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thesis entitled
RELATIONSHIP BETWEEN RURAL COMMUNITY HEALTH
CENTER" NILLINGNESS TO CONSIDER AN ALTERNATIVE
PRENATAL VISIT SCHEDULE AND THEIR PRENATAL CARE
PROVIDER MIX

presented by

Nicole L. Jamieson

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RELATIONSHIP BETWEEN RURAL COMMUNITY HEALTH CENTERS'
WILLINGNESS TO CONSIDER AN ALTERNATIVE PRENATAL
VISIT SCHEDULE AND THEIR PRENATAL
CARE PROVIDER MIX

BY

Nicole L. Jamieson

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE IN NURSING
College of Nursing

1998

ABSTRACT
RELATIONSHIP BETWEEN RURAL COMMUNITY HEALTH CENTERS'
WILLINGNESS TO CONSIDER AN ALTERNATIVE PRENATAL

VISIT SCHEDULE AND THEIR PRENATAL
CARE PROVIDER MIX

BY

Nicole L. Jamieson

Accessibility to maternity services for the United
States' rural population can be addressed through the
utilization of advanced practice nurses (APNs) and by
offering a modified prenatal schedule with fewer visits for
medically low-risk pregnant women based on the Expert
Panel's (1989) recommendations on the Content of Prenatal
Care. This study examined 70 rural community health
centers' (CHCs) prenatal care provider mix and their
willingness to consider an alternative prenatal structure.
The results indicated that the rural CHCs that employed APNs
as prenatal care providers were more likely to be willing to
adopt the alternative prenatal schedule than those centers
who employed only physicians, although this difference did
not reach statistical significance. Findings suggest that
the majority of the rural CHCs were employing APNs as
primary prenatal care providers and that these providers
were willing to offer a alternative prenatal visit
structure. This study implies that APNs as primary prenatal

care providers must be encouraged.

ACKNOWLEDGMENTS

I would like to thank the members of my committee:
Mildred Omar, PhD, RNC, Rachel Schiffman, PhD, RN, and
Andrew Hogan, PhD. Thank you all for your expertise,
patience and support throughout the writing of this thesis.
Your guidance has helped to make the completion of this
project a reality. A special thank you to Dr. Hogan and
Yea-lin Lin who provided assistance with the data analysis
of this project.

I wish to thank my family and friends for their
continuous love and encouragement throughout this endeavor.
To my parents, thank you for your never ending support and
faith in me in obtaining this goal. My deepest heartfelt
thanks to my husband, Troy, for his unending patience and
understanding throughout the writing of this manuscript.
Finally, to my son, Cole, whose birth provided me the
greatest fulfillment, in addition to challenge, along the

journey of this project.

iii

TABLE OF CONTENTS

LI ST OF TABLES O O O O O I O O O 0
LIST OF FIGURES . . . . . . . . . .

INTRODUCTION . . . . . .
Background to the Problem .
Statement of the Problem . .
Research Question . . . . .
Research Hypothesis . . . .

THEORETICAL FRAMEWORK . . . . . . .
Conceptual Definition of Study
Conceptual Framework . . . . .

REVIEW OF THE LITERATURE . . . . .
Critique of the Literature . .

METHODS . . . . . . . . . . . . . .
Research Design . . . . . . .
Sample . . . . . . . . . . . .
Operational Definitions of the
Instrumentation . . . . . . .
Protection of Human Subjects
Data Analysis . . . . . . .
Assumptions of the Study . .
Limitations of the Study . .

RESULTS 0 O O O O O O O O O O 0
Description of Sample . . . .

Variables

coco-<00.
DD
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Analysis of Research Question and Hypothesis .

DISCUSSION . . . . . . . . . . . .
sample 0 O O O O I O O O O O 0

Discussion of Results with the Conceptual

Framework . . . . . . . . . .

Implications for Advanced Practice Nursing

Primary Care . . . . . . . .

Recommendations for Further Research . .

SUMMARY . . . . . . . . . . . . . .

LIST OF REFERENCES . . . . . . . .

and

Appendix A: Field Procedures for the Primary Study
Appendix B: UCRIHS Approval for Primary Study .
Appendix C: UCRIHS Approval for This Study .

iv

Page

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p.

bflm Oath-PH

28
28
28
28
29
30
31
31
31

32

. 35
. 35

. 4O
. 42

. 48
. 49

Table 1:

Table 2:

LIST OF TABLES

Page
Frequencies of Sample Characteristics . . . . . 33
Contingency Table for Prenatal Care Provider

Mix and Willingness to Consider an
Alternative Prenatal Visit Schedule . . . . . . 34

LIST OF FIGURES

Page

Figure 1: The Health Services System . . . . . . . . . . 16

Figure 2: An Adapted Conceptual Framework for Evaluating
Prenatal Care From Starfield's Model of Health
serVices system C O O O O O O O O O O O O O O O 17

vi

INTRODUCTION

WM

Currently there are over 4 million births annually in
the United States (National Center for Health Statistics,
1995) with approximately one-quarter of these births
occurring in rural counties (McManus 8 Newacheck, 1989). As
many as one out of 18 women receives inadequate or no
prenatal care in the United States (Burks, 1992). The
literature has shown how important prenatal care is to
improving perinatal outcomes for mothers and infants (Hall,
1991; Nesbitt, Connell, Hart & Rosenblatt, 1990). The
provision of universally accessible and cost effective
prenatal health care is a primary objective in the United
States (Graveley & Littlefield, 1992; Long, Marquis, &
Harrison, 1994). Achieving this objective in rural settings
has often been difficult. Significant challenges exist in
providing adequate access to maternity services to the one-
fourth of the United States' population that lives in rural
areas (Nesbitt, 1996).

These issues of cost and accessibility of services have
hindered access to prenatal care for some rural pregnant
women (Hicks, 1992; Huntington & Connell, 1994; Rowland &
Lyons, 1989). Both the issue of cost and accessibility for
prenatal care in rural areas can be addressed through the
use of advanced practice nurses (APNs), which includes nurse
practitioners and certified nurse-midwives (CNMs), providing
prenatal care in rural settings (Blake 5 Guild, 1978;

1

Sekscenski, Sansom, Bazell, Salmon & Mullan, 1994; Weis,
1992). It has been shown that most medically low-risk
pregnant women and even certain groups of high-risk women,
especially the socioeconomically disadvantaged, can be
effectively managed by advanced practice nurses (Knoll,
1990). In addition, the issue of accessibility can be
partially addressed through a modified prenatal visit
schedule for medically low-risk pregnant women with less
frequently scheduled prenatal visits with a specific content
for each visit.

Rural pregnant women face certain barriers in accessing
and obtaining obstetrical services (Nesbitt, 1996). A
decline in the absolute number of primary prenatal care
providers has not only hindered access but has also affected
the continuity of care for rural pregnant women (Nesbitt et
al., 1990). Keeping the specified number of prenatal visits
as recommended by the American College of Obstetricians and
Gynecologists (ACOG) (1992) provides challenges for the
rural pregnant population. Geographical barriers, distance,
time, transportation and loss of work are just a few of the
reasons for the difficulties in obtaining prenatal care
services (Nesbitt, 1996; Nesbitt et al., 1990).

The Expert Panel (1989) on the Content of Prenatal Care
has recommended a reduction in the number of prenatal visits
for medically low-risk pregnant women (McDuffie, Beck,
Bischoff, Cross, & Orleans, 1996). With an alternative
prenatal visit schedule for medically low-risk rural women,
they would be able to take less time off from work for

2

prenatal visits and spend less money and time on babysitting
and transportation thus increasing the accessibility and
obtainability of adequate prenatal care for these women. In
addition, prenatal care providers would be available to see
more women thereby increasing accessibility to prenatal
care. However, rural prenatal care providers need to be
willing to implement the Expert Panel's recommendation of a
reduced prenatal visit structure as well as accept APNs in
the delivery of prenatal care services to rural women.

Community Health Centers (CHCs) provide comprehensive
primary care services including prenatal care to medically
underserved populations which includes rural populations.
Identifying prenatal care providers within rural CHCs who
are willing to consider an alternative prenatal visit
schedule could favorably impact the current cost and
accessability of services in rural areas. Studies have
shown that the majority of births occur to low-risk women
who require minimal medical intervention (Montquin, Gagnon,
8 Trainville, 1987) and that perinatal outcomes have not
declined with the implementation of the Expert Panel's
alternative prenatal visit schedule for low-risk women
(McDuffie et al., 1996).

The purpose of this study was to determine if there was
an association between the willingness to consider an
alternative prenatal visit structure based on the Expert
Panel's (1989) recommendations for medically low-risk
pregnant women and the prenatal care provider mix currently
providing prenatal care in rural community health centers.

3

WM

Nearly one-fourth of the United States' population
lives in rural areas where significant challenges to
providing adequate access to maternity services exist
(Nesbitt, 1996). Availability of prenatal care providers in
rural areas has declined (Thompson, 1996) with 60% of all
rural counties having no practicing obstetricians (Bureau of
Health Professions, 1992) and 79% of rural counties with
215,000 annual births having no source of clinical prenatal
care by any provider (Bureau of Health Professions, 1992).
One solution to increase the availability of prenatal care
providers in rural areas is through the use of APNs. As a
direct result of increased numbers of providers of prenatal
care services, continuity of care should be improved for the
rural pregnant population. Advanced practice nurses are
frequently more willing to work in underserved areas and are
less costly providers of prenatal care (Davis, McAdams, 8
Tilden, 1994; Shi, Samuels, Ricketts, 8 Konrad, 1994).
Prenatal care delivery, including the prenatal visit
structure, has been guided by ACOG's standards of practice
(Baldwin, Raine, Jenkins, Hart, 8 Rosenblatt, 1994). The
American College of Obstetricians and Gynecologists consists
of a uni-disciplinary, uni-specialty team of physicians with
expertise in the areas of obstetrics and gynecology. The
Expert Panel was composed of a multi-disciplinary team of
physicians and advanced practice nurses with expertise in
the areas of obstetrics and gynecology. The current
prenatal visit schedule evolved chiefly in response to the

4

problem of maternity hypertension; however, there is no
scientific basis for this (Baldwin et al., 1994). Interest
in exploring the potential of an alternative delivery model
of prenatal care delivered by advanced practice nurses has
emerged.

Providing accessible, appropriate, and affordable rural
prenatal care is a national problem which demands scientific
attention. There is limited research on alternative
prenatal care delivery models in rural areas. The purpose
of this study was to add to the body of knowledge by
examining if there was an association between the
willingness to consider an alternative prenatal visit
structure and the prenatal care provider mix currently
providing prenatal care in rural community health centers.
If an association is identified, rural community health
centers, health planners, and policy makers can use this
information to help promote increased utilization of
advanced practice nurses as direct providers of prenatal
care in rural areas. In addition, this information can be
used to recommend modifications of the current prenatal care
visit schedule for medically low-risk pregnant women.

This study examined the prenatal care provider mix in
rural community health centers and their willingness to
consider an alternative prenatal visit structure using
advanced practice nurses. A secondary analysis using
primary data collected by Omar, Schiffman, and Hogan (1997)
was done. In the primary study, consenting executive
directors of rural CHCs were asked to complete the

5

Partnership for Rural Prenatal Care Delivery Survey. The
completed survey supplied information about the type of
prenatal care providers at the rural community health
centers, rural CHCs' characteristics, and willingness to
consider an alternative prenatal visit schedule based on the
Expert Panel's recommendations and provided by APNs.
W

Is there an association between the willingness of
rural community health centers to consider an alternative
prenatal visit schedule for medically low-risk pregnant
women and the prenatal care provider mix currently providing
direct obstetrical care in these health centers?
WW

There will be an increase in the willingness of rural
community health centers to consider an alternative prenatal
visit schedule for the medically low-risk pregnant
population when the community health center is staffed by
both physician and advanced practice nurse prenatal care
providers than when the community health center is staffed
by physician prenatal care providers.

Theoretical Framework

This section includes the conceptual definitions of the
study variables. Secondly, the conceptual model using
Starfield's Health Services System (Starfield, 1992) is
described. The concepts, prenatal care provider mix and
willingness to consider an alternative prenatal visit

schedule, are defined conceptually.

: l J E E' il' E 5! i M i 1]

WW
W. As a result of
difficulties with recruitment of physicians, many rural
communities are employing nonphysician providers (Blake et
al., 1978; Sekscenski et al., 1994; Weis, 1992). A
community or migrant health center on the average employs
2.7 nonphysician providers, including 1.4 nurse
practitioners, 1 physician assistant, and 0.3 certified
nurse-midwife (Shi et al., 1994). Nesbitt (1996) states
that it is essential for rural family physicians, nurse
practitioners, and certified nurse-midwives to embrace the
idea of collaborative practice in order to enhance both the
quality and quantity of maternity care for the low-risk
population.

Specifically, prenatal care provider was defined as a
provider of prenatal care services who has met the
prescribed educational requirements, and is licensed and
certified, if applicable, as set forth by state law, to
practice in that particular state. Physician providers
represent those health care providers who have 11 years or
more of higher education. As a result, the medical
profession deems its physicians as having the expertise that
is needed at the diagnostic stage of the medical assessment
process (Avery, 1995). Most physicians tend to focus mainly
on the diagnosis and management of a disease process, while
under-emphasizing the assessment of the client in a holistic
manner, including psychosocial issues. Most medical work is

.7

he

divided among specialties, with considerable overlap between
«and among the primary care physician and some specialists.
‘One factor that seems to influence where physicians choose
to provide their services is professional and social status
(Gordon, Meister, 8 Hughes, 1992). These authors have
divided the physician reward structure into three parts:
prestige, economic benefits, and service. Urban settings
carry predominately prestige associated with academic
medical centers. Suburban areas include secondary and
tertiary centers outside of academic medicine where economic
rewards hold sway. Finally, rural settings pertain to
primary care areas where service is highlighted. Davis
(1994) illustrated that most physicians preferred to
practice where they could schedule time off, and where they
had the support of consulting colleagues and access to more
specialized assistance when needed. In addition, the
American Medical Association insists that every team needs a
leader and that only a physician can fill that role (Avery,
1995). McLain (1988) also states that many primary care
physicians are continuing to be taught values that promote
hierarchical relationships.

Advanced practice nurses have a minimum of a
baccalaureate nursing degree which provides them with a
basic foundation of knowledge and skills. Typically, the
education of the advanced practice nurse is at the masters
level with advanced didactic and clinical preparation that

l'las further prepared them to assess, diagnose, manage, and
Prescribe in the primary care arena. Advanced practice

8

nurses are licensed, certified, and can work independently
or in collaboration with other members of the health care
team. Advanced practice nurse are specially trained to
manage a variety of acute and chronic health problems as
well as healthy states through health promotion and disease
prevention behaviors. The APN can be a generalist or
specialist just like their collaborating physician. The
APN's scope of practice pertains to one's field of t
expertise. According to the Pew competencies needed for

health professionals in 2005 (National Organization of Nurse

_ '. .1.-

Practitioner Faculties, 1995), the APN's scope of practice

must include: care for the community's health, provision of

 

contemporary clinical care, participation in the emerging
system and accommodation of expanded accountability,
ensuring cost-effective care and using technology
appropriately, practicing prevention and promotion of
healthy lifestyles, involving patients and families in the
decision-making process, managing information, and
continuing to learn. The literature describes the
effectiveness of the APN as having better listening skills,
spending more time with patients, delving more into
psychosocial issues, and being better patient educators
(Weis, 1992). The advanced practice nurse has developed
strong interpersonal communication skills and counseling
techniques while in the nurse/client relationship.

For the purpose of this study, provider mix was defined
as a model of prenatal care delivery by one of two groups of
prenatal care providers. One group consisted of a

9

physician(s) and could include an obstetrician, family
practice physician, or a general practice physician who was
currently providing direct prenatal care services to the
population of women serviced by the rural community health
center. This model of prenatal care delivery formulated an
uni-disciplinary team approach. The second group consisted
of a combination of any of these physicians with an advanced
practice nurse and could include a nurse practitioner or a r
certified nurse-midwife who were in a collaborative practice
together. This model of prenatal care delivery constituted
a multi-disciplinary team approach.

11'] J . l : . i E 1| l l E l 1 Il' ll _t
schedule. A solution needs to be formulated that addresses

 

the problem of providing adequate access to rural maternity
services. Nesbitt (1996) states that childbearing women in
rural areas are not being offered adequate and appropriate
services under current models for prenatal care. Nesbitt
suggests that rural caregivers must develop new prenatal
care models that serve their low-risk population. In
addition, these prenatal care providers must be willing to
offer an alternative visit structure to the appropriate
population. Advance practice nurses have been educated
regarding the importance of fostering health assessment and
promotion. An altered model of prenatal care corresponds
with the philosophy of advanced nursing practice. The
Expert Panel on the Content of Prenatal Care has recommended
a form of this new schedule. They have described this model
as fewer visits for healthy, low-risk women by combining

10

visits for risk assessment and health promotion (McDuffie et
al., 1996).

Currently, the prenatal visit schedule across the
United States is based on the recommendation of the American
College of Obstetricians and Gynecologists which state that
generally women with uncomplicated pregnancies should be
examined approximately every four weeks for the first 28
weeks, every two to three weeks until 36 weeks of gestation
and then weekly thereafter (ACOG, 1992). In order to
decrease the challenges in providing accessible rural
obstetrical care, it is imperative that a prenatal visit
schedule for rural women with low obstetrical risks be
developed which can meet the specific needs of these women.

The Expert Panel on the Content of Prenatal Care was
commissioned by the Department of Health and Human Services.
This Panel was designed to assess the content of the current
prenatal visit structure scientifically and systematically.
They identified that the timing and frequency of the current
prenatal visit schedule was lacking in sound empirical
studies (Baldwin et al., 1994). The Panel evolved a
recommended visit schedule from scientific evidence and
expert clinical judgement regarding the effectiveness for
identifying and modifying risk and the success of medical
and psychosocial interventions in the provision of prenatal
care (U.S. Public Health Service, 1989). A reduction in the
number of visits was based on the assumption that high
quality care would be offered, that prenatal care providers
would be easily accessible to the women, that the women

11

would continue to be screened for changing risk states
throughout their pregnancies and that there would be no
detrimental effect on the perinatal outcome. Specifically,
the Expert Panel on the Content of Prenatal Care established
an alternative prenatal visit structure which proposes ten
prenatal visits for a nulliparous woman and eight prenatal
visits for a multiparous woman. This is in comparison to
the American College of Obstetricians and Gynecologists'
proposed thirteen to fourteen prenatal visits for a full-
term pregnancy. For the purpose of this study, willingness
to consider an alternative prenatal visit schedule was
defined as the stated opinion given by the rural CHCs'
directors regarding the prenatal care providers currently
providing prenatal care within their rural CHCs and the
willingness of these prenatal care providers to consider
implementing a different prenatal visit schedule consisting
of fewer prenatal visits for their medically low-risk
clients based on the Expert Panel's recommendations with
this care being provided by an APN.
Rnra1_ngmunity_flealth_§entgrs. The literature defines
rural as a delimited geographical area characterized by a
population that is small, relatively sparse, and isolated,
to varying degrees, from metropolitan hubs (Miller, Farmer,
8 Clarke, 1994). Rural communities are unique in their
combination of structural characteristics such as population
size and composition, human and economic resources,
'employment patterns, density, and cultural norms (Miller et
al., 1994). Rural areas are often medically underserved.

12

This means that there is a shortage of health personnel.
Indicators that are used to ascertain this are infant
mortality rates, ratio of primary care physicians to the
population, percentage of population ages 65 and older, and
percentage of population below the poverty level (Shi et
al., 1994).

Community health centers have a direct mission to a
designated medically underserved area. Their main goal is
to provide comprehensive, coordinated, preventative, and
community-based primary health care services to their target
population. This target population includes those rural
patients that are low-income, uninsured, or underinsured.
In addition to providing basic health services, community
health centers must have a governing board with 51 percent
of the membership composed of users of the center (Davis et
al., 1994). The member communities, where the community
health centers are located, develop and operate the centers.
In addition, with help from the health care staff, the
consumer board develops a health care plan and implements
intervention strategies. Emphasis is on designing health
care programs that meet the needs of the rural population
group. Care provided usually centers on promoting health
and preventing disease, in addition to curative care.
Organizationally, all CHCs have a medical director and an
executive director. It is unclear to how much, if any,
nursing leadership is present. For the purpose of this
study, rural community health center was defined as an
organized operation that provides comprehensive,

13

coordinated, preventative, and community-based primary
health care services, including prenatal care, to their
rural patients who are low-income, uninsured, or
underinsured.

Concentuallramemrk

The conceptual framework for this study was derived
from Starfield's (1992) model of the health services system
which is a basis for evaluating primary care. The
definition for primary health care is essential in the
understanding of the model and organization of the health
services system. Starfield specifies that primary health
care must constitute first contact, longitudinality,
comprehensiveness, and coordination (or integration) of
health care services.

Primary care is the basic level of care that should be
provided equally to everyone (Starfield, 1992). The two
goals of the health services system are optimization of
health and equity in distributing resources. Primary care
is utilized to achieve these goals. Primary care focuses
it's services on the community's problems and complaints.
It provides preventive, curative, and rehabilitative
services to maximize health and well-being of each
individual member of the community. People's responses to
their health problems are greatly influenced by their
primary care provider's approach to the management of their
care. Primary care facilitates the organization and
utilization of all resources of the community, basic as well
as specialized, directed at promoting, maintaining, and

14

improving health. Under this definition, an appropriate
source of primary health care must be directly accessible to
everyone and it must be continuous over the span of time.
Primary care services must respond to a variety of problems,
including needs for preventative measures.

Starfield (1992) has provided a framework for measuring
attainment of primary care in the model on the health
services system (see Figure 1). Every health services
system has three types of components: structure, process,
and outcome. In this model, Starfield has attempted to
describe an approach to measure primary care that is based
on certain structures and processes within the health
services system. Two basic assumptions of this model are:
(a) before important activities can occur, certain
structural attributes must be in place, and (b) the
performance of those activities must be properly addressed.

The main focus of this study was on the rural community
health centers' current structure for the delivery of
prenatal care services. The structure of the health
services system consists of the resources needed to provide
services. The structural aspect consists of nine main
components: personnel, facilities and equipment, range of
services, organization, management and amenities,
continuity, accessibility, financing, and population
eligible. For the purpose of this study, as shown in Figure
2, the structural component of personnel was of interest.
Personnel, in this study, pertains to those providing direct
prenatal care services. The personnel mix who directly

15

A Basis for Evaluating Primary Care

STRUCTURE

PROCESS "

I

of care

Receipt
of care

 

OUTCOME

\

 

 

Personnel

Facilities and equipment
Range of services
Organization

Management and amenities

Continuity
Accessibility
Financing
Population eligible

 

 

Provision

l—
L.

Problem recognition
Diagnosis
Management

 

 

 

Reassessment
PERSONS

4—»

 

Utilization
Acceptance and
satisfaction
Understanding

 

 

Participation

 

l

 

 

Longevity

Activity

Comfort

Perceived well—being
Disease
Achievement
Resilience

 

 

figure I. The health services system. Source: Starfield, 1992.

16

 

V

 

 

Social
and
physical
environment

 

 

 

A Basis for Evaluating Primary Care

STRUCTURE

PROCESS "'4

 

 

Personnel

Facilities and equipment
Range of services
Organization

Management and amenities
Continuity

Accessibility

Financing

Population eligible

 

 

I

Provision
of care

I"
l_

Receipt
of care

 

OUTCOME

MILL. The health services system. Source: Starfield, I992.

\

Problem recognition
Diagnosis
Management
Reassessment

 

 

Utilization
Acceptance and
satisfaction
Understanding

Participation

l

 

 

 

 

 

V

 

 

 

Social
and
physical
environment

 

 

 

Longevity

Activity

Comfort

Perceived well-being
Disease
Achievement
Resilience

 

 

16

 

 

A Basis for Evaluating Prenatal Care

 

0 Personnel - Prenatal care
provider mix H—
0 Range of services -

STRUCTURE Prenatal care services *7

 

 

 

0 Current prenatal
visit schedule

I 0 Willingness to

consider an

alternative

prenatal visit

schedule

_ _ _'=-=.—_—.=-_T=-=-==-_ — — ‘— Rural
PROCESS ITidedically low-risk rural pregnant woman” community

health centers

Provision
of care

 

V

 

 

 

 

Utilization,

Receipt acceptance and

of care participation of an

\ alternative prenatal
visit schedule and
prenatal care provider

mix

0 Cost effectiveness

OUTCOME ° Satisfaction
0 Birth outcomes

 

 

 

 

 

 

 

 

 

 

 

 

 

figure}. An adapted conceptual framework for evaluating prenatal care from Starfield's
model of health services system. Source: Starfield, 1992 (Revised).

17

t.

provide prenatal care can include one or any combination of
the following: family practice physicians, general practice
physicians, obstetricians, or advanced practice nurses.

Also included in the structural component is the
facilities and the organization of services. In rural
communities, which reflect the study's environment,
community health centers are largely responsible for the
provision of prenatal care to the population they serve
(Davis et al., 1994). Consequently, these services need to
be continuous, accessible, and affordable. Organization of
services depicts who is responsible for providing the
different aspects of care. In most rural community health
centers, advanced practice nurses are providing services
that were once reserved for family practice physicians and
obstetricians. These vacancies are available to them due to
the shortages of these health care providers and their
willingness to work in these underserved areas (Davis et
al., 1994; Shi et al., 1994).

It is also important to note the process and outcome
components of the health services system. In this model,
the process component contains two segments: the provision
of care and the receipt of care. Under the provision of
care, also the focus in this study, providers must recognize
the needs that are present in the individual clients that
they serve and the community as a whole. This problem
recognition is essential in determining what diagnosis,
management, and treatment plans are needed. The provision
of care that community health centers offer refers to the

18

current prenatal visit protocol for medically low-risk
pregnant women which can include: (a) ACOG guidelines (i.e.,
every 4 weeks for the first month, every 2-3 weeks between
weeks 28-36, and every week for 36+ weeks), (b) Expert Panel
on the Content of Prenatal Care recommendations (i.e.,
reduced number of scheduled visits [8-10 visits] occurring
at week 6-8, 8-12, 16, 24-28, 32, 36, 38-39, 40+), and (C)
other (i.e., anything not included in [a] or [b]). This
area also pertains to the willingness to consider an
alternative prenatal visit structure by those who are
currently providing prenatal care in the rural CHCs. The
segment on receipt of care refers to the utilization,
acceptance, and participation of an alternative prenatal
visit schedule and primary prenatal care provider mix.
While not the main focus of this study, the last component
of the health services system, the outcome, needs to be
addressed. Cost effectiveness, birth outcomes, and
satisfaction are three measurable outcomes of providing an
alternative prenatal visit schedule to the medically low-
risk rural pregnant population.
Review of Literature

This section examines the empirical literature relevant
to the variables under study: (a) prenatal care provider mix
in rural areas, and (b) willingness to consider an
alternative prenatal visit schedule. In addition, any
direct literature relating prenatal care provider mix and an

alternative prenatal visit structure was reviewed.

19

56

Pr

10

Twenty-three percent of the nation's population live in
rural areas (Nesbitt et al., 1990). An adequate number of
primary prenatal care providers to service this population
needs to be available. There is an increasing shortage of
family-practice physicians and obstetricians in rural areas
(Hueston 8 Murry, 1992; Weis, 1992). General and family
physicians make up two-thirds of rural maternity care
practitioners in the United States (Nesbitt, 1996).
Unfortunately, this group has left rural obstetrics in the
greatest numbers (Nesbitt, 1996). As a result, advanced
practice nurses are being presented with increased
opportunities to practice because of these vacancies (Davis
et al., 1994; Weis, 1992). The reasons for the undersupply
of rural physicians has been addressed throughout the
literature. One reason cited in the literature reports that
medical students are influenced to enter specialty fields
and urban practice sites that offer higher pay reimbursement
under the present system (Davis et al., 1994; Weis, 1992).
Declining rural economies, rural hospital closures, and
changes in technology of medicine are also factors that have
impacted the growing shortage of physicians in many rural
areas of the country (Gordon et. al., 1992).

Advanced practice nurses offering prenatal care
services is one answer to the shortage of prenatal care
providers in rural areas. Establishing an alternative
Prenatal visit schedule that meets the needs of the rural
(low-risk pregnant population is another possible solution
ifor the medically underserved. A review of the literature

20

 

focusing both on physician and advanced practice nurses in
the provision of prenatal care in rural areas is presented
in this section. Very few articles with a focus on APNs in
rural prenatal care were found in reviewing the literature.
Two of these selected articles which were current and
relevant are reviewed. In addition, four studies were
identified and reviewed which dealt with the effects of
offering an alternative prenatal visit schedule for women at
low-risk for antenatal complications.

Hueston and Murry (1992) described a three-tier model
for the delivery of rural obstetrical care using a nurse-
midwife and family physician copractice. In this model, the
nurse-midwives were responsible for routine low-risk
obstetric care. Family physicians provided the higher-risk
consultations and surgical interventions. The results of
the study suggested that the health care needs of an
indigent, underserved rural population were better met by
combining the skills of nurse-midwives and family physicians
with surgical backup provided by a consulting obstetrician.
With this new approach to prenatal care, the maternity
center was able to increase the obstetrical care that was
available to every woman in the region. The overall rate of
deliveries without prenatal care decreased significantly
from 29.9 per 1,000 deliveries in 1985 to 2.9 per 1,000
deliveries in 1989. As a result, this utilization of
certified nurse-midwives in practice with family physicians
has offered rural areas the ability to provide obstetrical
‘care in a less costly and more effective manner.

21

 

stz
m
sax
Hes
St:
the
of

co:

stL

(pie

Shi, Samuels, Ricketts, and Konrad (1994) conducted a
study which compared the use of nonphysician providers in
rural and urban Community and Migrant Health Centers. The
sample for this study included 383 Community and Migrant
Health Centers with 243 being rural and 140 being urban. A
survey instrument was mailed to the executive directors of
the health centers. The survey focused on the utilization
of nonphysician providers and the staffing models for the
community and migrant health centers. The results of this
study illustrated that advanced practice nurses were more
likely to be employed by larger centers and those who were
affiliated with nonphysician provider training programs.
The findings of the survey also revealed that advanced
practice nurses were capable of providing quality care
equivalent to physician providers. The APNs provided
quality care within their areas of competence equivalent to
the quality of comparable services provided by physicians.
They concluded that the use of advanced practice nurses as
primary care providers in rural areas is one answer to
providing care to the nation's underserved.

A study conducted by Binstock and Wolde-Tsadik (1995)
compared the impact of a reduced visit schedule on
continuity of care as compared to the current prenatal visit
schedule. Two groups (n=549) of low-risk pregnant women
were divided in which the experimental group received a
reduced number of prenatal visits, on average, eight visits,
and the control group received, on average, 13 prenatal
visits. The results of this study revealed no significant

22

pregnancy outcome differences between the two groups. The
number of prenatal visits was reduced by 27% for the
experimental group and was not associated with any adverse
changes in maternal or perinatal outcomes. Interesting,
however, was that a higher level of patient satisfaction was
reported in the experimental group than the control group
regarding the number of prenatal visits. They concluded
that an alternative prenatal care program for low-risk
patients reduced resource utilization without adversely
affecting prenatal care process variables, pregnancy outcome
or patient satisfaction.

A randomized controlled trial was conducted by
McDuffie, Beck, Bischoff, Cross, and Orleans (1996) to study
an alternative prenatal visit schedule of fewer prenatal
visits than the standard ACOG prenatal visit guidelines for
low-risk women. Prenatal care was provided by teams
composed of obstetrician-gynecologists and practitioners,
which included nurse practitioners, physician assistants, or
certified nurse-midwives. A total of 2764 pregnant women
who were judged to be at low-risk for antenatal
complications were included in the study. The participants
were randomly assigned to either an experimental schedule
(nine visits) or to a control schedule (14 visits) with
additional visits as indicated or as desired by the patient.
The alternative prenatal visit schedule (experimental group)
followed the recommendations of the Expert Panel on the
Content of Prenatal Care and included a prenatal visit
schedule consisting of fewer visits than traditionally

23

provided. The study's findings revealed no significant
differences between those obtaining care following the
current standard schedule of prenatal visits and those who
followed the lower-frequency of prenatal visits. The
experimental group of women rated their prenatal care as
good to excellent and having the “right” number of visits.
The authors theorized that the use of this alternative
schedule would lower the cost of delivery of prenatal care
to low-risk women, without in any way adversely affecting
perinatal outcomes. Even though the average visit
difference of 2.7 was observed, the researchers speculated
that-the savings in direct medical costs for the estimated 2
million low-risk pregnant women receiving care each year in
the United States would be considerable. The authors
further stated that the societal benefits of the Expert
Panel's guidelines would be even greater when indirect
medical costs such as work absence, travel time and child
care were taken into account.

In 1996, a multicenter randomized controlled trial was
conducted by Tucker, Hall, Howie, Reid, Barbour, du V
Florey, and McIlwaine. Their main objective was to compare
the routine antenatal care provided by general practitioners
and midwives with that of an obstetrician led shared care.
The sample included 1,765 women at low-risk of antenatal
complications and were associated with 51 general practices
linked to nine Scottish maternity hospitals. Both groups of
prenatal providers decided on the clinical content and
proposed fewer visits for multiparous women than for

24

 

 

primiparous women. The results of this study showed that
the general practitioner and midwife group displayed greater
continuity of care and a reduced number of routine visits.
In addition, both groups expressed high satisfaction with
care and acceptability of the allocated style of care.
Overall, the authors concluded that low-risk pregnant women
can be effectively managed by a general practitioner and a
certified nurse-midwife while being offered a prenatal
program with fewer visits. They recommended that a new
style of antenatal care be developed and offered to those
who qualify which would match the resources available to the
needs and satisfaction of those women.

Sikorski, Wilson, Clement, Das, and Smeeton (1996)
carried out a randomized controlled trial comparing two
schedules of antenatal visits. Their main objective was to
compare the clinical effectiveness of the traditional
British antenatal visit schedule (control group) with a
reduced schedule of visits (study group) for low-risk women,
together with maternal and professional satisfaction with
care. The study population received shared care from
physicians and certified nurse-midwives. The control group
(n-1,416) consisted of 13 visits and the study group
(n=1,378) consisted of seven visits for nulliparous women
and six visits for multiparous women. The results of this
study showed that there were no significant differences
between the two groups for variables relating to pregnancy
related hypertensive disorders, labor, maternal morbidity,
or perinatal morbidity. The women in the study group saw

25

significantly fewer caregivers and thus received less
conflicting advice which improved their continuity of care.
The majority (82%) of the professionals reported that they
would like to see a reduction (from the traditional 13
visits) in the overall number of routine antenatal visits.

When synthesizing these four studies which have dealt
with the effects of offering an alternative prenatal visit
schedule for women at low-risk for antenatal complications,
one commonality arises. Offering an alternative prenatal
visit schedule is an appropriate and effective way for
providing obstetrical services to the medically low-risk
pregnant population. All of these studies have shown that
maternal and neonatal outcomes have not been adversely
affected by providing prenatal care with fewer visits than
that which has been traditionally recommended and offered.
In addition, three out of four of these studies utilized a
multi-disciplinary team approach in the provision of
antenatal care. These specific studies support the
utilization of advanced practice nurses who are in a
collaborative practice with a physician in providing direct
prenatal care to medically low—risk women.
E il' E ll 1.] I

As the population of rural underserved individuals in
the United States continues to grow, the problems of
adequate access to rural prenatal care for medically low-
risk pregnant women is also compounded. Community health
centers provide the health care for rural populations.
However, an appropriate delivery model for prenatal care

26

must be developed based on the needs of the community. An
alternative prenatal care program for medically low-risk
patients has been shown in the above literature review to
reduce resource utilization without adversely affecting
perinatal outcomes.

The current health care delivery system continues to
fall short of providing accessible and risk-appropriate
prenatal care for the rural pregnant population.
Consequently, further research is essential to evaluate an
alternative prenatal visit structure that can increase
access, decrease unnecessary use of services, lower costs
and improve maternal satisfaction in these medically
underserved areas. The Expert Panel's recommendations have
not been greatly tested or widely accepted by the majority
of practicing primary prenatal care providers. Further
studies need to be performed to determine the
appropriateness of this alternative model of delivering
prenatal care to the rural low-risk pregnant population.

The four studies that were reviewed clearly showed that
an alternative prenatal visit schedule for medically low-
risk rural pregnant women was consistent with good antenatal
outcomes. In addition, three of these studies involved a
multi-disciplinary team approach in the provision of
prenatal care. These teams contained physicians practicing
with advanced practice nurses as direct providers of
prenatal care. The literature did not address the adoption
of an alternative model of prenatal care by a specific type
of prenatal care provider. The present study will hopefully

27

begin to fill the gap of linking a certain prenatal care
provider mix with an alternative form of prenatal care
delivery.
Methods

Researchfisisn

This was a descriptive study using secondary data from
the primary study'TProvision of Prenatal Care Services by
Rural Community Health Centers in the United States' (Omar
et al., 1997). The primary study used a survey to describe
the provision of prenatal care in rural community health
centers in the United States. Field procedures for the
primary study are in Appendix A.
Sample

The sample for this study consisted of 70 responses
from executive directors of rural CHCs for which there were
complete data. Inclusion criteria consisted of those rural
community health centers that: (a) employed or did employ an
APN within the current year, (b) provided prenatal care
delivery services, and 0 had a minimum of 4 prenatal users
per month. The sample in the primary study consisted of 162
completed surveys. Surveys were originally sent to 352
rural community health centers in the United States
resulting in a 46% response rate for the primary study. The
primary study's sample represented the entire population of
rural community health centers in the United States.
OperationalJefinitionuthuariables

2renatal_garg_ngyider_mix was defined as the
provider(s) the executive directors identified on Item 5 of

28

the Partnership for Rural Prenatal Care Delivery Survey.

The respondents were asked to identify all providers who
provided direct prenatal care at their rural community
health center. Choices of provider were: (a) physician:
obstetrician, family practice physician, or general practice
physician, and (b) advanced practice nurse: nurse
practitioner or certified nurse-midwife. For the purpose of
this study, provider mix was defined as two groups of
prenatal care providers: (a) physician only group, or (b)
physician with an advanced practice nurse group.

Hill' I 'i 1! l' l J . ll
schedule was operationally defined as the response the
executive directors identified on Item 8 of the Partnership
for Rural Prenatal Care Delivery Survey. The respondents
were asked on Item 8 “Would your prenatal care providers be
willing to consider an alternative prenatal visit schedule
for your medically low-risk pregnant women based on the
Expert Panel's recommendations on the Content of Prenatal
Care with fewer prenatal visits, and provided by an Advanced
Practice Nurse with a prescribed content for each prenatal
visit, including risk assessment and health promotion
activities?” This was a forced choice dichotomous item: (a)
Yes, or (b) No.

Instrumentation

There was one instrument utilized in this study, The
W- This
instrument was developed by the principal investigators of
the primary study. The Partnership for Rural Prenatal Care

29

Delivery Survey is a 14 item self-report instrument with
forced choice responses. The survey allows the respondents
to provide information about: the provision of prenatal
care, provider(s) who deliver prenatal care, providers who
deliver the infants, willingness to use advanced practice
nurses in the provision of prenatal care delivery, current
prenatal visit structure, willingness to consider an
alternate prenatal visit structure, and acceptance of
advanced practice nurses as primary prenatal care providers
by the clients. The instrument does not have reported
reliability or validity. Four additional forms were
included with the survey: (a) Perinatal User Profile, (b)
Community and User Characteristics, 0 Current Services
Provided, and (d) Current Staff Profile which provided
characteristics and other information about the population
served by the rural community health centers. These are
required federal forms for documentation and are completed
by the community health centers each year.
2 l l' E H S l' l

The primary study used volunteer respondents who
completed the mailed survey. No potentially dangerous or
adverse effect to the participants for participating was
known or identified. The primary study (Omar et al., 1997)
was approved by Michigan State University's Committee on
Research Involving Human Subjects (Appendix B). The data
utilized for this study has been maintained on a disk by the
investigators. The respondents were entered by
identification numbers only. Thus, no link can be made with

30

the name or site of any respondent for this study. Approval

to conduct secondary analysis was obtained from the

University's Committee on Research Involving Human Subjects

prior to any data analysis (Appendix C).

DaIn_Andl¥fiifi
Data analysis was done using the SPSS/PC+ computer

program. Descriptive statistics present the characteristics

of the rural community health centers and included total
number of prenatal users, number of deliveries, number of
low birth weight infants, number of very low birth weight
infants, and mortality data. An analysis of variance

(ANOVA) was performed on the rural community health centers'

characteristics to ascertain possible statistically

significant differences by prenatal care provider mix.

To answer the research question, a contingency table
was constructed in which the frequencies of the two study
variables, prenatal care provider mix and willingness to
consider an alternative prenatal visit schedule, were cross-
tabulated. To answer the hypothesis, the chi-square test
was used. A significance level of 0.05 was used.
Assnmnticnmuhgfitudx

Assumptions of the study include the following:

1. The responses to the questionnaire and supplemental
forms reflect honestly and accurately the rural
community health centers' practices and protocols.

2. All data were entered accurately.

LinitationuthLSLudx
Limitations of the study include the following:

31

1. Possible bias in response rate.
2. Limited responses and return rate are associated with
using a mailed survey.
Results
W

In this descriptive study using secondary data, a total
of 70 rural CHCs' executive directors' responses were
analyzed on the variables, willingness to consider an
alternative prenatal visit schedule and prenatal care
provider mix currently delivering prenatal care services to
their obstetrical population. This study's sample size was
smaller than the primary study for data analysis purposes.
Data analysis was done only on cases which had complete data
for the study variables and had over 48 prenatal users per
year. Generally, the rural CHCs' characteristics can be
described as servicing a small to a large population of
pregnant women which affects the total number of deliveries.
Birth outcomes were generally positive. Table 1 summarizes
the characteristics of the sample.

A one way analysis of variance (ANOVA) between the
rural CHCs' characteristics and prenatal care provider mix
was completed. This was done to identify any differences
between rural community health centers with the physician
only group and the physician with an advanced practice nurse
group. No significant differences were found. Overall, the
rural community health centers' characteristics were not

significantly different between the two provider groups.

32

Table 1.
BMW-£125

 

 

Characteristic n(Missing) M SD Min Max
Total Prenatal Users 70(0) 449 563 54 3520
I of Deliveries 68(2) 229 290 O 1714
i of Low Birth Weight Infants 65(5) 15 40 0 292
I of Very Low Birth Weight Infants 65(5) 2 3 0 18
Neonatal Mortality 64(6) 0.6 0.9 O 3

 

E J . E E l : l' i H ll 1

Research_guestign: Is there an association between the
willingness of rural community health centers to consider an
alternative prenatal visit schedule for medically low-risk
pregnant women and the prenatal care provider mix currently
providing direct obstetrical care in these health centers?

A cross-tabulation between the willingness to consider
an alternative prenatal visit schedule and prenatal care
provider mix was completed (see Table 2). No association
was found between the two study variables. Twenty-two
percent (n=14) of the rural CHCs employed only physicians to
provide their prenatal care services, while 78% (n=49) of
the rural CHCs employed both physicians and advanced
practice nurses to deliver prenatal care to their
obstetrical population. Out of those CHCs (n=44) which
stated a willingness to consider an alternative form of
delivering prenatal services, 73% (n=36) from the physician
with an advanced practice nurse group and 57% (n=8) from the

33

Table 2.

. . .
fl?D§1naEnCx_TahéE_IgE_2I3naf?%_Cazf7229§1derrflixfidndI
Sshednle_iflsfill

 

Prenatal Care Provider Mix
Willingness to

Consider an Physician only (nsl4) Physician with APN
Alternative Prenatal «

 

(n-49)
Visit Schedule
n 1 n 1
Yes 8 57 36 73
No 6 43 13 27

 

physician only group identified a willingness. Overall, 70%
(ng44) of the rural CHCs stated that they would be willing
to offer an alternative prenatal visit schedule, and 30%
(n:19) stating their unwillingness to change their current
prenatal protocol.

HYRQIhfifiiS: There will be an increase in the
willingness to consider an alternative prenatal visit
schedule for the medically low-risk pregnant population when
the community health center is staffed by both physician and
advanced practice nurse prenatal care providers than when
the community health center is staffed by physician prenatal
care providers.

There was an increased willingness to consider an
alternative prenatal visit schedule with the employment of
advanced practice nurses, but it was not statistically

significant, (1, n=63)=0.16,p>.10.

34

Discussion
Sample

There were two main findings from this study. First,
advanced practice nurses were greatly utilized in the rural
CHCs surveyed. Seventy-eight percent of the executive
directors (n=49) reported that their rural CHC employed
advanced practice nurses as part of their prenatal care
delivery team. This large percentage of APNs practicing in
rural areas is consistent with the literature which states
that APNs are often more willing to work in these
underserved regions (Davis et al., 1994; Shi et al., 1994).
In addition, rural CHCs may provide a supportive environment
for APNs as well as a multi-disciplinary team approach to
prenatal care. Advanced practice nurses provide competent
obstetrical care for those who are medically low-risk and
function well when in a collaborative practice with
physicians. This model of care seems to correspond with
larger rural community health centers' policy of care. This
may explain why a great many of the rural CHCs surveyed
realized the value of the APN in the delivery of prenatal
care services to their pregnant population and consequently
were utilizing the APNs' expertise in their rural health
centers.

Less than one-fourth (n=14) of the rural CHCs reported
that they only employed physicians to provide the prenatal
care at their sites. This may be due to a variety of
reasons. One reason may be the rural CHCs' size and
financial status, such that only those CHCs that were larger

35

in size and population serviced employed advanced practice
nurses as primary prenatal care providers (Shi et al.,
1994). Smaller CHCs may not have adequate space or may lack
financial funds to support additional primary providers.
Rural CHCs may only employ physician providers if the CHC
can only support one prenatal provider; a nurse practitioner
would be unable to be a replacement for a physician prenatal
care provider. Reimbursement may also play a role in the
employment and recruitment of certain primary prenatal care
providers.

The second main finding from this study pertains to the
willingness that was reported by the rural CHCs' executive
directors to consider implementing an alternative prenatal
visit protocol. While there was lack of statistical
significance to support the hypothesis, this can be viewed
from a positive perspective. Regardless of the provider
mix, the results showed that the majority of the rural CHCs
were willing to consider an alternative form of prenatal
care services. Seventy percent (n=44) from both groups of
providers declared a willingness to consider offering an
alternative prenatal model of care. Furthermore, over half
(ns8) of the physician only rural CHCs expressed positive
interest in an alternative form of delivering prenatal care
services. The Expert Panel has recommended that a prenatal
visit schedule with fewer visits is an effective way to
provide obstetrical care to medically low-risk pregnant
women. Those rural CHCs that utilized APNs and indicated a
willingness to implement an alternative prenatal visit

36

protocol may be due to an alternative philosophy of care by
the multi—disciplinary team. The community health centers
that employed physician only providers may view the
alternative prenatal care protocol as a way to see more
pregnant women thus increasing accessibility to prenatal
care.

Over one-quarter (ng19) of the rural CHCs reported that
they would be unwilling to consider an alternative model for
delivering prenatal care. This unwillingness may be related
to the use of a uni-disciplinary approach to prenatal care
by obstetricians in those specific rural community health
centers. This uni-specialty approach adheres to ACOG's
guidelines for prenatal care protocols. The current
standard of care for prenatal care may also account for some
unwillingness to consider implementing a modified prenatal
visit schedule. Another issue important to consider in
initiating a change to a reduced prenatal visit model is the
impact on the reporting of adequacy of prenatal care which
currently is based on a specified number of prenatal visits.
Reporting anything less than the current standard would be
considered less than adequate prenatal care. This
accountability could have implications for future funding
and operational management. Consequently, community health
centers as well as private practices may be reluctant to
change their current prenatal visit protocol to a model with
a reduced number of onsite visits.

Another reason why some rural CHCs may have reported an
unwillingness to consider offering an alternative prenatal

37

visit protocol may be related to the concept of change.
Most people are comfortable with the status quo.
Consequently, they are reluctant to undergo any form of
change. Prenatal care providers may be uncertain of what
the effects of implementing this type of change in the
current prenatal protocol would have on birth outcomes. In
addition, many obstetrical providers may truly believe in
the importance of having the current recommended number of
prenatal visits which are needed for assessment, monitoring,
education, and counseling.

While not the focus of this study, several rural CHCs'
characteristics were examined and compared between the two
provider groups. The important finding to note here was
that there were no significant differences in several of the
critical birth outcome indicators between the two groups.
This suggests that birth outcomes were equivalent regardless
of prenatal care provider mix. This would lend support for
use of the advanced practice nurse as a primary prenatal
care provider.

Some limitations to the study's findings include a
small sample size which resulted from using a mailed survey
and having incomplete data. While there was a small sample
size, it can still be considered representative of those
rural health centers that provide prenatal care services to
four or more prenatal users per month. Consideration of the
nonresponders to the survey is important. Nonresponders may
have been: a) unwilling to change to an alternative prenatal
visit schedule possibly due to a lack of interest or low

38

volume, b) smaller rural CHCs that only employed physicians,
c) nonproviders of prenatal care, or d) unable to answer the
survey. Therefore, the results of this study may not have
changed even with additional responses. Increased credence
can be given to the findings of the study.
Wm

The results of this study provide support for the
adapted conceptual model from Starfield's (1992) Health
Services System. Under personnel in the structural
component, there was support for a provider mix. Rural
community health centers in this study utilized either a
physician only or a physician with an advanced practice
nurse as prenatal care providers. The provision of care
corresponds with the process component. This aspect of the
model dealt with the rural CHCs' current prenatal visit
schedule and their willingness to consider offering an
alternative prenatal visit structure. While no rural CHC
had already adopted the alternative prenatal visit schedule,
more than three fifths of the rural CHCs, regardless of the
prenatal care provider mix, reported a willingness to offer
an alternative prenatal visit schedule, while only slightly
less than one third identified an unwillingness to change
their current prenatal practice.

While not the focus of this study, outcomes were
addressed in the description of the rural CHCs'
characteristics and included: number of low birth weight
infants, number of very low birth weight infants, and
neonatal mortality data. Birth outcomes can be used as one

39

indicator to measure how effectively APNs are providing
prenatal care services. Birth outcomes, however, can be
influenced by other factors besides the advanced practice
nurse and prenatal care. Overall, this model is effective

for evaluating prenatal care.

. D 0
us . e.: e ;e .. ‘e ’ . ' \ : .e .'e ' u’. . ;

The findings from this research study confirm that APNs
are providing prenatal care to the rural medically low-risk
population in multi-disciplinary health care teams. The
data has shown, consistent with the literature, that there
is a large percentage of APNs providing prenatal care in
rural community health centers (Sekscenski et al., 1994;
Weis, 1992). In addition, the data has shown that there
were no observable differences in birth outcomes regardless
of the prenatal care provider mix. The APN can use this
information to further lend support to the continued
utilization of APNs as providers of prenatal care services.
Improved accessibility to prenatal providers as well as to
obstetrical services for the medically underserved pregnant
population can be influenced by the APN's crusade to be
recognized and sought after as direct providers of primary
prenatal care.

For those rural areas that lack an advanced practice
nurse as a provider of care, the APN can educate the general
public on the role and value of an advanced practice nurse
as a primary provider of prenatal care services as well as
those rural CHCs who employ physicians only. The APN can
encourage utilization of APNs if and where appropriate.

40

In rural CHCs where there currently exists an APN with
a physician in the delivery of prenatal care services, the
APN has several responsibilities and opportunities to
discern the needs of the pregnant population that they are
servicing. The APN must continue to be a leader in the
movement towards accepting and utilizing an alternative
prenatal visit schedule for those who qualify.

In rural CHCs where there was a willingness to use an
alternative model of prenatal care, the APN should encourage
the adoption of this prenatal visit schedule with fewer
visits as recommended by the Expert Panel (1989) on the
Content of Prenatal Care. The APN can facilitate in
altering the current protocols for delivering prenatal care
services to the medically low-risk along with the other
appropriate personnel at the rural CHCs. The traditional
prenatal care guidelines need to be adjusted to include
health promotion and risk assessment into a reduced number
of visits. Also, advanced practice nurses can assist in
designing a system to measure and track selected outcomes of
utilizing this alternative prenatal visit structure. It is
essential that the APN consistently give positive
reassurance and feedback to the prenatal care providers and
to those rural CHCs' personnel involved during the adoption
of this altered model of providing obstetrical care.

In rural CHCs where there was not a willingness to
consider offering an alternative prenatal visit schedule,
the APN should inform them of a safe and effective
alternative form of delivering prenatal care services to

41

those who are risk appropriate. Determining reasons for
this unwillingness to change the current protocol of
prenatal care visits may assist the APN in deciding where to
channel his/her efforts and in the most efficacious manner.
Furthermore, the advanced practice nurse should seek a pilot
test to verify that offering an alternative prenatal visit
schedule is an effective model for delivering prenatal care
to those who are medically low-risk and that there are no
adverse effects in providing this altered protocol.

Even with the limitations of this research study, the
information provided can be used to recommend modifications
of the current prenatal visit schedule for the medically
low-risk rural pregnant population based on the overwhelming
willingness of the majority of the rural primary prenatal
care providers to offer such an alternative form of
delivering antenatal care. In addition, the continued
promotion of the increased utilization of advance practice
nurses as direct providers of prenatal care in rural areas
is encouraged.

RecommendatinancLEuriheLResearch

Further replication of this research study with greater
emphasis on increasing the response rate is needed to
further test the research question and hypothesis. An
additional area to research would be to survey the prenatal
care provider groups in rural CHCs about: (a) their
willingness to consider an alternative format for delivering

prenatal care and (b) their current prenatal protocol.

42

Further research would also include determination of
why rural CHCs either were or were not willing to consider
an alternative prenatal visit schedule. In addition,
exploration of why rural CHCs either were or were not
employing advanced practice nurses as part of their prenatal
care provider team is encouraged. Advanced practice nurses
need to promote research that examines the effectiveness of
utilizing the alternative prenatal visit schedule and
prenatal care being provided by an APN. Additional studies
which determine how clinical policies are reviewed and
revised in rural CHCs are recommended.

The utilization of APNs as primary prenatal care
providers is an important way both to achieve cost
containment and improve access to quality primary prenatal
care for those residing in medically underserved regions
(Shi et al., 1994). This study has shown that the majority
of the rural CHCs were employing APNs as part of their
prenatal health care team. Consequently, research with this
focus may assist in the continued recruitment of this highly
skilled and competent group of obstetrical providers for the
rural pregnant population.

Summary

This study examined if there was an association between
the prenatal care provider mix currently providing prenatal
care in rural community health centers and the willingness
to consider an alternative prenatal visit schedule. The
findings did not support an association between the two
study variables.

43

The study did reveal that advanced practice nurses were
part of the provider mix in the provision of prenatal care
services to the majority of rural populations which is
consistent with the current literature (Sekscenski et al.,
1994; Weis, 1992). The findings identified that the
majority of rural primary prenatal care providers were
willing to consider implementing an alternative prenatal
visit schedule in their practice. This implies that a shift
from the traditional ACOG guidelines to a more cost
effective and needs appropriate structure for delivering
obstetrical care to the medially low-risk rural pregnant
population is an option.

The problems with adequate access to rural obstetrical
care for medically low-risk pregnant women is compounded
with the continued growth of the rural underserved
population in the United States. The literature has shown
that the current health care delivery system remains
inadequate in providing accessible and risk-appropriate
prenatal care services for the rural pregnant population
(Bureau of Health Professions, 1992; Nesbitt, 1996).
Utilization of advanced practice nurses in the delivery of
prenatal care is one logical solution to this dilemma.
Application of the Expert Panel's recommendation of a
reduced number of prenatal visits which focuses on risk
assessment and health promotion for the medically low-risk

pregnant population is another possible answer.

44

LI ST OF REFERENCES

LIST OF REFERENCES

American College of Obstetricians and Gynecologists.
(1992) W- (8th
ed.). Washington, DC: Author.

Avery, L.H. (1995). Nurses and physicians attempt to
define collaboration and practice roles.

WM) . 107-110-

Baldwin, L.M., Raine, T., Jenkins, L.D., Hart, L.G., 8
Rosenblatt, R. (1994). Do providers adhere to ACOG
standards? The case of prenatal care. Obstetrigs_and

WM) , 549-555.

Binstock, M.A., 8 Wolde-Tsadik, G. (1995). Alternative
prenatal care: Impact of reduced visit frequency, focused

visits and continuity of care. J9nrna1_gf_ngprgdngtiyg
WI?) . 507-512-

Blake, R. L., 8 Guild, P. A. (1978). Mid-level
practitioners in rural health care: A three-year experience

in Appalachia. WU). 15- -22.

Bureau of Health Professions. (1992). Rural_hgalth
' ° ' ' . Rockville, MD:
Bureau of Health Professions.

Burks, J.A. (1992). Factors in the utilization of
prenatal services by low-income black women. Nurse

MW(4)I 34: 46: 49'

Davis, R., McAdams, R., 8 Tilden, N. (1994). Primary
care access. In J. E. Beaulieu 8 D. E. Berry (Eds. ). Rural
' ° , (pp. 203- 225).
Ann Arbor, MI: AUPHA.

Gordon, R.J., Meister, J.S., 8 Hughes, R.G. (1992).
Accounting for shortages of rural physicians: Push and pull
factors. In W. M. Gesler 8 T. C. Ricketts (Eds. ). Health_in

- \. o :u' .° 0' 9‘00. -00 0 t . o : :‘Q ‘:
(pp. 153-178). New Brunswick: Rutgers
University Press.

Graveley, E. A., 8 Littlefield, J. H. (1992). A cost-
effectiveness analysis of three staffing models for the

delivery of low-risk prenatal care. American_lgnrna1_gf
W0). 180-184-

Hall, M.H. (1991). Commentary: What are the benefits
of prenatal care in uncomplicated pregnancy? Birth+_18(3),
151-152.

45

Hicks, L.L. (1992). Access and utilization: Special
populations-special needs. In L.A. Straus 8 N. Walzer
(Eds.)., ' ' '
gnyizgnmgnt, (pp. 20-35). Westport, CT: Praeger.

Hueston, W.J., 8 Murry, M. (1992). A three-tier model
for the delivery of rural obstetrical care using a nurse
midwife and family physician copractice. The_lgnrnal_gf

Rural_Healtb1_fi(4). 233-290-

Huntington, J., 8 Connell, F.A. (1994). For every
dollar spent - the cost-savings argument for prenatal care.

The_Neu_Enaland_Journal_2f4uedicinel_331(19). 1303-1307-

Knoll, K. (1990). Certified nurse-midwives, nurse
practitioners, and family practice physicians in the
delivery of prenatal care. In I. R. Merhatz 8 J. F. Thompson

(Eds ). New_neranectixes_on_nrenatal_care1 (pp 603- -629)

New York: Elsevier.

Long, S. H., Marquis, M. S., 8 Harrison, E. R. (1994). The
costs and financing of perinatal care in the United States.

American.J9urnal_of_£nblic_Healtb1_84(9). 1473-1478.

McDuffie, R.S., Beck, A., Bischoff, K., Cross, J., 8
Orleans, M. (1996). Effect of frequency of prenatal care
visits on perinatal outcome among low-risk women. Journal_gf

American_Medical_Association1_215(11). 847- -851-

McLain, B. R. (1988). Collaborative practice: The nurse
practitioner's role in its success or failure. Nurse

Practitioner1_13(5), 31- 32, 34- 3s, 38.

McManus, M.A., 8 Newacheck, P.W. (1989). Rural
maternal, child, and adolescent health. Health_figryiges

Research1_23(6), 807-847.

Miller, M. K., Farmer, F. L., 8 Clarke, L.L. (1994).
Rural populations and their health. In J.E. Beaulieu 8 D.E.
Berry (Eds. )., -

perspectixg, (pp. 3-25). Ann Arbor, MI: AUPHA.

Montquin, J., Gagnon, R., 8 Trainville, C. (1987).
Maternal and neonatal outcome in pregnancies with no risk

factors. Canedian_Medical_Asscciaticn_lcurnall_135. 728-
732.

National Center for Health Statistics. Births,
marriages, divorces, and deaths for 1994. (1995). Monthly

Yital_Stat1_Bs91153(12), 1-2.

(1995). Advanced Nursing Practice: Curriculum Guidelines
and Program Standards for Nurse Practitioner Education (2nd
ed. ). Washington, D. C.: Author.

46

Nesbitt, T.S. (1996). Rural maternity care: New models
of access. nizgn+_zz(3), 161-165.

Nesbitt, T. S., Connell, F. A., Hart, L. G., 8 Rosenblatt,
R. A. (1990). Access to obstetric care in rural areas: Effect

of birth outcomes. Amer1can_1onrnal_of_£nblic_Health1_&Q(7).
814-818.

Rowland, 0., 8 Lyons, B. (1989). Triple jeopardy:
Rural. poor. and uninsured. Health_£erxices_nesearch1
21(6), 975-1004.

Sekscenski, E.S., Sansom, S., Bazell, C., Salmon, M.E.,
8 Mullan, F. (1994). State practice environments and the
supply of physician assistants, nurse practitioners, and

certified nurse-midwives. The_New_England_lonrnal_of
Medicinel_1ll. 1266-1271-

Shi, L., Samuels, M.E., Ricketts, T.C., 8 Konrad, T.R.
(1994). A rural-urban comparative study of nonphysician
providers in community and migrant health centers. Enhiig

Health_Benortsi_192(6). 809-815-

Sikorski, J., Wilson, J., Clement, 8., Das, S., 8
Smeeton, N. (1996). A randomized controlled trial comparing
two schedules of antenatal visits: The antenatal care

PrOjcct- Br1tish_nedical_lonrnal1_112(7030). 546-553-

Starfield, B. (1992).
exalna119n1_and_nolic¥1 New York NY: Oxford

Thompson, J.G. (1996). Economic effects on the out
migration of obstetric services in a rural county. The

lonrnal_of_Bnral_Health1_1z(2). 100-1-9.

Tucker, J.S., Hall, M.H., Howie, P.W., Reid, M.E.,
Barbour, R.S., du V Florey, C., McIlwaine, G.M. (1996).
Should obstetricians see women with normal pregnancies? A
multi center randomized controlled trial of routine
antenatal care by general practitioners and midwives
commered with shared care led by obstetricians. British

Medical_lonrnall_112(7030). 554- 559

U.S. Public Health Service. (1989). Expert Panel on
the Content of Prenatal Care. Cazihg_£gr_gnz_£ntnrgi_1hg
. Washington, DC: U.S. Department

of Health and Human Services.

Weis, E. M. (1992). Preparing and recruiting nurses for
innovating rural practice roles. In L.A. Straus 8 N. Walzer
(Eds. )., '

. (pp. 90-101). Westport, CT: Praeger.

47

APPENDIX A

Appendix A

Field Procedures for the Primary Study

The survey was mailed to the executive directors of 352
rural community health centers. A cover letter explaining
the study was included with the survey. The letter
requested that they complete and return the survey in the
self-addressed envelope within two weeks. Consent to
participate in the study was assumed when the survey was
completed and returned. A postcard was sent two weeks after
the initial mailing as a reminder to complete and return the

survey.

48

APPENDIX B

 

UWWIOF
RESEARCH
AND
GRADUATE
STUDflfii

Why Committee on
Research Involving
mun-amnns
ammuu)
MUWthnumefly
usuhwmmaMnamwu
hdtmmeflmom
«BN406
mumsnaa

FAX 51 ”‘32-"?!

la! IS m antncajm
«hwaummonmuow

 

MICHIGAN STATE

U P“ l V Elli S I‘T Y

 

March 1, l995

TO: Mildred Omar
A230 Life Sciences Bldg.

RE: IRBI: 94-151

TITLE: BARRIERS EXPECTATIONS AND PATIENT SATISFACTION
AS PREDICTORS OP PRENATAL CARE UTILIZATION AND
NATERNAL AND INFANT OUTCOMES IN BENZIE COUNTY,
MICHIGAN

REVISION REQUESTED: N/A

CATEGORY: l-C

APPROVAL oars: 03/01/95

The University Committee on Research Involving Human Subjects'(UCRIHS)
review of this project is complete. I am pleased to adv se that the
rights and welfare of the human subjects appear to be adequately
protected and methods to obtain informed°consent are appropriate.
lhegeéozgévthe UCRIHS approved this project including any revision

s e e.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project ond one year must use the green renewal
form (enclosed with t e original :gproval letter or when a
pro ect is renewed) to seek :gdat certification. There is a
max! of four such expedit renewals ssible. Investigators
wishin to continue a roject beyond the time need to submit it
again or complete rev .

 

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form.
revise an ap roved protocol at an 0 her time during the year
send your wr tten request to the CRIBS Chair, requesting revised
approval and referencing the project's IRE I and title. Include
in our request a descr ption of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

PROBLEMS

CHANCES:/ Should either of the followin arise during the course of the
work, investi ators must noti I UCRIHS romptly: (1) problems
(unexpected e de effects comp aints, e c.) involv ng uman
subjects or 1:; changes in the research environment or new
information icating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we c

an be of any future help lease do not hesitate to contact us
at (517)355-2180 or FAX (517)3 8

- 171e

Sincerely,

   

avid E. Wright, P
UCRIHS.Chair

4E)

APPENDIX C

 

GRADUATE
STUDIES

Ibhmflhtbmmflunm
Aueudumnhhg
Hmuaauhd:
(uamun

NbfipflheUMemu
zfihammwaunhflan

517/3552!”
FM 517/4324!“

MICHIGAN STATE
u N I v E R s I T Y

 

April 3. 1998

TO: Mildred Omar

RE: IRBR: 98-23
TITLE: RELATIONSHIP BETWEEN RURAL COMMUNITY HEALTH
CENTERS' HILLINGNESS TO CONSIDER AN ALTERNATIVE

PRENATAL VISIT SCHEDULE AND THEIR TYPE OF
PRENATAL CARE PROVIDER

REVISION REQUESTED: N/A

CATEGORY: l-E

APPROVAL DATE: 03/30/98

The university Committee on Research Involving Human Sub ects'(UCRIHS)
review of this roject is complete. I am pleased to adv se that the
rights and wel are of the human subjects appear to be adequately
rotected and methods to obtain informed consent are a ropriate.
Therefore, the UCRIHS approved this project and any rev sions listed
above .

RININAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek u ate certification. There is a
maximum of four such expedite renewals ssible. Investigators
wishing to continue a project beyond the time need to submit it
again or complete rev1ew.

REVISIONS: UCRIHS must review an changes in rocedures involving human
subjects, rior to in tiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at an 0 her time during the year
send your written request to the CRIHS Chair, requesting revised
approval and referenCing the project's IRB # and title. Include
in ur request a description of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

Should either of the followin arise during the course of the
work, investigators must noti UCRIHS promptly: (l) roblems
(unexpected side effects comp aints, a c.) involving uman
subjects or 2) changes in the research environment or new
information ndicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help, please do not hesitate to contact us
at (517)355-2180 or FAX (517)4 2- 171. -

Sincerely,

 
  

vid E. Wright, P
UCRIHS Chair
DEW:bed

\: Nicole Jamieson

50

"IIIIIIIIIIIIII“