Study results in prolonging pregnancy and improving infant mortality and morbidity are consistent with those of Olds,17
and colleagues. Our intervention, however, differs from most reported programs of prenatal care in scope of services, educational preparation of nurse provider, and its focus on women at greater risk of delivering LBW infants. Our sample of mostly Medicaid recipients also differs from many reported studies.
Most reported prenatal home care programs focus on monitoring uterine activity to intervene early in preterm labor.12,13,18,19
Nurses might provide patient teaching regarding preterm labor but most often review uterine activity with the woman by telephone and report results to the physician. Nurses’ educational specialty preparation is seldom noted. In addition, study samples might not consist of women at high risk of delivering LBW infants.
For high-risk women who need frequent prenatal care and monitoring, prenatal care delivered at home that substitutes for routine physician clinic visits following study protocols has many advantages. It reduces transportation problems, the need for child care, long waits to be seen, and interruption of medical regimens such as bed rest. This approach provides continuity of care by having an APN that specializes in caring for women with high-risk pregnancies provide direct care, with physician backup, and by making services of the APN available to the woman and family 7 days a week through a telephone service. For example, intervention women had an average of 50 telephone contacts with APNs from enrollment in the prenatal period to 6 weeks postpartum. Continuity of care, monitoring of the woman’s physical status, coping, and adherence to the medical plan, allows for early detection and earlier intervention when problems arise. Overall, physicians were receptive to the APN model of care. There were disagreements, however. As the study progressed, physicians approached the APNs with a patient they believed needed the program and the APN expertise; the APNs had to remind them that this was a randomized controlled trial.
The safety and efficacy of the study intervention were demonstrated by lower fetal/infant mortality (2 vs 9); hospital days saved (>750 total days); fewer women being hospitalized prenatally (41 vs 49); and fewer infants being rehospitalized (18 vs 24) in the intervention group compared with the control group. Although more women in the intervention group vs the control group had a postpartum hospitalization (17 vs 11), the intervention group had 42 fewer hospitalized days. These outcomes were achieved in a sample of mothers in which 36.5% had less than a high school education, 78.8% were unmarried, 91.8% were receiving Medicaid, and 60.7% had a reported annual income of less than $12,499. Acceptability of the study approach was demonstrated by significantly greater satisfaction with care in the intervention group, the low refusal rate (n = 6, 3.2%), and the low attrition rate of enrolled women (n = 11, 6.4%). Nine of the 11 dropouts (5.2% of all participants) occurred after pregnancy loss or infant death.
Some of the greatest improvements in outcomes were in infants born at 32.9 weeks’ gestation or earlier (9 in the intervention group vs 13 in the control group) and in those weighing 1750 g or less at birth (6 in the intervention group vs 12 in the control group). Success in prolonging gestation to term was especially evident in women with twin pregnancies (77.7% vs 33.3%). The intervention, in addition to providing support, teaching, and counseling, allowed women to remain on bed rest rather than traveling to the physician’s office or clinic, which often required women to make several bus transfers with small children. For some women, attending prenatal care involved 10 hours from door to door.23
For women at risk or stabilized with preterm labor, such visits were especially stressful and were relieved by APN prenatal care delivered at home.
The intervention’s success in prolonging gestation resulted in reduced hospital charges for newborns. Healthcare charges greatly favored the intervention for infants born at <26 weeks’ gestation ($0 vs $949,594), and 26.1 to 28.9 weeks’ gestation ($386,781 vs $1,594,852. Differences in healthcare charges were far less for infants born at 29.0 to 32.9 weeks gestation ($657,762 vs $779,313) and 33.0 to 36.9 weeks’ gestation ($641,280 vs $858,209). Intervention group costs were consistently lower in all infant groupings and often reached statistical significance. In addition, the APN intervention cost is small relative to the magnitude of the savings. Similar results have been demonstrated using the APN model of care in other patient groups.14,23–26
A major study limitation was that the sample was African American and poor, thus limiting generalizability to other racial or economic groups. In addition, the longitudinal design of the study, with multiple data points, resulted in missing data after pregnancy loss and infant death. However, study results that demonstrate improved maternal and infant outcomes and reduction of healthcare charges are important in systems of capitated payment. Study results demonstrate improved pregnancy and infant outcomes and overall cost savings for a group of women who were predominantly Medicaid recipients, similar to those enrolled in managed care organizations.
The study approach also has long-term health and economic benefits for infants, families, and society. Healthier infants require fewer healthcare services, fewer educational services, and reduced caregiver and financial burden for families. Healthier infants also have a greater probability of becoming independent, productive members of the nation’s workforce and society. We conclude that models of care such as that used in this study provide a reasoned solution to improving pregnancy and infant outcomes while reducing healthcare costs.