Community prenatal care: An “integrated” approach

CURRENT

OPiNlON

ROBERT

C.

GEORGE

BLINICK,

New

York,

New

WALLACH,

M.D. M.D.

York

Meeting the need for impoved prenatal care has led to innovative approaches to clinic organization and management. De&wry of aQtima1 prenatal care is based on availability of services and acceptability to pa&stats. Greater involvement cif the obstetrician is dependent on imQroving the system to facilitate hisservices and exploit his capabilities. Modest erependitures can transform an institutional setting into an inviting, comfortable locus where exQectant mothers will not be impeded from seeking care. The di&x&es of clinic attendance for pregnant women of low socioeconomic order are largely related to time factors. T&se factors, to a great degree, can be overcome by a system of “integrated” clinics, where the traditional separationof obstetrics and gynecology is broken down. The advwstages of the “integrated” clinics include great* availability of prenatal service, ending of self-referral with wasted physician-Q&rut encounters, elimination of duQ&ate examinations for the patient, and better patient-utilization of services. This improved utilization leads to more time for establishing raQQort and lessening anxiety, more time for delivering prenatal educatkn, and more time for di&weri~g artd $reati%g medical problems. A prenatal care program t&g. these $winciiQEes has demonstrated improved patient acceptability with a leta rage of failed aQQointrnents, high incidence of first-trimester registration and increased numbersof clinic visits.

THE IMPORTANCE of early and complete medical care for pregnant women is widely recognized. Recognition and treatment of problems arising from, and associated with pregnancy, are facilitated by the initiation and delivery of prenatal care as early in pregnancy as possible. The involvement of women in continuing medical surveillance, with preconceptional care available, is an ideal means for ensuring early

complete prenatal care. Despite the support of governmental agencies and many branches of the medical professions, there has been only limited progress in this country in the decreaseof per&@ mortality and morbidity, and comparable st&tics for other nations refkkt our lessenedst&us in this area.sjQlI8 There is a widely recognized synergism between the faihn+e of certain groups of low socioeconomic order to get optimal medical care and the urgency of the need for medical care in these ~2% &es be.!P-UP*L ** 5~ 71 I* /&, a &p&y tween need and utiliition of professional

From the Deaartment of Obstetrics and Gynecofa Gouver+teut Health Services Program,

%th

Israel

Medical

Center.

808

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Number

105 5

resources8 The white, educated, middleincome expectant mother, whose prenatal needs may be least demanding, seeks and receives early specialized medical care; the black or non-English-speaking, low-income mother-to-be, of poor nutritional background, and subject to the greatest hazard, seeksand gets curtailed medical serviceslate, or not at all23 I2 Although strides have been made in the over-all plan of organization for the delivery of medical care in low income areas,6 few effective steps have been taken to improve the picture of obstetric care. Some of the criticism leveled at medical care programs in related areas bear restatement for prenatal care. The situation of disease-orientedphysicians confronting problemswith roots in the family and community is real and difficult.6 The modern obstetrician is trained to recognize and effectively treat a wide variety of “medical” diseases, such as diabetes, rheumatic heart disease, and anemia. He is an experienced surgeon, ready to circumvent the mechanical hazards which previously claimed the health or lives of many mothers and babies. He knows and can handle the inherent diseasesof pregnancy : toxemia, coagulation defects, and uterine infection. He is also a well-rounded doctor, able and anxious to render complete medical care with due recognition of conditions surrounding the patient and her family. But, in the usual context of the clinic serving a low-income clientele, the obstetrician all too often gets a fleeting look at a woman in late pregnancy and has little background information available. This woman, then, either is delivered uneventfully and disappears or presents with the organic emergency conditions the obstetrician knows and with which he is scientifically prepared to cope. The obstetrician thus is limited to using only a few of his medical and technical skills. This type of system of care for the poor is attuned to many routine cases interspersed with occasional crises. The oftcited lack of personal involvement may indeed be due to the structure of the system rather than shortcomings of the physician.

Community

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care

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Training programs carried out in such settings appear to attach low importance to personal interest. In addition to the orientation of the physician, another source of frequent negative comment is the physical setting of the obstetric clinic. Long, hard benchesin a dimly lit, trash littered, unpainted waiting room are the hallmarks of older systemsthat tend to depersonalize the care offered to the patient.lO Unhygienic, poorly equipped examining stalls with no provision for privacy complete the unhappy picture. In this setting, the gayest expectant mother and the most committed obstetrician would have difficulty being comfortable. The patient’s allotment of time is usually overlooked, but is a major problem for expectant mothers in lower socioeconomic groups. Multiple pressing demands on time can deter the patient from successfulparticipation in any program of medical care. Primacy in allotting time is often given to dispatching and collecting school children, marketing, meal preparation, and housekeeping. Infants require baby-sitters before the mother can attend the clinic, and there is not always another person at home to whom this task may be entrusted. The man of the family, when available, may have a job at odd hours, further lesseningthe ability of the woman to attend the clinic. Distance from the clinic and problems with transportation are frequent problems.ll And, attention to other health needs at the samemedical facility may not leave time for prenatal clinic becauseof conflicting appointments. A critical factor in the failure to deliver prenatal care is the break in continuity associated with the usual system of separate clinics in gynecology and obstetrics. Countless patients with irregular bleeding or a missed period will visit a gynecology clinic once or twice to have the diagnosisof pregnancy made and confirmed. Following these visits, a referral is usually offered to the prenatal clinics. The patient has not been involved in any ongoing program, has not been made to feel that her pregnancy is an important event, and doesnot feel that any-

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thing important need be done. She has only a verbal direction to another clinic, sometimes reinforced by an informal scrap of meaningless directions. She paper with knows that a new physician and repetition of examination awaits her. The chain of events tends to discourage early clinic registration and creates the pattern of late, irre‘gular, and incomplete prenatal care.l’ In April, 1966, the Beth Israel Medical Center instituted prenatal care at the Gouverneur Health Services Program. The Gouverneur building is located at the extreme southern boundary of the Lower East Side of New York City. The clientele is predominantly of Puerto Rican background with substantial numbers of Negroes and Chinese, and other groups are sparsely represented (Santo Domingo, Cuba, elderly European Jews). The people, in general, are of low socioeconomic order, with a high illiteracy rate. The patients now seen for obstetric care at Gouverneur would previously have gone to Beth Israel Hospital clinics or other facilities near the periphery of the Lower East Side. The rise in numbers of patients seen at Gouverneur was accompanied by a fall in those seen at Beth Israel Hospital. The average number of prenatal patients seen each year at Gouverneur is 790. Knowing that the patients seen for obstetric care constituted a high-risk population, efforts were made to organize the new clinic to promote earlier and easier involvement of the patients with medical care. The problems outlined above were seen as challenges to be faced and led to several lines of action, some with little precedent. The first concrete move toward making the clinics inviting was the rehabilitation of the physical plant. The clinic is located in a 55-year-old building with obsolete fixtures. Improved lighting, frequent painting of the walls with bright colors, window curtains, and prints on the walls have made for much more acceptable appearance. Seats in the waiting area are individual, modern in design, comfortable, and in sufficient numbers for most occasions. History taking and physical examination are performed in small

closed rooms to assure privacy. A modest expenditure provided all the equipment that might be found in a private office, and this equipment is replaced promptly when defective or missing. There is much to be desired in further improvements, but much has been accomplished in making the clinic’s appearance more attractive. A second challenge to plans for making prenatal care more inviting was the involvement of physicians, nurses and other staff. Fortunately, the staff of the Department of Obstetrics and Gynecology of the Beth Israel Medical Center has picked up this challenge, and there is now an attending physician at every clinic session, in addition to the resident staff. The attending physicians are, of course, available for consultation to the residents, but as part of their routine and daily role in the clinic, the attending physicians see and examine the patients. In this way, the clinic patients have the services of the most experienced members of the staff, and the level of care is thereby elevated. The resident staff has responded well, knowing that there is always consultation at hand, and earlier dispositions can be effected for most problems. A concomitant benefit of resident participation is that the same physicians see patients in the clinics and the hospital, assuring continuity of care and familiar personnel for the patients upon hospital arrival. Major sources of strength have been found in the expanded roles of nurses, social workers, dietitians, aides, and technicians. Redistribution of tasks and continuing education have increased the types and amount of services offered to patients. New approaches in this area will be the subject of a subsequent paper. The third, and perhaps the biggest, roadblock to the delivery of optimal prenatal care is the time factor. As described above, obligations to other children, housekeeping, family, other health needs, and travel problems have discouraged patients from early and regular involvement in prenatal care. To meet these problems, several new meth-m ods have been employed, but the major innovative technique has been the “integra-

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tion” of clinics. Initially, as had been the custom, there were separate clinics for obstetrics, gynecology, and family planning. These traditional lines of clinic organization have now been crossed and all the clinics of the department at Gouverneur are now “integrated”: at each clinic session, patients are seen for care in any of the areas of obstetrics, gynecology, or family planning. With the addition of evening clinics on 4 nights each week, a patient may get prenatal (or gynecologic or family planning) care, morning, afternoon, or evening, 5 days a week (with the exception of Friday night, for which paraprofessional staff cannot be recruited). With complete free choice of time, there is almost never a situation in which the patient cannot make and keep an appointment. Several corollaries have been found to the offering of around-the-clock availability of prenatal services. Self-referral, the practice of a staff seeing a pregnant patient in a gynecologic clinic and then referring her to the same staff for prenatal care in an obstetrical clinic, has been eliminated. When pregnancy is diagnosed, or suspected, in any of the integrated clinics, the full history taking, physical examination, and laboratory investigation for a known pregnancy are instituted. If there is no pregnancy, the patient has undergone a good medica work-up. If pregnancy is confirmed, the patient has been involved at first contact with the program of prenatal care. Repeat pelvic examination, which is distasteful to many patients and deters their return, is eliminated. The patient is generally interested in the results of the laboratory survey and a “handle” is thereby created. The education and counseliing for pregnancy is started and the patient is swept along with the ongoing program, closing the gap between the gynecologic work-up for amenorrhea and the obstetric care for an expectant mother. If abnormalities are discovered, the time available for consultation and treatment is greatly expanded for the early prenatal registrant. With more time to see the patient, a better organized, patient-oriented approach is pos-

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sible, the staff gets to know the patient better, and she is more relaxed and cooperative. The greater rapport established between staff and patient lessens the patient’s anxiety and leads to earlier reporting of complaints, fewer missed visits, and more successful delivery of medical care. Objective evaluation of improvement in prenatal care is difficult but there are data indicating the success of this program. The percentage of patients registering in each trimester of pregnancy has undergone a marked change since the integrated clinics were started. When the clinics were first started, the proportion of early registration was greater than in the units where the traditional dichotomy between obstetrics and gynecology was maintained. The improvement was felt to be due to the change in the first two major factors described earlier, physician orientation and the physical appearance of the clinic. With the continued use of the integrated clinics, the improvements were maintained and became more marked, so that after two years of service, third-trimester registration is now down to 11 per cent (Table I), The reasons for continued late registration include recent immigration, recent arrival in the community, and, distressingly, a small group that is convinced by previous

Table 1. Trimester prenatal

of registration

for

patients Percentage of patients

Trimester 1 2 3

Table II. Number

1966 22 56 22

of prenatal Percentage

No.

of visits 1-4 5-8 9-12 13+

1968 44 45 11

visits of patients

1966

1968

55 30 11 1

13 37 33 16

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experience that there is nothing to be gained by early involvement. An outreach program for these recalcitrant patients is now underway. Increased utilization of obstetrical services has grown pari passu with the earlier registration of pregnant patients. A striking improvement in the number of clinic visits for each patient has been achieved. At the outset, more than half had less than five visits, and this is now down to less than one in seven patients. The group of patients get-

November 1, 1969 Am. J. Ohst. & Gym.

ting more than eight physician visits has now reached almost half of the total group (Table II) . Patient acceptance of the program is also indicated by a low rate of failed appointments of prenatal patients (“no-shows”) . The rate for failed appointments, where the patient has not changed appointments or appeared earlier, has varied between 2.2 per cent and 4.1 per cent. The over-all rate has been about 3 per cent.

REFERENCES

1. Buetow, K. Cl.: Am. J. Pub. Health 51: 217, 1961. 2. Donabedian, A., and Rosenfeld, L. S.: New England J. Med. 265: 1, 1961. 3. Erhardt, Cl. L., editor: Infant Mortality, New York City, miscellaneous tables, New York, December, 1967, Health Services Administration, Office of Program Planning. 4. Fox, R. I., Goldman, J. J., and Brumfield, W. A., Jr.: Pub. Health Rep. 83: 597, 1968. 5. Gallagher, E. B.: Am. J. Pub. Health 57: 2127, 1967. 6. Gibson, C. D., Jr.: Am. J. Pub. Health 58: 1188, 1968. 7. Kincaid, J. C.: Brit. M. J. 1: 1057, 1965.

8. Kissick, W. L.: Am. J. Pub. Health 58: 23, 1968. 9. Lesser, A, J.: Children 11: 13, 1964. 10. McLaughlin, M. C.: Am. J. Pub. Health 53: llSi, 1968. 11. Monahan, H. B., Spencer, E. C.: Children 9: 114, 1962. 12. Csofsky, H. J.: Obst. & Gynec. 31: 437, 1963. 13. Shapiro, S., Schlesinger, E. K., and Nesbitt, R. E. C.: Infant, Perinatal, M.aternal and Childhood Mortality in the United States, Cambridge, M.assachusettsj 1968, Harvard University Press.