, Medicaid savings in
newborn medical care were $2.91.

Parker and Abrams (1992) replicated an earlier study by
Scholl on weight gain and birth outcomes. They found, like
earlier researchers, that low prenatal weight gain was
associated with low birth weight. Springer, Bischoping,
Sampsells, Mayes, and Petersen (1992) studied weight gain
with outcomes of birth weight and gestational age. They
found that women who were underweight reduced the infant's

gestational age at birth by 1.82 weeks.

H alth i n

Health education plays an important part in promoting
optimal birth outcomes. Health education in pregnancy
includes nutritional counseling, smoking cessation

awareness, avoidance of alcohol and illicit drugs, and

 

22

exercise. McCurdy's (1992) Colorado health project targeted
988 women to determine the effects behavioral changes had on
low birth weight. The researchers found that women who
resolved their behavioral risks had fewer low birth weight
infants than those who did not (3.7% versus 11.1%). They
also found that decreasing only one or two behavioral risks
had positive effects (see Table 1). Other researchers

found that smoking cessation in the first half of pregnancy
will provide the same low birth weight risk as a non—smokers
(Floyd et al., 1993). McDonald et al. (1992) found that
women with increased alcohol intake have low birth weight
infants. They also found in their study population that
smoking accounted for 35% of low birth weight infants and

11% of premature infants.

Table 1.

Bshaviggsl Risks sad Risk sf Delivsring ng Bigth weigh;
Igfants [Adapted from findings of McCurdy. (1992). Colorado

mm; D- 2621-

Risk Behavior % of Risk % of Risk
Behavior Change No Change

 

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Sssisl suppogt

Social support is the network of resource, tangible and
psychological, that assists persons or families to cope with
life events. Tangible support is the specific behavior or
resource that is provided or shared. Psychological support
is provided through emotional and informational assistance
(Knox & Snowden, 1989). Pregnancy is a life cycle event
that is also influenced by concurrent stressors: concerns
with medical care, family relationships, neighborhood crime,
financial insecurity, and/or isolation. The woman must
appraise the stressors, identify coping mechanism, and react
to the situation.

"Coping mechanism and sources of social support are

important to stress assessment in that they provide

a basis for understanding each individual's potential

for psychological adjustment throughout the pregnancy"

(Knox & Snowden, 1989, p. 181).
Pregnancy may exert negative effects.

"It may divert a woman or couple's attention from

the pregnancy and decrease the priority of pregnancy-

related events...Stress may create unhealthy coping

behaviors including smoking, substance use, inadequate

rest, and excessive work. It may alter interpersonal

relations and decrease the resources available to the

woman" (Culpepper & Jack, 1993, p. 606).

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McAnarney and Stevens-Simon (1990) found that
psychologically stressed women gained less weight and had
infants of lower birth weights. Bryce, Stanley, and Garner
(1991) also found that stress in pregnancy was associated
with premature births and low birth weight infants.
Williamson and LeFevre (1992) studied the relationship of
tangible support and perinatal outcomes in Missouri from
1984-1986. They found that women with low tangible support
(no or only one reliable support person) had a higher rate
of neonatal death, neonatal intensive care unit stays, low
birth weight, and low APGAR scores (a scoring system that
evaluates the physical condition of the newborn at birth and
the immediate need for resuscitation) (Olds, London, &
Ladewig, 1992) than those women with moderate or high
tangible supports (two or more people). Zuckerman, Amaro,
Bauchner, and Cabral (1989) studied 1014 women between 1984-
1987 to determine the relationships of depressive symptoms
in pregnancy and maternal health status and behaviors. They
found that depressive symptoms were significantly associated
with poor maternal health behaviors of poor weight gain,
smoking, and alcohol and cocaine use.

Rofe and Goldberg in 1983 (Istvan, 1986) studied the
relation of blood pressure to stressful environments just
prior to childbirth in Israel. They found consistent
increases in blood pressure with increasing level of stress

exposure (as determined by the level of terrorist activity).

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They found 20% of women in low stress areas had diastolic
blood pressures above 85 mmHg as compared to 49% from high
stress areas.

A stressful environment can also be the home
environment itself. Based on findings from the second
National Family Violence Survey (Newberger, Barkan,
Lieberman, McCormick, Yllo, Gary, & Schnechter, 1992) 154
acts of violence per 1000 women occurred during the first
four months of pregnancy and 170 acts of violence per 1000
women occurred during the fifth through ninth months of
pregnancy. Bullock and McFarlane (1989) studied the effects
of battering in pregnancy on birth outcomes. In their study
of 589 women, the percentage of battered women who gave
birth to low birth weight infants was twice that of the non—

battered woman (12.5% versus 6.6%).

Summ F ctors hat nfluence Perinatal Outcomes:
Research has identified components that are successful

in improving perinatal outcomes:

1. Initial and ongoing risk assessment and adequate
prenatal care.

Barriers of excessive stress, ambivalence about the

pregnancy, and poor understanding of or low value of

prenatal care are significant predictors of obtaining

inadequate prenatal care. Every dollar spent on prenatal

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26

care saves $3.38 in care of the low birth weight infant
(Harvey & Fober, 1993).

2. Nutritional counseling

There is a positive relationship between adequate early
weight gain, decreased substance use/abuse behavior, and
gestational age/birth weight (Springer et al., 1992). WIC
participation decreases the number of low birth weight and
very low birth weight infants born annually (Buescher

et al., 1993).

3. Education to reduce or eliminate unhealthful habits
Smoking and alcohol use is associated with low birth weight
and premature infants (McDonald et al., 1992).

4. Social support services

Low birth weight infants are more likely to be associated
with women who are battered. There are conflicting findings
on the relationship of early prenatal care, birth weight,
and neonatal mortality with social support programs
(McDonald & Coburn, 1988; Piper, Ray, & Griffen, 1990;

Goldfarb et al., 1991).

C r 8
Research findings document the complexities of our
ecosystems: optimal perinatal outcome is greater than the
sum of the factors. Programs that address perinatal
outcomes, and thus family outcomes, must address the whole

ecosystem of the pregnant woman and her family to provide

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27

success. The National Commission to Prevent Infant
Mortality in 1988 reported (Sharp, 1993, p. 18):
"Unless every pregnant woman and infant in the United
States has access to early, good, quality,
comprehensive prenatal and pediatric care, no progress
will be made in the area of infant mortality."
Programs developed that address perinatal outcomes and the

pregnant woman and her family are reviewed briefly.

Csmprshsgsivs Prsnstsl Care Programs

Comprehensive prenatal services include prenatal care
and psycho-social supports. Comprehensive care has the
"potential to ensure that the diverse elements of care are
provided through an integrated package of coordinated
services" (JessOp & Stein, 1994). Ideally this integrated
package should be located in one setting.

"One—stop shopping describes a client-centered system

that enhances access to care by improving integration

and coordination among programs, ensuring comprehensive

delivery of services and simplifying enrollment
procedures and eligibility criteria for health and
social services and financial assistance" (Macro
Systems, 1990, p. 1).

There are several one-stop shopping programs in the United

States that provide comprehensive prenatal services:

28

Pregnancy Aid of Snohomish County, Everett, Washington:
Provides emergency supplies of baby food and
formula, emergency housing, prenatal vitamins,
public information programs for schools and
community groups, problem-solving assistance for
clients facing red-tape difficulties. (Healthy
EQLhEIB snd hsalthy babies, 1986).

Birthright Pregnancy Care Center, Hastings, Nebraska:
Work with clients on a one to one basis addressing
problems of abuse, housing, education, clothing,
transportation and legal aid (Healthy mothsrs and
hsslthy bsbies, 1986).

Healthy Start, nationwide programs: Mobilizes
communities to pull together health, housing,
nutrition, social, job training, and economic
development services to assist low income pregnant
women (Sharp, 1993).

Jackson-Hinds Community Health Center, Jackson,
Mississippi: Provides basic medical care
(prenatal, post-partum, family planning, and child
health), laboratory services, pharmacy, nutrition
education, WIC, social services, homeless shelter,
home visitation program, and high—risk infant

tracking (Macro Systems, 1990).

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Duvall County Public Health Unit, Jacksonville,
Florida: Provides prenatal care, post-partum
care, family planning, WIC, and presumptive
Medicaid eligibility (Macro Systems, 1990).

Childbearing Women's Project, Barre, Vermont: Provides
prenatal care, WIC, home visits, delivery service,
and assistance with Medicaid forms (Macro Systems,
1990).

Comprehensive care programs differ greatly in scope and
breadth from one agency or locale to another. Prenatal care
programs that provide home visitation for social support and
home assessment are one type of comprehensive care service.
Blondell and Breart's 1992 meta-analysis of three randomized
controlled trials of 1410 women who had prenatal
complications found no statistical significance in home
visitations on antepartal hospitalizations. However,
Helewa, Heamon, Robinson, and Thompson (1993) contribute an
annual savings of $148,000 to home visiting in mild pre-
eclampsia management in their 1985-1989 study of 321 women
in Winnipeg, Canada.

The National Commission to Prevent Infant Mortality has
included home visitation as a strategy to improve perinatal
outcomes (Olds, 1992) Bryce et a1. (1991) found no
significant difference on the effectiveness of home visiting
with the prevention of premature births in their study of

1970 women in Western Australia. Conversely Olds' (1992)

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study of 400 women in Elmira, New York found that women who
received home visitation had reduced smoking, improved
nutritional intake, and had 75% fewer premature births than
their comparison groups.

The 1980s saw school-based teenage clinic developing to
address the special issues of adolescents: relationships,
decision-making, sexual concerns, sexually transmitted
diseases, contraception, and teen pregnancy. A study of
school-based clinics and their effectiveness on birthrates
in St. Paul, Minnesota 1971-1986 showed no difference in
school-wide birthrates (Kirby, Resnick, Downes, Kocker,
Gunderson & Potthoff, 1993). Setzer and Smith (1992)
studied 339 teenaged mothers in Dallas finding no
significant differences in gestational age, infant birth
weight, or repeat pregnancy rates in school—based and non
school-based programs.

Both home visitation and school-based health care
programs provide some components of comprehensive prenatal
are services. Other programs have developed that stress
prenatal care, psychological support, and financial
assistance. Sokol reports comprehensive prenatal care is
associated with higher birth weights and improved perinatal
outcomes (Showstack et al., 1984). Felici, Granados, Ances,
Hebel, Roeder, and Heald (1981) studied a comprehensive
prenatal care program for inner city teenagers. They

matched the 67 teenagers aged 15 and below with a

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31

comprehensive group of 67 inner city teenagers who received
standard obstetrical care. The teenagers in the
comprehensive group were seen by a physician, nutritionist,
and social worker. The study group had 9% low birth weight
infants as compared to 20.9% in the control group. Rabin,
Seltzer, and Pollard (1991) also studied comprehensive
prenatal care programs for teenagers. Their study matched
teenagers in comprehensive care to teenagers in standard
adult obstetrical clinics. They found lower maternal and
infant mortality, more frequent contraceptive use, increased
regular school attendance, and decreased repeat pregnancy
rate in the teen comprehensive care group. Horwitz,
Klerman, Kuo, and Jewel (1991) looked at teenage mothers via
long term follow-up of the Young Mother's Program. The
Young Mother's Program was one of the first comprehensive
programs for pregnant teens in the United States that
provided obstetrical care, social services, and educational
services. At the 20-year follow-up the women who were
members of the comprehensive program reported a greater
sense of control over their lives, had higher educational
aspirations for themselves and their children, understood
their roles as mothers, and reported little social
isolation. McLaughlin, Altemeier, Christensen, Sherrod,
Dietrich, and Stern (1992) studied the effects of
comprehensive care and birth outcomes among low income

women. The comprehensive prenatal care group received care

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from a team consisting of nurse-midwives, social workers,
nutritionists, psychologists and paraprofessional home
visitors while the control group received standard
obstetrical care. Multiple regression analysis showed that
comprehensive prenatal care was related to higher birth

weights for primigravidas but not for multigravidas.

Case_uanes§ment_2rggrem§

In 1988, Vince Hutchins of the U.S. Bureau of Maternal
and Child Health called for a new approach to care for the
vulnerable populations of pregnant women and children:

"A system that assures effective continuity of care

with appropriate monitoring, referral, and specialized

services..." (Hutchins, 1988, p. 2).
This system, case management, coordinates community based
services through continuity of care that emphasizes an
individualized approach to patient care and a commitment to
the ideals of comprehensiveness, thus empowering client
decision-making, enhancing psychosocial functioning, and
promoting health. Case management requires multi-
institutional and interdisciplinary efforts to influence
economic, social, and lifestyle issues as well as access to
health care to promote improved perinatal and family

outcomes .

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In September 1990, the United Nations' Convention on
the Rights of the Child was signed by over seventy world
leaders. Within a year 105 countries had ratified this
document that specifies in Article 24:

"The recognition of the child's right to the highest

attainable standards of health, including appropriate

prenatal and postnatal care for all mothers, taking
measures to diminish infant and child mortality, and
the development of preventive care, including family

planning services" (Mawn & Bradley, 1993, p. 78).
Absent from the list of national and world signatures was
the United States. The American Academy of Pediatrics
endorsed this treaty statement and has asked President
Clinton for support. President Clinton has asked the U.S.
State Department to review the Convention to determine if it
is consistent with state laws (Haggerty, 1994). Despite the
absence of the U.S. ratification, states throughout the
United States have initiated case management programs to
improve perinatal outcomes.

The Teen Parent Initiative Pilot Program was a five-
year case management program in Texas. Two separate
programs were developed: TEAM (Training and Education for
Adolescent Mothers) and Redirection. These two programs,
with similar services although different formats, provided
on-site comprehensive service of education, job development

and training, child care, and health services of prenatal

34

care and family planning along with case management services
of counseling, brokering, advocacy, and linkage (Isss_
Psrsnt, 1987). While project TEAM was discontinued in its
third year due to financial problems with the parent agency
(Tssn Parsst, 1990), both programs had success in terms of
lower low birth weight rates and lower repeat pregnancy

rates (see Table 2).

Table 2.

Low Birgh weight and Pregsansy Recidivism Rates (Results
abstracted from the Isen Psrsnt Initiative Pilot Prggram of
1mg. 1991) .

National Rate TEAM Redirection

 

at One Year

Repeat

Pregnancy
at Two Years

 

 

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35

Families with a Future (Illinois Department of Health,
1990) was Illinois' case management program to reduce infant
mortality. This program brought to targeted areas
throughout the state integrated community-based health and
social services to ensure access and utilization of needed
services to pregnant women and their families. The results
were dramatic for the non urban areas. Infant mortality was
deceased 22.4% in the non urban targeted areas. Neonatal
mortality also decreased by 23.5% in the non urban targeted
areas. The targeted areas in Chicago saw a smaller decline
in infant and neonatal mortality that the researchers
attributed to the complex and persistent social problems
that face Chicagoans.

Project CONNECT in New York City is a collaborative
effort to facilitate access to and expand delivery of health
and human services to pregnant and parenting women through
comprehensive case management and provision of priority
access to needed services. Special attention is given to
high-risk women presenting with late or no prenatal care,
pregnant teenagers, substance/alcohol abusers, and HIV
positive women (Randolph & Sherman, 1993). Since this is a
relatively new program, statistical evidence of

effectiveness is not available.

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Another program in its infancy is the New Mexico
Families FIRST (Families and Infants Receive Services and
Training) project (Mawn & Bradley, 1993). Families FIRST is
a 4-year demonstration project for Medicaid eligible
pregnant women and their children in four sites throughout
the state. The program provides a nursing case management
approach that includes education, outreach, and care

coordination.

Prsgsts; Care Programs Summary

Comprehensive and case management programs addressing

 

prenatal care attempt to answer the charge given to the
world at the WHO/UNICEF 1978 Alma Ata conference, Health for
all by the year 2000. Article VII of the Declaration of
Alma-Ata states (Owen, 1987, p. 15):
"Primary health care relies at local and referral
levels on health workers, including physicians, nurses,
midwives, auxiliaries, community workers, as well as
traditional practitioners, as needed, suitably trained
socially and technically to work, as a health team and
to respond to the health needs of the community."
Although multidisciplinary and interdisciplinary efforts
have addressed perinatal outcomes, these programs vary
greatly in their scope, breadth, and degree of interaction.
Conflicting findings exist between similar and dissimilar

comprehensive programs; thus, no statistical inferences can

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37

be determined. The effectiveness of case management program
for reducing risk and improving both perinatal and family
outcomes have not been fully documented perhaps due to the
infancy of these programs. This dissertation will
investigate the effectiveness of community-based
comprehensive case management in the prenatal care setting

in improving perinatal outcomes as well as strengthening the

family unit.

CHAPTER 3

A REVIEW OF CONCEPTUAL FRAMEWORKS

Case management is proposed as a method for improving
perinatal outcomes. The method provides not only
comprehensive health care services, but also promotes
primary interventions as well as secondary and tertiary
interventions. The proposed comprehensive approach to case
management in the perinatal setting not only impacts
perinatal outcomes but focuses on the pregnant woman and her
family ecosystem promoting wellness throughout the life
cycle.

Both Neuman's nursing system model and family ecosystem
framework utilize general systems theory to identify the
concepts of wholism and non-summativity. The frameworks
provide for woman with her unique characteristics and
interactions as the central core of the model. Boundaries
that protect and defend this core from the environments that
interface and interact with each other and with the central
core are identified. Together the frameworks provide a
model of wellness that represents a multicausal relationship
between the environments and the human environed unit (the

central core). When entropy occurs, or when boundaries can

38

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39

no longer protect and defend, the synthesized framework
provides the basis for a dynamic and interactive process to
maintain, restore, or attain optimal wellness. This process
is entitled case management. The scope and process of
community-based, comprehensive, perinatal case management
will be identified through the conceptual theories and their
synthesis. This will enable the researcher to discuss the
implications of the research findings with special emphasis
to community-based primary nursing care and to provide a

critical science perspective.

Family Esosystem Framework

Although the conceptual framework of family ecosystem
is relatively new (since the late 1970's), it has its roots
stretching back into the last century. In 1866 Ernest
Haeckle coined the term "ecology" to conceptualize the
relationship of an organism with other organisms and with
their environments (Grief & Lynch, 1983). In 1892 Richards
proposed that:

"environment was being transformed by technology, but,

people must retain some control over their lives and

environment...[Ecology is] a means for applying
principles, methods, and results of science for
improvement of peoples lives and their environment"

(Bubolz & Sontag, 1993, p. 420).

4O

Ecology was not, however, considered a true science until
1915 when Robert Park published his ecological study of the
city and its peoples in an article entitled: The city:
Suggestions for the investigation of human behavior in city
environment (Wirth, 1961). In the 1950's Hawley introduced
the family in an ecological perspective. Using Tonnies'
ideas of Gemeinschaft and Gesellshaft to show the
relationship of the family unit to its environment.
(Gemeinschaft is conceptualized as the individual being born
into a small homogeneous and intimate group in which
interrelations are personal and based upon common interests.
Gesellshaft is conceptualized as the individual matures and
moves out into a large universe of interrelations
characterized by impersonality and functional specialization
(Hawley, 1950, p. 208).

In 1970, Hook and Paolucci brought forth the concept of
family as an ecosystem:

"The family is a life support system, dependent on the

natural environment for physical sustenance and on the

social environment for humanness and for giving quality

and meaning to life" (Bubolz & Sontag, 1993, p. 423).
This concept borrows from general systems theory especially
in regard to two aspects:
1. Cybernetic communication
2. The action of one unit affecting the rest of the

system.

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41

Family ecosystem builds upon ecological theory by
concentrating on the linkages among systems and how a change
in one system will produce a change in another system. In
the family ecosystem, the family is placed at the core of
the universe (the human environed unit) and the environments
that interface and interact with the family encircle it.
Bubolz, Eicher, and Sontag (1979) conceptualized these
environments as the human behavioral environment, the human
constructed environment, and the natural environment (see

Figure 1).

 

Figure 1.

E o s m- A.M . Adapted from:
Bubolz, M, Eicher, J, and Sontag, M. (Spring
1979). me E mi

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42

Bronfenbrenner used a similar nesting model (see Figure 2)
but identified the environments in a general systems
perspective of microsystem (the family), mesosystem
(relations among family and community), exosystem (community
and neighborhoods), and macrosystem (cultural beliefs and

institutions).

 

Figure 2.
MW. Adapted from:
Bronfenbrenner, U. (1979) The esslggy of

human devslspmsnt: Expsrimssts by sagurs
ssg_gssigs. MA: Harvard Press.

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43

The family ecosystem perspective was developed to address
problems related to the family and its environments.

Up to this period research delved into the family through
the sum of its members therefore not looking at the

unit by and of itself. This perspective allows the family
to be viewed through its life cycle stages. The family
ecosystem framework allows the family to be studied and
assessed through its interaction and within the environment
and the changes among the environments. The underlying
values at the base of family ecosystem theory are those
concerned with human betterment: economic adequacy,
justice, freedom, and peacefulness. Family ecology's
scope:

"attends to special problems of groups and subcultures

who lack power, self determination, and access to

resources and who experience discrimination and
prejudice. These...include racial and ethnic
minorities, the handicapped, women, the poor, and to

old" (Bubolz & Sontag, 1993, p. 427).

The scope of the family ecosystem perspective can be
addressed as a macrotheory as it allows for a broad range of
phenomena to be researched "that cannot be adequately
studied by using other paradigms or theories of more limited
scope" (Bubolz & Sontag, 1993, p. 428). Siporin in 1979

(Grief & Lynch, 1983, p. 56) stated that the family

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ecosystem framework "accepts diverse theoretical

orientations, such as psychoanalytic, problem-solving,

behavioral, existentialist, and other approaches".

Adolescent pregnancy, family boundary ambiguity, eldercare,

child abuse, and marital discord are among the phenomena

studied.

Family ecosystem theory is evolving as more scientists
are utilizing the concepts and model in their studies. The
theory analyzes family and describes family relationships to
the environments within a circular causality and reciprocal
interactional process.

The key assumptions of the family ecosystem include:

1. The family ecosystem is a semi-closed, mutually
interacting group of people who have a common theme,
goals, interests, and possessions.

2. "The family carries out physical-biological sustenance,
economic maintenance, psychosocial, and nurturance
functions for its members, for itself as a
collectivity, and for the common good of society"
(Bubolz & Sontag, 1993, p. 425).

3. Society is an organization of specialized, functioning
parts, each of which is essential to the survival of
the whole (Hawley, 1950).

4. The human environed unit and its environments can be
viewed as nested systems that interface though the

use of feedback loops.

feeds;

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2“ iv»
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45

5. The family ecosystem is a cybernetic system. It
maintains control and adaptability by informational
feedback (Moran, 1982).

6. The family and its environments are dependent upon each
other. The action of one part affects the actions of
the other parts.

7. The family ecosystem has an adaptive nature, thus it is
able to react to and respond to change within the
environments and stresses within the human environed
unit.

8. The family ecosystem is dynamic.

9. The family ecosystem maintains homeostasis.

10. Families interact with multiple environments (Bubolz
& Sontag, 1993).

11. The family and its environments are linked by the flows
of energy, matter, and information (Moran, 1982).

12. Equifinality is an integral part of analyzing family
ecosystems.

‘The major concepts of the family ecosystem perspective
include:

1. System: A group of components that interact with each
other in a symbiotic relationship so that the whole is
greater than the sum of the parts.

2. Ecosystem: The relationship (boundaries, interactions,

and interfaces) of an organism (man, family, or

organization) with its environments.

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46

Environment: "The sum total of the physical,
biological, social, economic, political, aesthetic, and
structural surroundings for organisms" (Bubolz, Eicher,
& Sontag, 1979, p. 29).

Family: A semi-closed, mutually interacting system of
independent personalities who have a common theme and
goals characterized by long-term, intimate, reciprocal
relationships occupying a common living space for a
period of time and utilizing and sharing resources.
They may be connected by blood, marriage, adoption, or
culturally recognizable forms of unity and they share a
past history, a present reality, and a future
expectation, often, of transgenerational relationships
(Hook & Paolucci, 1970; Melson, 1980; Kramer, 1985).
Interface: The area where two ecosystems share a
common semi-permeable or permeable boundary that allows
for exchange of data between those ecosystems or
transformation of resources.

Boundaries: "The mechanism by which systems monitor
the intake and output of information and resources"
(Kostelnik, Stein, Whiren, & Soderman, 1988, p. 10).
Adaptation: The ability of an individual or group to
change based on the stressors they encounter or the
environment which has changes usually secondary to

humankind's interaction with that environment.

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47

Communication: A transactional process whereby a
message is transmitted from a source to a receiver via
one or more channels. This message is goal-oriented
and is influenced by noise or barriers that may

include attitudes, beliefs, values, and cultural modes
of the sender and/or receiver.

Social structure: "The established pattern of

internal organization of any social group. It involves
the character of the sum total of the relationships

which exist between the members of the group with each

other and within the group itself" (Fairchild, 1961,
p. 293).
Relationship: "A tie or bond in which a person

invests energy into another person, object, or activity
and the formation of a commitment" (Blitsen, 1971,

p. 59).

Energy: The exchange of heat or calories needed to
transform one resource into another resource.

Resource: "Those tools which one has at his/her
disposal to use to obtain goals or to satisfy wants or
needs" (Wehlage, 1985, p. 215).

Time: The concept of calendar, history, future,
season, pace, and duration as a dimension in which all

ecosystems are involved to some extent.

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48

14. Human environed unit: "An individual or group of
individuals who have feelings of unity, share some
common resources, goals, values, interests, and have
some sense of common identity" (Bubolz et al., 1979,
p. 29).

15. Interaction: The exchange of energy between two or
more organisms or units usually through the processes
of communication or social behavior.

The family ecosystem is a construct of the family
embedded in the environments, and the interactions among and
between them, the components of the environments, and the
family (see Figure 3) (Bubolz et al., 1979). Later

theoretical formulation by Bubolz and Sontag has adapted the

environments:

1. Natural environment to natural physical-biological.
2. Human constructed environment to human built.

3. Human behavioral environment to socio-cultural.

For this paper the former descriptions are used for ease in
synthesizing the family ecology framework and the Neuman

system model. Each of these will be discussed in brief.

 

F‘r‘

IC‘ .3 [*3 7'?

49

Hanna Constructed Environ-at

 

 

Figure 3.

Waite.- Adapted from: Bubolz.
M., Eicher, J., & Sontag, M. (Spring, 1979).
W. p- 29.

Family Unit

The family unit is located at the core of the family
ecosystem. Family is defined by the concept human
environed unit. Based on general systems theory, the whole
is greater than the sum of the parts. Therefore, in the
family ecosystem the family unit is greater than the sum of
the individual members. Also based on systems theory, a

change in any one part will produce change in the whole.

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Thus, in the family ecosystem, a change in any individual
such as adaptive behavior, will produce a change in the
entire family. The family processes are regulated by the
dimensions of energy, space, and time. According to Melson
(1980, p. 173):

"the perception of energy resources is limited,

not only by family perceptual style, sensory awareness,

information seeking, and the life, but also by the

family's links to the other environmental systems

within which it is embedded--the legal, economic,

education, and political systems".
The social mechanisms of energy include fueling, investing,
and mobilizing (Kantor & Lehr, 1975). Fueling is concerned
with the acquisition of energy. It involves surveying,
tapping, charging and requisitioning. Energy investing
consists of reconnoitering, attaching, committing,
detaching, and accounting. Energy mobilization involved
gauging, budgeting, mustering, transforming and
distributing.

Melson (1980, p. 75) defines space as "the process by
which family members act on and in their spatial
environment". This process addresses three separate but
interrelated concepts of territorial space, personal space,
and privacy. These concepts are further divided into the
components of bounding, linking, and centering (Kantor &

Lehr, 1975). Bounding is the boundary regulation component

 

 

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of the family. It consists of four mechanisms: mapping,
routing (the direction of traffic within the home and
family), screening (permeability of the boundaries), and
patrolling. Linking is the regulating of distance. It has
five mechanisms: bridging, buffering, blocking out,
channeling, and recognizing. Centering is the organizing of
the space in which the family lives. It includes locating,
gathering, design, arranging and spending.

The time dimension has three components: orienting,
clocking, and synchronizing. Orienting consists of four
mechanisms: past, present, future, and non-temporal.
Clocking is keeping track of date, day of week, and time
through the use of sequencing, duration and pacing.
Synchronizing includes setting, coordinating, and
programming. Thus these three dimensions of energy, space
and time are "the physical media through which each family
system marks off its pathways for obtaining the goal they

seek" (Hill, 1984, p. 9).

W

The environment can be structurally divided into three
sub-environments that are both distinct yet interrelated.
These sub-environments are the natural environment, human
constructed environment, and the human behavioral

environment (Bubolz et al., 1979).

52

The natural environment "supports human life in that it
provides the energy and materials on which all life depends"
(Bubolz et al., 1979, p. 29). Three components help to
regulate life: space-time, physical, and biological.
Space-time is concerned with the "three-dimensional expanse
in which events occur and in which matter and energy exist"
(Bubolz et al., 1979, p. 29) and the duration and sequencing
of those events. The physical component addresses the
living organisms of plants and animals that help to regulate
the natural environment.

The human constructed environment is defined by Bubolz
et al. (1979, p. 29) as "an environment altered or created
by human beings". Three components: socio-physical,
socio-cultural, and socio-biological, are concerned with the
prevalent systems of humankind--agriculture, business-
economics, politics, education, medicine, religion, and
technology. The socio-physical component specifically
addresses modifications to the environment in terms of
roads, cultivation of the land, buildings, clothing and
technological machines. The socio-cultural component is
concerned with aesthetics--language, law, and social
institutions. The socio-biological component encompasses
modifications to plants, animals, and humans through the use

of genetic engineering and programs such as reforestation.

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The human behavioral environment is "the environment of
human beings and their biophysical, psychological and social
behaviors" (Bubolz et al., 1979, p. 30). The components
address the family structure--family form, size, living
space, and territoriality--and the socialization (the social
component), attitudes, values, and beliefs (the
psychological component), and population--density, age,
fertility rates, family planning, and body movements--
posture (the biophysical component) (Bubolz et al., 1979;
Hildebrand, 1987).

The conceptualization of these environments suggests
that they are structurally separate, but in reality they are
embedded within each other and are essential in providing
the family with the resources necessary for life. The
environments pose limitations and constraints, possibilities
and opportunities that guide the family in its decision-

making behavior (Bubolz & Sontag, 1993).

W

The central mode of the family ecosystem framework is
interaction. (The interactions are characterized by the
dotted lines in Figure 3). Interactions occur in five ways:
(Borland, 1987):

1. Interaction within the family unit.

2. Interaction between the family unit and the

environments.

54

3. Interaction within one of the environments.
4. Interaction among the environments.
5. Interactions between family units.

These four ways are not distinct but can occur
simultaneously. One of the assumptions regarding family
ecosystems is the idea of cybernetics. This notion is
inherent to this component. Information enters the family
unit though inputs from the environments as matter and
energy and as feedback from family processes. The family
examines this information that "moves them to either change
its patterns of internal organization, rules, goals, and
eternal relatedness or try to maintain its previous patterns
(Bubolz & Whiren, 1984, p. 6). The result of family
decision—making is then returned to the environments as
output in the form of transformed energy (as material goods,
information, waste products, and human resources). These
outputs in turn are utilized by the environments and by
other ecosystems (Andrews, Bubolz, & Paolucci, 1980). The
family ecosystem is dynamic thus the cybernetic process is a
constant, at times unconscious, state of exchange. However,
the family ecosystem attempts to maintain homeostasis so
there is a state of relative balance and stability

throughout this interactive component.

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Nesmag Nursing Systems Model Framework

Neuman's systems model (NSM) is a nursing conceptual
model that was first published in article form in 1972 by
Neuman and Young for graduate nursing education (Neuman,
1972). The article, A model for teaching total person
approach to patient problems, introduced the nursing world
to a wholistic approach to clients, environments, and
stressor relationships. Over the next two decades the model
expanded into one of the three most utilized nursing models
for nursing research internationally (Beckman, 1994). The
model is amenable to interdisciplinary use throughout health
and human services research (Neuman, 1982).

The model can be described as either grand or macro
theory due to its origins and applications. Betty Neuman
drew upon major theories in the development of her model:

. §§§Lél£= From which the concepts of wholism,
perceptual fields, and homeostasis are borrowed.

. Sslye's stgess thssgy: The stressors and their
relationships to woman and her environment form the
basis of the NSM.

. Wisdesbash: Neuman used this theory to link the
nursing process to stressors and interventions. She
also adopted the validation of client behaviors and
perceptions with client cooperation as a central tenant

in the NSM.

56

. t ms: General systems theory ties the theory and
concepts together in an open dynamic system that is in
a state of equilibrium with the environment. It
provides the unifying focus of non-summativity (where
the whole is greater than the sum of its parts).
Neuman's model views each client (individual, family or
community) as "a core surrounded by three hypothetical
boundaries--lines of resistance, normal line of defense, and
flexible line of resistance" (Thibodeau, 1983, p. 106) that
protect, buffer, and defend against stressors--
intrapersonal, interpersonal, and extrapersonal, in the
environment. The role of the nurse is to provide
interventions through primary, secondary, and tertiary
levels of prevention thus assisting the boundaries to
maintain or return to an optimal wellness state for the
client (see Figure 4).
The key assumptions of the Neuman Systems Model
include:
1. The client is in a dynamic energy exchange with the
environment (Neuman, 1989b).
2. Each stressor is different in its potential to disturb
an individual's equilibrium or normal line of defense

(Fawcett, 1986).

57

 

 

 

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Figure 4.
Neumss Systsm Msdsl. Adapted from: Neuman,

B. (1979). NUEsisg Rssesrsh, 21(3).

Each system is a dynamic composite of the
interrelationships between physiological,
psychological, socio-cultural, developmental and
spiritual variables that are present at all times and
determine the nature and degree of the systems'
reaction to the stressor (Fawcett, 1986).

Each client, over time, has evolved a normal range of
responses which is referred to as the normal line of

defense or wellness (stability state).

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58

Each client system has a set of internal resistance
factors (lines of resistance) which function to
stabilize and return the client to the normal line of
defense or possibly to a higher level of stability
following an environmental stressor reaction (Neuman,
1989b).

There are internal, external and created environments
in which the individual maintains varying degrees of
harmony and balance between the three.

The client is in a reciprocal relationship with
environment by interacting with this environment
through adjustment or accommodation (Marriner,

1986).

The major concepts in understanding the complexities of

the Neuman systems model include:

1.

Stressors: Tension-producing stimuli that have the
potential for creating disequilibrium, situational or
maturational crises or the experience of stress.
Basic structure energy resources: Basic survival
factors or energy resources that are unique to the
individual but within a common range of responses
(Marriner, 1986).

Flexible lines of resistance: Internal factors that

help the person defend against a stressor.

 

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4. Normal line of defense: The state of wellness or
adaptation the person has maintained over time that is
considered normal for that person.

5. Flexible lines of defense: Protective buffer for
preventing stressors from breaking through the solid
line of defense.

6. Degree of reaction: A person's relationship to stress.

7. Reconstitution: The state of adaptation to stressors
in the internal and external environment.

8. Intervention: Activities that reduce the person's
encounter with the stressor and/or strengthens the
lines of defense to reduce the reaction.

9. Wholism: Viewing a person or subject in its entirety
as a unit that can't be divided into its component
parts without destroying its integrity (Barnum, 1987).
The Neuman systems model is a construct of three

components that guide the nursing process: person,

environment, and stress. Each will be described briefly and

in relation to the nursing process.

P son

The Neuman systems model views nursing as the
profession that emphasizes the "wholeness" of the
individual, thus maintaining and promoting wellness through
the interrelationships of the variables and moving the

patient towards negentropy. Energy moves either toward

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extinction (entropy) as in a closed system by gradual
disorganization, increasing randomness, and dissipation, or
toward evolution (negentropy) as a system absorbing energy
increases its organization and complexity and develops
toward a more steady or wellness state (Neuman, 1989b).
Negentropy and entropy are on the opposite ends of a
health or wellness continuum. Homeostasis preserves the
character of this system so that an adjustment in one
direction is countered by a movement in the opposite
direction, both movements being approximate rather than
compensatory. This homeostasis is dependent on the
interrelationships of the variables that compose a person.
In systems theory it is the whole of the parts rather than
the sum of the parts that provide the essence of the person.
.Neuman (1989b, p.10) states:
"Wholism is both a philosophical and biological
concept, implying relationships and processes arising
from wholeness, dynamic freedom, and creativity in
adjusting to stress in the...environment."
Nursing emphasizes the wholeness of an individual in the
maintenance and promotion of health. The profession examines
the variables that influence an individual's response to
life cycle events. It is through this examination that
assessment occurs and a data base is established to develop
diagnoses and client-centered goals, plan nursing

interventions, and evaluate outcomes. The variables are the

 

 

61

central core of the basic energy structure:

. Physiological--Body structure and function, age, sex,
gender, and metabolic function.

. Psychological-~Mental processes, attitudes, feelings,
and relationships.

. Sociocultural-—Combined social and cultural functions
which encompass lifestyle patterns, ethnic and cultural
background, geographic and economic factors.

. Developmental--Growth patterns and maturation levels.

. Spiritual--Values and beliefs that integrate all the
other dimensions of the person (Corrine, Bailey,
Valentin, Morantus, & Shirley, 1992).

Thus each client is viewed wholistically:

"As a unique, feeling individual with potentials for
strength, wisdom, and untapped resources. Health is
the maintenance of the dynamic relationship of body
(developmental and physiological variables), mind
(psychological and sociocultural variables), and spirit
(spiritual variable) in a constantly fluctuating

society and environment" (Blattner, 1981, p. 13).

Envirsnmest

Fawcett, (1986, p. 150) defines environment as:
"the viable arena which has relevance to the life

space of an organism."

 

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In the Neuman model, as in general systems theory, a person
is in interaction with the environment, interfacing with it
though assimilation or accommodation. Accommodation is the
process of adjusting behavior to adapt to environmental
changes whereas assimilation is the process of adjusting or
changing the environment to meet an individual's needs
(Thibodeau, 1983).

The environment can be sub-divided into three parts--
internal, external, and creative environments. The internal
environment consists of all forces or interactive influences
internal to or contained within the boundaries of the client
system. The external environment consists of all the
influences that exist outside the boundary system.
Connecting and intersecting these two environments is the
creative environment. The creative environment involves the
exchange of matter, energy, and information through the
process of cybernetic feedback implicit in general systems
theory. Neuman describes the creative environment in her
1989 model expansion (Neuman, 1989b, p. 32):

"The creative environment...is a symbolic expression of

system wholeness. It acts as an immediate or long-

range reservoir for existence or the maintenance of
system integrity expressed consciously, unconsciously,
or both simultaneously. This environment represents
the client's unconscious mobilization of all system

variables, including the basic structure energy

 

 

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63

factors, toward system integration, stability and

integrity. It is inherently purposeful though

unconsciously developed, since its function is to offer

a protective shield or safe arena for system function.

It is spontaneously created, increases or decreases, as

warranted by a special condition or need. It

supersedes or goes beyond the internal and external
environments encompassing both."

The model reflects the environmental influences on
health. The client is in a constant state of change with
reciprocal environmental interactions, always moving either
toward a dynamic state of wellness or toward illness.

Health is reflected in the level of wellness on the
continuum of entropy and negentropy. When system needs are
met a state of optimal wellness exists, conversely, unmet
needs reduce the wellness state. Nursing interventions are
directed toward counteracting entropy and are based on
nursing assessment and the client's perception of unmet
needs and environmental influences with a view toward
meeting desired goals and outcomes.

Nursing interventions are purposeful actions (levels of
prevention) to help the client maintain, attain, and/or
retain system stability. The three levels of prevention are

(Marriner, 1986; Hall & Weaver, 1985):

64

1. Primary: Strategies that focus on altering
environmental factors prior to the loss of health or
the onset of illness.

2. Secondary: Strategies to reduce the prevalence of
entropy by either altering the factors which led toward
illness of by early diagnosis and treatment thus
minimizing the adverse effects and controlling
complications.

3. Tertiary: Strategies to reduce the residual effects of
the illness, minimize the loss of function, and to
return recovered individuals to society at an optimal
level of wellness.

§££§§§Q£§

Stressors are tension-producing stimuli with the

potential for causing disequilibrium (Neuman, 1989b). The

three types of stressors are (Cross, 1985):

1.

Intrapersonal: Forces occurring within the individual:
anger, physical abilities, coping mechanisms, values,
beliefs, fears, and health needs.

Interpersonal: Forces occurring between two or more
individuals such as parent-child relationships, role
expectations, emotional support, and relationships with

others.

65

3. Extrapersonal: Forces occurring outside the
individual: unemployment, peer pressure, housing
needs, and community influences.

The concept of wholism (non-summativity, the
interrelationships of the variables in the basic energy
structure core, and the environments) determine the amount
of resistance the client has to stressors and whether a
reaction will occur. All stressors have a potential for
reaction but the lines of defense determine the reaction
outcome. The flexible lines of defense are dynamic and
rapidly altered to provide a buffering effect against the
stressor or stressors. This flexible line of defense is
easily influenced by physical impairments such as inadequate
rest, poor diet, or alterations in activities of daily
living (Louis, 1989). When these impairments are present,
the stressors can easily penetrate through to the normal
line of defense. The normal line of defense represents a
unique stable state for the client. It identifies whom the
person has become over time--thus the steady state,
lifestyle, coping patterns, developmental and spiritual
influences, and cultural identity. (Beckman, Boxley-Harge,
Bruick-Sroge, Harris, Hermiz, Meininger, & Steinkeler,
1994). Entropy or illness occurs when this line is
jpenetrated. The body's next line of defense moves in but
the ability to cope with additional stressors is greatly

reduced. The lines of resistance are the resource factors

66

that help a person defend against stressors. When these
lines are penetrated, entropy and often death occur unless
immediate interventions are enacted.

The penetration of these lines of defense is based on
the time of stressor occurrence, the past and present
condition of the person, the nature and intensity of the
stressor, and the amount of energy required for
accommodation or assimilation. Thus the entire nursing
process (assessment, diagnosis, goals, interventions, and
outcomes) is put to work. Nursing diagnosis requires a
thorough assessment of the client. This assessment is based
on data received from nursing's perception of the client as
well as the client's perceptions of his or her own unique
characteristics or variables and the ability to focus on the
processing of stressors that influence the stability of
existing patterns. Thus nursing assessment is the first
step of the nursing process and includes:

1. Knowledge of all the factors influencing a person's
perceptual field.

2. The meaning a stressor has and what is seen as a
consequence of the present situation.

3. Support mechanisms, to include past coping patterns,
social support systems, and how similar stressors were

handled in the past.

67

Establishment of a nursing diagnosis is the second step
of the nursing process and includes:

1. Identification and resolution of perceptual differences
between the nurse and the client.

2. Identification of the potential or actual stressor.

3. Determination of a woman's level of wellness (her
strengths, positive adaptations, and health

behaviors).

The third step includes the delineation of goals and
interventions to assist in meeting those goals. These goals
are accomplished through nursing interventions that have
their roots in public health theory: levels of prevention.
The levels of prevention--primary, secondary and
tertiary--are on a continuum and encompass one another
through a reciprocal energy exchange to promote health and
wellness.

Collaboration occurs between the nurse and the client

to identify goals and intervention strategies.
Reconstitution or the return of the body system to stability
is the primary goal of nursing interventions.
Reconstitution may occur at, beyond, or below the woman's
normal line of defense. The second goal is to reduce or
minimize risk factors and adverse conditions. The third
goal is to reduce the degree of reaction to a stressor’

(Thibodeau, 1983).

68

Health promotion or primary prevention should work in

concert with secondary and tertiary prevention to prevent

recidivism and to promote optimal wellness (Neuman, 1989).

Primary intervention strategies that strengthen the flexible

lines of defense include (Fawcett, 1986):

1.

7.

8.

Classifying stressors as to client system threat to
stability and prevent stressor invasion.

Providing information to maintain or to strength
existing client system strengths.

Supporting positive coping and functioning.
Desensitizing existing or possible noxious stressors.
Motivating toward wellness.

Coordinating/integrating interdisciplinary theories and
epidemiological input.

Educating/re-educating.

Using stress as a positive intervention strategy.

Secondary intervention strategies successful in

strengthening the normal line of defense include (Fawcett,

1986):

1.

Following stressor invasion and protecting basic
structure.

Mobilizing and maximizing internal/external resources
toward stability and energy conservation.
Facilitating purposeful manipulation of stressors and

reactions t0 stressors.

69

4. Motivating, educating, and involving the client in

health care goals.

5. Facilitating appropriate treatment/intervention
measures.

6. Supporting positive reactions toward illness.

7. Promoting advocacy through coordination and
integration.

Tertiary intervention strategies required to strengthen

internal lines of resistance include (Fawcett, 1986):

1. Attaining or maintaining maximum level of wellness and
stability during reconstitution.

2. Educating, reeducating, and reorienting as needed.

3. Supporting the client in appropriate goal directedness
and change efforts.

The fourth step is evaluation of outcomes. Attainment
of goals is evaluated following interventions as a basis for
confirming or reformulating of goals and interventions.
Outcomes are the end-result of care or a measurable change
in the health status or behavior of clients. The four types
of outcome evaluation are (Jones, 1993):

1. Clinical--Client's response to health and human

service needs.

2. Functional--Maintenance or improvement of physical
functioning.
3. Financial-—Achievement of outcomes with most efficient

use of resources.

70

Perceptual-—Client's satisfaction with outcomes, care

received or provided.

Summary
The family ecosystem framework is the basis of client

and family-centered approaches to care. The model provides

the construct of the family and the environments in which

the family is embedded. The central mode is interaction--

among, between, and within environments and other

ecosystems. The Neuman system's model utilizes the nursing

process to strengthen the ecosystem's lines of resistance
and defense thus promoting or maintaining wellness. The

integration of these two unique but complementary models is

the foundation of community-based case management.

Case Management Systhssis

Case management is an approach to the coordinating and

delivering of health and human services. The approach

Preposed is characterized by client and case worker
interactions over time toward mutually agreed upon goals.
The intent is to assure that all clients receive the

8ex‘vices necessary for their health and well-being

(W. 1990).

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Case management is a tool of this century. Seventy

years ago, social work pioneers emphasized the need to

consider the total family to assess individual problems and

-t01mobilize community resources to develop a network of

gsupportive services (Kirkhart & Rudolph, 1989). However,

jgt.wasn't until the past decade that case management entered

tJne maternal-child health arena. Public Law 99-272

(<:onsolidated Omnibus Reconciliation Act) mandated that case
“management services be covered under Medicaid (Kirkhart &
Rudolph, 1989, p. 30):
"States will be allowed to cover case management
services without regard to requirements that Medicaid
services be available throughout a state...Case
management services will be services which assist

individuals eligible under Medicaid in gaining

access to needed medical, social, educational and

other services".

October 1986 saw further legislation under P.L. 99-457

(ladlucation for the Handicapped Act) which provided a family-

CeIltered care approach to case management. Several states

began to develop case management services in maternal-child

health by the end of decade: New Mexico, New York,

I 1 l inois , and Texas .

72

Comprehensive, community-based case management networks
relevant community and county agencies to plan strategies
and collaboratively work with the client to prevent adverse

pregnancy outcomes by (Culpepper & Jack, 1993):

Determining risk status of the pregnant woman and her

1.
family.

2:- Ensuring that women and their families are educated
regarding risk and modification strategies.

3.. Developing a comprehensive care plan that integrates
medical, obstetrical, and psychosocial care.

4.. Providing intervention required for risk reduction.

5.. Assisting in reducing barriers to service.

6.. Providing timely follow-up and monitoring of care.

Case management services are directed toward the client who

has multiple service needs that cannot be met by the

individual care provider. For the pregnant woman who is

high-risk for medical, psychosocial, and/or obstetrical
factors, thus high-risk for poor perinatal outcomes, case
management is essential.

Community-based case management expands the process of
individual case management as traditionally performed within

an organizational structure. A tri-level approach allows for

8e:r'vice delivery (see Figure 5) . An umbrella agency

eliminates many barriers that inhibit effective utilization

of preventive services (fragmented services, inadequate

reSources, duplication of efforts, and interaction among and

73

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 5.
' se mana m nt: A chema.

between agencies) by forming a network of health and human
Service providers who provide a multidimensional approach to
family needs. This agency develops policy, intervention
Strategies, and work plans, designs outreach, and analyzes

data in terms of maternal and child mortality and morbidity.

The case management agencies provide services of
asSessment, diagnosis, goal setting, and intervention

Strategies with client participation and keeps comprehensive

data on referrals, dynamics of services and outcomes. The

community-based agencies identify at-risk pregnant and

parenting women referring them for case management services

74

In turn, these agencies receive referrals for services from

the case management agencies.

Case management can be conceptualized as an integrated

(delivery network that:

1. Is internally managed.

:2. Provides a continuum of providers to meet population
needs.

:3. Develops service integration and linkages.

4.. Coordinates care that ensures clients receive adequate
services appropriately.

5.. Ensures quality through uniform data analysis and

accountability.

Ann integrated service network allows health and human

service providers to respond to the unique needs of their

lxacal service areas and clientele (Sstting rslstionships
Liege, 1993) .

The implementation of case management is the five step
Process of assessment, diagnosis, goal setting,
intervention, and evaluation within the ecosystem of the

(zlaient (see Figure 6). The successful application of case

r“ariagement is dependent on the integration of the case

miariager, the service delivery system, and the client.

75

 

 

 

 

 

 

 

 

 

 

 

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76

Asssssment and Diagnosis

The case manager in a community-based case management

delivery system may come from health care, human services,

or community outreach. The case manager must be able to

perform a thorough assessment, establish an advocacy

relationship, understand community resources, circumnavigate

complex multiple service systems, direct goal setting,

develop a plan of care, and evaluate outcome criteria. The

case manager spans boundaries, incorporating the social

system approach into practice while learning how to move

freely within and across the systems in all their

complexities (Cervera & Videka-Sherman, 1989) . The case

manager is the catalyst in the implementation of case
management that improves perinatal outcomes.

The family ecosystem model provides the framework the
Case manager needs for assessment of the pregnant woman.
This model brings into purview the complex ecological

slistem. The model focuses on the sources of nurturance,

Stimulation, and support which are essential for survival

(Kumabe, 1989) .
At the central core of the family ecosystem model is

the human environed unit--the pregnant woman. This core

contains the essence of woman--her physiological,
psYi’ohological, developmental and spiritual being that has

been molded by culture, ethnicity, relationships,

77

occupation, and socioeconomics. It is a fluid and dynamic
state that responds to ideas, feelings, and events. The
pregnant woman is nested within the environments of the
family that act as stressors of meliors--"experiences which
promote well-being and protect against effects of stressors"
(Bubolz & Sontag, 1993, p. 433). Together the case manager
and.the pregnant woman examine the ecosystem along with the
traditional assessment of medical-nursing history and family
strengths and resources to determine the level of wellness.
Together they assess the impact of potential or actual
stressor on the lines of defense (see Figure 7). The Neuman
system model requires a thorough assessment of concurrent
stress and identification of coping responses, resources,
and Options (lines of resistance). Assessment of concurrent
stresscms involves examining the occurrence of responses to
ordinary life stresses (concerns about medical care,
finances, sense of being overloaded with responsibilities).
Stressful events are those perceived as involving harm,
loss, threat, or challenge (Knox & Snowden, 1989).
Diagnosis, therefore, develops from the assessment of the

Pregnant woman, her uniqueness, and responses to stressors.

78

 

Figure 7.

'Th u Environ ni - Mod 1 thesis.

 

a rv ' s
'rhe next step is goal identification and planning of

interventions. This step includes identifying resources,

establishing and prioritizing goals and developing specific

steps to reach these goals, establishing time lines for goal

completion, and developing alternative plans. An essential

Part of goal identification is the reality check--making
sure goals reflect where the woman is and where she wants to

be- Goal identification often includes the techniques of

reframing and relabeling. Reframing allows the woman to see

that change is possible and that she has the ability to

79

impact that change. Relabeling emphasizes the positive by
focusing on the benefits of change (Kumabe, 1989). These
two steps assist in empowering the woman to take action for
improved perinatal outcome.

Intervention planning includes referral (linking the
woman with needed services in the community), follow-up,
advocacy, and supportive counseling. Integrating the
interventions of all disciplines into the plan promotes
coordinated care and negates the potential for fragmented
care (Nugent, 1992). Interventions are targeted toward the
lines of defense to support and strengthen them. Primary
interventions support a family's strengths and assist in
building the family's capacities (Anderson et al., 1991).
These interventions include health education, nutrition,
psychological support, adequate housing, recreation,
employment, and preventive physical exams. Secondary
interventions are aimed at the lines of resistance
reinforcing and strengthening the family's ability to relate
to each other, treating illness, and mobilizing resources
from environments that interface and interact with the
pregnant woman and her family. Tertiary interventions occur
when some degree of reconstitution or stability has
returned. Tertiary interventions attain or maintain a
maximum level of wellness by supporting the family in goal
directedness and change efforts (Fawcett, 1986) through

parenting education, educational advocacy and job training.

80

These intervention strategies gain support in the
family ecosystem framework process of adaptation:
"Survival, quality of life, and conservation of the
environment, including the sustained yield of natural
resources, depend on the ways and means by which humans
achieve adaptation. Attention is given to the
importance of selective perception, values, decision-
making, and human actions as they influence adaptation
and selection and use of resources as means toward
attainment of goals, satisfaction of needs, and quality
of the environment" (Bubolz & Sontag, 1993, p. 422).
Each intervention is planned with the client. The pregnant
woman and her family are the decision-makers. Family
ecology stresses that decision-making is the central
cybernetic system of the family. It involves the
identification, comparison and evaluation of alternatives
and the choice of one of the alternatives. When a decision
has been made the family evaluates this decision (usually
unconsciously or informally) by the consequences or sequelae
that arise. This evaluative process may lead to change
within the family ecosystem and thus creates dynamic

interactions.

81

Evsluation

The final step is that of evaluation. Evaluation is
dependent upon continuity of care between the case manager,
the woman, and community organizations. Evaluation assesses
how well goals are being met, if intervention strategies
need to be changed, and if goals need to be readdressed or
discarded. The evaluation of client outcomes is both
formative and summative. Formative evaluation is focused on
implementation of the case management process while it is
being delivered and while it can still be modified.
Summative evaluations are terminal evaluations that occur
after a client is discharged from case management, including
not only the quantity of care, but the cost effectiveness of
that care (Nugent, 1992). These steps are on a continuum
interfacing the wellness continuum. As a woman achieves an
optimal state of wellness, the case manager withdraws from
her environment, summarizing where the woman has been, is,
and where she is going.

Community-based, comprehensive perinatal case
management within the context of the two theoretical models,
Neuman systems model and family ecology framework, promotes
a community-wide approach to improving perinatal and family
outcomes through the management of stressors that impede the
pregnant woman in obtaining health and human services. The
synthesis of these two frameworks provides guidance in

designing, delivering and evaluating services for families

82

utilizing a multidisciplinary perspective. The model
synthesis recognizes the influence of family attributes,
activities, and processes on the quality of family life. It
allows exploration into "activities and processes that
facilitate accessing, creating, utilizing, and preserving
resources for the purpose of...family betterment" (Westney,
1993, p. 450). Comprehensive perinatal case management
promotes the wellness of the family ecosystem facilitating
interdependent and competent family function within the
environments using available resources to maintain a state

of wellness.

CHAPTER 4

STATEMENT OF THE PROBLEM

Purpose

The synthesized conceptual framework of case management
will guide the author in her investigation to determine if
comprehensive community-based perinatal case management
affects the perinatal and family outcomes of prenatally

at-risk clients.

Hypotheses

To meet the objectives of this research, the following

hypotheses are proposed:

H01 There is no relationship between receipt of
comprehensive community-based perinatal
case management services and birth outcomes.

H11 There is a positive relationship between receipt
comprehensive community-based perinatal case
management services and birth outcomes.

This hypothesis has found support through the Consensus
Conferences. Their report Access to prenatal care: Key to

preventing low birth weight states (Curry, 1987, p. viii):

83

84

"Increased access to prenatal care is an important
and necessary step in reducing the incidence of low
birth weight babies born in the United States.
Assuring that all women and children have access to
basic life needs, including food, clothing, shelter,
and health care, is essential to improving the health
of pregnant women and of the present and future
children of the nation".
Sharp (1993) points out that the rate of low birth weight
infants began to increase during the 1980's, while at the
same time, the proportion of women receiving early and
continuous prenatal care declined significantly. McLaughlin
et al. (1992) studied the effect of comprehensive prenatal
care on birth weight using a randomized design. They found
the comprehensive prenatal care was related to higher birth
weights for primigravidas (women with a first pregnancy) but
not for multigravidas (women with second or greater
pregnancy). A study done by Parker and Abrams (1992)
compared national guidelines formulated for weight gain by
the Institute of Medicine and actual weight gain from women
who delivered in California in 1988. They found that low
maternal prenatal weight gain was associated with a more
than double risk of a small-for-gestational age infant (SGA)
and high maternal prenatal gain with both a doubled risk of
large-for-gestational age infant (LGA) and a 20-30%

increased risk of cesarean section. McDonald, Armstrong,

85

and Sloan (1992) found that smoking accounted for 39% of low
birth weight infants for gestational age, 35% of low birth
weight infants, and 11% of preterm births. Depressive
symptoms and thus associated poor health behaviors that are
a link to infant outcomes were studied by Zuckerman et al.
(1989). They found that depressive symptoms were
significantly associated with being single, older,
unemployed, and having a lower income, but not with a
mother's education or age.

As a subset for the above hypothesis, the following

hypotheses are also proposed:

H02 Among pregnant teenagers there is no relationship
between birth outcomes and the receipt of
community-based comprehensive prenatal case
management services.

H12 Among pregnant teenagers there is a positive
relationship between birth outcomes and the
receipt of community-based comprehensive prenatal
case management services.

McAnarney and Hendee (1989) found that infants who were born
to mothers less than 15 years of age were more than twice as
likely to weigh less than 2500 grams at birth and are nearly
three times more likely to die within the first 28 days of
life. Felici et al. (1981) study of adolescents found that
environmental factors influence the incidence of low birth

weight babies. They went on to find that comprehensive

86

prenatal care programs resulted in 9% of the teens having
low birth weight babies as compared to the 20.9% of the
control group.

Ho3 There is no relationship between receipt of
community-based comprehensive prenatal case
management services and family stability.

H13 There is a positive relationship between receipt
of community-based comprehensive prenatal case
management services and family stability.

This hypothesis has found support with the Zuckerman et al.
(1989) study on depressive symptoms during pregnancy and the
link to infant outcomes. They found that the number of
homes in which a woman had lived in the past three years was
positively associated with symptoms of depression. A 1983
study for the National Governors' Association found that
women living in poverty areas in the United States were
three times more likely to receive no prenatal care as
compared to women living in non-poverty areas (Hutchins,
1985). The Alan Guttmacher Institute reports that sixteen
percent (16%) of women at risk for unintended pregnancy had
a family income below the federally designated poverty level
and another twenty-six percent (26%) were relatively close
to the poverty level (Klitsch, 1993). However, a study of
live births in Tennessee during 1984-1987 showed that
Medicaid enrollment expansion did not improve the use of

early prenatal care nor improve birth weight of neonatal

87

mortality rates (Piper, Ray, & Griffin, 1990).
Transportation was one of the barriers to obtaining adequate
prenatal care found in the Oregon study by Harvey and Fober
(1993). Bullock and McFarlane (1989) developed a study to
determine if the stress of physical abuse would affect the
incidence of low birth weight. They found that battered
women gave birth to low birth weight infants nearly twice
the rate that of non-battered women. Another study
addressed social support in the home in preventing preterm
births, but they found no correlation between the two
(Bryce, Stanley, & Garner, 1991). The Second National
Family Violence survey found that violence during pregnancy
occurred frequently: 154 acts of violence per 1000 women
during the first four months of pregnancy and 170 acts of
violence per 1000 women during the fifth through ninth
months (Newberger et al., 1992).
As a subset of the above, this hypothesis is proposed:
H04 Among pregnant teenagers there is no relationship
between receipt of community-based comprehensive
prenatal case management services and family
stability.
H12 Among pregnant teenagers there is a positive
relationship between receipt of community-based
comprehensive prenatal case management services

and family stability.

88

Welcher, in her analysis of studies at Johns Hopkins in
1982, noted that adolescent mothers who completed high
school and had used contraception regularly also had higher
self-esteem and clearer, more realistic goals than other
teen mothers (O'Sullivan & Jacobsen, 1992). A study of
former adolescent mothers at 20 years long-term follow-up
for the Young Mother's Program (one of the first
comprehensive programs for pregnant teens in the United
States in 1967-1969) found that those who attended and
completed the program had higher educational aspirations for
themselves and their children (Horwitz et al., 1991).
Ambler and Dull (1987, p. 206) examined the research on
teen-age pregnancy and educational status. They summarize:
"Parenthood before age 18 reduces high school
completion rates by 50% for women and 25% for men and
reduces income by 80% for families headed by teenaged

mothers".

ggnggptual Definitigns
The major variables to be investigated are birth
outcomes (dependent variable), family stability (dependent
variable), and prenatal care services (independent
variable). Figure 8 illustrates the variables and their
factors within the model synthesis. These variables are

defined conceptually and operationally:

89

 

M l h i : V ri 1 s d Fa tor Uh er

BIRTH OUTCOMES: Conceptually, birth outcomes are
defined as the status and well-being of the infant at the
time of birth. An optimal birth outcome is an infant born
after the completion of thirty-seven weeks gestation with
APGAR scores seven or greater at one and five minutes, and
with a birth weight above 2500 grams (Frigoletto & Little,
1988; Arias, 1993). Operationally this is defined as the
gestational age in weeks, birth weight in grams, one minute

APGAR score, and five minute APGAR score.

90

FAMILY STABILITY: Conceptually family stability is
defined as the family's ability to enhance the competence of
their members to cope with the demands of other
organizations in which they must function, to utilize these
organizations, and to provide satisfactions and a mentally
healthy environment intrinsic to the well-being of the
family. It assumes that sustenance in the form of food and
protection for physiologic survival is essential.
Operationally this is defined as living situation,
parenting, financial situation, employment, health status,
personal development, and education.

PRENATAL CARE SERVICES: Conceptually prenatal care
services are the health and human services received during
the antepartal period of pregnancy. Conceptually prenatal
care services are defined as case-managed services,
comprehensive services, and routine obstetrical services.
Routine obstetrical services are those prenatal services
rendered by a board-certified/eligible obstetrician-
gynecologist. They include high-risk screening and
treatment/referral, pregnancy-related examinations and
testing, and counseling for pregnancy-related conditions
such as premature labor, genetics, labor, and family
planning. Comprehensive services are those services
rendered by an on-site multidisciplinary health care team
consisting of a registered dietitian, medical social worker,

WIC intake worker, nurse educator, Medicaid examiner, PCAP

91

examiner, genetic counselor, and OB-GYN advanced registered
nurse practitioner or certified nurse-midwife. These
services include nutritional counseling, family-partner-
individual counseling and treatment, assessment and
enrollment in Medicaid and/or PCAP as well as food stamps
and HEAP, genetic counseling and testing, WIC enrollment to
include receipt of WIC checks and services, prenatal
education program for early pregnancy and prepared
childbirth classes (with individual teen prenatal education
program), educational advocacy, assessment for preparation
of new family member, referrals for employment and training,
and medical prenatal care services for low to moderate
pregnancy risk clients with physician co-management for high
pregnancy risk clients. Case management services include
all comprehensive services plus community-based case
management for continuity of health and human services to
provide advocacy, brokering, and linkage by the case manager
for the pregnant woman and her family over an established
period of time. Case management agencies specific to this
study include the Maternal Health Center (the site for
comprehensive prenatal care services), Catholic Charities,
Planned Parenthood's Circle and TASA programs, Jefferson
County Public Health Department (with liaison with Public
Health Departments of St. Lawrence, Lewis, and Oswego

Counties), and North Country Children's Clinic's Adolescent

92

Pregnancy Program. Other agencies that provide case
management services but are not included in interagency
agreements are the Oswego County Options Program, Mercy

Mental Health, and Cornell Cooperative Extension.

Case Management in the North Country

Case management is an approach to the coordination and
delivery of health and human services characterized by
client/worker interactions over time toward a mutually
agreed upon goal whose intent it is to assure that every
client receives all of the services necessary to health and
well-being (Interagencv aqreement, 1990).

The North Country Prenatal/Perinatal Council, Inc.
(NCPPC) is one of New York state's comprehensive
prenatal/perinatal networks that is funded through the
Department of Health. The NCPPC covers a three-county area
in Upstate New York. (Jefferson, St. Lawrence, and Lewis
counties are outlined on the map in Figure 9). The tri-
county area has a population of approximately 250,000 people
with 93.6% White. Twenty-two percent of the population are
females of childbearing ages (15-44 years of age). Although
only a small percentage of the populations of Lewis and St.
Lawrence counties, Ft. Drum U.S. Army Installation brings in
a population of approximately 25,000. Perhaps due to the
close relationship to Canada (Jefferson and St. Lawrence

counties border the provinces of Ontario and Quebec),

93

 

 

 

 

NewYorkShtc

 

Figure 9.
N h un Prena a1 P rina al oun i1

Ing, Tri—ggungy Area Map.

foreign-born citizens account for three percent of the
population. The average per capita income is $25,000 for
households and $29,200 for families, however, 10.9% of the
families reside in poverty (U.S. Department of Commerce,
1993). Table 3 describes the demographics per county. Many
consumers from Northern Oswego county utilize the service of
the NCPPC due to geographical access. The NCPPC functions
as the coordinating council for health and human service

provisions for pregnant women and their children.

LIL

Popu

Perc

Femai

Per (

 

94

Table 3.
Tri- 1 i n a hi

Jefferson St. Lawrence
County County

Population 110,943 111,974

Percent by Race
White
Black
Native American
Asian
Hispanic

Females
(age 15-44)

% of pop.

Per Capita Income
Households $25,929 $25,599 $23,799
Families $29,535 $29,208 $29,004

[Percent poverty
' Entire Pop.
Families

 

 

l‘

[.1710 '11

y re‘e

re:erI‘als

A‘

.:89 lg anaf
4

95

The case management model developed by the NCPPC

utilizes a systems approach that resembles Bronfenbrenner's

nested ecosystem model approach (see Figure 10). Each

 

Figure 10.
e n e f h o

Prenagallperinagal Council, Ing.

system interfaces and integrates its services with the other

in a cybernetic environment. Community-based organizations

are educated by the NCPPC to identify psycho-social and
socio-economically at-risk pregnant and parenting clients.

They refer clients into case management as well as receive

referrals from specific services from case managers. The

case management agencies are contracted by NCPPC for

individual or group case management. The case manager works

with the cl
problems (p
“:rategies,

manager ini
4}. The ca
referrals,

agencies pr
for assessm
Board takes
ccmittee tc‘
interventionl
”Ordination
identifieS c

The North CO

”yrganiZatiOn
52a“ v

.e S Cove;
1- ‘5-

96

with the client in the assessment of needs, diagnosis of
problems (potential or real), planning for intervention
strategies, and evaluations of services and goals. The case
manager initiates referral for community services (see Table
4). The case management agencies keep comprehensive data on
referrals, dynamics of services, and outcomes. These
agencies present their data to the case management committee
for assessment and recommendations to the NCPPC. The NCPPC
Board takes the recommendations from the case management
committee to develop policies and community and regional
intervention strategies as well as provide integration and
coordination among community-based organizations. Table 5
identifies community organizations involved in the NCPPC.
The North Country Prenatal/Perinatal Council, Inc. is a new
organization that originated in 1989 in response to New York
state's Governor Mario Cuomo's 1986 State of the State
Address to reduce maternal and infant mortality and
morbidity. This organization originated through the passage
of a bill in the New York legislature that expanded Medicaid
eligibility to 185% of poverty for pregnant women and
infants through the first year of life (Randolph & Sherman,
1993). In the first year of implementation the program
developed rapidly and established itself in the community

(Blodgett, 1991):

Prim
Pre:
WIC

Infa

Cris

Child
prEVe

Pregr

 

Table 4.

.. -rv' - R- - a1:

97

Prgnét§l12§rin§§al ggungil, Inc.

Types of community service referrals

 

Primary health care
Prenatal care

WIC

Infant/child health care
Crisis intervention
Counseling

Rape crisis
Family'planning
substance abuse services
Domestic violence services
IMental health services
Parenting classes

’Child abuse/neglect
prevention/protection

program

Educational services
Life skills

Housing assistance
Adoption services
Income maintenance
Emergency Food
Childbirth classes

Job training/employment
Youth services
Transportation
Medicaid/Public assistance
Emergency shelter

Expanded food/nutrition
program (EFNEP)

 

 

 

98

Table 5:
Case Management Organizations of the Nbrth Country
Prenatal/Perinatal Council, Inc.

- ase ' ion
Salvation Army WIC
Head Start Housing Authority
Area churches Community Action Council
YWCA Domestic Violence Program
Food Bank House of the Good Samaritan
Area schools Department of Social Services
Health care providers Mercy Mental Health
Alcoholics Anonymous Chrysalis
US Army, Ft. Drum Cornell Cooperative Extension

WW
Catholic Charities
Maternal Health Center
Lewis County Public Health
Jefferson County Public Health
Nerth Country Children's Clinic
St. Lawrence County Public Health
Planned Parenthood of Nerthern New York

N010 04 s '__‘t—. . P_‘_ . o ' __ Bro.-
) .A. Barton Hospital
Catholic Charities
American Red Cross
E. J. Nbble Hospital
Maternal Health Center
Consumer representatives
Lewis County Opportunities
Lewis County Health Department
Nerth Country Children's Clinic
St. Lawrence Psychiatric Center
South Jefferson School District
Private physician representatives
Jefferson County Health Department
St. Lawrence County Health Department
Planned Parenthood of Nerthern New YOrk
St. Lawrence Department of Social Services
Alcohol and Substance Abuse Council of St. Lawrence

 

.4

(h

\J

 

99

A data base was developed to track birth outcomes and
to evaluate issues affecting service delivery and to
analyze relationships.

Public service announcements on expanded PCAP (prenatal
care assistance program), Medicaid, effects of alcohol
in pregnancy, and WIC outreach.

Professional conferences were given on prenatal drug
and alcohol use.

Development of early pregnancy classes.

Development of a resource library in each of the three
counties for clients and professionals.

Publication of New Parent News.

Collaboration with community education programs:

a. Health fair with Jefferson County Council on
Alcoholism.

b. Fetal alcohol syndrome awareness campaign with
Kiwanis.

c. Development of prenatal care information and

assessment packet with Head Start.
d. "Babies and You" project to area schools in
cooperation with the March of Dimes.

Training of case managers.

sinc

communitl’

J

k)

(11

(3‘
.

\J

(D

 

 

 

100

Since its development the NCPPC has impacted the
community through a variety of programs and services

(Blodgett, 1993):

1. Expansion of community based organizations.

2. Alcohol education program given at WIC sites.

3. Nurturing program for teens implemented.

4. Development of-a personal pregnancy manual.

5. Public service announcements on "Don't Shake the Baby"

and teen pregnancy.
6. Provided annual conferences on teen sexuality.
7. Coordinated HIV education program at Jefferson

Community College's Women's Health Conference.

8. Expanded early pregnancy educational sites.
9. Applied and received grants for:
a. Smoking cessation program in pregnancy

b. Lead program
c. HIV/AIDS peer education in coordination with Red
Cross and South Jefferson School District.
10. Presented paper to American Public Health Association
on community networking.
11. Member of New York state task force on teen violence.
The NCPPC is a member of the Central New York Health
Systems Agency (CNYHSA). The CNYHSA is "part of a network
of federation of local health and human service providers
and consumers who collaboratively work to identify and

resolve problems of the local geographic area" (Randolph &

throughout
New York ST
perinatal ;

September 2

 

 

 

101

Sherman, 1993, p. 74). The Executive Summary Report of
CNYHSA in 1992 cited the NCPPC as a model to be adOpted
throughout the region. In 1994, the NCPPC was cited by the
New York State Department of Health as the model agency for
perinatal case management (Knight, personal communication,

September 1994).

CHAPTER 5

METHODOLOGY

Subjecss

The Maternal Health Center at the House of the Good
Samaritan is a nurse-managed perinatal health service
agency. The center is an ambulatory clinic within a
hospital setting and provides prenatal, intrapartal,
postpartal, and limited family planning health care
services. It is designated a "one-stop perinatal center" as
it provides prenatal and postpartum health care, Medicaid
eligibility determination, WIC nutritional counseling and
services, adult and teen perinatal education, nutritional
services, social work counseling, and teen prepared
childbirth classes. Case management services are provided
by two case managers. Care is provided by an obstetrical-
gynecological nurse practitioner, certified nurse-midwife,
registered dietitian, master's level social worker,
registered nurse educator, WIC nutritional counselor,
Medicaid eligibility counselor, and social services intake
counselor to women of the tri-county area and northern
Oswego county. Health care collaboration is provided by a

board-certified obstetrician-gynecologist from OB-GYN

102

corporati<
provided C
Jefferson
cerporatic
services c
:anagement
These phys
three fami

[0.

was. Army

The M5
approximate

Case manage

 

 

 

103

Associates of Northern New York.

OB-GYN Associates of Northern New York is a medical
corporation of five obstetrician-gynecologists. They
provided obstetrical and gynecological services to women of
Jefferson County and surrounding communities. The medical
corporation does not provide comprehensive (one-stop)
services or case managers but it does participate in case
management as a referral community based organization.

These physicians along with the Maternal Health Center and
three family practice physicians from neighboring Ft. Drum
(U.S. Army installation five miles north of Watertown)
provide prenatal care and delivery services to over two
thousand women annually (House of the Good Samaritan, 1993).

The Maternal Health Center provides services to
approximately 350 clients annually with one-third of them
case managed. These case managed clients account for one-
third of all the case managed clients of the tri-county area
served by NCPPC (Blodgett, 1993). To be considered eligible
for case management service the woman must be at-risk
psychosocially, socioeconomically, or medically for poor
perinatal outcomes. .All women who enter prenatal care in
the central New York region (see Figure 11) are assessed for
risk by use of the Regional Perinatal Risk Assessment tool
(see Appendix B). Women who score moderate to high are
offered case management services along with selected low

risk clients depending on perceived needs. Case management

104

 

 

 

 

New York Stat e

 

Figure 11.
e n ral New Y rk Heal s em
Mien.

is briefly described by the health care provider or by the
prenatal care intake worker. A referral to a case
management agency is made outlining initial needs of the
client and/or establishing reason(s) for case management.
This referral is signed by the provider and the client. The
client receives one copy of the form. The provider keeps
one copy and forwards the remaining two copies to the case
management agency. Upon receipt of the referral form, the
case management agency assigns a case manager to contact the

client, explain the program, perform a needs assessment, and

‘O dD'Drn‘Ll

V.“

.F
w‘thdraw L

retrospect
the Good 8.
drawn from
Center and
Samarita..

the Matern

58W York .

Internal F

 

arit
medical cc
H‘sease

”A s ,
H
W‘lul

tiOns

 

105

to determine intervention strategies. The client may

withdraw from case management services at any time.

S ' th tu

The data for this dissertation derive from a
retrospective study of women who delivered at the House of
the Good Samaritan, Watertown, New York. Subjects were
drawn from case management records of the Maternal Health
Center and delivery log books of the House of the Good
Samaritan who received prenatal care services from either
the Maternal Health Center or OB-GYN Associates of Northern
New York. During the period October 1991--May 1993, 108
women who had accepted case management services through the
Maternal Health Center delivered. These women (np=108) were
matched to women who had received comprehensive care at the
Maternal Health Center (D¢=108) and to women who had
received obstetrical care at OB-GYN Associates of Northern
New York (n3=108) . The women were matched on age, parity,
and marital status. Women who presented with high-risk
medical conditions (e.g., diabetes, cardiac disease, renal
disease, chronic hypertension, and gross obesity) that are
known to impact birth outcomes were omitted from the study
(n1=8, n,=14, n3=12) . Women who were diagnosed during the
first 20 weeks of pregnancy with obstetrical or fetal
conditions (twins, incompetent cervix, fetal anomalies) that

also impact birth outcomes were also omitted from the study

106

(n1=3, n2=7, n3=2) . Initial data were collected from
delivery log books from the House of the Good Samaritan,
Watertown, New York. Descriptive data on birth weight,
gestational age, type of delivery, APGAR scores, and
intrapartum complications were obtained. Due to incomplete
entries in the delivery log book several subjects from each
prenatal care group were excluded leaving a final sample of
231 which consisted of 81 women who received case management
services, 73 women who received comprehensive care, and 77

women who received standard obstetrical care.

Instrumsnts

The survey instrument (see Appendix C) combined three
separate tools: Regional Perinatal Assessment Form,
Psychosocial Risk Form, North Country Prenatal/Perinatal
Council, Inc. referral and case management forms. The
survey tool also included demographic information not
included in any of the other instruments.

Mawn and Bradley (1993) performed an extensive review
of the literature regarding prenatal assessment tools. Their
review and analysis of ten widely used risk assessment tools
that contained all or part of the Institute of Medicine's
(IOM) identified risk factors (see Table 6). This confirmed
the 1985 IOM finding that "no consensus exists regarding any

tool that is acceptable as a reliable and sensitive method

Table 6.. 7
Identified

 

 

Socio—Demo
Factors

 

Age <15 or

<High scho
education

Underweigh

Impoverish

Smoking

 

 

Single
Non‘White
Alcohol us
Heavy Phys

work

(5 fth ta

Substance

 

Table 6.

107

Idsntifieg Pegigasal Risk Fsctors

Socio-Demographic
Factors

Medical or
Reproductive
Factors

Pregnancy
Factors

 

Age <15 or >34

<High school
education

underweight
Impoverished

Smoking
Single
NOn-White

Alcohol use/abuse

Heavy physical
work

\
)
Stress

<5 feet tall

Substance use/abuse

DES exposure

Genital anomalies

Maternal nephritis
Maternal diabetes

Maternal heart
disease

Maternal
hypertension

Maternal
liver disease

Incompetent cervix

Short

interpregnancy
interval <1 year

Exposure to

environmental
toxins

Poor weight gain

Absent/inadequate
prenatal care

Antepartal bleeding

Placenta Previa

Isoimmunization

History of previous l

abruption

Prior preterm birth

Prior IUGR infant
Prior low birth

weight infant

Prior ABO
incompatibility

History fetal
or neonatal death

Incompetent cervix

1
I

of predic:

 

{Mawn & E:

The E
the obste:
was devel:

Regional E

 

used exten

and mltrit
I'lSk Stat-A
assessme:11
considEre
score tha'
APPEHOILX
.

‘6

Low :

(\J
3:
O

D:
(D

of.

108

of predicting risk in pregnant women in various populations"
(Mawn & Bradley, 1993, p. 80).

The Regional Perinatal Risk Assessment Form utilized by
the obstetrical health care providers in Watertown, New York
was developed by the State University of New York (SUNY)
Regional Perinatal Center, Syracuse, New York. This form is
used extensively throughout the Central New York Health
Systems Region. The tool encompasses the majority of IOM
identified risk factors and expands two areas, psychosocial
and nutritional factors. Clients are assessed for their
risk status at their first prenatal visit. (A second
assessment is performed in the third trimester but was not
considered in this study.) The tool uses a summative risk
score that is reflective of the identified risk (see

Appendix B):

1. Low: No identified risk factors.
2. Moderate: Three or less identified risks.
3. High: A combination of four or greater moderate

factors, or one high risk factor for poor outcome or
low birth weight.

4. Very high: Two high risk factors for poor outcome or
low birth weight, or one factor for very high risk for

low birth weight.

 

 

 

new factor

the NCPPC
psychosoc.
literatur
with hi-r
in the Re
prOVide g

test pil‘

109

The psychosocial and nutritional assessment consist of
several factors but each receives one score. Both
assessments received further investigation by the NCPPC.
While the nutritional assessment had aspects covered in the
overall assessment, the psychosocial assessment addressed
new factors not previously identified. It was determined by
the NCPPC that more emphasis needed to be placed on
psychosocial factors which are supported by findings in the
literature linking low birth weight and infant mortality
with hi-risk psychosocial factors. The factors identified
in the Regional Perinatal Assessment Form were revised to
provide a more objective scoring system. This revision was
test piloted at the Maternal Health Center by a master's
degree social worker with postgraduate training in family
issues. This revised tool was adopted for use by the NCPPC,
Inc. in 1991.

The referral and case management forms have been used
within the NCPPC since 1990. The forms have been revised
twice to better serve the needs of the clients, community-
based agencies, and case managers as well as to increase
lines of communication and clarity.

The instruments identified have not been proven
statistically to be either reliable or valid, however they
have been used in various practice settings to assist the
health care provider in determining risk along with thorough

assessments, monitoring, and clinical appraisals. Woolery

110

(1994) found that most preterm birth risk screening
instruments currently in use have not developed scoring
indices that reflect psychometric standards thus decreasing
their reliability and validity. The IOM state "a well-
constructed risk-assessment tool can be a useful adjunct to
clinical judgment" (Mawn & Bradley, 1993, p. 80).
"Reliability is the ability of a measure to produce
consistent results" (Rudestam & Newton, 1992, p. 67). The
tools identify women who are at-risk for poor perinatal
outcomes. Wall (1988) notes that 30% of all pregnancies are
high-risk, however, these pregnancies result in only 50% of
the poor perinatal outcomes. Stewart and Nimrod (1993)
identify the flaw in reliability of risk scoring systems.
They point out that risk scoring systems will identify only
40% of women who will have a preterm birth. Gabbe, Niebyl,
& Simpson (1991) state that the most significant factor for
a preterm birth is a previous preterm birth, thus showing
that risk scoring of primigravidas (women with a first
pregnancy) is limited in determining premature birth risk.
Woolery's (1994) review of the literature found that:
"existing preterm risk screening instruments include
factors that are not valid predictors of preterm-birth
risk and fail to include factors reported in the
literature that may be valid predictors of preterm

birth" (p. 141).

111

While most poor perinatal outcomes are influenced by prior
pregnancies, a significant number are influenced by
psychosocial risks. The NCPPC suggests that with further
identification of psychosocial issues and greater scoring
weight an increased number of women at-risk for poor
outcomes may be identified.

Validity indicates that a measure in fact measures what
it purports to measure (Rudestam & Newton, 1992, p. 67).
The tools utilized identify at-risk women, they do not
identify perinatal outcomes. The instruments seek to
explain outcomes in terms of factors that may or may not
affect the outcomes. The advantage of a risk scoring
instrument is that it identifies women who are at risk so
that the health care provider can initiate medical, socio-
economic, and psychosocial interventions and referrals thus
deleting or modifying the factor(s) that may affect poor
perinatal outcomes. Thus the validity of the instrument

changes as intervention strategies are introduced.

W
Approval of the research was obtained through Michigan
State University Committee on Research Involving Human
Subjects (UCRIHS) (see Appendix A). Contact was made with
Ruth Ellen Blodgett, Executive President of the North
Country Prenatal/Perinatal Council, inc., Linda Knight,

Manager of the Maternal Health Center, Michael Golden,

112

Department of Medical Records at Samaritan Medical Center
(formerly House of the Good Samaritan), and Drs. Sylvia
Reimer and Paul Kruger, senior partners of OB-GYN Associates
of Northern New York (see Appendix A). Permission was
received to obtain data identified on my survey instrument
from delivery logs, case management minutes, on-line case
management care plans, referral forms, and inpatient and
outpatient medical records.

All data were retrospectively abstracted at least one
year following the birth identified during the period
October 1991 to May 1993. Initially data were collected

from delivery logs including:

1. Maternal age

2. Marital status at time of delivery
3. Birth weight of infant

4. Gestational age

5. Type of delivery

6. Length and type of labor

7. Intrapartal complications
8. Neonatal complications
9. Prenatal care provider

10. APGAR scores

11. Gravidity and Parity

113

In-patient records were then reviewed for labor and
delivery course, partner/family support/involvement during
labor, delivery, and/or post-partum stay, infant well-being,
maternal-family-infant attachment, referrals initiated
during hospitalization and intrapartum/postpartum
complications or deviations from normal. Out-patient
records were reviewed for antepartal course (risk status,
complications, trimester of entry into prenatal care,
referrals, birth plans, support systems) postpartum visit
and follow-up (included patient and health care provider
assessments of family interactions, infant well-being, and
physical findings), family planning, progress notes from
social services, public health or other referral agencies,
and subsequent health or pregnancy visits. Case management
records, minutes, and referral forms were assessed for
reasons of entry into case management, length of time in
case management, identification of case management agency
and case manager, types and numbers of referrals and follow-
through, and provision of care. Many times one record would
have incomplete data entry but that deficiency would be
addressed in another record (e.g., use of contraceptive
method would not be addressed in out-patient record at time
of postpartum visit but it was entered in case management

minutes that the client had Norplant inserted).

114

The author collected all data and all patients were
identified by medical record number for cross-referencing of
data between resources. When all data were collected,
medical record numbers were deleted and an identification
number was assigned randomly within each prenatal care
category. These procedures helped to insure client

confidentiality.

Data were entered for statistical analysis on an IBM
compatible computer system using SPSS for Windows, Release
6.0 (Norusis, 1993a and 1993b). Descriptive statistics were
analyzed for each variable using cross-tabulation and
frequency distribution tables.

The principle analytic techniques for the first
hypothesis regarding birth outcomes and case management
perinatal care were chi-square and analysis of variance
(ANOVA). The second hypothesis on family stability and case
management was analyzed by chi—square. All tests of
statistical inference were measured at .05 level of
significance.

ANOVA uses sample data to draw conclusions about
populations. The purpose of ANOVA is determine if
differences between the samples are due to chance (sampling
error) or to systematic treatment effects. The F statistic

in ANOVA is based on variance between sample means. The

115

formula is (Gravetter & Willnau, 1992):

F = vsgisnce between sample means

variance expected from sampling error

Chi-square determine how well the frequency
distribution for a sample fits the population distribution
of the hypothesis. It can also determine if there is a
relationship between two variables. The X’statistic

measures how well the data fit they hypothesis:

XF== 2: Jll_%L£Jj

The results of the statistical analyses will be

discussed in the next chapter.

CHAPTER 6

RESULTS

An Ovsrvisw of Demographic and Obstetrical Characteristics

Demographics

The population in the study was matched on the
demographic characteristics of age and marital status. In
spite of the attrition of the subjects due to high-risk
medical/obstetrical conditions and/or incomplete records,
the population varied only slightly. The 231 women ranged
in age from 13 to 33 years at the time of delivery. The
mean age was 18 years. The obstetrical care group (n=77)
had 66.3% teenagers, the comprehensive care group (n=73) had
65.0%, while the case managed group (n=81) had 70.2%.
Marital status also showed comparable results (see Table 7).

Statistical differences were noted when comparing
educational characteristics. Obstetrical care and
comprehensive care groups had a comparable percentage of
subjects who had dropped out of school (24.7% and 28.8%
respectively) compared to the case managed group who had a
rate twice as high (50.6%). Differences were also noted in

high school completion rates. Obstetrical care subjects had

116

117

 

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118

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119

a 33.7% high school completion rate, comprehensive care
subjects had 43.8%, and case managed care subjects had
24.7%. Chi-square statistical analysis shows these
differences in high school completion rates to be
statistically significant (2F=7.0268, df=2,
significance=.0298).

There were major differences noted among the prenatal
groups in financial payor status. The women in the two
groups that obtained their prenatal care at the Maternal
Health Center (comprehensive care=91.8% and case managed
care=97.5%) were major recipients of health care that was
paid fully, or at least substantially, by federal or state
mandated health programs (Medicaid, Public Assistance, or
New York State Prenatal Care Assistance Program) as compared
to 57% of women who received their care from OB-GYN
Associates of Northern New York.

Thus the case managed group contrasted with the other
two groups in education and with obstetrical care recipients
in financial payor status. The case managed recipients also
had a slightly higher teenage population. Three
characteristics, decreased education, lower socioeconomic
status, and adolescence, are directly related to the
unfavorable birth outcomes of low birth weight and
prematurity (Cartwright et al., 1993; LeHew, 1992; McAnarney

& Hendee, 1989; Ringdahl, 1992; Stevens & O'Connell, 1992).

120

Obstetrical Characteristics

The sample was matched on fecundancy. Approximately
half of all the subjects were experiencing their first
pregnancy with two-thirds of the women in each prenatal care
group delivering their first infant. The variance in
gravidity (the number of times a woman has been pregnant)
and parity (the number of births) is due to abortions (any
pregnancy loss prior to twenty weeks of gestation).

Comparable modes of delivery exist among the three
prenatal care groups (see Table 8). Onset of prenatal care
showed only slight variance between the obstetrical care and
comprehensive care recipients with two-thirds of the
subjects entering care in their first trimester (first 14
weeks) of pregnancy. Although slightly over half of the
case managed recipients entered prenatal care in the first
trimester and one-third of them entered in the second
trimester, these variances were not statistically
significant.

Over one—half of all the subjects had no antepartal
complications. The major complications encountered are
listed in Table 9. While subjects who received case
management services had more complications (45.7% as
compared to 32.5% for obstetrical care recipients and 41.1%
for comprehensive care recipients) this was not a

statistically significant difference. Few subjects from any

121

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Table 8 .

122

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. 83:00. a 033.

123

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suzouu osauuusauusn
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nuuonmfln Hoseauaumou
wasus< ou0>mm

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124

of the three prenatal groups presented with intrapartal
complications. While Table 10 identifies the major
complications encountered in the intrapartal period it does
not account for the actual clients involved as many of the
complications are compounded in each pregnancy, for
instance, an abruptio placenta (a condition where the
placenta separates from the lining of the uterus) can also
result in fetal distress and may be due to PIH (pregnancy

induced hypertension.)

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126
Psrinapsl Risk Asssssmsnp
Perinatal risk assessment status was inversely related
between the case managed subjects and the control subjects
who received comprehensive care and standard obstetrical
care (see Figure 12), however, all three prenatal groups had

clients in each risk assessment category. The majority

Perinatal Risk Assessment

 

 

 

8
J

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_C\\\\\\\

I

 

 

 

 

LT

\\\\

I

 

 

 

 

 

 

-. \
x \
r \ ~ \
\, ‘

 

 

 

 

Figure 12.

geripstal Risk Asssssmenps by Prenapsl gare
Tips

127

of the clients in the study and control groups had risk
assessments that relied heavily on psychosocial and/or
demographic characteristics and clients who had medical or
obstetrical risk were not included in the study population.
The SUNY Health Science Region Perinatal Assessment and the
NCPPC Psychosocial Risk Assessment combined to give clients
their perinatal risk score (see Table 11). Using chi-square
analysis the results showed statistically significant

differences 2?(4, n=231)= 96.97, p<.05.

128

 

Mblz
ouao 0>wus0sounsmu

a s
Benz
cuwv mo cuspsmum

253m “in.

 

129

Birth Oupcomes
Birth outcomes of completed gestational weeks, birth
weight, and APGAR scores are reported using risk scores and
age criteria as well as prenatal care groups. Each birth
outcome factor will be discussed separately and then as a
whole. The results will be discussed in terms of the
hypotheses:

Hn. There is a positive relationship between receipt
of comprehensive community-based perinatal case
management services and birth outcomes.

Hm, Among pregnant teenagers there is a positive
relationship between birth outcomes and receipt
of community-based comprehensive prenatal case

management services.

Gespational Age

There is slight variation in the number of completed
weeks gestation and prenatal care groups. Infants born
prior to 37 completed weeks gestation (260 days) are termed
premature and considered to be at-risk for neonatal
complications of patent ductus arteriosus (delayed closure
of the connection between the aorta and the pulmonary
artery), episodic apnea (cessation of breathing for 20
seconds or longer or less than 20 seconds when associated
with cyanosis, bradycardia, and or limpness),

intraventricular hemorrhage, retinopathy, and neurological

130

diseases (Olds et al., 1992; Gabbe et al., 1991). These
infants are usually of low birth weight and require
prolonged hospitalization which impacts family bonding that
can have a major impact on family functioning (Gabbe et al.,
1991). Infants born after 42 weeks gestation are considered
postdates or post-mature and are at neonatal risk for
hypoglycemia, jaundice, polycythemia, meconium aspiration,
seizure activity, and cold stress due to loss of
subcutaneous fat. The majority of the subjects in the three
prenatal groups delivered term infants (38-42 gestational

weeks) (see Table 12).

131

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132

Using ANOVA there were no statistical significant
differences found between the type of prenatal care and
completed weeks of gestation at birth. No significant
differences were found when adolescents were analyzed

separately (see Table 13).

Table 13.
WW

 

Entire Population
Between Groups .5
Within Groups 11972.5
Total 11973.0

(Adolescent Population

1 Between Groups .5
‘Within Groups 5305.5
Total 5306.0

 

Bipph weigh;

Birth weight varied somewhat between the three prenatal
care groups (see Table 14). Overall case managed infants
(mean = 3366.914 grams) weighed 21.7 grams more than infants
from the standard obstetrical care group (mean=3345.221
grams) and weighed 142 grams less than infants from the

comprehensive care group (mean=3509.137 grams). There was a

133

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oumuopoz

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134

greater range of birth weights with standard care infants
(482-4450 grams) and case managed infants (1645-4593 grams)
as compared to comprehensive care infants (2580-5103 grams).
Using ANOVA there is no statistical significant
difference in the three prenatal care groups nor when
adolescents are analyzed separately (see Table 15). This
can also be easily viewed by graphic analysis in Figure 13.
With the factoring of birth weight, risk status, and
prenatal care grouping, statistical difference by Chi-square
is found that is directly related to the inclusion of risk
of low birth weight and macrosomia infants. This analysis
is demonstrated graphically for low birth weight and
macrosomia infants in Figures 14 and 15 respectively. Chi-
square analysis for low birth weight shows statistically
significant findings 2?(4, N=10)=71.21, p<.05 and for

macrosomia X’(4, N=33)=15.72, p<.0005.

135

Table 15.
ANOVA pf Bigph weight by Prenatal Cars Group

 

Entire Population
Between Groups 4.9
Within Groups 202979.9
Total 202984.8

Adolescent Population
Between Groups 1.0
Within Groups 6224.8
Total 6225.8

 

136

 

BIRTHWEIGHT BY PRENATAL CARE
akin; 2 2 1‘

 

 

 

 

 

 

 

 

Figure 13.

Espgspp pf pr, Ayersgs. spg Mssrpspmis Birth
Weights p1 Prsnapsl Care Group.

 

137

LBW BY RISK/PRENATAL CARE

 

 

 

 

 

 

 

 

 

 

 

Figure 14.
w B' h Wei ht b nat l C re

 

 

MACROSOMIA BY RISK/GROUP

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

Figure 15.

Mscrosgpis p1 Prsnspal ere Grpup and
rum.

138

APGAR Scorss

There were slight differences in APGAR scores at one
and five minutes of the three prenatal care groups with case
managed infants scoring slightly higher means at both one
and five minutes as well as less deviation (see Table 16).
ANOVA statistical analysis concludes no statistical
differences between the three groups for either one or five
minutes APGAR scores for either the entire population or for

the adolescent population separately (see Table 17).

139

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140

Table 17.
f e ' u Fiv M' re

Prenatal gage Grpup.

F F
(obt) (crit)

Source:
One Minute APGAR
Entire Population

Between Groups 5.1 2.55

Within Groups 510533.? 2239.2

Total 510538.8

Adolescent Population
Between Groups 9.9 2.0
‘Within Groups 208530.7 1363.0
Total 208540.6

Five Minutes APGAR

Entire Population
Between Groups 2.4 1.2
‘Within Groups 738985.6 3241.2
Total 738988.0

Adolescent Population
Between Groups 4.9 2.0
‘Within Groups 324610.0 2121.6
Total 324614.9

 

141

W

In the examination of birth outcome as a whole rather
than as the four separate parts (APGAR 1 minute, APGAR 5
minutes, birth weight, and gestational age) with the
independent variable of prenatal care grouping, there are
found no statistical differences between the groups using
multivariate analysis (MANOVA) (see Table 18). Factoring in
risk status as an independent variable statistically

significant findings resulted (see Table 19).

142

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144

Summapy of Birth Outcomes

Analysis of the 231 subjects showed that there were no
statistically significant differences in any of the four
separate birth outcome variables (completed weeks gestation,
birth weight, one minute APGAR, and five minutes APGAR)
among the three prenatal care groups. The only
statistically significant finding occurred when data were
extrapolated from birth weight data however the small number
of subjects makes difficult application to the general
population. When factoring in for perinatal risk status,
statistical significance was found in the grouped variable
of birth outcome which helps to show the interactional
effect of risk status on birth outcome. The birth outcome
analysis shows that women who are at-risk for poor birth
outcomes may have similar birth outcomes as women who use
standard obstetrical care when they seek prenatal care using
perinatal comprehensive care or case managed services to

reduce their risk factors.

145

Family Stability

The variable family stability was assessed
approximately one year post delivery of the infant. In this
study, family stability has been identified to be the result

of three major but interrelated factors:

1. Family outcomes.
2. Infant outcomes.
3. Client outcomes.

Family stability variables address the hypotheses:

H13 ‘There is a positive relationship between receipt
of community-based comprehensive prenatal case
management services and family stability.

Hm .Among pregnant teenagers there is a positive
relationship between receipt of community-based
comprehensive prenatal case management services

and family stability.

Fsmily Outspmes

Family outcomes refer to monogamous partner
relationships, supportive nuclear/extended family, standard
housing, and lack of violence in the home. In each of three
categories, partner relationships, supportive family, and
housing, subjects in case managed groups had increased
'variance from the other subjects (see Table 20). This

'variance was not found to be statistically significant

146

except for teenagers in the standard housing factor (see
Table 21) Over 18% of teenagers who received case managed
services live in substandard housing as compared to 3% of
teens receiving comprehensive services and 0% of teens who
received standard obstetrical care. The fourth factor, the
presence of domestic violence in the home (by either a
family member or partner) showed remarkable variance in the
case managed subjects for both the entire population and for
the teenage population. Approximately 15-17% of case
managed clients reported domestic violence. This factor was
also proven to be statistically significant at p<.01 for

teens and p<.005 for the entire population.

147

uaso usssa

Had
hnusmm osossuxm
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Sumo usssa

. HH‘
humanoiusasm
ussuumm uSOEmmosoz

 

 

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- 46 .-.4o.fi|1ln1.

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148

 

Sumo momma

   

  

and
sussuoa> suummsoo
mmuossuusnxm

 

 

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v S 6.3 92: 25 .35 comes

     

m.n u--- 02
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msumsom
mumpcmum mm:

        

 

 

sumo osmmsmz sumo sumo s>umsssouosoo sumo mo sanmuum>

  
   

. guru—~00. ON ”Ha—0H.

149

Table 21.
Family Qpppoms Faspprs Using Chi-Sgpsrs.

Significance

 

Monogamous Partner
Relationship

Supportive Nuclear/
Extended Family
All
Teens Only

Lives in Standard
Housing

All

Teens Only

Experiencing Domestic
‘Violence

All

Teens Only

 

*p<.05
**p<.01
***p<.005

 

150
Infan; Qppgpmes

Infant outcomes were assessed at birth and at least one
year post delivery. Factors included care provider at birth
and at one year of age, resolution of custody issues,
participation of the father of the child in infant care, use
of WIC (if eligible for services), and need for child
preventive/protective services.

There were only slight differences in the study factors
of father of child participation, care provider at birth,
and unresolved custody issues (see Table 22). There were
significant differences found in infant care giver at one
year of age, need for child preventive/protective services,
and WIC enrollment that were found to be statistically
significant using chi-square analysis (see Table 23).
Perhaps more dramatic is the difference noted in care
provider status at birth and at one year. In each prenatal
care group the parent (birth mother or father) as primary
infant care provider decreased approximately 28%. The
infant's grandparent(s) provided infant care to

approximately 25% of all infants at one year of age.

151

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add
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haco sassy

Ham
sumo unmumu
mu ssumauouuumm

vauno no usnumm

 

sumo osmmmmz sumo

sumo s>umssssudsoo

sumo m0

 

 

152

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assume zuuum a .«Mam

 

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153

haze mssse

Ham
msSmmH hpODsso
ms>HomsusD mmm

o.ooa Oz
nun: ms» >Hfl0 massfi

o.ooH oz

nun- ms» Add

osuusvsm msou>usm s>uuosuoum
\o>uuos>ouo ouuuu

 

sumo psmmsmz sumo

sumo s>usss£suasoo

sumo mo sanmuum>

 

.Ao.usoo. NN anmB

Table 23.
f m Fa r n 1—
Factor’ df l?(obt) Significance

 

Father of Child Participates

in Infant Care
All 2 3.39
Teens Only 2 2.44

Continues on WIC
All 2 11.34 ***
Teens Only 2 9.44 **

Infant Care Provider

At Birth
All 4 7.28
Teens Only 4 1.88

Infant Care Provider

at One Year

5 .All 6 12.87 ***
l Teens Only 6 8.05

Requires Child Preventive/

Protective Services

[ All 2 11.38 ***
Teens Only ' 2 5.29

Has unresolved
Custody Issues

 

All 2 3.76

Teens Only 2 .99
*p<.05
**D<-01

***p<.005

155

Client Outcomes

Client outcomes included employment or education status
(dependent on age), pregnancy recidivism, use of family
planning methods, need for mental health services during the
first year post delivery, and involvement in legal
difficulties (incarcerations, juvenile delinquency, and
misdemeanor and felony arrests).

Statistically significant findings included pregnancy
recidivism, employment and educational factors (see Table
24). Case managed subjects had twice as many repeat
pregnancies as did the control groups (see Table 25),
however, this did not hold true when teenagers were analyzed
separately. Although not statistically significant, case
managed subjects also had lower use of family planning
methods. Employment status dropped experientially in each
prenatal care group and was shown to be a statistically

significant finding.

156

Table 24.
Q1i p; Qppsgms Faspors gsing phi-sgpsrs.
Factor df 16(obt) Significance

 

Repeat Pregnancy
Within One Year

of Delivery
All
Teens Only' 2 3.64

N
G
IF
U

I-

Uses Family

Planning Methods
All 2 2.00
Teens Only 2 2.50

Required Mental
Health Services
Within One Year
of Delivery

.All 2 3.73

Teens Only 2 1.31
\Involved in Legal
Problems

A11 2 3.03
‘ Teens Only 2 1.01
VContinues Education/
1Schooling

Teens Only' 2 6.06 *

(Is Employed
A11 2 14.63 ***

 

*p<.05
**p<.01
***p<.005

157

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.uuamuumdlumuddUIualmddumuduuudaluumuduumu

.mN sdnmh

158

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Ham
msuuasouuuun
Hmmsa msu>mx

aaso massh

and
msou>usm suHmsm

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sumo Usmmsm: smmo

sumo s>ummsssunsoo

sumo m0

ououuum>

 

.Ao.usoo. mu anmB

159

uu<
nouOuoem nu

xaso sasss
mcuuoouom\oouumo=om
saw: msscuusoo

 

sumo commas: sumo

sumo s>ummsssuosoo

ouomuum>

 

. “mfufloov mN Odo—Mn.

CHAPTER 7

CONCLUSIONS

Discussion of Findings

The at-risk prenatal client suffers from poverty. This

poverty may be the kind associated with lack of money or it

may be an invisible type of poverty that affects wellness.

Spector (1979) in the introduction to the book Cultural

Diversity in Health and Illness describes poverty:

"The term poverty implies both visible and invisible
impoverishment. Visible poverty refers to lack of
money or material resources, which includes clothing,
poor sanitation, and deteriorating housing. Invisible
poverty refers to social and cultural deprivation such
as limited employment opportunities, inferior
educational opportunities, lack of (or inferior)
medical services and health care facilities, and an

absence of public services".

Comprehensive, community-based perinatal case management

attempts to reduce the visible and invisible poverty of its

clients by assisting the client through the maze of health

and human services in meeting the actual and perceived needs

of the client. Case management services help to empower the

160

161

woman and her family to improve the health and well—being of
their ecosystem.

It is widely accepted that being teenaged, single,
poor, having less that a high school education, and being of
a minority race or ethnic group places a woman at-risk for
low birth weight and premature infants. LeHew (1992) found
that teen pregnancies are linked to high unemployment,
poverty, and lack of educational attainment for the parents.
He also found that the child of teenaged parents is at an
increased risk for social and behavioral problems, and at
risk for lower intellectual and academic achievements. Case
managed clients of the Maternal Health Center are generally
teens, therefore, the sample population consisted of
approximately 70% teenagers--approximately 80% were single.
These two factors were controlled for across the three
groups. Even though the subjects were matched on these two
factors the differences in their educational attainment were
markedly different. Approximately 50% of the case managed
clients were high school dropouts compared to 25% and 29% of
the standard obstetrical and comprehensive care clients.
Over 97% of the case managed clients and 90% of the
comprehensive care clients received federal or state
financial assistance with medical care compared to 57% of
the women who received standard obstetrical care. This
variance could be related to Department of Social Services

intake workers recommending the one-stop shopping perinatal

162

services at the Maternal Health Center.

Case managed clients entered prenatal care later than
did the other clients, however, most entered prenatal care
prior to 20 weeks gestation. Cartwright et al. (1993) found
that 5% of all teens do not receive prenatal care. Lincoln
and Johnson (1987) report that women who do not obtain
adequate prenatal care double the risk of having a low birth

weight infant and are at risk for prematurity.

Birph Qppcomes

While case managed clients had increased incidence of
premature labor antepartally (13 subjects as compared to 3
and 5 for the standard OB care and comprehensive care
subjects) the premature delivery rate was similar to the
clients who received standard obstetrical services. This
premature delivery rate (13%) is well above the national
average (9.3%).

Statistical significance was found when low birth
weight and macrosomia infants were analyzed. The national
average for low birth weight deliveries is 12.7% (Gabbe
et al., 1991). Women who received care with OB-GYN
Associates of Northern New York delivered 7.8% of their
infants of low birth weight as compared to Maternal Health
Center clients who had 0% for comprehensive care and 4.9%
for case managed care clients. It is even more remarkable

that the low birth weight range for standard obstetrical

163

clients (who were generally at low-risk) was 468 to 2260
grams. Case managed clients (who were at high-risk) ranged
from 1645 to 2360 grams. These findings are supported by
Isberner and Wright (1987) who found that comprehensive
prenatal care programs decrease low birth weight and
prematurity. Case managed clients also had fewer macrosomia
infants (9.9%). This compared significantly to both the
national average of 11.4% and 18.2% and 15.1% of the
standard obstetrical and comprehensive groups. It was also
significant in view of the fact that the case managed
clients had a higher incidence of gestational diabetes which
is linked to macrosomia infants.

While APGAR scores were not statistically significant,
case managed clients consistently had infants with higher
scores at one and five minutes. Currently there is
controversy on whether APGAR scores predict neonatal and
infant mortality, however, these scores at least improve the
incidence of a healthy status of the infants. Collins,
Dunckel-Schetler, Lobel, and Scrimshaw (1993) report that
women who received more prenatal care support delivered
babies who appeared healthier at five minutes as indicated
by their APGAR scores. Perhaps the involvement of the case
manager with the pregnant family assists in this factor as
the case manager develops a supportive relationship that

lasts over several months to two years with the client.

164

Case management did improve the perinatal outcomes of
at-risk clients in the study population. At each variable
of birth weight, gestational age at delivery, and APGAR
scores, case management subjects were found to have similar

results to women who received standard obstetrical care.

F mi S 'li

Turner, Grindstaff, and Phillips (1990) found that
family support is predictive of more favorable outcomes for
both the infant and the teenaged mother. Supportive families
were seen across the three groups, although case managed
clients were perceived as having less supportive family
members. Logsdon, McBride, & Birkimer (1994) found that
perceptions of social support change over time. There was
little difference found among the groups in monogamous
partner relationships.

Statistically significant findings on domestic violence
and the need for child abuse/neglect preventive/protective
services point to the discrepancy of a supportive family
environment. Newberger et al. (1992) studied domestic
violence in pregnancy finding that as the pregnancy
increases so do the acts of violence. Bullock and McFarlane
(1989) also studied prenatal battering finding that low
birth weight deliveries increase with battering. Few studies
address battering post-delivery. Culpepper and Jack (1993)

found that stress and pregnancy can alter interpersonal

165

relationships. It may be that the violence that began or
continued prenatally may have become routine and thus
continued post delivery.

Child preventive/protective services were required by
case managed clients at statistically significant rates.
Data obtained did not detail what services were needed nor
the reasons. It was noted that there was a significant
increase in the percentage of infants who were placed in
foster care and who were released for adoption within the
year following delivery.

Over the course of a year the primary care provider for
the infant changed drastically. In each prenatal care
group, the birth parent(s) turned to the infant's
grandparent(s) to provide care for the infant approximately
28% of the time. This held true for both the adult and the
teen populations. No data are provided to determine the
factors behind this occurrence for this sample. Current
research on grandparents who parent their grandchildren show
that severe problems in the nuclear family (Jendrek, 1994)
and parental drug addiction (Burton, 1992) are two of the
major reasons.

Kalmuss and Namerow (1990) found that teenagers were
more likely to have a closely spaced second birth than women
who delayed childbearing to after adolescence. They also
found that women who continued schooling were significantly

less likely to experience a closely spaced birth. The tri-

166

county area of the study has the second highest teen
pregnancy rate in the state (NYSDOH, 1992). (The Bronx is
the highest.) It is also among the highest in the state for
pregnancy recidivism among its teenagers. Case managed
clients were twice as likely to have a second pregnancy
within a year of delivery. The national pregnancy
recidivism rate is 30.9%, well below that found in the case
managed clients (43%) (T n r n nitia iv Pilot
Projegts, 1991). Erickson (1994) found that teenagers who
used drugs, lived in substandard housing, were illegal
immigrants, resided in poverty, and were school dropouts had
higher repeat pregnancy rates which correspond to many of
the factors in this study.

The findings related to family stability imply that
case management acts more as a response to the conditions
associated with high-risk status than as a source of aid in
overcoming the obstacles that caused the condition to
develop. Thus the hypothesis that case management has a
positive effect on family stability cannot be supported.

The findings do suggest that there are positive influences

on family stability.

167

Limitations

The study examined two important variables, birth
outcomes and family stability, across three prenatal care
groups of women who received varying degrees of supportive
services. The major limitation found was that the client's
participation in any of the three prenatal groups was due to
self-selection. Selection criteria could be based on a
variety of factors: previous use of a health care provider
for either obstetrical or gynecological services,
recommendations from family and/or friends, desire for a
certain health care provider (physician versus nurse-midwife
or nurse practitioner), referral into a certain program, or
lack of knowledge of existence of the other prenatal care
programs.

Measuring increments of medical, social, and health
education services is important in determining the
significance of the variables but this data is difficult to
collect. The North Country Prenatal/Perinatal Council, Inc.
has an extensive data base that allowed access to most of
the required data. Additional data that were collected from
medical records were often scanty, missing, or unreadable.

A third limitation was the inability to precisely
determine the extent of prenatal care services received by
the subjects. Case management and comprehensive care
subjects had documented number, kind, and type of follow-up

for referrals to community service agencies, as well as

168

client goals and perceived needs. Rarely were any referrals
or social histories documented for women receiving standard
obstetrical care except for those women who requested
adoption services. The interaction between the case manager
and the client, the health care provider and the prenatal
patient, and the referral agencies and the consumer were
rarely documented. Exceptions to this documentation dearth
were notes by the social worker, adolescent pregnancy
counselor, and the WIC counselor. Often teenage clients and
a few adults had assessments performed by the public health
nurses that provided much insight in the social, family, and
partner interactions.

The sample used in this study may limit the
generalization of the results for other populations. The
population was rural-based and had long standing roots in
the community. It was not unusual to have a great
grandparent attend the birth of a new family member. The
population resides in a climate that experiences six months
of cold, snowy winter each year which limits travel outside
the region. Three small sub-populations exist within the
White low to middle class majority-~a transient military
population, an emigree population of Ukraines, and a small
Hispanic community. Each of these groups resides in small
closely-knit pockets throughout the tri-county region. The
'U.S. military and Hispanic populations are young and usually

experiencing new parenthood. The military woman (active or

169

dependent) tends to be married with few social supports
outside the military community while the Hispanic

woman is usually single with a strong support system. The
Ukrainian woman tends to be a grand multigravida (has had
five or more births), speaks little English, has little
support systems outside her family, and has limited

knowledge of U.S. health and human services.

W

This study supports the theoretical frameworks of
family ecosystems theory and Neuman's system model that
show:

"Recognition of childbearing as a process that bridges

social and biological domains that leads to the

hypotheses that [demographic] and psychosocial
factors...may also be influential in...pregnancy

outcomes" (Turner et al, 1990, p. 44).

Neuman's system model incorporates well within the case
management approach. It assists with better utilization of
the levels of prevention. The findings of the family
stability variable suggest that there is a need for
increased tertiary and primary services for the at-risk
client. The case managers and the North Country Prenatal
Perinatal Council, Inc. can use this information to

formulate new programs to address domestic violence and

170

child abuse/neglect. The need for public awareness and
development of community programs to keep teenagers in
school and to increase the availability of standard housing
for teens can be addressed through the North Country
Prenatal Perinatal Council, Inc. Based on research by
Burton (1992) and Minkler, Driver, Roe, & Bediark (1993)
grandparents who parent their grandchildren have increased
needs for community support in terms of psychological,
physical, and economic factors. Programs need to be
developed using a community-based network such as the case
management network of the North Country Prenatal Perinatal
Council, Inc. for these families.

The family ecosystem framework guides the health care
provider and the human services provider in their assessment
of client strengths, resources, and stressors. It allows
the client to be viewed wholistically and in interaction
with the environments. The development of programs and the
continuation of comprehensive or case management program
requires the guidance of the family ecosystem framework to
be successful. The whole is greater than the sum of its
parts.

Further research into family stability factors needs to
be addressed through controlled intervention studies to draw
definitive conclusions. Valid and reliable measures need to
be developed to address these factors. The incorporation of

ethnographic research may assist with more objective

171

indicators of family stability.

Social workers, home economists, day care and school
teachers, nurses, physicians, psychologists, community
action workers, and politicians need to continue to work in
an interdisciplinary manner through community-based action
programs in interaction with consumers to continue programs
that support families in empowerment. The U.S. needs to
ratify the Convention on the Rights of the Child in 1995 in
Egypt to declare that we are truly working toward the goal
affirming "children need special care and attention...and
placing emphasis on the primary caring and protective

responsibilities of the family" (Haggerty, 1994).

Summagy

The research examined the effects of comprehensive,
community-based perinatal case management on perinatal
outcomes and family stability. Women who had received case
management services were matched to women who received
either comprehensive or standard obstetrical care and
delivered at the House of the Good Samaritan, Watertown, New
York.

Drawing on the literature on perinatal risk status and
associated perinatal outcomes, it was hypothesized that
receipt of comprehensive, community-based perinatal case
management would have a positive relationship on perinatal

outcomes. It was also hypothesized that the demographic and

172

psychosocial factors associated with poor perinatal outcomes
would improve with case management thus promoting family
stability. The literature has shown conflicting effects of
comprehensive care programs for pregnant women but little
research on the relatively new concept of perinatal case
management has been published.

The results of the study provided support that
comprehensive, community-based perinatal case management
does have a positive effect on perinatal outcomes especially
in terms of gestational age at delivery and birth weight for
the psychosocially at-risk client. Mixed support was found
for the hypothesis that comprehensive, community-based
perinatal case management had a positive effect on family
stability. Although strong relationships were found between
several measures of family stability, the relationships were
due largely to demographic characteristics.

Case management programs that have integrated community
networks have a positive influence in the life cycle of the
childbearing family. These programs need to be identified,
studied, and modeled to support the family ecosystem thus

improving the health and well-being of the family.

APPENDIX A

Correspondence Related to Research Involving Human Subjects

  

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173

MICHIGANSTATE
UNIVERSITY

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review of thi pr:3:§t‘g: iete. em red to adv t23m
riztta and wa.r Stain as?" ecte a er to he ad;:?atum

ected and methode to in m: are mapgr at
retore. than scnxar approved this progect inc
iated above.
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the a r val date ehown ehove. Investigatr ra::1enningm
we a project heo nd ene er meet waet green mew
term (encieaed witht origi arovai {m or when a
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euhjecta. ior to in tiati a change. 8! th is done at
the time o renewal leaee wee the reen renewal arm to
revise an approved pr tocoi at an her time during the pear
eend your written regueat to the 1W5 Chair. regueetingm mime.

Prove! and relerencingtm we ject'e Ill la title. lnciede
pr regueet a deacr ion or 1the change and an revieed
g"rm-ante. cenaent to or advertiaementa that applicable.
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work. inveati atora meet moti {m pr” 1% :I==:r
(a mrpected a; eiten comp ainte. e c involv
eohjecte er .in the reeearch environment

internation nsicatigz. greater rieht to the human ash ecte ”than
emiated when the protocol waa previesaiy reviewed approved.
up an future he ieaae do not hesitate to contact me

:g' i817:J$8-2 {OJ JIAS 48173138-1103.

lincerelyo

 

174

248 Market Street
Lexington, Kentucky 40507

Ms. Linda Knight, ARNP

Director, Maternal Health Center
House of the Good Samaritan

830 Washington Street

Watertown, New York

Dear Ms. Knight:

I am a doctoral student at Michigan State University, East
Lansing, Michigan. I am preparing to do my dissertation on
Community-Based Comprehensive Perinatal Case Management and
the impact it may have on birth outcomes and family
stability. Since your program has been cited by the New
York State Department of Health as a model agency for one-
stop perinatal services and community-based case management
services I would like to collect my data from your clients.
I understand you are also vice-president of the North
Country Prenatal-Perinatal Case Management Agency. My data
collection will consist of the following:

1. Review all inpatient and outpatient medical records,
case management minutes, case management computer
files, delivery logs of clients who delivered at the
House of the Good Samaritan, Watertown, New York during
the period of October 1991-May 1993:

a. Match all case management clients with
comprehensive perinatal service clients and
routine obstetrical clients.

b. Based on conversations with you, this would
include approximately 100 clients of each type of
prenatal service.

c. Excluded from the study would be those clients
with high-risk medical conditions that are known
to impact birth outcomes.

2. Confidentiality of clients will be maintained as only
medical record numbers will be utilized. All files
will be kept in a locked file cabinet to further
provide confidentiality.

175

All results will be shared with you and the two agencies you
represent. Also included will be information on the clients
that are best served by case management and the types of
services they utilize as compared to clients receiving other
prenatal services. The results of this study are expected
to be completed by Winter 1994.

Thank you for your time and cooperation.

Sincerely,

Donna Scheideberg, CNM

176

248 Market Street
Lexington, Kentucky 40507

Dr. Paul Kruger

OB-GYN Associates of Northern New York
530 Washington Street

Watertown, New York

Dear Dr. Kruger

I am a doctoral student at Michigan State University, East
Lansing, Michigan. I am preparing to do my dissertation on
Community-Based Comprehensive Perinatal Case Management and
the impact it may have on birth outcomes and family
stability. Case management clients will be matched with
clients who have received comprehensive care services and
standard obstetrical services. My data collection will
consist of the following:

1. Review all inpatient and outpatient medical records,
case management minutes, case management computer
files, and delivery logs of clients who delivered at
the House of the Good Samaritan, Watertown, New York
during the period of October 1991-May 1993:

a. Match all case management clients with
comprehensive perinatal service clients and
routine obstetrical clients.

b. Based on conversations with Mrs. Linda Knight of
the Maternal Health Center, House of the Good
Samaritan, this would include approximately 100
case managed clients. I will match these with 100
clients who received comprehensive services and
who received standard obstetrical services.

c. Excluded from the study would be those clients
with high-risk medical conditions that are known
to impact birth outcomes

2. Confidentiality of clients will be maintained as only
medical record numbers will be utilized. All files
will be kept in a locked file cabinet to further
provide confidentiality. Also no specific health care
provider will be identified, only the type of prenatal
care service that was utilized by the client.

177

All results will be shared with you and your health care
practice. The results of this study are expected to be
completed by Winter 1994.

Thank you for your time and cooperation.

Sincerely,

Donna Scheideberg, CNM

178

248 Market Street
Lexington, Kentucky 40507

Mr. Michael Golden
Director, Medical Records
House of the Good Samaritan
830 Washington Street
Watertown, New York

Dear Mr Golden:

I am a doctoral student at Michigan State University, East
Lansing, Michigan. I am preparing to do my dissertation on
Community-Based Comprehensive Perinatal Case Management and
the impact it may have on birth outcomes and family
stability. My data collection will consist of the
following:

1. Review all inpatient and outpatient medical records,
case management minutes, case management computer
files, and delivery logs of clients who delivered at
the House of the Good Samaritan, Watertown, New York
during the period of October 1991-May 1993:

a. Match all case management clients with
comprehensive perinatal service clients and
routine obstetrical clients.

b. Based on conversations with Mrs. Linda Knight,
Director, Maternal Health Center, this would
include approximately 300 clients who delivered
during the period October 1991-May 1993.

c. Excluded from the study would be those clients
with high-risk medical conditions that are known
to impact birth outcomes.

2. Confidentiality of clients will be maintained as only
medical record numbers will be utilized. Upon
completion of data collection and computer file entry,
the medical record number will be eradicated. All
instruments will be kept in a locked file cabinet to
further provide confidentiality. No health care
provider will be identified, only the type of prenatal
care service that was received.

179

All results will be shared with you and the House of the
Good Samaritan. The results of this study are expected to
be completed by Winter 1994.

Thank you for your time and cooperation.

Sincerely,

Donna Scheideberg, CNM

APPENDIX B

SUNY Health Sciences Perinatal Risk Assessment Form

180

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APPENDIX C

Instrument

182

DATA COLLECTION WORK SHEET

The instrument contained on the following pages is a
compilation of instruments used to assess perinatal/family
risk factors in the agencies that are part of the North
Country Prenatal/Perinatal Case Management Agency, Inc.
Perinatal and family outcomes, utilization of case
management resources, and utilization of comprehensive care

resources are the variables assessed using this instrument.

183

DATA COLLECTION WORK SHEET
CASE MAMGEMENT : A PANACEA FOR IMPROVED OUTCOMES ?

Instrument Number (1-3)

 

1. Medical Record Number
2. Age (4)
(1) 13-15
(2) 16-17
(3) 18-19
(4) 20-24
(5) 25-29
(6) 30-34
(7) 35+
3. Financial Payor (5)
(1) Self
(2) Medicaid
(3) PCAP

(4 ) CHAMPUS

(5) Active Duty Military

(6) Private Insurance

(7) PCAP & Private Insurance

( 8 ) PCAP & CHAMPUS

(9) CHAMPUS & Private Insurance

 

4 . Gravida (6)
(1) 1
(2) 2
(3) 3
(4) 4
(5) 5
(6) 6+
5. Parity at delivery (7)
(1) 1
(2) 2
(3) 3
(4) 4
(5) 5
(6) 6+
6. Father of Child Involved in Pregnancy? (8)
(1) No
(2) Yes
7. Marital Status (9)
(1) Single

(2) Married

10.

ll.

12.

13.

14.

15.

16.

184

 

Level of education (10)
(1) In secondary or elementary school

(2) Dropout

(3) High School graduate/GED completion

(4) Attended some college

(5) College graduate

Infant one minute APGAR (11)
Infant five minute APGAR (12)
Weeks of completed gestation at birth

of infant (13)
(1) Below 28 weeks

(2) 28-29 weeks

(3) 30-31 weeks

(4) 32-33 weeks

(5) 34-35 weeks

(6) 36-37 weeks

(7) 38-39 weeks

(8) 40-41 weeks

(9) 42+ weeks

Infant Birth weight in Grams (14-17)

Type of Delivery (18)
(1) Vaginal

(2) VBAC

(3) Vacuum

(4) Forceps

(5) Primary cesarean section

(6) Repeat cesarean section

Type of Prenatal Care (19)
(1) Standard CB

(2) Comprehensive

(3) Case-Managed

Type of Labor (20)
(0) None

(1) Spontaneous

(2) Augmented

(3) Induced

Trimester of onset of prenatal care (21)

(O)
(1)
(2)
(3)
(9)

None

First Trimester

Second Trimester
Third Trimester

Unknown

 

17.

18.

19.

Antepartum Complications

185

(22-23)

 

(either pregnancy or medical)

(00)
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)

Intrapartum Complications

None

Sexually Transmitted Disease
Oligohydramnios
Polyhydramnios

Mild PIH

Severe PIH or HELLP
Gestational Diabetes,
Gestational Diabetes,
Severe Anemia
Incompetent Cervix
Postdates

Unresolved Premature Labor
Resolved Premature Labor
IUGR

Placenta Previa

Other, not stated

non insulin
insulin-requiring

(24-25)

 

(either pregnancy or medical)

(oo)
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)

Initial Infant Caretaker

(1)
(2)
(3)

None

Malposition

Abruptio Placenta

Positive GBS

Mild PIH

Severe PIH or HELLP

Fetal Anomaly (ies)

Fetal Distress

Shoulder Dystocia

PROM

RDS

IUFD

Postpartum Hemorrhage
Nuchal Cord (or other cords)
Failure to Progress/CPD
Chorioamnionitis

Retained Placenta
Precipitous Labor or Delivery
Meconium

(26)
Biological Parent
Foster Parent

Adoptive Parent

20.

21.

22.

186

Case Management Agency Prenatally (27)
(0) None

(1) Maternal Health Center

(2) Catholic Charities

(3) Planned Parenthood

(4) Public Health Nursing

(5) North Country Children's Clinic/APP

(6) Mercy Mental Health

(7) Oswego Options

Case Management Agency

Postpartum/Long Term (28)
( 0) None

(1) Maternal Health Center

(2) Catholic Charities

(3) Planned Parenthood

(4) Public Health Nursing

(5) North Country Children's Clinic/APP

(6) Mercy Mental Health

(7) Oswego Options

Case Manager (29)
( O ) None

(1) RN

(2) ARNP/CNM

(3 ) MSW

(4) Community Health Worker

(5) Mental Health Worker

(6) Pregnancy Counselor

(7) Community Service Worker

(8)

Other

23.

24.

187

What criteria were cited for entry into case

management?

(01) Pregnant age 17 and under (30-31)

(02) Social stressors in home (32-33)
(poverty, housing, finances) (34-35)

(03) Poor socio-economic conditions (36-37)
(M3, PA, self-pay, illegal alien) (38-39)

(04) Single, no support systems (40-41)

(05) Poor use of medical care (42-43)
(over use, under use, (44-45)
non-compliance)

(06) Poor parenting skills

(07) History of drug/alcohol abuse--resolved

(08) Alcohol/drug abuse (self/partner)-—unresolved

(09) History of emotional problems/treatment--resolved

(10) Emotionally unstable (previous or current
psychiatric treatment (inpatient/outpatient)--
unresolved

(11) History of foster care/child abuse (self/
children)--resolved

(12) History of foster care/child abuse
(self/children)--unresolved

(13) History of physical/sexual abuse--resolved

(14) History of physical/sexual abuse-~unresolved
(Note: Abuse by current significant other
should be noted under marital problem/domestic
violence)

(15) Marital problems/domestic violence

(16) Serious medical, genetic, or fetal complications

(17) Serious physical/cognitive disability
(self/partner)

(18) Incarcerated mother

(19) Ambivalence, negative or extreme anxiety re:
pregnancy

(20) Wanted an abortion

(21) Considering adoption

(22) Others, not stated

(23) Non-applicable/none

What is the Psychosocial Risk

Assessment Score? (46)

(1) O

(2) 1-2

(3) 3-4

(4) 5 or higher

25.

26.

188

What major categories were cited for
comprehensive prenatal services?
Please rank order.

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)

Living/Housing Situation
Parenting Needs
Financial Status
Educational Needs
Employment Needs

Health and Well-being

-Personal Development

Age
None or Non-Applicable

Identify what specific areas under
each category were identified for
comprehensive prenatal services?

(Identify the top four areas of each category.)

a.

Living/Housing Situation

(0) None

(1) Permanent Housing Needed
(2) Emergency Shelter Needed
(3) Homemaker Services

(4) Residential Living Services
(5) Independent Life Skills

(6) Emergency Food

(7) Emergency Clothing

Parenting Needs

(00) None

(01) Pediatric Health Care

(02) Breastfeeding Education
and Assistance

(03) Parent to Parent Program

(04) Family Friends Program

(05) Nurturing Program

(06) Foster Care Services

(47)
(48)
(49)
(50)
(51)
(52)
(53)
(54)

(SS)
(56)
(57)
(58)

(59-60)
(61-62)
(63-64)
(65-66)

(07) Child Prevention/Protection Services

(08) Adoption Services

(09) Developmental Assessment
(10) Adolescent Parenting Program
(11) Resolve Paternity Issues
(12) Custody Issues

(13) Child Care Services

d.

e.

f.

Financial Needs
None

(0)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)

(0)
(1)
(2)
(3)
(4)
(5)

189

Transportation

Public Assistance
Medicaid

Food Stamps

Child Support

(67)
(68)
(69)
(70)

Advocacy to Obtain or Retain Benefits

WIC

HEAP
Educational Needs

None

Tutoring

BOCES

Adult Education

Child Care

GED

Transportation

(6)
(7)
(8)
(9)

Employment and Training Needs
None

Job Placement

Job Skill/Training
Employment Counseling
Child Care

(0)
(1)
(2)
(3)
(4)
(5)

Academic Counseling
Educational Advocacy
Prepared Childbirth Classes

Transportation

Health and Well-Being

(oo)
(01)
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
(11)

None

Dietitian

Genetic Counseling/Testing
Family Planning Services
High-Risk Obstetrical Care

(71)
(72)
(73)
(74)

(75)
(76)
(77)
(78)

(79-80)

 

(81-82)

 

(83-84)

 

(85-86)

 

Alcohol/Drug Treatment or Services

Mental Health Services
Domestic Violence
Gynecological Services
Smoking

Dental Health Care
Learning Disabled

27.

28.

29.

190

g. Personal Development
(0) None (87)
(1) Counseling Services (88)
(2) Establish or Identify Client
Goals (89)
(3) Alcohol/Drug Counseling (90)

(4) Mentoring
(5) Partner Relationships
(6) Family Relationships

Total Number of Referrals/Services
Initiated. (91-92)

Total Number of Referrals/Services
Followed-Through by the Client (93-94)

 

Reasons why referrals/services were
not followed through by the client.

a. Access problem/services not
available in area
(0) Non-applicable (95)
(1) No
(2) Yes
b. Crisis in clients/life prevented
obtaining of services
(0) Non-applicable (96)
(1) No
(2) Yes
c. Denied services by provider
(0) Non-applicable (97)
(1) No
(2) Yes
d. Ineligible for services
(0) Non-applicable (98)
(1) No
(2) Yes
e. Provider at maximum capacity,
not taking new referrals
(0) Non-applicable (99)
(1) No
(2) Yes
f. No longer applicable to client's
situation (but not met)
(0) Non-applicable (100)
(1) No

(2) Yes

191

Quit services before completion

(0) Non-applicable (101)
(1) No

(2) Yes

Unknown
(0) Non-applicable (102)
(1) No
(2) Yes

30. Postpartum Case Management Follow-up
Services

(0)
(1)
(2)
(3)

(4)

None or non-applicable (103)
Failed to return PP, lost to care
Discharged from Case Management Services
Refused Continuing Case Management Services,
although need(s) still present

Continues Case Management Services

31. Postpartum Case Management Agency

a.

b.

Did Case Management Agency Change?

(0) Non-applicable (104)
(1) Yes
(2) No

Postpartum Case Management Agency

(0) Non-applicable (105)
(1) Maternal Health Center

(2) Catholic Charities

(3) Planned Parenthood

(4) Public Health Nursing

(5) North Country Children's Clinic/APP

(6) Mercy Mental Health

(7) Oswego Options

(8) Other

32. Family Outcomes at 6 to 9 months

a.

Client Outcomes

1. Continues with education (106)
(0) Non-applicable
(1) Yes
(2) No
( 9) Unknown
2. Using family planning (107)
(0) Non—applicable
(1) Yes
(2) No

(9) Unknown

192

Has housing that meets standard

living requirements. (108)
(O) Non-applicable

(1) Yes

(2) No

(9) Unknown

Continues in parenting/nurturing

program (109)
(O) Non-applicable

(1) Yes

(2) No

(9) Unknown

Meeting goals as previously

established (110)
(O) Non-applicable

(1) Yes

(2) No

(9) Unknown

Employed (111)
(O) Non-applicable

(1) Yes

(2) No

(9) Unknown

Having legal problems (112)
(0) Non-applicable

(1) Yes

(2) No

(9) Unknown

Requires new or ongoing Mental

Health Services (113)
(0) Non-applicable

(1) Yes

(2) No

(9) Unknown

Repeat pregnancy within this time

period (114)
(O) Non-applicable

(1) Yes

(2) No

(9) Unknown

193

b. Infant Outcomes
1. Infant caretaker: (115)

(1) Infant cared for by mother
(2) Infant care shared with grandparents
(3) Infant in foster care
(4) Infant adopted out
(5) Infant death
(9) Unknown

2. Father of baby participates
in infant care (116)
(0) Non-applicable
(1) Yes
(2) No
(9) Unknown

3. Child preventive/protective services
required (117)
(O) Non-applicable
(1) Yes
(2) No
(9) Unknown

4. Continues with WIC (118)
(0) Non-applicable
(1) Yes
(2) No
(9) Unknown

c. Family Outcomes at 6 to 9 months

1. Stable partner relationship (119)
(0) Non-applicable
(1) Yes
(2) No
(9) Unknown

2. Father of baby continues with family
involvement. (120)
(0) Non-applicable
(1) Yes
(2) No
(9) Unknown

3. Custody issues resolved (121)
(0) Non-applicable
(1) Yes
(2) No

(9) Unknown

 

194

Domestic Violence services
required

(0) Non-applicable

(1) Yes

(2) No

( 9) Unknown

Family (parents, siblings)
supportive of mother and baby

(0) Non-applicable
(1) Yes

(2) No
(9) Unknown

(122)

(123)

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