Lu 2010

Medical Care Research and Review
Supplement to 67(5) 198S–230S

Innovative Strategies to © The Author(s) 2010
Reprints and permission: http://www.
Reduce Disparities in the sagepub.com/journalsPermissions.nav
DOI: 10.1177/1077558710374324
Quality of Prenatal Care in http://mcr.sagepub.com
Underresourced Settings
Michael C. Lu1, Milton Kotelchuck2, Vijaya K. Hogan3,

Kay Johnson4, and Carolina Reyes5
Abstract
This study examined what innovative strategies, including the use of health information
technology (health IT), have been or can be used to reduce disparities in prenatal
care quality in underresourced settings. Based on literature review and key informant
interviews, the authors identified 17 strategies that have been or can be used to
(a) increase access to timely prenatal care, (b) improve the content of prenatal care,
and (c) enhance the organization and delivery of prenatal care. Health IT can be used
to (a) increase consumer awareness about the importance of preconception and
early prenatal care, facilitate spatial mapping of access gaps, and improve continuity of
patient records; (b) support collaborative quality improvement, facilitate performance
measurement, enhance health promotion, assist with care coordination, reduce
clinical errors, improve delivery of preventive health services, provide decision
support, and encourage completeness of documentation; and (c) support data inte
gration and engineer collaborative innovation.
Keywords
prenatal care, disparity, quality, underresourced setting, access, content
This article, submitted to Medical Care Research and Review on December 14, 2009, was revised and
accepted for publication on April 22, 2010.
1
University of California–Los Angeles, Los Angeles, CA
2
Boston University School of Public Health, Boston, MA
3
University of North Carolina at Chapel Hill, Chapel Hill, NC
4
Johnson Consulting Group, Inc., Hinesburg,VT
5
University of Southern California, Los Angeles, CA
Corresponding Author:
Michael C. Lu, Department of Community Health Sciences, University of California Los Angeles School of
Public Health, Box 951772, Los Angeles, CA 90095-1772, USA
Email: mclu@ucla.edu
Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Lu et al. 199S
Health care disparities are the differences or gaps in care experienced by one popula-
tion compared with another population. As the 2008 National Healthcare Quality
Report shows, Americans too often do not receive care that they need, or they receive
poor quality care (Agency for Healthcare Research and Quality [AHRQ], 2009b). And,
as the 2008 National Healthcare Disparities Report shows, some Americans receive
even worse care than other Americans (AHRQ, 2009a). The quality of health care is
different for different people in America.
Prenatal care is a case in point. Quality health care is care that is timely, equitable,
safe, patient-centered, efficient, and effective (Institute of Medicine [IOM], 2001). For
prenatal care, disparities exist across multiple dimensions of quality. For example,
there are significant racial–ethnic disparities in the receipt of timely prenatal care. In
2006, Hispanic and non-Hispanic Black women were 2.3 times as likely to receive late
(beginning in the third trimester) or no care as were non-Hispanic White women (Mar-
tin et al., 2009).
Another dimension of health care quality is equity. Equitable care means care that
does not vary in quality because of personal characteristics such as sex, ethnicity,
geographic location, or socioeconomic status (IOM, 2001). Unequal treatment in
prenatal care has been well documented (Brett, Schoendorf, & Kiely, 1994; Kogan,
Kotelchuck, Alexander, & Johnson, 1994; Kotelchuck, Kogan, Alexander, & Jack,
1997). For example, using the National Maternal and Infant Health Survey, Kogan,
Kotelchuck, et al. (1994) found Black women were less likely than White women to
receive advice from their prenatal care providers about smoking cessation and alco-
hol use. The difference between Blacks and Whites also approached significance for
receiving breast-feeding education. Furthermore, even if all women had equal access
to prenatal visits and received equal treatment during those visits, their prenatal care
may still be inequitable. Inequitable care means care that does not address the unique
challenges and vulnerabilities made relevant by differential life experiences based
on social characteristics such as gender, ethnicity, language preference, geographic
location, and socioeconomic status. For example, providing prenatal care in the
patient’s preferred language improves her understanding of and adherence to the
care plan. Documenting the patient’s preferred language and providing care in her
language of choice are not consistently practiced, even though policies and stan-
dards for language preference have been developed for health care organizations
(e.g., National Standards on Culturally and Linguistically Appropriate Services;
U.S. Department of Health and Human Services, 2001). As another example, a
major component of prenatal care is health education to promote behavioral changes.
Thus a clinic visit is only the prelude to the full completion of the care. To fully
attain the effects of care, the woman then needs to take that education to her home
and follow through with it (e.g., eat more healthy foods). If her social environment
in the community or home does not have the resources to support these behavioral
changes (insufficient income or no neighborhood stores to purchase healthy foods),
the care plan remains unfulfilled, and the effectiveness of the care remains limited,
despite the practitioners’ best intentions.

200S Medical Care Research and Review Supplement to 67(5)
Finally, health care quality is measured by its effectiveness in achieving a desired

health outcome. For more than two decades, increasing access to prenatal care has
been the cornerstone of our nation’s strategy for reducing disparities in infant mortal-
ity and low birth weight (LBW; Alexander & Kotelchuck, 2001). In large part as a
result of federal and state legislative initiatives to expand access to prenatal care, the
use of early prenatal care has increased substantially over the past two decades. Fur-
thermore, the Black–White gap in early prenatal care has also closed considerably
over the same time period. However, this decrease in the prenatal care gap has not led
to significant decreases in the Black–White gap in LBW, very low birth weight
(VLBW), and infant mortality. Disparities in LBW and VLBW have persisted. And
while infant mortality declined 45.2% for all races during 1980-2000 in large part due
to technological advances in neonatal intensive care, the Black–White ratio of infant
mortality increased 25.0% (from 2.0 to 2.5; Martin, Hamilton, Ventura, Menacker, &
Park, 2002).
The persisting disparities in prenatal care quality and perinatal outcomes have
spurred new ideas and new strategies in prenatal care. The authors have been commis-
sioned by the AHRQ to write a case study examining what innovative strategies have
been or can be used to reduce disparities in prenatal care quality in underresourced
settings. We reviewed innovative strategies along three dimensions of care: (a) strate-
gies to increase access to timely prenatal care, (b) strategies to improve the content of
prenatal care, and (c) strategies to enhance the organization and delivery of prenatal
care. We contend that for prenatal care to become a more effective tool for addressing
perinatal disparities, it has to become more timely, comprehensive, and integrated. A
secondary aim of this case study is to examine how health information technology
(health IT) has been or can be used to reduce disparities in prenatal care quality. We
were less interested in how health IT has been or can be used to “tweak” prenatal care
quality; implementing electronic prenatal records in a fragmented care model, we
believe, is not sufficient quality improvement for reducing perinatal disparities. Rather
we explored how health IT has been or can be used to help transform prenatal care so
that it can become more timely, comprehensive, and integrated. In light of the unparal-
leled opportunities for health care quality improvement created by the ongoing health
care reform efforts and, more specifically, the support for investment in health IT
enabled by the American Recovery and Reinvestment Act (2009), we conclude our
case study with recommendations for a research and action agenda for reducing dis-
parities in prenatal care quality in underresourced settings.
New Contribution
This case study makes several contributions to the literature. First, it offers, to our
knowledge, the most comprehensive synthesis of innovative strategies that have been
or can be used to reduce disparities in prenatal care quality in underresourced settings.
Most extant studies have focused on strategies for increasing access; much less atten-
tion has been paid to improving content or enhancing organization and delivery of

Lu et al. 201S
prenatal care. We contend that increasing access to an ineffective care model does not
constitute quality improvement. For prenatal care to become a more effective tool for
addressing perinatal disparities, it has to become not only more timely but also more
comprehensive and integrated.
Second, this case study goes beyond previous reviews in its examination of innova-
tive applications of health IT in prenatal care. While previous reviews focused primar-
ily on more “traditional” uses of health IT, such as the use of electronic medical records
(EMR) to reduce clinical errors or encourage completeness of documentation, this case
study explores more innovative applications of health IT to increase access, improve
content, and enhance organization and delivery of prenatal care, such as the use of
health IT to support performance measurement or engineer collaborative innovation.
Most important, this study offers a set of 22 recommendations for a research and
action agenda for reducing disparities in prenatal care quality in underresourced set-
tings. Our literature review revealed a paucity of research on prenatal care quality;
many innovative strategies presented in this article lack a strong evidence base (or
research design to generate an evidence base). Our key informant interviews identified
a number of barriers, including the lack of infrastructure and technical support, for
adoption of innovative strategies, including the use of health IT, to improve prenatal
care quality in underresourced settings. It is our hope that this article will stimulate
further dialogue and spur new research and new action to close the quality gap in
prenatal care.
Method
We conducted a literature review of innovative strategies that have been or can be
used to address health care disparities in prenatal care in underserved settings. For the
purpose of this case study, we defined “underresourced setting” as a setting characterized
by a lack of patient, provider, or community resources to achieve timely, comprehensive,
and integrated prenatal care. Original research, systematic reviews, meta-analyses,
and commentaries were identified by searching PubMed. Search terms (as well as any
restrictions used in the search) are described in the discussion under each topic.
Abstracts were then reviewed to identify relevant articles; relevant references cited in
these articles were also reviewed to verify completeness of the literature search. The
case study did not call for a systematic review; therefore no formal scoring of the qual-
ity of evidence was performed. However, we paid close attention to study methodology
and pointed out methodological limitations throughout the case study, where relevant.
In addition to the standard hierarchy of research design, we also considered the
aggregate validity, generalizability, and coherence/consistency of the body of evi-
dence. Particular attention was paid to evidence of effectiveness for reducing perinatal
disparities. All retrieved articles were reviewed for innovative applications of health
IT. Search terms such as “electronic prenatal records,” “short messaging service,”
and “text messaging” were also used to search for potential applications of health IT
in prenatal care.

Given the relative paucity of published research on innovative strategies (including

health IT) to reduce disparities in prenatal care quality, we supplemented our literature
review with nine key informant interviews. These key informants were chosen because
they are widely regarded as “innovators” in prenatal care; they have developed, imple-
mented, and/or evaluated some of the most innovative programs in prenatal care, many
of which were highlighted in the case study. The interviews were conducted in-person,
by phone, or via email with these innovators. While the content of the key informant
interviews varied by the content expertise of the key informants, generally the key
informant was asked to (a) describe the innovative program that he or she has devel-
oped, implemented, or evaluated; (b) describe evidence of effectiveness for improving
prenatal care quality; (c) describe evidence of effectiveness for reducing perinatal
disparities; and (d) describe the use of health IT in the program, including barriers to
and opportunities for innovations in health IT to improve prenatal care quality and
reduce perinatal disparities. Finally, we synthesized the results to identify major areas
for innovation and developed a set of recommendations based on our findings for a
research and action agenda for reducing disparities in prenatal care quality in under-
resourced settings.
Results
We identified 17 strategies that have been or can be used to reduce disparities in pre-
natal care quality in underresourced settings (Table 1). Here we present our findings
along three dimensions of care: (a) strategies to increase access to timely prenatal care,
(b) strategies to improve the content of prenatal care, and (c) strategies to enhance the
organization and delivery of prenatal care. For each dimension, we also explore how
health IT has been or can be used to address health care disparities in prenatal care.
Strategies to Increase Access to Timely Prenatal Care

Over the past two decades, significant efforts have been made at the national, state,
and local levels to increase access to timely prenatal care. In this section, we
reviewed evidence of effectiveness for two such efforts—Medicaid expansion and
preconception–interconception care—and explored several potential applications of
health IT to reduce disparities in access to timely prenatal care in underresourced
settings.
Medicaid expansion and other policy initiatives to increase financial and nonfinancial
access to timely prenatal care for low-income pregnant women. Between 1986 and 1990,
concerns about the high infant mortality rate in the United States galvanized a series
of legislative reforms to extend Medicaid coverage to poor and near-poor pregnant
women and infants. Congressional action was based on two assumptions: (a) financial
barriers were an important obstacle to care and (b) prenatal care use was a critical
determinant of birth weight, which, in turn, affects infant mortality and morbidity
(Dubay, Joyce, Kaestner, & Kenney, 2001).

Lu et al. 203S
Table 1. Promising Strategies to Reduce Disparities in Prenatal Care Quality in Underserved

Settings
Increasing access to timely prenatal care
1. Medicaid expansion and other policy initiatives to increase access to timely prenatal
care
2. Preconception and interconception care
3. Use of health information technology (health IT; e.g. text messaging) to increase
consumer awareness about the importance of preconception and early prenatal care
4. Use of health IT (e.g., geographical information system) to facilitate spatial mapping of
access gaps
5. Use of health IT to improve continuity of patient records
Improving content of prenatal care
6. Continuous quality improvement (e.g., Breakthrough Series)
7. Performance measurement
8. Enhanced prenatal care
9. Use of health IT to support collaborative quality improvement
10. Use of health IT to facilitate performance measurement
11. Use of health IT to enhance health promotion and patient education
12. Use of health IT to assist with care coordination
13. Use of health IT to reduce clinical errors, improve delivery of preventive health services,
provide decision support, and encourage completeness of documentation
Enhance organization and delivery of prenatal care
14. Service integration
15. Group prenatal care
16. Use of health IT to support service integration
17. Use of health IT (e.g., Collaborative Innovation Network) to engineer collaborative
innovation
We searched key terms “Medicaid expansion,” “prenatal care utilization,” and “pre-
natal care access” in PubMed and reviewed references cited in original and review
articles. We identified a total of 12 published original articles on the impact of Medic-
aid expansion on prenatal care utilization (L. M. Baldwin et al., 1998; Braveman,
Bennett, Lewis, Egerter, & Showstack, 1993; Dubay et al., 2001; Epstein, Lee, & Hamel,
2004; Haas, Udvarhelyi, Morris, & Epstein, 1993; Joyce, 1999; Kuo, Gavin, Adams, &
Ayadi, 2008; Long & Marquis, 1998; Marquis & Long, 1999; Piper, Mitchel, & Ray,
1994; Piper, Ray, & Griffin, 1990; Rittenhouse, Braveman, & Marchi, 2003). While
earlier studies with short-term follow-up produced mixed findings, later studies with
longer follow-up showed substantial gains in prenatal care utilization (L. M. Baldwin
et al., 1998; Joyce, 1999; Kuo et al., 2008; Rittenhouse et al., 2003). In the only pub-
lished national study, Dubay et al. (2001) found significant declines between 1986 and
1993 in the proportion of women initiating prenatal care after the first trimester. This
national study is probably of higher quality than most previous state-specific studies
because of its larger sample size, greater generalizability, and an analytic model that
more adequately controlled for confounding by time-varying factors.

In California, MediCal eligibility for pregnant women was increased to 200% of

the federal poverty level in 1990. In addition, California adopted a series of public
health policies to address financial and nonfinancial barriers to prenatal care, includ-
ing elimination of MediCal asset tests, implementation of continuous eligibility and
presumptive eligibility, shortening of application forms, and creation of public health
programs aimed at improving outreach, care coordination, and case management for
underserved women, including the Black Infant Health Program and Adolescent Fam-
ily Life Program.
One such program is the Comprehensive Perinatal Services Program (CPSP).
CPSP is a state program that—prior to MediCal’s transition to managed care—offered
financial incentives to prenatal care providers for providing enhanced prenatal care for
MediCal patients. CPSP provides additional reimbursement to CPSP-certified prena-
tal care providers who offer enhanced services in nutrition, social services, and health
education. The extra financial incentives dramatically increased provider participation
in MediCal; in so doing, CPSP eliminated one of the greatest barriers to prenatal
care access for low-income women in California—the lack of participation in Medi-
Cal among prenatal care providers (Korenbrot, Gill, Clayson, & Patterson, 1995). CPSP
also incentivized enhancement of prenatal care content and, in so doing, helped cre-
ate hundreds of early prototypes of “medical homes” for pregnant women throughout
California.
A 2003 (Rittenhouse et al.) study of the impact of California’s policy initiatives found
that between 1989 and 1999, the proportion of women with first trimester initiation of
prenatal care increased from 72.6% to 83.6%, and the increase could not be explained by
changes in the economy, maternal characteristics, the overall organization/delivery of
health care, or other social policies. The authors concluded that while causality cannot
be inferred, the observed improvements in prenatal care utilization are largely attribut-
able to the “multifaceted public health effort” to increase prenatal care access and repre-
sent “an important victory for public health in California.”
Preconception and interconception care. Traditionally, “early” prenatal care has been
defined as first-trimester care or initiation of prenatal care before 13 completed weeks’
gestation. There is, however, a growing recognition that even “early” prenatal care may
not be early enough. Early prenatal care may be too late to prevent most birth defects.
Organogenesis begins early in pregnancy; starting folic acid supplementation after
closure of the neural tube at 6 weeks (28 days after conception) has no demonstrated
benefit for preventing neural tube defects (Milunsky et al., 1989). Placental develop-
ment begins even earlier, starting with implantation at 7 days postconception. Poor
placental development has been linked to such pregnancy complications as preeclamp-
sia and preterm birth (Norwitz, 2006) and may play a role in fetal programming of
chronic diseases in later life (Godfrey, 2002). Early prenatal care is too late to prevent
most abnormal placental development.
Most important, early prenatal care is often too late to restore allostasis (Lu, Tache,
Alexander, Kotelchuck, & Halfon, 2003). Allostasis refers to the body’s ability to main-
tain stability through change (McEwen, 1998). Examples include feedback inhibition on

Lu et al. 205S
the hypothalamic–pituitary–adrenal (HPA) axis to keep the body’s stress response in

check (McEwen, 1998) or modulation of the body’s inflammatory response by the
HPA axis (Chrousos, 2000). In the face of chronic and repeated stress (psychological
or biological), however, these systems can get worn out. If a woman enters pregnancy
with worn-out allostatic systems (e.g., dysregulated stress or inflammatory response),
she may be more susceptible to a number of pregnancy complications, including pre-
term birth.
This growing recognition of the limits of prenatal care and the importance of wom-
en’s health before pregnancy has spurred a national movement for preconception care.
In 2005, the CDC convened a national summit and issued a set of recommendations to
improve preconception health and health care in the United States (Johnson et al.,
2006). A second national summit was convened in 2007, and a Select Panel on Pre-
conception Care has been assembled to develop tools and guidelines in six areas of
preconception care: clinical care, public health, policy and financing, education and train-
ing, consumer awareness, and research.
Despite this growing movement in preconception care, to date relatively few well-
designed studies of the effectiveness of preconception care have been conducted. In
the most comprehensive systematic review to date, Korenbrot, Steinberg, Bender, and
Newberry (2002) abstracted more than 470 articles on research trials of preconception
care services published since 1990. Only 19 research trials met their review criteria.
Evidence for the effectiveness of preconception care was found for preventing unin-
tended pregnancies, having sexually active women of reproductive age take dietary
folate supplements, and providing women affected by diabetes and hyperphenylalane-
mia with nutrition services.
We searched PubMed for additional articles published since Korenbrot’s systematic
review using key terms “preconception” and “preconception care” and identified six
additional trials (Cena et al., 2008; Elsinga et al., 2008; Glueck, Goldenberg, Wang,
Loftspring, & Sherman, 2004; Hillemeier et al., 2008; Lumley & Donohue, 2006;
Schwarz, Sobota, Gonzales, & Gerbert, 2008). One study found that by reducing pre-
conception weight and by maintaining these insulin-sensitizing effects throughout
pregnancy, a combination of metformin and diet reduces the likelihood of developing
gestational diabetes among women with polycystic ovarian syndrome, and it prevents
androgen excess for the fetus (Glueck et al., 2004). Two studies found preconceptional
counseling was associated with increased folate knowledge and use (Cena, Joy, Hene-
man, & Zidenberg-Cherr, 2007; Schwarz et al., 2008), while three additional studies
found evidence for improved knowledge and health behavior, but not birth weight (Els-
inga et al., 2008; Hillemeier et al., 2008; Lumley & Donohue, 2006).
A special subtype of preconception care is interconception care. Interconception care
refers to a package of health care and ancillary services provided to a woman and her
family between pregnancies (Lu et al., 2006). It is, in essence, preconception care for a
subsequent pregnancy. For women with prior adverse pregnancy outcomes (e.g., pre-
maturity, fetal death), interconception care offers a critical window of opportunity for risk
reduction before their next pregnancy. However, an important barrier to interconception

care, particularly for many low-income women in underresourced settings, is termina-

tion of their Medicaid coverage for pregnancy at 60 days postpartum.
We searched key terms “interconception care” in PubMed, and identified only four
original articles on interconception care (Andrews et al., 2006; Badura, Johnson,
Hench, & Reyes, 2008; Biermann, Dunlop, Brady, Dubin, & Brann, 2006; Tita et al.,
2007). Two studies (Andrews et al., 2006; Tita et al., 2007) examined the impact of an
interconception antibiotic regimen among women with prior preterm birth on endo-
metrial microbial flora and recurrent preterm birth in a subsequent pregnancy. While
the interconception antibiotics were associated with lower acquisition and higher reso-
lution of microbes, they did not result in reduction of recurrent preterm birth. Two
articles (Badura et al., 2008; Biermann et al., 2006) reported on three interconception
care projects: Grady Memorial Hospital Interpregnancy Care (IPC) Program in
Atlanta, GA; the Magnolia Project in Jacksonville, FL; and the Healthy Start intercon-
ception care projects. While both the Grady Memorial IPC Program and the Magnolia
Project have reported promising results, their findings are limited by small sample size
and potential for selection bias. Presently the Healthy Start projects lack clear research
design and sufficient funding to allow for meaningful evaluation. We are aware of
three other interconception care programs in Denver, Philadelphia, and Los Angeles;
however, none of the studies have yet reported results in peer-reviewed publications
and thus are omitted from our review. Clearly, further research is needed for precon-
ception and interconception care.
Applications of Health IT to Increase

Access to Timely Prenatal Care
With respect to health IT, we identified several potential innovative applications of
health IT to reduce disparities in timely prenatal care in underresourced settings: increas-
ing consumer awareness, facilitating spatial mapping of access gaps, and improving
continuity of patient records.
Increase consumer awareness. Health IT can be used to help get the word out about the
importance of preconception care, early prenatal care, and interconception care. Increas-
ingly, consumers are turning to various social media outlets such as blogs, Twitter,
Facebook, and YouTube for their health information. An innovative use of health IT
for health messaging is short messaging service (SMS, also known as text messaging).
SMS has many benefits over other modes of communication, including being low
cost, easy and convenient to use, and highly accessible and popular, especially among
younger women aged 15 to 24 years (M. S. Lim, Hocking, Hellard, & Aitken, 2008).
We searched key terms “text messaging,” “prenatal,” and “sexual health” and reviewed
references cited in original and review articles; 12 studies were identified (Cornelius
& St. Lawrence, 2009; Dhar, Leggat, & Bonas, 2006; Dobkin, Kent, Klausner,
McCright, & Kohn, 2007; Dyer, 2003; Kegg, Natha, Lau, & Pakianathan, 2004;
Levine, McCright, Dobkin, Woodruff, & Klausner, 2008; E. J. Lim, Haar, & Morgan,
2008; Mackenzie, 2009; Mak & Bastion, 2006; Menon-Johansson, McNaught, Mandalia,

Lu et al. 207S
& Sullivan, 2006; Murray, Gray, Bourne, & Dabbhadatta, 2006; Van den Oever &
Van Mens, 2006). However, most of the studies lacked adequate sample size, a clear
research design, or appropriate comparison group to allow meaningful evaluation of
their effectiveness in changing sexual and reproductive health and health-seeking
behaviors (M. S. Lim et al, 2008). None of the studies addressed the use of SMS to
promote preconception or timely prenatal care in underresourced settings.
One example of the use of SMS to increase consumer awareness of sexual and
reproductive health is SexInfo (Levine et al., 2008). SexInfo was developed by the San
Francisco Department of Public Health in response to rising gonorrhea rates among
African American youth. It is an information and referral service that can be accessed
by texting “SEXINFO” to a 5-digit number from any wireless phone. Within seconds,
participants receive a message back with codes telling them to text, for example,
“what 2 do if ur condom broke”; “2 find out about STDs”; and “if u think ur pregnant.”
Participants are then texted back basic health information or referrals for in-person
visits. These text messages may open doors for health messaging about the importance
of preconception and early prenatal care, especially for certain hard-to-reach popula-
tions (e.g., adolescents); their effectiveness in changing health-seeking behaviors
appears promising but remains to be shown in future studies.
Facilitate spatial mapping of access gaps. Health IT can be used to facilitate data col-
lection on race, ethnicity, and language spoken; such data are foundational to being
able to identify risk, stratify data, and identify access gaps. Health IT can also be used
to facilitate spatial mapping of access gaps in preconception and early prenatal care.
Application of geographic information systems (GIS) technology can help in describ-
ing and tracking disparities in health care access and health outcomes (Graves, 2008).
We searched key terms “geographical information systems,” “prenatal care,” and
“pregnancy” and identified two descriptive studies on the use of GIS for service plan-
ning in prenatal care (McLafferty & Grady, 2004; Curtis, 2008). Curtis (2008) described
the use of GIS for spatial analyses of prenatal care use (number of prenatal visits,
month prenatal visits began, and no prenatal visits) for the Baton Rouge Healthy Start
Program. GIS maps were generated to locate hotspots of neighborhoods with high
proportions of women receiving no prenatal care; these hotspots were then seeded
with paraprofessionals who are locally accepted community members who have
received some training and would keep an “eye out” for pregnant neighbors. In the
aftermath of hurricane Katrina, the GIS system was used to provide geospatial support
for disaster rescue and then for recovery. Katrina may have hastened the uptake of
GIS, including the use of Google Earth/Maps as a geospatial tool and a spatial video
acquisition system (SVAS) used to capture community information (e.g., the propor-
tion of returnees to an abandoned neighborhood). Further research and evaluation of
the use of health IT (e.g., GIS) to facilitate spatial mapping of access gaps and to assist
with service planning in preconception and prenatal care are needed.
Improve continuity of patient records. Health IT can be used to improve the continu-
ity of patient records, from preconception to prenatal to intrapartum to postpartum–
interconception to women’s health care. Presently, in many underresourced settings,

prenatal care records are often missing from labor and delivery, and labor and delivery
records are often inaccessible at the postpartum visit. Furthermore, maternal records
are not routinely linked from one pregnancy to the next, and newborn records are not
linked to maternal records. These critical discontinuities in patient records pose a sig-
nificant threat to the quality of health care. For example, too often screening for type 2
diabetes may not get done at the postpartum visit or at the annual well-woman exam,
as is recommended for women with a history of gestational diabetes, if the health care
provider is unaware of the woman’s prenatal history.
EMRs can help improve continuity of patient records. Bernstein, Farinelli, and
Merkatz (2005) reported a significant reduction in the occurrence of missing prenatal
records from labor and delivery after implementation of the electronic prenatal record.
Additionally, they demonstrated that the available record was more up to date. In
many underresourced settings, the problem of discontinuities in patient records is
often exacerbated by the discontinuities in providers (from prenatal to intrapartum to
postpartum care). Health IT can improve the continuity of patient records by linking
preconceptional, prenatal, intrapartum, and postpartum–interconception records, inpa-
tient and outpatient records, primary care and specialty services records, laboratory
and radiographic records, and maternal and child records. For providers working in an
underresourced settings, this could have a tremendous impact on reducing staff time
spent tracking down records, reducing costs by avoiding duplications, and improving
quality by reducing errors resulting from missing records.
Strategies to Improve the Content of Prenatal Care

Disparities exist in both access to and content of prenatal care (Brett et al., 1994;
Kogan, Kotelchuck, et al., 1994; Kotelchuck et al., 1997). In this section, we review
evidence of effectiveness for three innovative strategies to close disparities in the con-
tent of prenatal care—continuous quality improvement (CQI), performance measurement,
and enhanced prenatal care. We also explore how health IT can be used to close dis-
parities in the content of prenatal care.
Continuous quality improvement. CQI programs have the potential to close the gap
between what is recommended and what is done in prenatal care. CQI is a method of
continuously examining processes and making them more effective (Bennett et al.,
2009); this approach has been successful in improving health care quality in many
areas outside of prenatal care. However, presently there is a paucity of research on
CQI programs in prenatal care. We searched for key terms “continuous quality
improvement” and “prenatal care” and identified only one published clinical trial of
CQI in prenatal care (Bennett et al., 2009). Bennett et al. reported on the CQI experi-
ence of a practice-based research network focused on developing CQI processes for
maternal care among 10 family medicine residency training sites in the northeastern
United States (the IMPLICIT Network). The Network focused on five topics for CQI:
smoking, asymptomatic bacteriuria, bacterial vaginosis (for women with history of
preterm birth), interpregnancy interval, and depression. The Network achieved significant

Lu et al. 209S
improvement in care processes for three screening activities: (a) prenatal depression
symptomatology (by 15 weeks’ gestation), (b) screening for smoking at 30 weeks’
gestation, and (c) postpartum contraception planning.
We are aware of two other prenatal care networks that have implemented innova-
tive CQI programs: Improving Prenatal Care in Vermont (IPCV) and Healthy Births
Care Quality Improvement (HBCQI) initiative of the Los Angeles Best Babies Net-
work (LABBN). Both Networks are noteworthy in their adoption of the Breakthrough
Series (BTS), developed by the Institute for Healthcare Improvement (IHI), as their
framework and methodology for rapid systems change (Kilo, 1998). BTS is a collab-
orative health care quality improvement (QI) method that relies on the spread and
adaptation of existing knowledge to multiple sites to accomplish common aims. It
takes what are established as clinical guidelines or best practices but are not routinely
practiced and brings together health care providers to focus on bridging that gap
through rapid cycles of change. BTS has shown remarkable improvements in the health
of individuals living with diabetes, hypertension, and asthma, as well as improved
child immunization rates and Chlamydia screening among adolescent girls. In the only
published study of the use of BTS in maternity care, Flamm, Berwick, and Kabcenell
(1998) reported that of 28 health care organizations that participated in the collabora-
tive BTS (which involved three 2-day learning sessions, weekly conference calls, and
a dedicated Internet site), 15% achieved cesarean delivery rate reductions of 30% or
more during the 12-month period of active collaborative work. An additional 50%
achieved reductions between 10% and 30%.
The HBCQI of LABBN is the largest ambulatory-based quality improvement col-
laborative working with 10 clinical sites to improve ambulatory perinatal care prac-
tices. The collaborative focuses on a set of clinical conditions derived from the literature
and expert meetings using a modified Delphi system. Providers of prenatal care work
to improve the assessment of strengths and risks and the provision of health promotion
and evidence-based interventions for pregnant and postpartum women. Community
members participate in the process to enhance and enlighten providers’ perceptions of
areas for systems change, pregnant woman’s strengths and needs, and to provide links
to community resources and services. Women receiving care at the collaborative sites
receive comprehensive, culturally sensitive, and linguistically appropriate perinatal
care according to guidelines for health promotion, assessment, screening, evaluation,
intervention, and follow-up. LABBN has developed a web-based system for reporting
that allows for ongoing tracking of data and development of performance updates.
With 10 clinical sites participating, preliminary results have demonstrated sustained
improvements in first trimester depression screening using the PHQ-9 screening tool
(MacArthur Initiative on Depression & Primary Care, 1999), increasing documented
depression screening from 36% to 86% over 12 months. The LABBN has also dem-
onstrated improvements in diabetes screening of high-risk patients in the first trimes-
ter from 50% to 85% and improvement in plans to exclusively breast-feed from 25%
to 80% in nine clinics with the introduction of breast-feeding education and support
in the ambulatory setting.

Performance measurement. Performance measurement is another strategy that can

be used to close the gap between what is recommended and what is done, based on the
premise “what gets measured gets done.” This strategy has been employed by state
and local governments, payers, hospital accreditation bodies, and professional organi-
zations for improving health care quality. Performance measurement is often linked to
change strategies; two of the most widely used strategies for accelerating quality
improvement are public reporting and pay-for-performance (Berwick et al., 2003;
Chassin, 2002; Hibbard, Stockard, & Tusler, 2005; Institute of Medicine, 2002; Lin-
denauer et al., 2007; Millenson, 2004). Public reporting stimulates interest in quality
on the part of physicians and hospital leaders, perhaps by appealing to their profes-
sional ethos or the creation of market advantages (Marshall, Shekelle, Leatherman, &
Brook, 2000). Pay-for-performance programs are intended to strengthen the business
case for QI by rewarding excellence and reversing what have been described as per-
verse financial incentives that can deter hospitals from investing in QI efforts (Dudley,
Miller, Korenbrot, & Luft, 1998; Epstein et al., 2004; Millenson, 2004). It should be
noted, however, that the use of public reporting and pay-for-performance as change
strategies has to be further explored in underresourced settings where patients may
have more limited choices of providers, and providers may operate under different
sets of incentives.
Traditionally, obstetrics has lagged behind many other areas of health care in per-
formance measurement, but in recently years, maternal care measures have made
some progress. Both the Joint Commission Accreditation of Healthcare Organizations
(The Joint Commission) and the American College of Obstetricians and Gynecolo-
gists have proposed several maternal care measures (Korst et al., 2005). Most recently,
the National Quality Forum (NQF, 2009)—a consensus standards body that endorses
national health care performance measures—has endorsed 17 consensus standards
that address care received by mother and newborns, such as cesarean rate for low-risk
first birth women and elective delivery prior to 39 completed weeks gestation. While
these measures represent progress in performance measurement in maternal care, all
are hospital-based, and none are related to ambulatory prenatal care quality. The only
prenatal care “performance measures” currently in use are the two Healthcare Effec-
tiveness Data and Information Set (HEDIS) measures (rate of first trimester prenatal
care; rate of postpartum visit; Korst et al., 2005). There has been some work recently
on the development of performance measures for “ambulatory care sensitive condi-
tions,” that is, conditions that require hospitalization but may be preventable with
better quality ambulatory care, such as hospital admissions for gestational pyelone-
phritis (Korst et al., 2006) or uncontrolled diabetes (AHRQ, 2008), but such measures
still require some refinement and have not been widely adopted for performance mea-
surement in prenatal care. Further research on the use of performance measurement to
improve the quality of prenatal care and reduce perinatal disparities is needed.
Enhanced prenatal care. In the past two decades, prenatal care has shifted from being
primarily a medical intervention to encompass a much broader public health interven-
tion that encompasses (a) the detection, treatment, or prevention of acute and chronic

Lu et al. 211S
conditions; (b) incorporation of preconception care and postpartum care to improve

outcomes; (c) incorporation of prenatal care as an integral component of women’s
health; (d) screening and treatment for detrimental health behaviors; and (e) incorpo-
ration of interventions to improve the health and well-being of the newborn, such as
breastfeeding education, parenting classes, domestic violence screening, depression
screening, nutrition assessment, and self-care skills. Enhanced prenatal care—also known
as coordinated, augmented, enabling, enriched, comprehensive, or “wrap-around”
prenatal care services—has been widely used to improve the content of prenatal care,
particularly for low-income populations. Enhanced prenatal care typically refers to
routine prenatal care visits combined with ancillary services. These ancillary services
may entail outreach efforts, counseling about the Special Supplemental Nutrition Pro-
gram for Women, Infants and Children (WIC), case management, social work, psy-
chosocial counseling, social support, health promotion/education, transportation,
home-visits, and follow-up services to facilitate the ongoing use of the prenatal ser-
vices offered (Alexander & Kotelchuck, 2001).
We have already mentioned several models of enhanced prenatal care. The Califor-
nia Perinatal Services Program (CPSP) enhances prenatal care with nutrition counsel-
ing, social services, and health education (Korenbrot et al., 1995). Most Healthy Start
programs enhance prenatal care with care coordination, case management, and home
visitation (Badura et al., 2008). Despite its popularity, the effectiveness of enhanced
prenatal care for improving perinatal outcomes or reducing perinatal disparities has
not been clearly demonstrated. Fiscella (1995) reviewed evidence of effectiveness of
three types of enhanced prenatal care for preventing LBW or preterm birth: home visi-
tation programs, comprehensive care programs, and preterm prevention programs.
Home visitation programs typically involve visits to women’s homes during preg-
nancy by trained nurses, social workers, or lay family workers; women typically receive
education, psychological support, case management, and linkage with needed ser-
vices. Fiscella found that randomized controlled trials of home visitation involving
more than 4,000 at-risk women showed no overall reduction in rates of LBW infants
or preterm delivery. Comprehensive care programs have usually included detailed
assessment of a woman’s needs during pregnancy, along with a comprehensive plan
designed to address each of her needs or risk factors. Care is often provided by multi-
disciplinary teams that may include obstetricians, nurse-midwives, nurse clinicians,
nutritionists, social workers, and psychologists. Randomized controlled trials of com-
prehensive care involving nearly 1,700 women have shown no improvements in over-
all birth weight or LBW rates. Preterm prevention programs have targeted women
identified through various risk-scoring systems and provided either weekly or biweekly
prenatal visits and cervical examinations, detailed education sessions regarding the
signs of early labor, hot lines, and case follow-up and tracking. Preterm prevention
programs involving nearly 3,000 women at high risk have also failed to reduce rates
of preterm delivery or LBW. Thus, the effectiveness of these enhanced prenatal care
programs for preventing LBW or reducing perinatal disparities remains widely debated
and warrants greater attention in future perinatal health services research. It should

also be noted that Fiscella’s review examined the impact of prenatal care on only three
immediate birth outcomes—perinatal death, LBW, and preterm birth; the impact of
enhanced prenatal care on other short- and long-term health outcomes for children and
families remains largely unexplored (Olds et al., 2007).
Applications of Health IT to Improve

the Content of Prenatal Care
Health IT can be used to improve the content of prenatal care. We identified five
potential applications of health IT to reduce disparities in the content of prenatal care
in underresourced settings: supporting collaborative quality improvement, facilitating
performance measurement, enhancing health promotion and patient education, assist-
ing with care coordination, and other, more “traditional” applications of health IT for
reducing errors, improving delivery of preventive health services, providing decision
support, and encouraging completeness of documentation.
Support collaborative quality improvement. Health IT can be used to facilitate com-
munication among members of a learning community and offer a forum for ongoing
dialogue in the interim between face-to-face meetings. Web-based registries have
been used in the collaborative learning model as a mechanism for clinical sites partici-
pating in a QI collaborative to assess monthly progress and share lessons learned with
participating clinics. The IHI has widely adopted this tool in multiple learning col-
laboratives. Both the LABBN’s HBCQI and the federal Healthy Start interconception
care program provides web-based support to providers participating in the CQI net-
work. Boushon, Provost, Gagnon, and Carver (2006) reported on the use of a virtual
BTS (VBTS), in which the three face-to-face meetings were completely eliminated.
Instead, the VBTS took place by Internet and telephone, using web-based collabora-
tion software and audioconferencing. For the 17 organizations completing the VBTS,
the average number of days to next-available appointment fell from 23 to 10 days. The
Improvement Assessment Scale showed 59% of teams at level 4 or above (“signifi-
cant” improvement, with most changes implemented, and evidence of sustained improve-
ment in outcomes and plans for spread). Potential direct cost savings were about
$12,000 as compared with a traditional CQI network that requires face-to-face meet-
ings. Six months after the VBTS’s conclusion, 70% of the teams that achieved signifi-
cant improvement either maintained gains or improved their results. The authors
identified IT support as one of the prerequisites for success.
Facilitate performance measurement. Health IT can be used to facilitate performance
measurement. As discussed earlier, the use of performance measurement in prenatal
care is quite limited at present. One of the biggest barriers to performance measure-
ment in prenatal care is the lack of a health IT infrastructure in most ambulatory set-
tings. Many prenatal care providers, particularly those in underserved settings, still
use paper prenatal records. Abstracting data from paper records for the purpose of
performance measurement can be very labor-intensive and costly. With the right
health IT system, data can be recorded more accurately and abstracted more efficiently.

Lu et al. 213S
These data can be reported electronically, which can facilitate more timely feedback
for quality improvement purposes. With health IT, performance measurement in pre-
natal care can be expanded to include not only the rates of prenatal and postpartum
care but also other measures that provide a more comprehensive assessment of the
multiple dimensions of prenatal care quality.
Enhance health promotion and patient education. Health IT can be used to enhance
the content of prenatal care, especially for health promotion and patient education.
Increasingly, patients are finding information about self-care from the Internet, and
websites such as MyPyramid (http://www.mypyramid.gov) can provide useful tools
for nutritional self-assessment and education to pregnant women.
Another example of using health IT to enhance patient education is provided by an
AHRQ-funded study at Boston Medical Center on the use of a computer-animated
virtual nurse to provide discharge instructions to patients about to be discharged from
the hospital (Jack et al., 2009). The animation can be brought to a patient’s bedside via
a computer on a wheeled kiosk. The patient is able to control the interaction with a
touch-screen display. Typically, patients spend about 30 minutes with the virtual
nurse, as compared with on average less than 8 minutes with the discharge nurse. The
virtual nurse has the potential for reducing costs and improving care quality. Results
to date indicate that low health literacy patients find the system easy to use and even
preferable to receiving the information from a live doctor or nurse. Patients who have
a clear understanding of their after-hospital care instructions, including how to take
their medicines and when to make follow-up appointments, are 30% less likely to be
readmitted or visit the emergency department than patients who lack this information
(Jack et al., 2009). Such technologies need to be tested for linguistic and cultural
appropriateness as well as patient acceptability. More important, whether the patient
living in underresourced settings can and will follow through on recommendations
given by such a web menu planner or virtual nurse, in the context her social environ-
ment in the home or community, needs to be evaluated.
Assist with care coordination. Care coordination and case management are integral to
most enhanced prenatal care programs. Health IT can help link clients to needed
services. A good example is the Healthy City website (http://www.healthycity.org/),
which maps community services as well as demographic, economic, and health data in
Los Angeles County down to the ZIP code and census tract level using GIS technology.
In addition to assisting with spatial mapping and service planning, the website can help
a care coordinator or a client locate a wide array of services in the neighborhood, rang-
ing from those dealing with basic needs such as food and housing, to health care, educa-
tion, income security, criminal justice, and legal services, just to name a few.
Other applications of health IT to improve the content of prenatal care. There are sev-
eral other “more traditional” uses of health IT for improving the content of prenatal care.
First, health IT can be used to reduce errors. Electronic medical records (EMR) have
been used to reduce medication errors (e.g., wrong dosage, missed drug interactions)
for hospitalized patients. In prenatal care, errors often occur when tests are not done
(screening for asymptomatic bacteriuria) or when follow up of abnormal results

(e.g., elevated blood pressure, group B streptococcus) does not occur. These errors
may be more frequent in a busy, understaffed clinic and can be largely avoided through
the use of reminders and alerts in the EMR.
Second, health IT can also be used to improve delivery of preventive health
services through prompts and reminders. EMR can generate these prompts and
reminders to the health care provider when a patient is due for her Pap smear,
immunization, mammography or colonoscopy. In prenatal care, EMR can improve
risk assessment by generating prompts and reminders to the prenatal care provider
to screen for intimate partner violence, depression, and other important topics that
are often missed during risk screening. Similarly, EMR can improve health promo-
tion by offering prompts and reminders to the prenatal care provider to talk to her
patients about nutrition, breast-feeding, family planning, and other important health
promotion topics.
Third, health IT can also be used to provide decision support to prenatal care pro-
viders. Examples in other areas of health care include EMR-generated reminders for
physicians to prescribe erythropoietin to cancer patients with hemoglobin levels less
than 12 g/dL (Kralj, Iverson, Hotz, & Ashbury, 2003) and a provider order-entry sys-
tem that prompted physicians to provide prophylaxis to patients at risk for venous
thromboembolism, which resulted in reduced rates of deep venous thrombosis and
pulmonary embolus (Kucher et al., 2005). In prenatal care, EMR can be used to remind
physicians to prescribe progesterone to eligible patients with a documented history of
spontaneous preterm delivery. Algorithms can be developed to guide clinicians on
the use of biophysical (e.g., sonographic cervical length) and biochemical (e.g., fetal
fibronectin) markers for prediction of preterm birth or the decision to use invasive
versus noninvasive tests for prenatal diagnosis of Down syndrome.
Fourth, health IT also can be used to encourage completeness of documentation.
Complete documentation is important to facilitate communication among providers,
especially in underresourced settings where the patient is more likely to encounter
multiple prenatal care providers. Eden et al. (2008) conducted a pre- and postinterven-
tion study to evaluate the impact of an EMR on documentation completeness and
patient care in a labor and delivery unit. They found that paper admission records were
significantly more likely to miss key clinical information such as chief complaints
(contractions, membrane status, bleeding, fetal movement) and prenatal laboratory
results and history (varicella, group B streptococcus, human immunodeficiency virus).
They noted that although more time was spent on computer activities, which resulted
in a more complete labor and delivery record, time spent on direct patient care was not
affected and actually increased.
In sum, health IT can be used to reduce errors, improve delivery of preventive
health services, provide decision support, and encourage completeness of documenta-
tion. Presently, there is a paucity of research and evaluation on the use of EMRs in pre-
natal care; in fact, our literature search using key term “electronic prenatal record”
identified only two original articles (Bernstein et al., 2005; Eden et al., 2008) and five
reviews/commentaries (Bernstein & Merkatz, 2007; Bradley & King, 1998; Miller, 2003,

Lu et al. 215S
2008; Phelan, 2008). Further research on the use of electronic prenatal records in under-
resourced settings is needed.
Strategies to Enhance the Organization

and Delivery of Prenatal Care
Presently, there is a great deal of fragmentation in the organization and delivery of
prenatal care. Women needing multiple services often have to take time off from work
on different days, arrange child care, find transportation to get to their appointments at
different locations, and fill out duplicative records, and still they may not get the ser-
vices they need because the referral paperwork is missing or the providers did not
communicate with each other. Such fragmentation in service delivery can deter access
to care, particularly in underresourced settings. For low-income women in rural areas,
finding transportation to multiple locations can be challenging (Jesse, Dolbier, &
Blanchard, 2008; Omar, Schiffman, & Bauer, 1998). For immigrant women with lim-
ited English proficiency, making multiple appointments, filling out multiple forms,
applying for multiple benefits, and maneuvering through a complicated, fragmented
system can be quite daunting. Such fragmentation can also weaken quality of care,
especially in underresourced settings where the challenge is not only about connecting
the dots, but some of the most critical dots (e.g., oral health services, mental health
services, childbirth education classes) may be missing altogether.
Closing the quality gap in prenatal care will require not only increased access and
improved content but also enhanced integration of health services. In this section we
will examine strategies to make prenatal care more integrated. Because of a lack of
published studies on service integration in prenatal care, we will discuss two models
of service integration based on our key informant interviews—DC Developing Fami-
lies Center and Northern Manhattan Perinatal Partnership MCH Life Course Organi-
zation. We will also explore an innovative model of group prenatal care called
Centering Pregnancy. Last, we will examine how health IT can be used to enhance the
organization and delivery of prenatal care.
The DC Developing Families Center. DCDFC is an exemplary model of service inte-
gration in prenatal care. It is a medical home (or, to avoid overmedicalizing pregnancy,
a family resource center) where all services are provided under one roof in a personal-
ized setting that is easily accessible to the low-income communities of Carver Terrace
and Trinidad/Ivy City in northeast Washington, DC. DCDFC is a collaboration of
three private, nonprofit health, child development, and social service providers: the
DC Birth Center, the Healthy Babies Project, and Nation’s Capital Child and Family
Development (http://www.developingfamilies.org). The DC Birth Center provides
well-woman preventive health services and care for women of all ages; maternity
services and family-centered birth, either in a home-like birthing center or at Wash-
ington Hospital Center; family planning services; STD screening and treatment; pedi-
atric primary care, including well-child annual exams, immunizations, and treatment
of minor illnesses; and help in applying for health insurance. The Healthy Babies

Project, Inc., is a community-based support system for pregnant and parenting women
in Washington, DC. Services include pregnancy testing and family planning counsel-
ing; risk assessment and case management; home visits; crisis intervention; classes in
childbirth and health education; smoking cessation, prenatal yoga, and parenting classes;
and referrals to emergency services and mothers’ and fathers’ support groups. The
Nation’s Capital Child and Family Development (NCCFD) operates the DCDFC
Child Development Center serving infants and toddlers. It operates 15 other early
childhood centers (6 weeks to 5 years); 9 school-age centers (4 to 12 years), and 24
family child care providers (6 weeks to 12 years). NCCFD also provides job training,
GED (high school equivalency) classes, and a first-time home buyer’s program.
The DCDFC is one of a growing number of family resource centers that are provid-
ing prenatal care within a more integrated framework of service delivery. The paucity
of published data to date makes it difficult to evaluate the effectiveness of “medical
home” or “family resource center” for improving prenatal care quality or perinatal
outcomes. This innovative yet untested model of service integration warrants greater
attention in future health services research.
MCH Life Course Organization. The Northern Manhattan Perinatal Partnership (NMPP;
see http://www.sisterlink.com/) and its Central Harlem Healthy Start program have
taken service integration to the next level with the establishment of an “MCH Life-
Course Organization” that brought together not only prenatal care and early child-
hood programs but also child welfare, housing, health systems change (building a
birthing center in Harlem), economic opportunities, and a legislative agenda in an
integrative, life-course approach to improving perinatal health in central Harlem.
The agency also actively advocated for reforms in urban services that directly affect
the health of its target population. NMPP embarked on a campaign to reduce the
number of bus depots in the community. It likewise supported the building of super-
markets that provide healthier foods to its constituents. With the gentrification of
Harlem and its social and economic cost on poor and working class residents, NMPP
collaborated with other groups to put pressure on local public leaders and private
sector representatives to increase the growth of affordable housing. Many Harlem
Healthy Start consumers have taken advantage of the more than 82,000 units that
have been built so far. NMPP introduced a job readiness program that has placed
more than 890 women in full-time and part-time employment. At the policy level, it
supported the empowerment-zone legislation initiated over a decade ago, which
infused Harlem with up to $300 million in block grants for community revitalization
and job-creation projects.
NMPP and the Central Harlem Healthy Start Program have served more than 9,500
women, and their children have been linked and maintained in care. Since the pro-
gram’s inception in 1990 when the infant mortality rate (IMR) was 27.7 infant deaths
per 1,000 live births, the IMR in central Harlem has plummeted to 5.1 infant deaths
per 1,000 live births in 2004 (Koshel 2009). It remains unclear how much, if any, of
the reduction in IMR in central Harlem is attributable to program effects or other fac-
tors, such as demographic shifts in the past decade. Nonetheless, NMPP represents a

Lu et al. 217S
unique, innovative model of service integration across multiple sectors, and it merits
greater attention in future health services research.
Centering Pregnancy. Centering Pregnancy (CP) is a multifaceted model of group
prenatal care that integrates the three major components of care—health assessment,
education, and support—into a unified program within a group setting. Eight to 12
women with similar gestational ages meet together, learn care skills, participate in a
facilitated discussion, and develop a support network with other group members. Each
pregnancy group meets for a total of 10 sessions throughout pregnancy and early
postpartum.
Presently there is a paucity of research on CP. Our PubMed search using key terms
“Centering Pregnancy” and “group prenatal care” identified 11 original articles on CP
(K. Baldwin, 2006; Grady & Bloom, 2004; Hackley, Applebaum, Wilcox, & Arevalo,
2009; Ickovics et al., 2003; Ickovics et al., 2007; Kennedy et al., 2009; Klima, 2003;
Klima, Norr, Vonderheid, & Handler, 2009; Rising, 1998; Robertson, Aycock, &
Darnell, 2009; Skelton et al., 2009). While these studies showed promising results,
including increased satisfaction among predominantly low-income African American
(Klima et al., 2009), Hispanic (Robertson et al., 2009), and adolescent women (Grady
& Bloom, 2004) compared with traditional prenatal care, most studies were limited by
their small sample size and potential for selection bias.
In the largest study of CP completed to date (Ickovics et al., 2007), pregnant women
(n = 1,047), predominantly African American (80%) aged 14-25 years, were randomly
assigned to either standard or group care. Women with medical conditions requiring
individualized care were excluded from randomization. Participants received care in a
group setting with women having the same expected delivery month. Timing and
content of visits followed obstetric guidelines from Week 18 through delivery. Each
2-hour prenatal care session included physical assessment, education and skills build-
ing, and support through facilitated group discussion. Structured interviews were con-
ducted at study entry, during the third trimester, and postpartum. Using intent-to-treat
analyses, women assigned to group care were significantly less likely to have subop-
timal prenatal care and preterm birth, had significantly better prenatal knowledge, felt
more ready for labor and delivery, and had greater satisfaction with care, compared
with those in standard care. Breastfeeding initiation was higher in group care. There
were no differences between the two groups in birth weight or in costs associated with
prenatal care or delivery. To date this remains the only high-quality study that has
examined the effectiveness of CP for improving birth outcomes; further research on
this promising model of prenatal care is warranted.
Applications of Health IT to Enhance the

Organization and Delivery of Prenatal Care
Finally we examined how health IT has or can be used to improve the organization and
delivery of prenatal care. We identified two potential innovative applications of health
IT to reduce disparities in the organization and delivery of prenatal care in underresourced

settings: the use of health IT to facilitate service integration and promote collaborative
innovations.
Facilitate service integration. Health IT can be used to facilitate service integration.
Service integration requires data integration. Service integration within a family
resource center or a maternal and child health (MCH) life course organization can be
enhanced by an integrated data system. There are, however, a number of challenges
that have to be overcome to achieve data integration in underresourced settings. The
first challenge is to establish a means of identifying individual clients across different
care delivery systems (Mills, 2006). The ability to create an integrated record system
depends on the development of a “universal person index” as well as considerations
for standardizing and integrating other aspects of the electronic record. This universal
person index should also allow linkage of maternal records to child (family) records.
Many individual health facilities are working to create a “master person index” (MPI),
and some integrated delivery systems are attempting to combine these MPIs into a
single “enterprise person index” (EPI). MPIs or EPIs can help data integration across
sectors, such as health system with early childhood programs. Primary efforts to estab-
lish these linkages will depend on standardization across multiple MPI files and link-
age protocols. The second challenge is to establish a common integrated data system
given different funding streams with different reporting requirements. Improved col-
laboration among funders is needed to allow for data integration across systems. The
third challenge is data protection. Safeguards need to be put in place to protect patient
confidentiality across multiple data systems.
Promote collaborative innovation. Health IT can also be used to promote collaborative
innovation. As reviewed earlier, innovations are needed in many areas of prenatal
care, from pre-/interconception care to CQI to models of service integration. Health IT
can be used to connect innovators in prenatal care in a collaboration innovation net-
work (COIN). COINs are virtual communities of innovators “with a collective vision,
enabled by the Web to collaborate in achieving a common goal by sharing ideas, infor-
mation, and work” (Gloor, 2006). Such networks have been used to promote innova-
tions in other areas of medicine (e.g. SpineConnect), technology (e.g., Linux, Intel,
IBM), businesses (e.g., Union Bank of Switzerland), and government (e.g., United
Nations; Gloor, 2006). A COIN is needed to engineer innovative strategies for reduc-
ing disparities in prenatal care quality and perinatal outcomes.
Discussion
In this case study, we examined what innovative strategies, including the use of health
IT, have been or can be used to reduce disparities in prenatal care quality in underre-
sourced settings. In all, we identified 17 strategies that have been or can be used to
reduce disparities in prenatal care quality in underresourced settings. We found evi-
dence of effectiveness for Medicaid expansion and other policy initiatives (e.g., CPSP)
in increasing access to and reducing disparities in timely prenatal care. It should be
noted, however, that these initiatives did not completely close the access gap, and that

Lu et al. 219S
many nonfinancial barriers to prenatal care persisted despite improved financial access.
We also argued that for prenatal care to be “timely,” it needs to begin before preg-
nancy. There presently is a paucity of research on preconception and interconception
care, and innovative programs such as the Magnolia Project or other Healthy Start
Interconception Care projects lack clear research design and sufficient resources to
allow for meaningful evaluation. AHRQ and other funders can play an important role
in supporting effectiveness research in preconception and interconception care.
With respect to health IT, we identified three potential applications of health IT for
reducing access gaps in underresourced settings. Health IT can be used to increase
consumer awareness about the importance of preconception and early prenatal care
(e.g., via SMS), facilitate spatial mapping of access gaps (e.g., using GIS), and
improve continuity of patient records (e.g., with EMR). However, we found only a
few descriptive studies of the use of these innovative technologies in prenatal care;
more research on these promising strategies is needed.
In many underresourced settings, disparities exist in both access to and content of
prenatal care. We reviewed three strategies for closing disparities in the content of
prenatal care: CQI, performance measurement, and enhanced prenatal care. We found
three networks that have implemented CQI in prenatal care (IMPLICT, HBCQI,
IPCV); while preliminary results are promising, further research is needed to evaluate
the effectiveness of these CQI strategies for improving prenatal care quality and
reducing perinatal disparities. Performance measurement can also be used to address
the quality gap, especially if it is linked to change strategies such as public reporting
or pay-for-performance. Although in recent years some progress has been made in the
development of maternal care measures, most are hospital-based, and only two are
related to prenatal care “quality” (rate of first trimester prenatal care; rate of postpar-
tum visit). Further research on the use of performance measurement to improve the
quality of prenatal care and reduce perinatal disparities is needed. It is important to
also consider how performance measurement can be linked to change strategies in
underresourced communities. Another strategy for closing the quality gap in prenatal
care is enhanced prenatal care. Despite its wide adoption in public health, the effec-
tiveness of enhanced prenatal care programs for preventing LBW or reducing perinatal
disparities remains unproven and warrants greater attention in future perinatal health
services research.
With respect to health IT, we identified several potential applications of health IT
for reducing disparities in the content of prenatal care in underresourced settings.
Health IT can be used to support collaborative quality improvement, facilitate perfor-
mance measurement, enhance health promotion and patient education, and assist with
care coordination. Health IT can also be used to reduce clinical errors, improve deliv-
ery of preventive health services through prompts and reminders, provide decision sup-
port, and encourage completeness of documentation. Again we found a dearth of
published reports of such innovative applications of health IT in prenatal care; in fact,
our literature search identified only two original articles and five reviews/commentar-
ies on the use of electronic prenatal records. While the potential of health IT for quality

improvement and cost savings is clearly recognized by many providers in underserved

settings, there are two major barriers to wide adoption: lack of resources to make that
initial investment in health IT, and lack of ongoing technical support. AHRQ and
relevant agencies can play an important role in promoting the development and adop-
tion of health IT, including electronic prenatal records, in underresourced settings.
Last, we identified several strategies for improving the organization and delivery
of prenatal care. We highlighted two innovative programs—the DC Developing
Families Center and the Northern Manhattan Perinatal Partnership’s MCH life course
organization—as models of service integration in prenatal care. These programs are
transforming themselves from what Halfon, DuPlessis, and Barrett (2008) described
as a 1.0 operating system (e.g., prenatal care provider assisted by an office staff with
little to no referral network), to a 2.0 system (e.g., prenatal care provider with estab-
lished referral network and care coordination), and or even a 3.0 system that is verti-
cally integrated across levels of care, horizontally integrated across sectors, and
longitudinally integrated across time. We contend that for prenatal care to be a more
effective tool for addressing perinatal disparities, it needs to be redesigned with higher
levels of service connectivity and systems integration in mind. AHRQ and other relevant
agencies can play a major role in supporting research and evaluation for such redesign.
Health IT can be used to improve the organization and delivery of prenatal care.
First, systems integration demands data integration. There are, however, a number of
challenges that have to be overcome to achieve data integration in underresourced set-
tings, including the need for investment in an integrated data system, standardization
across multiple MPI (master person index) files, development of linkage protocols and
data protection, and collaboration among funders with different reporting require-
ments using different data systems. Second, health IT can be used to connect innova-
tors in prenatal care through a Collaborative Innovation Network (COIN), whose
common goal is to engineer collaborative innovations in prenatal care. Innovation is
not an option; it is required if we are to come up with more effective strategies for
improving prenatal care quality and reducing perinatal disparities.
We conclude with the following three observations. First, more research and evalu-
ation are needed for most, if not all, innovative strategies reviewed in this case study.
There has been a gross underinvestment in research on prenatal care quality. Many
promising strategies, from interconception care to CQI to performance measurement
to service integration, lack a strong evidence base. Thus, we developed a set of 22
research and action recommendations based on our findings (Table 2). Collectively
these recommendations form the basis for a research agenda on health care disparities
in prenatal care.
Second, efforts to improve pregnancy outcomes and efforts to eliminate dispari-
ties, while related, may have differing underlying factors and require differing
approaches. An evidence base developed solely for the purpose of improving preg-
nancy outcomes may change the slope of the trends toward improvement in the rates
for all population groups but not necessarily reduce the disparities. An example is the
consistent decline in sudden infant death syndrome (SIDS) rates in all ethnic groups

Lu et al. 221S
Table 2. A Research and Action Agenda for Reducing Disparities in Prenatal Care Quality in
Underresourced Settings
Increase access to timely prenatal care
1. Convene an expert group to define the timing and content of “early” prenatal care.
Early prenatal care should be defined as initiation of care not by the end of the first
trimester, but earlier in pregnancy. Support research to build the evidence base for the
effectiveness of “early” prenatal care
2. Support research on barriers and facilitators to “early” prenatal care and preconception
care, such as regular source of care, as well as innovative strategies to overcome
these barriers among Agency for Healthcare Research and Quality (AHRQ) priority
populations and in underresourced settings
3. Convene an expert group to study how policy initiatives, including financial and
nonfinancial incentives, can be used to increase access to, enhance content of, and
promote service integration in preconception and prenatal care
4. Support research and evaluation on the effectiveness of preconception and
interconception care for addressing perinatal disparities. Support establishment of a
network of Centers of Excellence in Preconception and Interconception Health Care,
with a mission to promote quality, training, and research in pre- and interconception care
5. Support research and evaluation of the use of short messaging service (also known as
text messaging) and other social media to promote the use of preconception and early
prenatal care in underresourced settings
6. Support research and evaluation of the use of health information technology (health IT;
e.g., geographical information system) to facilitate community mapping of preconception
and early prenatal care use and assist with service planning
7. Provide infrastructural and technical support to improve continuity of patient records
in underresourced settings across preconception, prenatal, intrapartum, postpartum,
and interconception care. Relevant agencies (e.g., AHRQ) should support research and
evaluation of the use health IT to improve continuity of patient records
Improve content of prenatal care
8. Convene an expert group to redefine the content of prenatal care, with an emphasis on
eliminating perinatal disparities. From a life-course perspective, the content of prenatal care
should be redesigned with greater emphasis on promoting women’s health, including greater
integration with preconception, postpartum, and interconception care; family planning; and
reproductive life planning, as well as preventive health services and primary care
9. Support research and evaluation of the use of the Institute for Healthcare Improvement
(IHI) Breakthrough Series and other continuous quality improvement (CQI)
methodologies for improving the content of prenatal care. One approach is to create a
practice-based research network (PBRN) for prenatal care to investigate questions related
to community-based prenatal care practice and to improve the quality of prenatal care
10. Support development of performance measures in prenatal care. Support research and
evaluation of how performance measurement in prenatal care can be linked to change
strategies to reduce disparities in prenatal care quality in underresourced settings
11. Support the development of an evidence base for the delivery of enhanced prenatal and
preconception care that specifically addresses the unique vulnerabilities posed by social
inequities that result in disparities in prenatal care quality and perinatal outcomes
12. Provide infrastructural and technical support for the use of health IT in support of
collaborative quality improvement projects in prenatal care
(continued)

Table 2. (continued)
Improve content of prenatal care
13. Provide infrastructural and technical support for the use of health IT for the purpose of
performance measurement in prenatal care
14. Support research and evaluation of innovative uses of health IT (e.g., web-based menu
planners, virtual nurse) to enhance patient education and health promotion in prenatal care
15. Support research and evaluation of innovative uses of health IT (e.g., Healthy City; see
http://www.healthycity.org/) to assist with care coordination in prenatal care
16. Provide infrastructural and technical support for development of innovative health IT
applications in underresourced settings, including the use of electronic prenatal records,
to reduce errors, improve delivery of preventive health services, provide decision
support, and encourage completeness of documentation in prenatal care
Enhance organization and delivery of prenatal care
17. Convene an expert group to design the 3.0 system of prenatal care, with attention to
improving vertical integration across levels of care, horizontal integration across sectors,
and longitudinal integration across time. Furthermore, AHRQ and other relevant
organizations should support a research network to develop and evaluate these 3.0
systems of prenatal care
18. Support research and evaluation of the effectiveness of “medical home” or “family
resource center” for improving service integration in prenatal care and reducing
disparities in perinatal outcomes, especially in underresourced settings
19. Support research and evaluation of the effectiveness of “MCH Life-Course
Organization” (see http://www.sisterlink.com/) for improving service integration
in prenatal care, and reducing disparities in perinatal outcomes, especially in
underresourced settings
20. Support research and evaluation of the effectiveness of Centering Pregnancy (see http://
www.centeringhealthcare.org/pages/centering-model/pregnancy-overview.php) and
other models of group prenatal care for improving pregnancy outcomes and reducing
disparities in perinatal outcomes, especially in underresourced settings
21. Provide infrastructural and technical support for the development of integrated data
systems in underresourced settings to facilitate service integration
22. Establish a collaborative innovation network in prenatal care under the existing AHRQ
PBRN mechanism. The mission of this prenatal care collaboration innovation network
(PC-COIN) is to engineer innovations to address disparities in prenatal care quality
and perinatal outcomes in underresourced communities. Support pilot studies to
evaluate the use of PC-COIN to engineer innovations and quality improvement in
prenatal care
after the introduction of Back to Sleep campaigns demonstrating the effects of an

evidence-based intervention; but yet the disparity did not concurrently decline (Pickett,
Luo, & Lauderdale, 2005).
Third, efforts to reduce disparities in prenatal care quality in underresourced set-
tings require a multilevel approach in aiming to (a) advance important conceptualiza-
tions (e.g., early, timely, preconception and prenatal care), (b) support applied research,
(c) support infrastructural and technical support, and (d) explore policy strategies.
Local programs cannot do this alone. Furthermore, underresourced communities may

Lu et al. 223S
have a much greater learning curve with many of the strategies described (e.g., EMR,
performance reporting, participation in QI collaboratives) and thus may require greater
levels of technical and financial support. It is imperative that policy makers, funders,
health plans, and other stakeholders consider how to leverage resources to remove
barriers and support innovations in these underresourced settings that traditionally
have not been the target of QI or health IT initiatives.
Last, we caution against a blind faith in health IT as a quick fix to health care dis-
parities in prenatal care. Health IT alone will not close the quality gap in prenatal care;
simply implementing electronic prenatal records in a fragmented care model, we believe,
is not sufficient QI for reducing perinatal disparities.
In this case study, we explored how health IT has been or can be used to help trans-
form prenatal care so that it can become more timely, comprehensive, and integrated.
This big picture has to be kept in mind as we deliberate on how to invest health IT
monies to address health care disparities in prenatal care.
Authors’ Note
The opinions cited herein are those of the authors and do not necessarily represent the views of
the U.S. Department of Health and Human Services or the Agency for Healthcare Research and
Quality.
Acknowledgment
We would like acknowledge the following individuals for their invaluable input to our case
study: Peter Bernstein, MD, MPH; Carol Brady, MA; Mario Drummond, MS, LCSW, MBA;
Anne Lang Dunlop, MD, MPH; Brian Jack, MD, MD; Hugh McDonough, EdM; and Sharon
Rising, MSN, CNM, FCNM. We would also like to thank Shakeh J. Kaftarian, PhD, and Cecilia
Rivera Casale, PhD, at AHRQ for their support and guidance, and Jessica Chow, MPH, and
Angela Kim, MPH for their assistance with preparation of the manuscript.
Declaration of Conflicting Interests

The author(s) declared no conflicts of interest with respect to the authorship and/or publication
of this article.
Funding
The author(s) disclosed that they received the following support for their research and/or author-
ship of this article: This work was supported by the Agency for Healthcare Research and Quality
(AHRQ) through contract P233200900421P.
References
Agency for Healthcare Research and Quality. (2008). Prevention quality indicators: Techni-
cal specifications [version 3.2]. Rockville, MD: Author. Retrieved from http://www.quality
indicators.ahrq.gov/archives/pqi/pqi_technical_specs_v32.pdf
Agency for Healthcare Research and Quality. (2009a). National healthcare disparities report
2008 (AHRQ Publication No. 09-0002). Rockville, MD: Author.

Agency for Healthcare Research and Quality. (2009b). National healthcare quality report 2008
(AHRQ Publication No. 09-0001). Rockville, MD: Author.
Alexander, G. R., & Kotelchuck, M. (2001). Assessing the role and effectiveness of prenatal
care: History, challenges, and directions for future research. Public Health Reports, 116,
306-316.
American Recovery and Reinvestment Act. (2009). Retrieved from http://frwebgate.access
.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h1enr.pdf
Andrews, W. W., Goldenberg, R. L., Hauth, J. C., Cliver, S. P., Copper, R., & Conner, M.
(2006). Interconceptional antibiotics to prevent spontaneous preterm birth: A randomized
clinical trial. American Journal of Obstetrics and Gynecology, 194, 617-623.
Badura, M., Johnson, K., Hench, K., & Reyes, M. (2008). Healthy Start lessons learned on
interconception care. Womens Health Issues, 18, S61-S66.
Baldwin, K. (2006). Comparison of selected outcomes of centering pregnancy versus traditional
prenatal care. Journal of Midwifery & Women’s Health, 51, 266-272.
Baldwin, L. M., Larson, E. H., Connell, F. A., Nordlund, D., Cain, K. C., Cawthon, M. L., . . .
Rosenblatt, R. A. (1998). The effect of expanding Medicaid prenatal services on birth out-
comes. American Journal of Public Health, 88, 1623-1629.
Bennett, I. M., Coco, A., Anderson, J., Horst, M., Gambler, A. S., Barr, W. B., & Ratcliffe, S.
(2009). Improving maternal care with a continuous quality improvement strategy: A report
from the Interventions to Minimize Preterm and Low Birth Weight Infants through Continu-
ous Improvement Techniques (IMPLICIT) Network. Journal of American Board of Family
Medicine, 22, 380-386.
Bernstein, P. S., Farinelli, C., & Merkatz, I. R. (2005). Using an electronic medical record to improve
communication within a prenatal care network. Obstetrics and Gynecology, 105, 607-612.
Bernstein, P. S., & Merkatz, I. R. (2007). Reducing errors and risk in a prenatal network with an
electronic medical record. Journal of Reproductive Medicine, 52, 987-993.
Berwick, D. M., DeParle, N. A., Eddy, D. M., Ellwood, P. M., Enthoven, A. C., Halvorson, G. C.,
Wilensky, G. R. (2003). Paying for performance: Medicare should lead. Health Affairs
(Millwood), 22, 8-10.
Biermann, J., Dunlop, A. L., Brady, C., Dubin, C., & Brann, A., Jr. (2006). Promising practices
in preconception care for women at risk for poor health and pregnancy outcomes. Maternal
and Child Health Journal, 10(5 Suppl.), S21-S28.
Boushon, B., Provost, L., Gagnon, J., & Carver, P. (2006) Using a virtual breakthrough series
collaborative to improve access in primary care. Joint Commission Journal on Quality and
Patient Safety, 32, 573-584.
Bradley, J. H., & King, D. E. (1998). Electronic medical records for prenatal patients: Chal-
lenges and solutions. Journal of Computational Chemistry, 15, 316-322.
Braveman, P., Bennett, T., Lewis, C., Egerter, S., & Showstack, J. (1993) Access to prena-
tal care following major Medicaid eligibility expansions. Journal of the American Medical
Association, 269, 1285-1289.
Brett, K., Schoendorf, K., & Kiely, J. (1994). Differences between black and white women in
the use of prenatal care technologies. American Journal of Obstetrics and Gynecology, 170,
41-46.

Lu et al. 225S
Cena, E. R., Joy, A. B., Heneman, K., Espinosa-Hall, G., Garcia, L., Schneider, C., . . .
Zidenberg-Cherr, S. (2008). Learner-centered nutrition education improves folate intake
and food-related behaviors in nonpregnant, low-income women of childbearing age. Journal
of the American Dietetic Association, 108, 1627-1635.
Cena, E. R., Joy, A. B., Heneman, K., & Zidenberg-Cherr, S. (2007). Low-income women
in California may be at risk of inadequate folate intake. California Agriculture, 61,
85-89.
Chassin, M. R. (2002). Achieving and sustaining improved quality: Lessons from New York
State and cardiac surgery. Health Affairs (Millwood), 21, 40-51.
Chrousos, G. P. (2000). Stress response and immune function: Clinical implications. Annals of
the New York Academy of Sciences, 917, 38-67.
Cornelius, J. B., & St. Lawrence, J. S. (2009). Receptivity of African American adolescents
to an HIV-prevention curriculum enhanced by text messaging. Journal for Specialists in
Pediatric Nursing, 14, 123-131.
Curtis, A. (2008). From healthy start to Hurricane Katrina: Using GIS to eliminate disparities in
perinatal health. Statistics in Medicine, 27, 3984-3997.
Dhar, J., Leggat, C., & Bonas, S. (2006). Texting—a revolution in sexual health communica-
tion. International Journal of STD & AIDS, 17, 375-377.
Dobkin, L., Kent, C., Klausner, J. D., McCright, J., & Kohn, R. (2007). Is text messaging key to
improving adolescent sexual health? Journal of Adolescent Health, 40, S13.
Dubay, L., Joyce, T., Kaestner, R., & Kenney, G. M. (2001). Changes in prenatal care tim-
ing and low birth weight by race and socioeconomic status: Implications for the Medicaid
expansions for pregnant women. Health Services Research, 36, 373-398.
Dudley, R. A., Miller, R. H., Korenbrot, T. Y., & Luft, H. S. (1998). The impact of financial
incentives on quality of health care. Milbank Quarterly, 76, 649-686.
Dyer, O. (2003). Patients will be reminded of appointments by text messages. British Medical
Journal, 326, 1281.
Eden, K. B., Messina, R., Li, H., Osterweil, P., Henderson, C. R., & Guise, J. M. (2008). Exam-
ining the value of electronic health records on labor and delivery. American Journal of
Obstetrics and Gynecology, 199, 307, E1-E9.
Elsinga, J., de Jong-Potjer, L. C., van der Pal-de Bruin, K. M., le Cessie, S., Assendelft, W. J.,
& Buitendijk, S. E. (2008). The effect of preconception counselling on lifestyle and other
behaviour before and during pregnancy. Womens Health Issues, 18, S117-S125.
Epstein, A. M., Lee, T. H., & Hamel, M. B. (2004). Paying physicians for high-quality care.
New England Journal of Medicine, 350, 406-410.
Fiscella, K. (1995). Does prenatal care improve birth outcomes? A critical review. Obstetrics
and Gynecology, 85, 468-479.
Flamm, B. L., Berwick, D. M., & Kabcenell, A. (1998). Reducing cesarean section rates safely:
Lessons from a “breakthrough series” collaborative. Birth, 25, 117-124.
Glueck, C. J., Goldenberg, N., Wang, P., Loftspring, M., & Sherman, A. (2004). Metformin
during pregnancy reduces insulin, insulin resistance, insulin secretion, weight, testosterone,
and development of gestational diabetes: Prospective longitudinal assessment of women
with polycystic ovary syndrome from preconception throughout pregnancy. Human Repro-
duction, 19, 510-521.

Gloor, P. A. (2006). Swarm creativity: Competitive advantage through collaborative innova-

tion networks. New York, NY: Oxford University Press.
Godfrey, K. M. (2002). The role of the placenta in fetal programming: A review. Placenta, 23,
S20-S27.
Grady, M. A., & Bloom, K. (2004). Pregnancy outcomes of adolescents enrolled in a Centering
Pregnancy program. Journal of Midwifery & Women’s Health, 49, 412-420.
Graves, B. A. (2008). Integrative literature review: A review of literature related to geographi-
cal information systems, healthcare access, and health outcomes. Perspectives in Health
Information Management, 5, 11-13.
Haas, J. S., Udvarhelyi, I. S., Morris, C. N., & Epstein, A. M. (1993). The effect of providing
health coverage to poor uninsured pregnant women in Massachusetts. Journal of the Ameri-
can Medical Association, 269, 87-91.
Hackley, B., Applebaum, J., Wilcox, W., & Arevalo, S. (2009). Impact of two scheduling sys-
tems on early enrollment in a group prenatal care program. Journal of Midwifery & Wom-
en’s Health, 54, 168-175.
Halfon, N., DuPlessis, H., & Barrett, E. (2008). Looking back at pediatrics to move forward in
obstetrics. Current Opinion in Obstetrics & Gynecology, 20, 566-573.
Hibbard, J. H., Stockard, J., & Tusler, M. (2005). Hospital performance reports: Impact on qual-
ity, market share, and reputation. Health Affairs (Millwood), 24, 1150-1160.
Hillemeier, M. M., Downs, D. S., Feinberg, M. E., Weisman, C. S., Chuang, C. H., Parrott, R.,
Chinchilli, V. M. (2008). Improving women’s preconceptional health: Findings from a ran-
domized trial of the Strong Healthy Women intervention in the Central Pennsylvania women’s
health study. Womens Health Issues, 18(6 Suppl.), S87-S96.
Ickovics, J., Kershaw, T., Westdahl, C., Magriples, U., Massey, Z., Reynolds, H., & Rising, S. S.
(2007). Group prenatal care and perinatal outcomes: A randomized controlled trial. Obstet-
rics and Gynecology, 110, 330-339.
Ickovics, J., Kershaw, T., Westdahl, C., Rising, S. S., Klima, C., Reynolds, H., & Magriples, U.
(2003). Group prenatal care and preterm birth weight: Results from a matched cohort study
at public clinics. Obstetrics and Gynecology, 102, 1051-1057.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st
century. Washington, DC: National Academies Press.
Institute of Medicine. (2002). Leadership by example: Coordinating government roles in
improving health care quality. Washington, DC: National Academies Press.
Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., . . .
Culpepper, L. (2009). A reengineered hospital discharge program to decrease rehospitaliza-
tion: A randomized trial. Annals of Internal Medicine, 150, 178-187.
Jesse, D. E., Dolbier, C. L., & Blanchard, A. (2008). Barriers to seeking help and treatment
suggestions for prenatal depressive symptoms: Focus groups with rural low-income women.
Issues in Mental Health Nursing, 29, 3-19.
Johnson, K., Posner, S. F., Biermann, J., Cordero, J. F., Atrash, H. K., & Parker, C. S. (2006).
Recommendations to improve preconception health and health care. MMWR. Morbidity and
Mortality Weekly Report, 55(RR06), 1-23.
Joyce, T. (1999). Impact of augmented prenatal care on birth outcomes of Medicaid recipients
in New York City. Journal of Health Economics, 18, 31-67.

Lu et al. 227S
Kegg, S., Natha, M., Lau, R., & Pakianathan, M. (2004). Communication with patients: Are
e-mail and text messaging the answer? International Journal of STD & AIDS, 15, 46.
Kennedy, H. P., Farrell, T., Paden, R., Hill, S., Jolivet, R., Willetts, J., & Rising, S. S. (2009).
“I wasn’t alone”—a study of group prenatal care in the military. Journal of Midwifery &
Women’s Health, 54, 176-183.
Kilo, C. M. (1998). A framework for collaborative improvement: Lessons from the Institute for
Healthcare Improvement’s Breakthrough Series. Quality Management and Health Care, 6,
1-13.
Klima, C. (2003). Centering Pregnancy: A model for pregnant adolescents. Journal of Mid-
wifery & Women’s Health, 48, 220-225.
Klima, C., Norr, K., Vonderheid, S., & Handler, A. (2009). Introduction of Centering Preg-
nancy in a public health clinic. Journal of Midwifery & Women’s Health, 54, 27-34.
Kogan, M. D., Kotelchuck, M., Alexander, G. R., & Johnson, W. E. (1994). Racial disparities
in reported prenatal care advice from health care providers. American Journal of Public
Health, 84, 82-88.
Korenbrot, C. C., Gill, A., Clayson, Z., & Patterson, E. (1995). Evaluation of California’s state-
wide implementation of enhanced perinatal services as Medicaid benefits. Public Health
Reports, 110, 125-133.
Korenbrot, C. C., Steinberg, A., Bender, C., & Newberry, S. (2002). Preconception care: A
systematic review. Maternal and Child Health Journal, 6, 75-88.
Korst, L. M., Gregory, K. D., Lu, M. C., Reyes, C., Hobel, C. J., & Chavez, G. F. (2005). A
framework for the development of maternal quality of care indicators. Maternal and Child
Health Journal, 9, 317-341.
Korst, L. M., Reyes, C., Fridman, M., Lu, M. C., Hobel, C. J., & Gregory, K. D. (2006). Ges-
tational pyelonephritis as an indicator of the quality of ambulatory maternal health care
services. Obstetrics and Gynecology, 107, 632-640.
Koshel J. (2009). Promising practices to improve birth outcomes: What can we learn from
New York (MCHB Technical Assistance Report). Retrieved from http://www.mchtaproject
.com/ny-report-final.pdf
Kotelchuck, M., Kogan, M. D., Alexander, G. R., & Jack, B. W. (1997). The influence of site
of care on the content of prenatal care for low-income women. Maternal and Child Health
Journal, 1, 25-34.
Kralj, B., Iverson, D., Hotz, K., & Ashbury, F. D. (2003). The impact of computerized clinical
reminders on physician prescribing behavior: Evidence from community oncology practice.
American Journal of Medical Quality, 18, 197-203.
Kucher, N., Koo, S., Quiroz, R., Cooper, J. M., Paterno, M. D., Soukonnikov, B., & Goldhaber, S. Z.
(2005). Electronic alerts to prevent venous thromboembolism among hospitalized patients. New
England Journal of Medicine, 352, 969-977.
Kuo, T. M., Gavin, N. I., Adams, E. K., & Ayadi, M. F. (2008). Racial disparities in Medic-
aid enrollment and prenatal care initiation among pregnant teens in Florida: Comparisons
between 1995 and 2001. Medical Care, 46, 1079-1085.
Levine, D., McCright, J., Dobkin, L., Woodruff, A. J., & Klausner, J. D. (2008). SEXINFO: A
sexual health text messaging service for San Francisco youth. American Journal of Public
Health, 98, 393-895.

Lim, E. J., Haar, J., & Morgan, J. (2008). Can text messaging results reduce time to treatment of
Chlamydia trachomatis? Sexually Transmitted Infections, 84, 563-564.
Lim, M. S., Hocking, J. S., Hellard, M. E., & Aitken, C. K. (2008). SMS STI: A review of the
uses of mobile phone text messaging in sexual health. International Journal of STD & AIDS,
19, 287-290.
Lindenauer, P. K., Remus, D., Roman, S., Rothberg, M. B., Benjamin, E. M., Ma, A., &
Bratzler, D. W. (2007). Public reporting and pay for performance in hospital quality
improvement. New England Journal of Medicine, 356, 486-496.
Long, S. H., & Marquis, M. S. (1998). The effects of Florida’s Medicaid eligibility expansion
for pregnant women. American Journal of Public Health, 88, 371-376.
Lu, M. C., Kotelchuck, M., Culhane, J., Hobel, C. J., Klerman, L. V., & Thorp, J. (2006). Pre-
conception care between pregnancies: The content of internatal care. Maternal and Child
Health Journal, 10(5 Suppl.), S107-S122.
Lu, M. C., Tache, V., Alexander, G., Kotelchuck, M., & Halfon, N. (2003). Preventing
LBW: Is prenatal care the answer? Journal of Maternal, Fetal and Neonatal Medicine,
13, 362-380.
Lumley, J., & Donohue, L. (2006). Aiming to increase birth weight: A randomised trial of
pre-pregnancy information, advice and counselling in inner-urban Melbourne. BMC Public
Health, 6, 299.
MacArthur Initiative on Depression & Primary Care. (1999). Patient health questionnaire: PHQ-
9. Retrieved from http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/
phq9/
Mackenzie, H. (2009). A text messaging trial in family planning clinics. Studies in Health Tech-
nology and Information, 146, 154-159.
Mak, D., & Bastion, L. (2006, October). Sending out an SMS: An impact and outcome evaluation of
the Western Australian Department of Health’s 2005 Chlamydia Campaign. Paper presented at
the Australasian Society for HIV Medicine conference, Melbourne, Victoria, Australia.
Marquis, M. S., & Long, S. H. (1999). Medicaid eligibility expansion in Florida: Effects on
maternity care financing and the delivery system. Family Planning Perspective, 31, 112-116.
Marshall, M. N., Shekelle, P. G., Leatherman, S., & Brook, R. H. (2000). The public release
of performance data: What do we expect to gain? A review of the evidence. Journal of the
American Medical Association, 283, 1866-1874.
Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., Kirmeyer, S., &
Mathews, T. J. (2009). Births: Final data for 2006. National Vital Statistics Report, 57(7),
1-101. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf
Martin, J. A., Hamilton, B. E., Ventura, S. J., Menacker, F., & Park, M. M. (2002). Births: Final
data for 2000. National Vital Statistics Reports, 50(5), 1-104.
McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England Jour-
nal of Medicine, 338, 171-179.
McLafferty, S., & Grady, S. (2004). Prenatal care need and access: A GIS analysis. Journal of
Medical Systems, 28, 321-333.
Menon-Johansson, A. S., McNaught, F., Mandalia, S., & Sullivan, A. K. (2006). Texting
decreases time to treatment for genital Chlamydia trachomatis infection. Sexually Transmit-
ted Infections, 82, 49-51.

Lu et al. 229S
Millenson, M. L. (2004). Pay for performance: The best worst choice. Quality and Safety in
Health Care, 13, 323-324.
Miller, D. W., Jr. (2003). Prenatal care: A strategic first step toward EMR acceptance. Journal
of Healthcare Information Management, 17, 47-50.
Miller, D. W., Jr. (2008). The transition from paper to digital: Lessons for medical specialty
societies. AMIA Annual Symposium Proceedings, 6, 475-479.
Mills, M. E. (2006). Linkage of patient records to support continuity of care: Issues and future
directions. Studies in Health Technology and Informatics, 122, 320-324.
Milunsky, A., Jick, H., Jick, S. S., Bruell, C. L., MacLaughlin, D. S., Rothman, K. J., & Willett, W.
(1989). Multivitamin/folic acid supplementation in early pregnancy reduces the prevalence of
neural tube defects. Journal of the American Medical Association, 262, 2847-2852.
Murray, C., Gray, B., Bourne, C., & Dabbhadatta, J. (2006, October). Using new technologies
to increase STI testing behaviour among gay men in inner Sydney. Paper presented at the
Australasian Sexual Health Conference, Melbourne, Victoria, Australia.
National Quality Forum. (2009). National voluntary consensus standards for perinatal care 2008.
Retrieved from http://www.qualityforum.org/Publications/2009/05/National_Voluntary_
Consensus_Standards_for_Perinatal_Care_2008
Norwitz, E. R. (2006). Defective implantation and placentation: Laying the blueprint for preg-
nancy complications. Reproductive Biomedicine Online, 13, 591-599.
Olds, D. L., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K., . . . Bondy, J.
(2007). Effects of nurse home visiting on maternal and child functioning: Age-9 follow-up
of a randomized trial. Pediatrics, 120, e832-e845.
Omar, M. A., Schiffman, R. F., & Bauer, P. (1998). Recipient and provider perspectives of bar-
riers to rural prenatal care. Journal of Community Health Nursing, 15, 237-249.
Phelan, S. T. (2008). The prenatal medical record: Purpose, organization and the debate of print
versus electronic. Obstetrics and Gynecology Clinics of North America, 35, 355-368.
Pickett, K. E., Luo, Y., & Lauderdale, D. S. (2005). Widening social inequalities in risk for sud-
den infant death syndrome. American Journal of Public Health, 95, 1976-1981.
Piper, J. M., Mitchel, E. F., Jr., & Ray, W. A. (1994). Presumptive eligibility for pregnant
Medicaid enrollees: Its effects on prenatal care and perinatal outcome. American Journal of
Public Health, 84, 1626-1630.
Piper, J. M., Ray, W. A., & Griffin, M. R. (1990). Effects of Medicaid eligibility expansion
on prenatal care and pregnancy outcome in Tennessee. Journal of the American Medical
Association, 264, 2219-2223.
Rising, S. S. (1998). Centering Pregnancy: An interdisciplinary model of empowerment. Jour-
nal of Nurse-Midwifery, 43, 46-54.
Rittenhouse, D. R., Braveman, P., & Marchi, K. (2003). Improvements in prenatal insurance
coverage and utilization of care in California: An unsung public health victory. Maternal
and Child Health Journal, 7, 75-86.
Robertson, B., Aycock, D. M., & Darnell, L. A. (2009). Comparison of centering pregnancy
to traditional care in Hispanic mothers. Maternal and Child Health Journal, 13, 407-414.
Schwarz, E. B., Sobota, M., Gonzales, R., & Gerbert, B. (2008). Computerized counseling for
folate knowledge and use: A randomized controlled trial. American Journal of Preventive
Medicine, 35, 568-571.

Skelton, J., Mullins, R., Langston, L. T., Womack, S., Ebersole, J. L., Rising, S. S., & Kovarik,
R. (2009). CenteringPregnancySmiles: Implementation of a small group prenatal care model
with oral health. Journal of Health Care for the Poor and Underserved, 20, 545-553.
Tita, A. T., Cliver, S. P., Goepfert, A. R., Conner, M., Goldenberg, R. L., Hauth, J. C., &
Andrews, W. W. (2007). Impact of interconception antibiotics on the endometrial microbial
flora. American Journal of Obstetrics and Gynecology, 196, 226.e1-226.e6.
U.S. Department of Health and Human Services. (2001). National standards for culturally and
linguistically appropriate services in health care. Washington, DC: Author.
Van den Oever, M., & Van Mens, L. (2006, August). The combined use of Internet and SMS
targeting hard to reach sex workers working as escorts. Paper presented at AIDS 2006—
16th International AIDS Conference, Toronto, Ontario, Canada.

Lu 2010

Uploaded by

Copyright:

Available Formats

Lu 2010

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Lu 2010

Uploaded by

Copyright:

Available Formats

Medical Care Research and Review

Supplement to 67(5) 198­S–230S

Michael C. Lu1, Milton Kotelchuck2, Vijaya K. Hogan3,

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Finally, health care quality is measured by its effectiveness in achieving a desired

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Given the relative paucity of published research on innovative strategies (including

Strategies to Increase Access to Timely Prenatal Care

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Table 1. Promising Strategies to Reduce Disparities in Prenatal Care Quality in Underserved

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

In California, MediCal eligibility for pregnant women was increased to 200% of

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

the hypothalamic–pituitary–adrenal (HPA) axis to keep the body’s stress response in

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

care, particularly for many low-income women in underresourced settings, is termina-

Applications of Health IT to Increase

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Strategies to Improve the Content of Prenatal Care

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Performance measurement. Performance measurement is another strategy that can

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

conditions; (b) incorporation of preconception care and postpartum care to improve

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Applications of Health IT to Improve

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Strategies to Enhance the Organization

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Applications of Health IT to Enhance the

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

improvement and cost savings is clearly recognized by many providers in underserved

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

after the introduction of Back to Sleep campaigns demonstrating the effects of an

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Declaration of Conflicting Interests

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Gloor, P. A. (2006). Swarm creativity: Competitive advantage through collaborative innova-

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

Downloaded from mcr.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015

You might also like

Supplement to 67(5) 198S–230S